AmCham biz.hk Mar 2016 Supplement - Healthcare Providers

HE AL TH CA RE PR OV IDE RS

Marketing Ban on Milk Formula in a Free Market Economy Benefits of breastfeeding are scientifically proven and widely known, but exclusive breastfeeding is no longer a norm in many communities. In the free market economy of Hong Kong, concerns that a legislation would go further than most international standards are indication of a call for the formulation of a more suitable regulation that places a top priority on children’s health and finds a balance while protecting the rights of the trade and consumers

By Channy Lee

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biz.hk 3 • 2016

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ccording to Transparency Market Research, the infant formula market in Asia Pacific was valued at US$10.3 billion in 2013, and is predicted to expand to be worth US$18.2 billion by 2020. China’s presence is particularly notable in the region, a growing market which has bought an estimated 40 percent of the world’s baby milk formula in 2014.

The market for formula milk is correspondingly large in Hong Kong. While shopping in any one of Hong Kong’s supermarkets or local drug stores, one can expect to face a plethora of choices of formula milk. The options available range from Japanese brands to those of Australia and New Zealand, formulated specifically for infants between six and 36 months old.

But concomitant to the continuously increasing demand for formula products are concerns in a dynamic market where early cessation of breastfeeding is encouraged and consumption of formula milk over breastmilk is endorsed. The formula milk market is often characterized by prevalent and extensive promotion of breastmilk substitutes, and that is precisely the area around which heavy restrictions have long loomed.

The “Hong Kong Code of Marketing and Quality of Formula Milk and Related Products, and Food Products for Infants & Young Children” is a major part of the government’s effort to regulate breastfeeding over formula milk, placed under persistent scrutiny from parent groups and workers in healthcare and formula companies.

Basis of claims Benefits of breastfeeding are scientifically proven and widely known. Beyond its nutritious superiority to formula milk, many research reveal that breastfeeding also nurtures infants in the optimal immunological and emotional environment for growth while contributing to prevention of chronic conditions. It is therefore recommended by the World Health Organization (WHO) that infants be breastfed exclusively in their initial six months post-partum for the well-being of both mothers and their children.

But exclusive breastfeeding is no longer a norm in many communities. Over the past few decades, trends have turned from primarily breastfeeding to some deeming formula more nutritious and well suited for children’s health. Based on an annual survey conducted by the Hong Kong Department of Health in 2014, breastfeeding rate stood at 80 percent on leaving hospital, but fell to 22 percent after a month, and below five percent after six months.

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As the burgeoning need to promote breastfeeding became evident with diminishing inclination towards exclusive breastfeeding, WHO adopted the International Code of Marketing of Breastmilk Substitutes in 1981. Commonly referred to as the Code, the unbinding health policy framework prohibits unethical marketing of formula as well as provision of free samples to parents and health facilities.

Many jurisdictions since then have followed suit of the WHO guidelines. Within three years after the Code was passed, 130 countries either passed legislation or formulated policies in varied forms to restrict advertising. To develop a version of the Code that is suited for Hong Kong, the Hong Kong Department of Health also set up a taskforce in June 2010 and subsequently issued a draft of the Hong Kong Code in 2012.

Concerns raised With the purported aim of eradicating factors that contribute to low breastfeeding rate in the region, the Hong Kong Legislative Council responded to what it refers to as aggressive marketing of formula milk, with regulations in two parts: The larger framework being the Hong Kong Code enforced as a voluntary guideline; and two legislations concerning nutrition labelling and advertising claims on product packaging.

Once implemented, the Hong Kong Code will serve as a recommendation for manufacturers and distributors of formula products as well as workers in the healthcare facilities, targeting not only advertising of formula milk but also formula-related products such as bottles manufactured for feeding infants. The two food laws, on the other hand, are intended to regulate provision of inaccurate information through labels and overselling of benefits that breastmilk substitutes bring about.

So far in Hong Kong, only the former of the two laws has been implemented, and only a draft of the Hong Kong Code has been released. Public consultation results were reported to the Legislative Council Panel on Health Services in July 2014, which inferred that the delay may be due to policy debates that are especially contentious in the context of Hong Kong.

A research from The Lancet, a medical journal in the UK, states that the compound annual growth rate (CAGR) predictions for milk formula in China and Hong Kong from 2014 to 2019 were 15.9 percent and 12.8 percent, respectively, compared to the world average of 9.5 percent. Such a large market in the Greater China Region is explained with the huge local demand for breastmilk

Photo: Thinkstock

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Breastfeeding rate on discharge from hospitals, 1992-2012 85.8 73.9

75

61.8 51.3

50 25

37.8 19.0

12

11

20

10

20

09

20

08

20

07

20

06

20

05

20

04

20

03

20

02

20

01

20

00

20

99

20

98

19

97

19

96

19

95

19

94

19

19

19

19

93

0 92

Breastfeeding rate on discharge(%)

100

Source: Baby Friendly Hospital Initiative Hong Kong Association

Breastfeeding patterns among babies born in 2012 100

82.5

Percentage(%)

Breastfeeding(All forms) 55.5

44.3

50

32.7 22.1

25 0

Exclusive breastfeeding

68.6

75

21.7

19.1 2.3

Less than onr month

One month

Two months

Four months

Six months

Age of babies Source: Family Health Service, HK Department of Health

substitutes from working mothers in Hong Kong and those from the Mainland.

For mothers in Hong Kong, the dire need for formula milk arises from the number of hours they invest into work, leaving them deprived of the time and resources to breastfeed their children as recommended. For those from the Mainland, high costs of formula milk products in China followed by subsequent upsurge of parallel trading have increased the product’ market value in Hong Kong.

Despite the two-can limit on the amount of infant formula a person can take over the border between Hong Kong and Mainland China – which aimed to curtail parallel trading – Mainland consumers still account for the majority of sales. It is a key concern among formula producers that the Hong Kong Code will mostly affect these 70 to 80 percent of consumers that are not the primary targets – the local mothers – of the administration’s goal of encouraging breastfeeding.

Exemplified by concerns as such, it further fuels the debate that the city is branded as a free

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market economy. Limiting free flow of communication between the business sector and consumers may be of detrimental damage to the free market, undermining the freedom of business operations. Results from public consultations about the administration’s proposals imply that the general public’s primary concern is consumers’ right to make informed choices, also a key value in a free market economy.

Any excessive ban on marketing and promotional practices could limit access to legitimate information to which all consumers are entitled – and could potentially lead to inaccurate information from unofficial sources, undermining parents’ capacity to make choices based on information about food for their children.

Manufacturers and distributors should be required to act morally responsible, but the responsible industry players who comply with all relevant regulations in Hong Kong should also be respected for their right to communicate evidence-based information.

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Breastfeeding rate (%) in selected countries and areas

Norway (2010)

Breastfeeding rate (%) (initiation)

at 1 month

at 2 months

at 4 months

at 6 months

98.5

84

75

48

10

Exclusive breastfeeding rate (%)

Australia (2012)

96

-

-

39

15

UK (2012)

81

-

-

12

1

US (2013)

76.5

48.6

42.5

29.1

16.4

-

66.9

56.1

44.9

27.9

-

51.6

55.0

55.8

-

94.7

-

-

19.3

14.5

Taiwan (2013) Japan (2011) Malaysia (2010) Singapore (2013)

96

35

28

-

1

Hong Kong (2012)

82.9

22.1

21.7

19.1

2.3

Source: Family Health Service, HK Department of Health

Larger Context The government continuously reiterates the importance of aligning local policies concerned with formula marketing to international standards.

An important aspect in which they differ, is the range of products covered by the code.

The WHO Code recommends exclusive breastfeeding for infants during their initial six months after birth. Regarding follow-up formula which is intended to be a part of the weaning diet, the Code declares that “products covered by this standard are not breastmilk substitutes and shall not be presented as such,” excluding follow-up formula from the range to be covered by a ban.

Similarly, the Hong Kong Code targets products sold for not only those under the age of six months but also up to 36 months. This is another point in the trade’s argument that the administration is pushing for overachieving policies that goes beyond a merely effective strategy in encouraging breastfeeding and intervenes in interactions between the trade and consumers.

The argument sets forth that such large demand for formula milk in Hong Kong should be noted not just as an indication of low rate of – or unwillingness to – breastfeeding, but rather as an indication of mothers’ inability to breastfeed due to external barriers laid upon them.

As for the blanket ban on nutrition and health claims, many practices in developed economies place a strong emphasis on scientific substantiation and evidence-based claims, following established procedures to evaluate nutrition and health claims.

The European Union, for instance, allows for nutrition and health claims on infant and young

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child formula given that expert panels approve of the claims after an extensive review procedure.

Furthermore, the United States only enforces bans on a specific type of nutrition claims, those that compare the nutrient content of products to others. Conversely, there is a blanket ban on advertising of formula products in the Republic of Korea, but there are now talks of lifting the ban in recognition of the population educated enough to judge for themselves what is best for their children, and for the sake of inducing more economic opportunities.

There are factors other than marketing of breastmilk substitutes contributing to a low breastfeeding rate, and it is questioned whether banning certain marketing strategies – either with a voluntary or a legislative approach – will serve as an effective method of encouraging breastfeeding. In fact, a survey conducted by Hong Kong Infant and Young Child Nutrition Association and the University of Hong Kong Public Opinion Programme in 2012 found that over 50 percent of respondents disagreed on that low breastfeeding rate is a result of formula advertisements in the locality.

It is essential that more effort is put into improving Hong Kong’s poor breastfeeding rates and securing an appropriate level of nutrition for children. But claims presented on both ends of the policy debate are reasons of significant implications. In the free market economy of Hong Kong, concerns that the Hong Kong Code is more trade restrictive than necessary and goes further than most international standards are calling for the formulation of a more suitable regulation that places a top priority on children’s health and finds a balance while protecting the rights of the trade and consumers.

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In Search of a Sustainable Pipeline Antibiotics – a class of drugs commonly used in modern day medicine and designed to selectively target and kill disease-causing microbes – are postulated to have saved millions of lives but are also becoming increasingly ineffective due to the rise of antimicrobial resistance. To stop the spread of superbugs, a truly unified response from the global population is necessary

By Channy Lee

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biz.hk 3 • 2016

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ir Alexander Fleming warned of bacteria becoming resistant to penicillin in 1945 when he accepted the Nobel Prize for his discovery of the first commercialized antibiotics. Antibiotics, a class of drugs commonly used in modern day medicine and designed to selectively target and kill disease-causing microbes, are posing a worldwide challenge larger than what Fleming had cautioned. That is, the existing family of antibiotics is becoming increasingly ineffective in the fight against bacterial infections.

In 2013, it was estimated by Centers for Disease Control and Prevention (CDC) that more than two million people fall ill every year with antibiotic-resistant infections in the US, causing at least 23,000 deaths.

The number of deaths puts to foreground the critical case of rising antibiotic resistance, which is classified as the ability bacteria develop over time to overcome the pathogen-malignant effect of antimicrobial agents.

The market for this essential class of drugs is part of a larger problem. The pipeline for antibiotics is, in effect, gradually turning obsolete because few new antibiotics have proved to be an effective alternative and even fewer have been approved for the greater market in the last 30 years. After 70 years of birth of the revolutionary medicine, the healthcare industry – and governments worldwide – stands before a race against fast-adapting bacteria.

A post-antibiotic era?

The discovery of antibiotics is postulated to have saved millions of lives. The medicine has enabled the progress of treatment and surgery with preventive measures of disease-causing infections, promoted stable growth in livestock animals, while significantly reducing the possibility of an epidemic outbreak. It remains a weapon of choice among healthcare professionals in the fight against bacterial infections – and will be so in the foreseeable future.

The use of antibiotics, however, has continued to expand in ways that critics say are having a negative impact on the pharmaceutical effects of the drug and are leading to the rise of antimicrobial-resistant bacteria. Viruses or bacteria developing resistance to drugs is a natural phenomenon, but the case of antimicrobials, namely antibiotics, has been greatly exacerbated by a plurality of misuse and overuse.

According to a study conducted by CDC, a total of 262.5 million courses of antibiotics were prescribed for outpatients in 2011, which is equivalent to 842 prescriptions per 1,000 people. Being so familiar with a drug prescribed so often, many demand antibiotics as a form of treatment for virus-induced illnesses, such as a cold or a flu, for which antibacterial compounds are useless.

How Antibiotic Resistance Happens

1.

3.

Lots of germs.

A few are drug resistant.

The drug-resistant bacteria are now allowed to grow and take over.

2.

Antibiotics kill bacteria causing the illness, as well as good bacteria protecting the body from infection.

4.

Some bacteria give their drug-resistance to other bacteria, causing more problems.

Source: Centers for Disease Control and Prevention, US Department of Health & Human Services (Antibiotics Resistance Threats in the United States, 2013)

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Antibiotics are optimally prescribed only in 50 percent of the time, and even when prescribed properly and accordingly, many patients have a tendency to stop taking the drug when they feel better. They can lead to the growth of antibiotics resistance in patients and the spread of resistance strains. In some countries, access to antibiotics is simply too easy because they are commercially available over the counter, exposing the drug to potential abuse.

Inessential use of antibiotics also prevail across livestock raising, with hundreds of animals being fed with antimicrobial-administered food or through direct injection in animal husbandry. Pervasive acceptance towards such practices has contributed to the emergence of a threat to public health alongside the danger arising from overconsumption of antibiotics among humans.

Gonorrhea and tuberculosis, for example, used to be diseases that could be cured in a few days with antibiotics. It is no longer the case as antimicrobial resistant genes continue to spread among strains of bacteria because the constant use of antimicrobials can fundamentally alter microbial ecosystems of humans.

As a result, microbes began to fight back for survival in a natural selection process and are now winning by out-doing the arsenal of medicine.

Strains of tuberculosis completely drug-resistant that emerged in India a few years ago have now been identified worldwide.

A vicious cycle Fundamentally, reducing misuse and overuse of antibiotics in human medicine and food production is one way to alleviate the drugs’ declining effectiveness. The need for containment of antimicrobial resistance has been recognized decades ago on a global scale, as evidenced by the Resolution of the World Health Organization (WHO) in 1998, which urged member states to formulate appropriate measures to tackle antimicrobial resistance.

There are multiple dimensions as to why the historically stable and effective use of antibiotics is failing. Resistance is a problem on its own, and the fact that there are few alternatives once resistance renders existing antimicrobial agents no longer reliable has expanded the battle against antimicrobial resistance beyond the realm of bacteria and drugs themselves.

From 1983 to 1987, there were 16 new antibiotics approved by the US Food and Drug Administration.

From 2008 to 2012, only three were approved. More than 20 large pharmaceuticals had programs to develop new antibacterial agents twenty years ago.

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“From 1983 to 1987, there were 16 new antibiotics approved by the US Food and Drug Administration.

From 2008 to 2012, only three were approved. More than 20 large pharmaceuticals had programs to develop new antibacterial agents twenty years ago. The number was down to four in 2013.”

The number was down to four in 2013. Researchers have even noted a diminishing supply of existing drugs, although still far from a critical point.

When it comes to antibiotics, the drugs are not working and neither is the market, partly due to a larger focus on drug development for anti-viral infections and other diseases. The commercial valuation of any new antibiotic is tricky because of the uncertainty a drug may involve. Plus, it is harder to estimate actual future demand for antibiotics than those for other long-term drugs targeting, for example, cancer or heart diseases.

The investment on developing new antibiotics is risky business because drug resistance may emerge any time after they are introduced to the market.

The financial burden of research and development, in terms of resources and time, is immense. On average, it takes 23 years for an antibiotic development to realize some return on investment, according to estimates by the UK Review Committee on Antimicrobial Resistance.

The paradox in establishing a sustainable supply of antimicrobial agents is: there must be enough demand and purchases just to offset the development cost and help fund R&D of the next-generation antibiotics; yet, there must be minimal use of the drug in order to extend its effectiveness and to prolong shelf-life before resistance develops again.

The good news is: governments are getting involved. British Prime Minister David Cameron in 2015 appointed former Goldman Sachs chief economist Jim O’Neill to head the UK Review Committee on Antimicrobial Resistance – to specifically devise a comprehensive plan to tackle the issue of antimicrobial resistance. The consensus is that the world market needs a fix to steer away from the direction headed towards a global epidemic.

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Examples of How Antibiotic Resistance Spreads George gets antibiotics and develops resistant bacteria in his gut.

Animals get antibiotics and develop resistant bacteria in their guts.

Drug-resistant bacteria can remain on meat from animals.

When not handled or cooked properly, the bacteria can spread to humans.

Fertilizer or water containing animal feces and drug-resistant bacteria is used on food crops.

Vegetable Farm

George stays at home and in the general community.

Spreads resistant bacteria.

George gets care at a

hospital, nursing home or other inpatient care facility.

Resistant germs spread directly to other patients or indirectly on unclean hands of healthcare providers.

Drug-resistant bacteria in the animal feces can remain on crops and be eaten. These bacteria can remain in the human gut.

Patients go home.

Healthcare Facility

Resistant bacteria spread to other patients from surfaces within the healthcare facility.

Source: Centers for Disease Control and Prevention, US Department of Health & Human Services (Antibiotics Resistance Threats in the United States, 2013)

Racing against the clock No new major class of antibiotics has been discovered since 1987, according to WHO. In spite of a pessimistic outlook, there are indications of new approaches to the development of a class of medicine deemed so vital in the fight against bacterial infection in the human body. Some involve looking back to precursors of modern day treatments that served the same purpose prior to the discovery of antibiotics, and microbiology is an entirely new approach to the objective.

Then, there are the proposed solutions leveraging economic means – close to 100 pharmaceutical companies and trade associations at the World Economic Forum in Davos earlier this year issued a joint statement urging more action on the governmental level to incentivize development of new antibiotics. Public-private partnerships have since been surfacing, and governments across the globe have issued plans to drive research and development for new antibiotics.

De-linkage is another economic option being proposed by economists, where profitability would be ‘de-linked’ from volume of sales. Although controversial, it may prove useful “given the difficulty

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in significantly curtailing use, [the] incentive for drug companies to sell more drugs, and weak market incentives for private companies to undertake research into areas that society needs but are not profitable. Translated into a procedure, one or several lump sums would be paid to the developer regardless of how many courses of drugs are sold.”

The World Economic Forum has identified antimicrobial resistance as a global risk beyond the capacity of any organization or nation to manage or mitigate alone. At the World Health Assembly in May 2015, a global action plan on antimicrobial resistance was adopted, outlining five objectives in an approach that requires coordination among numerous international sectors and actors. It is set to acknowledge the importance of securing a sustainable pipeline for replacing drugs that are no longer effective.

To stop the spread of superbugs – bacteria which have become resistant to antibiotics typically used to combat the microbe – it is yet to be clear which solutions will be sufficient to compensate for the circumstances of reduced economic incentives and strenuous regulatory requirements. The crisis therefore is not just a convoluted challenge posed on the healthcare sector, but calls for a truly unified response from the global population.

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The Labelling of Genetically Engineered Food The Guidelines on Voluntary Labelling of GM (Genetically Modified) Food for Hong Kong has been in place since 2006. In a conversation with biz.hk, Alison Van Eenennaam, an expert in genomics and biotechnology and Cooperative Extension Specialist in the Department of Animal Science at University of California-Davis, discusses the safety of genetically modified food for human consumption and challenges associated with mandatory labelling

By Leon Lee

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Photo: Thinkstock

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G

enetically engineered (GE) foods have been in the market since the early 1990s. And since the beginning, there has always been debates on its use and safety for both human and animal consumption. About 90 percent of genetically engineered crops globally, such as corn and soybeans, are consumed by livestock.

A major issue raised by concern groups is that consumers are not informed of exactly what’s in the food or what’s been genetically modified. They advocate for mandatory labelling of GE foods to differentiate ones that have been modified or those that contain GM (genetically modified) components. According to the World Health Organization, the three main health concerns with GM foods are the potential problems with allergic reactions, gene transfer and outcrossing.

Currently, regulations on GM food vary around the world. In the US, GM products are assessed by an agency with the Department of Agriculture, but the Food and Drug Administration does not require those products to be approved before marketing for sale. So far, there has been no cases reported of harmful effects from the consumption of approved GM food globally.

In Hong Kong, the Food and Environmental Hygiene Department conducted a regulatory impact study on the possibility of introducing a labelling scheme for GM food in 2002. According to their report, there would be no increases in costs to the food trade under a voluntary labelling scheme.

However, if it were mandatory, there would be cost increases, especially for small and medium enterprises. The Guidelines on Voluntary Labelling of GM Food for Hong Kong has been in place since 2006.

To learn more, biz.hk sat down with Alison Van Eenennaam, Cooperative Extension Specialist at the University of California-Davis and a leading expert in the field, who was in Hong Kong late last year for a seminar on the topic. biz.hk: Let’s start off with GM foods. What is the process like?

Van Eenennaam: You’re basically bringing in a piece of DNA from, perhaps, another species to give your plant a particular characteristic. Like the papaya, for example. It’s resistant to ringspot disease. That’s the only thing that that piece of DNA does. It doesn’t produce a protein, and it doesn’t do anything to it, except making it disease-resistant.

We often breed disease resistance using other breeding methods like radiation mutagenesis where you can nuke the genome, then select the

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ones that are resistant to a disease, and bring it into the population. I’m a breeder and geneticist, and we do this all the time. There’s nothing unique about this breeding method that has unique risks associated with it. biz.hk: Do you believe that labelling of GM foods is necessary?

Van Eenennaam: In the US, labelling is reserved for a material difference in the products. So, if maybe there are peanuts in the product, you need to know there are peanuts because you might have an allergy. In this particular case, we’re talking about a breeding method. There are lots of different breeding methods that are used, and we don’t typically mandate that you have breeding methods on the label of a product. Typically that’s for safety concerns.

There’s no safety issue here so if you’re going to have mandatory labelling for this breeding method, I want to know why because if I get a papaya that says GM, what does that mean. It doesn’t really tell me anything. It doesn’t tell me what it’s genetically modified for. In the US where there’s a lot of genetically modified crops that are grown, basically all of our processed food probably contain sugar or oil from a GM plant.

There’s no mandatory labelling of GM food [in the US]. There is a couple of voluntary programs for people that want to differentiate themselves as being non-GM. So there is a non-GMO (genetically modified organism) project and also [one for] organic food, both of which don’t allow the use of that particular breeding method in their products. That provides a choice for consumers in the marketplace who are actually worried about this. biz.hk: Would you elaborate on that?

Van Eenennaam: We do that with a lot of different production methods in the United States – kosher, halal, grass-fed, cage-free chicken. But it doesn’t mean that everybody that’s not halal has to label their stuff as being non-halal. Typically, the way it works is that people who want it have a differentiated market that they pay more for. They bear the cost of keeping all of their products separate. We don’t ever have a system where the rest of the food supply has to go through the expensive labelling for something that’s not associated with safety.

We absolutely have to label for composition and nutrients for allergens and products “made in a factory that might contain gluten,” but we never have to label for “brought to the supermarket on a red truck” because it’s not germane to the product

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itself. It doesn’t change the composition or the safety or anything to do with the product. biz.hk: Besides an increase in cost, what are the impacts of mandatory labelling of GM food?

Van Eenennaam: When you talk about mandatory labelling, it’s a law. If you didn’t label it or if you labeled it incorrectly when, for instance, the sugar you used in fact came from a plant [producing] genetically engineered foods, then you would be liable for legal responsibilities or getting a lawsuit.

Sugar, for example, comes from sugar beets or sugar canes. Sugar beets are genetically engineered, sugar canes are not. Sugar is about half genetically engineered and half not. But the product itself is sucrose. It doesn’t have any DNA or protein, and there’s no way to tell whether it came from a genetically engineered sugar beets or non-genetically engineered sugar canes.

If I were to correctly label a product that contains sugar, I would have to have segregation in the entire supply chain of all the sugar that comes from sugar beets in order to make sure it gets labelled correctly. Now let’s do the same for oil.

Similarly, oil doesn’t contain DNA or protein so there is no idea if it came from a genetically engineered plant or not. To do that, you would have to do an entire supply chain segregation of oil.

You can imagine all the ingredients in a cookie.

There’re probably 30 ingredients and lot of vitamins and minerals. There’s just a lot to it to accurately label a cookie. Now let’s try that with the hundreds of thousands of processed foods. biz.hk: It does sound like an enormous task, but what about the safety of eating GM foods?

Van Eenennaam: [People] think there is something in the food like some type of a nasty chemical or something toxic. All it is, is a breeding method that was used in the process to create this particular plant, and the plant itself is not dangerous because we eat DNA all the time. The basic digestion is that you digest proteins and DNA and then metabolize it. So what is it that’s dangerous? There’s nothing in the food other than the idea that it’s just food.

There’s nothing there, but there’re all these benefits that we never talk about. The papaya is disease-resistant, and if it weren’t for that gene being introduced, there would be no papaya industry in Hawaii.

Often people get bogged down in how you genetically engineer something without talking about why. Why we do it is because there are ways we can address these problems in agriculture that we can’t address in any other way except through using this technology. Disease resistance is particularly

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compelling because we seriously won’t have these crops unless we’re allowed to use some of these technologies to develop resistant varieties.

As an agricultural scientist, I see this as a really valuable breeding method that I would like to use to create disease-resistant animals and plants that are incredible sustainability options. We can’t use this technology now but I’m certainly comfortable with the safety of it and am feeding it to my kids. And I already do.

Dr Alison Van Eenennaam is a genomics and biotechnology researcher and is Cooperative Extension Specialist in the Department of Animal Science at University of CaliforniaDavis. Her outreach program focuses on the development of science-based educational materials including biotechnologies of genetic engineering (GE) and cloning.

She has served on several national committees including the USDA National Advisory Committee on Biotechnology and 21st Century Agriculture and as a temporary voting member of the 2010 FDA Veterinary Medicine Advisory Committee meeting on the AquAdvantage salmon (the first GE animal to be evaluated for entry into the food supply).

Van Eenennaam is the recipient of the 2010 National Award for Excellence in Extension from the American Association of Public and Land-Grant Universities as well as the 2014 Borlaug Council for Agricultural Science and Technology (CAST) Communication Award.

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Taking Care of Your Heart Heart diseases are the third leading cause of death in Hong Kong and account for approximately 13 percent of overall fatalities. In the city, 11 people died of coronary heart disease per day on average in 2013.

Danica Yau, Medical Affairs Specialist at Wyeth Nutrition Hong Kong, with a focus on paediatric nutrition, obesity and diabetes, provides an easy-to-understand guide to a heart-healthy diet

By Channy Lee

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biz.hk 3 • 2016

biz.hk: What are some of the most common heart issues?

Yau: Heart diseases refer to a spectrum of conditions involving the heart and blood vessels, being largely categorized by the part of circulatory system where the problem arises and different causes behind.

The most common heart disease in Hong Kong is coronary heart disease, which occurs when blood flow to the heart muscle is limited due to a blood clot. This is often a result of the buildup of cholesterol layer inside coronary arteries, and it can lead to a heart attack. Other common heart problems include hypertensive, chronic rheumatic and congenital heart diseases. biz.hk: How prevalent are these diseases in Hong Kong? Are there any risk factors especially pertinent to the Hong Kong or Asian population?

Yau: Heart diseases are the third leading cause of

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death in Hong Kong, accounting for approximately 13 percent of deaths. In 2013, 11 people died of coronary heart disease per day on average. Although the rate is considerably lower than that of Western countries, it is still important to note risk factors that make the population of Hong Kong more prone to heart diseases.

Diabetes is more common in Hong Kong compared to the world average, and diabetic patients are about two times more likely to develop coronary heart disease. Severe air pollution in Hong Kong and China increases the risk as there is growing evidence that exposure to particulate matter (an air pollutant) contributes to prevalence of heart diseases. Chronic stress that is especially prevalent in a fast-paced city like Hong Kong is also associated with an increased risk. biz.hk: What is the significance of healthy eating in reducing the risk of heart diseases?

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Type of dietary fat

Impact on heart heath

Examples of food sources

Cholesterol

• LDL (bad cholesterol) – contributes to blocked arteries and risk of heart disease • HDL (good cholesterol) – helps protect arteries from plaque formation

• Eggs • Squid and eel • Cakes

• Limit intake to less than 300 mg/day

Saturated fat

• ↑ Total cholesterol level • ↑ Heart disease risk

• Regular fat dairy products and fatty meat • Palm oil and coconut milk • Cakes, pastries, biscuits and deep fried foods

Trans fat

• ↑ Both total and LDL levels • ↓HDL level • ↑ Heart disease risk

• Cakes, pastries, biscuits and deep fried foods • Found in low levels naturally in beef, lamb and dairy products

• Try to limit and replace with unsaturated fats • Saturated fat: <10% of total daily energy intake (<5-6% if already have abnormal lipid levels) • Trans fat: <1 % of total daily energy intake

Unsaturated fat: Mono-unsaturated fat

• ↓ LDL level • ↓ Heart disease risk

• Olive oil, canola oil and peanut oil • Nuts • Avocados

• Replace saturated and trans fats

Unsaturated fat: Poly-unsaturated fat (Omega-3 fats such as DHA)

• Oily fish such as salmon and sardine • Eggs and meat such as lean beef • Seeds, walnuts, soybeans and canola oil

• 500 mg omega-3 fats per week (e.g. 2-3 servings of 150 g oily fish) • Additional benefit of DHA in pregnant women is that higher intake (600-800 mg/day) may provide greater protection against early preterm birth

Unsaturated fat: Poly-unsaturated fat (Omega-6 fat)

• Sunflower, soybean and sesame oils • Walnuts, pecans and pine nuts • Sunflower seeds

• Replace saturated and trans fats

Yau: Healthy and balanced nutrition is a key focus of disease prevention as such approaches are also recommended by authorities. Diet is an important modifiable factor as it not only helps reduce the risk of heart diseases, but also reduces the chances of comorbidities such as obesity, high blood pressure and abnormal blood lipids. But diet alone may not suffice. A healthy lifestyle involving physical activities with abstinence from smoking and alcohol is concurrently needed to support heart health. biz.hk: What is a healthy diet for the heart?

Yau: The broad principle of a heart healthy diet encompasses the following: Choose • A range of fruits and vegetables (≥ 5 servings/day) • Skim or low-fat dairy products, or alternative calcium supplemented foods and drinks (1-2 glasses/day) • Lean meat and fish (5-8 taels/day) • More nuts and legumes • More wholegrains • Vegetable oils (limit cooking oil to 2 teaspoon max per person in each meal) Limit • Red meat • Foods high in saturated fat and trans fat (eg cakes, biscuits) • Foods high in salt (e.g. processed meat like bacon, sausages and spam) • Sweets and sugar-sweetened beverage • Alcohol Following the above dietary pattern will reduce the intake of sodium and sugar, while consuming more fiber and achieving an optimal fatty acid intake profile.

Emphasis should also be placed on portion control and corresponding calories for weight management.

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Diet tips

biz.hk: How do dietary fats play into a heart healthy diet?

Yau: Fat is a macronutrient and is a fuel and energy source for the body, while also aiding in the absorption of fat-soluble vitamins such as vitamin E. Very importantly, dietary fat plays a role in body cholesterol levels. Cholesterol is the waxy substance that occurs naturally in the body but forms plaque that narrows or even blocks arteries when there is an excessive amount.

Fats are categorized by their structure and properties, each impacting heart health in different ways (see above table). One fact about dietary fats that needs particular attention is, eating large amounts of food containing saturated and trans fats is a more relevant dietary cause of high blood cholesterol level than consuming cholesterol- containing foods. biz.hk: Is there an aspect of culinary culture or eating habits that needs to be further promoted?

Yau: Eating out being a prominent part of Hong Kong’s culture, it is important to know how to choose healthier alternatives while doing so. This includes simple choices such as adding a side of vegetables, removing the skin from chicken wings, choosing fish over steak, limiting sodium rich sauces such as oyster sauce, asking for less rice for calories and portion control, and opting for coffee or tea without sugar.

When grocery shopping, the nutritional content of food products may not always be evident, and there is a likelihood that they can be easily misunderstood due to common misperceptions. By paying closer attention to nutrition labels on food packaging to compare nutrient levels, we can be a step closer to a healthy heart.

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biz.hk: Any food myths that must be busted?

Yau: It is a myth that eggs, particularly the yolk, should be avoided for health reasons of the heart.

Fat found in eggs is mostly unsaturated – the healthy fats - and cholesterol found in eggs (220 mg per egg on average) is limited in amount to affect our blood cholesterol level.

The Australian Heart Foundation recommends up to 6 eggs each week as part of a healthy balanced diet without increasing the risk of heart diseases.

In addition, the Hong Kong government advises to avoid consuming other high cholesterol foods on an egg-day to prevent exceeding the daily upper-limit cholesterol intake of 300 mg.

Another widespread myth is that there is no limit to consumption of good fats – the notion that it can be consumed as much as one wants. While it is true that the good fats may help support heart health, one needs to keep in mind that fat is the most calorie dense macronutrient with 9 kcal per gram, while carbohydrates and protein both contain 4 kcal per gram.

The reference values for daily energy intake are 2350-2400 kcal and 1850-1900 kcal for adult men and women, respectively, and a diet with fat as 15-30 percent of total energy intake is recommended.

Lastly, it is a myth that vitamin supplements can aid in preventing heart diseases. Some people have turned to vitamin supplements with the notion that vitamins with antioxidant properties are beneficial for heart health. However, the American Heart Association, based on available scientific data, concluded in 2004 that the use of vitamin supplements is not justified, and a dietary pattern with wholesome foods is recommended instead.

The latest recommendation made by the Association states vitamin supplements may only be considered if intake from a normal diet is deficient, with the advice of healthcare professionals.

biz.hk: What are some other lifestyle factors to consider for a synergetic effect in prevention?

Yau: There are several tips to preventing heart diseases in everyday life. It is important to exercise regularly, at least 30 minutes every day to maintain cardiovascular fitness. With that, a healthy weight should be maintained. Using Body Mass Index (BMI) as a measure, BMI of 18.5-22.9 and waist circumference of less than 90 cm and less than 80 cm for men and women, respectively, are considered healthy.

Secondly, smoking should be avoided. Tobacco in every form and exposure to second-hand smoke are harmful. Overall, learning to recognize and manage stress in healthy ways will contribute to the prevention of heart diseases, as some individuals tend to over-eat, smoke and consume alcohol when under stress.

More importantly, any individual experiencing heart disease symptoms should seek medical attention from healthcare providers. Dietary information about maintaining a healthy heart only serves as a reference for the general public.

biz.hk: Who should be most concerned about eating right for the heart?

Yau: Men of advancing age and those with a family history of heart diseases are at higher risk and hence it is an aspect of their health requiring more attention. However, with the current trend of heart-related problems, it is recommended – and always best – to establish a healthy eating pattern from a young age. If not, we need to start now. A healthy diet for the heart is also aligned with overall health: appropriate body weight, less prone to diabetes, cancers and other non-communicable diseases. So everyone can benefit from it in different ways.

Danica Yau is a medical affairs specialist at Wyeth Nutrition Hong Kong. She is an Accredited Practising Dietitian (Dietitians Association of Australia) and Accredited Dietitian (Hong Kong Dietitians Association), with an interest in paediatric nutrition, obesity and diabetes. She graduated from the University of Sydney with a Bachelor of Science (Honors) degree in Nutrition and has recently completed a Master of Science degree in Endocrinology, Diabetes and Metabolism at the Chinese University of Hong Kong.

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HEALTHCARE PROVIDERS Hong Kong Adventist Hospital – Stubbs Road 40 Stubbs Road, Hong Kong SAR China

Company Activities/History Hong Kong Adventist Hospital - Stubbs Road (HKAH-SR) offers a comprehensive range of services in a safe and comfortable environment. The Hospital operates first-class equipment and state-of-the-art facilities. Our team of highly skilled medical professionals is committed to ensuring optimal treatment, promoting healthy lifestyles, and restoring patients back to health in body, mind and spirit.

The Hospital has accreditations from international associations including: • Australian Council on Health Care Standards (ACHS) • Health Promoting Hospital (HPH), the global network initiated by the World Health Organization • Hong Kong Laboratory Accreditation Scheme (HOKLAS) • ISO 22000 Certification for Food Safety Management Systems

Highlights of Our Services • 24-hour urgent care services • Out-patient clinic and specialist centers • The Heart Center, Cardiac Catheterization & Interventional Center, and Arrhythmia Center / Electrophysiology Laboratory provide world class cardiology services • Oncology Center is the only facility in Hong Kong equipped with CyberKnife G4 and TomoTherapy • Operating Rooms, Robotic and MIS Center is equipped with the da Vinci robotic surgical system • Minimally Invasive Spine Surgery Center (MISS) offers a full range of spine care, including invasive and non-invasive treatments

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Hong Kong Adventist Hospital – Stubbs Road 40 Stubbs Road, Hong Kong, SAR China Tel: (852) 3651 8888 Fax: (852) 3651 8800 Email: hkahinfo@hkah.org.hk

www.hkah.org.hk

Adventist Medical Center Unit 1606-10, 16/F., Hang Lung Centre, 2-20 Paterson Street, Causeway Bay, Hong Kong Tel: (852) 2782 2202 Fax: (852) 2782 3022

www.adventistmedical.hk

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Mead Johnson Nutrition (Hong Kong) Limited 25/F, ACE Tower, Windsor House, 311 Gloucester Road, Causeway Bay

Nourish the Best Start in Life

Contribute to the Community

Mead Johnson Nutrition (MJN) was one of the first companies in the United States to focus scientific research on nutrition for infants and children. For more than a century, it has led the way in developing safe, high-quality and innovative nutrition products, guided by our mission “To nourish the world’s children for the best start in life”.

MJN was built on a foundation of science-based nutrition.

Globally, we operate four MJN Pediatric Nutrition Institutes in the United States, Singapore, China and Mexico. These centers connect MJN’s researchers to scientists and healthcare professionals around the world, putting us at the forefront of pediatric nutrition science. MJN was listed on the New York Stock Exchange in 2009 and is part of the Standard & Poor’s 500 Index.

MJN has been supporting local families for more than 40 years. We offer regular parenting advice and healthcare information to consumers through a wide variety of channels, including the MJN Mothers’ Club, service hotline, as well as social media platforms such as Facebook and WeChat.

To support the local community, MJN has been supporting the “Feeding Hope” program initiated by The Boys' and Girls' Clubs Association of Hong Kong since 2009 to improve health and nutrition for children in low-income families. The program recorded a total attendance of over 90,000 to date.

Last October, Mead Johnson Hong Kong donated HK $1 million to the Joshua Hellman Foundation for Orphan Disesase (JHF) to launch VITAL STEP, a screening and education program to help parents safeguard their newborns against Inborn Errors of Metabolism (IEM), which can have serious consequences, including death. To foster wider public awareness, award-winning film director, Adrian Kwan Shun-fai produced a micro film based on a true story of an IEM patient.

Fast facts about Mead Johnson

• Founded in 1905 by Edward Mead Johnson • Employs approximately 8,000 employees globally • Sells more than 70 products in over 50 markets • Operates 4 MJN Pediatric Nutrition Institutes worldwide

In Aug 2015, MJN invited 19,726 HongKongers to build a toy block model, setting a new Guinness World Record™ for the ‘Most Participants in Toy Block Model Building’.

Service / Product:

Nutrition Product About the service / MJN’s portfolio of brands represents specialized pediatric nutrition products Product: parents have trusted for more than a century to encourage healthy growth, support brain development and address common feeding issues. Our products include milk formula for routine feeding, to those for rare metabolic disorders that require specialized treatment.

Ms. Ruthia Wong, Vice President and Key Personnel: General Manager of Hong Kong (852) 2510 6321 Tel: Fax: Contact Us:

(852) 2969 5528 www.meadjohnson.com.hk/contact-us

In Oct 2015, MJN partnered with JHF to launch a public awareness campaign, calling all Hong Kong expecting parents to take the vital step to safeguard their newborns from IEM. * Nielsen Infant Milk Formula Market Track Service data shows that Mead Johnson ranked first in Sales Volume and Sales Value within the Infant Milk Formula market from May 2002 to April 2015 in total Hong Kong supermarkets and drug stores.

(Copyright©2015, The Nielsen Company)

www.meadjohnson.com.hk biz.hk 3 • 2016

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HEALTHCARE PROVIDERS Wyeth Nutrition Hong Kong 12/F Lincoln House, Taikoo Place, 979 King’s Road, Island East, Hong Kong

Science as Foundation Wyeth Nutrition is part of Nestle S.A. We develop premium-quality nutritional products scientifically-designed to meet the needs of people in different life stages. As pioneers in infant nutritional science, our mission is to provide the best nutritional support for future healthy outcomes. In the past century, Wyeth Nutrition has leveraged clinical rigor, scientific research, world class manufacturing and product safety standards to drive scientifically-sound solutions that offer parents confidence, help nourish children and support their healthy futures.

Professionalism as Principle At Wyeth Nutrition, quality and professional integrity are our highest priorities. Our commitment to quality and integrity has always extended beyond formulation to manufacturing.

Milk formulas are among the most stringently regulated consumer products in the world. We manufacture our products with reference to food quality and safety standards set by the Codex Alimentarius Commission, a body run jointly by the United Nation's Food and Agriculture Organization and World Health Organization, and we comply with all regulations in the countries where we operate.

We bring to the manufacture of nutrition products the same diligence and attention to detail used in pharmaceutical production, striving for total consumer confidence in our products. With our persistence of state-of-the-art facilities and the strictest standards of quality and safety, all formula products of Wyeth Nutrition Hong Kong are manufactured by its plants that achieve ISO and HACCP certifications in recognition of their manufacturing excellence.

Key Personnel: Tel: Fax: Email:

* IMPORTANT NOTICE: The World Health Organization recommends exclusive breastfeeding during the first 6 months of life and continued breastfeeding for as long as possible. Products shown are formula milk for young children aged 6 months to 3 years and above, or nutritional supplement for women who are planning to become pregnant, who are pregnant, or who are breastfeeding, and are not breast milk substitutes. Before taking any maternal supplement, please consult your healthcare professional to determine which product is appropriate for you. For picky eating children, should provide them with normal diet and continue to correct their picky eating behavior. If there is any question, please consult doctors or dietitians for details.

Nutrition Product Wyeth Nutrition Hong Kong offers a full line of safe, quality and scientifically-designed nutrition products, including infant formula, follow-on formula, growing-up formula, prenatal and lactating supplements, and adult supplement.

Ms May Chung, Country Business Manager (852) 2599 8888 (852) 2599 8999 enquiryhk@wyethnutrition.com

www.wyethnutrition.com.hk 62

Starting with the first infant formula brand, Wyeth Nutrition has created many firsts that have advanced the science of children’s nutrition, such as the first formula to carry an expiration date to ensure freshness, the first infant formula enriched with alpha-lactalbumin, a high-quality whey protein, etc. We share your vision of success and will continue to develop the most innovative nutritional products of today and tomorrow.

In addition to maintaining our leadership, we are also committed to create shared value for our society by driving and supporting various corporate social responsibility programs with our different stakeholders.

WYE-PM-033-FEB-16

Service / Product: About the service / Product:

Nourishing Pioneers – For More Than 100 Years and Beyond

WYETH® is a registered trademark of Wyeth LLC. used under license.

biz.hk 3 • 2016

BODYQ Health Specialists Suite 1701, Hong Kong Pacific Centre, 28 Hankow Road, Tsimshatsui, Kowloon, Hong Kong

Company Activities/History

Services include:

We are a Comprehensive Health Management service based in Hong Kong • Represent a group of medical specialists of different specialties • Mostly graduated from UK, HK or Australia

• Specialist outpatients and 24 hour emergency medical and surgical services • Inpatient services with access to all private hospitals in Hong Kong • House call service to client’s home or hotel • Medical Transport and Medical Escort service to and from China • Comprehensive medical check up plans for both personal and corporate clients • Vaccination service in clinic and at corporate venues • Health seminars both in clinic and at client venues • Strong Partnership with most International Insurance companies • Cater for both local and expat patients from Hong Kong and China

“YOUR HEALTH IS OUR CONCERN” 24 HOUR HOTLINE: +852 699 33 993 Key Personnel:

Ms. Zenki Chua

Tel:

(852) 2369 2222

Mobile:

(852) 6993 3993

Email:

info@bodyQ.com

www.bodyQ.com

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