Exercising as a family makes you healthier

02Jul

Exercise together for better health

Electronic gaming is increasing as a way for families to ‘chill out’ together. While it’s great to spend time together as a family, don’t forget the importance of being active together either.

Why physical activity?

Lack of physical activity is one of the leading risk factors for death worldwide, according to the World Health Organisation (WHO)[i].

WHO states regular physical activity will:

help maintain a healthy weight
improve cardiovascular fitness
improve muscular strength
aid bone health
reduce the risk of diseases such as diabetes and cardiovascular diseases (including heart disease, stroke and high blood pressure)
reduce the risk of developing some cancers
reduce the risk of depression.

Kids who exercise regularly can also enjoy these extra benefits[ii] [iii]:

an increased ability to learn
improved short-term memory, reaction times and creativity
increased cognitive development
reduced stress
improved strength, flexibility and endurance
better able to handle physical and emotional challenges of growing up
better sleep
improved confidence.

How much activity?

Physical activity shouldn’t be confused with structured exercise.

Current recommendations for physical activity are [iv]:

at least 60 minutes of moderate to vigorous-intensity activity daily for children 5-17 years of age
150 minutes of moderate-intensity activity weekly for adults 18-64 years of age.

According to Active Health Kids Australia, only 19 per cent of Australian children aged 5-17 years are getting enough physical activity, with 71 per cent of kids in this age bracket exceeding more than the recommended two hours of screen time per day. [v]

It’s clear that our children need to get away from the screens and off the couch!

Exercise as a family

Exercising as a family is not only fun (and often inexpensive), but it’s an important way to show your children what a healthy lifestyle is.

Exercising together will help your children establish good exercise habits as well as provide an opportunity to learn the importance of regular exercise and good nutritional habits.

Some great ideas to be active as a family include:

At the park — throw a Frisbee, fly a kite, walk the dog, kick a ball, ride your bike, use the playground.
At home — plant a garden, paint a fence, sweep a patio, dance in the living room, jump rope, rake leaves.
At the beach — play cricket or volleyball, walk along the beach, go for a swim, go sailing.
In the snow — build a snowman, toboggan or ski, have a snowball fight, go ice-skating.
Out and about — go hiking, participate in a fun run, ride your bikes, go bowling, abseil, kayak, go rock climbing, talk a walking tour of your city.
Take a class — take up dancing, learn how to play tennis, take up karate or swimming lessons.

Of course, the activities above are only a guide. Choose something you’d all like to do and give it a go. Perhaps you could set aside a regular time to be active together and take turns in choosing the activity.

Whatever you do however, make a commitment to get your family off the couch and into exercise!

References:

[i] World Health Organisation, Physical activity, Last update January 2014; accessed 1 July 2015 http://www.who.int/mediacentre/factsheets/fs385/en/

[ii] Raise Smart Kid, The Benfits of Exercise on Your Kid’s Brain, published not specified; accessed 1 July 2015 http://www.raisesmartkid.com/3-to-6-years-old/4-articles/35-the-benefits-of-exercise-on-your-kids-brain

[iii] Kids Health, Kids and Exercise, last reviewed February 2012; accessed 1 July 2015 http://kidshealth.org/parent/nutrition_center/staying_fit/exercise.html

[iv] World Health Organisation, Physical activity, Last update January 2014; accessed 1 July 2015 http://www.who.int/mediacentre/factsheets/fs385/en/

[v] Active Health Kids Australia, Report Card on Physical Activity for Children and Young People, published 20 May, 2014; accessed 1 July 2014 http://www.activehealthykidsaustralia.com.au/wp-content/uploads/2014/05/ahka_reportcard_shortform_web.pdf

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The real cost of obesity

26Jun

Overweight and obesity in Australia is reaching epidemic proportions.

We are now one of the fattest nations in the developed world with the prevalence of obesity more than doubling in the last 20 years.[1]

The most recent statistics from Obesity Australia indicate that 63 per cent of our country is overweight or obese, with 28 per cent obese. According to their 2014 report, No Time to Weight, obesity is a major health and societal factor for the Australian population. [2]

Unfortunately, things are likely to get worse with projections seeing around 70% of Australians being overweight or obese, by 2025, with around a third of the Australian adult population falling into the obese category.

Personal cost

It is well documented that carrying too much weight is dangerous for your health. While obesity is not a disease, it does contribute to the development of other diseases. [3]

Health problems and consequences of being overweight include:

cardiovascular disease such as hypertension (high blood pressure)
coronary artery disease and stroke
obstructive sleep apnoea
insulin resistance and type 2 diabetes
non-alcoholic fatty liver disease
cancer
osteoarthritis
cognitive impairment
mood and anxiety disorders, including depression, negative body image and poor self-esteem.

If the thought of developing the above diseases isn’t enough to shock you, what about dying early?

Obesity Australia states that 40-year old obese women who don’t smoke will lose around 7.1 years of life, while obese male non-smokers will die 5.8 years earlier than expected. This is compared with their normal weight counterparts. [4]

The financial cost

As well as costing people years and quality of life, obesity is costing our country billions every year.

Estimating the financial cost of obesity is complicated. However, 2008 figures from Obesity Australia puts Australia’s total obesity cost at $58.2 billion per year. [5]

Costs relating to obesity include loss of productivity, carer’s costs, health system costs, and wellbeing. The total financial and lost wellbeing costs broken down by obesity-related diseases are as follows:

Cardiovascular disease

Financial cost $2.8 billion
Lost wellbeing $31.8 billion
TOTAL $34.6 billion

Cancer

Financial cost $695 million
Lost wellbeing $9.0 billion
TOTAL $9.7 billion

Type 2 Diabetes

Financial cost $3.0 billion
Lost wellbeing $5.3
TOTAL $8.3 billion

Osteoarthritis

Financial cost$1.8 billion
Lost wellbeing $3.8 billion
TOTAL $5.7 billion

That’s an awful lot of money to spend on disease!

The future

There is no doubt Australia is at a crossroads.

If the rate of obesity continues to grow at the projected rate, it’s fair to say the financial and wellbeing costs will also grow — to overwhelming proportions.

However, by taking steps to lose the excess fat, improve health and wellbeing, we as a nation can turn the statistics around. Not only can we save billions of dollars, we can improve our quality of life, and our life expectancy.

If you feel you need to take control of your weight and health, speak to your health care practitioners and consider joining your local fitness studio and/or take some personal training sessions.

References

[1] Modi, Monash University, Obesity in Australia, last updated 6 August 2013; accessed 24 June 2015 http://www.modi.monash.edu.au/obesity-facts-figures/obesity-in-australia/

[2] Obesity Australia, No Time to Weight. Obesity: A National Epidemic and Its Impact on Australia, published 27 March 2014; accessed 23 June 2015, http://www.obesityaustralia.org/resources-1/no-time-to-weight

[3] Ibid pp18-19

[4] Ibid p 20

[5] Ibid pp26-27

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Orthorexia: are you at risk?

19JunJune 19, 2015

There is a new trend in town and it has a name: Orthorexia nervosa, or more simply, orthorexia.

However, it can be hard to diagnose because at its core is a desire to eat more healthily — and most of us want to do that.

The term ‘orthorexia’, originally coined in 1997 by Dr Steven Bratman, describes an unhealthy obsession with eating healthy food. The term is derived from ‘anorexia’ with ‘ortho’ meaning “straight” or “right”.

Despite orthorexia not being recognised as a clinical diagnosis in the DSM-5 (Fifth edition of the Diagnostic and Statistical Manual of Mental Health) — a handbook used by health care professionals in the US and much of the world as an authoritative guide to mental health disorders [1]— it is widely accepted that it is an eating disorder.

What is Orthorexia?

Put simply, orthorexia is an unhealthy obsession with healthy eating. What may start out as a ‘health kick’ or simply an attempt to clean up one’s diet and include more healthy foods, can quickly turn into something sinister.

While anorexia focuses on restricting food intake in the quest to achieve a certain body shape (usually ‘thinness’), orthorexia restricts the types of foods themselves. Orthorexics will only eat foods deemed ‘clean’, ‘healthy’ or ‘wholesome’.

Following a vegetarian, vegan or any other nutritionally sound eating plan is fine. Reading food labels and making informed decisions about which foods to eat, is also fine. However, when a seemingly innocent attempt to clean up one’s diet, turns into a fixation on food purity and quality, alarm bells should ring.

Dr Steven Bratman, author of the website Orthorexia.com says that people with orthorexia have developed “an extreme, obsessive, psychologically limiting and physically dangerous disorder”.[2]

Sufferers become consumed with what to eat, how much to eat and are constantly striving to ‘eat right’ and ‘be good’. Self-esteem becomes a direct reflection upon how well they eat and they may even begin to feel superior to others, based upon their dietary choices.

As the disorder takes hold, food choices become more restrictive and the obsession with food takes precedence over other activities and interests in their life. Because food choices are so restricted, the person’s health may begin to suffer (which is ironic given that the disorder was born out of a desire to be healthy). In some cases, a person may become malnourished, sick and may even die.

According to Bratman, the disorder “has an aspirational, idealistic, spiritual component, which allows it to become deeply rooted in a person’s identity”.

What are the symptoms?

Living a healthy lifestyle doesn’t mean you are orthorexic. However, key signs [3] [4]that you need to look out for include:

You find healthy food a primary source of happiness and meaning, even spirituality
Your lifestyle interferes with relationships, work, friends or family
Food helps you feel in control and eases feelings of anxiety and insecurity
You have to take your diet to further extremes to get the same ‘kick’ out of it
When you stray from ‘pure’ foods, you feel a compulsive need to cleanse
Your interest in healthy food controls your life
You sometimes wish you could just eat and not worry about the quality of your food
You wish you could spend less time thinking and preparing food and more time on other things
You panic if you do not have control over everything that goes into your mouth, particularly when someone else has prepared a meal for you
Following the ‘perfect’ diet is the most important thing in your life
You feel guilt or self-loathing when you ‘eat off plan’
You feel in control when you stick to the ‘right’ foods
You feel superior to others, based upon your food choices.

What role does social media play?

According to Google statistics, the number of searches for terms such as ‘paleo’, ‘vegan’ and ‘gluten’ has risen significantly over the past 10 years, with a considerable rise since 2011. [5]This is not to say following these lifestyles are bad, but it’s important to remember that orthorexia begins with a desire to eat ‘healthily’ and rightly or wrongly, these terms have become synonymous with health.

With social media being such an integral part of our lives, orthorexia can be easily fuelled. How many ‘sugar-free’ or ‘carb-free’ or ‘guilt-free’ posts of food you see in one day on your social media feed? A key problem is that many assume that those posting such pictures and recipes are ‘experts’, particularly if they have a large following.

However, as we learned in the case of ‘wellness guru’ Belle Gibson (the young woman who lied about overcoming terminal brain cancer and using that lie to build an empire), not everything is always as it seems. Those who seem to be ‘in the know’ can actually be dishing out incorrect and dangerous advice.

Add to the mix the trend of photographing your ‘clean’ plate and uploading it to Instagram, Twitter or Facebook, and the positive feedback and praise that often follows, it is easy to understand how eating well turns to a dangerous obsession.

How should you eat?

While adopting a healthy lifestyle is great, living a life that centres around restricting food choices is not. Food should be used to nourish and fuel or bodies, but it should also be enjoyed — free from rules, guilt or anxiety.

The Dietitians Association of Australia (DAA) recommends eating a wide range of foods from each food group — lots of fruit and veggies, legumes, wholegrain cereals and breads, lean meat, fish, poultry, eggs, nuts and seeds and low-fat dairy — and limiting foods with added sugars, saturated fat, salt and alcohol. [6]

Rather than excluding food groups, or labelling them ‘good’ or ‘bad’, the DAA encourages enjoying all foods. It recommends categorising foods into two groups; ‘everyday foods’ and ‘extra foods’. Obviously ‘everyday’ foods can be enjoyed every day, while ‘extra foods’ should be enjoyed sometimes and in small amounts.

The DAA also warn against relying upon nutritional information found online, including social media. It believes that many people with orthorexia are mistaken about food and nutrition, which is often caused by inaccurate information from less reputable sources. When it comes to dietary advice, the DAA recommends seeking the advice of trusted health professionals.

Treating orthorexia

The US-based National Eating Disorders Association says that recognising orthorexia can be difficult, particularly given society’s value of healthy eating and thinness[7]. It can also be easy for sufferers to hide behind the thought that they are eating well, and insist that they do not have a problem.

Like many eating disorders, orthorexia can be treated with the help of professionals, although the road ahead for sufferers is not always easy. If you suspect you or someone you know, is suffering from orthorexia, or any other eating disorder, speak to your health care professional.

References:

[1] American Psychiatric Association, What is DSM and why is it important? Published unknown; accessed 18 June 2015 http://www.dsm5.org/about/pages/faq.aspx

[2] Stephen Bratman, Orthorexia, What is Orthorexia? published 23 January, 2014; accessed 18 June 2015 http://www.orthorexia.com/what-is-orthorexia/

[3] Karin Kratina, National Eating Disorders Association, Orthorexia Nervosa, published unknown; accessed 18 June 2015 https://www.nationaleatingdisorders.org/orthorexia-nervosa

[4] Stephen Bratman, Orthorexia, What is Orthorexia? published 23 January, 2014; accessed 18 June 2015 http://www.orthorexia.com/what-is-orthorexia/

[5] Google.com, Trends, accessed 19 June 2015, http://www.google.com/trends/explore#q=paleo%2C%20vegan%2C%20gluten&cmpt=q&tz=

[6] Dietitians Association of Australia, Orthorexia, published unknown; accessed 18 June 2015 http://daa.asn.au/for-the-media/hot-topics-in-nutrition/orthorexia/

[7] Karin Kratina, National Eating Disorders Association, Orthorexia Nervosa, published unknown; accessed 18 June 2015 https://www.nationaleatingdisorders.org/orthorexia-nervosa

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Out in the cold atop the corporate ladder

11Jun

The corporate ladder: it can be lonely at the top!

You have mapped out your career. You have set your goals and you are putting the wheels in motion to climb the corporate ladder. But what if the reality does not live up to your expectations?

For many career-minded people with ambitions of climbing the corporate ladder, making it to the top may seem like the ultimate goal. However, what if that position meant that you were lonelier, more stressed, more anxious and desperately unhappy. Would you aspire to be there?

A double-edged sword

There is nothing wrong with ambition or wanting an executive job. After all, executives often have more challenging and interesting roles, they may get more ‘perks’ and they certainly take home a larger pay packet.

However, a recent CEO Snapshot Survey by Harvard Business Review [1] suggests that 50 per cent of CEOs feel lonely and isolated, and believe it is hampering their performance. When it comes to first-time CEOs, nearly 70 percent of them reported feeling so lonely that it had a negative impact upon their capacity to fulfil their role.

Feeling lonely and isolated can easily lead to burn-out, depression, psychological exhaustion or a complete emotional breakdown.

Yet stressed executives are not speaking up. Anecdotal evidence suggests they feel enormous pressure to perform, they may feel overwhelmed at the responsibility they hold and perhaps even feel that people are ‘looking up to’ them and ‘watching what they do’. There is also the belief that feeling stressed is a sign of weakness or incompetence in doing the job.

Figures from SANE Australia suggest that almost half of Australians who took time off work due to depression did not disclose the reason to their employers. [2] The national study involving more than 1000 workers found that 48 percent of those who didn’t inform their employer of their reason for taking time off felt they would be putting their job at risk to do so.

Mental health in the workplace

According to research conducted in 2011[3] , Australian executives are twice as likely to experience symptoms of mood and personality disorders, as the general population. The study found that between 38 and 40 per cent of the executive population experience psychological distress compared with 20 per cent of the rest of the population.

The study also found that there had been significant increases in anger issues, anxiety, work-related stress and depression.

It found that personality disorders among executives were higher than the normal population. Disorders included narcissistic personality disorder, borderline personality disorder and in some cases antisocial disorder.

Being a stressed boss also filters throughout the workplace. Workers become less engaged, more miserable and more likely to be the target of bullying behaviour, leading to more sick days taken by employees who are not happy in their jobs.

Researchers of the study believe factors contributing to high levels of stress in executives include highly competitive work environments, increasing pressures to perform and the effects of the global financial crisis.

In addition, executives are less likely to engage in regular exercise, proper nutrition, work-life balance and psychological coping skills — all of which help protect from depression. Their busy schedules also lead them to believe they simply ‘don’t have time’ to look after themselves.

For female executives the problem is exacerbated further by issues of inequality and feeling that their male colleagues ‘simply won’t listen to them’. [4]

What can be done?

It is widely accepted that stress in the workplace is a problem and many workplaces are taking the issue seriously. However, it can be difficult to know just how to tackle the problem, particularly when mental health has a stigma attached to it.

One initiative tackling the problem of mental health in the workplace is Heads Up[5]. An initiative launched by Beyond Blue in conjunction with the Mentally Healthy Workplace Alliance, it is designed to give individuals and businesses tools, strategies and the latest information to promote a mentally healthy workplace for executives, leaders, managers and employees.

This program is free to join and provides step-by-step instructions on how to create a plan for a mentally healthy workplace, along with tips on how to talk about the issue, how to seek help, and how to support people in the workplace who may be suffering.

According to Heads Up over 6 million working days are lost each year in Australia due to depression. Left untreated, it can have devastating effects for individuals and businesses. In fact, depression is costing Australian workplaces $10.9 billion annually in absenteeism, lost productivity and compensation claims.

However, research by Price Waterhouse Coopers[6] has shown that for every dollar spent on effective interventions to create a mentally healthy workplace, businesses will reap a $2.30 return of investment.

According to the research, interventions should involve:

Raising awareness and reducing stigma
Supporting staff with mental health conditions
Creating a positive working environment.

While executives are often slow to speak up about personal mental health issues , Heads Up believes business leaders can play a key role in creating and maintaining mentally healthy workplaces.

Key actions they can take include being committed to mental health in the workplace; making it an objective of the business or workplace; integrating good health and safety management into all business decisions, policies and procedures; as well as speaking openly about mental health in the workplace.

Supporting and instigating programs designed to shed light on the issue of mental health will not only validate workplace policies and practices to be more mentally healthy, but will help everyone dealing with the effects of depression.

Hopefully, it will also empower executives to take a stand for themselves.

If you or a friend or family member are suffering from depression please call Beyond Blue on 1300 22 4636 or Lifeline on 13 11 14.

References:

[1] BRW, It’s lonely at the top, published 18 April, 2012; accessed 4 June 2015, http://www.brw.com.au/p/sections/features/it_lonely_at_the_top_r6pGqMHiG6tPGiGN42ucDP

[2] SANE, Depression in Australian workplaces more ‘hidden’ than in Europe: new research, 2013; accessed 4 June 2015 https://www.sane.org/news-comment-2013/1222-depression-in-australian-workplaces-more-hidden-than-in-europe-new-research

[3] Davidson Trahaire Corpsych, MEDIA: Key staff driven to disorder at work, published 19 March 2011; accessed 6 June 2015, http://www.davcorp.com.au/media/9475/The%20Australian%20-%20Key%20staff%20driven%20to%20disorder%20at%20work.pdf

[4] Forbes, For Executive Women, It Can Be Lonely at the Top, published 1 May 2009; accessed 5 June 2015 http://www.forbes.com/2009/05/01/executives-c-suite-leadership-forbes-woman-power-careers.html

[5] Heads Up, http://www.headsup.org.au/

[6] Heads Up, Creating a mentally healthy workplace: Return on investment analysis, date of publication unknown; accessed 9 June 2015 http://www.headsup.org.au/docs/default-source/resources/bl1269-brochure---pwc-roi-analysis.pdf?sfvrsn=6

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Australians gain weight every winter!

22MayMay 22, 2015

Stay lean and happy this winter

Picture this: The skies are grey and the weather is cold. You are kicking back on the couch, the heater is on and you may even be snuggled under a blanket. You’re watching your favourite movie or perhaps reading a good book. Beverage of choice is a hot chocolate or even a glass or two of wine. And let’s not forget those sneaky snacks.

Sound good?

Well, let us fast-forward a little. The sun is shining, birds are singing and the weather has warmed up. You feel on top of the world after feeling sad and depressed during the grey months. You just love this time of year. Everything is new and fresh. You decide to wear your favourite jeans — the ones that you feel fantastic in. The only trouble is….they don’t quite fit anymore. And all of a sudden, your mood plummets.

Sound familiar?

Australians gain weight every winter

If it does, you are not alone. A 2012 study [1] from the NSW Food Authority and NSW Health found that almost half of Australian adults gain two kilos over winter, with the average weight gain anywhere from two to five kilograms.

The study, one of the first to investigate winter eating habits in relation to fast food and snack consumption also found:

90 per cent of Australians eat more fast and snack foods and takeaways during winter because doing so makes them feel ‘warmer and happier’
36 per cent of Australians are concerned about gaining weight over winter
59 per cent believe any weight gain over winter will be due to eating more fast food and snacks and exercising less.

Well, at least they understand why they are likely to gain weight.

Should we be concerned over gaining between two and five kilos over winter? After all, it will be easy to shift when the warmer weather hits, won’t it?

Perhaps not. Swedish researchers found that just one month of overeating can lead to weight gain that lasts for years. [2] It seems that overeating and a lack of exercise may affect body fat levels and make it harder to lose weight.

Luckily, we can prevent winter weight gain by changing two key things: what we eat and how much we move.

Eat to be lean

Contrary to popular belief, winter food can be comforting without being stodgy and heavy. Try these tips to lighten up your plate:

Choose warming oats with skim milk and fruit over sugar-laden cereals.
Avoid adding salt to food.
Avoid adding extra fats to foods (i.e. butter to mashed potato).
Bake, steam or grill instead of frying in oil.
Roast meat or take advantage of a slow cooker.
Choose whole grains over processed white varieties of rice, pasta, bread, etc.
Snack on fruit, low-fat yoghurt, nuts and seeds instead of biscuits, cakes, muffins etc.
Choose veggie sticks or pretzels instead of chips and popcorn.
Limit calorie-laden beverages such as wine, hot chocolate, soft drink and fruit juice.
Limit takeaway foods to once a fortnight.

And of course, you should eat a wide variety of foods to ensure your vitamin intake is adequate.

Move to be happy

The other side to the equation is to continue moving throughout winter. You may need to change the type and location of your exercise (it can be a little uncomfortable running in the cold rain), but this gives you an opportunity to try new things and use new muscle groups.

While exercising outside may not be so appealing, research shows that regular exposure to cold weather may be a healthy and sustainable way to help lose weight. [3] .

Exercising outside also leads to greater emotional well-being and better sleep than exercising indoors, as found in a 2014 study from Finland [4] . Furthermore, increasing your exposure to sunlight may reduce your risk of developing Seasonal Affective Disorder (SAD) — a type of depression linked to change of seasons. Other research has also found outdoor exercise can decrease tension, frustration and depression. [5]

What type of exercise?

While the benefits of outdoor exercise are many, it may not always be possible or practical to exercise outside, so we have come up with some great ideas for outside and inside exercise. Some ideas include:

Outside
Walking, personal training, group classes, jogging, running, hiking, skiing, tobogganing, ice-skating, cycling, footy, netball, tennis, golf

Inside
Swimming, yoga/Pilates, weight training, gym sessions, group classes, personal training, ten-pin bowling, treadmill, Wii fit, exercise DVDs, boxing class, rock climbing

Remember, any kind of exercise, whether it be done indoors or outdoors will reap benefits.

While it is important to enjoy a bit of couch-time every now and then, don’t set up camp on it during winter.

Get outside and keep moving!

References:

[1] NSW Food Authority: Media Release, Australians expected to gain 15 million kgs this winter, http://www.foodauthority.nsw.gov.au/news/media-releases/mr-27-jun-2012-winter-eating#.VV1LpPmqqko

[2] Ernersson A et al. (2010) Long-term increase in fat mass after a four week intervention with fast food based hyper-alimentation and limitation of physical activity. Nutrition & Metabolism, 7:68. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936436/

[3] van Marken Lichtenbelt et al. Cold exposure -- an approach to increasing energy expenditure in humans.Trends in Endocrinology & Metabolism, January 2014

[4] T P Pasanen, L Tyrväinen K M Korpela, The Relationship between Perceived Health and Physical Activity Indoors, Outdoors in Built Environments, and Outdoors in Nature, Applied Psychology: Health and Wellbeing, 2014, Volume 6, Issue 3, pp324-346, http://onlinelibrary.wiley.com/doi/10.1111/aphw.12031/pdf

[5] J Thompson Coon, K Boddy, K Stein, R Whear, J Barton, M H. Depledge. Does Participating in Physical Activity in Outdoor Natural Environments Have a Greater Effect on Physical and Mental Wellbeing than Physical Activity Indoors? A Systematic Review. Environmental Science & Technology, 1 March, 2011, Volume 45, Issue 5 pp1761-1762, http://www.ncbi.nlm.nih.gov/pubmed/21291246

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