Taking LGBTQ+ Health to Heart: An Interview with Dr. Carl Streed, Jr., on LGBTQ+ Older Adults, Heart Health & Frailty

Hands forming a heart shape with a rainbow flag in the view at the beachFor “Pride Month,” we wanted to focus on Lesbian, Gay, Bisexual, Transgender, and Queer+ older adults’ heart health as a possible risk consideration for frailty.

There is increasing recognition of a multitude of health inequities that exist across many areas of wellness for LGBTQ+ people throughout the lifespan. In addition to age-related changes in cardiovascular risk, older LGBTQ+ adults are at high risk for poor heart health outcomes related to LGBTQ+ specific life stressors and psychosocial, behavioral, and physiologic factors. Further considerations include increased prevalence of diabetes, tobacco abuse, and the use of hormonal therapies in transgender individuals.

Stemming from their lived experiences, or perceived and actual discrimination from present day physicians, many LGBTQ+ older adults mistrust health care providers; consequently, delaying doctor visits may lead to an LGBTQ+ patient being diagnosed when they present with overt clinical disease rather than an early disease stage, where institution of preventative measures may impact patient care.

Last June, the New York Times ran a story titled, “Why L.G.B.T.Q. Adults Are More Vulnerable to Heart Disease” that interviewed several high-profile cardiology researchers and experts on LGBTQ+ health. Among them were Dr. Erin Michos, a current cardiologist at Johns Hopkins Medicine who is also affiliated with the American Heart Association, and Dr. Carl Streed, Jr., who attended medical school at Johns Hopkins University and completed his internal medicine residency at the Johns Hopkins Bayview Medical Center. Dr. Carl Streed, Jr., is now an Assistant Professor at Boston University Chobanian and Avedisian School of Medicine and the Research Lead for the GenderCare Center at Boston Medical Center.

Dr. Carl Streed, Jr., is an Assistant Professor at Boston University Chobanian and Avedisian School of Medicine and the Research Lead for the GenderCare Center at Boston Medical Center.

Dr. Carl Streed, Jr.

For this blog, Dr. Streed kindly answered a few questions on this topic, keeping in mind the context of frailty research.

Tony Teano: With regard to function, how may poor coronary/vascular health lead to frailty?

Dr. Streed: Poor heart health limits the ability to engage in physical activity that reduces the likelihood of frailty. It also limits additional activities, such as community engagement, that are protective against frailty. 

Tony Teano: Within the LGBTQ+ community, are some sexual minorities and gender diverse/expansive people more at risk than others?

Dr. Streed: LGBTQ+ communities are not homogenous and so have significant variation in risk factors for CVD and outcomes. Additionally, persons with multiple marginalized identities can face significant disparities in CVD risk and outcomes (e.g., Black cisgender lesbians, Black transgender women, etc.). There are unique minority stressors that lead to differences in coping mechanisms as well as physiologic changes in response to stress. 

Tony Teano: What are the top few things physicians can do to better evaluate LGBTQ heart health?

Dr. Streed: Improved Sexual Orientation and Gender Identity (SOGI) data collection could help. Also, improved training of clinicians and improved screening of stressors unique to LGBTQ+ persons may make a difference. 

Tony Teano: What interventional steps might LGBTQ+ older adults consider taking above and beyond those for the general population?

Dr. Streed: I would advise to get connected to community, especially through LGBTQ+ community centers. Engagement in any physical activity, especially that which improves daily function can also help, as can getting connected to cessation programs tailored for LGBTQ+ persons if you are still smoking.

Many thanks to Dr. Streed for taking the time to answer these questions. For more information on these matters, please see the following related research and news:

Right now, there is not an abundance of frailty research on LGBTQ+ older adults. However, Johns Hopkins investigators are making strides to contribute to our understanding of aging research among marginalized populations. For example, the JHU Diversity Leadership Council funded a crowd-sourced grant that Frailty Science team member Brian Buta, MHS, pitched earlier this year (about which you may find a related blog here).  Over the spring term, this Diversity Innovation Grant (DIG) helped train 20 research coordinators, scientists, and staff to be more culturally competent at recruiting diverse older study participants. “This is a first step towards improving diversity in aging research at Johns Hopkins, and staff from the Schools of Medicine, Nursing, and Public Health participated in it” said Mr. Buta, adding that the training “covered historical and societal barriers to participating in research among racial/ethnic and sexual and gender minorities. Being aware of such barriers and understanding the importance of treating potential research candidates from these communities with dignity and respect, especially during the recruitment stage, is critical to achieve diverse representation in our research studies, and ultimately, to meet the health needs of those who are most vulnerable.”

The Center on Aging & Health (COAH)’s DIG training builds upon another DIG training from the JHULesbian couple at the beach with Rainbow Flag Division of Geriatric Medicine and Gerontology’s Mosaic Initiative collaboration with Medicine for the Greater Good, “Geriatricians Engaged and Ready for LGBTQ+ Aging, Health & Wellness” (“GEARed”—about which you may learn more here). GEARed trained 18 geriatric faculty and staff in 2022, and the team continues to hold quarterly meetings, and updates are reported at faculty meetings. Also, this year, the JHM Office of Diversity, Inclusion & Health Equity relaunched their “Proud Partner” training—an interactive LGBTQ+ allyship educational offering to improve the ability to interact with and support our LGBTQ+ patients, learners, and co-workers—available to Johns Hopkins faculty and staff through MyLearning in the JHU portal. Moreover, JHU/JHM is taking an active role in transforming LGBTQ+ heath care.

Finally, you may be interested in past COAH & Frailty Science blogs on LGBTQ+ older adults:

Many thanks to Dr. Monica Mukherjee with the Johns Hopkins University Division of Cardiology for providing editorial input for this blog.

What Can Digital Health do for Geriatric Oncology? – advancing equity and meaningful use

Frailty, Oncology, and the Geriatric Assessment

Frailty in older adults with cancer is associated with poor outcomes such as mortality (Augustin et al., 2016Soubeyran et al., 2012), functional decline (Hoppe et al., 2013) and toxicity from chemotherapy (Hurria et al., 2011). Major organizations like the American Society of Clinical Oncology recommend using a comprehensive geriatric assessment (CGA) to identify vulnerabilities such as functional impairment, comorbidities, and cognition as well as institute CGA-driven interventions like exercise or nutritional rehabilitation (Mohile et al., 2018) that have been shown to significantly reduce the risk of high-grade toxicity without compromising survival in vulnerable cohorts with geriatric impairments (Mohile et al., 2020).

Importantly, geriatric assessment improves outcomes even when implemented by physicians other than geriatricians (Moreno et al., 2022). However, surveys of oncologists in 2019 (Dale et al., 2021) and again in 2020 (Gajra et al., 2022) show poor uptake of CGA tools by oncologists, with about 50% being aware of national guidelines (Dale et al., 2021) and 40% using a CGA to inform treatment decisions (Gajra et al., 2022). Better solutions are needed now and beyond to ensure the equitable delivery of guideline-based care; Digital Health Technology (DHT) is poised to be that solution in the coming decade.
Digital Health Technologies

According to the FDA, DHTs include computing platforms, connectivity, software, and sensors for health care and related uses. Examples of DHTs range from mobile applications apps for wellness from generally accessible platforms like Headspace – which aims to provide meditation and stress management to users across the globe – to more specialized applications like Cankado, an electronic patient-reported outcome (ePRO) application that facilitates symptom survey collection for both clinicians and researchers in advanced cancer.

Using tablets or computers to facilitate symptom and CGA survey data collection in older adults has proven feasible (McCleary et al., 2013). Thus, DHT provides an opportunity to increase the use of CGA assessments by non-geriatricians and decrease the burden of collecting such data during time-limited clinical visits. DHT-based ePRO collection could even improve longevity in patients with cancer by more rapidly alerting providers to high-risk situations that patients may not recognize as such, as well as improving the response times and rates by clinical staff providing targeted symptom care (Denis et al., 2019). Wireless sensors and wearable devices could provide clinicians and researchers with surrogate markers of frailty (Razjouyan et al., 2018) as well as cognitive impairment (Razjouyan et al., 2020), and other markers of vulnerability such as falls (Warrington et al., 2021). However, much more work needs to be done to realize a comprehensive vision of a usable and feasible “smart medical home” for older adults with cancer and frail older adults generally.

Barriers to Digital Health Adoption

Equally important is the tremendous potential of such tools, in combination with telehealth conferencing applications, to deliver multidisciplinary CGA interventions to underserved and rural populations (DiGiovanni et al., 2020). With Pew Research data showing that in the past decade, the gap in smartphone adoption between adults in their 60s compared to those in their 20s has shrunk, tablet adoption by older adults has grown to 44%, and in 2022 75% of older adults identify themselves as internet users, DHT seems like an obvious choice for many data collection and communication challenges.
However, a “digital divide” by location and aging impedes the adoption and implementation of DHTs in geriatric oncology. Over 30 million Americans do not have broadband infrastructure access, many of whom are located on Tribal lands. Without access to adequate internet, the ability of DHT to facilitate communication between patients and clinicians is vitiated.


Age-related changes in visual, motor, and cognitive function also act as barriers to the implementation of technological tools for older adults, in particular the “screen”-based delivery of many DHT applications (Loh et al., 2018). Navigating websites, compactly spaced keyboard buttons, long sets of instructions, and a sense of medical information overload are commonly reported barriers to the adoption of DHTs by this population (Hasnan et al., 2022). When confronted by surveys that are long or include jargon, older patients are therefore at risk of under-reporting due to mental fatigue or cognitive impairment (Kotronoulas et al., 2021).

Most patients and caregivers report low self-perceived electronic health literacy and less confidence in evaluating online health information for cancer decision-making (Verma et al., 2022). There also exists a complex interaction between the older patients’ sense of well-being and their own assessment of their cognitive abilities, which plays a key role in the adoption of wearable use among older adults (Farivar et al., 2020).
Enhancing Digital Health Equity for Older Adults

Interesting design suggestions to optimize uptake and engagement with DHT by older adults include using image or voice prompts, large font sizes, and more pictures/symbols than words for those with literacy issues (Loh et al., 2018). Perceived usefulness could also be improved by providing recommendations of when to visit the ER, medication lists or physical activity reminders, and access to up-to-date, user-friendly cancer disease status and treatment information (Hasnan et al., 2022). Methods incorporating the patient perspective into DHT development through Human-Centered Design is another important concept. By interviewing older users, and examining all aspects of usability, cyclic user testing, and iterative design, developers of DHT can promote applications with better equity and applicability to the diverse components of this heterogeneous population (Harte et al., 2014).

Unobtrusive monitoring is another potential solution, allowing clinicians to obtain patient data without requiring the direct engagement of the participant. This field has been exploring the feasibility of ambient smart sensors that are already integrated with commonly used home items to provide automated measures of health status (Bokharouss et al., 2007Rashidi et al., 2010). Testing such solutions and designing them with the needs and values of the intended population is critical to bridging this divide and developing truly equitable solutions.

One of the goals of geriatric oncology is to enhance older adult clinical trial participation so that we may expand the evidence base in this rapidly evolving field. DHTs again have the potential to act as monitors of patient-centric outcomes and thereby enhance the interpretability and generalizability of clinical treatment trials. DHTs can provide a longitudinal health status assessment by reliably collecting measures of well-being, function, and nutrition in addition to ePROs.

Digital health

The Geriatric Remote Initiative (GeRI), led by myself and mentors from both Drug Development and Gero-Tech at the University of Chicago and supported by the Conquer Cancer Foundation’s Young Investigator Award in Geriatric Oncology, is co-designing a cloud-enabled connected-systems platform with startup Prosilient Systems, composed of a tablet, a wearable, and a scale. There has been some preliminary work on sensor-based assessments of frailty (Blinka et al., 2021Bian et al., 2022). A key feature of this initiative is the participation of key stakeholders, including older patients with cancer, cancer survivors, and caregivers of those with cancer. Thus, our platform will be a novel, technology-based data collection platform, iteratively improved with user feedback and vetted by patients from diverse oncology environments as well as human-centered design specialists able to be adapted and integrated into any geriatric oncology research setting.

Examples of wearable tech for digital health

Excitingly, there are over 100 recruiting Digital Health Studies in Oncology currently registered on, ranging from Digital Biomarker discovery to health coaching and symptom management. However, few of these cater to frail adults specifically. As we have seen, barriers to adoption and lack of data supporting DHTs predictive or prognostic capacities in a frail population persist. Such issues need to become a focus of DHT research, given the major effect of frailty on outcomes.

New AI/Technology & Aging Research Collaboratory: Pilot Proposals Due Feb. 18

The recently funded Johns Hopkins Artificial Intelligence and Technology Collaboratory for Aging Research (JH AITC; website) seeks to improve the health and well-being of older adults through novel uses of artificial intelligence and new technologies.  Combatting frailty and its outcomes are important aims of this Collaboratory.   

The JH AITC is funded by a $20M federal grant from the National Institute on Aging (P30AG073105).  It is one of three centers at leading research institutions participating in this innovative Collaboratory: the other two are at the University of Massachusetts and the University of Pennsylvania. 

The scientific vision of the JH AITC is led by experts from the Johns Hopkins University schools of MedicineNursing, the Whiting School of Engineering, and the Carey Business School.  Stakeholders, including older Americans and caregivers, technology developers and innovators, and industry partners, will also play a key role in informing the development of novel and adaptive technologies to improve the health and independence of millions of older Americans.  To propel these efforts, the JH AITC is now offering a call for pilot proposals, including those that are relevant to frailty and resiliency in older adults.   The Requests for Proposals can be found here:

The JH AITC’s tagline provides a concise summary of their role and mission: “Engineering Innovations to Change Aging.”  You can learn more background about this transdisciplinary effort at Johns Hopkins University here.