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Australian Open – Hot Tennis. To play or not to play? That is the question!

18 Jan, 14 | by Karim Khan

By tennis physician, Dr Babette Pluim (@DocPluim)

RodLaverThe scorching Australian Open has stirred up debate as to how safe it is to play tennis under extreme conditions. Some claim that it is part of the game, just like wind, rain, and playing late at night and that you just have to deal with it. Prepare, and try to beat the heat!

Others find the conditions to be unacceptable and too dangerous for health, and argue that play should be stopped when drinking bottles start melting on the court surface. Their main concern is that the extreme heat may lead to severe heat illness and possibly even the death of an athlete.

Emotions run high in these heated conditions, so let us try to separate fact and fiction by using available science.


A number of studies have investigated the thermoregulatory response of tennis players to heat stress.[1-3] These show that core temperature can be maintained at a safe level across a wide range of environmental conditions and is determined mainly by the intensity of the exercise and the resulting metabolic rate. The cooling mechanisms of the body (sweating and cutaneous vasodilatation) work in optima forma under normal environmental conditions and thermal equilibrium is reached and maintained after approximately 40 minutes of tennis match play.

However, in hot ambient conditions, core body temperature (CBT) is determined not only by the metabolic rate, but also by the environmental heat load.[3] The body’s cooling system has to work hard to reduce excessive heat when both the metabolic rate and environment heat load are high, causing extra strain on the heart. Work by Périard et al, who studied male tennis players during tennis match play in cool (~19°C WBGT, 22ºC) and hot weather (~34°C WBGT, 37ºC), showed  mean CBTs of ~38.7ºC under cool and ~39.4ºC under hot conditions, respectively.[3]  In addition, adverse environmental conditions (e.g. high air temperature, high humidity, solar radiation and no wind) will result in a high skin temperature and increased thermal discomfort (irrespective of the actual CBT).

As thermal discomfort increases, players decrease the pace of the match, which results in a drop in metabolic rate: an excellent example of autoregulation.[1,3] Players will generally take additional measures to cool their bodies and may use fans, ventilators, parasols, ice vests, ice towels, and cold water. BJSM’s ‘Online First’ includes a systematic review on the effect of cooling by Professor Christopher Tyler (UK). Currently the heat rules in tennis allow juniors, women and seniors to have a ten-minute break – and 15 minutes for wheelchair tennis players – between the second and third set to allow some extra time for cooling the body when the WBGT hits 30.1°C. This can reduce the CBT by 0.25°C.[4]

When must play stop?

But is there an air temperature or a WBGT when CBT will continue to rise over 40°C up to 42°C, because the environmental heat load is so high and the metabolic heat production so great that equilibrium cannot be reached? When are tennis players at risk of developing hyperthermia and possibly heat stroke and multi-organ failure? When do we need to stop play?

Cooling is easier in tennis than in some sports. American Football is requires players to wear protective clothing and running requires high intensity continuous work. In those sports, heat illness is more common than in tennis.

However, even the tennis player may be at risk if he/she is ill (cytokines raise the temperature set point), is severely dehydrated (less circulating blood to the skin and less cooling), has an underlying heart condition (increased strain on the heart) or has autonomic dysfunction (high spinal cord injury, less sweating). In these situations, great care must be taken to protect the players from potentially life threatening heat illness or heart problems.

This year’s Australian Open has illustrated that there should be an upper limit above which play should be suspended, even for healthy athletes. This upper limit seems to be around an air temperature of 42°C-43°C or a WBGT of 32°C; if not for the players, at least for the long-suffering spectators!


1. Morante SM, Brotherhood JR. Air temperature and physiological responses during competitive singles tennis. Br J Sports Med 2007;41:773-8.

2. Hornery D, Farrow D, Mujika L, et al, An integrated physiological and performance profile of professional tennis. Br J Sports Med 2007; 41:531-536

3. Thermal, physiological and perceptual strain mediate alterations in match-play tennis under heat stress. Périard J, Racinais S, Knez W, Herrera C, Christian R, Girard O. Br J Sports Med 2014  (accepted)

4. Tippet M, Stofan J, Lacambra M, et al, Core temperature and sweat responses in professional women’s tennis players during tournament play in the heat.  J Athletic Training 2011, 46:55-60


Babette Pluim  is a Sports Physician KNLTB and Deputy Editor BJSM. Tennis, healthy lifestyle, injury prevention, sports medicine education. Follow her on twitter:  @DocPluim





And the winner of the BJSM education content poll is…

16 Nov, 12 | by Karim Khan

…Groin pain/ hip pain!

That’s right, out of close to 100 respondents, nearly half indicated that they want more BJSM education content on groin pain / hip pain. We will be sure to take these results back to BMJ headquarters.

The full break down of poll results are:

  • Groin pain/ hip pain: 49%

  • Management of hamstring strain: 13%

  • Cardiac pre-participation assessment: 9%

  • Cardiac resuscitation at sporting events (what should be present at every game?): 12%

  • ACL management (conservative or operative?): 17%


Thanks to everyone who voted, we really value your feedback. Stay tuned  for new research articles, assessment techniques, and tutorials from the experts.

For now here are some great articles already free online:

Weir. 2011. Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain

Thorborg. 2011. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist 

Noehren et all. 2009. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome.

Designer Bodies: Anabolic steroid use in high schools

2 Aug, 12 | by Karim Khan

By Dr Glen Hagemann

Sports Physician and President of the South African Sports Medicine Association (SASMA)


Last year Discovery Sharksmart  anonymously surveyed 9824 male pupils attending 20 high schools in South Africa regarding various lifestyle behaviours.  One section of the questionnaire related to the use of anabolic steroids, the results of which proved both interesting and somewhat surprising. The response rate to the survey was in excess of 85% meaning that the results could be seen as representative of the high school population surveyed. In the survey approximately 5% of the respondents acknowledged having tried steroids at some stage in their lives – this figure was lowest for grade 8’s (1.2%), as expected, and highest for grade 12’s (9.5%). It is possible that these figures are indeed an underestimation of the real situation as a result of under-reporting.

The results of the survey are not only surprising in that they reveal the relatively frequent use of anabolic steroids, but also because the main reason reported for steroid use is for self-image reasons, and not for enhancing sporting performance, as is the common perception. Two thirds of the pupils who had used steroids stated that they did so primarily to “look good”, while only a third did so to perform better on the sports field. Incidentally, the main source for obtaining steroids by schoolboys was reported to be from gyms.

We then looked at the association between steroid use and other lifestyle factors, using a statistical measure called “the odds ratio”. This ratio measures the strength of the association between two behaviours; the higher the odds ratio, the stronger the association.  We found that steroid use and a perceived excessive pressure to perform on the sports field had an odds ratio of 2.5. Other associations with steroid use in order of increasing strength are: physical violence (odds ratio = 4.2), suicidal thoughts (odds ratio = 4.4), recreational drug use (odds ratio = 5.5) and hard drug use (7.2).

The finding that steroid use has the strongest association with recreational and hard drug use, and the weakest association with sports performance, suggests that steroid use in our schools is a “lifestyle” or social problem; it is more of a social behaviour undertaken for social reasons, similar to the use and abuse of mind altering drugs like marijuana, ecstasy and cocaine. With this in mind then, it was easier to understand why half of the nearly 10,000 respondents indicated in the survey that they did not consider the use of steroids as “cheating”; the notion of cheating is only relevant to a sporting context.

In this material world of designer clothes, shoes, accessories and electronics, have some of our youth reached a point where the use of body altering drugs like anabolic steroids to produce designer bodies is just an extension of this culture?

The South African Sports Medicine Association (SASMA) is one of 8 international member societies that partners with BJSM. See the South Africa focussed issue of BJSM (June 2012) by clicking here.


Sports injuries are freak accidents – or are they?

10 Apr, 12 | by Caroline Finch

 Guest Blog by @CarolineFinch

Cross Fertilising ‘Injury Prevention’ journal (IP) and BJSM

Compared to many other health issues, it seems that it is not hard to get media stories about sports injury into our daily newspapers.  What seems to be hard, is the coupling of such stories with positive injury prevention messages.

An interesting paper in the February 2012 18(1) issue of Injury Prevention reports an analysis of US new stories and their use of the phrase “freak accident” in the reporting of injury events. The Editor’s Choice paper by Smith et al identified 250 human injury stories over a 5-year period that used this phrase. The vast majority of stories (61%) related to injuries sustained by professional athletes and these mainly focussed on the nature or impact/outcome of the injury. Only 9% of the professional athlete injury news stories contained any clear prevention content.


This study is consistent with the findings from an Honours student project I supervised in 2009 (Sarah Hester, University of Ballarat).  We undertook a daily hand check of three Victorian (Australian) newspapers and identified 3215 media stories mentioning injury or injury-death and recorded the context in which those injuries occurred.  We also found the majority of stories to relate to injuries in sport (64% of the total) and hardly any of these mentioned injury prevention at all (<1%) (unpublished data).

There is ample anecdotal evidence that many people believe sports injuries to be an inevitable consequence of participation in sport.  It is not surprising that this view is common if the popular media fails to mention prevention, either directly or indirectly, in their stories.  The term “freak accident” just reinforces any belief that injuries in sport cannot be prevented and further implies that they are the result of just bad luck.  Public health orientated injury experts have long argued against the use of the term “accidents” because of the connotations of this word, and its use has been banned in BMJ journals since 2001.  Readers of the British Journal of Sports Medicine (BJSM) also well know that sports injuries in result from a combination of factors, and are certainly not freak events with no aspect of predictability or preventability.

Perhaps it is time for sports injury prevention researchers and sports medicine practitioners to actively work towards also have the word “accident” banned from all popular media coverage of sports injuries in both professional and recreational athletes. 

As long as major attitudinal barriers to sports injury prevention such as “there is nothing I can do to reduce my risk of injury in sport” and “of course everyone who plays sports get injured” prevail, all of our broad-based population efforts to implement injury prevention programs will largely fail.  Rather than just talking about the impact of injuries in terms of a need for ongoing medical treatment and time away from sport, we should also be routinely providing journalists and the media with simple messages about how the same sorts of injuries could be prevented in the future. What a better situation it would be for a future media analysis to find a strong reporting theme relating to guaranteeing lifelong participation in sport precisely because injury prevention is inevitable.

Success stories:

The AMSSM Annual Meeting (April 21, 2012) opens with a keynote session on Injury Prevention. It includes international sports injury prevention stars including Roald Bahr (Norway), Per Holmich (Denmark), Mark Saffron (US) and Martin Schwellnus (SA)

BJSM publishes 4 Sports Injury Prevention Themed issues annually. These are called the ‘IPHP’ issue of BJSM – Injury Prevention and Health Protection. You can find the archive of IPHP issues here


Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

Is the global movement ‘tipping’? Exercise IS medicine

2 Feb, 12 | by Karim Khan

Three exciting updates from the frontlines of health promotion through physical activity.

Illustration by Liisa Sorsa, 23.5 hours video

First, congratulations to Professor Steven Blair for winning the Bloomberg Manulife Prize for the Promotion of Active Health. This international competition celebrates a researcher whose work promises to broaden understanding of how physical activity, nutrition or psychosocial factors influence personal health and well-being.

Professor Blair has tirelessly raised awareness of the burden of low fitness. His dedicated data gathering and adroit analysis has allowed him to deduce that physical inactivity is the biggest public health problem of the 21st century. His 2009 editorial in BJSM shares this title and has been downloaded more than 20,000 times (available free online).

To read more about the award, follow this link to the Globe and Mail.

Secondly, after garnering global attention, Mike Evan’s videos 23.1/2 hours is being translated into multiple languages. Sports Medicine colleagues will ensure the video can be enjoyed by speakers of Arabic, Spanish, Chinese, and Italian. And there will likely be more offers to come.

This will further enable the first physical activity ‘YouTube sensation’ – 23 1/2  – to promote behaviour change, while recognizing the physical activity challenges in a wide range of countries.

While 1.6 million hits demonstrates 23.1/2’s current success, translation into multiple languages may take this video to the ‘next level’ with a goal of 10 million views!

The video has already gained international traction as shown by the breakdown of views per country: US 844, 664, Canada 320, 000, UK 61, 345, Australia 49, 100, India 32,000, Netherlands 14, 977, Singapore 13,761, Germany 13, 345, Malaysia 11, 986, Sweden 11,589, Israel 11, 387, Saudi Arabia 10, 786, Mexico 10, 607…and the list goes on.

If you haven’t watched the video yet, check it out here (and note Steve Blair’s fun cameo at around 2 minutes 50).

And a third exciting sign of progess was Scotland appointing a physician to head their campaign against physical inactivity.

Doctor Andrew Murray (@docAndrewMurray) – who clearly has to differentiate himself from his colleague “Andy Murray” (@andy_murray).

The more important of the two, although seemingly not by # of Twitter followers, Doctor Murray, makes the point that having a low level of fitness is equivalent in risk to having diabetes, smoking, and being obese combined”. BJSM likes that emphasis – amazing but true. All the best in the job DocAndy – we look forward to interviewing you for a BJSM podcast (with subtitles).

For more information on this check out the BBC article: GP runner Andrew Murray given sports education role

So – things are moving in the right direction – let’s all take up the cudgels and promote, promote, promote. Remember that Kotter said transformational changes takes 10 times as much communication as you expect it will need (plus 7 other things: see BJSM article on Kotter’s eight-step programme for transformational change).

Related BJSM publications

Rhodes RE and Dickau L. 2011. Moderators of the intention-behaviour relationship in the physical activity domain: a systematic review . BJSM. Published Online First: 25 Jan, 2012.

Burton NW, Khan A, and Brown WJ. How, where and with whom? Physical activity context preferences of three adult groups at risk of inactivity. BJSM. Published Online First: 20 Jan, 2012.

Bauman A, Titze S, Rissel Cand Oja P. 2011. Changing gears: bicycling as the panacea for physical inactivity? BJSM 45:761-762. (Free online!)

Khan, KM. 2009. Mid-year review: physical inactivity universally accepted as the biggest public health problem of the 21st century, shoulder exam challenges, and progress against the scourges of anterior knee pain and ACL injuries. BJSM, 43:469-470. (Free online!)

23 and a half hours video passes 2 million views!

12 Dec, 11 | by Karim Khan

Mike Evans circulated this to his hockey team of kids early in December 2011.  #1 educational video on YouTube. Remember that low fitness (<30 mins of physical activity daily) kills more Americans that smoking, diabetes, and obesity combined (smokadiabesity).

Click on this link. Watch it, share it. Do it yourself.

Encourage patients to watch it and start today! Great ‘sticky’ message capturing Steve Blair’s evidence that this treatment will save more American’s lives than a cure for smoking, diabetes and obesity put together. That’s a fact!

It passed 2 million views in February, 2012. Wow!!

ACL update…first day at UKSEM 2011, London

24 Nov, 11 | by Karim Khan

Reporting from UKsem 2011 – the largest Sports and Exercise Medicine and performance Conference in Europe. London’s Excel conference centre 23rd November – no downtime for the BJSM blog!

Richard Frobell opened with 3 major revelations. #1. ACL injuries are associated with arthritis – whether you have a reconstruction or not.  (citation classic, 103 citations to date).

#2. Give a piece of rehabilitation a chance! Not everyone needs a knee reconstruction. Really? New England Journal of Medicine RCTs demonstrating that = 1; disputing it = 0. (See Frobell, 2010, 53 citations already), THE hot topic of 2010/2011 and great to have Dr Frobell here himself. Audience experts included the IOC’s Lars Engebretsen so discussion was energetic. They were seen breakfasting together later so no risk of Scandinavian Spring just yet.

#3. There is limited return to sporting activity after ACL rupture. With or without surgery. This is where I was about to slash up. Depressing keynote stuff. Who chose him?

But then the good news. Prevention is key and possible. There are success stories. More of that tomorrow’s program. Sessions on prevention of football and tennis injuries, of knee and groin debacles. Hope springs eternal, no need to jump into the boxing ring that is available here for conference attendees. No need to walk up to the fencers, brandishing only the complimentary Prograin Minitub from maximuscle and say in true Homer Simpson fashion, ‘give it your best shot pal, I don’t need that poncy white protective gear, go on, try me!’.

Seriously though, I am a Frobell fan as BJSM readers and podcast listeners know. Great clinical insights, great presentation. Privilege to be in the shop at the same time as the KneeMaster.

Great day planned for Thursday 24th and BJSM Blog will be there. Blair, Dvorak, Daniel Coyle from the Talent Code, Bahr, Franklin-Miller. Track us on @BJSM_BMJ and you’ll be first with the updates. And competitions are in the wings!

Say hi to journal manager Claire Jura at the BJSM booth (ground floor, right side) and sign up for free stuff.

And do your ACL prevention exercises daily!

Teaser video – Richard Frobell kindly agreed to do a 20-second spot for the podcast of a conversation on ACL management he had with Lars Engebretsen. The discussion will be hosted on the BJSM podcasts – which are getting 4000 listens per month!

FIFA’s “11 for Health” programme goes global – roll-out in Mexico

7 Jul, 11 | by Karim Khan

FIFA Media Release

There is no better stage than the FIFA U-17 World Cup to launch a programme designed to enhance the health and well-being of young people through football in the host country. The passion for the game in Mexico can be felt in every corner of the country and exactly this unique power of football has been combined in a comprehensive health programme, “11 for Health”, to use football as a tool in prevention and education. FIFA, the Ministry of Health, the National Commission of the Social Health Protection System, FIFA and the Mexican Football Association (FMF) joined forces at the Ministry of Health in Mexico City on 1 July 2011 to announce the roll-out of the Football for Health initiative. In the first phase of the programme, schools in seven cities in Mexico will participate, namely in Mexico City, Guadalajara, Monterrey, Puebla, Colima, Culiacán and Oaxaca.

Photo: George Hatcher, Flickr Creative Commons

“Physical activity, such as football, is indispensable for building a healthy population. The ‘11 for Health’ programme fits perfectly in our national health promotion activities. It offers an effective, feasible and low-cost tool to improve the health of the young people who are our future,” explained Mexico’s Health Minister, Dr José Ángel Córdova Villalobos, at the launch event in the presence of Prof. Jiri Dvorak, FIFA Chief Medical Officer and chairman of the FIFA Medical Assessment and Research Centre (F-MARC), Justino Compeán, CONCACAF Vice-President and FMF President, Decio De Maria, FMF General Secretary, and Salomón Chertorivski Woldenberg, National Commissioner of the Social Health Protection System.

“With the creation of ‘11 for Health’, FIFA has embarked on yet another path to use football as a direct tool to improve the life of young people. The ‘11 for Health’ emphasises the power of football far beyond the boundaries of the football pitch. This can only be achieved with the support of governments. With the cooperation of the Ministry and the National Commission of Social Health Protection System here in Mexico, we will set the ball rolling for the young Mexican generation,” explained Prof. Dvorak.

Following successful pilot evaluations of the ’11 for Health’ programme in South Africa (2009), Zimbabwe (2010) and Mauritius (2010), Mexico will be the first country outside Africa to implement this health programme. Colombia and Brazil are expected to follow. The pilot study showed that the simple health messages, when combined with different elements of football play, such as defending, heading, shooting and attacking, were indeed able to considerably improve knowledge and change attitudes towards health among the boys and girls. Playing also helped to reduce obesity.
The “11 for Health” programme complements the Mexican government’s “5 Pasos por tu Salud”  (“Five Steps for Your Health”) and “Mídete, cuida tu peso” (“Measure Yourself, Watch Your Weight”) campaigns in order to harness the full potential of using football to promote health. Playing football, ambitiously or just for fun, has been shown in scientific studies to be a particularly healthy sport and reduce the risk factors for many diseases indicated by the World Health Organization (WHO). Based on these findings, F-MARC decided to combine the direct health effects of the game with its unique power in education and prevention to create this comprehensive health programme, using top players such as Mexico’s Carlos Vela and Javier “Chicharito” Hernández, Argentina’s Lionel Messi and Portugal’s Cristiano Ronaldo, to name just a few, to deliver health education messages to young people.

“The most important project at present and in the future goes far beyond the game itself: the focus of ‘Football for Health’ is not on players’ health but on the health of communities and society as a whole. Football’s popularity means it has the potential to play a unique role in disease awareness and prevention. For the Mexican Football Association, it is imperative that we promote health and put together this programme with FIFA and the Ministry of Health,” explained Justino Compeán.
Click here for for more information.

Obituary for Professor Eric Arthur Newsholme, MA, DSc, (PhD, ScD Camb)

7 Apr, 11 | by Karim Khan

By Lindy Castell

Eric Newsholme died peacefully in hospital from heart failure a few hours after slipping into a coma on 17th March 2011.  Although those of us who were close to him were well aware of his heart and circulation problems over several years, it was nevertheless a shock and, as many have observed, untimely.

He had not completed his final project, which was a book on the scientific basis for outstanding physical performance in football.  Football was a very appropriate topic for Eric, since he was born in Liverpool, England in May 1935 and was a lifelong devotee of Liverpool Football Club. He used to express surprise that so many premier league football clubs showed little, if any, interest in therapeutic nutrition when an expensive player was hors d’combat.  Those of us who acted as occasional amanuenses, due to Eric’s intense distrust of computers, were aware of his current interests.  Eric would request reprints which we could obtain via Pubmed: he initially tried his hand at the vernacular, asking one of us to achieve this by “surfing the internet, or whatever it is that you do!”

Eric read Natural Science at Cambridge and this was followed by a PhD in Biochemistry.  In 1964 he moved to Oxford University to work with Sir Hans Krebs: he became a Fellow of Merton College and a Lecturer at the Department of Biochemistry in 1973.   Eric was a rare example of a talented researcher who was also an outstanding teacher.  He certainly captured the attention of undergraduates.  The usual trend is for numbers to decline during a term’s series of lectures:  Eric’s lectures were exceptional, in that the reverse occurred, and numbers of students attending actually increased as word got round.  Dr Chris Milne (Australasian College of Sports Physicians) who encountered him as a visiting lecturer in London says:

“I was fortunate to be exposed to Eric’s superb teaching whilst completing the Diploma Course in Sports Medicine at the London Hospital Medical College in the 1980s.

“I had experienced some teaching from exercise physiologists during my undergraduate and postgraduate years, but none from an exercise biochemist.  It was great to hear about the Krebs cycle from someone who had worked alongside Hans Krebs himself.  For most of us, a study of the Krebs cycle is only palatable following a small libation with C2H5OH, but Eric made it possible without any such premedication!  He had the knack of making complex scientific ideas simple to understand and, in my view, was second only to the famous science fiction (and fact) writer Isaac Asimov in that regard.

“On hearing of Eric’s untimely death, I pulled out an article he co-wrote with Tony Leech entitled ‘Fatigue Stops Play’ (New Scientist, 22 September 1988 p39‑43).  It is a masterpiece in communication of complex scientific principles in layman’s terms, such that coaches can make good use of the material.  It even anticipates some aspects of Tim Noakes’ ‘Central Governor’ model by several years.”

More than 50 PhD students and a similar number of postdoctoral scientists received research training in Eric’s lab.  He was regarded by them as a gifted and inspirational supervisor.  As one of his former DPhil students said:  “Eric was an excellent supervisor who taught me how to be a scientist, always probing and questioning and never rushing, always stressing the importance of paying attention to detail.  These are qualities I am trying to pass on to my students, both undergraduate and postgraduate.”   A frequent tribute to Eric from graduate students and colleagues alike was his kindness and courtesy.  He would spend time discussing an individual’s research ideas regardless of the quality:  equally, he enjoyed coming into the lab and saying to whoever was around “I have this crazy idea….!” to prompt what he hoped would be a lively discussion, involving challenges to his concepts.

He frequently advised us on, and tried to adhere to, the principle which Krebs instilled in him, viz. that you should only make one point per sentence.  We were not always successful!   His use of red pen on first, second, third and more of his and our drafts was legendary.  In pre-computer days, his secretary (upon presenting him with a 5th draft of a paper) said:  “You can read it but sit on your hands!” It says much for his teaching that, out of more than 40 Oxford DPhil theses which he supervised, only one thesis was deemed unsatisfactory at the first review.

Eric published over 300 research papers and reviews:  his textbooks (Regulation in Metabolism by Newsholme & Start (1973) and Biochemistry for the Medical Sciences by Newsholme & Leech (1983) provided many biochemists with much knowledge of intermediary metabolism and metabolic control.  In particular, Newsholme & Start (1973) was regarded by many as a classic.  Eric recently updated his 1983 textbook to become ‘Functional Biochemistry in Health and Disease’ with Tony Leech (2010).

His first full paper (with his PhD supervisor , Sir Philip Randle, in Biochem. J. 1961) was on the regulation of glucose uptake by muscle.  Four of his papers on muscle metabolism of fatty acids, ketone bodies, glucose and pyruvate, (two of which were in Nature) expanded on the “glucose-fatty acid cycle” data first published by Randle, Garland, Hales and Newsholme in the Lancet (1963).  About 20 of the 100 papers that Eric published in the Biochemical Journal are recognized as seminal papers by the research community.

Eric took up marathon running in his mid-30s and successfully completed around 40 marathons:  this gave him a considerable appreciation of energy metabolism in exercise.  However, his work on the biochemistry of exercise and potential nutritional therapy initially stemmed from an unusual occurrence:  his 6-yr-old daughter suffered from a particularly aggressive form of Guillain-Barre syndrome (inflammatory demyelinating polyneuropathy), and was paralysed for 6 months.  She rapidly recovered to full health after receiving daily doses of sunflower seed oil and home-based physiotherapy.  Eric recognized that, in order to understand the possible mechanisms for this outcome, he would need to “get his feet wet in immunology”.  He was fortunate to receive advice and generous help with facilities from immunologists Simon Hunt and Siamon Gordon at the Dunn School of Pathology in Oxford.

Work in the late 70s, early 80s with a DPhil student, MSM Ardawi, resulted in the discovery (among others) that the amino acid, glutamine, was used as a fuel at a surprisingly high level in resting, unstimulated lymphocytes. In vitro work in Eric’s lab by another student, Mark Parry Billings, demonstrated that, despite the presence of all other essential nutritional components in cell culture medium, only when glutamine was decreased did a decrease in the proliferative ability of lymphocytes occur.  Philip Newsholme (Eric’s son) and, later, Philip Calder (also students) showed that glutamine was essential for macrophage function.  On becoming aware of a decrease in some key immune cell numbers after prolonged, exhaustive exercise, Eric hypothesized that a lack of glutamine might be responsible.

Glutamine is a metabolic fuel for many cells and a nitrogen donor for purine and pyrmidine nucleotide synthesis, and thus for DNA synthesis:  there is an extensive literature on the role of glutamine in clinical situations, to which Eric’s group has contributed, showing that burns and major trauma are associated with very low glutamine levels in the blood.  Several field studies confirmed that the plasma concentration of glutamine was indeed low (by 20-25%) in endurance runners after an event, as well as in overtrained athletes at rest.  Subsequent studies on more than 150 marathon runners showed that the provision of glutamine within the recovery period reduced self-reported illness (mostly upper respiratory tract infections) by around 43% compared with placebo.  Five other published studies unequivocally show similar decreases.

Disappointingly, it has not so far been possible to demonstrate which aspects of the immune system are affected by restoring plasma glutamine to normal physiological levels.   However, this situation is similar to some other, more recent studies which have looked at different supplements and self-reported illness.

Eric’s work in the biochemistry of exercise extended to the central fatigue hypothesis, fatigue emanating from the brain rather than from muscle.  This is based upon the effects of a surge of unbound tryptophan, uniquely splitting from albumin in the blood, crossing the blood-brain barrier (in competition with branched chain amino acids, BCAA) to increase the synthesis of the neurotransmitter 5-HT which is involved in fatigue.  Eric suggested that the provision of BCAA might combat the surge in tryptophan (a precursor for 5-HT, also known as serotonin) and thus reduce premature fatigue.   Some studies with BCAA vs placebo have shown some effect on physical performance, others have not.  Several central fatigue studies have shown an increase in mental performance.  Most of the studies showing no effect of BCAA did not measure mental performance:  this is an unfortunate omission, since the mental component required to maintain a given power output is clearly of considerable importance.

The third major aspect of Eric’s input into exercise biochemistry concerns fatty acids and the immune system.  This work was carried out largely with his former student, Philip Calder, whose excellent research in this area is widely reported and has certainly made an impact on exercise nutrition.  It is hoped that their contribution to sports science in this area will be reviewed elsewhere.

Eric’s book with Tony Leech and Glenda Duester (Eric’s daughter) “Keep on Running” (1994) included his hypotheses.  It is an extremely practical book, including running schedules from Bruce Tulloh and high carbohydrate/low fat recipes for athletes (not just runners), but the biochemistry is also there if the reader is interested.

Eric’s key contributions almost certainly emanated from his desire to provide quantitative descriptions of complex metabolic pathways, and to consider whole body metabolism, not just the cell or tissue in which the study was conducted. All students and members of the Newsholme laboratory were made familiar with this approach!  Another principle which he liked to instil in us was:  “you can never prove or disprove a hypothesis:  you can only add to the evidence for or against it.”  A senior academic colleague from the 1980s recalls “He was such a stalwart seeker after truth, and possessed an inspiringly independent mind”.

What is unquestionable is that many scientists, all over the world, have worked on Eric’s novel ideas for years, adding to the evidence for or against the hypotheses.  This is true not just of past members of the Newsholme group, who now have their own successful laboratories in the UK, Europe, North America, South America, Asia and Australia.

Eric was also a man of integrity and never expected nor received royalties from firms producing the amino acids on which he worked.  He did receive research funding from pharmaceutical companies (there are few who do not!) but, true to form, always maintained an intransigent view about independence.  Eric was once described to me (by an innovator in sports science) as being “the greatest metabolist this country has ever produced”.   In an earlier appreciation of his work (The Biochemist, 2006) it was said:  “Throughout the 1970s and 1980s, the University of Oxford was the base of….key researchers [who] have shaped our understanding of the regulation of energy metabolism in health and diseases.  Hans Krebs, Philip Randle, Derek Williamson and Eric Newsholme all pursued their own research within areas they each considered to be the most important aspects of metabolic regulation….Of all these great names, Eric arguably has had the most impact at ‘grassroots’ level….”

It seems fitting to close with Eric’s own words, speaking of his retirement, as part of a message to the inaugural meeting of the revised Metabolic Discussion Group this March:

“….I find biochemistry and especially Metabolism impossible to neglect, and I am delighted that recently it seems to be close to being restored to a central core of Biochemistry, at least in relation to research related to clinical problems and medicine!”  [EAN, 7 March 2011]

Eric passed on his enthusiasm for running marathons to his wife, Pauline, who completed even more than he did, including the New York marathon to celebrate her 60th birthday!  He is survived by Pauline, whom he met while undertaking his National Service and married in 1959;  his son Philip, daughters Glenda and Clare;  six grandchildren and one great-grandchild.

[The material on Eric’s publications is reproduced in part from Past Times (by Philip Newsholme, John Challiss and Greg Cooney;  published in The Biochemist (2006).  I am grateful to Chris Milne, Simon Hunt and Elizabeth Opara for permission to use their tributes, and to Philip Newsholme for commenting on  this obituary]

Lindy Castell is a  Senior Research Associate, University of Oxford, Green Templeton College, United Kingdom

Canada lowers the bar for physical activity…to make people more active?

9 Feb, 11 | by Karim Khan

The 2007-2009 Canadian Health Measures Survey indicated that only 15% of adult Canadians were active for a recommended 60 minutes of moderate to vigorous activity per day. Younger Canadians were even less active with 9% of boys and 4% of girls aged 5 to 17 meeting the health-benefit informed goals of 60 to 90 minutes of physical activity per day.

That the majority of Canadians failed to meet the minimum standards to experience health benefits suggests the need for further actions to encourage exercise uptake and decrease environmental barriers to physical activity.

(see related BJSM publications:

Remarkably, the Canadian Society of Exercise Physiology’s (CSEP) response to the survey outcomes was to lower the Canadian Physical Activity Guidelines. Adults are now only recommended to exercise 150 minutes per week, and children are recommended to exercise 30 minutes a day with a gradual progression to 90 minutes. The CSEP legitimizes these changes by stating that the new guidelines are in-line with the World Health Organization standards.

Mark Trembley, chair of the CSEP, stresses that these new targets are the minimum recommendations. He states that due to the progressive nature of benefits from physical activity “more is better.” The changes are also designed to be less intimidating to Canadians that may “give up before they start” if they think they can’t meet recommended guidelines.

Despite the well-meaning intentions of the CESP, I am concerned that lowering our recommendation for physical activity sends completely the wrong signal to the community. Clearly 150 minutes per week makes enormous health differences compared with nothing but to change the message when a survey has shown abject failure seems like changing the ‘obesity’ cut-off in BMI to 50 so that Canada becomes a thinner nation.

So the practical challenge is — how can we (on a local, national, and global level) create more enabling environments that encourage physical activity and promote healthy behaviour changes?

What do you think about this?  Please respond in the boxes below the blog. Or write to the BJSM editor to have your own comments posted in this main blog page (attributed to you).

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