Dr Ronesh Sinha Talks Digital Health Solutions to Combat Heart Disease Disparities

Ronesh Sinha, MD | Image credit: Cardiometabolic Health Congress

In this interview with The American Journal of Managed Care^® (AJMC^®), Ronesh Sinha, MD, an internal medicine physician at Sutter Health, shares how working from home because of the COVID-19 pandemic has impacted cardiovascular health more than most people may realize. He also discusses employers' growing interest in the Sutter Health value-based care model, patients feeling predestined to develop heart disease or diabetes based on family history, barriers to cardiovascular care, and more.

Sinha also serves as the medical director of employer strategy at Sutter Health, where he collaborates with local companies to develop innovative health and wellness initiatives, as well as medical director for Sutter Select, overseeing the health benefits of the organization's workforce.

AJMC: Heart disease rates are growing rapidly, particularly in women and millennials. Can you share some insight on why these disparities may be occurring?

Sinha: We've been seeing these rising rates already. There's been an inflection point where death rates from heart disease have gone up; through COVID-19, that's gotten even worse. And there's a lot of theories around this, I think there's generally a few different things. The first thing is we've progressively moved to a lifestyle that's become so much more sedentary than it was before. There are a lot of conveniences that came out of COVID-19 in the last several years where you can get anything delivered to your doorstep. But the problem is, people are just walking less, they're less active; a lot of people experience a lot of stress that happened before the pandemic, through the pandemic, and then after the pandemic. Those are some factors that really have an influence on the choices we make around nutrition. So, there's all of these issues that are already affecting our metabolic risk, and then on top of that, health inequities with access to health care.

People have actually across the board become a little bit more disengaged about preventive health. We're seeing in a lot of companies and health claims that people are getting less mammograms for cancer screening, less cholesterol tests done. And part of it is a lot of us have become very inert. We sort of are used to being in our homes working and doing everything, so the thought of seeing your dentist or a doctor becomes really foreboding for anybody in any class. But then with those with lower socioeconomic background, we're seeing that that barrier was already high, and now it's even thicker in terms of them getting adequate access to health care, which is what really motivated me around how we can create digital health solutions where you don't necessarily come in to see the doctor, because a lot of people of Black or Latino background have a lot of skepticism about providers in the health care system. So how do we create programs where they can be in the safety of their own house, use a sensor—maybe a blood pressure cup or glucose sensor—and then digitally access health education information, so it's not as foreboding? And there's always an economic barrier for people that are working. It's like getting inside a car or vehicle or transportation to get to a doctor's office, having to pay for that, having to pay for parking—those are all barriers to proper health care.

AJMC: What role do modifiable risk factors have on the burden of heart disease?

Sinha: I'll be giving you the bad news with all the dark statistics, but the good news we are finding through worldwide global studies. Whenever I look at studies, I like to quote studies that involve all different major ethnic groups, and the MESA [Multi-Ethnic Study of Atherosclerosis] study is one of them that show anywhere from 85% to 90% of these diseases are modifiable through lifestyle changes. And I've seen that in my clinic, because a lot of people that come into my clinic that tell me mom had diabetes, dad had heart disease, and they have a very fatalistic attitude. They almost feel like they're predestined to develop heart disease and diabetes. But we've found over and over that when we implement the right lifestyle changes where they're a little bit more physically active and eating healthier than mom or grandparents, they really don't end up developing prediabetes, or diabetes, or the severity of that condition is far less.

When people come into our program, that's one thing there's a lot of anxiety around. There's a large segment of people who feel like they're predestined to develop these conditions, and we're able to really implement lifestyle changes, and they can see those numbers improve in real time after they implement it. And that's really powerful for them, because right now, getting access to a doctor is a very challenging situation. If you want to talk to your doctor about your latest cholesterol, you would have to wait 3 or 4 plus months to see them. But if you're doing a program where you're getting that data directly and we can educate you on what the numbers mean, at least while you're waiting to see your doctor, you're getting some real-time data that can motivate some behavior change.

AJMC: What are some barriers to better health care and cardiovascular outcomes, and how can they be addressed?

Sinha: I think the first thing is people don't necessarily understand that things that feel like a natural part of our daily behavior—for example, working from home, like sitting and or standing for prolonged periods of time—it's become second nature to us. But we don't realize the impact that actually has on our cardiovascular health.

I'll give you a very specific example. When you look at daily walking step data, we see that when people are getting more than 7000-8000 steps a day, their risk of heart disease, cancer, and death, based on physical activity, kind of plateaus. You see improvements, and then the risk kind of plateaus. When you get below 6000 or 5000 steps a day, that's when all risk factors go up dramatically. And when people aren't aware of that, like if they're wearing an Apple Watch or Fitbit, they haven't realized that over the last few years because of their work from home behavior, their steps have gone down by 2000-3000 steps. So, they used to walk 7000 and now they're doing 4000-5000. And they're just not aware of the fact that that's having a huge impact on how they metabolize glucose, what happens with body weight, blood pressure, all of that. So, we're having to speak in a bit of a different language to motivate people around that.

The other thing that people are understanding with the glucose sensor is a profound impact that stress has on their blood glucose. You hear about the fact that stress is bad for my health, but when you actually see what happens to your glucose level after you've been in an argument, after back to back to back meetings, and you're under high stress, people are in disbelief that their glucose can go up 50-60 points just from emotional stress.

I think doing this program has really highlighted for us how these daily lifestyle things that might feel normal are really having a significant metabolic impact on our health. We're really having to provide messaging around health, that's a little bit different than what's been messaged 10, 15, 20 years ago where we were just like, "eat less, exercise more, eat healthy foods." That's all core to it, but there are other things that are part of our daily lifestyles that we're trying to address through the program.

AJMC: Can you elaborate on the financial aspects of Sutter Health’s value-based model?

Sinha: We are right now in the early phases. The way our program works right now is, if an individual signs up for our program, they would pay a registration fee, and the glucose sensor may or may not get covered by their insurance. That's the first iteration of our program. But now as we're going towards thinking about value-based care opportunities, the thought now is we're looking for donor funding and we're actually getting some attention to provide scholarship funds for those that can't afford registration or that can't afford the glucose sensors.

Diabetes and cardiometabolic disease is a huge health spend for a lot of companies, whether they're tech companies or they're municipalities or transportation, and they're looking for scalable ways to actually improve the lives and reduce the health spend on that population. So, at some point, what's going to happen is we get more resources, and in 2025 we plan to scale more aggressively. We want to take this program into employers—employers have shown interest—but then we would contract with them directly and the employer would provide this program as a benefit to all of their employees. We're going to do a small pilot just under the Sutter Health workforce to see what the impact is of providing this program to that population and then measuring outcomes. Did it really have an impact on glucose? Are people feeling more energy? We see a lot of people's mental health improve once their glucose numbers are more stable.

We're actually going to be doing an IRB (Institutional Review Board) sponsored study to look at all these outcomes starting in August, and we want to look at different demographics. If we look at certain ethnic groups and certain socioeconomic backgrounds, is a tech-centric solution like this really going to have impact on that population? So, more to come. We haven't engaged in direct widespread value-based care right now, we're doing it in an organic and growing level, but in the next year or year and a half, we're going to be disseminating this much more widely and we're going to be studying outcomes to see the impact of the program.

This transcript has been lightly edited for clarity.