20130205 health post

YOUR GUIDE TO LIVING WELL

TUESDAY, FEBRUARY 5, 2013

HEALTH POST

NO END TO BEAUTY INDUSTRY ROW >PAGE 8

LIGHTEN UP AND LET IT FLOW >PAGE 12

y on: Henr Illustrati Wong

Energy crisis The scourge of chronic fatigue syndrome

>PAGE 6

2 NEWS 3-D PRINTING

HEALTH BITES

Breakthrough on stem cells

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Jeanette Wang jeanette.wang@scmp.com Three-dimensional printing is all the rage: from crafting musical instruments and prosthetic limbs to constructing a manned base on the moon.

In the field of health, Heriot-Watt University in Edinburgh, in collaboration with Roslin Cellab, a Scottish stem cell technology company, are leading the way in developing 3-D stem cell printing for commercial uses.

In the latest breakthrough, published today in the journal Biofabrication, the team has succeeded in printing human embryonic stem cells (hESCs) for the first time. Many studies have experimented with fabricating 3-D tissues and organs by combining artificial solid structures and animal, not human, cells.

“The generation of 3-D structures from hESCs will allow us to create more accurate human tissue models which are essential for in-vitro drug development and toxicity testing,” says study coauthor Dr Will Wenmiao Shu, from Heriot-Watt. “Since the majority of drug discovery is targeting human disease, it makes sense to use human tissues.”

In the longer term, this may also pave the way for incorporating hESCs into artificially created organs and tissues ready for transplantation into patients.

The hESCs are originally derived

A colony of human embryonic stem cells, which can now be printed. from an early-stage embryo to create “stem cell lines” which can be grown indefinitely and differentiate into any cell type in the body. Until now, these cell cultures had been too sensitive to manipulate by printing.

A valve-based printing technique was used, tailored to account for the sensitive properties of hESCs. Shu says: “We found that the valve-based printing is gentle enough to maintain high stem cell viability, accurate enough to produce spheroids of uniform size and, most importantly, the printed hESCs maintained their pluripotency – the ability to be differentiated into any other cell type.”

Jason King, of Roslin Cellab, says: “This is a scientific development which we hope and believe will have immensely valuable long-term implications for reliable, animal-free drug-testing and, in the longer term, to provide organs for transplant on demand.”

ASK THE DOCTORS MAHESH CHOOLANI Q: I’ve been taking birth control pills for almost seven years and decided to stop taking them as of my last cycle last week. What kind of changes should I be expecting?

A: Most women would have very few untoward effects upon stopping birth control pills (oral contraceptive pill, OCP). As your hormones readjust once you stop the OCP, you might experience some weight loss, oily skin or premenstrual symptoms.

Usually, when your periods return after stopping the OCP, they remain similar to what they were like before you started using the pill.

For some women, the periods might become heavier or irregular, but very occasionally the cycles do not return

Jeanette Wang jeanette.wang@scmp.com Working out how to avoid Alzheimer’s Work out now and continue to reap the benefits later. A new study in the United States has found that having a higher fitness level in midlife appears to be associated with a lower risk of developing Alzheimer’s disease and other types of dementia in later years. Between 1970 and 2009, researchers at a community health clinic carried out an exercise treadmill test to assess the baseline fitness levels of 19,458 non-elderly, community-dwelling adults who were in generally good health. The researchers reviewed date from Medicare, the US national health insurance programme, for the patients who became eligible to receive benefits between January 1, 1999, and December 31, 2009. They found that patients who were physically fit earlier in life were much less likely to develop dementia than those who were less fit.

Solution to gnawing doubts on research Many experimental drugs work very well in rodents but fail miserably when tested in people – but this may change in the near future. Scientists at the University of Southern California in Los Angeles have genetically engineered mice that possess an immune response system more like a human’s. In a study published by the Proceedings of the National Academy of Sciences, the USC researchers “humanised” certain cell molecules in mice to produce a desired response to the cancer drug á-galactosylceramide. “It’s the best model we have in the field,” said assistant professor Weiming Yuan, principal investigator of the study. “We’ve basically set a platform to fast-track the identification of immunotherapies that can kill cancer and also make vaccines stronger.” He added: “Before, it would have been a guess as to whether the drug would work in people. Now, the chance of success goes from one out of 100 to one out of five.”

Making sense of taste loss With food being one of the joys of life, losing one’s sense of taste could be depressing.

But a new study published in the journal Stem Cells offers hope for the development of techniques to grow and manipulate new functional taste cells for both clinical and research purposes. Scientists at the Monell Centre in Philadelphia have identified the location and certain genetic characteristics of elusive taste stem cells on the tongue located in clusters called taste buds. Two types of taste cells contain chemical receptors that initiate perception of sweet, bitter, umami, salty, and sour taste qualities. A third type appears to serve as a supporting cell. A remarkable characteristic of these sensory cells is that they regularly regenerate, with an average lifespan of 10 to 16 days.

immediately and could take for up to one year for the menses to return (post-pill amenorrhoea).

Fertility often returns soon after the menstruation restarts.

Dr Mahesh Choolani is a consultant obstetrician and gynaecologist with the Choolani Clinic at Mount Elizabeth Novena Specialist Centre in Singapore

> 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

Where the living is wheezy Living close to the equator guarantees you warm weather all year round, but it could also put you at a higher risk of developing asthma and allergies, according to new research in the Annals of Allergy, Asthma & Immunology. The culprit: exposure to UV-B rays, which is higher in areas closer to the equator. “This increase in UV-B may be linked to vitamin D, which is thought to modify the immune system.

These modifications can lead to an elevated risk of developing allergy and asthma,” says lead study author Vicka Oktaria.

NEWS 3 DETOX

Of cleansing, calories ... and cocktails ......................................................

Jeanette Wang jeanette.wang@scmp.com It’s that time of the year when detoxing is in fashion, as people look to undo the damage caused by weeks of holiday indulgences and the upcoming Lunar New Year.

Capitalising on the trend, Armani/Aqua, the chic restaurant in Chater House where “couture meets cuisine”, has launched a five-course detox tasting menu that claims to cleanse the body without compromising on taste.

Working with a “well-respected British-based nutritionist” (Aqua’s director of marketing Eliot Sandiford declined to give a name), the restaurant’s chefs specially designed low-fat and low-carb portioncontrolled dishes, each containing fewer than 300 calories.

The dishes are anchored by six ingredients the restaurant calls “heroes” – beetroot, walnut, sage, cod, melon and figs – selected based on their scientifically proven benefits, such as antioxidant and antidepressant, and superior nutritional properties (such as vitamins, minerals and fibre).

“The idea of dieting is always so demoralising. We wanted to put together something interesting and tasty that would still remain light and to help our guests achieve their goals,” says the restaurant’s general manager, Max Rhodes.

Detox purists would be up in arms over the menu. A detox is traditionally a low-calorie diet of water, fruit, fruit juices and/or raw vegetables. No processed sugar, salt, unhealthy fats, caffeine – and certainly no alcohol or tobacco.

It’s believed – but never proven by research – that this will purge toxins from food additives, pesticides and pollutants from the body. The result: increased energy, clearer skin, headache relief and perhaps even weight loss.

But having all five courses of Armani/Aqua’s tasting menu (HK$688) will set you back by 861 calories, including 24 grams of fat, 55 grams of protein and 112 grams of carbs. This one meal is more than 40 per cent of my recommended daily intake of 2,000 calories, according to – and stated on the restaurant’s menu – Singapore Ministry of Health guidelines.

What is more contentious is that

diners have the option of pairing the courses with four “Retox Cocktails” for an additional HK$300. The restaurant has tried to put a healthy spin by using “hero” ingredients in the drinks, such as Pomegranate & Rosemary Martini (pomegranate is a “superfruit” high in antioxidants) and a muddled avocado and tequila concoction called Avorita (avocado is packed with essential nutrients).

“There’s been a lot of objection over the cocktails,” says Tony Paese, the restaurant’s manager, “but sometimes you need pleasure also.”

If your goal is just to eat healthier, however, then the detox menu could be for you – but hold the alcohol, and order the dishes à la carte.

I recommend just having the main course: roasted fillet of Mediterranean Sea cod with butter bean and vegetable ragout (HK$288). With plump, melt-inyour-mouth meat and a thin crispy layer of fennel and breadcrumbs, the fish (high in omega-3s) tasted indulgent but has just 287 calories and three grams of fat.

The portion size is decent, but if I was hungrier, I’d then also have the second course: roasted vegetable soup with walnut & sage pesto

Beetroo t cheese carpaccio with and a c itrus an goat’s d mint glaze (HK$118), at 163 calories and 8.9 grams of fat. Roasted and puréed zucchini, bell peppers, eggplant and pumpkin make the soup thick and creamy without additional fat.

Since its launch on January 1, 227 sets of the tasting menu have been sold, of which 159 included the cocktails, says Rhodes. The most popular à la carte dishes have been the cod and the starter of beetroot carpaccio with goat’s cheese (HK$138). The restaurant will stop serving the detox menu on February

28. However, Rhodes says if there is demand, some or all dishes may continue. The cocktails, he says, have been very popular, and there could be more of such antioxidant mixes in future. Wheatgrass and apple daiquiri, anyone?

Alas, one meal does not a detox make, but the Armani/Aqua detox menu will certainly leave you feeling virtuous and lighter – in the belly and the wallet.

4 HEALTH MULTIVITAMIN SUPPLEMENTS

Body guards ......................................................

Sasha Gonzales healthpost@scmp.com When John Chia read that a diet high in antioxidants could slash a person’s risk of developing cancer, he began to incorporate more fruit and vegetables into his diet. Not satisfied with just eating healthily, he also started taking dietary supplements daily for “extra antioxidant insurance”.

“At 41, I feel better than ever,” says the father of three. “If antioxidants can prevent cancer, then I’m guessing that the higher my antioxidant intake, the higher my level of protection.”

He might be on to something.

In a recent study published in The Journal of the American Medical Association, it was found that daily multivitamin supplementation reduced the risk of total cancer in men by 8 per cent. Although the study showed it did not reduce the risk of prostate cancer and site-specific cancers such as

colorectal cancer, lung cancer and bladder cancer, and cancer mortality, the results are nevertheless significant.

According to registered dietician Carmen Lo Ka-man, cancer results from damage to DNA in cells, causing the cells to grow out of control. There are a number of causes that lead to cell damage, among them chemicals found in cigarette smoke, radiation from too much sun or radioactive exposure, pesticides or herbicides in food, genetic abnormalities, and even some viruses.

Lo adds that the food we eat also affects DNA function, although the exact mechanisms are unclear. “The link between diet and cancer is complicated, and scientists have not yet unravelled the exact mechanisms involved. This is because diets are made up of different foods containing many nutrients that interact in different ways in individuals,” she says.

Based on scientific evidence, the

World Cancer Research Fund has produced recommendations on food, nutrition and physical activity to help reduce the risk of cancer.

Although the study is encouraging, it is important to remember that multivitamins are not the magic bullet when it comes to cancer prevention. What is more effective is adopting habits that support our immune system and optimise cell function. In addition to taking antioxidant-rich multivitamins, which support our own antioxidant production and

Only wholefood vitamins offer the nutrients in the form found in food, ones known to offer protective benefits GRAEME BRADSHAW, FOUNDING DIRECTOR OF THE INTEGRATED MEDICINE INSTITUTE

WHAT MEN NEED Graeme Bradshaw of the Integrated Medicine Institute shares his expertise on what vitamins and minerals men require most. ● Vitamin D A five-year study of more than 120,000 people found that men with the highest vitamin D intakes had a risk of colorectal cancer that was 29 per cent lower than men with the lowest vitamin D intakes. ● Folic acid is especially important to men who drink because alcohol interferes with the body’s ability to absorb folic acid. In a study of more than 45,000 male health professionals, intake of more than two alcoholic drinks a day doubled the risk of colon cancer. Drinkers are somewhat protected by B-complex supplements with folic acid. Green vegetables are excellent sources of folic acid, which may play an additional role in their anti-carcinogenic effect through other phytonutrients. ● Zinc deficiency leads to poor health in the prostate gland as it limits the gland’s capacity to detoxify testosterone. A 2010 Swedish study of men with localised prostate cancer found that high dietary zinc improved survival by 36 per cent over a six-year follow-up. Vegetarian men are most prone to low levels of zinc.

neutralise excessive free radicals that can damage DNA, it is imperative that we eat well, stay adequately hydrated, minimise our intake of toxins, get adequate exercise and sleep, and live a balanced lifestyle, says Charles Au, co-founder and director of Verita Advanced Wellness in Singapore.

According to Graeme Bradshaw, naturopath, homeopath and founding director of the Integrated Medicine Institute, the nutrients that best protect against cancer are folic acid, vitamin B6 and B12, which prevent damage to DNA; selenium, which purges our body of carcinogenic substances; and vitamin C and zinc, which optimise white blood cell performance and boost our immunity against disease.

As helpful as multivitamins are, they are no replacement for a healthy, balanced diet based on natural wholefoods. In fact, fruits and vegetables are still the way to go to minimise your cancer risk.

Bradshaw adds: “A large number of studies have shown that increased consumption of fresh fruits and vegetables – about five servings a day – is associated with a reduced risk for most types of cancer. Of course, natural dietary sources of nutrients are better than synthetic vitamin sources but the question is whether most people’s diets provide the optimal level of nutrients. The answer is usually no.

In Hong Kong, the average fruit and vegetable consumption is two servings a day.”

MEDICAL 5 CASE HISTORY

This joint’s on fire ......................................................

Eileen Aung-Thwin healthpost@scmp.com

Illustration: Angela Ho

If your diet does not provide enough vitamins and minerals, then taking daily multivitamin supplements is better than nothing. You might also need multivitamins if you suffer from deficiency diseases or for other medical reasons. It is best to discuss your supplementation needs with your health care professional.

Most multivitamins on the market are synthetic and do not replace the beneficial effects of food-based antioxidants.

However, says Bradshaw, we know that optimal levels of these natural antioxidant nutrients are rarely achieved in the diet.

If the correct form – which is the natural food state – of antioxidants can be taken as a multivitamin, then the problem of sub-optimal dietary levels is solved.

Food-state multivitamins act like foods, delivering the optimal levels of protective nutrients. They are far superior to synthetic vitamins.

“I recommend these food-state or whole-food vitamins that use the natural forms of antioxidants and vitamins.” says Bradshaw.

“Only food-state or whole-food vitamins offer the nutrients in the complex form found in food, ones known to offer protective benefits.

These supplements are absorbed twice as well, last twice as long in the body, and have enhanced activity owing to their more complex forms, compared to synthetic vitamins.”

Mr Chan was an active 30-year-old fireman who had to meet the gruelling physical demands of his job. But in 1997 a deepening pain in his left hip eventually left him unable to walk for more than five minutes without resting.

Walking up and down stairs, getting in and out of vehicles and any other activity where he had to bend at the hip became excruciatingly painful. Aware of his discomfort, his work supervisor gave him a desk job to minimise his physical activity and pain.

An orthopaedic specialist diagnosed Chan (whose name has been changed for reasons of patient confidentiality) as suffering from avascular necrosis, or AVN, which is a common cause of hip joint damage in Asians.

Avascular necrosis is a condition in which the bone dies because it isn’t getting enough blood. It commonly afflicts the shoulder and hip joints, but can also affect other large joints like the knee, elbow, ankle and wrist.

According to Dr Jason Brockwell, a specialist in orthopaedics and traumatology, the hip joint is particularly susceptible to AVN because the head of the thigh bone, or femur, is a cul de sac when it comes to blood supply with only one route for the blood to travel in and out. Hence, if the blood supply to the femoral head is reduced or interrupted, there is no alternative blood supply.

Although the cause of AVN is a disrupted blood supply, the cause for the disruption is not always clear.

Trauma or injury of some kind can sometimes precede AVN, as can radiotherapy and diseases such as sickle-cell disease, atherosclerosis, gout and diabetes.

Alcohol and long-term steroid use are also known culprits.

Brockwell explains that both substances affect fat metabolism and can lead to clotting of small blood vessels. He says that steroids are a common component in traditional medicine, and long-term use can give rise to AVN. In many cases, however, the cause of AVN is unknown. Chan fell into this category.

Brockwell says that mild cases of AVN can resolve on their own once blood supply is re-established. But once the bone dies and collapses, the only option facing patients is a

It [BHR] uses a more durable material for the artificial ball and socket joint than conventional ones, and presents less risk of joint dislocation

total hip replacement. In such an operation, the entire head and neck of the femur are removed and replaced with an artificial ball and socket joint.

Brockwell says that although such a method works well, it lasts only about 20 years as the artificial implants wear out. Furthermore, the range of motion for the hip is not as wide as for the natural and undamaged hip, and the hip joint is at risk of dislocation.

Hence, young patients like Chan are often reluctant to undergo hip replacement surgery because they face the high possibility of having to do it again in 10 or 20 years’ time.

Chan refused the surgical option and tried to manage his pain with analgesics and by minimising his activity. Three years after the onset of AVN in his left hip, Chan was diagnosed with AVN in his right hip, too.

In 2003, Chan chanced upon a health forum that introduced a new type of therapy for AVN sufferers.

Called Birmingham Hip Resurfacing (BHR) surgery, the method removes only the damaged bone and conserves more natural bone compared to the traditional method.

It uses a more durable material for the artificial ball and socket joint than conventional ones, and presents less risk of joint dislocation.

Brockwell says retaining more natural bone gives rise to a greater range of motion and better function.

He says this is especially important for Asians, who are more likely to squat or sit on the floor, which BHR enables one to do.

Studies show that patients who undergo BHR walk 10 per cent faster, have a higher level of sporting activity and a lower mortality rate at six years after the hip surgery than those who undergo traditional hip replacement, Brockwell says.

Although the longevity of the BHR joint compared to the conventional hip replacement surgery is unknown, the promise of better function was enough to sway Chan. The following year, Chan underwent BHR for his left hip. He was discharged from the hospital four days later and returned to sports in six months.

In 2006, Chan underwent BHR for his right hip.

He reports a better range of motion in his hips than before AVN struck. “Not only can I return to my original duties, I run four kilometres each day and go hiking regularly.”

6 COVER STORY

Daze of Illustration: Henry Wong

More than 10 per cent of Hongkongers may be suffering from a debilitating disorder for which there is no simple cure. Many will never recover from it, writes Richard Lord

H

ave you felt disabled by exhaustion for at least six months with no obvious medical reason? Have you also experienced bouts of weakness, pain, impaired memory or problems sleeping?

Some doctors may diagnose you as having chronic fatigue syndrome (CFS), but others are sceptical that such a condition even exists.

Despite being recognised as a major public health problem since the late 1980s, the lack of uniformity of symptoms and causes among patients has complicated the diagnostic process and development of treatments.

“As family physicians in Hong Kong, we almost never diagnose CFS; it’s more a label, a functional diagnosis, a description,” says Dr Billy Chiu Chi-fai, a specialist in family medicine at Hong Kong Sanatorium and Hospital.

Instead, when a patient presents with the symptoms of CFS, he says, doctors will test for other conditions before, in most cases, diagnosing the symptoms as evidence of a psychosomatic disorder, anxiety, depression, a mood disorder, neuritis (inflammation of the nerves), insomnia or one of a number of other similar conditions.

In Hong Kong, it’s estimated that 10.7 per cent of adults experience chronic fatigue syndrome. This was based on a study published in 2010 of 5,000 Chinese people aged 18 years or older, led by University of Hong Kong clinical psychologist Richard Fielding.

The reported rates of CFS have ranged from 0.037 to 18.3 per cent in the general adult population, according to another HKU study, on the effects of qigong on the symptoms published in the Annals of Behavioral Medicine last year.

Researchers worldwide have paid increasing attention to CFS – known as myalgic encephalomyelitis – in

Many patients with chronic fatigue syndrome encounter a lot of scepticism about their illness DR ELIZABETH UNGER, CDC

recent years as the search for a definitive cause and cure continues.

In November, Ohio State University researchers reported the discovery of a potential diagnostic method to identify at least a subset of patients with CFS. In a pilot study of six patients, scientists detected specific antibodies linked to the latent Epstein-Barr virus reactivation in blood samples from those who had experienced some key CFS symptoms and had responded to antiviral treatment.

“Part of the problem in trying to identify an agent or biomarkers for chronic fatigue syndrome is the extreme variability among people who say they have CFS,” says virologist Ron Glaser, co-author of the Ohio State study. “How to sort that out has held the field back a lot of years.”

CFS seems to affect women more than men – Fielding’s study found that 13.1 per cent of women and 8.1 per cent of men experienced the disorder. Factors linked with increased odds of CFS included age (being younger increases the odds), being a retiree, having had chronic health problems, poor mental health and a lower quality of life score. Those who exercised three to five times a week were less likely to report chronic fatigue compared to the sedentary.

Other studies show CFS varies in severity: some sufferers have a fairly

COVER STORY 7

f their lives normal life, while others are reliant on other people for the most basic tasks. Only a fifth of sufferers can work full time, while half can’t work at all. For many, it’s a life sentence: less than 10 per cent of adult sufferers recover fully, although more than half of children do.

Leading CFS researcher Judy Mikovits says many subclinical CFS cases exist in the population but are not picked up in epidemiological studies. “The disorder of CFS will be harder to separate out in developing countries as it merges with many common and often chronic infections and requires expertise not likely available in such countries.”

CFS mimics many other disorders, making diagnosis difficult. Among the conditions and diseases mimicked are: cancer, hypothyroidism, sleep apnea, narcolepsy, hepatitis B and C, substance abuse, mental disorders (major depressive disorder, bipolar affective disorders, schizophrenia) and severe obesity.

But an international study of more than 37,700 people published in 2009 in the Australian and New Zealand Journal of Psychiatry found five domains of chronic fatigue that were robust across cultures and health care settings, and consistent with the 1994 international consensus criteria.

The five are: prolonged fatigue and musculoskeletal pain, impaired neurocognitive function, sleep disturbance and symptoms suggestive of inflammation.

The study authors concluded that chronic fatigue states can be readily identified in the community and at all levels of health care.

They add: “Consequently, it is likely that they share common risk factors, are underpinned by a common pathophysiology and may respond to common treatment strategies.”

The US Centers for Disease Control and Prevention (CDC) inclusion criteria for CFS remains the most widely used in the field.

Apart from fatigue that has persisted or relapsed for six or more months, CFS patients must also have four or more of the following eight distinctive symptoms: impaired memory or concentration capacity, post-exertional malaise, sleep problems, muscle pain, arthralgia (joint pain), headaches, recurrent sore throat and tender cervical or axillary lymph nodes.

Some physicians, however, are not confident enough to make a diagnosis, says Chiu. “Some doctors are not trained to deal with such conditions and feel overwhelmed by the repeated attendance of patients with unspecified symptoms.” Those with training in holistic care or a background in psychology or counselling are often better able to manage patients, he adds.

There are other controversial aspects to CFS – its causes. It could be biological, viral, environmental, genetic, psychological, some combination of those or something else entirely. The lack of readily identifiable causes has led many sufferers to feel stigmatised.

“Many patients with chronic fatigue syndrome encounter a lot of scepticism about their illness,” says Dr Elizabeth Unger, CFS research chief of the CDC. “They have difficulties getting their friends, colleagues, co-workers and even some physicians to understand their illness.”

Attempts to identify a physical cause, however, have so far foundered.

Viral suspects to have been suggested include the Epstein-Barr virus,

Dr Billy Chiu says some physicians are not confident enough to make a diagnosis.

the herpes virus and mouse leukaemia viruses. A 2009 study in the journal Science, of which Mikovits was an author, linked it with a virus called XMRV, but that was retracted when the results turned out to be caused by a lab contaminant.

There are measurable physical

changes associated with CFS, but scientists are unsure if they’re the cause or an effect. Sufferers often have weakened immune systems or abnormal blood levels of hormones produced in the hypothalamus, pituitary gland or adrenal glands.

Unger led a study last year that showed a decreased response among sufferers in an area of the brain known as the basal ganglia, which is responsible for functions such as motor activity and motivation in response to reward.

“The findings indicate that a biological process involving neurocircuits in the brain that regulate motor activity and motivation as well as fatigue are altered in people with CFS,” says Unger. “CFS is not treated as a psychological or psychosocial condition but, similar to other chronic illnesses such as cancer or heart disease, body and mind interactions play an important role in improving functioning and life satisfaction.

“It is most likely that a variety of factors may play a role in CFS and each patient’s history of illness differs. Infections, trauma, stress, surgery, hormones and genetics may all interact in ways we don’t yet fully understand.”

Existing treatments for CFS are limited in their effectiveness. Because Western treatments and medications are often associated with limited clinical benefits and possible undesirable side effects, complementary and alternative therapies are often used by individuals with chronic fatigue to manage their symptoms.

The most common are cognitive behavioural therapy, dealing with the patient’s perception of the condition and its symptoms; and graded exercise therapy, a form of physiotherapy involving gradual increases in activity. But evidence for the effectiveness of both is mixed.

From the perspective of traditional Chinese medicine, chronic fatigue and CFS are caused by blood stasis due to qi (vital energy) deficiency and/or emotional constrain; therefore, stimulation of the blood and qi circulation is the core treatment strategy.

The HKU qigong study randomly assigned 64 participants to either an intervention group that did a fourmonth qigong programme or a control group. Fatigue symptoms and mental functioning were significantly improved in the qigong group compared to the control.

Speaking with a counsellor to work around the limitations of CFS on your life can also help, says Chiu. “Feeling more in control of your life can improve your outlook dramatically.”

Mikovits adds: “Controlling stress; boundary setting of physical, emotional and cognitive activities; and attention to proper sleep and diet modification are the first and most important clinical steps to take. A search for the key or keys to individual cases of CFS can turn up … clinical conditions unique to that person.

“Our modern lifestyle involves far more stress than previous generations: oxidative stress in general; increased travel and exposure to different environmental toxins and pathogens from other countries; poorer nutritional value of foods; polluting elements in our environment that used to not be there.” healthpost@scmp.com

8 HEALTH BEAUTY INDUSTRY

Battle lines

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Elaine Yau elaine.yau@scmp.com As the debate over how to regulate the beauty industry rages on in Hong Kong, a top plastic surgeon from South Korea was recently invited by Chinese University’s faculty of medicine to share his experiences on industry regulations with local doctors.

Dr Hong Joon-pio, director of the plastic surgery department at the ASAN Medical Centre in Seoul, says the cosmetic surgery industry is largely regulated by market forces in South Korea. “The way we achieve excellence is through competition and cutting-edge surgeries,” he says.

“In Korea, plastic surgeons never want a monopoly. It’s never an issue. The plastic surgery market is so busy that they don’t have time for that [kind of] discussion.”

It’s a different matter in Hong Kong, where it seems the stakeholders involved in the beauty industry – beauticians, plastic surgeons, specialists in dermatology and general practitioners that carry cosmetic procedures – are each keen

100,000 The number of workers said to be employed in the beauty industry in Hong Kong

Federation of Beauty Industry founding chairman Nelson Ip. Photo: Edmond So

to protect their own turf. As a result, discussions over how to strengthen regulations in Hong Kong – which all stakeholders agree needs to be done – have been controversial.

The local beauty industry went into a tailspin after blood transfusion therapy left one woman dead and three others critically ill in October last year. Following the tragedy, the government set up a steering committee to review the regulation of private health care facilities in the city. A consensus has not been reached on how to distinguish between medical procedures and cosmetic services since the first meeting of the committee in December.

Under South Korean legislation, any procedure that penetrates the skin, including tattooing and ear piercing, is considered a medical procedure that should be done only by doctors, Hong says. “But the law is not enforced obsessively, so ear piercing is still done by beauticians.”

One in five South Korean women has had plastic surgery. In the affluent Gangnam district alone – with a population of about half a

million – there are 500 plastic surgery clinics. Only 100 of these are run by board-certified plastic surgeons. But all of them are legal: in South Korea, if you have a medical licence, Hong says, “you can do everything”.

The catch: plastic surgeons that are not board certified are not allowed to use their name in the clinic’s name. “For example, if I call it ‘Dr Hong Plastic Surgery’, this means I am board-certified,” Hong explains. “If you see a clinic that doesn’t use the doctor’s name, it means the surgeons are not certified by the plastic surgery board.”

So customers are free to choose, and they make their preference known: the 100 clinics run by boardcertified surgeons garner 80 per cent of the income in Gangnam. “[These clinics] charge more and do more complex procedures. But [the government] is not stopping nonplastic surgeons from doing plastic surgery procedures,” says Hong.

If something happens to a patient treated by a non-boardcertified surgeon and the patient takes legal action, Hong says, the malpractice tribunal will be comprised of board-certified surgeons – hence a favourable ruling is unlikely. “So that’s the way to decrease risk for patients,” he says.

“In Korea if you kill a patient, they take away your licence and you have to do something else for the rest of your life. So doctors know the risk of doing something they [are not qualified for].”

Dr John Yu Ho-tak, a specialist in dermatology and venereology in Hong Kong, knows his limitations.

Using a skin cancer patient as an example, Yu says if the cancer is situated below the neck, he “will be happy to remove it”. But if it’s near the eyes, he will refer the patient to a plastic surgeon, who is trained to perform flaps and skin grafts. “Although we can do it, it’s not our expertise,” says Yu. “For some aggressive doctors, they will do everything.”

He says the main problem in Hong Kong is that the government does nothing to stop doctors from misleading the public. To become a specialist in dermatology, Yu had to

have specialist training in a hospital for at least seven years on top of his five-year medical school training. In comparison, a general practitioner can call himself a skin doctor after simply spending a few months completing a diploma in dermatology, after medical school training and a one-year internship at a government hospital.

Cosmetic surgery, in fact, can be performed by any medical practitioner in Hong Kong, says Yu, as medical training covers plastic and reconstructive surgeries.

“As long as you don’t call yourself a specialist in plastic surgery and both the doctor and patient are willing to be subjected to the risk, you can perform any cosmetic surgery provided you have the necessary operating equipments and anaesthetic support.”

Professor Andrew Burd, chief of Chinese University’s division of plastic, reconstructive and aesthetic surgery, says many of the plastic surgeons in the city have no training in cosmetic surgery. However, his

HEALTH 9

Dr John Yu demonstrates radio frequency treatment.

Photo: K.Y. Cheng

major concern has more to do with the safety of facilities where these surgeries are carried out.

A young woman died after a beauty centre referred her to a gynaecologist to have breast enlargement surgery in 2010. There was an alleged overuse of anaesthesia by the gynaecologist and the case is under review in the Coroner’s Court.

“If you treat patients in a clinic that doesn’t have resuscitation equipment and you use intravenous anaesthetic techniques that can cause [cause a patient’s heart to stop], it’s an unsafe environment,” says Burd.

“The government must take an active role in ensuring facilities and environments in which procedures are performed are safe and regulated.”

Opening a beauty centre in Hong Kong only requires that it is registered like every other business.

Since such centres are not classified as clinics, there’s no law to regulate them. They rope in skin doctors

The government must take an active role in ensuring facilities and environments in which procedures are performed are safe and regulated PROFESSOR ANDREW BURD

and plastic surgeons to conduct high-risk procedures such as liposuction and double eyelid surgery. The centres are not required to be equipped with resuscitation equipment to deal with emergencies.

There’s also no law to regulate the sale of machines used to perform laser treatment or operate intense pulsed light equipment.

Beauty centres purchase them and then operate like small-scale clinics with consultation and surgery rooms.

“Our regulation lags behind Singapore and Macau. Such laser procedures should be conducted by registered doctors,” says Dr Chan Wai-man, a specialist in ophthalmology and chairman of Hong Kong Surgical Laser Association. He says that damage by laser treatment is irrevocable; even indirect contact with lasers and intense pulsed light can cause permanent damage to skin and eyes.

Federation of Beauty Industry chairman Nelson Ip Sai-hung

disagrees. He argues that if high-risk cosmetic procedures – such as those that use laser and intense pulsed light equipment – are considered medical, then many beauty salons would fold. There are 5,000 beauty salons in Hong Kong, of which 60 per cent to 70 per cent have such equipment he says.

“Those [doctors who want high-risk procedures to be defined as medical] just want us to do massage and facial,” says Ip. “A dangerous procedure is not necessarily medical. I can’t accept [the idea of defining] tattooing and ear piercing as medical. Medical [procedures] should involve diagnosis, treatment of diseases, the use of drugs or surgery and symptom improvement.”

Ip says there should be a system for beauticians to get trained and pass an assessment to be granted a licence to practise.

“Without legislation and a licensing system, there’s no punishment when something [goes wrong]. For doctors, they will get

their licence revoked. A licensing system with rules will have a deterrent effect on the beauty industry,” says Ip. Dr Chow Pak-chin, Medical Association co-vice-president and a specialist in ophthalmology, says legislation should be taken a step further to cover four areas – equipment import, installation, repair and use by personnel.

The Undesirable Medical Advertisements Ordinance enacted in 2007 should also be expanded to cover inaccurate and exaggerated beauty advertisements that lack scientific basis, he says.

Dr Ying Shun-yuen, a plastic surgery specialist and member of Hong Kong Association of Cosmetic Surgery, criticises the government for failing to enforce the ordinance stringently. “Even obscene publications have to be wrapped in plastic bags with warnings. But unproven and harmful medical cosmetic procedures can be promoted with impunity.”

10 FITNESS MARATHON MANIA WEEK 10

Mind over muscle ......................................................

Laura Walsh (left) and Rachel Jacqueline stride out in the Mid-Levels. Photo: Dickson Lee

Rachel Jacqueline healthpost@scmp.com

TRAINING DIARY

It’s no secret that training for a marathon requires hard work, as early mornings, thigh-thrashing long runs and pushing nearsickening speeds become the norm.

Unfortunately, physical training alone is not enough to ensure you cross the finish line on race day.

Training the mind is essential for performance in endurance exercise, insists renowned sports scientist Dr Tim Noakes. While a marathon forces your body beyond its energy reserves and pushes muscles to the max, Noakes believes it is the brain – not the body – that dictates your limits.

Scientists previously thought the body had limitations and when those were exceeded, the systems failed, you got tired and you stopped. Noakes’ theory, on the other hand, known as the Central Governor Model, stipulates that the body’s function and performance during exercise is a process regulated by the brain.

Noakes believes our bodies would never allow us to continue to the point of total collapse. Rather, he views the brain as the “control box” forcing the body to slow down or stop so we arrive at the finish intact, retaining a state of homeostasis that includes steady blood glucose and body temperature. It does so by sending a message to your body to activate less of your muscle mass when it is under threat during maximum exertion.

Fatigue is therefore not a physical phenomenon, but an emotion that can be controlled, argues Laura Walsh, former Hong Kong triathlete and mental health sports counsellor.

“However bad you feel, it’s your brain playing a trick on you, trying to make sure you don’t damage yourself.” So, to keep going or run faster, you need to learn to activate a larger mass of muscles than your brain is allowing.

Locating that switch and developing “mental endurance” is the key to finding new limits and conquering your marathon goals, says Walsh.

“Mental endurance is the ability to ‘carry on’ when you feel your body is telling you to stop. It’s about understanding that the body is in fact able to continue, instead of allowing the physical signals to be interpreted as the necessity to quit.”

I completed my first long road run this week and it wasn’t as daunting as I had anticipated. I stuck to my instructions on keeping up my nutrition during the run and I never really felt tired. I did sneak in a few water stops and checked my phone on the way (I still find running for that long a little tedious), so my pace was a little bit off, but I feel like I’m on track. Next week’s big run will be the true test.

While there are, of course, physical thresholds which our bodies cannot exceed – high core temperatures, dehydration, lack of energy – that point is in fact beyond where your brain is telling you it lies.

Notwithstanding all of the above, mental strength is no substitute for training, however. “Mental endurance only comes after the physical advantages from training, such as weight loss, increased lung capacity, stronger muscles and so on have been gained,” Walsh says.

Once you have acquired the necessary fitness, you can work on this next stage of performance.

Reprogramming the brain’s limiting messages begins with pinpointing your motivation to run.

“You need to understand and know the big ‘why’ behind why you are doing the race in the first place, otherwise it’s too easy not to fight the temptation to quit,” she says.

The next priority is to visualise the race and imagine yourself finishing. “Before the gun is even close to going off, our brains have decided the outcome,” says Walsh.

“Visualisation is extremely powerful in keeping the mind focused on the present,” she says, suggesting you focus on positive images such strength, endurance, efficiency and speed while you’re running.

Trainer Clinton Mackevicius is fond of visualisation techniques while racing. “I visualise how I want to be feeling at certain parts of the race,” he says. “In order to relax while running fast, I also think back to previous sessions where I can sync my running gait into a pattern that allows me to run easier without losing pace.”

Keeping positive is essential, continues Walsh. She suggests writing down positive affirmations

DIET 11 BOOK REVIEW

Controlling your tempeh ........................................

Jeanette Wang jeanette.wang@scmp.com

Australian trainer Clinton Mackevicius is coaching the author for her first marathon. Photo: Felix Wong and rehearsing them before the race.

“For example, if you have difficulties running up hills, instead of cursing and thinking how awful the hills feel, write down how you will cope with the hill and what you will say to yourself, like ‘shorten your steps, lean into the hill’,” she says. “Same scenario, just different thoughts and, most likely, results.”

Mackevicius, too, keeps a positive mantra in mind when he runs. “I never lose sight of the finish line when I run I and never let doubt enter my mind,” he says.

Rather than telling yourself to not think about running such a long way, Walsh says staying focused will help you to work through the mental obstacles you will encounter. “The brain doesn’t understand a negative, so by focusing on not doing something, you are in fact doing it.”

Devising a race plan can alleviate anxiety on race day, while keeping your mind engaged, says Mackevicius. “You should always go in with a race plan A, and also a plan B if things don’t go accordingly,” he says. By actively telling the brain what to do, you will remain in the

The true greats have learned to look at the discomfort of the event as a challenge to be overcome LAURA WALSH, SPORTS COUNSELLOR

Tim Noakes, exercise and sports scientist.

present and have greater control over your emotions.

Walsh reminds runners that pain is a subjective experience that can similarly be controlled. “To begin with, change the word you use to describe this sensation. Pain has such negative connotations that creates anxiety and heightens the feelings you are experiencing,” she says. Just as we can train our mind to work beyond the urge to quit, we can retrain how it interprets pain.

“Instead of thinking of pain as being awful, understand the sensations you are feeling are simply your body’s physiology of hard effort.”

Above all, have an unwavering belief in your potential. “The truly great runners don’t always have the highest VO2 max, or the greatest cardiac output (we wouldn’t need to have competitions if this was the case; it could all be decided by numbers in an exercise physiology laboratory),” says Walsh. “The true greats have learned to look at the discomfort of the event as a challenge to be overcome, and thus have that fantastic ability to never, ever give up.”

Drills consist of two sets of 60 high-knees / 60 bum-kicks / 20-metre knee-drives / two 10-metre strides PE = perceived exertion, on a scale of 1 to 10, with 10 being the hardest

Focus

Active recovery

Duration

30 to 40 mins

Description 10 mins warm-up and warm-down Week 11: 40 mins at PE 5 Week 12: 30 mins at PE 5 Stretches and drills

TUE Speed

WED

THU

Rest

Slow run

FRI Threshold session

30 to 40 mins

20 to 40 mins 25 to 35 mins

10 mins warm-up and warm-down Week 11: 4 x 5 mins at race pace with 2 mins walk/slow jog recovery in between Week 12: 10 x 1 min at race pace with 1 min recovery in between

Week 11: 40 mins at PE 4 Week 12: 20-30 mins at PE 4

10 mins warm-up and warm-down Week 11: 8-10 x 2 mins at PE 6 with 1 min recovery in between Week 12: 15 mins at PE 5 with stretches, drills and strides

SAT Rest

THE TASTE TEST PANCAKE MIX .....................................................

Jeanette Wang jeanette.wang@scmp.com Hakubaku Hot Cake Flour with Mix Bean and Cereal HK$43 for two 150 gram packs, Jasons Food & Living This Japanese product is made with wheat flour, barley, millet, black sesame, adzuki bean, soy bean, black rice and foxtail millet – which trump white refined flour for nutrition. Combine one packet with 90ml milk and an egg.

Verdict: the batter rises in the griddle to form wonderfully fluffy speckled pancakes with a hint of black sesame flavour. Needed a bit more milk as the batter was a tad thick.

Cherrybrooke Kitchen Pancake & Waffle Mix HK$69 for 510 grams, Jasons Food & Living Vegans and people with allergies would appreciate this mix as it is free of gluten, peanuts, eggs, nuts and wheat. Combine one cup of mix with ¾ cup rice milk (use soya or regular milk if you like) and 2 tsp vegetable oil.

Verdict: batter is super thick and pancakes are heavy, dense and unappetising.

Marathon training: weeks 11 and 12 The writer moves into the final block – the tapering phase – of the 12-week training plan designed by running coach Clinton Mackevicius.

MON

How many calories does a Portobello vegan tempeh burger with mayo and pesto sauce, and a side of kale salad dressed in peanut sauce, have? The same amount as a fourpiece fried chicken meal with French fries: about 1,150 calories.

Dietitian and nutrition expert Rachel Beller cuts the vegan meal down to 400 calories through some easy tweaks: put a grilled tempeh patty on half a whole wheat bun, top with some grilled Portobello slices and a spoonful of pomodoro sauce, and pair with a side of steamed kale with diced tomato and lemon.

In Eat to Lose, Eat to Win, Beller, who dishes out advice on US television show The Biggest Loser, shares other truths behind so-called healthy meals – such as sushi and salad – and offers easy advice for an immediate meal makeover.

Unlike many other dieting or

weight-loss books, she focuses on what you should eat, not what you shouldn’t. And fundamental to her philosophy is a diet where veggies come first, followed by lean protein, healthy fat and a modest serving of carbs.

No obsessing over calories or weighing of portions.

This approach, coupled with great hunger-inducing food photography, makes Beller’s 246page full-colour book a good read for anyone seeking practical advice for weight-loss and health.

She suggests more than 30 recipes for 10 days’ worth of meals, and recommends specific products to buy at the supermarket.

What I really appreciate most is that Beller backs her advice up with science, and that’s what makes her and the book credible – despite her slightly overenthusiastic Los Angeles cheerleader tone.

SUN Long run 50 to 60 mins Week 11: 50-60 mins at PE 5 Week 12: Race day

SCMP

Canterbury Naturals Gourmet Chocolate Waffle & Pancake Hand-crafted Baking Mix HK$33.90 for 453 grams, Jasons Food & Living All natural and free of trans fat, this pancake mix introduces a bit of decadence to breakfast with the addition of dark chocolate. The simplest to make of the three: just add two cups of water to the contents to make about 16 10cm pancakes.

Verdict: makes moist, slightly sweet pancakes with an almost cake-like centre. The chocolate means it burns easily on the griddle.

12 WELL-BEING PERSONAL BEST

Rachel Oliver healthpost@scmp.com Many of us know what it is like to feel stuck. We feel trapped in our daily lives, everything is an effort, we feel like we are going nowhere, time drags and we wish we were doing anything but what it is we are actually doing. This, those in the know will tell us, is the polar opposite of being in a state of “flow”.

Needless to say, anyone who is in a state of flow is having a different time of it. They are enthralled with their chosen activity, everything happens for them with ease, time flies by, and they live in a paradiselike world of their own. We may just dismiss these kinds of people out of hand as freaks of nature or as members of the privileged few, but experts say the state is available to all of us. We just need to know some of the rules in order to get there – and then, ideally, stay there. “[Flow] is a state in which people are so involved in the activity, where the attention is invested in realistic goals and the skills match the requirement of the task,” says Cindy Chan, clinical psychologist at CCPS in Central. She says there are some basic things we need to do to be in this state, which essentially include being challenged, rewarded, focused, in control and being present in the moment.

“It must be a challenging activity that requires skills,” she says.

“There is a merging between action and awareness, so the person is so involved that they stop becoming aware of themselves. There must

be clear goals and immediate feedback. [There is a] loss of self-consciousness so I am not aware of myself any more. And time passes, so I don’t have a sense of time any more.”

Chan cites a classic example of a “flow” experience as being one where a surgeon can spend up to 10 hours in surgery, fully immersed in his job and able to operate at full capacity without knowing any time has passed. “This is a flow experience,” she says. Chan stresses that the activity must be intrinsically rewarding in itself, which is the reason why the surgeon can spend so long doing this one thing.

And that is the secret ingredient held by the person most likely to remain in a state of flow, Chan adds: the autotelic. “There is a kind of person with an autotelic personality, which includes curiosity, persistence, low self-centredness and performing activities for intrinsic reasons and this personality is more likely to have flow experiences,” Chan explains.

For those who do not feel they fit into that category, there is an easy place to start in order to experience what flow feels like in the first place, says Michelle Tanmizi, a certified life coach and trainer who runs Zama International in Tung Chung. The key, she says, is to clear one’s mind, focus on the task at hand and seize upon a meaning that makes it rewarding, whatever it is.

Performing a task as distinctly unchallenging as the washing up can be, if nothing else, a flow training session, she says. “To get into a state of flow washing dishes is

Illustrati on: Adolf o

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Arranz

Flow your own way

The key is to focus on the task at hand and seize upon a meaning that makes it rewarding MICHELLE TANMIZI, LIFE COACH AND TRAINER

to change the meaning. So [you could see it as] a great time to talk to my mum, it’s kind of therapeutic, I get to be in my own space and everyone leaves me alone.”

For those who cannot find any meaning in what they are doing, she suggests re-evaluating the set of

emotions that are causing the dissatisfaction. “This is about managing your state,” she explains.

She uses a technique with clients that takes them step by step through their different emotions and perceptions until they can see something positive in what they previously thought negative, hence creating a proverbial ladder to the state of flow at the top.

“It’s about the questions I ask to finding something positive,” she explains. “Your work, even if it is menial, it means you have the power to choose. It’s about changing the meaning.”

Perseverance is key, says Cedric Signori, communications specialist, coach, motivational speaker and managing director of Bright Step

Consulting. This is also about finding a sense of peace and contentment in what we are doing and it won’t come easily to everyone. “We cannot reprogram the mind in one go, so you have to train every day,” he says. “It’s like when you are doing meditation.

Lots of people try and don’t succeed at all and give up. Why? They have a lot of expectations.”

The key thing to keep coming back to when we lose hope, he says, is to look at our core motivation and ask ourselves why we are doing what we are doing in the first place. “The first thing for people to do is understand and perceive what they want,” he says. “What do you want to do? A lot of people don’t know what they want to do.”

But whatever it is, he says, what is vital is that it is achievable. “You have to be realistic,” he says. “If you want to sing, you can sing in a bar but you don’t have to be number one in the charts.”

Chan concurs, adding that the key reason why the goal needs to be realistic is that it provides the necessary feeling of satisfaction that comes from achievement, which you need to keep you in the state of flow in the first place. “That’s crucial,” Chan says. “It’s because if the goal is not realistic, or if there is no immediate feedback, then the person will feel frustrated and no satisfaction can be maintained.

Feedback is very important as that is what gives the sense of satisfaction.”

Which is good news for anyone thinking they have to become a famous painter or brilliant surgeon to be in flow. You don’t.