20120228 health post

YOUR GUIDE TO LIVING WELL

TUESDAY, FEBRUARY 28, 2012

HEALTH POST Tomorrow’s World Rare Disease Day aims to bring attention to sufferers >PAGE 6

Against all odds

THE PERILS OF A LOW-FIBRE DIET

TRAIL RUNNER’S GUIDE TO HK

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>PAGE 8

2 NEWS APP OF THE WEEK

OBESITY

Stay one step ahead of your baby’s development

Nifty ways to cleave your blubber ......................................................

Jeanette Wang jeanette.wang@scmp.com

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Katie McGregor healthpost@scmp.com WebMD Baby Free Rating 10/10 Some months back we reviewed an app to take you through pregnancy.

In a “pregnancy” most would envy, several months later we have a fictional, for-the-sake-of-thisreview, two-week-old baby called Miranda. We highlight that this is a fictional baby to reduce the e-mails of congratulations.

WebMD is a US company known for its medical information websites, which have more than 100 million users per month. With advertising revenue in the hundreds of millions of US dollars, you would not expect a product from WebMD and WebMD Baby to disappoint.

WebMD Baby is an all-in-one baby organiser. It doesn’t just give you advice, it also makes it easy to keep baby records in one place. The app promotional video suggests you can do all this with one hand while holding the baby with the other. I would say this is bad advice, unless you have a docile baby.

To use the app, register and then enter the baby’s details, such as name and date of birth. If you have multiples, it allows you to “Add Baby”. If only it were that easy.

Whenever you log in, you will see age-relevant articles, tips and advice checklists such as what to expect at the one-month check-up. All articles have been reviewed for accuracy by a medical doctor, and you can check out the source research.

If you want more information, flip to the Baby 101 section, where you can browse through categories

such as Just for Dads, Parenting Tips, Milestones and Illnesses & Emergencies. The information can all be downloaded onto your iPhone, so you won’t need to worry about getting caught out if you don’t have internet access.

The highlight is the Journal section. In the haze of the first months, it’s not always easy to remember to record things, and you do need to do this, from baby’s first smile – you can photograph or video this – to the frequency and category (wet, dirty, both) of nappy changes.

You don’t want to photograph this.

The Feeding tracker is well thought out, allowing you to record the time spent feeding your baby, or to set up a schedule with an alert.

With a tap of your finger, you can record how much your baby spends on the left or right side if breastfeeding, or on the bottle. This helps keep things balanced.

And if you are into sharing, you can post your key moments on Facebook or e-mail friends.

By the end of 2015, the World Health Organisation predicts that the planet will have approximately 2.3 billion overweight people aged 15 years and above, of whom more than 700 million will be obese.

That’s a scary statistic, first because children (who are becoming increasingly overweight) are not included in the figures, and second because it means, mathematically, that two out of five people are likely to be overweight.

Hongkongers reportedly reached that rate in 2010, although the age range surveyed by the government was different. Among adults aged 18 to 64, 21.7 per cent were obese, and another 18.7 per cent were overweight.

Body mass index (BMI), which is calculated by dividing the person’s weight in kilograms by their height in metres squared, is the standard.

So, for example, a 1.67-metre-tall person weighing 61kg would have a BMI of 21.9, which is in the normal range (18.5 to 22.9). A BMI of 23 to 24.9 is considered overweight; 25 or above is obese.

But the scale is not the only indicator of weight. The Health Department recommends a combination of BMI and waist circumference to establish the clinical measurement of being overweight or obese. A bodybuilder would have the weight, but also a slimmer waistline, because muscles are denser and take up much less volume than fat. Lean body mass is also metabolically active and needs more calories to maintain.

A large waist indicates fat around the heart, kidneys, liver and pancreas. If the waistline is growing, so is the risk of developing chronic diseases.

Nearly 22 per cent of all Hong Kong adults are obese. Photo: Reuters For Asian adults, the point at which this increased risk kicks in is at a waistline of 90cm or above for men and 80cm or above for women, according to the WHO’s Western Pacific Regional Office. This does not apply, however, to those under 18 and pregnant women.

The steps to successful weight control have been preached many times: keep a balanced diet, get regular physical activity, ensure safe weight loss (0.5kg to 1kg per week), and seek advice from professionals for an individually tailored and monitored programme.

But what about “contagious” weight loss? Researchers at Brown University in the US suggest that shedding pounds can have a ripple effect. The study, published online in the journal Obesity, is the first to examine the effectiveness of an online, team-based weightloss competition.

The researchers looked at the results of the 2009 Shape Up Rhode Island campaign, a 12-week statewide competition that included 3,330 overweight or obese

QUIZ

ASK THE DOCTORS DR ANTHONY LUKE

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1. According to the US National Eye Institute, studies show that a greater risk of AMD sets in at what age? a. 50 b. 60 c. 70

Reuters, Daily Mirror Q: I’ve practiced yoga for years, and I’m 48 years old. Lately, my knees have started to hurt in some of the poses.

Why is this happening?

A: Yoga involves deep stretching and strengthening exercises while achieving a state of mental focus through breathing.

Research has found yoga to be helpful for individuals with various medical conditions and has led to improvements in overall well-being.

Specifically for the knee, studies on Iyengar yoga and strengthening exercises found them useful for patients with knee osteoarthritis (natural wear and tear of the joints that can lead to pain with age).

However, yoga can aggravate knee injuries of those who perform some of the poses, especially when there is over-stretching or kneeling involved.

The most common cause of knee pain in active individuals involves the kneecap

individuals representing 987 teams of between five and 11 members each. Participants who lost at least 5 per cent of their initial body weight tended to be on the same teams. Those who reported higher levels of teammate influence increased their odds of achieving this level of weight loss by 20 per cent.

Lead author Dr Tricia Leahey of Miriam Hospital and Alpert Medical School at Brown says the findings show “teammates influenced each other, perhaps by providing accountability, setting expectations of weight loss, and providing encouragement and support”.

“We’re all influenced by the people around us, so if we can harness this positive peer pressure and these positive social influences, we can create a social environment to help encourage additional weight loss.”

Perhaps it’s time for the Health Department to start a similar citywide weight-loss competition with some attractive prizes for winners.

Preaching can go only so far.

(patello-femoral pain). Being extremely flexible at the joints is a risk factor for kneecap problems. Kneecap pain is often exacerbated when you bend the knee while weight-bearing, such as squatting or kneeling.

If this is the case, you may need to modify the pose to avoid bending the knee too much, such as keeping it from bending less than 90 degrees. Your teacher may be able to suggest alternative positions. If the knee pain is persistent for more than a couple of weeks despite changing your activities or the pain is worsening, it may be time to let your physician take a look.

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

> 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

Age-related macular degeneration (AMD), an eye condition, has been in the spotlight recently after Oscar-winning actress Judi Dench revealed she was suffering from it.

She has lost part of her eyesight and struggles to read scripts or see people sitting in front of her.

There’s been widespread media speculation that Dench, 77, is going blind, but she has disputed this.

“In response to the numerous articles in the media concerning my eye condition ... I do not wish for this to be overblown,” she said. “This condition is something that thousands and thousands of people all over the world are having to contend with. It’s something that I have learnt to cope with and adapt to – and it will not lead to blindness.”

AMD leads to the loss of central vision but leaves peripheral vision unaffected. The painless condition is caused by the degeneration of the macular, the centre part of the retina that lets you see fine detail necessary for reading, driving or doing close-up work. AMD has

2. Figures from the WHO show that AMD accounts for what percentage of global blindness? a. 2 b. 8 c. 15

Actress Judi Dench, 77. Photo: AFP two forms: wet, which is abnormal blood vessel growth in the macula, and dry, in which the macula degenerates and atrophies.

“I had wet in one eye and dry in the other. They had to do these injections, and I think it’s arrested it.

I hope so,” said Dench.

“I can’t read scripts anymore because of the trouble with my eyes.

Somebody comes in and reads them to me, like telling me a story.”

How much do you know about AMD? Test yourself here.

3. Apart from advanced age, which of the following is a non-controllable risk factor for AMD? a. family history b. female gender c. white race 4. Which of the following modifiable risk factors of AMD is the most significant? a. smoking b. diet c. exercise Answers: 1. b; 2. b; 3. all are correct; 4. a (it’s the third most significant risk factor after old age and family history) (Additional reporting by Jeanette Wang)

NEWS 3 HEALTH BITES .....................................................

Jeanette Wang jeanette.wang@scmp.com No pain, no grain Exercise is good for you and – thanks to an initiative by a local fitness training company – also for those less fortunate. Circuit25 has launched the All4One charity scheme, where every calorie burned by participants attending its circuit training classes is translated into an equal caloric donation, in the form of rice, to the needy. On average, a participant burns 800 calories per class – about four bowls of cooked rice, or two bowls of uncooked rice. The total calorie burn at the end of each quarter will be converted into rice donations; the first will be on March 31 with St James’ Settlement the beneficiary. To do your part, just attend a Circuit25 (www.circuit25.com) class. Price per session starts from HK$100 (part of a 50session package) to HK$200.

Sweet pick Fancy turning plain fruit into a delicious dish?

Head to a Wellcome supermarket and pick up their new fruit recipe booklet for just HK$5. The booklet, which features eight recipes by the World Cancer Research Fund Hong Kong, is published in support of Sunday’s Beat the Banana Charity Run at the Tsim Sha Tsui Promenade organised by WCRF HK. It also comes with a 10 per cent discount card for all fruit at Wellcome, so you can stock up on those Korean strawberries or Chilean blueberries used in the recipes. All proceeds from the sale of the booklet will go to WCRF HK for research and education in cancer prevention. Shane Bourk, head of fresh foods for Wellcome, is the Banana Man that runners will be looking to beat this Sunday.

SAFETY

Exercising after sunset raises issues, so here are some tips ......................................................

Alison Johnson From wearing reflective clothing to planning safe routes, “personal safety must be a top priority for anyone running after the sun sets”, says Jean Knaack, executive director of the Road Runners Club of America. Things to consider: • Don’t wear earphones You need to hear everything around you when you can’t see as well. Although listening to just one earphone is better than two, it’s still too easy to be distracted.

• Reflect yourself Choose bright, fluorescent clothing and wear reflective tape on points of motion such as your elbows and ankles to help drivers spot you from a distance. Make sure you have reflective material along your sides

as well as on your front and rear. If all your running clothes are darkcoloured, wear an orange or yellow reflective safety vest.

• Face the traffic You can react more quickly to oncoming vehicles than when they approach behind you.

• Run with a partner Another person is best, although a dog can be a crime deterrent. If you go alone, tell someone when you’re leaving, when you expect to be back and what route you’ll be taking.

• Avoid unlit areas Deserted streets and wooded trails are especially bad ideas at night; stick to familiar and well-lighted routes. Also steer clear of bushes and parked cars, where people can easily hide, especially after dark.

• Identify open stores Make sure your route includes businesses that keep nighttime hours, where you can go in case of an emergency. If you’re nervous about a situation or person, follow your instinct and stop in a safe spot.

• Carry a cellphone and identification If you don’t bring an ID card, write your name, phone number, blood type and any important medical information on an inside sole of your shoes. McClatchy-Tribune

Bird flu forces park closure Yet another dead bird – an oriental magpie robin – in Yuen Long has tested positive for the H5N1 avian flu virus, bringing the total number of dead birds in the city confirmed H5N1-positive to 11 as of last Tuesday. Early this month, a trio of infected dead birds was collected in Yuen Long over a span of 10 days, leading to the closure of the Hong Kong Wetland Park, which is within a three-kilometre radius from where the carcasses were found. The park will be closed until next Tuesday as a precautionary measure. During this time, it will step up cleansing and disinfection, wild bird monitoring, and publicity about avian flu prevention. The indoor section of the park will remain open.

Fill up on fish A diet lacking in omega-3 fatty acids may cause your brain to age faster and lose some of its memory and thinking abilities, according to a study by the University of California, Los Angeles, published today in the journal Neurology.

There are two major types of omega-3 fatty acids – ALA, from vegetable sources (such as kale, flaxseed, canola or soya bean oil), and EPA and DHA, from fatty fish (such as salmon). In the UCLA study, a series of tests and magnetic resonance imaging brain scans were conducted on 1,575 dementia-free people with an average age of 67. Those whose DHA levels were among the bottom 25 per cent of the participants had lower brain volume compared with people with higher DHA levels. Similarly, those with levels of all omega-3 fatty acids in the bottom 25 per cent scored lower on tests of visual memory, problem solving, multitasking and abstract thinking.

4 MEDICAL CASE HISTORY

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Eileen Aung-Thwin healthpost@scmp.com Bloody diarrhoea was a common occurrence for Henry Wong, 53.

He had suffered from a type of inflammatory bowel disease called ulcerative colitis for a decade. However, despite the cramping, abdominal discomfort and diarrhoea associated with the disease, Wong resisted taking proper care of his health. He was much too busy managing his factory in China.

Although several medications were available to help control the inflammation in the colon, Wong (real name withheld for patient confidentiality reasons) chose to use only oral steroids to manage his condition.

He failed to keep a close watch over his diet. While ulcerative colitis patients are advised to avoid foods very high in fibre, such as bran, beans, nuts and seeds, he took it as licence to avoid fruits and vegetables altogether and indulged in a diet high in meat and low in fibre.

One morning, the sight of his diarrhoea shocked Wong badly.

Instead of the bright red blood that was he was accustomed to seeing in his stool, he saw a black, tarry mess.

He hurried to the Hong Kong Sanatorium & Hospital to see his doctor, Dr Annie Chan On-on, director of the Gastroenterology & Hepatology Centre.

When stool turns black, it usually means that the blood in the stool has been in the gastrointestinal (GI) tract for some time.

As ulcerative colitis affects the large intestine and rectum, bleeding caused by this condition often results in fresh-looking blood, because the blood does not stay in the body for long before it is expelled with the stool.

Chan first thought that the bleeding was occurring somewhere higher up in the GI tract. She ordered a gastroscopy for Wong.

A thin, fibre-optic instrument was inserted via Wong’s mouth and throat into his stomach and duodenum (the first part of the

small intestine). Chan found no sign of trouble there.

But Wong continued to purge and was getting weaker. Barely hours after his admission into hospital, he started to feel weak and dizzy. His systolic blood pressure plunged from 120mmHg to 80mmHg. Tests showed that the internal bleeding was severe – he had already lost a third of his body’s blood. Instead of 15 grams of haemoglobin per decilitre of blood, Wong’s reading hovered around 10g/dl.

Chan gave him a blood transfusion immediately, but she also needed to locate the site of bleeding right away.

She used a red blood cell nuclear scan to track down the site of the bleeding. A small amount of radioisotope, a radioactive substance, was injected into Wong to tag his red blood cells. A scan then told Chan how the cells were behaving inside Wong’s body.

Blood was leaking into his caecum, a pouch located where the small intestine, large intestine

Illustration: Angela Ho

Lack of care and fibre a

SURGERY

Jurisdictions of the ......................................................

Elaine Yau elaine.yau@scmp.com

There is little awareness about oral and maxillofacial surgery. Photo: Corbis

If you feel pain in your jaw, what kind of specialist should you see?

Most people would turn to either an ear, nose and throat (ENT) specialist or a head and neck surgeon. But the person you should really be seeing is an oral and maxillofacial specialist.

Specialists in the field – OMF for short – say that public awareness of the dental discipline is so low that patients suffer unnecessary delay in treatment. Despite the abundance of healthcare information in the media and online, public understanding of this medical speciality still remains scant. “[Those with oral and jaw ailments] often come to us after numerous referrals, which waste time and money,” says James Chow Kwok-fai, president of the Hong Kong Association of Oral and Maxillofacial Surgeons.

Chow says OMF is the only speciality that treats disorders of the temporomandibular joint, the small joint located in front of the ear where the skull and lower jaw meet.

“When patients feel pain in the joint, they will go to ear, nose and throat doctor as they feel pain in front of the ear,” he says. “The ear, nose and throat doctor will transfer him to an orthopaedic doctor who will refer the patient to us.

Temporomandibular joint disorders are no different from other orthopaedic ailments JAMES CHOW, PRESIDENT, HK ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONS

[Most of our patients come to us] through referrals.”

The poor public understanding of the speciality was revealed recently in a survey conducted by OMF specialist Alfred Lau Sze-lok. In June last year, 104 people aged 18 years or above were interviewed on how much they know about the field. Three out of four of the respondents said they had never heard of the speciality. For those who had heard of the discipline, they wrongly subsumed general dentistry, dental cleaning and orthodontics into OMF surgery.

Lau says OMF surgery involves oral and jaw surgeries. “We do all surgeries inside the month such as the removal of wisdom teeth and tongue tumours. Cosmetic surgeries include shortening protruding chins and mandible (lower jaw) reductions, to make the face slimmer. We also treat patients born with congenital deformities like cleft lips and asymmetrical faces.”

Lau says the poor public understanding of the discipline has to do with the overlapping of OMF surgery with some medical disciplines in Hong Kong.

“There’s a clearer distinction between our field and other dental disciplines overseas. But in Hong Kong, general dentists can also do surgeries involving wisdom tooth and dental implants. There’s no regulation proscribing general dentists from doing the surgeries.

MEDICAL 5

lethal combination and appendix meet. Because it is far away from the anus, the blood would have darkened while it travelled down the full length of the large intestine and out of the body.

While Chan now knew the location of the bleeding, she did not know why. A colonoscopy was done using an endoscope – a thin, flexible tube with a camera on the end – and Chan was able to have a clear view of Wong’s large intestine. Inside, she found numerous pouches in the wall of Wong’s ascending colon and caecum.

These pouches are called diverticula. Although not proven, the cause of diverticulosis (the condition of having diverticula) is widely thought to be linked to a low-fibre diet.

The condition is more common in Western societies, where processed foods and low-fibre diets are commonplace.

About 10 per cent of Americans over 40 years of age suffer from it.

Low-fibre diets often cause constipation, and straining to eliminate stool can cause weak

jaw But if the surgeries are to be conducted near nerves and there are high risks involved, the patients will be referred to us.

“Our work also overlaps with that of ear, nose and throat specialists and head and neck doctors who do surgeries involving tongue cancer, salivary glands and the jaw.”

There are 51 registered OMF specialists in Hong Kong. The University of Hong Kong is the only tertiary institute that provides training of OMF specialists.

In Hong Kong, a graduate of a five-year dental degree has to get specialist training for a further six years for qualification. Because the dental specialists have to get involved in surgeries, they have to be well-versed in medicine in addition to their dental training, Lau says. “We need to know pre- and post-operative care and common diseases like diabetes and heart disease.”

While Hong Kong categorises OMF surgery as a dental discipline, countries like Britain subsume it under the school of medicine, requiring practitioners to receive specialist training in both dentistry and medicine, lasting 12 years. But Chow questions the need for such lengthy training.

“The 12 years is on top of the five-year dental degree,” he says.

“If we follow what Britain does, we [would] need to invest a lot of resources into training.”

Lau agrees: “Many things learnt as part of a full medicine course can be wasted. Disciplines such as gynaecology have nothing to do with us.”

Chow says some patients have run into problems with insurers because OMF is sometimes classified as a dental speciality. “Due to their lack of understanding of the speciality, insurers see some of our patients as purely dental cases, which are not covered under insurance policies. They even teach our patients to shun our speciality so that they can make insurance claims.

Other patients who want to be eligible for claims check themselves into hospital even though their condition does not require a hospital stay. In fact, temporomandibular joint disorders are no different from other orthopaedic ailments.”

Lau says rising public awareness can lead to better collaboration between OMF specialists and other medicine professionals. “For example, in a surgery on jaw bone reconstruction, we and orthopaedic doctors can work together. After we remove a chunk of tumour-infested jaw, we need the help of orthopaedic doctors to extract bone from the leg for reconstruction.

“Ear, nose and throat or cosmetic doctors involved in jaw surgeries do not know much about teeth alignment. A collaboration with us can provide better treatment for patients.”

Low-fibre diets often cause constipation, and straining to eliminate stool can cause weak spots in the colon to bulge out

spots in the colon to bulge out, thereby creating the diverticula.

However, no one knows what actually causes these pouches to form.

In Wong’s case, several of the diverticula were actively bleeding – blood vessels in the weakened walls of the pouches had burst and were leaking copious amounts of blood.

Using the endoscope, Chan injected adrenaline directly into the bleeding sites to cause the blood vessels to constrict and to close. The bleeding promptly stopped.

Wong was very lucky that the bleeding in the diverticula had been arrested in time. Chan says that the rate of blood loss could have been fatal.

Other complications are also possible. The diverticula can become inflamed in a condition called diverticulitis, resulting in fever, chills, abdominal pain and nausea. A large enough diverticulum can burst and perforate the intestinal wall.

The diverticula can also become infected as bacteria collect in

the pouches, which can potentially lead to the development of abscesses that would need to be drained by a doctor. Perforated diverticula could also leak pus into the abdominal cavity.

The damage caused by infection can also cause tissue to stick together abnormally, or even result in partial or total blockage of the intestines.

Faeces can even become trapped in the pouches and become impacted.

This wake-up call made Wong realise that he needed to better manage his underlying condition, and he was finally willing to make the necessary changes to his medication and diet.

Chan gave him a topical medicine in an enema form that he had to administer daily to control the ulcerative colitis in the left side of his colon, and he remained on a low dose of steroids. With his newfound compliance, Wong’s condition improved, and the bouts of bloody diarrhoea diminished.

6 COVER STORY Twenty-four-year-old Ricky Cheng (right) and his seven-year-old brother Cheuk-ki (below right) both have mitochondrial disease; Sarah, 13 months (centre) has Prader-Willi syndrome; Chung Wing-kei, aged five (far right) suffers from Pompe disease.

Photos: Nora Tam

Illustration: Henry Wong

One in Neglected by governments and drug companies, patients with rare genetic diseases face a life of pain and suffering, writes Elaine Yau

I

magine being dealt a death sentence at the age of five. For Chung Wing-kei, it’s becoming a harrowing possibility after the Hospital Authority decided last December to stop subsidising the medicine that keeps her alive.

Wing-kei, affectionately known as Kei Kei, is one of seven people in Hong Kong who suffer from Pompe disease, a rare disorder that disables the muscles including those of the heart. Though she loves eating cakes and swimming, she can’t do either of those things – she’s confined to a wheelchair, breathes through a respirator and, because of weak oral muscles, is fed only liquid food through a tube connected to the stomach.

Once every two weeks, she gets an enzyme injection. The medicine costs more than HK$90,000 per month, and the Hospital Authority had been subsidising the treatment since 2008.

But an expert panel reviewed her case last August and told Kei Kei’s mother, Man Shuk-man, that the subsidy would stop if the girl was not taken off the respirator by the end of November last year.

“Without the medicine, her condition will keep worsening until she dies,” says Man, a clerical worker, who has since launched fundraising campaigns to help pay the medical bills.

“However, with continuous treatment, she can have a normal lifespan.”

Thousands of people suffer from rare diseases in Hong Kong. While there are no official numbers, Stephen Lam Tak-sum, president of the International Federation of Human Genetics Societies, says several hundred rare diseases have been recorded in local medical literature.

Countries vary in how they define

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t d c d

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d o m t o t

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COVER STORY 7

n a million

rare disease. In the US it’s a disease that affects fewer than 200,000 people; in Europe it’s one that affects less than 1in 2,000 people. In Hong Kong, Lam says in general, a rare disease has an incidence rate of less than 1in 10,000.

“While local medical school involves teachings on such diseases, many doctors have never seen even a single case in their lifetime, rendering diagnosis for patients difficult,” he says.

With tomorrow being Rare Disease Day, paediatricians and patient support groups worldwide are calling on governments to boost resources for studying rare diseases and treating patients. They say patients are mostly abandoned by local governments and pharmaceutical companies which deem it not cost-effective to pour resources into researching cures for diseases that afflict only a tiny population.

There are more than 5,000 rare diseases listed in the world with new ones being described every week in medical literature, and no available treatment for between 4,000 and 5,000 of these afflictions. About 80 per cent of them are genetic in origin.

According to the Pompe Community (www.pompe.com), Pompe disease is estimated to affect about 1in 40,000 live births. It’s caused by a defective gene that results in a deficiency of an enzyme, which leads to excessive build-up of glycogen, a form of sugar. This build-up causes muscle weakness, poor weight gain, heart enlargement and lung infections.

Just like Pompe, many rare diseases are caused by gene mutations that affect the production of enzymes which are necessary for specific chemical reactions in the body,

according to Professor Albert Li Man-chim from Chinese University’s department of paediatrics.

“The lack of enzymes leads to metabolic diseases,” he explains. “In many cases, both parents carry the mutated gene and that does not affect them at all. But after the two mutated genes are combined, there’s a onefourth chance that the offspring will be afflicted with the disorder.”

Other children may get a rare disease from a hidden mutated gene from either the paternal or maternal side.

Sarah, a 13-month-old Danish baby, failed to receive active genes from a specific section of her father’s chromosome 15 and was diagnosed with Prader-Willi syndrome last December at Queen Mary Hospital.

People normally have a pair of these chromosomes, one from each parent.

The disorder, with an incidence rate of 1in 20,000, causes poor muscle tone, short stature and a chronic feeling of hunger that can lead to excessive eating and life-threatening obesity.

Sarah’s mother Rikkle, who has another daughter Emma, two, quit her job with a medical equipment company after she gave birth to Sarah. She and her husband Anders, a financial manager, spend thousands of dollars a month on growth hormones for their child to support healthy development and strengthen muscles. Fortunately for the couple, the government has decided to reimburse the cost of the drug starting from April.

While Kei Kei and Sarah have had their rare conditions diagnosed, the difficulty of getting a diagnosis in Hong Kong creates much anguish for parents, says Christina Hellmann, chairman of the Joshua Hellmann Foundation for

Orphan Diseases which provides support to rare disease sufferers under the age of 19.

She says that some tests may be complicated, so specimens have to be sent overseas, but up to 30 per cent of the blood cells in the specimen can deteriorate in the process. Other tests can be done here, but may be expensive. Hellmann says the foundation is raising money to set up a local laboratory centre in collaboration with the government.

“We hope that the lab could be set up at the Centre of Excellence in Paediatrics which is due to open in 2016 [at the Kai Tak development in Kowloon Bay]. With the lab, doctors can do the diagnosis in Hong Kong,” she says.

Hellmann set up the foundation in 2007 after her son Joshua died at the age of 15 from the rare neuro-degenerative disease Melas syndrome. The foundation has paid for the diagnosis of 42 children with rare diseases so far – and has thereby helped the children receive the appropriate treatment.

One beneficiary is Candy Cheng, a mother of five. Three of her children have suffered from mitochondrial disease type five. Her youngest son, Cheuk-ki, seven, was diagnosed last year with the disease. Her second son passed away at the age of three because of complications from pneumonia in 1993. Her eldest son, Ricky, 24, is blind and wheelchair-bound.

With an incidence rate of 1in 5,000, it is estimated that there are at least 1,400 sufferers of mitochondrial disease in Hong Kong. Mitochondria are the parts of cells that generate energy for the body. Defects in mitochondrial DNA can cause poor growth, muscle weakness, visual and hearing problems,

Many doctors have never seen even a single case in their lifetime, rendering diagnosis difficult STEPHEN LAM, PRESIDENT OF THE INTERNATIONAL FEDERATION OF HUMAN GENETICS SOCIETIES

learning disabilities, heart, liver and kidney disease, neurological problems and dementia.

It wasn’t until Cheuk-ki’s diagnosis that Cheng realised what was wrong with her sons. “After my sons were born, they lacked mental acuity and suffered from weight loss and muscle spasms. I visited every hospital in the city and no one could tell me what was wrong with my sons. Their condition just kept deteriorating.”

In 2010, the foundation arranged for a sample of Cheuk-ki’s muscle cells to be sent to Holland, and the results confirmed the disease. However, there are no drugs available for it.

Cheng says her sons take vitamins and tendon-loosening drugs to treat the symptoms. “Although it can’t be cured,” she says, “at least now I know what’s afflicting them.”

Even when treatments are available, they may be too costly. Expensive enzyme replacement therapies are usually used for rare metabolic disorders, says Stephen Ma On-tat, vice chairman of the Hong Kong Mucopolysaccharidoses (MPS) & Rare Genetic Diseases Mutual Aid Group.

MPS is a group of inherited metabolic disorders that affects organ function and mental and physical development. Ma, whose 19-year-old son suffers from MPS type six, says the enzyme therapy treatment, which became available in 2004, costs more than HK$4 million per year.

Members of the mutual aid group took to the streets in 2007 to fight for the treatment’s inclusion in the Hospital Authority’s Drug Formulary. Only drugs for clinical indications in this database are subsidised. “The authorities look at it from an economic point of view,” says Ma. “They only act following intense public and media pressure.”

The government responded by setting up an expert panel on rare metabolic diseases in 2007, which reviews rare disease cases and decides whether they warrant subsidised treatment. The panel eventually included three of the seven types of MPS on the formulary in 2010 – types one, two and six. There is presently no cure for the remaining types.

So far, the panel has only reviewed four diseases: Pompe, MPS, Fabry and Gaucher’s. Ma says its operations are opaque. “I don’t know which members constitute the panel.”

It’s the same panel that has decided to stop Kei Kei’s subsidies, and Ma is wary of the possibility of that situation one day too.

The Hospital Authority says the panel will continue to assess applications from patients with MPS. “We will consider whether to provide individual patients with subsidised treatment. Meanwhile, the Hospital Authority will provide timely support to patients according to their condition and medical needs.” elaine.yau@scmp.com

8 FITNESS

SWEAT TRAIL RUNNING

Run for your lives ......................................................

Rachel Jacqueline healthpost@scmp.com Ten years ago, Hannes Niggli had never run before in his life. At the time, Niggli identified himself as someone who would have preferred to “drive 10 metres than walk it”.

But after going on a trail run with a friend one day, Niggli was hooked.

The Swiss-born Hong Kong resident of 22 years, and a selfproclaimed trail running addict, has clocked almost 2,000 kilometres running on trails in the past year.

Today, Niggli, 48, runs almost every day to push himself and “be close to nature”.

For some, running for more than 30 minutes sounds torturous; but for a growing number of trail runners like Niggli, running for the best part of a day is relished.

Unlike the certainty of a road run, trail runners may contend with all sorts of terrain during a run – from rocky ascents, to flat paths and uneven trails along rolling hills.

The challenge – and the joy – of trail running is the unpredictability of the terrain. Combined with picturesque scenery and the invigorating outdoors, there is no need for music or any other form of entertainment.

Sounds crazy? Perhaps.

However, the increasing number of Hongkongers running on country trails suggests that the sport is more than just a trend.

This year, at least five new trail running events are on offer in the city. These include the Lantau50 in March (a 51 kilometre race on Lantau Island) and the Sea To Summit in April, which will start at Deep Water Bay and end at The Peak, offering sweeping views of the South Side along the way.

As the race and participant

Train the mind … and the distance doesn’t seem so scary MICHAEL MADDESS, RACE DIRECTOR, ACTION ASIA EVENTS

Competitors enjoy a hard-earned drink after completing last year’s 30th Oxfam Trailwalker. Photos: Jonathan Wong, Fung Ka-fai

numbers have increased, so have the distances. Two Saturdays ago, 750 participants from 28 different countries took to the trails in the New Territories in the Vibram Hong Kong 100. The event, the city’s first solo 100 kilometre trail race, had three times the participation than its inaugural race last year.

Trail runners are also looking further afield for new running terrain. Hong Kong-based Action Asia Events (AAE) has introduced a third multi-day ultramarathon event in Mongolia this year – in addition to its existing race offerings – and plans to add a fourth in Bhutan in 2013.

AAE’s race director, Michael Maddess, attributes the take-up of ultramarathon races to the opportunity for participants to have their own inspirational story and to “experience the local culture in some off-the-track place”.

But it hasn’t always been this way. According to Keith Noyes, director of race and outdoor events organiser Seyon Asia, trail running’s short history in Hong Kong kicked off in 1989 with the Mountain Marathon hiking series.

Noyes took over the event in 1998 and renamed it King of the Hills. The race has transformed into a hallmark of Hong Kong’s trail running scene. In the past

three years, approximately 100 to 150 additional participants have joined each race. Last Sunday, about 520 participants raced the fourth and final Hong Kong Island leg of the 2011/12 series.

Perhaps surprisingly, those attracted to trail running in Hong Kong are not just young, male athletes. According to race organisers, the increase in participation in the sport has come mainly from women aged 30 to 39 and 50-plus. Noyes says the demand has been so great that new categories were introduced in the 2010/11 King of the Hills series for men over the age of 60 and women over 50 in the halfmarathon category.

Felix Shum, director of Xtraventure Training and Events (XTE), which organises the Sea to Summit race, believes that Hongkongers are embracing trail running as a way to “get away from home and work and enjoy nature”.

Noyes adds that it’s a great way to take the mind off everyday stress and get a great “endorphin buzz”.

He also cites the lower rate of injury compared to road running as a motivating factor. While trail runners are more at risk of a sprained ankle, “the usual injuries associated with running – knee injuries, lower back pain – are

FITNESS 9 BRIDAL BOOTCAMP WEEK 4

Punch to beat the paunch ......................................................

Jeanette Wang jeanette.wang@scmp.com

Sandro Gianella on a morning run near Tai Tam reservoir

With a thunderous, flashing left hook, the opponent is floored and so dead to the world that the referee doesn’t even need to count.

Chalothorn Vashirakovit raises his hands in victory, celebrating one of his most stunning knockouts yet.

This all takes place in Chalothorn’s head, of course. As he trains under Pure Fitness boxing coach Jimmy Leung in an attempt to lean up for his wedding next month, he sometimes imagines he’s Manny Pacquiao knocking out Ricky Hatton in that 2009 light welterweight championship fight.

Reality, however, bites.

“Chalothorn wasn’t too well co-ordinated at first,” says Leung, who started working with the groom-to-be a month ago as part of a six-week fitness programme.

“He was particularly weak in twisting and rotation control.”

To be fair, it was Chalothorn’s first attempt at boxing. Although a

I now realise the power that drives the punches and kicks comes from the core muscles CHALOTHORN VASHIRAKOVIT, GROOM-TO-BE

almost non-existent”, says Noyes.

This is likely due to the varied and softer terrain.

For the runners, it seems it’s more than just a chance to get outdoors – it’s a way to transform their lives. James Stewart, 28, says trail running provides “the perfect platform to step out of my world and get into the hills. “ Most of the time there is absolutely nothing going through my head … I’m not looking out for cars or weaving around people,” he says. “I run for the sense of achievement that I get at the end of a run.”

It’s is also a way to become part of a growing community of like-minded people. This company of fellow runners is one of the motivating factors for Claire Price, 42. “You meet lots of interesting people,” she says.

While the sport appears to display the ultimate level of athleticism and endurance, this should not deter those wanting to give it a try. While photographing the Racing the Planet 100 kilometre race in Nepal in 2010, adventure photographer Wong Ho-fai, 27, thought: “If they can do it, I can do it as well.”

A year later, he completed the same race. Today, he’s an accomplished trail runner

Photographer Wong Ho-fai completed his first trail run a year ago

HEAD FOR THE HILLS To sign up for a race, visit the following sites Action Asia Events: www.actionasiaevents.com King of the Hills: www.seyonasia.com Lantau50: www.lantau50.com Vibram HK 100 Ultra Trail Race: www.vibramhk100.com XTE: www.xte.hk

sponsored by the adventure sports equipment company, Salomon.

While Ho had hiked and rock climbed in the past, he has progressed from novice runner to expert in only two short years.

The move into longer, ultramarathon distances appears to be a natural progression for trail runners, rather than a conscious choice. While Price, a record-holder for many trail races in Hong Kong and overseas, started with 30 to 40 kilometre distances, after 10 years on the trails she finds that 100 kilometre races are now “quite normal”.

In addition to the obvious health benefits, trail running offers the ultimate mental challenge.

“Train the mind … and the distance doesn’t seem so scary,” says Maddess, himself a top trail runner. “The next thing you know … you’re crossing the finish line and have changed your life and priorities forever.”

With this city offering the perfect topography for trail running and the need for nothing more than some basic fitness, a pair of running shoes (trail is best but road will do too), and the decision to do something different, it seems that nothing should stand in the way for even more people to start blazing Hong Kong’s trails.

native of Thailand, where kickboxing is a national sport, he is certainly not a natural.

“I struggled so much with the co-ordination, especially the footwork, in the beginning,” says Chalothorn, 30, an investment associate with a global investment firm. “What surprises me most is how much of the power [in boxing] comes from the core. When I watched matches on TV, I thought it was all about the arms and legs, but I now realise the power that

drives the punches and kicks comes from the core muscles.”

Leung says boxing is an explosive and intense full-body workout that is great for training the heart, burning fat and achieving a defined physique. It also helps balance one’s body shape, as the workout doesn’t isolate any particular body part.

The once-a-week, hour-long boxing sessions involve many rounds of short bouts of intense work – such as punching and kicking a pad or bag, doing sit-ups, and agility ladder training. Leung monitors Chalothorn’s heart rate throughout, adjusting the rest time between intervals accordingly.

At the start, Leung says, Chalothorn’s recovery time was “fairly long”, but it has improved greatly over the weeks, with the rest time now halved to only about a minute.

Chalothorn, a former road cyclist until he became sedentary four years ago, likens boxing to the attacking sprints in cycling. “I find that my heart rate is constantly at the upper end of my aerobic zone.

However, the interesting thing is that I don’t really pay that much attention to it because, most of the time, my mind is focusing on punching the target,” he says.

The next day he is reminded how hard he worked by his aching hamstrings (from the kicking), calves (from the tip-toeing involved in the footwork) and core (from the twisting).

Boxing has been a great complement to the training sessions that he has three times a week under Matthew Ha, a personal trainer at Pure Fitness Admiralty. With a little more than two weeks to go to the wedding in Phuket, Thailand, Chalothorn is giving it his all to achieve his goal of losing 5kg and gaining a cut body.

Even his friends are cheering him on. Recently, one sent him a topless photo of buff actor Ryan Gosling from the film Crazy, Stupid, Love as a form of inspiration.

“It’s quite a stretch as a target,” says Chalothorn, “but that’s fine.”

Chalothorn Vashirakovit kicks out as Jimmy Leung watches. Photo: Nora Tam

10 WELL-BEING WALKING HOME

Visas and other woes ......................................................

Rob Lilwall healthpost@scmp.com Over the past month, my expedition partner, Leon McCarron, and I have made fast progress south along the Yellow River, and then crossed from the province of Shanxi into Shaanxi, and out of the mountains and onto flat, fertile plains that will lead us to Xian, the capital of Shaanxi and the ancient capital of China. We are now very nearly halfway through our 5,000-kilometre walk home to Hong Kong from Mongolia.

However, our progress suddenly came to a temporary halt due to that rather modern traveller’s woe – a visa headache. We had watched the days left on our Chinese visa tick down for the past few months, and when it had almost run out, we faced the option of either attempting to renew it within China (time consuming, expensive, small chance of success), or stop walking (marking our exact spot) and jumping on a plane for a “turn-around-flight”.

We’d fly to another country, get off the plane, and then (more or less) get back on the plane and fly back again to get a new stamp on our multiple-entry visas.

We opted to do just this from Xian’s airport, but decided against flying to Hong Kong. Instead, we flew north and back to the border with Mongolia, which we re-entered by land. Then, two days later, we turned around and re-entered China. It seems the operation has been a success, though it does seem rather absurd.

This is not the first time I have had visa headaches to deal with. On my three-year Cycling Home From Siberia expedition, visa renewal was

not the problem, but rather sorting out new visas, as I was travelling through a lot more countries.

I have a British passport, which is a pretty good one for visas on the whole – at many places (such as Japan, South Korea, Thailand, Europe) I could just get it stamped when I arrived at the border. Other places (such as China, Nepal, India and Pakistan) were reasonably straightforward: I just had to apply for the visa at the embassy in the country where I was previously (for example, I got my Indian visa in Nepal).

There was also a third tier of places, however, where things got considerably more complicated – especially in countries that had been part of the Soviet Union.

For example, as my friend Al Humphreys and I prepared to cycle across Siberia in the winter, we needed, at minimum, a threemonth visa. A tourist visa was only for one month, so we had to get a business visa. We were told we simply needed to write a letter to the Russian embassy explaining why our business needed to take us into Russia.

So we invented a business called the “English Wildman Wafflings”.

Al created a letterhead, which declared him the president and me the vice-president. In the letter we explained that we needed to go to Russia to further EWW’s business relations with the motherland.

A few weeks later, we received our three-month visas.

Another complicated place for visas was in Central Asia, where, after a lot of research and planning, I ended up getting my visa for Pakistan and Iran, and a Turkmenistan letter of invitation in

Lilwall’s visa headaches echo his situation during his Cycling Home From Siberia trip. Photo: Rob Lilwall Delhi. I then cycled to Islamabad, where I got my visa for Uzbekistan; onwards to Peshawar for my Afghan visa; then in Kabul I used my Delhi letter of invitation to get my visa for Turkmenistan. Somehow I made it through and across all these crazy borders – through no small amount of luck, the plan worked.

From my experience, my top tips for sorting out visas for your journey would be: first, visit the website of the country’s embassy. (A good one will tell you what you need to do – and hopefully it’s a straightforward process.) Second, cross-reference the embassy website information with an up-to-date guidebook.

And finally, have a look on the Lonely Planet Thorn Tree website – which is basically a chat room where travellers all over the world exchange up-to-date information.

In the letter we explained that we needed to go to Russia to further business relations with the motherland

EAT SMART

Firm and fair: ling is just the thing for an absolute beginner ......................................................

Jeanette Wang jeanette.wang@scmp.com Ling – the largest member of the cod family, which grows to 2 metres long – is popular for its mild flavour, versatility and good value. The firm, white flesh stands up to all types of cooking – pan-frying, grilling or baking – making it simple to handle even for novice cooks.

This recipe from the Tsui Wah Restaurant chain involves salting and then poaching ling fillets for a few minutes, a healthy method that needs no oil. Each serving has 150 calories, six grams of fat, eight grams of carbohydrate and 18 grams of protein.

I’d hold the sea salt, though – at 747 mg of sodium per serving, there’s room to cut back on the

seasoning. Let the tomato purée and balsamic vinegar do their magic.

Sea-salted ling fillet with tomato purée and balsamic vinegar Serves 2 160 grams ling fillet 1 ⁄2 tsp salt 2 tsp olive oil 1 1⁄2 tbsp minced garlic 3 pieces white shimeji mushroom 3 pieces fresh shiitake mushroom 2 asparagus spears, blanched 1 red capsicum, sliced into rings 1 yellow capsicum, sliced into rings 4 lettuce leaves 1 ⁄4 bowl fresh tomato purée 1 sprig mint 1 tbsp balsamic vinegar • Season fish fillets with sea salt and set aside.

• Heat oil in a wok. Sauté minced garlic, then add mushrooms and stir-fry until aromatic. Season with sea salt and place on a lettuce leaf on a plate.

• Make another arrangement on the plate with a stalk of asparagus and a few rings of red and yellow capsicum over another lettuce leaf.

• Repeat these arrangements on another plate.

• Bring water to the boil, then reduce heat to low. Poach fish fillets for four minutes until cooked through. Transfer to the plates and pour the tomato purée over them.

• Garnish with mint and serve with balsamic vinegar.

Recipe provided by the Health Department as part of its EatSmart@restaurant.hk campaign.

For more information, visit restaurant.eatsmart.gov.hk

As a final resort, there are also dozens of visa agents around. They will charge you (perhaps US$50 or US$100) to sort out a visa, but they save you a lot of headaches, and may be able to get you a visa you could never get on your own. This is what I had to do for Iran.

With the new stamp in our passports, we are good to go for another few months of serious walking. And three months should be, I hope, almost enough time to reach home.

Rob Lilwall’s previous expedition, Cycling Home From Siberia, became the subject of an acclaimed motivational talk, a book, and a National Geographic TV 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

WELL-BEING 11 THE TASTE TEST SALSA ......................................................

Jeanette Wang jeanette.wang@scmp.com

Pilpel Capsicum Turkish Salsa 200 grams for HK$70, City’super This vegan salsa isn’t your regular salsa. In fact, it contains no tomatoes, but 80 per cent roasted capsicum. Blended with Turkish herbs and spices and a touch of chilli, it’s richly coloured, flavoured and textured – and thoroughly addictive.

Verdict: delicious as a dip, but also a as chicken marinade and pasta sauce.

Douglas Pieterse credits his wife, a former champion kickboxer, with overhauling his diet, which consisted of ‘lots of junk and fast food’

FIT & FAB

His body of evidence Santa Barbara Roasted Garlic Salsa 397 grams for HK$46, City’super You don’t want to be talking to (or kissing) anyone after eating this, as the garlic and coriander flavours are strong in this chunky, tangy salsa. The fresh tomatoes and diced peppers give an enjoyable slight crunchiness to the dip.

Verdict: Watch out for the preservatives in this one.

La Mexicana Hot Salsa 453 grams for HK$47, City’super At 10 calories per two tablespoon serving, and low in fat, sugar and sodium, this salsa seems like the perfect indulgence with a bag of tortilla chips. It has a good balance of diced fresh tomatoes, peppers, onions, coriander, garlic and spices.

Verdict: tasty and not that spicy, but note the preservatives.

......................................................

P. Ramakrishnan rama.p@scmp.com The rule of thumb is simple: you cannot go to a dentist who has bad teeth, visit a doctor who has poor health habits, and you surely can’t be trained by someone who looks like they could use a sit-up or 20.

The merits and perils of the job are such that personal trainer Douglas Pieterse, 30, co-owner of Sweat gym on Stanley Street in Central, has to maintain a fit and fabulous physique. Not much of a challenge for someone listed in a magazine as one of the eight best bodies in Hong Kong, right?

“I don’t really know what to say to that, but I was surprised when the magazine opened with my shot,” says Pieterse.

“There was a rugby player who had eight-pack abs.”

As a Brazilian jiu-jitsu exponent, he’s never had to wrestle with weight or wage a battle of the bulge. “For the job, yes, I do think it is important to lead by example,” he says. “It’s important that I know what the clients are going to experience; I convey the exercise to them. Working out is not easy; it’s a commitment.”

With a wife, two sons under the age of two, a full-time job and an overbooked schedule, it’s amazing that Pieterse finds time to work out. “My day often starts at 5am and ends quite late. In the middle, I make time to work out, usually in the late afternoons, the non-prime

time hours, when most people are at work. I also ensure that I dedicate some time to my own workouts on weekends.”

I heard your wife, Joey Lee, a former champion kickboxer, really kicked your diet into gear.

She did. The prime changes were made post-marriage, as she’s very careful about what she eats. As a busy personal trainer, I ate really badly. I ate lots of junk and fast food, as time was a limitation. In between appointments, it was KFC, McDonald’s, cookies and sandwiches loaded with trans fats.

I grabbed whatever I could find.

It’s true I didn’t have six-pack abs before because, as much as I trained, you cannot out-train a bad diet.

What did you start eating?

Lots of greens. Now my diet mainly consists of whole foods, vegetables and fruits. No surprise there. But it’s also making sure I make time to eat right. For breakfast, oats and

I didn’t have six-pack abs before because, as much as I trained, you cannot out-train a bad diet DOUGLAS PIETERSE, PERSONAL TRAINER

flax seeds with bananas or apples.

Afternoons are hard, and I have to confess, even now I basically eat what I can get my hands on.

Evenings tend to start with vegetables, broccoli, cauliflower and vegetable soup. Soups give that false sense of filling you up so you don’t overeat. I have a small piece of meat for protein, followed by more fruits to end the meal.

There are some people who seem to be at the gym all the time and yet see minor results. What are people getting wrong?

If you are not constantly challenging your body, you will see no results. The body loves being challenged so it can adapt, so make sure you step out of your comfort zone to get the best results from your training.

What’s a good machine to use to get biceps?

I don’t like using machines to work on isolated muscles. If you want bigger biceps, I suggest you start working on your pull-ups or chinups. This will allow you to work other muscle groups, too, and give you a better workout. The rope that we have hanging off the ceiling may look like it’s mainly for the arms, but it’s also for a full upper body exercise. Muscles don’t work in isolation.

Hong Kong seems to be teeming with gyms and new fads of training.

What’s Sweat’s appeal?

It’s a relatively small enterprise

with two full-time and two parttime trainers, and we put together individual programmes for all our clients. With high intensity workouts, it’s a goal-oriented programme. Lots of the generic gyms follow some kind of strict programme. We go by what our clients need and like; we read each client and adapt our training to them. You know why most people leave gyms? Boredom. No one wants to do the same thing again and again, and they don’t want to be clumped together with a bunch of others who have different body types and needs.

But isn’t gym work repetitive by it’s very nature?

You have to change the patterns.

We do circuit training, which is fun as it’s different each time. We use machines like the Airdyne bike and PowerMax bodyweight training tool. When we first introduce them to clients, they are amazed.

They’re very simple pieces of equipment, but fun.

You work with a lot of youngsters.

How do you encourage them to try to be healthy?

I have found the best ways to encourage youngsters is to lead by example, make the sport a game so they enjoy it, and set attainable goals which give them a sense of success.

Can your wife kick your butt?

Most likely – I haven’t taken the time to find out.