Navigating Healthcare – Patient Safety and Personal Healthcare Management

Summit

Keys to Successful Conferences

How do you describe the CNS Summit and what it offers – the word impossible springs to mind. Even the name can be a little misleading especially for medical folks who might look at that and think “Central Nervous System” but actually its stands for Collaborating for Novel Solutions

Innovation
CNS Summit Collaborating for Novel Solutions

This coming year will be the 10th year of the event and it continues to get better – testing new ideas and concepts for conferences to make the event valuable on multiple levels. The history and experience reminds me a lot of friendships and how they develop – the first interaction can be awkward and uncertain but intuitively you get a sense that the person you are talking to is someone who will be a friend pretty quickly (science suggests it is not minutes or seconds but a 1/10th of a second). Over time the relationship deepens and you learn more, and understand more, and how much you enjoy working with, learning from, sharing and sometimes just hanging out. So it is with the CNS Summit or more frequently know as “Summit”.

Photography
Photography Techniques from Experts

Where else can you come to a conference and get clever new ideas and techniques on how to use your mobile phone camera in interesting and creative ways from the incredibly talented and inspiration photographer Asa Mathat (recommend instagram @AsaMathat to get a sense of his incredible lens on the world and people). He is a renowned Photographer to the stars, creator of the big pink ribbon and at Summit – photographer for attendees as well!).

(Hint – Don’t think in traditional planes of movement and use your volume buttons as triggers and when you reach the end of your panorama, just reverse direction to switch it off).

CNSSummit Asa Mathat Photo Booth
Asa Mathat Photo Booth at Summit

Areas Covered

It hard to categorize the conference into a bucket – it benefits from being not too big so as not to overwhelm but large enough to attract an impressive diversity of participants and speakers. The mix includes leaders from the Pharmaceutical Industry, digital health, medical and device companies and technology companies.

Insights continued from cancer survivors who parlayed their personal experiences to focus on taming the data mountain in healthcare and science, the pharmaceutical executive who nearly died from a side effect of a drug that had a life changing effect on the personal trajectory that allowed for a rethinking the model of industrial production of pharmaceuticals.

CNSSummit WoodyWhisky
Woody’s Whisky Tasting Selection

Of course for this Whisky Librarian, there is even a special highlight put on by Woody Woodaman – the whisky tasting that raises money for a fund set up in his wife’s name Betty Jean Memorial Scholarship Fund to support nurse training. The conference floor is always offers new concepts and technologies – everything from taste experiences to the highly popular hugging booth set up by friend and colleague Andrew Chacko.

Each year is an eye opening experience full of surprises that Amir Kalali the conference Chief Curator keeps close to his chest like a proud parent who know’s he’s picked the best birthday gift for their child and can’t wait to reveal it.

This year there were many mind blowing presentations – for me “Breaking the Logjam in Medical Imaging” by Mary Lou Jepsen from Openwater that pushed the boundaries of wearables by offering a path to an MRI wearable. Sounds far fetched – not if you approach the problem with a different lens and understand that our photo sensor chips have reached a sensitivity of a micron – the wavelength of infrared. Combine this with the fact that our bodies are translucent to red and near infrared light – but red light scatters but this is not random, it is deterministic and reversible if you can record a hologram of it. So with some clever use of relatively old technology that allowed us to move from overhead foils

CNSSummit OverheadFoils
Remember these Devices?

to LCD projectors we are all accustomed to. This now allows the generation of ultrasound waves from small devices and using the change in phase of the light as it passes through the red light (you all know the doppler shift experiment you learnt in physics at school) they are now able to find vasculature at higher resolution than MRI and fMRI and even have additional capabilities to differentiate between oxygenated and non-oxygenated blood as achieved with the fMRI

Absorption of Hemoglobin for fMRI
Mapping Oxygenation of Blood in Real-time

But the resolution is now down to a few microns which is at the size of neurons, meaning they have the ability to see into our bodies at the detail of our nervous system… real time!

Image Resolution of Neurons
Neuron level granularity of Imaging

Combined with the early science that shows we can reconstruct what we are thinking and seeing based on analysis of our brain activity (Reconstructing visual experiences from brain activity evoked by natural movies, Nature – pdf). Most exciting the project is driven by a challenge to deliver a low cost, better imaging solution, to everyone, given that 2/3 of humanity lacks access to imaging.

Final Conference Day

 

The highlight for me was the last day – which according to my research and discussions with others, is just like every other conference poorly attended with many people missing the best elements.

It included two amazing presentations by the compassionate and gentle Daniel Friedland (Leading Well from Within), the wonderful, funny and insightful Chris Hadnagy (Social Hacker and previous guest on my radio show) and Stephanie Paul’s fun and eye opening Improv experience and included Asa Mathat participating and recording the activities with his unique eye. This picture captures the fun and learning we had as we learnt and connected

CNSSummit LastDayFun

So my Incremental step for you is set aside Oct 31 – Nov 3, 2019 for Summit 2109 (It is the 10th anniversary so I’m imagining Amir and the guiding council is thinking hard about making this event super special) and you to will have the learning opportunity and fun as you find a new friend in CNS Summit

CNSSummit AsaMathatandNick

And one more Incremental step – if you are taking the time to go to a conference, don’t head out before it finishes but rather plan to enjoy the last sessions where organizers often try to save the best till last.

Summit was originally published on Dr Nick – The Incrementalist

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Consumer Rights Driven Data Access

The Bluebutton Innovator

 

The Incrementalist - Mark Scrimshire

This week I am talking to Mark Scrimshire (@eKiveMark) a fellow Walking Gallery member and Entrepreneur in Residence at NewWave and on assignment as Medicare Blue Button 2.0 Innovator at CMS where he is designing and implementing the new API to enable 53 million Medicare Beneficiaries to share their claims information with the applications, services and research programs they choose to trust.

His work extends back to 2010 when the initial concept of the Blue Button was conceptualized but it took several years before this started to really take off with the concept of View, Download and Transmit. One of the key Incremental Steps to get this interoperability rolled out centered on changing the positioning of HIPAA from a barrier to sharing and portability to an enabler. Ironic when you consider that it stands for “Health Insurance Portability and Accountability Act”! Listen in to find out the details behind the change and a key incremental step to progress – changing the messaging

Part of this changed messaging centers on the Office of Civil Rights (OCR) and the clear guidance to direct consumers to have the right to access their data in electronic format. As promised in the broadcast here is the Rights to Access Memo they issued in September 2015 and something I carry with me to all my medical appointments.

He shares his view on how to move toward interoperability and his incremental step connected with the Fast Healthcare Interoperability Resources (FHIR, pronounced “Fire”) set of Resources and removing complexity and simplifying the approach the is a recurring theme for Incremental Improvements.

Don’t let perfection stand in the way of progress

You can read more about the project in the FHIR Wiki he mentioned here. Listen in to hear Mark talk about the new project and how he is turning the oxymoron of Explanation of Benefits (EOB) which fails to provide insights to the people it is directed at and how the DaVinci project. The move from the old model of Fee for Service (FFS) to paying for outcomes is also driving a whole shift in data accessibility and utility and willingness to share which is exciting for our the consumer rights driven access movement.

Their Incremental steps to improvement include the huddle but listen in to hear what other incremental steps you may be missing that has added significantly to their team-based approach, coordination and success


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

Consumer Rights Driven Data Access was originally published on Dr Nick – The Incrementalist

Digging in to Your Social Media Feed

Social Security
Digging into your Social Media Data

It was with interest I read a recent Viewpoint article in the Journal of American Medical Associations (JAMA) titled: Social Determinants of Health (SDoH) in the Digital Age, Determining the Source Code for Nurture authored by Dr. Freddy Abnousi, the head of healthcare research at Facebook, along with a couple of other authors, Dr. John Rumsfeld, Chief Innovation Officer at the American College of Cardiology (@DrJRums) and Dr. Harlan Krumholz, Professor of Medicine at Yale (@hmkyale)

They rightly point out the major contribution of social determinants of health – a fact highlighted as far back as to 1946 and the World Health Organization (WHO), but the research has been hampered by the inability to capture accurate granular data which is mostly self-reported (with the associated unreliability). We do need better approaches and the social networks offer a tantalizing look into data of this nature with a peek into online behavior, data that is posted by the millions of users who engage daily online.

They offer an intriguing potential to pre-identify suicidal ideation, “with enough advance warning and accuracy to stage a peer-driven intervention“. The opportunity to identify high risk for opioid addiction or finding those at highest risk of cardiovascular mortality and engaging with the users corresponding social network who would be “tasked with responsibilities”.

There is much to applaud in the concept but it raises some serious and challenging issues in my mind

1) Informed Consent is a major challenge and history and recent revelations do not engender any confidence that this data or insights would not be used against the patients or their families

2) De-Identification of data is already problematic – when you consider Intensity Analytics ability to identify individuals and behavior simply from their interaction with a keyboard

3) Trust is broken across so many areas and the current system is working as designed – a business. It is highly unlikely that users would ever *knowingly* give their consent

4) Healthcare consumers in the United States are struggling while the business of healthcare continues its march towards profit. Intuitively any insights from an SDoH program would have to focus on the best economic solutions which are mostly non-healthcare solutions (food, housing, income, education)

We need insights and data to provide the data to support and effect change and this idea has merit – but without some real changes to the business of healthcare, it will struggle to take off or deliver value to our population. I’d suggest a better incremental step would be to look at this data to show the underlying struggles of the users and creating a catalyst for change

 

Digging in to Your Social Media Feed was originally published on Dr Nick – The Incrementalist

Should You be Taking a Statin

Statin, Cholesterol, Heart
Are statins the wonder drug for your Heart Health

 

The answer to that question is complex and individual and before thinking about that you should have a basic understanding of cholesterol in your body. You can learn about this from my video and blog post

Statins

In the previous episode, I talked about Cholesterol in your body. This week as a follow up I’m talking about Statins, a group of drugs that lower the level of cholesterol in the body. They work by acting on the liver’s mechanism for producing cholesterol inhibiting the enzyme Hydroxy-methylglutaryl-coenzyme A reductase (HMG-CoA reductase).

Anatomy
The Human Circulatory System

We know that cholesterol is closely linked to atherosclerosis – the formation of plaques that build up on the walls of our arteries and contain cholesterol and that these plaques can rupture or break off and cause blockages that cause cardiovascular disease that ranges from the mild decrease in blood flow to our limbs to the severe effects that throw blood clots into our brains and heart causing strokes or heart attacks. But as we learned last time – cholesterol is not all bad – it is an essential part of our body systems making up parts of cell membranes and integral to several signaling molecules.

Statins are also known to have additional effects beyond the simple reduction in cholesterol levels and production in our body and several studies have shown that these drugs also reduce inflammation in the cell walls which is not connected to the cholesterol-lowing effect. In fact, this effect occurs rapidly and is seen as soon as 2 weeks after starting statin therapy

Statins Drugs

Drugs
Medication choices

There are multiple Statins around the oldest and best known is Atorvastatin (widely known by its brand name Lipitor) with its breakout general usage in 1996. The good news is this drug is off patent and there are plenty of low-cost generic options available and there is lots of safety data gathered given it has been in widespread use for over 20 years.

But Statins are not side-effect free and some find themselves suffering from constipation, diarrhea, and fatigue and in some 5-10% of people muscle cramps that can make the drug intolerable. This can be mitigated with some of the newer variant drugs that can help mitigate or even completely reduce the muscle cramps and other side effects. There is a rare and significant effect of causing diabetes in a small percentage of patient’s which is an important factor to consider when considering if Statins are right for you.

New Research on Statin Therapy

There has been lots of research and trials and the most recent I mentioned in the video the HOPE-3 trial which had a multifactorial design – meaning multiple variations on treatment therapies were tested in different populations.

They had a diverse group of patients divided up into multiple groups in a 2×2 factorial design that had groups being treated with a statin, an Angiotensin-converting enzyme (ACE) inhibitor for blood pressure and a diuretic hydrochlorothiazide also for blood pressure (BP). They had 12,000 people with a follow up to 5 years and they maintained good adherence for drugs of around 75%.
Overall, the anti-hypertensives did not reduce the risk of cardiovascular events at all – but there were differences depending on whether or not you had hypertension when you entered the trial. Interestingly the combined statin with an antihypertensive treatment was no better than a statin alone. And the data offered a clear benefit for Statins for those at intermediate risk of cardiovascular disease.

The details of this are nicely summarized here and the article includes links to the 3 published studies that were published from the data. One of the specific questions answered by this study is on that one cardiologist friend of mine and I have discussed before – should Statins be placed in the drinking water like fluoride. Given the cost and the side effects associated with statins, the answer is no for economic reasons as well as increased risk of side effects.

In the intervening time since I recorded this video another paper was published:
Finding the Balance Between Benefits and Harms When Using Statins for Primary Prevention of Cardiovascular Disease: A Modeling Study, and a new set of guidelines from the American College of Cardiology (ACA)/American Heart Association (AHA) on the management of cholesterol in the blood: 2018 ACC/AHA Multi society Guideline on the Management of Blood Cholesterol

Which emphasizes a heart-healthy lifestyle but then details some very specific “high-intensity” statins to focus on specific cholesterol levels in people who are at high risk or with proven clinical cardiovascular disease (they reference ASCVD or atherosclerotic cardiovascular disease) alongside detailed clinical guidelines for stating therapy based on specific risk and disease assessments in individuals. There are too many variations to make any generalization beyond what I stated in the video – start with the incremental step of knowing your numbers and the details of your family history and medical history as contributing factors to your risk assessment to take with you and discuss with your doctor to decide what’s right for you

Once you have your numbers you should calculate your 10-year risk of heart disease or stroke using the Atherosclerotic Cardiovascular Disease (ASCVD) algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. This is available from several sources including this from MDCalc or this one which includes a spreadsheet you can download to plug in your values as well.
To include the new updated guidelines from 2017 and the ASCVD Risk Estimator Plus tool (background available here) you can download the app with updated guidelines from 2017 for Apple iOS but Android is a little more challenging with a generalized cardiology app which does not get as good reviews.

Ultimately the decision is a very personal one and is driven by data and supported by clinical evidence. There are no quick global answers, but it is an important decision for everyone to consider, especially if you have any contributing factors in your family history, past medical history or are suffering from any aspects of cardiovascular disease.

Listen in to hear the details Statin Therapy and if its right for you

Incremental steps – Deciding on a Statin

  • Measure your Blood Cholesterol
    Gather the details of your medical history
    Use the ASCVD calculator to give you a guide based on the clinical research
    Bring everything to your doctor and discuss the evidence data and make a personalized decision together

 

The evidence is clear for those in the groups that have treatment with a statin recommended that the benefits outweigh the risks and side effects.

Should You be Taking a Statin was originally published on Dr Nick – The Incrementalist

Your Body and Cholesterol

This week I’m talking about Cholesterol. What it is, where does it come from (hint your diet is only a small part) and what does your body use it for

Fatty Foods – Are they as bad as we think?

 

It’s interesting that when you search for cholesterol the recurring image is of Eggs which have been closely linked with Cholesterol and to some degree part of a simplistic link that associates food that contain cholesterol with cholesterol levels in our body but it’s not that simple.

Cholesterol

The word Cholesterol comes from the Greek Chole for bile and sterus for solid and adds an “ol” at the end for hydroxyl functional group or alcohol bond on the molecule. It is a lipid molecule and is found in cell membranes and in signaling molecules like our the hormones Progesterone, Estrogen and Testosterone. Suffice to say our body needs it so the idea you get rid of all your cholesterol to be healthy won’t work.

So what does it mean for your health, how much should you eat and what are all these HDL, LDL and VLDL measures your blood test and what do they mean for you? Listen in to find out the details of the cholesterol measurement and what they mean to you and what Incremental Steps you should be taking regarding cholesterol in your diet an for your health.

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Your Body and Cholesterol was originally published on Dr Nick – The Incrementalist

Using Advanced Trauma Life Support Methodology in Population Health

 Preventative Health for Everyone

 

NewImage

This week I am talking Joshua Scalar, MD, MPH, Chief Medical Officer for BioIQ where they are working to seamlessly connect people to preventative health testing by removing the friction from the system and allowing as many people as possible to access essential, cost-effective life saving preventative testing services.

Josh had an interesting path to his current role – find out how a Saxophone playing band member became a passionate advocate for patient engagement and widespread and easy access to preventative services

Hear how Advanced Trauma Life Support (ATLS) insights offer a model and guide for the triage and delivery of preventative care that should address a problem that by some estimates has only 8% of people accessing fully validated life-saving preventative care opportunities in the United States

Like many of my other guests, Josh made the point that one of the clear incremental steps to getting patients and consumers to access preventative services is

Making the right choice the easiest choice

Hear how he and his team have addressed a basic problem of colonoscopy screening that is an effective and well-tested method of picking up and preventing untimely death from colon cancer but is still poorly adopted. As he points out – colon cancer killed 50,000 people in 2017 – that’s more than the opioid epidemic did but it continues to lack the focus and attention warranted.

Listen in below to find out how this can be applied to Diabetic Retinopathy – preventing blindness that is a high risk for Diabetic patients


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


 

Listen along on HealthcareNowRadio or on SoundCloud

Using Advanced Trauma Life Support Methodology in Population Health was originally published on Dr Nick – The Incrementalist

Making it Easier to do the Right Thing

Behavioral Health for Positive Impact

Behavior

This week I am talking to Matt Wallaert (@mattwallaert), Chief Behavioral Officer at Clover Health. I have listened to Matt on a few occasions, most recently at the FitBit Captivate event in Chicago so I was excited to get to talk to him one on one.

Matt plays an unusual and atypical role in Clover Health – he is their Chief Behavioral Officer, a title and role that is not commonly found. He is a Social Psychologist who focuses on Judgement and Decision Making and is most well known for applying behavioral science to practical problems.

We explore behavioral health influences and how we can create interventions that will have a positive impact. How do we create incremental steps and test these and then roll out of programs to have a positive impact on health? He wanted to have an impact and wanted to make things better for people and over the course of his career has managed to do so in many places but is now focused on healthcare and specifically personal health. There’s a recurring theme in many of my INcremental interviews and I heard it again from Matt:

Assume you are going to fail

As Matt puts it – “don’t set up a durable process – for example, if you are doing a mailing do that yourself vs getting your marketing department to create the mailing”. Then head out to the next step – a Test. It is not hard to find behavioral changes that work – but that’s not the only requirement as the change has to work well enough and are scalable enough that you really want to roll them out widely.

Incremental Step to Behavioral Health

It’s not just finding good behavioral changes but rather things that are worthwhile and scalable

“If behavior is your outcome and science is your method – then you are a behavioral scientist”

As Matt says we have to make it easier to do the right thing and not blame individual choices and health behaviors when we make poor health, decisions. Listen in to find out why there are significant cultural differences in flu vaccination take up rates and what incremental steps can be taken to improve on that and hear why it is important not to blame people for poor health behaviors. Learn how they are behaving like Netflix or Pandora that can can match you to the right videos or music we should be able to match you to the right doctor

 


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

Making it Easier to do the Right Thing was originally published on Dr Nick – The Incrementalist

Is Intermittent Fasting Right for You?

Does Intermittent Fasting Work?

Fasting
Eat Stop Eat

This week we I’m covering the world of Intermittent Fasting. What’s that you ask – in its simplest form

Eat – Stop – Eat

In other words, challenging your body with no intake of calories for a variable amount of time. In my case I fast for about 36 hours with my last meal in the evening of day 1, I eat nothing on day 2 but do drink plenty of water and allow myself coffee and tea but without any milk (or sugar) and my next meal is breakfast on day 3

But there are plenty of variations on this that range from the 5:2 program that has you eating 5 days and fasting 2 days but non-consecutively and in some cases allowing for a small number of calories (500-100) or the 18 hour fast where you only eat food between the hours of 12 and 6 pm and fast the remainder of the time through to some who fast for more than a day.

Listen in to the video to find out what are the good things about intermittent fasting and what are the downsides and what the various types of intermittent fasting methods are and how you might take an incremental step and try them out.

 

If you are interested in finding out more I have linked to some additional papers and articles to give you some more reading

Links to Studies on Intermittent Fasting

Harvard study shows how intermittent fasting and manipulating mitochondrial networks may increase lifespan
Intermittent fasting promotes adipose thermogenesis and metabolic homeostasis via VEGF-mediated alternative activation of macrophage in Mice
Is fasting the fountain of youth?
Study Fasting for 72 Hours can Regenerate the Entire Immune System of Humans!

Can I ask a favor – if you like the video, please subscribe to my channel, and if you don’t leave me your feedback/thoughts on how I can improve things?

Is Intermittent Fasting Right for You? was originally published on Dr Nick – The Incrementalist

The Healthcare Huddle

 Delivering the Care Patients Want

NewImage

This week I am talking to Dr. Jay Mathur, Associate Regional Medical Director for Caremore Health Systems in Connecticut. A program that started 25 years ago in California and has now expanded to multiple states and has been in Connecticut for a little over a year. This is the medicine that we went to medical school to practice, the opportunity to deliver the care that patients and families want.

We know that the poor typically live alone and quite often socially isolated and their zip codes play a part in their health status but sometimes it can be their shopping experience and availability of food not just their zip code that is a key determinant of health. We talked about some of this in my interview with Dr. Won Chun from Carrot Health

Team Sport
The Healthcare Huddle

Listen in to hear how they select the hardest patients with the most complex diseases and chronic conditions as and learn the key elements in their success that are tied to the early morning huddle where everyone shares the upcoming day, tasks and resource allocation getting everyone on the same page. All I could think of was the scene from The Replacements and Shane Falco’s huddle:

Huddle Fight

They have a range of team members with their Clinical Partners as the glue that keeps everything together and others on the team including Social Workers, Psychiatrists, Case Managers and physicians playing a supporting role to each other

Glory Lasts forever

From a patient standpoint, it all starts with a detailed assessment and importantly introducing all the team members to the patient using a range of technology tools to facilitate and improve efficiency

Their Incremental steps to improvement include the huddle but listen in to hear what other incremental steps you may be missing that has added significantly to their team-based approach, coordination and success


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

The Healthcare Huddle was originally published on Dr Nick – The Incrementalist

How Good is BMI as a Health Indicator?

How do You Measure your Healthiness?

A recent conversation with my brother about Body Mass Index or BMI got me thinking about this data point and how we use it. Many of you are probably familiar with the value – it shows up on your weighing scales right after displaying your weight

Obesity BMI
Digital Weighing Scale

And if your scales don’t offer it you can always calculate your BMI with a multitude of online calculators (simply put weight divided height)

But there are some challenges with this simplistic value – not least of all the Obesity Paradox – the counterintuitive notion that obesity may be associated with longer survival.

Muscle Mass

A recent study published in PLOS One: Muscle mass, BMI, and mortality among adults in the United States: A population-based cohort study that delves into this deeper and offers some explanation of this counterintuitive notion that having a high BMI can be associated with longer survival. The results offered a clearer picture into our bodies and the relationship between these measures and our health status and long-term survival. There was lots to digest but this chart captured an essential point

Health
Risk of Mortality BMI and Muscle Mass

The Blue line represents people with “Preserved Muscle Mass” – in other words, those that have more muscle vs less. The Red Line for people who have lower muscle mass. I’m simplifying a complex detailed study a little but essentially but here goes

TL;dr: Healthier longer survival for people who sit in the middle range of BMI and have more muscle mass. For those with high or low BMI muscle mass has a positive impact on improving long-term survival

Listen in to find out the importance of Muscle Mass and what Incremental Steps you should be taking to improve your health

 

Can I ask a favor – if you like the video, please subscribe to my channel, and if you don’t leave me your feedback/thoughts on how I can improve things?

How Good is BMI as a Health Indicator? was originally published on Dr Nick – The Incrementalist