Author: mwh-med56doc

Throat Cancer – Not Just A Smoker’s Disease

Throat cancer refers primarily to malignant tumours of the voice box and the lining of the muscular tube that lies behind it. The main risk factors are smoking and alcohol and these are synergistic when both factors are present. Throat cancer usually affects older males but it can also affect younger patients of any gender who are non-smokers and non-drinkers too. This article aims to inform the reader of the structure, disease process and management of this type of cancer and what to watch out for to avoid unnecessary delay in treatment.

Anatomy and physiology

The throat is a complex structure consisting of the muscular tube (pharynx) that connects the back of the nose and throat to the gullet (oesophagus) and voice box (larynx). It allows for the safe flow of food and fluids to the gullet and of air through the larynx into the lungs. The larynx consists of muscles, cartilage and nerves which are designed to safeguard the airway, protecting it from potential entry of food and drinks by “closing” itself off. This reflex is paramount in survival and is what allows us to thereafter generate immense force from our lungs to produce a cough to clear the airway. Failure to do so can result in choking and lead to chest infections such as pneumonia.

Other functions of the larynx include voicing and the capacity to strain and raise the abdominal pressure. There are three main parts of the larynx (Fig 1): the upper part is the supraglottis; the middle, the glottis – where the vocal folds/cords are located; and the lower part is the subglottis, where the voice box joins the windpipe (trachea). The lining of the throat is known as its mucosa. It is the toxic irritation of cigarettes and alcohol with their chemical compounds that alter the cells of the mucosa causing them to change their appearance and behaviour leading to an irreversible genetic alteration and to cancer. Genetic factors, exposure to certain chemicals and chronic exposure to acid, viral infections and other irritants have been postulated as causes in other patients.

Symptoms and signs

Patients with throat cancer present in several ways. Hoarseness in patients with no obvious precipitating cause exceeding a fortnight should be referred on for specialist investigation. Lesions on the true vocal folds affect their vibratory capacity and result in an abnormal rough voice. If the mass of the tumour or its extension reduce the mobility of either or both cords, the voice can sound breathy too. Swallowing difficulties and choking are also symptoms that can be present as signs of possible throat cancer.

Throat or ear pain on swallowing are also important complaints that warrant investigation. Blood in the saliva and increasing noise while breathing and shortness of breath can be later features of throat cancer and warrant rapid referral to an ENT surgeon. Patients with extension of their cancers may, rarely, present with disease that has spread to the lymph nodes in their neck which are often painless and hence should be seen urgently for further assessment.

History and examination

A full history is sought and risk factors ascertained. The state of the patient is appraised to assess the severity of the disease, especially in cases where the airway is either compromised physically, potentially leading to asphyxia, or in its inability to protect the lungs from aspiration of ingested solids and liquids. Thereafter, patients are examined with particular attention paid to their larynx, back of the tongue and side of their throats. This is achieved using a flexible fiberoptic endoscope known as a nasendoscope which is passed via the nostril, through the nose and above the voice box. Other methods of examining the larynx include using a laryngeal mirror and rigid endoscopes that are angled so they can visualise the throat through the mouth.

Investigations

Imaging of the neck and throat are achieved using sophisticated cross-sectional imaging modalities such as an MRI or CT scan. Further investigation includes examining the patient’s upper aerodigestive tract under a general anaesthetic with concomitant biopsies of the lesion/s in question with analysis by the pathologist. Thereafter, the confirmed cancer is staged and treatment recommended after discussion in a multi-disciplinary tumour board made up of specialist oncologists in surgery, radio and chemotherapy, pathology, radiology and specialist nurses, speech therapists and dietitians.

Treatment

Throat cancer may present at various stages, often divided into early or late. There are also pre-cancerous stages that if untreated may develop into cancer. Hence, treatment is tailored to the disease and patient along with risk factors such as persistent smoking, drinking etc. Early cancers can be treated with a single modality of treatment – that is, either by surgery alone or radiotherapy.

The decision to use a particular modality is made based on the site and accessibility of the  tumour, the ensuing risks to the voice and swallow and cost. Minimally invasive surgery utilising lasers (Figure 2A and 2B) has been well established as an effective method to treat laryngeal cancer. It is very accurate and can be repeated unlike radiotherapy that is often a one-off treatment and therefore rarely repeatable.

More advanced cancers require more aggressive treatment including the incorporation of chemotherapy where applicable to radiotherapy. Transoral robotic surgery has also been used to great success and in cases where patients may have already had radiotherapy and salvage surgery is advocated but carries higher risks of complications. Open surgery has become less common currently as “laryngeal preservation” is advocated to avoid what is generally a mutilating removal of the voice box with subsequent permanent changes to the patient. Total laryngectomy, however, in cases of advanced cancer is still a very oncologically sound and effective operation.

Voice rehabilitation

With the loss of the larynx comes the obvious loss of the capacity to speak. Along with this is the fact that the patient’s throat is no longer at the junction box between the airway (trachea) and food way (oesophagus). The patient therefore has a complete separation between the two tubes with the windpipe now attached to the skin of the neck below the removed voice box.

Various ways of voice rehabilitation have been developed including “oesophageal speech” where the patient swallows air and belches it out in a controlled manner causing vibration of the back of his tongue, mouth and lips while moving his tongue to speak. Other ways include the use of a speech valve – a purpose-built device that is inserted through the back wall of the windpipe into the oesophagus. This valve allows for the channelling of air from the lungs into the oesophagus and similarly out through the mouth causing vibrations that result in sound.

An electronic device that resembles a microphone known as an electrolarynx can be used and this transfers vibrations from the cheek to the device.

Finally, some patients rely on sign language and writing to communicate.

Conclusion

Laryngeal cancer is a cancer that can affect the young and old. It is seen in non-smokers and non-drinkers too. Symptoms that affect the voice box and throat that do not improve after a fortnight or so such as hoarseness, pain, swallowing problems, cough and shortness of breath should be referred on for specialist input quickly.

Singapore Medical Specialists Centre Breaks New Grounds In Vision Enhancement

One of the most common applications for lasers in the treatment of eye problems is in refractive correction. Due to its high safety and efficacy, laser vision correction for refractive errors has today become a mainstream approach. Providing freedom from glasses and contact lenses, it is sought after not just for convenience and cosmetic effect, but also for practical reasons, such as facilitating participation in sports, enhancing one’s career, and lifestyle pursuits. In many cases, quality of life is significantly improved following successful laser vision correction.

Compared to the first generation of laser vision correction treatments, such as the flapless Photorefractive Keratectomy (PRK) which is associated with post-op pain, longer recovery, and side effects of haze, the newer treatments, such as the flap-based Laser-assisted In Situ Keratomileusis (LASIK), are vastly more popular as they result in much shorter downtime and a higher satisfaction rate. While some patients may experience some degree of dry eyes, particularly in the treatment of higher eye power, they generally recover with proper post-operative care.

Third generation technology, such as the still-maturing Small Incision Lenticule Extraction (SMILE), a keyhole operation combining the flaplessness of PRK with the quick recovery of LASIK, can deliver even more stable results. Any small chance of eye power regression and cornea weakening (ectasia) can also now be prevented by corneal collagen cross-linking (XTRA).

Swiss Ziemer LDV™ Z8 Technology
A recent addition to the armamentarium in the refractive surgery world is the highly innovative and mobile FEMTO LDV™ Z8 Laser by Ziemer, an advanced technology that has brought a new level of accuracy, flexibility, speed, and mobility to laser eye surgeries. With its low energy (the lowest amongst all femtosecond lasers), it comes on the back of a highly respectable and continuous lineage. As an established FDA-approved femtosecond laser purpose-built for LASIK and corneal and lens surgeries, it has its roots in versions Z2, Z4, and Z6. The unique LASIK performed on the Ziemer platform is called Z-LASIK. Distinct from other makes of femtosecond lasers, the proprietary FEMTO LDV Z8 uses extremely fast, short pulses of low range pulsed light, which gives rise to a faster creation of the corneal flap (the first step of the Z-LASIK procedure) – within just 30 seconds.

The nanojoule laser allows for a gentle approach that produces an extremely smooth interface, reducing the stress on corneal tissue and post-treatment inflammation. As a result, patients can expect more rapid healing and improved vision in a shorter time frame. The laser’s small footprint and mobility also means that patients are not required to shift during different steps of the treatment, improving patient comfort and streamlining the surgical process. The flap creation is then followed by excimer laser treatment in the second step of LASIK (SMSC uses a proven NASA excimer technology, iDESIGN 2.0 VISX STAR S4, including wavefront-guided LASIK treatment).

What is interesting is that the FEMTO LDV™ Z8 does not just deliver bladeless all-laser LASIK for the treatment of refractive errors such as myopia, hyperopia, astigmatism, and presbyopia with high precision. Its adjustable 3D LASIK flap configuration is also versatile and customisable, like the Z6, with the additional advantage of an Optical Coherence Tomography (OCT) to visualise the Bowman membrane and previous LASIK interfaces, a feature of Z8 that enables finer precision work, such as LASIK retreatments or thinflap femtosecond LASIK (femtosecond sub-Bowman’s keratomileusis).

In lens surgeries, the Z8 laser delivers documented excellent results in Femtosecond-assisted Cataract Extraction Surgery. With its low energy levels, the
laser cuts are fine and precise, allowing for safe surgeries even in complex lens exchange and cataract operations. The mobility of the laser unit allows it to be positioned in the operating theatre right next to the patient, doing away with patient movement between equipment changes, creating a more comfortable experience. The Z8 is the only laser that is feasible when bilateral sequential femtosecond-laser assisted cataract surgery is opted for.

In addition to the above indications, the Z8 is able to perform femtosecond arcuate keratotomy for the treatment of astigmatism using a non-invasive method. Furthermore, Ziemer is on the cusp of releasing its Z-lenticule extraction treatment (yet to be formally named), its own version of SMILE, with added ability for centration, projected improvement in accuracy, and precision. Anticipated in the first quarter of 2020, it will be an attractive option for laser vision correction candidates seeking a flapless alternative.

Ziemer Z8 + Galilei G6
The breakthrough Z8 femtosecond laser can coordinate with the FDA-approved Galilei G6 scanner to create a complete Ziemer ecosystem. The Galilei G6, built on the G4 model, is a dual-Scheimpflug imaging/scanning device that captures up to 300,000 spots on the cornea on both its front and back surfaces and incorporates an optical biometer and Artificial Intelligence assessment technologies. It is precise for assessments for LASIK and SMILE/Zlenticule and for lens implant treatments like the Implantable contact lens (ICL), lens exchange, and cataract surgeries. The unique combination of the Galilei G6 scanner and Ziemer Z8 laser streamlines the application of pre-operative measurements, thereby improving LASIK and SMILE/Z-lenticule as well as ICL, lens exchange, and cataract surgery pre-planning, providing a clearer picture to achieve a safe and great visual outcome.

The Singapore Medical Specialists Centre is proud to be the first in Singapore to have the Ziemer Z8 combined with the Galilei G6. With OCT guidance for LASIK, we are confident we can enhance your vision with increased precision.

Children’s Ear, Nose and Throat Problems

Children commonly have issues with their ears, nose and throat. This is partly because of the natural physiological process of development which can make them prone to viral infections and allergies to name a few. While the common cold and ‘flu’ affect children and adults alike, the complications of these often ‘minor’ ailments can lead to more serious problems. An example would be tonsillitis which in the past when untreated could cause problems with the heart valves!

Thankfully this is very rare now. Nasal congestion and ‘sinus’ issues may spread to the eye (potentially causing blindness) through the thin bone that separates it from the nose. Commonly, children can have a blocked or painful ear which may affect their hearing, reducing their attention span, affecting speech and language and causing behavioural problems too. Allergy to dust mite, pets and different plant pollen is very common.

Sneezing, itching of the eyes and nose as well as a runny or blocked nose are typical symptoms. Referral to an ear, nose and throat (ENT) surgeon for an allergy test as well as treatment for their symptoms is highly recommended. Currently, treatment using a tablet placed daily under the tongue can help cure patients with some of these allergies and in many cases it helps avoid other conditions such as asthma later on in life.

Some pointers you can use to check on your child:
1. Does your child snore?
2. Does your child have recurring colds that progress into a sinus infection?
3. Does your child always complain of headache, and/or giddiness?
4. Does you child have a short attention span?
5. Does your child sneeze?
6. Does your child always feel tired and sleepy?

Ear, Nose & Throat Cancer
There are several types of cancers that an ENT and head and neck surgeon manages. They tend to affect adults and generally men who smoke and drink although this is not always the case. Cancers of the back of the nose (Nasopharyngeal cancer, NPC) tend to affect non-smokers and drinkers of Chinese ethnicity more than other populations. These cancers can be screened for in high risk groups. They present without much warning – with pain or bleeding being uncommon symptoms. A lump in the neck, blocked nose and blocked ears with some hearing loss may be the initial complaint. Quick referral to an ENT surgeon is strongly advised to assess the back of the nose with a special video telescope known as a nasendoscope.

Biopsies and scans may be necessary thereafter. Other cancers such as tonsillar (oropharyngeal) cancer are becoming more common partly due to a viral driven pathway – the human papilloma virus (HPV). Patients may present with an enlarged tonsil, swallowing issues or a neck lump. They tend to be younger and the condition is not caused by smoking and alcohol. Thyroid cancers are commoner amongst younger women and have a good prognosis usually. Surgery is the main treatment and in some cases it is done in combination with radio-iodine treatment.

Salivary tumours are rare. They are also treated surgically as the main management option. These tumours can affect the ‘major’ glands but are more aggressive in the minor ones that are dotted all over our oral cavity and throat. Any lump that is new within the mouth or neck should therefore be investigated if it does not regress or disappear after a fortnight or so.

Hearing Loss
Hearing loss affects the young and old. Childhood hearing loss can be due to genetic causes or birth issues. Certain drugs can also cause hearing loss. The commonest causes in children tend to be less serious and usually improve and disappear as the child develops. Often, the cause is a developing Eustachian tube which is short and less angled compared to an adult. Blockage or failure to clear mucus in the middle ear results in hearing loss which can also cause ear infections. Large adenoids (lymphoid structures similar to tonsils) can act as physical barriers to the opening of the Eustachian tubes and be a nidus for infection too. Surgery can help treat these conditions and is commonly performed in recalcitrant cases.

Age-related hearing loss is becoming a global concern as research continues to demonstrate its link with dementia. Many elderly patients become socially isolated and are not provided with the right recommendation for treatment – be it hearing aids or even cochlear implants. As the hearing begins to weaken, other functions take over the hearing centre in the brain creating a situation where the hearing areas of the brain do not ever recover from. Early referral to an audiologist and ENT surgeon is recommended.

Lower your blood pressure with right lifestyle choices

BLOOD pressure (BP) continues to be an important determinant of our health and has significant implications for many diseases including stroke, heart disease, kidney damage and eye disease. Understanding how our lifestyles impact our blood pressure can help us make the right decisions in maintaining a healthy range of BP.

Normal BP fluctuation
There is a diurnal physiological variation in BP, which rises on wakening in the early morning when the person gets up, reaches a plateau during the morning, decreases slightly in the early afternoon and rises again in the early evening. The BP then decreases gradually in the late evening, drops sharply after falling asleep and is lowest during sleep at about 3am. The BP increases again by about 20 per cent between 6am and 8am, around the time of awakening. If the sleep-time relative systolic blood pressure (SBP) decline is 10 per cent or more, this sleep pattern is considered a normal dipper pattern. In the majority of normotensive persons, the decrease in BP from daytime to night time is about 10 per cent to 20 per cent.

While many may think that this is due to your internal body clock, in truth, the variation associated with the sleep wake cycle is largely influenced by mental and physical factors. Hence, in shift workers, BP is high during work at night and low during sleep in the day.

Morning BP surge
The typical physiological morning elevation in BP is more a function of activity rather a function of the time of the day. Those who remain supine in bed after waking up do not show much change in their BP, which rises rapidly only when the person gets upright. The extent of BP elevation is related to the level of physical activity. In some patients with hypertension, an exaggerated increase in BP is seen and this is termed the morning surge.

Upon awakening and getting up and commencing activities of daily living, there is a large surge in your “fight or flight” hormones, namely the catecholamines (such as adrenaline). This results in increase in heart rate, increase in BP, greater pumping action of the heart, increase in your arterial vessel tone and decrease in the calibre of the arteries.

Other awakening changes include an increase in your body steroids (cortisol) level, and “thickening” of the blood (due to increased tendency of the platelets to stick together and an increase in blood viscosity). These changes result in an increased demand for oxygen by the heart, decrease in oxygen supply to the heart and “thickening” of the blood. These changes may help to explain the increase in heart and stroke events during the morning. Analysis of combined trial data has demonstrated an approximately 40 per cent increase in incidence of heart attacks, close to 30 per cent increase in incidence of heart-related deaths and close to 50 per cent increase in incidence of stroke, as compared to other periods of the day. In addition to the morning surge, hypertensive patients tend to have no dip in BP (non-dipping) at night. The nighttime non-dipping is associated with damage to key organs (such as the heart, brain and kidney) and heart disease.

Stress and BP
As everyone knows, stress increases BP. The stress of doing housework or rushing to work in the morning may cause an exaggerated surge in morning BP and even morning hypertension. Workplace stress can also cause daytime hypertension. A study reported that more than 20 per cent of civil servants who had workplace hypertension had normal BP during health examination. Interrupted sleep results in elevated BP and may contribute to the non-dipping of BP at night. It has been shown that hospitalisation can reduce stress, resulting in lower BP in the day and reduced difference between daytime and night-time BP in hypertensives. Activities such as meditation can also lower BP effectively.

Lifestyle and BP
There is little surprise that obese individuals have higher BP values than normal individuals. The good news is that weight loss in hypertensives can result in reduction in BP. Many obese individuals have obstruction of their upper airway resulting in snoring and a condition called obstructive sleep apnoea. This decrease in oxygen delivery to the body as a result of airway obstruction during sleep is associated with an increase in nighttime BP.

During exercise, BP increases and post-exercise, it decreases. This post exercise drop is due to a relaxation of the tone of the blood vessels and usually lasts for several hours. Several studies have also shown that regular exercise lowers BP in both normotensives and hypertensives. The impact of exercise on BP is  dependent on the time of exercise, with morning exercise resulting in decrease in daytime BP and evening exercise decreasing night-time BP in non-dippers (hypertensive pattern), but not dippers (normal pattern).

Taking a hot shower usually causes a rise in BP initially, but if you are immersed in a hot bath, BP will decrease with even further decrease immediately after the bath. It will gradually return to the baseline levels after about one hour. For smokers, studies using ambulatory BP monitoring have shown that only daytime BP is elevated, and it is higher on smoking than on nonsmoking days. Therefore, chronic smoking can cause daytime hypertension.

Food and BP
It has been observed that there is a mild increase in BP during meals as a result of increased physical activity, followed by a fall after meals as a result of dilatation of the vessels in the gut in response to food consumption. This post-prandial drop in BP is minor in the young but may be more pronounced in the elderly, in hypertensives, and following a high-carbohydrate meal (as compared to high-fat meal).

The peak of the post-prandial reduction in BP is at about one hour and persists for more than two hours. It is a well-known fact that a high sodium intake increases BP and a low sodium intake can decrease it. In contrast, dietary intake of potassium and magnesium is inversely related to BP. Hence, the consumption of fruits and vegetables that are rich in potassium and magnesium may decrease BP in hypertensives. Coffee lovers may be surprised to know that consumption of coffee can transiently increase the BP by up to 10 mm Hg for about one hour. Much of this is believed to be due to the effects of caffeine on the body. Conversely, the consumption of cocoa or dark chocolate appears to be associated with a significant reduction in 24 hours’ BP.

Conclusion
Shedding excess weight by exercising, followed by a hot bath immersion, consumption of dark chocolate, fruits and vegetables (high in magnesium and potassium) and ending the day with stress-relieving meditation is a perfect recipe for lowering the blood pressure. In addition, reducing salt, coffee, excessive weight, smoking and stress will certainly help you achieve the ideal BP and ultimately a healthy life.

Understanding the ‘cytokine storm’ that is Covid-19

I was on vacation in Japan around Christmas when I first heard the news on CNN, of a strange virus that was causing pneumonia in a cluster of patients in  Wuhan. On reading the report on my smartphone, I felt a shiver down my spine. This was because the description of the illness resembled the “cytokine storm” of the Sars virus. The shiver down my spine was prescient; as of current writing we are in Dorscon Orange with 86 patients diagnosed, 5 in intensive care and 47 patients discharged and well.

In China, despite the heroic and unprecedented actions of locking down an entire province, the epidemic rages on. The silver lining is that the heroic actions by the Chinese have bought us some time for our local actions to take effect. So what is this “cytokine storm” that you keep hearing about? In essence when a virus attacks a host, it is like an invasion. The virus lands on a beachhead – in humans it is usually in the throat – and starts multiplying in large numbers.

When there is a high viral concentration or viral load, the virus enters the blood stream or moves through lymphatic system or via secretions, and can spread to other organs. In the case of Covid-19, it spreads deeper into the lungs where it targets a receptor called the Angiotensin Converting Enzyme receptor. Why do some patients have a mild disease while others are warded in intensive care? This is because when there is a huge viral load, the body responds massively. In healthcare workers, our immune systems are constantly challenged as we meet lots of patients daily and are exposed to the viruses or bacteria that they carry.

Our immune system is primed to deliver an overwhelming response especially in the face of a huge viral load. It is precisely this overwhelming response that may make us very ill and be warded into intensive care. So, you may not realise that our healthcare workers are under a great deal of stress during this period as our risk is way higher than the average patient.

As for the public, what should they be aware of so that they can help themselves? We know the virus is spread via droplets. This means that when someone coughs, the droplets fly through the air for about 10 feet (three metres) and settle on surfaces. The mucus in the droplet protects the virus whilst the droplet is on a surface. The mucus usually dries up in 30 to 60 minutes and the virus dies. However, when an unsuspecting person touches the surface with his hands and  then proceeds to touch his eyes, face or hair, the virus can then be transmitted. The entry to a host is usually via mucus membranes; these line the inside of our mouth, nose and eyes. As for the hair, the droplet can cling onto hair and be protected by headgear. Hence, I tell my patients that hand hygiene is of the utmost importance and they must always wash their hands before they touch their eyes, face or flick their hair.

Do we really need to use hand sanitisers for hand hygiene? The reality is that soap and water will do. We also know that the coronavirus is quickly inactivated by plain tap water. However, we must get rid of the mucus envelope that protects the virus. Hence the soap is useful and for surfaces we need to ensure that the droplets with attendant load of mucus is cleaned off. We then come to masks. The current advice is that masks are useful for preventing those who are sick from infecting those who are well. The surgical mask is enough to stop droplet transmission.

There is no need to wear the N95 mask. In fact, when you wear the N95 mask for a period of time, you will get fatigue from breathing against resistance. Therefore, we do not encourage patients with chronic heart or lung diseases to wear N95 masks routinely. For healthcare workers who wear N95 masks for a long duration, we do feel the effects of that added work of breathing at the end of the day. For those who are well, should they wear masks? The perspective is that we have 30,000 to 35,000 patients daily in Singapore with upper respiratory infections of all sorts. Maybe a couple of hundred will be pneumonia cases and Covid-19 infections will probably number less than two handfuls. The idea is to avoid crowds as we cannot contact trace a crowd of people. However, I tell my patients that life must go on and if you are meeting your family members, friends and colleagues for a meal, contact tracing is simple as you know everyone.

As for fear of the virus, this is the stuff that epidemics are made of. The difference between Sars, H1N1 and the current situation is that the feed from social media is massive. We are constantly inundated by chats, videos and articles coming through our smartphones. The fear captures and amplifies the individual’s mind and soon he or she starts to think or say things in an illogical manner. This is so obvious when you are reading the feed from chatgroups.

When we are angered by a close shave, such as when an office colleague is ordered to be quarantined, we tend to think the worst of our colleagues. When we are fatigued and tired at the end of the day from our workload and our worries about the virus, and we read of the demise of the eye surgeon in Wuhan and his pregnant wife, you think of the safety of your family and are worried sick. When we receive news or read something that reflects our emotional state, our brain tends to amplify or exaggerate the pervasiveness, degree and severity of that situation.

It is important that we trust the experts, or make sure that our news comes from reliable sources and sieve out misinformation and fake news. Please do not believe claims that the virus is airborne, conspiracy theories on the origin of the virus, need for the whole population to wear masks or false claims about the competence of health authorities and governments. In Singapore, our leadership has the institutional memory of the Sars epidemic and the dress rehearsal of the H1N1 pandemic. We also have the logistics, preparation and the physical capability in terms of isolation rooms and intensive care. Most importantly, the leadership has the political will to take tough action when necessary and the people will listen, respond and act responsibly when we need to. As we speak, the Public Health Preparedness Clinics are being activated. Do spare a thought for our healthcare workers as they strive and struggle in the days ahead, often with their own burdens, fears and tensions pushed aside for the heroic task at hand.

Feasting or fasting in the festive season?

THE Christmas festivities are barely over and Chinese New Year is already rolling round. We have just recovered from the wine and dine of the Yuletide season and are trying to shed the extra kilogrammes. The gym instructors will tell you that there is a surge in the beginning of the year in gym attendance as people grapple with added body weight and the weight of their New Year resolutions! There has been a lot of interest in intermittent fasting and low carbohydrate diets. Intermittent fasting is practised in various ways. One is to fast on alternate days or to fast two to three days in a week, while an alternative way is to reduce the number of hours in a day for eating.

Hence you have regimens such as 5:2, where you fast for two days in a week, or fasting for 14 hours daily for five days in a week and gradually increasing it over months to 16 to 18 hours daily. The whole idea about intermittent fasting is to switch the body to use ketones as a fuel as opposed to glucose. The brain needs to use glucose to power itself and in fasting states, it uses ketones. The ketones comes from fat breakdown.

Caveman situation

The idea of intermittent fasting is to recreate the caveman situation where they did not cultivate crops and had to survive from hunt to hunt. The fasting state induces ketone production or ketosis and it takes only eight to 10 hours of fasting before ketones start to rise in the bloodstream. The rise is marked when the fasting period hits 24 hours. The ketones are not just a fuel; they are also powerful triggers of certain pathways that the body needs to overcome the challenge of fasting. These pathways allow the cells to mount antioxidant response, repair damaged DNA, increase number of mitochondria that are the powerhouses of the cell, remove damage structures inside the cell and reduce inflammation.

In short, the body conserves by shutting down growth and reproduction, enhancing response to stress, favouring repair mechanisms and ensuring cell survival. When the fast is broken and the patient starts to eat, the glucose levels rise, the ketones fall, the body starts to increase protein production resulting in growth and repair. Hence the intermittent fasting regimen together with exercise results in long-term adaptations that are useful. Is intermittent fasting the panacea to our growing obesity rates globally? There is a lot of research ongoing in different areas such as intermittent fasting in cancer, degenerating illnesses of the brain, asthma, autoimmune disease, diabetes, obesity and cardiac diseases.

A lot of data is in animal studies and we are still missing long-term, megasized trials. Other issues include gorging during the feeding states as you still have to restrict your calories when you break the fast; there is also irritability, hunger and “brain fog” when your brain starts using ketones as a fuel. Thankfully, these side effects resolve within a month of starting your regimen. The other popular strategy is the use of low carbohydrate diets. A healthy diet comprises of 45 to 65 per cent of carbohydrates. A moderate carbohydrate diet comprises 26 to 44 per cent, a “low” carbohydrate diet is 10 to 25 per cent and a “very low”  carbohydrate diet is 10 per cent or less. The remaining is either protein or fat. The diets that trigger ketosis are usually low or very low in carbohydrate and high in fat. High protein intake in a low carbohydrate diet can negate ketosis.

Does a low carbohydrate diet work? The data shows that such diets do work, and they can result in increased metabolism. We are not sure how this is achieved but it could be due to changes in stress and thyroid hormones. There is also remarkable initial weight loss due to loss of body water as ketones are diuretic in nature. The loss of water is also due to lower insulin levels and the depletion of the glycogen stores in your liver. The weight loss in the short term is much better than your normal low fat diet. In the longer term, that is, six months or more, the gains between low carbohydrate and low fat diet evens out. It is also very  difficult to sustain a very low carbohydrate diet. The other thing to note is that your muscle mass may also deteriorate with low carbohydrate diets and so it is important to make sure you eat enough protein and not just fat.

I am often asked if cholesterols will be affected by a low carbohydrate diet. The response of cholesterols levels may be quite varied. If the patients eats a lot of saturated fat, the LDL or bad cholesterol will rise. Hence we usually tell patients on such diets to monitor their cholesterol profiles. The triglycerides are heavily influenced by glucose and hence such diets do lower triglycerides. In diabetic patients, the triglycerides and blood glucose levels are reduced by such diets.

Not all diets are equal

Among the low carbohydrate diets, not all are equal. For example, they found the diets that were more Mediterranean and Paleolithic in nature were useful in diabetics. Those with higher protein and lower fat were also useful. Is there a down side to such low carbohydrate diets? Well, they found that it was not helpful in blood pressure patients, it may produce changes in the gut bacteria and it is not helpful with inflammation. We believe that the arteries are inflamed, therefore triggering blockages. Is there increase in longevity if we partake in such diets? The data shows that if we substitute the carbohydrates that we forego in such diets with animal fat or protein, longevity is reduced.

However, if we use plant-based fat or protein, longevity is enhanced. In the final analysis, we have found that patients do lose weight with low carbohydrate diets and intermittent fasting. We have to be aware that such diets are not fads or trick diets. One can lose weight by cutting off a leg; “trick diets” try to get you to reduce your calorie intake by making you consume too much of one item, be it pineapples or apples or whatever. Ultimately, as we leave one festive season and move into the next, be mindful of what you eat, try to eat in moderation, control your portion sizes, maintain your exercise and enjoy the goodwill and fellowship of kin, friends and colleagues.

Dr Chong Yeh Woei
Senior Physician (Internal Medicine)
MBBS (S’pore), MRCP (UK) Internal Medicine

THE BUSINESS TIMES WEEKEND JANUARY 18, 2020

Vision 20/20: viewing the world perfectly

AT the dawn of a year and decade, it is fitting to review and renew our goals. 2020 holds special meaning for everyone who appreciates the sense of sight and especially for me as an eye specialist. “20/20 vision” is medical parlance for normal or optimal visual sharpness: what a healthy eye should be able to see clearly, at 20 feet. “Vision 2020: The Right to Sight” is also the name of a World Health Organization (WHO) project that was launched in 1999 as part of an ongoing project commenced 30 years ago, with the aim of eliminating avoidable blindness globally by 2020.

A global guidance and blueprint for eye care systems, Vision 2020 started with advocacy for intervention against eye diseases such as cataract, glaucoma, diabetes, Vitamin A deficiency and trachoma (parasitic river blindness prevalent in Africa) as its first priorities. To sum up Vision 2020, WHO published its comprehensive World Report on Vision last year, freely available on the Internet. Although unmet needs still exist, the project has seen unprecedented progress and is deemed successful by most yardsticks. There has been a very significant reduction in cases of eye infections and blindness from Vitamin A deficiency, as well as the ongoing reduction in prevalence of blindness among adults, including treatable causes.

Nevertheless, continuous focus is necessary as these results can’t keep pace with the growth of an ageing population. The report includes the global magnitude of the issues, successes, what remains to be done, recommended strategies and paths charted for the future. The causes of vision impairment and their impact on financial burden are of particular interest to me. The figures are staggering: at least 2.2 billion people have vision impairment globally. At least one billion of these (an underestimation according to the report) could have been prevented or are unaddressed, with 123.7 million suffering from unaddressed refractive errors.

Cataract comes in second at 65.2 million. These eye conditions are projected to increase due to population ageing, as well as environmental and lifestyle changes. From the report, the cost of the coverage gap for global unaddressed refractive errors and cataract was estimated to be US$14.3 billion. In the world, there are an estimated 2.6 billion people with myopia (of which 312 million are under 19 years old) and 1.8 billion with presbyopia. These contributed to losses in annual global productivity estimated to be US$244 billion and US$25.4 billion, respectively. The prevalence of myopia is the highest in East, South and Southeast Asia. It was reported in these regions that the economic burden of uncorrected myopia was more than double that of other regions and equivalent to one per cent of gross domestic product (GDP).

A simple calculation should convince one of the highly cost-effective outcomes for addressing treatment of myopia, presbyopia and cataract – my three main areas of practice in ophthalmology – in any health care system. There are several points in the report that strike a pertinent yet sensitive note. First, the issue of funding for management of the commonest eye condition, that is, refractive errors, which in many countries are mostly out-of pocket. These include the costs of spectacles, deemed an assistive device, as well as contact lenses and refractive surgeries such as LASIK. Second, the potential role for public-private partnerships to improve eye care services. What is new for this decade is the focus of “integrated people-centred eye care” as a continuum of health intervention.

This is a new addition to the WHO project’s action plan to now include integration of eye care into health care systems, ideally across all sectors, and, for this, four important strategies are proposed. These are to empower and engage people and communities, reorientate model of care, coordinate services within and across sectors, and create an enabling environment. In my mind, these are applicable to both policymakers and the public. Integration of eye care into health care is here to stay. For the general public, it should translate to ensuring good eye care and visual habits from the groundup, starting in the family, schools, public institutions, at work and at leisure.

It also means having eye protection in sports and in relevant occupations and attending eye screenings regularly even when the eyes feel fine, as some eye diseases are silent in the initial stages where they can be controlled and potentially reversed. Ensuring good general health and lifestyle is key in maintaining good eye health. Our eye clinic also welcomes the new decade with an addition of the services provided. Incorporating a Refractive and Cataract Surgery service  on site has long been our aim. We look forward to deliver safe, effective and integrated eye care with the addition of the trusted Johnson and Johnson Star S4 iLASIK excimer laser with FDA approved wavefront guided treatment via its latest iDesign 2.0 and the Swiss-made Ziemer Z8 femtolaser for OCT-guided thin flap LASIK surgery, being the first in Singapore, as well as for laser cataract surgery.

These will help address the most common eye conditions in the world – namely myopia, presbyopia and cataract – in an efficient and affordable manner.
The Ziemer Z8 also looks forward to providing further innovations in flapless refractive lenticule treatment for myopia in the near future. Eye screening enabled with artificial intelligence for front-of-eye diseases by dual-Scheimpflug imaging and back-of-eye diseases by digital angiography and fundal camera remains our go-to option, a sign of the times.

Dr Daphne Han
Senior Consultant Ophthalmologist
MBBS (Melbourne), MMed, MRCS, FRCS (Edinburgh), FAMS

THE BUSINESS TIMES WEEKEND JANUARY 11, 2020

Ready to run on the big day?

Some vital dos and don’ts that will ensure you have a memorable marathon experience

Singapore marathon fever is upon us once again. And it is going be a momentous event for a lot of us. You probably have been training for this for the last few months with building up your weekly mileage, enduring weekly long runs, doing speed work with interval training and, last but not the least, letting your body rest and recover. By this time, you would have scaled back on your training in preparation for the big day. So how tough is it to run a 26-mile race? The first person to run the marathon, a Greek soldier called Pheidippides, collapsed and died. Currently, the best marathoners in the world are invariably the Kenyans; they run the race in a little over two hours. The main fuel to support a marathon comes from glycogen. The main storage of glycogen is in the liver and the muscles which provides enough fuel for about two hours. Hence, if you take more than two hours to run the race, you have to top up your fuel supply, usually by eating.

Fuel for a run commonly comes in the form of bananas, chocolate or energy gels. The energy gels contain carbohydrates in form of maltodextrins and glucose with potassium and sodium. Maltodextrins are long chains of glucose molecules. They are pre-digested simple carbohydrates and resemble the food that has been digested by the stomach. Hence the absorption is rapid in the intestine. These maltodextrins also serve the purpose of being isotonic with little water needed. The thing to remember is that you got to accustom yourself to drinking isotonic fluids while taking these gels on the run prior to the big race. It is recommended for an average runner to take a gel patch every 30-45 minutes in a marathon. The other important thing to consider is your hydration status. You should hydrate yourself adequately during the last week prior to race day. You should, by now, be able to gauge how much fluid you would need during the training runs in the same humidity and temperature. Hence, on race day you would know how to drink appropriately. One should not depend purely on the sensation of thirst before drinking.

Often, when you feel thirsty, the body is already dehydrated. Thirst is regulated by a centre in the brain stem which senses the concentration of the circulating blood. When the blood concentration rises, the brain stem sends a signal to the body giving you a sensation of thirst. This signal is often ignored during a run when there is too much excitement and euphoria. There is also a risk when one drinks too much. This is commonly seen in the slower runners who would be drinking more at water stations and yet sweating less. That can lead to a situation called hyponatremia, where the sodium level in the blood drops due to dilution from over-drinking. This can cause altered mental state and confusion. This brings us to the matter of a runner who collapses during the run; it could be from hyponatremia, heat disorder, low blood sugar or from a heart condition. In our hot and humid climate our major concern is heat disorder.

The temperature in the body rises from dehydration, excessive heat production due to running and the lack of heat dissipation from our warm and humid weather. Heat disorder is quite insidious and must be recognised by the paramedical and medical personnel deployed during the race. The immediate treatment is to get the collapsed heatstroke runner into a body cooling unit before evacuating him to hospital. Wearing the right shoes is important too, and for most of us, cushioning shoes are critical to buffer the constant pounding on the road. Some of us are flat-footed and need motion and stability control shoes. Some runners buy special socks; wearing light mesh clothing is useful in our climate, as well as applying Vaseline to chafing parts of our bodies. Chafing is caused by constant rubbing of the moving body parts against the running gear which causes the bruising of the skin. The common sites are the nipples, the groin and the armpits. The conditioning of the mental state is as important as the physical preparation.

The feeling of not being able to complete the race comes soon after the euphoria during the start of the race has evaporated. This is compounded by the heat, loss of stamina to complete the 26 miles, and low body fuel. Some runners listen to music to distract themselves, carry on a conversation, or merely admire the environment and the cheering crowd. Positive thinking helps tremendously to minimise the awkward feeling of not being able to complete the race. When you have completed the race, head for the medical post if you are feeling unwell. Otherwise, keep moving as there can be risk of fainting due to venous pooling when the overworked muscles suddenly become inactive. Do make sure you drink water and isotonic drinks. When you have reached home, continue to drink water and isotonic drinks and listen to your thirst. Do eat protein-laden and carbohydrate-rich food. You should continue to move around and do get rest, naps and a good sleep to let the muscles and the heart to recover quickly.

Getting yourself a sports massage may also help and do not race competitively for a fortnight or more. If you have injuries, remember to ice, rest, compress and elevate the affected limb. You can take some an anti-inflammatory medication and, if in doubt, go see your family doctor for evaluation. Finally, do go out there today and enjoy your run that you have been training for quite a while. You don’t always have to finish it if you can’t and you don’t have to run it all the way.

Just listen to your body and you will have a great, once-in-a-lifetime experience.

Dr Chong Yeh Woei
Senior Consultant Physician (Internal Medicine)
MBBS (Singapore), MRCP (UK) (Internal Medicine)

THE BUSINESS TIMES WEEKEND 30 NOVEMBER 2019

Guarding against diabetes-linked eye disease

Early and regular eye screening is the best defence for diabetics against loss of vision

Several years ago, while volunteering as a consultant to teach local eye doctors for a charitable organisation in rural China, I was eager to share the strategies applied in healthcare in Singapore against the rise of diabetes mellitus, an increasingly common disease. I believed that our emphasis on public education, early screening and management of diabetes with a view to prevent and delay complications work well. To my fellow ophthalmologists in the Chinese hospitals, I recommended our methods of early and regular eye screening for detection of diabetes- associated eye diseases, such as cataracts, glaucoma and diabetic retinopathy, the latter being an eye disease that affects the retina, the receptors of light at the back of the eye.

For the far-flung corners of the land, I showed them examples of mobile eye screening services, on a bus, that several countries such as Britain and Singapore employ. It was my sincere wish that my suggestions would be heeded by the hospital I visited, as the cases of diabetic eye disease that I witnessed there were very advanced and some beyond hope of repair. And I counted my blessings of being both a provider and user of the Singapore medical system. Let’s refresh ourselves about diabetes and the importance to guard against it. Just two years ago, a single medical condition, diabetes mellitus, was flagged for the first time, to my knowledge, at the National Day Rally by Prime Minister Lee Hsien Loong, as a national priority that needed to be addressed.

Complications

A metabolic disease that affects the control of sugar in our bodies, diabetes can result in complications such as blindness, kidney failure and gangrene, consequently requiring amputations. It also makes diseases like heart attacks and strokes more common. One in nine adults aged 18-69 here suffer from it, and the figure increases in the older age group. Type II diabetes affects the majority of the sufferers especially those over 40 yet is highly preventable by lifestyle modification. It costs taxpayers S$1 billion a year, and the figure is expected to increase yearly.

For my part, where the eyes are concerned, once diabetes has been diagnosed, usually from a referring doctor, it is imperative that the patient begins a lifelong routine of eye screening and examinations. This is so that any diabetes-related eye diseases, particularly diabetic retinopathy, can be detected and treated early. Diabetic retinopathy, a form of microvascular disease, stems from ischaemia (a lack of oxygen supply to the affected tissues), which can eventually result in the sprouting of abnormal blood vessels in the retina and elsewhere.

These abnormal blood vessels tend to bleed and scar, obscuring vision and causing further complications such as raised eye pressure, in a condition called neovascular glaucoma which can result in a painful blind eye, irreversible in its advanced stages. Diabetes can also cause retina detachment, a stage of disease so advanced that even surgery often fails to restore a patient’s sight. Yet other diabetes sufferers lose vision at an earlier stage through diabetic maculopathy, where the macula, an area of the retina akin to its “heart”, becomes swollen. Diabetes, as mentioned above, also increases the likelihood of getting cataracts and glaucoma.

The eye screenings, in the early years of diabetes, may be performed as part of a general health check in clinics equipped with eye photography services (fundal photography), even without doctors on site. This service can be found at many clinics, in the government and private sectors, and is increasingly being introduced into premises such as optical centres. A major trend is for Artificial Intelligence to assist in the interpretation of the images obtained, to reduce redundant clinic attendances.

Once signs of diabetes-related eye diseases are detected, it is important to then present to an eye clinic for further management, which may include more frequent eye examinations or commencement of treatment. Treatment of diabetic retinopathy and maculopathy usually involves firstly managing the underlying diabetes. Strict blood sugar control is vital to stabilising the related eye diseases. Beyond that, either lasers or injections into the eye of a family of medicine called anti-vascular endothelial growth factors (anti-VEGF) are then prescribed. The anti-VEGFs, albeit costly, are wonderful game changers in the treatment of diseases affecting the retina in the past 15 years.

Severe scarring

Without it, many patients would be doomed to blindness. This is due to the fact that despite the effectiveness of retinal lasers in stabilising diabetic retinopathy, they can result in severe scarring that jeopardises vision, a side-effect that can be largely avoided by the anti-VEGF injections. Fast forward to November 2019, and I found myself rather piqued in my eye clinic by a recent case of a patient who consulted me for a second opinion for a cataract operation. The patient’s diabetic eye disease had been up until recently managed by a local tertiary eye clinic. As part of routine pre-operative screening for my patient’s cataract operation, a thorough eye examination and pre-operative tests are compulsory.

For diabetes sufferers, I also highly recommend undergoing a blood test called the HbA1C to check for long-term control of the disease, as poor control of diabetes can complicate the recovery and results of eye surgeries such as for cataracts. For this patient, these tests yielded evidence of mild diabetic retinopathy but under-the-radar sub-optimally controlled diabetes. In this case, the elective cataract surgery is rescheduled pending stabilisation of diabetes by the medical team, a best practice preference.

As an ophthalmologist, I believe that although my focus is on eye care, it is a holistic healthcare that we should aim for, hence the team-based multi-disciplinary approach in my current medical practice. Indeed, the eyes are the windows to our health. Yet, although the eyes don’t lie, even with the sharpest eye, one does need to take a step back to see the full picture.

Here’s to a full picture for all our diabetes patients, with stable, healthy eyes!

Dr Daphne Han
Senior Consultant Ophthalmologist
MBBS (Melbourne), MMed, MRCS, FRCS (Edinburgh), FAMS

THE BUSINESS TIMES WEEKEND NOVEMBER 16 – 17, 2019

Watch that hidden poison in your rice

Besides seafood, rice products have the highest arsenic content. Long-term exposure to arsenic is linked to cancer

Many may be surprised that the large majority of cancers are related to environmental causes and genetic causes comprise a minority. Hence, the air we breathe, the food we eat and the water we drink – they all have a bearing on our health. Rice is a major food staple in this part of the world. Just recently, one of my patients, Mdm A, who had been eating a brand of rice which is less commonly consumed by the public but is available in high end supermarkets, was surprised that after consuming it for one year, her blood arsenic level was significantly elevated.

Arsenic in food: seafood and rice. Arsenic is a naturally occurring metal element that is present in water, air and soil, and is absorbed by some food crops as they grow. The forms of arsenic can be broadly divided into two categories; inorganic and organic. The term organic here refers to the chemical form and not the method of growing rice. While inorganic arsenic is the main toxic form of arsenic, the common form of organic arsenic (predominantly DMA) can also be toxic though organic arsenic compounds are generally considered to be of little toxicological significance.

The highest levels of arsenic are found in fish, crustaceans, and seaweed, but the arsenic is mainly organic and hence considered to have relatively minimal toxicological effect. Seafood aside, rice products have the highest arsenic content. Rice, being grown in flooded soils, is exposed to higher arsenic content in the soil and rice plants have evolved efficient mechanisms of capturing arsenic from soil solution. Hence, rice has higher levels of inorganic arsenic than other cereal foods.

Permissible levels of arsenic

Arsenic is classified by The International Agency for Research on Cancer, the European Food Safety Authority and the United States Food and Drug Administration (FDA) as a carcinogen based on the association between long-term exposure to arsenic with skin, lung and bladder cancers. Studies have linked high chronic (prolonged or long-term) exposure with adverse health effects in multiple organ systems including the stomach, kidneys, liver, and in coronary heart disease and diabetes.

Hence, in April 2016, the FDA proposed a limit of 100 parts per billion (ppb) for inorganic arsenic in infant rice cereal to reduce infant exposure to inorganic arsenic. In January 2016, the European Commission implemented regulations controlling the level of inorganic arsenic in rice products. For example, the inorganic arsenic content in rice destined for the production of food for infants and young children should not exceed 0.1 mg/kg wet weight.

Arsenic content in rice: high levels in rice bran and rice milk

The arsenic content in rice varies according to the type of soil where it is grown, the processing of the rice and the way of cooking the rice. In terms of the source of rice, in a publication in October 2015 in Environmental Science and Pollution Research journal, comparison of arsenic content from different sources of rice grains showed that on the whole, rice grains from United States of America had twice the level of arsenic of rice from Asian countries.

Generally, basmati rice is lower in arsenic than other kinds of rice whereas brown rice has a higher content of arsenic than white. Brown rice is higher in inorganic arsenic than white rice as arsenic is concentrated in the bran that is removed by milling to produce white rice. The amount of arsenic present in rice products also depends on the way the rice product is processed. Rice bran is  composed of the hard outer layers of the rice grain and it contains a large amount of fibre. Although often thought of as a healthy fibre food product, one may be surprised to know that among the rice products, the highest arsenic concentration has been found in rice bran.

Rice cakes and rice crackers are popular snacks but the arsenic content can be higher than that in cooked rice. While consuming rice milk, be aware the arsenic content is higher than the amount that is generally allowed in drinking water. In the United Kingdom, children younger than 4½ years are advised against having rice milk because of arsenic concerns. The US Environmental Protection Agency, the European Union and the World Health Organization have set a level of 10 μg per litre for total arsenic concentrations in drinking water.

Reducing arsenic in rice by soaking

Studies by Mosley and Meharg from the United Kingdom showed that by soaking the rice overnight before cooking, using a ratio of 5 times as much water as rice, only 18 per cent of the arsenic remained in the rice. The time the rice is soaked in water allows the arsenic to leave the rice into the water. The following day, drain the water and rinse the rice thoroughly with fresh water. Add 5 parts of water to each part of rice and cook till the rice is tender. Do not boil the rice till it is dry. Drain the water again and rinse the rice with hot water to get rid of the cooking residual water.

However, if the rice is cooked till there is no more water or it is cooked with a rice cooker, the arsenic is reabsorbed into the rice. If the same ratio is used for cooking but not soaked overnight, 43 per cent of the arsenic remained in the rice.

Putting arsenic in rice in perspective

Before you decide to change to a no rice diet, you should know that the lung cancer and bladder cancer risk attributable to lifetime exposure to all rice products is a small portion of all cases of these cancers, at 39 cases per million people (10 cases/million bladder cancer and 29 cases/million lung cancer). This additional 39 cases are a small fraction of the 90,000 per million people who develop lung and bladder cancer over a lifetime from all causes.

Rice is not the only source of arsenic in food. A 2014 European Food Safety Authority (EFSA) report stated that the main contributor of inorganic arsenic, except for infants and toddlers, was grain-based processed products (nonrice-based). In the ESFA report, other important contributors to the overall intake in all age classes were rice, milk and dairy products and drinking water. Food experts do not consider the consumption of rice products a few times a week a health risk, and rice continues to be a part of the international recommendations on food.

Things to note

Remember the following when making decisions on rice:

  • Do not be fooled by “organic” rice labels – they have no bearing on the arsenic content.
  • White rice has a lower content of arsenic compared to brown rice.
  • Asian sources of rice have lower arsenic content.
  • Young children below 5 years should avoid rice milk and reduce rice-based snacks.
  • Apparently “healthy” rice bran has the highest arsenic content among rice products.
  • Cooking rice the right way can minimise the arsenic to negligible levels.
  • Eating the “right” rice will have no significant adverse impact on your health. Hence, there is no need to give up your chicken rice, nasi biryani and nasi lemak!

Dr Michael Lim
Medical Director
MWH Heart Stroke and Cancer Centre
MBBS, MRCP (UK), M Med (Int Med), FAMS (Cardiology), FRCP (Edin)

THE BUSINESS TIMES WEEKEND 9 NOVEMBER 2019