1. Measuring and Managing Healthy Living Bioelectric Impedance Analysis Administrator Edition

2. Measuring and Managing Healthy Living PLEASE NOTE The content of this slide deck is for informational purposes only. BIA technology is not intended to prevent, cure, diagnose, or treat any particular disease state. BIA technology does not replace the educated judgment of a licensed health care professional.

3. Measuring and Managing Healthy Living The US spends more on healthcare per capita ($8668) and more on healthcare as a percentage of GDP (17.2%) than any other nation. From 2011 data

4. Measuring and Managing Healthy Living Meta-analysis of almost 15,000 patients in multidisciplinary hospital and geriatric settings 145 cited references

5. Measuring and Managing Healthy Living Evidence-based medicine requires evidence

6. Measuring and Managing Healthy Living Scale Weight “Yes – I have weight…” Putting a patient on the scale only to confirm a total weight is like… drawing a blood sample only to confirm that the patient has blood

7. Which components are changing - fat, lean dry mass, fat free mass, intracellular water, extracellular water…? Measuring and Managing Healthy Living

8. Skin Fold Caliper Typically 3-7 sites on the body Variable inter-rater reliability Calipers only measure subcutaneous fat No TBW, ICE, ECW, or Phase Angle data Staff training & time-intensive Many patients report finding the procedure socially uncomfortable Courtesy Defender Body Fat Calipers

9. Courtesy Seattle pacific University Photo Courtesy ADP Technology Measuring and Managing Healthy Living Water and/or Air Displacement Lung air volume can compromise the accuracy of data Many patients report being fearful of immersion, claustrophobic, or being too self-conscious to be tested No TBW, ICW, ECW No Phase Angle data.

10. Measuring and Managing Healthy Living Dual Energy X-ray Absorptiometry Two radiation sources scan the body, some of which is absorbed by the bone & soft tissue. Most commonly used to determine bone mineral/skeletal health, and also measures fat and muscle. Height must be under 6’6” Weight must be under 350 pounds. There is still no TBW, ICW, ECW or Phase Angle data.

11. Measuring and Managing Healthy Living Bioelectrical Impedance Analysis

12. Measuring and Managing Healthy Living “Biological material is conductive and constantly changing. BIA can measure the electrical conductive properties of living things, and illustrate their changes over time.” - Rudolph J. Liedtke

13. Measuring and Managing Healthy Living In 1981, the US Navy ordered 4 BIA devices to be customized by RJL Systems, for use in the extreme conditions on Mt. McKinley. Studying naval soldiers in high altitude, correlating body composition fluids, correlating their results with blood and urine analysis.

14. Measuring and Managing Healthy Living Limitations of other BIA methods (standing & hand-held) Standing body composition devices are less accurate than RJL BIA, due to: central venous pressure unstabilized callouses on hands & feet temperature variables on palms & feet moisture variations on palms & feet

15. Limitations of other BIA methods Signal path differences Handheld models: hands, arms, upper chest Standing models: heels, legs, pelvis Measuring and Managing Healthy Living

16. Limitations of other BIA methods: Hand-held Hand Held Skin temperature dropping just 8.4’C causes an 8% error in Reactance, and an increase in Impedance (Z), due to changes in cutaneous blood flow and muscle. Gudivaka, 1996

17. Measuring and Managing Healthy Living Limitations of other BIA methods: Standing Foot to Foot Correlation, R =.71, vs. Hand to Foot Correlation, R=.96 Jebb, 2000

18. Measuring and Managing Healthy Living Limitations of other BIA methods: Consumer-grade devices Consumer grade BIA devices have been found to be even less accurate than skin fold thickness methods Peterson, 2011

19. Measuring and Managing Healthy Living Quantum BIA Cleared by the FDA as a Class II Medical Device, to assess body composition & fluid distribution 510 (K) Clearance for BC Software (available on MAC, PC, iPad) For use on healthy humans, ages 3-94 years.

20. Measuring and Managing Healthy Living Quantum BIA Actual Body Mass Index Impedance Phase Angle Research Equation Body Fat Fat Free Mass Total Body Water Intra-Cellular Water Extra-Cellular Water Basal Metabolic Rate Daily Energy Expenditure

21. Measuring and Managing Healthy Living Proper BIA Protocol

22. Measuring and Managing Healthy Living Proper BIA protocol Remove sock, stocking, jewelry, and any other metal objects from the electrode sites and the side of the body being tested. Remove cellphone or other electronic device from body Supine position on a flat surface Arms out 30’ from waist, and palms down

23. Proper BIA protocol Clean the 4 electrode sites with alcohol pad, and allow to dry (about 30 seconds) Measuring and Managing Healthy Living

24. Proper BIA protocol

25. Measuring and Managing Healthy Living Where you’ll see RJL BIA: Integrated and Functional Medicine Preventive and Lifestyle Medicine Hospitals and Private Practice University and Military Research NASA, NOAA NIH CTCA Mayo Clinic, Cleveland Clinic, Harvard, Yale…

26. Measuring and Managing Healthy Living BIA technology has been utilized in over 2000 research studies and scientific articles to date.

27. Measuring and Managing Healthy Living 10/2013 AMA Annual Meeting CPT 0358T formally defines BIA Whole Body Composition, supine position, with interpretation and report effective July 1, 2014

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29. Kerrie Saunders Director of Education Paul Maletz Production Manager Michael Liedtke Director of Business Development Barry Callahan Chief Technology Officer William J. Pauly Director of Sales Joshua Myers Engineering Technician Jeff Polly Office Manager Rudolph J. Liedtke Founder & CEO

30. Measuring and Managing Healthy Living BIA measures whole body reactance (Xc) and resistance (R), the two components of impedance.

31. Measuring and Managing Healthy Living Fat Fat Free Mass (aka Lean Body Mass = skeletal muscle, nerves, organs, water, smooth muscle) Extra- Cellular Water Intra- Cellular Water Total Body Water LDM ( Lean Dry Mass ) TOTAL BODY WEIGHT

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34. FAT STORAGE Visceral around the organs, aka: central, abdominal (generally include hepatic fat) Subcutaneous just beneath the skin, and in limbs So…..

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36. Contribution of body composition to nutritional assessment at hospital admission in 995 patients: a controlled population study U. Kyle, A. Morabia, et al, BJN (2001), 86, 725-731, Degree of malnutrition was significantly underestimated by BMI and serum albumin BIA-FFM identified patients with low FFM, and low or high Fat DXA-BIA correlate r=0.986 FFM FFM should therefore be included in optimal objective nutritional assessment Measuring and Managing Healthy Living

39. Practitioners can customize strategies for optimal therapeutic outcomes

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43. Hydrated cells vs. Dehydrated cells Photo Credit http://prakashthanwani.com/wp-content/uploads/2012/03/normal-dehydrated-cell1.jpg

44. Measuring and Managing Healthy Living Phase Angle Humans typically range between 3-9

45. Measuring and Managing Healthy Living Can phase angle determined by BIA assess nutritional risk? A comparison between healthy and hospitalized subjects U. Kyle, E. Soundar, et. al. Clin Nutr (2012), 875-881. Low PA associated with low serum albumin and moderate-to-severe risk by NRS2000 and SGA. PA is a useful screening tool at hospital admission without constraints of measuring body weight or body height

46. Measuring and Managing Healthy Living Phase Angle See the specified reference range on each individual report, based upon unique client factors Many practitioners report making a referral for further assessment and diagnosis for Phase Angle under 4 Phase angle is calculated by finding the ratio of reactance divided by resistance, and taking the arctangent of that ratio. Phase angle is normally expressed in degrees Increased hydration is usually associated with higher phase angle Practitioners typically say “higher is better”

47. Measuring and Managing Healthy Living Phase Angle PA is derived directly from the relation between reactance and resistance, and therefore is an indicator of water distribution Phase angle reflects the relative contributions of fluid (resistance) and cellular membranes (capacitance) of the human body. By definition, phase angle is positively associated with capacitance and negatively associated with resistance Phase Angle sometimes shows a temporary drop during fat loss Most useful when analyzed and interpreted as a trend.

48. Measuring and Managing Healthy Living Many practitioners tell us they monitor for change… Reactance Phase Angle Capacitance Fat Free Mass Lean Dry Mass Intracellular Water Resistance Impedance Fat Extracellular Water

49. Measuring and Managing Healthy Living Practitioners specifically target FAT loss to help achieve… Cardiovascular risk Blood sugar & insulin Total cholesterol Blood pressure LDL cholesterol Triglycerides Medication reduction/elimination when possible Gynecological conditions Symptoms of arthritis Cardiovascular function Improved quality of life Healthy sexual function HDL cholesterol Better fitness & lifestyle compliance Hormone balance

50. Measuring and Managing Healthy Living Ideal Weight Notations (recent exercise, surgery, etc.) Lab biomarkers: measurements, HgBA1C, Lipids, BP, etc. Store, email, print Tables, graphs, F&F, size of report Equation Sets BC 3.0 Software for MAC & PC (included in device kit) Report Options

51. Measuring and Managing Healthy Living Population Equation Options NHANES-III (General Population) This equation set is appropriate for general populations, and the Fat, FFM, and TBW formulas have been validated with NHANES-III New Pediatric (Ages 4 – 19; also validated for obese children) Mexican Adults (Male & Female ) Native Americans Obese (BMI > 30 ) African American (Obese ) Athletic HIV All Body Types (BMI adjustable)

52. Measuring and Managing Healthy Living Lifestyle Factor Upgrades: Food & Fitness

53. Measuring and Managing Healthy Living Designed to allow patients to see and navigate CHOICES, helping to make food fun again.

54. Measuring and Managing Healthy Living Food Categories Categories help lifestyle medicine practitioners target and customize patient preferences and nutritional needs and patient preferences.

55. Measuring and Managing Healthy Living Food Category Titles Higher Protein Higher Carbohydrate Higher Fat Calcium rich Snacks

56. Measuring and Managing Healthy Living Designed to allow practitioners to more easily address and customize many sample food options, including: wheat-, dairy-, egg-, gluten-,and cholesterol-free, and high fiber, vegan, and vegetarian diets

57. Measuring and Managing Healthy Living Hummus Sprouted bread Earth Balance™ Yam or sweet potato Almond milk Soy milk Hemp milk Coconut milk Rice milk Green/red/purple grapes Cherries Dates/figs Spinach Collard greens Bok choy Vegetarian chili Black bean salsa Garbanzo beans Blueberries Strawberries Raspberries Non-dairy mayonnaise Sliced red or green peppers All fruit jam/conserves Veggie Burger Black bean burger Brown/wild rice Quinoa Baked potato Teff Millett Chia seeds Ground flax seeds Walnuts Purslane greens Romaine or red lettuce Green beans Jicama soy/rice/oat/coconut ice cream whole grain muffin Mueslix or granola 3-bean salad Lentil couscous or bulgur wheat salad Bean, rice & veggie burrito Minestrone soup Vegetable soup Bean soup Pea soup HealthEnhancedOptions

58. Measuring and Managing Healthy Living Menu Options Note: The Standard Menu Options are listed for patient familiarity. Specific recommendations are determined during the patient-practitioner interaction.

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60. The many forms of fitness…

61. Measuring and Managing Healthy Living Designed to include a spectrum of lifestyle activities and exercises, helping you show your patients they are already moving, they just might need to move MORE.

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63. Note: FFM could also be divided into Bone Mineral Content (BMC) + Lean Soft Tissue (LST) BMC is the mineral deposits of the skeleton. LST includes organs, connective & supportive tissues, & SMM. Skeletal Muscle Mass (SMM) is required for posture and movement.

64. Measuring and Managing Healthy Living How do we measure health?

65. Measuring and Managing Healthy Living Tracking options also include:  HgbA1C  TC  HDL  LDL  Triglycerides  BP  Vitamin D  Neck  Shoulder  Waist  Hip  Wrist

66. Measuring and Managing Healthy Living Every combination of these biomarkers should be considered in true evidence- based medicine  HgbA1C  TC  HDL  LDL  Triglycerides  Vitamin D  BP  Neck  Shoulder  Waist  Hip  Wrist  Fat Pounds  Fat Percent  Fat Free Mass  Lean Dry Mass  Total Body Water  Intracellular Water  Extracellular Water  Impedance  BMI  Phase Angle

67. Measuring and Managing Healthy Living There is a direct and causal relationship between all of these biomarkers.

68. Measuring and Managing Healthy Living Upcoming this year… New measures: Lean Soft Tissue, Skeletal Muscle Mass, Bone Mineral Content Practitioner Report format option Segmental BIA 35 th Anniversary Event October 2014

69. Measuring and Managing Healthy Living Affordability & Quantum ROI The average BIA technician can analyze 32 individuals in an average 8 hour day. $20-$125 nationwide reported range, per test. Consider adding this additional revenue stream to your practice.

70. Measuring and Managing Healthy Living Affordability & Quantum ROI The opportunity to recommend your appropriately selected products Graphic or tabular images of individual results & progress Repeat analyses to monitor changes

71. Measuring and Managing Healthy Living Affordability & Quantum ROI Consider offering: Health Fair Specials Lower cost Analysis fee, with referral to RJL’s Free Online BIA calculator Discount for new patients from Fair “BIA Days” at your office Free, Half-price, 2 for 1, Bring a Friend, etc.

72. Measuring and Managing Healthy Living Collateral Gains Mitigating patient lifestyle reporting errors Protocol development Ability to strategically shift individual patient protocols when needed Practitioner protocol evaluation

73. Measuring and Managing Healthy Living Quantum IV (includes BC software for MAC or PC) $2590 Consider: You can get started now, and still benefit from new software release Prices increase in 2015

74. Measuring and Managing Healthy Living a. Purchase b. Finance c. Lease options around $115/month d. Trade-in $250 credit for old and non-RJL devices Access to RJL BIA

75. Measuring and Managing Healthy Living TRAINING RESOURCES YouTube videos Website resources USB drive included Superb customer service

76. William Pauly, Director of Sales 33939 Harper Avenue Clinton Township, MI 48035 (800) 528-4513 www.RJLSystems.com Photo Credits: Sunrise – Santa Banta, Midday – Dreamstime.com, Sunset –David baker We invite your Questions! (feel free to also use the Chatbox option)