Factors Influencing Treatment Outcomes

Treatment outcomes are influenced by more than most people think.

To the average person who rings up a clinic, books and appointment and then shows up to get help with their painful problem, the expectation is that the treatment will do something, and hopefully make them feel better.

Often, people do get better, but not because of what they had done treatment wise.

If someone feels better, does this even matter? Is the outcome all that is relevant?

To me it does.

And it should to you as well.

Why?

Well, firstly, if you are paying for treatment and getting better despite what was done, not because of it, then you are wasting your money. I don’t know about you, but I work too hard to be wasting my money.

Secondly, if there is risk associated with a particular treatment, and an equally effective alternative is available that has less risk, well it’s obvious you would want the safer option.

Thirdly, if we know what influences treatment outcomes, we can strive to optimise all the variables.

So what are the factors influencing treatment outcomes?

Your Condition

If a practitioner wanted to look really good, they could focus on treating acute low back pain.

Simply seeing people for 12 weeks would give them approximately a 70-80% success rate (condition resolving), no matter what they did! (1) This is because for most people, acute low back pain is a self limiting condition that gets better with time. Experienced practitioners can probably predict your recovery more accurately (and there is research to support this). Essentially, they could just play the numbers and end up looking good. (2)

There are many similar conditions that do get better with time, and what research is showing us, is that often minimal management is just as good as lengthy treatment plans. (3, 4)

On the flip side, there are some conditions which we simply cannot treat, but rather have to settle for managing as well as we can. Many (but not all) chronic pain conditions fall into this category.

Time

Recall how I mentioned many conditions improve with time?

Well if you suffer from one of those, then you need to be patient. This is often lacking. I don’t know if impatience is more prevalent these days compared to decades past, but it definitely makes people do silly things.

Things like taking too much medication, seeking out controversial treatments and “doctor shopping” for stronger analgesics are all too common.

If a practitioner says the best course of action is to do nothing and wait, then they aren’t being lazy, and they are definitely not idiots (as is commonly mentioned to me in practice). What it means, is they are likely trying to save you from unnecessary interventions, which all have potential costs and risks.

Your Expectations

There is growing body of research showing that your expectations have a big influence on whether you get better.

This isn’t a case of new-age “believe in it and it will come true” stuff either.

Rather, if you expect a certain outcome, both consciously and unconsciously your behaviours and thoughts end up shaping that outcome.

This has to do with all sorts of things, but I like to credit the concept of priming for some of it. (5)

Priming is when you are shown words, pictures or similar with a certain theme, and then you are unconsciously influenced by them. Studies have used elderly words with students for example, and the students have changed posture and walked more slowly. When young words were used, they moved quicker and stood taller.

Because of this, managing expectations is one of the most important aspects of treating pain. If you are expecting to get better in 2 weeks, but you have a 2 month condition, you will need to adjust your expectations accordingly.

Likewise, if you expect you won’t get better because you are “old” and have lots of “wear and tear”, well chances are, you won’t.

Your Current Health Status

People who are healthier recover from injuries faster.

People who recover well from injuries are less likely to go on to develop chronic pain.

If you have co-morbid conditions you are likely to recover slower than someone your age with the same condition who is healthier.

Some things are in your control: what you eat, how much you move, whether you drink and smoke or take drugs.

Some things aren’t in your control: genetic predisposition, accidents, environmental factors.

All you can do is to try and maximise the positive things you can control, minimise the negative and worry as little as possible about the rest.

Your Socioeconomic Status

This isn’t talked about much, because in Australia (and many other cultures) it is generally taboo to talk about money.

If you are in a low income household, or unemployed (not by choice), then your both your current health status and your recovery from painful problems are negatively affected.

The eminent British epidemiologist Prof Sir Michael Marmot, the president of the World Medical Association and presenter of 2016’s ABC Boyer lectures, has shown that a person’s lifestyle and health choices (what medical types like to call your “risk factors”) simply cannot account for the differences seen in death and disease among people of different incomes. In his landmark Whitehall study, which examined British men working in different levels of the public service, those on the lowest grade of employment still had double the risk of dying from heart disease – even when accounting for all the factors we traditionally think of as causes. There was a clear gradient of risk between levels, with deaths decreasing as the public servants climbed the employment ladder. (6)

Being an osteopath, I’m not trying to solve all our political and social issues, but they must be considered when considering outcomes.

Practitioner Skill

This is a topic that interests me to no end. Two great questions linger in my mind:

  1. How much of somebody’s outcome is down to practitioner skill?
  2. What components of practitioner skill are the influential ones?

If you look at all the other factors, you can see pretty quickly that practitioners often take more credit than they deserve for achieving positive outcomes, then turn around and blame every other factor but themselves when they don’t.

I feel that the skill of a practitioner is not only having good diagnostic and treatment skills, but being able to have all these listed factors circulating in their minds simultaneously, while also giving people the voice, space and time they need to explain their story.

They then need to put all this information together into a plan of action that people can understand and apply, so that they actually achieve the desired outcomes.

I think that selecting a good practitioner can actually be the difference between developing chronic pain or not. There is evidence to suggest appropriate identification of risk factors, coupled with education and reassurance all reduce the likelihood pain progresses from acute to chronic.

So what makes a skilled practitioner?

I would say they all have highly developed the following attributes:

  • Clinical knowledge
  • Clinical reasoning
  • Clinical skills
    • Assessment and diagnostic skills
    • Treatment skills
    • Rehabilitation skills
  • Communication skills
  • Experience

Each of these areas is a massive topic, which means it takes time to develop them.

This doesn’t mean that more experienced = more skilled. Rather, it means you need to be continually learning and applying, so that your experience is congruent with the current scientific understanding.

All this complexity is why they call it practice. 

Conclusions

The purpose of this post was to illuminate the complex nature of treating pain and injury, and why things don’t always go to plan.

This is why it is important to have the right support. Family and friends are a good starting point, as they can provide social support and reassurance, but for anything more than a simple strain, often it is good to have medical management, to (hopefully) prevent the slide from acute to chronic.

Good education from the beginning, appropriate management (not over management, not under management) and a view to long term outcomes, not just symptom relief are all signs you are in the right hands.

It’s always funny to me that someone will happily drive half way across the city to go shopping, but when it comes to health professionals, many people choose convenience.

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 


 

 

References

(1) Prognosis in patients with acute low back pain

(2) Predicting recovery in patients with acute low back pain

(3) Effect of early supervised physiotherapy on recovery from acute ankle sprain

(4) Comprehensive physiotherapy program or advice for whiplash

(5) Blink: Reading Guide – Chapter Two

(6) Our so-called ‘universal healthcare’: the well waste money and the poor get sicker

 

Movement Quality, Health and Fitness

When it comes to movement quality and fitness, nature had it right all along.

Developing movement quality before fitness is hard-wired into us.

We crawl before we walk.

We walk before we run.

First we develop the quality and control of movement. Then we start doing more of it, which develops our capacity of movement (fitness).

This is the pathway that humans have followed forever, until recently.

Now, around about the age of 5, we send children off to school, where they learn to sit still. We even give out stickers to the kids who do it best.

At this age, things aren’t too bad though. We have about 4 years of movement “training” under our belts compared to 1 year of sitting.

Fast forward to age 10, and that ratio is now 4:6, not great, but still not too bad.

Let’s accelerate to 18, when most kids, now young adults are graduating from high school.

They’ve now been sitting for the majority of their day for 14 of their 18 years.

Many would have played sports recreationally, and suffered injury as a result.

Can you see the problem?

And we are only looking at an 18 year old, who for all intents and purposes, is in the peak of youth, and physical potential.

What happens when we hit 40, 50 and beyond?

Fitness First, Then Injury?

You’d think getting fitter and healthier would be easy. Our bodies are designed to thrive after all.

The problem is, people start out with poor general health.

Think of the average person over 30. They are likely over stressed, possibly anxious or depressed. Body functions like their digestion, elimination and breathing are dysfunctional. Their physiology is impacted by poor sleep quality and quantity, and abnormal light exposure. And, they aren’t moving at all, with the average Australian clocking in at a measly 4000 steps per day. (1)

For the average person who decides to take action and make themselves healthier, it’s an uphill battle before they’ve started.

So when they start exercising with intense, and often short term programs, they are actually adding more stress on to an already stressed body. Combine this with a restrictive diet, and the situation becomes even worse.

It doesn’t take a genius to work out that this might be too much.

Get Healthy First

What should you do instead?

Before you jump head first into an intense exercise program, commit to walking*.

Sounds too easy?

That’s the point.

If you walk daily, you experience a myriad of health benefits that compound. This sets you up for more intense work in the future, if that’s your goal.

Walking is sustainable, so you can do it for the rest of your life (and you should).

You can walk outside, which is ideal, but if weather or safety doesn’t permit, you can walk on a treadmill.

The whole point of starting with walking, is that it is supposed to be mentally and physically achievable. Success breeds success.

All this walking will:

  • Reduce your stress levels
  • Improve your body composition
  • Improve your cardiovascular health
  • Allow you some “down time” in our constant “on” world

This in term will help you sleep better, so your mood improves as your brain and hormones start to balance out.

As a result, it becomes easier to improve your diet, because you aren’t fighting against a stressed out and fatigued brain that wants quick fixes of sugary, salty and fatty convenience foods.

The principles of a healthy diet are simple. Changing your diet is not, because it is about changing your habits.

For most, the best approach is to work with a dietitian or nutritionist. Because in most cases, it isn’t a lack of information that stops people making change. Everyone knows they should eat more vegetables, but most don’t eat enough.

If you can’t, or don’t want to, you can try and change yourself.

For the best chance of success, you want to change one thing at a time. This is why I recommend walking first. It establishes a healthy habit which can have a snowball effect.

With nutrition, change one meal at a time.

Check out the Australian dietary guidelines. Then, starting with breakfast, look to improve your diet one meal at a time. Once a breakfast becomes a healthy habit, move on to lunch and so on.

If you can start walking regularly, and get your diet in order, you are more than half way to a healthy lifestyle that minimises your risk of all kinds of diseases.

This also enhances your quality of life, which is often overlooked – it’s not just how long you live, but how well you live.

This process might take time. Months, even years for some. So it is important to learn how to relax, both physically and mentally.

You can’t keep putting stress upon stress and expect good results, let alone good health.

Learning how to relax physically and mentally allows your body to recover, which is when your body repairs and your health improves.

Everyone is different, but I find things like having a spa/steam, getting a massage, going for a walk and reading a book great ways to relax either alone, or with family/friends.

Again, the challenge here is more mental, the feeling of being in a “rush” to get fit.

It’s funny, because usually this rush is felt after years of doing nothing. Hence the appeal of “12 week programs”. A better approach would be a “12 month program”, but often this is felt as being too slow. The same people who feel 12 months is too long will undoubtedly be saying “wow, that year has just flown by” come December.

The simple act of getting healthier will improve your fitness, but trying to get fit when you aren’t healthy won’t improve your health, and can often harm it.

Then Move Well

Movement quality, like health, is often skipped over in the chase for capacity.

Like skipping the “get healthy” stage, skipping movement quality is a recipe for future injury.

The problem is, movement quality is hard to measure.

Doctors will be able to tell you whether you are healthy enough to exercise with intensity, they won’t be able to tell you if you are ready for a loaded squat or running.

There is no one way to move well, but there are common features on moving well. Think of watching a high level dancer. It likes smooth, controlled, almost effortless. They are moving well.

Moving well is a lifetime endeavour (are you sensing a theme?), but to start out, you can perform some simple tests to see what your starting point is like.

  • Can you touch your toes?
  • Can you reach over and under your shoulders and touch your fingertips, without straining?
  • Can you squat to below parallel without your heels rising or losing your balance?
  • Can you stand on one leg with your knee lifted above your hip for more than 10 seconds?
  • Can you perform a plank for 30 seconds? What about a push up? What about 5?

Most of these movements are simple, yet involve a lot of physical capability. If you can’t perform them, are you ready to be running for 30 minutes or performing “functional high intensity workouts”?

If you lack some fundamental movement quality, you don’t have to put your fitness on hold – remember, improving your health, in this case your movement quality, will improve your fitness.

Improving your movement quality doesn’t mean you don’t get to use load either. Load can often be corrective.

But it does mean identifying why you aren’t moving well.

If you have a mobility issue, simply adding load won’t resolve it. Likewise, if you aren’t moving well because of impaired sensory function, you will want to address that.

Moving well is a continual process, but after you have established a healthy base, you will likely want to build capacity.

Next, Develop Your Fitness

You need fitness too.

Especially later in life, when having low physical capacity becomes problematic.

The key though, is to build your fitness/capacity before you get older. The earlier you start, the better, but it’s never too late. Never.

How much fitness, or capacity do you need? Enough to do what you need to do, with a little left over.

This left-over is termed the physiological buffer zone (2).

It is basically your margin for error.

The bigger your buffer zone, the more you can do without breaking down, getting injured or ending up in pain.

A favourite study of mine showed that in US Marine recruits, those with low Functional Movement Screen (FMS, a simple screen to assess movement quality) scores and a low 3 mile run time had a much high probability of getting injured during physical training (3).

Both the run and the FMS were predictive, but the combination was much higher.

This suggests that moving well, or being fit alone is beneficial, but moving well *and* being fit has a compounding effect.

High Training Loads Protect Against Injury

Lots of recent research in sports science is showing that high training loads are protective of injury. (4)

This means, the more work you do, the more resilient you become.

However, how you get to those high training loads matters.

If there is a sudden jump in workload, that is a big risk factor for injury, so you have to build up slowly. If you look to fit people for inspiration, and try and model what they are doing, you are failing to take into account that it likely to them years to achieve their current level.

Monitoring your workload is important, so that you can know when to push and when to back off. A good personal trainer or exercise physiologist can help you, and will accelerate your progress.

Conclusions

This is a lifetime process.

If you do it correctly, focusing on health as your priority, then you set yourself up for a lifetime of benefits.

It’s definitely not easy.

You will have periods where you feel like it is all clicking.

You will have periods where it all seems so hard.

But, if you establish healthy habits, then you can continue with the behaviours that benefit you no matter what life throws at you.

 

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 


 

 

References

*If you are unable to walk due to disability, then a similar low intensity replacement is ideal, but for able bodied people, walking is the best option.

(1) Australian Daily Steps

(2) Movement Reserve: Enhancing the Physiological Buffer Zone

(3) FMS and Aerobic Fitness Predict Injury

(4) Monitoring Athlete Training Loads: Consensus Statement

(5) Andrew Read and Greg Dea seminar, September 2016: Advanced Program Design

Do You NEED To Exercise To Be Healthy?

Kids Exercise

Integrative Osteopathy is situated within a gym.

Our treatment process will often include exercise or exercise advice for many patients, who are often already gym goers or exercising in another way.

Exercise has many benefits to almost all aspects of health and well being. Does this mean everybody should exercise?

Often, patients will talk about how they “should” be exercising, despite not enjoying exercise in the past.

Part of the challenge of practice is finding exercise that people enjoy doing, as this is often the biggest factor in whether someone sustains the habit for the long term.

However, for some people, exercise is not an option, either because of physical limitation, time restrictions or lack of enjoyment.

For these people, and everyone else, this post explores whether you need exercise to be healthy.

The short answer is no, but it’s a lot more complicated than that.

What is exercise?

Exercise is any activity performed with a specific physical/health outcome in mind.

This is in comparison to activity that is incidental, or part of your normal daily life (including work).

Example: going for a walk for no other reason than to move your body and maintain your health (specific physical outcome) compared to walking to the local shop to buy something you need.

Whilst both are the same activity, it is the intention that defines whether something becomes exercise.

We have developed exercise to compensate for our ever decreasing activity levels in daily life, as well as for enjoyment and to derive specific.

To add to the mix, sport is a form of physical activity, but it is not necessarily exercise.

Sport is a competitive activity played with the objective of winning. Sport can be healthy and a form of exercise, particularly when pursued recreationally, with little/no care to the outcome, but as soon as the outcome is the driving factor, it is no longer exercise, as health is often sacrificed for increased performance.

To recap:

  • Exercise is an activity performed for a physical/health outcome.
  • Sport is a competitive activity performed with the objective of winning.
  • Incidental physical activity is that which occurs when performing your normal activities of daily living, researchers call this NEAT (Non Exercise Activity Thermogenesis).

What is health and fitness?

A discussion about health and fitness is useless if everyone has their own definition of what each is. The following are commonly used definitions, found via google dictionary.

Health = “the state of being free from illness or injury.”

Fitness = “the quality of being suitable to fulfil a particular role or task.”

Using these definitions, you can see that you don’t necessarily need to be healthy to be fit for a particular task.

It’s easier to understand with an example:

In 2003, Cameroon footballer Marc-Vivien Foe died in the middle of a competitive international fixture. It was later found, via autopsy, that he suffered from a genetic condition called hypertrophic cardiomyopathy (1), which made him susceptible to sudden death during exercise. Here was a highly fit man who had a serious health issue that ultimately lead to his premature death.

There are numerous other examples of extremely fit people suffering from serious health issues, enough so, that it is fair to say that fitness does not equal health.

The Effects of Exercise on Health and Fitness

We know that exercise can improve your fitness as measured by a number of different metrics.

We also know that exercise can improve your health, also measured by a number of different metrics.

What isn’t talked about as much, is that exercise can decrease your fitness and harm your health. 

Because exercise is such a broad term, it is very difficult to be specific with claims. What is important to understand, that how you exercise is almost as important as whether you exercise, or don’t.

When we look at the harmful effects of exercise, they generally stem from two issues:

  1. Poor quality (poor technique, leading to an increased injury risk)
  2. Too much (over training, causing systemic stress leading to a multitude of issues like increased injury risk, hormone dysregulation, immune suppression and chronic fatigue)

If you address these two issues, then there are definitely health benefits to be had, but it must always be remembered that when exercising for both health and fitness gains, there is a point of diminishing returns. That is, you have to work ever harder, doing more, for ever diminishing gains.

Additionally, the are also other reasons to exercise. Most of these involve quality of life – looking better, feeling stronger or more capable etc. These factors can indirectly improve your health and help you enjoy life more.

Done properly, exercise can improve your health and wellbeing. Done poorly, at best, exercise is a waste of time, at worst, it is leading to injuries or other health issues.

“Exercise as medicine”

Much recent research has focused on exercise interventions as medicine. This is because exercise, when properly controlled and administered, tends to have numerous positive effects, crossing multiple body systems, with minimal side effects.

Although the mechanisms of action are not all clear, they are continually being explored, and more is being learnt annually.

However, when viewing exercise as medicine, we have to accept that people needing medicine are already unhealthy in some way.

Thus, in this case, exercise is akin to taking a drug – it has a specific physiological effect. This is why we have seen the emergence of Accredited Exercise Physiologists (AEP) in Australia, to administer exercise to people with various diseases/health conditions.

And, just as we wouldn’t (shouldn’t) take drugs without a prescription, using exercise as medicine can also involve risks.

The other side of the coin is exercise as prophylactic medicine. Does exercising when you are already healthy, make you “more healthy”?

Very possibly. There is a lot of data to support the reduced risk of many conditions amongst those who exercise.

If health is defined as being free from illness and injury, we can use exercise to prolong our good health, by reducing risk factors for specific conditions. This is done by optimising certain physical qualities, based on statistical averages, in essence, becoming “more healthy”.

The confounding factor here, however, is that most data uses controls the reflect the average person. Research shows that the average person does not meet the physical activity guidelines as recommended by the government health authorities.

So the question becomes, do people experience more health benefits from exercise compared to those who are simply physically active, but don’t engage in formal exercise?

All the research we have come across suggests that the most important factor is to be physically active for at least 30 minutes per day, but it doesn’t matter if this is incidental activity like NEAT, formal exercise or anything in between.

Does exercise extend your life?

We have discussed how exercise can improve your health, and as a result of this, the quality of your life.

However, one issue that seems to be misunderstood is exercise’s role in extending (or not) our lifespan. After all, it’s only natural to want to live as well, and as long as possible.

The following factors influence our lifespan (4):

  • Genes
  • Environmental
    • Year of birth
    • Socio-economic status
    • Education
    • Occupation
    • Smoking
    • Alcohol
    • Body-mass index
    • Diet (?)
    • Physical activity (?)
    • Intra-uterine conditions
  • Medicines

Quiet the list.

One accepted view is that lifespan/longevitiy is predominantly predetermined by genetic factors, which are then influenced by our environment and lifestyle.

Thus if we have a healthy genetic base, living a certain lifestyle will help promote longevity.

Perhaps the most interesting work on this topic comes from the “Blue Zone” group, which started when National Geographic commissioned an article on longevity.

Author Dan Buettner came up with 9 different “lessons” that cover the lifestyle of people in the Blue Zones. They are:

  1. Moderate, regular physical activity.
  2. Life purpose.
  3. Stress reduction.
  4. Moderate calories intake.
  5. Plant-based diet.
  6. Moderate alcohol intake, especially wine.
  7. Engagement in spirituality or religion.
  8. Engagement in family life.
  9. Engagement in social life.

Although physical activity is on top of the list, an article in The New York Times covering the Blue Zones expands a little further:

In the United States, when it comes to improving health, people tend to focus on exercise and what we put into our mouths – organic foods, omega-3’s, micronutrients. We spend nearly $30 billion a year on vitamins and supplements alone. Yet in Ikaria and the other places like it, diet only partly explained higher life expectancy. Exercise – at least the way we think of it, as willful, dutiful, physical activity, played a small role at best.

What really matters though, in relation to this post, is whether exercise makes us live longer. A recent study out of Finland sought to answer that.

Without getting too complex, the authors stated:

Based on both our animal and human findings, we propose that genetic pleiotropy might partly explain the frequently observed associations between high baseline physical activity and later reduced mortality in humans.

What this means, is that there is one genetic component that influences physical activity levels, cardiorespiratory fitness and risk of death.

So it is not that exercising makes you live longer, but rather being active and your lifespan share the same genetic link. 

All this suggests, is that there are people who exercise that live both long and short lives, and there are people who don’t exercise who live both long and short lives.

So if you are exercising to live longer, you might want to consider your entire lifestyle, and even then, reconsider.

Decide to exercise because you enjoy it and its effects, not because you want to live longer.

So do you need to exercise?

So far it has taken almost two thousand words to get to the point where we can answer the original question.

You should now have an understanding that such a question does not have a clear cut answer.

It really comes down to the reasoning, i.e. why you want to exercise, and the execution, i.e. how you exercise.

Only you can decide if you need to exercise, but our recommendations are:

You should exercise if:

  • You enjoy exercising
  • You lead a relatively sedentary life, so exercise is your main form of activity
  • You have certain health conditions that would benefit from exercise
  • You are looking to improve certain fitness qualities
  • Your quality of life improves with exercise, be it for physical, psychological or social reasons

You do not need to exercise if:

  • You do not enjoy exercising
  • You lead an active life, i.e. you incur lots of incidental activity (walking, lifting etc) in your occupation and/or activities of daily living
  • You are already healthy, and happy with your current fitness levels

You should not exercise if:

  • You have underlying health risks that may be affected by exercise (if in doubt see you doctor and ask about a referral to an exercise physiologist).

Conclusions

At Integrative Osteopathy, we believe in leading a healthy and happy life.

The definition of health is universal, and the code to healthy living has generally been cracked. Physical activity is a big part of that. What isn’t universal is the need for formal exercise, if you are already very active in your day to day life. In fact, exercise can play a part in increasing physical activity, but it doesn’t substitute for regular physical activity in an otherwise sedentary individual.

The often overlooked factor in much heath research is happiness, which is a very individual thing.

Happiness and satisfaction in life are gained from engaging in meaningful pursuits – whether it be working to create things, grow or support a family, hobbies that express your creative side, physical pursuits that challenge your body and mind or whatever else.

We know the benefits of physical activity, but the recommendations from health bodies only talk about the type and amount. They don’t mention intangibles like enjoyment and meaning, and that’s fine, they’re not meant to, they’re public health recommendations, not personal health recommendations.

Whilst your doctor might suggest otherwise, the only person who can really say if you need to exercise, is you.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

 

References

(1) Wikipedia:https://en.wikipedia.org/wiki/Marc-Vivien_Fo%C3%A9

(2) Exercise as medicine: http://www.ncbi.nlm.nih.gov/pubmed/26606383

(3) Exercise is medicine, at any dose?: http://jama.jamanetwork.com/article.aspx?articleid=2468899

(4) Determinants of longevitiy: http://user.demogr.mpg.de/jwv/pdf/Vaupel-JIM-240-1996-6.pdf

(5) Blue Zones: https://www.bluezones.com/

(6) The Island Where People Forget To Die – http://www.nytimes.com/2012/10/28/magazine/the-island-where-people-forget-to-die.html