The mobile phone as a personal health system for global health

• Health is a state of physical, mental and social well-being not only the absence of infirmity and disease WHO 1948

• Understanding health not as the absence of disease, but rather as the process by which individuals maintain their sense of coherence (resilience) and ability to function well in the face of changes in themselves and their environment (from Aaron Antononovsky 1987)

The mobile phone as a personal health system for global health

Holism

Holistic is an approach to practice that goes beyond the traditional medical model to consider the patient’s mind, body, emotions, and spirit in the context of his or her family’s beliefs, values, culture, and community

Happiness score - SWEMWBS • Item 1 – I've been feeling optimistic about the future• Item 2 – I've been feeling useful• Item 3 – I've been feeling relaxed• Item 6 – I've been dealing with problems well• Item 7 – I've been thinking clearly• Item 9 – I've been feeling close to other people• Item 11 – I've been able to make up my own mind about things

GNH not GNP is the social wellbeing indicator

How should global wellbeing be measured?

USA spends >15% of GNP and is no 38 in life expectancy

Happiness and health

• The effect of happiness on longevity in healthy populations is remarkably strong.

• The size of the effect is comparable to that of smoking or not.

Thai Integrative care cycle

ANS-HRV

Modern biomedicine

The core of a scientific Wellness Program

mindfulness

activitynutrition

health

Each of these affect ANS function in a measurable individual way, and collectively balanced can restore optimal resilience and health

ICT

Some of the actors required for social wellbeing on which the health of the nation depends

The challenge

• The need: a fusion of East and Western medicine

• The science behind the change

• The solution - from Technostress to Technohealth

• The opportunity for 21st century global health – a national simulator for inclusive personalized health

mHealth Alliance Gaps and barriers – a policy white paper 2010

• Treatment Compliance (SMS) - 43• Data Collection and Disease Surveillance – few studies 34• Health Information Systems (no EMR) and Point-of-Care

Support - 30• Health Promotion and Disease Prevention - 25• Emergency Medical Response – 37

From The WestImaging Neurosciences‘Omics’ SciencesSystems Biologypsychobiology

From The EastEnergy MedicineMeditation &Mindfulness, breathing

Autonomic nervous system

Personalizing public health care

Note the role of mind and breathing

24 hour HRV

The relationship between ANS- HRV and lifestyle, disease risk, and disease progression – or regression- follows below

Blue tooth

5 day recording

HRV,

3D motion and position

Blue tooth

24 hour recording

Respiration,

HRV,

3 D motion and position

temperature

Three examples of wearable wireless biomonitors

HRV3D emotion (Mega electronics)

24 hour heart rate recorder

Using wireless biomonitoring locally and remotely

A digital image of the mind & body from a heart beat signal

Laboratory accuracy from a consumer device

Conventional way of analyzing and reporting ANS- HRV – reducing the value of a personal dynamic biomarker

Averaged over time and grouped

Slow deep breathing (6/min) is a test of ANS condition and a biofeedback ‘tool’ for tracking response to self-improvement, or decline. ANS-HRV function can be reptrained

HRV-RSA – personal biomarkerDiabetes

HRV power related to severity of Coronary Arterial Disease

Progressive loss of HRV with increasing severity of CAD

1

2 3

200

0

The autonomic nervous system (now easily measured) is affected by chronic stress and most diseases – loss of heart rate variation predicts the risk for illness and premature death– but is ‘reversable’ by improved lifestyle

8 a.m. 8 a.m.

Healthy

Obese

HeartDiseasediabetes HypertensionStrokeMentalcancer

l

BreathingHeart rate

sleep

The ‘social’ & lifestyle stress pathway to illness & death

Social wellbeing

Mental wellbeing ANS-HRV & Immune resilience social determinants

Physical wellbeing

Mental stress social stress

Depression

ANS-HRV & immune depression

diet Metabolic stress

activity

smoking

ANS-HRV & immune dysfunction drugs

Cellular & vascular injury

Organ specific diseases cardiovascular

mental disorder metabolic syndrome diabetes arrhythmic - infective death

cancer other ANS-HRV – immune failure

Death

Phenotype

Genotype

The link to infection and critical care medicine

24 hours

A healthy 24 hour heart rhythm pattern is a Nepalese Buddhist Tulku

chanting – meditation - sleep Sala dance

Critical brain heart rhythms from health to stress

Healthy

stress

5 minutes

Respiratory rhythm (RSA) exists in the heart rate rhythm (15 per minute) at rest during deep sleep in healthy people – seen in the top trace and expanded in the window on the right. This shows good relaxation and autonomic nervous system (ANS) balance – resilience. This same oscillation (RSA) is increased, slowed & synchronised when breathing is slowed to 6 breaths per minute during pranayama breathing. Repeated daily this practice restores or improves heart rate variability (biorhythms), relaxation and wellbeing.

Deep sleep

pranayama breathing

Camel 1 pranayama compared with resperate at 6 breaths/minute

20 minutes

The oscillation in heart rate (top blue line) with pranayama breathing at 6 breaths/minute is much greater than breathing at 6 breaths a minute with resperate * (an FDA approved breath training device for treating hypertension)

Coordinated slow breathing and movement increases the psychophysiological benefit

measure Value - range

PeTCO2 mm Hg 29 - 43

Vt (L/min) 4.6 -8.2

Abdomen % 20 - 85

VT (L) 0.25 - 0.60

Te (sec) 1.5 – 5.0

Ti (sec) 1.2 – 2.2

Frequency (min) 10 - 21

Individuality of breathing pattern in healthy man (n = 41)

Individuality of breathing pattern remains during sleep, over years in adult life, genetic (twins). Future personalized care will factor in cardiorespiratory as well as behavioural differences

Heart failure with periodic breathing ‘controlled’ by ‘yoga’ breathing

SaO2

resp

HRV

Resp vol

B

10 minutes

6 breaths / minute

Meditation and exercises (e.g. Yoga, Thai traditional stretch, Tai Chi ) improve physiological synchrony and well being – heart rate and breathing coherence are particularly important.

1 hour

10 minutesheartmath

Breathing entrained for maximum RSA in heart rate

6 breaths a minute

Some benefits of slow breathing

• increase 'resting' HRV (RSA) and reduce sympathetic (stress) activity

• increase baroreceptor response • reduce blood pressure (in hypertensives) • improve immune responses • increase expiratory control • reduce breathing frequency • reduce heart rate • increase thoracic diameter • increase oxygenation and exercise performance in heart failure • increase brain blood flow (during slow breathing) • increase EEG theta activity • increase a feeling of wellbeing and relaxation

Personalized exercise – getting it right

Some people get no metabolic benefit from endurance training while others get metabolic value from resistance training – they are genetically different

Phasic exercise training

Comparing endurance training with phasic exercise training

Training recovery equally with exertion (phasically) improves muscle and cardiovascular function – metabolic recovery. Qi Gong and Tai Chi achieve similar benefits

GETTING MORE FROM LESS (exercise)

This is a 30 minute recording from an experienced practitioner demonstrating 8 QiGong standing movements performed at 6 per minute with co-ordinated slow diaphragmatic breathing. The precision of each movement can be seen with the heart rate oscillating at the same rhythm. This shows optimal relaxation – mental and physical during exercise

Brain imaging techniques show distinct forebrain links of the ANS to cardiac sympathetic activity, emotion and cognition, with laterality related to behavioural responses. Meditation and breathing alter brain structure and function

Mobile HRV is now a sophisticated specialist clinical test and on-line consumer self-care tool

Personalised health status – diagnostic tests and serial assessment

Range of on - and off-line training and biofeedback toolssupervised and self managed

effective breathing

effective relaxation

effective exercise

effective diet

effective ???

Networked across region – test site

Mobile telemonitoring service -

Institute for Alternative Futures

Mobile wireless biomonitors + knowledge = n-of-1 R&D

Out-moded by th

e mPHS = n-of-1

study

NB n-of-1 study was devised in 1988 for designing RCTs where patient behaviour was a prominent factor! – seldom used

Elements of a personal health system

• Wearable wireless biosensors – ‘click-clunk’

• Personal psychophysiology – 24-hour HRV-3D activity; RSSMD values *

• Lifestyle diary – HRV-3D related to life events (sleep, relaxation, stress, exercise etc)

• mICT (mobile – tablet)

• Cloud service – database – on- and off-line service

• Remote testing – tilt test; valsalva; fixed rate & slow diaphragm breathing; balancing; stress & emotion testing

• Biofeedback – direct (personal data) & indirect (program guides)

• Personal Health Record and clinical guidelines

• EDUCATION - User friendly results and display; incentive, reward and fun; ‘games’

* hierarchical levels of investigation and therapy

mICT

mPHS

Integrated Health Services to include Health Promotion, Disease Prevention - SDHI

Ethical Biomedical

R&D - EBRD SDHI - PsyPhys knowledge base

Civic health

HiAP

SDHI

Public health

Education

3rd parties & Commercial

ICT

Biomedicine is fragmented & misaligned

Developing mPHS for integrative careLab on chip inclusive interfaces 3rd generation sensors intelligence infuse with EBRD

Level 3

Level 2

Level 1

Incremental levels of ICWS biomonitoring for wellbeing, risk reduction, early diagnosis, disease management and research

1,500 x PHS = 24-hour HRV/activity belts EPHR

Investigations may pass between level 1, 2 or 3 for diagnosis or research. Serial ANS-HRV24 contextualized measurement is the foundation of all personal programs

ALL CITIZENS - annual, monthly, more – wellbeing self- assessment

Mind-body re-training/ biofeedback

Specific mind-body re-hab training/ biofeedback Diagnosis and rehab

High-level community investigation and research

- shared-care patients

200 x PHS = 24 hour HRV, activity, breathing with oximetry, BP as required. Portable scanning

TeleMed clinics

Ambulatory and polyclinic investigations sleep disorders; EEG; portable scanning; other technologies

TeleMed clinics