Merging Precision and Healthy Living Medicine

Tailored Approaches for Chronic Disease Prevention and Treatment

Ross Arena, PhD, PT, FAHA, FESCProfessor and Head

College of Applied Health Sciences

University of Illinois at Chicago

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Relationships with Financial Sponsors:

- Grants or Research Support: None

- Speakers Honoraria: None

- Consulting Fees: None

- Patents: None

- Other: None

Faculty Presenter Disclosure

Cardiology for the Non-Cardiologist

Faculty: Ross Arena

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Potential for conflicts of interest: None

Disclosure of Financial Support

Cardiology for the Non-Cardiologist has received financial support from Pharmaceutical companies Bayer, Bristol-Meyers Squibb/Pfizer, Servier, Novartis, Amgen, AstraZeneca and Merck in the form of unrestricted educational grants.

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• While we have received unrestricted educational grants from several pharmaceutical companies, most presentations have no mention of specific products and are unrelated to the supporting companies or their products. No specific presentations will be supported or sponsored by a specific company.

• Information on specific products will be presented in the context of an unbiased overview of all products related to treating patients.

• All scientific research related to, reported or used in this CME activity in support or justification of patient care recommendations conforms to the generally accepted standards.

• Clinical medicine is based in evidence that is accepted within the profession.

Mitigating Potential Bias

Chronic Disease Crisis: Diabetes▪ The number of people with diabetes has risen from 108 million

in 1980 to 422 million in 2014

▪ The global prevalence of diabetes* among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014

▪ Diabetes prevalence has been rising more rapidly in middle-and low-income countries.

▪ In 2015, an estimated 1.6 million deaths were directly caused by diabetes. Almost half of all deaths attributable to high blood glucose occur before the age of 70 years.

▪ WHO projects that diabetes will be the seventh leading cause of death in 2030

▪ Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use are ways to prevent or delay the onset of type 2 diabetes

▪ Diabetes can be treated and its consequences avoided or delayed with diet, physical activity, medication and regular screening and treatment for complications

Source: WHO

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Unhealthy Living is the Reason

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>20,000 Swedish Men

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“By pursuing complementary strategies within and outside

the health system, we can achieve the promise

demonstrated by Åkesson and colleagues, as well as by a

wealth of additional evidence, that the great majority of

cardiovascular events are preventable or can be delayed

until late in life by means of a healthier lifestyle.”

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Prescription for Activity–Promoting the Healthspan

Active Lifestyle

Healthy Body Weight

Reduced Levels of Local Inflammation

Reduced Levels of Systemic Inflammation

Lower blood glucose, blood pressure, improved arterial function, reduced arterial plaque and abnormal cell growth

Lower risk of chronic disease, improved function and quality of

life, prolonged healthspan

Adapted From: Pedersen BK. The diseasome of physical inactivity--and the role of myokines in muscle--fat cross talk. The Journal of physiology. 2009;587:5559-68.

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▪ Prospective Urban Rural Epidemiology [PURE] in 135335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and highincome countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa

▪ Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect).

▪ For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality.

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▪ The Nurses’ Health Study, a prospective study that was initiated in 1976, enrolled 121,700 registered nurses who were 30 to 55 years of age.

▪ Alternate Healthy Eating Index includes 11 food components, each scored from 0 (unhealthy) to 10 (healthiest) and selected on the basis of evidence of an association with the risk of chronic disease.

▪ Alternate Mediterranean Diet score includes 9 components, each scored as 0 (unhealthy) or 1 (healthy) according to whether the participant’s intake was above or below the cohort-specific median levels.

▪ DASH score includes 8 components, each scored from 1 (unhealthy) to 5 (healthiest) according to a participant’s quintile of intake.

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"Overall, our findings support the recommendations of the 2015-2020 dietary guidelines, which recommend several healthy eating patterns. It is not necessary to conform to a single dietary plan to achieve a healthy eating pattern,"

◼ Seven health factors and lifestyle behaviors that support ideal cardiovascular health

◼ One simple Heart Health Score (0-10 points) to help participants know where they stand

◼ Higher score positively associated with improved overall health including diabetes, cancer, stress, and depression

◼ Science-based metric

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Overall, each unit increase in

CVH metrics was

associated with a pooled

hazard ratio for cardiovascular

disease mortality of 0.81

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In the 2 cohort studies of US white individuals, we found that overall, 20% to 40% of carcinoma cases and about 50% of carcinoma deaths can be potentially prevented through lifestyle modification. Not surprisingly, these figures increased to 40% to 70% when assessed with regard to the broader US population of whites, which has a much worse lifestyle pattern than our cohorts. Notably, approximately 80% to 90% of lung cancer deaths could be avoided if Americans adopted the life-style of the low-risk group, mainly by quitting smoking. For other cancers, from 10% to 70% of deaths could be pre-vented.

A total of 89,571 women and 46,339 men from 2 cohorts were included (Nurses’ Health Study, the Health Professionals Follow-up Study, and

US national cancer statistics

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Unhealthy living patterns: Physical inactivity

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In 2013, just over 2 in 10 adults and 1 in 10 children and youth met the Canadian Physical Activity Guidelines

Physical Inactivity –Chronic Disease Pathway

Physical Inactivity

Excess Adipose Tissue

Local Adipose Inflammation

Chronic Systemic Inflammation

Insulin Resistance, Hypertension, Arterial Dysfunction, Plaque, Abnormal Cell Growth

Chronic Diseases: Cardiovascular, Diabetes,

Cancer

Adapted From: Pedersen BK. The diseasome of physical inactivity--and the role of myokinesin muscle--fat cross talk. The Journal of physiology. 2009;587:5559-68.

Unhealthy living patterns: Diet

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Unhealthy living patterns: Obesity

▪ Worldwide obesity has nearly tripled since 1975.

▪ In 2016, more than 1.9 billion adults, 18 years and older, were overweight. Of these over 650 million were obese.

▪ 39% of adults aged 18 years and over were overweight in 2016, and 13% were obese.

▪ Most of the world's population live in countries where overweight and obesity kills more people than underweight.

▪ 41 million children under the age of 5 were overweight or obese in 2016.

▪ Over 340 million children and adolescents aged 5-19 were overweight or obese in 2016.

▪ Obesity is preventable.

Source: WHO

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Why isn’t HLM more effective?

▪ How we practice

All or none, one size fits all message

150 minutes or more of moderate to vigorous PA/week

5 or more servings of fruits and vegetables per day

▪ Where we practice

Traditional clinical settings using a reactive approach

▪ Limited stakeholder collaboration

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Rethinking Healthy Living Medicine

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“an emerging approach for disease treatment and

prevention that takes into account individual variability in genes, environment, and lifestyle for each person”

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“Among participants at high genetic risk, a favorable lifestyle was associated with a nearly 50% lower relative risk of coronary artery disease than was an unfavorable lifestyle.”

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How we deliver HLM

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Nutrition/Physical Literacy

Cognitive Literacy

Emotional Literacy

Social Literacy

Nutrition/Physical Literacy

Cognitive Literacy

Emotional Literacy

Social Literacy

Figure 1: Health Harmonics Framework

Practitioner Patient

Legend: = Harmonic Node – Shared Meaning

McNeil A and Arena R: The Evolution of Health Literacy and Communication: Introducing Health Harmonics: Progress in Cardiovascular Dieseases. In Press

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Narrow definitions of PA

When asked “what counts” as PA, low active participants tended to define PA in ways using a specific and narrow set of standards that traditional PA recommendations have used to educate people about PA, such as signs that they were exerting themselves in high-intensity exercise (e.g., increased heart rate and/or sweating, or feeling “like you’re burning something”) and for the “right” amount of time (e.g., 30 min).

Low active participants also described feeling pressured by these criteria and not able to achieve them: “You have to do this at this time, and you have to commit to these hours. You have to do this activity.

One low active participant said that walking her dog was a barrier to being active, which implied that she did not believe dog-walking counted as valid PA.

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stratification of conventional nutritional guidelines into population subgroups by age, gender and other social determinants, individual approaches issued from a deep and refined phenotyping, and a genetic-directed nutrition based on rare genetic variants having high penetrance and impact on individuals’ response to particular foods

Where we deliver HLM

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Focus on Healthspan: “The period of life that is generally healthy and free from serious disease.”

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Making Changes right HERE"I just have to say, I can have a really bad day, but when I know the Academy is coming, it makes me

feel so much better!" -

Jamarion Smith, 4th grader Smyth

Elementary School "To be able to make a difference with such young lives in their

nutritional choices is so rewarding. Encouraging healthy eating habits at an early age strengthens my professional goals and development." - Manal

Qadeer, UIC Nutrition CP Student

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Leveraging technology in HLM

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Professional HLM Education

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Healthy Living Practitioner™ Certificate

▪ Train health professionals to deliver healthy living medicine

▪ 22 credit course work taken as electives

▪ 15 students enrolled

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The Healthy Living Practitioner

Didactic ComponentCourse Credit Load Rubric NumberUpstream Prevention: Epidemiology, Economics and Policy

3 HLP 500

Health Communication and Literacy 3 HLP 505Preventive Health Screening 1 HLP 510Nutrition for Healthy Living 3 HLP 520

Exercise and Physical Activity for Healthy Living 3 HLP 525Behavioral Counseling for Healthy Living 2 HLP 530Use of Technology for Healthy Living 2 HLP 535Healthy Living Seminar 2 HLP 560

Practical ComponentHealthy Living Practicum 3 HLP 590

Putting it all together

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Built Environment

Technology

Individualized Body Habitus

Plan

Individualized Plan for Not

Smoking

Individualized Diet Plan

Individualized Movement Plan

Health Communication

Genomics

Precision in Healthy Living

Medicine

Precision in Healthy Living Medicine

Arena et al. Current Problems in Cardiology, In Press

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Prof.

Orgs.

Global Population

Population -Nations

Population-Local

Communities

Family Unit-Individual

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Thank you and questions

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