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Secondary hypertension occurs in a significant proportion of adult patients (~10%). In young patients, renal causes (glomerulonephritis) and coarctation of the aorta should be considered. In older patients, primary aldosteronism, obstructive sleep apnoea and renal artery stenosis are more prevalent than previously thought. Primary aldosteronism can be screened by taking morning aldosterone and renin levels, and should be considered in patients with severe, resistant or hypokalaemia-associated hypertension. Symptoms of obstructive sleep apnoea should be sought. Worsening of renal function after starting an angiotensin-converting enzyme inhibitor suggests the possibility of renal artery stenosis. Recognition, diagnosis and treatment of secondary causes of hypertension lead to good clinical outcomes and the possible reversal of end-organ damage, in addition to blood pressure control. As most patients with hypertension are managed at the primary care level, it is important for primary care physicians to recognise these conditions and refer patients appropriately.

Obesity, defined as a condition of excessive body fat with adverse effects on health, is an increasing global problem which contributes to chronic disease burden and health care costs. The Singapore Ministry of Health (MOH) released Clinical Practice Guidelines (CPG) in 2004, aimed at providing best evidence-based recommendations for diagnosis, classification, evaluation and multidisciplinary management (diet, physical activity, medication and surgery) of overweight and obesity in adults and the pediatric population. This article summarizes the guidelines, discusses their utility in Singapore and strategies for increasing their use, and briefly outlines updates in management since the CPG’s publication. A revised CPG is urgently needed in view of the increasing prevalence of overweight and obesity in Singapore and the numerous advances in the management of overweight and obesity.

Introduction Abdominal obesity and type 2 diabetes mellitus are associated with sexual and endothelial dysfunction, lower urinary tract symptoms (LUTS), and chronic systemic inflammation. Aim To determine the effects of diet-induced weight loss and maintenance on sexual and endothelial function, LUTS, and inflammatory markers in obese diabetic men. Main Outcome Measures Weight, waist circumference (WC), International Index of Erectile Function (IIEF-5) score, Sexual Desire Inventory (SDI) score, International Prostate Symptom Scale (IPSS) score, plasma fasting glucose and lipids, testosterone, sex hormone binding globulin (SHBG), inflammatory markers (high-sensitivity C-reactive protein [CRP] and interleukin-6 [IL-6]) and soluble E-selectin, and brachial artery flow-mediated dilatation (FMD) were measured at baseline, 8 weeks, and 52 weeks. Methods Over 8 weeks, 31 abdominally obese (body mass index ≥ 30 kg/m2, WC ≥ 102 cm), type 2 diabetic men (mean age 59.7 years) received either a meal replacement-based low-calorie diet (LCD) ∼1,000 kcal/day (N = 19) or low-fat, high-protein, reduced-carbohydrate (HP) diet (N = 12) prescribed to decrease intake by ∼600 kcal/day. Subjects continued on, or were switched to, the HP diet for another 44 weeks. Results At 8 weeks, weight and WC decreased by ∼10% and ∼5% with the LCD and HP diet, respectively. Both diets significantly improved plasma glucose, low-density lipoprotein (LDL), SHBG, IIEF-5, SDI and IPSS scores, and endothelial function (increased FMD, reduced soluble E-selectin). Erectile function, sexual desire, and urinary symptoms improved by a similar degree with both diets. CRP and IL-6 decreased with the HP diet. At 52 weeks, reductions in weight, WC, and CRP were maintained. IIEF-5, SDI, and IPSS scores improved further. Conclusions Diet-induced weight loss induces rapid improvement of sexual, urinary, and endothelial function in obese diabetic men. A high-protein, carbohydrate-reduced, low-fat diet also reduces systemic inflammation and sustains these beneficial effects to 1 year.

Background Numerous hormones secreted by the gut,during both the fasted state and in response to a meal,influence gastrointestinal motor and/or sensory func-tion, and appear to contribute to the pathogenesis ofdelayed gastric emptying associated with gastropare-sis, functional dyspepsia (FD) and feed intolerance incritical illness. Gut hormones are, accordingly,potential targets for the management of these patients.Purpose This article will discuss the hypersensitivityto enteral fat and endogenous (nutrient-stimulated)and exogenous cholecystokinin (CCK) in patients withFD, and the elevation in both fasting and postprandialCCK levels evident in this group. It will review the useof pharmacological agonists of motilin and ghrelin,which accelerate gastric emptying, in the managementof gastroparesis and FD. The frequent finding ofmarkedly delayed gastric emptying in the critically illwill be examined; this is associated with elevatedplasma CCK and peptide YY in both the fasted andpostprandial states, which may account for theincrease in small intestinal nutrient inhibitory feed-back on gastric motility in this group. The conceptsthat the rate of gastric emptying is a major determi-nant of postprandial glycemic excursions in diabetes,and that modulation of gastric emptying may improveglycemic control, will be addressed; in type 1 andinsulin-treated type 2 diabetic patients, co-ordinationof insulin administration with nutrient delivery andabsorption should be optimized, while type 2 patientswho are not on insulin are likely to respond to dietaryand/or pharmacological interventions which slowgastric emptying.Keywords diabetes, gastroparesis, glucagon-like pep-tide-1, cholecystokinin, peptide YY, ghrelin.

Objective To determine the effect of ageing on the performance of glycosylated haemoglobin A1C (A1C) for the diagnosis of diabetes mellitus (DM) in Southeast Asians. Methods A1C was measured in 511 subjects (mean age of 52.4 years; range 14–93) undergoing the 75-g oral glucose tolerance test (OGTT). Using receiver operating curve (ROC) analysis, the performance of A1C for the diagnosis of diabetes (using different standard criteria) was compared between 4 groups: n =156), 45–54 ( n =132), 55–64 ( n =122), ≥65 years ( n =101). Results Subjects aged ≥65 years had the highest false-negative rates with fasting plasma glucose (60.8%) and A1C (35.1%), the smallest area under ROC curve (0.723, 95% CI 0.627–0.820), the lowest sensitivity (58.7%, 95% CI 50.4–65.7) and specificity (71.1%, 95% CI 57.3–82.6) of A1C 6.5%, compared to the younger age groups. Conclusion OGTT is preferable for diagnosis of DM in older Southeast Asian adults.

Aim: To investigate the relationship between outdoor work and pterygium formation in a hospital-based case-control study in Singapore. Method: Sixty-one patients with pterygium (49 males, mean age 54.2 years) and 125 controls (41 males, mean age 50.2 years), excluding patients with cataract and age-related macular degeneration presenting at outpatient clinics of the Singapore National Eye Centre were interviewed face-to-face with a standard questionnaire. Demographic data and information on outdoor work and eye protection, were collected. Results: Thirty-eight subjects (20.4%) were outdoor workers and 148 (79.6%) were indoor workers. Outdoor workers were more likely to be male smokers and alcohol drinkers with lower family income and higher sunlight exposure than indoor workers. The crude odds ratio for pterygiumin outdoor workers was 7.0 (95% confidence interval 3.2, 15.3). The adjusted odds ratio was 4.2 (95% confidence interval 1.7, 10.1). Conclusion: There is a statistically significant association between outdoor work and pterygium formation, which may be related to the higher exposure to sunlight and dust in outdoor workers. Efforts may be made to educate outdoor workers to wear proper equipment to protect their eyes against excessive sunlight.

Background Lower urinary tract symptoms (LUTS) in men are associated with obesity, particularly central obesity as measured by waist circumference (WC), and may improve with weight loss. We aimed to compare effects of a meal-replacement based diet with isocaloric reduced-fat plan on LUTS and nutrient intake in obese Asian men. Methods Obese Asian [mean (range) body mass index of 32.9 (30.5–42.3) kg m–2] men [mean (range) age 40.2 (30–61) years] were randomised to a reduced-fat (< 30% of energy) diet [conventional reduced-fat diet (CD) group; n = 23] or meal-replacement-based plan [meal replacement (MR) group; n = 23], to reduce daily intake by 2000 kJ for 12 weeks. Results CD and MR groups had statistically significant and similar reductions in weight (−2.6 ± 1.9 kg versus −4.2 ± 3.8 kg), overall LUTS severity measured with International Prostate Symptom Scale (IPSS) scores (−1.71 ± 1.93 points versus −2.42 ± 2.12 points) and insulin resistance [homeostasis model assessment (HOMA) calculated from plasma glucose and insulin]. The MR group had significantly greater decreases in WC (−4.8 ± 3.3 cm versus −2.5 ± 2.3 cm), fat mass (−2.47 ± 3.63 kg versus −1.59 ± 2.32 kg), fat intake, plasma C-reactive protein, and in storage LUTS score (−1.59 ± 1.33 points versus −1.00 ± 0.87 points), which was associated with a decreased fat intake (r = 0.48, P = 0.03). A decrease in overall IPSS score was associated with reductions in weight, WC and HOMA. Conclusions Weight loss as a result of CD or MR had similar efficacy in relieving LUTS. MR produced greater reductions in fat intake, adiposity and storage LUTS.

According to World Health Organization, in 2010 there were over 1 billion overweight adults worldwide with 400 million adults who were obese. Obesity is a major risk factor for diabetes, cardiovascular disease, musculoskeletal disorders, obstructive sleep apnea, and cancers (prostate, colorectal, endometrial, and breast). Obese people may present to the gastroenterologists with gastroesophageal reflux, non-alcoholic fatty liver, and gallstones. It is important, therefore, to recognize and treat obesity. The main cause of obesity is an imbalance between calories consumed and calories expended, although in a small number of cases, genetics and diseases such as hypothyroidism, Cushing's disease, depression, and use of medications such as antidepressants and anticonvulsants are responsible for fat accumulation in the body. The main treatment for obesity is dieting, augmented by physical exercise and supported by cognitive behavioral therapy. Calorie-restriction strategies are one of the most common dietary plans. Low-calorie diet refers to a diet with a total dietary calorie intake of 800-1500, while very low-calorie diet has less than 800 calories daily. These dietary regimes need to be balanced in macronutrients, vitamins, and minerals. Fifty-five percent of the dietary calories should come from carbohydrates, 10% from proteins, and 30% from fats, of which 10% of total fat consist of saturated fats. After reaching the desired body weight, the amount of dietary calories consumed can be increased gradually to maintain a balance between calories consumed and calories expended. Regular physical exercise enhances the efficiency of diet through increase in the satiating efficiency of a fixed meal, and is useful for maintaining diet-induced weight loss. A meta-analysis by Franz found that by calorie restriction and exercise, weight loss of 5-8.5 kg was observed 6 months after intervention. After 48 months, a mean of 3-6 kg was maintained. In conclusion, there is evidence that obesity is preventable and treatable. Dieting and physical exercise can produce weight loss that can be maintained.

Introduction Obesity and inactivity are associated with erectile dysfunction and hypogonadism. Aim To compare the effects of low volume (LV) and high volume (HV) of moderate-intensity exercise on sexual function, testosterone, lower urinary tract symptoms (LUTS), endothelial function, and quality of life (QoL) in obese men. Main Outcome Measures Weight, waist circumference (WC), body composition, International Index of Erectile Function 5-item (IIEF-5), International Prostate Symptom Scale (IPSS) (for LUTS), and 36-item Short Form Survey version 2 Instrument (SF-36) (for QoL) scores, plasma testosterone, sex-hormone binding globulin, glucose, insulin and lipids, and endothelial function (by Reactive Hyperaemia Index [RHI] using finger plethysmography) were measured at baseline and 24 weeks. Methods Ninety abdominally obese (body mass index > 27.5 kg/m2, WC > 90 cm), sedentary (exercise ∼80 minutes/week) Asian men (mean age 43.6 years, range 30–60) were prescribed a diet to reduce daily intake by ∼400 kcal below calculated requirement and randomized to perform moderate-intensity exercise of LV ( Results Weekly exercise volume was significantly greater in the HV (236 ± 9 minutes) than the LV (105 ± 9 minutes) group. The HV group had significantly greater increases in IIEF-5 score (2.6 ± 0.5 points) and testosterone (2.06 ± 0.46 nmol/L) and reductions in weight (−5.9 ± 0.7 kg, −6.2%), WC (−4.9 ± 0.8 cm, −4.9%), and fat mass (−4.7 ± 1.0 kg, −14.5%) than the LV group (−2.9 ± 0.7 kg, −3.0%; −2.7 ± 0.7 cm, −2.5%; −1.1 ± 0.8 kg, −3.2%; 0.79 ± 0.46 nmol/L; and 1.8 ± 0.5 points). Improvements in IPSS and SF-36 scores, and RHI, were similar. Conclusions Moderate-intensity HV aerobic exercise > 200 minutes/week produces greater improvements in sexual function, testosterone, weight, WC, and fat mass than smaller exercise volume. Khoo J, Tian H-H, Tan B, Chew K, Ng C-S, Leong D, Teo RC-C, and Chen RY-T. Comparing effects of low- and high-volume moderate-intensity exercise on sexual function and testosterone in obese men.

Far from being a passive reservoir for digestion and absorption of food, the gastrointestinal tract is a dynamic participant in the regulation of appetite and energy homeostasis. During meals, distension of the stomach and delivery of the products of carbohydrate, lipid, and protein digestion to the small intestine act synergistically to limit food intake. Satiation is induced by the activation of vagal afferent nerves terminals in gastric and intestinal walls, and the secretion of peptide hormones such as cholecystokinin, leptin, glucagon-like peptide-1, oxyntomodulin, and peptide YY from specialized mucosal cells in the stomach and small intestine. These gut peptides exert their effects by endocrine and paracrine actions, the latter via vagal afferents. The vagus interacts with the enteric nervous system and the central nervous system to coordinate satiation signaling. In addition to inhibiting appetite centers in the hypothalamus and brainstem, gut hormones prolong the exposure of the gastrointestinal tract to nutrients by slowing gastric emptying and intestinal transit. The mechanisms by which nutrients stimulate the release of gut hormones are now known to include activation of mucosal “taste” receptors and G-protein coupled receptors in the small intestine by carbohydrates, proteins, and fatty acids. Pharmacological agonists and antagonists of gut peptides are potentially useful for the management of obesity, type 2 diabetes, gastrointestinal motility disorders, and cachexia of critical illness.

Objective American Diabetes Association (ADA) has recently recommended the use of glycated haemoglobin (HbA1c) to diagnose diabetes mellitus. We aim to determine if indeed this recommendation applies to the population in Singapore and whether it varies with age. Method This is a cross sectional study of 90 patients without previous history of diabetes who underwent screening and had both oral glucose tolerance test (OGTT) and HbA1c done at the same time. These patients were stratified into 4 age groups. Result We found that HbA1c of 6.2% is the best cut-off to diagnose diabetes using ROC curve analysis. At the specified HbA1c, the area under ROC curve (AUROC) reduces as age group increases suggesting that sensitivity and specificity of HbA1c as diagnostic marker reduces as age increases. Conclusion HbA1c has a low sensitivity to diagnose diabetes in older Asian subjects and caution is required when using HbA1c in isolation. This raises the possibility that a different cut-off value for different age groups may be more appropriate.

Abdominal obesity and type 2 diabetes mellitus are associated with erectile and urinary dysfunction in men. The extent to which sexual function and lower urinary tract symptoms (LUTSs) are improved by weight loss remains unclear.We compared the effects of 8 weeks of a low-calorie diet using meal replacements (Kicstart) on insulin sensitivity, plasma testosterone levels, erectile function (measured by the five-item version of the International Index of Erectile Function, IIEF-5), sexual desire (measured by the Sexual Desire Inventory, SDI) and LUTS (measured by the International Prostate Symptom Score, IPSS), in abdominally obese (body mass indexor=30 kg m(-2), waist circumference (WC)or=102 cm) men (mean age 49.7 years) with uncomplicated diet or oral hypoglycemic-treated type 2 diabetes mellitus (n = 19) or without type 2 diabetes mellitus (n=25), with a control group of nondiabetic men (n = 26) with similar body mass index and WC.Weight loss of ∼ 10% was significantly associated with increased insulin sensitivity, plasma testosterone levels, IIEF-5 and SDI scores, as well as reduced WC and IPSS scores, in diabetic as well as nondiabetic men. The degree of weight loss was significantly associated with improvements in plasma testosterone levels (r = -0.34), erectile function (r = -0.26) and LUTS (r=0.65). Reduction in LUTS was significantly associated with increased plasma testosterone (r = -0.35), erectile function (r = -0.42) and sexual desire (r = -0.40).Diet-induced weight loss significantly and rapidly improves sexual function, and reduces LUTS, in obese middle-aged men with or without diabetes.

5,619,926.58 person years in our analysis. During a median of 3 years, ~ 10% of our cohort of first cancer patients (n: 135,725/1,391,490) developed a second primary cancer. Of them, 2,214 (1.6%) had a second esophageal cancer. Cancer patients had a 1.7 higher risk of developing any esophageal cancer (SIR: 1.7 (95% CI: 1.6-1.7)) and a 2.2 higher risk of developing ESCC (SIR: 2.2 (95% CI: 2.1-2.4)) as compared to the general population. The SIR for a second ESCC after lung cancer was 3.70 (95% CI: 3.0-4.5). There was a remarkably high risk for developing a second ESCC in patients diagnosed with head-and-neck cancer with a SIR of 22.4 (95% CI: 20.0-25.0). In male patients the SIR for head-and-neck cancer was 19.3 (95% CI: 16.9-22.0) and 36.9 (95% CI: 29.8-45.4) for female patients. Of the 9,584 female patients with a first head-and-neck cancer 92 developed a second ESCC with a Number Needed to Screen of 96. Conclusions This first nationwide, population-based study in the Western world on the incidence of ESCC in head-and-neck cancer survivors shows that these patients have a 22 times higher risk of developing ESCC. This observation is even more pronounced in female patients. These data suggest that that head-and-neck cancer survivors may benefit from periodical screening for ESCC.