A PUBLICATION FOR
PRIMARY CARE PHYSICIANS
MCI (P) 097/03/2013
SLEEPing POSITIONS AND THEIR EFFECTS ON YOUR HEALTH
breathe easier, Look Better Lacrimal Drainage Obstruction Causes Wet Eyes Too
The Burning Issue
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ADVISORY PANEL: Emeritus Professor Feng Pao Hsii Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Adjunct Assistant Professor Chong Yew Lam Dr Tan Kok Leong Mr Joe Hau
in this issue
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09 Developing Good Sleeping Habits 14 8 Sleeping Positions And Their Effects On Your Health 18 Eat Right, Sleep Tight – Drive Away Insomnia With The Right Food 21 Up All Night 23 GERD: The Burning Issue
26 Breathe Easier, Look Better 28 Lacrimal Drainage Obstruction Causes Wet Eyes Too
Welcoming a brand new year of
TSH celebrated several milestones such as the successful launch of our Health City Novena Master Plan and inaugural Singapore Patient Conference. Catch up on these exciting events and more medical news and services in our In The News section (Pages 4-8)! As we usher in the New Year, it is inevitable that we will get tied up with personal commitments, family and work responsibilities, stress and a fast-paced lifestyle. To cope with them, we will most likely choose to sacrifice sleep, thinking that we can always catch up on lost sleep. More than dark circles under your eyes, dry skin and dull hair, sleep deprivation can contribute to a host of health problems such as decreased immunity, diabetes, high blood pressure and weight gain as well as affect your ability to do certain cognitive and physical tasks. Sleep is an essential time for your body to perform routine maintenance, encode long-term memories and heal from the hustle and bustle of everyday life. In fact, you’re helping your body while you sleep!
In this issue of GP BUZZ, we want to help you understand that sleep will improve nearly every aspect of your life and inspire you to make it a higher priority. Learn how good sleeping habits, diet and exercise can help you achieve overall better sleep in our insightful articles (Pages 9-22 and 30-33). Plus, ever wondered how your sleeping position affects your health? Check out 8 Sleeping Positions And Their Effects On Your Health (Pages 14-17)! Other features focus on gastrointestinal and eye conditions such as gastro-oesophageal reflux disease (GERD) and lacrimal drainage obstruction respectively as well as how patients breathe and look better through surgery (Pages 23-29). What’s more, try our nutritious Eight Treasures Meat Congee recipe, which is easy to prepare and good for your overall well-being (Page 34)! From all of us at GP BUZZ, thank you so much for all your support in the past year and cheers to happiness, prosperity, good health and not forgetting, good sleep in 2014! The GP BUZZ Editorial Team
january - march 2014
in the news
in the news
TTSH Medical Social Worker Honoured at the Outstanding Social Worker Award (OSWA) 2013
Cardiac CT Scans May Predict Heart Disease Better than Existing Tests for Some Patients
new study published in the journal, Radiology, by researchers from the University of British Columbia found that Coronary Computed Tomography Angiography (CCTA) scans could help predict heart attack risk in patients who were suspected of having coronary artery disease, but did not have risk factors such as high cholesterol, elevated blood pressure or diabetes. The study focused on a sample of 5,262 patients who received the CCTA scans and were followed-up two years later. These patients were asymptomatic. 104 patients experienced a major adverse cardiovascular event.
his year, Ms Carmen Wu, a Senior Medical Social Worker (MSW) of Tan Tock Seng Hospital (TTSH), has been conferred the Promising Social Worker Award 2013 by His Excellency, President of Singapore, Dr Tony Tan Keng Yam at the Outstanding Social Worker Award (OSWA) 2013, organised by the Singapore Association of Social Workers on 28 October.
Findings from the study revealed that the group with coronary artery disease might have gone undetected and untreated because the participants did not possess the standard risk factors that would have alerted their doctors to heart problems. Over a quarter of the patients had plaque build-up in their arteries and 12% had more serious obstructive disease. The study displays an example of CCTA’s usefulness in the screening of such patients and helping their doctors intervene with treatments or lifestyle recommendations that could minimise the risk of heart attack.
Both CCTA and Cardiac CT Calcium Score examinations are available at AmRad in Tan Tock Seng Hospital – one of Singapore’s largest one-stop imaging and intervention specialist centres. With sub-specialty expertise in head and neck radiology, cardiac radiology, musculoskeletal radiology, body imaging, ultrasound and interventional procedures, AmRad is also well-equipped with advanced imaging equipment such as the Integrated Picture Archiving and Communications System (PACS) and the Radiology Information System (RIS), which allow images to be captured, distributed and archived digitally. This ensures a faster turnaround time for our patients’ reports.
A CT scanner used at AmRad. References Jonathon Leipsic et al (19 February 2013). Cardiovascular Risk among Stable Individuals Suspected of Having Coronary Artery Disease with No Modifiable Risk Factors: Results from an International Multicenter Study of 5262 Patients. Radiology. Published online.
Contact AmRad at 6250 5350 for more information.
Scar-free Way to Remove Stomach Cancer Cells Now Available
an Tock Seng Hospital introduced a new procedure for removing cancer cells from the stomach without leaving any scars.
Now available for patients with very early-stage cancer, this procedure involves inserting a long tube encased with a blade, down the patient’s mouth and oesophagus. Surgeons will then use the needle-like blade to cut out parts of the 2mm-thick top layer of the stomach’s inner lining, where gastric cancer usually forms.
According to Dr Stephen Tsao, Consultant at the Department of Gastroenterology and Hepatology who learnt the procedure in Japan, this endoscopic submucosal dissection method can also be used to remove polyps in the intestines that can lead to colon cancer. Since its pilot run early this year, a total of 20 patients with early-stage gastric or colon cancer have benefited from the new method.
Dr Stephen Tsao explaining the new procedure to a patient.
Since its inception in 1998, OSWA has honoured outstanding social workers for their professional dedication and contributions towards the healthcare and community sectors.
include the setting up of the MSW Clinic in the Memory Clinic, an effort aimed to provide holistic, one-stop care for our patients and caregivers. Another noteworthy effort from her career involves the establishment of TTSH’s first Volunteer Programme in Palliative Care – the “Life Enlightening Programme”, which trains and recruits volunteers to serve our patients who face end-of-life issues. Outside of work, Carmen also participates as a member of the Family Violence Workgroup in Tanglin, doing her part to contribute to a violence-free society.
Carmen’s inspiring influence on the lives of our patients began in 2009. In her role as a Senior MSW, she ensures the accessibility of medical social services across multi-disciplinary teams and quality psychosocial support to our patients and their caregivers. Her key contributions
Ms Carmen Wu receiving the Promising Social Worker Award 2013 from His Excellency, President of Singapore, Dr Tony Tan Keng Yam.
Contact Endoscopy Centre at 9720 8601 (Mon - Fri: 8.30am - 5.30pm). 04
in the news
in the news
TTSH ORGANISES INAUGURAL SINGAPORE PATIENT CONFERENCE AND LAUNCHES CARECONNECT
Gold Award for Health City Novena Master Plan at the 2013 Singapore Landscape Architecture Awards
an Tock Seng Hospital (TTSH)’s Health City Novena Master Plan won a Gold Award for Excellence in the Master Planning category at the 2013 Singapore Landscape Architecture Awards on 22 November.
ore than 300 guests comprising patients, family members, caregivers, volunteers, patient support group members, healthcare professionals and Tan Tock Seng Hospital (TTSH) staff gathered on 25 October 2013 to witness TTSH’s first ever Singapore Patient Conference – a platform that brought patients and healthcare professionals together to share and learn new ideas to create a better overall healthcare experience.
The event, organised annually by the Singapore Institute of Landscape Architecture (SILA), serves to honour and showcase the best works from the nation’s landscape architects. Officially launched on 30 August, our Health City Novena Master Plan impressed judges with its high level of integration within a mixed development. Its accessibility and circulation are facilitated by landscape design, with lush green features strategically employed to buffer the multiple functions that create harmonious and efficient integration within the complex.
Moving insights and personal stories were shared at the conference by patients, volunteers, community partners and healthcare professionals. The open dialogue setting exposed all members of the audience to the values of community giving, collaborative care and support – underscoring the need for an improved healthcare experience to empower patients and enhance their healing journeys ahead. In conjunction with the inaugural Conference, Tan Tock Seng Hospital also launched CareConnect – a one-stop information hub that provides patients and community partners access to a multitude of resources within and beyond the hospital. Guest-ofHonour from the Singapore Patient Conference, Associate Professor Muhammad Faishal Ibrahim, Parliamentary Secretary for the Ministry of Health and Ministry of Transport took time off his busy schedule to launch CareConnect. Together with the provision of educational materials, CareConnect will schedule monthly talks, training programmes and volunteer-led activities to benefit both patients and their caregivers and family members.
Official opening of CareConnect by Associate Professor Muhammad Faishal Ibrahim (third from left) with (from left) Ms Rosalind Wong, Chairman of Diversional Therapy Unit, Professor Philip Choo, CEO of TTSH, Mr Michael Poh, Leader of TTSH Cardiac Rehabilitation Patient Support Group, Associate Professor Thomas Lew, Chairman, Medical Board of TTSH and Mr Cheng Koh Siong, a volunteer from our Volunteer Guiders Programme.
Our Guest-Of-Honour, Associate Professor Muhammad Faishal Ibrahim sharing his insights on patient experience at the opening of the Singapore Patient Conference.
With the award, the Health City is indeed off to a great start, on its journey as one of the latest additions to Singapore’s Regional Health System.
Our distinguished speakers and Dr Eugene Fidelis Soh, COO of TTSH (fourth from left) at the Singapore Patient Conference.
Contact CareConnect at 6357 8018, write to us at firstname.lastname@example.org or visit www.ttsh.com.sg/careconnect.
in the news
Direct Access Endoscopy – Bringing Convenience to GP Partners and Patients
Developing good sleeping habits A patient undergoing endoscopy.
an Tock Seng Hospital (TTSH) now offers one-stop direct access endoscopy every Wednesday.
General practitioners (GPs) are offered direct access to endoscopy services and can refer patients to TTSH without specialist consultation. Following the endoscopy, patients will then be referred back to their GPs, who will be notified by TTSH on major findings from the endoscopy reports. Prior to the endoscopy, GPs need only provide their patients’ particulars and contact details for our nurses to disseminate pre-procedural counselling and information such as leaflets, fasting and medication advice for chronic conditions. GPs will also receive drugs for bowel cleansing, complete with printed instructions.
Who is suitable for Direct Access Endoscopy? • Patients referred for direct access endoscopy should generally be healthy. • Chronic medical conditions such as hypertension or diabetes, if well controlled, do not preclude patients from enjoying this service.
While we are all aware of the importance of getting enough sleep, a recent editorial in the Annals, a journal by the Singapore Academy of Medicine, has found that one in three people is getting so little sleep that badly affects health. Read on for tips to achieve better quality of sleep.
• Patients scheduled for a colonoscopy will need to take purgatives to clean out their bowels. Hence, patients with renal impairment, heart disease or electrolyte imbalances should first be referred to a specialist. • Elderly patients above the age of 70 should ideally be referred to a specialist for an evaluation, rather than direct access endoscopy.
Contact Endoscopy Centre at 9720 8601 (Mon - Fri: 8.30am - 5.30pm) for more information on direct access endoscopy.
CME Schedule January – March 2014 Musculoskeletal Workshop for Family Physicians CME POINTS
4 CME points
1 & 8 March 2014
2.00pm – 6.00pm
TTSH Annex Building 1, Level 2, Room 11 (Pearl’s Hill) Yvonne Chong Contact: 6357 2364 Email: email@example.com
* Subject to the approval of Singapore Medical Council. For an updated listing of CME and event schedule, please visit http://www.ttsh.com.sg/gp/. Information is correct at the time of publishing.
and increased mortality, while other studies have also shown that bad sleeping habits have a stronger correlation with mortality than smoking or lack of nutrition and exercise. A person’s performance at work or in school can be negatively affected due to a diminished attention span and ability to focus. Shortage of sleep may also result in migraines and tension-type headaches, which cause attention difficulties and affect memory and academic performance.
ven a moderate sleep debt can interfere with a person’s stamina, judgement, coordination, mood and immune system. Over a longer period, a person can be put at risk to a host of lifestyle diseases such as obesity, heart problems and diabetes. A study showed that such individuals
exhibit higher levels of coronary artery calcium, which pre-dispose them to heart attacks. Lack of sleep also causes people to crave either very sweet or salty-greasy food, which are bad for health and lead to obesity. Numerous studies have linked partial sleep deprivation or disruption to decreased longevity
Research has shown that sleepdeprived individuals are more prone to making mistakes. While lack of sleep may affect a person’s mood and relationships, bearing associations to psychiatric conditions, it has also correlated to an increase of transport and industrial accidents at work. In an increasingly connected cosmopolitan world, people are getting less sleep from prioritising work, social needs, studies and commuting. A study of 2,000 students at the National University of Singapore and the Nanyang Technological University found that Singaporeans sleep as little as an average of 6.2 hours a day. While this is a couple of hours shy of the widely recommended seven to eight hours of sleep for adults, pre-schoolers and children require even more sleep, with a recommended duration of 11-13 hours a day.
How do we achieve better sleep quality? Here are some suggestions to help lead the mind into compliance with a healthy sleeping schedule. a) Maintain good sleep hygiene. A regular schedule and routine for sleep will condition your body to become drowsy in preparation for sleep. Getting habituated to a set routine at bedtime works well because it programmes the mind and body to a set of expectations: sleeping at the same time every night, in the same bed with the same routines. Likewise, getting up every day at the same time, even on weekends, will help to reset your biological clock. It may be difficult forcing yourself to sleep at the beginning of the routine, but persisting with the schedule will have you falling asleep with ease throughout the first week. According to a report in the Boston Globe, a study of insomniacs found that those who had successfully established proper sleep routines were able to reduce their sleepless periods (after retiring to bed) by 54%. This percentage is significant, considering that a control group using relaxation therapy only experienced a 16% reduction, while a placebo group only had a 12% reduction. Pre-bedtime routines can add a sense of security and stability to an otherwise stressful and fragmented life. They calm and eliminate stress for the individual, thus facilitating sleep. Try a relaxing activity 30-60
minutes before going to bed. Anything that is relaxing will help you unwind such as dimming the lights, taking a warm bath, practising guided meditation, listening to soothing music or having a cup of herbal tea. b) Sleep at a temperature that is comfortable for you. Lower the temperature of your bedroom before sleep. Cool temperatures make for better sleep because they lower your body temperature and help you achieve deep sleep. An internal clock triggers the body’s temperature. Although the average body temperature for human beings is about 36.9 degrees Celsius, it fluctuates in a regular pattern on a daily basis. Body temperature hits its lows between 3am and 6am, then climbs steadily through the morning before dipping again at around 3pm. The ideal range for a good sleep should be 20-22 degrees Celsius, though this can differ from one person to another. c) Wear socks and mittens to bed. Wearing socks and mittens to bed can also trick the mind and body into getting better sleep. Socks and mittens widen blood vessels in the hands and feet, which are a necessary step in inducing sleep, according in a Swiss study. This dilation of the blood vessels precipitates the cooling of the blood as it flows through the open channels near the surface of the
skin. When body temperatures fall, sleep automatically follows. d) Do not go to bed hungry. Hunger will keep you alert and tense. A bedtime snack containing the amino acid, tryptophan, is best. The body converts tryptophan to sleep-inducing chemicals. Having a small, lean slice of turkey (rich in this amino acid) with a piece of toast is best. Another alternative is an oatmeal cookie with a glass of milk (also rich in tryptophan). Also, this does not mean that one should indulge in a sumptuous supper before bedtime because overeating also disrupts sleep. e) Avoid drinking caffeinated beverages and smoking. Both caffeine and nicotine are stimulants and disrupt your ability to get to sleep. Try not to have any drinks containing caffeine for at least six hours before you go to bed and if you are a smoker, put a ban on smoking cigarettes at night. f) Avoid having mobile phones in the bedroom. If these are in your room, switching them off will give you a better night’s rest. Many people who own smartphones use them as alarm clocks, making it all too easy to check emails one last time before falling asleep. This makes it
difficult to ever feel unplugged from work and social networks. The itch to check in at all hours of the night or wake up to the sound of a text message disrupts our sleep.
alert during the day. However, the production of this hormone increases during the night, allowing us to feel relaxed and drowsy. Getting two hours of sunlight during the day will ensure that the natural waking and sleeping cycles of the body are maintained.
While there is no scientific evidence that the wavelengths emitted by electronics affects sleep, shutting mobile phones off removes the subtle stress of needing to be responsive and connected. This, in turn, will help you achieve more restful sleep. g) Get up and do something if you cannot fall asleep. If you are still awake 30 minutes after retiring to bed, get up and read a book, preferably one that you know is difficult to read. Research shows that the longer you lie awake in bed, the less likely you will have a night of uninterrupted sleep. It is far better to get up and do something
else until you feel sleepy. Try to be in a different part of the bedroom or in a different room. Return to bed only when you feel sleepy and do this as many times during the night as needed. This conditions the body to sleep when you eventually fall into bed.
Focusing on staying awake rather than trying to fall asleep can also do the trick. In what is known as â€œparadoxical intentionâ€?, the mind that focuses on being awake will relax sooner than the mind struggling to fall asleep. h) Get sufficient sunlight each day. Getting at least one to two hours of sunlight each day can also help a person get better sleep. Research suggests that getting enough sunlight keeps our biological clocks on track. The hypothalamus controls basic functions such as food intake and body temperature. It is influenced by light, which regulates the secretion of melatonin, a hormone that controls the circadian rhythm of our body (when we sleep and when we stay alert). During the day, sunlight slows the production of melatonin, which is a reason why we feel so
i) Exercise to sleep better. People in good shape tend to have better sleep. Numerous studies have described the links between exercise and mental health benefits such as reductions in depression and anxiety and improvements in self-esteem. Many of our bodily functions depend on physical movement to work properly, but regular exercise also raises cortisol levels, which are responsible for keeping us awake. Exercising early in the morning when cortisol levels should be elevated or mid-afternoon well before bedtime, will make sure that they are returned to low levels by the time you go to bed. Try separating your training routine from your bedtime routine by at least three hours. j) Do not engage in vigorous exercise just before going to bed. Engaging in stimulating activities just before bed increases your state of arousal and puts the body in a sympathetic tone (fight or flight state). This makes it difficult to wind down and sleep. k) Create a good environment conducive for sleeping. Sleeping in total darkness is great for improving the quality of your sleep. Make sure your bedroom is dark, cool
and well-ventilated. Use blackout blinds, turn off or remove all lightemitting diode (LED) lamps and alarm clocks and TVs from the bedroom and reduce any ambient light. l) Read before bedtime. Watching TV or working on a laptop before bedtime will increase your exposure to blue light and suppress your melatonin production. Reading is a relaxing activity, which can also be tiring. Sitting in front of a TV is generally more passive and overly stimulating.
The Department of Otorhinolaryngology (Ear, Nose and Throat) at Tan Tock Seng Hospital has a Sleep Clinic that provides holistic solutions for patients with obstructive sleep apnoea problems. The Sleep Clinic has a multidisciplinary team including the ENT surgeon, respiratory physician, dietitians, physiotherapists, bariatric surgeons and prosthodontist. For more information on the Sleep Clinic, please contact Clinic 1B at 6357 8384 (GP) / 6357 8007 (Enquiry).
m) Melatonin is the primary sleep hormone. We generally produce it in the pineal gland and it is produced as we prepare for sleep. However, modern day life comes in the way of this production. In addition, some occupations such as shift-based workers or cabin crew/plane pilots are more prone to erratic sleep patterns. In some instances, melatonin supplements can help. Low doses of about 3mg before bed have been shown to work fine. If you still have difficulty falling and staying asleep, make sure you see a physician because insomnia can be triggered by physiological conditions such as sleep apnoea, menopause or depression. Some drugs that can disturb sleep include antidepressants, beta-blockers, diuretics and painkillers. Some of these patients may benefit from onward referrals to specialised sleep disorder clinics based in hospitals.
Dr Chong Yaw Khian Dr Chong Yaw Khian is a Consultant with the Department of Otorhinolaryngology at Tan Tock Seng Hospital (TTSH). He currently runs the Snoring and Sleep Apnoea Clinic at TTSH and his main clinical interests are in otology and sleep disorders.
ON YOUR BACK WITH ARMS RESTED UPWARDS This so-called â€œstarfishâ€? position is also good for the back. Whether you have your arms up around your pillow or not, sleeping on your back may also help to prevent facial wrinkles and skin breakouts. However, like the arms-down back sleeping position, this one can also result in snoring and problems with acid reflux. Plus, having your arms up can place unnecessary pressure on nerves in your shoulders, causing pain and discomfort.
Sleeping Positions and Their Effects On Your Health Have you ever considered the importance of your sleeping posture? You may or may not have a preference, but your sleeping position can directly affect your health. While the best sleeping posture is generally considered to be sleeping on your back with your arms by your sides, here are eight common sleeping positions and their effects to help you discover how the way you sleep affects your well-being.
Sources: http://dailyhealthpost.com/8-sleeping-positions-and-their-effects-on-health/ http://www.webmd.com/sleep-disorders/features/sleep-position-and-sleep-quality http://americanpregnancy.org/pregnancyhealth/sleepingpositions.html http://www.huffingtonpost.com/2011/04/24/best-sleep-positions_n_852787.html http://www.menshealth.com/health/sleep-position-master http://www.mayoclinic.com/health/sleeping-positions/LB00003_D&slide=3
ON YOUR BACK WITH ARMS AT SIDES Sleeping on your back with your arms to the side is generally considered to be the best sleeping position for spine health and your neck, so long as you do not use too many pillows. That said, back sleepers tend to snore more than those in other positions and may be more prone to sleep apnoea.
ON YOUR SIDE WITH ARMS OUT
Sleeping curled up into a ball with your knees drawn in to your chest and your chin tilted down may be comfortable, but it can strain your back and neck.
FACE DOWN Sleeping on your stomach can improve digestion, but unless you have developed a way to breathe through your pillow, it most likely leads to you tilting your face in one direction or the other. This can put a lot of strain on your neck. Sleeping face down can also cause back pain, since the curve of the spine is unsupported.
PILLOWSUPPLEMENTED Regardless of which sleeping position you prefer, it is highly likely that you can get a better nightâ€™s rest with less pain in the morning by supplementing your body with a pillow.
This position has many of the same benefits as sleeping on your side with your arms positioned straight down. However, any side-sleeping can cause shoulder and arm discomfort due to restricted blood flow and pressure on the nerves, which may be exacerbated by having your arms out in front of you.
The extreme curl of the foetal position can also restrict deep breathing. That considered, sleeping in a foetal position could have you sleeping like a baby if you experience problems with snoring or if you are pregnant.
ON YOUR SIDE WITH ARMS AT SIDES When you sleep on your side with both arms down, the spine is best supported in its natural curve. This can definitely help reduce back and neck pain, while also reducing the risk of sleep apnoea. The downside is that sleeping on the side can contribute to skin ageing due to gravity, meaning facial wrinkles and sagging breasts.
Back-sleepers can put a small pillow under the arch of their spine, side-sleepers can place a pillow between their knees and stomach-sleepers can place a pillow under their hips to support the joints to allow for full, pain-free relaxation.
ON THE RIGHT SIDE If you are a side-sleeper, the side you sleep on also makes a difference. Sleeping on the right side can worsen heartburn, while sleeping on the left side can put strain on internal organs like the liver, lungs and stomach (although minimising acid reflux). For pregnant women, doctors typically advise sleeping on the left side, since this can improve circulation to the foetus.
Eat Right, Sleep Tight Drive away insomnia with the right food
What you eat may potentially affect how you sleep. To get a good night’s rest, it is important to eat food that relaxes your mind and body, rather than food that may cause discomfort or stimulate your senses.
Why is good sleep important? In Singapore, a recent study showed that one in three people are sleep-deprived, which, in turn, badly affects health. Quality of sleep has a huge impact on daily life as being sleep-deprived can affect a person’s productivity and concentration at work. It also affects emotional well-being, potentially causing irritability and moodiness. Numerous studies have found a relationship between the quantity and quality of sleep and various health problems such as the increased risk of diabetes, high blood pressure, heart disease, obesity and depression. Other studies also indicate that dietary factors can play a part in getting a good night’s rest. Did you know that consuming certain foods can help promote rest and relaxation?
How can we improve sleep with the right food?
Do not consume excessive alcohol.
Small amounts of alcohol can help you fall asleep, but drinking too much can cause insomnia. Having too much alcohol can suppress the rapid eye movement (REM) sleep state that is essential for a good night’s rest. Alcohol is also dehydrating and may leave you feeling thirst, which can disrupt your sleep.
Watch your caffeine intake.
Beverages or foods that contain caffeine (e.g. chocolates, coffee and soft drinks) can affect sleep. Caffeine is a stimulant that affects people, depending on the amount consumed. If you are sensitive to caffeine, reduce your intake or limit consumption to mornings only.
Avoid eating high-fat content and heavy, large meals at night.
Consuming a heavy meal in the evening or right before bedtime may cause indigestion and heartburn, which can disrupt sleep since the meal is more difficult to break down and will take a longer time to digest. Similarly, lying down on a full stomach can also cause indigestion and heartburn. It is recommended to consume any meals at least three hours before going to bed.
UP ALL NIGHT Sleeping is a daily affair. However, falling asleep can be challenging at times. Studies have shown that sleep deprivation can affect mental well-being. Learn how you can make your way to slumberland with greater ease and pave the way to better mental health.
Try drinking milk.
Drinking a glass of milk before bed may help you relax. Dairy products contain tryptophan, an essential amino acid, which helps in the production of sleep-inducing brain chemicals such as serotonin and melatonin. Dairy products also contain calcium, which helps the brain use the tryptophan to manufacture melatonin. It is important to note that these may not be suitable for individuals who may be lactose intolerant.
Take a light snack.
Hunger in the middle of the night may interfere with sleep. To avoid hunger, a light snack such as a glass of milk, some biscuits or a piece of fruit could be eaten before bedtime to promote sleep.
Try drinking herbal tea.
A common way of helping with sleep is to have a cup of tea. Teas such as chamomile, passion flower and valerian may potentially have a sedative effect.
Do not drink too much fluids before bedtime.
Try to avoid drinking too much fluids too close to bedtime, so as to reduce the need to go to the bathroom during the night, especially for individuals with urinary incontinence.
andy Gardner underwent an experiment by not sleeping for 11 days (264 hours) in 1964. During his experience, Gardner was noted to exhibit behavioural and concentration problems, leading to moodiness, memory loss and hallucination. Although he recovered after sleeping for a few good nights, he had proven that sleep deprivation can be dangerous to a person’s health.
Ms Ong Yawei Ms Ong Yawei is a Senior Dietitian at Tan Tock Seng Hospital. She completed her Master of Dietetics at Deakin University in Melbourne, Australia. She specialises in nutritional management of surgical patients and individuals with gastrointestinal diseases.
Though we would unlikely put ourselves through such an ordeal, we may still be unintentionally depriving ourselves of sufficient sleep. In the long run, we could experience difficulties in memory, concentration and alertness, thus increasing our risk in work-related and road traffic injuries. Sleep deprivation has also been proven to be the cause of several varieties of medical illnesses. Our sleep can be affected by factors like our environment, diet and stress from daily life. Stress can affect us emotionally and physically.
The right amount of stress can push us to excel. However, too much stress can definitely disrupt the quality of our sleep. Here are some tips to help ease your stress for a better night’s sleep: 1. Create a conducive sleeping environment. A quiet, dark and cooling environment can help promote good quality sleep. Of course, let’s not forget the importance of having a comfortable mattress and pillow. 2. What happens at work, stays at work. Everyone needs a balance between work and their personal life. It is never healthy to live a life that revolves only around your job. Thinking about work before sleep can keep your mind active and stimulated, which, in turn, can prevent you from falling asleep.
3. Identify your stress. Of course, not all problems have a solution or can be solved immediately. However, by knowing what causes you stress, you are more likely to be able to find a remedy. As for problems that do not have any immediate solutions, it is probably not a bad idea to keep an optimistic perspective and learn to let go of them. 4. Make sleep a priority. When it is time for sleep, it is time to sleep. Sleep should not be compromised simply because you have uncompleted tasks.
5. Stop being a clockwatcher. It can be stressful when you are unable to fall asleep at night. However, staring at the clock and checking the time repeatedly at night only increase your stress and anxiety. If you are feeling anxious and have difficulty falling asleep, try getting out of bed and doing something relaxing such as listening to music that soothes you. Return to bed only when you are feeling calm and sleepy. 6. Seek professional help. Prolonged sleep deprivation can affect our daily functions. If you find yourself struggling with your daily routine due to poor quality of sleep or a prolonged lack of sleep, do consider seeking out professional help from your general practitioner. 7. Relaxation techniques. a. Breathing Exercises Deep breathing is one of the most common relaxation techniques that can be practised not just before sleep, but at any time, wherever you are. b. Guided Imagery Select a place that you identify with peace and serenity. Visualise yourself being there. To gain the most out of the experience, include sensory details such as the smells, sounds, sight and feel of the place in your visualisation.
c. Progressive Muscle Relaxation This technique helps you to relax and eases tension in various parts of your body that are tense from stress. d. Aromatherapy This can be considered a passive stress-relieving technique as you can continue with your regular activities with aromatherapy. However, if you are applying this technique before sleep, try focusing your attention on the aroma, allowing the scent to soothe you to sleep. Sleep may seem natural and effortless at times. However, due to hectic schedules and the stress of everyday life, we may be unintentionally depriving ourselves of precious sleep, which allows our bodies to repair and rejuvenate. It may seem forgiveable to forego an extra hour of sleep for your priorities, but the reality is such that you may be harming yourself in the long run by being deprived of good sleep.
Ms Lanurse Chen Ms Lanurse Chen is a Senior Psychologist at 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.
GERD: The Burning Issue Gastro-oesophageal reflux disease (GERD) is a discomforting condition encountered by many. Besides treating the symptoms, it is important to know the extent of injury due to acid reflux and exclude a premalignant condition known as Barrettâ€™s oesophagus at the distal gullet. Treatment ranges from using simple antacids to surgery, depending on the extent and severity of the condition. Oesophageal cancer surveillance is also recommended for patients with Barrettâ€™s oesophagus.
What is GERD? Gastro-oesophageal reflux disease (GERD) is a highly prevalent gastrointestinal (GI) disorder and is one of the most common GI conditions encountered in our clinical practice. GERD refers to a combination of signs and symptoms resulting from the reflux of stomach and duodenal contents into the gullet, also known as the oesophagus. These symptoms may be severe in nature and may occur frequently enough to negatively impact a patient’s quality of life. Patients with GERD frequently experience interrupted sleep at night. Their performance at work and social life may also be affected.
▪ Heartburn and regurgitation,
where a hot, burning sensation in the chest or throat is usually experienced and corresponds mainly to the amount of gastric content being propelled upwards from the stomach into the oesophagus, which induces local inflammation.
▪ Sour taste and throat discomfort. ▪ Although a majority of patients
experience all of the above symptoms, others may have unusual presentations including angina-like chest pains or airway-related problems such as asthma.
Besides these disturbing symptoms, one major concern is the presence of oesophageal erosions caused by gastric acid. The other worry is the development of a pre-malignant condition at the distal oesophagus, known as Barrett’s oesophagus, associated with the acid reflux in patients suffering from GERD. The main reason for gastric contents returning to the oesophagus may be related to either an incompetent valve at the distal oesophagus, known as the lower oesophageal sphincter or an abnormal relaxation of this valve. The resultant two-way movement of food content, coupled with any increase in the intra-abdominal pressure due to various conditions, may result in a significant amount of gastric acid gushing back into the oesophagus. Depending on the frequency and extent of this regurgitation, oesophageal injuries of varying degrees may occur.
Diagnosis To diagnose GERD, the most practical way is a thorough and accurate review of the patient’s history. Typical symptoms of heartburn or regurgitation will provide the basis for diagnosis in most cases. In the absence of these symptoms, a short course of acid suppression treatment with proton pump inhibitors (PPIs) may be employed as a strategy to aid in the diagnosis. In more difficult cases, more elaborate investigations including
This is usually performed at intervals of two to three years, depending on the clinical and preceding histological findings. In the event of early malignant transformation, endoscopic therapy or surgery may be required as part of the definitive treatment.
a 24-hour pH and impedance study may be required to confirm acidic or weakly-acidic reflux. Besides arriving at the diagnosis, one frequent challenge faced in the management of GERD is to estimate the extent of oesophageal injury. This information is crucial in deciding the long-term management plan. Unfortunately, the magnitude and duration of symptoms do not necessarily correlate well with the actual physical injury in the oesophagus. Patients with more severe symptoms may have minimal or no oesophageal injury, while others with mild or minimal symptoms may suffer from severe oesophageal erosions. The other challenge is to have an effective way to filter out cases that exhibit a higher risk of developing lower oesophageal cancer due to Barrett’s oesophagus.
Upper Gastrointestinal Tract Endoscopy (Gastroscopy) Through a simple and quick procedure like upper gastrointestinal tract endoscopy (gastroscopy or OGD), physicians can directly inspect the oesophagus and stomach to determine the extent of injury due to acid reflux. Gastroscopy involves inserting a flexible video endoscope through a patient’s mouth and oesophagus into the stomach under direct
Tan Tock Seng Hospital (TTSH) offers one-stop direct access endoscopy every Wednesday. For more information on direct access endoscopy, please contact Endoscopy Centre at 9720 8601 (Mon - Fri: 8.30am - 5.30pm).
vision. This procedure can be completed within 10-15 minutes with minimal risk or discomfort. Light sedation may be given before the procedure, although it may not be necessary. With the gastroscope being flexible and steerable, the physician is able to inspect the oesophagus, stomach and the first two segments of the duodenum in a single setting. Tissue samples can also be taken via the working channel of the scope for histological analysis when necessary. This allows the extent of injury and the presence of Barrett’s oesophagus to be confirmed to guide the subsequent management and surveillance strategy.
Treatment The goals in the treatment of GERD are to relieve recurring symptoms
and prevent any serious complications. Simple measures including lifestyle modifications such as raising the head of the bed when sleeping and over-the-counter medication like antacids may help. In established cases, on-demand PPI treatment driven by patients’ symptoms may be one of the common strategies employed by healthcare professionals. In more advanced cases, long-term medicine or even surgery may be required to alleviate symptoms and prevent further complications. It is not uncommon for patients with GERD to undergo repeated upper endoscopy at regular intervals, to look for any malignant tissue transformation from Barrett’s oesophagus.
Dr Quan Wai Leong Dr Quan Wai Leong is a Consultant in the Department of Gastroenterology and Hepatology and the Director of the Endoscopy Centre at Tan Tock Seng Hospital. His areas of interest include endoscopic retrograde cholangiopancreatography (ERCP), spyglass cholangioscopy, endoscopic mucosal resection (EMR), enteral stenting, double-balloon enteroscopy (DBE) and video capsule endoscopy (VCE).
Breathe Easier, Look Better
and celebrities, she feels the pressure to look good. She is keen to improve her breathing and is also concerned about how septorhinoplasty can help her look better. Septorhinoplasty can be performed to: • correct nasal septal deviation • straighten the bridge of the nose • increase or reduce the height of the tip of the nose • reduce a bony or cartilaginous hump • narrow the nostrils • refine the tip of the nose After a thorough consultation and analysis of the facial and nasal structures, the surgeon will determine the areas of deformity, the cartilaginous support of the
Nasal obstruction is a common complaint of many patients in the primary care sector. While most cases can be treated with medications such as antihistamines or nasal sprays, some patients require special attention, especially those who have a ’crooked’ nose and underlying nasal septal deviation. In this article, we explore a case study of the surgical options available for a patient with a blocked nose.
ennifer (not her real name) is a young, fit office worker who has a stable job and enjoys cycling during weekends. She has symptoms of runny and blocked nose on most days of the week and finds no alleviation of her symptoms, despite the regular use of nasal steroids. She has always noticed that her nose looked ‘crooked’. Upon diagnosis, Jennifer has both allergic rhinitis (AR) as well as nasal septal deviation, which are very common conditions. Approximately 10-20% of the global population suffers from AR. Studies have found that the prevalence of deviated nasal septum (DNS) ranges from 20% in children to 90% in adults.
Most patients with AR and DNS can be managed successfully with nasal steroids, oral or topical decongestants. However, there are a significant number of patients like Jennifer who need surgical intervention, as they have a significant septal deformity or may have other associated problems such as inferior turbinate hypertrophy or nasal polyps. As with all young people, Jennifer is very tech savvy and familiar with beauty trends via social media avenues such as blogsites and Instagram. Like most young adults inundated with pictures of friends
patient’s nose as well as aesthetic ideals. To achieve the cosmetic and functional goals, grafts are often needed to provide structural support and augmentation. The grafts can be harvested from the nasal septum, ear cartilage or rib cartilage. Allogenic grafts and alloplastic implants can also be used. The surgeon will discuss the choice of using grafts or implants with the patient extensively before a decision is made. With more otolaryngologists trained in facial plastic surgery in Singapore and various parts of the world, more patients can look forward to achieving their functional and aesthetic goals.
Deviated nasal septum (DNS)
Septoplasty or Septorhinoplasty • Septoplasty is a surgical procedure that is done to correct DNS, without changing the external appearance of the nose. • Septorhinoplasty corrects DNS and can also alter the framework of the nose, thereby improving the appearance of the patient. It can either be functional or cosmetic.
Inferior turbinate hypertrophy
Turbinate reduction procedures or partial excision
Medical treatment with oral/topical steroids or functional endoscopic sinus surgery
Dr Valerie Su-Lin Tay Dr Valerie Su-Lin Tay is an Associate Consultant in the Department of Otorhinolaryngology at Tan Tock Seng Hospital. She completed her undergraduate studies and otorhinolaryngology training in Singapore. To pursue her interests in facial plastic surgery, she completed a one-year fellowship in Navi Plastic Surgery Clinic, a high volume cosmetic surgery clinic in Seoul. She has experience with fillers, endonasal rhinoplasty, blepharoplasty as well as facial bone surgery.
Lacrimal Drainage Obstruction Causes Wet Eyes Too
punctum (Figure 2). Treatment for this is surgical excision and possibly canalicularnasolacrimal duct stenting with a Crawford tube.
Canalicular Problems Infection of the canaliculus (canaliculitis) results in a localised area of erythema with only very mild infero-nasal swelling and tenderness to the lower punctum. It is most commonly idiopathic in etiology and results in characteristic sulphur granule formation by Gram-positive Acinetobacter or the Nocardia species of bacteria.
Epiphora or chronically wet, irritated eyes is most commonly caused by infection, atopy or lid-lash abnormality and frequently associated with dry eyes. This counter-intuitive reason is related to reflex lacrimation from a disruption of the tear surface due to a deficiency of one or more of the components of the tears.
ccasionally, there could be other less common causes for these symptoms, including the obstruction of the lacrimal drainage system. The pathology may occur at different levels; involving the lacrimal punctum (obstruction, stenosis, ectropion), canaliculus (foreign body, infection, stricture) or naso-lacrimal duct. Unfortunately, most of these conditions are not easily managed outside of a specialist setting, since they commonly require some form of surgical
procedure. However, early recognition by the family physician or general ophthalmologist will facilitate the initiation of appropriate therapy.
Punctal Problems Punctal pathology such as stenosis (Figure 1) or occlusion is recognised as a reduction in the size of the punctal aperture. A minor surgical procedure such as a simple two-snip or three-snip procedure can reverse the occlusion and enable the further examination of the
distal canaliculus. Presence of an epithelial-lined canalicular cyst usually implies distal occlusion of the canaliculus, with accumulation within the lumen of mucin produced by goblet cells. Treatment for
Figure 1: Punctal stenosis.
aesthetic reasons requires excision of the cyst and the sacrificing of the involved canaliculus. Epiphora can also result from the malpositioning of the punctum such as in cases of lower lid ectropion, where the punctum is separated from the tear lake. In these cases, punctal reappositioning to the globe can be achieved with a lid-tightening procedure with inverting sutures. Tumours such as compound naevi may also involve the
Treatment requires mechanical removal of the sulphur granules with a micro-curette and instillation of appropriate antibiotics. Not infrequently, a cause of obstruction should be sought as retained punctal plugs may cause mechanical obstruction and predisposition to canaliculitis.
NasoLacrimal Duct Problems Nasolacrimal duct obstructions can be recognised when fluorescein dye is retained for longer periods in the tear lake. The obstruction leads to accumulation of tears and mucus in the nasolacrimal sac and when this occurs, application of pressure over the medial canthal region may result in retrograde passage of tears and mucus through the lower punctum.
Syringing of the canalicular system will show reflux of irrigating fluid through the opposite paired canaliculus. The chronic tear stasis will predispose to lacrimal sac infection (dacryocystitis) (Figure 3) with localised swelling, tenderness and erythema at the infero-nasal quadrant of the eye. Treatment is with systemic antibiotics and possibly percutaneous drainage and/or emergent dacryo-cystorhinostomy.
Figure 2: Compound naevus involving the punctum.
Figure 3: Dacryocystitis.
Dr Goh E-Shawn Dr Goh E-Shawn is a Consultant with National Healthcare Group Eye Institute at Tan Tock Seng Hospital and a member of the Oculoplastics Service. After completing his fellowship at the Mayo Clinic, Rochester, Minnesota, USA, he returned with an interest in surgery, orbital tumours and oculofacial plastic surgery for orbital tumours and oculofacial plastic surgery. He has been invited regionally and internationally to participate in meetings on these topics.
Exercise and Sleep: Snoozing till the Sun Comes Up Sleeping disorders are increasingly common in modern societies, with 10-50% of the adult population being affected globally. Sleep loss and disturbances negatively influence well-being and health, potentially causing daytime sleepiness as well as affecting moods and mental abilities. Long-term sleeping problems are also associated with illnesses such as cardiovascular diseases, obesity and depression. Individuals with high levels of fitness tend to report better quality of sleep and have less problems falling asleep. Regular aerobic exercises and stretching are simple and effective strategies to get a good nightâ€™s sleep, although it is important to exercise at the correct intensity and time of day.
Why is sleep important?
Sleep occupies approximately one-third of your life and thus plays a correspondingly important role in maintaining health and function. During sleep, your body recovers energy from the day’s activities and allows the mind to consolidate important memories.
also make you more irritable and prone to depression, diminished memory and learning abilities. Moreover, when you are tired and sleepy from a poor night’s sleep, you are more likely to make mistakes at work during the day, which could increase the risk of hurting yourself accidentally.
Inadequate or disturbed sleep will not only result in increased fatigue and sleepiness during the day, but
Prolonged periods of poor sleep patterns can also affect your immune system and have been
associated with illnesses such as cardiovascular diseases, type 2 diabetes, obesity, anxiety disorders and depression. Besides having a regular diet and exercise, getting good quality sleep is just as important for maintaining good health.
Who are affected by sleeping disorders? Although there are no official figures, it is estimated that there may be around 800,000 Singaporeans suffering from sleeping disorders, with women and older adults being more at risk. This figure has increased steadily over the years and is comparable to other countries. As Singapore’s population continues to age, the proportion of people affected by sleeping disorders will likely grow.
What can you do to improve sleep quality? Although drugs and medication can help improve the quality of sleep, long-term use can lead to drug dependence and drug tolerance may require higher doses to be effective. People who exercise regularly and are physically fit fall asleep faster, experience sounder sleep and feel more refreshed upon waking up. They also experience less daytime sleepiness, depression and enjoy improved quality of life. Simple and inexpensive, exercise can help people who struggle with sleeping disorders.
There are three reasons why exercise may help improve your sleep quality. Exercise can stabilise the body’s internal clock and reduce daytime sleepiness, thus helping the body maintain uninterrupted sleep at night. Studies have shown that highintensity exercises increase the amount of the sleep-promoting substance, adenosine, in the body. Lastly, exercise also helps to ease anxiety and stress – important factors that may disturb sleep.
Types of exercises that can help improve sleep quality When done at moderate intensity (60-75% of maximum heart rate*), aerobic exercises such as jogging, stationary cycling or treadmill walking have been found to be beneficial for improving sleep quality. The exercises should be done for 35-45 minutes per session, at least four times a week. You may need about four to six weeks to get used to the exercise, so it is advisable to start at 15-20 minutes for the first two weeks, at 55-65% of your maximum heart rate and slowly build up your endurance to the recommended intensity. The timing of the exercise also plays a role in affecting sleep quality. Studies found that morning exercisers who did aerobic exercises for at least 225 minutes (five 45-minute sessions) a week
had less trouble falling asleep, as compared to others who exercised for less than 180 minutes (four 45-minute sessions) a week. However, this trend of improving sleep quality through increasing amounts of exercise was not noted in people who exercised in the evening or at night. Exercising in the evening or at night before sleep is not an uncommon practice as most people believe physical fatigue is equivalent to sleepiness. Although this may not be entirely correct (you can feel tired, but not sleepy after a vigorous sprint), there may be a reason why some people report sleeping better and feeling more refreshed after exercising late at night. During deep sleep, the body’s core temperature will decrease rapidly. This phenomenon may be mimicked when the heated body cools down after exercising, tricking the body to slip into sleep easily. Although late-night exercise does not seem to affect the quality of sleep significantly, the body’s heart rate can remain elevated during sleep for up to three hours. This reduces time for the heart rate and blood pressure to decrease. However, it is important to note that chronically elevated blood pressure may produce wear and tear on the cardiovascular system. Rather than exercising vigorously at night, studies have found that
15-30 minutes of low-intensity stretching of the upper and lower body can also improve sleep quality. Stretching helps reduce muscle stiffness and helps the body to relax and prepare for sleep.
Conclusion Sleeping disorders can be frustrating, but when done correctly, regular aerobic and stretching exercises are simple yet powerful remedies to help manage them. * Maximum heart rate = 220 - age
Mr Chen Yanzhang Mr Chen Yanzhang is a Physiotherapist at the Musculoskeletal Outpatient Department at Tan Tock Seng Hospital. He graduated from Curtin University with a Bachelor of Science (Physiotherapy) in 2009. He has a special interest in exercise and strength training for the elderly.
References • Reid KJ et al (2010). Aerobic exercise improves selfreported sleep and quality of life in older adults with insomnia. Sleep Medicine. 11(9): 934-940. • Myllymaki T et al (2011). Effects of vigorous late-night exercise on sleep quality and cardiac autonomic activity. Journal of Sleep Research. 20: 146-153. • Tworoger SS et al (2003). Effects of a year-long moderate intensity exercise and stretching intervention on sleep quality in postmenopausal women. SLEEP. 26(7): 830-836. • Youngstedt SD and Kline CE (2006). Epidemiology of exercise and sleep. Sleep and Biological Rhythms. 4: 215-221.
Ingredients Poria (茯苓) 15g Codonopsis (党参) 20g Atractylodes rhizome (白术) 15g Lotus seeds (莲子) 30g Lily bulb (百合) 30g Chinese yam (山药) 30g Fox nuts (芡实) 30g Job’s tears (Chinese barley) 15g (中国薏米) Lean meat, minced 250g Rice grains 2 cups Clean water 3l
Methods 1. Rinse the rice grains, lotus seeds, lily bulb, fox nuts, Chinese yam and Job’s tears and soak them in water for an hour.
Eight Treasures Meat Congee Health Benefit The Eight Treasures Meat Congee (porridge) contains ingredients that help strengthen digestive functions, dispel dampness to clear muscle fatigue and nourish the heart to calm the spirit. Using codonopsis, atractylodes rhizome, poria, Chinese yam, lotus seeds, lily bulb, fox nuts and Job’s tears, it is particularly beneficial for people with weak constitution, who feel easily tired and have poor bowel movement. For flavour, the addition of minced lean meat to the congee makes for an exceptionally savoury meal.
Palliative care is an approach that focuses on improving the quality of life of patients and families suffering from life-limiting illnesses by providing relief from physical, emotional and spiritual suffering. It is now recognised as a specialty and has become an integral part of good patient care in the continuum of cancer and chronic illnesses. The provision of good palliative care requires both sound clinical knowledge and compassion. The authors of ‘The Bedside Palliative Medicine Handbook’ have taken great pains to provide the readers with a clear, succinct and practical guide to palliative care, which will be useful to all medical practitioners by the patient’s bedside.
2. Rinse the codonopsis, atractylodes and poria with water and put them into a Soilon tea bag. Seal the bag tightly around the opening using a string. Place the sealed bag into a pot and add 3 litres of water. Boil for 30 minutes. 3. Add the soaked rice grains, lotus seeds, fox nuts, Chinese yam and Job’s tears to cook for an hour. Remove the Soilon bag and add the lean meat to cook for another 15 minutes. 4. Add seasoning according to preferred taste and the congee is ready to be served. 5. Congee thickness can be adjusted by adding more or less water, according to personal preference.
Contraindication Not suitable for people with gastroenteritis and people suffering from a flu or fever.
The Bedside Palliative Medicine Handbook
Recipe was designed by Tan Tock Seng Hospital’s Complementary Integrative Medicine Clinic.
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Uncover the goodness of eight Chinese herbs through 18 delicious and easy-toprepare recipes, gathered by Tan Tock Seng Hospital’s Complementary Integrative Medicine Clinic! Herbs for Health, Food for Life includes a collection of appetisers, beverages, main courses, side dishes and desserts. Gain exclusive insights on how to integrate more than 2,000 years of Traditional Chinese Medicinal wellness knowledge into your daily diet and achieve the wellness and good health you desire. This bilingual cookbook is now available for sale at Clinic 6B (Level 6 Medical Centre) and at the Health Enrichment Centre (Level 1). For enquiries on the purchase of the book, please email Clinic6B@ttsh.com.sg.