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.
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