femal sex

i want to welcome you to the seventhannual women's health forum which the wisdom center runs and wisdom as youjust heard was created by the dean's ...office through a strategic planningprocess with a vision statement of healthy women and men from conceptionthrough the life course and a mission of advancing human health across thelifespan through research and education

femal sex, in women's health, the biology of sex differences andgender medicine which i'll explain to you as we go along. just to orient youthis is a whole track in health matters were very excited to be partnering withthem today, and when i finish i'll come

back to this slide and introducejennifer tremmel, assistant professor of medicine who is the clinical director ofthe women's heart health at stanford. and also jody prochaska — judith prochaska — who justarrived and that's really great. and then i want you to know that we'regoing to move over to the clark center for a speed panel and women's cancer andthen we come back here after lunch at one o'clock for a final set of talks onskin and bones and sleep health. so the topic of why sex and gendermatter 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 keyissues of sex and gender and how it impacts health of women and some of theunique health features. i'm not going to talk about sex differences, there's not enoughtime. i'll just focus on unique issues forwomen i want to touch on the important role of caregiving in women which is ahuge burden that obviously many men do as well but women have a higher burdenon that and then end with a little bit on sex and gender identity. so to start with a sex and genderconcept i want to make the distinction so youunderstand that we see these as very

different entities so when we talk about sex the instituteof medicine back in two thousand one released their report having looked atall of the biology that basically saying that sex does matter they defined it as a biological qualityor classification of sexually reproducing organ organisms generally male or female according toreproductive function and organs that derive from the chromosomes. and because chromosomes are in every cell they basically said every cell has sexand what you should know is that very

few cell biologist ever tell you aboutthe 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 sociocultural issues and although the iom reported this as, or presented this as aperson's self representation of male and female what's really important from biology isthe role of gender norms and gender roles on biology. it influencesbiology and very profound ways that i'll give you a couple examples as we goalong. and also gender relations. people

treat you differently because you're awoman. so just as we talk about race, ethnicissues, and we talked about socio-economic issues being a woman, the whole world treats you differentlythan if you were a man and that said many people want to identify withsomething other than the way they were designated at birth or as they weredesignated at birth and that's your gender identity. and i'll just draw yourattention to the general innovation site here at stanford (inaudible) has really been driving this important message and she and i are very closelyworking on this. now if we talk about sex

in the old days you had to be bornbefore they knew what sex you were and then they would say "oh it's a boy" or "it's agirl" based on your genitalia. now you canfind out ahead of time, but then over time bones start to change because of thechromosomes and hormones, and we end up with some very cleardifferences 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 ofdifferences in our bones and these are genetically driven as well as hormonal eso i'm putting here the pelvis. this is

the most sexually dimorphic bone in yourbody because the evolutionary pressure to get that head out of that pelvis ifyou're a woman is so high that you're dead if you don't get that out. and so there's very powerfulgenetics working on those bones that hardly anyone is really studied. on theother hand there's a lot of pressure to keep a nice narrow pelvis so that youcan run and you can be local moding and so those two pressures diverted a lotof the male-female pathways. on top of that we have lots of otherbody composition changes so we generally think of men as being more muscular

obviously we have a very muscular womenand we think of women has having more fat much of this is essential fat veryimportant for reproductive function and health and we distribute that fat indifferent places based on hormones so there's a lot of biology that is veryintegrated in the medical outcomes that we talked about. on the other hand wehave gender. gender is really the social meaning of being female and maleand you can just see some examples this changes over history it changes in different cultures itchanges within cultures and it has very profound effects

so for instance one reason that man isstronger than women isn't just because they have more muscle but we make themcarry a lot of stuff and so we had to kind of fight our way like let me carrythat. and now that i'm older it's like it'sfine you know you can carry that. so anyway. and then i want to make anexample so in addition to that example this is agreat example of where gender can actually completely change biology so for a thousand years chinesefoot-binding was in practice it was a sign of beauty to have the smallest footpossible you want a third three to four

inch foot and so they started bindinglittle girls feet when they were five to seven years of age and thegirls the the mother and law would go and look at the girl to be sure that herfoot was small enough and beautiful enough before she would be married now obviously you can't walk on thatfoot, 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 theycouldn't walk unless you are poor, in which case you need your feet to workand so you didn't get your foot bound. now i will tell you that we actuallystill have a lot of stuff like this

going on if we look at the u.s. today we stillare you know making it a little bit harder for women to walk around andthat's part of our culture. women drive this just probably more than men so it'snot men doing this to women, it's something as part of culture. now to comeback 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 cellis, but we do know that most animal studies are done in male animals. this was a review that was came out in2009 looking at all of those different

disciplines the blue is where its male-driven thebig red one is in reproduction where obviously we would have more female andthe purple is what we would see as the goal, which is to have both sexes, so wecan look at is there a difference or not and only twenty-six percent of animalstudies fell in that category. a little better in humans sixty percentoverlap still a lot more blue except for the category of reproduction and this isa serious issue because what we now learned is that women metabolize drugsdifferently they metabolize alcohol differently than men and we have thiscrisis where a lot of drugs have gone to

market without being adequately testedand women. eight of 10 that have been pulled off the market have been because of veryadverse reactions and women that should have been studied before they ever wentto market. a very popular story came out about two years ago on zolpidemwhich is the leading sleep medication for insomnia. women get a lot moreinsomnia so they use this much more often and what they found is that fifteenpercent of women were waking up the next day eight hours after taking it stillwith 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 drugthat has a male and a female dose and you see it comes in a pink bottle in abluebottle many men should be taking a lower dose and now they have to take itfrom the pink bottle in this society that's like putting a stop sign on thebottle. so again we need precise medicine and weneed to start to think about what's the right drug for men and women and just tomake the point this is not just body weight a lot of things related to bodyweight, but woman's body composition is different the way we metabolize ourlivers different all of this needs to be studied. the nih gets it. in 2014 theybasically said we need to start to

balancing we need to start having in ourbasic animal work now at that time they actually said cells as well when the when the update came out fromthe nih last year they only focused on animal studies because they found outthat the cells they have the cell lines they don't even know what sex they arebecause they've been transformed in such a way that we're not even clear what thesex 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 youinclude males and females. we recognize

that it is important for theinterpretation of the data and that if you don't include that you have to havestrong justification in your grant for why you don't have males and females inanimal and human studies. now just to say a few unique things if you're notaware women are mosaics. it's like a calico cat. calico cats arealmost always female and it relates to the fact that early on and i realize nowi thought i'd have a pointer, but i'll draw your attention to the egg and yousee this egg being ovulated there that eggs is going to have two x's — one fromthe mother's mother and one from the mother's father, and if you can see itthere's a little sperm that's about to

reach that egg in the fallopian tubethat sperm the sperm are either the x the father's x that came only from hismother, or the father's why they came only from his father, we can actuallytrack 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 withmany exceptions — and i don't have time for all those exceptions — but theimportant point i wanted to make here is that once those to unite the fate issealed in a very interesting way because as the that embryo starts to develop decisions have to be made we don't wanttwo 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-fivepercent, and what you're seeing on that diagram of the mosaic is that a randomthing occurs where an x, the father's x is inactivated one tissue in onecell and the mothers and the other, but take a look at how early this happens this is happening in the embryonicdevelopment before any organ is made before we even have all of the layers soit's very very early on and this is one reason why identical twin girls are notas identical as identical twin boys because it could be a completelydifferent random process but at any rate

those cells are every tissue in yourbody is a mosaic so that if we look at the retina we have some if there's an excellentproblem in the retina of the red and green cones for vision are on the retinaare on the x chromosome the blue is not so blue doesn't havethat sexual problem but basically boys are more likely going to be color blindbecause 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 withtissues that are less likely to be expressing that that x hemophilia isanother very good example and the last

one i want to mention is a rare issuethat relates it looks a little bit more like the calico cat to let you know thatyou have sweat glands all over your body that are from these mosaics and so youhave big patches where if you have this particular x problem you can't sweat. and so for a female shecan still regulate her temperature in the good tissue, but for a male with thatx he dies very early because he can't regulate his temperature so it's rare wehave lots of those that no one has studied because we're studying everygene in the universe and paying very little attention to this —

that's not precise health that's notprecise medicine. we need to be more precise. then i'll just quickly sayif you're not aware something else that's big difference between men andwomen is that the the egg the the germ cells do all of theirdivisions up to the last one before you're born and boys they stopped muchbefore that so that what we have is a situation that women are born with allthe eggs they'll ever have they don't start ovulating until pubertyboys don't even have that division until puberty then they start that process. and anotherbig 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 reproductivelycapable up until they're they're dead. this is us. this is a graph of showingyou the eggs, and you can just see how every five years you drop, you drop you drop so that veryfirst really big drop is age 35, there's not many eggs left by the 40 andby 45, there's hardly anything left to getpregnant, you're lucky or you do assisted reproductive technology, areally important issue for older women,

and that the next thing is going to bemenopause, which will come back to. i first want to just go back again tothe embryo and let you all know that every person in this room started outwith the potential of being either male or female and then because of thechromosomal compliments and a number of factors a decision is made in embryologywhere you're either going to go down the male path and you're going to retain thethe tubes that you need to be a male, you're going to have a testis. or, you godown the female path and the the indifferent gonad will become an ovaryand you're going to have the tubes that you need to be a female, the female organstays 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 needto get that out and also because of the testes and thetestosterone we're going to change the external genitalia which could be maleor female at the outset. so we all have the abilityto be either of these sexes and decisions are made that we live with. nowi will tell you other transitions, this was actually transition slide of pubertybut it had breast developing and and pubic hairdeveloping which we thought wasn't quite right for this audience perhaps, but iwill say that an important thing is that

then part of puberty is the menstrualcycle women for from age 13, or 11 to 51 so that's 40 years have menstrual cycleswhere their biology is changing through the month. this is one reason no one to studyfemales because it's too complicated like yeah but we are and we should study itthat's precision and so we changed all every through the month but we might notlike it pregnant and what you'll hear from dr. tremmel after i finish, is thatpregnancy is a big cardiovascular stress test that is like a very profoundphysiological change that women go through. some women actually develophypertension during pregnancy that

predisposes them to hypertension later — not really sure which comes first, thepredisposition or the stress test, and also gestational diabetes,pregnancy alone causes lots of differences between men and women. weactually know that cells from the embryo reside in women after like 30 yearsafter they've delivered that baby that probably relate to some of theautoimmune diseases so we have lots of issues that are really precise. the other thing just to kind of gothrough the lifespan here what you're seeing is really kind offocusing on bones before i do that i

want to come back to those eggs that avery big difference between men and women is that the egg, the ovum isthe source of the estrogen. in the case of males the sperm are unrelated to they're influencing each other but thetestosterone making cells are different from the sperm and so you can continuemaking testosterone you continue having sperm. for females it's all together andbasically you hit a point where there's not enough eggs anymore so there's notenough estrogen anymore and in addition to things that arehappening with estrogen dropping and related to bones, women suffer forabout three years with hot flashes which

is a very serious issue no one was even studying that until thewomen's health initiative came out because it's like well, women don't diefrom menopause so why would we worry about it? it's a huge quality of life issue. i will justquickly say that when we talk about the causes of death in men and women they'revery similar with obviously breast cancer being exception only 1% of breastcancers are men, but i will point out that it's not the leading cause ofcancer death, lung cancer is. we are going to have aset of talks on the cancers and women

note that breast cancer is the secondleading 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 inalmost all of those cancers that are really interesting that we don't havetime to talk about. i don't have time to also talk about thecaregiving issues, but we actually think about the women as the chief medicalofficer of most families. they really are the ones that have to know about drugsthey have to take care of children they have to take care of spouses and takecare of parents they have a huge burden

of care giving, and so i'm going to endby just talking about sexual health. i don't have time to talk about thisexcept to say that the world health organization recognized the sexualhealth not as a dysfunction and the focus ofabsence of dysfunction, but actual health and to just kind of finish this, we know that sexual values vary a lot bysocioeconomic status, practices, policies in our culture, i would call our cultureof 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 tocompletely enjoy this

and furthermore because we're sodichotomous — good-bad, men-women — we also don't accept the range ofpossibilities for peoples' gender and sexual identity. all of these are things that the wisdomcenter feels is very important and that we will continue. now i'm going to actually not engagequestions you'll have me all day long and you can ask me questions, so what i want to do now is take my timeto introduce our next speaker so jennifer tremmel is

the clinical director of the women's hearthealth at stanford she's going to be talking to you about women and heartdisease your risk and what you can do about it, and when she finished she willgo right to jody prochaska, who will be talking about heartbeats and tweets, social media support groups forpromoting heart health. i then just want to remind you that we'll begoing to the clark center for the women's cancer panel, and then returninghere later for the skin and bones and sleep health. i'm going to pass itover to dr. tremmel now who i've known for a very long time and she has reallyrevolutionized women's heart health at

stanford — we would not have a clinic, so this is a very wonderful part ofstanford. 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 shortbit of time so i'm going to hopefully give you some good highlights today — alittle bit about heart disease in women as well as maybe some tips to take careof yourself. i'm an interventional cardiologist so iopen up heart heart arteries and also take care of women in clinic westarted a program in 2007. our mission is

really on through prevention diagnosisand treatment of cardiovascular disease and its impact on psychosocialwell-being to provide comprehensive cardiovascular care to women acrosstheir lifespan utilizing an evidence-based personalizedmultidisciplinary approach. and really what we hope to do ultimately is toeliminate sex and gender disparities in cardiovascular medicine. the team at stanford started out withmyself and a nurse practitioner and now there are 15 or 16 of us. we have severalcardiologists, preventive cardiologists, psychologists, dietitian.

i even have a postdoctoral fellow who'sa man. we're very proud of him and he'sdoing great work with us as well. i'm always the party pooper when i get up here so i has give you thecold 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 isthe leading cause of death among women in the united states. it's also a leadingcause of death among men. it's a second leading cause of death forwomen aged 45 to 64, and the third

leading cause of death for women 25 to44. i think we often think of it as though it's an old person's disease andthat'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 ofevery three women. this is where i say look to your leftlook to your right — for one of you that will be your causeof death. it kills five times as many women asbreast 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 stuffand all of that, and certainly breast

cancer is important, but we really doneed to focus on cardiovascular disease and where our red dresses so that weraise awareness. when we look compared to men we know that more women have died fromcardiovascular disease every year since 1984, and compared with men, womenhave higher lifetime risk of stroke and also women are morelikely to die after their first heart attack than men. i mean there's lots of reasons for thatwomen aren't always aware that they're having a heart attack,

they often take too long to get tothe 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'reworking 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 greatesthealth 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 likesomebody's gonna have heart disease you know, and i think you can pick outwho's going to have heart disease and o know we have people in this room whohave heart disease. these are the faces of heart disease.these women are survivors in our clinic they were at our go red luncheon with theamerican heart association recently and they had the strength to tell theirstory so that other women could know. butthese are the faces of heart disease, right, so these aren't necessarily whatyou might think. the good news is that most ofcardiovascular disease is preventable.

you can't help who your parents were, andyou can't help getting older, although i'm trying to work on that one, but thereare several things that are modifiable and so everyone should know their risks. it turns out ninety percent of womenhave one or more risk factor for heart disease or stroke. so pretty much everybody in this roomhas something that they need to work on to improve their cardiovascular health. these are the things that you shouldknow as preventable risk so your cholesterol level so you need to knowwhat your cholesterol level is, having a

high ldl or bad cholesterol is not agood thing, or having a low hdl or good cholesterol, in addition diabetes, you don't want tohave diabetes, basically people have diabetes we say you basically haveheart disease already it's an equivalent. knowing your blood sugar and makingsure that it's preferably under a hundred if it's between a hundred ahundred and twenty-five you're basically pre-diabetic and above 125 you havediabetes. knowing your blood pressure as well highblood pressure is associated with cardiovascular disease.

don't smoke. most people in this areaknow this but actually the highest rates of increase smoking are currently inyoung women, unfortunately. having a sedentary lifestyle, and that means thatyou're getting less than 30 minutes of moderate-intensity physical activity onmost 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 usuallylook at so if you have a body mass index of 25 to 30 you're overweight and if it's greaterthan 30 you're obese. there are other risk factors and theseare kind of the classic ones you're

going to hear some about stress and wethink stress you know plays a big role also pregnancy is a little marker for usand i think we don't do a good job of kind of capturing women at that time andletting them know that your risk may be elevated based on what happened to youduring pregnancy. women who develop gestationaldiabetes get high blood pressure preeclampsia have a preterm delivery orgain excess weight that they ultimately never lose have a almost double the riskof developing cardiovascular disease in the next 10 years — it's actuallypretty quick that this plays plays a role in terms of your risk.

so one of the things we do in clinicnow is try to capture these women right after their pregnancy even thoughthey're busy with other things and let them know what their risk is andhopefully do something about it i think this american heartassociation score is a nice thing you can do so you could go online if you want andit basically will take you through all of those risk factors that i talk to youabout and you can calculate your own score andsee where you are. what about the symptoms? this isone area where women seem to be a little

bit under informed and that couldcertainly be to your disadvantage if you don't recognize that you're having aheart problem. we want women to be well informed and women do have symptoms that are different than men. the classic isstill chest pain and that's the most common thing that will see in women andmen. this is not necessarily a pain. it's somesort of discomfort it can be a burning pain. it can be sharp, it can be pressureheaviness some sort of discomfort generally vague in the chest area and itoften 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 willhave shortness of breath when they're having a heart problem. you may getsweaty, have light headedness feel nausea these sorts of things so these are allsigns that you could be having a problem and things that you need to payattention 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 waythat women are different than men is that they have more symptoms often andit 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'mhaving chest pain and they'll pay attention to you. then when you havethese symptoms you need to get help right so you need to call 911 and havesomeone help you can take an aspirin as well this isn't the time to be like oh maybenot now you know i need to have what i get my clothes outof the dryer before i do this or you

know i've got to get the kids off tolunch or whatever if you have the opportunity another nice thing to lookat online if you youtube it is called just a little heart attack it features the actress elizabethbanks it's from the american heart association. it's basically a womanhaving all these symptoms while she's running around and trying to get herkids ready and she called 911 and they say oh yeah we'll be there soon and she looks around and sees the messand she's like could you wait 10 minutes you know because she wants to get thehouse ready — so that's not what you want

to do. just briefly having a stroke isdifferent so you develop weakness or numbness on one side of your body oryour face if you're having a stroke difficulty speaking, double vision orconfusion. stroke are basically a heart attack of the brain rather than of theheart. i wanted to close with three stepsthat you guys can hopefully take today and these are kind of i would say nottraditional in terms of what doctors talk about so all those things i talkedabout how important getting your blood pressure down, cholesterol, etc., but ithink there are other things and

certainly taking care of women andclinic all the time these issues come up. the first thing is i would advisethat you work less, and that's not such a bad thing is it? i can't tell you how many women thatcome into the clinic and they are working their butts off all the time. andyou know i'm all for lean in and i'm you know all four women being strong and anddoing great things, but i can tell you that a lot of women are literallykilling themselves from working this hard. you know they're trying to have itall, and that may not be possible and ultimately if we sit down and talk aboutwhat do you want it to end of your life,

i don't think it many of them want tosay i want to look back and say gosh i worked really really hard, and they'renot enjoying other things and they're not taking time for other things. and so i would encourage people to lookat your schedule and find out is there anywhere i can cut back. i have a patient who she works with thestock market, and the stock market opens at six am out here, and so shewas 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 andreally start she didn't have a good answer for that but she did tell me shedidn't have enough time to exercise and she didn't have enough time to be withher family and that sort of thing so we worked on cutting back can you gohome at four can go home at three so things like that. the second thing i would recommend issleep more. also a good thing. sleep has become or has been i think abad word in a lot of respects. you're tough if you don't sleep much.

i mean i certainly grew up in thatenvironment, 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 ithink people are not getting enough sleep. they're struggling withsleep. when we looked at our clinic insomnia was all over the place and soour psychologists work with people to help them sleep better, learn how torelax when it's time for bed, put your iphone away, and things that arekeeping 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. andspeaking of which, the last thing i would recommend is that you make more goodchoices than bad. this is just a simple bit of advicefor everyday life, everything that we do is a choice. alright, so if i pick up the cookie, or idon't pick up the cookie. if i go for my walk, or i don't go for mywalk — 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 abad choice again, that would be ridiculous but if you can make more good choicesthan bad ones over your lifetime you're going to ultimately have betterheart health and i think overall better health. so i will close with that thank you verymuch. 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 atstanford in the research lab, and we've

been using social media to betterunderstand how to help people make a heart healthy changes, looking a lot attobacco and starting to look at into physical activity as well. so the titleheartbeats and tweets social media support groups for promoting hearthealth. starting out i do want to have adisclaimer, this type of intervention is not going to be you know globallyeffective for everybody, and so this is just a joke that it's got great reach interms of potential for social media, but it's not going to be the perfect fit forevery 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 andforty characters." twitter's the platform that we've been using, it's thetechnology that we're after. i'm not a huge twitter user, but we have beenusing 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 inmaking those changes. then, as a scientist, it's fantastic because we'recollecting all these data and you can see how people are dialoguing andconnecting with each other and making

these choices, making these good and badchoices, and reporting back to each other. so why social networks? one of the firststudies 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 3,000women with repeat surveys over time. and what they found is that social networksrelated to health. so how connected people were involved intheir church, if they were married that was health positive so these are some initial intoindication of that social connections

can in and of themselves impact yourlongevity. so how does social networks affecthealth? in a number of ways — that person to person contact, you canactually get some negative effects so you can get the flu from somebody, or youcould get secondhand smoke exposure from somebody, so that could be kind of negative orpositive somebody could invite you to go for a walk, somebody could offer yousomething healthy to eat. through access to resources, money, job information sharing, to the provision of social support, being there when somebody's dealing withstress and just listening can be a huge

way that social support can affecthealth. through social influence if you're seeing everyone around youdrinking more water are getting up in the middle of the day you're working ata stand-up desk, those kind of positive health changes can impact you. thenthrough social engagement again having the cognitive, interpersonal and kindof 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) andfowler and they looked at how people know each other and how they'reconnected this is on a college campus

and when they initially asked who areyour close friends i don't have a laser pointer but that'sthe one on the top left there you see that there are some connections but it'snot a completely filled in map and then when they asked ok who are your closefriends and fellow club members so there are different clubs on school on campustogether so they know each other, that started to get a little more dense, andthen 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 yourfacebook friends with and oh my gosh it gets really dense. so we areincredibly more connected network

potentially but actually what they foundis that that density it kind of clouds what's going on because that noteverybody in your facebook page is going to impact you. so when we are usingthese social network platforms like with twitter we're going to actually try to getcloser 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 socialmedia connections that might be going on that it stays focused on the behavior ofinterest. this shows you how social media haschanged 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 tobaccobecause it is so relevant to heart health and it's also a really fantasticrisk behavior to teach us how two people change. how do people struggle with somethingthat's an addiction that's out there in society and that they are exposed to that's very social. that's whatwe've been focusing on and because it's

the number one cause of preventabledeath in the us, so while you may not see many smokersand around here, nationally about seventeen percent of adults smoke.the goal is to get that down to twelve percent. so if we're going toreach 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 inmy mind in my office hoping that somebody will knock on the door and sayokay doc i'm ready to quit smoking, but

actually going out and reaching peopleout there. over eighty percent of us teens use social media; sixty-fivepercent 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 ithelps a big number of people quitsmoking and therefore the job is done well no, because if the drug has sideeffects if the drugs expensive if the drug has to be prescribed by a doctorthat 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 themedications, if it's less expensive is if it's easier to access, then its reach canbe 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 gettinghelp with quitting smoking online and that was found to be high. about half of those surveyed and thestudy in england and what predicted whether they were interested in usingthe 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 werefrequent users of the internet, so that's kind of the audience that itmight be a better fit for. why twitter? what is twitter? so with twitter you areconstrained in terms of how many characters your message can be but you can send multiple messages it'snot that you can't say more than one thing. huge use, over 320 millionmonthly active users and it's about a quarter of online users use twitter. it'sthe highest use use among adults under 50 among urban residents and in theupper income brackets and eighty percent

of twitter users use it on their mobiledevice on a phone or ipad or something and though it's widely used as we seevery little study in terms of it being a platform for helping people changehealth behaviors. so while you might use it? you can havepersuasive message and getting out there you can retweet messages and so that canfurther 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, soyou can personalize it and as i said that content can be passed around.

it's accessible, it's free, you can lookand get a sense of what the members are the themes it's going on in in a in a group in the community andit's accessible distributed at any time day or night. our initial studies that we did welooked at it to see what's going on in terms of what's being discussed abouttobacco in twitter already and we saw this kind of explosion of activity whenmiley 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 thinkamong young people talking about tobacco. and we looked at the content but thesentiment that was being communicated and a lot of it was you know we love youno matter what miley or please quit smoking miley that kind of thing. itgive us some insights in terms of what kinds of messages get retweeted whichthe kind of was engaging in that community so as public health people who might bea little more nerdy ok then so then the users of twitter andfollowing miley, how we might engage with that audience to keep the young womenfrom 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 studiedthat and saw over a hundred and fifty quit smoking groups on twitter. they had a fair number of smokers offollowers rather about a hundred followers and we found that almost half of the accountswere inactive, they hadn't had any tweeting in the last month so fairamount of interest out there are some activity but then it dying down.

we also saw a lot of commercializationso on these sites people are hawking laser treatments and herbs andsupplements and that kind of thing meditation tapes and such, and alsoe-cigarettes and this was done a fairly you know for five years ago before youserve as hot as they are so i would say now probably every site talk aboute-cigarettes. only eight talked about quit smoking like a quit smoking groupand when we look at the content it wasn't consistent with what we wouldrecommend in terms of best practices. so lots of interest on twitter, but maybenot using it to the optimal way that it could.

so popular, virtually free, interactive available 24-7, and then we can observewhat's going on. but there also may be some limitations of the engagement, andinteractivity may be low, it may die out and may not be consistentwith clinical practice guidelines and then privacy can be a concern. we got funded by the nationalinstitute of drug abuse to do an intervention to look to develop thisplatform and see if it could work - see if we could have high quality highengagement and longevity this is my colleague dr. connie peshman with theuc irvine in the school business and

we did a randomized controlled trial to see if wecould we help people quit smoking, would their engagement relate to theirquitting smoking, and then what predicted engagement. this was publishedrecently in tobacco control. i won't go into all the eligibilitycriteria, but key was that they had to be daily smokers who wanted to quit and werequired 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 wescreened people to make sure they were

eligible. we randomized them, we followedthem 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 oftheir employment, and largely caucasian, which is unfortunate, so we've gotten funding to to continue in a more diverse group. they smoked about apack per day for about 17 years on average and they are moderatelydependent 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 fromthe study and then half a randomized into a private peer to peer supportgroup on twitter or not so we isolated that effect there are 20people in the groups for the quick the peer to peer groups they were encouragedto treat each other daily for a period of a hundred days and we would cede thegroups with the topic every day while you're trying to quit now how are you managing your withdrawalwho's supporting you in this process so that means we match those seeds so thatthey were evidence base and then

everybody everyday got a message sayingyour group really appreciated hearing from you yesterday or all your group missed you pleaseplease tweet today so that we have that interaction this shows that tweeting over timestarting out with highest activity right when the group is starting and then itdoes die over time and we heard from some of the members i don't want to tweet anymore abouttobacco i'm quit i don't want to be to trigger to use so we do see this as atime-limited treatment and not forever

treatment this shows among the groups that changesover time and then on average the group's had over a thousand tweets most of the people did participate inthe average about 59 tweets over that this shows where we had the peaks and wehad the peaks in the morning at that with the twelve percent where weexceeded for the topic of the day and then another where we told them wehaven't heard from them and then another will be seated for the topic of the dayin the afternoon so about a quarter of the tweets werefrom what we were putting in there but

three quarters of it was a spontaneousinteraction that they're having with each other which is great and this showssome of the variability among the groups but very pretty consistent i'll share an example of what we wereseeing this one says that i've smoked but i hide when i when i do because i'mashamed the other individuals that who are youhiding from your you're the one that wants to quit start over and try againanother person shared its ok to trip you just need to get back on track it soundslike you want to quit maybe you need more patches the same person who startedthat i'm going to get more and start

fresh thank you it's ok to stumble just keepgetting back up you can do it and that same person initially when i saw myselfall feeling i stop tweeting so much didn't want to bring the rest of youdown and then shared you need to keep tweeting maybe we can bring you back upand then another know we are here all here to help anytime day or nightyou want to smoke we're here to help you so really gets at what we are getting orhoping to develop in terms of having the accountability that supportencouragement that evidence base around the the the patch use and so forth andthen on a highlight only three more days

to my 60 days smoke-free never wouldhave 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 knowthat feeling too so celebrating their successes this just shows that we we looked at whowas communicating with who we found that those who quit smoking and those whorelapse still connected with each other it's not that the quitters were runningoff and celebrating but they were trying to bring up those who had relapsed aswell

we looked at over the time course wherewas the activity and it did peek in the middle and then in terms of theirdensity and in relationships with each other and then it did start to fade outover time in terms of the quit rates we saw two full greater quit rates if theywere in our tweet to quit group forty percent reported being quit compared totwenty percent in the comparison group that was among people we were able tointerview among those if we counted those who wedidn't reach as back to smoking the quit rates for thirty-three percent versuseighteen percent that was significant we found that men did better at quittingsmoking in both groups and this has been

seen in the literature and so we're verycurious about that and we saw that if they participated that was related themore tweeting they did the more likely they were to quit smoking these are the gender differences on bothgroups mended better than women so we're curious what we have all thesedialogues that's going on in the group's what isit that women are talking about that might be different from men and actuallythe words are using we're pretty similar and that shows the frequency in terms ofhow often they're using the words although men talk a little bit moreabout craving women should wear a little

bit more talking about emotional orsupport of stuff like lol when we looked at the social the semantic networks howare 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 thepatches the nicotine replacement was very central to their communications whereas for the women the patches weremore on the periphery so not so much of a focus and for womenthey talk about cold turkey which the

man really we're not talking about and then they were much more socialemotional social connecting talking about husbands and birthdays andexcitement and kinda thing so we think that process maybe different by gender with that we keep going so we found it help people quit smokingwe did find a gender difference with this we've got funding with fromthe national caner institute now to do a trial where we look at women onlygroups compared to coed compared to arkansas comparison condition and we'regoing to continue the group's out

further and more time to see in terms ofsustaining the quitting this is the new study and tweet2quit 2.0, that'sthe design i just mentioned we also have funding from the stanford cancerinstitute to develop a program for latino smokers and doing bilingualgroups online and then also working with jennifer we've got a project underway tweet for wellness and this is merelypezzo postdoc we're using the same platform but for promoting walking andif you're interested you can certainly i

reach out to us and there's some contactinformation thank you. the preceding program is copyrighted bythe board of trustees of the leland

stanford junior university please visit us at med.stanford.edu