Wednesday, 30 May 2018

Probiotics and microbiota

With yesterday as World digestive health day , this is a great time to talk about gut health and the impact it can have within many areas of our biology.

 My research has taught me more about the importance of probiotics than I already knew.

Microbiota is the name given to the microbe population living in our intestine. Making up 90% of our cells! Containing 100s of trillions of microorganisms including at least 5000 different species of bacteria. The microbiota are important in nutrition, immunity and the brain.
The Microbiome is the combined genetic microorganisms in a particular environment.
Millions of years of co-evolution have moulded this human microorganism interaction into a symbiotic relationship where the gut bacteria contribute essentially to human nutrient metabolism and in return occupy a nutrient rich environment.

Children born vaginally get much needed microbes as they pass through the vaginal canal from the mother.  Yet those who are born by cesarian section tend to suffer more with asthma, allergies and leukaemia, (Neu, 2011.) Breast fed children have an intake of  sugars containing sialic acid which promotes infant growth through healthy microbiome, (Nestle Nutrition Insitiute), due to feeding the microbes.

Seratoin production is thought to be produced to the massive quantities of 90% within the gut, (Yano et al., 2015) which gives evidence to show those with altered microbiome will suffer further with depression and mental health issues, (Evrensel and Ceylan, 2015). A major role is played by the gut microbiome in bidirectional communication between the gut and brain. The Brain - gut axis communicates its systems between the Central Nervous System and Gastero Intestinal Tract, (Burokas, 2015.) As Burokas published in Science Direct, the gut microbiota can be a key regulator of mood, cognition, pain and obesity.
The immune cells are stimulated by a population of microbiota.  Those with impaired microbiome shows dendritic cells are reduced in the ability to stimulate pro inflammatory T cell responses.

Short chain fatty acids (SCFA) are produced in the gut and this aids the body immune systems and metabolic functions. When dietary fibre is fermented in the colon, short chain fatty acids are produced. They have many physiological roles in body functions.  Butyrate is important for colon health and is a  SCFA which arises from the bacterial fermentation of dietary fibre.  Produced by the probiotics, Butyrate is an important food for the cells lining the colon (colonocytes). Increasing the energy production and cell proliferation, there may be a protective element against colon cancer. The colonic inflammatory response if mediated by the presence of Butyrate. 70% of the energy needed for colonocytes is provided by this SCFA.  It is beleived there is a preventative and therapeutic potential to counteract inflammation mediated ulcerative colitis and colorectal cancer by the increase of modulation of the immune response and inhibiting tumour genesis.

Non starch polysaccharides  feed the microbiome.  Contributing to the host digestion (us).
Polyphenols are phytochemical fund in vegetables, legumes, chocolate, cranberries and green tea.  The consumption of these carries a reduced risk of chronic disease.  The low absorption rate in the upper gasteroinstestinal tract will benefit the colon.  Once the microflora break them down, they may change into bacteria themselves and possibly play a prebiotic role to modify the microbiota favourably.

Wu et al, (2011) studied the long term diet and the association with the microbiome.  Gut health is important.  As 70% of the immune system is in the gut, we need to know the factors affecting the microbiome. 
The largest affect is the host species, body mass, age, lifestyle and smoking.
Medium affecters: Antibiotic use
Medium-small: Drugs, exercise, genetics, pet co-habitation.
Small affect: Short term dietary intervention.

Can a daily supplement help?  I would say the best bet is to take one, while the stomach acid is quiet (IE not before or after food but about 2 hours either side) and definitely without adding any hot drinks. Heat will kill the important bacteria within the supplement.  Try it, you might be surprised how amazing you feel. 


Sunday, 13 May 2018

Vitamin D and the fortification of milk

1941 saw the exposure of solar exposure and cancer risk.  Later studies found associations with low vitamin D levels associated with type 1 diabetes mellitus, autoimmune issues such as inflammatory bowel disease, MS and animal studies supported low vitamin D causing increased inflammation and cancer.

Adequate levels of 25 hydroxyvitamin d (OHD25) is considered a level of about 50nmol/L at the end of winter and 10-20nmol/L higher at the end of summer. The institute of medicine vs the endocrine society state the guidelines inappropriately conclude the benefits of vitamin d are at 75nmol/L 25OHD and above. Mistakenly concluding all persons with serum 25OHDlevels below 50nmol/L are deficient.

UK DoH recommends a plasma concentration of 25nmol/L

In 2016 public health england published a report advising that 10 micrograms are advised daily to support bones, teeth and muscle. This advice was published in line with recommendations from SACN to suggest this safe level for everyone over 4 years old. SACN did not take into account the vitamin D from sun exposure as the synthesis of the vitamin through the skin is complex. PHE advises that throughout the months from March until October the majority of the public gain enough vitamin D through sunlight and a balanced diet.  During the winter, dietary sources are relied on.  IT is difficult for people to meet the 10 microgram recommendation. Fortification of foods will assist with those who are less likely to get out in sunlight and those who do not consume enough naturally through diet.

Deficiency  - corresponds with blood levels with clinical evidence of bone disease such as rickets or osteomalacia. Once levels are below 20-25nmol/L a very high risk is present.
Insufficiency is a biochemical term. No clinical evidence of disease is present. PTH levels may be elevated in the blood.
Some studies do not differentiate yet the differentiation will really determine a change of numbers reported on the studies.

A large number of studies exist to show low 25OHD is associated with increased risk of cardiovascular disease, hypertension, type 2 diabetes mellitus, cancer, autoimmune disease and increased mortality.

Is vitamin D simply a good marker for health? Were the randomised control trials started early enough? Were these studies including looking at calcium?

Vitamin D toxicity is rare but potentially serious.
HypervitaminosisD is not caused by diet or sum exposure but rather intake of a supplement at levels of 60,000 IU a day for several months.  As the body regulates the vitamin D produced from sun absorption really very well, fortification may be an excellent answer to gain better status levels from the diet.  Fortified foods do not contain major amounts of vitamin D and are regulated closely.
Toxicity from vitamin D has a main consequence of hypercalcemia in the blood. Symptoms noted are nausea, increased urination and weakness.  Possible progression pathways are into bone pain, kidney problems and the formation of calcium stones. Treatment includes stopping vitamin D intake and restricting calcium in the diet.

Naturally occurring vitamin D can be found in fatty fish and fish liver oils.  A plant source of vitamin d is mushrooms although this is vitamin d2 yet animal products contain vitamin d3.

The largest source of dietary vitamin d is fortified foods.  Namely milk, orange juice and cereals.
Vitamin D is essential to bone metabolism and calcium absorption.
Vitamin D deficiency is common among older adults as they have impaired ability to synthesise vitamin d from the sun


Monday, 12 March 2018

Do you have a simnel cake image?

My magazine column will see me post a recipe of simple cake prior to Easter.

I need images!

Do you have any nice photos of your simnel cake you would allow me to use for my publication?  You will get the credit and retain the copyright.  Please send them to my email

You see, this year I have simply run out of time to bake and take a photo of a simnel cake.  I would love your help!

Thank you in advance


Wednesday, 28 February 2018

Deciding to heal

Deciding to heal.

Medical intervention is life saving.  We know this.  Those who save lives are totally incredible and we need eternal gratitude for all those who have been touched by these lives.

There is zero doubt in my mind about this.  There are times, we simply need help.
My final year of my degree has highlighted the importance of taking control of ones own health, mind, body and as always, spirit (although that’s not often mentioned in my science degree.)  Biochemistry, physiology and the body is a miracle.  How does everything work together so synchronously for us to thrive as humans?  Honestly, I believe a certain degree of miracle must be present.  Being designed so beautifully, our cells and organelles are factories for our health, without them, no oxygen. Without oxygen, no life.  Without lungs, no oxygen… see my point.  Symbiosis is truly ever present and when things go wrong, we sometimes need to ask why.

Laying blame is wrong.  No one wants to be sick.  No one chose to make himself or herself ill.  Yet the chronic diseases we see so prevalent in this world are often preventable. This is a fact.  Yet do we know how?  Why do we suffer such illnesses?  Can they be reversed?
Research, research, research.
The information is out there.  Sadly, often our doctors simply do not have the time to go through finer details and we could be left in wonder of what to do next.

Finite details might just switch on the knowledge or motivation for change.
I have a story rather like this.

Forever a sick child,  we were given antibiotics on most occasions. There was a time the primary reason for visiting the doctors was to ‘get some antibiotics’. Now we know this is not the best route to take in all occasions, yet life saving in others.  Finally we know that antibiotics are to fight bacterial infections, hence the name.  My teenage years were also troubled with health issues which carried on through infertility, hormonal and other chronic pain manifestations.
My symptoms here will not be described in detail but please be aware of a few descriptions approaching. 
Many surgeries, all non specific and seemingly unrelated, followed and a general feeling of not being my best came to a head in 2009. Shocking issues from the gut we stopping me in my tracks. Putting on the brakes of life until the symptoms were so bad I was heavily loosing blood all day, every day.  The GP seemed to think more surgery might be needed and gave me a follow up appointment which was definitely not treated as urgent.  Things got worse, I ended up in the hospital and after surgery and biopsies I was told they were looking for harmful tumors. 
How could I share this with my parents?  They already buried my brother and there was only me left.  You can’t help but think of the worst-case scenario but I should have worked harder on relaxing inside as much as my outer appearance seemed.

During the surgery, I was informed that my colon was heavily ulcerated.  They suspected ulcerative colitis.  Immediately I began research.  Specifically into Inflammatory bowel conditions.  It’s known as IBD and is the collective term for crohns and colitis.  Being inflamed anywhere in the body is not a good place to be. Yet already I was motivated and determined to do what I could to help myself.

Results were in. The biopsies showed Crohns disease.  A disease from anywhere from mouth to anus in the digestive system.  It will also have the ability to penetrate right through the tissue layers which is life threatening.  Alongside gastritis, a hiatus hernia and flattened villi (showing Coeliac disease – a gluten allergy).  So, while this sounded a pretty grim story and the potential need for lots of surgery, I became determined.

Burning candles at my desk late into the night, I was busy reading more and more, going deeper and deeper while I waited for more medical appointments.  Finding a diet detailing The Specific Carbohydrate diet, I read a book by Elaine Gottschall “Breaking the Vicious cycle” and read it cover to cover in one sitting.  Why had I never heard of all this stuff?  You can heal from your nutrition?  You can heal your gut and it changes everything, even mindset! I was astonished. 

Immediately I requested an appointment with a dietitian at the local hospital and I began eating the way the book instructed instantly. 
Science moves on quickly and I’m pleased to say that today, the NHS does now recommend the low FODMAP diet for those struggling with digestive health which is not too dissimilar to the Specific carbohydrate diet.  Yet in 2009 I left the dietitian clinic in floods of tears when they spoke to me of ‘a varied and balanced diet’ and showed me the Eatwell Plate full of grains and starches.  Inside I was screaming but remained polite.   I knew this was wrong as I had already begun eating bone broths and eliminating sugars as well as the gluten which had been harming my body all these years through allergy.
My gastroenterologist gave a long list of prescriptive medicine for me to use.  Two of them were essential at the time but turned me inside out with pain so I got off those as soon as I could possibly do safely.  We had a heated conversation; I was frustrated – his exact words, “You can’t deal with crohns without medication or surgery.”  I cried.  I would. I was determined.  I knew what I had read.  Keeping an open mind to what he said was unthinkable.

Continuing to spend much time in the kitchen with careful preparation of my nutrition, continuing to research, beginning to wear bikinis in case he was right and I needed abdominal surgery….everything changed.
Beginning a running regime I was determined to run a race in totality.  Just 5k, that would do.  Dance has always been my passion and I began to compete, doing great with my amazing dance partner and ending up finalists of the nationals from 160 couples down to 5.  We didn’t win but that didn’t matter.
My body transformed unrecognizably.  I was feeling fit and well, my horrific symptoms I saw before surgery disappeared within 3 weeks. 
The following summer, for the first time, I had no hay fever.  My constant ear infections which also needed previous surgery and I lost my hearing bones in one ear, had gone.  Totally.
Never in my life had I felt so amazing.

More difficult conversations with the gastroenterologist led to a place of ‘agreeing to disagree’.  I knew then that diet was the key to making significant improvements.  While this was a dramatic way of eating, it was necessary to heal.  Being transparent, things have slipped since and I can feel it. But easily, I pull things back and see the same wonderful results over and over.

They say you are what you eat.  You definitely are a product of your absorption.  While my degree has taught me much about the systems of metabolism I feel the important lesson to pass on is to listen to your body.  This far, 9 years later I am blessed to still be in better health without surgery or medication.  My crohns went into remission after 3 weeks and that is where it has stayed.

* If you have any health concerns I would always recommend seeking the advice of a health professional as well as listening to your body.


Saturday, 6 January 2018

A report on obesity and physical activity.

Obesity and Physical activity

A report to show how increasing physical activity may give health benefits in relation to lower obesity rates.

Louise Usher

1.0 Introduction……………………………………………..2

1.1 Obesity…………………………………………..2
1.2 Physical Activity and obesity…………..2
1.3 Chronic disease………………………………2
1.4 Prevalence of obesity……………………...3

2.0 Method…………………………………………………….4

2.1 Search strategy………………………………4

3.0 Results……………………………………………………..5

3.1 Physical Activity and obesity…………..5

4.0  Physical activity guidelines………………………7

4.1 Government initiatives………………….7
4.2 Local initiatives……………………………..8
4.3 Results of interventions…………………9

5.0 Summary…………………………………………………11

6.0 References………………………………………………12

1.0 Introduction

1.1 Obesity

Obesity is defined by body mass index. This does not highlight the prevalence of morbidity and mortality associated with those who are overweight nor carry excess abdominal fat. (Kopelman, 2000).

63% of adults in 2015 were classed as being overweight (a BMI of over 25) or obese (a BMI of over 30). (,2017)
According to Public health England (PHE), obesity related ill health cost the NHS £6.1 billion in 2014-2015. (Mary, 2014)

A myriad of reasons driving obesity rates higher, the majority of people know that eating a healthy diet and being physically active will help prevent weight gain but the act of beginning these steps is not always easy. (Haslam and James, 2005) 

1.2 Physical Activity and obesity

The obesity epidemic is impacted by genetics as well as energy imbalance through high energy foods and as lives are currently more sedentary, the physical activity has decreased, (Kopelman, 2000).  Hence, less energy used through physical activity. Individuals increasing physical activity may see an energy deficit (van Baak, 1999) and begin to facilitate weight loss.

While the UK government has used various approaches for the treatment of a healthier lifestyle (, the obesity epidemic continues to rise (Rutter et al., 2017).  Chronic disease caused by an association of inflammation (diabetes type 2, cardiovascular disease, cancer) (Shacter and Weitzman, 2002) give threat to health such that improved understanding of immunological processes to regulate obesity may assist with lowering obesity-associated disorders. (Kanneganti and Dixit, 2012)

1.3 Chronic disease.

 An ageing population is an unpreventable cause of chronic disease (, 2015). 
The ageing population is predicted to continue to grow as the figure 1 demonstrates below,

Fig 1 – Ageing population in developed countries.

As the cornerstones of obesity treatment, (diet, exercise and physical activity) the government aims to promote theses methods as a forefront to medical and bariatric treatment, (González-Muniesa et al., 2017).

1.4 Prevalence of obesity

In 2002, 23% of men and 25% of women were reported to be obese, (Rennie and Jebb, 2005). Some evidence shows that higher rates of obesity are reported in those of a lower socio-economic status.  Figure 2 shows a predicted figure for the future which is much debated. However,  as previously discussed physical activity is beneficial to health, (Miles, 2007).

Fig 2 - predicted trend for obesity.

Obesity demonstrates a risk factor for chronic ‘lifestyle’ diseases.  Weight loss is associated with improvement of symptoms, (Poulain et al., 2006). Etiology of a multifactorial nature includes genetics, metabolism, lifestyle and environment.  The health risks of obesity carried around the abdomen area show strong association with comorbidities such as type 2 diabetes, dyslipidemia, coronary heart disease and hypertension, (Poulain et al, 2006).

2.0 Method

2.1 Search strategy

Peer reviewed paper of systematic review were found by searching Google Scholar, NHS Uk, The Lancet, Pubmed, DoH, PHE, Nutrition

Many government websites were targeted to find past statistical evidence in relation to actions taken for a positive direction into better health using physical exercise.  During these searches, the NHS website of a critical review was enlightening reading.  The Daily mail article questioning the 1980s fat guidelines on saturated fat published in 1983 in the UK.  When the researchers used available evidence at the time the results of randomized control trials supported the recommendations made.  Observational studies would have been a positive way to confirm or deny any findings.  The NHS website points out the reporting gives a potentially dangerous report.  The NHS website still states that a diet high in saturated fat could lead to obesity while also advising that current guidelines are that a small amount of saturated fat should be incorporated as part of a balanced Mediterranean style diet, (www.NHS.UK, 2015). hosts a blog named Public Health Matters.  In March 2017, Kevin Fenton wrote an interesting article in relation to obesity and the food environment. He quotes PHE estimated in 2014 that there are over 50,000 fast food and takeaway outlets in England and how this may impact health.
The Foresight paper gave great information on tackling obesities and predicting by 2050, 50% of women, 60% of men and 25% of children would be obese.  Within this paper the author highlights the issues once again with chronic disease.  Particularly type 2 diabetes, stoke and coronary heart disease as well as cancer and arthritis.

Likening tackling obesity with tackling climate change, the Foresight paper feels a whole society change is needed with commitment. (McPherson, Marsh and Brown, 2007).

3.0 Results

3.1 Physical activity and obesity

A sedentary lifestyle, physical inactivity and over consuming energy balance are a fact of human behavior currently.  The World Health Organisation (WHO) identifies inactivity as the fourth leading risk factor for global mortality.  Globally, causing 3.2 million deaths, (World Health Organization, 2014).  While previously demonstrated the issues with obesity can be multi factorial, regular moderate intensity activity has significant benefits for health (World Health Organization, 2014). The WHO also boldly state physical activity can reduce the risk of cardiovascular diseases, diabetes, colon and breast cancer and depression.
As well as helping to control weight.

The BMJ reported a research based finding in figure 3.

REF: BMJ 2009;338:b688
Figure 3 BMJ cohort study on the results of physical activity and mortality.

A population based cohort study was carried out on 2205 men aged 50 in the years 1970-1973.  At ages 60, 70, 77 and 82 years old they were reexamined to see total mortality.  The objective of this study was to examine how a change in physical activity influences mortality in comparison with smoking cessation.

They concluded increased physical activity in middle age is followed by a reduction in mortality to the same level as seen in men with high physical activity of a more constant level.  Results show a comparable result with smoking cessation.

(Kadoglou et al., 2007) carried out an interventional study to the anti-inflammatory effects of exercise training in patients with type 2 diabetes mellitus (DM).

Stating that chronic inflammation along with DM is strongly associated with increased cardiovascular health compromises,  Kadoglou et al hoped the study would evaluate aerobic training may have an effect on inflammatory markers on patients with DM.

Encouraging results were found as the exercise treated patients showed improved glucose control, lipid profile and Vo2 peak as well as decreased insulin resistance and systolic blood pressure.

The 60 subjects did not undertake significant weight loss yet purely with physical activity saw improvements in metabolic profile.

4.0 Physical Activity guidelines

4.1 Government initiatives

Previously detailed here, the government website hold many claims to the benefits of activity within this info graphic below set as figure 4,5 and 6.

Figure 4 – The government state a health benefit of multi factorial nature by aiming for more physical activity.  Better sleep, healthy weight, stress management and all together improvement in quality of life is documented.  Claiming type 2 diabetes may be lowered by 40%, cardiovascular disease lowered by 35% and falls, dementia and depression by 30%.  Back pain may be alleviated as well as pain in joints by 25% and the risk of colon and breast cancer may be reduced by 20%.

Figure 5 – To achieve the aims stated above, the guidelines suggest 4 main ways in which to change for the health benefits to be achieved.  Being more active helps heart and mind and ways to be more active suggest running, walking, playing sport, cycling.  Sitting down is heavily documented at the present time.  Less TV and sofa sitting is suggested.  Coupled with building strength by going to the gym, doing weight bearing exercise such as yoga will help keep muscles bones and joints strong.  Reducing a chance of falls can be achieved by improving balance. Undertaking dancing or tai chi are great suggestions for this.

Figure 6 -  While the government initiative suggests starting somewhere is better than not starting at all, 2 days per week is recommended for the strength training and movement.  While sitting down for long periods, it is suggested taking breaks to move around. 75 minutes of high impact exercise of vigorous intensity is recommended where the participant gets out of breath.  Less vigorous is considered moderate intensity and this should be at least 150 minutes per week.

4.2 Local initiatives

2014 saw Medway council “supporting healthy weight” team (SHW) host an Obesity Summit.  This was well attended by voluntary, private and public sector partners.  Aiming to develop a framework for obesity,  the SHW team was working with children and adults to help achieve a healthy weight.
The national child measurement programme saw 23.3% of 4-5 year olds and 32.7% of 10-11 year olds in Medway either overweight or obese.

The aim was to support obesity prevention in the Medway local plan.

A meeting was held in February 2013 by Nick Bundle the Speciality registrar for Public Health NHS Medway.  Entitled “The scope for tackling obesity in Medway through the built environment”.

Recognising that adult obesity levels in Medway are estimated to be 30 percent (worse than the national average),  the meeting discussed the more recent research showing the matter of obesity not being simple  matter of poor decisions of food and lack of physical activity. Available food and affordability are issues that face Medway residents.  This public health matter saw the local professionals deciding to work closely with teams in the council to reshape the local environment.

National planning policies now highlight the promotion of healthy communities.
Medway has a joint health and wellbeing strategy to run from 2012 to 2017.  This tackles obesity as a priority and works with councils to plan to achieve this.

Links to transport and green spaces are promoted for physical activity. Even though the health outcomes do not currently reflect this.  This new policy also restricted the opening of hot food takeaways.  Allotments were funded more than previously with revenue channeled from planning contributions.  However, these plans can only be influenced when there is an application for change of use or new build.  They cannot be revoked as a public health matter.

During this meeting, public health realized a lack of evidence cannot be a reason for inaction.  Yet shaping the environment into less obesogenic is a step in the right direction.
The Department of Health and NICE guidelines began to recognize the importance of shaping the community to enable easier ways to focus on a less obesogenic environment.

4.3 Results of intervention
Public health England published a report on July 4th 2017  detailing the health profile of the Medway towns.  There is a definite concern within Medway. ( With a lower life expectancy than the national average (8.2 years lower for men and 5.8 years lower for women) and a statistic that 21% of children live in low income families, the figures are suggestive that more needs to be done.  In year 6 within the local area, 20.9% of children in 2017 were measured within the obese range.

Figure 7 from Public health England Ref:( Showing the estimation of Medway age profiles between 2015 and the estimate in 2018. 

The aging population within Medway shows signs that death will be higher than the national expected average for those ages 75 and over. 

5.0  Summary

While much evidence is proven within this report that initiatives are taking place both nationally and locally, the long term outlook shows more may need to be done.

The local Medway area is showing that research has proven some issues may be those from lower socioeconomic classes either having issues with affordability or education.  There is far more to this issue as we can see from the evidence within this report. However, even globally with changes being made to the bigger picture, we are showing more and more need for a different approach.

Without doubt,  physical activity will benefit obese patients, therefore lowering the prevalence of chronic disease.  Diseases such as type 2 diabetes mellitus, coronary heart disease, cardio vascular health, mental health, dementia and cancer can all become less prevalent with healthy lifestyle changes such as diet and physical activity. This is clear.  However,  even with steps in place for obese and overweight patients to undertake more physical activity, this may not be being carried out.   
A wider approach of a more conclusive change is needed which within the evidence of this report is being likened to the changes made to approach the issues raised within climate change. 

The aging population outlined in the figures above show not only increases in age throughout the future years yet also the risks of chronic disease increasing.  To tackle the obesity epidemic strongly would help this population to age well and healthy.  While there is no doubt diet plays a huge part in obesity, the evidence presented here has proven clearly that while diet can help lower and prevent obesity,  an increase in physical activity even without weight loss will lower the prevalence and incidence of chronic disease and improve the health and lifestyle of those affected.  Living well will benefit those previously at risk of chronic disease and this can be achieved with an increase in physical activity. 

Local and national initiatives need a more vigorous approach to change the course of the evidence and predictions shown within this report.

6.0 References

van Baak, M. a (1999) ‘Physical activity and energy balance.’, Public health nutrition, 2(3A), pp. 335–339. doi: DOI: 10.1017/S1368980099000452.

González-Muniesa, P., Mártinez-González, M.-A., Hu, F. B., Després, J.-P., Matsuzawa, Y., Loos, R. J. F., Moreno, L. A., Bray, G. A. and Martinez, J. A. (2017) ‘Obesity’, Nature Reviews Disease Primers, 3, p. 17034. doi: 10.1038/nrdp.2017.34.

Haslam, D. W. and James, W. P. T. (2005) ‘Obesity’, in Lancet, pp. 1197–1209. doi: 10.1016/S0140-6736(05)67483-1.

Kadoglou, N. P. E., Iliadis, F., Angelopoulou, N., Perrea, D., Ampatzidis, G., Liapis, C. D. and Alevizos, M. (2007) ‘The anti-inflammatory effects of exercise training in patients with type 2 diabetes mellitus.’, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology, 14(6), pp. 837–43. doi: 10.1097/HJR.0b013e3282efaf50.

Kanneganti, T. D. and Dixit, V. D. (2012) ‘Immunological complications of obesity’, Nature Immunology, pp. 707–712. doi: 10.1038/ni.2343.
Kopelman, P. G. (2000) ‘Obesity as a medical problem’, Nature, 404(6778), pp. 635–643. doi: 10.1038/35007508.

Mary, E. a. (2014) Adult Obesity and Type 2 Diabetes About Public Health England, Public Health England. doi: 2014211.

McPherson, K., Marsh, T. and Brown, M. (2007) Tackling Obesities:Future Choices-Modelling Future Trends in Obesity {&} Their Impact on Health, Foresight.

Available at:,1BM2C,4Q47OG,4H8QX,1.

Miles, L. (2007) ‘Physical activity and health’, Nutrition Bulletin, 32, pp. 314–363. doi: 10.1111/j.1467-3010.2007.00668.x.

Poulain, M., Doucet, M., Major, G. C., Drapeau, V., Sériès, F., Boulet, L.-P., Tremblay, A. and Maltais, F. (2006) ‘The effect of obesity on chronic respiratory diseases: pathophysiology and therapeutic strategies.’, CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 174(9), pp. 1293–9. doi: 10.1503/cmaj.051299.

Rennie, K. L. and Jebb, S. a (2005) ‘Prevalence of obesity in Great Britain.’, Obesity reviews : an official journal of the International Association for the Study of Obesity, 6(1), pp. 11–12. doi: 10.1111/j.1467-789X.2005.00164.x.
Rutter, H., Bes-Rastrollo, M., De Henauw, S., Lahti-Koski, M., Lehtinen-Jacks, S., Mullerova, D., Rasmussen, F., Rissanen, A., Visscher, T. L. S. and Lissner, L. (2017) ‘Balancing Upstream and Downstream Measures to Tackle the Obesity Epidemic: A Position Statement from the European Association for the Study of Obesity’, Obesity Facts, 10(1), pp. 61–63. doi: 10.1159/000455960.

Shacter, E. and Weitzman, S. A. (2002) ‘Chronic inflammation and cancer’, Oncology (Williston Park, NY), 16(2), pp. 217–26, 229–2. Available at: papers3://publication/uuid/3F492291-1D16-43CA-9DB3-4EF2578B9A08.
World Health Organization (2014) WHO | Physical activity, WHO.

Word count (excluding ref – 2277)
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