The mobile phone as a personal health system for global health

1. 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)

2. 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

3. 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 How should global wellbeing be measured? USA spends >15% of GNP and is no 38 in life expectancy GNH not GNP is the social wellbeing indicator

4. 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.

5. Thai Integrative care cycle ANS-HRV Modern biomedicine

6. mindfulness breathing health nutrition activity Each of these affect ANS function in a measurable individual way, and collectively balanced can restore optimal resilience and health

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

8. 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

9. 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

10. Personalizing public health care From The West Imaging Neurosciences ‘Omics’ Sciences Systems Biology psychobiology From The East Energy Medicine Meditation & Mindfulness, breathing Autonomic nervous system

11. 24 hour HRV Note the role of mind and breathing The relationship between ANS- HRV and lifestyle, disease risk, and disease progression – or regression- follows below

12. Three examples of wearable wireless biomonitors Blue tooth 24 hour recording Respiration, HRV, 3 D motion and position temperature HRV3D emotion (Mega electronics) Blue tooth 5 day recording HRV, 3D motion and position 24 hour heart rate recorder

13. Using wireless biomonitoring locally and remotely

14. A digital image of the mind & body from a heart beat signal Laboratory accuracy from a consumer device

15. Conventional way of analyzing and reporting ANS- HRV – reducing the value of a personal dynamic biomarker Averaged over time and grouped

16. Diabetes HRV-RSA – personal biomarker 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

17. HRV power related to severity of Coronary Arterial Disease 1 Progressive loss of HRV with increasing severity of CAD 3 2

18. 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 200 sleep Heart rate Healthy Breathing 0 Obese Heart Disease diabetes Hypertension Stroke Mental cancer l . . 8 a.m 8 a.m

19. The ‘social’ & lifestyle stress pathway to illness & death Genotype Phenotype Social wellbeing Mental wellbeingANS-HRV & Immune resiliencesocial determinants Physical wellbeing Mental stresssocial stress Depression ANS-HRV & immune depression diet Metabolic stress activity smoking ANS-HRV & immune dysfunctiondrugs Cellular & vascular injury Organ specific diseases cardiovascular mental disorder metabolic syndrome diabetes arrhythmic - infective death cancer other ANS-HRV – immune failure Death The link to infection and critical care medicine

20. A healthy 24 hour heart rhythm pattern is a Nepalese Buddhist Tulku chanting – meditation - sleep Sala dance 24 hours

21. Critical brain heart rhythms from health to stress Healthy stress 5 minutes

22. Deep sleep pranayama breathing 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.

23. Coordinated slow breathing and movement increases the psychophysiological benefit Camel 1 pranayamacompared with resperateat 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)

24. 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

25. Heart failure with periodic breathing ‘controlled’ by ‘yoga’ breathing 6 breaths / minute B HRV resp Resp vol SaO2 10 minutes

26. 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. Breathing entrainedfor maximum RSA in heart rate 6 breaths a minute 1 hour heartmath 10 minutes

27. 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

28. 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

29. GETTING MORE FROM LESS (exercise) Comparing endurance training with phasic exercise training Phasic exercise training Training recovery equally with exertion (phasically) improves muscle and cardiovascular function – metabolic recovery. Qi Gong and Tai Chi achieve similar benefits

30. 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

31. 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

32. 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 tools supervised and self managed effective breathing effective relaxation effective exercise effective diet effective ??? Networked across region – test site

33. Mobile telemonitoring service -

34. Institute for Alternative Futures Mobile wireless biomonitors + knowledge = n-of-1 R&D

35. Out-moded by the 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

36. 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

39. Developing mPHS for integrative care Lab on chip inclusive interfaces 3rd generation sensors intelligence infuse with EBRD mICT Ethical Biomedical R&D - EBRDSDHI -PsyPhysknowledge base HiAP SDHI Public health Education 3rd parties & Commercial ICT Civic health mPHS Integrated Health Services to include Health Promotion, Disease Prevention -SDHI Biomedicineis fragmented & misaligned

40. Incremental levels of ICWS biomonitoring for wellbeing, risk reduction, early diagnosis, disease management and research Ambulatory and polyclinic investigations sleep disorders; EEG; portable scanning; other technologies TeleMed clinics High-level community investigation and research - shared-care patients Specific mind-body re-hab training/ biofeedback Diagnosis and rehab 200 x PHS = 24 hour HRV, activity, breathing with oximetry, BP as required. Portable scanning TeleMed clinics ALL CITIZENS - annual, monthly, more – wellbeing self- assessment Mind-body re-training/ biofeedback 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