COMPREHENSIVE
SOLDIER & FAMILY FITNESS
BUILDING RESILIENCE
ENHANCING PERFORMANCE
CSF2 Update to IOM
PCC
LTC Daniel T. Johnston, MD, MPH
Medical Director, CSF2
• 1 Mar 2012
1
Resilience= Physical + Mental
COMPREHENSIVE
SOLDIER & FAMILY FITNESS
BUILDING RESILIENCE
ENHANCING PERFORMANCE
Physical
Adapted from
WHO
Proper Activity,
Nutrition, Sleep, Healthy
Behaviors for optimal
performance/resilience
Family
Social
Part of unit that is
safe, loving
supportive
Able to develop and
maintain trusted,
valued relationships
Soldier
Family
Member
DA Civilian
Spiritual
Emotional
Strong Core Values and
Beliefs. Meaning and
purpose in life.
“Best Possible Self”
Demonstrates self
control, stamina,
character
To maximize
health, we must
focus on a total
assessment
package
COMPREHENSIVE
SOLDIER & FAMILY FITNESS
BUILDING RESILIENCE
Has the GAT been validated?
ENHANCING PERFORMANCE
Broad Program Analysis, Technical Reports #1 & #2
• Soldiers who completed suicide, who tested positive for illicit drug use, and who committed violent
crimes were significantly less resilient or psychologically healthy than Soldiers who did not engage in
these activities.
• Officers who were promoted ahead of peers are more emotionally and socially healthy than Officers
not promoted early.
• Officers selected for command are more emotionally and socially healthy than Officers not selected
for command.
• Together these reports showed that resilience and psychological health are linked to important
behavioral outcomes.
GAT as it stands today
Life Orientation Scale
Scheier, Carver, & Bridges (1994)
Brief Strengths Inventory
Work as a Calling Scale
Wrzesniewski et al. (1997)
Peterson, Park, & Seligman (2005)
Peterson & Seligman (2004)
•Optimism
•Work engagement
Brief Multidimensional
Measure of Spirituality
Fetzer Institute (1999)
•Individual strengths
•+/- Coping strategies
•Spirituality (not religiosity)
•Strength of familial relationships
Military Family Fitness Scale
Directorate of Basic Combat Training
Experimentation & Analysis Element
Ft. Jackson, SC
Organizational Trust Scales
Original Items
Peterson & Park (In Press)
•How well the Army supports families
•Family support for serving in Army
•Trust in unit, leadership, peers
Mayer, Davis, & Schoorman (1995)
Mayer & Davis (1999)
Sweeney, Thompson, & Blanton (2009)
Coping Strategy Scales
Carver, Scheier, & Weutraub (1989)
Peterson & Park (In Press)
•+/- Affectivity (emotions)
•Strength of friendships
•Catastrophic thinking
Military Family Fitness Scale
Directorate of Basic Combat Training
Experimentation & Analysis Element
Ft. Jackson, SC
PANAS
Watson, Clark, & Tellegen (1989)
•Depression
UCLA Loneliness Scale + Original Items
Russell, Peplau, & Furguson (1978)
Russell, Peplau, & Cutrona (1980)
Peterson & Park (In Press)
Pessimistic-Optimistic
Explanatory Style
Patient Health Questionnaire - 9
Peterson et al (2001)
Kroenke, Spitzer & Williams (2001)
FOUO
4
GAT Score and Healthcare
Utilization
Average Number of Visits to Primary Care Provider by Emotional Fitness Score
(per deployment as reported on the PDHA)
7%
What are the health habits of
these people?
Twice as Many Healthcare Visits
6.64
6%
5%
Healthcare Visits
4.76
4%
3.76
3.72
3%
2%
1%
0%
<2
2-3
3-4
4-5
Emotional Fitness Scores by GAT (on a scale from 0-5)
FOUO
n=100K
5
RealAge + GAT The Universal Health
Assessmen (Feb 2013 Launch)
What is the RealAge Test®? A scientific, but simple to take test
that quantifies the impact of your lifestyle behaviors, family
history, medical conditions & social connections into a unique
single calculation of your body’s health
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Real Age Founded by Dr. Michael Roizen, Dr Keith Roach, Dr
Mehmet Oz of the Cleveland Clinic
29 million people have taken the RealAge Test
4 billion+ health facts in our database
4 million active RealAge members
1 billion annual engagement e-mails sent
Incorporates Activity, Sleep, and Nutrition into broader test
for maximum impact and maximum understanding and
training approaches while keeping it fun, engaging and useful
for reporting to senior leaders on health of the force and
healthcare costs predictions
FOUO
6
Real Age Test
Backed by hard medicine and science
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500 studies reviewed to create the current test
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Patented algorithm based on CDC and census mortality data, with weighting
that eliminates double counting of factors
•
From the most reputable health journals, including:
New England Journal of Medicine
Annals of Internal Medicine
JAMA
Lancet British Medical Journal
FOUO
7
Process, Methodology & Science
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The RealAge Test gauges the body's physical age, not its calendar age by looking at
many different factors that impact mortality. The most powerful, not surprisingly, are
smoking, blood pressure, and blood cholesterol, but many other factors also affect
overall mortality, including diet (especially fat intake) and physical activity.
The medical and scientific team that created the original RealAge Test during the 1990s
reviewed thousands of studies to eventually settled on about 65 factors that affected
RealAge. This expert team was led by Michael Roizen, MD and current Chief Wellness
Officer at the Cleveland Clinic and current Chief Medical Officer Dr. Keith Roach
Working with a mathematician at the University of Chicago, the team developed and
patented an algorithm that allows large numbers of risk factors to be considered
together as a group, and to take into account the interactions between risk factors and
the tendency of behaviors to co-vary.
In 2011 the team completed a substantial update of the medical, scientific,
mathematical and technological components of the RealAge Test which took more than
2 years start to finish.
The scientific research, which lasted almost exactly a year, identified 556 new trials as
primary and secondary sources for the RealAge Test. Based on this data, the team
removed some original factors, reweighted others, and added several new ones that
have only recently been proven to have an independent effect on overall mortality and
thus on RealAge (for example, having health insurance).
FOUO
8
Methodology & Science
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The requirements for altering or adding a new factor to the RealAge Test are quite
stringent. The foundation study must reflect major research and be published in a
peer-reviewed scientific or medical journal, such as The New England Journal of
Medicine, Annals of Internal Medicine, or the Journal of the America Medical
Association.
At least three confirmatory studies must have been published in similar journals.
The key study must pass a critical test: Has its results changed the way medicine is
prescribed or practiced?
In addition, each study is assigned a quality score based on its methodological strength,
so that a large, well-designed, multicenter, placebo-controlled trial has greater weight in
calculating RealAge than a study that shows only an epidemiologic association.
The algorithm to calculate RealAge has also been improved, mainly by looking
individually at a risk factor’s effect on cardiovascular, cancer, accident, and all other
causes of mortality, so that it is easier to adjust for the tendency of behaviors to covary with one another.
Another important part of the new algorithm is the normalization of the studies.
RealAge is defined such that the hypothetical “average” person has a RealAge exactly
equal to the person's chronologic age. To make that work correctly, the results from the
scientific studies have to be normalized against a standard population (almost always
the US population).
FOUO
9
Methodology & Science
• This requires use of data from the Census Bureau, the Centers for
Disease Control, or the Department of Vital Statistics. As the
population changes, the normalization has to be changed as well.
• The company and it’s medical team does quarterly reviews and
updates of the RealAge test, reviewing the medical literature and
maintaining the accuracy of the population means (for example,
renormalizing both weight and diabetes prevalence has to be done
continuously).
• At the same time, with over 29 million people having taken the test,
we often can see how the population is changing even before other
data is published.
• Also, the new technology behind the RealAge Test now makes
updating the test much faster—it can be done within a few days of an
important study being released.
FOUO
10
“Risk” Age components for
younger populations
• Evaluates mortality risk for adults as separate test or combined with
traditional risk factors as part of RealAge test
• Also capable of evaluating morbidity (serious injury and all injury risk) as a
stand-alone product
FOUO
11
RiskAge factors
• Driving
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–
Motorcycles
Helmet effect
Bicycles, skateboards, scooters
Looks at experience, equipment, type of
riding
Recreational sports
Football, others (high school, college, pro
data)
Horseback riding
Helmets, experience
Alcohol
Cannabis
Driving speed
Cell phone use
Texting
Car size
Miles driven
Seat belts
Front airbags
Side airbags
Electronic stability control
Prescription drugs/sedatives
FOUO
Auto racing
Boating accidents
Firearm accidents (civilian data)
Skiing, snowboarding
Private (general) air travel
Skydiving, bungee jumping
12
Targeted messaging
HFP provides targeted web based
messaging and smart phone apps
•
Resulting in:
• A personalized grow younger plan to help
consumers GET HEALTHIER and GROW
YOUNGER
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Ongoing consumer dialogue delivered to
targeted patient communities (based on
deep condition data) across :
• Healthy Living Action Plans
• Doctor Visit Guides
• Risk Assessments
• Condition Topic Centers
• Healthy Living Tips & Videos
FOUO
13
LaFarge / RealAge Employee Pilot in
partnership with the Cleveland
Clinic: Workforce Resilience
March 22, 2012
FOUO
14
A holistic resilience metric
Compares a person or population to an “average” person
in the United States
A person who is as healthy as the average
American will have a “RealAge Delta” of 0
The difference between
someone’s RealAge and their
calendar age is known as their
“RealAge Delta”
FOUO
45
45
Calendar Age
Real Age
15
RealAges (and costs) increase for people with
chronic conditions
DIABETIC EXAMPLE
46.8
45
Medical costs per year
Average
Diabetic
$8,373
$13,218
+ $4,845
Calendar Age of
Diabetic
RealAge of
FOUO
Diabetic
16
Population Analysis
LaFarge’s average RealAge is 1.9 years higher than the
average calendar age…
49.0
47.1
LaFarge Average
Calendar Age
+1.9
LaFarge Average
RealAge
FOUO
17
…reflecting a proliferation of
chronic health issues and habits
LaFarge employees that were…
Calendar Age
78%
Overweight
49.7
Calendar Age
24%
Smokers
High cholesterol
sufferers
Diabetics
47.7
46.0
52.4
Calendar Age
8%
49.3
52.4
5%
Calendar Age
53.3
56.6
FOUO
+2.0
+6.4
+3.1
+3.3
18
Both women and men are older
than their calendar ages…
Women = 13%
Calendar Age
45.3
45.8
The men by a much bigger
difference than the women
+0.5
Men = 87%
Calendar Age
47.1
49.0
FOUO
+1.9
19
Opportunity to focus programs on
groups w/ combined risk factors
63 employees
1,172 employees
Overweight + Diabetes + Smokers
Overweight + Smokers
Calendar Age 51.9
+7.4
Calendar Age 46.5
59.3
Smokers
300 employees
Overweight + Diabetes
Calendar Age 53.5
+6.4
52.9
108 employees
+3.3
Overweight + High Cholesterol +
Smokers
56.8
Calendar Age
Diabetics
High
Cholesterol
Sufferers
48.4
55.6
+7.2
405 employees
Overweight + High Cholesterol
4,897 Employees
with Weight
Problems
FOUO
Calendar Age
49.1
+3.2
52.3
20
Results: Of 960 employees, 388 (40%)
consented to participate; of these, 345
(89%) completed the baseline health
survey. After 6 months, 70% of the
345 participants had opened 50% or
more of the daily emails. In addition,
75% of participants continued to open
at least one email a week through
week 26 of the study. Email opening
rates did not vary by gender, age,
income, education, ethnicity, or
baseline health behavior. Conclusions:
The rate of enrollment and sustained
participation document the feasibility,
broad reach, employee acceptance,
and potential value of using electronic
communications for health promotion
in the workplace.
FOUO
21
COACH Program vs. RealAge
• RCT at University of Illinois published 2011
• COACH program vs RealAge
– COACH program: participants received in-person
and telephonic, biweekly meetings x 12 months
with RN and certified health coach
– RealAge program: participants received a single email recommending they sign up for RealAge
program
FOUO
22
Hughes 2011: results
• COACH program 95% uptake
• RealAge 57% uptake
– 94% of those who took test had meaningful
interaction with web site going forward
– Confirms findings of Franklin 2006 showing 81% of
RealAge participants continuing to open mail >23
weeks after taking RealAge test
FOUO
23
Hughes 2011: Results
• COACH:
– Improved diet, exercise measures
– No improvement in waist circumference
• RealAge
– Reduction in waist circumference at 6 and 12
months (p=0.05)
FOUO
24
Consumers
Seeking
Health
Information
Integrated
Sharecare
Platform:
2013
Integrated
Health
and Fitness
Platform:
2013
Leveraging .com
Assessment
Action
Support
1B Health video and test
tips sent via email +
published in real-time
A single unified
dashboard tracks
progress across
multiple solutions in
real-time
Connection
Social media, email to
build trusted
relationships between
Soldiers, Families, and
DA Civilians
HFP recommends
content, geo-targeted
fitness experts, AWCs,
and communities based
on results
User completes .mil
GAT, RealAge Test and
creates Personal Profile
USER
ENGAGEMENT
Progress
Onboarding
Fitness problems passed to
provider - Virtual Consult
Data
Recommended
programs based on
conditions and desired
outcomes (i.e., weight
loss)
Synthesis + Improvement
Data = better service.
More sophisticated
analyses performed to
help manage wellness
more efficiently and
effectively
Through QAs, Apps,
better search and
empowered users the
system knowledge
becomes cumulative
COMPREHENSIVE
SOLDIER & FAMILY FITNESS
BUILDING RESILIENCE
ENHANCING PERFORMANCE
HFP Demo- Landing page from GAT
Observation
To understand the Health of the Force (a dimension of readiness) and if interventions are working (policy, training,
counseling, medical treatment), a set of metrics can be developed and monitored which requires:
Share Access to Scientific Knowledge & SMEs
Share Data Meaning & Data Assets
Share Access to Tools & Tool SMEs
Provide secure safe place to test models/tools on near real date
To identify persons with increasing risk of unhealthy behavior is much more difficult
Groups that can share
science, tools, data:
VA/DMDC
BUMED-FHI
NCCOSC
USAPHC
USARIEM
TRAC Fort Leavenworth
TRAC Monterey
DUSA -- STARRS
Army G3 – CSF
PERSEREC
G2 – Risk Tool Evaluation
ARI
MRMC
A Safe Place to test
models/tools:
The Person-Event
Data Environment
(PDE)
Sharing= Time and Cost Savings
PDE
27