Women and Sex Differences in Medicine:  Precision Health for Women

Women and Sex Differences in Medicine: Precision Health for Women


I want to welcome you to the seventh
annual Women’s Health Forum which the wisdom Center runs and wisdom as you
just heard was created by the dean’s …office through a strategic planning
process with a vision statement of healthy women and men from conception
through the life course and a mission of advancing human health across the
lifespan through research and education in women’s health, the biology of sex differences and
gender medicine which I’ll explain to you as we go along. Just to orient you
this is a whole track in health matters were very excited to be partnering with
them today, and when i finish I’ll come back to this slide and introduce
Jennifer Tremmel, Assistant Professor of Medicine who is the Clinical Director of
the Women’s Heart Health at Stanford. And also Jody Prochaska — Judith Prochaska — who just
arrived and that’s really great. And then I want you to know that we’re
going to move over to the Clark Center for a speed panel and women’s cancer and
then we come back here after lunch at one o’clock for a final set of talks on
skin and bones and sleep health. So the topic of why sex and gender
matter and precision health for women is really much more than a 15 minute talk,
which is all I have time to do today, so I’ll try and touch on some of the key
issues of sex and gender and how it impacts health of women and some of the
unique health features. I’m not going to talk about sex differences, there’s not enough
time. I’ll just focus on unique issues for
women I want to touch on the important role of caregiving in women which is a
huge burden that obviously many men do as well but women have a higher burden
on that and then end with a little bit on sex and gender identity. So to start with a sex and gender
concept I want to make the distinction so you
understand that we see these as very different entities so when we talk about sex the Institute
of Medicine back in two thousand one released their report having looked at
all of the biology that basically saying that sex does matter they defined it as a biological quality
or classification of sexually reproducing organ organisms generally male or female according to
reproductive function and organs that derive from the chromosomes. And because chromosomes are in every cell they basically said every cell has sex
and what you should know is that very few cell biologist ever tell you about
the sex of the cell or even know about it which is not very precise medicine.
And so one of the issues is to get them to recognize that precision concept gender on the other hand is the socio
cultural issues and although the IOM reported this as, or presented this as a
person’s self representation of male and female what’s really important from biology is
the role of gender norms and gender roles on biology. It influences
biology and very profound ways that I’ll give you a couple examples as we go
along. And also gender relations. People treat you differently because you’re a
woman. So just as we talk about race, ethnic
issues, and we talked about socio-economic issues being a woman, the whole world treats you differently
than if you were a man and that said many people want to identify with
something other than the way they were designated at birth or as they were
designated at birth and that’s your gender identity. And i’ll just draw your
attention to the general innovation site here at Stanford (inaudible) has really been driving this important message and she and I are very closely
working on this. Now if we talk about sex in the old days you had to be born
before they knew what sex you were and then they would say “oh it’s a boy” or “it’s a
girl” based on your genitalia. Now you can
find out ahead of time, but then over time bones start to change because of the
chromosomes and hormones, and we end up with some very clear
differences that overlap a lot. We have many tall women and we have many short men, but we generally have an overlap. We also have a lot of
differences in our bones and these are genetically driven as well as hormonal e
so I’m putting here the pelvis. This is the most sexually dimorphic bone in your
body because the evolutionary pressure to get that head out of that pelvis if
you’re a woman is so high that you’re dead if you don’t get that out. And so there’s very powerful
genetics working on those bones that hardly anyone is really studied. On the
other hand there’s a lot of pressure to keep a nice narrow pelvis so that you
can run and you can be local moding and so those two pressures diverted a lot
of the male-female pathways. On top of that we have lots of other
body composition changes so we generally think of men as being more muscular obviously we have a very muscular women
and we think of women has having more fat much of this is essential fat very
important for reproductive function and health and we distribute that fat in
different places based on hormones so there’s a lot of biology that is very
integrated in the medical outcomes that we talked about. On the other hand we
have gender. Gender is really the social meaning of being female and male
and you can just see some examples this changes over history it changes in different cultures it
changes within cultures and it has very profound effects so for instance one reason that man is
stronger than women isn’t just because they have more muscle but we make them
carry a lot of stuff and so we had to kind of fight our way like let me carry
that. And now that I’m older it’s like it’s
fine you know you can carry that. So anyway. And then I want to make an
example so in addition to that example this is a
great example of where gender can actually completely change biology so for a thousand years chinese
foot-binding was in practice it was a sign of beauty to have the smallest foot
possible you want a third three to four inch foot and so they started binding
little girls feet when they were five to seven years of age and the
girls the the mother and law would go and look at the girl to be sure that her
foot was small enough and beautiful enough before she would be married Now obviously you can’t walk on that
foot, so those women had to be carried and and one reason we have rickshaws and we have some of the things that we had to transport women around because they
couldn’t walk unless you are poor, in which case you need your feet to work
and so you didn’t get your foot bound. Now i will tell you that we actually
still have a lot of stuff like this going on if we look at the U.S. today we still
are you know making it a little bit harder for women to walk around and
that’s part of our culture. Women drive this just probably more than men so it’s
not men doing this to women, it’s something as part of culture. Now to come
back to biology, if you’re not aware most of our basic science is based on males we don’t know what the sex of the cell
is, but we do know that most animal studies are done in male animals. This was a review that was came out in
2009 looking at all of those different disciplines the blue is where its male-driven the
big red one is in reproduction where obviously we would have more female and
the purple is what we would see as the goal, which is to have both sexes, so we
can look at is there a difference or not and only twenty-six percent of animal
studies fell in that category. A little better in humans sixty percent
overlap still a lot more blue except for the category of reproduction and this is
a serious issue because what we now learned is that women metabolize drugs
differently they metabolize alcohol differently than men and we have this
crisis where a lot of drugs have gone to market without being adequately tested
and women. Eight of 10 that have been pulled off the market have been because of very
adverse reactions and women that should have been studied before they ever went
to market. A very popular story came out about two years ago on zolpidem
which is the leading sleep medication for insomnia. Women get a lot more
insomnia so they use this much more often and what they found is that fifteen
percent of women were waking up the next day eight hours after taking it still
with lots of this in their system going and driving to work and having accidents,
compared to only three percent of men. Now in fact that is the only FDA drug
that has a male and a female dose and you see it comes in a pink bottle in a
bluebottle many men should be taking a lower dose and now they have to take it
from the pink bottle in this society that’s like putting a stop sign on the
bottle. So again we need precise medicine and we
need to start to think about what’s the right drug for men and women and just to
make the point this is not just body weight a lot of things related to body
weight, but woman’s body composition is different the way we metabolize our
livers different all of this needs to be studied. The NIH gets it. In 2014 they
basically said we need to start to balancing we need to start having in our
basic animal work now at that time they actually said cells as well when the when the update came out from
the NIH last year they only focused on animal studies because they found out
that the cells they have the cell lines they don’t even know what sex they are
because they’ve been transformed in such a way that we’re not even clear what the
sex of the cell is so it’s not exactly a precise cell to be studying. so if you’re not aware as of this year it’s absolutely required that you
include males and females. We recognize that it is important for the
interpretation of the data and that if you don’t include that you have to have
strong justification in your grant for why you don’t have males and females in
animal and human studies. Now just to say a few unique things if you’re not
aware women are mosaics. It’s like a calico cat. Calico cats are
almost always female and it relates to the fact that early on and I realize now
I thought I’d have a pointer, but I’ll draw your attention to the egg and you
see this egg being ovulated there that eggs is going to have two x’s — one from
the mother’s mother and one from the mother’s father, and if you can see it
there’s a little sperm that’s about to reach that egg in the fallopian tube
that sperm the sperm are either the X the father’s X that came only from his
mother, or the father’s why they came only from his father, we can actually
track whole cell lines based on Y chromosomes we can look at whole human migration based on Y chromosomes because only males can pass it to males with
many exceptions — and I don’t have time for all those exceptions — but the
important point I wanted to make here is that once those to unite the fate is
sealed in a very interesting way because as the that embryo starts to develop decisions have to be made we don’t want
two Xs in most cells. 75 percent of cells have to be completely inactivating those Xs and then there’s a variation in the other twenty-five
percent, and what you’re seeing on that diagram of the mosaic is that a random
thing occurs where an X, the father’s X is inactivated one tissue in one
cell and the mothers and the other, but take a look at how early this happens this is happening in the embryonic
development before any organ is made before we even have all of the layers so
it’s very very early on and this is one reason why identical twin girls are not
as identical as identical twin boys because it could be a completely
different random process but at any rate those cells are every tissue in your
body is a mosaic so that if we look at the retina we have some if there’s an excellent
problem in the retina of the red and green cones for vision are on the retina
are on the X chromosome the blue is not so blue doesn’t have
that sexual problem but basically boys are more likely going to be color blind
because they only have one X and what we learned is that the X that isn’t reducing a mutation seems to overtake the other ones and females, so they end up with
tissues that are less likely to be expressing that that X hemophilia is
another very good example and the last one I want to mention is a rare issue
that relates it looks a little bit more like the calico cat to let you know that
you have sweat glands all over your body that are from these mosaics and so you
have big patches where if you have this particular X problem you can’t sweat. And so for a female she
can still regulate her temperature in the good tissue, but for a male with that
X he dies very early because he can’t regulate his temperature so it’s rare we
have lots of those that no one has studied because we’re studying every
gene in the universe and paying very little attention to this — that’s not precise health that’s not
precise medicine. We need to be more precise. Then i’ll just quickly say
if you’re not aware something else that’s big difference between men and
women is that the the egg the the germ cells do all of their
divisions up to the last one before you’re born and boys they stopped much
before that so that what we have is a situation that women are born with all
the eggs they’ll ever have they don’t start ovulating until puberty
boys don’t even have that division until puberty then they start that process. And another
big difference is that girls — we’ll come back to the other difference, the point being, that a girl’s run out, women run out, and we have menopause. Men continue being reproductively
capable up until they’re they’re dead. This is us. This is a graph of showing
you the eggs, and you can just see how every five years you drop, you drop you drop so that very
first really big drop is age 35, there’s not many eggs left by the 40 and
by 45, there’s hardly anything left to get
pregnant, you’re lucky or you do assisted reproductive technology, a
really important issue for older women, and that the next thing is going to be
menopause, which will come back to. I first want to just go back again to
the embryo and let you all know that every person in this room started out
with the potential of being either male or female and then because of the
chromosomal compliments and a number of factors a decision is made in embryology
where you’re either going to go down the male path and you’re going to retain the
the tubes that you need to be a male, you’re going to have a testis. Or, you go
down the female path and the the indifferent gonad will become an ovary
and you’re going to have the tubes that you need to be a female, the female organ
stays up in the pelvic cavity. The male organs come out of the cavity,
sperm can’t live very well in the body in the body temperature and so we need
to get that out and also because of the testes and the
testosterone we’re going to change the external genitalia which could be male
or female at the outset. So we all have the ability
to be either of these sexes and decisions are made that we live with. Now
I will tell you other transitions, this was actually transition slide of puberty
but it had breast developing and and pubic hair
developing which we thought wasn’t quite right for this audience perhaps, but i
will say that an important thing is that then part of puberty is the menstrual
cycle women for from age 13, or 11 to 51 so that’s 40 years have menstrual cycles
where their biology is changing through the month. This is one reason no one to study
females because it’s too complicated like yeah but we are and we should study it
that’s precision and so we changed all every through the month but we might not
like it pregnant and what you’ll hear from Dr. Tremmel after I finish, is that
pregnancy is a big cardiovascular stress test that is like a very profound
physiological change that women go through. Some women actually develop
hypertension during pregnancy that predisposes them to hypertension later — not really sure which comes first, the
predisposition or the stress test, and also gestational diabetes,
pregnancy alone causes lots of differences between men and women. We
actually know that cells from the embryo reside in women after like 30 years
after they’ve delivered that baby that probably relate to some of the
autoimmune diseases so we have lots of issues that are really precise. The other thing just to kind of go
through the lifespan here what you’re seeing is really kind of
focusing on bones before I do that I want to come back to those eggs that a
very big difference between men and women is that the egg, the ovum is
the source of the estrogen. In the case of males the sperm are unrelated to they’re influencing each other but the
testosterone making cells are different from the sperm and so you can continue
making testosterone you continue having sperm. For females it’s all together and
basically you hit a point where there’s not enough eggs anymore so there’s not
enough estrogen anymore and in addition to things that are
happening with estrogen dropping and related to bones, women suffer for
about three years with hot flashes which is a very serious issue no one was even studying that until the
women’s health initiative came out because it’s like well, women don’t die
from menopause so why would we worry about it? It’s a huge quality of life issue. I will just
quickly say that when we talk about the causes of death in men and women they’re
very similar with obviously breast cancer being exception only 1% of breast
cancers are men, but I will point out that it’s not the leading cause of
cancer death, lung cancer is. We are going to have a
set of talks on the cancers and women note that breast cancer is the second
leading cause of cancer death, but it even though it’s the most common cancer,
but then there’s some other very unique cancers that we will talk about. There’s actually sex differences in
almost all of those cancers that are really interesting that we don’t have
time to talk about. I don’t have time to also talk about the
caregiving issues, but we actually think about the women as the chief medical
officer of most families. They really are the ones that have to know about drugs
they have to take care of children they have to take care of spouses and take
care of parents they have a huge burden of care giving, and so I’m going to end
by just talking about sexual health. I don’t have time to talk about this
except to say that the World Health Organization recognized the sexual
health not as a dysfunction and the focus of
absence of dysfunction, but actual health and to just kind of finish this, we know that sexual values vary a lot by
socioeconomic status, practices, policies in our culture, I would call our culture
of sex-negative culture, where we think about good girls and bad girls, and sluts and
virgins from the past, and that basically women aren’t really given the freedom to
completely enjoy this and furthermore because we’re so
dichotomous — good-bad, men-women — we also don’t accept the range of
possibilities for peoples’ gender and sexual identity. All of these are things that the wisdom
Center feels is very important and that we will continue. Now i’m going to actually not engage
questions you’ll have me all day long and you can ask me questions, so what I want to do now is take my time
to introduce our next speaker so Jennifer Tremmel is the Clinical Director of the Women’s Heart
Health at Stanford she’s going to be talking to you about women and heart
disease your risk and what you can do about it, and when she finished she will
go right to Jody Prochaska, who will be talking about Heartbeats and Tweets, social media support groups for
promoting heart health. I then just want to remind you that we’ll be
going to the Clark Center for the women’s cancer panel, and then returning
here later for the skin and bones and sleep health. I’m going to pass it
over to Dr. Tremmel now who I’ve known for a very long time and she has really
revolutionized women’s heart health at Stanford — we would not have a clinic, so this is a very wonderful part of
Stanford. And Jennifer’s a wonderful person. So thank you and that was a great talk.
Good morning. I’m really glad to have the opportunity to be here. We have a short
bit of time so I’m going to hopefully give you some good highlights today — a
little bit about heart disease in women as well as maybe some tips to take care
of yourself. I’m an interventional cardiologist so I
open up heart heart arteries and also take care of women in clinic we
started a program in 2007. Our mission is really on through prevention diagnosis
and treatment of cardiovascular disease and its impact on psychosocial
well-being to provide comprehensive cardiovascular care to women across
their lifespan utilizing an evidence-based personalized
multidisciplinary approach. And really what we hope to do ultimately is to
eliminate sex and gender disparities in cardiovascular medicine. The team at Stanford started out with
myself and a nurse practitioner and now there are 15 or 16 of us. We have several
cardiologists, preventive cardiologists, psychologists, dietitian. I even have a postdoctoral fellow who’s
a man. We’re very proud of him and he’s
doing great work with us as well. I’m always the party pooper when I get up here so I has give you the
cold hard facts about cardiovascular disease and everyone gets depressed. I’m going to do that now so get ready (audience laughter) As you know cardiovascular disease is
the leading cause of death among women in the United States. It’s also a leading
cause of death among men. It’s a second leading cause of death for
women aged 45 to 64, and the third leading cause of death for women 25 to
44. I think we often think of it as though it’s an old person’s disease and
that’s not necessarily the case. The women we see in clinic, the mean
age is actually in the fifties. Heart and cardiovascular disease kills one out of
every three women. This is where I say look to your left
look to your right — for one of you that will be your cause
of death. It kills five times as many women as
breast cancer and almost twice as many women as all forms of cancer combined. So it’s a big deal I mean you can see a lot of pink stuff
and all of that, and certainly breast cancer is important, but we really do
need to focus on cardiovascular disease and where our red dresses so that we
raise awareness. When we look compared to men we know that more women have died from
cardiovascular disease every year since 1984, and compared with men, women
have higher lifetime risk of stroke and also women are more
likely to die after their first heart attack than men. I mean there’s lots of reasons for that
women aren’t always aware that they’re having a heart attack, they often take too long to get to
the emergency room and then physicians still are not terribly aware
of women, their symptoms, and what to do with them, etc., so that’s something we’re
working on. This statistic is really bothersome to me; even when women say,
“yeah, I know its leading cause of death” they don’t internalize this information.
Only twenty percent of women actually think that heart diseases their greatest
health threat. They think it’s somebody else,
this won’t be my problem — that’s not true. I’ve given you the statistics;
it is your problem. And you can’t profile heart disease.
You know I think people also say well you know I don’t look like
somebody’s gonna have heart disease you know, and I think you can pick out
who’s going to have heart disease and O know we have people in this room who
have heart disease. These are the faces of heart disease.
These women are survivors in our clinic They were at our Go Red luncheon with the
American Heart Association recently and they had the strength to tell their
story so that other women could know. But
these are the faces of heart disease, right, so these aren’t necessarily what
you might think. The good news is that most of
cardiovascular disease is preventable. You can’t help who your parents were, and
you can’t help getting older, although I’m trying to work on that one, but there
are several things that are modifiable and so everyone should know their risks. It turns out ninety percent of women
have one or more risk factor for heart disease or stroke. So pretty much everybody in this room
has something that they need to work on to improve their cardiovascular health. These are the things that you should
know as preventable risk so your cholesterol level so you need to know
what your cholesterol level is, having a high LDL or bad cholesterol is not a
good thing, or having a low HDL or good cholesterol, In addition diabetes, you don’t want to
have diabetes, basically people have diabetes we say you basically have
heart disease already it’s an equivalent. Knowing your blood sugar and making
sure that it’s preferably under a hundred if it’s between a hundred a
hundred and twenty-five you’re basically pre-diabetic and above 125 you have
diabetes. knowing your blood pressure as well high
blood pressure is associated with cardiovascular disease. Don’t smoke. Most people in this area
know this but actually the highest rates of increase smoking are currently in
young women, unfortunately. Having a sedentary lifestyle, and that means that
you’re getting less than 30 minutes of moderate-intensity physical activity on
most if not all days of the week, and so thinking about if that applies to you. Then having excess weight and where your body mass index is what we usually
look at so if you have a body mass index of 25 to 30 you’re overweight and if it’s greater
than 30 you’re obese. There are other risk factors and these
are kind of the classic ones you’re going to hear some about stress and we
think stress you know plays a big role also pregnancy is a little marker for us
and I think we don’t do a good job of kind of capturing women at that time and
letting them know that your risk may be elevated based on what happened to you
during pregnancy. Women who develop gestational
diabetes get high blood pressure preeclampsia have a preterm delivery or
gain excess weight that they ultimately never lose have a almost double the risk
of developing cardiovascular disease in the next 10 years — it’s actually
pretty quick that this plays plays a role in terms of your risk. So one of the things we do in clinic
now is try to capture these women right after their pregnancy even though
they’re busy with other things and let them know what their risk is and
hopefully do something about it I think this American Heart
Association score is a nice thing you can do so you could go online if you want and
it basically will take you through all of those risk factors that I talk to you
about and you can calculate your own score and
see where you are. What about the symptoms? This is
one area where women seem to be a little bit under informed and that could
certainly be to your disadvantage if you don’t recognize that you’re having a
heart problem. We want women to be well informed and women do have symptoms that are different than men. The classic is
still chest pain and that’s the most common thing that will see in women and
men. This is not necessarily a pain. It’s some
sort of discomfort it can be a burning pain. It can be sharp, it can be pressure
heaviness some sort of discomfort generally vague in the chest area and it
often radiates other places. For women it’s very common, to go up into the jaw, or it may go into left shoulder, left arm, or on the right arm, or it can can go in the back. It can do a lot of different things so it’s not always classic women also will
have shortness of breath when they’re having a heart problem. You may get
sweaty, have light headedness feel nausea these sorts of things so these are all
signs that you could be having a problem and things that you need to pay
attention to. And it’s interesting, I tell people this, and I actually had a woman come up after the last time we gave a talk who came up and said I’m so glad you told that because you know a week later I had those symptoms and ended up in the emergency room. So certainly make note of these. One way
that women are different than men is that they have more symptoms often and
it gets confusing for doctors. Doctors are much better if you just come in and say I’m having chest pain so if you are just come in and say I’m
having chest pain and they’ll pay attention to you. Then when you have
these symptoms you need to get help right so you need to call 911 and have
someone help you can take an aspirin as well this isn’t the time to be like oh maybe
not now you know I need to have what I get my clothes out
of the dryer before I do this or you know I’ve got to get the kids off to
lunch or whatever if you have the opportunity another nice thing to look
at online if you YouTube it is called just a Little Heart Attack It features the actress Elizabeth
Banks it’s from the American Heart Association. It’s basically a woman
having all these symptoms while she’s running around and trying to get her
kids ready and she called 911 and they say oh yeah we’ll be there soon and she looks around and sees the mess
and she’s like could you wait 10 minutes you know because she wants to get the
house ready — so that’s not what you want to do. Just briefly having a stroke is
different so you develop weakness or numbness on one side of your body or
your face if you’re having a stroke difficulty speaking, double vision or
confusion. Stroke are basically a heart attack of the brain rather than of the
heart. I wanted to close with three steps
that you guys can hopefully take today and these are kind of I would say not
traditional in terms of what doctors talk about so all those things I talked
about how important getting your blood pressure down, cholesterol, etc., but i
think there are other things and certainly taking care of women and
clinic all the time these issues come up. The first thing is I would advise
that you work less, and that’s not such a bad thing is it? I can’t tell you how many women that
come into the clinic and they are working their butts off all the time. And
you know I’m all for lean in and I’m you know all four women being strong and and
doing great things, but I can tell you that a lot of women are literally
killing themselves from working this hard. You know they’re trying to have it
all, and that may not be possible and ultimately if we sit down and talk about
what do you want it to end of your life, I don’t think it many of them want to
say I want to look back and say gosh I worked really really hard, and they’re
not enjoying other things and they’re not taking time for other things. And so I would encourage people to look
at your schedule and find out is there anywhere I can cut back. I have a patient who she works with the
stock market, and the stock market opens at six am out here, and so she
was going home at 5:00pm, and I was wondering, why are you working
starting at six am and going home at five pm. All of her staff goes home at three, nobody’s there anymore the east post is closed what are you doing and
really start she didn’t have a good answer for that but she did tell me she
didn’t have enough time to exercise and she didn’t have enough time to be with
her family and that sort of thing so we worked on cutting back can you go
home at four can go home at three so things like that. The second thing I would recommend is
sleep more. Also a good thing. Sleep has become or has been I think a
bad word in a lot of respects. You’re tough if you don’t sleep much. I mean I certainly grew up in that
environment, right, as physicians the less we sleep — (in a funny voice) I didn’t sleep for two hours I don’t sleep 41 hours you know — but in fact sleep is a wonderful thing, and I
think people are not getting enough sleep. They’re struggling with
sleep. When we looked at our clinic insomnia was all over the place and so
our psychologists work with people to help them sleep better, learn how to
relax when it’s time for bed, put your iPhone away, and things that are
keeping you awake, so that you can get more sleep — people get more sleep when people take better care of themselves they have the energy to exercise, they have the energy to make the right choices. And
speaking of which, the last thing I would recommend is that you make more good
choices than bad. This is just a simple bit of advice
for everyday life, everything that we do is a choice. Alright, so if I pick up the cookie, or I
don’t pick up the cookie. If I go for my walk, or I don’t go for my
walk — all choices right, and so every time before we do these things, we can say hmmm, do I want to make a good choice here or a bad choice? Sometimes you can make a bad choice and that’s ok, that’s part of life right? If I got up and said don’t ever make a
bad choice again, that would be ridiculous but if you can make more good choices
than bad ones over your lifetime you’re going to ultimately have better
heart health and I think overall better health. So I will close with that thank you very
much. Wonderful thank you Jennifer, that was terrific. I’m very pleased to be here with you all today and be among Marsha and Jennifer. Now i’m going to take you into some work that we’re doing at
Stanford in the research lab, and we’ve been using social media to better
understand how to help people make a heart healthy changes, looking a lot at
tobacco and starting to look at into physical activity as well. So the title
Heartbeats and Tweets social media support groups for promoting heart
health. Starting out I do want to have a
disclaimer, this type of intervention is not going to be you know globally
effective for everybody, and so this is just a joke that it’s got great reach in
terms of potential for social media, but it’s not going to be the perfect fit for
every issue that you’re dealing with. “I’m so glad you agreed to meet in person there are some things that just can’t be said in a hundred and
forty characters.” Twitter’s the platform that we’ve been using, it’s the
technology that we’re after. I’m not a huge Twitter user, but we have been
using it effectively in our in our science. T’s useful both in terms of bringing people together who may be across the U.S., potentially across the globe,
struggling with a health issue, health behavior, and supporting each other in
making those changes. Then, as a scientist, it’s fantastic because we’re
collecting all these data and you can see how people are dialoguing and
connecting with each other and making these choices, making these good and bad
choices, and reporting back to each other. So why social networks? One of the first
studies to look at how social networks impact health was done in the San Francisco Bay area, done in Alameda County. It was a three thousand men, over 3,000
women with repeat surveys over time. And what they found is that social networks
related to health. So how connected people were involved in
their church, if they were married that was health positive so these are some initial into
indication of that social connections can in and of themselves impact your
longevity. So how does social networks affect
health? In a number of ways — that person to person contact, you can
actually get some negative effects so you can get the flu from somebody, or you
could get secondhand smoke exposure from somebody, so that could be kind of negative or
positive somebody could invite you to go for a walk, somebody could offer you
something healthy to eat. Through access to resources, money, job information sharing, to the provision of social support, being there when somebody’s dealing with
stress and just listening can be a huge way that social support can affect
health. Through social influence if you’re seeing everyone around you
drinking more water are getting up in the middle of the day you’re working at
a stand-up desk, those kind of positive health changes can impact you. Then
through social engagement again having the cognitive, interpersonal and kind
of joys that you get from connecting with others and also can be stressful so those are the positive and the negative.
How our social networks changing? This is some work done by (inaudible) and
Fowler and they looked at how people know each other and how they’re
connected this is on a college campus and when they initially asked who are
your close friends I don’t have a laser pointer but that’s
the one on the top left there you see that there are some connections but it’s
not a completely filled in map and then when they asked ok who are your close
friends and fellow Club members so there are different clubs on school on campus
together so they know each other, that started to get a little more dense, and
then who are your close friends club members and roommates and at the bottom left, and you see it’s getting further dense, and then they say okay who are your
Facebook friends with and oh my gosh it gets really dense. So we are
incredibly more connected network potentially but actually what they found
is that that density it kind of clouds what’s going on because that not
everybody in your Facebook page is going to impact you. So when we are using
these social network platforms like with Twitter we’re going to actually try to get
closer to the close friends piece so that we are forming these private groups so that people can connect with each other and not have all the extraneous social
media connections that might be going on that it stays focused on the behavior of
interest. This shows you how social media has
changed over time. There are more and more applications being built.
Facebook has obviously been a leader in the space, and Twitter is also there, Snapchat, LinkedIn, WordPress, or a number of different social media types. I’m going to focus now on tobacco
because it is so relevant to heart health and it’s also a really fantastic
risk behavior to teach us how two people change. How do people struggle with something
that’s an addiction that’s out there in society and that they are exposed to that’s very social. That’s what
we’ve been focusing on and because it’s the number one cause of preventable
death in the US, so while you may not see many smokers
and around here, nationally about seventeen percent of adults smoke.
The goal is to get that down to twelve percent. So if we’re going to
reach that goal, and that’s a 2050 Healthy People Goal, we’re going to need innovation. Our group has been looking at social media as that innovation so that we can reach out and reach people in their daily lives not just waiting in
my mind in my office hoping that somebody will knock on the door and say
okay doc I’m ready to quit smoking, but actually going out and reaching people
out there. Over eighty percent of US teens use social media; sixty-five
percent of US adults use social media. I’m going to show this slide so you understand that it’s not just the efficacy of a treatment that
impacts on a public health level. So it’s not just that I invent a drug and it
helps a big number of people quit
smoking and therefore the job is done well no, because if the drug has side
effects if the drugs expensive if the drug has to be prescribed by a doctor
that can be a lot of barriers to getting that reach out to the population. Even if the social media intervention,
even if it doesn’t have a blockbuster efficacy is as big as some of the
medications, if it’s less expensive is if it’s easier to access, then its reach can
be bigger and so then you can have a really good, well broad global impact. There have been some survey studies to see what’s the interest level among smokers for getting
help with quitting smoking online and that was found to be high. About half of those surveyed and the
study in England and what predicted whether they were interested in using
the web to quit smoking, was if they wanted to quit, if they had urges to smoke,
they were feeling compelled to use, if they were younger, and if they were
frequent users of the internet, so that’s kind of the audience that it
might be a better fit for. Why Twitter? What is Twitter? So with Twitter you are
constrained in terms of how many characters your message can be but you can send multiple messages it’s
not that you can’t say more than one thing. Huge use, over 320 million
monthly active users and it’s about a quarter of online users use Twitter. It’s
the highest use use among adults under 50 among urban residents and in the
upper income brackets and eighty percent of Twitter users use it on their mobile
device on a phone or iPad or something and though it’s widely used as we see
very little study in terms of it being a platform for helping people change
health behaviors. So while you might use it? You can have
persuasive message and getting out there you can retweet messages and so that can
further a message so that it gets out more broadly. You can have social influence of opinion,
leaders you can have it tailored and directly delivered to individual users, so
you can personalize it and as I said that content can be passed around. It’s accessible, it’s free, you can look
and get a sense of what the members are the themes it’s going on in in a in a group in the community and
it’s accessible distributed at any time day or night. Our initial studies that we did we
looked at it to see what’s going on in terms of what’s being discussed about
tobacco in Twitter already and we saw this kind of explosion of activity when
Miley Cyrus who is a Disney star was caught smoking and her fanbase just exploded in a matter of three days over four thousand Tweets We can’t know for certain but we think
among young people talking about tobacco. and we looked at the content but the
sentiment that was being communicated and a lot of it was you know we love you
no matter what Miley or please quit smoking Miley that kind of thing. IT
give us some insights in terms of what kinds of messages get retweeted which
the kind of was engaging in that community so as public health people who might be
a little more nerdy ok then so then the users of Twitter and
following Miley, how we might engage with that audience to keep the young women
from starting to smoke. But then we also look to see
how Twitter is being used in terms of people developing quit smoking groups.
Is it already being done? And we did see some activity out there. So we studied
that and saw over a hundred and fifty quit smoking groups on Twitter. They had a fair number of smokers of
followers rather about a hundred followers and we found that almost half of the accounts
were inactive, they hadn’t had any tweeting in the last month so fair
amount of interest out there are some activity but then it dying down. We also saw a lot of commercialization
so on these sites people are hawking laser treatments and herbs and
supplements and that kind of thing meditation tapes and such, and also
e-cigarettes and this was done a fairly you know for five years ago before you
serve as hot as they are so i would say now probably every site talk about
e-cigarettes. Only eight talked about quit smoking like a quit smoking group
and when we look at the content it wasn’t consistent with what we would
recommend in terms of best practices. So lots of interest on Twitter, but maybe
not using it to the optimal way that it could. So popular, virtually free, interactive available 24-7, and then we can observe
what’s going on. But there also may be some limitations of the engagement, and
interactivity may be low, it may die out and may not be consistent
with clinical practice guidelines and then privacy can be a concern. We got funded by the National
Institute of Drug Abuse to do an intervention to look to develop this
platform and see if it could work – see if we could have high quality high
engagement and longevity this is my colleague Dr. Connie Peshman with the
UC Irvine in the school business and We did a randomized controlled trial to see if we
could we help people quit smoking, would their engagement relate to their
quitting smoking, and then what predicted engagement. This was published
recently in tobacco control. I won’t go into all the eligibility
criteria, but key was that they had to be daily smokers who wanted to quit and we
required that they be daily Facebook users so that they were familiar with checking in with a social media group,
with a virtual group. I won’t go and show you all this but we
screened people to make sure they were eligible. We randomized them, we followed
them over 60 days and we have over seventy percent that we followed up with,
which is good. They were middle-aged, mostly female,
varied in terms of their education, in terms of marital status, in terms of
their employment, and largely Caucasian, which is unfortunate, so we’ve gotten funding to to continue in a more diverse group. They smoked about a
pack per day for about 17 years on average and they are moderately
dependent terms of their addiction to nicotine. We randomized them to two groups, everybody was referred to quitsmoking. gov which is the National Cancer Institute site for helping people quit smoking everybody receive nicotine patches from
the study and then half a randomized into a private peer to peer support
group on Twitter or not so we isolated that effect there are 20
people in the groups for the quick the peer to peer groups they were encouraged
to treat each other daily for a period of a hundred days and we would cede the
groups with the topic every day while you’re trying to quit now how are you managing your withdrawal
who’s supporting you in this process so that means we match those seeds so that
they were evidence base and then everybody everyday got a message saying
your group really appreciated hearing from you yesterday or all your group missed you please
please tweet today so that we have that interaction this shows that tweeting over time
starting out with highest activity right when the group is starting and then it
does die over time and we heard from some of the members I don’t want to tweet anymore about
tobacco I’m quit i don’t want to be to trigger to use so we do see this as a
time-limited treatment and not forever treatment this shows among the groups that changes
over time and then on average the group’s had over a thousand tweets most of the people did participate in
the average about 59 tweets over that time this shows where we had the peaks and we
had the peaks in the morning at that with the twelve percent where we
exceeded for the topic of the day and then another where we told them we
haven’t heard from them and then another will be seated for the topic of the day
in the afternoon so about a quarter of the tweets were
from what we were putting in there but three quarters of it was a spontaneous
interaction that they’re having with each other which is great and this shows
some of the variability among the groups but very pretty consistent I’ll share an example of what we were
seeing this one says that I’ve smoked but I hide when I when I do because I’m
ashamed the other individuals that who are you
hiding from your you’re the one that wants to quit start over and try again
another person shared its ok to trip you just need to get back on track it sounds
like you want to quit maybe you need more patches the same person who started
that i’m going to get more and start fresh thank you it’s ok to stumble just keep
getting back up you can do it and that same person initially when I saw myself
all feeling I stop tweeting so much didn’t want to bring the rest of you
down and then shared you need to keep tweeting maybe we can bring you back up
and then another know we are here all here to help anytime day or night
you want to smoke we’re here to help you so really gets at what we are getting or
hoping to develop in terms of having the accountability that support
encouragement that evidence base around the the the patch use and so forth and
then on a highlight only three more days to my 60 days smoke-free never would
have thought that would happen 60-day smoke free for me today congrats to you mine was yesterday it feels good to be smoke-free i know
that feeling too so celebrating their successes this just shows that we we looked at who
was communicating with who we found that those who quit smoking and those who
relapse still connected with each other it’s not that the quitters were running
off and celebrating but they were trying to bring up those who had relapsed as
well we looked at over the time course where
was the activity and it did peek in the middle and then in terms of their
density and in relationships with each other and then it did start to fade out
over time in terms of the quit rates we saw two full greater quit rates if they
were in our tweet to quit group forty percent reported being quit compared to
twenty percent in the comparison group that was among people we were able to
interview among those if we counted those who we
didn’t reach as back to smoking the quit rates for thirty-three percent versus
eighteen percent that was significant we found that men did better at quitting
smoking in both groups and this has been seen in the literature and so we’re very
curious about that and we saw that if they participated that was related the
more tweeting they did the more likely they were to quit smoking these are the gender differences on both
groups mended better than women so we’re curious what we have all these
dialogues that’s going on in the group’s what is
it that women are talking about that might be different from men and actually
the words are using we’re pretty similar and that shows the frequency in terms of
how often they’re using the words although men talk a little bit more
about craving women should wear a little bit more talking about emotional or
support of stuff like LOL when we looked at the social the semantic networks how
are the words related to each other not just frequency counts there we saw some differences and we saw that men were more likely to talk about saving money so a financial aspect and for men the
patches the nicotine replacement was very central to their communications whereas for the women the patches were
more on the periphery so not so much of a focus and for women
they talk about cold turkey which the man really we’re not talking about and then they were much more social
emotional social connecting talking about husbands and birthdays and
excitement and kinda thing so we think that process may
be different by gender with that we keep going so we found it help people quit smoking
we did find a gender difference with this we’ve got funding with from
the National Caner Institute now to do a trial where we look at women only
groups compared to coed compared to Arkansas comparison condition and we’re
going to continue the group’s out further and more time to see in terms of
sustaining the quitting this is the new study and Tweet2Quit 2.0, that’s
the design i just mentioned we also have funding from the Stanford Cancer
Institute to develop a program for Latino smokers and doing bilingual
groups online and then also working with Jennifer we’ve got a project underway Tweet for wellness and this is merely
pezzo postdoc we’re using the same platform but for promoting walking and
if you’re interested you can certainly I reach out to us and there’s some contact
information thank you. The preceding program is copyrighted by
the Board of Trustees of the Leland Stanford Junior University please visit us at med.stanford.edu

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