15 minute read
Self-care and the need for interactive ICT
Long-term conditions threaten to bankrupt the NHS, as lifelong drug packages allow us to live longer but less healthy lives. If our overfed, stressed, under-exercised lifestyle is at the root of the problem, then millions of us will need help to make big changes. The health trainer role is full of potential, but they and people with or at risk of LTCs also need expert knowledge and support. Fortunately, advances in interactive ICT can now put a health coach in every pocket and every home.
Why is self-care essential?
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The purpose of healthcare should be to enhance an individual’s total wellbeing (physical, emotional, social and spiritual), to prevent and reduce disease, and to enable and empower individuals to live longer, healthier and happier lives. Modern medicine has achieved a huge improvement in acute care and dramatically reduced infant mortality rates. But more than 75% of the healthcare costs in the UK, Europe and America are related to long-term or chronic conditions (LTC). This high prevalence is partly due to our longer lifespan, but arguably it has a great deal to do with the 21st century way of life.
Our body (and mind) is a wonderful holistic system: intelligent, interconnected, self-regulating and self improving. The human organism evolved for, and is still best adapted to, what is commonly termed the huntergatherer way of life. But our modern lifestyle bears little relation to that of our neolithic ancestors, and is very different from the conditions and ways of life that our bodies have been finetuned for.
For most of us, car, bus or sofabound, life involves minimal necessary physical activity. And there is an abundance of food, often intensively produced and processed, though too little of what we choose to eat is the sort of fresh fruit and vegetables that our metabolism is programmed for.
Yet, sluggish though the modern lifestyle can be, our appetite for sugar, salt, meat, and alcohol is undiminished. Add to these factors the modern day curse of sustained psychological stress, and it seems unsurprising that so many metabolically overloaded, torpid 21st century bodies fail to cope with this long-term abuse; nor that they eventually break down, causing many people to develop chronic illnesses and LTCs. Obesity, hypertension, diabetes, and cardio-metabolic syndrome have become endemic problems that undermine the health and wellbeing of millions.
The InterHeart research project published in the Lancet 1 included more than 26,000 patients in 52 countries. It found that:
• Nine simple and modifiable risk factors are strongly associated with acute MI worldwide.
• The nine risk factors account for more than 90% of the population attributable risk (PAR) globally and in most regions.
• Implementing preventive strategies based on our current knowledge would prevent the majority of premature CHD worldwide.
The pharmaceutical solution has been to develop drugs that affect the chemistry of small sub-systems in the body. This approach, though it might improve bio-chemical markers and extend lifespan, and even stop or reduce symptoms, often gives rise to long-term side effects when the medication impacts on other systems of the body. Furthermore, in order to work, drugs such as statins and anti-hypertensives need to be taken every day, for life. The aim of this enormously expensive pharmaceutical project is life extension, and the reduction of harm for strokes and heart attacks. Research tells us that it is achieving these aims, and in the process generating staggering profits for the big pharmaceutical companies. But is this the only solution for the millions of individuals involved, or the best solution for the NHS? Treating people this way has caused the healthcare costs to rocket, but already the figures suggest that people, though they live longer, do not gain quality of life in proportion to their added years. Healthcare costs are therefore increasing while at the same time, major end-of life care expenditure is merely deferred. So the current solution is simply not working and governments everywhere are beginning to realise that sustainability will depend largely on a move away from over-reliance on drugs, and the promotion of self-care.
Empowering and enabling individuals to take care of themselves
The DH strongly recommends self-care because investing in it ‘…will reduce GP visits by between 24% and 69% and hospitalisation by 50%’. The DH, having found that more than 90% of people with long-term conditions want to be more active ‘self-carers’, has made it a high priority that people should be ‘…supported and enabled to self-care and have active involvement in decisions about their care and support.’
The Prime Minister announced on 1 April 2009 that the NHS will begin offering screening to all people aged between 40 and 74 (NHS HealthCheck) to assess their cardiovascular risk. The question is whether this becomes just a jumping off point for yet more lifelong prescriptions, or whether it is used as a great opportunity to empower people, motivate them and educate them about reducing their risks by living healthier lives.
However, ways of life that have been ingrained by habit and culture over many years will not be easy to change. It will require more than a few leaflets. Perhaps personalised coaching, monitoring and periodic follow-ups would help ensure that people maintain their new positive habits. But they would be very costly programmes, and GPs have neither the time nor the training needed to motivate their patients, educate them and support their change in lifestyle and behaviour. Nor would the majority of GPs necessarily be able to ‘walk the talk’. So although the initial screening is likely to be conducted in GP centres, there is a danger that time-poor GPs, whose training is biased toward prescribing, will instead simply reach for their prescription pads. Yet if patients fail to change their lifestyle, the NHS will incur ever greater costs and perhaps these patients will develop other long-term risks and side effects. And so the vicious circle of disempowerment, high costs and unhealthy lifestyle closes at the very point where it should be broken.
How can we deliver an effective self-care solution to over 10 million people?
An obvious way forward would be to train more (and less costly) healthcare trainers. They would be taught how to assess each patient’s risk factors and how to best motivate them, and would know how best to coach them to improve their nutrition and lifestyle, reduce their stress, and stop smoking. The problem is that to do these things well each trainer would have to learn quite a lot about nutrition, understand some cardiology and physiology, and very importantly – psychology and coaching, especially in the area of motivating people to change their lifestyle, and implement positive habits. Yet even trained psychologists are not necessarily successful in helping people to change poor eating habits, reduce weight, or stop smoking. So even with 10,000 brilliant healthcare trainers it would take a long time and be very expensive for each one of them to successfully coach 1,000 of the 10 million patients who might benefit. Clearly we need to tackle the problem another way.
For example could we use IT to combine in some user-friendly way the relevant knowledge and support approaches that coaches/trainers would find useful? What if we brought together the contributions of cardiologists, nutritionists, and psycho-physiologists, and were to combine them with what’s known about motivational interviewing and behaviour modification? Would it not be very helpful indeed to encapsulate all this knowledge in an interactive self-care multi-media coaching programme and make it available to millions of people at minimum cost and maximum quality? A self-care multimedia system such as this would not just help to train the trainers costeffectively, but would also give every patient confidence that their efforts for change were based on the best selfcare knowledge available.
Are there effective methods to change unhealthy habits and prevent LTC?
There are two additional interesting challenges:
Some habits, such as smoking and exercise, are ‘extrinsic behaviours’ although they affect our long-term health and risks of LTCs. Certain subconscious habits –our breathing rate, heart rate, blood pressure and responses to stress for instance – are crucially influential, for these ‘intrinsic behaviours’ can seriously dysregulate our organism, undermine health and wellbeing and so set the scene for the development of LTCs.
For example imagine this scenario.
John is 42-years-old and spends most of his time at work sitting in front of a monitor. He is not aware that the combination of sitting most of the time, and the stress (pressure from his boss and customers and bursts of anxiety) changes the way that he breathes. His breathing has become fast and shallow, his heart rate and blood pressure have also increased. It would be a necessary challenge for John to improve this intrinsic behaviour, before its dysfunction converts into frank pathology. But how can he be taught to breathe more slowly from his abdomen and so reduce his heart rate, anxiety levels and blood pressure?
John also smokes, drinks a lot of coffee and alcohol, eats too much junk food, and is overweight. He is used to this lifestyle – even thinks it is ‘normal’, so the second challenge would be to change such habits. John already knows that smoking is not good for him; it is written on every cigarette box, and it isn’t likely that one session even with a very good health coach would change a habit so deeply physiologically, psychologically and culturally entrenched. Changing always takes us out of our comfort zone, so it calls for special kinds of intervention, and motivation; and it simply takes time. They are costly commodities.
However, it has been realised that these challenges can be met by integrating information and communication technologies (ICT) and inexpensive sensors with interactive self-care programmes. A number of good clinical trials have demonstrated how several chronic conditions, including hypertension, diabetes and irritable bowel syndrome, can be better managed and controlled by using interactive ICT to modify both extrinsic and intrinsic behaviours, and to support lifestyle changes.
A large percent of the population suffers from anxiety and depression. Drugs are not effective for most of the population (mild and moderate depression). However cognitive behavioural therapy (CBT) has been shown to be more effective than medication especially in preventing relapses, but there are too few trained CBT psychologists and there is a long waiting list to see them in the NHS.
We have collaborated with psychologists and psychiatrists from the Institute of Psychiatry to develop eight sessions of interactive self-care presented as a computer-based multi-media programme (called Beating the Blues). Clinical trials have shown that this programme was more effective than ‘usual treatments’ in primary care. NICE recommended this programme for the treatment of anxiety and depression and many thousands of NHS patients have benefited from it.
IBS is a long-term condition affecting more than 15% of the population, and medication is often relatively ineffective, especially in severe cases. We collaborated with Professor Epstein at the Royal Free Hospital and developed a bio-interactive self-help programme to treat IBS. Two clinical trials have suggested this system could deliver very promising results. Patients with several years’ history of IBS who had not responded well to other treatments and who completed eight interactive self-help sessions showed between 75% and 82% improvements in anxiety, abdominal pain, stool consistency and bowel urgency. Improved global wellbeing was reported by 85%, and long-term improvement by 65% of those taking part. To the best of our knowledge no medication has produced such good results.
Bio-interactive self-care systems can help patients to modify ‘intrinsic behaviour’. In the case of IBS patients, severe anxiety and bowel urgency are associated with high arousal levels (stress) and faster than normal peristalsis (the rhythmic contraction of the intestinal muscles which push the food forward). The team created a 3D animation of a ‘journey inside the bowel’, and linked it to the user’s arousal level, which is measured by a ‘skin-resistance’ sensor attached to the finger. As the user learns to reduce their arousal level, the images in the animation reflect their relaxing, and so, through a biofeedback process, the
user learns to slow down the animation and their peristalsis. Most patients can learn to control the animation, and within eight weeks to control and improve their anxiety and peristalsis. This type of bio-interactive coaching can be used to train patients to control other ‘intrinsic behaviour’ and prevent and control other conditions such as hypertension and asthma.
The latest generation of biointeractive self-care programmes
In order to train patients to overcome anxiety and depression, we have incorporated psychological knowledge and methods into interactive multimedia sessions that include audio, video and animation. The aim is for patients to learn the principles of CBT, and acquire self-help skills for life. Though CBT can be useful for some conditions and some people, not every patient and every condition benefits. However, one of the advantages of computerised coaching is that it allows each individual to chose the particular combination of the best known treatment methods customised to their conditions, preferences and needs.
During the last five years Health-Smart Ltd has developed an advanced bio-interactive self-care system that integrates knowledge from a multi-disciplinary expert team, with wireless multi-parameter sensors and advanced psychological and behavioural methods. The team has also created a comprehensive software engine that can transform interactive protocol scripts into user friendly and effective bio-interactive self-care programmes.
Dr Ameet Bakhai, a senior consultant cardiologist at Barnet & Chase Farm and The Royal Free Hospital has been guiding Health-Smart in the development of a comprehensive self-care solution –SmartHeart – to prevent and control hypertension and other vascular diseases. SmartHeart’s bio-interactive healthcare assessment can monitor the user’s physiology (breathing rate and pattern, heart rate (HR), and HR variability, blood pressure, stress/anxiety level, ECG), as well as track body measurements (weight, height, waist circumference and so on), detailed nutrition and lifestyle profiles (including alcohol use, smoking and physical activity), medical history and medications. Clinicians can add test results such as lipid and glucose levels. In fact a point of care blood test machine can even be connected to SmartHeart.
SmartHeart can then present users with their modifiable risks, and encourage them to see how they might reduce their risks and gain extra healthy years of life by modifying some unhealthy habits. SmartHeart is designed to help users choose targets, and to prepare their own customised prevention plan. Patients with modifiable risks can also attend interactive self-help sessions in primary care or community settings, and eventually at home or via interactive applications on their mobile phones.
SmartHeart educates users, empowering them and motivating them to improve their habits, and coaching them on how to make healthy changes and implement them in their daily lives. Each session is customised to the user’s risk profile and preferences. For example a patient with high blood pressure and high anxiety who is overweight but not a smoker will be trained on how to improve nutrition, achieve and maintain weight loss, reduce anxiety and to relax. Users can also be trained to slow their breathing down (which can significantly reduce BP) and so reduce their heart rate (and increase heart rate variability). In addition, a smoker would receive the smoking-cessation coaching.
We intend to find ways of making SmartHeart available to everyone who needs it, so that healthcare stakeholders will be able to benefit from this new generation of biointeractive self-care. Our hope is that PCTs who implement it will find that they reduce their costs, while improving the long-term care and health of their patients. We believe that GPs who use it will save time, get more information about their patients, and that their time will be freed up to focus on improving other areas of care. And we know from previous experience of bio-interactive self-care systems that they powerfully motivate patients to improve not just their lifestyle but even to directly stabilise their dysregulated physiology.
We believe it may be possible using bio-interactive self-care technology to bring about a new era in the prevention and management of long-term conditions, enabling people at risk to live longer and healthier lives with far less need of medication. Our planned research also aims to show that bio-interactive self-care can produce a healthy reduction in the NHS’s disastrous over-dependence on lifelong drug-taking.
Written by:
Tuvi Orbach
CEO, Health-Smart
I am an entrepreneur who focuses on harnessing advanced science and technology to enhance life. I have set up several companies with this aim in mind. My ultimate aim is to provide solutions which can empower people to improve all aspects of their life and overall wellbeing; from their physiology, emotions, and cognitive state, to their social and spiritual lifestyle, in order to enjoy longer, healthier, happier, enhanced, fulfilled lives. I believe that it is important to enhance current mainstream science and medicine to encompass consciousness, awareness and a holistic approach.
Jane Vazquez
Health Education ‘Physiologist’, Health-Smart
As a result of a childhood where encyclopaedias and alternative healthcare books were my bedtime reading, I decided to study physiology at university. My studies fuelled my amazement at the human body and I became a great believer in a holistic approach to health which I enthusiastically conveyed to all I met through the years. At Health-Smart I have been able to convert my own knowledge and that of other experts to help write and develop a programme aimed at empowering people to take care of themselves and lead happier, healthier lives.
