Thursday, January 3, 2019

Ten Contrarian Predictions for Healthcare in 2019

The Disease Management Care Blog resurfaces momentarily to repost a "Ten Healthcare Predictions for 2019" post from LinkedIn.  The busy DMCB is CEO of The Care Centered Collaborative at the Pennsylvania Medical Society and the thoughts below do not express the views of The Collaborative or of The Society. 

They do reflect a belief in physician leadership.

1. 2019 Will Be the Year of the Doctor
After a spending years in the health reform wilderness as commoditized “providers,” doctors will reassert their hard-earned professional designation.  Large health systems will see an uptick in physician-administrator tensions, physician-owned entities that honor the profession will have less trouble poaching talent and the ratio of employed to independent physicians will stabilize.  Contrary to expectations, independent physician entities will cater to millennial doctors’ underappreciated skepticism about corporate healthcare.

2. Physician-led CINs – Health Information Technology Reaches Critical Mass
As their fee-for-service (“volume”) income wanes and payments are shifted to reward quality (”value”) the independent physicians take advantage of advances in information technology to organize into clinically integrated networks (CINs).  Declining costs and increasing sophistication of these information systems is lowering the barriers to market entry. This will enable the best of both worlds: local independence and regional interdependence.  These entrepreneurial doctors will be the surprise alternative to  health system consolidation, hospital market  dominance and one-size-fits all approaches to care. Financial savings from other group purchasing arrangements will be icing on this cake.

3. From Revenue Centers to Cost Centers – The Emperor Begins to Lose His Clothes
As hospitals scramble to get even bigger by buying one another, constructing new wings and launching slick branding campaigns, these glass and steel behemoths will begin to contrast with unflattering local stories about inability of patients to get a timely appointment and a convenient care plan. These noisy patients will use more social media to point out something that elected officials, regulators and academics are missing: that these complex mega-health care organizations cost more than they give. Unfortunately, this alone won’t be enough to lead to change, but.....

4.  Unholy Alliances – It’s What Lies Under the Emperors’ Clothing
The Wall Street Journal confirmed what many physicians suspected about hospital-insurer collusion. 2019 will show how prevalent this is: enterprising local reporters will find that their health system has been using its local market dominance to dictate terms to health insurers.  No longer just a matter of fat fee schedules and lavish quality bonuses, terms of these contracts will leak and inform local markets, showing anti-steering clauses, secretive pricing arrangements, extra fees and the exclusion of lower-cost alternatives.  As news of these arrangements spreads, embarrassed health insurers will pull back from these agreements and look for network alternatives.  Combined with #2 above, patients will be willing switch to these alternatives and large health systems will begin to see declines in the rate of increase in their outpatient revenue. 

5. Risk Transfer Transfers Gain Pace
Health insurers are ultimately in the business of “risk transfer,” in which the potential cost of a future healthcare event is accepted in exchange for money.  This monetized risk increasingly being sliced, sorted, allocated and re-transferred. While this innovative area of insurance has been dominated by large systems, increasing actuarial sophistication and growing risk appetite of smaller networks – including physician CINs -  will lead to limited and profitable risk transfer arrangements.

6.  Social determinants of health – Accountability is incomplete without fixing them.
As risk transfers to providers grow, awareness of underlying socioeconomic threats to patient claims expenses will evolve in a Stages of Change arc from “precontemplation” in 2018 to “action” in 2019. An impatient mandate to “do something!” to manage social determinants will prompt frontline healthcare workers will begin to use some of the upfront premium revenue from their risk arrangements to mitigate the impact of determinants, such as poor social supports, low education, and insufficient income. Unencumbered by an insurer mindset, there will be investments in community-based supports, patient education and non-medical services.

7. More Venture Capital
The allure of artificial intelligence, connected health, the human genome, block chain, consumerism, making the inefficient more efficient and more will drive another run at finding “The Innovation” thatwill finally transform healthcare.  Alas, this is less a function of the potential of market change than the lack of investment opportunities elsewhere.  Good luck!

8. All Eyes on Medicaid 
An accommodating posture in CMMS will enable the leadership of state Medicaid programs – and their managed care insurance partners – to innovate.  One area ripe for change are quality metrics, which have been dominated by entities such as the NCQA, NQF and AHRQ. Criticized for being disconnected from what patients really value, state Medicaid Directors will show a willingness to adopt new measures and reward health systems that can move these new needles.  Physician-led CINs will lead the way and they’ll start by arguing that a number one priority should be measures of social determinants of health.  By the way, venture capitalists (see 7 above) will miss this bus.

9 The JPMorgan- Amazon-Berkshire Thingy Will Go Nowhere.
Didn’t these companies’ ERISA plans already exploit the low hanging fruit?  Between Warren Buffet’s hardnosed actuaries, blockchain’s unreadiness for prime time, the limits of Alexa-style healthcare consumerism, and Atul Gawande being the Peter Principle personified, this three-way alliance will remain stuck in countless video conference rooms in Seattle, New York City and Omaha.

10. Medicare for All Takes Off
The Donald will demonstrate once again that he has no ideological moorings, no respect for fiscal responsibility and no embarrassment from co-opting his opponents’ ideas. Once the fight over The Wall has been squeezed for every possible advantage, the President will shamelessly signal he’s open to a version of “Medicare for All.”  Why not?  Insurers will see opportunity in the expansion of government-paid managed care business, employers will welcome a way out of paying for commercial health insurance, voting Boomers’ may be grateful for being fast-tracked to Medicare eligibility and the House Democrats’ momentum will become ten times more complicated. To the chagrin of his detractors everywhere, Mr. Trump will give the impression he really has a chance at a second term. MFA might even pass.

Monday, December 11, 2017

Science or Marketing?

The Disease Management Care Blog's colleague, Otto Wolke, R.Ph., a former Vice President of a managed care pharmacy plan and industry leader, submitted the following post. 
He speaks truth to power.
With sixty plus years of observing the pharmaceutical industry, I have an urgent need to provide a perspective that I hope pharmacists, physicians, insurance benefit managers and the Federal Government will heed. As we enter a new world of personalized medicine, new FDA decisions on priority reviews and the push for faster drug review process, the line that separates science and marketing has never been more important.
While the pharmaceutical industry has produced some amazing drugs and there are many thousands of dedicated scientists, there is an unconscionable waste of healthcare dollars, not only in the US, but around the world. Only two countries allow advertising of prescription medicines: the United States and New Zealand.
That translates to $6 billion dollars that provides much more marketing than science. Those billions could be six new breakthrough drugs, or perhaps research that could discover why prescription medications are not only are a major reason for hospitalizations, but also deaths.
You can add the billions paid in drug liability settlements, and more billions paid in fines to the FDA for non-compliance because of faulty and/or misleading information as well as the marketing off label use.
Imagine even a portion of these additional dollars being invested in real science to produce the medicines of the future.
The recent disclosures about unethical pricing and possible collusion in the generic industry just scratches the surface of the consequence of allowing marketing instead of science to direct the industry.
This not only applies to pharma, but to the medical device industry as well.
I could write a book, but several have already been done, perhaps one of the best written by Peter C. Gotzche, co-founder of the Cochrane Collaboration. His book is entitled Deadly Medicines and Organized Crime and is aptly subtitled How Big Pharma Has Corrupted Healthcare.

Monday, December 19, 2016

Clever Rap Anthem About Electronic Health Records

ZDoggMD makes some good points, slips in a sly reference about one EHR provider and salutes another.

Ten years that have passed since I wrote this article, and we still have a way to go.

Monday, November 21, 2016

Countering the Cruel Tutelage of Healthcare Access, Quality and Cost: How mHealth Can Do It Faster, Better and Cheaper

While there many maxims about the delivery of healthcare, the MedSolis Chief Medical Officer PHB has discovered that three in particular stand out:

1) Many healthcare outcomes are more a function of social, economic and cultural determinants than medical quality. Zip code trumps diagnosis code.

2) Say's Law warns us that healthcare utilization may be a function of  sevice availability rather than need. As a result, compelling innovations like this or this can be "additive" to healthcare, not "substitutive." Demand trumps discovery.

3) Healthcare access, quality and cost are interdependent, and improvements in one has downsides in the other two.  For example, price controls can lead to lower access in the form of queues. Increasing quality can drive up prices.  And, Obama's healthcare reform emphasizing better access arguably led to higher prices.  
Trump's rhetoric trumps brainy Obamacare.

Naturally, there are exceptions to every rule.  And the PHB wonders if healthcare technology's mHealth may offer an important exception to rule number three.

If so, there are important implications for U.S. healthcare delivery.

An important mHealth mantra for MedSolis is "faster, better, cheaper."  mHealth is defined as as any medical practice supported by devices such as mobile phones, patient monitoring devices, personal digital assistants (PDAs) and other wireless technology. A considerable body of literature on the topic shows that patients using mHealth can access the information they need to make informed choices, that those informed choices serve greater engagement, and that this leads to fewer avoidable complications.

Examples from the MedSolis #mHealth archives:

Mary Jones* has diabetes, and uses her smart phone paired bluetooth-enabled blood sugar monitor to assess her diabetes control versus diet, exercise levels and medications. Her A1c improves, which correlates with her future health care costs.  She not only sees her outpatient physicians less often, but the A1c data inform public measures of quality and decreases the likelihood of depression.  Ms. Jones has hit the trifecta: lower cost, higher quality and better access to more care.

William Smith* has heart failure and has just been discharged from a hospital. He uses a telemonitoring-linked home scale to detect the subtle increases in weight from fluid retention that can herald an exacerbation of his condution.  William knows how to increase the dose of some of his medicines leading to return of his weight to normal. William has avoided an unnecessary night in the emergency room.  What's more, the avoided readmission is an important measure of quality. Mr. Smith has also hit the trifecta of lower cost, higher quality and better access to more care.

Bottom line: as healthcare consumes a greater fraction of the U.S. gross domestic product, the cruel tutelage** of healthcare acess-cost-quality can be mitigated by faster-better-cheaper.  Whether it's Obamacare, Repeal, Replace or Trumpcare, the the value proposition of mHealth will endure.

*Names and scenarios are realistic, but ultimately fictional
** With apologies to Pai Mei and his fans

Thursday, November 10, 2016

Winners and Losers in the Trump Health Reform Universe

While readers digest the reality of a Trump Presidency and Republican control of both houses of Congress, the Population Health Blog (PHB) has been trying to assess the "down ballot" implications for healthcare and mHealth providers.

While the universe has been turned upside down, its initial reaction for mHealth is bullish.  As for the rest....... read on.

While he was a wacky campaigner, the PHB suspects that Mr. Trump's "campaign promises" were really opening negotiating positions.  While immigration, the Supreme Court and business regulatory reform will be top of mind, he'll eventually get around to making deals in the healthcare space, because that is his nature.  That is the real wild card and increases uncertainty.

That being said, what can the PHB predict?

Given Mr. Trump's and the Republican majority antipathy to Obamacare, the Affordable Care Act is likely to be gutted. While U.S. Senate Democrats can create mischief with the filibuster, many are also up for election in two years. As a result, commercial insurance premium subsidies, the minimum benefit, the IRS penalty and ACOs are toast.

Because it's working pretty well, the PHB rates it as unlikely that Congress will alter the basic underpinnings of fee-for-service Medicare and the Medicare Advantage programs. Unfortunately, however, that also means that the complex reporting and payment changes of MACRA - and its premise of "value-driven" Medicare - will stay on track.

According to The Washington Post, more of the federal support of Medicaid will transition to block grants. The PHB suspects that when the budgeting is done, the Republicans will trade greater local leeway for less money. It remains to be seen how states will  respond by altering eligibility requirements.

So, over the short term who wins and who loses?

Patients lose - but slightly: those who are outside of Medicaid, many of them will buy skinnier coverage or not buy any commercial insurance.  While that will mean that many will forego needed medical care, Obamacare's deductibles were already leading in that direction. Those in Medicaid will find their healthcare coverage dependent on their state's fiscal priorities; on the other hand, many Governors will fight to do the right thing. Medicare patients will do OK.  The good news is still that if anyone shows up at 3 AM with motor vehicle trauma, the system will still take care of them.

Hospitals/Inpatient Service Providers lose and a lot: Without premium subsidies, more persons will forego commercial health insurance, and Medicaid will have less money.  Since a lot of inpatient healthcare utilization is preference insensitive, that means more bad debt and deeper fee schedule discounts. By the way, interest rates are destined to rise, making hospital debt more expensive.  They'll consolidate, and a pro-business climate in D.C. may make this easier.

Physicians neutral: while physician incomes will also be buffeted by more bad debt and deeper Medicaid discounts, the PHB suspects a critical mass of docs were increasingly disenchanted with Obamacare and its impacts on their professionalism. While policymakers and organized medicine groups (such as the AMA) may argue that this is a Pyrrhic Victory, all of this will be overshadowed by the top line impacts of MACRA, which is not going away.  This will quickly eat up the docs' bandwidth. They'll continue to consolidate into larger groups, but away from hospitals, which can no longer afford them.

Organized Medicine loses: the AMA and many of its sister organizations supported Obamacare and stayed inside the Beltway Bubble. Eight years later, those chickens are coming home to roost. They now have to choose between being part of a new solution or being a member of the loyal opposition. Both are unpalatable.

Health Technology/mHealth wins: patients will look for tech solutions that offer faster, cheaper or better care that include, for example cloud-based guidance for diabetes control, remote provider advice web sites and home telemonitoring.  To the degree that it offers a substitutive level of care, insurers will gladly pay for it, and since there are revenue opportunities for providers, they'll pay for it too. A pro-business posture in Washington DC, a focus on other healthcare issues and less regulatory overhang means that apps, devices, gadgets, big data, The Cloud and SasS will continue to expand. The future remains bright for companies like MedSolis.

Long term? This depends more on the economy. If it can return to 3% growth and if the labor participation rate increases, more persons will be able to afford housing, transportation, education and healthcare.

Thursday, November 3, 2016

The Latest Health Wonk Review Is Up!

Do you care about baseball?  Do you fret about politics?

Neither does the Population Health Blog. But that doesn't mean heading over to Brad Wright's Health Wonk Review: The Game 7 of Politics Edition  at Wright on Health isn't work your time. His post skillfully ties two of America’s favorite and most contentious pastimes together.

Tuesday, November 1, 2016

Information Technology Expertise vs. Literacy: A Lesson from the Hillary Campaign for President

Whatever Population Health Blog (PHB) readers may believe about the 1) the timing of FBI Director Comey's announcement about the discovery of a cache of Huma Abedin emails "that appear to be pertinent to the investigation," or 2) the Wikileaks hack of the Clinton emails, the campaign's pattern of lightly securing confidential information and moving it across multiple technology platforms is disconcerting.

Ms. Abedin is apparently at a loss to explain how so many the "pertinent" emails ended up on a home laptop.  The Population Health Blog (PHB) suspects it was a combination of autosaving and autoforwarding run amok.

In the meantime, it has been reported that the Clinton campaign chair used "p@ssw0rd" as the password for his johnATpodesta email account. Once it was targeted, the PHB believes may have been just a matter of probing it repeatedly with a series of commonly used passwords.  Once one account is hacked, it can be used to email viruses and malware to unsuspecting recipients.

No one should expect that the leaders who run national political campaigns should be IT experts.  It's also true that no one or organization is immune from an advanced persistent threat.  But that doesn't mean that these leaders - who aspire to oversee executive branch policymaking - don't have a duty to be IT literate.  

The absence of Republican leaks is intriguing. While hackers may be showing favoritism, the PHB wonders if this episode in 2008 prompted future GOP campaigns to take the threat seriously.  In addition to applying IT policy and procedure (for example) as well as relying on experts to identify and defend the crown jewels, their leaders - aware that their digital musings could end up on the front page of The New York Times - probably internalized some basics:
  • While email is never secure, the likelihood of a hack can be reduced by using unique passwords and regularly changing them;
  • Email attachments, including embedded pictures, are a common method of delivering viruses and malware;
  • There are important differences between storage and backups. The latter can resurrect an entire data base, is less prone to mismanagement and typically offers encryption.
This is not rocket science.  Understanding these and other basics - i.e. having literacy - is an important piece of IT security in any organization.  That's especially true in the healthcare sector, where we learned our lesson years ago.  The hard way.

In numerous posts (for example), the PHB has repeatedly questioned the ability of a federal bureaucracy to competently coordinate healthcare delivery.  In addition to the complexity, cronyism, concentration of risk, unintended consequences and politics, the PHB believed the health-policy illiteracy of the decision-makers made them unequal to the blue-pill vs. red-pill task.

Alas, is the same true when it comes to the oversight of the United States' information infrastructure? If a future President, her Chief of Staff and her most trusted advisers are flummoxed by or ignore the fundamentals of account passwords and backups, could this illiteracy lead to IT poor decision-making in a future White House administration?

You be the judge!

Image from Wikipedia

Friday, October 7, 2016

The Latest Health Wonk Review is Up

That's right, Paduda's Pre-election pundit ponderings is now present for your perusal and learning pleasure.

Friday, September 30, 2016


According to this BloombergTechnology report, "some" customers of health insurer Aetna will get a discount on Apple's smartwatch. In the meantime, Aetna's employees will get the watch at "no cost" to " beta test a new wellness reimbursement program."

While media reports imply that this is one more step toward a Manifest Destiny of scaling healthful behaviors to lower U.S. healthcare costs, the Population Health Blog is more sanguine:

1. The impact of wellness programs - exercise promotion, healthy eating and lifestyle management - on short term health insurance claims expense is highly variable.  There's lots of peer reviewed literature like this that shows "fitness" is not a healthcare money-saving slam dunk.

2. In addition, wellness programs are far more likely to be successful if they are tailored, multi-modal and sustained over time. Kudos to Aetna, which linked the smartwatch to a broader employee wellness program that probably meets that gold standard.  As for the "other customers," the PHB doubts that the one-time provision of a wrist gadget will do anything to mitigate their healthcare costs.

3. It is the conceit of today's Silicon Valley Robber Barons to think that no problem is immune to their business models. Just like Carnegie and Rockefeller, the Gates and Zuckerbergs seem to believe that but for (their) information technology, the world could be a better place.  Apple's executives can't be blamed for its "features to help our customers live a healthy life" hype.

4. But even if some of Apple's executives are immune to the hype, their marketing department undoubtedly understands that "cause related" appeals to societal fitness builds brand. Plus, if the earned media helps deflect attention away from Apple's lackluster stock price and Aetna's other travails, all the better.

5. It's difficult to know for sure, but the PHB doubts that Aetna is deploying any of its customers' premium to underwrite their cost for the Apple smartwatches.  Rather, this is far more likely to be a group purchasing discount in which Apple agrees to less margin in exchange for a bulk purchase.  That's probably also part of the math for the Aetna employees, with the rest of the economics of the wellness program simply being part of Aetna's administrative overhead.  

Nonetheless, the PHB is intrigued by the downstream possibilities of a Wintel-like alliance between a major commercial health insurer and a major information technology company.  What's described above is small potatoes compared to the larger possibilities of data sharing*, big-data analytics, co-branding, mutual investments, joint ventures and administrative combinations.

Think Aepple.  You read it here first.
*After this post was published, this news report came out.

Tuesday, August 23, 2016

When Diet Meets Technology

This is a post authored by the folks at ph360. The Population Health Blog was intrigued by the innovative combination of personalized dietary wellness management, evidence-based medicine, consumerism, artificial intelligence and a digital concierge.

Discoveries in biology, genetics, epigenetics, biotypology, and medicine are revealing that the best approach to being healthy and staying that way is to have a diet that is right for your body (1). What works for an “average” person may – or may not - be optimum for you.

So how do you know what’s right for you?

Welcome to the future of healthcare, where mHealth diet applications will come to the rescue. While today’s apps are rudimentary and require a lot of manual input, technology advances are making dietary apps highly advanced, automated and tailored.

The ideal app of the future will reconcile individual human physiology, and its adaptation to changes in environment and lifestyle, to provide more complete, detailed and personalized recommendations for staying well and reaching health goals (2).

Emerging technology will combine algorithms that calculate the risk of disease, monitor current lifestyle habits and health trends, and predict a future trajectory with recommendations of best practices for disease prevention or management. Genetic and phenotypic factors will be used to calculate health risks, and identify trends to provide tailored protocols. Wearable technology will monitor and signal important biological functions, and the continuous data collection will increase computer learning that further refines the technology. New discoveries will automatically update these systems so that users feel more confident and minimize faddism.

Though it seems like all of this is far into the future, it’s actually not. Sophisticated applications that consider a holistic approach to preventative medicine through such technology are already emerging.

Enter Shae

Matt Riemann, suffered from a rare genetic condition called Familial Amyloid Polyneuropathy.  This causes nerve dysfunction and has a life expectancy of approximately 10 years after onset.

In the course of collaborating with many specialists, scientists, geneticists and others, Matt not only overcame his condition but created ph360. With the premise that each person is unique, the ph360 platform guides a personalized approach to dietary health.

ph360 was launched two years ago, and after accounting for body measurements, genetic data, health history, and lifestyle, aggregates 10,000 data points and more than 500 ratios to recommend personalized food, fitness and lifestyle changes that achieve optimal health.

The Details

Shae, is built on the ph360 program.

First, body shape and structure are measured to gain insight on morphology, biotypology, and genetics. Research in epigenetics, for instance, has found that height is associated with cardiovascular conditions (3), digestive health (4) and even cancer (5). Waist circumference is related to cardiovascular risk (6) and diabetes (7). Various body ratios, such as height to weight, have been medically associated with increased risk of osteoporosis (8), certain metabolic conditions (9) and important hormone levels (10).

Health surveys are also used to get a better gauge of health risks. For example, skin and hair color is associated with the risk of sun damage (11), nail structure can indicate mineral deficiencies (12), and lifestyle choices can increase or decrease the likelihood of disease onset or progression (13, 14). Chronobiology (15) and the natural human aging process are considered (16) to provide insights on how sleep and stress affect health and well being (17) or how health risks may increase or change with age (18).

Shae takes ph360’s insights one step further by providing 24-7 support for ph360 users as a “Virtual Health Assistant.”  It’s being engineered to use interactive voice and text conversations to communicate a personalized health plan with users in real time via their phone, tablet, laptop or smartwatch. Shae will connect with wearables and analyze a user’s data to make practical recommendations regarding diet, exercise, and lifestyle activities that directly influence their health.
Following users through their day and responding as circumstances – such as environment, activity, diet and stress levels change, these are some of the things that Shae will communicate:

Recommended specific foods ideal for the person, indicate why and provide nutrient information, recipes and shopping lists for the recommended foods that the user selects.
Recommended the very best exercises for the individual’s fitness goals and specific body type, the ideal time of day to exercise and best sports to play.
How to integrate Geomedicine through GPS, making recommendations for foods, activities, transportation and more based on where the person is in the world.
How to optimize your schedule based on body rhythm to help minimize stress and increase productivity.

Shae has been funded on Kickstarter and is currently being funded on Indiegogo. Version 1.0 will be available in October 2016.  Upgrade versions will be released every few months with version 1.5 arriving in July 2017.  The upgrades are all covered in the original purchase price.


1. Ferguson, L. R., et al. "Guide and Position of the International Society of Nutrigenetics/Nutrigenomics on Personalised Nutrition." Journal of Nutrigenetics and Nutrigenomics 9.1 (2016): 12-27.

2. Ferguson, Lynnette R., ed. Nutrigenomics and nutrigenetics in functional foods and personalized nutrition. CRC Press, 2013.

3. Lee, Crystal Man Ying, et al. "Adult height and the risks of cardiovascular disease and major causes of death in the Asia-Pacific region: 21 000 deaths in 510 000 men and women." International Journal of Epidemiology (2009): dyp150.

4. Asao K, Kao WH, Baptiste-Roberts K, et al. Short stature and the risk of adiposity, insulin resistance, and type 2 diabetes in middle age: the Third National Health and Nutrition Examination Survey (NHANES III), 1988–1994. Diabetes Care 2006;29:1632–7.

5. Kabat, Geoffrey C., H. Dean Hosgood III, and Thomas E. Rohan. "Adult Height in Relation to the Incidence of Cancer at Different Anatomic Sites: the Epidemiology of a Challenging Association." Current Nutrition Reports 5.1 (2016): 18-28.

6. Nazare, Julie-Anne, et al. "Usefulness of measuring both body mass index and waist circumference for the estimation of visceral adiposity and related cardiometabolic risk profile (from the INSPIRE ME IAA study)." The American Journal of Cardiology 115.3 (2015): 307-315.

7. Chamnan, Parinya, Hansa Choenchoopon, and Suvit Rojanasaksothorn. "Abstract MP93: Waist Circumference Has a Stronger Association With Diabetes Than Body Mass Index: Results From a Large Health Examination of 355,310 Thai Men and Women." Circulation 131.Suppl 1 (2015): AMP93-AMP93.

8. Asomaning, Kofi, et al. "The association between body mass index and osteoporosis in patients referred for a bone mineral density examination." Journal of Women's Health 15.9 (2006): 1028-1034.

9. Jacobsson, J. A., et al. "Genetic variants near the MGAT1 gene are associated with body weight, BMI and fatty acid metabolism among adults and children." International Journal of Obesity 36.1 (2012): 119-129.

10. Osuna C, J. A., et al. "Relationship between BMI, total testosterone, sex hormone-binding-globulin, leptin, insulin and insulin resistance in obese men." Archives of Andrology 52.5 (2006): 355-361.

11. Veierød, Marit Bragelien, et al. "Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi." Cancer Epidemiology Biomarkers & Prevention 19.1 (2010): 111-120.
12. Cashman, Michael W., and Steven Brett Sloan. "Nutrition and nail disease." Clinics in Dermatology 28.4 (2010): 420-425.

13. Roberts, Christian K., and R. James Barnard. "Effects of exercise and diet on chronic disease."  Journal of Applied Physiology 98.1 (2005): 3-30.

14. Moritani, Toshio. "The Role of Exercise and Nutrition in Lifestyle-Related Disease." Physical Activity, Exercise, Sedentary Behavior and Health. Springer Japan, 2015. 237-249.

15. Lloyd, David, and Ernest L. Rossi, eds. Ultradian rhythms in life processes: An inquiry into fundamental principles of chronobiology and psychobiology. Springer Science & Business Media, 2012.

16. Lin, Jue, Elissa Epel, and Elizabeth Blackburn. "Telomeres and lifestyle factors: roles in cellular aging." Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis 730.1 (2012): 85-89.

17. Mullan, Barbara A. "Sleep, stress and health: A commentary." Stress and Health 30.5 (2014): 433-435.

18. Singh, Gitanjali M., et al. "The age-specific quantitative effects of metabolic risk factors on cardiovascular diseases and diabetes: a pooled analysis."PloS One 8.7 (2013): e65174.