YOUR GUIDE TO LIVING WELL
TUESDAY, MAY 22, 2012
HIVE TALKING: IT STARTED WITH AN ITCH >PAGE 5
ORGANIC HOBO WITH A TASTE FOR ADVENTURE
Illu str at ion :B ria nW an g
All in the mind The healing power of the placebo >PAGE 6
2 NEWS APP OF THE WEEK
ASK THE DOCTORS DR ROGER TAN
Stress relief – forget about it ...................................................... Katie McGregor firstname.lastname@example.org Don’t Sweat Meditation 9/10 Free Take a moment to insulate yourself from distractions and interruptions. A good intention, made a little more feasible with the Don’t Sweat Meditation app. The expression “don’t sweat the small stuff” became a catch phrase after the publication of the now deceased Dr Richard Carlson’s book, Don’t Sweat the Small Stuff ... and it’s all small stuff. The book is a compilation of advice on how to live a more peaceful, fulfilling life by focusing on what is important. This is important because stress is a killer. The app is produced by Carlson’s “soulmate” Kristine Carlson, together with her friend, Bob Beth, and is clearly designed to sell more books. But, unusually, there is value in the app itself. Advice shared from the book such as “Ask yourself the question … will this matter a year from now? Most of the time it won’t, and I laugh and I save my energy for joy (Chapter 16, pg 45)”, or “Repeat to yourself … I have the humility to admit that, in most cases, I create my own emergencies … (Chapter 22, page 61)”, is all good. But taking time out to chill out, or meditate, allows space in your life for these ideas to become reality. Without that time, most of us are just too stressed to even take the ideas on board. The app brings the two aspects together.
In the app, the advice is called an intention. To set up, you select one of the many intentions for your meditation, select whether you want the intention repeated once or on several occasions, and whether you want your background music track to be “magic”, “strings” or “trust”. You can also select your meditation duration, from one minute through to 30. There are no excuses for not taking a moment out of your life to calm down and get a reality check. Beth leads the meditation, where you are encouraged to put your mind in quiet mode, breathe deeply and rhythmically, and allow your busy thoughts to “ride out on your out breath”. Carlson reads out the affirmation. The result is relaxing and calming, so much so that I do not recommend using it before bedtime as you’ll be asleep before the first affirmation is read.
Q: I often wake up in the middle of the night having to urinate. Is this a problem? It surely is disrupting my sleep. A: Urination at night is known medically as nocturia. It is a common problem, particularly as we age, and many surveys showed that it is a common problem in men and women. A survey done in the US involving healthy people of age 60 years and above demonstrated 65 per cent of the men and 63 per cent of the women reported nocturia; the number of night trips to the toilet was similar for both and one-quarter of them reported making more than two trips in a night. Another report also revealed that the older one gets, the more frequent nocturia occurs. Below the age of 30, 3 per cent of women and men reported nocturia; for ages 30–59, 7 per cent of women and 6 per cent of men experienced the problem, and at age 60 and beyond, the figures were 27 per cent for women and 32 per cent for men. The causes of nocturia are generally harmless; many people get up simply because they have more urine to pass out. The reason for the excessive volume may be as simple as excessive water intake, particularly in the later part of the day. Consuming coffee, alcohol or medication known as diuretics (typically these medications are used for high blood pressure or legs swelling) in the
urge to void before it is really full. Infections, inflammation and “sensitive” bladder (known as overactive bladder) can worsen this situation. In elderly men, benign enlargement of the prostate also produces excessive bladder activity. However, nocturia can reflect important diseases outside the urinary system. The two most common are diabetes and heart failure. Some hormonal disorders can also be present with nocturia. So, it is important to discuss the problem with your doctor and if necessary, tests can be carried out to ascertain the underlying causes. A few simple steps can be taken to improve the symptoms of nocturia: •Reduce fluid intake in the evening. Drink as little as possible especially within four or five hours of bedtime. •No alcohol, tea or coffee particularly late in the day. •Review your medications. If you are taking a diuretic, ask your doctor if a milder preparation or another type of drug would be as good for you – but don’t make changes on your own. •Establish good sleeping habits. •Ask your doctor if you suspect diabetes, bladder problems or any other condition that might increase your urine flow.
evening can increase urine production at night. In addition, people who do not sleep well often get out of bed and go to the toilet when they wake up. Changes in the bladder also contribute to frequent urination at night, especially in older adults. The bladder tends to get smaller and stiffer as we get older; it also becomes more sensitive to the presence of urine, so it produces the
Dr Roger Tan is a renal physician from Gleneagles Hospital in Singapore
Scientists pinpoint genes for schizophrenia delusions; negative symptoms including indifference, reticence and general apathy. Niculescu stresses, however, that “genes are not destiny”. “The environment plays a role, as well. The genes we identified play a role in brain connectivity, so they can lead to more creativity in certain individuals or clinical illness in others.” The findings are published in the Nature journal Molecular Psychiatry. Test your knowledge of schizophrenia here.
...................................................... Nanci Hellmich Contrary to popular belief, many healthy foods are no more expensive than junk food, according to a large new analysis by the US government. Andrea Carlson, an economist and co-author of the report from the Department of Agriculture’s Economic Research Service, and her colleague Elizabeth Frazao gathered pricing data on more than 4,000 foods and ranked them by price based on calories, weight and portion size. They placed the foods into the five groups – grains, dairy, protein, fruits and vegetables – and added a category for unhealthy foods, which included items that were high in sugar, sodium and/or saturated fat, such as cookies, desserts and sweetened breakfast cereals. Carlson says one of the best ways to think of food costs is to consider
portion size: “How much do you have to pay to put something on your plate?” Overall, the economists concluded: • When considering portion size, the ranking from least to most expensive is: grains, dairy, vegetables, fruit, protein and less healthy foods. • Grains, such as bread, pasta and rice, are the cheapest foods no matter how you measure – by portion, weight or calories. • Protein, such as meat, chicken and fish, is the most expensive food by portion size, but there are low-cost proteins such as beans and eggs. • Fruits and vegetables are lower in price per portion overall than unhealthy foods. • When trying to eat a healthy diet, protein and vegetables are the most expensive recommendations to meet, followed by fruit. McClatchy-Tribune
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Illustration: Dietrich Madsen
Putting a price on portions
...................................................... Agence France-Presse and Jeanette Wang Scientists claimed last week to have pinpointed the genes most responsible for schizophrenia in a breakthrough they say will allow better diagnosis and treatment of the debilitating mental illness. In a study involving genetic information from thousands of schizophrenic patients as well as healthy controls, the researchers said they had identified hundreds of genes involved and how they work together to produce the illness. This understanding can help the development of better tests and treatments for the condition, says study author Dr Alexander Niculescu of the Indiana University
School of Medicine in Indianapolis. “If they are determined to be at higher risk, then they would be followed more closely by doctors, told to avoid stress, alcohol and drugs, treated with counselling, nutritional supplements [such as Omega-3 fish oil capsules] and even anti-psychotic medications early on to prevent the development of full-blown illness,” says Niculescu. He says the research team tested their findings in other patients, as well. At early onset, schizophrenic patients will experience insomnia, anxiety, paranoia, and social withdrawal. Latter stage symptoms tend to be more visible: positive symptoms include disorganised thinking and speech, auditory/visual hallucinations and
1. What is schizophrenia? a. Another term for multiple personalities, also known as dissociative identity disorder b. A group of mental disorders in which people have a difficult time telling the difference between real and unreal experiences c. A term used for people who hear internal voices 2. When do people with schizophrenia typically begin to show symptoms? a. Between birth and age five b. Between ages 12 and 18 c. Age 18 and onwards 3. According to the Diagnostic and Statistical Manual of Mental Disorders, how long must someone show symptoms of schizophrenia and continual psychological disturbance to be diagnosed with the disorder? a. Two months b. Six months c. One year 4. What is the prevalence of schizophrenia in Hong Kong? a. One in 10 b. One in 100 c. One in 1,000 Answers: 1. b; 2. c; 3. b; 4. b
NEWS 3 SHORTS TOBACCO
Passive smoking children face long-term health problems ...................................................... Jeanette Wang email@example.com Parents, think twice before lighting up in front of your children: you could be setting them up for long-term respiratory illness, according to a study presented last Sunday at the American Thoracic Society International Conference in San Francisco. Earlier studies had established a link between parental smoking and childhood respiratory illness, but in this study, University of Arizona researchers looked at whether these effects persisted into adulthood. “This study shows that exposure to parental smoking increases the risk of persistence of respiratory symptoms from childhood into adulthood independent of personal smoking,” says Juliana Pugmire, one of the researchers. “Persistent respiratory illness in childhood and
young adulthood could indicate an increased risk of chronic respiratory illness and lung function deficits in later life.” The researchers drew data from the Tucson Epidemiological Study of Airway Obstructive Disease (TESAOD), a population-based, prospective study initiated in 1972 that enrolled 3,805 individuals from 1,655 households in the Tucson area in an effort to assess prevalence rates and risk factors of respiratory and other chronic diseases. Participants completed questionnaires issued every two years until 1996. For this study, the researchers used data from 371 individuals who were enrolled in the TESAOD as children under 15 years of age. The researchers looked at the reported prevalence of active asthma, wheeze, cough and chronic cough, which was defined as a persistent cough that lasted for three
HEALTH BITES ...................................................... Jeanette Wang firstname.lastname@example.org You don’t want to know The final word from the US Preventive Services Task Force: PSA-based screening for prostate cancer for all men is not recommended, as the harms outweigh the benefits, regardless of age. The Task Force published its views online today in Annals of Internal Medicine. It considered two major trials – one in the US and another across seven European countries – of PSA (prostate-specific antigen) testing in asymptomatic men to assess the test’s life-saving
benefits and found no significant reduction in deaths. Conversely, nearly 90 per cent of men with PSAdetected prostate cancer undergo early treatment with surgery, radiation, or androgen deprivation therapy. Evidence shows up to five in 1,000 of these men will die within one month of surgery, and between 10 and 70 men will survive, but will suffer urinary incontinence, erectile and bowel dysfunction. However, some experts reject the finding, saying it’s based on flawed studies with inadequate follow-up time.
Every little bit helps Stanford scientists have devised the genetic equivalent of a binary digit – a “bit” in computing jargon – that allows for repeated encoding, storing and erasing of digital data within the DNA of living cells. This could become a powerful tool for studying cancer, ageing, development in organisms and even the natural environment. “Essentially, if the DNA section points in one direction, it’s a zero. If it points the other way, it’s a one,” explains one of the scientists, Pakpoom Subsoontorn. Researchers, for example, could count how many times a cell divides, and that might some day give scientists the ability to turn off cells before they turn cancerous. The researchers reapplied natural enzymes adapted from bacteria to flip specific sequences of DNA back and forth at will. They call their device a “recombinase addressable data” (RAD) module. The study, which took three years, was published online yesterday in the Proceedings of the National Academy of Sciences.
straight months. They found that 52.3 per cent of the children were exposed to environmental tobacco smoke (ETS) before age 15. After adjusting for sex, age, years of follow-up and personal smoking status, it was found that ETS exposure in childhood was
significantly associated with several persistent respiratory symptoms. “Persistent wheezing from childhood into adult life has been shown to be associated with lung function deficits,” notes Pugmire. “Chronic bronchitis [defined as chronic cough and phlegm] is a
significant risk factor for chronic obstructive pulmonary disease [COPD] development later in life. Therefore, the persistence of symptoms like chronic cough and wheeze into young adulthood may indicate a susceptibility to lung function deficits and chronic respiratory illness with age.” A study by Hong Kong Polytechnic University researchers published in 2010 in the Journal of Advanced Nursing looked at students aged 13-15 years old in two schools and found that 44.7 per cent of students had parents who smoked. Of these, 13.2 per cent had tried smoking, compared to 3.8 per cent in those with nonsmoking parents. Pugmire says future studies will be needed to examine the potential synergistic effects of personal smoking and exposure to parental smoking on risk of COPD morbidity and mortality in middle to late adult life.
Pole yourself together Nordic walking helps heart failure patients to safely increase exercise intensity and gain additional cardiorespiratory benefits from exercise than walking without poles, according to research presented yesterday at the Heart Failure Congress in Belgrade, Serbia. The aerobic workout, which involves walking with poles and mimicking the motions of cross-country skiing, is one of the fastest developing forms of physical activity in Europe, and is safe for older patients. “In Nordic walking we have a big workload because we use additional muscle groups,” says lead author Andrzej Lejczak, a physiotherapist at the Military Hospital in Wroclaw, Poland. “We walk with four limbs, so we’re exercising our arms and legs at the same time – that’s why we have such a beneficial response.” The study involved 12 heart failure patients and 12 healthy adults, and both groups were able to reach a higher heart rate and fatigue level when walking with poles than without.
Let’s go native People who live off the land and grow what they need to survive have lower age-related increases in blood pressure and less risks of atherosclerosis, according to two new studies in the journal Hypertension. These conditions typically increase with age, raising risks for heart attack, stroke, kidney disease and death. But University of California, Santa Barbara, researchers, who followed more than 2,000 indigenous adults in 82 Tsimane villages in the Amazon basin, found that heart disease and
stroke aren’t inevitable with age. Tsimane – forager-horticulturalists who subsist on plantain, rice, corn, manioc, fish and hunted game – have blood pressure two to eight times lower than 53 societies around the world. In the other study researchers in Belgium compared atherosclerosis risk in traditional pygmies – hunter-gatherers living in the equatorial forests of Cameroon – to two neighbouring groups: semiurbanised pygmies and farmers known as the Bantu. A traditional lifestyle was found to blunt the effect of ageing on atherosclerosis.
4 MEDICAL CANCER COMBINATION THERAPY
A matter of buying time ...................................................... Jeanette Wang email@example.com Diagnosed with stage-four lung cancer three years ago, the prognosis for Ms Sin didn’t look good. With cancer cells that had spread from her lungs to her brain, bones and liver, Sin (full name withheld for patient confidentiality reasons) was given three to four months to live. But a treatment combination of chemotherapy and a relatively new drug that prevents angiogenesis – the formation of new blood vessels – managed to control the disease, relieve pain, and extend her life by more than two years. Sin, who was in her 50s, lived for 26 months before succumbing to the cancer. The drug that helped her is bevacizumab (beh-vah-SIH-zoomab), which is sold under the brand name Avastin and made by Genentech, an arm of the Swiss drug maker Roche. It’s designed to bind to and inhibit a protein that plays a critical role in tumour angiogenesis, and hence stop the growth and spread of cancer cells. Large-scale clinical trials confirming the efficacy and safety of the drug in patients with advanced or recurrent non-small-cell lung cancer (NSCLC) date to 2005. But two sub-studies on only Asian patients, published last year and revealed to local media a fortnight ago, give new hope for late-stage lung cancer patients in Hong Kong, where lung cancer is the biggest cancer killer. The sub-studies reveal that the treatment combination of bevacizumab and chemotherapy increases the median survival time of late-stage Asian lung cancer patients to two years or more. More importantly, for reasons not yet known to scientists, Asians seem to respond better to the drug. “We can see that bevacizumab enhanced the survival rate of Asian patients, with its efficacy on Asians perhaps outperforming that on other ethnicities,” says Dr Daniel Chua Tsin-tien, a clinical oncologist and an investigator in one of the studies. Data for the two sub-studies was each taken from two international Roche-sponsored studies, Avastin in Lung Cancer (AVAiL) and Safety of Avastin in Lung Cancer (SAiL). AVAiL involved 1,043 patients recruited from 150 centres in 20 countries across Europe, Eastern Asia, Australia, Central and South America, and Canada between February 2005 and August 2006. Of these, 105 were Asian – from Taiwan, Hong Kong and Thailand. They were randomised into three groups: one received 7.5mg of bevacizumab per kilogram of bodyweight and chemotherapy; another received double that drug dose and chemotherapy; and the last group received a placebo and chemotherapy. Results showed the combination of lower-dose bevacizumab and chemotherapy was most effective at extending median overall survival to 28 months (compared with 17.4
Bevacizumab is approved in Hong Kong but patients are not subsidised for the drug, which costs HK$15,000-HK$20,000 per shot. Photo: Bloomberg months in the placebo group) and increased the response rate to 48.5 per cent (compared with 10.3 per cent in the placebo group). At this dose, progression-free survival was also raised to 8.2 months (compared with 6.1 months in the placebo group). “The actions of bevacizumab and chemotherapy are synergistic,” says Chua. Dr Kenneth Tsang Wah-tak, a specialist in respiratory medicine who was part of the AVAiL sub-study with Chua, explains the lower dose was more effective than the higher dose perhaps because of a “saturation issue”. “When there’s too much of the drug, the side effects exceed efficacy. A low dose also makes the drug cheaper for patients,” he says. The other study, SAiL, was designed to further confirm the safety and efficiency of bevacizumab by involving a broader, “real world” patient population. It enrolled 2,212 patients with untreated, locally advanced, metastatic or recurrent non-squamous NSCLC – including many who were excluded from AVAiL, such as the elderly (aged over 65) and those with poor performance status. Of the study patients, 314 were Asian – from the mainland, Hong Kong and Taiwan – of an average age of 55.5 years and recruited between August 2006 and June 2008. They received either 7.5 or 15mg of bevacizumab per kilogram bodyweight every three weeks plus chemotherapy for up to six cycles, followed by only bevacizumab until disease progression.
It enhanced the survival rate of Asian patients, with its efficacy on Asians perhaps outperforming that on other ethnicities DR DANIEL CHUA, CLINICAL ONCOLOGIST
Adverse events were reported in 75 per cent of the patients, the most common being proteinuria (an excess of serum proteins in urine), hypertension and bleeding. Most of these were manageable and required no termination of treatment. In addition, 84 per cent saw their disease stabilise, or the tumour shrank or disappeared. “The conclusion of both AVAiL and SAiL has reflected that antiangiogenesis targeted drug bevacizumab can safely ameliorate the patients’ condition without sacrificing their health,” says Tsang. Lung cancer claimed 3,696 lives in Hong Kong in 2010, accounting for 28.3 per cent of all cancer deaths. The disease is the most common cancer in men and No 3 among women after breast cancer and colorectal cancer. In 2009, the incidence rate was 55 per 100,000 men and 25 per 100,000 women. Smoking is the most important cause of lung cancer, though nonsmokers are not spared – which was the case with Sin. In fact, the SAiL study authors note that “never smokers with NSCLC are found disproportionately high in Asian patients, particularly females with adenocarcinoma”. There are two types of lung cancer: NSCLC accounts for 80 per cent of all cases, and small cell lung cancer (almost always caused by smoking) the remainder. NSCLC can be further sub-categorised: adenocarcinoma, found in the glands of the lungs that produce mucus, constitutes 60 per cent of NSCLC cases among Asians. Because adenocarcinoma tends
to develop in the periphery of the lungs, its early symptoms are often non-specific – chest pains, prolonged coughing, shortness of breath and coughing up blood. Hence, Tsang says most patients are diagnosed when the cancer is at stage three or four. “Until you’re in trouble, you don’t know,” he says. Adenocarcinoma shows some response to chemotherapy. But because of side effects and the resistance that cancer cells develop to the treatment, the chemotherapy often can’t be sustained. But for about 60 per cent of adenocarcinoma patients who lack a certain epidermal growth factor receptor (EGFR) gene mutation – and therefore not suited to EGFR-specific targeted therapy – chemotherapy was the only choice until bevacizumab came along. “For patients without EGFR gene mutation, if an aggressive first-line therapeutic approach is employed, such as chemotherapy with bevacizumab, the survival of patients is more likely to be lengthened and their quality of life guaranteed,” says Chua. The treatment combination is approved by the US Food and Drug Administration and European Medicines Agency for first-line treatment of late-stage NSCLC patients. In Hong Kong, bevacizumab is approved but not government-subsidised, costing HK$15,000 to HK$20,000 per shot. Chemotherapy costs HK$15,000 to HK$25,000 per course. Bevacizumab is also used to treat other forms of cancer in the colon, pancreas, breast and kidney cells.
...................................................... Jane E. Brody
o la H nge :A tion stra Illu
Bill Brancaccio, from New York state in the United States, inherited a sharp mind and brawny physique from his family; and something else: a susceptibility to hives. The itchy, red welts can last for minutes or for days, sometimes recurring for weeks, months or even years. Brancaccio’s first attack occurred in his midteens. “I became allergic to cold water,” he says. “I went swimming and developed hives all over my body. They went away in an hour or two, but recurred every time I swam.” When he was stung by a bee a year or so later, hives popped out over half his body and lasted about a day. Then, he was a 21-year-old college senior. “All of a sudden, out of the blue, I had hives over my entire body. Only my face was spared.” Despite a series of treatments that did little more than add 18kg to his athletic frame, the attack lasted from March to August. He said his intensely itchy body “looked as if it had been burned”. To hide his ugly skin and ease the itchiness, he wore long sleeves and long trousers. But the itching kept him awake night after night. He had to drop some classes, but managed to graduate and get a job in finance in New York city. But doxepin, the drug that finally suppressed the hives, made him so sleepy that he repeatedly dozed off on a desk during six weeks of job training. Brancaccio has a condition called chronic idiopathic urticaria, which dermatologists believe is an autoimmune disorder and has a prevalence of 0.1 to 3 per cent in Europe and the United States. It often runs in families. Brancaccio’s mother, Lydia Brancaccio, experienced her first episode of hives only recently. But, she says, “My mother, sister and daughter have them, and they can last for weeks.” Her sister reacts to sun, and even sun-blocking clothing doesn’t help. The disorder, Bill says, “exposes you to the limits of modern medicine”. The term “idiopathic” indicates that the cause is not known. The name “makes it seem like the problem is solved”, he says. “But you’ve still got hives.” Hives of one sort or another afflict about one person in five at some time during their lives. For most, the problem is short-lived or acute, lasting less than six weeks. A specific cause, or trigger, can usually be identified. Common triggers of acute urticaria include: medications such
Itching for a cure as antibiotics, aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), and opiates; foods such as nuts, peanuts, fish and shellfish, wheat, eggs, milk and soybeans; infections of all kinds, including upper respiratory infections; insect stings, especially by bees and wasps; allergens such as latex or pollen; and physical stimuli such as cold, heat, exercise or sweat. Dr Vincent S. Beltrani, a dermatologist in Poughkeepsie, New York, noted that in patients whose symptoms have an identifiable
Hives of one sort or another afflict about one person in five at some time during their lives
cause, “the episode usually resolves spontaneously within hours after the trigger is removed”. But the likelihood of finding a cause for chronic urticaria is quite small, Dr Supriya Varadarajulu, allergist at the Park Nicollet Clinic in Minneapolis, says. In a few cases, a cause can be identified by taking a careful history, “but usually the condition remains idiopathic,” says Varadarajulu. Studies have indicated that up to 40 per cent of patients with chronic urticaria, especially those
more severely affected, have antibodies targeting the body’s own tissues circulating in their blood. These patients or their blood relatives may have other autoimmune disorders, such as thyroid disease, diabetes or lupus. About a quarter of patients with chronic urticaria have thyroid autoantibodies, and many of them are found to have thyroid dysfunction. Unfortunately, treating their thyroid condition does not eliminate the hives, Varadarajulu says. Some people who get hives also have a related condition called angioedema, a swelling of tissues deep in the skin (hives develop at the skin’s surface). Although angioedema usually doesn’t cause itchiness, it can cause pain or a burning sensation. It most often involves the lips, eyelids, face, arms and legs, and genitalia. Varadarajulu said the swelling can show up suddenly and last for hours or days. The duration of chronic hives varies widely. According to Beltrani, it disappears in three to 12 months in up to half of patients, but persists for up to five years in 20 per cent of patients and for 20 or more years in 1.5 per cent. Half of patients will have recurrences from time to time. He and Varadarajulu emphasise that there is no magic bullet, or even a standard treatment, for chronic idiopathic urticaria. Rather, a series of antihistamines are commonly tried, both singly and in combination. Varadarajulu says one of the newer non-sedating oral antihistamines is the treatment of first choice, although patients often need twice the standard dose. Sometimes Zantac or Tagamet is added. Although normally prescribed for heartburn, these drugs have antihistamine properties. The option that helped Bill, doxepin (brand name Sinequan) is an antidepressant with both antihistamine properties and potent anti-itch action. It causes severe sedation and dry mouth, however, and is used only if less debilitating therapies fail to bring relief. Still, chronic urticaria remains a challenge because “the extreme itchiness can drive people crazy,” Varadarajulu says, and, usually, no cause can be found. Nonetheless, antihistamines can control the disease well until it spontaneously resolves over time. Bill had to take doxepin for many weeks after his hives abated to keep them from recurring. Now 30, living and working in Manhattan, he has been in remission for years. “I don’t know why, but I no longer react to cold water or bee stings,” he says. The New York Times
6 COVER STORY
Twist of faith The placebo effect is not only a scientific fact, it is helping shape the future of medicine, writes Richard Lord
59 • The percentage of patients who, in a 2010 study, knowingly took placebos but reported reduced symptoms and adequate relief from irritable bowel syndrome
hen the University of Hong Kong released the results of a study into the effectiveness of acupuncture in treating depression recently, it wasn’t the fact that 19.4 per cent of patients reported an improvement in their symptoms that was surprising. The surprise was that 8.8 per cent of the patients in the study showed an improvement from so-called placebo acupuncture, which used needles that look like the real thing but don’t do what real ones do. Patients’ health, it turns out, can improve simply because of the expectation of improvement from receiving medical attention. In other words: the placebo effect is about a lot more than sugar pills. “The placebo effect is complicated; we don’t know how much it’s related to expectation and how much to biochemical effects,” says one of the men behind the HKU study, Dr Roger Ng Man-kin, chief of service in the department of psychiatry at Kowloon Hospital. What’s more, Ng says, expectation and medicine aren’t mutually exclusive: “If you have hope about something and then expose the brain to a scan, you’ll see changes. Adjusting your mind
activity can result in changes to the brain. It’s hard to separate physical and mental effects, because they both cause activity in the brain. “The placebo effect is even more prominent in providing psychotherapy. There’s quite a bit of expectation and quite a bit of support that are part and parcel of the treatment.” Medical wisdom acknowledges that the placebo effect works. The view came to widespread attention in 1955, when doctor and medical ethics expert Henry Beecher published his paper The Powerful Placebo. Various studies popped up over the years that appeared to support his view. But it wasn’t until 2001 that a systematic review of all the available material was conducted – and it contradicted medical orthodoxy by finding that there was no robust evidence for the effect, except perhaps for treating pain. The 2001 review has been controversial ever since, mostly because it aggregated results from many different diseases. The effect of placebos varies wildly depending on which type of condition you try to treat with them – from zero for blood poisoning, to 80 per cent with duodenal wounds.
There’s quite a bit of expectation and quite a bit of support that are part and parcel of the treatment DR ROGER NG, DEPARTMENT OF PSYCHIATRY AT KOWLOON HOSPITAL
There are a few things known about placebos. They seem to work better on children than adults, for example, and they don’t work at all on people with Alzheimer’s, because their brains have lost the ability to form expectations. Neuroimaging shows placebos seem to affect the dorsolateral prefrontal cortex, the part of the brain responsible for high-level functions such as working memory and attention. Naloxone, a drug that is usually given to counter overdoses of opiates such as heroin, was found in 1978 to block the effectiveness of placebos, suggesting that endogenous opioids – the pleasure chemicals, such as endorphins, that the body generates to counteract pain – are involved in the effect. The placebo effect also has a converse: the nocebo effect (in Latin, placebo means “I shall please”, and nocebo, “I shall harm”), a term coined in 1961 to describe the harm an inert substance can do if it’s perceived by the patient to be dangerous. A study published in the journal Pain in 2009 found that in every placebo-controlled trial ever done on a migraine drug, people in the control group who received a dummy sugar pill felt similar side effects to whatever drug they
COVER STORY 7
thought they were getting. Those who got the placebo instead of the painkiller, for example, reported digestive problems. Here’s another twist: in a study published in PLos One in 2010, researchers found that placebo pills benefited patients even when doctors explained what they were taking. Researchers divided 80 study participants who suffered from irritable bowel syndrome (IBS) into two groups. One group received no treatment for their condition while the other received sugar pills that they took twice a day. Three weeks later, 59 per cent of study participants who knowingly took the placebos reported reduced symptoms and adequate relief from irritable bowel syndrome, whereas only 35 per cent of the control group reported similar results. Placebos seem to have more of an effect on conditions that involve subjective patient reporting of symptoms, and less on those where symptoms can be externally and objectively verified. Pain is particularly amenable to placebo treatment, along with chronic fatigue syndrome and depression. “In psychiatric medicine, what you notice is that it takes about two weeks for the body to absorb
medication,” says Dr Justin Grayer, a member of the Hong Kong Psychological Society’s division of clinical psychology. “Some people say they feel better a lot quicker than that; it could be their bodies, but it could also be the placebo effect. I think that if people expect to feel better, there’s a chance they will feel better.” A study from Harvard Medical School’s Programme in Placebo Studies and the Therapeutic Encounter, established last year, found that the physical symptoms of asthma patients receiving placebo treatment didn’t diminish, but they described themselves as feeling better. “Thoughts and feelings influence the body,” says Dr Edward Shen, clinical psychologist at the Matilda Medical Centre, who specialises in traditional Chinese medicine and energy medicine, the form of Western alternative medicine that emphasises a putative qi-like life force. “This is where placebos fit – into the workings of the mind. If you don’t believe that the mind can affect physical matter, then you don’t believe in placebos. If you believe in energy affecting matter, then the placebo effect is central.”
The main use of placebos, of course, has nothing to do with deceiving people. As in the HKU study, they’re used as a control in medical trials, a point of comparison so that any effects of the treatment being tested can be isolated. Patients not knowing what they’re getting is a necessary evil; giving people placebo drugs for actual medical treatment is always ethically dubious. “It’s part of professional ethics that people need to provide informed consent,” says Grayer. “You need to know what something is in order to properly consent to it, so that rules out placebo drugs completely.” It also raises something called the placebo paradox: it may be unethical to prescribe a placebo, but it may also be unethical to choose not to prescribe something that has a chance of being effective. Fortunately, physical treatments, including pills, and also creams, inhalants, injections and acupuncture, aren’t the only types of placebo. Shen argues the whole edifice of clinical practice is a kind of placebo: if part of the effectiveness of all treatments is rooted in patient belief, then clinical practice has moulded itself to reinforce positive associations that help people get
better. People are likelier to get better if their doctor expresses confidence that they will – so in a way, the doctor can be a placebo. “The only way out is to package it in non-physical terms,” says Shen. “So, it becomes about the credibility of the physician. If you walk into a doctor’s surgery in Hong Kong, they have all their certificates and diplomas displayed on the wall. The way they dress, the spectacles they wear … It’s all about creating an impression that will make you believe in the doctor’s ability. That’s the placebo effect. “You can even say hope is a kind of placebo.” Could the wealth of information available on the internet erode people’s impression of medical omniscience, and cause the placebo effect to diminish? “I would say yes, because now there’s so much medical knowledge among patients,” says Shen. “Sometimes a patient knows more about their condition than their doctor.” At present, however, the opposite seems to be happening, with the effect becoming more pronounced over time – possibly a result of information overload, or of reporting bias. “People who are
trialling a treatment are much more likely to announce positive results,” says Ng. “Then it goes onto the internet, where it’s picked up by people who may or may not be experts. There’s a material from uncontrolled studies that might not be scientifically sound. When you type a word in, you might think that the treatment is going to be effective – and that’s why the placebo effect is increasing. If people are looking for a novel treatment, they’re probably quite desperate about their condition and haven’t responded to treatment. Their hope increases with a new treatment, and so the placebo effect is going to be increased.” So the placebo effect is helping to shape the future of medicine. With so many variables, its workings are still a mystery, but it has all sorts of potential implications for the role of the mind in physical well-being. “The mind and the body are so close together,” says Ng. “One affects the other. It’s why mental health care and physical health care are getting closer together. People who have a psychological illness are likelier to be physically ill, and people with a physical illness are likelier to be psychologically ill.” firstname.lastname@example.org
8 HEALTH ORGANIC LIVING
A taste for greener pastures ...................................................... Jeanette Wang email@example.com How far would you go for organic food? Most people don’t care about it; others do but aren’t willing to pay a premium or go out of their way to get it. Then there’s Harry Yuan, who spent a considerable amount of time and money travelling around the world in search of food that is local, sustainable and organic. Starting from Hong Kong in January last year, Yuan, 26, along with friend Bruce Aguirre, visited more than 25 countries before ending the trip a couple of months ago in San Francisco, in the US, where they both reside. Calling themselves Organic Hobo, the duo documented their travels through blogs, photos and videos on organichobo.com. Now, they hope to turn their adventure into a television series, pitching a 13-episode season to television networks in Asia and the US. Yuan says Organic Hobo’s goal is to inspire. “It’s inspiration for people to change. I hope to inspire people who are curious about travelling and eating good food; and people who are sitting on a couch to take that holiday they have always wanted.” The idea for this adventure was sparked during Yuan’s family holiday to New Zealand to usher in 2010. At that time, Yuan, a freelance
Harry Yuan and Bruce Aguirre during a tour of Bolivia National Park in Las Rocas. The duo call themselves Organic Hobo, and travel the world in search of organic food experiences
fitness and nutrition coach, was beginning to dabble in videography – and made a birthday video for his mother, Hong Kong veteran actress Cheng Pei-pei. Cheng, seeing how much her son loved to travel and make videos, offered to buy Yuan a round-theworld ticket – if he found a purpose for the trip. “Ideas shot around, and it became evident I wanted to change the way people thought about food,” says Yuan. So he called Aguirre, 37, a photographer and bartender, and Organic Hobo was formed. “Hobo” in their name refers more to the pair’s migratory nature than being homeless and penniless. That said, they had a pretty tight budget of about US$100 a day for two. Apart from his mother’s contribution, his father sponsored about US$60,000, Cheng’s friends chipped in, and Yuan dipped deep into his own savings. “We had to get very crafty with how we spent our money,” says Yuan. “The more we spent on the cost of living, the less we would have to spend on the focus – food. We ended up meeting people and staying with them, calling friends of friends, people who saw our videos on Facebook [and looking for lodgings on] couchsurfing.org. “There were days we spent nothing – the kindness of others was one of the most amazing experiences we had.”
I hope to inspire people who are curious about travelling and eating good food HARRY YUAN, ORGANIC HOBO
It’s hard not to develop a ravenous appetite after checking out the Organic Hobo videos and photos. From Japanese temaki-style tacos in Colombia, to liquid nitrogen frozen ice cream in San Francisco, to Cambodian-style barbecued fish (cooked by burying in the ground under hot coal), the visuals provide a temporary escape for the taste buds and mind – especially when viewed over takeaway lunch in front of the office computer. But the organic experience goes beyond just food. For Yuan and Aguirre, organic is an entire lifestyle grounded in basic, natural and spontaneous activities – think travelling without a fixed schedule, bungee jumping off a platform on a bicycle in New Zealand, rock climbing (sans rope) over water in Thailand, and basically avoiding all things touristy. Asked to pick the highlights of the trip, Yuan had three: • New Zealand. “It’s one of my favourite places on the planet. It’s clean, does not have too many people, the food quality is
awesome, and the people are warm and all adrenaline junkies.” • Budapest. “A beautiful European city. People cared about buying local. In the summer, the city is amazing – there’s something magical that sucked us in.” • Colombia. “People are friendly and the food is really good. The lifestyle is laid back and progressive. It’s very up-and-coming.” When in Hong Kong, Yuan’s favourite organic spots are Eat Right restaurant and wine bar and Life Café, both in Central. While he hopes to see more organic restaurants in the city, he says what is really needed are more farm-totable restaurants that aren’t necessarily labelled “organic” but are rooted in the philosophy of local and sustainable. There are a few such places, such as Yin Yang in Wan Chai and Linguini Fini and The Chairman in Central. With all the good food on the trip, how did he stay in shape? “I have a rule of 80 per cent of the time good, 20 per cent bad,” says Yuan, with a golden tan and lean, muscular physique. “I think it’s necessary to have that 20 per cent because you only get to live once. But finding the perfect balance is tough. I once went through an only-healthy phase for over a year, and completely lost myself in it. You don’t want to be the guy that everyone’s afraid to eat dessert with.”
FITNESS 9 GET FIT FOR GOLF WEEK 2
...................................................... Nicole Chabot firstname.lastname@example.org You’ve heard it from your father: stand up straight; stop slouching! It’s great advice for golfers, too. Good posture allows for balance, the foundation of every good swing. By keeping your balance, you can deliver the clubhead to the ball with both speed and accuracy. Without balance, the swing loses tempo and falls apart.
“It’s not often that you see a pro hitting a bad shot when they have stayed on balance. After most poor shots, the player finishes offbalance,” says touring professional James Stewart, executive director at the J&J Golf Academy at Discovery Bay Golf Club. “If you make a conscious effort to stay balanced, you’ll be surprised at how many good shots you hit.” To enhance his stability, former Hong Kong No 1 Stewart does balance and posture exercises
regularly under golf biomechanics coach Ross Eathorne at Optimum Performance Studio in Central. Eathorne says most golfers have poor posture – even professionals. “I am amazed at their skill level – that they can drive the ball so far without pain,” he says. “Imagine how good they’d be if they spent three to nine months correcting their posture.” Imagine how good a golfer you could be if you worked on your posture, too. Try these movements demonstrated by Stewart. Prone cobra What it works: conditions the postural muscles and re-establishes optimal spinal alignment for all of the golf clubs. Method: lie face down. Lift shoulders, turning elbows outwards. Keep chest open. Hold for 30 seconds, then return to start position. Rest for 15 seconds and repeat. A set consists of four to eight repetitions; do one or two sets with one-minute rest.
Forward Swiss ball roll What it works: strengthens abdominals, hip flexors and shoulder extensors. Good for stabilising the spine through the full range of club lengths and maintaining spine angle for the duration of the swing. Method: kneel on ground with forearms resting on ball. Slowly roll ball forward, keeping abdominals engaged. Return slowly to start position and repeat. A set consists of six to 10 repetitions; do two or three sets with oneminute rest.
Bent over row What it works: improves postural endurance of the back, butt and hamstrings, and strengthens the shoulder girdle. Method: bend slightly at the waist. Ensure chest is up to keep lumbar spine angle aligned. Lift dumbbells towards chest over two counts, squeezing shoulder blades together. Return over two counts to the start position. A set consists of eight to 12 repetitions; do two or three sets with oneminute rest in between.
Horse stance What it works: trains all key stabiliser muscles in the spine; particularly good for those who experience lower back pain while putting. Method: kneel on ground with hands on the floor. Extend right leg out and left arm, keeping them the same height as the hips. Ensure the spine and heel are neutral. Hold for 10 seconds, then return to start position and repeat on opposite side. A set consists of 10 repetitions; do one or two sets with oneminute rest.
Russian twist What it works: strengthens core muscles and lower back stability. Method: Lie face up with shoulders on ball and feet on the ground. Keep abdominal muscles engaged. With palms together, point hands upwards. Rotate to the left over two counts, and to the right over two counts. A set consists of 10 to 12 repetitions; do two or three sets with one-minute rest.
Pro golfer James Stewart (white shirt) gets coaching from Ross Eathorne. Photos: Jonathan Wong
Kneeling on Swiss ball What it works: conditions balance, dynamic posture and co-ordination; will help improve putting and chipping the most. Method: kneel on ball for one to three minutes.
10 WELL-BEING WALKING HOME
Going with the ﬂow ...................................................... Rob Lilwall email@example.com My cameraman, Leon McCarron, and I are now nearing the final stages of our long walk from Mongolia to my home in Hong Kong. Today, we have at last reached the outer edges of Guangzhou, and from here it is just a few days’ hike to Lo Wu, so the end is really in sight. One of the highlights of this expedition has been to see the incredibly changing landscapes of China, which can be roughly divided into the drainage basins of the three great rivers of the mainland. The first was the Yellow River, known as both the Mother of China (for in its flood plains, Chinese civilisation was first recorded as growing) and the Sorrow of China (because of its terrible floods). We met the river in early January after a week of walking along the Great Wall through the curvy, yellowish, loess mountains of Shanxi province. Here the wall is almost never visited by tourists, yet it is a place where it still marches onwards, relentlessly to the west, up and down and over thousands of hills. Millions of people in this region still live in yaodong, or cave houses, built into the sides of the hills, and in the cold weather we were grateful that they would refill our almost frozen water bottles with warm water and sometimes even invite us to stay the night. As we walked south beside the Yellow River, we were often stunned to see it entirely frozen over, and in other places it carried giant, car-sized blocks of ice rapidly downstream. Two months later, just south of the plains of Xian, we walked through China’s longest tunnel in the Qinling Mountains, which turned out to be quite an ordeal because of the carbon monoxide fumes we inhaled. It was here that we crossed our next watershed and
entered the Yangtze River basin. The landscapes of the Yangtze were so very different from those of the Yellow. Gone were the smooth yellow hills; now we were walking through an angular land of limestone peaks covered with thick temperate forests. Spring had arrived, so we sent our tents home and, when in the countryside, camped out in lightweight bivvy bags. The hills started to fill with blossoms, and we wound round the spurs of huge valleys where farming communities grew crops on terraced hillsides that were the steepest I had ever seen. The farmers were mostly elderly men and women who worked nimbly on the precipitous terraces; I would have wanted to wear a safety harness just to venture onto them. We eventually descended to the Yangtze River, crossing it just upstream of the famous Three Gorges, in Chongqing municipality. South of the Yangtze, after yet more giant limestone mountains and just before Guangxi, we crossed into our final drainage basin – that of the Pearl. While the Yellow and the Yangtze are the most famous of China’s rivers, the Pearl River is the third of the giants that run through the country. The landscapes of these Pearl tributaries included the famous limestone karsts. We walked from Guilin to Yangshuo beside the Li River, and I was amazed to see the changes in Yangshuo since I was last there as a backpacker seven years ago. Back then it was full of Western travellers wielding Lonely Planet guides. Now the town had expanded hugely and the number of Westerners was dwarfed by Chinese tour groups flocking through the streets. That same week I read an article in China Daily about young Chinese starting to go backpacking as well as the more standard form of taking tours. And then this week, on the road here in Guangdong, we met
Taking a sunset dip in the mighty Yangtze River. Photo: Rob Lilwall three Chinese cyclists in their early 20s riding from their home on the coast all the way to Lhasa, Tibet. It is amazing and encouraging to see China getting into adventurous travel mode. It has also started raining a lot recently, and the weather increasingly resembles that of Hong Kong. The Sui River, which we have been following, is close to bursting its banks with muddy water. Last week, we took a quick swim to cool down from the blazing sunshine. We were about 50 kilometres upstream of where it meets the Pearl River proper, but I’ll count it as a Pearl River swim because I don’t think I will be taking a dip in Guangzhou where it’s more polluted by industry. In February when we swam in
It is amazing and encouraging to see China getting into adventurous travel mode
the Yellow River, it was filled with slabs of ice. In March we took a dip in the Yangtze which was calm and cool and beautiful. Our Pearl swim, while not exactly beautiful in the brown water, certainly cooled us off. Soon we will be home in Hong Kong. Come along to our welcome home party and celebration in Wan Chai next week on Wednesday. Find out more at our website. Rob Lilwall’s previous expedition, Cycling Home From Siberia, became the subject of an acclaimed motivational talk, a book, and a National Geographic TV series. He has been writing in Health Post about the progress of his new expedition, Walking Home From Mongolia, which is in support of the children’s charity Viva. walkinghomefrommongolia.com
Knead for speed: why ﬂat out is a good place to start for beginners ...................................................... Jeanette Wang firstname.lastname@example.org Home-made bread is nutritious, tastes better, and doesn’t have the preservatives found in store-bought versions. But the hours of kneading and proofing can be intimidating for some. Here’s a simple flatbread recipe that any beginner can try. It takes just a bit of elbow grease and a short time in the oven. Pair it with an equally speedy chicken stir-fry for a tasty, nutritious meal. Chicken with fresh asparagus, pine nuts and home-made bread Serves 4
For the bread 300ml water 600 grams flour 1 tsp olive oil ½ tsp dark soy sauce Sesame seeds • Mix water with flour to make a dough. • Knead the dough until springy, then flatten. • Cut into a square. • Brush with olive oil and sprinkle with flour. Roll up. • Divide into several smaller pieces of dough and flatten them. • Dilute dark soy sauce with 1 tbsp water and brush dough surface with mixture. • Sprinkle with sesame seeds and bake for 10 minutes at 230 degrees Celsius.
For the chicken 1 tsp olive oil 100 grams minced chicken 150 grams sesame seeds 50 grams fresh asparagus 20 grams pine nuts 50 grams water chestnuts • Heat oil in a wok. • Stir-fry chicken until aromatic. • Add remaining ingredients and sauté. • Transfer to a plate and serve with home-made bread. Recipe provided by the Health Department as part of its EatSmart@restaurant.hk campaign. For more information, visit restaurant.eatsmart.gov.hk
WELL-BEING 11 PERSONAL BEST
Let’s hear it for the poise ......................................................
Last year, during a yoga workshop in London, a participant raised his hand to ask, “How do we find emotional balance inside ourselves when there’s so much chaos and imbalance in the world around us?” His probing question gets to the heart of why anxiety and depression have reached such epidemic proportions today. In fact, it’s our outer focus – and what it does to our minds and bodies – that lies at the heart of our emotional struggles. Today’s professional climate demands that we perform at high levels externally, but gives us no guidance for assessing our inner emotional and spiritual progress. So we measure ourselves and one another by our output: where we live, where our children go to school, how successful we are in our jobs, how much work we produce. There’s nothing inherently wrong with outer focus or the drive to produce – both play key roles in our creativity. But they usually work best as a natural extension of inner focus and inspiration. The dilemma: how do we move at our own pace when everyone seems to be racing along at lightning speed? And how do we cultivate inner focus when it feels like the world demands outer focus? Looking inward is the first step in developing emotional balance. A yogi friend of mine remarked over tea the other day that his wife, long known for her strict emotional control, was suffering from acute colitis. She meditated every day, he told me, but she looked deeply unhappy during and after her meditations. “Sometimes, I wish she’d just let her anger out,” he said wistfully. “All I ever get from her is the silent treatment.” His wife’s stomach problems told the story: the anger she couldn’t express was devouring her from the inside out. “Zen on the outside, chaos on the inside,” he said. It can be tempting to think that emotional balance means mastery
Illustration: Henry Wong
Bo Forbes email@example.com
Even the most disruptive emotions, such as grief and anger, add richness and spice to our lives over our emotions: that we don’t feel them deeply, or even at all. Yet we are biologically primed for reaction: emotions are wired into us. Few of us, even yogis, can encounter a dramatic display of anger without an answering burst of our own, or weather a romantic rejection without taking a hit to our selfesteem. Even the most disruptive
emotions, such as grief and anger, add richness and spice to our lives. True emotional balance is not about getting rid of emotions, or only feeling positive ones. It is about how we relate to our emotions and to what they leave behind. After we’ve shot an emotional arrow into a loved one, for instance, can we reduce the angry after-effects, or do we keep fighting? When our heart has been broken, how long does it take to restore our self-esteem? When we’re emotionally balanced, we experience the full range of fear, anger, sadness, or shame. We may even briefly immerse ourselves in these emotions. The important thing for emotional health is that we learn to be present with our emotions – to feel them fully, then let go and return to centre. This requires a
dynamic balance between the activating and resting parts of our nervous system. Emotions are mediated through the autonomic nervous system, which has two branches: the sympathetic (fight-flight-freeze) and parasympathetic (rest-and-digest). This two-pronged system structures our emotional well-being. Think of a car. The sympathetic nervous system is like the accelerator: it revs us up and provokes an emotional response. The parasympathetic system is like the car’s brake: it slows down the nervous system and returns us to our emotional centre. The more we press the accelerator and move into nervous system overdrive, the more deeply we wire in that pattern. Eventually, overdrive becomes our default
THE TASTE TEST VIRGIN COCONUT OIL ...................................................... Jeanette Wang firstname.lastname@example.org
Spectrum Organic Unrefined Virgin Coconut Oil HK$118 for 414ml, ThreeSixty Made in the US and certified organic by the US Department of Agriculture, this oil has a flavour that is supposedly brought out best by either sautéing over medium heat or baking. With excellent moisturising ability, the benefits go beyond the kitchen: massage the liquified oil into skin or apply to hair for one hour, then rinse thoroughly. Verdict: this had the strongest sweet coconut flavour of the three, which takes getting used to in fritatas or stir-fried foods.
Extra Virgin Coconut Oil HK$150 for 500ml, manna.hk Unlike the olive oil world, which draws a distinction in quality between “extra virgin” and “virgin”, there’s no such standard with coconut oil. What’s important, though, is that this is cold-pressed and unrefined, meaning it hasn’t been chemically processed. Verdict: smooth and light, this tasted closest to a fresh, young coconut. Bali’Sun Virgin Coconut Oil HK$210 for 473ml, jirehhealthhk.com This oil is produced in Thailand through a proprietary process called rapid enhanced chill phase, which speedily separates the oil from a coconut milk emulsion. This is said to intensify the oil’s antioxidant-like properties, making it easier to digest. Verdict: clean and crisp, this was the lightest oil of the three in texture and flavour.
mode, and it’s harder to put on the brakes and find our balance. How, then, do we learn to balance the nervous system? This is where yoga and mindfulness practices come into play. For the past 20 to 30 years neuroscientists have studied the effects of both on emotional health. Yoga and mindfulness help to balance the nervous system and create emotional health in the following ways: • Contemplative practices, such as meditation and restorative yoga, help calm the nervous system and build resilience to stress. • Contemplative, relaxation-based practices such as restorative yoga help reduce anxiety and depression. • Even a 10-minute daily yoga practice increases stress resilience and helps with emotional balance – perhaps even more, research suggests, than a twice-weekly 90-minute practice. This doesn’t mean, however, that you need to give up your favourite yoga practice. “Infrastructure interventions” are tools that make your yoga practice more therapeutic: they balance the nervous system, strengthen the immune system, promote physical health, and build resilience to stress, anxiety and depression. You can integrate them into any style of practice, or craft an entire yoga practice using them. For example, try slowing down your practice and lengthening the transitions between poses. This helps all movement emanate from core strength and integrity, which also makes your practice more challenging. These therapeutic practices help unravel the deeply woven emotional patterns of anxiety and depression, and create the embodied awareness that leads to lasting change. Bo Forbes is a yoga teacher, integrative yoga therapist, and clinical psychologist with more than 22 years of clinical experience in mind-body healing. She will be teaching at the Evolution Asia Yoga Conference in Hong Kong next month. See asiayogaconference.com for details