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Is your wellness vendor snookering you? Take this quiz to find out.

Is your wellness vendor snookering you? There are certain facts that vendors are not exactly forthcoming about. This is because facts represent an existential threat to the “pry, poke and prod” industry. See how many facts you know — and how many they’ve suppressed — by taking this quiz.

You’ll earn more points, the closer you are. You don’t have to be exact — and honestly I’d worry about you if you got the exact answers to every question. I’d love you for it, but I’d still worry about you.


  1. Wellness vendors claim they can save significant money by reducing hospital admissions for diabetes and heart attacks, because those admissions are very common. How many admissions per 1000 covered lives does the average employer incur in a typical year?

  2. The Health Enhancement Research Organization claims a certain savings figure for wellness PEPM. But that’s before taking into account vendor fees, extra doctor visits, tests, and prescriptions, compliance issues, employee time needed, overhead and basically anything else. In other words, what is the PEPM savings figure that at Bain & Company we used to refer to as “profit before cost”? Answer to the nearest one dollar. Hint:  the answer is somewhere in this quiz.


  3. To eventually save money someday, you first need to improve/reduce the risk profile of your population. According to eternal optimist and wellness promoter-in-chief Ron Goetzel, what is the maximum percent improvement in a risk profile that a company can expect after 2 to 3 years of wellness programming @$150 PEPY?


  4. Speaking of Ron Goetzel, he said “thousands of wellness programs” fail to get good outcomes. What round number did he claim have succeeded?


  5. And speaking of Ron Goetzel again, he finally admitted it was “hard” to force employees to change behavior. How many “very’s” did he put in front of the word “hard” in that admission?


  6. The Wishful Thinking Factor, totally coincidentally abbreviated as WTF, is defined as: Total claimed cost reduction/total number of risk factors reduced. What is the average WTF for the last six Koop Award-winning programs, on average? (Hint: the real ratio of savings to risk reduction is about 0.05x, since even if savings does not lag risk reduction, a maximum of 5% of spending is wellness-sensitive.)


  7. Speaking of risk reduction, employees in the most recent Koop Award-winning program, Wellsteps/Boise, originally tallied 5293 risk factors. Approximately how many risk factors did those same employees tally after participating, excluding dropouts?


  8. In a participants-vs-non-participants study design, what percent of the perceived savings is due to the invalidity introduced by the study design itself in which unmotivated employees are used as the control for motivated employees, rather than health improvements attributable to the actual program itself, according to all four studies conducted on this topic, including three by wellness promoters?


  9. If you use Interactive Health as a vendor hyperdiagnosing the stuffing out of your workforce, what is the annual percentage of employees that will likely be told they have “newly discovered conditions”  that “require” a doctor’s intervention?


  10. Of 1000+ wellness vendors, how many are validated by the Validation Institute?


Answers:

  1. 2. Yes, only 2. All this wellness fuss is about 2 admissions per 1000 employees. Derivation: the roughly 150,000,000 employees and dependents covered by commercial insurance (mostly from employers) generate roughly 150,000 heart attacks and 120,000 diabetes events.  See the HCUP database and enter “410” for heart attacks and 250 for diabetes admissions for the ICD9 for the most recent full year (2014). Scoring: Give yourself 1 point for guessing 4 to 10 and 2 points for guessing fewer than 4.  

  2. One dollar. $0.99 PEPY. As is well-known, they tried to walk this figure back once they realized they had told the truth. Scoring: Give yourself 1 points for guessing $1.00, since the answer in the hint was on that very same line.

  3. 2%. That’s a few dollars PEPY in savings. (Looks like the HERO report was pretty close, its own protestations notwithstanding.) And you paid $450/employee over 3 years to achieve it.   Actually it was 1% to 2%, but we asked for the maximum. Scoring: Give yourself 2 points for 2% or less, 1 point for 4% or less. 

  4. Only 100. Besides Johnson & Johnson, Mr. Goetzel has never disclosed any of the other 99 without others making the observation that they self-invalidate according to their own data. Scoring: 2 points for 200 or fewer, 1 point for 400 or fewer.

  5. 4. In The Healthy Workplace Nudge, Rex Miller gets Ron Goetzel to admit that “changing behavior is very very very very hard.” Gosh, Ron, do you suppose this might explain why an employer population’s risk factors never noticeably decline? Scoring: 2 points for 4, 1 point for 3 or 5.

  6. Infinity. That’s because of the next question. The 21% risk factor increase for Wellsteps more than offset the trivial risk reductions achieved by the previous years’ winners. The actual WTFs for the previous years will be the subject of a future posting. Scoring: give yourself a point if you guessed that the WTF was 5 or higher. That would be 100 times the actual figure and still way below the wellness fantasy-league figure.

  7. 6397. Risk factors rose 21%. And yet somehow, even though the risk profile was deteriorating sharply, the risk profile of the population was also improving enough for Wellsteps to claim that healthcare costs declined 30%. 30% is enough to wipe out wellness-sensitive medical events for the entire Boise teacher population and about 30,000 of their closest friends. (Wellsteps originally admitted that costs increased, but took that slide down when it occurred to them that telling the truth would be inconsistent with their marketing strategy.) Scoring: 1 points for 5500 to 6000 or 6600 to 7000, 2 points for 6001 to 6599.

  8. 100%. It turns out that the participant-vs-non-participant study design is responsible for all the perceived savings that wellness vendors claim for programs. The New York Times just explained how, in the landmark University of Illinois study, both the “gold standard” RCT methodology and the invalid par-vs-non-par methodology were used and had completely different results. This also happened three other times (summarized here) — with Newtopia, Health Fitness Corporation, and a study done by the chairperson of the Koop Committee showing how feeding diabetics more carbs would reduce their costs by improving their health. Literally, 4 studies — all of which were run by people trying to show savings — showed exactly the same thing. Scoring: all or nothing — 1 points for 100%.

  9. 45%. This is because running 40 inappropriate tests on every employee makes it inevitable that at least 1 or 2 of those tests reveal a false positive. Scoring: Give yourself 2 points for guessing between 40% and 50%, 1 point for 30% to 39% or 51% to 60%.

  10. Four. All four are honest and make modest claims they can defend or valid contractual representations.  AND, they actually screen according to guidelines! (In the wellness industry, doing something appropriate merits an exclamation point.) They are: It Starts With Me, Splashlight, Sustainable Health Index, and US Preventive Medicine. That’s <1% of all wellness vendors. Scoring: give yourself 1 points for 8 or fewer.


 

Scoring:

0-2 points. Has your wellness vendor sold you a bridge too?

3-5 points:  Your wellness vendor is blocking your internet connection

6-9 points:  Nice work!

>9 points:  Send your fifth-grade math teacher a thank-you note for doing a better job than the wellness vendors’ teachers did.

 

Interactive Health fails fact-check by…college intern

A long-since forgotten essay on the history of hospitals by Lewis Thomas includes the story of a doctor who claimed he could diagnose typhus by examining inpatients’ tongues. He would examine their tongue…and a few days later they would indeed develop typhus. Turned out the doctor was spreading the typhus pathogen by feeling all the patients’ tongues without washing his hands.

Keep this anecdote in mind as you read the following.


Seems like I’m not the only one to show that Interactive Health’s numbers never, ever, ever, ever add up. And it looks like you don’t have to have taught economics at Harvard to do it, or even be old enough to rent a car. Rather, a triple-digit IQ is all it takes. Tom Rosenbaum, a “data analytics intern” at AP Benefit Advisors in Maryland, completely invalidated one of Interactive Health’s more headscratching claims.


By way of background, Interactive Health’s strategy is to convince HR departments that their company is simply overrun with ridiculously unhealthy employees whose medical spending will explode at some point in the future…and send almost half of the employee population to the doctor to allegedly prevent that from happening. That, of course, requires screening the stuffing out of them today, at considerable expense.

I’ve asked them repeatedly on Linkedin to please explain:

  1. how the US Preventive Services Task Force can be so misinformed about so many Interactive Health screens being so inappropriate and
  2. how their own panel of 43(!) tests is clinically proven to somehow save money by increasing (not a misprint) the number of employees who think they are sick, and the corresponding number of doctor visits.

Their “response” is invariably to delete my comments. Here is one example:

Quite the contrary to “the impact of heart disease growing by the minute,” heart health is actually, shockingly, one of the major public health/medicine success stories of our generation.  Deaths due to heart disease, and heart attacks themselves, are down by about 2/3 since 1969. I merely tried to inform their posting with a fact, but by the time you see their posting, facts will have been deleted. [Update: they already are deleted, along with many supportive comments I received on this posting. Usually they delete my comments within minutes, so I’ve started posting them at night so they can stay up for a few hours.]


Enter Tom Rosenbaum

Their new revenue-maximization strategy is to tell employers it’s not just older employees they need to worry about. It’s younger employees too.  And it’s not just medical issues that plague the younger workforce. It’s also mental health issues. Their specific language:

Workers under 35 are more likely to struggle with mental health issues, such as stress, depression and anxiety.

Tom decided to fact-check this particular item using actual data. It turned out:

  • 5.39% of older workers had claims for these mental health items, vs. 5.33% of younger workers
  • Older workers spent 32% more on antidepressants than younger workers

This insight got him into Employee Benefit Adviser as likely the youngest person ever to author a column for them. And the second-youngest person ever to get mentioned in They Said What.

Of course, it is possible that Interactive Health’s data is different than everyone else’s, and here’s why. According to their White Paper:

Here’s perhaps the reason why their customers’ employee stress levels are so much higher than average. If someone tells you that you have a “condition” and you “should be directed to a doctor,” you’d be stressed out too.

Something very similar happened to me when I let Interactive Health fiddle with my calves and tell me they were tight and could cause problems — one went into spasm shortly afterwards.

Luckily I didn’t let them anywhere near my tongue.

 

 

Journal of the American Medical Association on the Harms of Overscreening

They Said What has always noted the complete and utter worthlessness of screening the stuffing out of employees. The wellness vendor response to this observation?  To double down on overscreening. One recalls the immortal words of the great philosopher Inspector Louis Renault: “Owing to the seriousness of this crime, I’ve instructed my men to round up twice the number of usual suspects.”

Here is one such vendor, the lucky recipient of a follow-up profile to be published next month.

Their litany of tests before my initial observations about their overscreening were published:

Their current roster of tests, setting a new wellness industry record:


However amusing it may be to remark on the rampant epidemic of very stable genius-itis in the wellness industry (and it is), screening the stuffing out of employees is no laughing matter. It is harmful. Here is the current Journal of the American Medical Association on the harms of screening. Unfortunately the entire article is behind a paywall, but the abstract basically highlights the wellness industry business model:

Overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop.

This is of course exactly what hyperdiagnosis is all about — and the poster child for hyperdiagnosis is none other than the winner of the 2017 Deplorables Award, Interactive Health. A single Interactive Health display captures it all, the breathless braggadocio about sending employees to the doctor because they flunked one or more of the 43 tests that Interactive Health runs, with no regard for the harms that JAMA has identified:

So, in all seriousness, can we please, please stop the hyperdiagnostic madness and start screening according to the US Preventive Services Task Force guidelines?

Extensive Wellness Industry Expose Reaches Popularity Milestone

The most comprehensive expose of the “pry, poke and prod” industry is likely to have broken the 1000-download threshold by the time you read this.

Published by the leading law-medicine journal, it is their second-most-popular paper of all time. Curiously, while this is the oldest law-medicine journal in the country and has covered a multitude of topics over many decades, the most popular paper of all time is also a smackdown of pry, poke and prod programs.

Because TSW doesn’t lie (that’s part of the reason we are so unpopular amongst the HERO crowd and its sycophants), I would acknowledge that the methodology they use to measure popularity favors more recently published articles, and ours is “only” a year old. Even so it is quite a feat because, while we are close on the feels of #1, there is a big gap between us and the #3 article.


In the structured world of law, as opposed to the “Wild West” of wellness, there are rules. That’s why I chose the leading law-medicine venue for this expose.

One rule of evidence is that some of the best evidence — one of the few exceptions to the hearsay exclusion — is what’s known as an “admission against interest.” An admission against interest is “a statement by a party that, when uttered, is against the party’s pecuniary, proprietary, or penal interest.”  It’s even more compelling if it is captured electronically, as on a live mic, or in print.

The best example is Robert Durst accidentally admitting that he killed his wife during a bathroom break while being interviewed for a documentary, when he was still miked. You’d have to be, as Larry David might say, pretty pretty pretty pretty stupid to make admissions against interest when you are miked or in print.

One would think.

And yet the wellness industry’s entire modus operandi is to do exactly that. All that remains is for someone like me to point these things out, take a screen shot (the equivalent of Durst being miked), and then sit back, make some popcorn, and watch them react. Reacting is also a form of evidence. Reacting the way a guilty person would react is prima facie evidence of guilt. (To use the examples from the TSW landing page, think OJ and the white Bronco or Lance Armstrong and just about anything he said or did after being accused.)

Needless to say, the wellness industry’s very stable geniuses never step out of character when it comes to guilty reactions. This runs the gamut. Sometimes, as with Bravo, they pull down the incriminating screenshot immediately after being outed. Or, as with Interactive Health, they simply excise the incriminating data from their “research report” and call it a “research summary.” (And also they try to bribe me not to talk about them any more. I’m just sayin’…)

Or, as with Wellsteps, they act out with unsupported and creatively spelled recriminations.


Or sometimes simply trying to erase history. This is the specialty of Ron “The Pretzel” Goetzel, twisting and turning his words to do exactly that, not realizing that we keep screenshots. Here is the “before” and “after” picture of him erasing the smoking-gun evidence that a program’s “impact” was due entirely to separation into participants-vs-non-participants rather than pry, poke and prod. Note that from 2004 to 2006, separation between participants and non-participants increased almost 20%before there was even a program to participate in.

Before (what really happened):

In order to maintain the fiction that participants-vs-non-participants is a valid study design, Ron simply removed the labels from the x-axis:

Lest anyone domiciled in a state where marijuana is now legal think the first one was a mistake and was corrected as soon as they noticed, they actually repeatedly reprinted and reused the original in many forums, like this one:


Sometimes, and this was my favorite of Ron “The Pretzel” Goetzel’s twists and turns, he literally rewrote history, in the form of forging a letter from the Governor of Nebraska, once he admitted the initial claim of saving the lives of 514 cancer victims was exposed as a fraud:

Original:

nebraska cancer koop award

Doctored:

nebraska polyps


Here is your assignment: pass this along to everyone you know and ask them to read the article. Then hopefully it will be time to write the history of wellness the way it should be written. And keep a screenshot in case Goetzel tries to rewrite it.

 

Congressional candidate running hard against forced wellness

In this hyperpartisan era, conservatives and liberals agree on only one thing: forcing employees into outcomes-based wellness programs is one of the worst ideas in the history of ideas. If you scroll down our feature In The News, you’ll see wellness gets equal treatment by right-wing publications like Newsmax and The Federalist as well as left-wing publications like Slate and Mother Jones.

Opposing forced wellness has already propelled one candidate into elective office: Matthew Woessner, whose leadership in Penn State’s faculty revolt against the punitive “pry, poke and prod” plan proposed by Highmark and Ron Goetzel, was elected President of the university’s faculty senate. Matthew is a self-described Republican libertarian.

In keeping with the bipartisan nature of wellness, it is fitting that the first Congressional candidate to take on the wellness industry is, conversely, a Democrat, Jenny Marshall. Jenny (as she likes to be called) is running against Virginia Foxx (R-NC5), who chairs the House Committee on Education and the Workforce. A powerful combination of this lucrative committee chairmanship, lack of ethics and a gerrymandered “safe” district (at least until voters find out about this bill), allows Foxx to “represent” the American Benefits Council rather than voters in her district. Indeed, I suspect she has nary a single constituent who supports employees being pried, poked and prodded into submission. It is not at all clear how this bill would benefit her district.

Any controversy over whether forced wellness saves a nickel or even improves health has long since been laid to rest. Hence, the American Benefits Council’s enthusiasm for forced wellness is all about making programs so onerous and unappealing that employees prefer to pay the $1000 fines rather than be subjected to the indignity and potential harms of being pried, poked and prodded by unlicensed, unregulated wellness vendors.

On the other hand, these programs can be very lucrative for employers, who can claw back large chunks of their insurance premiums forfeited by non-compliant employees. Vendors have already figured out how to offer “immediate savings” for employers through collecting these fines from employees.

Unless Foxx’s bill becomes law, this lucrative, misanthropic, anti-employee loophole will be closed December 31, thanks to the ruling in AARP v. EEOC, which will prevent employers from forcing employees into “voluntary” wellness programs.

Foxx’s HR1313, known colloquially as the Employee DNA Full Disclosure Act, would override this common-sense federal court decision.  Worse, it would allow employers to force not only employees but their children into these programs. And not just prying, poking and prodding them, but collecting their DNA as well. Yep, your children’s DNA is fair game if this bill passes.  It is so onerous that even much of the wellness industry opposes it, though they stand to benefit from it.

It is headed for a floor vote sometime this spring, having been voted out of her committee on — get ready — a straight party-line vote.  (So much for the GOP standing for individual rights.)


Jenny Marshall fights back

Jenny has posted a summary of this bill right on her campaign website.  Asked for a comment, she replied: “Foxx’s bill could very well be the worst proposed legislation in the history of Congress. Its intrusiveness would make Orwell blush. I can’t figure out why she would want to invade the privacy of her constituents like this, other than raking in big dollars from lobbyists. For too long now, Foxx has turned a deaf ear to the wants and needs of the people of our district, and for that betrayal should be voted out of her seat.”


You can donate to her campaign

If this bill passes, the very stable geniuses at “outcomes-based” wellness vendors like Bravo, Interactive Health, Wellsteps, Corporate Wellness Solutions, and Staywell will be able to trample employee rights to privacy, fine them and harm them — for no reason other than to enrich their own coffers, and those of their corporate overlords. Absent this legislation, millions will be thrilled to be freed from their anti-employee jihads on December 31 — and employers can find kinder, gentler conventional programs, a la Redbrick or unconventional ones like Limeade (and/or Quizzify, of course) instead.

The way to keep this bill from passing? Vote Foxx out of office.  Shed no tears for her. She will get a lucrative job, possibly representing the American Benefits Council in their quest to collect fines from employees — just like she does now.

Only starting in 2019 her paycheck will come directly from them, as opposed to indirectly, as it does now.

The donation link to Jenny Marshall is here.

The Very Stable Geniuses at Interactive Health Introduce a “Smoking Recession Program”

Interactive Health has once again proven themselves worthy of the 2017 Wellness Industry Deplorables Award.

How do we know this? They recently announced the industry’s first “smoking recession program.”

I don’t smoke, but it would be worth taking up the habit just to see what is entailed in this Smoking Recession Program, because otherwise they are keeping the contents under wraps, presumably so that previous winners of the Deplorables Award don’t copy them.

One possibility, suggested by Alert Reader Jon Robison, is that a great way to quit smoking is to lose your job and no longer be able to afford the habit.

Another possibility is that Interactive Health wants smokers to switch to Parliament, which offers a recessed filter.

Interactive Health’s idea behind the recessed filter is probably that because your lungs are farther away from the smoke, you live longer.



If you haven’t already done so, sign up for the webinar on AARP v. EEOC on January 18. You’ll be joined by thousands of other industry executives and HR professionals. We will be covering not only what happened, but how you can make lemonade out of it.

In the immortal words of the great philosopher Dizzy Dean, don’t fail to miss it.

Announcing the Winner of the Wellness Industry’s 2017 Deplorables Award: Interactive Health

Winning a Deplorables Award is no easy feat for a wellness vendor. You have to out-lie, out-harm and generally out-stupid many worthy competitors. Yet this year’s competition wasn’t even close. Fitbit might have won on lies and stupidity alone, but no one was ever harmed by wearing an activity tracker. Interactive Health clobbered them in harming employees.  Like Wellsteps (the 2016 Deplorables Award Winner) they managed to do that multiple ways. This award covers the harms, the lies, and the stupidity. Truly the perfect storm of workplace wellness.


The Harms

Interactive Health’s signature move is conducting mass screens so inappropriate that doctors doing essentially the same thing — paying people to take this panoply of tests and then billing insurance — would lose their licenses.

Needless to say, when you do all sorts of inappropriate tests, you find all sorts of non-existent problems, and send all sorts of employees to all sorts of doctors. This isn’t simple overdiagnosis. This is classic hyperdiagnosis as described in our 2015 posting.

This is what we wrote in that posting, and it appears Interactive Health is the poster child for it. As compared to overdiagnosis, which is the unfortunate byproduct of well-intentioned efforts to help patients who present with symptoms, hyperdiagnosis is:

  1. pre-emptive — employees aren’t asking to be diagnosed, don’t have symptoms, want to be left alone, and often aren’t even old enough to have the stuffing screened out of them yet;
  2. either negligently inaccurate or purposefully deceptive (and IH has been requested many times to stop doing inappropriate screenings but they continue unabated);
  3. powered by pay-or-play employee forfeitures for non-participation, of the type about to become illegal in 2019;
  4. all about the braggadocio – wellness companies love to announce how many sick people they find in their screens…

…And here is Interactive Health doing exactly that:

What do you do after you round up all sorts of unsuspecting employees with inappropriate screens? Obviously, you bombard them with inappropriate advice, of course.  Specifically, the huge percentage of employees at risk for diabetes — thanks to those “a1c tests for everyone” (which of course are specifically not recommended by the USPSTF) are supposed to drink full-fat dairy, not skim. And absent hypertension, they are also not supposed to avoid salt. Quite the contrary, maintaining US-average salt consumption appears to be protective against diabetes. (Not to mention that salty snacks often substitute for sweet ones.) We had no trouble finding these studies online. Hopefully Interactive Health will use some of their award money to purchase an internet connection.

Fortunately, most employees pay no attention to Interactive Health’s 1500-word single-spaced tomes, so it’s unlikely their antediluvian advice harmed anybody.

Third, speaking of harms, they also harmed me when I went in to be screened. Not just by announcing my PSA score when I specifically asked not to be tested for PSA, but by stretching my calf far enough to send it into spasm.


The Lies

The English language already has 450,000 words, the most of any language. And yet none of those words adequately describe the amount of lying done by Interactive Health, even after they’ve been caught.

They are claiming “amazing results” based on one study by an unknown, now-defunct consulting firm that couldn’t even pay its internet provider. (The consulting firm had also made up a set of qualifications in which, other than articles and prepositions and conjunctions, every word was a lie.)

Once the lies were initially exposed, they paid me to stop writing about them for a while. I agreed, provided that they stop lying — meaning that I can write about them ad nauseam.

The smoking gun for the initial lie was that they accidentally admitted that they didn’t really reduce any risk factors. You can’t save a gazillion dollars by reducing employees’ wellness-sensitive medical events if you can’t improve employees’ wellness. According to their own figures (and of course excluding dropouts and non-participants, whose risks likely climb), their risk reduction was quite trivial. How trivial? The Wishful Thinking Multiplier — savings divided by the number of risk factors temporarily reduced — exceeded $50,000.

After that expose, they sealed their front-runner status for a Deplorables Award by simply trying to suppress the evidence. They took the trivial risk reduction displays out of that study, and now only make available the bowdlerized version, which they call a “research summary.” The only way you can get the raw risk reduction data is by scrolling down this post. Rule one in wellness whistle-blowing: always take screenshots.

And most recently, they’ve become strong proponents of Wellsteps’ strategy, bragging about how many high-risk employees became low-risk without mentioning that roughly as many low-risk employees became high-risk.  Suppose you flip 100 coins. It’s not enough to say that of 50 heads, 25 became tails. You also have to admit that 25 of the tails flipped to heads. At the end of the day, nothing changed. Here are the heads-to-tails, from their website. (By the way, this is also not true, even on its face.)


The Stupidity

Ask any employer what is the “new smoking” in terms of employee hazards and mortality. Most will say opioids, of course. Not Interactive Health. For them the “new smoking” is…

interactive-health-sitting-smoking

Hey, Interactive Health, maybe you can find a smart person to explain this particular statistic to you:

  • According to the CDC, the number of annual deaths caused by smoking480,000
  • According to the CDC, the number of annual deaths caused by sitting0

Here are some other differences between the two activities: Chairs don’t carry excise taxes or warning labels. If you’re under 18, you can buy a chair without a fake ID.  Workers are allowed to sit inside the building. Chairs don’t make you clothes smell, cause lung cancer or dangle from the lips of gunslingers in old John Ford westerns. Sitters aren’t assessed health insurance penalties. Your Match date will not feel misled if he or she catches you taking a seat, even if your profile didn’t disclose that you sit.



And finally…

Take The Interactive Health IQ Test

Which of these images is most unlike the others?

interactive-health-iq-test

 

 

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