4
May

Digital Health Summit 2014: Track-a-holism: A Disorder Worth Having?



so this next session is called traka hall ism is this a disorder worth having what we we started thinking this year about habits and the the word quantified self was a hot topic last year and I was thinking to myself what the quantified self errs are the people that are so obsessed already and they're so healthy that what about the other people out there that need that that that actually need these these habits and so this session came came to birth so I want to welcome Leslie Ziggler who's not only a good friend but she's an incredible entrepreneur designer health advocate and her motto do or do not there is no try have a great session I figure you can't go wrong with Yoda right so thank you for getting your lunch we hate we would hate to be the thing standing between you and food but welcome to track ahall ism so i'll be the first one to say it I am I am Leslie and I am a track aholic I actually spent an entire year of my life while i was i was part of the founding team at rock health which is a startup accelerator in san francisco and i spent a full year of my life actually tracking absolutely everything that i was doing so you know obviously a lot of the stuff that these guys are working on is really appealing to me but went through that process of you know what does all this data mean how do I deal with all of these different devices what do I do about this and then really like how does how does this stuff start becoming useful I think quantified self is a pretty buzzy buzzy thing right now so these guys are going to shed some light on you know what's going on with manufacturing and the device side how do we actually start making sense of what those devices are and what their uses are and then also we have a very interesting new product that i will let Rob explain a bit better but maybe we can just go start with with mr. Kraft when we were when we were standing outside we were talking about extreme cases right so these extreme cases of track ahall ism can you share the one that you were talking about well as a physician I'm a bit of a tropic haul up I'm wearing like you know six or seven devices plus a patch those are just the ones you can see that's right I've got the other patches like right here one extreme case you know we think about quantified self or track ahall ism around often simply wearable devices and vital sign data but I meant one gentleman a tack us meet up who was reporting all his thoughts for like ten years and need a database of all his thoughts we could look up what he was thinking when and where and that's a bit of a scary scary thing but as we get more connected to our devices in our our google glass and beyond will have access at any more of our prior states so track hallows my think should attract tracking tracking i'll go well beyond our sort of usual quantified self state well Rob do you want to talk for a second about maybe we can just give a little background for everyone if you want to talk a little bit about Soylent absolutely so my name is Rob and Soylent I would describe as a form of qualified food I am a quantified self enthusiast slash guinea pig I like to try things and I thought it was perhaps high time that we started looking very closely and breaking down our food and trying to quantify better and have a better visibility of exactly what we're eating rather than just basing things on tradition and you know bringing food into the loop on health and healthcare I think would be very very advantageous in the long run so in order to you know quantify food as it is so ingrained into our bodies you know it because us to qualify our health as much as possible as well so I don't wear many devices but I do sometimes use the the decks con sensor I'm really excited to see the CEO Terry here and get my blood work done regularly I even have a seaman's dimension expand chemistry analyzer in my basement so I can measure my own blood it was getting too expensive to send stuff up to the lab all the time but I just see that I believe that an ounce of prevention is worth a pound of treatment and that in order to improve one was first measure and so by having better visibility of our health and our food I think that we could you know do a lot for preventative care and overall health and wellness and what's really interesting about Soylent so I don't know how many people in the room have tried to track food can I get a anyone yeah okay it's terrible it is the worst because nothing there is no easy way to do it it's all kind of you know I think it has this many calories whatever what I think is really interesting about Soylent is it's actually kind of the opposite of tracking it takes that whole business of trying to keep track of all the calories and all the stuff completely out of it so you can focus on other things why don't you anything that's gonna happen with that one of the other tracking elements now is the microbiome fact that you can have track your GI tract bugs throughout there's a company called you by him doing that that's gonna help inform better nutrition as well as a kind of chronic thumb authority bowel disease elements like even obesity yeah I'm still waiting to get my sequence back from people on both buddy yeah very very exciting get Jessica on that so you know in in the vein of devices so we've got our two hour to device makers here on the other end would love for you both just to talk a little bit about form factor and how you how you both look at that uniquely i'm going to start jen sure yeah so I I I too am a fat colic I never made the house without in fact I sleep with these so this is a tracker that as an ECG this is a tracker that has a optical heart rate monitors it's getting to your point about the bone factor I think one of the things that we think is really important is that you should be able to visualize what you had a has been right away so you don't have to really have to wait for you to sync the data to a phone to a be able to visualize it so we actually have on both of these devices you can actually mode in and you can actually see the activity and the sleep pattern for the entire day and kind of the moon factors kind of dictated by that requirement that's great yeah and i'm christian i work for sony mobile and i'm here because actually at CES relaunching my our new product the sony smartband so that's how we tie into mobile health and also we launched a product smartphone as called the c1s which features n plus which helps us tie into are basically all kind of sport activity trackers that's on the market today so that's how we fit into this mobile health space I think we actually have a video dad you yes shell off I'll have a short video clip explaining the new sony Sony band real ownership so please any plan to bring it to apples so we have us Apple fan girls came yeah so our phones are android-based so we support all Android for the three devices and we know iOS is huge especially in states so perhaps going forward this is something we can consider yeah so along the lines of this form factor think so everyone who's you know raising their arms at this point it's all wristbands right and this this was the thing at CES last year to right you know fifth it finally launched a wristband everyone's got a wristband you know I would love to hear just you know feel free to chime in I do we think wristbands are the right form factor I mean they're they're kind of wonky and clunky it's hard when you're on your laptop and your type thing you know it's a little kludgy if you're going on a run so maybe yeah we look at you looked at the concept of dynamic we're wearability and what that concept is that there are certain parts on the body that's more amenable to a tracking device list is actually one of them there's an area around the neck here around the waist around the ankle the top of your the foot but I think the risk is actually I think an ideal acceptable position because wristwatches has been around for a very long time and it's kind of fashionably acceptable and the other kind of big advantages that you should be able to kind of glanced at it and be able to take into information but we did actually early on working with NASA looked at devices that go on the upper arm as well as a ground ahead but this is acting for consumer application just seems to be the most ideal finish you got some thoughts say I think one element I so my academic had is I shared the medicine track at a program called singularity University and a program called future med now called exponential medicine and I think a lot of this quantified self and these technologies will start to disappear as we move into this Internet of Things and so this is still sort of in I think sort of in the Q s 1 point 0 era but as we get the MC 10 type patches things in bed and our clothes and our cars the the connects in our homes that start to measure us this will be way beyond wearable and you know that Google now of quantified health will start to emerge so you know imagine having a GPS for your health care they might show up in your Google glass or elsewhere notifications from all these elements because i think it's no one device it's going to be enough for four track a holics or actually for really prevention diagnosis and therapy it's going to be the integration and my favorite examples you know like your car has 300 sensors you don't care about any of them you don't want to glance at them you want to know when your own check engine light goes on and that means that's the landing of the sensors the big data the analytics the sort of the IBM Watson that can learn about you I like to call it for dick till it excels the form factor will soar disappear there may also be something to be said for for putting aesthetics and fashion first you know someone may want to signal to their friends and their in their colleagues that they are the type of person that likes to track and is very serious about their health and you know but people want a high degree of individualization for this sort of thing I mean you look on the trade show you know there's one there's only a couple colors of iPhones but there's thousands of these different cases so people love to express themselves with their devices these days and seems like fashion is really merging with technology and so getting the you know the hardware down first and then taking stepping back and looking at the use case and you know people been wearing these technologies these watches for a long time and it seems like it's not really that much about telling time it's you know it's a it's an accessory so maybe having taking a more traditional maybe even analog watch face sort of form factor with the tracking maybe something that could get it into a new market and I'm thinking about around the same lines actually I mean sometimes color is not enough to be able to switch colors but plastic rubber I might not be for everybody somebody switch up you want to have some kind of leather bracelets or textile fabric play-based and so I think to not look techie it's very important to many people to not be able to you don't have to explain yourself like what's that when you restore what are you wearing right now so it has to blame your style yeah that's important yeah I mean if you look at companies like mc10 who's always been a favorite of mine and I'm actually working with now you know what's so interesting is it's just this patch and it flexes with your body built for the human body not against seeking the body but that it brings me to this other point which is okay we've got wristbands we've got external patches that do things that can sense things you know different analyt analytes and whatnot who on the panel would actually would you allow someone to implant something how do we feel about in Atlanta we're talking about disorders I'll volunteer like implant whatever you want as long as I never have to track another calorie another food like I'm in AI think that would be the next step in terms of having passive tracking and abstraction in just on the amount of different parameters and the precision of that it seems to be that there's only so far that a surface device can give you and that having something maybe not completely inside but at least some component of which which interacted with in you know past the skin may be mandatory actually the new generations of medical devices planted defibrillators and ASE DS neural pacemakers those that are in a body and track things they can often communicate with IP addresses and apps you heard about Dick Cheney turning off his connectivity he couldn't be hacked much a good thing if he had been so that even raises the issue of you know what happens when someone hacks your insulin pump or your pacemaker and then who even owns the data I think you go campus he was here who had to had trouble getting the data from his own implantable devices and I one thing we haven't mentioned here yet is we're still all you know wearing individual information you can share things with jawbone and others in the community but when this will get more powerful I think in the broader context is this idea of it's been mentioned here participatory healthcare and just like google map google maps or ways allows you to share your location and your speed you could have a little privacy you and then getting some information back about what's the right route to school or where's the traffic jam or the police hanging out and I think there's an element to blend track ahall ISM with big data and sharing kind of the idea of being a data donor will be a part of that whether it's implanted or or wearable I think one downside about implantable is that I personally like to get try new things every couple maybe people to you haven't you just getting very small yeah could have several I guess at the same time but also like we spoke yesterday is perhaps a pill could be interesting as well that's true that's very familiar to us to take a medicine pill and it's not as scary as to implanting something and we know what's going to happen with that pill eventually so yeah but again the gut is a very chaotic environment and getting the blood I think would be have the most of the useful metrics in order to track you know hormones different perhaps not even just for tracking butts of in health care you know having the the patient take a drug and having visibility of the concentration in the blood stream rather than just say oh you're big I take 60 milligrams per you know seeing exactly the dose that's in the bloodstream I think would be very valuable for the treatment so we have two physicians on the panel and I'm curious how you see on you know the whole movement of quantified self actually entering into medicine in the meaningful way I think we're still kind of you know the two are still at odds right like most of these devices are not reimbursable they're not seen as medical devices they're not regulated that way I don't think counting the number of steps that you have should be regulated but you know do you have any thoughts as to how medicine starts playing with qantas a quantified self I think it's sort of the opportunity to move from quantified self to quantified health and I talked a lot of physicians and others who are still sort of clueless about the fact that there's a connected blood pressure cuff that you can buy in an apple store and that you could prescribe that to your patients as a tool so I think part of the meme of this meeting and as we're seeing the sheet change is that as a physician I can prescribe you an app on device hopefully that data flows back I said Leslie I'm prescribing you exercise let's see how you do even if you never I never look at that date of the Hawthorne effect might mean stay more on top of what you're doing and the incentives are trying to be aligned by audix and others so the progressive car insurance model and his physicians are getting more reimbursed based on value and outcome I'll start being incentivized to prescribe those sorts of technologies it may be checking your microbiome and your 23 Emmy data and others to integrate that in as part of your care plan do you think doctors are doing enough to encourage the tracking and prevention rather than the treatment well I mean the sea change opportunity is to move to you know healthcare not sick care and that's where a lot of these things are going to going to meld maybe I'll just mention briefly something that uh of this BS sort of a special announcement here I get asked all the time which one of these devices is right for me or as a physician what to prescribe so I'm actually you can get early peek I'll just need the slide deck up given the explosion of digital health devices in this new realm of moving to potentially quantified health and the concept the consumers are now getting on the bandwagon as well as potentially clinicians and there's the idea of the smartphone physical that should has started in others the new tools for for everybody to start using the trick is how to make sense of those and if you go to you know down on the floor here and say yes you're overwhelmed even in an apple store now there are 30 plus connected health technology so the challenge is to sort those out so based on that issue just our soft announcing here will officially launch in week or two Bionic health which is sort of eight the first marketplace and community for all of digital health for curation for community for comparison so you might want to figure out which one of these is right for you if you're swimmer you're a biker or your runner you may need different form factors you can rate them you can see all the scales look at the comparison engine so even as simple as you know the wearable elements like a jawbone has different comparisons to a to a Fitbit and how do you make sense of those so would love for you to take a look at that there's comparison engines if you try it out now put in the code digital health and get fifteen dollar store credit and we love sort of feedback about how that emerges as a platform to connect of ratings and grow this movement in way well so I saw price on there as one of the comparison metrics and actually I think this is a really important you know right now these devices they're getting more widespread they live in the apple store they live in places people people go and you know people are more used to talking about this now but they're still kind of priced out of reach of most people so I would love to hear from you guys you know kind of when you're making these products obviously there's a hard costs there's rd there's a lot that you have to recoup but how do we actually price these products so more people can afford to use them not everyone can afford 150 bucks for a wristband yeah but this is a very still new type of devices but I mean a year from now I think we see that in most product categories that the prices are rolled over time and I think that will happen eventually in this category of devices as well as components become sheath / as volumes go up so the price point we see right now is because also that's the value of the products right but over time I think we can see different price prices coming out for different moments now I think there don't be too two trends so generally the prices will come down but I think over time also there'll be more features added to it so we we are starting from monitoring motion primarily but we had heart babe for example and we're working on a nasa'a sponsored research on looking at other parameters such as some measurement of stress for example and as as technology progresses I couldn't see that we would get more could a physiologically relevant information that's monitored by the devices so that brings us to probably the most important thing that I think these devices are still kind of missing especially at you know from my experience I mean I was tracking I tried like 80 different devices and apps and things and at the end of it I had this great big spreadsheet and I took it to my doctor and I said look what I did isn't this great and he's like yeah great what if what am I supposed to do with that right so you know like beautiful visuals on the video that you showed you know a lot of the device used mo the things that I saw in yours how are we actually going to get from a place where these devices you know live on our bodies but they don't really tell us anything when we need to when do we need to know it we all want to move to proactive health care so theme of this meeting I think and continuous data can predict it we want to move to an era of predictive and continuous in proactive health care and as a physician again if I'm getting every EKG and and pick up that you might have I'm going to be overwhelmed so we need the filters in place not just for the individual so you get sorted out the right information but as a clinician I want to get that ping of the five patients in my clinic who's hypertension is out of control that need to come in and and we know behavior changes hard row through clinicians and patients I think another element of this needs to integrate with design thinking we have myers brigg tests for a personality what if we had a myers-briggs for behavior change so I know that your app and your UI needs to be different than mine and the way you the way you display it and make that meaningful they may even get to the point where you know the hardware and the measurement is really commoditized and the analysis is the kid is the killer feature and the defense ability of these different companies you know whoever has the best algorithm who can catch something the earliest based on the same set of data or parameters maybe that be you guys are gonna work on baby yeah can you talk about any anything past soylent actually um I would just say that I you know the idea of fun is to abstract away the details of a lot of the complexity of food and then you know with health and body we would like to do largely the same thing and using some of the I think will eventually become industry standard hardware and measurement devices closing that loop basically with your consumption in your behavior is something we would like to offer basically be you know they're all people come in all shapes of sizes and all these different parameters and having more personalization and more passive monitoring is something that is it going to need to happen as device makers how do you guys look at kind of making sense of this data in what and what Daniel said it which i think is really important which is like these don't need to just be reactive they actually need to be predictive and start learning things about you so I think one good example what we're working with NASA on al program and I take a good example of proactive kind of preventive procedures what NASA is doing with the crew looking to do with the crew and these the crews of obviously very healthy people but you put them in an environment let's say for the Mars program where they have to be in a very confined space six people things could get crazy and to prevent that they want to monitor each of the croup example they have the science of being able to monitor it the levels of activity and sleep the sleep patterns and one thing they can do is if someone is kind of going down the path where the sleep pattern is very poor they're very sedentary then the flight surgeons can come back and say hey you really got to get your sleep schedule back in track so I think something like that but it's actually applicable here as well as if we have a big data you're able to kind of collect data over longitudinal period stem we ought to be able to kind of detect kind of trance that's going to take you to our place as that's not so good and an algorithm like perhaps say it looks like if you continue to on this trend if your sleep that's going to be good it's going to be much worse and your health is going to be negatively impacted you should do this type of especially some others metrics that can be very hard to measure like stress yeah and something that may be a little more abstract and a lot of things go into that you can see that you know someone's very stressed they're going to start making bad decisions and catching that earlier is obviously better but that's not a simple blood test its price I'm concerned so I think one thing that's really nice about a tracker that's on the same person all the time is that it may be difficult to kind of measure between people but you can it's much easier to see deviations from the same person because you can very quickly establish a baseline which you kind of determine as normal and you basically look for deviation from the norm to kind of get that something that might be wrong and also I think it's very important to put all this data into context so yes showing data to user might be not enough for him to understand what's going on in his life so that's one thing we try to do we try to put all the data on everything the user is doing ankle so instead of showing a user took 3,000 step last Tuesday the use for caring abacus perhaps see it because it was raining and I was stuck in hotel as well so then this makes much more sense and also if you can't go back or review a week yes see that you have been spending 15 hours in a car commuting it will inspire you to about doing being active during the week and this will start to interact with your environmental & A panel to do with Robert Scoble and thinking about you know the integration of smart homes and all this data it may know from your mood and you're tracking data when you come in the house that you've had a lousy day it's been raining out for the right kind of music on and light the fire and I think will be other elements of that that's sort of start to blend together one problem this may run into though is trying to determine what is normal you know how we can each other but they would have a relatively bad day maybe every day is bad I hope not but I ran into this problem soon you're sending my blood to different labs everyone seemed to have different reference levels and there's seem to be not that much agreement on a lot of these different things so even if you know we can't even agree for now what is the normal range for some of these parameters what if something the ideal range is something completely different so how do we really determine what is normal when there's so much variation in different peoples biology's will start to be our own controls and that goes beyond just our biometric you know blood-based levels I mean mood for example can be picked up by your voice on your phone and if you're let's say take an extremely you're bipolar patient if you're manic or you're depressed your pace of speech is dif different if you're getting parkinson's your voice will change those things can be picked up as well and when that blends with knowing your genomic predilections your current microbiome and the camera on your smartphone and tablet they can pick up your heart rate and your emotions that's where it really starts to get interesting Oh speak up guys um so I think there's an elephant in the room that no one's really addressing but I think we're going to have to start thinking about as these technologies become more mainstream which is who owns the data and how do we deal with that and how do we responsibly you know when their incentives and awards and things you know for insurers like how does how do these devices start playing in that environment because it's coming yeah I think really it's it's the first time and you history where we are able to get big data from relatively healthy people i think it's a on present unprecedented event and i think this whole kind of the issues of you know who exactly who owns the data what is a fair kind of use of the data by the companies have aggregated them i think all of that's going to be settled I guess so within a few years I mean I think clearly by default it should be private but if you look at just the sheer potential of something like Watson being able to churn through all of this data being generated that would you know the upside is so high I mean should we even encourage people or of what incentives could be offered in order to get people to share their data and I liked what dr. Kraft said about some sort of progressive model where your health insurance premiums may be a little lower if you were if you were doing a lot of proactive Lee healthy behavior and maybe an additional factor for that can be willingness to share this data for basically the greater good we're in the face book hero we can now opt in be ready early you had two different rooms we heard about you know give me your damn data theme there's data donors or there's folks out of the Netherlands or the name of people to opt-in not to share their genomic information they're wearable information and again when we start to crowdsource the big data which is really the small data from my digital exhaust when the early ears Arab being able to do that but as these exponential curves happened with AI big data and sensors it'll I think it's going to be much more meaningful and in terms of the question really who Pam starts to pay for this now it's at about a pocket hundred hundred hours 44 device I think in the near future some of the payers the progressive ones will start to say okay well we'll cover you doing this and your insurance premium will be lower and if I prescribe you a blood pressure cuff or de cometer or an exoskeleton a downstream that will be something that's start to beat it starts to be covered and one great example that coming together I shouldn't really rock health company Armada health it's not just a sensor or a dashboard it's often community we have to do things for our soldiers in the trenches they've taken pre-diabetics who are about to become diabetic put them in a social counselor I give them a connected scale and can show pretty credibly that taking an old model was done with people in person you can change that outcome I think that'll be paid for by the ventures I think even today if you go on out to a google search you may not even today when you do a Google search you may not really be conscious of it that somewhere someone's someone's collecting all of your interests and all that and I think there really is a big issue of working out the privacy issue as the devices become much more prevalent yeah allowing people to X by me that was a big conversation for a while was dead you know there were some device makers that and apps for that matter that weren't letting users actually export their data so you know I think the those days the the walled garden days are hopefully behind us but I think we have a lot of questions left to answer so I wanted to make sure we had a little bit of time for audience questions because I know that there probably are some that I would love to just close out and see predictions what does the future hold no start okay dr. Craig the futures coming faster than you think so I think the future is going to be again the blending of these technologies again this idea of the OnStar for the body you know multiple it's no one sense there's no one piece of data as the integration of that to have your own proactive check engine light if you are trying to avoid an accident all the way to knowing your your your your jeans and beyond to help track and manage it chronic disease like diabetes or heart failure and that we're going to go into the the norm the the track hall is a melon will be something that's prescribed and when you're sent home from the hospital after a case and beyond it's going to be part of the prescription I think there will be a gradual ramping up you know not really an inflection point but as time goes on it'll just become more fashionable and because it is very useful people will have much more of a desire and you know much more of a social visibility and incentive to just you know maybe monthly checkups and not wearing something that will measure everything every 15 minutes but regularly getting a panel of tests and just tried to measure everything prevent everything and then as time goes on that will get the you know differential will decrease in the precision will increase and eventually I think that preventive health care will be a software problem as we just have it's just variables yeah I could share a little bit about kind of the research that we're doing with NASA which is it's kind of a blue sky research that's going to come to I guess fruition in three to four years and some of the stuff that working on currently is looking at markers for blood pressures one of the mark are being able to measure vasoconstriction that's kind of related to stress are we looking sorry so yes I'm we're looking at the parameters beyond just motion and hard way which is very readily available today we're looking at being able to measure markers for blood pressure or markers for vasoconstriction electrodermal activity of perspiration and building a sense of fusion engine that kind of God takes all these disparate information together and make some sense out of it for example one that is really important i think is being able to put it stress and fatigue from these variable are various parameters so maybe three years from now we have this really smart devices that's on your vest I'm more hoping for a mass market deduction so that more and more people track their health then maybe get aware of how they're living the life I think small improvement will will can lead to huge effect for for everybody yes knowing how you live your life and make small change it's the empowered patient movement the new drugs empowered patient the sweeping the CEO of your own health all that becomes part of knowing your own information not just the data but what it means and how to steer yourself rooting down paths great I see one question already hi my name is sippy weibo Lake I'm with Fitness trucking I have something of a sports background I use digital health both of my personal life and in my business um I've gotten to the point now where I use time trackers to track how much tracking and quantifying I'm actually doing throughout the day my question is is all the quantifying that I do and I think that we all do we don't want to just see the numbers because all it's interesting we want to move from quantifying to optimizing ourselves and I just my question is what will it take to get to that point where you know I track my food my moods my sleep my sports training business what will it take to integrate the the nutrition with the sports and the performance so that there's some app or device that says well you woke up at this time your resting heart rate was this this is what you ate yesterday you train your fatigue level is this so you should train this amount today you should study this amount today you should eat butternut squash and so I want something that integrates all of this obstacle you're scaring me I I think the biggest obstacle which is a key factor in your health is being able to accurately monitor what you're taking in because the calories expended it so it's I think it's a relatively well solve problem but the calories taken in and the quality of the nutrition you're taking and it's really hard because right now you really have to list that down manually and that that I don't it hopefully does unless you're unless you're taking Soylent which takes away that's it takes guy so the answer is toilet is all the problem though tell them saw ya know that's very good point that you know measurement only gets you so far you have to act on it and at some point you know the software or app or whatever can recommend all at once and tell you what it would take to optimize but it will always at some point beyond the user and I think we should have that amount of freedom also serendipity kind of takes all the spontaneity out of life to just know another question my name is Marcus shawl from MK shawl consulting in Maryland and we talked about the analytics in having discrete inputs in terms of collecting the data do you all have actual objectives that you're trying to hit in those is analytical and discrete is the inputs that we calculate or the inputs that we are collecting my simple one is sleep that's an underrated element of healthcare it's pretty easy with these devices to tell whether you're deeper light sleep they're not necessary picking up your REM cycles that was EO that went away so that's what we very discreet that all of us could be paying attention to that can be done out with simple apps and wearables and that can have a significant health impact I think there's a lot to be said for a picking your goal and after you meet that not worrying about it there's a lot to be said for a sort of standard you know for me I picked you know standard set by the US military in terms of help you know if you can do this number of pushups this number of sit-ups this smile time and then if I keep my you know body fat percentage at a certain level that's enough and then not really worried about that unless you know you cross that threshold so I think that can reduce the amount of stress as to continually optimizing just picking a point where that's good enough you're not glad yes so for me the lesson initiated I'm not really an athlete but I think the two things I can do readily I think sleep is really key and then just raising the level of physical activity even if it's just walking those two I think I can control you're welcome does anyone else have a question no okay think quick k well I think that wraps us up then we're two minutes ahead of time oh my gosh I know yay for being on time right panel quantify panel

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