YOUR GUIDE TO LIVING WELL
HEALTH POST
TUESDAY, FEBRUARY 14, 2012
DOES MARRIAGE MAKE YOU LIVE LONGER? >PAGE 8
OUR EXPERTS BUST SOME MEDICAL MYTHS >PAGE 10
Mending broken hearts with the next generation of cardiac device
>PAGE 6
Rhythm and malady
2 NEWS QUIZ
ASK THE DOCTORS DR ANTHONY LUKE Q: Do I need an electrocardiogram (ECG) before exercise? A: An electrocardiogram (ECG) is a tracing of the electrical activity of the heart, which can be used to look for structural and rhythmic abnormalities in the heart. I’ll answer first for young athletes, then athletes over 50 years old. Young: there have been some recommendations that an ECG can be used to screen for causes of sudden death in young athletes. An ECG can identify abnormalities in cases of hypertrophic cardiomyopathy in about 90 per cent of cases. The best test is still an echocardiogram (ultrasound of the heart). An article in The New England Journal of Medicine outlined the experience of Italian physicians, who perform ECGs during the pre-participation physical exam on all athletes. They identified different conditions with these ECGs,
...................................................... some of which precluded participation by some athletes. Unfortunately, the value of the ECG to prevent injuries still needs to be clarified. At present, the American Heart Association recommends only the pre-participation physical exam and not a routine ECG unless there is clinical concern to get one. Older: if you are an older athlete, an ECG may be recommended, especially if you are getting into a new exercise programme. With competitive athletes over 35 years of age, the risk of sudden cardiac death is estimated to be between one in 15,000 and one in 50,000. So check with your physician before starting an exercise programme. The American College of Sports Medicine recommends a stress test for anyone participating in moderate to vigorous activity and on men over 45 and women over 55 with two risk factors for coronary artery disease. Such factors include family history of heart disease, hypertension, cigarette smoking, high cholesterol, diabetes, obesity and a sedentary lifestyle. A stress test involves walking on a treadmill with a pattern of increasing difficulty, while an ECG is taken. Dr Anthony Luke is an associate professor of clinical orthopaedic surgery at the University of California, San Francisco. Reprinted with permission of the American College of Sports Medicine’s ACSM Fit Society Page, summer 2008 newsletter
Jeanette Wang jeanette.wang@scmp.com There are good calories and bad calories, but sugar is “toxic beyond its calories” and should be controlled like alcohol and tobacco to protect public health. So argues a team of University of California, San Francisco researchers in a report published in Nature two weeks ago. Worldwide consumption of sugar has tripled in the past 50 years, and the researchers say sugar is fuelling a global obesity pandemic and health crisis. It has contributed to 35 million deaths annually worldwide from such noncommunicable diseases as diabetes, heart disease and cancer. Obesity, they say, is just one marker of damage: 40 per cent of people with metabolic syndrome – the key metabolic changes that lead to diabetes, heart disease and cancer – are not clinically obese. Far from “empty calories”, at the levels consumed by Americans – 70,000 calories in sweet drinks alone consumed by the average person per year – the researchers say the health hazards of sugar mirror the effects of drinking too much alcohol (which is the distillation of sugar). Their suggestion: use similar interventions that have reduced alcohol and tobacco consumption, such as levying special sales taxes, controlling access, and tightening licensing requirements on vending machines and snack bars that sell high sugar products in schools and workplaces.
Are you sugar smart? Take the test. 1. The main source of added sugar in our diet comes from: a. beverages b. sweets c. bread and bread products 2. For a man whose recommended daily energy intake is 2,000 calories, dietitians advise that his daily sugar intake be limited to: a. four teaspoons b. five teaspoons c. six teaspoons 3. Which of these is not a natural sugar? a. saccharine b. galactose c. dextrose 4. Which country leads the world in sugar production? a. United States b. China c. Brazil Answers: 1. a; 2. b (or 25 grams); 3. a; 4. c
PREVENTION
Signs point to a more physically active life ...................................................... Jeannine Stein What does it take to make people more physically active? Maybe just a sign. Signs posted in buildings prompting people to take the stairs instead of the lifts proved successful in getting them to hoof it, a study has found. Signs were placed in three multi-storey buildings in New York: a three-storey health clinic, an eightstorey academic site and a 10-storey affordable housing building. The signs featured a pictogram of a man walking up stairs with text that read, “Burn calories, not electricity. Take the stairs”. The sub-message read, “Walking up the stairs just two minutes a day helps prevent weight gain. It also helps the environment.” The signs were on every floor of the health clinic and affordable housing unit and in the lobby of the academic building. Researchers tallied 18,462 trips up and down the stairs at the various sites. Right after the signs were posted, stair use increased 9.2 per cent at the health clinic, 34.7 per cent at the academic building and 33.6 per cent at the affordable housing site.
At the health clinic and affordable housing units, the signs were left in place, and increased stair use was pretty much maintained for a nine-month follow-up. “Human-made environments in everyday life offer many opportunities for maintaining health, controlling weight and preventing disease,” says lead author Dr Karen Lee. Lee, with the New York City Department of Health and Mental Hygiene. She adds: “One of those health opportunities is stair climbing – a vigorous activity that can burn more calories than jogging.” The study was published online in this month’s issue of the American Journal of Preventive Medicine. McClatchy-Tribune
> CONTACT US Deputy Culture Editor: Choong Tet Sieu tetsieu.choong@scmp.com Health Post Editor: Jeanette Wang jeanette.wang@scmp.com General inquiries: healthpost@scmp.com Advertising: tel: 2565 2435; e-mail advertising@scmp.com
APP OF THE WEEK
Memory game too boring to inspire anything other than forgetfulness ..................................................... Katie McGregor healthpost@scmp.com Memory Matrix From 99 US cents Rating 3/10 Apparently the rot of elderly forgetfulness and fuzzy thinking sets in earlier than the scientists had originally thought – at about 45 – according to a recent study published in the British Medical Journal. However, other studies suggest that if you don’t want to lose it, you have to use it. Memory Matrix by Lumosity appeared to be just the app to stimulate my brain while in bank queues or waiting for the lift. The science section told me that one of the most important types of memory is known as working memory, which is used for temporarily storing and manipulating information; critical for reasoning, problem solving and language. Memory Matrix is designed by Lumosity scientists to improve this faculty. So I started playing the game, which comprises an expanding grid where you are briefly shown a pattern of blocked-out squares, and you then repeat the pattern to the best of your ability on the next screen by touching the same
Perhaps I am fooling myself, but I believe my brain’s refusal to be improved had 100 per cent to do with boredom
squares in the clean grid. It starts with a three-by-three grid and expands to a five-by-five grid in 15 rounds per game. I realise that on my own I am not a scientifically acceptable statistical sample, but I found that my memory retention got worse each time I played, with my score sinking from 1,140 to 905. Perhaps I am fooling myself, but I believe my brain’s refusal to be improved had 100 per cent to do with boredom. Yes, the game is boring. You can brighten things up by creating an account with Lumosity and receiving a free seven-day trial for the online service, where you’ll find many more games, said to improve speed, memory, problem solving, flexibility and attention. The website is not designed for viewing on an iPhone, but you can download and pay for a selection of the game apps at prices ranging from 99 US cents to US$1.99. Lumosity does give you the option to try before you buy in a “free” app called Brain Trainer with five free sessions of a mix of the games. If I’d discovered this before buying the Memory Matrix app, I would be 99 cents the richer. While I cannot judge the efficacy of the online Lumosity program, the app failed to inspire me. I’ll stick with Words with Friends.
NEWS 3 HEALTH BITES
THINK ABOUT IT
...................................................... Jeanette Wang jeanette.wang@scmp.com
Know your stuff, and where to store it
Veg out for 21 days It’s not about being a couch potato, but about following the 21-Day Vegan Kickstart, a free online programme created by the non-profit Physicians Committee for Responsible Medicine in the US. It’s based on clinical research by the organisation’s president, Dr Neal Barnard, which shows low-fat, plant-based diets can help people lose weight, reverse diabetes, and implement long-term changes in eating habits and health. A Chinese version will kick off on March 5, offering nutrition and cooking tips, and recipes like brown rice sushi and mapo tofu. “Celebrity coaches” such as Gao Yuanyuan, Louis Cheung and Khalil Fong will inspire you. Sign up in Chinese at www. 21DayKickstartChina.org; in English at www.21DayKickstart.org.
Go bananas for charity Always wanted to outrun a banana? Here’s your chance. The annual Beat the Banana run organised by the World Cancer Research Fund Hong Kong is back. Try to chase down a life-sized version of the fruit in the three kilometre fun run, or if you’re a serious runner, join the six kilometre elite race, in which the winner will win a trip to compete in a similar race in London in May. The local race will run on Sunday, March 4 along Tsim Sha Tsui East Promenade. Register by Monday at www.wcrf-hk.org. But be quick, it’s limited to 1,000 participants.
My name is Mike Krzyzewski Having an easy-to-pronounce name is more likely to win you friends and favour in the workplace, according to a study published in the Journal of Experimental Social Psychology. The study used a range of names from Anglo, Asian, and Western and Eastern European backgrounds. Those with more pronounceable names were more likely to: be favoured for political office and job promotions; win a political race, based on a mock ballot study; and rise more quickly to superior positions in law firms, based on a study of 500 first and last names of US lawyers. “It’s important to appreciate the subtle biases that shape our choices and judgments about others. Such an appreciation may help us ‘de-bias’ our thinking, leading to fairer, more objective treatment of others,” says study co-author Dr Simon Laham from the University of Melbourne. Incidentally, Krzyzewski (above) is pronounced shuh-SHEV-skee, and he is the men’s basketball coach at Duke University in North Carolina.
Let them eat cake Dessert is said to be bad for any diet, but it seems having sweets – and for breakfast – could aid weight loss success. Researchers from Tel Aviv University randomly assigned 193 clinically obese, non-diabetic adults to one of two diet groups with identical caloric intake. The first group was given a low-carbohydrate diet including a small 300 calorie breakfast, and the second was given a 600 calorie breakfast high in protein and carbs, always including a dessert item like chocolate. Halfway through the study, participants lost an average of 15kg each. But in the second half of the study, those in the low-carb group regained an average of 10kg, while the big breakfast group lost another 7kg. Adding dessert items to breakfast can control cravings throughout the rest of the day, the authors say in their report published in the journal Steroids.
...................................................... Prevention Magazine Usually we don’t give much thought to where we stow things, but perhaps we should. Choosing the wrong storage spot may shorten the shelf life of some items and increase the health risk of others. Consider these words of wisdom when deciding where your belongings belong and where they don’t. Toothbrushes Worst place: the bathroom sink – it’s too close to the toilet. With every flush, toilet spray can be propelled as far as 1.8 metres, showering the sink with bacteria. Best place: behind closed doors in a medicine cabinet or a nearby cupboard. Handbags Worst place: any surface normally used for food preparation or eating. Handbags are terrific microbe magnets carrying about 10,000 bacteria per 6.5 sq cm, possibly even faecal bacteria. It’s not surprising, though, when you think of all those nasty spots where we park our handbags: bus seats, restaurant floors, bathroom stalls. Best place: A drawer or chair – any place except where food is prepared or eaten.
Medicine Worst place: the medicine cabinet. A steamy bathroom can reach up to 37.8 degrees Celsius, which could affect the potency of many common medications. For example, the effectiveness of Lipitor – a common cholesterol drug – could be compromised at 25 degrees or higher. Best place: a cool, dry place such as a pantry or hall closet. Television Worst place: wherever you dine. Research shows that TV watching encourages mindless eating. Best place: up or down a flight of stairs from your kitchen. When snacks take more effort to get
to, you’ll be less likely to munch while watching. Nighttime reading light Worst place: overhead. These fixtures emit a relatively bright light – enough to delay the body’s secretion of the hormone melatonin, according to research. This can set you up for a restless night since melatonin levels are a major cue for your body to prepare for sleep. Best place: anywhere but the bedroom. A better lighting alternative: a low-powered light clipped to your novel. It provides enough light to read but leaves the room dark enough for your brain to drift into sleep mode. McClatchy-Tribune
4 MEDICAL
Improvements to cancer screening programmes and tests has led to earlier and faster disease detection, and a higher survival rate. Photo: SCMP Pictures
CASE HISTORY
...................................................... Eileen Aung-Thwin healthpost@scmp.com Mr Wong, 71, had spent decades working as a toy factory worker and sailor. After years of toil, he finally retired and could enjoy life at a leisurely pace with few worries. His daughter had grown up and married and was working as a nursing officer at a local hospital, and he enjoyed good health. The first hint of trouble, however, surfaced when he noticed a red tint to his urine. Wong (whose full name has been withheld for reasons of confidentiality) was worried, but tried to ignore it since he felt no pain. When the reddish hue did not go away after a few weeks, he mentioned it to his daughter. Although blood in the urine, or haematuria, is a fairly common condition and could be indicative of many conditions, Wong’s age was a risk factor for more serious ailments. His daughter insisted he see Professor Anthony Ng Chi-fai, a urologist from Chinese University’s department of surgery. Ng put Wong through a series of tests, including urine screening, computed tomography (CT) scans and a cystoscopy, where a narrow
tube with a light and camera on the end is inserted into the bladder through the urethra. Ng found multiple tumours, the largest being four centimetres in diameter, in Wong’s bladder. He had bladder cancer. His history of working with plastics at the toy factory may have been a predisposing factor. Ng performed a minimally invasive procedure on Wong – a transurethral resection of bladder tumour, where the lesions were removed using a cystoscope. Wong suffered minimal discomfort and healed fast. The cancerous tissue showed that Wong had grade-three superficial transitional cell carcinoma – that is, the cells forming the innermost lining of the bladder had become abnormal and multiplied too rapidly. The cell
Bladder cancer has a nasty habit of recurring in 50 to 80 per cent of cases
abnormality was considered high, and such cancers can be aggressive. Another cystoscopy a month later found that the bladder was free of any further sign of cancer, and the operation was considered a success. However, bladder cancer has a nasty habit of recurring in 50 to 80 per cent of cases. To minimise the risk of recurrence, Ng used a common immunotherapy called intravesical Bacillus Calmette-Guerin (BCG) treatment. BCG is a vaccine of live, weakened tuberculosis bacteria that stimulates the body to produce cancer-fighting substances, and it is introduced via a catheter into the bladder where the liquid is held for a few hours and then drained. Wong was to receive weekly BCG treatment for six weeks, followed by a monthly dose for 10 months thereafter – a well-established regimen that’s been in use for more than 20 years. For the first six weeks, Wong suffered only a mild, common side effect – slight irritation of the urethra and bladder that caused him to urinate more frequently. Then Wong started to experience difficulty passing urine. He needed to strain more to empty his bladder, and the stream of urine grew increasingly slower.
Illustration: Angela Ho
Rare complication muddies the waters
MEDICAL 5 FROM THE EXPERTS
Testing times for us all ...................................................... Dr Ada Ma healthpost@scmp.com It’s no surprise that cancer has now emerged as one of the major health burdens worldwide. In Hong Kong, the total number of new cancer patients per year has almost tripled from 8,900 in the mid-1970s to about 25,977 in 2009. That constitutes an annual rise of 2 per cent in the overall number of new cancer cases reported by the Hong Kong Cancer Registry. More than 60 per cent of cancers occur in people over the age of 60, so the increase in rates could be explained partly by our ageing and expanding population. One in four men and one in five women will develop a cancer by the age of 75. Twenty years ago, the No 1 cancer risk for men in Hong Kong was lung cancer, and today it still tops the list. But there has been a change in the ranking of the other cancers: they are now bowel (colorectum), prostate, liver and stomach, in that order.
Being physically active and managing stress is still your best protection against cancer
One day, he was alarmed to find that despite feeling a great urge to urinate, he simply could not pass urine. In great distress he was rushed to the hospital, where a catheter was inserted into his urethra to drain the urine. Wong had no other complaints or symptoms, but Ng found that his prostate was slightly enlarged. As the prostate wraps around the urethra, an enlarged prostate could “squeeze” the urethra and cut off urine flow. Ng put Wong on an alpha-blocker, a medication to relax the muscles in the prostate and bladder neck. Two days later, the catheter was removed and Wong could pass urine normally. But two days later, a distressed Wong was back at the hospital, unable to urinate. A catheter was used to relieve Wong’s discomfort but Ng now planned to remove part of his enlarged prostate. Before the planned procedure, Wong started to complain of growing discomfort and swelling in his perineum – the area between the scrotum and the anus. A CT scan showed that fluid had built up in the prostate, causing it to swell and enlarge the perineum. Guided by ultrasound, Ng drained
the fluid using a special needle and extracted 25 millilitres of pus. Tests showed that the bacteria in the pus were the same strain as the BCG. The tuberculosis bacteria had somehow migrated from Wong’s bladder into his prostate and caused a localised infection. Once the bacteria travel outside of the bladder, the patient risks developing tuberculosis. So Wong was put on a one-year course of a four-drug antibiotic cocktail. He also needed weekly removal of the pus build-up in his prostate. Eight weeks after the infection was discovered, Wong could finally urinate on his own. Ng stopped BCG treatment but maintained close watch over Wong for any recurrence of the cancer. After two years, Wong remains cancer-free. This complication arising from BCG treatment is rare: only a few cases have ever been reported, Ng says. Ng says that while the enlarged prostate was caused by a BCG-related infection, the extended period of using a catheter had resulted in pus build-up in the prostate. Because Wong did not exhibit signs of sepsis or infection, it was initially a challenge to pinpoint the cause of his urination problems.
Bowel cancer has overtaken liver cancer to become the second most common cancer in men since the mid-1990s and the incidence of prostate cancer before to 2000 was much lower. One reason for the change could be the adoption of a more Western diet – red meat and saturated fat are a big risk factor for both bowel and prostate cancers. In women, cancers of the breast, bowel, lung, uterus and thyroid are the most common in Hong Kong. In the past 12 years, breast cancer has replaced lung cancer as the leading cancer in women. Lung cancer is the biggest killer of both genders. In the past, more than 90 per cent of cases were diagnosed in smokers; in recent years, however, an increasing number of women who have never smoked have been diagnosed with adenocarcinoma of the lung. It was later identified that they were carrying a specific gene mutation. The good news is that you can now be tested for this and it can be treated with targeted therapy.
In recent years, breast cancer awareness has increased in the city owing to a 60 per cent surge in breast cancer cases in the past 10 years. In 2009, 2,945 female breast cancer cases were diagnosed; about eight women in Hong Kong are diagnosed with breast cancer every day. The silver lining is that for both men and women, the rate of stomach and nasopharyngeal cancers, which are more common among Asians, has fallen significantly. While lifestyle factors play an enormous role in reducing the risk of getting cancer, better screening programmes and diagnostic testing has led to earlier disease detection, which usually translates into better treatment, outcome and cure. That said, eating a healthy diet, being physically active and managing stress is still your best protection against cancer. Cancer screening is vital and blood tests alone are not adequate, as some tumour markers may give false negative
results. We know, for example, that annual mammogram screening for women aged 50 or above results in a relative risk reduction of death from breast cancer of 15 per cent. Annual pap smears with HPV testing can also detect pre-malignant lesions, and colonoscopy is recommended within certain age and risk groups to help detect pre-cancerous conditions. With our busy lifestyles, it is easy to forget to take proper care of our health. But being aware of changes in your body and your age, and your lifestyle and genetic history, will help determine your cancer risk in order for your doctor to work out a prevention plan. Speak to your doctor about risk factor assessments that can help you better understand which screening tests you would benefit from. Dr Ada Ma is a specialist in medical oncology who works with the team at Central Health Medical Practice focusing on cancer screening and prevention
6 COVER STORY
And the beat go Heart patients are given fresh hope thanks to a new generation of cardiac device, writes Elaine Yau
10 Number of hours the LVAD batteries last before they need to be recharged
S
.K. Jain, 59, could hardly walk up the stairs a year ago. His heart was in such a bad state that he felt nauseated and breathless all the time. A diagnosis in 1999 showed his heart’s left ventricle was swollen, and he has undergone a number of treatments since, eventually leading to the installation of a pacemaker in Mumbai in 2003. However, his condition kept getting worse, so his doctor recommended a heart transplant in 2008. With a donor heart hard to come by, Jain was on the edge of death last year. Fortunately, a cutting-edge medical device came to his rescue. Doctors at Queen Mary Hospital installed a left ventricular assist device (LVAD), which takes over the left ventricle’s job of pumping and supplying blood to the body. The surgery and the pump cost a hefty HK$2 million, but Jain is grateful for his second chance at life. “I felt and breathed better a day after the surgery,” he says. Without nausea, he now also eats very well. Jain, an information technology professional, is one of eight patients who have had the surgery since the LVAD was introduced in Hong Kong in 2010. The device gives a glimmer of hope to those on the waiting list for a heart transplant. There are now 18 patients on the list, according to cardiologist Cheng Lik-cheung. “Some patients die because no timely donor heart is available,” says Cheng. For young end-stage heart patients, the LVAD can serve
as a bridge to eventual transplant surgery. For those aged over 65 and not qualified for a heart transplant due to illnesses such as cancer, he says it can be destination therapy, as a last-resort treatment. There are 200 to 300 patients diagnosed with terminal heart disease every year in Hong Kong – and only one in 10 eventually gets a heart transplant, according to Elaine Chau Mo-chee, a cardiologist at Hong Kong Sanatorium and Hospital, which has so far conducted one LVAD surgery. The remaining 90 per cent are almost certain to die because therapy, such as the installation of a pacemaker and defibrillator, no longer works. “But an LVAD can give them medium- to long-term survival with a good quality of life,” says Chau. Heart failure develops when one or more of the four chambers of the heart fails to keep up with the volume of blood flowing through them. It can be caused by a variety of underlying diseases and health problems. Each side of the heart has two chambers – an atrium (upper chamber) and a ventricle (lower chamber). The left side of the heart is crucial for normal heart function; the left atrium receives oxygen-rich blood from the lungs and pumps it into the left ventricle, the heart’s largest and strongest pump, which supplies blood to the body. This left side is usually where heart failure begins. More than 90 per cent of those with terminal heart disease have left ventricular
S.K. Jain with the LVAD control unit, which can operate from an electrical cable or batteries. Photo: Felix Wong
I didn’t have the strength to play with my two kids or even wash my hair. I needed to rest five times if I walked 500 metres MR NG, HONG KONG’S SECOND LVAD RECIPIENT
failure, says Chau. The LVAD works by pumping blood from the left ventricle to the aorta, the body’s largest artery. Data collected on patients worldwide who have received the LVAD shows that the pump can be used for up to seven years after implant, says Cheng. Although it first appeared in 1970, it was not until the 1990s that the device was small enough to be implanted into the chest cavity. This third-generation model weighs only 290 grams and is silent and vibration-free. The surgery is a routine procedure in the West. In 2010 alone, there were about 2,500 LVADs implanted in the US, according to Henry Ford Hospital in Detroit. But Chau says it’s been a “steep learning curve” in Hong Kong. Heart surgeons in the city are experienced in heart transplants, with more than 100 done since the first in 1992. But Chau says an LVAD surgery is more “technically” complicated. About four years of preparation were needed for the first surgery last year, he says. Twenty-two medical personnel worked on the procedure, which lasted 12 hours. “Post-operative care is also of much importance,” says Chau. “An infected wound will affect the patient’s survival, and the amount of warfarin [blood thinner] the patient takes should be properly calculated. An overdose will give rise to the risk of bleeding, and an insufficient dosage will lead to blood clots and stroke.” A healthy heart pumps out between 55 and 70 per cent of its blood with each beat. Heart failure is diagnosed when the ejection fraction (a measure of pumping efficiency) drops below 45 per cent. Mr Ng, 44, the second patient to get an LVAD in Hong Kong, says his ejection fraction dropped to 10 per cent before he received the surgery in 2010 at Queen Mary Hospital. “My life was a constant struggle. I didn’t have the strength to play with my two kids or even wash my hair. I needed to rest five times if I walked 500 metres,” says Ng, the owner of a trading firm, who blames his 30 years of drinking and smoking for his heart disease.
A small cable connects an external control unit and batteries to the internal LVAD unit. The open incision on the skin that the cable goes through must be kept dry, clean and bandaged at all times to prevent infection. The pump is operated by a pair of batteries that last around 10 hours. If the batteries run down, the patient can die within minutes. Cardiologist Cheng says both patient and caregiver have to complete a test on patient care before being discharged from hospital. The artificial heart cannot be exposed to water, and so showering and going out when it’s raining are impossible, Jain says. Instead, he takes sponge baths every day. Each morning after waking up, he records his temperature, blood pressure and heart rate in a logbook, and checks that the device is running properly. When sleeping or working in his room – Jain works from home from 9am to 6pm – the device is plugged into a socket. But as the cable is only four metres long, he switches to batteries when he moves around his home. He visits the doctor about every five weeks. Ng says he can’t exercise too much, as sweating will increase the chance of wound infection, and has to wear shoes with plastic soles to prevent static electricity from interfering with the device. He also carries a letter wherever he goes: it states that no external cardiac compression can be done on him in case of a medical emergency, and that he must be sent to only Queen Mary Hospital or Hong Kong Sanatorium and Hospital, the only two hospitals that have facilities to deal with LVAD patients. Patients in the West are advised to make end-of-life decisions before the LVAD is installed. If the heart pump patient suffers multiple organ failure or brain damage, ethical or legal problems over whether and when the artificial pump should be disconnected might arise. But Chau says there’s no such concern in Hong Kong. “We assume a patient dead if his brain is dead,” she says. “We won’t keep him alive with the artificial device.” To minimise his health risks and ensure quick access to proper medical care in case of emergencies, Ng says he avoids taking long trips. “I needed to visit the mainland three to four times every week for business in the past,” he says. “I don’t do that now. I would rather earn less money.” In return, he gets to spend more time with his family. “In the past, as I spent too many days away from home, my wife was estranged from me and my kids avoided me,” he says. “Now I have my family back.” elaine.yau@scmp.com
COVER STORY 7
oes on
How it works Aorta The largest artery, it receives blood pumped from the left ventricle and carries it to the rest of the body
A left ventricular assist device (LVAD) helps the heart pump blood around the body when it is no longer able to. Some LVADs pulsate, mimicking the action of the heart, while others such as the one shown here provide a continuous flow of blood, leaving the user with no pulse.
Basic set-up
External battery pack Weighs about 500g and lasts about 10 hours before needing recharging
Aorta carries oxygen-rich blood to the rest of the body
Left ventricle Blood from here enters the LVAD
Left ventricle
Blood flow
Inflow cannula
Skin entry site
System controller
Outflow cannula Outlet stator Diffuses blood
Motor Tiny spinning propeller-like screw provides the flow of blood
Installation of the device Sternum
The point the device will enter the skin is punctured with a needle, and the wire threaded through Wire to system controller Controller gives a warning or an alarm if power is low or device is not working properly The line must not be bent too sharply, and should leave some slack in case it is tugged on
Note: specifications here based on Heartmate II by Thoratec; other models may vary
Pump housing
Rotor Spins at around 7,000 revolutions per minute
Inlet stator Straightens the flow of blood as it enters the pump
Pump capacity Pumps blood throughout the body at up to 10 litres per minute, the output of a healthy heart Stomach muscles
Source: Thoratec
SCMP Graphic: Simon Scarr, Kaliz Lee, Bay Leung
8 HEALTH VALENTINE’S DAY
Well-being is a state of the heart ...................................................... Monica Proctor healthpost@scmp.com Love can bring out the best and worst in people, and a growing body of research is finding that love can also play a critical role in the health of couples. Last month, a study from the University of Utah in the US looked at the effect of a four- to seven-day separation on the health and well-being of 34 co-habitating couples. The tracking included testing the couples’ saliva for cortisol, a hormone associated with stress. The research team, led by Professor Lisa Diamond of the psychology department, found that physical separations increased cortisol levels and had negative impacts on their sleep and level of positive interactions. “During separations, only lengthy phone calls appeared to ‘stand in’ for contact,” says Diamond, whose work focuses on the nature and development of affectional bonds. “The findings can contribute to our emerging understanding of the processes through which long-standing romantic ties are beneficial for our health.” Linda Lee, a Hong Kong resident and retired information technology professional who has just celebrated her 17th wedding anniversary, says she leads an active lifestyle as a result of her marriage. She and her husband share many common interests, such as dancing, golf, tennis, skiing and hiking. On the flip side, a divorcée and finance professional who declined to be named says she drank more alcohol during her marriage. “It took a few years before I realised the implications of being in that relationship,” she says. It is well-documented that married people tend to be healthier than unmarried people. According to Hui Liu, an assistant professor and sociologist at Michigan State University in the US, there are two theories for this. One is that being married gives you more access to social support and economic resources. The other is that being divorced or widowed hurts health. But a study led by Liu that was published in the September 2008 issue of the Journal of Health and Social Behavior found that the gap between the married and unmarried is narrowing, arguably due to changing marriage trends. Citing data from the US National Health Interview Survey, she found that health has improved for unmarried men in particular, perhaps due to better access to social resources and support that traditionally came from spouses. In Hong Kong, marriage rates have declined in the past 10 years, and people are marrying later, while non-marriage and divorce rates are increasing, according to statistics released last month by the Census and Statistics Department. Professor Grant Evans, an anthropologist at the University of Hong Kong, says this is the first time in recent history that he has witnessed a growing non-marriage rate in the city that is higher than that in the West.
A mass wedding in Kaohsiung, Taiwan. Studies suggest that married couples enjoy better health than their unwedded counterparts. Photo: Xinhua Yet it seems perceptions on marriage are positive. In a study titled “Trends in Family Attitudes and Values” led by HKU Professor Nelson Chow, 1,000 Hong Kong residents in Sham Shui Po, Shau Kei Wan and Tin Shui Wai were surveyed and it was found that in 1993 only 26.7 per cent believed that married people were happier than unmarried people; in 2006 the figure rose to 39 per cent. “Married people seem to be happier simply because they start off in a better mental state, enjoy mutual psychological support, and develop a meaningful, trusting relationship, which allows them to develop good communication and social skills, allowing them to solve conflicts and maintain other relationships,” says Samson Tse Shu-ki, associate professor at the HKU’s department of social work and social administration. Counselling psychologist Catriona Rogers points out that marriages can be blissful if the couple communicates in a positive way. She cites research by Dr John Gottman, a leading US researcher on marriage and parenting, which shows that to build and maintain a good relationship, there needs to be five times more positive communication than negative – criticism, contempt, defensiveness and stonewalling – or it will end in unhappiness and divorce. However, having companionship – whether with a spouse, partner or
Pick your friends and lovers carefully because they influence you more than you think DR SIMON SHERRY, DALHOUSIE UNIVERSITY
friend – could also go in the other direction, encouraging gambling and addictions. A recent study by Dalhousie University, a Canadian school in Halifax, Nova Scotia, has found binge drinking can be contagious between romantic partners. The researchers looked at 208 unmarried heterosexual dating couples in their early 20s who had face-to-face contact at least five days a week and had dated for at least three months and an average of close to two years. Over the 28 days, the researchers found that they were able to predict one partner’s binge drinking based on the other partner’s binge drinking. “In some respects, this is a cautionary piece of research,” notes Simon Sherry, an assistant professor in the university’s psychology department. “Pick your friends and lovers carefully because they influence you more than you think.” If you’re interested in adopting healthier habits, new research by Massachusetts Institute of Technology suggests you’ll have a better chance of success if you find a friend with similar traits to share the experience. In the internet-based study, published in December in the journal Science, participants paired with others of similar body mass, age, fitness level and diet preferences were three times as likely to adopt healthy behaviour as those matched randomly. Whether married or single, it’s
important to surround yourself with healthy social relationships. They can be as important as not smoking when it comes to your lifespan, and can result in a 50 per cent greater likelihood of survival than those with poor or insufficient social relationships. This is according to a study of 308,849 individuals over 71⁄2 years published in PLoS Medicine in July 2010 by researchers from Brigham Young University in Utah and the University of North Carolina in Chapel Hill. The authors of the study note the importance of these results even for babies’ life expectancies. In the mid-20th century, mortality rates for infants in orphanages were substantially decreased with changes in practice and policy to promote social interaction. They note that medical professionals were stunned to learn that infants would die without social interaction. To conclude, they make a compelling case for social relationships to be added to the list of risk factors such as diet, exercise and smoking, and suggest making it part of medical evaluations and screenings. They infer that medical care could recommend enhanced social connections; hospitals could involve patient support networks in treatment regimens, and health care policies could likewise benefit from accounting for social factors in efforts aimed at reducing mortality risk.
DIET 9 RECIPE FOR HEALTH
It’s all Greek ..................................................... Elle Kwan healthpost@scmp.com
NUTRITION
Little pots of gold
Since losing 27 kilograms six years ago, the founder and director of the Cambridge Weight Plan Hong Kong, Sarah Armstrong, has focused on helping others reach and maintain weight goals. Yogurt is a natural choice for healthy eating, she says. Her yogurt recipe features plain Greek yogurt, which is strained to remove high levels of lactose, sugar and whey, resulting in a thick, creamy texture even for the reducedfat versions. Greek yogurt contains as much as double the protein of other varieties, making it a great option for those looking to cut meat intake. It can also replace sour cream and cream cheese in savoury recipes. Adding fruit and nuts to yogurt not only keeps you feeling full longer, but also feels just as indulgent as a sugared breakfast or dessert. This recipe, says Armstrong, is high in antioxidants, protein and good fats, and low in sugar and carbs – all in a sub-200 calorie package. Fruit and almond yogurt swirl Serves 2 1 dessert apple, with peel on, finely chopped 125 grams blueberries 300 grams Greek yogurt 10 grams sliced almonds Cinnamon to taste
..................................................... Elle Kwan healthpost@scmp.com Yogurt has been around for millennia, but it’s seen a global boom in recent times. Statistics from data research company Euromonitor International show that retail sales of probiotic goods hit US$21 billion in 2009, despite recession doom and gloom, with interest in digestive health propelling sales. Promoting good digestive health has been led by that buzzword: probiotics. The World Health Organisation calls these “live microorganisms”. Said to be responsible for good overall health and wellbeing, probiotics have become especially known for their supposed ability to soothe the digestive tract
We don’t advise milk for people with upset stomachs, but yogurt may be a comfort CHRISTINE JONKERS, NUTRITIONIST
and aid digestion because of their “healthy bacteria”. The promise of an inexpensive, highly available product packed with these healthy bacteria has proved alluring. Yakult, the Japanese drink, led the market in 2009 with a 29 per cent share, according to Euromonitor.
But if achieving good gut health is a top priority for you this year, look at labels. There has been much confusion over the actual benefits yogurt can offer. Case in point: court rulings on yogurt maker Dannon in the US in 2009 found the company guilty of falsely misleading consumers in advertising for its Activia and DanActive products. Both yogurts sold for 30 per cent more than other brands because they claimed special bacterial ingredients that the company advertised as clinically proven to help strengthen immune systems and regulate digestion. Soon after, regulators in Europe banned advertising similar health benefits that could not be backed up with hefty scientific research. This is not to say that yogurt cannot be good for digestive health.
EAT SMART
Simple pleasures of the tenderloin ...................................................... Jeanette Wang jeanette.wang@scmp.com It’s a muscle that does very little work, and that’s why the tenderloin is the most prized part of an animal. It needs just a little salt and coarse black pepper to taste good. This simple recipe comes from Orchard Garden Cafe & Restaurant, which has four outlets in Hong Kong. You can replace the garlic and spring onion with green and red bell
pepper, onion and/or carrot to increase the dietary fibre of the dish. Beef skewers with garlic slices Serves 1 2 cloves garlic, sliced 2 stalks spring onion 120 grams beef tenderloin 1 ⁄4 tsp salt and black pepper 1 ⁄3 tsp olive oil • Bake garlic slices in 270- to 300-degree Celsius oven for five to seven minutes.
• Slice spring onion into six strips. • Slice beef into six small cubes and season with salt and pepper. • Thread beef cubes onto skewers alternating with spring onion. • Heat oil in a griddle. • Pan-fry beef skewers and serve with sliced garlic. This column features recipes provided by the Health Department as part of its EatSmart@restaurant.hk campaign. For more information, visit restaurant.eatsmart.gov.hk
Though a milk product, live cultures in yogurt means the body digests it differently – and more easily – than actual milk, says Christine Jonkers, a nutritionist with Super Natural. “This is why we don’t advise milk for people with upset stomachs, but yogurt may be a comfort,” she says, adding that yogurt may also suit those with lactose intolerance. However, the cultures in yogurt have not been proven to “boost” the health of the digestive tract, says Jonkers. Tests so far have been small in scale, and companies must offer substantial proof of their claims before being allowed to advertise. Yogurt has other advantages: it can contain up to 30 per cent of an adult’s daily calcium needs and half what children require, as well as being a rich protein source. So, it’s worth including in your diet.
• Place chopped apple in a bowl and microwave on high for one minute. • Add blueberries to the apple and microwave for a further one to two minutes. Leave to cool. • Place some fruit in the bottom of a glass and sprinkle with almonds and cinnamon. • Add a layer of yogurt. • Repeat, building up layers and finishing with a final layer of fruit sprinkled with almonds and cinnamon. • Serve chilled.
Chan Cudennec, a cleansing specialist and founder of Sol Wellness, goes for the most natural yogurt possible: plain and full-fat. This is because manufacturers may add artificial sweeteners or increase sugar levels in lower-fat varieties to mask the loss or try to replicate consistency of the creamier, full-fat versions. Furthermore, flavoured choices can be high in sugar, she says. “It varies from brand to brand, but some are very high in sugar content; it’s quite shocking and clear that they are catering to kids who like sweets,” she says. Try buying plain types and adding fruit at home for a healthy snack, mix it in a smoothie or add to savoury dishes, Cudennec suggests. Yogurt is an unbeatable ingredient in dressings and sauces.
10 FITNESS
Our groom-to-be gets to grips with Bulgarian bag ...................................................... Jeanette Wang jeanette.wang@scmp.com If it’s good enough for Olympic wrestlers, it’s definitely good enough to whip the average human into shape. Chalothorn Vashirakovit, our groom-to-be on a six-week bridal bootcamp to lean up and lose 5kg, would attest to that after his first encounter with the Bulgarian bag. “I definitely felt the work in my core, back and thighs. They were aching all over the next day ... I almost had to roll out of bed instead of sitting up,” says the 30-year-old investment associate with a global investment firm. Before being introduced to the fitness tool last week by personal trainer Matthew Ha of Pure Fitness in Admiralty, Chalothorn had never seen nor heard of the Bulgarian bag. It’s been a favourite among gym-goers in recent years for functional fitness – or fitness that helps in everyday movement. Created in 2005 by former Bulgarian Greco-Roman Olympic wrestler Ivan Ivanov, the bag resembles a crescent-shaped leather bolster. But there’s no
Compared with circuit training on machines … this was more fun and engaging CHALOTHORN VASHIRAKOVIT
hugging required. Instead, by swinging, spinning, throwing, lifting, pulling and performing other multi-planar movements with the bag, the body is put through a workout that combines both cardio and strength. Ha says this creates a higher metabolic demand on the body, leading to higher fat and calorie burn. “In Bulgarian bag training, two different actions must work
together: resistance and overall body movement. The ballistic nature of the exercises creates a challenge for the muscles that cardio or a strength workout alone does not achieve,” he says. “So it’s tops for fat loss, core stability and strength training, and really builds cardiovascular endurance, as well.” Chalothorn had plenty of time to become acquainted with the Bulgarian bag last week – through four sessions of circuit training with it. Although it took a while to grasp and get used to the motion and technique of using the bag, he was soon in the swing of things. “It was a pretty strenuousness method of working out without feeling bored,” he says. “Compared with circuit training on machines the previous week, this was more fun and engaging. “What I didn’t like so much about it is that for some of the exercises with the bag, no one specific muscle group is isolated. Hence, you can kind of cheat a little bit to get the exercise done. In my opinion, this exercise is most effective if the form or technique is perfect.” The hardest part of his weight-loss programme, he says, has been keeping to a healthy diet. He’s started having breakfast and a smaller lunch and dinner, and snacking on fruit instead of chocolate. But he has found it a challenge to avoid carbohydrates, especially rice. “Come on,” he says, “I’m Thai, after all.” With two weeks of training under Ha and boxing coach Jimmy Leung completed so far, Chalothorn says he feels “more firm” and his trousers are “slightly looser”. And while there has been no drastic change in body fat and weight as yet, Ha says there’s a visible difference in his trainee’s abs – the eight-pack is starting to peek through. “I think his jawline is more pronounced, too. I’m looking forward to seeing only one chin soon,” says Chalothorn’s fiancée, Melina Lee. “I think overall his physique is also leaner, and he is starting to look better in his clothes.”
Rob Lilwall on the banks of the Yellow River. Parts of the river were frozen solid but as Lilwall and expedition partner Leon McCarron continued downstream it became a flowing body of water, carrying huge blocks of ice
PERSONAL BEST
Of tales and truths ...................................................... Sasha Gonzales healthpost@scmp.com We hear these proverbs all the time – and many of us live by them – but do they hold any truth, or are they merely empty adages? Here’s the experts’ take on 10 of the most common health axioms. 1. An apple a day keeps the doctor away: TRUE There is definitely truth in this one, according to Charmain Tan, registered dietitian at Seventeen Nutrition Consultants (www.my17.com). “Apples are high in fibre, vitamin C and antioxidants, so eating them every day keeps your digestive and immune systems healthy,” she says. A high-fibre diet is strongly believed to prevent colorectal cancer and other ailments. Apples also contain phenols, which Tan says reduce bad cholesterol and increase good cholesterol. A recent Cornell University study found that the flavonoid quercetin contained in apples protects brain cells from neuro-degenerative disorders such as Alzheimer’s disease. So, munch away.
Chalothorn swings the Bulgarian bag as personal trainer Matthew Ha looks on. He aims to lose 5kg in time for his wedding day. Photo: K.Y. Cheng
2. You are what you eat: TRUE About 90 per cent of the diseases that
afflict humans are diet-related, says Tan, so if you eat junk, you can expect to feel like it, too. Obesity, gout, diabetes, heart, kidney and liver disease are all directly associated with what you consume. Alcohol and processed foods are also linked to depression. So, eat for your health and stick to simply prepared, low-fat, high-fibre “whole” foods that are rich in vitamins and minerals, and avoid fatty, high-sodium and overly processed ones. 3. Eat breakfast like a king, lunch like a prince and dinner like a pauper: TRUE At breakfast, your body replenishes its glucose levels in preparation for the day ahead. So if you skip breakfast, you will be less alert, and your attention span and productivity will suffer, Tan says. Eating breakfast also helps curb hunger and stops you from binge eating later in the day. The more active your day is, the more foods you should eat that provide sustained energy – such as wholegrain toast and cereal, fresh fruit or oatmeal. “Lunch should be medium-sized, or substantial enough to fuel you for the afternoon,” adds Tan. “The portion should be smaller than breakfast but larger than dinner.
Keep dinner small, light and simple to avoid weight gain. “If you eat a large dinner, your body can’t use all the energy in the food and therefore stores it as fat,” she says. 4. If you go out with wet hair, you’ll catch a cold: FALSE “Technically, there is no causal link between catching a cold or the flu, both of which are due to viral infections,” says Dr Winnie Mui, a general practitioner at Dr Lauren Bramley & Partners. “A wet head is just uncomfortable in cold weather, and the water can freeze in your hair in colder temperatures. A number of studies have been conducted on the link between wet hair and colds, and none has been able to provide any scientific proof of cause and effect for this old wives’ tale.” 5. Use it or lose it: TRUE You might have heard this one in reference to hearing. Interestingly, there is something called auditory deprivation, says Mui. “This is a medical term that refers to loss of stimulation to hearing that weakens the nerves, muscles and areas of the brain responsible for hearing,” she explains. “With the onset of hearing loss due to a variety of reasons, it’s important to get proper hearing aids
WELL-BEING 11 WALKING HOME
Down to the river ...................................................... Rob Lilwall healthpost@scmp.com After almost two weeks of walking along the Great Wall, we finally reached the edge of a huge valley, which we descended on a road of swerving switchbacks. About halfway down, we looked across a gully to see another Great Wall watchtower, so we scrambled across to it, and as we arrived, gasping, at its base, there it was below us: Huang He, the mighty Yellow River. I had seen the Yellow River once before – in the city of Jinan, when I was cycling down the east coast about seven years ago. There, near the river’s mouth, the river was a turgid, brown-yellow mass, and in the stifling, humid summer air, it looked almost boiling. Here, in the middle course, the river was a deep grey and brown colour. We could see a huge dam upstream across the river, which was frozen solid, although below the dam, the river was flowing again. Huge cliffs well over 100 metres high encased the river, and, as we followed it as part of our 5,000 kilometre walking expedition, we saw a series of twisting cliff roads, villages and occasional factories that ran along the top. The Yellow River is known as the “mother of China” because through the millennia it has fertilised and
irrigated the land, and it is here that China’s earliest documented civilisations arose. But it’s also known as “the sorrow of China”, because of its propensity for regular and terrible floods, which through the centuries are thought to have killed millions of people. The reason for the floods is that the river carries huge quantities of sediment – mostly loess, the soft yellow earth of the river’s upper and middle reaches. In fact, it carries more than 36kg of sediment per cubic metre of water, compared with the less than 2kg by the Nile. This sediment is then deposited on the riverbed downstream, meaning the bed is always rising, and so huge embankments are needed to control the river. While the huge number of dams built in the past 50 years have tamed the river somewhat, it still poses many challenges, not least that the silt is always clogging up the dams. What’s more, due to pollution, half of its water is now considered biologically dead, and because of excessive use, since the late 1970s the river has often run dry before it even reaches the sea. We hiked down the side of the hill to the water’s edge and followed a path that led to the next village about 10 kilometres downstream. That night we camped in a flat area of small trees, rather nervous about the following day because we would
The Yellow River carries more than 36kg of sediment per cubic metre of water; the Nile, less than 2kg
have to walk along a treacherous slope of loose rock beneath the high cliffs and above the icy river. We picked our way along the scree for much of the morning. Blocked by sheer cliffs ahead of us, we had to follow a gully high up into the hills again, through a scattering of villages. Eventually, we found a road that led us down, two days later, to Hequ county on the east side of the Yellow River in northwest Shanxi province. A smart car pulled
up just as we approached the city centre, and a friendly man invited us back to his family house for dumplings and wine. From Hequ we continued south along the river. Another 50 kilometres downstream, it finally became a flowing body of water, full of massive blocks of ice and snow, and mostly frozen along its edges. We had planned to carry portable inflatable kayaks and use them when we reached the river. However, we abandoned the plan earlier on in the expedition as the delays so far meant that the river was going to be dangerously frozen in parts. As we walked along the river, I thought it was the right decision because there was quite a high risk of drowning in the unfrozen parts. This week, we will reach the incredible Hukou Waterfall, where we will cross into Shaanxi, the neighbouring province of Shanxi, and head to the ancient capital of Xian.
Jeanette Wang jeanette.wang@scmp.com
PitaBoon Pita Bread With Whole Wheat 10 pieces for HK$29, City’super Baked in Hong Kong, these palm-sized pieces are ideal for making mini-stuffed sandwiches for children or as party finger food. Contain no additives or preservatives. Verdict: crisp on the outside and wonderfully chewy inside.
Heritage Wholemeal Pitta Bread Six pieces for HK$35, City’super Imported from Britain, these make a good alternative to pizza base. Spread on tomato purée, add your favourite toppings and a sprinkling of mozzarella, and grill for a quick and easy treat. Verdict: wholesome in flavour, but a tad dry and floury.
9. Sitting too close to the TV will ruin your eyes: FALSE This is nothing more than good old scaremongering. Mui insists that there’s no direct correlation between a viewer’s distance from the television and your vision. Sitting too close to the tube may strain your eyes and cause fatigue, but your eyesight will not be any the worse.
Illustration: Bay Leung
6. He who takes medicine and neglects diet wastes the skills of the physician: TRUE This Chinese proverb recognises the importance of food in disease prevention. One cannot rely solely on medication to recover from an illness or control disease, says Tan. It is
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Rob Lilwall’s previous expedition, Cycling Home From Siberia, became the subject of an acclaimed motivational talk, a book, and a National Geographic television series. Every week in Health Post, he will write about the progress of his new expedition, Walking Home From Mongolia, which is in support of the children’s charity Viva. www.walkinghomefrommongolia.com
says Mui: “Feeding a cold helps maximise your body’s nutrient levels, giving your immune system the energy to fight the viral infection. And the idea of starving a fever may stem from a loss of appetite during the illness. When the body’s digestive activity is reduced, it is believed that the immune system can function more efficiently.”
to continue stimulation of your hearing apparatuses so you don’t lose the hearing you have left.”
THE TASTE TEST PITA BREAD
important to also adopt a healthy diet to keep your body functioning properly. For example, if you suffer from diabetes, your medication will work more effectively if you also watch your sugar, salt and fat intake and exercise regularly.
“With this mindset, you will eat healthily and live a longer, happier life. Eating healthily does not mean giving up your favourite foods; you can still treat yourself, but don’t go overboard. Moderation is a key so that you don’t feel deprived.”
7. Eat to live, don’t live to eat: TRUE “If you can understand this concept and apply it, you will not feel guilty for not eating right,” Tan says.
8. Feed a cold, starve a fever: FALSE There is nothing to support this one, but medically, the following may explain why it is so widely accepted,
10. Wait an hour to swim after you’ve eaten: TRUE Growing up, you might have been told to wait for your food to digest before jumping into the pool. And there might be an element of truth in this, according to Mui. The muscles in your limbs and your stomach will compete with each other for blood and oxygen, and when this happens, you risk getting cramps in your stomach and/or limbs.
Luk Ming Bakers Pita Whole Wheat Six pieces for HK$28, City’super Large and light, the thin skin of this bread doesn’t hold up well when filled. Instead, try slicing it into triangular chips, toast until crisp and serve with hummus or other dips. Verdict: much lighter than typical whole wheat varieties.