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Interview with Drew Schiller about the Future of Digital Health

Drew Schiller is co-founder and Chief Technology Officer at Validic, a health and wellness technology company that operates as digital health’s Rosetta Stone for disparate health data. Before starting Validic, Drew was the principal at a Web development firm as well as the founder and developer of a dietary nutrition website. Companies that benefit from Validic’s API are able to build products that pull data from a variety of mobile health apps, wearables and in-home medical devices. Drew is at the forefront of mHealth innovation. You can follow him at his personal blog:

1) When we first met, the ANT+ Fit SDK was being heralded as the way health apps were going to be able to communicate with one another. Obviously a lot has changed since then – but not enough. Data interoperability is still a major design hurdle for many digital health innovators. Now mobile manufactures like Google, Apple and Samsung are trying to become conduits and interpreters of these disparate data sources. How have the advent of Google Fit and Apple HealthKit affected Validic’s business model?

It has not actually changed our business model at all. In fact, it has accelerated things quite a bit. The entrance of Apple and Google into this area has created awareness. Anytime you have the world’s largest leading consumer electronics companies entering a new market, the entire ecosystem benefits. This has resulted in an accelerated interest from consumers in personalized generated data. We’re seeing accelerated interest from the investment community. These are signals digital health is here to stay — that all of these massive companies are placing huge bets. So, from that perspective, their entry has been tremendous for Validic.

Furthermore, these solutions are doing little to mitigate that a lot of digital health device manufacturers don’t use open standard protocols because they want to add additional security layers on their devices and/or they want to stream additional information that is not part of standard protocols. Also, you have fitness tracking devices that are streaming all kinds of proprietary information, and they do not want just anybody to have access to that because the analysis of that data is part of their secret sauce.

In order to actually connect with these devices at the device level, you oftentimes have to work direct with the manufacturer to get the proper SDK, the proper coding for it to decrypt the device’s serialization. In that sense, true interoperability has to happen at the data layer. So, once the data is off the device that’s where we can standardize and normalize the data. That’s where we can provide some sort of method to create interoperability. That’s where we play. We will connect directly to Bluetooth devices if that’s where we need to be. We will also connect directly to APIs in the cloud. We also have mechanisms with many companies to send data directly to us. So, we allow for interoperability wherever the data is coming from. Our methods are a different approach than a lot of other players in this space, which gives us an advantage.

2) Piggybacking off this topic, futurist Graeme Codrington made a bold prediction about Apple regarding Health Tech in a recent Fast Company article that by 2025, “There is no doubt that with their iOS 8 released Health app and their integration of myriad health apps with the Apple Watch, Apple are making a play in this space, and by 2025 are likely to be the world’s leading remote and proactive health care company.” Do you believe there is merit to assume a product company like Apple or Samsung will end up evolving into a health-care company?

I certainly think that they will have divisions of their companies that are successful, but can you name any dominant player in the health-care industry today? I mean, there is no one dominant player. So, I think that statement, albeit sensational, is a fallacy. Samsung already has a massive business building MRI machines. They build X-ray machines and X-ray equipment. They already have a pretty massive health-care business. It is not on the consumer side, but it certainly is something that’s core to their global entity.

I do believe companies like Apple will be a big factor in health care in 2025. I think that they are going to continue to make great devices. I think that they’re going to sell boatloads of them because that is the game that they’re in. If you look at what they have done with iPhones, look at what they have done with the iPad, these are transformative platforms and I think the Apple watch has the opportunity to do that too eventually. Do I think companies like Apple and Samsung are going to solve all of the world’s problems related to health care? No, I do not. But, do I think they’re going to provide a really valuable product that adds even more value to the health-care system over time? Yes, I do.

3) The narrative regarding wearables is fairly pervasive in health tech, but how is the Internet of Things (sensors outside of wearable devices) going to change health technology in ways that are currently unexpected?

One way that the Internet of Things in general is improving things is that there is now scale. The fact that sensors are becoming cheaper, and more cost efficient, and yet give higher resolution of data I think is really helpful.

You now have smart asthma inhalers that are able to measure your breathing; in real time when you’re inhaling the device it gives you the correct calculated dosage of medicine, as well as the GPS coordinates of the location that you’re taking that dosage. With this type of data we can start to look at casual factors at a population level. For instance, determine where people are having the most number of attacks and start to look at environmental conditions. At the population health level, you can ask questions like, “In this particular area, at this particular time of day, asthma rates are spiking by 50 percent. Why?” We are starting to be able to do interesting things like that at scale with these type of connections.

There is a company called Aldebaran building a prototype for a next generation robot. It is five and a half feet tall. It would be in your home and it has the ability to not only communicate with you, but also has the ability to help you up if you fall. So, this is great for in-home elder care. It also has the ability to help with medication adherence. It has the ability to help you decide the pill you’re supposed to take and it can record you actually taking it. Then, if there are any problems, it has the ability to call for help. It’s a 24-hour, always-on solution for care for people who need that in their homes.

A company called Proteus is doing amazing things with ingestibles. You wear a patch on your stomach and you ingest a pill, and when the pill is in your body it is activated and powered by the enzymes in your stomach and communicates with the patch (that’s on your skin). It tracks your dosage, the medication, and the time that it was taken. So, it knows what was in your body and at what time. This type of technology could save the health-care industry billions of dollars due to wasted and unused medication consumption.

4) Putting yourself in the role of a futurist, what are your hopes and predictions for health tech over the next decade?

We’re starting to see some really interesting things. One thing I will say about health care, is that unfortunately health care is slow to adopt new technologies. This is an industry that, for some good reasons actually, still largely relies on pagers and fax machines for everyday communication. The primary reason why adoption is slow is because new technologies that are brought into health care need to be bulletproof. They need to be perfect — or as perfect as you can get them — because when you are dealing with data and/or a message that could make or break a patient’s well-being you really need to make sure delivery is perfect.

Health care has the opportunity to have massive disruption from ideas that have taken place outside health care. I think that we are starting to see that already taking shape with the current wearables movement. Devices like Fitbits and Jawbone are now commonplace. What is exciting is we are starting to see new sensors that were developed in areas outside of health, but are starting to make their way to health care.

For example, there is a company called SunSprite that we connect with, which is a wearable tracker you wear on your person to measure the amount of sunlight exposure you get in a day. This is great for patients with Seasonal Affective Disorder. Sunlight trackers, light exposure meters, these things have been available for a long time, but never in a wearable context for health care (in this case specifically for patients with Seasonal Affective Disorder). So, that is one example of the future.

Another good example is we are seeing John Hancock Life Insurance, very recently, are starting to use wearable trackers as a metric for adjusting your life insurance premiums in real time. Just like you can go to your Progressive auto insurer and they put a device in your car, and they adjust your auto insurance rates based on how well you drive, this is something where your life insurance company is giving you a wearable tracker and adjusting your life insurance premiums based on how you live.

There is an abundance of opportunities for us to learn from other industries, and apply it to health, and apply new technologies to health in really innovative ways. I think that some of the most innovative things that we’re going to see moving forward are also better ways of making health care more frictionless and seamless.

5) Validic has had to keep up with a market that has been in a constant state of flux, iteration, and evolution. What are three key product development and/or product user experience concepts (specific to health) that you could highlight from your experience that can benefit digital health creators?

1) I would say getting the user experience right — and this is for app developers and device makers alike — in my experience patients who have a specific disease state… they’re happy to have monitoring around that disease, but they don’t want to be constantly reminded that they have a disease. So, for example, there is a company that’s developing a continuous blood pressure wearable. In their initial user testing, they had the blood pressure reading on the watch face every time you look at your wrist. Well, patients with hypertension, they are just trying to look at the time. They don’t want to be in a meeting at work wondering if the meeting is starting late and they look down for the time and they’re reminded that, oh, by the way, I have hypertension, right? So, from a user interface perspective, it’s important to provide users the quantification and provide the measurements, but don’t necessarily remind the patients of the problem. In fact, some of the user feedback that I’ve heard are things like, “Can you just not even show me the data and just send it directly to my physician because I want them to have it? It’s important that they have it, but it’s not important for me to see it all the time, right?” So, I think that getting UX right is always going to be important.

2) Patients only care about their health when they have to. So, what I mean by that is, for example, if I’m a 45-year-old, obese man and I know I need to cut down on my meat, and salt intake, and maybe drink less, certainly I already know all of that, right? But, I’m not going to be overly worried about it until I have a pre-heart disease episode where the situation highlights I need to make a change, right? This reality is a really hard problem to solve in health care. It is something that I think health-care companies often forget. They’re solving for future problems, as if people always care about what is going on today. Patients generally only care when something “happens.” That doesn’t mean that we can’t affect positive behavior change before that negative event occurs. We just need to incentivize the behavior change to something that the patient will care about. I think that’s something that is often missed, we design like the person or patient is going to care at the onset without a trigger or incentive.

3) What we’re starting to see is that patients who do use a wearable tracker are also more likely to keep track of other information. When you have a person that has genuinely adopted a wearable, you now have identified a person who has made self-tracking part of their routine. This trend is also being driven organically somewhat by the growing market share of wearables. This is important because the desirable experience for this segment is different than the casual user. If the digital health experience is tailored to this user type — knowing that the efficacy of a particular intervention can potentially have broader user experience implications — we likely can increase overall usage by lowering the adoption barrier.

Interview with Al Lewis about Workplace Wellness Programs

Al Lewis is an outspoken voice in health care and workplace wellness. He is the author of several books on these topics including Why Nobody Believes the Numbers: Distinguishing Fact from Fiction in Population Health. He has founded and held senior positions at a variety of health-related organizations including the Population Health Alliance. Al’s latest endeavor Quizzify is one of only a few population health companies to measure its outcomes validly and guarantee savings for the organizations it serves.

1) Your graduate focus at Harvard was law. Before you discovered that most health-care measurement methodology is flawed, what was the initial impetus that led you to the pursuit of exploring, examining and developing a career that revolves around health care and corporate wellness?

I went from Harvard Law School and I was going to become a lawyer. I stumbled into this recruiting session for a consulting firm and there was this guy giving a recruiting presentation and I was just mesmerized by it. The guy was a manager at Bain and Company by the name of Mitt Romney. I applied for a job at Bain and I didn’t become a lawyer.

I worked at Bain for eight years and toward the end Bain was imploding at the time. I jumped ship and went to work at a health-care company and that’s how I got into health care. Then, I stumbled into a job as a Chief Executive and Chairman of a NASDAQ health-care company called Peer Review Analysis in 1993. In 1995, we merged with another company and I had to find another job. Once again, I kind of stumbled in a new role, this time in disease management, but I figured out that there was an opportunity there, especially in the Medicare population. There was so much chronic disease and yet doctors were getting reimbursed very little. Primary care doctors were getting reimbursed very little and there was nobody watching patients between visits.

At the time, I thought there was an opportunity for disease management and I started the company Disease Management Purchasing Consortium. During that time health plans — and to some extent employers — just jumped onboard. I started basically putting these programs in place, and was doing that merrily until somebody came along and essentially said that my measurement was wrong and that, in fact, disease management saved much more money using something called “prospective identification,” some wacky methodology that their actuaries told them to use. The belief is that they were actually saving a lot more money. I thought, this doesn’t look right. So, I sat down with a spreadsheet and compared my methodology to theirs and, guess what? My methodology overstated the savings and so did theirs. In my book Why Nobody Believes the Numbers I compare prospective identifications, annual requalification, and it turns out both overstate savings and you have to do something different altogether.

When I went back and looked at all the numbers I’d put together for people, they were all wrong. The savings didn’t exist. So, apparently, it is perfectly fine with other people to do this, but it was not fine with me. What happened next is detailed in the 2007 blog post: A Founding Father of DM Astonishingly Declares: “My Kid is Ugly”.

Since then, after writing Why Nobody Believes the Numbers, I basically went rogue and started naming names, built They Said What?, I call out the liars, etc. But, it wasn’t my first choice. I was essentially forced into it. I mean Rachel Carson wrote to Monsanto and pointed out the hazards of DDT very nicely and they didn’t do anything. So, that’s when she went rogue. I basically did the same thing, except that in my case, it’s more [Silent Spring author] Rachel Carson meets Dave Barry.

2) In a recent article about the folly of content curation and the way information now gets disseminated, the author Katie Herzog argues that in the age of the Internet we often herald things that distort the bigger picture. Beyond the frustration you have publicly shared that Baicker’s seminal research is continually used to support the efficacy of employee wellness programs, how does an organization effectively find the signal within the noise? How do you believe organizations should define success?

First, let’s define wellness as two types of wellness, wellness done for employees and wellness done to employees. Now, wellness done for employees is basically not quantifiable. It is things that employees want to do, and you are making it easy for them to do it. Maybe they want fitness facilities. Maybe they want better food. Maybe they want flex-time. Whatever it is, it is not things that they have to be bribed to do or punished if they don’t do. And that’s the big difference between wellness for and wellness to employees. I don’t think there’s anyone who objects to wellness for employees. I’m a big fan. But, what the Affordable Care Act is about and what the controversy is about is wellness done to employees.

The thing about wellness done to employees is that the results have to be quantitative to justify the expense. Wellness done to employees, you have to either bribe employees or fine them into doing it. If somebody likes something, they’ll do it for free. Coercion damages morale. This is, by the way, is according to a Health Education Research Organization (HERO) report.

HERO are the ones who admitted the morale impact, but you don’t have to be a rocket scientist. Just look at the comments on essentially any article in the lay media about wellness and it is all negative. So, advocates of wellness done to employees have to justify it with math. Math is shockingly easy to do.

Regarding math, some people do it, but many people don’t. Consultants don’t like it because they can’t really charge that much for it. In this case, done right it also shows the opposite of what they expect. You can start with page 22 or 23 of the HERO report that lists a bunch of diagnoses which have corresponding ICD-9 codes. HERO didn’t list them, but anyone who wants them can get them from me. I’m happy to send them. The June posting on the Quizzify blog has a Wellness ROI template all ready to go that has the ICD-9s in it.

The HERO report did their own ROI analysis and they found $.99 in in savings per employee per month from reduced hospital admissions. That, by the way, was without adjusting for the fact that many of the costs at the population level are coming down anyway. So companies are actually turning out an entire wellness program to save $1.00.

Now, you have to subtract the cost of the program. Let’s say the program is $1.50 an employee a month. Good luck finding a wellness program that cheap. Most start at $100 a year per employee. So, then you compare the cost of the program to the reduced claims cost, and that gives you your best-case scenario for savings. I say best case because you have other costs of wellness besides the vendors, consultants, and lost work time, and that kind of thing.

So to somewhat answer your question, you cannot define success by monetary savings. That’s why I’m offering a $1 million reward to anyone who can show that it does, because it doesn’t. My million dollars is very safe.

3) In a recent interview with James Pshock from Bravo Wellness, Pshock resurfaced something for me that I think is at its core, true. Organizations — when they begin as entrepreneurial endeavors — are not generally created to shoulder the burden of employee health care. This is a burden progressively being assigned to enterprise through policy — although few would disagree that a business should be concerned with the well-being of their employees. Based on your experience and opinion of workplace wellness, what do you believe is the obligation of an employer when it comes to employee well-being? 

As an entrepreneur, my job is basically to not put up roadblocks, to stay out of their way, and to be responsive if they have health or personal issues. The staff I have at Quizzify is dedicated, highly productive, motivated.

I don’t have an “obligation” to provide for their well-being per se. But, if I don’t provide for their well-being, either their productivity might suffer or they’ll go somewhere else. So, I don’t need to be told by the ACA, by Congress or the President what I can and can’t do with my employees. I’m going to do the best thing for my employees regardless.

The absolute, positive, last thing that I would ever do to my employees is institute a pry, poke, prod, and punish wellness program. It would cost me money. It wouldn’t save me any money. It would damage their morale. And it would drive a wedge between me and them.

Since you brought up Bravo Wellness, if you go to my expose of their previous website (which they bowdlerized following my exposé) they were essentially bragging about how they can save an organization money immediately by “fining” employees. They also spend a lot of time talking about their appeals process. I would not — in a thousand years — put in a wellness program where I fine my employees for things that have nothing to do with work, where a wellness program was so unpopular that I needed an appeals process to get out of it.  Not to mention the very questionable screens they want to run on your employees.

4) In some of the assertions you make regarding the folly of using motivational tools to promote wellness you’ve used Penn State as an example of how things can go wrong when an organization utilizes extrinsic incentives in an attempt to persuade employees towards better health.  In a recent WellSteps seminar, Dr. Steven Aldana said that after checking in with Cassandra Kitko, an adjustment was made at Penn State that merely repositioned the penalty as a reward? In other words, little has changed there although the remarketing of economic incentive has muffled the criticism. In your experience have extrinsic motivators ever been effective? Or, in your opinion, are economic incentives always going to be “forced wellness”? If yes, how? If no, why do you think that is?

Dr. Steven Aldana is not one for fact-checking. He has called me a liar before, but has never provided an example of where I have allegedly lied. I don’t mind. As you can tell, I love the fact that he’s calling me a liar. The truth is Penn State’s original program is gone. It’s done. There’s no spinning of that statement. His statement is incorrect and I’m pretty sure he knows that he is incorrect. If you look at Dr. Aldana’s website, he’s got a wellness ROI calculator. If you put in zero for “annual cost increase”, it doesn’t matter what other variables you put in, by the year 2020, you always save $1,359 an employee. So, he essentially made it up.

In terms of extrinsic motivation, I actually do find that there is a place for extrinsic motivation. The thing about extrinsic motivation is that it only works once. It works to get somebody to try something. And, after that, they have to like what they are doing … they have to want to do it on their own. Otherwise, you simply have to basically keep paying them, and paying them, and paying them to perform the desired behavior. I, myself, was extrinsically motivated to do something healthy once. In fact, ironically — and here’s the fun part. This is that NASDAQ company I was telling you about, Peer Review Analysis, and we were going to switch to self-insurance. I looked around, and we had a lot of nurses there. Nurses, ironically, have horrible health habits. So, I thought: well, if we are going to go to self-insurance anyway, I should have a fitness contest and give people $50 as a reward for participating in fitness activities. What happened is that, of the 100 people in the company, the same 20 who played on the office Frisbee team and the volleyball team were the same people who signed up for this program. The other 80 could have cared less. I, myself, signed up for the program. What I started doing was, out in the western suburbs here of Boston, is I started riding my bicycle to work in mid-town to collect the $50. Well, guess what? That was 1994 and, essentially, every trip I take from mid-town Boston that doesn’t involve snow, rain, or dead of night, I do on my bicycle today because I basically paid myself $50 to do it once and I loved it!

So, I think motivation has a role, but it’s a role of trial and it’s a role of doing something once. It’s not a role of continuing to raise incentives until you get someone to do what you want them to do. We don’t need to force people to do things that they just don’t want to. It is not good for companies, and it is certainly not good for employees.

5) One thing I have found challenging about the recent affinity the workplace wellness industry has had with BJ Fogg is that his popular behavioral model softens the importance of environment. It takes the work of Kurt Lewin and then glosses over the significance of external factors. As a layman of your work, I get the sense that you also advocate that wellness “wins” can be made through environmental design. Is my assumption correct? And in addition to this assumption, right or wrong, where else do you see organizations getting it right?

Yes, without question. I am far from an expert in this field. In my opinion, what you want to do as a company, and if you listen to the wellness industry they advocate this, too, it’s all about creating a supportive culture. As the leader of a company myself, what I’m trying to do is I’m trying to make my organization be as valuable as possible. Part of that is creating an environment where people want to come to work. But, ironically, wellness vendors have essentially nothing to do with creating a culture that makes people excited to go work. To the contrary, the evidence shows many of these types of programs create cultures that do the opposite.

Simply being mindful of environmental factors can have a huge impact. I have an excellent example of that in my book with Tom Emerick, Cracking Health Costs. Back to Peer Review Analysis — it’s going to sound silly — after employees complained about the conditions of our bathrooms I contacted the management of our office building we were in and asked, “How much extra would I have to pay you to clean the bathrooms twice a day?”

We came to an agreement and I paid them probably less than what would have financed a wellness program for probably 20 people. So, for the cost of the wellness program for 20 people, I had the restrooms cleaned twice a day and I don’t think there was an employee in the company who didn’t take notice and was grateful.

What did this accomplish? The organization was telling the employees they mattered. And you weren’t telling them by making some pronouncement that they mattered or by giving them lunch once a month. What you were telling them on a daily basis, doing something very unglamorous — I mean you can’t get more unglamorous than that — is that they matter.

Interview with Bill McBride about Fitness Delivery

Bill McBride is the co-founder and CEO of Active Sports Clubs. He is an industry veteran in the field of health and wellness, and has served as the Chairman of the Board of Directors for IHRSA, a Board Member on ACE’s Industry Advisory Panel, and currently serves as a Medical Wellness Advisor for the Medical Wellness Association. Bill also sits on the advisory board of several other companies including Fit3D, Club Solutions, Club Industry and previously has worked with Zuberance and MiGym. Bill has been a mentor of mine for several years. You can learn more about Bill at his personal website

1) Given your vast experience in the wellness industry what are three universal truths in “getting it right” that apply to all fitness delivery (not just health clubs) that have surprised you in the sense that they are not industry standards?
  1. There is a lot of fitness delivery that is “contracted” on the assumption it is all homogeneous – a commodity. I need a clean “house”, so I hire a housekeeping company.  I need fitness, so I hire fitness people.  Fitness is very personal and people that are qualified and engaging are critical; but for a company, the brand delivery and standards that the brand represents are also critical.  Getting the right people on the bus, training, and “enrolling” fitness delivery professionals seems to be a constant challenge in all aspects of fitness delivery (regardless of distribution channel).  I am not surprised by this fact, but I am surprised by the slow progression in solving this problem on a broader scale.
  2. The true power of group fitness is often discussed and most people “get it”, but it hasn’t been truly leveraged as of yet. Think for example of “Debbie’s Class” – Debbie is a member.  Why not have a class just for Debbie and her friends?  Why not personalize group fitness further?  This could be done with school mom groups, civic groups (Girl Scouts), and neighborhood friends that walk together, etc.  Personalizing group fitness is rarely approached in this way. Approximately 44 percent of club members exercise with a friend. There is an opportunity there. 
  3. I’m surprised by how many health clubs look the same in regards to layout and offering. The lack of true differentiation and uniqueness in the space seems intriguing.  This is what Curves figured out earlier on.  We need different configurations and approaches to bring in new members. 

2) Why do you think the health club industry has not been more involved in the evolution of health technology? Only recently are you seeing health clubs really integrated with digital health devices, when the industry (as the experts in the area of wellness) could have had more of a hand in shaping these products?

Human nature seems to favor a scarcity mentality, instead of an abundance mentality.  I think club operators were (or in many cases are) afraid of outside “competition” that could cost them members.  Even my friends at MYZONE, whom I’m a big fan of, were reluctant to open their system for participants to download their data at home until recently.  I asked them over 4 years ago to open their system because I wanted our members to download and see their data in real time.  Their position back then was ‘no’, we want users to go to the club to download their data, this forces a club visit for our clients’ clubs/gyms. In their defense, they viewed their product as a club retention tool, not an activity increasing tool. While on the surface that may make some sense, just as scarcity mentality always seems to make sense in the short-term.  But long-term, an abundance mentality always wins out.  MYZONE came around and gave me some credit in their shift in thinking, but the world has already realized it’s a transparent, information-based reality now. Clubs have to realize this and embrace broader thinking as active lifestyles will always need professional human support.

3) You and I are both fans of Michael Porter. I just read Zero to One where Thiel builds off Porter’s ideas and suggests that the current entrepreneurial dogma of iterating off competitive ideas is a race to the bottom. In the book Thiel highlights using examples how perfect competition can destroy an industry. I believe a case could be made that is happening in the health clubs industry, especially anyone that goes up against the main chain operators. Where are people getting is right in the industry? Put another way, what are the common attributes of the players that are able to rise above the low cost health club model?

This is the million-dollar question.  The high-end that can’t be replicated with ease (cost of entry too high) will always serve a consumer need: Exclusive, lifestyle, family and prestige based. These companies create an emotional bond, evoke status and its members are brand connected and in many cases for generations (think Four Seasons, fine dining, etc.).  The low cost play will also have a steady stream (think fast food or Motel 6). It’s the accidental middle that are in the most trouble.  Middle price point players with a strong value proposition (reasonable but not low price) and a very controlled expense structure can do nicely if engineered properly.  Now for the current twist, we have the boutique offerings – not a high cost of entry, but a very high perceived service level.  In this modality, I think boutique hotel (Kimpton or Joie de Vivre).  These are high service offerings and very nice, but relatively small and some “nostalgically older”.  The concepts that are too trendy seem to be short-lived.  So anticipated trends versus modalities that stay around is another avenue of consideration worth thought. For example karate, yoga, Pilates and cycling have proven not to be trends. And how low can the low price point go? I heard recently of a $5 a month club.  At some point soon, I expect to see a “free” club model with all revenues and profits come from ancillary programming like retail, clothing lines and ads within the club. Free with premium offerings, or a play like Pact where you actually get paid to workout.  I agree with you that a large segment of the industry doesn’t appear to be working towards adaptation. 

4) Guessing that you do not think this question is an all or none proposition, how do you think the rapid expansion of workplace wellness programs, and the emergence of open access residential wellness solutions, will evolve how (and who) is providing fitness delivery today?

There are many corporate wellness companies in the space already.  The older ones are simply staffing agencies.  Nothing wrong with that, but there is an opportunity for the health club management providers to play a much bigger role than they do today.  Free fitness access is here in a lot of places and it will continue to grow.  Parks, trails, in hotels, on company campuses and residential complexes – access to activity and fitness is going to continue to rise.  Wellness is a nebulous term.  What does that mean?  Lifestyle engagement and promotion of activity through fitness, movement, sport and recreation will grow and prosper.  The industry (health club or health club/fitness center management) must realize the genie is getting out of the bottle..  Think abundant solutions and total well-being, not just fitness and not just what can accomplished in a single space.

5) I know you enjoy the guesses of futurists and are an inherent forward-thinker. Regarding fitness delivery, you wrote a great article for Club Insider (Are We Asking The Right Question?) where you answered the question, “what will be the same in ten years?” Your argument for taking this approach was it is a more compelling question than “what will be different in ten years?” This is probably true; however, it does leave me the opportunity open to ask it, “What will be different in how we will deliver fitness in ten years?”

I believe the industry will be forced to morph from sales and marketing with great facilities (as the current historic primary focus) and more towards programming, coaching, wellness/medical services in very engaging environments.  We will see different looking clubs (I hope) with much more holistic services and creative designs.  I envision it to Lifestyle Centers …not just rooms with equipment, as those rooms and outdoor spaces with equipment will be commonplace by then.  And not just studios to move around like we have today… It will be more about the “feeling” and “community”.  This is where technology and wellness/medical integration will be game changing.  I see more with wearables and digital health that support total well-being, disease management and prevention.  Technology that can help people form and maintain habits, make activity/exercise more “fun” or “tolerable” and support individuals utilizing wellness professionals to improve their quality of life.  A lot of people in our industry focus on results.  Results are a by-product of a great offering.  The focus should be on delivery and habits.  I do believe that great structural design, warm & friendly social activity and innovative programming will always be around …just as we will still have hotels for rooms away from home, and great restaurants for good meals on the go …but there will be disruption like hotels saw with the shared economy (Airbnb) and restaurants saw with social shopping (Groupon). There are big things on the horizon and I am excited for the future.


Interview with Dr. Robert Rucker about Nutrition and Academics

Dr. Robert Rucker is a Distinguished Professor Emeritus in the Department of Nutrition and the School of Medicine at the University of California at Davis. A list of his accomplishments include tenure as the President of American Society for Nutrition, an American Association for the Advancement of Science Fellow, as well as an American Society for Nutrition Fellow. Dr. Rucker has over 35 years of experience researching nutrition and biochemistry. He is also my father and is the ghostwriter for almost all of the pyrroloquinoline quinone (PQQ) content found on this website.

1) One of the debated topics in nutrition is whether weight management is really just a matter of calories in/calories out; or alternatively, significantly influenced by the types of calories that are consumed. Based on your rich understanding of nutrition and biochemistry, where have you landed on this debate?

This question is not as easy to address, as some would make it.  Energy regulation – the factors associated growth, work, and maintenance of body temperature – is complex and multifaceted.  Clearly when energy intake is less than needed, body tissue becomes a metabolic energy source; however, weight gain or loss as inferred from periodically weighing oneself on a scale is not a function of a simple algorithm, particularly in the short-term.  As it relates to weight gain or loss of body tissue, each of the major components contain differing amounts of energy.  For example, a pound of stored fat is ~ equivalent to 3600 kCal per pound.  Muscle tissue is the equivalent of 700-800 kCal per pound.  Independent of its water content, a well-nourished adult has about 400-500 grams or 1600- 2000 kcal of stored carbohydrates, mostly as liver and muscle glycogen.  When or how much of a given tissue is utilized as energy sources varies depending on the timing of meals, exercise, and a need to maintain body temperature. Utilizing tissue energy also causes varying amount of water release. Thus, 2-3 days of severe dieting (e.g., generating a 3000-4000 kCal deficit) could translate into a one-pound loss or a 5-7 pound loss, as measured on a bathroom scales, depending on factors in addition to only estimating calories-in minus calories-out.

Regarding diet composition, there are a number of scenarios wherein the composition of food also plays a role in net weight gain and loss.  An obvious one is a diet high in simple sugars, particularly fructose or high fructose corn serum (HFCS).  Our knowledge of the control energy homeostasis has increased dramatically over the last decade resulting in an appreciation that food or energy intake is orchestrated by complex signals originating from adipose tissue, the pancreas, and the gastrointestinal tract, plus others.  Differences in food composition can affect these signals, which in turn can influence food intake and body heat regulatory circuits.   With respect to fructose or HFCS, both are weak stimulators of insulin and the adipose-derived hormones that control food intake, in contrast to glucose, a much stronger stimulator.  Moreover, although fructose is eventually converted to glucose, the process is not rapid and fructose, as such, is not “stored”.  And, fructose is a better “driver” of triglyceride synthesis than glucose.  Add to this that body heat regulation is very precise.  Compounds, such as fructose, that are rapidly absorbed and are not easily sequestered or rapidly metabolized can compromise body heat regulation.  Thus, calories from fructose or HFCS are less likely to allow one’s metabolic system to regulate itself at least in the short term. 

What can happen? The liver slows oxidative metabolism when there are energy excesses, particularly if an abnormal elevation in the body core temperature can result.  What the liver may perceive as an excess of potentially hazardous fructose-derived calories are converted to triglyceride and next sequestered away in adipose as a protective strategy.  In this regard, some of the energy derived from fructose is rendered ‘out of the picture’ and may even result in some weight gain, because of its conversion and “storage” as fat.  

Again, these kinds of questions are not easily addressed.  An example that I sometimes use in lectures is that over the course of a year, most in the class will consume anywhere from ~ ½ to one million calories (at a daily expenditure of  ~1500 to 2500 kCal per day, which translates into consuming a ~ton of food per year).  Given that an annual normal weight gain or loss is usually no more than a pound or two, it says a lot about the exquisite precision of food intake regulation, as well as body mass and heat regulation.  Throw in dozens of genetic factors and other variables and it is easy to ascertain that there are good reasons for controversy and our inabilities to address (easily) weight management when it deemed important.

2) Given all that you have researched, what are the three most impressive compounds you have come across (other than PQQ)? You can choose either based on their historic significance and/or the fact you have been impressed by their demonstrated physiological benefit.

In the late 1700s – Antoine Lavoisier, the so-called “Father of Nutrition and Chemistry” described that metabolism and oxygen were inexorably linked.   He also demonstrated oxygen was related to animal heat production.  Accordingly, oxygen would be one of the molecules.  In the latter part of my career, concepts related to cell signaling and secondary signaling molecules begin to be major influences.  As a consequence, Nitric oxide (NO) and 3′-5′-cyclic adenosine monophosphate are two others that I would add.  NO is an important cellular signaling molecule involved in many physiological and pathological processes; cyclic-AMP works in part by triggering the activation of certain proteins involved in cell signaling.  Knowledge regarding their underlying mechanisms of action facilitated my way of thinking about the mechanisms of action of certain dietary biofactors, such as pyrroloquinoline quinone (PQQ).

3) As the world increasingly points to poor nutrition for the rise in healthcare costs, little has been done to improve the nutritional education in top-tier medical schools. You were a nutrition professor at a top-tier medical school. Why do you think this is?

A part of the answer is that there is no medical board certification for nutrition.  There are 24 boards that certify physician specialists.  Many hospitals demand that physicians must be board certified to practice or bill for a specialty.  Accordingly, when there are nutritional issues, they are usually handled by a paramedical (i.e. a dietitian or a nurse) or occasionally a pharmacist with nutrition as a sub-specialty.

With that said, many medical schools do give nutrition training some kind of “lip-service”, although it is often less than it used to be. Most medical schools have moved to more integrated curricula and problem-based learning. At Davis there used to be a strong course in nutrition, but as the Davis medical school curriculum became more and more integrated, the visibility of nutrition was truncated.  Regrettably, as long as nutrition remains as a non-board certified area, I don’t sense that there will be a move to make nutrition more visible, even though there is seldom an argument regarding its importance.

4) On the topic of research, some of the fondest conversations I’ve had with you are discussions regarding the thoughts of intellectuals who take either side of Thomas Kuhn’s work. We have discussed articles like The Truth Wears Off and books like Laboratory Life. Do you think there is “real world” truth to be found, or do you think as seekers of the “truth” we are tasked with inventing it?

As a starting point, I agree with Kuhn’s premise that scientific advances are characterized by dynamic shifts in thinking, i.e. what he defines as paradigms,  ” universally recognized scientific achievements that, for a time, provide model problems and solutions for a community of practitioners”.  In my life time, the major paradigm shifts that have most influence my thinking as a biologist have been: 1) the Watson and Crick model of DNA and its importance, 2) concepts related to cell signaling, 3) concepts important to epigenetics (changes in metabolic regulation caused by gene expression rather than an alteration of the genetic code itself), 4) polymorphisms  (metabolic changes caused by point mutations in a gene or genes), and descriptions based on metabolic allometric scaling (ways of describing how the characteristics of living creatures change with size).  If I were to note more fundamental principles – Darwinian evolution, the principles of thermodynamics applied to biology, and the concept of nutritional essentiality in the context of given nutrients or metabolic processes would be at the top of the list.  Each of these paradigms can be described historically in the context of Kuhn’s stages of scientific development, which ends with the establishment of concepts that truly influence changes in how we think about a problem.

Regarding ‘Are there real world truths to be found?’ I certainly hope so. However, to find such truths, I would argue that one has to engage in clear rational thinking directed at seeking out evidence for the truth; a process along the lines of what Richard Dawkins implies, when he emphasizes the importance of asking the right question.  In contrast, inventors of “truth” in my experience tend to be more concerned with faith, authority, or profit (in a broad context).

Although far less philosophical, the Jonah Lehrer article in the New Yorker, The Truth Wears Off, also provides some very important perspectives that – as you note – have been the topic of several of our discussions.  With respect to nutrition, this has been an interesting period, particularly as it relates to the assessment of validity and reliability of certain nutrition-related assertions and their presumed relationship to important health issues.  In some instances, our lack of rational thinking has caused some “true believers” to promise too much.  For a premise to become health policy, the data and observations behind it must be reliable and reproducible.  Unfortunately, we too often let belief and personal perceptions over ride the facts of a given question or premise. 

With regard to why there is so much controversy as it relates to nutrition, some reasons that are developed in the Lehrer article, such as those offered by John Ioannidis (e.g., Why most published research findings are false. 2005; PLoS Med 2: e124) are provocative.  However, they are mostly statistically in nature.  Now that we have larger and presumably better databases and better tools to examine them, plus the ability to ask better questions, it should not be surprising that some amount of previously published research may not be easily or consistently replicated.

I tend not to throw barbs, if the studies in question are complex in nature and initially were carried out for a good purpose.  As an example – In studies of osteopenic bone diseases, such as osteoporosis, the highest rates for hip fracture, as an outcome measure, are often observed in those of Scandinavian decent, who are located predominately in the North Central parts of the US. The lowest rates for hip fracture are observed in those of African decent, who are located predominately in the South.  Consequently, it is not unreasonable to surmise that observations related to hip fractures made 3-4 decades ago in studies performed in Minnesota or North Dakota may not match the results of similar studies, if repeated using a contemporary and highly diverse Californian or Floridian based subject pool, some of whom may be a blend of an identifiable Scandinavian and African-derived gene pool. Further, studies for purposes of comparisons are often difficult to match with respect to the age, sex, and/or activity levels of subjects.  It is now more difficult to control environmental and epigenetic factors than in the past, because of our ability and freedom to travel or consume more diverse diets.  With more genetically diverse subject populations and more complexity in lifestyle, there is greater likelihood that there may be regression to some kind of statistical mean, i.e. less significance noted in a study than may have been noted previously. 

Other issues are barriers that we have rightly put into place for the protection and more ethical treatment of subjects. For example, many of the early paper regarding basic human nutritional requirements were reasonably correct in their conclusions.  However, the studies were often performed using institutionalized individuals (prisoners or mental patients) who could be studied for long periods or subjected to metabolic risks using protocols that simply cannot be used today. 

The ways that we report and characterize research can also present problems. Current research often uses past research as a potential starting point or platform, i.e. Kuhn’s second level of discovery before an actual paradigm emerges.  However, most research (past and present) is/was not published unless its outcome demonstrates some type of statistically significant positive effect.  It is the common practice of most journals not to publish null or negative observations.  Again, it is not unreasonable that some current replications of past work may differ, particularly when there is a better sampling of subjects and use of improved analytical methods. 

More troubling to me is the mismanagement of data by those who should know better.  The reason why some health-oriented work cannot be reproduced is because it is the product of data dredging designed mostly to identify relationships with some arbitrary level of statistical significance. If the “data dredge” is merely a search for statistical significance, it is too easy to make wrong inferences.  There is little wrong in using an arbitrary statistical endpoint to better define a hypothesis or question, but to report such findings as facts without some type of independent conformation or validation is disingenuous at best.  More egregious, of course, is reporting only selected data in order to show some kind of statistically positive effect.  There is also dishonest reporting.  When I was more involved in journal editing and management, it was troubling to discovery that work using the same pool of subjects had been published in different formats in other journals.   The issue was not so much self-plagiarism or lack of consolidation; rather, it was the implication that the observation submitted to a given journal was from different sets of independent observations. The number of independent research papers on a given substance is sometimes used as a measure that the product is safe or efficacious. One may have a different opinion of efficacy or safety with the knowledge that the reported data was from a single set of subjects, rather than multiple independent sets of subjects and each reported in separate papers.

Regrettably, the commercial nutritional supplement business is perhaps the worst offender.  Very little research is done independently and most often is driven by marketing goals.  As we now know, it is possible to buy the results that you might want from some of the commercial research outlets for publication in one of the dozens of online journals, many of which serve as “vanity presses”.  The other areas that compromise good nutritional practice are the constraints placed on the policing of the supplement industry, because of the Dietary Supplement Health and Education Act and the impact of having it as a part of our National Institutes of Health, a National Center for Complementary and Alternative Medicine.  The Center’s goal is to support research and provide information about complementary health products and practice, but what it defines as evidence-based medicine often isn’t, and credibility is given to alternative concepts, where little is deserved.

5) Piggybacking off that, as I embark on my own journey aspiring to be an expert in the field of workplace wellness, based on your vast experience, what advice can you pass down to me as I continue the search for “truth” with a drive to contribute to the greater good?

Success, particularly the effective movement of ideas, is all about “networking”.   Bruno Latour and Steve Woolgar clearly make this point in their book, LABORATORY LIFE: The Construction of Scientific Facts. I was lucky enough to be mentored by individuals who can trace their academic history back to those who discovered or defined the functions of given vitamins or nutritionally essential minerals.  What was transferred to me, as a part of that network, was a way thinking; also the importance of maintaining a high integrity. It is also essential to have a thought out, as well as thoughtful, work plan; and, as Latour and Woolgar note, one’s credibility rests on whether you are perceived as reliable.  The challenge is to maintain integrity in workplaces (e.g., the commercial aspects of nutrition and wellness) that often talk about integrity and validly, but seldom want to test for it, and that are driven in large degree by the marketing of what are sometimes shallow promises.