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  1. 1. A PUBLICATION FOR PRIMARY CARE PHYSICIANS MICA (P) 242/03/2012 September-November 2012 A HOLISTIC APPROACH TO BREAST CANCER Reversing Osteoporosis Fix the Leak: Urinary Incontinence High Heels and You: A Podiatrist’s Perspective 01
  2. 2. contents editor’s note 11 A Dedication to in every issue All Women T he biological make-up of Support Group Care Advocates for 03 editor’s note males and females are their tireless work and passion in 04 in the news distinct and unique, helping patients cope with the which explains the healing process (Pg 11). Our Healthy 05 CME CALENDAR complexity of the health Recipe also features a delicious challenges and issues impacting men low-fat, low salt option for cancer 32 fitness and women today. patients (Pg 35). The GP BUZZ editorial team: Lee Wei Kit 35 healthy recipe Jessie Tay In conjunction with the nation-wide In addition to Breast Cancer, we also Celine Ong Breast Cancer Awareness Month in feature other pressing health October 2012, this issue of GP BUZZ challenges associated with ADVISORY PANEL: is dedicated to all women (the womanhood and share real-life Associate Professor Thomas Lew daughters, mothers and accounts of recovery by our patients. Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih in this issue grandmothers) as we unravel the Learn about reversing the effects of Dr Chong Yew Lam health concerns of the female osteoporosis (Pg 16), the prevalence 29 Dr Tan Kok Leong Joe Hau 06 Holistic Approach A community. of high cholesterol and heart disease to Breast Cancer in young women (Pg 23), angle In Singapore, Breast Cancer is the closure glaucoma (Pg 12) and urinaryWe value your feedback on how we can enhance the content of GP Buzz. Please send in your 11 Keeping Abreast most common cancer amongst incontinence (Pg 26). comments and queries to gp@ttsh.com.sg women, with over 1,500 diagnoses © All rights reserved. 12 Angle Closure Glaucoma every year between 2005 to 2009*. Our team of Allied Health No part of this publication may be reproduced – An Ocular Emergency The good news is that Cancer is no Professionals also bring to you a or transmitted in any form by any means longer a death sentence so long as we podiatrist’s perspective on without prior consent from the publisher. 16 Reversing Osteoporosis take active steps to reduce our risks. prolonged wearing of high heels (Pg 29), managing a healthy diet plan 20 The Truth About Our cover story (Pg 6) on Breast (Pg 20) and targeted exercises for Carbohydrates Cancer presents the strides that Tan battling those love handles (Pg 32). Tock Seng Hospital Breast Clinic is already making towards establishing We hope you can draw inspiration 23 Understanding Cholesterol 16 32 and Heart Disease a multi-disciplinary treatment approach to combat this disease. We from the knowledge shared in this issue and help take proactive steps share the story of one Breast Cancer to care for the wonderful women 26 Fix the Leak: survivor’s treatment journey and the amongst us. Urinary Incontinence importance of regular screening for early diagnosis and timely Happy reading! 29 High Heels and You: treatment. We also pay tribute to A Podiatrist’s Perspective our dedicated TTSH Breast Cancer The GP Buzz Editorial Team * Source: The Singapore Cancer Registry, Interim Annual Registry Report, Trends in Cancer Incidence in Singapore, 2005-2009 by the Health Promotion Board, Singapore. September-November 2012 03
  3. 3. in the news in the news CME Schedule September - November 2012 Endocrine Seminar 2: A Brief Glimpse Into the challenges encountered in Endocrinology CME POINTS 2 CME points* DATE 15 September TIME 2.00pm - 4.00pm Official opening of SIMTAC by Health Minister Mr Gan Kim Yong. VENUE Theatrette, Tan Tock Seng Hospital, Level 1 From left to right: Dr Eugene Soh, Chief Operating REGISTRATION Officer, TTSH; A/Prof Thomas Lew, Ms Cynthia Lee DETAILS Chairman Medical Board, TTSH; DID: 6357 2373 Mr Gan Kim Yong, Minister for Health; Mdm Kay Kuok, Email: cynthia_lee@ttsh.com.sg Chairman, NHG; Clinical A/Prof Lim Tock Han, Asst CEO (Education & Research), NHG; GP Forum - Eye Talk & Hands-On Workshop A/Prof Tham Kum Ying, ACMB Talk: Approach To Common Eye Conditions (Education), TTSH; A/Prof Loo Shi Medical Director, SIMTAC Workshop: Demonstration of Examination Techniques with Patients IN State-of-the-Art Simulation CME POINTS 2 CME points* THE DATE 15 SeptemberNEWS Training Facility in TTSH TIME VENUE 2.00pm - 4.00pm TTSH Eye Centre, Tan Tock Seng Hospital, Level 1 O REGISTRATION Ms Wasumathe Sundaram n 18 July 2012, National Healthcare Various scenarios from routine medical DETAILS DID: 6357 7687 Group (NHG) unveiled its new examinations to emergency resuscitations, and Email: wasumathe_sukumar@ttsh.com.sg simulation training centre at Tan Tock even some rare clinical cases can be simulated Seng Hospital (TTSH). The Simulation and in the state-of-the-art training facility. This Updates on prostate conditions and nocturia in the elderly Integrated Medical Training Advancement ensures that healthcare professionals gain Centre (SIMTAC) is a 1,000 square metre sufficient practical training, thus minimising CME POINTS 2 CME points* (10,000 sq ft) facility which provides a the chance of error with real-life patients and DATE 15 September platform for realistic training scenarios, improving patient safety. TIME 1.00pm - 4.30pm enabling healthcare professionals to safely and efficiently experience a diverse range of Professor Philip Choo, NHG Assistant CEO and VENUE National Neuroscience Institute Tan Tock Seng Hospital (Basement 1) clinical situations for practical training. TTSH CEO, feels that TTSH is well placed to serve as a hub to advance the effective use of REGISTRATION Ms Janet Padmakumari James DETAILS DID: 6357 3086 Located on the fourth floor of TTSH’s simulation in education, both for practising Email: janet_padmakumari_james@ttsh.com.sg Emergency Block, SIMTAC houses an operating clinicians and students. Prof Choo said: “The theatre, an emergency room, an intensive care role of simulation in medicine is an important Dealing with Gastrointestinal Diseases unit, wards and outpatient consultation rooms; tool in the education of healthcare CME POINTS 2 CME points* each a near identical replica to the real thing. professionals. In this controlled and safe DATE 06 October environment of deliberate practices, the The rooms are further equipped with lessons learnt allow trainees to achieve the TIME 1.00pm - 4.30pm computerised interactive simulation demanding measures of competence in VENUE Theatrette, Tan Tock Seng Hospital, Level 1 mannequins which mimic physiological knowledge, skills and behaviour.” REGISTRATION Ms Chiang Han Fong responses of a human being – from breathing DETAILS DID: 6357 7897 and blinking to bleeding and even cold, clammy Email: han_fong_chiang@ttsh.com.sg skin – as well as advanced integrated audio- Realistic training environment and computerised * Subject to the approval of Singapore Medical Council. visual systems to facilitate trainee learning. interactive simulation mannequin for practical learning. For an updated listing of CME and event schedule, please visit http://www.ttsh.com.sg/gp/. Information is correct at the time of publishing. 04 05
  4. 4. cover story cover story T he Breast Clinic at Tan diagnosis within two weeks of We recognise that the low holistic patient visit flow that the centre is optimally Tock Seng Hospital first consultation. screening rates of 30-40% is which shortened the time equipped to treat breast cancer (Breast Clinic@TTSH) the main reason affecting from diagnosis to treatment patients. These practices have was established in 2009 with The next milestone would be mortality and with other for patients (refer to Figure 1). been adopted widely in the vision to improve the to continuously improve the centres in Singapore still Major studies have shown that countries such as the United treatment outcomes and treatment outcomes for our seeing symptomatic patients multi-disciplinary management States (National Accreditation enhance the healing journey breast cancer patients. at a late stage. Another improves survival rates in of Breast Centres) and Europe of our patients. possible reason is the failure patients. (EUSOMA). Early Screening is Important to provide appropriate and Two years into its The nation-wide timely treatment. Many of the elements Patient-centred Treatment establishment, the Breast BreastScreen Singapore highlighted in the new patient As much as we are striving for Clinic@TTSH achieved same programme (modeled after A Recognised Process for visit flow meet the clinical excellence, we day imaging for up to 50% of the Australian national Treatment international criteria understand that each breast our patients, reaching our screening programme), The Breast Clinic@TTSH (required for certification of cancer patient is unique as target of cutting down celebrates its 10th developed a seamless and breast centres) and is proof conditions and needs would diagnosis to within two weeks anniversary this year. of first consultation. This was Although Singapore is one of an important milestone as it the only countries in Asia Figure 1: reduced patients’ anxieties, with a nation-wide screening The new visit flow for patients at The Breast Clinic@TTSH especially for those found programme to identify more with benign tumours. patients at an early stage, we still struggle to reduce GP / Polyclinic refers Patient arrives for appointment, Surgeon advises 1 week Post-operation. patient to The Breast Clinic. where Mammogram and Ultrasound surgery. Patient Patient returns for follow-up. The team continues to work at mortality caused by breast are done before seeing Surgeon. will also meet Surgeon will also present the proposed with Plastic post-operation treatment plan. increasing this percentage of cancer. Surgeon reviews the results with patient surgeon if Appointment is fixed and Trucut Biopsy is done if necessary. necessary. Surgery On the same day patient will see: and patient is informed. - Surgeon Another appointment is scheduled to - Breast Care Nurse review Biopsy results. - Radiation Oncologist (if necessary) - Medical Oncologist (if necessary) A HOLISTIC What you 1 week 3 days - 1 week Breast Clinic retrieves referral letters on weekly basis. 1-2 weeks 1 week 1 week Post-operation. The Breast Tumour Board meeting is APPROACH TO held in the morning. Multi-disciplinary don’t Surgeon-on-duty will screen each referral letter to decide specialists are present to discuss each see... if patient needs Mammogram or Ultrasound. patient’s case and to propose the most suitable treatment plan according to Mammogram or Ultrasound is booked on the day patient each patient’s condition. arrives for first appointment at The Breast Clinic. Surgery Specialists will then go to their allocated Consultation Rooms to see Clinic receives referral letter patients whose treatment plan will from TTSH Contact Centre. involve their discipline. Disclaimer: The workflow depicted may vary with the individual patient’s condition and is not a standard workflow.06 07
  5. 5. cover story cover story vary. Given the vast expanse to healing. This has been of medical knowledge and highlighted in the the variety of treatments international breast centre needed for each breast accreditation which places cancer patient, a single emphasis on outreach medical professional will not activities not just to the have the full capability of general public but also to the treating this disease. cancer survivors. The Breast Clinic@TTSH Through support group conducts regular multi- activities and programmes for disciplinary team (MDT) our breast cancer patients, meetings where all clinicians we aim to further enhance in varied specialities come and care for their health together to discuss the and well-being. We hope management of each breast to support and transit our cancer patient; share medical patients from their treatment knowledge of each patient’s and ease them back into their tumour characteristic; and normal lives. the patient’s psychosocial uniqueness. With our breast While we forge ahead for cancer patients, there is not more effective treatment The Multi-disciplinary Breast Team just one standard protocol or outcomes for breast cancer, a pathway but a unique regular breast screenings are treatment angle for each. still pivotal to the timely and The emphasis of MDT is on successful treatment of this condition. With our breast Dr Chen Jia Chuan, Juliana collaborative decision-making and treatment planning. As GPs (General Practitioners) cancer patients, Dr Juliana Chen is the Clinical Director and Consultant at The Breast Clinic@TTSH. She did her post-graduate fellowship training at NSW Breast Cancer Institute at Westmead Hospital The concept of a multi- taking on the important role there is not just one Australia. Dr Chen is also actively involved in the TTSH Breast Cancer Support Group. disciplinary forum to share in primary care, you are knowledge among clinicians uniquely poised in encouraging standard protocol or References from different disciplines is women to do their regular a pathway but a 1. The requirements of a specialist breast unit, EUSOMA, Eur J Cancer 36(2000) 2288-2293 2. Certification of breast centres in Germany: proof of concept for a prototypical example of quality not new to oncology. breast checks and go for assurance in multidisciplinary cancer care, Brucker SY, Bamberg M, Jonat W et al, BMC Cancer Holistic Approach to timely breast screenings and seek early treatment. Early unique treatment 2009, 9:228 3. Multidisciplinary breast centres in Germany: a review and update of quality assurance through benchmarking and certification, Wallwiener M, Bruker SY, Wallwiener D. The Steering committee, Recovery detection can improve breast angle for each. Arch Gyanecol Obstet 2012, 1671-1683 4. Developing and measuring a set of process and outcome indicators for breast cancer. Stordeur S, At the Breast Clinic@TTSH, cancer outcomes and survival Vrijiens F, Devriese S et al. The Breast 21(2012): 253-260 5. Cancer multidisciplinary Team Meeting: Evidence, Challenges and the Role of Clinical Decision we adopt a holistic approach rates. Support Technology. Patkar V, Acosta D, Davidson T et al International Journal of Breast Cancer 201108 09
  6. 6. cover story cover storyA Patients JourneyNew Lease Of LifeAfter Breast CancerGloria was healthy for most of her For the next few months, Gloria could have confidence in treating48 years until April 2010, when she underwent a regime of taking my condition.found out that she had contracted traditional Chinese medication and Breaking A National Record, Largest Human Pink RibbonStage Two cancer in her right did not seek further treatment at By November, Gloria underwent From left to right:breast. the hospital. a full mastectomy on her right TTSH Breast Cancer Support Group Care Advocates breast with reconstruction. The Nurse Clinician, Josephine Anthony Senior Clinical Coordinator, Christine TeoIt was a chance observation after a operation was a success and she Clinical Coordinator, Theresa Lee Senior Nurse Clinician, Patmavathy D/O Chellaiyyashower that she noticed in the The support experienced little pain post-bathroom mirror that the size of her surgery. However, Gloria still hadbreasts were uneven. Upon self- group in TTSH really gave to undergo chemotherapy andexamination, the mother-of-two felt me the strength to go radiation therapy to clear thea hard lump in her right breast. through the punishing cancer entirely from her body.Concerned, she made an appointment post-surgical treatment.immediately for a mammogram at It was a trying time emotionallySengkang Polyclinic in May 2010. Having health professionals and physically for Gloria as she Keeping ABREAST and fellow patients struggled to cope with the sideThe results of the mammogram around you who can fully effects of fatigue, nausea, and hairwere not encouraging, and Gloria empathise with what I was loss from the chemotherapy andvisited Tan Tock Seng Hospital radiotherapy. She was also very(TTSH) for detailed tests. going through helped me conscious of the physical loss of her through this difficult period. right breast. Established since 2001, TTSH Breast Cancer SupportAt the Breast Clinic in TTSH, Gloria The counsel and advice that Group was formed to provide information and offerunderwent a thorough mammogram, they have shared with me It was at this time that Gloria got psychological support to women who are going through The TTSH Breast Cancer Support Groupultrasound and biopsy. She received helped me cope and accept involved in the TTSH Breast Cancer the life threatening disease, which is the most common achieved a significant milestone onher results within the same day and Support Group, which is 3 June 2011 by creating a Singaporeit was confirmed that she had Stage my body and this is really coordinated by the doctors, nurses cancer amongst woman in Singapore. record with the formation of theTwo breast cancer, and that a life-saving. and staff of the Breast Clinic. ‘Largest Ever Human Ribbon’. This wasmastectomy was required. The TTSH Breast Cancer Support Fund, under the umbrella of Tan Tock in conjunction with the first year Currently, Gloria is cancer-free and Group was initiated by clinical staff Seng Hospital Community Charity anniversary of the Breast Clinic@TTSHAn operation date was set in “My friends who knew that I had enjoying life with her new-found and has garnered continuous support Fund for needy patients. which aimed to bring across themid-July. However, the day before cancer and was taking herbs all told friends she has made from the from our members through their message of unity to raise awareness ofthe surgery, Gloria decided to take me I was looking better. However, I TTSH Breast Cancer Support Group. active involvement and participation Counselling sessions are provided by breast cancer.a chance on a friend’s knew deep down that the cancer in Apart from regular meet up in the outreach activities. our breast cancer survivors from therecommendation to seek treatment my body was still there.” sessions with them, Gloria has TTSH Breast Cancer Support Group to Breast Clinic@TTSH and the TTSHfrom a Chinese physician instead, learnt to make time for regular Members with common interests address the emotional needs of the Breast Cancer Support Group willand cancelled the surgery. In late October 2010, Gloria returned exercises such as qi gong, zumba were brought together to work newly diagnosed breast cancer continue to raise awareness for breast to TTSH for treatment and saw Adj and yoga. towards the goal of supporting patients. During these sessions, the cancer through outreach programmes“I was so scared. All I wanted was Asst Prof Patrick Chan, Chief of women in their battle against breast survivors share information and and the support network.to remove the cancer from my body Specialty and Senior Consultant at She is now always ready to lend a cancer. Apart from the creation of personal experiences with theas soon as possible, but at the same The Breast Clinic@TTSH. listening ear and share advice with social platforms for our patients and patients to help them come to terms We strive to help more breast cancertime, I was terribly afraid of surgery other breast cancer patients. “Be survivors, the handmade crafts from with their condition and journey patients and their loved ones copeand how I would look like after the I knew I did not have much time left positive and look on the bright side. our past activities and workshops also along with them in their recovery with the disease and smoothen theprocedure.” to spare. I wanted a doctor whom I You are not alone in this journey.” helped raise money for the Breast process. healing journey.10 11
  7. 7. feature feature Angle Closure size compared to the Caucasian Glaucoma eye. Even among the Asian races, the Chinese individual has a tendency to have smaller eyes, and this is especially so for the female gender. Smaller eyes are also – An Ocular Emergency common in those with a hyperopic refractive error, and overall the smaller eye translates to a shallower anterior chamber with a higher potential for angle closure. Acute angle closure glaucoma is one of the most common of all ocular One of the main risk factors for sudden angle closure in already emergencies which affects the Asian population, especially elderly Chinese narrow anterior chamber angles is women. As it is potentially sight threatening, a correct diagnosis the development of a cataract in elderly individuals over 60 years of with immediate institution of appropriate treatment age. As the cataractous lens Figure 1 – Normal angle structure and configuration measures is critical to ensure the best possible outcome. becomes larger and more bulky, it pushes the iris forward to close off the angles with the resulting precipitous rise in IOP.G laucoma, according to Acute angle closure glaucoma (AACG) drainage angle of the anterior statistics compiled by the is one of the most common ocular chamber where the trabecular 2. DIAGNOSING AACG World Health Organisation, emergencies, and is characterised by meshwork and Schlemm’s canal is Typical symptoms of AACG are aremains the second most common very high intraocular pressures (IOP). located (Figure 1). Unable to triad of blurred vision, eye paincause of blindness worldwide after Also potentially sight threatening, the escape, the fluid then collects with ipsilateral one-sidedcataract. The majority of this success of its treatment rests on early behind the iris and pushes the headache, and nausea and/orsight-threatening glaucoma is of the interventional measures aimed at peripheral iris forwards (iris bombe) vomiting. In some cases, theopen angle type, an asymptomatic reducing the IOP as rapidly as to close off the angle (Figure 2), individual may even be able to givedisease that slowly but surely robs possible. resulting in a sudden, dramatic rise a history of intermittent episodesthe individual of sight while often in IOP. As a prolonged rise in IOP of headache associated withremaining undetected until a late 1. PATHOGENESIS could potentially cause long-term blurred vision, which may be anstage. As a result, this characteristic The key pathogenetic mechanism in damage to the optic nerve, urgent indication of previous episodes ofhas earned it the moniker ‘The silent AACG is a pupil block, whereby treatment is of the essence. intermittent angle closure.thief of sight’. In Asia, however, the apposition between the iris and thenarrow angle type of glaucoma is anterior lens surface prevents Asians are especially vulnerable to On examination, the typical Figure 2 – Closed angle resulting from pupil block and iris bombeprevalent and associated with a much aqueous humour from passing this form of glaucoma, as the Asian presentation is a triad of a red eyemore dramatic clinical presentation. through the pupil to reach the eye is often somewhat smaller in with a mid-dilated, fixed pupil and12 13
  8. 8. feature feature done in both eyes on the same day resulting in quick relief of her headache. Upon more detailed checks and A Patients Journey follow-up by Dr Leonard Yip, Senior Saved Consultant of the National Healthcare Group Eye Institute @ Tan Tock Seng Hospital, Madam From How’s intraocular pressure in the further management is warranted right eye remained high despite the and the mainstay of treatment is treatment given. Dr Yip then went BlindnessFigure 3 – A patent laser peripheral a laser peripheral iridotomy (Figureiridotomy (arrow) on to recommend combined cataract 3), which alleviates pupil block and and glaucoma drainage surgery for re-establishes aqueous outflow, Madam How. By Timely thereby resulting in a drop in the a hazy, oedematous cornea. IOP. Post surgery, Madam How’s recovery The peripheral iris is often in Treatment and rehabilitation journey was a forward-bowed (bombe) 4. CONCLUSION smooth. She was advised to wear an configuration, evidence of the AACG is an ocular emergency that eye-shield while asleep at night for underlying pupil block mechanism. we need to be vigilant for in our the first week, avoid carrying heavy In addition, the eye would likely be ageing population given its items, and also avoid any water from ‘rock-hard’ to palpation because of propensity for affecting Chinese the very high IOP. females aged 65 years and above. Worsening headaches The pain on the right side of her headaches on the right side of her splashing into her eye. head was unbearable and so Madam head, which she thought were caused As it is potentially treatable, can mean something How Suet Keng, 69, admitted by the hot and humid temperature in On the day after the surgery, Madam 3. EMERGENCY TREATMENT a correct diagnosis and rapid MEASURES appropriate intervention is critical serious. In the case of herself to the Emergency Singapore. She did not pay very much How came back to TTSH for a follow- Department of Tan Tock Seng attention to this since the pain was up and Dr Yip found that her In an ocular emergency, immediate to ensure the best possible visual Madam How Suet Keng, Hospital (TTSH) on the Sunday relieved by over-the-counter intraocular pressure was well under referral to an eye specialist for outcome. serious consequences evening of 2 August 2009. That day, painkillers or medications prescribed control. Madam How now only visits apart from the throbbing pain in her by her General Practitioner (GP). TTSH every six months for regular could have followed if head that extended down to her However, the headache on the right check-ups since she has made a full she had not sought nose, Madam How complained of side of her head took a turn for the recovery. She has resumed her usual redness and blurred vision in the worse. At night and in the dark, she treatment in time. right eye. also complained of seeing sudden lifestyle and rejoined her karaoke Dr Vernon Yong mates for her weekly singing sessions. Dr Vernon Yong is the Deputy Director and Senior Consultant at the sparks of red light. National Healthcare Group Eye Institute @ Tan Tock Seng Hospital. Dr Yong underwent a one-year fellowship at the Lions Eye Institute in As a full time homemaker, Madam When asked about what she gleaned Perth Australia. His interests are in treating an aging population for How’s time was divided between Finally, after much persuasion from from this episode, Madam How said: glaucoma and population screening. household chores and ferrying her her daughter and on the “Do not ignore headaches and minor grandson to and from childcare. In recommendation of her GP, Madam aches and see a doctor early. For her leisure time, she would join her How visited TTSH on 2 August 2009. glaucoma patients, treat the Dr Jeanne Ogle friends from the neighbourhood in In the Emergency Department, she condition early when it is still not a Dr Jeanne Ogle is a Principal Resident Physician at the National Healthcare Woodlands for a karaoke singing was found to have acute angle big issue”. “My neighbour who was Group Eye Institute @ Tan Tock Seng Hospital. She obtained her Fellowship from the Royal College of Surgeons (Edinburgh) and also holds a Masters session. closure glaucoma and cataract in the formerly a white collar professional Degree in Ophthalmology from the National University of Malaysia. Her right eye. Appropriate medications before his retirement is now blind area of interest is glaucoma and in addition to clinical work, she is also involved in teaching optometrists, medical students, and advanced diploma In 2008, however, Madam How’s life were quickly administered before since he did not seek timely nursing students. was disrupted by perpetual laser peripheral iridotomies were treatment.” Madam How added. 14 15
  9. 9. feature feature Reversing Osteoporosis Osteoporosis (the “brittle bone” condition) has now silently become a global health problem. It is called the ‘silent’ disease because the inexorable bone loss comes with no symptoms. I t is estimated that there problem. This is very pertinent usually have a lower peak patient, lead to disabilities or are approximately 1.6 to Singapore. bone mass to start with. even cause death. million hip fractures in the world today. This epidemic The Ministry of Health has Men do most of the heavy Statistics have shown that about would increase to over six stated that the prevalence of manual and physical work. one in five persons will die times by the year 2050. This osteoporosis in Singapore is Heavyweight bearing and within the year of sustaining an implies a heavy health bill to very much similar to that of muscular activities lead to osteoporotic hip fracture and both the rich and poor nations, Europe and USA. In the three denser bones. Moreover, one in three will become not to mention the resultant decades since the 1960’s, the women at menopause (usually wheelchair-bound or bed-ridden. morbidity and mortality. number of osteoporotic hip between 45-52 years), have fractures has increased their oestrogen and The possible effects of Osteoporosis five-fold from 75 cases to 403 progesterone levels drop fast. osteoporosis are: Landscape in Singapore cases per 100,000 population It is possible that menopausal Osteoporosis is a bone and in women over the age of 50 women lose up to a fifth of i. Hip Fractures endocrine disease in which years and this figure will set to their bone mass five to seven These are serious effects of there is reduction of density increase with the ageing years after menopause. This osteoporosis. If untreated, and quality (micro- Singapore population. often leads to the pain, loss of mobility, architecture) of the bone, development of osteoporosis. malunion, leg shortening and leading to fragility of the Some 800 to 900 osteoporotic deformity can develop. The skeleton. The bones then have hip fractures occur annually in In men, however, testosterone mortality rate of hip fracture a propensity for fracture. The Singapore. Approximately one levels are maintained up to patients in their advanced age bones that are likely to in five patients died within one 70 years; therefore men and with comorbidities is 20% fracture include the hip, the year of the fracture, and one generally develop osteoporosis within a year of the diagnosis. spine and the wrist. in three became wheelchair much later. 30% of them would be wheel- bound or bedridden. chair or bed-bound. Post-menopausal women and Effects of both elderly men and women Why Women are More Osteoporosis Surgery is recommended to fix are most susceptible. Prone to Osteoporosis Most people believe that the fractures or to replace the The prevalence of osteoporosis is benign and is femoral component of the hip The World Health Organisation osteoporosis is higher in part of the normal ageing joint (Figure 1 and 2). The considers osteoporosis second women. This is due to the fact process. This is not true as the patient would however be only to cardiovascular disease that women are generally osteoporosis can potentially subjected to anaesthetic and as a global healthcare smaller than men. Women limit the mobility of the operative risks.16 17
  10. 10. feature feature Debunking Myths of Osteoporosis ii. Vertebral Since the effects of side effects to some of these Only women are prone to osteoporosis. Fractures osteoporosis can be fatal, treatments and hence it is This is certainly not true. While the lifetime risk of These cases cause pain and the best treatment for this important to seek specialist osteoporotic fractures in women is 30% to 50%, the same deformity of the spine, a condition is to take preventive advice. in men is 15% to 30%. stooped posture and a loss in measures now or from a young height. Acute cases may be age. If the young have an Some of the common treatment Women who suffered from osteoporotic hip treated with bed rest, adequate intake of calcium methods include prescription of fractures are mainly from America and analgesics and calcitonin. (like milk and related Calcium and Vitamin D Northern Europe. Suitable cases may be treated products), lead a healthy supplements which are useful lifestyle of regular exercise adjuncts for other treatment While it is true that the highest risks of hip fractures are with vertebroplasty or and avoid junk food, alcohol options, especially in elderly seen in Norway, Sweden, Iceland, Denmark and the USA, kyphoplasty. and smoking, osteoporosis can patients; treatments to restore there is a rising trend of osteoporotic hip fractures in Asian largely be prevented. bone density and prevent cities like Singapore and Hong Kong. It is estimated that one iii. Wrist Fractures fractures include hormone in four hip fractures occurs in Asia and Latin America. By These lead to pain, deformity, Treatment is still available replacement therapy, 2050, one out of two hip fractures will occur in Asia! stiffness of the wrist and hand and weakness. They may be even if a fragility fracture has biphosphonates, calcitonin, treated conservatively with a occurred. SERMS (Selective Estrogen Osteoporosis is benign and is part of the plaster cast or surgically with Receptor Modulators), normal ageing process. metallic implants. Surgery Treatment Options Strontium Ranelate, The consequences of osteoporosis are definitely not benign. permits early mobilisation and A variety of treatment options Teriparatide and Prolia About one in five persons will die within the year of early return of function of the are available for osteoporosis (Denosumab). Presently, the sustaining an osteoporotic hip fracture and one in three will wrist and hand. patients. There are however biphosphonates hold sway. become wheelchair-bound or bed-ridden. There is no treatment for osteoporosis. This is not true. Prevention is the best treatment. If the young have an adequate intake of calcium (like milk and A/Prof Low Yin Peng related products), lead a healthy lifestyle of regular exercise A/Prof Low Yin Peng is an Emeritus Consultant in the Department of Orthopaedic Surgery in Tan Tock Seng and avoid junk food, alcohol and smoking, osteoporosis can Hospital. He graduated from the University of Singapore largely be prevented. Treatment is still available even if a with the degrees of M.B.B.S.. He was Head and Senior fragility fracture has occurred. Consultant of the Department of Orthopaedic Surgery of TTSH from 1988 to 2001. Presently, he chairs the Domain Specific Review Board and has oversight of Clinical Research Taking calcium and Vitamin D supplements in the National Healthcare Group, Singapore. He is also a fellow of the Royal College of Surgeons of Edinburgh. prevent osteoporosis. Patient’s physique, genetic attributes, lifestyle, References: co-morbidities and medication all play an important role 1. Health Promotion Board, Singapore Government in the development of osteoporosis. 2. The Worldwide Problem of Osteoporosis: Insights afforded by Epidemiology. Riggs BL, Melton LJ Bone. 1995 Nov; 17(5 Suppl) 505S – 511S Investigations for osteoporosis are painful, 3. International Osteoporosis Foundation: Osteoporosis Fact Sheet 4. Hip Fracture Incidence Rates in Singapore 1991-1998. Koh LK, Saw SM, expensive and involve a lot of radiation. Lee JJ, Leong KH, Lee J. Osteoporosis Int. 2001; 12 (4): 311-8 5. International Osteoporosis Foundation Asian Regional Audit, Singapore The DEXA (Dual Energy X-ray Absorptiometry) scan is a 6. WHI Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. Principal Results from the Women’s Health painless investigation using less than one tenth of the Initiative Randomized Control Trial. JAMA; 288(3): 321-333 July 17, 2002 radiation of an ordinary chest X-ray. It is very much cheaper 7. Denosumab for Prevention of Fractures in Postmenopausal Women withFigure 1 – Xray film of the pelvis of a 69 year old lady showing an osteoporotic Figure 2 – The fracture was treated a few days later with internal fixation, to Osteoporosis. Steven R Cummings, MD., Javier San Martin, MD., Michaeland comminuted fracture of the left hip. She was admitted recently to Tan expedite rehabilitation and to prevent physical deconditioning. than an ordinary MRI scan. R McClung, MD., et al. N Engl. J Med 2009; 361:756 August 20, 2009Tock Seng Hospital after a fall. 18 19
  11. 11. feature featureThe Truth About Carbohydrates Hunger is also suppressed because the carbohydrates are often replaced by protein which provides higher satiety. Appetite is further Energy Balance and Weight Management ENERGY ENERGY BURNED With the increasing number of people What are carbohydrates and why are they decreased as the process of ketosis becoming overweight, a desperate search Q essential for us? or accumulation of ketones in the CONSUMED FROM BASAL Carbohydrates break down into sugars to provide an blood occurs as the body begins to FROM METABOLISM, for an instant method to shed the excess burn fat. FOOD AND DAILY ACTIVITIES, important source of energy for our bodies, especially ourweight arises. Low carbohydrate diets have brain. Without adequate carbohydrates in our diet, we DRINKS PHYSICAL ACTIVITY become increasingly popular even though may experience fatigue, suffer from poor mental function A low carbohydrate diet often 1 g fat provides 9 Calories carbohydrates are an essential part of our and have decreased stamina and endurance. eliminates the fatty and sugary 1 g carbohydrate provides 4 Calories diet to provide energy, vitamins, minerals foods which are high in calories, 1 g protein provides 4 Calories The complex and unrefined carbohydrates are often rich leading to a substantial decrease in 1 g alcohol provides 7 Calories and fibre. In the long run, such a diet is calorie intake and thus weight loss. in fibre, vitamins, carotenoids, phytochemicals and trace unsustainable, ineffective for weight minerals like calcium and potassium which are essential Energy consumed = Energy burned Weight maintenance loss and can be damaging to the body. for health. Is this method of dieting Know the truth about this fad diet, Q healthy? Energy consumed < Energy burned Energy consumed > Energy burned Weight loss Weight gain How did the fad of low carbohydrate diets for In the long run, low carbohydrate its associated controversies, and learn healthy eating habits. Q weight loss come about? diets are not recommended for The obsession with eating minimal amount of losing weight. Figure 1 – Calorie counting and energy balance for weight management carbohydrates for weight loss originated in 1872. Dr William Harvey, an English surgeon, recommended a This is because as time passes, the diet with minimal carbohydrates and mostly protein to diet becomes unsustainable, Reducing carbohydrates may also saturated fat and cholesterol which William Banting in order to lose weight. Banting ineffective and can be damaging to cause one to avoid intake of fruits, raises the low-density lipoprotein subsequently lost 20kg from an initial 90kg in a year, the body. wholegrains and sometimes (LDL) cholesterol levels. and had continued weight loss. Although Harvey was vegetables which can lead to criticised for the lack of scientific theory, the public Prolonged ketosis can lead to constipation due to the lack of For people who suffer from gout, was fascinated and quickly adopted this diet for rapid symptoms of headache, mental fibre. These foods also contain excessive intake of protein foods weight loss. In the 1990s, this low carbohydrate diet fatigue and bad breath. soluble fibre which help reduce high increases the intake of purine, was once again made famous with the Atkins diet, the cholesterol levels and are shown to which may aggravate gout flares. Zone diet and the Carbohydrate Addict’s diet, which When the suppression of appetite reduce high blood pressure when In people with diabetes, a very practiced a similar regime. from ketosis subsides, cravings may combined with a reduced sodium high protein diet can accelerate result and any carbohydrates or intake. They also contain essential the progression of diabetic renal Why do low carbohydrate diets lead to initial sugary foods eaten quickly restore vitamins and minerals which can disease. Additional protein also Q weight loss? glycogen stores and the water lead to deficiencies if one persists increases the urinary loss of When there are insufficient carbohydrates obtained associated with it, thus putting back in such a diet. calcium, leading to osteoporosis. from the diet, the body sugar stores known as glycogen the weight that was lost initially. are broken down to glucose to maintain normal blood When one decides to have a low Overall, weight reduction is only sugar levels for daily activities. Since glycogen is made During exercise, fatigue quickly sets carbohydrate diet, they inevitably achieved when calorie intake is up of glucose units bound together by water molecules, in if a consistent lack of dietary replace the carbohydrates with lower than calorie expenditure the breakdown of glycogen leads to excretion of water, carbohydrates has resulted in proteins, commonly animal proteins. (Refer to Figure 1). The underlying resulting in rapid initial weight loss. depleted glycogen stores of energy. Meats, poultry or dairy are higher in cause of obesity stems from large20 21