Eczema or atopic dermatitis is a chronic skin condition often causing red itchy inflamed skin which can range in severity from mild to severe. 

According to statistics around 15 million people in the UK live with this condition and in 2015 GP’s in England wrote around 27 million prescriptions for various topical agents costing around £169 million. If you are thinking to yourself that more and more people are suffering from this you’d be right in your assumption. An  NHS funded study has shown that the numbers of cases have risen by 40 % in 4 years. 

What we do know about the condition is that it is an allergic condition with 80% of sufferers having raised IgE antibodies. Eczema patients have positive allergy tests and around two thirds have a family history. Many also suffer from other atopic conditions such as asthma and hay fever. 

The standard treatment protocols involve simply managing symptoms via emollients and sometimes steroids and if infection is triggered due to scratching, antibiotics. Allergens are also tested for although these tend to focus on only IgE mediated reactions. 

Other considerations….


Immune function

We are back to finding our root cause. So first lets look at what’s going on in the immune system. The allergy antibody IgE is elevated in 80% of cases and this is activated by a type of white blood cell, a helper cell called TH2. Mast cells can release higher amounts of histamine leading to the itch that we associate with eczema. Then there’s the issue that around 90% of sufferers also have a predominance of the bacteria Staphylococcus aureus on the skin which their immune system is unable to kill. Often scratching can activate this infection and cause some potentially severe staph infections. So how do we prevent this vicious circle? Well we have to do everything we can from day one to promote our gut/immune function. In our immune system we have regularly T cells sometimes known as Treg, which are involved in immune suppression and immune tolerance. It’s known that an unhealthy gut can lead to a decrease in these important cells and therefore an imbalance in our TH1/TH2 cells with the TH2 cells being unregulated. Studies have indicated that the use of probiotics from birth can confer a reduction in TH2 dominance and symptoms of AD at 13 months old versus placebo. 


Breast feeding

Studies have shown that breast feeding is associated with a reduced risk of eczema and other allergies. However there is a caveat here in that although breast milk may confer antibody protection, in at risk children it may also be necessary for the feeding mum herself to remove common allergens which may unwittingly be triggering the problem as these proteins pass through the milk. Common allergens being dairy, peanuts and eggs. That said, the advice is to introduce these common allergens while breast feeding at the 6 to 12 month stage and to then continue to breast feed for a further 6 months following this introduction. 


Older and formula fed children 

In older and  formula fed children a study looking at triggers for eczema indicated that Peanuts eggs and milk have been shown to account for 80% of adverse reactions to foods in people living wth contact dermatitis. Other common triggers and are wheat, fish and soy. 

The hygiene hypothesis. Are we just too clean? 

Epidemiological studies, especially those looking at migration from one country to another indicate that we acquire the same immune disorders as soon as we move  to another area so environmental factors are playing a huge role. Lifestyle changes have led to a decrease in infection in the industrialised world and this has been shown to be inversely correlated with increases in allergies and autoimmunity.   Studies have also shown that exposure to animals or growing up on a farm confers protection from a young age as we are exposed to a greater variety of bacteria which leads to activation and modulation  of innate and adaptive immune response. In one large Swiss study, nearly 14,000 children were surveyed between 2006 and 2007, with over 3,000 farming children and around 11,000 non-farming children. In this study, 38% of the non-farming children had allergies compared to 19% of the farming children. 

Digestive compromise
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Those living with allergies have commonly got some level of digestive compromise and  dysfunction. Stomach acid which normally assists in the removal of infection and therefore has a protective role, can commonly become low and therefore play a role in  weakening our immune system and make us more prone to infection. It also sets us up potentially for the leaky gut phenomenon which puts us at risk of further food sensitivities of the IgG variety (delayed reaction)   and chronic inflammation. If you have intestinal permeability you may also be experiencing other health challenges e.g. fatigue, brain fog, headaches, depression, sinus, IBS, reflux, joint pain, and autoimmunity. This is also why I see many clients in clinic who may be coming along for help getting to the root of their eczema but who also have any number of the aforementioned symptoms.  A lack of a very important nutrient zinc can ensue as a consequence of low stomach acid. This nutrient is essential for immune, gut, hormone  and skin health. It affects appetite, smell and taste of food, so in children who have a narrowing of food choices and are no longer enjoying certain foods, zinc deficiency may be at the heart of this. It is also a particular problem in cases of acne in teenagers so look out for changes in eating and appetite in older children and test their zinc levels. This can be done with a very simple taste test which all the family can do.  Adequate zinc is also required for healing the gut. 

Gut Flora and probiotics

Because our immune system resides primarily in the gut we need to look at gut bacteria. We also need to weed out any trouble makers Interestingly yeast overgrowth is a common cause of eczema.  It’s also a very common problem as the western diet of high sugar, refined carbs and low fibre sets up the perfect conditions for this to grow. In addition, yeast overgrowth can result from long term medication use e.g. antibiotics, steroids and the oral contraceptive pill. We therefore need to ‘weed and seed’ the gut, get the infections out and the good bacteria in to assist with immune balancing and symptom resolution. 

​Risk factors for allergies in children 

​This relates to those factors which influence the health of the micro biome from day one. In an ideal world we need to be focusing on the gut health of mum prior to a planned pregnancy as this is what baby inherits. Areas of concern are

• maternal gut dysbiois, an imbalance of microbes with some overgrowth of potentially harmful bacteria, yeasts and other organisms and a lack of healthier microbes. ( All of this can be identified at pre-pregnancy)
•  Antibiotic use by mum during pregnancy, labour or while breast feeding. (This one can be corrected with probiotic at each stage) 
• Cesarian birth. (Again this can be off-set with probiotics) 
• Lack of breast feeding during the first 4 months of life
• ​Antibiotics given to baby during the first 4 months of life. (Again probiotics can be given from birth and at any time following to off-set this) 

The Swansea Study

This was a large study by the University of Swansea Medical School  with 454 mother/baby pairs who were given Lab4b probiotics containing Lactobacilli and Bifidobacteria both during the final month of pregnancy and the first 6 months of  infancy to evaluate whether this would prevent allergy in children. The results showed that versus placebo, the probiotic groups did indeed confer a protective effect on prevention of eczema and also prevention of allergic reaction to common allergens including pollen, cows milk, eggs and dust mites. 
Prof. Steve Allen, concluded the following key message from the trial:‘Lactobacilli and Bifidobacteria administered to pregnant women and infants aged 0-6 months prevented atopic sensitization and atopic eczema.

The babies given the Lab4b probiotics were 57% less likely to develop atopic eczema than those receiving the placebo.

The babies given Lab4b were 44% less likely to develop allergic reaction to common allergens, including pollen, cow’s milk, egg and house dust mite.

A subject that we're getting more and more questions about these days is how food intolerance can impact sports performance. Testing is growing in popularity as more and more of our top professionals have found that removing foods that they are intolerant to can have a big impact not only on their health but also their performance. In the Tennis world, it was Djokovic who famously removed food intolerances in his diet and he credits this for his ability to remain at the top of his profession.

Food intolerance is estimated to effect 45 percent of the population and can show itself in a variety of symptoms, for example, headaches, migraines, IBS, eczema, joint pain, unexplained fatigue among others. More on food intolerance and health can be found here. One of the difficulties for sports people and a common trap that they can fall into unwittingly is that they can follow diets that can become quite repetitive and find themselves eating a lot of the same foods which can itself lead to food intolerance. An example of this would be eating a high number of eggs as it is a protein rich food. But if we become intolerant to this food, we can find ourselves with various symptoms, fluid retention and sub-optimal sports performance. Another common intolerance is to dairy products, so imagine the number of sports people out there who are regularly consuming whey based proteins in shakes and protein bars who may be impairing their performance without realising it. Intolerance to specific foods can also lead to challenges around weight management, so if you are finding that you are struggling to lose weight even although you believe that your diet and exercise program is optimal, it may be that you have underlying food intolerance which could be driving inflammation and leading to some challenges around losing weight. Typically people find that they lose a few of those extra pounds fairly quickly after removing problematic foods as they lose fluid retention and going forward find that they are better able to maintain an optimal weight for them.

A number of studies have indicated that a risk factor for food intolerance in sport can result from very intense training which can impact our immune  system negatively and lead to impaired intestinal barrier function which allows food proteins to find their way into our blood system. One study published in the British Journal of Sports Medicine concluded that "sports performances and health in elite athletes depend on food intolerance in many ways. The elimination diet for 3 months significantly improved health, body composition and faster lowering HR after cardiopulmonary testing."

The particular test that we offer is from the Lorisian laboratories and they have a number of case studies after working with a number of high profile sports professionals and sports teams, notably Newcastle United and Wigan Warriors Rugby League Team. Some examples of individuals are marathon runner Paula Radcliffe, Professional rugby players Peter Stringer and Rob Vickerman, triathlete Matt Perry, International Hockey Player Mike Shaw and runner Dani Rowlinson.

Paula Radcliffe found out she was intolerant to egg, chicken, wheat, tomatoes and dairy and said, “After I cut these foods out of my diet, I was able to run without doubling up in pain. I have a lot more energy and I am back to my normal self. It truly made such a difference to my life and I would recommend it to anyone else suffering from symptoms like these.”

England Rugby 7's player Rob Vickerman had always followed a protein rich diet designed to help fuel his training and assumed the foods he was eating were the best possible choices to compliment his exercise. He said,  "At no point throughout my professional career did I even think about awareness of my nutritional make up. I, like many of my peers ticked the usual boxes of high protein quantities, low carb and fats without really knowing what was good for me or why."

Rob Vickerman is a classic example of someone eating the very foods he was intolerant to and in very high amounts which led to some health challenges. He says, “To overlook what fuelled me meant I was perhaps missing the most important information contributing to my performance. I used to react somewhat 'typically' after taking protein shakes, seemingly no different to the majority of my teammates. I never questioned this, nor the fact when I had eggs I would have a similar reaction, bearing in mind I was having 20-30 eggs a week.” 

Triathlete Matt Perry also benefitted his sports performance after taking the test. He said, ”I have lost over an inch from my waist and lost 17lbs in weight. My energy levels throughout the day are higher; I am more focussed and clear headed. Also in my first triathlon of the season I knocked 17 minutes off my time from last year... A simple test and re-education on your eating habits can turn your life around.” 


Are there any other tests relevant to optimising sports performance?
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One that I recommend is the Optimal Nutritional Evaluation which is a simple and convenient urine test which analyses key nutritional biomarkers including antioxidants, B vitamins, minerals, digestive support and amino acids. The report also gives advice not only on any nutritional deficits you may have but also suggested nutrients and optimal dosing for you to rectify any deficiencies or imbalance. 

Our nutritional status is impacted not only by what we eat but what we absorb of what we eat. We may therefore require further support in the form of digestive enzymes and probiotics. As excessive sport is known to impact free radical damage, we also need to be mindful of optimising antioxidants in the diet. Another factor which we can't underestimate in sport is stress, not only because it impacts performance but also because it can have a negative impact on our digestion and absorption of nutrients. Another test which may therefore be appropriate in some cases is cortisol.  It is well known in sport that mind set and keeping stress under control can be pivotal in taking us to the next level. 


For further information for individuals or for teams contact us at info@nourishinginsights.com or phone 01224 969637. We are open Tuesday to Saturday.

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"In the jungle, the mighty jungle, the lion sleeps tonight..."

Even the lion, the king of the jungle needs rest time. Interestingly the lion sleeps between 10-20 hours a day. Isn’t it quite astonishing that animals know instinctively how to project manage, how to conserve energy and how to make the best use of their own personal resources. We, on the other hand are inclined to forget to bring the concept of rest into our lives and in our modern day 24/7 culture, real rest has become elusive. We may think we are resting when we are sitting on our bottoms. However, with the television in the corner of the room, a laptop on our knee, a phone in our hand and a mug full of our chosen caffeine or other stimulant, are we really resting in the true sense? Is it any wonder therefore that we can’t even sleep properly these days? Most of us will have experienced difficulties with sleep onset and also getting good quality continual sleep. Sleep problems are becoming a bit of an epidemic across the western world. You can read some of our top tips for a good night's sleep here. 


Working under the functional medicine umbrella, we recognise sleep as one of the fundamental functional pillars when it comes to health. Sleep is when our bodies heal, repair and are restored. During the day, our cortisol levels should change with sunrise and sunset. Ideally, they should be higher in the morning and gradually come down across the day with lower levels in the evening to prepare our bodies for sleep. However, imagine a body which is out of balance and which is producing too much cortisol in the middle of the day and/or in the evening. This is becoming all too common a problem these days as we are overstimulated, not just from our exposure to electronics and the internet but being part of a culture that puts pressure on us to work in the evenings , checking emails etc. So we feel we have to keep going when our natural rhythms need to prepare the body for sleep.


Imagine what would happen if lions lived their lives the way many of us do, without adequate time of rest. There would probably be a lot of hungry and angry lions wandering about and let's face it we don't want to come face to face with a 'hangry'l ion!! Lions spend the majority of the day resting which in terms of their survival makes perfect sense. They expend a lot of energy when they hunt so if they were to move around during the day when they don’t need to they would waste a lot of their energy and end up creating more work for themselves by having to hunt more regularly. Lions rest because they know they need to. So what can we learn from lions?

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Lions teach us that periods of rest can help us to be productive when we need to be. A lack of rest and adequate sleep impacts our work lives, relationships, mood, hormone balancing, blood sugar, libido, adrenal and thyroid function, immune system and so the list goes on..... in other words every aspect of our health. It is as necessary for our own survival as it is for lions. So how do we find rest in the modern world?


Our top tips 

• Start the day with a wake up light that increases the light slowly, waking you up gently so you don’t get a sudden big cortisol spike. Wake up lights can help restore the sleep/wake cycle and are good prevention for SAD. 
• Limit caffeine to early part of the day, going for herbal and fruit teas in the afternoon
• Build rest into the day by eating slowly and mindfully, celebrating each meal and each valuable nutrient
• Limit time on social media and set limits on Facebook and Instagram.  This will prevent addictive scrolling and overstimulation from screen time. Also, imagine how more productive we'd be if we replaced our scroll time with some mindfulness or a short walk etc?  
• Spend time in the outdoors. If you can’t leave the office because of time constraints or weather, simply close your eyes and listen to the sounds of nature. There are many apps including the calm app which offer a much needed escape and a time of rest in the middle of a busy working day. If we did ten minutes 2 or 3 times a day over a lunch break or after work this would give us a time of rest.
• I recommend all of my clients to use relaxation music. In an office situation, you could use ear phones. So if you are stressing over a mountain of emails give yourself the gift of rest by listening to some relaxation music and you will find you will be able to tackle one email at a time without stressing over the other 50 emails waiting underneath— they can wait.
• Breathing techniques. Taking some deep breaths and simply focussing on the breath for a few minutes can take us out of the fight or flight state and get us into rest and digest. I often recommend this to clients prior to having lunch, especially if they are people who are inclined to eat quickly and are prone to indigestion. A body that is in a sympathetic dominant state, ready to run from a tiger (or his boss!) is not a body that’s ready to sit down and properly digest his food. 
• Take up yoga or pilates. Join a class or start doing it in your own home. There are many online videos on youtube. Boho beautiful is one of the yoga channels we really enjoy. 
• Take a power nap during the day. Research suggests napping during the day can improve memory and creativity. 
• Book a massage, reflexology or other therapy for relaxation. 
  

Finally, do whatever you need to, to incorporate patterns of rest into your day.  What you find restful might be completely different to another person.  Whether you find rest in a hobby like knitting or singing, do something that helps you relax. Your body will thank you for it.

And breathe...... 

1. Pukka Bamboo Reusable Travel Cups £8.99 -
These have been a firm favourite since they launched last year. They would make an ideal Secret Santa gift as they come in a range of colours and who doesn't drink tea or coffee?

2. Booja Booja The Gourmet Selection £17.79 -
If you haven't tried Booja Booja you are seriously missing out! This selection contains 20 perfect dairy free truffles in 6 different flavours. A beautiful gift or perfect alongside coffee at the end of a dinner party. We also have fine de champage £9.95 and hazelnut £7.35.

3. Spacemasks - £15 -
Sometimes you can be so busy that taking time out just doesn’t seem possible. This is where your Spacemask comes in. You are about to encounter Interstellar Relaxation. Within minutes of putting on your Spacemask you will feel it warm up and start to mellow your tired eyes and face. The soft jasmine smell will help to transport you away. Somewhere between Jupiter and Andromeda. The perfect antidote to festive overindulgence!

4. Back, Neck and Shoulder Massage £28 -
Who couldn't use a massage to recover from the stress of Christmas? Make getting through January that little bit easier for someone you love with a voucher for a relaxing massage.

5. The Lumo Diffuser £79.99 -
A firm favourite the Lumo looks beautiful and fills your home with the scent of gorgeous essential oils. It can be set for 2, 5 or 10 hours and has a number of light colours to choose from. We also have the Petal diffuser - £49.99 and the Elephant diffuser - £55 which is ideal for little ones.

6. Pukka Tea Caddies £9.99 -
Tea caddies in every colour of the rainbow. These beautiful ceramic and bamboo tea caddies would be a welcome addition to any kitchen. Each comes in it's own wee box making it very easy to wrap. Why not pair with a box of tea for the perfect gift?

7. DoTerra's Favourites Trio - £30
Presented in a gorgeous reusable tin these three oils are must haves through the winter months. Balance to keep you grounded through the chaos, OnGuard to support your immune system and Breathe to help you take it all in!

8. Kaerlig Beauty Soaps  in Red and Blue - £8.99
Locally produced in Aberdeenshire these luxurious hand soaps are a pleasure to use. Chose from Red scented with  grapefruit and bergamot essential oils. Or Blue scented with spearmint and Lime essential oils.

9. Natural Facelift Facial £40 -
Feel 100 years older by the time Christmas dinner is over? Turn back time with our Natural Facelift Facial. Using Japanese massage and facial reflexology points to smooth fine lines and plump the skin.

10. Christmas Morning Hamper £30 -
Everything you need to start the day on Christmas Morning: Primrose's Kitchen Raw Carrot, Apple & Cinnamon Muesli; Pukka Gorgeous Earl Grey; Clipper Roast & Ground Arabica Decaf Coffee; Struan Scottish Heather Honey; The Fruit Tree Organic Fruit Jam; Amphora Festive Candle.

Calcium is an essential mineral for bone and teeth health. Although almost 99% of calcium is found in the bones and teeth, it is also found in the blood, muscles and other tissues. Calcium plays an important role in heart and nerve health, blood clotting, hormone secretion and muscle contraction.  Additional functions include helping to control levels of magnesium, potassium and phosphorus in the blood. Calcium is the most abundant mineral in the human body, and so it is vital that we are meeting our requirements for optimal health.

Calcium is clearly a vital mineral for health, but in order to maximise the benefit of consuming calcium rich foods, there are other factors we have to consider. For example, did you know that to properly absorb calcium, we also need magnesium, vitamin D and vitamin K2. If we don’t have adequate amounts of these vitamins on board, our ability to absorb any calcium we do eat is impaired. This is one of the reasons why it is better to get the calcium our bodies require from food sources or complex food supplements rather than isolated calcium supplements which aren’t always well absorbed.

So what are the best food sources of calcium?

Some of the best sources of calcium include sardines, organic milk, organic yoghurt and kefir, kale, collard greens, chickpeas, almonds and figs. Other good sources include sweet potatoes, bone broth, green leafy vegetables, beans, and broccoli.

Currently, the NHS recommended daily allowance of calcium is 700mg, although you will see other experts recommending that we consume up to 1000mg per day for adults and 1200mg for over 50 year olds. However, the key thing we have to consider is absorption. As I always explain to people, we are not just what we eat, nor are we just what we absorb of what we eat, but we are also what our food ate!

Impact of changing farming practices

Intensive chemical farming practices have impacted minerals in the soil leading to our foods being depleted of vital minerals such as magnesium and calcium. Some conventional farmers have stopped properly rotating crops and replenishing the soil with natural fertilisers such as manure, which means our foods are much lower in calcium than they were in our grandparents time. Our advice therefore, is where possible to choose organic foods which have been shown to have higher nutrient value and higher antioxidant value in numerous studies, the largest to date being from Newcastle University.

Other absorption challenges

Gastrointestinal problems and conditions such as IBS, leaky gut syndrome, reflux,  IBD and coeliac disease cause further problems with the absorption of nutrients. Any inflammation in the digestive tract impairs the absorption of nutrients. Counterintuitively therefore consuming dairy when you have a dairy intolerance does not mean that you will be able to absorb all the calcium from the food. Malabsorption of nutrients is of particular concern for those with IBD and coeliac disease who are at higher risk of other conditions such as osteopenia and osteoporosis as a result of their condition. For this reason, they are also often deplete in a wide range of nutrients, regardless of how good their diets are.

Other issues such as low stomach acid which can be caused by stress, H-pylori, bacterial infections, antacid use, proton pump inhibitors and certain other medications can also lead to the malabsorption of calcium and other minerals. Add to this the fact that many drug medications actually deplete much needed minerals and vitamins and you can see where we can fall into difficulties. Sometimes therefore supplementation may be needed to normalise areas of concern such as stomach acid levels and digestive enzyme function.

Low Vitamin D

Many people have low vitamin D levels which impacts calcium absorption in the body. This is of particular concern for people who live in the northern hemisphere as during the winter (from October to March in the UK) sunlight doesn't contain enough UVB radiation for our skin to be able to make vitamin D. As sunlight is our bodies primary source of vitamin D, this is of major concern and is one of the reasons why the NHS now recommends everyone supplement with vitamin D over the winter months. During the summer, suncreams also block vitamin D absorption which means that if you are not having at least 20 minutes of unprotected sun exposure every day, you may be deficient in this vital nutrient. Good levels of vitamin D3 are essential for calcium intestinal absorption as vitamin D can increase calcium absorption in the intestinal tract by up to four times the normal rate. We normally recommend a vitamin D dose based on body weight. If you would like to test your vitamin D to optimise levels, we have testing services available at the Aberdeen clinic.

Low Vitamin K2

As we know, D3 helps the body to absorb calcium, but vitamin K2 helps the body carry the calcium to your bones. This is important as calcium which is absorbed but not properly utilised in the body may be deposited into soft tissue causing cysts. Excess calcium in the blood stream can also be deposited in the kidneys where it may cause kidney stone formation. Vitamin K2 also ensures that the calcium is properly utilized and doesn't bind to oxidized LDL cholestrol, creating plaques which can cause blockages in the arteries. 

It can be so easy to fall into the trap of finding our favourite foods and forget about the variety of nutrients and minerals we get from a range of foods. Look at the list above and think about whether you are incorporating a good range of foods with calcium. If you are concerned that you may not be or think you would find it hard to incorporate enough into your diet on a regular basis, or have any of the gastrointestinal problems listed, it may be a good idea to find a good supplement form. Supplements we normally recommend are in combination form, alongside other essential nutrients for bone health. For people with gastrointestinal problems, we often recommend transdermal products which bypass the gut and are absorbed directly into the blood stream. BetterYou have designed a range of supplements for people with these kinds of issues. We particularly like their magnesium and calcium mineral lotion for bone health and their vitamin D and K2 spray.

If you have any concerns, or queries about optimal dosages you can always come and see us and ask for advice at 44 St Andrew Street, Aberdeen.



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Irritable bowel syndrome (IBS)  is a complex condition and is an umbrella term given to this functional disorder of digestion. One of the problems in getting a diagnosis is that there are other conditions that can mimic IBS. Often people assume they have IBS but there could be other issues lurking. This is why a trip to your family doctor can be helpful in ruling out other possible conditions. In fact conditions that mimic IBS can range from cancer to diverticular disease to coeliac disease. Metabolic disorders such a hypo and hyperthyroidism also impact bowel health. If you are experiencing abdominal distension, pain with bowel movements and relief afterwards or more frequent loose stools or find that you go between constipation and looser stools, a visit to the doctor can be useful to rule out other culprits. In IBS, the colon may either be squeezing too hard in the case of diarrhoea or not hard enough as is the case with constipation, neither of which are issues we should ignore long term.


IBS is thought to affect between 10 and 15 percent of the population and accounts for around 30 to 50% of referrals to gastroenterologists. However the true figure may be much higher as many just live with the symptoms and never seek help. It is also thought to be  a leading cause of missed work days behind the common cold. 


One thing’s for sure, the prevalence of IBS has increased in recent decades which begs the question, what has changed? What factors could be behind the increased issues with bowel and digestive function? Well when you are steeped in the research as I am, you can’t help but notice the increased evidence for changes to our gut flora which have impacted our digestive health. The reasons for this are many and complex but all sets us up for the perfect conditions for conditions like IBS. Here are just a few examples….

• increased use of antibiotics as medicines and also in the food chain.
• Other drugs like the oral contraceptive pill, non steroidal anti-inflammatory drugs like ibuprofen, and steroids all impact gut flora
• diets high in refined carbohydrates, sugars and processed foods generally
• low fermentable fibres in the diet
• dietary toxins
• chronic stress (yes this one impacts digestive health and  gut flora!!)
• chronic infection

So, you have your diagnosis, what next? Well fortunately there is much that can be done, but often that involves further investigations. Because of biochemical individuality there isn’t a one size fits all approach here. We need to identify our individual triggers and go from there. The most common approaches involve the following.

​Increase dietary fibre.

Although this can be an obvious starting point particularly if someone has constipation, we have to be careful about which fibres we choose. Keeping a food diary becomes useful here to note any individual difference in response to foods. In the past people have used wheat bran as a high fibre food. However due to the link between wheat and food allergy and intolerances this is perhaps better replaced with dietary sources of fibre from fruits and vegetables. Psyllium seed husks are a useful and popular way to supplement the diet and can relieve constipation. We also need to be mindful that certain high fibre foods can be a trigger for some people and we need to find our own balance here while we are healing our digestive system. For example, you may see it recommended that you should eat more soluble fibre with prebiotic benefits such as artichokes, leaks, onions and garlic which are ideal for many but if you are one of those who is affected by foods high in fodmaps, this is not going to be the best strategy! It’s also why an appointment with a Nutritional Therapist is invaluable to help you identify some of those challenges and also find out the WHY! We can find ourselves going in ever decreasing circles if we don’t find out the WHY and it can be very frustrating. 

Simple tip to do at home to support constipation

Soaked linseeds or chia seeds to relieve constipation. Soak 1-2 tsp of cracked linseeds in half a pint of warm water and  soak overnight. Drink on rising and follow with another glass of warm water. Delay breakfast for about half an hour. 

Food allergies/intolerances

It may surprise you to find out that the relevance of food allergies in IBS has been known about since the early 1900’s! Recent studies have shown that around two thirds of patients with IBS have at least one and often several food intolerances. As a result many people find marked improvement following elimination diets. In practice I find elimination diets to be the most helpful in eradicating or reducing symptoms and go from there to identify other triggers. It is quite clear that for some, certain foods provoke an inflammatory response which is thought to be behind IBS symptoms in practice an elimination of common culprits such as gluten and dairy can bring significant relief. Studies have indicated that the most common triggers are dairy and grains. But what if stress is also a component which needs to be addressed or what if there are other inflammatory aspects of foods which are contributing to symptoms? The nightshade foods are an example of this and are also common triggers for many. These include potatoes, tomatoes, aubergine and peppers. When I see people in clinic, the most helpful starting place from experience is the elimination diet. At this point some people also choose to take up the opportunity of food intolerance testing. However, we build a programme over time addressing all possible triggers. This means we are not just looking at foods but also our digestion, whether we eat quickly or slowly, how we prepare foods, our stomach acid levels, digestive enzymes and also whether other medications might be contributing to our symptoms. Sometimes a stool test is done to identify any signs of infection, inflammation and to get a full picture of digestive function. Although food diaries can be helpful at identifying trigger foods, if food intolerance as opposed to food allergy is the issue, testing can be more effective as IgG food intolerance reactions can be from 2 up to 72 hours following consumption. More info on the differences here.

Dietary FODMAPs (Fermentable oligo-di and monosaccharides and Polyols.)

For some people reducing foods that are high in FODMAPs can be the way forward. These are foods with short chain carbohydrates which are poorly absorbed and therefore find themselves being fermented by intestinal bacteria. This fermentation can produce gas and and lead to abdominal bloating. One example of  FODMAPs are oligosaccharides called fructans and include wheat based foods, onions and artichokes. Similar to fructans are galactans which are composed of chains of fructose with a galactose molecule on the end. These include legumes e.g. chickpeas, lentils, dried beans, cabbage and sprouts. A well known disaccharide that is implicated in IBS is lactose in dairy products but which also finds its way into other foods such as soups and sweets. Open studies have suggested that one in four patients will see a reduction in symptoms following a low FODMAP diet. This kind of approach can be particularly helpful in cases of SIBO. It doesn't mean eating low FODMAP's forever, as after a period of healing, gradual inclusion of previous trigger foods can be achieved with a very individualised approach. 

When IBS appears out of the blue…

If you’ve never had bowel issues before and have suddenly experienced a shift, many questions need to be asked. Obviously a change a living circumstances, different water, perhaps moving abroad or students living away from home for the first time whose diets have changed, all of these issues are going to cause some inevitable changes. However, often changes can follow on from a high stress period or trauma, sudden death, divorce, accident. In practice I’ve also come across clients who suddenly developed a shift in bowel function following a period on non steroidal anti-inflammatories (NSAIDs). Perhaps they were involved in an accident or recently developed arthritis which was followed by a time on NSAID’s. Equally, repeated infections such as UTI’s,  sinusitis, tonsillitis and chest infection etc can compromise our gut as a result of repeated rounds of antibiotics and we can find ourselves with IBS type symptoms. Therefore when I’m going through a very lengthy patient history I’m looking for these sorts of patterns which can trigger changes in both digestive and bowel function. Interestingly, autoimmune disease including Inflammatory Bowel Disease (Crohn’s and Ulcerative Colitis) and also increasingly common, underactive thyroid, can follow these kinds of long term use of particular medications due to gut/immune system compromise. If you are experiencing blood in the stool, we would recommend you attend your family doctor to rule out a potential IBD or anything sinister. When we do stool testing we can also see if there are any raised inflammatory markers such as calprotectin which would warrant further investigation via your GP and a secondary care referral.
Multiple rounds of antibiotics can also result in SIBO or small intestinal bacterial overgrowth, which basically means that there is an overgrowth of  the number and types of bacteria in the small bowel which would normally reside in the colon. SIBO can also be a part of the IBS story with IBS and low stomach acid as part of the risk factors for this. 

Natural approach and supplements

Primarily the Nutritional or Functional medicine approach involves identifying root cause and also triggers, be they food related, drug induced, infection or stress or a combination of factors. We then address the need for some gut healing including reinoculation with good bacteria or probiotics to redress current imbalance. Studies have shown that for some patients a 6 month supplementation with probiotic can reduce symptoms significantly. We use different probiotics which are each researched and appropriate in different situations according to patient history. It is essential to incorporate a gut healing approach so that at least some of the current food triggers or intolerances can be reintroduced back into the diet after a few months of healing and in a controlled manner. This is very much an individual approach and supports each case as we find it. We also offer symptomatic relief while we get to the bottom of individual triggers which can include peppermint oil for its antispasmodic benefits. However, the functional protocol which offers the most comprehensive approach to triggers and drivers in gastrointestinal challenges is as follows and  what we call the 5R approach. 


Remove: This can apply to eliminating pathogenic bacteria, viruses, fungi, parasites. Also foods that have become triggers. We also remove foods/drinks that are unhelpful to changing the ecosystem in our guts and make choices that support a healthier environment for the good bacteria. 
Replace: This involves identifying anything that is missing which could be contributing to a picture of compromise. Digestive enzymes are very relevant here and stomach acid. A lack of the necessary enzymes to break down and digest foods can lead to nutrient deficiencies and a range of symptoms and conditions can result. 
Reinoculate: This refers to the reintroduction of good bacteria or probiotics into the intestine to reestablish the microflora balance. This can incorporate food form and supplements as appropriate. 
Repair: The Gastrointestinal mucosa represents the largest mass of rapidly proliferating cells and repair is needed whenever there has been a loss of integrity of structure or function or both. Damage can result from chronic nutritional insufficiency, food allergen, dysbiosis, xenobiotic exposure (toiletries etc), pathological intestinal infection and chronic inflammation. Nutrients required include  glutamine , essential fats, and zinc. 
Relax: You may have heard of the gut brain connection and personal experience will indicate the impact of stress on gut health! However, when it comes to finding a comprehensive approach to  creating a healing environment in the gut it is essential to address this aspect. That means recognising and finding approaches to rebalance the mental, spiritual and emotional aspects of our lives so as to support a move away from sympathetic dominance to parasympathetic in digestive function. 

Whatever your story and range of symptoms, it's important that you get to the bottom (if you'll pardon the pun!) of this one. Living with compromised bowel and digestive function can compromise our immune health, mental health and long term leave us vulnerable to a  range of conditions. If we are not absorbing nutrients properly, this can lead to low energy levels and often we find ourselves with a range of unexplained symptoms further down the line if we continue to ignore the condition. To give an example of where IBS can cause nuisance, there are many out there who have experienced  repeated iron deficiency over the years. Often with the right support for gut healing this kind of problem can be prevented. 

Further information on what's involved in a Nutritional Therapy consultation here

Mushrooms have been used in traditional Chinese medicine for centuries but it is only in the last few decades that scientific studies have revealed some of their health benefits. There are over 100 types of mushrooms but some of the most studied for their health benefits are Shiitake, Cordyceps, Maitake, Oyster, Lion's Mane, Enoke, Reishi and Chaga. 

Mushrooms contain important vitamins, minerals and enzymes that have been shown in numerous scientific studies to boost the immune system. They also contain bioactive molecules that have  anti viral, anti inflammatory and antioxidant abilities.  

Due to their immune boosting properties, there has been a lot of research into the effect of mushrooms in Cancer prevention. Some studies have suggested that mushrooms can inhibit tumor formation and stop cell mutation whilst protecting healthy cells and increasing the bodies capacity to detoxify itself from harmful substances. According to the medical journal 3 biotech , "mushrooms anti-cancer compounds play a crucial role as a reactive oxygen species inducer, mitotic kinase inhibitor, anti-mitotic, angiogenesis inhibitor and lead to apoptosis, and eventually checking cancer proliferation." 

In 2000, a report published by Cancer Research UK and the University of Strathclyde looked at different types of mushroom and cancer. Pure extracts of exotic mushrooms such as shiitake, enoke, maitake and oyster were shown by researchers in China, Japan and Korea to have anti-tumour properties and be capable of stimulating the immune system to fight disease. In addition, the use of medicinal mushrooms was found to reduce the side effects of both chemotherapy and radiotherapy, including sickness and hair loss.

Another study published in the World Journal of Gastroenterology looked at the effects of chaga mushroom on cancerous human liver cells. The research reveals that chaga extract may be able to prevent liver cancer cell growth, which it has been thought make it a potential treatment for cancer in the liver. 

Medicinal mushrooms have also been shown to have ​special fighting abilities against deadly multi-resistant bacterial strains and microorganisms responsible for gut and skin problems. Interestingly, some substances present in antibiotics such as penicillin and tetracycline are derived from mushroom fungal extracts. 

Many types of mushrooms help to lower cholestrol levels naturally, support energy and improve brain function. Mushrooms such as Reishi are also considered to be adaptogens that lower cortisol and help your body to deal with stress and anxiety. Reishi mushrooms have also been shown to improve memory and concentration and because they contain lanostan, an antihistamine, they can also be beneficial for arthritis and soothe muscle aches. 

Cordyceps mushrooms can help to increase stamina and endurance due to their ability to help the body produce ATP. These mushrooms are also used as an adaptogen to increase energy and reduce fatigue. A 2010 study published in the Journal of Alternative and Complementary Medicine demonstrated that supplementation with Cs-4 (Cordyceps sinensis) improved exercise performance and contributed to overall markers of wellness in older adults. 

The study into medicinal mushrooms is a vast subject and there are many other health benefits and ongoing studies and research in the area. If you would like to learn more about medicinal mushrooms, pop into the shop and ask to speak to our nutritional therapist at Nourishing Insights, 44 St Andrew Street, Aberdeen. 

This week we are very excited to have become Aberdeen's very first stockist of Kaerlig Beauty. These beautiful liquid soaps are truly natural - no parabens, no alcohol, no colour and a pH of 7 - the same as water! Available in 3 colours Red, Blue or the unscented Naked. We've invited Amy to take over the blog and tell you all a wee bit more about her products and how she ended up making soap in the first place!

Hi - Amy Alexander here from Kærlig Beauty. I am thrilled that Nourishing Insights are stocking Red, Blue and Naked, my soaps!


These small runs of luxury liquid soap were born as a direct result of my experiences with breast cancer. After being diagnosed with triple negative cancer, an operation, chemotherapy (the dreaded hair loss), sickness and radiotherapy quickly followed and three people, in particular, took the brunt of it all. My very own heroes, 51, 17 and 16 picked me up and I owe them so much. They did not complain and got used to sickness being an unwanted companion. I am still cross that I couldn’t protect them all from seeing me poorly.

After treatment, I was somewhat surprised that I didn’t bounce back quickly. To put it bluntly, I was ravaged by treatment. Unlike so many others, I was not brave! Aside from the forced menopause, pain and sheer exhaustion, my skin was so thin, so dry and quite frankly, so ghastly. And to top it all, my hair was non-existent, although a wonderful wig helped me feel more like myself.  

My college background is in lecturing sociology and psychology. I recognised the impact that the illness and treatment was having on my mental health. I wanted to take back control.  Soap-making was a therapeutic hobby and so it made sense that the fight back would start there.

I kicked back. No more whining. No more avoiding the mirror. I signed up and completed a Diploma in Organic Skin-Care and embarked on a joyous journey that now includes a ‘big girl laboratory’, terrifying EU testing regulations and countless failures. I tell you what though, 51, 16 and 17 always smelt pretty good, even if my soaps didn’t look as smart as they do now!

The soaps are all locally made in Strichen, Aberdeenshire. They contain jojoba, castor and coconut oils and are loaded with extra glycerine for a real boost of skin-friendly. The stylish (modest, aint I?) glass bottles each have a colour assigned to them after countless sniff tests. What do you imagine Blue and Red to smell like?!  The exception is Naked, more about her later. 

Each is packed with essential oils: Blue smells so fresh, of spearmint and lime; Red is grapefruit and bergamot. It is rather boastful, I know, but they are lovely. The fragrance lasts ages! Oh, and they are truly natural - no parabens, no alcohol, no colour and a pH of 7 - the same as water!

What about Naked? Well, as the name suggests, it is naked, a pure soap. No fragrances, just gentle wonderfulness. A soap perfect for people who have sensitive skin. This is the soap that cleansed my skin so gently after treatment.

What makes these soaps stand out is the sustainability factor. I detest plastic and really wanted to help my customers be able to re-use, thanks to a cost-friendly refill pouch, a stylish product. And of course, the glass bottle will last for years.

I have been a vegetarian for almost 30 years and although sustainability was important, so was being cruelty-free. I didn’t want to make and use a product that had involved animal testing at any point in the supply chain. These soaps are proudly vegan!

And finally, the name is simply Danish for ‘caring’. I have a great deal of admiration for the Danish culture. I love the strong sense of family, of being present and of appreciating others and our world. And of course, the Danes are known for their cool style. I’m a bit of a fan!

What do you think your favourite colour will be?

Order online here. 

What is Endometriosis?
Endometriosis is a common women’s health condition affecting 1 in 10 women in which cells from the endometrium (lining of the uterus) appear and flourish outside the uterine cavity, usually on the ovaries. Symptoms can worsen at certain points during the menstrual cycle as cells are influenced by female hormones. Symptoms can include pelvic pain, painful periods, painful intercourse and infertility. It can also impact urinary issues and pain on urination and has been linked to interstitial  cystitis. Usually endometriosis is diagnosed after a laparoscopy of the pelvic cavity although pelvic ultrasounds are also used to detect endometrial tissue outside the uterus. The shedding of endometrial tissue long term can lead to scarring and chronic inflammation which has led many experts to suggest a strong autoimmune component to the condition. In clinical practice it is something we often see coexisting with other autoimmune conditions. 

Risk factors for endometriosis include: family history, a diet high in trans-fats, use of intrauterine devices, and unbalanced oestrogen levels.

Conventional Treatments
Symptoms are often managed with hormonal medication to suppress the natural menstrual cycle, plus painkillers to manage the associated discomfort. Occasionally progesterone creams may be prescribed. The most aggressive treatment is surgery, with some women opting for a hysterectomy. The long term use of non steroidal anti-inflammatory medication for pain can contribute to the problem as it sets us up for intestinal hyper permeability (leaky gut) which adds to the picture of inflammation, so safer and effective means of reducing inflammation are needed. Although laparoscopic removal of endometrial tissue can benefit sufferers for up to 2 years, symptoms generally return and the procedure itself can cause lead to further scar tissue. In an ideal world sufferers would be referred to Nutritional Therapists or Functional Medicine practitioners  to explore root cause/s and to address all angles. 

Natural Alternatives
The naturopathic approach to endometriosis is focussed on:

• ·         Reducing inflammation
• ·         Enhancing detoxification (especially of excess oestrogen)
• ·         Reducing symptoms
•          Balance hormones
•          Reducing/manage stress 

Reducing Inflammation
Inflammation is a huge driver for endometriosis. The Nurses Health Study II found that women who consumed the most trans-fats (hydrogenated vegetable oils often used in processed foods) were 48% more likely to be diagnosed with endometriosis. Women with the highest consumption of omega-3 fatty acids were 22% less likely to be diagnosed with endometriosis. Reducing the amount of omega-6 fatty acids at the same time as increasing omega-3s also helps reduce inflammation. Ideally we would have an omega-6:omega-3 ratio of 3:1 however the western diet is closer to 16:1!

Foods that are high in omega-6 and should be avoided include sunflower, corn, soybean and cottonseed oils. In addition to this opt for grass-fed meat as livestock fed a grain-based diet high in corn and soya produce meat high in omega-6.

Foods that are high in omega-3 include: Oily fish like salmon and mackerel; flax and chia seeds; organic free-range eggs; extra virgin olive oil; and walnuts. Some people may also benefit from supplementing with an omega-3 oil in the short term while they make dietary changes.

Antioxidants are very relevant to prevention and reversal of tissue damage in endometriosis, so it's important to increase our antioxidants in the diet via increasing vegetables and fruits (ideally organic). Vitamin C, A and E are beneficial and also resveratrol from red grapes, N-Acetyl cysteine,  pine bark, green tea and melatonin have been studied for their powerful antioxidant benefits with some interesting results.  

NAC (N-acetyl cysteine )
A 2013 study of 92 women with endometriosis showed that following 3 months of supplementing with NAC for 3 days a week each week led to cancellations of laparoscopic visits due to a reduction in symptoms. 

Pycnogenol from pine bark
A swiss study which gave women either Pycnogenol or GnRH (Gonadatropin releasing hormone) for 48 weeks showed a reduction in symptoms in both groups. Interestingly, after treatment stopped the benefits in the pycnogenol group lasted while the GnRH group relapsed after treatment. 

Melatonin 
A very interesting 2013 randomised, double blind placebo controlled study looked at
the analgesic, antioxidant and anti-inflammatory effects of melatonin in endometriosis with some very promising results.  Apart from improving sleep, melatonin was shown to reduce  the risk of using analgesics by 80%. Melatonin if supplemented needs to be started slow and gradually increased up to the 10mg dose used in this study. You can also support your own natural melatonin production by avoiding the blue light effect at night from computers and TV's, wearing amber glasses and sleeping in total darkness. Certain foods such as cherry, banana, oranges, kiwi  and pineapple support melatonin production as does supplementing magnesium. 

Enhancing Detoxification
Yes, we are talking about poo here! Actually detoxification involves the gut and the liver but it’s vitally important to make sure that we move our bowels at least once every day if we want to facilitate optimal detoxification. We also want to make sure that we are having a normal bowel movement. On the Bristol stool chart below we should be aiming for a 3-4. If you are having anything other than that pop in and have a chat because there are lots of things you can do to support healthy bowel function. Constipation is a common problem in hormonal imbalance across the board and we need to get to the root cause to eliminate this risk factor properly.

Increasing the amount of vegetable-based fibre in the diet is vital if we want to support our gut bacteria as this is what the good bacteria feed on. Increasing our intake of vegetable fibre has been shown to help clear excess oestrogen from the bloodstream. Cruciferous vegetables are particularly good at this so increase your intake of: broccoli, brussels sprouts, cabbage, kale and cauliflower. Supplementing with the right B vitamins can support detoxification of hormones promoting balance. Endometriosis often involves higher oestrogen over progesterone (which tends to be low), another commonly used herbal supplement which is used to rebalance the hormones is Agnus castus. There are further supplements which support this but these are advised on a case by case basis and depend on identifying individual challenges and possibly further testing. For some sufferers there may be an underlying SIBO (small intestine bacterial overgrowth) which needs to be dealt with. 

Balancing hormones 
This involves diet as well as removal or avoidance of a class of chemicals known as endocrine disrupters. That's because these chemicals found in our cleaning fluids, toiletries and cosmetics and plastic bottles actually exert a xeno-oestrogen or oestrogen mimicking effect. The trouble is our bodies don't know the difference between a real oestrogen and a pretend one so exposure to these chemicals needs to be avoided if we want to balance hormones. The increased exposure to these endocrine disrupters in modern living explains in part the increased challenges with  many hormonally driven conditions. So time to take a look at your bottles hiding under the sink and examine your toiletries. There are many alternatives available which avoid all the nasties such as parabens and phthalates etc. Using essential oils are a safer way to clean your home and good old fashioned vinegar and bicarb will save you money and unnecessary toxin exposure. 

Managing stress
Hormones don't work in isolation. The  endocrine system works as a team and managing our stress hormones is key to supporting any hormone challenges. It's also why a comprehensive assessment of stress hormones is included in my preferred hormone screening. When stress is chronic and cortisol is elevated, progesterone can drop leading to unpleasant symptoms such as moodiness, increased weight around the middle, sleep problems and breast tenderness. Supplementing with magnesium and adaptogen herbs can support this as can meditation, yoga and mindfulness. 

Reducing Symptoms
Studies have shown a significant reduction in symptoms in women who move away from eating higher-glycaemic carbohydrates (bread, pasta, rice, cakes, etc.), reduce caffeine and increase their intake of Omega-3 fatty acids. Caffeine can have be a problem for many women with endometriosis with one study showing consuming 150-225mg of caffeine per day (about 1-1.5 cups of coffee) increased the risk of endometriosis by 20% and those who drank more than 225mg of caffeine had a 60% increase. Supporting blood sugar balancing  is fundamental  for hormone balancing as these two are related. 

Turmeric has been shown to reduce inflammation, support blood sugar (important when you’re trying to reduce food cravings), reduce pain and support liver detoxification making it a key supplement in the support of endometriosis.

Magnesium, Ginger root and Devil's claw are also favourites as anti-inflammatories in place of NSAID's. Magnesium can be taken throughout the month with an increased dose the week prior to a period. Magnesium is commonly deficient in endometriosis and you may be  experiencing symptoms of deficiency such as twitchy eyes, restless legs, anxiety, palpitations, headaches, sleep problems. These are things I see commonly in clinical practice. It's important to find the right kind of magnesium and also the right dose for you so do get in touch to find out more. A simple way of using it in addition to oral supplementation is to use a spray on the abdomen daily and increase the week before a period. In addition to its anti-inflammatory benefits, magnesium  is also essential for energy, mood, sleep and blood sugar regulation. We also recommended epsom salt baths due to very good transdermal absorption. 



Food intolerance also play a part here in that if we continue to eat foods which we are intolerant to we add to the picture of inflammation. One of the biggest drivers in endometriosis is gluten and studies have shown a significant reduction in symptoms following a gluten free diet. However, when IgG food intolerance testing is done, we can see a further reduction in symptoms. Other food triggers can be dairy, soya, yeast, eggs, corn, peanuts, cane sugar and also foods in the nightshade family eg tomatoes, potatoes etc. Endometriosis has a strong link with IBS so following the anti-inflammatory protocol above and an elimination has been found to be supportive of  both conditions.

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Massage therapy can also help reduce symptoms. An Iranian study showed that massage of the back, sacrum and abdomen lead to a significant reduction in painful dysmenorrhea caused by endometriosis. Abdominal massage can also stimulate peristalsis in the large intestine therefore support detoxification. In addition to this abdominal massage can also help to breakdown scar tissue and adhesions.

In all cases risk factors and drivers are always  individual and an appointment with a Nutritional Therapist can help you uncover the triggers and drivers of your own condition and support you with an individualised protocol. We also have access to a range of tests including comprehensive hormone screening such as the DUTCH Test which covers reproductive hormones, stress hormones, melatonin levels, neurotransmitters and B vitamin metabolites.  We can also assist you with long term plans such as fertility and other co-existing health challenges. 

Always ask us first before choosing supplements as there may be drug nutrient interactions to consider or speak to your healthcare provider. Some off the shelf supplements may also contain food allergens and other additives. To book an appointment or for enquiries contact us here 

References:
https://academic.oup.com/aje/article/137/12/1353/155016
http://cancerres.aacrjournals.org/content/41/9_Part_2/3771.short
http://www.fertstert.org/article/S0015-0282(01)01991-4/abstract
https://academic.oup.com/humrep/article/25/6/1528/2915756
 http://europepmc.org/abstract/med/23334113
https://www.sciencedirect.com/science/article/pii/S0753332217346838
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093183/
https://www.ncbi.nlm.nih.gov/pubmed/17879831​
https://www.ncbi.nlm.nih.gov/pubmed/23737821​
https://www.ncbi.nlm.nih.gov/pubmed/23602498​

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