Tuesday, December 19, 2006

So how do I lower my cholesterol levels?

"Ok Doc, so you tell me that LDL is BAD and HDL is GOOD. How do I lower my LDL levels and increase my HDL levels?"

Why do you have high cholesterol in the first place?

I had a 43 year old male patient this week who was sooooooo happy to find that his cholesterol levels are so good even though, he claims that he eats really unhealthy hawker food and never excercises! Then I had this 42 year old female patient who is very strict about her diet, eats rolled oats every morning, takes cholesterol lowering medications, excercises regularly and yet has a high cholesterol level.

What does this tell us? It tells us that having a cholesterol problem is not solely based on what you eat and whether you excercise. If you have a cholesterol problem, it is because your liver is not able to regulate the cholesterol levels well. Your liver actually makes cholesterol for the your body's needs. It is a neccessary ingredient for buiding and repairing body tissues. Now if your liver somehow does not get rid of the bad cholesterol quick enough then cholesterol levels in the blood rises leading to problems.

So, for those unlucky enough to have a high cholesterol problem, you need to help your liver regulate cholesterol by eating less cholesterol rich foods. About 60% of all the cholesterol circulating in your body is made by the liver and 40% comes from what you eat. So by controlling your intake of cholesterol rich food, you can significantly influence your cholesterol levels.

You are what you eat!!

There are actually two different classes of food. One you should avoid and one you should eat more of.

Ones you try to eat less

These are the food that are high in Saturated Fats. In general, cholesterol comes only from animal fats but it is also necessary to reduce Saturated fats from plant souces as well.
The list is very long, but I just give you some categories to remember:

  • Egg yolks (white is ok)
  • Milk products like soft cheeses, butter and cream
  • Meats - Any fatty meat is bad, Sio Bak, Lard, Sausages, Luncheon meat, chicken skin etc
  • Organs - Kway Chap, Foie Gras, Chicken livers etc
  • Deep fried Stuff - Chips, Fries, KFC etc
  • Nuts that have lots of oil, like macademia and cashews
  • Coconut cream!! All the yummy lemak stuff
  • Dressings- all the creamy ones like mayonnaise and thousand island
  • Seafoods - Cavier, fish roe, Crab roe (hairy crab), Prawns.
  • Snacks, Desserts, Pastries, Ice Cream

Ones you eat more because they help lower Cholesterol levels

  • Oatmeal contains soluble fibres which help lower LDL (Good old Quaker Oats)
  • Walnuts and Almonds
  • Omega 3 fatty acids: There are 2 main sources. Fish such as Mackeral, Tuna, Trout and Salmon and plant sources such as Flaxseed, Walnut, Soybean oil and Canola oil

Contrary to popular belief, soybeans have not been shown to actually lower cholesterol levels

More info can be found here

When do I need to take medications?

Different strokes (pardon the pun) for different folks!! It all depends on your risk factors and how high you cholesterol is. We usually advise patients to try dieting first and if that doesn't bring the cholesterol down to an acceptable level then medications are started.


In this blog, we discussed about how to lower your LDL cholesterol, which is essentially through diet control. In my next blog, we will talk about how to raise your HDL levels. Remember that the old adage is true, you are what you eat!

Monday, December 18, 2006

How to read that Cholesterol Report

One of our readers wrote:

Dr, I love food, but my last cholesterol report showed that my cholesterol level is 324. Should I be concerned?

Why bother about cholesterol levels?

Think of your arteries as the piping of your kitchen sink and cholesterol as the oils that you flush down the sink everyday. If you ever have the privilege of opening up the pipe, you will get a dark sticky layer of gunk coating the inside of the pipe. This is similar to what cholesterol does to your arteries. Prolonged elevation of cholesterol will lead to narrowing of the arteries. If the arteries to the heart are blocked, you get a heart attack. If the arteries to the brain are blocked, you get a stroke.

How to read that Cholesterol Report

This is what a typical Cholesterol Report looks like. Let me highlight to you what is important.


This is related to having too many calories in the diet. Calories from sugar and other carbohydrates like rice, cakes, pasta etc are converted to Triglycerides to be stored in the body.
While the link between Triglycerides and Heart Disease is not has strong as with Cholesterol, it should not be allowed to get too high as it may lead to other problems such as pancreatitis and diabetes mellitus.

What to do?

Lose weight, cut down on sweets, soft drinks and alcoholic drinks, esp Beer. Omega 3 fish oils may be of benefit. If your Triglyceride levels are very high, (>400) the Doctor may prescribe some medications to lower it.

Total Cholesterol

People always tend to look at this but usually we don't use this number to determine if you need to take medications. That is because the Total Cholesterol is made up of the LDL and the HDL, so if your LDL is low but HDL is high, you might have a high Total Cholesterol level, but it may not necessarily be bad since it is good for the HDL to be high.

HDL Cholesterol

This is what we call "Good Cholesterol". The higher the better. Less than 40 is no good. Excercise can help raise HDB Cholesterol levels.

LDL Cholesterol

This is the one that we look at to determine if you need medications. Your target LDL level depends on you and the number of risk factors you have for developing heart disease. So for example, a 60 year old man who is obese, smokes has high blood pressure and diabetes will require his LDL levels to be <100. style="font-weight: bold;">The bottomline is that the LDL levels need to be adjusted to individual needs.

The Total Cholesterol/HDL ratio

This one is useful for research purposes. But in essence if your Ratio is low is good because it shows that you have a high HDL level compared to the LDL.

Want to know what your chances of getting a heart attack is over the next 10 years?

If you have your cholesterol report and blood pressure readings, you can calculate your 10 year CardioVascular Risk by clicking here

For more information about your Cholesterol Levels, click here

Thursday, December 14, 2006

New Mothers: What is this 6 in 1 Vaccination for my Baby?

One of our readers enquired about the 6 in 1 Vaccination that is available for newborns. So I thought I will just let you know about it.

The Vaccination Schedule for Singapore can be found here

Based on this schedule, your child will receive:

Birth: BCG and Hepatitis (Done at the hospital)
1 mth: Hepatitis
3 mth: DTP + Polio (Diphtheria, Tetanus, Pertussis)
4 mth: DTP + Polio
5 mth: DTP + Polio
6 mth: Hepatitis

This completes the vaccinations for the first year.

What is this 5 in 1 vaccination?

The smart scientists came up with what is known as a 5 in 1 vaccine. The 5 in 1 basically combines DTaP + IPV + Hib (Haemophilus Influenzae type B) into one vaccination. You may notice that there is a slight difference in the annotations. The "a" in DTaP stands for acelluar as opposed to whole cell vaccine. Acellular means that only purified Bacterial Parts are used in the vaccine as opposed to using the whole Bacteria. Acellular vaccines have been shown to have less side effects than whole vaccines.

IPV stands for inactivated Polio Virus as opposed to the Oral Polio which is a live virus given by mouth. The inactivated Polio Virus is incorporated into the 5 in 1 vaccine.

Haemophilus Influenzae type B (Hib) is not included in the schedule but it is an important vaccine to give to baby. Before the introduction of Hib, 10 -15 babies died in Australia each year from this disease, and 20-40% of the survivors were left with permanent neurological damage. So it is good to protect baby against this.

So as you can see, the new 5 in 1 vaccine offers many advantages over the old vaccination scheme.

So what is the 6 in 1 vaccination?

The clever scientists again made life easier for parents and doctors by coming up with a 6 in 1 vaccine. The 6 in 1 is actually the 5 in 1 plus the Hepatitis vaccine.

So instead of the old schedule where the baby needs to be given 5 injections, now the baby only needs to be jabbed 3 times. With 6 in 1 the schedule becomes:

Birth: BCG and Hepatitis (Done at the Hospital)
2 mth: 6 in 1
4 mth: 6 in 1
6 mth: 6 in 1

Less in injections means less pain and less chances for side effects to occur.

Our clinic offers packages for the new 6 in 1 as well as for the 5 in 1 vaccine. Do write to leslie.tay@gmail.com or call 67850311 for more information.

More information about childhood vaccines can be found here

Wednesday, December 13, 2006

What you should know about Cardiovascular Disease

Today's big health news is that Singaporeans only have a vague idea about how to prevent heart disease. So I have decided to write a series of blogs on the factors that affect the health of your heart and what you should do. Let me first start by giving you a real life scenario:

Mr M was a 42 year old patient of mine who has a history of high blood pressure and cholesterol. When I first saw him about a year ago, he was perfectly well, aside from high blood pressure and high cholesterol. He suffered no symptoms at all. He told me that he previously had an excercise stress test that showed some minor irregularities but he has not followed up on it. My advice to him was that he should go for a repeat excercise stress test and referred him to a cardiologist for follow up.

The months went by, and Mr M delayed going to the cardiologist because he felt he had no symptoms and did not want to do another stress test. I don't blame him, because in an excercise stress test, you go on a thread mill and have to run for a period of time. (How many of us like to do that?)

I finally suggested an alternative which was to do a 3D CT scan of the heart to look at the blood vessels of the heart which he finally agreed to do. An example of the 3D CT scan is shown above.

The 3D CT showed that his main artery was critically blocked and that his other 2 arteries have also narrowed. This means that at any time, he might suffer a massive heart attack. Within a week he had open heart surgery and had a 6 vessel bypass! The 3D CT scan had saved his life.

How you get a Heart Attack and Stroke

Cardiovascular problems (Cardio - heart, Vascular - blood vessels) are one of the biggest killers in Singapore. They occur when because of certain factors the blood vessels to the heart and brain narrow and eventually blood supply to these vital organs are cut off. The result is a heart attack or a stroke.

What are the Risk Factors for Heart Disease?

Below are the risk factors for Heart Disease, I like to divide them into 3 groups.

Group 1: Those things you can't do much about.

1. Male - if you are a man your risk goes up
2. Age - Men above 45 and women above 55 have higher risk
3. Genetics - If your parents have heart disease, you are at higher risk

Group 2: Those things you can do for yourself

1. Smoking - Stop smoking! Smoking dramatically increases risk of cardiovascular diseases
2. Alcohol - Too much drinking will also increase risk.
3. Obesity - Diet and Excercise and keep your weight to below a BMI of 23!

Group 3: The things you should consult your Doctor:

1. Hypertension - The silent killer, you may not feel any symptoms and the damage is gradual
2. Diabetes
3. Cholesterol levels

The bottomline is this: Prevention is better than cure and you should visit your doctor to discuss with him about how to prevent heart disease!

In the meantime, if you know your cholesterol and blood pressure readings, you may wish to calculate your 10 year risk of getting a heart attack by clicking this.

More information about Cardiovascular Risk Factors are found here

My next Blog in the Cardiovascular Health Series will touch on Cholesterol and how to read your cholesterol report.

Monday, December 11, 2006

Hepatitis B Carriers: What you need to know!

One of my patients said this to me:

Dr, I was diagnosed as a Hepatitis B carrier 2 years ago. What do I need to do?

Please listen, if you are a Hep B carrier, it is IMPERATIVE that you are regularly checked by a Doctor at least twice a year and that your spouse/partner is protected against Hep B.

Importance of Hepatitis B in Singapore

1. 4% of Singaporeans are Hep B carriers, so there are quite a lot of people carrying the virus in their bodies!

2. Of these, 25% will develop complications which may lead to liver failure and liver cancer.

3. If you are a carrier, you may transmit Hep B to someone else!

In a nutshell, if you are a Hep B carrier, there is a chance that you may develop liver cancer and that you may also spread it to others.

How to prevent spreading Hep B to others

Hep B is transmitted through bodily fluids and are transmitted through sex, sharing of contaminated needles and sharing of other things that may cause bleeding like toothbrushes, nail clippers and shavers. Make sure you don't be a HERO and donate your blood or sperm!

What to do for your family members

It is important that your spouse be screened for Hep B and receive vaccination as soon as possible. It is advisable for others in the family to be screened as well. If you are pregnant, then the baby will need special treatment at birth.

What YOU need to do for yourself

1. Find a Family Doctor and make sure you visit him every 6 months

2. You will need blood tests to check for liver problems every 6 months

3. You will need at an Ultrasound of the Liver at least every year and for some high risk patients, twice a year

4. If you are not vaccinated against Hep A you should do so.

5. Avoid alcohol as this will cause more problems for your liver


Hepatitis B carriers have a chance of developing liver cancer and should be seen by a doctor every six months. Their family members and other sexual contacts are also at risk and should be screened. Hep B is a bigger problem than AIDS and kills more people every year than AIDS so you should be very careful.

Thursday, December 07, 2006

For Men: Dr, how come my b---s shrink when I go swimming?

One of my patients asked me this question today!

I told him that I wanted to blog the answer and asked for his permission to take a photo of the organ in question. He declined of course. I quipped that it was because he was afraid someone might recognize him just by looking at that part of the body which got his wife laughing uncontrollably AT him. Trust is such a important quality in a husband and wife relationship, don't you agree?

The function of the male testicles are to produce sperms. It so happens that they function best at a temperature just cooler then normal body temperature. So during a hot day, the scrotal muscles relax so that the testicles will dangle further away from the body and when it is cold, the scrotal muscles contract to keep the testicles warm.

Here are some things you should not do if you wish to father a child:

1. Avoid Spas!! Soaking a long time in Spas with water temperatures above 40 degrees Celsius might be really relaxing BUT it may lower your sperm count!

2. Avoid long bicycle rides while wearing tight bicycle shorts! The tight shorts and the bicycle seat keep the testicles closed to the body and may compromise sperm production.

3. Avoid long hours sitting on your chair or car! You should get up and let them dangle every now and again!

4. Avoid Smoking and Alcohol as they may affect the sperm count!

An Interesting Postulation

It is a fact that sperm production decreases in hotter climates. So could it be that our low fertility rates are due to the fact that Singapore is hot and most of our guys work long hours sitting in their offices?

While you are thinking about this, I think I will just get out of my chair and go for a quick stroll!

For more information on how to optimise your fertility rate (for men) please have a look at this interesting article from MayoClinic. Click here.

Wednesday, December 06, 2006

Can I get Hepatitis B from eating raw Seafood?

Doctor, I know that I can get Hepatitis B from eating raw Seafood right?

This is perhaps one of the commonest misconceptions in Family Practice. The problem is that most patients do not differentiate between Hepatitis A and Hepatitis B which are two very different diseases altogether. So here are a few points to you understand the difference.

1. Hepatitis just means inflammation of the liver. This inflammation can develop from a whole range of conditions. Hepatitis A and B refer to inflammation of the liver caused by 2 different viruses, the Hep A and the Hep B virus.

2. Hep A is the one that you get from eating contaminated food and water. (Not just seafood, any food can be contaminated with the virus). When you get Hep A, you might get jaundiced and develop fever and have flu like symptoms. Most people recover fully from Hep A but some do develop chronic hepatitis and liver damage.

3. Hep B is transmitted through contact with blood or semen. It is spread through contaminated needles (drug abusers) as well as sexual contact. Hep B has more severe consequences than Hep A. People who contract Hep B may go on to become carriers who can spread the disease to others. A person suffering from chronic Hep B may also develop liver failure and liver cancer.

4. You can vaccinate yourself against both Hep A and B. The vaccination for Hep A consists of 2 injections 6 months apart. The Hep B vaccination is 3 vaccinations at 0, 1 and 6 mths.

This is only a short article to help you differentiate between Hep A and B. For more information you may like to read this.

In my next article, I will be talking more about Hep B carriers and what screening tests are required by ALL Hep B carriers.

Treating people not diseases

Our motto "Treating people, not diseases" was an inspiration from the film, "Patch Adams" where he told his peers that when you treat a disease, you lose, but when you treat the person, you will win all the time. Most of you would have seen this film where Patch Adams (Portrayed by Robin Williams) was this eccentric Doctor who would put on a clown's nose to entertain kids who were dying.

Most Doctors shy away from incurable patients because sometimes we feel powerless in those situations and sometimes it is because we do not want to be reminded of our own mortality. But Patch was different. He focussed on the patient, not the disease, so he felt that he could still do something for the patient even though there is nothing that can be done for the disease.

"Treating people, not diseases" is an mindset we adopt to remind ourselves that we are treating not just a headache, runny nose or a cough. It helps us remember that patients are real people who work to earn a living and have families who care for them and have joys and struggles in life.

I heard it said somewhere before that people are like onions. When you peel off the superficial layers, the deeper more significant problems emerges. This happens everyday in Family Practice. Let me illustrate with a typical situation:

A 25 year old lady comes to the clinic complaining of a headache. "Treating the disease" would be to make an accurate diagnosis and then to prescribe painkillers after making sure that the headache is not an indication of some serious event. That is treating a disease called Tension Headache. There is absolutely nothing wrong with that because the doctor has done what is expected of him both legally and morally.

When we try to treat the patient, the doctor takes the extra step to establish a relationship of trust whereby the outer layers of the onion can be peeled off to reveal the real underlying problem. I frequently have patients who present with seemingly innocent symptoms who are really suffering from depression or an inability to cope with the stresses of life. Some patients present with headache because they have not slept a wink, having to stay up the whole night looking after the newborn baby!

Many of our physical problems are a manifestation of psychiatric stressors. A condition like depression often masquarades as physical symptoms such as fatique, weight loss, menstrual changes, unusual sensations in the abdomen, chest or head, bodily aches and pain, dry mouth and difficulty breathing. The condition is common in stressed out Singaporeans but it is often not recognized by both the patient and her doctor. Unless the underlying depression is treated, the physical symptoms are likely to remain.

One of the most important roles of the Family Doctor is patient education, which is why I have started this blog. Many of the conditions are much better managed when the patient understands the rationale for treatment.

Asthma management is a very good example. Most parents who do not understand the rationale behind using Preventors often stop the medication prematurely. The parents who do understand the role of preventors are more compliant to give the medication for a longer period of time which result in the child being able to live without having to suffer the symptoms of asthma frequently. (For more info on Asthma, you may like to read the Asthma Series which have just been posted)

I will be the first to admit that "Treating people, not diseases" is sometimes difficult to do. I am far from perfect. (Some patients expect us to be superhuman and are surprised when a Doctor falls sick! If you prick us, do we not bleed?) Sometimes, after a long day, I get tired and it is much easier to just see the patient, prescribe some medication and send the patient home (Which is why it helps to close the clinic and take a nap in the afternoons) We can only say that we try our best.

If you have been our patient for a while, I hope this little article will help to explain our tagline to you and I hope you feel that we have tried to live up to the values that we espouse. If you have any thoughts or comments please feel free to express them by clicking the comments link at the end of the blog!

Monday, December 04, 2006

Asthma - What you need to know! Part 5

In Part 1, we discussed the issues facing the management of asthma in Singapore and we see that the most important thing is for parents to be empowered with the knowledge to manage their child's condition. In Part 2, we learnt about how to diagnose and stage the severity of Asthma. In Part 3, we discussed the different medications available and the difference between RELIEVERS and PREVENTERS. In Part 4, we looked at other ways of preventing Asthma by avoiding triggers.

In this last installment, we will bring it all together and discuss how to work with your Doctor to manage your child's Asthma.

The Asthma Action Plan

This is the Action Plan which I use in my clinic. It is the one produced by NUH under their I CAN! Asthma management program. I usually send children who need to have skin prick tests done to NUH as well.

The Action Plan helps parents to manage their child's asthma effectively by:

1. Clearly outlining the dosage of medications needed when the child is not having an Asthma Attack
2. Helping parents to recognize the onset of an Asthma Attack
3. Clearly outlining how medications should be increased based on the severity of the attack
4. Helping parents to know when they need to seek medical attention

So every child should have an Action Plan that is pasted on the fridge door so that parents can quickly refer to it when signs of Asthma start appearing.

The Peak Flow Meter

The Peak Flow Meter is used as a convenient way of assessing the severity of Asthma in the clinic or at home. By asking the child to blow into the device, you can gauge how severe the Asthma is by comparing it to the Peak Flow Reading when the Child is well.

If your child has Chronic Asthma, it may be useful to have one of these at home so that you can monitor the severity of Asthma your self. Sometimes in the very early stages of an Asthma attack, you don't get the wheeze or the shortness of breath. So, for example, when the haze situation returns and the PSI reading is high, the Peak Flow meter will help you gauge if your child is having Asthma even if he is not wheezing or coughing yet.

Wrapping it all up

I hope you found that the information contained in this 5 part series is useful in helping you better understand Asthma.

Knowledge means Empowerment. With the right knowledge, you, with your doctor's help can ensure that your child live a healthy and normal life!

Here are some more resources you can look at:

NUH's ICAN program
Asthma Patient Guide from Global Initiative for Astma
Asthma Patient Brochures from National Asthma Council Australia

Friday, December 01, 2006

Asthma - What you need to know! Part 4

In Part 3 we discussed the types of medications used in Asthma, in Part 4 we will look at other measures you can take to prevent an Asthma Attack

Avoidance of Triggers

Asthma is a form of allergic reaction. Being an allergy means that it is usually triggered by something. The commonest triggers are:

1. Cold and Flus
2. House Dust Mites
3. Animal furs like cats
4. Mould - I once had a patient who found that her asthma improved significantly when she thoroughly cleaned her aircon units!
5. The Haze or during the Seventh Month where there is a lot of burning papers
6. Smoking or 2nd hand smoke in the house

Knowing what triggers your child's Asthma will empower you to take some preemptive action to prevent the Asthma from occuring. The doctor will provide you with an ACTION PLAN which outlines what to do when the child is exposed to triggers. You should also take other steps to avoid the various triggers, for example, learning how to get rid of House Dust Mites around the home.

Food Allergies

Food is an uncommon trigger for Asthma. It only affects less than 5% of people with Asthma.

However, the common ones are:

1. Nuts
2. Fish and Shellfish
3. Milk
4. Eggs
5. Various Seeds
6. In the Singapore context, Bird's Nest is highly allergenic because of the impurities
7. Food additives


Some people get Asthma during excercise. This means the Asthma is poorly controlled. Children with excercise induced asthma should be managed by your Doctor. In general, Ventolin should be given half an hour before excercising and the child may need long term preventive medications.

A well managed child will be able to win an Olympic Gold Medal if the asthma is treated properly!

What else you can do.

Your doctor may arrange for a skin prick test in order to find out what exactly the child is allergic to. Then at least you KNOW what to avoid, rather then trying to be Kia Su and avoid everything!

For more information, you can click here

In Part 5, we will be discussing how to work with your Doctor to monitor and manage your Asthma