Posture and mood: implications and applications to health and therapy

This blog has been reprinted from: Peper, E., Lin, I-M, & Harvey, R. (2017). Posture and mood: Implications and applications to therapy. Biofeedback.35(2), 42-48.

Slouched posture is very common and tends to increase access to helpless, hopeless, powerless and depressive thoughts as well as increased head, neck and shoulder pain. Described are five educational and clinical strategies that therapists can incorporate in their practice to encourage an upright/erect posture. These include practices to experience the negative effects of a collapsed posture as compared to an erect posture, watching YouTube video to enhance motivation, electromyography to demonstrate the effect of posture on muscle activity, ergonomic suggestions to optimize posture, the use of a wearable posture biofeedback device, and strategies to keep looking upward. When clients implement these changes, they report a more positive outlook and reduced neck and shoulder discomfort.


Most people slouch without awareness when looking at their cellphone, tablet, or the computer screen (Guan et al., 2016) as shown in Figure 1. Many clients in psychotherapy and in biofeedback or neurofeedback training experience concurrent rumination and depressive thoughts with their physical symptoms. In most therapeutic sessions, clients sit in a comfortable chair, which automatically creates a posterior pelvic tilt and encourages the spine to curve so that the client sits in a slouched position. While at home, they sit on an easy chair or couch, which lets them slouch as they watch TV or surf the web.Figure 1 three collapsed positions

Figure 1. (A). Employee working on his laptop. (B). Boy with ADHD being trained with neurofeedback in a clinic. (C). Student looking at cell phone. When people slouch and look at the screen, they tend to slouch and scrunch their neck.

In many cases, the collapsed position also causes people to scrunch their necks, which puts pressure on their necks that may contribute to developing headache or becoming exhausted. Repetitive strain on the neck and cervical spine may trigger a cervical neuromuscular syndrome that involves chronic neck pain, autonomic imbalance and concomitant depression and anxiety (Matsui & Fujimoto, 2011), and may contribute to vertebrobasilar insufficiency –a reduction in the blood supply to the hindbrain through the left and right vertebral arteries and basilar arteries (Kerry, Taylor, Mitchell, McCarthy, & Brew, 2008). From a biomechanical perspective, slouching also places more stress is on the cervical spine, as shown in Figure 2. When the neck compression is relieved, the symptoms decrease (Matsui & Fujimoto, 2011).

Figure 2 head collapseFigure 2. The more the head tilts forward, the more stress is placed on the cervical spine. Reproduced by permission from: Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277–279.

Most people are totally unaware of slouching positions and postures until they experience neck, shoulder, and/or back discomfort. Neither clients nor therapists are typically aware that slouching may decrease energy levels and increase the prevalence of negative (hopeless, helpless, powerless, or defeated) memories and thoughts (Peper & Lin, 2012; Peper et al, 2017)

Recommendations for posture awareness and training in treatment/education 

The first step in biofeedback training and therapy is to systematically increase awareness and training of posture before attempting further bio/neurofeedback training and/or cognitive behavior therapy. If the client is sitting in a collapsed position in therapy, then it will be much more difficult for them to access positive thoughts, which interferes with further training and effective therapy. For example, research by Tsai, Peper, & Lin (2016) showed that engaging in positive thinking while slouched requires greater mental effort then when sitting erect. Sitting erect and tall contributes to elevated mood and positive thinking. An upright posture supports positive outcomes that may be akin to the beneficial effects of exercise for the treatment of depression (Schuch, Vancampfort, Richards, Rosenbaum, Ward, & Stubbs., 2016).

Most people know that posture affects health; however, they are unaware of how rapidly a slouching posture can impact their physical and mental health. We recommend the following educational and clinical strategies to teach this awareness.

  1. Practicing activities that raise awareness about a collapsed posture as compared to an erect posture

Guide clients through the practices so that they experience how posture can affect memory recall, physical strength, energy level, and possible triggering of headaches.

A. The effect of collapsed and erect posture on memory recall. Participants reported that it is much easier evoke powerless, hopeless, helpless, and defeated memories when sitting in a collapsed position than when sitting upright. Guide the client through the procedure described in the article, How posture affects memory recall and mood (Peper, Lin, Harvey, and Perez, 2017) and in the blog Posture affects memory recall and mood.

B. The effects of collapsed and erect posture on perceived physical strength. Participants experience much more difficulty in resisting downward pressure at the wrist of an outstretched arm when slouched rather than upright. Guide the client through the exercise described in the article, Increase strength and mood with posture (Peper, Booiman, Lin, & Harvey, 2016) and the blog, Increase strength and mood with posture.

C. The effect of slouching versus skipping on perceived energy levels. Participants experience a significant increase in subjective energy after skipping than walking slouched. Guide the client through the exercises as described in the article, Increase or decrease depressionHow body postures influence your energy level (Peper & Lin, 2012).

D. The effect of neck compression to evoke head pressure and headache sensations. In our unpublished study with students and workshop participants, almost all participants who are asked to bring their head forward, then tilt the chin up and at the same time compress the neck (scrunching the neck), report that within thirty seconds they feel a pressure building up in the back of the head or the beginning of a headache. To their surprise, it may take up to 5 to 20 minutes for the discomfort to disappear. Practicing similar awareness activities can be a useful demonstration for clients with dizziness or headaches to experience how posture can increase their symptoms.

  1. Watching a Youtube video to enhance motivation.

Have clients watch Professor Amy Cuddy’s 2012 TED (Technology, Entertainment, and Design) Talk, Your body language shape who you are, which describes the hormonal changes that occur when adapting a upright power versus collapsed defeated posture.

  1. Electromyographic (EMG) feedback to demonstrate how posture affects muscle activity.

Record EMG from muscles such as around the cervical spine, trapezius, frontalis, and masseters or beneath the chin (submental lead) to demonstrate that having the head is forward and/or the neck compressed will increase EMG activity, as shown in Figure 3.

Figure 3 Head position

Figure 3. Electromyographic recording of the muscle under the chin while alternating between bringing the head forward or holding it back, feeling erect and tall.

The client can then learn awareness of the head and neck position. For example, one client with severe concussion experienced significant increase in head pressure and dizziness when she slouched or looked at a computer screen as well as feeling she would never get better. She then practiced the exercise of alternating her awareness by bringing her head forward and then back, and then bringing her neck back while her chin was down, thereby elongating the neck while she continued to breathe. With her head forward, she would feel her molars touching and with her neck back she felt an increase in space between the molars. When she elongated her neck in an erect position, she felt the pressure draining out of her head and her dizziness and tinnitus significantly decrease.

  1. Assessing ergonomics to optimize posture.

Change the seated posture of both the therapist and the client during treatment and training. Although people may be aware of their posture, it is much easier to change the external environment so that they automatically sit in a more erect power posture. Possible options include:

A. Seat insert or cushions. Sit in upright chairs that encourage an anterior pelvic tilt by having the seat pan slightly lower in the front than in the back or using a seat insert to facilitate a more erect posture (Schwanbeck, Peper, Booiman, Harvey, & Lin, 2015) as shown in Figure 4.

Figure 4 backjoy insert sitting with spine markers

Figure 4. An example of how posture can be impacted covertly when one sits on a seat insert that rotates the pelvis anteriorly (The seat insert shown in the diagram and used in research  is produced by BackJoy™).

B. Back cushion. Place a small pillow or rolled up towel at the kidney level so that the spine is slight arched, instead of sitting collapsed, as shown in Figure 5.

Figure 5 sitting with and without pillowFigure 5. An example of how a small pillow, placed between the back of the chair and the lower back, changes posture from collapsed to erect.

C. Check ergonomic and work site computer use to ensure that the client can sit upright while working at the computer. For some, that means checking their vision if they tend to crane forward and crunch their neck to read the text. For those who work on laptops, it means using either an external keyboard, a monitor, or a laptop stand so the screen is at eye level, as shown in Figure 6.

Figure 6 laptop ergonomicsFigure 6. Posture is collapsed when working on a laptop and can be improved by using an external keyboard and monitor. Reproduced by permission from: Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017).

  1. Wearable posture biofeedback training device

The wearable biofeedback device, UpRight™, consists of a small sensor placed on the spine and works as an app on the cell phone. After calibration the erect and slouched positions, the posture device gives vibratory feedback each time the participant slouches, as shown in Figure 7.Figure 7 UpRight collapse erect

Figure 7. Illustration of a posture feedback device, UpRight™. It provides vibratory feedback to the wearer to indicate that they are beginning to slouch.

Clinically, we have observed that clients can learn to identify conditions that are associated with slouching, such as feeling tired, thinking depressive/hopeless thoughts or other situations that evoke slouching. When people wear a posture feedback device during the day, they rapidly become aware of these subjective experiences whenever they slouch. The feedback reminds them to sit in an erect position, and they subsequently report an improvement in health (Colombo et al., 2017). For example, a 26-year-old man who works more than 8 hours a day on computer reported, “I have an improved awareness of my posture throughout my day. I also notice that I had less back pain at the end of the day.”

  1. Integrating posture awareness and position changes throughout the day

After clients have become aware of their posture, additional training included having them observe their posture as well and negative changes in mood, energy level or tension in their neck and head. When they become aware of these changes, they use it as a cue to slightly arch their back and look upward. If possible have the clients look outside at the tops of trees and notice details such as how the leaves and branches move. Looking at the details interrupts any ongoing rumination. At the same time, have them think of an uplifting positive memory. Then have them take another breath, wiggling, and return to the task at hand. Recommend to clients to go outside during breaks and lunchtime to look upward at the trees, the hills, or the clouds. Each time one is distracted, return to appreciate the natural patterns. This mental break concludes by reminding oneself that humans are like trees.

Trees are rooted in the earth and reach upward to the light. Despite the trauma of being buffeted by the storms, they continue to reach upward. Similarly, clouds reflect the natural beauty of the world, and are often visible in the densest city environment. The upward movement reflects our intrinsic resilience and growth.       –Erik Peper

Have clients place family photos and art slightly higher on the wall at home so they automatically look upward to see the pictures. A similar strategy can be employed in the office, using art to evoke positive feelings. When clients integrate an erect posture into their daily lives, they experience a more positive outlook and reduced neck and shoulder discomfort.

Compliance with Ethical Standards:

Conflict of Interest: Author Erik Peper has received donations of 15 UpRight posture feedback devices from UpRight ( and 12 BackJoy seat inserts from Backjoy ( for use in research. Co-authors I-Mei Lin and Richard Harvey declare that they have no conflict of interest.

This report evaluated a convenience sample of a student classroom activity related to posture and the information was anonymous collected. As an evaluation of a classroom activity, this report of findings was exempted from Institutional Review Board oversight


Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017). Retrieved from

Colombo, S., Joy, M., Mason, L., Peper, E., Harvey, R., & Booiman, A. Posture Change Feedback Training and its Effect on Health. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback.42(2), 147.

Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at:

Guan, X., Fan, G., Chen, Z., Zeng, Y., Zhang, H., Hu, A., … He, S. (2016). Gender difference in mobile phone use and the impact of digital device exposure on neck posture. Ergonomics59(11), 1453–1461.

Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277-279

Kerry, R., Taylor, A.J., Mitchell, J., McCarthy, C., & Brew, J. (2008). Manual therapy and cervical arterial dysfunction, directions for the future: A clinical perspective. Journal of Manual & Manipulative Therapy, 16(1), 39–48.

Matsui, T. & Fujimoto, T. (2011). Treatment for depression with chronic neck pain completely cured in 94.2% of patients following neck muscle treatment. Neuroscience & Medicine, 2, 71­77.

Peper, E., Booiman, A., Lin, I. M., & Harvey, R. (2016). Increase strength and mood with posture. Biofeedback. 44(2), 66–72.

Peper, E. & Lin, I. M. (2012). Increase or decrease depression-How body postures influence your energy level. Biofeedback, 40 (3), 126-130.

Peper, E., Lin, I. M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood. Biofeedback, (45 (2), 36-41.

Schwanbeck, R., Peper, E., Booiman, A., Harvey, R., & Lin, I. M. (2015). Posture Changes with a Seat Insert: Changes in strength and not EMG. Applied Psychophysiology and Biofeedback, 40, 128–129.

Schuch, F. B., Vancampfort, D., Richards, J., Rosenbaum, S., Ward, P. B., & Stubbs, B. (2016). Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. Journal of Psychiatric Research77, 42–51.

Tsai, H. Y., Peper, E., & Lin, I. M. (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23–27.

We thank Frank Andrasik for his constructive comments.


Posture affects memory recall and mood

This blog has been reprinted from: Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood.  Biofeedback, 45 (2), 36-41.

When I sat collapsed looking down, negative memories flooded me and I found it difficult to shift and think of positive memories. While sitting erect, I found it easier to think of positive memories.               -Student participant

Charlie BrownThe link between posture and mood is embedded in idiomatic phrases such as walking tall, standing proud, and an upstanding citizen, versus collapsed, defeated, or in a slump–Language suggests that posture and mood/emotions are connected. Slumped posture is commonly observed in depression (Canales et al., 2010; Michalak et al., 2009) and adapting an upright posture increases positive affect, reduces fatigue, and increases energy in people with mild to moderate depression (Wilkes et al., 2017; Peper & Lin, 2012).

This blog describes in detail our research study that demonstrated  how posture affects memory recall  (Peper et al, 2017). Our findings may explain why depression is increasing the more people use cell phones. More importantly,  learning posture awareness and siting more upright  at home and in the office may be an effective somatic self-healing strategy to increase positive affect and decrease depression.


Most psychotherapies tend to focus on the mind component of the body-mind relationship. On the other hand, exercise and posture focus on the body component of the mind/emotion/body relationship. Physical activity in general has been demonstrated to improve mood and exercise has been successfully used to treat depression with lower recidivism rates than pharmaceuticals such as sertraline (Zoloft) (Babyak et al., 2000). Although the role of exercise as a treatment strategy for depression has been accepted, the role of posture is not commonly included in cognitive behavior therapy (CBT) or biofeedback or neurofeedback therapy.

The link between posture, emotions and cognition to counter symptoms of depression and low energy have been suggested by Wilkes et al. (2017) and Peper and Lin (2012),  . Peper and Lin (2012) demonstrated that if people tried skipping rather than walking in a slouched posture, subjective energy after the exercise was significantly higher. Among the participants who had reported the highest level of depression during the last two years, there was a significant decrease of subjective energy when they walked in slouched position as compared to those who reported a low level of depression. Earlier, Wilson and Peper (2004) demonstrated that in a collapsed posture, students more easily accessed hopeless, powerless, defeated and other negative memories as compared to memories accessed in an upright position. More recently, Tsai, Peper, and Lin (2016) showed that when participants sat in a collapsed position, evoking positive thoughts required more “brain activation” (i.e. greater mental effort) compared to that required when walking in an upright position.

Even hormone levels also appear to change in a collapsed posture (Carney, Cuddy, & Yap, 2010). For example, two minutes of standing in a collapsed position significantly decreased testosterone and increased cortisol as compared to a ‘power posture,’ which significantly increased testosterone and decreased cortisol while standing. As  Professor Amy Cuddy pointed out in herTechnology, Entertainment and Design (TED) talk, “By changing posture, you not only present yourself differently to the world around you, you actually change your hormones” (Cuddy, 2012).  Although there appears to be controversy about the results of this study, the overall findings match mammalian behavior of dominance and submission. From my perspective, the concepts underlying Cuddy’s TED talk are correct and are reconfirmed in our research on the effect of posture.  For more detail about the controversy, see the article by Susan Dominusin in the New York Times,  “When the revolution came for Amy Cuddy,”, and Amy Cuddy’s response (Dominus, 2017;Singal and Dahl, 2016).

The purpose of our study is to expand on our observations with more than 3,000 students and workshop participants. We observed that body posture and position affects recall of emotional memory. Moreover, a history of self-described depression appears to affect the recall of either positive or negative memories.


Subjects: 216 college students (65 males; 142 females; 9 undeclared), average age: 24.6 years (SD = 7.6) participated in a regularly planned classroom demonstration regarding the relationship between posture and mood. As an evaluation of a classroom activity, this report of findings was exempted from Institutional Review Board oversight.


While sitting in a class, students filled out a short, anonymous questionnaire, which asked them to rate their history of depression over the last two years, their level of depression and energy at this moment, and how easy it was for them to change their moods and energy level (on a scale from 1–10). The students also rated the extent they became emotionally absorbed or “captured” by their positive or negative memory recall. Half of the students were asked to rate how they sat in front of their computer, tablet, or mobile device on a scale from 1 (sitting upright) to 10 (completely slouched).

Two different sitting postures were clearly defined for participants: slouched/collapsed and erect/upright as shown in Figure 1. To assume the collapsed position, they were asked to slouch and look down while slightly rounding the back. For the erect position, they were asked to sit upright with a slight arch in their back, while looking upward.

Figure 1 body positionFigure 1. Sitting in a collapsed position and upright position (photo by Jana  Asenbrennerova). Reprinted by permission from Gorter and Peper (2011).

After experiencing both postures, half the students sat in the collapsed position while the other half sat in the upright position. While in this position, they were asked to recall/evoke as many hopeless, helpless, powerless, or defeated memories as possible, one after the other, for 30 seconds.

After 30 seconds they were reminded to keep their same position and let go of thinking negative memories. They were then asked to recall/evoke only positive, optimistic, or empowering memories for 30 seconds.

They were then asked to switch positions. Those who were collapsed switched to sitting erect, and those who were erect switched to sitting collapsed. Then they were again asked to recall/evoke as many hopeless, helpless, powerless, or defeated memories as possible one after the other for 30 seconds. After 30 seconds they were reminded to keep their same position and again let go of thinking of negative memories. They were then asked to recall/evoke only positive, optimistic, or empowering memories for 30 seconds, while still retaining the second posture.

They then rated their subjective experience in recalling negative or positive memories and the degree to which they were absorbed or captured by the memories in each position, and in which position it was easier to recall positive or negative experiences.


86% of the participants reported that it was easier to recall/access negative memories in the collapsed position than in the erect position, which was significantly different as determined by one-way ANOVA (F(1,430)=110.193, p < 0.01) and 87% of participants reported that it was easier to recall/access positive images in the erect position than in the collapsed position, which was significantly different as determined by one-way ANOVA (F(1,430)=173.861, p < 0.01) as shown in Figure 2.

Figure 2 emotional recallFigure 2. Percent of respondents who reported that it was easier to recall positive or negative memories in an upright or slouched posture.

The difficulty or ease of recalling negative or positive memories varied depending on position as shown in Figure 3.

Figure 3 access to memoriesFigure 3. The relative subjective rating in the ease or difficulty of recalling negative and positive memories in collapsed and upright positions.

The participants with a high level of depression over the last two years (top 23% of participants who scored 7 or higher on the scale of 1–10) reported that it was significantly more difficult to change their mood from negative to positive (t(110) = 4.08, p < 0.01) than was reported by those with a low level of depression (lowest 29% of the participants who scored 3 or less on the scale of 1–10). It was significantly easier for more depressed students to recall/evoke negative memories in the collapsed posture (t(109) = 2.55, p = 0.01) and in the upright posture (t(110) = 2.41, p ≦0.05 he) and no significant difference in recalling positive memories in either posture, as shown in Figure 4.

Figure 4 least most depressedFigure 4. Differences is in memory access for participants with a history of least or most depression.

For all participants, there was a significant correlation (r = 0.4) between subjective energy level and ease with which they could change from negative to positive mood. There were no significance differences for gender in all measures except that males reported a significantly higher energy level than females (M = 5.5, SD = 3.0 and M = 4.7, SD = 3.8, respectively; t(203) = 2.78, p < 0.01).

A subset of students also had rated their posture when sitting in front of a computer or using a digital device (tablet or cell phone) on a scale from 1 (upright) to 10 (completely slouched). The students with the highest levels of depression over the last two years reporting slouching significantly more than those with the lowest level of depression over the last two years (M = 6.4, SD = 3.5 and M = 4.6, SD = 2.6; t(46) = 3.5, p < 0.01).

There were no other order effects except of accessing fewer negative memories in the collapsed posture after accessing positive memories in the erect posture (t(159)=2.7, p < 0.01). Approximately half of the students who also rated being “captured” by their positive or negative memories were significantly more captured by the negative memories in the collapsed posture than in the erect posture (t(197) = 6.8, p < 0.01) and were significantly more captured by positive memories in the erect posture than the collapsed posture (t(197) = 7.6, p < 0.01), as shown in Figure 5.

Figure 5 Posture dependent ratingFigure 5. Subjective rating of being captured by negative and positive memories depending upon position.


Posture significantly influenced access to negative and positive memory recall and confirms the report by Wilson and Peper (2004). The collapsed/slouched position was associated with significantly easier access to negative memories. This is a useful clinical observation because ruminating on negative memories tends to decrease subjective energy and increase depressive feelings (Michi et al., 2015). When working with clients to change their cognition, especially in the treatment of depression, the posture may affect the outcome. Thus, therapists should consider posture retraining as a clinical intervention. This would include teaching clients to change their posture in the office and at home as a strategy to optimize access to positive memories and thereby reduce access or fixation on negative memories. Thus if one is in a negative mood, then slouching could maintain this negative mood while changing body posture to an erect posture, would make it easier to shift moods.

Physiologically, an erect body posture allows participants to breathe more diaphragmatically because the diaphragm has more space for descent. It is easier for participants to learn slower breathing and increased heart rate variability while sitting erect as compared to collapsed, as shown in Figure 6 (Mason et al., 2017).

Figure 6 collapse and physiologyFigure 6. Effect of posture on respiratory breathing pattern and heart rate variability.

The collapsed position also tends to increase neck and shoulder symptoms This position is often observed in people who work at the computer or are constantly looking at their cell phone—a position sometimes labeled as the i-Neck.

Implication for therapy

In most biofeedback and neurofeedback training sessions, posture is not assessed and clients sit in a comfortable chair, which automatically causes a slouched position. Similarly, at home, most clients sit on an easy chair or couch, which lets them slouch as they watch TV or surf the web. Finally, most people slouch when looking at their cellphone, tablet, or the computer screen (Guan et al., 2016). They usually only become aware of slouching when they experience neck, shoulder, or back discomfort.

Clients and therapists are usually not aware that a slouched posture may decrease the client’s energy level and increase the prevalence of a negative mood. Thus, we recommend that therapists incorporate posture awareness and training to optimize access to positive imagery and increase energy.


Babyak, M., Blumenthal, J. A., Herman, S., Khatri, P., Doraiswamy, M., Moore, K., … Krishnan, K. R. (2000). Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosomatic Medicine, 62(5), 633–638. 

Canales, J. Z., Cordas, T. A., Fiquer, J. T., Cavalcante, A. F., & Moreno, R. A. (2010). Posture and body image in individuals with major depressive disorder: A controlled study. Revista brasileira de psiquiatria, 32(4), 375–380.

Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363–1368.

Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at:

Dominus, S. (2017, October 18). When the revolution came for Amy Cuddy. New York Times Magazine,

Gorter, R. & Peper, E. (2011). Fighting Cancer-A Non Toxic Approach to Treatment. Berkeley, CA: North Atlantic Books

Guan, X., Fan, G., Chen, Z., Zeng, Y., Zhang, H., Hu, A., … He, S. (2016). Gender difference in mobile phone use and the impact of digital device exposure on neck posture. Ergonomics59(11), 1453–1461.

Mason, L., Joy, M., Peper, E., & Harvey, R, A. (2017). Posture Matters. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback, 42(2), 148.

Michalak, J., Troje, N. F., Fischer, J., Vollmar, P., Heidenreich, T., & Schulte, D. (2009). Embodiment of sadness and depression: Gait patterns associated with dysphoric mood. Psychosomatic Medicine, 71(5), 580–587.

Michl, L. C., McLaughlin, K. A., Shepherd, K., & Nolen-Hoeksema, S. (2013). Rumination as a mechanism linking stressful life events to symptoms of depression and anxiety: Longitudinal evidence in early adolescents and adults. Journal of Abnormal Psychology122(2), 339.

Peper, E. & Lin, I-M. (2012). Increase or decrease depression: How body postures influence your energy level. Biofeedback, 40(3), 126–130.

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood.  Biofeedback.45 (2), 36-41.

Singal, J. and Dahl, M. (2016, Sept 30 ) Here Is Amy Cuddy’s Response to Critiques of Her Power-Posing Research.

Tsai, H. Y., Peper, E., & Lin, I. M. (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23–27.

Wilkes, C., Kydd, R., Sagar, M., & Broadbent, E. (2017). Upright posture improves affect and fatigue in people with depressive symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 54, 143–149.

Wilson, V.E. and Peper, E. (2004). The effects of upright and slumped postures on the generation of positive and negative thoughts. Applied Psychophysiology and Biofeedback, 29(3), 189–195.

We thank Frank Andrasik for his constructive comments.


Breathing to improve well-being

Breathing affects all aspects of your life. This invited keynote, Breathing and posture: Mind-body interventions to improve health, reduce pain and discomfort, was presented at the Caribbean Active Aging Congress, October 14, Oranjestad, Aruba.

The presentation includes numerous practices that can be rapidly adapted into daily life to improve health and well-being.

Yes, fresh organic food is better!

organic pesticide

Is it really worthwhile to spent more money on locally grown organic fruits and vegetables than non-organic fruits and vegetables?  The answer is a resounding “YES!”  Organic grown foods have significantly more vitamins, antioxidants and secondary metabolites such as phenolic compounds than non-organic foods. These compounds provide protective health benefits and lower the risk of cancer, cardiovascular disease, type two diabetes, hypertension and many other chronic health conditions (Romagnolo & Selmin, 2017; Wilson et al., 2017; Oliveira et al., 2013; Surh & Na, 2008).  We are what we eat–we can pay for it now and optimize our health or pay more later when our health has been compromised.

The three reasons why fresh organic food is better are:

  1. Fresh foods lengthen lifespan.
  2. Organic foods have more vitamins, minerals, antioxidants and secondary metabolites than non-organic foods.
  3. Organic foods reduce exposure to harmful neurotoxic and carcinogenic pesticide and herbicides residues.


With the advent of chemical fertilizers farmers increased crop yields while the abundant food became less nutritious.  The synthetic fertilizers do not add back all the necessary minerals and other nutrients that the plants extract from the soil while growing.  Modern chemical fertilizers only replace three components–Nitrogen, Phosphorus and Potassium–of the hundred of components necessary for nutritious food. Nitrogen (N) which promotes leaf growth; Phosphorus (P which development of roots, flowers, seeds, fruit; and Potassium (K) which promotes strong stem growth, movement of water in plants, promotion of flowering and fruiting. These are great to make the  larger and more abundant fruits and vegetables; however, the soil is more and more depleted of the other micro-nutrients and minerals that are necessary for the plants to produce vitamins and anti-oxidants. Our industrial farming is raping the soils for quick growth and profit while reducing the soil fertility for future generations.  Organic farms have much better soils and more soil microbial activity than non-organic farm soils which have been poisoned by pesticides, herbicides, insecticides and chemical fertilizers (Mader, 2002; Gomiero et al, 2011). For a superb review of Sustainable Vs. Conventional Agriculture see the web article:

1. Fresh young foods lengthen lifespan. Old foods may be less nutritious than young food. Recent experiments with yeast, flies and mice discovered that when these organisms were fed old versus young food (e.g., mice were diets containing the skeletal muscle of old or young deer), the organisms’ lifespan was shortened by 18% for yeast, 13% for flies, and 13% for mice (Lee et al., 2017).  Organic foods such as potatoes, bananas and raisins improves fertility, enhances survival during starvation and decreases long term mortality for fruit flies(Chhabra et al, 2013). See Live longer, enhance fertility and increase stress resistance: Eat organic foods.

In addition, eating lots of fruits and vegetables decreases our risk of dying from cancer and heart disease. In a superb meta-analysis of 95 studies, Dr. Dagfinn Aune from the School of Public Health, Imperial College London, found that people who ate ten portions of fruits and vegetable per day were a third less likely to die than those who ate none (Aune et al, 2017).  Thus, eat lots of  fresh and organic fruits and vegetables from local sources that is not aged because of transport.

2. Organic foods have more vitamins, minerals, antioxidants and secondary metabolites than non-organic foods. Numerous studies have found that fresh organic fruits and vegetables have more vitamins, minerals, antioxidants, and secondary metabolites than non-organic ones.  For example, organic tomatoes contain 57 per cent more vitamin C than non-organic ones (Oliveira et al 2013) or organic milk has more beneficial polyunsaturated fats non-organic milk (Wills, 2017; Butler et al, 2011). Over the last 50 years key nutrients of fruits and vegetables have declined. In a survey of 43 crops of fruits and vegetables, Davis, Epp, &  Riordan, (2004) found a significant decrease of  vitamins and minerals in foods grown in the 1950s as compared to 1999 as shown in Figure 1 (Lambert, 2015).slide-1-redrawn-from-davis

Figure 1. Change in vitamins and minerals from 1950 to 1999. From: Davis, D. R., Epp, M. D., & Riordan, H. D. (2004). Changes in USDA food composition data for 43 garden crops, 1950 to 1999Journal of the American College of Nutrition23(6), 669-682.

3, Organic foods reduce exposure to harmful neurotoxic and carcinogenic pesticide and herbicides residues. Even though, the United States Department of Agriculture (USDA) and the United States Environmental Protection Agency (EPA) state that pesticide residues left in or on food are safe and non-toxic and have no health consequences, I have my doubts! Human beings accumulate pesticides just like tuna fish accumulates mercury—frequent ingesting of very low levels of pesticide and herbicide residue may result in long term harmful effects and these long term risks have not been assessed. Most pesticides are toxic chemicals and were developed to kill agricultural pests — living organisms.  Remember human beings are living organisms. The actual risk for chronic low level exposure is probably unknown; since,  the EPA pesticide residue limits are the result of a political compromise between scientific findings and lobbying from agricultural and chemical industries (Portney, 1992).  Organic diets expose consumers to fewer pesticides associated with human disease (Forman et al, 2012).

Adopt the precautionary principle which states, that if there is a suspected risk of herbicides/pesticides causing harm to the public, or to the environment, in the absence of scientific consensus, the burden of proof that it is not harmful falls on those recommending the use of these substances (Read & O’Riordan, 2017).  Thus, eat fresh locally produced organic foods to optimize health.


Aune, D.,  Giovannucci, D.,  Boffetta, P.,  Fadnes, L.T.,  Keum, N., Norat, T.,  Greenwood, D.C.,  Riboli, E.,  Vatten, L.J., & Tonstad, S. ( 2017). Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality—a systematic review and dose-response meta-analysis of prospective studies. International Journal of Epidemiology, 46(3), 1029–1056,

Butler, G. Stergiadis, s., Seal, C., Eyre, M., & Leifert, C. (2011). Fat composition of organic and conventional retail milk in northeast England. Journal of Dairy Science. 94(1), 24-36.

Davis, D. R., Epp, M. D., & Riordan, H. D. (2004). Changes in USDA food composition data for 43 garden crops, 1950 to 1999Journal of the American College of Nutrition23(6), 669-682.!_articles/Changes%20in%20USDA%20Food%20Composition%20Data%20for%2043%20Garden%20Crops%201950%20to%201999.pdf

Chhabra R, Kolli S, Bauer JH (2013) Organically Grown Food Provides Health Benefits to Drosophila melanogaster. PLoS ONE 8(1): e52988. doi:10.1371/journal.pone.0052988 

Gomiero, T.; Pimentel, D.; Paoletti, M. G. (2011). Environmental Impact of Different Agricultural Management Practices: Conventional Vs. Organic Agriculture. Critical Reviews in Plant Sciences, 30(1-2), 95-124; 

Lambert, C. (2015). If Food really better from the farm gate than super market shelf? New Scientist.228(3043), 33-37.

Lee, G., Kaya, A., Avanesov, A.S., Podolskiy, D.I., Song, E.J., Go, D-M., Jin, G-D., Hwang, J.Y., Kim, E.B., Kim, D-Y., & Gladyshev, V.N. (2017). Age-associated molecular changes are deleterious and may modulate life span through diet.Science Advances, 3(2), e1601833  DOI: 10.1126/sciadv.1601833

Mader, P., Fliebbach, A., Dubois, D., Gunst, L., Fried, P., & Niggli, U. (2002). Soil Fertility and Biodiversity in Organic Farming. Science, 296, 1694-1697. DOI: 10.1126/science.1071148

Oliveira, A.B., Moura, C.F.H., Gomes-Filho, E., Marco, C.A., Urban, L., & Miranda, M.R.A. (2013). The Impact of Organic Farming on Quality of Tomatoes Is Associated to Increased Oxidative Stress during Fruit Development. PLoS ONE, 8(2): e56354.

Read, R.  and O’Riordan, T. (2017). The Precautionary Principle Under Fire.  Environment-Science and policy for sustainable development.  September-October.

Romagnolo, D. F. & Selmin, O.L. (2017). Mediterranean Diet and Prevention of Chronic Diseases. Nutr Today. 2017 Sep;52(5):208-222. doi: 10.1097/NT.0000000000000228.

Surh, Y.J., Na, H.K. (2008). NF-κB and Nrf2 as prime molecular targets for chemoprevention and cytoprotection with anti-inflammatory and antioxidant phytochemicals. Genes & Nut 2: 313–317.

Wills, A. (2017). There is evidence organic food is more nutritious. New Scientist,3114, p53.

Wilson, L.F., Antonsson, A., Green, A.C., Jordan, S.J., Kendall, B.J., Nagle, C.M., Neale, R.E., Olsen, C.M., Webb, P.M., & Whiteman, D.C. (2017). How many cancer cases and deaths are potentially preventable? Estimates for Australia in 2013. Int J Cancer. 2017 Oct 6. doi: 10.1002/ijc.31088


Are you out of control and reacting in anger? The role of food and exercise


Fuming in anger, exploding in rage, shaking in fear, or trembling with anxiety, what can you do? How can you control your emotions and what can you do if you are reacting to a friend or colleague who is out of control? There are many useful self-directed approaches and traditional advice such as, “Count to 10 before you speak,” ”Sleep on it before acting on the decision you have made,” “Practice stress reduction techniques such as mindfulness meditation,” “Leave the situation,” or “Wait 24 hours before clicking “send” on an angry email response.”

These suggestions aim to reduce the strong negative emotions which could cause people to lash out at or totally withdraw from the perceived threat. Under perceived threat, we may react defensively and impulsively to protect ourselves. During those times we may say the meanest things to hurt the person as a substitute for inflicting actual physical harm.

In almost most cases when angry or frightened we may react automatically.  Thus having skills to recognize and interrupt the escalating cycle of negative emotions can facilitate resolving conflicts.  These skills allow us to react more cool headed, rationally, and recognize how our responses would impact other people and prevent future blow back from our excessive emotional response. It could also interrupt an escalating argument. Despite our best efforts, it is often difficult to change our emotional reaction especially when we feel threatened, hungry and tired.

Emotion regulation as described by Professor James Gross, Professor of Psychology at Stanford University, consists of 1) awareness that there  is a need for an unhelpful emotion to be regulated such as noticing an increase in heart rate or worry, 2) selecting a strategy to regulate the emotion such as thinking about positive memories such as a loving grandparent or practicing breathing, 3) implementing  and acting on this strategy  which means  doing the strategy at that moment when we don’t want to and all our impulses are saying “I am right, don’t change,” and 4) constant follow-up  to check if what we are doing is effective and if not, what needs to be improved (Gross, 213).

This approach can be very effective and may work even better by combining multiple strategies instead of only one technique.  The more skills you have and practiced the easier it becomes to master motional regulation.  Sometimes, psychological behavioral approaches may underestimate the role of biological factors such as diet, exhaustion and exercise that underlie emotional regulation.

Think of a four-year child throwing a temper tantrum. As a parent, it not useful to discuss with the child what is going on. Each suggestion may increase the tantrum. Instead the parent thinks, “My child is exhausted or hungry” (how many tantrums don’t occur when the child stays up after bed time or just before dinner?).  The millennium’s phrase, “hangry,” is the combination of hunger and anger.

The knowledge that food may prevent or reduce conflict is reflected in the cultural wisdom of most countries except the USA. In the Middle East you are offered tea and sweets before buying a small rug at the bazaar; in Japan or China, you are invited to a meal before beginning a business transaction.  The food and may slightly raise your blood glucose levels and encourage digestion which triggers a physiological state that is the opposite of that triggered by anger or fear.  It may also evoke positives feelings associated with eating such as family gatherings and parties. As the food and drink are a gift, it may allow you to perceive the other person more positively.  Thus, it is easier to be collegial and react more positively in challenging situations. The influence of rest and food has also been observed in Judicial rulings. Judges are much more likely to accept prisoners’ requests for parole at the beginning of the session–right after breakfast or lunch–than later in the session (Danzier, Levav & Avnaim-Pesso, 2011).

What can you do?

One useful mental strategy when you are out of control is to remind yourself that you are acting like a four-year-old child who is having a tantrum. Begin in the same way as you would with a four-year-old: take time out, eat some food, and get rest. Then in the clear light of the next day, after having eating a nutritious breakfast– not just a cup of coffee with a muffin–discuss and resolve what happened the day before that triggered the outburst. Similarly, when another person is out of control, do not to take it personally, he/she may be a momentary acting like four-year-old.

Keep in mind, whatever other people said or did during an outburst, they may have responded automatically because they experienced their survival being threatened.  Remember, how in a past moment of anger, you have said something very hurtful?  At the moment the words left your mouth, you wished you could have reeled them back in as you realized that it would be almost impossible to repair the damage.

From a biological perspective you were hijacked by the amygdala which is part of our emotional brain (Goleman, 2006). The amygdala processes information 22 milliseconds earlier than the rational brain and acts protectively before our rational brain, the neocortex, can assess the situation and respond. This reaction occurs because the information signals “we are in danger” and evokes the automatic defense reaction as shown Figure 1.

Lec05a Stress part 2

Figure 1. Triggering of a defense reaction is 22 milliseconds quicker from the amygdala than from the cortex. Thus we sometimes react without recognizing the consequences (adapted from Ropeik, 2011)

Implement the cultural wisdom of eating together first and then discussing business or challenging issues. Do not send negative messages by email or mail since that allows people to react asynchronously without having the social feedback to modulate their emotions.

Self-regulation of unhelpful emotions is challenging because negative emotions trigger the body’s defense reactions to prepare it for flight and fight. At that point, it is more and more difficult to perceive the long term consequences of our action– our only goal is to survive.  Even our cognitions change and we tend to interpret any information more negatively and may assume harmful intent. The more we are captured by our emotions, the more challenging is it to implement emotional self-regulation strategies.

Once the defense reaction has been activated, it is not the time to resolve conflict.  Dr. Gottman and colleagues at the Seattle Love lab, discovered that when couples argued and their heartrate went over a hundred (a possible biological marker of sympathetic activation) arguments could escalate. If the person whose heart rate went up spontaneously took a time out and did self-soothing, the couple had a lower divorce rate and higher marital happiness than those couples who continue the arguments (Gottman & Gottman, 2008).

One of the effective ways to begin emotion regulation is to leave the situation and first complete the fight/flight defense reaction.  If possible, this means interrupting whatever you are doing and exercise vigorously. After you have done a vigorous workout, emotional regulation is much easier as the ruminating thoughts have decreased or stopped.

Complete the alarm reaction with exercise

When you are upset take a break.  If possible, take a time out and exercise to complete the fight/flight response that was activated by the negative emotions. This is not always possible in a business or social gathering; instead, excuse yourself and go to the bathroom.  In the bathroom do the following five-minute exercise that was taught by Rinpoche Tarthang Tulku of the Nyingma tradition of Tibetan Buddhism as an approach to stop ruminating thoughts as shown in Figure 2.


Stand on your toes with the heels touching each other and lifted off the floor with your knees bent. Place your

hands on your sides, breathe slowly and deeply.  Do this next to wall to reach with your hand to steady you if you lose your balance.  Stay in this position for as long as 5 minutes. Do not straighten up, keep squatting.

In a very short time your attention will be drawn and captured by the burning sensation in your thighs. Continue.  After five minutes stop, shake your legs and relax.

After this exercise your thoughts have stopped and continue with the more cognitive approach of emotional self-regulation or return to the meeting. Warming: Do not do this if you have hip, knee or ankle difficulty.

Use heart rate biofeedback to signal you that you may be losing control.

Wear a heart rate monitor to signal you when your heart rate increases twenty to thirty beats above your personal baseline rate during a discussion or conflict. Use that feedback to stop and take time out and implement self-regulation practices such as exercise, breathing or meditation to allow your arousal to decrease. When feeling more calm, return to the meeting.


Food and exercise are powerful tools to augment emotional self-regulation and health.  In our research, Lena Stampfli and I have observed that many students who miss meals, have an unhealthy diet, do not the exercise, are sometimes irritable and experience difficulty in concentration. When San Francisco State University students implemented a four-week self-healing project as part of a class experience, the students who changed their eating behavior (eating breakfast, not skipping meals, reducing caffeine and simple carbohydrates and increase proteins, fats and fresh vegetables) and implemented daily physical exercise (e.g., yoga, jogging, and dancing), reported significant improvements in their energy level, fewer emotion outbursts and improved quality of life. They report some of the following:

“I thought I did not particularly like exercising and eating healthy, but when it is over I feel like I am on cloud nine!… I started to look forward to doing my exercises.” –A.M.

“I started to eat breakfast, I started biking to work and did a few [meditation] exercises before bed… I felt happier and more have energy to get through the day.” –C.B.

“I have learned that letting go of what no longer serves me allow room for healing and opportunities for growth… I can only imagine what years of healthy living could do for my well-being.” –K.S.

*I thank Pardis Miri, PhD, for her constructive comments.

The blog was adapted from Peper, E. (2017). Emotional control through mindfulness as path to mental health? Western Edition HP Journal. October.


Danziger, S., Levav, J.& Avnaim-Pesso, L. (2011). Extraneous factors in judicial decisions. Proceedings of the National Academy of Sciences of the United States of Amereidcal, 108(17), 6889-6892. doi:10.1073/pnas.1018033108

Goleman, D. (2006). Emotional intelligence. New York: Bantam.

Gottman, J.M., Gottman, J.S. (2008). Gottman method couple therapy. In A.S. Gurnam (Ed.)., Clinical handbook of couple therapy (4th ed.) (pp. 138-164). New York, Guilford Press.

Gross, James J., ed. (2013). Handbook of emotion regulation. New York, Guilford publications.

Ropeik, D. (2011). How Risky Is It, Really?: Why Our Fears Don’t Always Match the Facts. New York: McGraw Hill Education.

Treat yourself to a different point of view: Malcolm Gladwell’s podcasts-Revisionist History


Each time I listen to one of Malcolm Gladwell’s podcasts, Revisionist History, I experience a veil lifting from my eyes.  He reminds me that what I accept without question may not be correct.  Malcolm Gladwell is an English Canadian and author of five books including The Tipping Point: How Little Things Can Make a Big Difference, Outliers: The Story of Success, and  David and Goliath: Underdogs, Misfits, and the Art of Battling Giants. More recently he is the host of the podcast Revisionist History. His podcasts are goldmine of information. In every episode he re-examines something from the past or present—an event, a person, an idea, even a song—and asks whether we got it right the first time. He brings clarity to topics such as art, basketball, education, financial investment, and philanthropy. His  “out of the box” perspective lead me continuously to say, This really makes sense!  I wish I thought of that!

Treat yourself and listing to Malcom Gladwell’s podcasts, Revisionist History, It is a  journey through the overlooked and the misunderstood. For season 1 and 2 see:

First do no harm: Listen to Freakonomics Radio Episodes Bad Medicine


How come up to 250,000 people a year die of medical errors and is the third leading cause of death in the USA (Makary & Daniel, 2016)?

Why are some drugs recalled after years of use because they did more harm than good?

How come arthroscopic surgery continues to be done for osteoarthritis of the knee even though it is no more beneficial than mock surgery (Moseley et al, 2002)?

How come women have more negative side effects from Ambien and other sleep aids than men?

Is it really true that the average new cancer drug costs about $100,000 for treatment and usually only extends the life of the selected study participants by about two months (Szabo, 2017; Fojo, Mailankody, & Lo, 2014)?

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of the New England Journal of Medicine”Dr. Marcia Angell, longtime Editor in Chief of the New England Medical Journal (Angell, 2009).

Medical discoveries have made remarkable improvements in our health.  The discovery of insulin in 1921 by Canadian physician Frederick Banting and medical student Charles H. Best allowed people with Type 1 Diabetes to live healthy productive lives (Rosenfeld, 2002).  Cataract lens replacement surgery is performed more than three million times per year and allows millions of people to see better even though a few patients have serious side negative side effects.  And, there appears to be new hope for cancer. The FDA on August 30, 2017, approved a new individualized cancer treatment that uses genetically engineered cells from a patient’s immune system to produce remissions in 83 percent of the children and young adults who have relapsed after undergoing standard treatment for B cell acute lymphoblastic leukemia. (FDA August 30, 2017). The one-time treatment for this breakthrough cancer drug for patients who respond costs $475,000 according to the manufacturer Novartis. Yet, it will be years before we know if there are long term negative side effects.

The cost of this treatment is much more than the average cost of $100,000 for newly developed and approved cancer drugs which at best extend the life of highly selected patients on the average by two months; however, when they used with more typical Medicare patients, these drugs often offer little or no  increased benefits (Szabo, 2017; Freakonomics Radio episode Bad Medicine, Part 2: (Drug) Trials and Tribulations).

As the health care industry is promising new screening, diagnostic and treatment approaches especially through direct-to-consumer advertising, they may not always be beneficial and, in some cases, may cause harm.  The only way to know if a diagnostic or treatment procedure is beneficial is to do long term follow-up; namely, did the treated patients live longer, have fewer complications and better quality of life than the non-treatment randomized control patients.  Just because a surrogate illness markers such as glucose level for type 2 Diabetes or blood pressure for essential hypertension decrease in response to treatment, it does not always mean that the patients will have fewer complications or live longer.

To have a better understanding of the complexity and harm that can occur from medical care, listen to the following three Freakonomics Radio episodes titled Bad Medicine.

Freakonomics Radio episode Bad Medicine, Part 1: The story of 98.6.  We tend to think of medicine as a science, but for most of human history it has been scientific-ish at best. In the first episode of a three-part series, we look at the grotesque mistakes produced by centuries of trial-and-error, and ask whether the new era of evidence-based medicine is the solution.

Freakonomics Radio episode Bad Medicine, Part 2: (Drug) Trials and Tribulations. How do so many ineffective and even dangerous drugs make it to market? One reason is that clinical trials are often run on “dream patients” who aren’t representative of a larger population. On the other hand, sometimes the only thing worse than being excluded from a drug trial is being included.

Freakonomics Radio episode, Bad Medicine, Part 3: Death by Diagnosis.  By some estimates, medical error is the third-leading cause of death in the U.S. How can that be? And what’s to be done? Our third and final episode in this series offers some encouraging answers.


Angell M. Drug companies and doctors: A story of corruption. January 15, 2009. The New York Review of Books 56. Available: Accessed 24, November, 2016.

FDA approval brings first gene therapy to the United States, August 30, 2017.

Fojo, T., Mailankody, S., & Lo, A. (2014). Unintended consequences of expensive cancer therapeutics—the pursuit of marginal indications and a me-too mentality that stifles innovation and creativity: the John Conley Lecture. JAMA Otolaryngology–Head & Neck Surgery140(12), 1225-1236.

Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ: British Medical Journal (Online)353. Listen to his BMJ medical talk:

Moseley, J.B., et al, (2002). A controlled trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine. 347(2), 81-88.

Rosenfeld, L. (2002). Insulin: discovery and controversy. Clinical chemistry48(12), 2270-2288.

Szabo, L. (201, February 9). Dozens of new cancer drugs do little to improve survival. Kaiser Health News. Downloaded September 3, 2017.