While attending the Institute for the Future’s Health Horizons Fall Conference on Monday, one thing became eminently clear. The 21st century will be the era of brain, the last great scientific frontier. Due to societal shifts, environmental changes, and the fact that we are just living longer, we are poised to see a sharp rise in cases of diseases such as Alzheimer’s, Parkinson’s, autism, and post-traumatic stress disorder. The only thing worse than the increasing prevalence of brain disease is the sobering fact that few viable treatments currently exist.

For years, we’ve heard the mantra of behavior change and health. Exercise more and you’ll cut your risk for heart disease and stroke. Eat more fruits and vegetables and you can decrease your risk for colon cancer (or possibly prostate cancer, as discussed in a previous Decision Tree post, “Why Behavior Change is Better Medicine than Drugs”). Could behavior change serve our brain health as well as it did other organs of the body?

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“The human body does enormously well healing itself,” Keas founder, and ex-Google Health lead, Adam Bosworth told Health 2.0 conference-goers shortly after stepping on stage.  On the heels of an article in the New York Times that touted the company’s beta launch, Bosworth walked the crowd through the way we’ll keep ourselves healthy in the future, using Keas’ platform.

Of all people, Bosworth understood the potential power of the internet on health, where the collective wisdom of the patient population could reach thousands, or millions, of other people.  So he wondered, if people were readily turning to the web for information when they got sick, could customized, preemptive web advice keep people from getting sick in the first place?

By personalizing the measures we can take to stave off certain predisposed conditions, Keas’ Care Plans should improve our health.  But the real promise of the company, wasn’t in what Bosworth delivered onstage, but rather, in something he simply mentioned in passing.  Bosworth alluded to the idea that not only will Keas’ platform let people track their own health, but it could also allow people to keep tabs on their family’s health as well.

I saw this study in Science at the beginning of the month, and a summary was posted at The Scientist:

A bacterium that infects insects may provide a biological method for stunting the spread of a range of devastating human diseases. The bacteria may protect their hosts against disease-causing pathogens by hiking up the insects’ immune response, according to a study published online today (October 1) in Science.

Basically, mosquitoes were fed a certain bacteria, called “popcorn” Wolbachia, that did two things, 1.) boosted the immune system of the mosquitoes, which made them less likely carriers of diseases such as filarial nematodes (cause lymphatic filariasis), and 2.) cut the average lifespan of the mosquitoes in half.

Researchers are looking at the future possibilities of this promising treatment — a natural way to curb the dangerous infectious diseases spread by mosquitoes.  Questions remain whether the “popcorn” bacteria could also interfere with the mosquitoes’ ability to carry more dangerous diseases, such as malaria or the Dengue virus.

In a previous post, I talked about evidence that exercise can ward off dementia.  Now a study discussed at Science Daily shows new findings in the relationship between exercise and stroke.

Stroke is often causes by an ischemic event (lack of blood flow) in the brain, mostly due to a blood clot or atherosclerosis.  In essence, stroke is a caused by unhealthy blood vessels.  We’ve known for years that just as in heart disease, diet and exercise also go a long way in preventing stroke.

In this new study, the severity of the stroke in the exercisers and non-exercisers was similar, but those who exercised on a regular basis recovered much quicker.  These results are interesting because it shows that exercise could potentially be neuroprotective, and therefore, the brain is in much better shape to recover from a temporary lapse in blood flow.  So even if your exercise routine doesn’t prevent the stroke, your chances of recovering seem much better.

There were two posts at ScienceDaily today that discussed the consequences of mothers’ choices during pregnancy on the future health of their children.  The first stated that the children of mothers that smoked cigarettes during pregnancy were more likely to smoke in the future, and would find it harder to quit if they tried.  The second discussed the link between obese pregnant mothers and children who developed asthma.  Presumably, obesity causes a pro-inflammatory response, which may predispose the fetus to cytokines that cause respiratory inflammation that leads to the development of asthma in later life.

These posts have me thinking about just how much a mother’s life affects a fetus during pregnancy at the epigentic and developmental levels.  In my preliminary search, I’ve found a couple other interesting stories.  One article discussed how maternal feeding affects the biological clock of the fetus.  Another report talked about how maternal exposure to bisphenol A (BPA) changes fetal gene expression.

Does anyone have any interesting links on this topic to share?

A new Nature news story discusses the little known fact that there are two different types of adipose (fat) tissue: white and brown.  White fat tissue stores excess calories that are not used for energy as lipids, and typically accumulates around the hips and thighs of the girls, and around the belly of the guys.  Simply put, it’s the excess inches we try to get rid of through diet and exercise.  Brown adipose tissue (BAT), on the other hand, typically accumulates around the collarbone, shoulder blade, and neck area.  Originally thought to only be present in human newborns and animals, BAT is unique in that it burns excess fat calories, as opposed to storing them, to keep the body warm.

However, in recent studies published in The New England Journal of Medicine, researchers found metabolically active BAT in an unexpected place — on human adult volunteers.  The studies used Positron Emission Tomography (PET), which measures where consumed radio-labeled glucose is metabolized in the body.  Subjects were scanned either at room temperature, or in a cold room (17-19 deg Celsius), while their feet were repeatedly immersed in cold water (7-9 deg Celsius).  It turns out that with the cold room and ice-cold foot bath, there was a significant increase in the metabolic activity of the fat tissue around the collarbone and shoulder blades, compared to scans taken at room temperature.  Cold temperatures activate the sympathetic nervous system, and epinephrine (adrenaline) is released, which causes the body to warm itself.  These results show that in colder temperatures, calories may not be stored on your waist or hips, but rather, metabolized by the brown adipose tissue to keep you warm.

Despite their findings, it’s not suggested you take your lunch and head for the nearest walk-in freezer.  But the key finding is that BAT metabolism is triggered by adrenaline, the same hormone responsible for the “fight or flight” response.  Therefore, these results open the possibility that new drugs that activate the sympathetic nervous system to release adrenaline may be a viable treatment for obesity.

News of 23andMe launching an online community for expecting mothers, and a few recent journal articles talking about the dangers of environmental polychlorinated biphenyls (PCBs) on both prenatal and neonatal brain development, have got me thinking about the future of in utero preventive medicine.  Lesson: I guess it’s never too early to begin implementing a Decision Tree…

In my opinion, our inalienable rights should be restated as the title of this post suggests.  But despite my wishful thinking, health care costs continue to rise.  By 2030, the boomer generation will place 57.8 million people in the 66-84 age group, further burdening current government funding for Medicare.  The outlook is bleak, and the system needs fixing.  One idea for lowering health care costs is to move health services out of the clinic, and into the home.  New web-based services and personal diagnostic equipment now enable patients to receive medical care from the comfort of their living room.  Is it realistic this model will reduce costs and stick?  I’ll cover the web-based services in this post, and follow up with another post on home diagnostic equipment.

Web-based doctor’s appointments are now available in several states.  For example, at $10 per month, and $50 per consultation, SwiftMD offers an online health care plan in New York and New Jersey.  Within 30 minutes of scheduling an appointment, subscribers have either a phone conversation or an online video chat with an available physician.  If prescriptions are required, the physician sends the request electronically to the pharmacy of the subscriber’s choice.  A step further in service, Hello Health adds conveniences such as the ability to text, instant message, or tweet your doctor, and also offers clinic appointments or house calls for more serious conditions.  Both SwiftMD and Hello Health do not cover major medical expenses, so if the subscriber has to go to the emergency room or be admitted to the hospital, the cost is theirs.  Also, neither accepts insurance, but compared to ever increasing health insurance premiums and the number of uninsured patients, an affordable “pay for what you need” model may just work.

A recent article highlighted the services of Hello Health, and discussed the ways electronic media is reshaping health care.  More important than describing cool, new ways to communicate with your doctor, and boutique concierge services offered by modern clinics, the article does a fine job pointing out the importance of social networking in the future of health care.  Physicians use websites such as Sermo and UpToDate to stay abreast of advances in health care and treatment, as well as to network with other doctors in the field.  Patients, on the other hand, have traditionally been stuck with tools such as WebMD, NIH’s MedlinePlus, and the Mayo Clinic site, all of which just give background information on diseases, and pave the way for dangerous self-diagnosis.

Such patient websites provide little help to the proactive patient who is curious if others with a certain condition are experiencing similar symptoms or medication side effects.  Enter PatientsLikeMe, a website that focuses on user-generated data (via self monitoring and reporting) and lets others know what to expect on the road ahead.  PatientsLikeMe provides a useful social networking community if you are already diagnosed with a condition, but what if you are a 40-something male with a BMI of 28, blood pressure at 135/85, and recently diagnosed with metabolic syndrome?  Is there anyone out there with similar stats that can offer information about what regiments have kept them healthy?  In other words, let’s not wait until we are diagnosed with heart failure to seek out advice from our peers — we need social networking tools when we are still just “at-risk” for the disease.

While electronic access to your physician is much cheaper than going to an office visit, to truly drive health care costs down, we need to increase the personal responsibility of the public — we need to heighten our medical knowledge, track our own body metrics, and pool our data.  Social networking sites provide the necessary framework to disseminate such information and personal experiences across large populations.  Armed with the proper information, patients will be able to make their own decisions about their health.  Now that’s a true health care revolution — so go tweet your way to better health.  I’ll discuss home diagnostic testing soon…

The ideas behind The Decision Tree, in a sense, focus on ways to create the next-generation patient.  This new kind of patient will have to understand the context of their own medical self through a combination of genetics, personal metrics/data, and statistics.  Needless to say, understanding one’s own medical self will also require an increased medical literacy, where patients understand both their conditions, as well as where they fall within the spectrum of their disease.

Creating the next-generation patient will inevitably require new tools.  Website services, such as PatientsLikeMe, have been a step in the right direction towards increasing patient knowledge by empowering people with general knowledge of their conditions, as well as and providing information of what others in their shoes are experiencing.  However, focusing on the patient may only address half of the problem.

MedEncentive, a start-up company founded in 2003, approaches the issue of medical literacy by addressing both players in the problem, the physician and the patient.  MedEncentive’s product focuses on developing, or even better, redefining, the doctor-patient relationship.  A statistic listed on their website states that on an average office visit, the physician will interrupt the patient within seconds of entering the room, while the patient only comprehends a fraction of the information given to them by their doctors.  Drawing from my own mixed experiences dealing with physicians – including a recent diagnosis botched 3 times in a week – I could see how this could be true.  If a patient had an increased understanding of their conditions, perhaps this interaction would not be so one-sided.

The company’s core product is an incentive program for doctors and patients that centers around the exchange of medical information. Doctors who participate in the medical literacy program can earn about 20% more (~$15) per office visit by assigning their patients a “to-do” list.  The company mentions some of what this list might include, such as questionnaires which determine how much a patient understands about both their current health status and the conditions they’ve been diagnosed with, as well as how they would rate their doctor’s performance.  The patients earn rewards, such as copay reimbursements or health savings account credits, for completing their reading assignments and the questionnaires.

According to the company, a medically literate patient will communicate more efficiently with their physician, while medically illiterate patients will consume more health care resources.  But do people really care about this?  Sure, it would be nice to reduce health care costs and make doctors and patients best friends, but is it really a big deal if a patient doesn’t understand the ins-and-outs of their conditions? If you are not sold on the benefit of developing the doctor-patient relationship, consider the following figure.  It was taken from a study conducted by physicians at Northwestern University and Emory University on the 5-year mortality rate of an elderly population.  Medical illiteracy can become dangerous when it leads to an increased risk of death.  So based on the outcome of this study, MedEncentive’s thesis makes sense: when patients know more about their medical conditions, they have better health.

I acknowledge that there is a confounder to this study — it was conducted in an elderly population.  As we all know, the cognitive abilities of the elderly vary drastically across the population.  For example, your 90-year old grandfather may be self-sufficient, living on his own, and sharp as a tack, while my 90-year old grandmother requires assisted living.  So one question I asked myself when looking at this study was: are the people who are in the medically illiterate group also the ones who are in assisted living?  In other words, is the increased risk of death due to the fact that the patient doesn’t understand medical jargon, or is it due to an overall decline in their mental capabilities?  Luckily, the clinical team already addressed this question.  They found that both an increased medical literacy and a higher cognitive ability both independently indicated a longer, healthier life.  So those that understand their medical conditions will live longer, but so will those who can still do the New York Times crossword puzzle themselves.

My take: The benefits of medical literacy, as outlined here, are: 1.) knowledge can improve the doctor-patient relationship, and 2.) knowledge can improve health. The Decision Tree is not about a single factor influencing a healthy life, rather it discusses a collective set of behavioral changes that lead to new way to think about and treat disease. I think the results discussed here show that medical literacy is an important piece of the next-generation patient puzzle.  In the future, we will be asking a lot from patients, as more of the responsibility for staying healthy will be shifted to them.  So I like the approach of MedEncentive to get the doctor involved as well.  In the end, what we end up with is the next-generation patient, as well as a new breed of physician — one who is willing to break the current mold.

One thing I’ve learned covering technology over the years is to be wary of cool hardware. I’ve seen amazing devices and toys and gadgets and gizmos and scarce few of them ever catch-on. Which is to say, if it’s hard to make a good gadget, it’s even harder to make it succeed as something people actually want to buy and learn how to use and integrate into their lives. And when something does work – when something is good enough to get people to change the way they live and adjust their routine and introduce new habits – then there’s something about that product that deserves study.

This is a lesson I tried to keep in mind the other day when I met some folks from Proteus Biomedical, a Silicon Valley company that’s come up with a nifty system for self-monitoring via a data-gathering patch – aka a smart band aid – and smart pills. Called the Raisin system, Proteus’s approach is right in line with the stuff I’ve been researching for The Decision Tree, and the company’s CEO and scientists are fully versed in the promise and challenges of personalized medicine. The Raisin system comes down to hardware, so it’s far from a sure thing – but it’s innovative and intriguing enough to merit some consideration.

The Raisin system has two parts. First there’s the patch, a big band-aid thing that you slap on your chest. It collects physiologic data like heart rate, temperature, respiration rate and so forth (Since it’s not invasive it doesn’t collect chemical information like blood glucose or such). That information is sent, via Bluetooth, to your cell phone, where it is routed online. Voila, constant tracking and aggregation. The patch alone is cool – it’s not the only smart band-aid out there, and these things have been around for at least a decade. But it seems like a simple enough variation on the theme and sounds well designed. The second part of the Raisin system adds to the gee-whiz factor: it’s a tiny sensor chip that is lodged inside a pill. The sensor can detect when the pill is consumed, and that information is sent to the patch and from there to the Web.

The result is a system that can measure basic biometrics but also can track compliance – whether a patient is taking their medication. It could be used to assess when a patient is at some danger from missing a dose (if their pulse or breathing rate start racing, say) or conversely if there’s an overdosage.

Now this is where I could get a bit skeptical – it’s a hardware tool for compliance that comes with compliance issues all its own. Will people really tolerate a big bandaid on their belly 24/7? Will they remember to use a new one after a shower, or when they go on a trip? These are the sort of issues that may thwart the adoption of the system. But put those issues to the side for the moment. What’s cool about the Proteus Raisin system is that it’s capturing data that otherwise is lost, and then giving that data back to the individual (and their loved ones or doctor), in order to improve their health. It’s a nifty way to take these ideas about the power of data, the stuff I prattle on here about, and turn them into specific tools.

Of course, I’m hardly the first to hear the Proteus spiel. MIT’s Technology Review, Business Week, MedGadget, Wired.com, lots of places have covered the Raisin system. So I’ll offer two points that I find intriguing about it that haven’t been mentioned elsewhere:

1) Yeah, Proteus’ approach may have a compliance issue. But it’s an issue with smaller event space, so to speak, than the larger compliance issue of taking your medication three times every day. And if they can get people to wear the patch, they’re going to learn a lot more than whether they take their meds – They’ll get all sorts of bio-data that’s useful beyond any one drug prescription. So the system seems close to pulling off the difficult task of allowing for the passive collection of data and then enabling active engagement with that data. That is, they’ve turned self-monitoring into a simple, functional tool.

2) The Proteus approach is a relatively open one. The Raisin system is, obviously, proprietary, as is the data-collection hardware (whatever’s in that patch). But the Raisin execs said they don’t want to control control the interface for using that data, or how a patient uses their data – meaning the info collected via the Raisin system can be ported and integrated into other companies’ systems and products. I’m sure there may be restrictions to this, but taking them at their word, this means the folks at Proteus understand that data is only truly useful when it’s free to move – and when it’s our data, we should be able to move it whereever suits us. So if they say that a Google Health or a Patientslikeme.com could integrate the Raisin data into their own interface, along the lines of blogs adding a YouTube file. This is very reassuring, and would address some of what bothers me about the walls at Nike+ or Virgin HealthMiles – the data you stick there stays there, and it’s that much less useful.

So will Proteus’ Raisin system catch on? It’s a real question, because not only does it face the usual issues of a new piece of hardware in the marketplace but it also faces the additional burden of compliance from patients. But it certainly is the sort of thing that could make living by numbers more easy for people to get into. Even more, the effect of something like a Raisin may be greater than just improving how many pills we take. In an environment when some individuals are feeling overwhelmed by the number of pills they need to take in a certain order or at certain times, a feeling that can impede compliance and make us less likely to make the right choices, a Raisin system can actually give people the data that brings with it a sense of control, of management that transcends the daily schedule and manifests as a control over our broader conditions. It’s the sort of thing that make people feel like they’re treating their disease, rather than just holding it off. It’s the sort of thing that lets us start seeing our health as a series of decisions that we’re in charge of. And that’s something that deserves to catch on.