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Digital health platform Xealth strikes partnership with another big health IT vendor

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Xealth, a startup working to solve some of the logistical challenges faced by digital health companies, struck a partnership with Cerner. The Seattle-based company makes it easier to prescribe digital health tools and integrate them with health record systems.

The partnership is intended to make it easier for patients and their health teams to keep track of engagement with digital health tools and the effect on patients’ health.

“In order for digital health to have lasting impact, it needs to show value and ease for both the care team and patient,” Xealth CEO and Co-Founder Mike McSherry said in a news release. “We strongly believe that technology should nurture deeper patient-provider relationships and facilitate information sharing across systems and the care settings. It is exciting to work with Cerner to simplify meaningful digital health for its health partners.”

Cerner and venture capital firm LRVHealth also invested $6 million into Xealth. Last year, the company raised $14 million in series A funding, with investors including Providence Ventures and the Cleveland Clinic.

David Bradshaw, senior vice president of consumer and employer solutions for Cerner, said the partnership would give patients the opportunity to participate in their own treatment plans.

“Patients want greater access to their health information and are motivated to help care teams find the most appropriate road to recovery,” he said in a news release.

Xealth had already been integrated into Epic, and with this partnership, it will be tied into the two most widely used EHRs. The company is integrated with more than 30 different digital health solutions, ranging from diabetes management platforms such as Omada and Glooko, to Resmed’s connected sleep apnea machines, and patient engagement platforms like Twistle.

One of the startup’s clients, Providence St. Joseph Health, used Twistle in combination with Xealth’s platform to monitor patients with Covid-19 symptoms at home. It helped them keep track of patients’ temperature and oxygen saturation by providing an easy form for them to record their metrics.

Photo credit: a-image, Getty Images

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In California, dialysis industry spends big to protect profits

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The dialysis industry spent about $2.5 million in California on lobbying and campaign contributions in the first half of this year in its ongoing battle to thwart regulation, according to a California Healthline analysis of campaign finance reports filed with the state.

Last year, dialysis companies poured a record-breaking $111 million into a campaign to defeat a ballot initiative that would have capped their profits.

Photo: KHN

This year’s political spending, which includes an online and broadcast advertising blitz, is aimed at killing a bill in the state legislature that would disrupt the industry’s business model — and likely reduce its profits. The dialysis industry counters that the bill would threaten some low-income patients’ access to the lifesaving treatment.

“Nobody is spending $2.5 million out of the goodness of their hearts,” said David Vance, a spokesman for Common Cause, a nonprofit group that advocates for campaign finance reform. “That kind of money is spent to get the attention of legislators and to get results.”

And the spending doesn’t appear to be slowing. Since the most recent campaign finance reporting deadline, which showed a total of $2.5 million spent through June, a campaign committee backed by the industry has spent at least $470,000 more since then.

Dialysis filters the blood of people whose kidneys are no longer doing the job. People on dialysis, who typically need three treatments a week, usually qualify for Medicare, the federal health insurance program for people 65 and older, and those with kidney failure and certain disabilities.

But dialysis companies can get higher reimbursements from private insurers than from Medicare. One way dialysis patients remain on private insurance is by getting financial assistance from the American Kidney Fund, which helps nearly 75,000 low-income dialysis patients, including about 3,700 in California.

The American Kidney Fund receives most of its donations from DaVita Inc. and Fresenius Medical Care, the two largest dialysis companies. The fund does not disclose its donors, but an audit of its finances reveals that 82% of its annual funding in 2018 — nearly $250 million — came from two companies.

Critics of this system, including some California lawmakers, insurance companies and a powerful nurses union, say it’s a way for the dialysis industry to inflate profits by steering patients away from Medicare and other public insurance coverage to private insurance, which pays higher rates.

The measure under consideration in the legislature, AB-290 by state Assemblyman Jim Wood (D-Santa Rosa), would limit the private-insurance reimbursement rate that dialysis companies receive for patients who get assistance from groups such as the American Kidney Fund. The bill would also address a similar dynamic in drug treatment programs.

“The minute you try to close one of those loopholes, the folks involved spend millions and millions to fight you,” Wood said.

The state Assembly approved the bill in May, and the state Senate is now considering it. The legislature passed a similar measure last year that former Gov. Jerry Brown vetoed, saying the language was too broad and the move would have allowed providers to refuse care to some patients.

DaVita and Fresenius declined to comment and directed questions to Kathy Fairbanks, spokeswoman for the “Dialysis is Life Support” coalition, which includes dialysis providers, industry groups, patients and caregivers. She said the dialysis industry isn’t the only stakeholder trying to influence the political process.

Groups supporting the measure, including large insurance companies and labor unions, also are spending big, she said. For instance, a committee formed and funded by the Service Employees International Union-United Healthcare Workers West to support last year’s initiative — and challenge the dialysis industry and its profits — spent $580,000 in the first half of this year.

The $2.5 million in political spending by the dialysis industry between January and June falls into two categories: lobbying the legislature, and campaign contributions to support candidates and influence public opinion. Campaign spending made up about $1.3 million of the total.

DaVita accounted for the biggest chunk of the campaign spending: $580,000. Fresenius spent $270,000.

These contributions went to 48 of the state’s 80 Assembly members and 21 of the state’s 40 senators, primarily to their prospective 2020 or 2022 campaigns.

Of the 69 legislators who received money from DaVita and Fresenius, Assemblyman James Ramos (D-Highland) got the most: $16,800 in the first half of the year. Ramos did not respond to requests for comment.

Nine other Assembly members and two senators each also received more than $10,000 in contributions from DaVita and Fresenius.

The rest of the $1.3 million in campaign spending was doled out by the campaign committee formed and funded by the industry to defeat Proposition 8 last year. The “Patients and Caregivers to protect dialysis patients” committee spent $440,000 in the first half of 2019, mostly on an advertising campaign to sway public opinion against Wood’s measure.

The media campaign began by promoting the message “Dialysis is Life Support” via social media accounts and a slick website, which emphasized the importance of dialysis to people with kidney failure. But the messaging has shifted and is now urging people to contact their legislators to oppose the bill. The committee spent $33,000 on advertising with Politico and $26,000 with The Sacramento Bee, among others, according to campaign finance reports.

The coalition and the patients featured in the ads argue the measure will threaten the health care and possibly survival of the California patients who get assistance from the American Kidney Fund, which has said it would cease operations in the state if the bill is adopted.

Photo: pixhook, Getty Images

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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What are the opportunities for AI in healthcare and what Big Data challenges lie ahead?

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data, conceptual, informationNote: This article is the first of a two-part series. The quotes in this article have been edited and condensed for clarity.

Although artificial intelligence in healthcare is an area of intense interest, exploring the topic is akin to peeling an onion — each layer revealing a new set of opportunities and obstacles.

While clinical decision support and identifying targets for drug development are frequently cited as examples of where AI is impacting healthcare, a deeper dive on this topic soon reveals the limitations of some data sources, how some companies are addressing them, and where standards and best practices are needed for this relatively young and vibrant aspect of health tech to continue to evolve in life sciences and healthcare.

In a panel discussion at the MedCity CONVERGE conference exploring the opportunities and challenges posed by the data underpinning AI tools, panelists representing big pharma, health tech and clinical data networks shared some of their insights.

The participants included Chris Boone, Head of Real World Data and Analytics for Pfizer; Gaurav Singal, chief data officer at Foundation Medicine; Janak Joshi, chief technology officer and head of strategy at Life Image; and Nate Nussbaum, senior medical director at Flatiron Health. Brenda Hodge, chief marketing officer for healthcare at Nuance, served as the moderator.

One of the challenges in harnessing the data to support AI in healthcare is simply gathering it. Nussbaum explained how Flatiron Health sorts out the data:

“Teams of human abstractors review EHR data to understand what that unstructured documentation actually means and to pull the data out in a way so that we can use that as a source of truth and then use it to build models, use it to understand the quality of models, and then understand things like how much bias a machine-learning model has, introducing so that we can then ask research questions and have confidence in the answers.”

AI in oncology care — what’s being done and where is the potential?

Joshi cited the need for the clinical context found in unstructured data to assess therapy effectiveness. He cited collaborations between Life Image and life science organizations that are working to understand the potential indicators.

“We are working with a couple of companies on non-small cell lung cancer to identify the signals that can potentially indicate therapy effectiveness. How do you conduct comparative effectiveness by marrying both generic biomarker data as well as imaging data?

Radiomics is a relatively new concept of marrying generic biomarker data with imaging data. Currently, the output of this model is unknown. But what we are finding is an increasing need, utility and, most importantly, clinical relevancy of not using only medical claims data or structured data sets coming from EHRs but the unstructured data coming from everything else that surrounds the patient.

Joshi also cited another project the company is working on that illustrates how difficult it can be to develop accurate machine learning algorithms that effectively read and understand medical images in a clinical context.

“Writing a simple query that indicates how many patients diagnosed with non-small cell lung cancer were former smokers with cancer diagnosed specifically for the left lung is, actually, quite burdensome. The indication of ‘left lung’ is very hard to find in imaging data sets coming from PACS systems in hospitals. It is often a manually curated effort where a human says, ‘This is a left lung; this is a right lung,’ but, if you flip the image, you end up some of the false positives and false negatives.Life Image is essentially using [Cloud] AutoML functionality to identify that label. But, more important than the label, is going to be the classification around it. Once you know if it’s a left lung, you need to determine how many other left lungs exist in your data set and if there is a pattern at the pixel level associated with that. The labeling, classification, and normalization across multiple different vendors is a really hard problem to solve.”

Singal of Foundation Medicine offered short term and long term goals it has identified for AI.

“The long-term dream for us is that, by combining lots of different diagnostic components, we’ll be able to help inform the best treatment for every patient. I personally think that’s still quite a ways away. One place we’re spending a lot of time nowadays is in pathology images because every case we sequence we also get a pathology slide and we digitize [them]. That’s a place where I think, even in the near term, we’ll start to pull out new features and new biomarkers.”

Importance of access, availability, and curation of data sets

The most widely known obstacle to the curation of data sets that companies rely on for AI tech is how best to normalize/standardize the data.

Boone said that Pfizer relies heavily upon the data that it curates from its randomized clinical trials and work with partners like Flatiron Health and Foundation Medicine to access previously unseen real world data.

“How do we transform the way we do clinical research today, and what makes the most sense? We’re also thinking about, when we’re looking at [electronic care report forms] most of the data that we’re capturing now is captured, in essence, in these platforms that exist today. But there’s still that 30 percent that we know that is not there.” He noted that these collaborations with either company will help address data elements that should be captured.

To avoid black boxes and support transparency, context is critical

Although Boone emphasized that he likes working with startups and tech companies, he finds that they need to understand that it’s not enough to provide data — they need to explain how it was collected and the circumstances under which it was done.

“The argument that’s being made is that ‘we have the best data that you can find anywhere or captured in this context.’ I’m not even sure they understand how and why they’re capturing it. So, for us, context is probably the most important thing as you get into it. It can’t be this black box approach to, ‘Well, we captured this data in this way. You may not understand how we’re doing this.’ We can’t go to any regulator and say, ‘Well, they did it, and we trust that they did it the right way.’”

Joshi agreed that context and transparency are key to data access and utility of real world evidence and drug development.

“In order to develop a regulatory-grade data set, it’s not just about the data capture. You must understand the pathway or the point in the clinical workflow when the information was captured. A lung CT scan captured at a particular point in the patient’s pre or post-diagnosis workflow is actually a very important marker for how to interpret that data using either a machine learning or human interpretation.”

Linkability of data is also critical. Joshi noted that this becomes particularly difficult with pathology and claims data in oncology, of which an estimated 15 to 20 percent is biased due to incorrect diagnoses, duplicate diagnoses, or unintended diagnoses.

Next week: A look at the democratization of data and the need to balance this with ethical considerations.

Photo: Getty Images

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HealthVerity wants to enable healthcare’s big data future

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Data has become an increasingly valuable commodity in healthcare as organizations try to meet changing consumer demands and shifting business models and regulations.

One company building their business around this thesis is Philadelphia-based health data management startup HealthVerity, which recently raised a $25 million Series C financing round led by Foresite Capital. The company was initially founded in 2015 and has raised more than $42 million from investors.

HealthVerity COO and co-founder Andrew Goldberg said the new capital will be directed at building out the company’s sales and marketing teams, as well as its engineering staff.

The 50-person company targets large enterprises – mainly payer and pharma companies – and helps enable better internal data management and interoperability, while also allowing organizations to link assets to other outside data sources.

“The widespread digitization of medical records offers one of the best opportunities to transform patient care and improve the lives of millions,” Foresite CEO Jim Tananbaum said in a statement. “By building technologies that solve long standing challenges in the way that data can be organized, linked and licensed, HealthVerity has significantly enhanced the insights available on the patients and members of its valued customers.”

HealthVerity’s flagship cloud-based Marketplace product is a way for healthcare organizations and other companies to license healthcare data like pharmacy data, EMR clinical data, medical claims data and device data for research and business purposes. The company claims to have more than 20 billion medical transactions for 330 million patients on this marketplace.

Vetted users can use filters or key words to check to see if the data is available on the marketplace to answer their research query.

“They can do that in minutes when previous it was a process that took them weeks,” Goldberg said. “HealthVerity doesn’t own the data. What we do is we help bring buyers and suppliers together in a really efficient and cost effective way.”

Data vendors on the company’s marketplace use a product called HealthVerity Census to prepare their data assets for sale. Healthcare organizations can also use Census as a way to “align” disparate data sources to make an entire patient journey visible. Census deidentifies patient data to comply with privacy laws like HIPAA and the California Consumer Privacy Act, which goes into effect next year.

Companies using Census to manage their own internal data sets can then choose to license their data out on the marketplace.

The renewed focus on social determinants as a key part of a person’s holistic health led to the development of the company’s patent pending Cipher product which is able to combine non-HIPAA compliant consumer data like household income, family size, education level and social media usage alongside clinical data.

Goldberg took pains to underscore that organizations can only look at the data from a cohort level and the data can’t be linked to individuals. He added that privacy laws allow for the combination of consumer information with HIPAA-protected medical information if the data can’t be linked back to a specific patient.

Here’s an example of how the product works. A pharma company interested in increasing medication adherence could segment their non-adherent patient population by income, education or other demographic factors to help drive outreach strategy.

“You get more directional analytics way which could then allow you to drive campaigns like the way you can educate doctors if they come in contact with a patient who meets a certain criteria, this is the kind of story that works best,” Goldberg said.

HealthVerity’s latest product is Consent, a blockchain-based solution meant to help companies manage and track data use permissions across different forms ranging from email OKs to consents to access clinical information.

“We serve as a giant consolidation point for every consent that’s being captured so now you have an enterprise-level view on what permissions you do and don’t have,” Goldberg said.

This is becoming increasingly vital with the upcoming implementation of the California Consumer Privacy Act, which goes into effect next year and expands protections for how data is used, as well as disclosures of data usage to consumers.

“We serve as a giant consolidation point for every consent that’s being captured so now you have an enterprise-level view on what permissions you do and don’t have,” Goldberg said.

Picture: shuoshu, Getty Images

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HEALTH

Wisconsin High School Under Fire for Giving ‘Big Boobie’ and ‘Big Booty’ Awards to Cheerleaders

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Wisconsin High School Under Fire for Giving ‘Big Boobie’ and ‘Big Booty’ Awards to Cheerleaders – Health

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Livongo CEO Zane Burke on his move from Cerner, big tech’s intersection with healthcare

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Former Cerner President Zane Burke left the multibillion-dollar EHR giant last year after spending more than two decades at the company. Soon after, it was announced that he was taking the helm at Livongo, the chronic disease management company founded by former Allscripts CEO Glen Tullman.

The fast-growing company earned more than $60 million in revenue in 2018 and counts major employers like Delta Airlines, Target and Pepsico as customers. Mountain View, California-based Livongo has raised around $240 million funding, including a $105 million Series E round that valued the company at roughly $800 million.

MedCity News sat down with Burke at Livongo’s inaugural Signum conference in San Francisco to talk about his move to a startup company, tech giants’ entry into healthcare and Livongo’s 2019 priorities.

What follows is an edited transcript of the conversation.

How has it been moving from a huge public company to more of the startup mindset at Livongo?

It’s fascinating because starting here is very similar to when I started at Cerner in that they’re very similar size, so it kind of makes me go back to that time.

So trace for me what the young Zane was like back then?

It’s hard to imagine now I get that (laughs). When I started Cerner in 1996 we were less than a thousand people, around $150 million in revenue and just branching out into other parts of the business. So I’ve seen some of that size and how that can play out properly. I think the difference here is that this company’s path to those similar kinds of numbers has been exponentially faster. I think the runway and the opportunity for growth is much bigger, as is the opportunity to impact people in a meaningful way.

One thing I will say is we’re all in a business where nobody actually wants to utilize our services. None of us want to have a chronic condition or have a need for sick care. We actually all want to be as healthy as we possibly can be and as close to home as we can possibly be. That’s been the long term personal vision for me and Livongo was just a perfect fit as it related to the things that I really wanted to see accomplished.

You’re joining Livongo as they’re making the shift from selling sensors, testing strips and health coaching and into what they call Applied Health Signals, essentially being a combined data health company right?

I think it’s actually the combination of those things that makes Livongo unique. One is a is a platform by which you aggregate that data and then really create meaningful clinical and behavioral interactions. But I wouldn’t discount the fact that the devices are easy to use and we focus on how we create a great healthcare experience. Try to think about the last great healthcare experience you had.

I’d have to go back quite a while.

I can think of one primary care experience where it was a great experience, it’s really rare. We’ve seen it in other parts of our lives and I just say healthcare so ready for this.

You’re using AI and machine learning as part of your platform to personalize health recommendations, where do you see the role of genomics in that roadmap?

I do believe in personalized medicine at that level and I do think that’s going to make a difference. There’s just hard proof that that differences in genetic makeup absolutely makes a difference in medication and outcomes. We’re actually going to get there sooner, rather than later. We know what drugs work most effectively because we actually see what’s happening with the blood pressure levels and we’re getting the real-time data back. When you put that with genetic data then what do you have? That’s something that we already have our eyes on.

How do you see Livongo potentially integrating its data with platforms like Apple Health Records?

We actually do integration into Cerner’s EMR today and we’re open to that kind of dialogue with other EMRs or other ways to serve up data as we move forward. But that data is the person’s data. So we have a fundamental belief that people own the data, so the consent is going to have to come from the patient. We’re not just going to automatically be feeding it up.

I was a big supporter of (Apple Health Records) in my past role and I have my own data uploaded. I think that it’s just a first step at this point, I applaud any attempt to move my data closer to me, but the tricky part is the actual clinical relevance of that information. We have a lot of work to do as an industry to make it meaningful. You don’t really need to know that when I had a surgery seven years ago I was given this certain type of anesthetic.

Are you supportive of how CMS has used its regulatory power to wedge open data availability? 

I think what (Seema Verma) is doing exactly what’s needed because the industry hasn’t led with its chin. I think there are people that are seen as the villains in the conversation that may in fact have some responsibility. But there are some other villains behind the scenes that need to come forward and say my part in this is to be an open system and share my data freely.

I also have a very strong belief in the idea that the social determinants of health are every bit as powerful as what’s in the EHR. So I think that the Facebooks, Apples and Googles of the world ought to be sharing their data back. They need to belly up to the bar and serve their data back up should you as a person decide that you want to get your data out there for your benefit.

The big healthcare debate in politics is over Medicare-for-All, how is Livongo successful in that hypothetical world?

First off I don’t think I don’t think we’re going to end up with a single payer, but regardless our objective is to provide a great experience, a high value solution and we can provide that no matter who the payer is. So whether that’s the government as a payer or whether that’s the employers as a payer or whether that’s individual consumers.

Could we end up with things where we look at cost benefits as a country to say it makes social and economic sense to provide blood pressure medicine to people living with high blood pressure? I think so. Do I think Livongo has a future in that? Yes, I do.

A lot of digital heath companies selling to employers like Livongo and its competitors have been focused on broadening their platforms, where do you see this market continuing to evolve?

I haven’t seen anyone that’s gotten the breadth and the depth of what we’re trying to accomplish. I think we see a bunch of little niche players trying to pick off a piece of behavioral health or even within that, substance abuse or insomnia. You may have the best insomnia solution but do you really want to go to every plan or employer and have them purchase it?

In chronic conditions people have comorbidities and multiple elements, so it’s not going to create a great experience for users to have all these different niche pieces in there. And then the learning we’re going to get from those those interactions can have a dramatic impact on both the clinical outcome as well as the user experience side. It’s a big difference in terms of how we’re thinking of things from an enterprise level rather than that little niche.

What are the company’s major priorities over the rest of 2019?

It’s straightforward. One is scaling the company for growth in the right way. Historically we’ve continued to double in size in less than a year’s time. I would anticipate that’s kind of the trajectory we’re going to stay on.

I think you’re going to see us he into a couple other conditions as we move forward. We started the year with our behavioral health acquisition and you’ll continue to see us broaden out those chronic conditions. There’s some pretty logical areas like respiratory and musculo-skelatal conditions. And then we’ll have to look and study the data on how these things come together and interact.

Picture: Livongo

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FITNESS

Build Big Arms With The Hammer Curl

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If you’ve been spending hours in the gym trying to bulk up your biceps with classic curls and chin-ups, and yet remain entirely unsatisfied with the size of your upper arms, the chances are you’ve never heard of the brachialis muscle.

There’s no shame in that – who can keep tabs on all of the hundreds of muscles in the human body? However, the brachialis is one it’s worth getting acquainted with, because it’s a key muscle for anyone hitting the gym with the aim of building sleeve-busting upper arms.

Your brachialis muscles are found on the outside of your upper arms right next to the biceps. By targeting the brachialis in your workouts, you’ll add mass to your upper arms and help your biceps stand out more. And one of the best ways to work the brachialis is to add the hammer curl to your training routine. Here’s how to do it.

How To Do A Hammer Curl

Stand with your feet shoulder-width apart and a slight bend in your knees. Hold a pair of dumbbells in your hands with your palms facing towards your body – this is the main difference from the standard curl, which you start with your palms facing forwards. Keeping your elbows close to your body, slowly curl the dumbbell up to your shoulders. Pause for a second at the top of the lift, squeeze your biceps, then lower the weights under control.

Hammer Curl Variations

Seated hammer curl

Set up an adjustable bench at 90° so you can sit on the end of the bench with your back against it. Grab your dumbbells and let them hang at your sides with your palms facing each other. Keeping your back against the bench and your elbows tucked in, curl the weights up to your shoulders, then slowly lower them. The advantage of having your back against the bench is that it ensures your biceps are taking the load by preventing you from rocking your body and using momentum to help with the curl.

Rope cable curl

Using a cable machine means that you work against a consistent level of resistance throughout the movement. In the case of the hammer curl this means the same level of resistance at the top of the movement as the bottom. Attach a rope handle to the low pulley on a cable machine. Curl it up with your palms facing one another, keeping your core braced throughout the movement.

Alternating hammer curl with twist

In this variation of the hammer curl you lift one dumbbell at a time and twist your wrists at the top of the movement to hit the biceps from a different angle. Start with your wrists facing one another, then turn them to face you at the top of the curl so the position is the same as when doing regular biceps curls.

Lunge with hammer curl

If you consider doing one exercise purely to benefit your upper arms is an inefficient way to spend time in the gym, then pair the hammer curl with the lunge for a full-body hit. Holding a dumbbell in each hand by your sides, take a big step forwards on your right leg and lower until both your knees are bent at a 90° angle. Brace your core and curl the weights up, pause at the top, then lower them under control back to the start position. Push through your right foot to power back up to a standing position. The weighted lunge works all the major muscles in the lower body and you’ll also challenge your core as you maintain the lunge position while curling the weights. You can switch legs with each lunge or do all reps on one side and then the other.

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FITNESS

Woman Kicked Off Plane for Fat Shaming Her Seatmates and Calling Them ‘Two Big Pigs’

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Woman Kicked Off Plane for Fat Shaming Her Seatmates and Calling Them ‘Two Big Pigs’ – Health

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NUTRITION

Should I Have a Big Wedding?

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When people learn I’m Greek-American, their minds often turn to the movie My Big Fat Greek Wedding. I’m frequently asked, “Is that movie accurate? Was your wedding like that?” Yes, I respond. All of it. That movie basically sums up my wedding. I even have the pesky brothers who taught my fiancé all of the naughty swear words in Greek.

Planning a wedding can be stressful — particularly when it comes to the guest list. Maybe one partner prefers an intimate affair while the other wants to invite all of the neighbours in the subdivision. In my case, my husband and I knew from the moment we got engaged that our wedding was going to be big — and loud.

When I said “yes” to my not-Greek boyfriend, my mother began planning the biggest, fattest Greek wedding that she could. I had no control over it, and I did not care. My parents raised four very unruly children, and none of us ended up in jail, so my mom earned the right to plan my entire wedding, and it was big. The invite list was over 450 people — that kind of big.

I remember sitting with my then-fiancé in my parents’ family room one weekend. We had booked the grand hall, I had picked my dress, and next came the tightening up of other details. “OK,” my mom said, bringing out three sheets of paper covered in names. “It’s time to talk guest list.” She had a certain mischievousness in her voice. I knew exactly what that meant.

“You’re inviting the entire church, aren’t you, Mom?” I asked.

“Nooo,” she said. “But there are many people who we have to invite. So get started on your list, too.”

Our list didn’t even compare to my parents’. I’ll admit that at first, it bothered me a little. My young, selfish mind thought, “Isn’t it our wedding? We should get to invite more people than my parents!” But then I realised that the people on this grand guest list helped raise me, too. They wanted to attend my wedding and help us celebrate. Looking back, I feel grateful.

On the big day, when my three brothers opened up the church doors, the congregation was packed — standing room only. Thankfully, it wasn’t as uneven as the movie: my husband’s side of the church actually had guests in it, too. I felt the love of everyone as I walked down the aisle to the altar and again after we were announced as “husband and wife.”

The wedding reception felt like fireworks. My husband and I walked through the doors, and the Greeks lived up to their loud stereotype: cheering, standing, and whistling. After we ate and sauntered through our first dance as a couple, my husband and I floated through the classy decorated hall (not obnoxious, and very blue, like the movie) and greeted every single table. My husband shook the hands of people he had never met, and I hugged them all. We didn’t mind taking time out of our night to thank people who wanted to be present at our wedding. We felt the opposite, actually — really freaking grateful.

I don’t regret having a big fat Greek wedding at all. Some people may argue that having a large wedding is overly lavish and unnecessary. Sure, you’re right. But sometimes, having large weddings is just part of your big, tight-knit culture. I feel honoured that my parents could invite all of their closest relatives and friends. They were proud of their one and only daughter, and I was not going to be the one to rob them of that joy. If I had to do it all over again, I would — for my parents. Because sometimes your wedding day is bigger than you.



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WEIGHT LOSS

Woman Who Lost 350 Lbs. Shares Her Excess Skin After Liposuction: ‘It’s a Big Insecurity for Me’

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Jacqueline Adan is ready to share her biggest insecurity.

The Montessori preschool teacher, 31, lost 350 lbs. and now deals with excess skin, something she was body shamed for during two separate beach vacations. She’s undergone five skin removal surgeries — three on her upper body, one on the lower body and liposuction on her legs — but quickly learned that it isn’t an instant fix.

Adan has posted plenty of photos of herself since her surgeries, but for the first time, she decided to put up a video showing exactly what her legs — her biggest source of insecurity — look like now.

“This is getting very real, but I did want to be honest and open and share everything with you guys, so this is what we’re working with,” she said in an Instagram video on Monday. “They’re a lot more loose, as you can see. There’s a lot of it … There’s lots of dents, holes from the liposuction sucking out. This is kind of just what they are. They’re heavy, there’s a lot of it.”

Adan explained that she first had liposuction in January to get rid of some remaining fat in her legs, and is meeting with her surgeon this week to move on to the next step — skin removal.

“It’s a big insecurity for me, my legs, but at the same time, mentally it’s not just challenging, but physically,” she said. “As you can see, there’s a lot of weight. It’s heavy. Lifting my legs just to go up and down the stairs, in and out of bed, is hard because they’re so heavy.”

Adan said she decided to post this video to help her move past her insecurity.

“I wanted to share my legs with you because…well, because I am scared,” she wrote. “Even though I do not hate them anymore, I still feel very insecure with them. Even though I am insecure, I am not going to let them stop me from living my life or sharing them with you. This is real and this is me. This is what hard work looks like.”

And Adan — who certainly knows about body shaming — added that she refuses to be bothered by any negative comments about this video.

“You can call them ugly, nasty, big, fat, disgusting. Don’t worry anything negative you could ever say about them I have thought those things too,” she said. “I am now embracing my legs for what they are … I am not going to call them ugly anymore. These are my strong legs.”

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