A PUBLICATION FOR PRIMARY CARE PHYSICIANS

APRIL-jUNE 2015MCI (P) 088/03/2014

Scan the QR code using your iPhone or smart phone to view

GP BUZZ on the TTSHwebsite or visit

www.ttsh.com.sg/gp/.

Radix Pseudostellariae And Coarse Grain Fried Rice

healthy recipe

fitness: falls prevention exercises for the elderly

Can a man age graCiously

in the era of testosterone replacement

therapy?

ToTAl Knee RePlACemenT: Beyond The oPeRATion

contents

APRIL - jUNE 2015

The GP BUZZ ediToRiAl TeAm:jessie Tay

Evelyn TanMellissa Chew

AdViSoRy PAnel:Associate Professor Thomas Lew

Associate Professor Chia Sing jooAssociate Professor Chin jing jih

Adjunct Assistant Professor Chong Yew LamDr Tan Kok Leong

Dr Pauline Yong

GP BUZZ is a magazine by Tan Tock Seng Hospital, designed by

We value your feedback on how we can enhance the content of GP BUZZ. Please send in your

comments and queries to gp@ttsh.com.sg.

© All rights reserved. No part of this publication may be reproduced, stored in

a database, retrieval system or transmitted in any form by any means without prior consent from the publisher.

Although the publisher and author have exercised

reasonable care in compiling and checking that the information is accurate at the time of publication, we

shall not be held responsible in any manner whatsoever for any errors, omissions, inaccuracies, misprint and/or

for any liability that results from the use (or misuse) of the information contained in this publication.

All information and materials found in this publication are for purposes of information only and are not meant

to substitute any advice provided by your own physician or other medical professionals. You should not use the

information and materials found in this publication for the purpose of diagnosis or treatment of a health condition or

disease or for the prescription of any medication. If you have or suspect that you have a medical problem, you should

promptly consult your own physician and medical advisers.

04

14

09 18

02

in eVeRy iSSUe

03 editor’s note

04 in the news

14 UPdAtes on ChAs/CrisP

20 fitness

26 heAlthy reCiPe

in ThiS iSSUe

06 Can a man age graciously in the era of testosterone replacement therapy?

09 total Knee replacement: Beyond the operation

16 have i given myself a Break today?

18 osteoporosis and Calcium

This issue of GP BUZZ focuses on a series of health topics and carries a special focus on the allied health

professionals in Tan Tock Seng Hospital (TTSH).

The cover story uncovers the use of Testosterone Replacement Therapy (TRT) as a treatment for symptomatic hypogonadal men, thus allowing them to improve general well-being and age graciously. With the recent redesignation of therapists, pharmacists, radiographers and laboratory technologists as clinicians under the Allied Health Services & Pharmacy (AHS&P) Clinical Family Group of TTSH, this edition of GP BUZZ profiles the work of our AHS&P professionals from Physiotherapy, Psychology and Nutrition & Dietetics with three feature articles.

GP BUZZ outlined TTSH Physiotherapy Department’s comprehensive rehabilitation programme for patients who have undergone Total Knee Replacement (TKR) surgery, followed by a feature on relaxation therapy by our Psychological Services and a practical piece on osteoporosis and calcium by the Nutrition and Dietetics Department.

TTSH’s work extends to the community. As a member of the Regional Health System, the hospital is dedicated to empower the community in self-care and preventive care. TTSH’s annual Falls Awareness Day on 16 May is created to debunk the myth that falling is a normal part of ageing and can be prevented. Our physiotherapist recommends a few fall prevention exercises to reduce fall risks in the Fitness segment.

We end on a delicious note with a herbal recipe taken from the bilingual cookbook, Herbs for Health, Food for Life, produced by the Complementary Integrative Medicine Clinic (Clinic 6B) of TTSH.

In addition to the suite of health articles, GP BUZZ is pleased to introduce a centerfold pull-out for our GP partners. We understand that navigating the different healthcare schemes can be a daunting process. For a seamless and smooth collaborative experience, a pull-out depicting the process of referring patients under the Community Health Assist Scheme (CHAS) to Tan Tock Seng Hospital (TTSH) is included for your reference in your primary care clinic.

Have an enjoyable and healthy reading experience.

The GP BUZZ Editorial Team

T

editor’s note

03

2015 GP lo hei lUnCheon & eye inTeRACTiVe WoRKShoP

in the news

A/Prof wong hon tym, Medical director of nhGei (centre in white shirt) leads the lo hei with GPs.

Participants of the eye workshop with dr Vernon yong, deputy head, nhGei (top right).

For the second year, National Healthcare Group Eye Institute (NHGEI) and Tan Tock Seng Hospital (TTSH) brought our General Practitioners (GPs) together

for the ‘2015 GP Lo Hei Luncheon & Eye Interactive Workshop’. Held on Saturday, 24 January 2015, the event marked an auspicious beginning to stronger engagement with GPs in the community. It was graced by TTSH’s Chief Executive Officer, Dr Eugene Fidelis Soh, and Chief Operating Officer, Dr Jamie Mervyn Lim. The event was well attended by 60 GPs.

Adj. Asst. Prof Chong Yew Lam, Divisional Chairman, Surgery, delivered the welcome address and shared TTSH's Community Right Siting Programme with our GPs. A/Prof Chia Sing Joo, Medical Director, PEARL Services, also shared collaborative services available in providing seamless and integrated patient-centric care.

During the interactive eye workshop, A/Prof Wong Hon Tym, Medical Director of NHGEI, Dr Vernon Yong, Deputy Head and ten NHGEI consultants facilitated the session where GPs were taught simple and useful screening techniques that they could safely perform in their clinics.

nhGei oFFeRS SAme-dAy APPoinTmenTS

Depending on the level of care patients need and the time that appointment requests were made, patients can be seen by an eye specialist on the same day.

GPs can call 6359 6400 before noon for a same-day appointment with NHGEI. Appointment requests after noon will be seen by NHGEI the following day.

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ttsh engagement activities help to create a valued work environment.

in the news

2nd Win in Aon heWiTT’S BeST

emPloyeRS AWARd

Tan Tock Seng Hospital (TTSH) clinched the AON Hewitt’s Best Employers award 2015, for the second year in a row.

The award was given to recognise the hospital’s key engagement initiatives – a nursing-shared governance model for collaborative decision-making, a patient service associate framework, and ‘creatively inclusive’ health and well-being schemes.

TTSH spoke to staff and patients as part of its value-based journey of making the hospital a great place for working, healing, learning and becoming the best. Engagements are a core factor which helped in aligning organisational goals to staff aspirations, thus improving our professionals, and in turn, improving the quality of care we deliver to our patients.

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cover story

Can a man age graCiously in the era of testosterone replacement therapy?

In 1935, three independent research teams led by Adolf Butenandt, Karoly Gyula

David, and Leopold Ruzicka (sponsored by Schering, Organon, and Ciba, respectively) were successful in the synthesis of a hormone which “when injected into castrated animals, would restore their maleness”. This hormone was named testosterone, since it arose from the testes. It was not until 1939, that Butenandt and Ruzicka received the Nobel Prize for Chemistry, for their seminal work (pun intended) on the male hormone. Interestingly, the word “testis”

also means “witness” in Latin and the male gonads are

called “testes” as they “bear witness” to a man’s virility.

Testicular function declines progressively with age, but unlike menopause where the ovaries undergo rapid functional involution, the change in testicular function is incremental and of the same magnitude as that of other bodily organs. The rate of serum testosterone decline is estimated to be 1%

per year, once a man reaches his third decade of life.

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cover story

Testosterone is secreted according to a circadian rhythm, with peaks in the morning and troughs during the evening hours. This is why serum testosterone levels are usually checked between 7.00am and 11.00am.

controversies behind testosterone replacement therapy (trt)The main deterrent to Testosterone Replacement Therapy (TRT) among primary care physicians, is its presumed detrimental effect on the prostate gland. We now know that there is little evidence to suggest that TRT may increase the risk of developing subsequent prostate cancer, and that it is safe for men, regardless of race or family history of prostate cancer1.

Regarding the effect of testosterone on benign prostatic growth, there is evidence to show that TRT can be administered to patients with pre-existing lower urinary tract symptoms (LUTS) from benign prostatic hypertrophy. Studies have even shown that TRT improves LUTS2.

Recently, TRT was also associated with increased cardiovascular risk. It was shown that the studies quoted suffered from significant

limitations that weakened their evidentiary value for confirming a causal relationship between TRT and adverse cardiovascular outcomes. The limitations include short follow-up times, which preclude the assessment of TRT’s long-term benefits, unclear and questionable statistical methods, inability to compare results across studies due to differing outcomes and populations, and other limitations that involve unascertained information, non-validated endpoints, and the lack of compliance data.

The latest meta-analysis retrieving trials, which included 2,016 TRT-treated and 2,448 placebo-treated

men for a mean duration of 34 weeks, showed that TRT is not related to any increase in cardiovascular risk even when composite or single adverse events were considered. Not only is there no causal role between TRT and cardiovascular events, a protective effect of TRT on cardiovascular risk through the improvement of metabolic profile, reduction of body fat and increase in lean muscle mass were also observed in hypogonadal men with metabolic derangements3.

investigations prior to trtThe key to TRT is to offer it to men with confirmatory laboratory levels of low serum testosterone,

1 Tan Ronny B W, Silberstein John L, and Hellstrom Wayne JG. Testosterone and the Prostate. Sex Med Rev 2014;2:112–120.2 · Chapple CR, Wein AJ, Abrams P, Dmochowski RR, Giuliano F, Kaplan SA, McVary KT, Roehrborn CG. Lower Urinary Tract Symptoms Revisited: A Broader Clinical Perspective. Eur Urol 2008;54:563–9. · Pearl JA, Berhanu D, Francois N, Masson P, Zargaroff S, Cashy J, McVary KT. Testosterone Supplementation Does Not Worsen Lower urinary Tract

Symptoms. J Urol 2013;190:1828–33. · Shigehara K, Sugimoto K, Konaka H, Iijima M, Fukushima M, Maeda Y, Mizokami A, Koh E, Origasa H, Iwamoto T, Namiki M. Androgen Replacement

Therapy Contributes To Improving Lower Urinary Tract Symptoms In Patients With Hypogonadism And Benign Prostate Hypertrophy: A Randomised Controlled Study. Aging Male 2011;14:53–8.

3 Corona G, Maseroli E, Rastrelli G, Isidori AM, Sforza A, Mannucci E, Maggi M. Cardiovascular Risk Associated With Testosterone-boosting Medications: A Systematic Review And Meta-analysis. Expert Opin Drug Saf. 2014 Oct;13(10):1327-51. doi: 10.1517/14740338.2014.950653. Epub 2014 Aug 19.

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imaging (MRI) of the pituitary to rule out prolactinoma where indicated.

Prior to initiating TRT, a digital rectal examination (DRE) and serum prostate specific antigen (PSA) level must be performed. Men with abnormal DRE and/or elevated PSA should be referred to the urologist to rule out prostate cancer. Any requested fertility in the immediate future should be discussed with the patient as exogenous testosterone renders men subfertile. Other contraindications include breast cancer.

These men should be assessed for symptomatic improvement, serum testosterone, haematocrit, PSA levels on a three-month interval and DRE annually. In the event of raised PSA and/or abnormal DRE, referral to the urologist is recommended.

methods of trt deliveryIn Singapore, we have topical, oral and intramuscular preparations for TRT. Topical preparations require daily dosing. Intramuscular testosterone enanthate or cypionate are short-acting and administered every fortnightly, whereas testosterone undecanoate needs to be administered every three months. Oral preparations are not well absorbed and require intake with a fatty meal, and are hence less popular.

TRT allows symptomatic hypogonadal men to age graciously, as replacement to physiological levels of testosterone increases life expectancy, improves general wellbeing and controls cardiovascular risk factors.

with symptoms suggestive of testosterone deficiency (TD), and to replace the serum testosterone to physiological levels. Most common symptoms of TD include erectile dysfunction, decreased libido and decreased energy levels. Serum total testosterone levels of 8 nmol/L or less are widely accepted as low, and levels of 12 nmol/L and above are considered normal. Free testosterone levels should be measured if the total testosterone levels fall in the range between 8 to 12 nmol/L. Symptomatic males with free testosterone levels less than 250 pmol/L would benefit from TRT.

Other blood investigations that should be measured would be luteinising hormone levels and prolactin levels. If the serum prolactin is found to be elevated, the patient should be referred to the endocrinologist with a view to perform a magnetic resonance

cover story

Dr Tan Ban Wei, Ronny Dr Ronny Tan is a Consultant from the Department of Urology in Tan Tock Seng Hospital. He graduated with MBBS from National University of Singapore (NUS), was elected a Member of the Royal

College of Surgeons (Edinburgh) and conferred a Masters of Medicine (Surgery) from NUS. He completed his Advanced Specialist Training (Urology), board-certified in 2012 and became a Fellow of the Academy of Medicine, Singapore. He received the National Healthcare Group-Health Manpower Development Programme award and undertook his clinical fellowship in andrology, sexual medicine and urology prosthetic surgery with Professor Wayne Hellstrom at Tulane University (USA). He is an executive committee member of the Society for Men’s Health Singapore and a member of the International Society for Sexual Medicine.

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ToTal Knee ReplacemenT: Beyond The opeRaTion

day of operation

• Total Knee Replacement

Surgery

inpatient Stay and Rehabilitation

• 4 to 8 days• Up and walking

from day 1 after operation

• Trained to use walking aids over steps, stairs and level ground

First phase of Rehabilitation

• 2 weeks to 1 month• First doctor and

physiotherapy appointment

• Getting back on your feet without walking aids

Second phase of Rehabilitation

• Painless walking• Back to normal

outdoor activities and stair climbing

• Most functions returned within 3

to 6 months

With Singapore’s Golden Jubilee this year, our ageing population is seeing a rise in degenerative conditions diagnosed at the

clinical setting. A most common occurrence would be knee osteoarthritis, and consequently, the knee replacement that follows as a form of treatment.

As with any surgery, there are many considerations

made towards the patient, both before and after the surgery. At Tan Tock Seng Hospital, our rigorously monitored rehabilitation programme for Total Knee Replacement (TKR) surgery is tailored for patients who need help in getting the best out of their new set of joints.

In this article, we answer some of the most common concerns that patients may have after TKR.

WhaT To expecT poST opeRaTion

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iniTial dayS aFTeR TKRPatients are typically warded for about four to seven days. Their length of stay is adjusted according to their home care plan, how well they progress with rehabilitation, and their level of fitness.

Day one after the operation, a physiotherapist will help patients get out of bed, starting with the help of walking aids, and progressing by teaching them exercises that help them ensure that their ‘new joint’ stays at its best. Other things that will be covered during their stay in the hospital include: education on mobility around their home setting, advice on safety, caregiver training if necessary, as well as an individualised exercise regime, accompanied with exercise booklets.

BacK home A little help during the first few days can go a long way. Patients will normally be up and walking shortly after this period. However, some may require help when going outdoors, as well as with their household chores. Pain and stiffness, which are common post operation, is normally the biggest issue in the first month after the operation.

Some simple tips to make recovery smoother and uneventful:

A) Pain Control 1. Always take the pain medication prescribed by

the doctor.2. Medication should be consumed about 30 minutes

before home exercises, as this may help keep pain levels to a minimum.

3. An ice pack applied to the knee for 15 to 20 minutes every two to four hours helps in pain relief and limiting swelling and inflammation.

B) Stiffness Control 1. Perform the prescribed exercises – a range of

motion and strengthening exercises – at least two to three times per day.

2. Do not allow the knee to be in a prolonged position for more than 30 minutes without moving.

3. Perform gentle stretching before moving out of position – be it in the morning or before getting up from a chair.

oTheR common complainTS poST TKR: 1. DECREASED FUnCTIon It is common, for the first three to four

months post TKR for the patient to experience difficulty with movements that involve half squatting, moving up and down stairs, and prolonged walking (up to two hours). Being diligent with the prescribed exercises will aid in bringing about a quick recovery.

2. FEELInG BUCkLInG (GIvInG WAy) oR WEAknESS In THE knEES

It has shown that weakness of the quadriceps, one of the largest thigh muscles in charge of straightening the knee when walking, has been linked to earlier arthritis and pain in the knee. After the operation, there will be further weakness and it is common for this muscle to cause a feeling of imbalance, instability, giving way, as well as a fear of falling when a person walks or goes up and down stairs. Strengthening the quadricep muscles, along with the buttock muscles will help eliminate this.

Lastly, be brave during this period and keep moving, but do not overdo it. Walking too much in a day can worsen the swelling and pain.

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RecoveRy aFTeR TKR The duration of rehabilitation, as well as the number of sessions required vary from patient to patient. However, on the whole, outpatient rehabilitation generally spans two to four sessions and about three to six months in duration.

During the outpatient physiotherapy sessions, an individualised examination will be conducted to check on patients’ pain levels, joint swelling, amount of movement available in the joint, walking capabilities, strength and balance. The therapist will focus on improving joint mobility, pain relief modalities, and if required, move along with individualised exercise prescription to increase functional movements and begin gait retraining.

In the long term, it is important to follow up on the advice given by the doctors and physiotherapists – that will help with the recovery. Common advice would include avoiding any unnecessary stress on the joint, which may come from walking or standing for more than an hour at a time, without rest in between. Another important point to lengthen the lifespan of the knee replacement would be not to participate in high impact sports like basketball or football.

common exeRciSeS aFTeR TKR After the operation, many exercises can help strengthen and rebalance the leg muscles. Below are some exercises that are commonly recommended after TKR.

1) Isometric Quadriceps• Lie flat and tighten the muscle in the front of your thigh as much as

you can, pushing the back of your knee flat against the floor. This will pull your kneecap up your thigh, toward your hip.

• Hold the muscle tight for as long as you can. • Repeat this exercise 30 times, for about 3 times a day.

2) Double Leg Bridging• Lie flat on your back. Lift your hips towards the ceiling. • Make sure to tilt your pelvis and pull your belly button towards your

spine to engage your abdominal muscles. • Squeeze your buttocks to make them firm. • Hold this position for 10 seconds and repeat 30 times, 3 times a day.

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5) Calf Stretch• Place your feet hip width apart. • Place the leg you want to stretch as far back as

you can, without lifting your heel off the ground. • Hold for 30 seconds, repeat 4 to 6 times, 3 times

a day.

3) Inner Range Quadriceps• Place a ball under the exercising knee, straighten

your knee by squeezing the muscle located at the top of your knee.

• Hold for 10 seconds, repeat 30 times, 3 times a day.

4) Hamstring Stretch• Sit up straight, place your heel on the ground and

lean forward. • Ensure that you feel a stretch at the back of your

knee and thigh.• Hold for 30 seconds, and repeat 4 to 6 times, 3

times a day.

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Balance as well as progressive weight-bearing exercises are normally added later on in the rehabilitation phase, approximately five to ten weeks on.

7) Tandem Walk Exercise• Use a close-by wall or countertop for support when you first start this

exercise. • Stand straight and step your right foot forward so your right heel

touches the front of your left toes. Then place your right toes down so both feet are flat.

• Do the same with your left foot. Place it forward such that the left heel touches your right toes, then lower the left foot.

• Continue walking, touching your heels to your toes for the whole length of the countertop or hallway.

Ms Rachel Tang Ms Rachel Tang is a Physiotherapist from the Physiotherapy Department of Tan Tock Seng Hospital. She completed her undergraduate studies at the University of South Australia (UniSA), Australia.

She possesses 3 years’ experience working with musculoskeletal problems, and has specific interests in sports physiotherapy and ergonomics.

6) Step Up• Place your exercising leg onto a step. • Shift your full body weight onto the leg on the step and straighten both

your knee and hip. • Repeat 30 times, for 3 times a day.

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updates on chas / crisp

mAKinG PATienT ReFeRRAlS UndeR The CommUniTy heAlTh ASSiST SChemeTo make it easy for our primary care partners to work with Tan Tock Seng Hospital (TTSH), we developed a comprehensive chart listing the steps to refer patients under the Community Health Assist Scheme (CHAS) to TTSH.

GPs participating in CHAS can refer their patients for subsidised specialist outpatient

care at TTSH. Named referrals are not applicable for CHAS referrals.

CHAS referrals would require:• A duly completed 'CHAS cover note

for subsidised specialist outpatient care at a restructured hospital', including information on patient’s CHAS/Pioneer Generation (PG) card type, card number and expiry date.

• A referral letter and any documents on the patient’s medical condition that are relevant for the referral.

• All CHAS referred patients need to produce the duly completed CHAS cover note and referral letter at the point of registration in TTSH Specialist Outpatient Clinics.

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updates on chas / crisp

mAKinG PATienT ReFeRRAlS UndeR The CommUniTy heAlTh ASSiST SCheme

STePS To ReFeR ChAS PATienTS To TTSh:

TTSh ConTACT CenTRe1. Check if patient has CHAS/PG Card

2. Confirm if request is made by a CHAS GP & a CHAS Cover Note is available

TTSh ConTACT CenTReProceed with appointment booking

under subsidised class

TTSh ConTACT CenTReTo notify GP on:

1. Date and Time of Appointment2. Clinic Name and Location

GeneRAl PRACTiTioneR (GP)1. Remind the patient on appointment details

2. Remind the patient to bring along the necessary documents

TTSh ConTACT CenTReProceed with appointment booking

under non-subsidised class

yeS no

ChAS/PG CARd And ChAS CoVeR noTe?

GeneRAl PRACTiTioneR (GP) 1. Contact TTSH Appointment Line at 6359 6500

2. Provide Patient’s full name, NRIC, Date of Birth, Address and Contact Number

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hAVe i GiVen mySelF A

BReAK TodAy?

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Life in a highly efficient and developed country involves working under tight schedules, meeting numerous deadlines, and multi-

tasking various responsibilities. In the long run, this can take its toll on a person’s physical and mental wellbeing.

Relaxation therapy is an intervention technique that can be used to relieve psychological stress and tension. It helps people cope with stress, and reduce the harmful effects of stress on a person’s health and physical wellbeing.

Stress causes certain changes to our bodies, even if we are not aware of its effects. These changes may include an increase in heart rate, blood pressure, muscle tension, and rate of breathing. Most of the time, our body is able to relax and slow down, once a stressful situation eases. However, prolonged or repeated stressful situations may deprive our body and mind from the opportunity to relax. This can lead us to feel ‘stressed-out’. Simply put, this is what happens when we ‘over-stretch’ ourselves.

Therefore, relaxation techniques are something we can use daily, to create a ‘time-out’ for our body and mind to recover from stressors. By practising relaxation, we are consciously allowing ourselves to slow down, unwind, and relax.

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There are various types of relaxation techniques that can be practiced almost anywhere, and anytime. Here are some of the more common relaxation techniques:

1. BReAThinG exeRCiSeSDeep breathing is one of the most common relaxation techniques that can be practised not just before sleep, but anytime and anywhere. In this technique, the emphasis is on taking slow and deep breaths, with your attention focused on regulating the pace and depth of your breathing. You may also make use of your five senses - sight, smell, taste, hearing, and touch - as points of focus for your attention.

SENSES ExAMPLES

It can be anything that allows you to slow down, appreciate and unwind.

Sight Greenery, scenery

Smell Aroma candles or oils, tea, coffee

Taste Tea, coffee

Hear Music, ocean waves, a flowing river

Touch Stress ball, warm mug

2. GUided imAGeRy Guided imagery involves visualising a relaxing scene, place or image. This technique requires you to picture a place that symbolises peace and serenity. Visualise yourself being there to gain the most out of the experience, and include sensory details such as the smell, sound, sight, and feel of your visualisation. While focusing on your place of serenity, you are actually removing yourself, mentally, from the stressful situation and releasing any tension you may be experiencing.

3. PRoGReSSiVe mUSCle RelAxATionThis technique involves the tensing and relaxing of different muscle groups in your body. It allows you to relax and ease tension in various parts of your body that is under stress. You can choose to start from the head and neck, and work your way down to your toes. Alternatively, you may also work your way up from your toes, towards your neck and head. As you do this, your attention is focused on the difference between muscle tension and relaxation. In turn, this allows you to become more aware of your physical sensations.

SeleCTinG The TeChniqUe FoR yoUSince there is no one-size-fits-all technique, it is important to choose one that you will be comfortable with. Although all techniques serve the purpose of allowing relaxation and mental time-out from your stressors, the steps and instructions involved varies across techniques. Therefore, it is necessary to ensure that you do not feel overwhelmed by the steps. Whichever technique you choose, it should help you relax rather than increase your level of stress.

Small doses of stress may be necessary as drivers of better performance. However, we must ensure that we are not overwhelmed by our stressors. We can all learn to stop and ask ourselves: “Have I given myself a break today?”

Ms Lanurse Chen Ms Lanurse Chen is a Senior Psychologist from the Psychological Services of Tan Tock Seng Hospital. She graduated from Monash University, obtaining her Masters of Psychology in counselling. She is a member of the Singapore Psychological Society and the Australian Psychological Society. She is also a registered psychologist with the Singapore Register of Psychologists.

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oSTeoPoRoSiS And CAlCiUm

WhAT iS oSTeoPoRoSiS? Osteoporosis is a condition that weakens bones, as a result of reduced bone density. Every day, our body loses calcium through sweat, urine, faeces, and from shedding hair, skin and nails. The loss of calcium must be replaced through dietary sources, as the body cannot produce calcium on its own. The body’s ability for bone building is determined by the level of calcium, Vitamin D and hormones it takes in. A lack of calcium and Vitamin D can eventually increase one’s risk of osteoporosis.

hoW mUCh iS enoUGh?The recommended dietary allowance (RDA) for calcium ranges between 800 mg (for adults 19 to 50 years) to 1000 mg (for adolescents, pregnant/breastfeeding mothers, and adults 51 years and above). One should consume approximately two to three servings of dairy products or calcium-rich foods (Table 1) to meet these daily calcium recommendations.

lACToSe inToleRAnCePeople with lactose intolerance have difficulty digesting lactose (a type of natural sugar found in dairy products). However, small amounts of milk, yogurt and aged cheeses may still be well tolerated. Alternatively, choose non-dairy sources of calcium-rich foods or calcium-fortified products (Table 1).

SoURCeS oF ViTAmin dVitamin D promotes calcium absorption. 15 minutes’ exposure to the sun can produce a sufficient amount of Vitamin D within the body. In addition, some foods like cod liver oil, marine fatty fish (such as salmon, mackerel, cod fish and tuna), egg yolk* and animal’s liver* contain Vitamin D. Certain products such as breakfast cereals and margarine may also be fortified with Vitamin D.

* Individuals with high cholesterol should consume these foods in moderation by limiting egg yolk to no more than two to three servings per week, and animal’s liver to no more than once a week.

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Food Serving Size Calcium Content (mg)

Dairy Products

High-calcium milk powder 4 scoops (25g) 500 mg

Low-fat milk 1 glass (250ml) 380 mg

Low-fat yogurt 1 carton (150g) 240 mg

Low-fat cheese 1 slice (20g) 200 mg

Non-Dairy Products

Sardines (with bones), canned 1 fish (80g) 270 mg

Baked beans, canned 1 can (210g) 110 mg

Silken tofu ½ package (150g) 100 mg

Tau kwa 1 small cake (90g) 150 mg

Dhal, raw 1 mug (50g) 85 mg

Spinach, cooked 1 mug (100g) 140 mg

Chye sim, cooked 1 mug (100g) 140 mg

Broccoli, cooked 1 mug (100g) 50 mg

Kai lan, cooked 1 mug (150g) 195 mg

Calcium-fortified products

High-calcium soybean milk 1 glass (250ml) 450 mg

Enriched bread 2 slices (60g) 100 mg

Calcium-fortified orange juice 1 serving (240ml) 350 mg

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TABle 1: SoURCeS oF CAlCiUm-RiCh FoodS (SinGAPoRe heAlTh PRomoTion BoARd)

TAKe home meSSAGeAChieVe A heAlThy BAlAnCed dieT By ConSUminG:

- 2 - 3 servings of calcium-rich food daily

- 2 servings of fruits and vegetables daily (including legumes & dark leafy vegetables)

- Vitamin d-rich food (especially if there is a lack of regular exposure to sunlight)

Contributed by Ms Chng Chern yann, Dietitian, nutrition and Dietetics Department, Tan Tock Seng Hospital.

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FallS pRevenTion exeRciSeS FoR The eldeRlyFalling is a major cause of health problems among the elderly, and presents a major challenge to healthcare providers and health systems. Fall-related injuries can cause significant disability, loss of independence, and even premature death.

It is a misconception that falls can just ‘happen’, and that older adults are prone to falling, due to old age. Many people think falling is a normal part of ageing – but the truth is that most falls can be prevented, and everyone has the power to reduce the risk.

fitness

20

There are various reasons for falling in old age. It can happen as a result of inadequate lighting, poorly fitted footwear, impaired cognition or difficult medical conditions. In many

cases, it is not simply one, but a combination of underlying risk factors that leads to a fall. As the number of risk factors rises, so does the risk of falling. However, older adults have more fall risk factors, which are often related to health changes that are associated with ageing. One of the greatest risks is being physically inactive, which then leads to a negative impact on leg strength, flexibility, balance, and walking.

Falls can result in complications like fractures, long-term hospitalisation, and a reduction in both self-esteem and confidence. Due to these negative effects, falls and their consequences should never be overlooked among the elderly. Certain approaches need to be practised, to reduce the risk of falls.

Many falls among older adults are preventable, and it is crucial to offer a range of interventions for those at risk. Exercise is one of the most effective methods amongst different multifactorial interventions, as balance impairment and muscle weakness are the most prevalent modifiable risk factors for falls.

Regular exercise has proven to be extremely effective in reducing falls. It helps to improve strength, balance, functional mobility, and lower the chances of falling in older adults. This ranges from simple activities such as walking and swimming, to tailored exercise programmes. Exercise should be ongoing and of sufficient dose to maximise its benefits in reducing falls. However, medical conditions should be taken into account too.

A tailored programme for strength and balance training can help to reduce the risk of falls. Strengthening exercises are a form of resistance or weight-bearing activity that improves bone and skeletal muscle strength. It is recommended to involve the major muscle groups, such as legs, hips, back, abdomen, chest, shoulders, and arm muscles. Balance training is a type of exercise that focuses on the ability to control and maintain proper posture over the body’s base of support, either during movement or in the still position.

In a nutshell, integrating balance and strengthening exercises into everyday activities is an effective way to reduce the risk of falling. The following exercises are effective, yet easy to perform anytime and anywhere in a safe environment. Watch out for any pain or discomfort while performing the exercise! Should you have any queries about exercising, please seek professional advice from your doctor or physiotherapist.

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01

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sit to stand • Sit on a chair with arms across your chest.• Bring your feet behind your knees and lean forward

over the knees.• Stand with your trunk (centre part of your body)

upright and sit down on the chair again.• Repeat this 10 times.• Progress to the next level by decreasing the height

of the chair.

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FallS pRevenTion exeRciSeS

safety during the exercise:> Consult a doctor if you have multiple medical

conditions or not used to exercising.> Wear appropriate shoes and clothing during the

exercise.> Warm up and cool down before and after each

exercise session.> Start at a comfortable level, then gradually

increase the level of difficulty.> Drink sufficient water before, during and after

exercise.

stop the exercise if you experience:> Pain in your chest, neck, shoulder or arm> Dizziness or nausea> Profuse sweating> Muscle cramps> Severe joint pain

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0102

heel-raises• Hold onto a firm support to maintain balance.• Lift your heels off the ground.• Lower your heels again.• Repeat this 10 times.• Progress by reducing the hand support or

increasing the duration of the heel lift.

0102

toe-raises• Hold onto a firm support to maintain balance. • Stand with your back facing the wall for safety.• Lift your toes off the ground.• Lower your toes again.• Repeat this 10 times.• Progress by reducing the hand support or

increasing the duration of the toe lift.

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FallS pRevenTion exeRciSeS

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FallS pRevenTion exeRciSeS

single leg stance• Hold onto a firm support to maintain balance.• Stand on one leg and make sure that you are standing upright. • Maintain your balance for 10 seconds.• Perform with the opposite leg. • Repeat this 10 times.• Progress by reducing the hand support or by increasing the

duration of the single leg stand.

01 02

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Ms ooi Bee yin Ms Ooi Bee Yin is a Physiotherapist from the Physiotherapy Department of Tan Tock Seng Hospital. She gained exposure in treating older adults, from the acute inpatient setting, to subacute rehabilitation units. She is also currently working in the outpatient setting where she sees older adults with fall risks or who suffer recurrent falls. Her interest lies in fall prevention and management, particularly in the area of rehabilitation.

01 02

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step ups• Hold onto a firm support to maintain balance.• Step up with one leg then repeat with the

other leg.• Step down.• Repeat this 10 times.• Progress by reducing the hand support or by

increasing the height of the step.

date: 16 May 2015time: 9.00am - 3.00pmVenue: Bishan Community Club

For more information, please call Lynn Lee at 6359 6398 or email her at lynn_lee@ttsh.com.sg.

To learn more about falls prevention, join us at Bishan Community Club for Falls Awareness Day 2015! Understand your falls risk through basic screening and learn tips on how to prevent falls at home and in the community.

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FallS pRevenTion exeRciSeS

healthy recipe

Using herbs to maintain one’s wellbeing can be traced back to China in 1st century AD, during the Han Dynasty. The book by the Complementary Integrative Medicine Clinic (Clinic 6B) at Tan Tock Seng Hospital, Herbs for Health, Food for Life is written with the aim of maintaining health through one’s diet. Eight core herbal and food ingredients were chosen for this book based on core Traditional Chinese Medicine doctrines. The book features a series of delectable dishes for maintaining good health, taking into consideration taste, flavour and health benefits.

Here’s a recipe from the book.

RAdix PSeUdoSTellARiAe And CoARSe GRAin FRied RiCe太子参五谷抄饭

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HEALTH BEnEFITS• Radix Pseudostellariae strengthens the lung and spleen to tonify one’s Qi

and produce body fluid.• Egg enhances Qi and blood, and also nourishes the heart to calm the mind.• Corn and green bean clears damp-heat, enhances the liver and gallbladder,

and regulates digestion to increase one’s appetite.• Carrot strengthens the stomach and aids in digestion, while also promoting

better vision.• Pine nut moistens the lungs and lubricates the intestines for smoother

bowel movement.• Pork tonifies the digestive system.

The above, when cooked together with rice, also aids blood circulation.

ConTRAInDICATIonNot suitable for people with chronic gastroenteritis.

healthy recipe

RAdix PSeUdoSTellARiAe And CoARSe GRAin FRied RiCe

INGREDIENTS

Coarse grain rice 390gEggs 3Corn 150gGreen beans 150gCarrots (diced) 100g

METHODS1. Clean the Radix Pseudostellariae by

rinsing and soaking in water for 30 minutes.

2. Rinse the coarse grain rice. Submerge it with 4.5 cups of water and add in the Radix Pseudostellariae. Cook them together using the rice cooker.

3. Beat the eggs evenly and fry. Cut the fried egg into thin strips.

4. Boil the corn, green beans and carrots for 3 minutes. Drip dry for use later.

5. Pre-heat the frying pan and pour in the olive oil. Add the minced pork and pine nuts. Stir fry briefly for 10 minutes. Then, add in the corn, green beans and carrots, and stir fry together.

6. Add in the coarse grain rice and fried egg strips and stir fry for another 10 minutes. Food is ready to be served.

Pine nuts 150gPork (minced) 200golive oil 1 tspRadix Pseudostellariae 30g

herbs for health, Food for life includes a collection of appetizers, beverages, main courses, side dishes and desserts. You will be able to gain insight on how to integrate more than 2,000 years of Traditional Chinese Medicine wellness knowledge into your daily diet.

This bilingual cookbook is sold in Tan Tock Seng Hospital at Clinic 6B (Level 6, Medical Centre) and the Heritage Museum (Level 1), and available at major bookstores.

For enquiries on the purchase of the book, please email Clinic6B@ttsh.com.sg.

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MULTI-DISCIPLINARY SPECIALIST CARE

TTSH PEARL’s suite of clinics and services is guided by the four pillars of care through

Evidence Care, Destination Care, Team Care and Personalised Care. We remain committed to

delivering a higher level of patient care as We Value Our Patients Most.

For the full range of services in Tan Tock Seng Hospital, please visit our website at www.ttsh.com.sg.

PEARL CLINICS AND SERVICES(NON-SUBSIDISED)GP Appointment Hotline: (65) 6359 6500

CLINIC B1B•OrthopaedicSurgery Tel: (65) 1800-73275-00 Email:ClinicB1B@ttsh.com.sg

•Rheumatology,AllergyandImmunology Tel: (65) 6889 4027 Email: Contact@ttsh.com.sg

CLINIC 2B•GastroenterologyandHepatology•GeneralSurgery•Urology Tel: (65) 1800-73275-00 Email:Clinic2B@ttsh.com.sg

CLINIC 4B•DiabetesandEndocrinology•GeneralMedicine•Haematology•MedicalOncology•PsychologicalMedicine•PsychologicalServices•RenalMedicine•RespiratoryandCriticalCareMedicine Tel: (65) 1800-73275-00 Email:Clinic4B@ttsh.com.sg

CLINIC 6B•ComplementaryIntegrativeMedicine Tel: (65) 6889 4628 Email:Clinic6B@ttsh.com.sg

•Dental Tel: (65) 6889 4627 Email:Clinic6B@ttsh.com.sg

WELLNESS SERVICES•HealthEnrichmentCentre Tel: (65) 1800-73275-00 Email:HEC@ttsh.com.sg

•Travellers’HealthandVaccinationClinic Tel: (65) 6357 2222 Email:THVC@ttsh.com.sg

PEARL LIAISON CENTRE (PLC) Tel: (65) 6357 1590 Email:PLC@ttsh.com.sg