20120904 health post

YOUR GUIDE TO LIVING WELL

TUESDAY, SEPTEMBER 4, 2012

THE TICKER TIME BOMB >PAGE 4

A RUN AROUND THE BUND

Illustration: Brian Wang

>PAGE 10

Scratch and sniff

Allergies are on the increase in Hong Kong, but the city trails the West in treatment >PAGE 6

2 NEWS APP OF THE WEEK

HEALTH BITES

Pugilistic workout a big hit

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It all comes out in the wash Organic foods are often perceived as healthier than non-organic ones, but there’s little evidence to prove this, according to a study by Stanford University researchers published today in Annals of Internal Medicine. There is no strong evidence that organic foods are more nutritious or carry fewer health risks than conventional alternatives, although organic produce is 30 per cent less likely to be contaminated with pesticides. But the researchers say there are other reasons to go organic, such as taste preferences and concerns over the effects of conventional farming practices on the environment and animal welfare.

Katie McGregor healthpost@scmp.com Boxing Trainer HK$15 Rating 9/10 Boxing seems a perfect option for this time of year when you’re looking for something interesting to do in the gym, or at home if you’re happy enough to shadow box. If in doubt about your ability, heed app author Michael the Boxer, who says: “It’s boxing, not brain surgery.”

The app opens to a directory of short videos demonstrating a series of punches: jabs, hooks, uppercuts and combinations. Each punch or combination is numbered and you’ll need to pay attention to this because in the workout section, number combinations are called out to you while you do the drill.

Michael the Boxer is the star of the show and in the videos, which are about 11⁄2 minutes each, he talks you through the moves, providing useful metaphors to help you remember what to do and how to do it. When doing the straight right, for example, remember that when your punch lands, your thumb should be in the seven o’clock position. Your foot moves “as if grinding a cigarette into the floor”.

Once you have memorised a few of the punches, challenge yourself with the workout. Select your preferred number of rounds, the

length of a round, rest period and intensity – use your iTunes if you work out better to music. The default setting is three one-minute rounds, with a 30 second rest between rounds.

Round one starts with the bell, and Michael starts calling the numbers: “One, two; one, one, two, three; one, five, three.” You try and keep up.

They say boxing is one of the best exercises, as it conditions the whole body and improves agility.

It may not be brain surgery but a bonus benefit is certainly the memory reflex test as you recall which number belongs to which punch – without too much of a delay.

ASK THE DOCTORS DR ANTHONY LUKE Q: My nephew has cystic fibrosis. Is it safe for him to participate in sports?

A: Cystic fibrosis (CF) is the most common genetic disease in North America but has the lowest incidence among Asians.

It affects a gene that regulates chloride transport in the body, an abnormality that may cause secretions in the lungs, gastrointestinal tract, and the endocrine and reproductive systems.

Patients lose a lot of salt in their sweat, which is how doctors often make the diagnosis. Most individuals are diagnosed by age 10, and lung disease often affects individuals in their 20s.

For children with CF to lead safe and normal lives, adults should encourage them to participate in physical activities.

Coughing during exercise should not necessarily stop activity.

But consult with a sport medicine physician or paediatric respirologist first,

Jeanette Wang jeanette.wang@scmp.com

as exercise testing may be needed for those with severe conditions.

They may even join endurance events such as marathon running. Exercise usually has positive effects, helping ease symptoms and boosting confidence. To your nephew, I say, “Play ball!”

Dr Anthony Luke is a 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 Printed and published by South China Morning Post Publishers Ltd, Morning Post Centre, 22 Dai Fat Street, Tai Po Industrial Estate, Tai Po, Hong Kong. Tel: 2680 8888

Honey, I shrank my brain It’s a good idea to keep your blood sugar levels in check, even if you don’t suffer from diabetes. Many studies have shown a link between type 2 diabetes and brain shrinkage and dementia, but a study published today in Neurology finds even people whose blood sugar is on the high end of the normal range may be at greater risk of the same effects. A fasting blood sugar level of 10 millimoles per litre or higher is defined as diabetes, and a level of 6.1 mmol/l considered pre-diabetes. The study involved 249 people aged 60 to 64 with blood sugar in the normal range (below 6.1 mmol/l). Analysed over four years via brain scans, participants with higher fasting blood sugar levels within the normal range were more likely to have a loss of brain volume in the areas of the hippocampus and the amygdala, areas involved in memory and cognitive skills.

When growing up runs out of puff Children who use inhaled steroid drugs for asthma end up slightly shorter – about 1.2cm – at their full adult height than children who don’t use the drugs, new results show.

The findings were published online yesterday in The New England Journal of Medicine. Nearly 950 children aged five to 12 with mild to moderate asthma were involved in the study. They were divided into three treatment groups, receiving either inhaled steroid medication, inhaled non-steroid medication, or a placebo.

They were followed at regular intervals until they reached adult height. Those who took the inhaled steroid medication experienced slower growth in the first two years of the study and remained 1.2 cm shorter through adulthood.

Smoky coal link with lung cancer A study on a Chinese county where lung cancer rates are particularly elevated has identified a culprit: the use of smoky, or bituminous, coal for household cooking and heating. Published today on the British Medical Journal website, the study involved more than 37,000 individuals in Xuanwei county, Yunnan province. They were followed over 20 years, from 1976 to 1996, during which time more than 2,000 deaths from lung cancer were recorded. It was found that the risk of lung cancer death before 70 for men and women using smoky coal was 18 per cent and 20 per cent respectively, compared with less than 0.5 per cent among smokeless coal users. These risks are almost as high as those reported for heavy smokers in Western countries, which range between 20 per cent and 26 per cent.

NEWS 3 QUIZ

NUTRITION COCONUT OIL

Bright lights, big city linked to obesity

Here’s the good oil on how to combat tooth decay

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Jeanette Wang jeanette.wang@scmp.com Could Hong Kong’s rising obesity rate be due to the city’s bright lights?

Maybe, according to a paper by a University of Aberdeen chronobiologist published last week in BioEssays.

Dr Cathy Wyse suggests that electric light has allowed for work, meals and sleep at all hours of the day, causing daily or “circadian” rhythms to be disrupted.

These rhythms, controlled by a molecular clock present in every cell of the human body, include the sleep-wake cycle and hormone release. The default rhythm is almost exactly 24 hours, matching the daily cycle of the earth’s rotation.

Wyse calls this mismatch between the environment and body clock “circadian desynchrony”.

“The human clock struggles to remain tuned to our lifestyles, and I believe this causes metabolic and other health problems, making us more prone to obesity,” she says.

“Studies in microbes, plants and

animals have shown that synchronisation of the internal clock with environmental rhythms is important for health and survival, and it is highly likely that this is true in humans as well.”

The research suggests that some people may be more at risk of the effects of circadian desynchrony than others. For example, humans originating from equatorial regions may have clocks that are very regular, which might be more sensitive to desynchrony.

Wyse believes that desynchrony disrupts the systems in the brain that regulate metabolism, leading to an increased likelihood of developing obesity and diabetes.

“The reason for the relatively sudden increase in global obesity in the developed world seems to be more complicated than simply just diet and physical activity. There are other factors involved, and circadian desynchrony is one that deserves further attention.”

1. From where does the term “circadian” originate? a. It was discovered in 1729 by

INSECT-BORNE DISEASES

No scents and dark clothes keep bloodsuckers at bay ......................................................

Dr Francis Powers healthpost@scmp.com Hong Kong has repeatedly failed to address public health issues, even where simple, proven and costeffective methods are available. Take the topic of scents. Seemingly all products, from laundry detergents and soaps to hairsprays and moisturisers, contain added fragrance. Some enjoy this; others endure discomfort after exposure.

Hong Kong is well known for having mosquito-borne illnesses – dengue fever and Japanese encephalitis, to name two. The creatures are more than eager to sample your blood. Interestingly, the insects are attracted to these scents.

One wonders why, in a modern city with identified medical problems, unscented products are not available.

Most top-tier countries, specifically the “top 10 international cities”, have these available for disease diminution and for those who are allergic. But tropical locations have not been considered.

To find unscented products in Hong Kong, sufferers have to be diligent. Some order from overseas, paying enormous shipping fees.

Many do this to avoid exposure to

Deet, which is found in many insect repellent products. This is particularly important for infants, children, pregnant women and those with allergies.

As well as unscented products, one should also use common sense.

These winged vampires are most fearsome during the hours of dawn and dusk, so being indoors helps.

Covering bare skin is another approach. Mosquitoes are attracted to lighter colours. Sequins and other eye-catching items also attract them, like a shark to blood.

More bites occur during the wet season and in rural areas. Water, stagnant or with surface scum, is a breeding ground.

Sadly, romantic notions of swimming at dawn or dusk are seldom worth the risk.

Dr Powers is a fellow of the American Academy of Emergency Medicine

French astronomer Jean Circadian. b. It is derived from the two Latin words for “about” and “day”. c. It is named after the cicada, the insect in which circadian rhythms were first studied.

2. Which plant is useful in circadian research because its genome is close to being fully sequenced? a. Mustard plant b. Hibiscus plant c. Cactus 3. The “master clock” that controls circadian rhythms consists of a group of nerve cells in the brain known as the suprachiasmatic nucleus. How many nerve cells does it contain? a. 1,000 b. 10,000 c. 20,000 4. What is the best way to maintain a healthy circadian rhythm? a. Keep regular meal times b. Have uninterrupted nighttime sleep in complete darkness c. Be exposed to plenty of sunlight Answers: 1. b; 2. a; 3. c; 4. all are correct

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Jeanette Wang jeanette.wang@scmp.com With chemical additives in personal care products causing increasing concern, new research unveiling a natural antibiotic for oral health couldn’t have come at a better time.

Digested coconut oil is able to attack bacteria that cause tooth decay, a team from the Athlone Institute of Technology has found.

The scientists tested the antibacterial action of coconut oil in its natural state and coconut oil that had been treated with enzymes, in a process similar to digestion. The oils were tested against strains of Streptococcus bacteria, which are commonly found in the mouth.

They found that enzyme-modified coconut oil strongly inhibited the growth of most strains of the bacteria, including Streptococcus mutans – an acid-producing bacterium that is a major cause of tooth decay.

“Dental caries is a commonly overlooked health problem affecting

60 to 90 per cent of children and the majority of adults in industrialised countries,” says lead researcher Dr Damien Brady. “Incorporating enzyme-modified coconut oil into dental hygiene products would be an attractive alternative to chemical additives, particularly as it works at relatively low concentrations.

“Also, with increasing antibiotic resistance, it is important that we turn our attention to new ways to combat microbial infection.”

Brady says the findings also contribute to knowledge about antibacterial activity in the human gut. “Our data suggests that products of human digestion show antimicrobial activity. This could have implications for how bacteria colonise the cells lining the digestive tract and for overall gut health.”

Many previous studies have shown that partially digested foodstuffs are active against micro-organisms. Earlier work on enzyme-modified milk showed that it was able to reduce the binding of Streptococcus mutans to tooth enamel.

4 MEDICAL CASE HISTORY

Illustration: Angela Ho

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Eileen Aung-Thwin healthpost@scmp.com Tam Mei-lan, 86, was out of breath and out of options when she consulted Dr Elaine Chau, a cardiologist at the Hong Kong Sanatorium and Hospital.

The health crisis began when sudden chest pain and severe breathlessness landed Tam (whose name has been changed to protect her privacy) in hospital.

She had suffered a heart attack because not enough blood was reaching her heart.

Three coronary angioplasties followed, in which a total of eight stents (mesh tubes) were inserted into the arteries leading to her heart to keep them open.

After her third angioplasty, she suffered a sudden cardiac arrest, where blood stopped circulating in her body because her heart failed to contract sufficiently.

Doctors worked frantically to resuscitate her, fracturing a few of her ribs in the process.

But these frightening events were not what vexed Tam the most.

She had been enduring sudden and repeated episodes of chest pain and severe breathlessness, especially at night. Fighting for air distressed her so much that she was afraid to sleep.

She even used a breathing aid, or bilevel positive airway ventilator, to help her while she was sleeping.

Still, some of the attacks were so vicious and unrelenting that she had to be admitted to hospital every few months.

Her doctors had no satisfactory explanation or solution for her, so she sought out Chau for a second opinion.

When Chau did a physical examination of Tam’s carotid artery in her neck, she noticed an irregularity in the pulse. Using a stethoscope, Chau heard a murmur in Tam’s heart, indicating turbulent blood flow within it. While murmurs may be harmless, they could also signal a structural abnormality in the heart.

Tam’s besieged heart also beat in an irregular rhythm – a condition known as arrhythmia.

Chau needed a closer look at the structure of Tam’s heart. She performed an echocardiogram (ECG), which uses ultrasound waves to produce images of the organ – its chambers, valves and surrounding structures.

The ECG showed that Tam’s aortic valve – a three-flap tissue that

A better way to her heart opens to allow blood to flow from the left ventricle into the aorta, and closes to prevent the blood from flowing backwards – was thickened and caked with calcium deposits.

Because of this, the valve could not open sufficiently wide to maintain proper heart function.

Tam was suffering from severe aortic stenosis, or the abnormal narrowing of the aortic valve. This meant Tam’s heart had to work extra hard to pump blood through, thereby increasing its demands for oxygen. When the heart fails to get

Six months on, Tam has not suffered a single attack of breathlessness nor has she had to be admitted to hospital

the oxygen it needs, chest pain, or angina, occurs.

The increased pressure in the heart also causes increased pressure in the lungs, which has to return oxygenated blood to the heart.

Tam’s breathlessness was caused by the increased pressure in the blood vessels of the lung.

That she was breathless when lying down indicated that the disease was at an advanced stage and that the heart muscles were unable to compensate for the increased pressure.

Tam was at risk of sudden death.

The ECG results also showed that Tam’s open valve area was only 0.7sq cm. A normal valve opens to about 3sq cm. Her condition was critical, and she needed a new valve if she was to have any chance of survival.

However, given Tam’s advanced age and her other heart conditions, she had a 40 per cent to 50 per cent chance of dying on the operating table if she were to undergo a standard open aortic valve replacement surgery.

The procedure would involve making a 20cm incision in her chest, cracking open her sternum and placing her on a heart-lung machine. Given her chances with open heart surgery, however, no surgeon would touch her.

Thankfully, Chau had an alternative for Tam. A minimally invasive procedure called transcatheter aortic valve implantation (Tavi) had become available in Hong Kong about three years ago.

With Tavi, Tam’s diseased valve could be replaced by only making a 2cm to 3cm incision in the groin. A catheter (hollow tube) would be inserted into her femoral artery and manoeuvred up the arterial highway and into her heart under guidance from X-ray and ECG visuals.

A 5cm-long metal stent bearing a 26mm-diameter valve was delivered up the catheter and positioned where her calcified valve was. The new valve expanded, opening up and permanently replacing the diseased one.

Tam’s femoral artery needed to be at least 6mm in diameter to accommodate the catheter. A tiny woman who is less than 1.5 metres tall and weighs 40kg, Tam barely made it with a 7mm-wide artery.

A slew of scans and tests followed to enable Chau to map out the arterial route before the procedure.

The three-hour-long surgery went smoothly, and Tam was up and about 24 hours later.

Six months after the operation, Tam has not suffered a single attack of breathlessness nor has she had to be admitted to hospital.

Chau notes that Tavi has given severe aortic stenosis patients such as Tam – who would otherwise have no tenable treatment options – a fighting chance.

Although the procedure does carry some risks, such as a heart attack, stroke, damage to the heart or arteries, infection and so on, Tavi also offers fast recovery and a good outcome for patients.

HEALTH 5 BEAUTY

How to get up and glow ......................................................

Jemma Rogers healthpost@scmp.com Heat and humidity are the eternal summer foes of great skin and hair.

What’s a Hongkonger to do? We spoke to Ceri Silk from Glow with Ceri Silk spa, Robin Lomas from Paul Gerard hairdressing salon and Sarah Chung from Gentlemen’s Tonic for professional advice on how to get fabulous hair and skin this summer.

Sunblock Although sun exposure is needed for the body to make vitamin D, an essential nutrient for healthy bones, it can be extremely damaging to skin and hair. Smog and pollution may make it seem otherwise, but Hong Kong experiences high levels of ultraviolet (UV) radiation. Silk says one of her clients was sitting under an umbrella by the pool, but the reflection from the water and the tiles caused her face to get sunburned.

Sunburn is bad for your skin as it causes ageing, pigmentation problems, and irritates the skin.

In the long term, it can cause cancer.

It is therefore important to get a sunblock that protects your skin from both UVA and UVB rays.

Many sunblocks protect skin only from UVB rays, which penetrate the upper layer of skin.

But UVA has an effect on the deeper layer of skin which can cause more long-term damage.

Says Chung: “UV is definitely a key external force which causes damage to skin and hair.” To protect your hair from UV rays, there are shampoos, conditioners and styling products that contain UV protection to prevent breakages and keep your natural hair shine and colour.

Pollution protection The high levels of pollution in Hong Kong can be very damaging for both skin and hair. Heavy metals present in pollution, such as mercury, arsenic and lead, can accumulate in the skin and can cause pigmentation problems. Silk says they can also build up in hair and nails.

When exposed to pollution, the odd melanin cell can become overstimulated and cause uneven patches of darker skin. To prevent this, find creams that contain polysaccharides, which engulf such heavy metals, protecting your skin from the pollution.

Essential nutrients Vitamin C can help protect the body from pollution as it has powerful antioxidant properties. It has an anti-free radical action that protects the skin against UV radiation. It also helps in the formation of collagen, which helps to prevent premature ageing.

Vitamin C is water soluble and not stored in the body. Any excess is eliminated in urine. So daily doses of vitamin C are needed, says Silk.

It does not easily penetrate the skin, which is why a lot of vitamin C must be consumed in order to make a difference.

Apart from vitamin C, foods that are rich in omega-3 fatty acids, iron, zinc, and other essential vitamins, are needed to keep skin, hair and scalp healthy. The skin is the largest organ of the body and is the last to receive essential vitamins. So it is the first to show signs of any deficiencies caused by stress or illness.

Hair can grow up to 1.5cm a month, and the foundation of all new skin, hair and other tissue comes from nutrients in food.

Water The body is made up of 75 per cent water, and hydration is vital for the body and skin’s health. “Your skin is one of the body’s major organs responsible for elimination of toxins.

The more hydrated your body is the better your skin will perform this function,” says Chung.

Drinking too little water causes both skin and hair to become dehydrated and look dull and lifeless. Both coffee and alcohol have dehydrating effects on the body, so those who drink a lot of these substances must drink even more water to counter such effects.

Cleansing It is a common misconception that acne and other skin irritations come from dirty skin. Such irritations usually come from within.

Nevertheless, it is important to keep skin clean, as this will help to remove bacteria. But it is also a good idea not to over-wash the skin, as this will only irritate and worsen a skin condition.

One should have a daily cleansing routine for the skin. Don’t over-cleanse. The oil produced by the skin is necessary to protect the

There are many studies which show a correlation between emotional well-being and physical health SARAH CHUNG, GENTLEMEN’S TONIC

Ceri Silk from Glow with Ceri Silk spa (left); Gentlemen’s Tonic manager Sarah Chung. Photos: Thomas Yau, Jonathan Wong

body from external irritants. Bacteria are also harboured by the skin to give it a pH of 5.5. Excess oil production encourages bacteria to thrive and can cause infection, which leads to spots.

But if there is not enough oil, the skin will become dry and sensitive, as it will not have the oil and bacteria it needs to protect it.

Silk also suggests getting professional facials regularly. This is because although home cleansing products have improved in recent years, they still cannot reach the lower layers of skin that professional treatments do.

A spot or a pimple indicates a deeper infection. Refrain from squeezing spots. Although this may remove the top layer, it may also push the infection further into the dermis layer which may only worsen the problem.

Chung suggests using high quality products and avoiding ingredients such as alcohol, petrochemicals and parabens.

Regular trims In the summer months, long hair is likely to become frizzy and uncontrollable. Regular trims every six to eight weeks help, says Lomas.

More serious frizz problems may require a “Brazilian blow dry treatment”, which injects pure keratin (the natural substance in nails, skin and hair) into hair strands to nourish them. But Lomas advises caution for this treatment, as most

of the products used contain formaldehyde, a pungent gas that’s linked with cancer. Try to choose organic products that do not contain formaldehyde.

He suggests: “Start off with a stylist you trust, and let them guide you in what’s best for your hair.”

Relaxation “Be happy,” says Chung. “There are many studies which show a correlation between emotional well-being and physical health. So looking after your mental and emotional self will nurture your physical self.”

Stress releases hormones including adrenaline, noradrenaline and cortisol. These cause the blood vessels that supply nutrients to organs such as the skin to constrict, thereby reducing the amount of nutrients provided to these cells.

This inhibits the barrier function of the skin, causing dry and flaky skin, which is easily irritated.

Stress also affects breathing, and reduces the amount of oxygen in the bloodstream. In the long term, this can affect the health of the skin and all other tissue in the body.

Stress can also play a part in hair loss by forcing hair follicles into a resting phase, resulting in rapid, but not necessarily permanent, hair loss.

A massage can help to reduce tension in the skin and surrounding tissues, improve blood circulation, stimulate the lymphatic system and help you to mentally relax.

6 COVER STORY

Not up to

scratch

Allergies are are becoming more common in Hong Kong but a shortage of trained specialists is hampering treatment for sufferers, writes Richard Lord

A

llergy incidence in Hong Kong is somewhere in the middle of the international league table. But unlike most established urban centres, in Hong Kong it appears to be rising – something the city’s medical services might increasingly struggle to cope with, given that there’s no formal medical training for allergy specialists here.

Allergies affect up to 40 per cent of people globally, according to the World Health Organisation, and the rate is on the rise, particularly in industrialised nations. They occur when the body mistakes a normally benign substance for a toxic one, triggering the release of an antibody called immunoglobulin which affects white blood cells, provoking an inflammatory response.

Usually, that response is just uncomfortable. The most common is allergic rhinitis, which causes sneezing and a runny nose. Other unpleasant possibilities include allergic asthma, causing wheezing, coughing and shortness of breath; blocked and painful ears; eczema and hives; and stomach ache, bloating, vomiting and diarrhoea.

But allergies can also be dangerous – even fatal. With socalled anaphylaxis, inflammation is so rapid that it can become difficult to breathe, and can also result in dangerous drops in blood pressure and heart attacks.

There are many potential allergens. Among the most common is foodstuffs; in particular, nuts, seeds, milk, eggs, soy and shellfish.

Commonly self-diagnosed food intolerances such as lactose and gluten aren’t in fact allergies, and involve different physical responses to the unwanted substance.

Other top allergy offenders include pollen; insect stings; animal dander; house dust mites; medications, especially aspirin and antibiotics; and substances that come into contact with skin, such as latex, metals (mainly gold, cobalt, nickel and chromium), mould, perfume, formaldehyde and semen.

Some exceptionally unlucky people are allergic to water. Naturally, symptoms vary by allergen. Plant pollens cause you to sneeze, and food allergies cause all manner of unpleasant gastrointestinal effects.

As with most places, rhinitis is the most common form of allergic response in Hong Kong. But its most common cause is different here.

Most allergic rhinitis around the world is seasonal, triggered by pollen and known as hay fever. But in Hong Kong, the city’s predominantly urban environment means people come into less contact with pollen, and most cases are perennial rather than seasonal.

While the cause is not proven, Dr Terry Hung, an ear, nose and throat specialist at Matilda International

Hospital, has no doubt what’s to blame. “Airborne allergies are getting more common as the pollution is getting worse,” he says. “As there are more pollutants in the air, people are exposed to more allergens.”

Dr Lee Tak-hong, head of the new Allergy Centre at the Hong Kong Sanatorium and Hospital, recently returned to the city after spending most of his professional life in Britain. He says he’s noticed quite a few differences here.

“I’ve always felt that food was important here, and I’ve seen a lot of food allergies, especially in young babies. It’s very obvious to me that there are a lot of issues here with artificial flavourings and allergies.

Unfortunately, with a lot of Chinese food, there’s no research as to what’s actually in it, so diagnosis can be challenging.”

Frank Wong, chairman of the Hong Kong Allergy Association, says that labelling of allergens on food packaging is actually mandated under the Food Safety Ordinance introduced earlier this year, but so far has not been widely enforced.

There has been only one product recall to date because of the presence of an unlabelled allergen.

In the United States and Australia, he says, there are on average about 100 recalls a year.

“Either we’re doing so well, and

our manufacturers and importers are so stringent, or the government is not doing its work and we’re not noticing.” But recent incidents involving Chinese products exported to Australia with unlabelled allergens suggest that the latter is more likely.

In terms of symptoms, Lee says that a far larger number of patients here come to him with eczema than in Britain, and it’s often much more severe. There are two main reasons, he says. “One is under-diagnosis, and the other is that people have often gone to seek alternative help, and it’s often Chinese medicine.

Sometimes it works, but sometimes it doesn’t and only then do they come to see me.”

Lee estimates that about twothirds of the eczema cases he sees are caused by food, with milk and eggs by far the most common causes.

Heredity is the most important factor in allergies. Identical twins have the same allergies in 70 per cent of cases and fraternal twins 40 per cent. If neither parent has any allergies, there’s a 16 per cent chance of their child having one. If one parent is a sufferer, the odds are between 20 and 30 per cent. If both parents are, it’s about 50 per cent.

Lee pinpoints three other possible causes for the increase in allergies.

One is climate change, resulting in longer, hotter summers, making

COVER STORY 7

Allergy Centre director Lee Tak-hong shows photos of some of the foods to which people are allergic (above); skin prick tests (right, below) can detect common allergies but not those associated with medications.

Photos: Dickson Lee, Corbis

Airborne allergies are getting more common as the pollution is getting worse DR TERRY HUNG, SPECIALIST IN OTORHINOLARYNGOLOGY, MATILDA INTERNATIONAL HOSPITAL

pollen more abundant. Another is lack of sunlight, with several studies linking higher allergy levels with vitamin D deficiency.

The third is the so-called hygiene hypothesis. This suggests that our bodies are set up to deal with pathogens, but in our over hygienic world we don’t get exposed to enough of them. So our immune system starts attacking harmless microbes as if they’re pathogens, triggering the allergic reaction.

It seems to be supported by anecdotal evidence. Many allergies are far more common in the developed than the developing world, and in cities rather than rural areas. A recent study from Northwestern University’s Feinberg School of Medicine in Chicago found that, in the US, 9.8 per cent of children in cities had allergies, whereas only 6.2 per cent did in rural areas. For peanut allergy, the figures were 2.8 per cent and 1.3 per cent, and for shellfish allergy 2.4 per cent and 0.8 per cent.

A study from Finland suggests that children who grow up in rural areas may have more diverse bacteria in their bodies, and that the absence of certain bacteria appears to be associated with an increased risk of allergies.

There’s even a theory that our immune systems are habitually oversensitive because of clean drinking water. The idea is that the

parasites routinely present in untreated water secrete immune system suppressants inside us.

Because our water would have been unclean until relatively recently, we are said to have developed into symbiosis with the supposed invaders, leaving us dangerously over-sensitised without them.

Allergies are diagnosed by a skin prick test or blood test. But the tests can’t usually detect reactions to medications, for example, and can sometimes return false positives because they detect the presence of immunoglobulin rather than an actual allergic reaction.

The best course of action after detection is simply to avoid the allergen, but other possible symptomatic treatments include antihistamines and steroids. An intramuscular adrenaline shot is the usual treatment for anaphylaxis.

For people who can’t avoid an allergen and are seriously suffering, another option is immunotherapy, which involves vaccination with increasingly large doses of the allergen, causing tolerance to develop. It’s administered either under the tongue or by subcutaneous injection every eight to 10 weeks for three to five years.

Lee favours immunotherapy and says he uses it on patients with allergies to house dust mites, pollen, cat and dog dander, and bee and wasp stings, but Hung only

recommends it for patients whose symptoms are debilitating – those with breathing difficulties, or nearconstant sneezing. Otherwise, he says, over such a long time scale, the biggest problem is compliance. Plus, there’s a small risk of anaphylaxis.

While working in Britain, Lee says it became clear there were far too few trained allergists there, with doctors from other fields stepping in, mainly because they were the ones dealing with the symptoms.

That changed about a decade ago, when formal training for allergy specialists was introduced there.

Lee returned to Hong Kong to set up Sanatorium’s centre, the first in Asia, this year. He says the situation here is similar to that which Britain faced 15 years ago.

“Dermatologists, ENTs [ear, nose and throat doctors], and so on were treating allergies. All medicine had to be imported, and preventative strategies were not adopted as they should be. Public knowledge of allergies is very poor. That’s not unique to Hong Kong. It’s the same wherever allergies aren’t a medical discipline.”

While the HKAA gets government funding, Wong says the political situation has made officials slow to act. “In places like the US and Britain, there have been government organisations working on this for 20 or 30 years. But not here.” healthpost@scmp.com

8 DIET NUTRITION NEW HEALTH FOOD PRODUCTS

Chew the right thing ......................................................

Jeanette Wang jeanette.wang@scmp.com It felt like I had died and gone to healthy heaven. I was at the Natural Products Expo Asia held a fortnight ago at the Convention and Exhibition Centre in Wan Chai.

The three-day event featured more than 200 local and international companies showcasing more than 5,000 offerings ranging from food and beverages, dietary supplements, cosmetics and skincare products, spa facilities and supplies, to natural and raw ingredients.

Compared to last year, there was an almost 30 per cent increase in the number of exhibitors, according to trade show organisers. The event also attracted many buyers from across the region, where sales have grown rapidly.

“Despite the economic turbulence of the past few years, the health and nutrition industry has risen steadily since 2000,” says Len Monheit, executive director of Nutrition Business Journal. “The expected growth rate in 2012 will be about 7 per cent, with the highest rate of growth being in [the] natural and organic sector.”

The global health and nutrition industry will be worth about US$320 billion this year, according to a recent report by Nutrition Business Journal. In Hong Kong, the trend has been driven largely by an increasingly health-conscious, ageing population, and food scares across the border.

Here are some of the interesting selections at the expo.

Black garlic Garlic is one of the oldest known medicinal plants, but a natural process that turns its cloves black is said to boost its health benefits.

The bulbs spend three weeks in a machine fermenting in controlled heat and humidity, followed by one week on special racks on which they cool and dry.

Fermentation causes the sugars and amino acids to produce a darkcoloured substance called melanoidin, and is said to create a high level of antioxidants and a natural cancer-preventing compound called S-Allylcysteine.

Forms of fermented garlic have long been eaten in Korea and Japan.

But Scott Kim, a Korean-born American and founder of Black Garlic, is credited for creating the patented heat-curing process in 2004 and marketing black garlic as a “superfood” in the United States.

While it has been used by top chefs in Hong Kong for the past two years, it is only recently that the general public has started to eat it

Clockwise from left: black garlic, maqui berries and Nopalea, a cactus-based juice, were among the trendy treats at a recent health expo.

Photos: Marco Veringa, SCMP Pictures

molasses and sweet like fruit, with a chewy, almost gummy, texture. It was delicious.

and organic shops have begun to stock it, says Oliver LaObamas, who runs his family’s brand in Asia.

LaObamas Black Garlic products, made in Zurich, Switzerland, since 2009, come in a variety of forms: whole bulbs, cloves, a blended paste, powder and soda. Prices start from HK$40 for two whole bulbs.

Oliver LaObamas claims his company’s black garlic has up to 10 times more antioxidants than raw garlic, which Kim claims his has nearly twice as many antioxidants.

“Fifty per cent of our customers eat one black garlic clove in the morning for health purposes,” says LaObamas.

Some studies on mice suggest black garlic extract has anti-tumour properties, enhances the immune system, aids heart health and alleviates obesity.

However, hard evidence on this aged garlic is still scarce and more studies are needed to confirm its health benefits. But that’s not going to stop chefs from incorporating black garlic into meat, pasta, bread, chocolate and even cocktails.

After much persuasion from LaObamas, I gave a small bulb a go; just peel and eat. The garlic had just a faint odour and no acrid taste.

Instead it was rich like

Fifty per cent of our customers eat one black garlic clove in the morning for health purposes OLIVER LaOBAMAS

Maqui berry It seems the revered Brazilian superberry, acai, has lost its crown to a Chilean native. At the expo, a few exhibitors offered juices, powders and pill supplements made from the maqui berry, a small purple berry that grows wild throughout southern Chile’s Patagonia region.

The purple pigments of the maqui berry are anthocyanins, which have very high antioxidant properties. The berry is said to contain the most antioxidants of all fruits – two to three times more than the acai berry and goji (wolfberry).

Isabell Ho, general manager of Natural and Organic Living, a health food store in San Po Kong, Kowloon, says they started selling Juve Maqui Juice (HK$380 per 750ml bottle) in April. “The feedback has been very good,” she says.

Chan Man of Health Factor Foods Company, which runs the Manna Organic Station chain of stores, says freeze-dried maqui berry powder is new on its shelves. Just two grams of the powder a day, mixed into a smoothie, is needed to maintain health, he claims.

For centuries, Mapuche indians, the indigenous Chileans, have used the maqui berry – also known as Chilean wineberry – and the evergreen shrub it is harvested from.

The seeds of the plant can be eaten raw or used for brewing wine and chicha, a Chilean alcoholic beverage, and the leaves are used to prepare an infusion for treating sore throat and for dressing wounds.

Eating maqui berries is believed to help with

cardiovascular health and weight control, and is said to have antibacterial properties. But, once again, hard evidence is lacking.

Nopalea It’s red, crisp and refreshing, promising to bring “amazing health benefits”. Nopalea (pronounced “no-pah lay-uh”) is a health drink sourced from the fruit of the nopal cactus, which thrives in the Sonora Desert of the southwestern United States and Mexico. According to Fiona Ho, Hong Kong general manager of the juice’s US-based maker TriVita, the drink has been in the US market for two years and is just making its entry into Asia.

TriVita claims the nopal cactus (or prickly pear cactus) is the only plant that contains all 24 betalains – antioxidants that have mineralbalancing, detoxification and anti-inflammatory effects.

Some vegetables such as beets and rainbow chard contain only some betalains. As such, Nopalea protects against premature ageing, promotes cellular health and detoxifies the body naturally.

Each 32-ounce bottle costs HK$310 and is exclusively available from TriVita.

People are advised to drink three ounces of Nopalea two times a day for the first 30 to 60 days as this is the “loading phase where you really need to hit toxins hard and for it to flush out of the body”, then three ounces a day after this period “for maintenance”.

More than five million bottles have been sold worldwide. But do an online search and you’ll find as many glowing testimonials as quack-watch warnings against the drink. A lack of solid studies on the juice certainly doesn’t help.

DIET 9 THE TASTE TEST FLATBREAD ......................................................

Jeanette Wang jeanette.wang@scmp.com

Marks & Spencer Soft Flour Tortillas HK$32 for 400 grams, Marks & Spencer Tortillas are a quick meal staple: spread on whatever you fancy, roll or fold and eat. Perfect for fajitas, enchiladas, burritos and quesadillas.

There are eight pieces in this pack, each with 145 calories and two grams of fat.

Verdict: light and slightly chewy; as good as any we’ve sampled at a Mexican restaurant.

HEALTHY GOURMET

Culinary roots span the Adriatic ......................................................

Andrea Oschetti healthpost@scmp.com Two months ago, I cycled 2,000 kilometres on ancient Roman roads from Sicily to Istanbul, crossing Italy, Albania, Macedonia, northern Greece and Turkey. As a chef, I wanted to explore my Italian culinary heritage and see how it connects with other cultures in the Mediterranean basin. In the past few columns I shared my culinary journey through southern Italy; today I will take you across the Adriatic, heading east.

“Our food culture constantly changes. What our grandparents ate is different to what their grandparents ate, and to what we eat now,” says chef Gerti Zebel of Real Scampis, a restaurant inside the city castle of Elbasan, Albania. “My grandmother cooked almost everything in two fingers of oil; now we don’t do that. After communism, we learned about nutrition and healthier cooking techniques.”

While cooking is now lighter, Zebel wonders why obesity is increasing in Albania. He suggests it’s because in the past, everybody used to eat organic, locally sourced food and at home: “Now life is faster; we eat at fast food chains or we buy industrial food for meals at home.”

Albanian cuisine is Balkan in spirit but strongly influenced by the Mediterranean. Imam bajelldi is a traditional dish of oven-baked stuffed aubergines. The name means “the priest fainted” – possibly because the vegetables were so tasty he ate too much and passed out.

In Ohrid, Macedonia, Eli Struzan and her husband serve traditional Macedonian food in Restaurant Antiko, a small outlet built into the

ancient city gate. In Macedonia, as in the rest of the world, food choices are based on culturally accepted paradigms of what is good for us.

“We eat meat in our home every day: rice with chicken, sausages with potatoes,” Struzan explains. “If a man doesn’t eat meat, he won’t have a happy day.”

Animal products, however, use up large amounts of our body’s energy, enzymes and water. The fermentation and putrefaction processes that happen in our intestines after a fillet mignon acidify our blood. To compensate, calcium is taken away from our bones, thus weakening them.

Further, nearly 80 per cent of all antibiotics sold in the US are given to farm animals used in food production, according to a recent estimate by the US Food and Drug Administration. And the environmental impact of our meat consumption is unsustainable: 1kg of meat requires 20,000 litres of water; 1kg of veal needs 18kg of wheat. Despite this, we hold on to bad habits and cultural stereotypes.

Modern Thessaloniki, a city port in northern Greece, worked hard to eradicate the traces of her old past: the cosmopolitan, polyglot city that thrived during the Ottoman empire.

But while Ottoman wood houses

I dig into traditions.

Home-style food was really healthy and I want to bring it back HANDE BOZDOGAN, ISTANBUL CULINARY INSTITUTE

can be burned down and Muslim minarets demolished, the soul of a city lives on in its food.

Harris Georgoussis, my local host, takes me to a small restaurant with specialities from the Greek Ionian islands: the dish of swordfish rolls and grilled vegetables I am presented is as Greek as it is Italian.

The Greek financial crisis has made people smarter and healthier, he says. “My mother started growing her own vegetables to save on groceries. She enjoyed having her own vegetable patch and so started to grow more for other people. She now barters cucumbers for eggs and pays with peppers for small household services. People in Thessaloniki are starting to grow tomatoes on rooftops.”

In the evening, he takes me to one of several restaurant-bars in Ano Poli (Upper Town). Groups sit out along the street, discussing politics, sports or life, sipping wine and tasting appetisers. Food is healthy when it brings us together with our families and friends, and when we eat it in a joyful mood.

Hande Bozdogan is the heart and mind of the Istanbul Culinary Institute, which trains professional chefs and food lovers and provides thoughtful and delicious meals to the locals. “Turkish cuisine reflects many geographies and cultures of the past,” she says. “It is rooted in the Ottoman empire, which spanned Africa to Europe. The best produce from every corner of the empire was taken to the sultan first, and only after he had tasted them could the common people enjoy them. The sultan’s harem had women of many different nationalities and many types of foods were cooked to accommodate different tastes.”

Despite these rich traditions of Turkey, Bozdogan thinks the current situation is bleak. “Many restaurants now, particularly those that are part of a group or a chain, are mediocre,” she says. “The quality of the veggies in the market is getting worse; they look perfect but are tasteless.”

Bozdogan has her own farm in Gallipoli with 15 hectares of fruits and vegetables. The Institute’s restaurant uses no preservatives and nothing from a can. “I dig into traditions to propose dishes,” she says. “Home-style food was really healthy and I want to bring it back.

My mother’s table was always full of freshly cooked food.”

Bozdogan sums up her culinary philosophy: “Don’t interfere with how nature works; keep nature’s order and you will be healthy.”

Napolina Large Pizza Bases HK$38.50 for 300 grams, Gourmet This two-pack of pizza crusts from Italy makes whipping up a weeknight pie a breeze. Spread on toppings, bake at 200 degrees Celsius in an oven for 10 minutes and dinner is served.

Verdict: surprisingly light and crispy, and does not overpower toppings or leave you feeling bloated.

Aubergine stuffed with olives Serves 4 2 large aubergines 200 grams tomatoes 2 shallots A bunch each of parsley and mint 200 grams olives Salt, pepper and extra virgin olive oil Pomegranate sauce (or balsamic vinegar cream) • Slice aubergines lengthwise about 5mm thick. Grill briefly.

• Chop tomatoes, shallots, parsley and mint and mix with the olives. Add salt, pepper, extra virgin olive oil and the pomegranate sauce for a hint of acidity.

• Roll up the stuffing in the aubergine slices. Eat raw or bake for 15 minutes at 180 degrees Celsius.

Healthy Gourmet is a weekly recipe column by private chef Andrea Oschetti, e-mail address andrea@fioreblu.com

Old Time Bakery Gluten Free Wraps HK$75 for 250 grams, City’super These high-fibre organic wraps from Australia work for people with food intolerances to gluten, yeast, wheat, lactose or nuts because none of these ingredients are used. There are four pieces in each pack.

Verdict: dry, leathery texture and tastes of cardboard. Difficult to stomach more than one bite.

10 FITNESS The Bund is a good place for a longer run, all the way along the river’s edge. Photo: Xinhua

GREAT STRIDES SHANGHAI

Belt around the Bund ......................................................

Troy de Haas healthpost@scmp.com People say if you want see China’s past, go to Xian. If you want to see China’s present, go to Beijing. But if you want to see China’s future, you must go to Shanghai.

Shanghai literally means the city by the sea. It is divided into two parts by the Huangpu River: to its west is Puxi, on the other side is Pudong.

Puxi is the older part of the city, where most of the shops, restaurants and museums are located.

Pudong is the modern part, and is recognised for its rather unusual yet extremely impressive high-rises such as the Jin Mao Tower and the Oriental Pearl Radio and TV Tower.

As a running city, however, sadly Shanghai attracts no one.

With a growing population of more than 23 million, the traffic is heavy and the metro is crowded. As a runner, the first impression of Shanghai can be a nightmare. Green areas are limited, terrain is flat, and pollution is high.

Shanghai surprisingly has no official (English) running club. But it makes up for it with the country’s, and probably one of the world’s, coolest running websites, happy2run.com. Jam-packed with loads of local running information and forums, it’s highly interactive

and is guaranteed to point you in the right direction.

Best running spots Century Park: this is the mother of Shanghai’s parks – the largest in the city. It has wide-open spaces and is well located next to many leading hotels in Pudong district. It is rather quiet, apart from a few hawkers who will happily sell you a drink for two yuan (HK$2.40) as you run past. The 10 yuan entrance fee will give you access to many running paths with a loop of the entire park ranging from four to six kilometres.

Nearest Metro station: Century Park (exit 1 or 4), Line 2 The Bund: “Not another esplanade,” I hear you say. But the Bund is much more than just an esplanade – it’s a must-see for any tourist. What’s more, the best way to take it all in is on your own two feet.

A good place for a longer run, if you’re adventurous enough, is to head all the way along the river’s edge to the World Expo Park, where a tartan path awaits.

Nearest Metro station: Nanjing Dong Road, Line 2 Gongqing Forest Park: despite its inconvenient location in Puxi, about 15 kilometres from the city centre, the city’s second-largest green area is a lot less crowded

than the other inner city parks.

Complete with “forest” trails which criss-cross many waterways, it is a pleasant reprieve from the urban bustle.

Nearest Metro station: There is no direct Metro connection, although the park is just a 10-minute (1.2-kilometre) jog from Nenjiang Road Station, Line 8.

French Concession: this is ideal for running if you are willing to get up early in the morning. The area, which was once called “the Paris of the East”, offers a combination of leafy, tree-lined streets, European and Chinese blended architecture, and independent designer boutiques and cafes. Finish your run at Vienna Café on 25 Shaoxing Road and enjoy a delicate Austrian coffee.

Nearest Metro station: Hengshan Road Station, Line 1 The main event Toray Shanghai Marathon: the annual Toray Cup Shanghai International Marathon (shmarathon.com) takes place on December 2 this year and is by far the city’s biggest running event. The marathon, which starts at the Bund and finishes at the Oriental Sports Centre near the Expo Park in Pudong, is one of China’s four golden marathons, together with races in Dalian, Xiamen and Beijing.

Shanghai surprisingly has no official (English) running club. But it makes up for it with the country’s coolest running website

The course runs south from the Wai Tan area along the west bank of the Huangpu River, and crosses the 8,346-metre Nampu Bridge spanning the river. The roads are said to be wide and smooth, and lined with supporters.

Although the race has only been held for 12 years, it has gained popularity as it offers reasonably clean air, especially compared to the races in Hong Kong or Beijing. Last year more than 28,000 participants from 66 countries took on the challenge. The marathon also includes a half marathon and a five-kilometre health race.

Aprés run It doesn’t cost much to indulge in a post-run pampering leg massage, not to mention a delicious meal of traditional Shanghai dumplings to refill your energy stores. You can even learn how to make them in a local chef’s home.

Also, running gear, shoes and heart-rate monitors cost much less in China, so stock up before you go home. M1NT Bar (m1ntglobal.com) hosts the official Shanghai marathon after-party each year.

This is the first Great Strides, a six-week series of city running guides by Troy de Haas (left), a sports travel manager who represented Australia in orienteering, mountain running and tower running

WELL-BEING 11 FIT & FAB

As I live and breathe ......................................................

Rachel Jacqueline healthpost@scmp.com After Erich Felbabel established sporting apparel company O2 Creation in 2009, he knew sponsoring a triathlete would help promote the brand; but at a cost to the emerging business. So he decided he would sponsor himself – becoming a professional triathlete.

Not that it was a challenge for the 34-year-old Frenchman, who was hooked on triathlons after discovering the sport four years earlier while working in the automotive industry in Guangzhou.

“I was quite crazy,” he says.

“There were no triathlons in China so I would take the train to Hong Kong for a day just to race.”

When Felbabel later moved to Zhongshan, he took his sport to the next level by training for the 2007 Ironman Australia in Port Macquarie. He would jump the fence of the local pool to swim at 5am in the peak of winter, run on the road through polluted factories and ride his bike on a wind trainer in his apartment.

Despite the challenging training environment, he finished his first full ironman triathlon (3.8-kilometre swim, 180.2-kilometre cycle and 42.2-kilometre run) in a respectable 10 hours, 22 minutes and nine seconds.

The move to Hong Kong in 2008 allowed Felbabel to finally “get a breath of fresh air” and inspired O2 Creation. But he didn’t wish to sacrifice his training: “I knew when I started, I still wanted to enjoy myself and do more sports than I was doing before.” Being his own brand’s ambassador has allowed him to throw himself into his passion while still creating a thriving business.

Felbabel admits he is not as competitive as other pros, but the opportunity to race at an elite level has its perks. “When you compete as a pro, you start on the same line as the pros and you are putting your bike next to theirs. Of course, they are better, but still it is very cool.”

But intense training took its toll.

Two years ago he suffered an Achilles injury from overtraining. A torn hamstring injury from his youth also lingered and forced him to scale back on competing.

These days, Felbabel trains smarter, not harder, and considers himself a “lifestyle triathlete”.

“It’s not a sport, not a short-term target, not a job. Now it’s just something I do for leisure and pleasure,” he says.

What is it that gets you out of bed in the morning?

I love the challenge of running my own company. You always have 20 ideas on your mind; I have lists

Entrepreneur Erich Felbabel, creator and owner of O2 Creation, prefers cycling out of the three triathlon disciplines. Photo: Thomas Yau

everywhere. I also love the freedom that it gives me.

It’s been said that having a strong mind is more important than having a strong body when competing.

Do you agree?

I agree that there is a big mental part to completing triathlons, but I’ve never found it more important; maybe I don’t push enough. For me, when I’ve done the training, the mental part just comes naturally.

What’s your worst leg in triathlons?

Swimming – I hate it. I have to swim 1.9 kilometres in a half-ironman and takes me about 27 minutes, which is too long. I only do the swim so I can get on the bike, which is my favourite leg.

How do you keep up the intensity during a triathlon?

I love the competition. Because I’m not so good on the swim, I always

come out of the water at the back of the pack and then I’m competing and fighting for it from start to finish.

I enjoy working hard to overtake guys on my way to the front. It’s what keeps me going.

Has injury made you a better athlete?

My injuries have been a combination of bad luck and not knowing when to stop. Every athlete is used to pushing beyond the pain, but now I know when I need to rest and when to push, and in that way it has probably made me better. Also, after I got the Achilles injury, I took on a coach to learn how to train more intelligently.

Is it about quality or quantity of training?

I’m all about quality these days, since my injuries. There is no point running if you are sick as a dog, or doing too much if you lose the quality of the training. Having said

For me, when I’ve done the [physical] training, the mental part just comes naturally

that, it’s important to have a quantity of training behind you first, otherwise the quality training won’t work. There is a balance.

What’s your secret weapon?

I love sweets, which I know are bad, but it’s also a good thing as it means I can eat a lot of them during a race.

This allows me to eat lots when I’m on the bike and replenish my lost sugars and energy during a race.

In between juggling a business, children and a triathlon career, how do you relax?

During training there are plenty of sessions which include easier aerobic stuff, so that’s relaxing.

Otherwise, I like to read. Right now I’m reading Scott Jurek’s Eat and Run and my last book was a triathlon book. I guess these are all related to my sport, but it is still relaxing. When you like what you do, it’s never hard work.