Tag Archives: obesity

Mamamia! A Logical Fallacy Extravaganza in 7 parts: Trolling, Fat-Pride, BMI and Body Image.

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This is a rebuttal to a minefield of a post over at mamamia.com.au, from yet another journo seemingly in favour of the promotion of overweight, obesity and associated chronic diseases – all seemingly in disguise as the altruistic promotion of self-acceptance of body image.

I’m going to start this rebuttal by first disclosing a few potential conflicts of interest on my part:

  1. I work as an Exercise Physiologist with clients with chronic illness, musculoskeletal injuries, and other diseases, so I have a specific interest in overweight/obesity and how it impacts on their health conditions. You might even go so far as to say that my opinion is somewhat informed and that I have some background on the matter.
  2. I’ve written a post in the past on my blog Skeptifit.com about my views on the “Big is Beautiful” crowd. Admittedly sensational, but keep in mind that that too was a rebuttal to a misinformed journalist, so do excuse some of the loaded language.

In a nutshell, I’m not a supporter, and I believe the journos should stay out of healthcare alltogether and stick to what they know best, reporting the news, not attempting to understand and interpret scientific literature that is well outside their scope of practice.

Discussion Points:

1. “Concern trolling”. The author writes:

“At the bottom of nearly every article celebrating body diversity, you will likely find some version of the following comments:

Concern trolls? Don't think so!

Concern trolls? Don’t think so!

  • “Aren’t you promoting an unhealthy lifestyle?”
  • “I’m all about confidence, but this is just unhealthy.”
  • “I just don’t find fat people attractive, that doesn’t make me a bad person.”
  • “I have no sympathy for these people, they bring it on themselves.”
  • “Think of the children!”

This is not concern trolling, it’s genuine concern. The author is either unaware of what trolling is or is straw-manning genuine comments for trolling comments, and we’re left with the impression that she’s attempting to undermine any valid criticism that have been levelled at her or others by poisoning the well and launching personal attacks.
For a definition of what concern trolling actually is I’ll paste a defintion from Urban Dictionary, which I think is sufficient for our purposes (second definintion was clearer):

“In an argument (usually a political debate), a concern troll is someone who is on one side of the discussion, but pretends to be a supporter of the other side with “concerns”. The idea behind this is that your opponents will take your arguments more seriously if they think you’re an ally. Concern trolls who use fake identities are sometimes known as sockpuppets.

(eg) In the 2006 election, an aide to Congressman Charlie Bass (R-NH) was caught concern trolling the opposition on local blogs. While pretending to support Bass’s opponent, Paul Hodes, the aide argued that Hodes couldn’t win because Bass was an unbeatable candidate. Hodes won the election.”

I won’t go into depth examining semantics, technical vs colloquial usage of terms and different dictionary definitions. I think the tone of the opening speaks for itself and immediately calls into question the existance of alterior motives or conflicting interests on her part.

2. “People are allowed to make their own decisions regarding their own bodies, but we need to start treating people of all sizes with respect”

You deserve respect? Nope, you have to earn it.

You deserve respect? Nope, you have to earn it.

Nonsense. We no more need to respect a persons decision to live an unhealthy lifestyle than we respect their decision to engage in any other behaviour which might harm themselves or others, or that creates a burden on the healthcare system. An important distinction here – we respect their right to *make* that decision, but we don’t have to respect the decision itself, and we certainly don’t have to respect the person.

Many people might think I’m splitting hairs here, and I agree it’s a fine distinction, but again I think it’s an important one as I truly believe that respect is earned through displaying reasonable action and behaviour, and not freely given. In addition, the fact that all overweight/obese people immediately deserve respect for their lifestyle habits regardless what those habits actually are is an absurd generalisation which is almost as ridiculous as claiming that all overweight/obese people are in their condition because they are lazy. Neither extreme is correct, neither the straw-man examples provided by the author nor the authors position on the subject.

3. “BMI is BS”

Somewhat agree, for the reasons stated, but this is hardly a controversial point and most people (at least those who walk into my office) are already aware of this. Also this is only support for the fact that they should be talking to a health professional who takes a variety of anthropometrical and girth measurements to assess health measures within the context of other presenting chronic disease, rather than a simple BMI, and those readings then interpreted in context.
The historical points were an interesting read, however it’s a shame the link was broken and the source of the authors information can’t be verified (the source, not the information iteslf). It also makes one wonder why the sourced website might have pulled the page, if the link was the correct one in the first place.

4. “Fatness”

What exactly does this word mean? The author keeps using it as

Fatness? What?

Fatness? What?

though they’re trying to claim it and instill some sense of pride, which I guess is fine, but outside of that it’s a subjective term that adds absolutely no value to the discussion. While the inherent BMI problems with overweight and obesity were already outlined, they’re certainly much more useful classifications than totally subjective terms like “fatness” which appeal more to individual aesthetic preferences than anything else. Further to this, BMI certainly is a very useful tool for everyday, regular people who are not rugby players or pro athletes with an absurdly muscular build, as long as it’s interpreted within the context of other readings and measures.

5. “One’s relationship to food shouldn’t reflect on who they are as a human being”

Again, I call nonsense. Why shouldn’t it? Everything we do reflects on us as human beings, if your relatioship with food is unhealthy or you simply like to eat a lot, well I have news for you…that’s going to reflect on you, just like any other behaviour that you engage in reflects on you. You don’t get a free pass simply because some people (like the author) seem to want to make the issue taboo to discuss.

6. “But that’s not always the case: Multiple studies have seen little to no connection between weight loss and decreased risk of mortality.

Now this is probably the most salient point of the authors post, but again I think she missed the mark and is incredibly short sighted – perhaps due to her lack of expertise in the area of chronic disease.

The first link here is to an article posted on the NIH for people with Type 2 diabetes and obesity (not other demographics), so while it’s certainly informative for that sub-group of people it does not apply to the general population. The second link is a single study which shows that dietary intervention was not associated with improved health outcomes in the absence of exercise and health service interventions. It’s true that the issue of weight loss in overweight and obese people is controversial if they do not also present with other indicators of disease, but it’s also true that many overweight/obese individuals who also have chronic disease can see plenty of benefit from weight loss.

It seems as though the authors entire argument hinges on the Obesity Paradox, something which she’s implicitly generalising to all obese people as though it’s the norm. Just because there are exceptions for a small demographic doesn’t mean we should wholesale shift our position on the health risks of overweight and obesity, and I think the preponderance of evidence is still in favour of decreasing fat mass if a person is in the overweight/obese category, and achieving this objective through both nutritional and exercise-based methodologies.

7. “Not everyone wants to be skinny”

image

Image from original article

I find it kind of ironic that at this point, not only is the author implying that healthy weight = “skinny” (aka underweight, typically – so here she’s using a false dichotomy fallacy between being overweight or being skinny), and in addition to this slight of hand posts a picture of two women who for all intents and purposes, as far as can be seen from the picture, or at a relatively healthy weight range – which is exactly what health professioanls are advocating that most people should be striving to achieve!

Don’t drink the coolade, stay skeptical.
What are your thoughts?

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Counterproductive Cliche’s of the ‘Big & Beautiful’

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There’s a dangerous attitude out there, one which has been festering for a number of years and is probably a proponent of the Oprah Winfrey movement, I like to call it the “Big is Beautiful” syndrome. This particular group of people spout cliche after cliche, using faulty logic to support their denial that there is anything wrong with being overweight or obese and that people are spending far too much time on the topic of health, fitness and weight.

Obesity Campaign Poster

Obesity Campaign Poster (Photo credit: Pressbound)

Playing the Victim

These venomous types will twist and turn, claiming that they are discriminated against based on their size, that anorexic supermodels and superstars are providing negative role models for our youth (let’s do a reality check: are America and Australia full of overweight and obese, or have anorexics suddenly taken hold of the streets?), and that women should not be worried about their weight at any rate when, and I quote (from some random journo’s blog):

“Whining about weight is the ultimate shiny object that women continue to focus their attention on, instead of:
– fighting for social justice, at home and abroad
– running for political office and kicking ass when we win
– creating astonishing works of art
– waking up every single day grateful for their health and strength, the not-so-simple ability to walk and stand and reach for things without pain
– knowing that women all over the world are dying of starvation, malnutrition and in childbirth”

Etc etc ad nauseum, supposedly an extensive list of why you are misplacing your concerns, but in reality it’s an excuse list.

Did you get that? If there are problems in the world, or in politics, or with animal cruelty, or perhaps just your kitchen tap isn’t working properly, then you shouldn’t be “whining” or even thinking about your weight as there are more important things to worry about, and after all, you can only fix one problem at a time, right? RIGHT? (well…no, actually).

My Thoughts

I won’t lie, it irks me particularly when journo’s who have a good deal of exposure spout drivel continually, as they have a duty of care to do their best to dispense useful and accurate information, not catering to the fragile ego of a particular demographic who want to be coddled until they’re feeling the full glory of a  diabetes induced coma. Sure it feels good telling people what they want to hear, and everybody’s feeling-the-feels and congratulating each other on accepting themselves for ‘who they are’, but in the long-term there’s serious damage being done by this blatant disregard of reality (On the matter of journalists being scientifically illiterate and ignorant and dispensing horrendous advice is one which I plan to write about in the future).

house-built-on-sand

Bad health and excessive weight is a shaky foundation on which to build your emotional, intellectual and spiritual development.

The Moral

What’s the moral here? This isn’t just a whine about people who (ironically) tend to spend their time whining about people who are whining about their weight. The moral is this – do not let people like this, with their superficial facade of positivity and “oh honey you’re gawdjuss just the way you are!”, don’t let them tell you that you can’t or shouldn’t spend time improving yourself, your health, and your well-being, just because they have failed to do so themselves and need to surround themselves with other failures while propagating superficially positive but truly negative beliefs and attitudes. Don’t let them delude you into ignoring the consequences of being overweight or obese, nor how big these problems are in America and Australia and their impact on the healthcare system. If you find yourself tiring of conversations about health and weight, perhaps it’s time to do something about it.

Every person on this earth has the right and the obligation to take care of themselves and each other, but (and now it’s my turn for a cliche, so why not?) how can we take care of each other if we can’t or won’t take care of our own physical health? If we don’t create a very solid foundation, there is no chance of building a stable structure on top.

Don’t surround yourself with fake and dangerous, self-delusional positivity. Sometimes, a good hard smack in the face is good for us, and forces us to see what we’ve been ignoring for way to long. Let’s not delude ourselves or let others delude us, let’s stay true to our goals. Don’t ever let a random Joe tell you to “give it up”, because you can and will achieve greater health and well being if you just ignore those coddlers.

Is Big Really ‘Beautiful’?

Big is not “beautiful”, big is heart disease, obesity, diabetes, metabolic syndrome, arthritis, cancer, fatty liver disease and sleep apnoea, to name a few.

What are your thoughts? Is the “big is beautiful” attitude a problem that you often experience, and is it something that we should spend more time addressing?

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To Breakfast or Not To Breakfast?

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   Breakfast skipping, or intermittent fasting, has gained a lot of steam in the past year or two (“Big Breakfast Has Little Effect on Appetite“, “Extended Daily Fasting Overrides Harmful Effects of a High-Fat Diet“, “Skipping Breakfast Can Lead to Unhealthy Habits All Day Long“, “Could fasting be good for us?“, “Is breakfast making you fat?“, “The new appetite for fasting“). In fact I put the principle to use myself, and so thought this would be a great topic for my pathology research assignment. This report might be dry reading for those who aren’t used to reading scientific literature or associated nomenclature, so I’ll start by quoting the most relevant part of this report – the conclusion:

  “The key findings of this report are that breakfast appears to be clearly associated with weight gain in a dose-dependent relationship, though the direction of this relationship is not clearly established. Depending on the type of descriptive research method employed, different results are apparent, though the study by Schusdziarra et al. (2011) addressed some of these apparent contradictions.

   In conclusion, when interpreting the data in light of the contradictory nature of the research, there appears to be little evidence that breakfast skipping significantly contributes to overweight and obesity in adults, though individual factors such as age, obesity, exercise history, TDEE and TDEI should be taken into account and may in fact play a large role in the interpretation of the associations and correlations investigated in fasting and meal-skipping studies.”

   And there you have it, no real evidence for a causal relationship between breakfast skipping and weight gain, though the correlational data shouldn’t be dismissed out of hand and does provide us with some insight. Also, take into account that my critical analysis within this report only covers two pieces of primary literature, but that dozens of articles were accessed in the process. That said, I was forced to neglect the biochemical (grehlin, leptin, insulin, glucose, not to mention the interplay with lipid cells) physiological point of view somewhat in order to remain within the word limit for my report. If it’s the biochemistry of breakfast skipping that you’re after however, then I won’t reinvent the wheel – just head on over to Martin Berkhan’s blog “Leangains“, linked in the side panel, for more fasting biochemistry and references to primary literature than you can poke a stick at.

Without further delay, here’s the nuts and bolts!

(Feel free to comment at the bottom – what are your thoughts on breakfast consumption?)

Skipping breakfast: is it a significant contributor to overweight and obesity in adults?

Introduction

Overweight and obesity are growing health problems in Australia, with an increase from 57% of the population in 1995, to 61% in 2007-2008 (Health Risk Factors, 2012), having an enormous cost to the Australian government and society at an estimated $58 billion in 2008. Figure 1 shows data from the National Health Survey 2007-08, in which a larger proportion of overweight and obesity is prevalent amongst the aged adult population, particularly amongst males, with younger adults showing lower prevalence rates.

Figure 1: Proportion of Australian Adults Overweight or Obese (by age and sex). This figure illustrates increasing incidence of obesity with age (Health Risk Factors, 2012)

The importance of experimental investigation into the causal mechanisms of obesity becomes obvious in light of this data. This report sets out to examine associations between meal skipping (breakfast in particular), and overweight and obesity, and to challenge the long-held belief that breakfast is “the most important meal of the day” – a notion which has been picked up and discussed by the media in recent years (Roan, 2009) and mainstreamed by popular books such as Eat-Stop-Eat (Pilon, 2007).

This report will cover background information on obesity, including definitions, aetiology, pathogenesis, diagnosis and treatment. Two descriptive, observational studies will be analysed, summarised and critically evaluated in the context of other descriptive and experimental scientific research, and the strengths and weaknesses of each study and their separate contributions to this research question discussed. Finally, key-findings from the two studies will be restated and summarised.

Background Information

There are typically four different categories into which diseases may be placed; pathological, hereditary, physiological and deficiency disease. For the purposes of this report, obesity and overweight are considered from the context of their most prevalent cause, being physiological disease as a result of excessive nutrient intake and inadequate physical exercise (Obesity, 2012).

Bodyweight categories are grouped based on body mass index (BMI) measurements, with obese being in excess of 30kg/m2, overweight within the range of 25-29.9kg/m2, and a normal bodyweight falling in the range of 18.5-24.9kg/m2 (Overweight & Obesity, 2012).

Obesity is a chronic disease in which excessive amounts of adipose tissue are accumulated over time, leading to potential systemic issues and increased likelihood of comorbid disease (Weiss & Elixhauser, 2006). A caloric surplus is required over an extensive period of time for obesity to develop, usually necessitating low levels of exercise and a surplus in nutritional intake in order for total daily energy intake (TDEI) to exceed total daily energy expenditure (TDEE). Though this is the predominating cause of obesity, there are rare genetic disorders in which leptin insensitivity may cause obesity from childhood (Farooqi et al., 2007).

The pathogenesis of obesity is complex and only partially understood, though it’s clear that it depends on the function of several key metabolic hormones, including glucagon, insulin, leptin and ghrelin (Carlson et al., 2007), with adipose tissue itself also producing important mediators for the metabolism of triglycerides to adipose, including adiponectin, cytokines, chemokines and steroid hormones (Stanley L Robbins, 2012). Leptin is known to play a key role in the suppression of appetite (Duntas & Biondi, 2012), with decreasing levels of leptin being secreted when fat is lost from adipocytes – making long term weight loss more difficult. Insulin and glucagon control the transport of glucose into and out of the cells respectively, with long term blood-glucose levels and excessive lipid intake being tightly correlated with insulin resistance and type 2 diabetes (Fu, Gilbert, & Li, 2012). In addition, the risk of other comorbid diseases such as cardiovascular disease, gall bladder disease, osteoarthritis, bowel cancer and diabetes are increased in the presence of obesity (Schienkiewitz, Mensink, & Scheidt-Nave, 2012).

As obesity is defined as a BMI above 30kg/m2, diagnosis is simply made by utilising the formula BMI = weight/height2. The drawbacks of the simplicity of this formula lie in the fact that there is no distinction made between fat and muscle mess, therefore an incredibly muscular bodybuilder might be considered “obese” if only the BMI were used as a measurement. Obviously BMI needs to be utilised in the context of other available information to ensure the wrong demographic of “overweight” individuals are not captured and misclassified.

    Treatment for obesity typically lies in nutritional and exercise interventions, more specifically improving the quality of nutritional intake and decreasing the number of overall calories consumed along with implementation of an effective exercise program. Though this treatment is successful in a large number of obese subjects, particularly when delivered with cognitive behavioural therapy (Jakicic et al., 2012), those who suffer from hereditary causes and complications may require more medical intervention. Finally, some of the latest research by Mestdagh et al. (2012) involving intestinal bacteria and their role in the development of obesity opens interesting avenues for future exploration.

Annotated Bibliography & Critical Evaluation

Annotation 1

Huang, C. J., Hu, H. T., Fan, Y. C., Liao, Y. M., & Tsai, P. S. (2010). Associations of breakfast skipping with obesity and health-related quality of life: evidence from a national survey in Taiwan. International Journal of Obesity, 34(4), 720-725. doi: 10.1038/ijo.2009.285

This cross-sectional, descriptive study by Huang et al. used data from a National Health Interview survey in Taiwan which surveyed 15,340 individuals between the ages of 18 and 64. The study tested the association between breakfast skipping and obesity, as well as examining the possibility of a dose-dependent relationship between frequency of breakfast consumption and obesity.

The authors hypothesise that there exists an association between breakfast skipping and obesity, as well as a dose-dependent relationship in which an increased frequency of breakfast skipping is associated with an increased prevalence of obesity (amongst other behaviours deemed detrimental to health). The authors aimed to investigate these associations in adults as the majority of research conducted in this area in the past has focussed on a much younger demographic; primarily children and adolescents, making that research difficult to generalise to adults.

Although published in the International Journal of Obesity, the authors concede that the intended audience is specifically Taiwanese, and that the results are less applicable to other demographics, therefore these results are likely more relevant to Taiwanese health specialists and policy makers who are tasked with examination of potential causes and treatments for the growing obesity epidemic.

After careful analysis of the data, the authors conclude that breakfast skipping is associated with higher prevalence rates of obesity, in addition to being associated with other unhealthy behaviours such as smoking, alcohol consumption (though at what point this was considered detrimental to health was never addressed by the authors), and lack of exercise.

This study was chosen for analysis as it utilises a large segment of the adult population and is able to draw meaningful statistics due to this large sample size (n = 15,340).

Critical Evaluation

This study is relevant to this report as it directly investigates the association between frequency of breakfast skipping and prevalence of obesity, though there are advantages and disadvantages to their method of approach. One advantage is the fact that the authors utilised survey data, which allows a large breadth of information and amount of data to be acquired, however a major drawback of this approach is the inability to control confounding variables or tailor the data collected to include information such as macronutrient and micronutrient content and meal timing.

This study contributed to this report by confirming initial impressions that the majority of research is not applicable to the general adult population, as most studies examining the association between skipping breakfast (or fasting) and obesity are performed on a much younger demographic. This study also introduced the concept of a dose-dependent relationship, and more specifically that as breakfast-skipping increases so too does the prevalence of obesity. It also introduced the fact that breakfast skipping is associated with other unhealthy behaviours, including smoking, alcohol consumption, and lack of exercise. Finally, the associations found between breakfast skipping and lower scores of general health, vitality, mental health and social functioning helped to inform this report.

The authors addressed the research question by categorising the existing data into two groups: breakfast skippers and breakfast eaters (with breakfast skippers being those who ate breakfast once a week or not at all). The authors then analysed the percentage and P-value for each group, and subcategorised them into obese, smokers, alcohol drinkers, physically active, level of education, monthly income, marital status, and gender. The data was finally analysed using odds ratios.

This study gives direction for ongoing research into the links between breakfast dose (weekly frequency) and obesity, and helps to provide a basis for comparison of the results with other cross-sectional data as well as comparison with experimental, randomised controlled trials to compare and contrast the similarities and differences in outcomes.

Annotation 2

Schusdziarra, V., Hausmann, M., Wittke, C., Mittermeier, J., Kellner, M., Naumann, A., . . . Erdmann, J. (2011). Impact of breakfast on daily energy intake–an analysis of absolute versus relative breakfast calories. Nutr J, 10, 5. doi: 10.1186/1475-2891-10-5

This study sets out to investigate whether the reduction of caloric intake at breakfast can reduce the total daily caloric intake in a free-living and cross-sectional segment of the population, without compensatory eating behaviour. The study utilised 380 participants, 280 of which were obese and 100 of which were normal weight. Macronutrient and micronutrient intake were not analysed, though full nutrient details were gathered and recorded by each patient in the form of a food diary. This study focussed on the ratio of calories consumed at breakfast compared with those consumed throughout the entire day.

The authors introduce background information that shows seemingly contradictory studies and research around the effects of skipping breakfast or reducing caloric intake at breakfast and the prevalence of overweight and obesity. It’s proposed that these contradictory results between studies are a likely result of the different methodologies employed to manipulate the variables and analyse the data, particularly with regard to cross-sectional data vs. intraindividual analysis. The aim of this study was to compare two separate testing methodologies (cross-sectional data of a free living population and intraindividual analysis) on one data set and compare the results, helping to bridge the gap between studies utilising these separate methodologies.

This article was published in the Nutrition Journal, with the intended audience being those who are interested in nutritional research and have an understanding and appreciation of the application of the scientific process. This might include doctors, dieticians, exercise physiologists and other specialists with a nutritional interest, with repercussions for all segments of the healthy, overweight or obese populations.

The primary conclusion drawn by the authors is that a lower caloric intake at breakfast decreases the total daily caloric intake (with no compensatory eating behaviour), though this is put in the context of equivocal and at times contradictory research. This text was chosen for evaluation in part due to this balanced perspective of the available and contradictory studies, and the intent by the authors to resolve some of these differences.

Critical Evaluation

This study is relevant to this report as it puts into context the apparently conflicting research. It increases understanding by showing that a higher energy intake at breakfast is associated with an increased TDEI, but that this should be put into context of the energy expended during the day – particularly the amount of physical exercise engaged in. It also demonstrates the complexity of the issue and the difficulty of drawing clear conclusions on the issue of breakfast skipping or breakfast size and its association with overweight and obesity.

The authors address the research question by utilising patients from a hospital outpatient department, having them keep accurate logs of all food that was consumed and at what time of the day it was consumed. Both intra-individual data and ratio of daily energy intake were analysed from records taken over a two week period.

This study can be used for ongoing research into the differences in ratio between breakfast and total daily energy intake, and how this relates to obesity in studies that utilise different methodologies (preferably randomised controlled trials).

Conclusion

The key findings of this report are that breakfast appears to be clearly associated with weight gain in a dose-dependent relationship, though the direction of this relationship is not clearly established. Depending on the type of descriptive research method employed, different results are apparent, though the study by Schusdziarra et al. (2011) addressed some of these apparent contradictions.

In conclusion, when interpreting the data in light of the contradictory nature of the research, there appears to be little evidence that breakfast skipping significantly contributes to overweight and obesity in adults, though individual factors such as age, obesity, exercise history, TDEE and TDEI should be taken into account and may in fact play a large role in the interpretation of the associations and correlations investigated in fasting and meal-skipping studies.

 

References

Carlson, O., Martin, B., Stote, K. S., Golden, E., Maudsley, S., Najjar, S. S., . . . Mattson, M. P. (2007). Impact of reduced meal frequency without caloric restriction on glucose regulation in healthy, normal-weight middle-aged men and women. Metabolism, 56(12), 1729-1734. doi: 10.1016/j.metabol.2007.07.018

Duntas, L. H., & Biondi, B. Md. (2012). The interconnections between obesity, thyroid function, and autoimmunity: the multifold role of leptin. Thyroid. doi: 10.1089/thy.2011.0499

Farooqi, I. S., Wangensteen, T., Collins, S., Kimber, W., Matarese, G., Keogh, J. M., . . . O’Rahilly, S. (2007). Clinical and molecular genetic spectrum of congenital deficiency of the leptin receptor. N Engl J Med, 356(3), 237-247. doi: 10.1056/NEJMoa063988

Fu, Z., Gilbert, E. R., & Li, D. (2012). Regulation of Insulin Synthesis and Secretion and Pancreatic Beta-Cell Dysfunction in Diabetes. Curr Diabetes Rev.

Health Risk Factors. (2012). Australian Bureau of Statistics, Retrieved 16/09/12, from http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/1301.0~2012~Main%20Features~Health%20risk%20factors~233.

Jakicic, J. M., Tate, D. F., Lang, W., Davis, K. K., Polzien, K., Rickman, A. D., . . . Finkelstein, E. A. (2012). Effect of a stepped-care intervention approach on weight loss in adults: a randomized clinical trial. JAMA, 307(24), 2617-2626. doi: 10.1001/jama.2012.6866

Mestdagh, R., Dumas, M. E., Rezzi, S., Kochhar, S., Holmes, E., Claus, S. P., & Nicholson, J. K. (2012). Gut microbiota modulate the metabolism of brown adipose tissue in mice. J Proteome Res, 11(2), 620-630. doi: 10.1021/pr200938v

Obesity. (2012). Medline Plus, Retrieved 18/09/12, from http://www.nlm.nih.gov/medlineplus/obesity.html.

Overweight & Obesity. (2012). Centers for Disease Control and Prevention, Retrieved 16/09/12, from http://www.cdc.gov/obesity/adult/defining.html.

Pilon, Brad. (2007). Eat Stop Eat. Ontario, Canada: Strength Works Inc.

Roan, Shari. (2009). The new appetite for fasting, Sydney Morning Herald. Retrieved 25/08/12, from http://www.smh.com.au/lifestyle/diet-and-fitness/the-new-appetite-for-fasting-20090403-9muo.html

Schienkiewitz, A., Mensink, G. B., & Scheidt-Nave, C. (2012). Comorbidity of overweight and obesity in a nationally representative sample of German adults aged 18-79 years. BMC Public Health, 12(1), 658. doi: 10.1186/1471-2458-12-658

Schusdziarra, V., Hausmann, M., Wittke, C., Mittermeier, J., Kellner, M., Naumann, A., . . . Erdmann, J. (2011). Impact of breakfast on daily energy intake–an analysis of absolute versus relative breakfast calories. Nutr J, 10, 5. doi: 10.1186/1475-2891-10-5

Stanley L Robbins, Vinay Kumar, Ramzi S. Cotran (2012). Robbins Basic Pathology (NINTH EDITION ed.).

Weiss, A. J., & Elixhauser, A. (2006). Obesity-Related Hospitalizations, 2004 versus 2009: Statistical Brief #137 Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville MD.

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