We’re in the middle of the sānfútiān 三伏天, the three ten-day periods signifying the hottest days of summer. In the west we call it “dog days of summer” for reasons which escape me. But my point is that it’s hot. Darn hot, and humid. And there’s no way that any fruits, vegetables or meats can survive more than a couple hours in this heat before starting to spoil or grow healthy colonies of unhealthy bacteria. Major groups including the WHO and the USDA all mention how exposed foods should be stored and chilled if left out for more than two hours — and only one hour if it’s very hot, over 90 °F/32 °C.
So let’s mix this fact of biology with Beijing’s charming images of the summer: watermelons baking in the sun from dawn to dusk on truck beds, their donkeys patiently waiting. Oh, and how about everyone eating barbecued lamb chuanr, sitting in tiny chairs at the mobile stands on every corner at night, playing cat-and-mouse with the police? Or the expat-preferred Sanyuanli food market’s meat stalls filled with piles of meat — uncovered, open to the non-chilled air, flies flittering between hanging carcasses. And this is supposed to be where top restaurants buy their food?
In my clinic, I’ve seen a more than usual summertime spike in diarrhea and food poisonings, but I’ve also never seen such a high amount of spoiled produce as I see this summer. I’ve never had problems with watermelons before, but twice this week my watermelon was already skunked when I cut into it at home, already fermented in the sun. Even my wife got diarrhea this week after eating sushi — at the most popular sushi restaurant in Beijing, no less. And how many Beijing street corners are filled with people laying out their vegetables and fruits on the pavements?
So the point here is to be careful during these six weeks of peak summer. Be watchful of what you eat and where you eat. And don’t assume that it’s a safe restaurant or market just because “every expat goes there.” No place is safe from Biology 101.
My tips for the next few weeks
My wife and I are cutting way back on buying and eating all meat, especially fish. If we do buy meat, we certainly would only stick to top-end hypermarkets with wrapped meats on cooled racks, including Carrefour, Walmart and Metro (our favorite).
We also get much more of our produce from the hypermarkets instead of our usual local one. And we’re more vigilant about peeling and soaking. And if anything tastes a bit funny, as did our watermelons this week — toss it out and try again tomorrow.
Maybe its also not a bad idea also to be proactive and buy some anti-diarrhea OTC medicines now to keep at home. My personal must-have are bismuth tablets from the US (Pepto-Bismol, AKA “the pink liquid”, sadly not available in China). But Smecta powder (蒙脱石) and probiotics (the good bacteria in yogurt) may come in handy, as well as loperamide pills (洛哌丁胺) just in case the diarrhea gets bad.
But don’t let me scare you totally from summer fun: there are some restaurants that are doing the right thing. If you’re truly craving for street food, you could try the skewers from restaurant chain Meizhou Dongpo 眉洲东坡, usually rated A for food safety. I like their 串肉 firstly because their streetside grill runs on gas, which is much cleaner and safer than coal. More importantly, their meats are chilled and wrapped up in a cooler right next to the grill. Check out their photos below:
Suddenly it’s summer again and I’m already noticing more patients coming in with diarrhea and the typical “gastro” symptoms that spike every summer. It’s usually not a big deal for adults, but I worry mostly about babies and toddlers, who can quickly dehydrate after a couple of days of severe diarrhea. That’s why my top priority in talking with the parents is to help their child stay hydrated. The basics include continuing to eat normal foods if possible, and certainly continue breast-feeding. As for fluid supplements, the best treatment remains the official WHO-approved Oral Rehydration Salts, which are sold OTC in all pharmacies worldwide. In America, the most common version is called Pedialyte. Pure water, by the way, is not the best treatment — it’s critical that sodium salts and sugar are included in it as well, in very specific amounts. That’s because you need glucose and sodium specifically to work together on a special molecule in our cells which helps to rehydrate.
So the first choice is to try to continue normal eating habits and get some official ORS packets or pre-made solutions (Pedialyte) at your local pharmacy or clinic. But what about all those sports drinks, sodas or juice? After all, don’t the Gatorade-type brands specifically advertise they can replenish your essential nutrients? What’s the actual data showing if these are helpful — or harmful?
The general consensus is that none of the above options are ideal. Juice, especially apple juice, also can make diarrhea worse. This is because there’s so much sugar and other ingredients in many of these drinks that their osmolality is much higher than a normal body can handle, and this higher osmolality actually pulls more liquid from your cells — making your dehydration and watery diarrhea worse, not better. Here’s a neat table from a good review article which shows the data from ORS compared to Coke, Pocari, Gatorade and other common brands:
An important column is the far right, showing osmolarity. Notice how much higher is Coke and energy drinks when compared to official ORS. Pocari Sweat is closer but still has much more glucose and much less sodium. I have another graph below from another review article which details why juices and chicken broth also are not ideal. Notice how apple juice is too concentrated, and chicken broth has too much salt:
|Liquid||Electrolyte content (mEq per L)|
|Na+||K+||HCO3||Carbohydrate (g per L)||Osmolality (mOsm per kg)|
|Cola||2||0.1||13||50 to 150, glucose and fructose||550|
|Ginger ale||3||1||4||50 to 150, glucose and fructose||540|
|Apple juice||3||20||0||100 to 150, glucose and fructose||700|
|Gatorade||20||3||3||45, glucose and other sugars||330|
Na+ = sodium; K+ = potassium; HCO3 = bicarbonate.
Let’s hear from the experts
The take-home message, especially for parents, is that you should not reach for Gatorade, Coke, apple juice or many other drinks when you or your child are throwing up and having diarrhea. But don’t just take it from me; let’s hear from some experts. Here’s a nice synopsis from my Academy of Family Practice, from their article on management of acute gastroenteritis in children;
The time-honored “clear liquids” most often used by parents or recommended by physicians in the past are not appropriate for use in oral rehydration therapy. Drinks such as colas, ginger ale, apple juice and even commercial sports drinks (e.g., Gatorade) are inappropriately high in carbohydrates and osmolality(Table 7).11 They can cause osmotic worsening of diarrhea, and their low sodium content may contribute to the development of hyponatremia. Tea should not be used because of its low sodium content, and chicken broth is contraindicated because of its high sodium content.5,11 Furthermore, food should not be arbitrarily withheld because continued feeding or the early resumption of feeding improves outcome.
So you all get the idea now. As an aside, I think that sports drinks in general are a lot more hurtful than helpful, especially with childhood obesity rising so quickly. Here’s some helpful advice from the American Academy of Pediatrics:
Specific AAP recommendations regarding use of sports drinks and energy drinks in children and adolescents include the following:
- Pediatricians should educate patients and their parents regarding the potential health risks of energy drinks and sports drinks and explain the significant differences between these types of drinks. The terms should not be used interchangeably.
- Energy drinks should never be consumed by children or adolescents, because the stimulants they contain pose potential health risks.
- Children and adolescents should avoid and restrict routine consumption of carbohydrate-containing sports drinks, which can increase the risk for overweight, obesity, and dental erosion.
- For pediatric athletes, sports drinks should be consumed in combination with water during prolonged, vigorous physical activity, when rapid replenishment of carbohydrates and/or electrolytes is needed.
- For children and adolescents, water, not sports drinks, should be the principal source of hydration.
Gastroenteritis — diarrhea caused by bacteria from our foods — peaks in the summer but can occur all year. This is common all over southeast Asia, especially during the summer months as bacteria thrive in the heat. Expats can easily get gastro from street food vendors, but even 5-star restaurants aren’t immune from this if the staff and cooks aren’t using proper bathroom and food handling protocols. Pregnant women have the same risks of infection and should be especially choosy about where and what they eat, since a bad bout of “gastro”, while usually not serious for mom, can sometimes cause serious problems for her baby. Most infectious causes don’t directly affect your baby, but specific bacteria like listeria and salmonella can directly cross the placenta and cause harm. You should see your doctor quickly if you have more severe symptoms such as fever, bloody diarrhea, dehydration, or any changes in fetal movement.
Fortunately, those more severe cases are not common, and most pregnant women can get through those uncomfortable days with simple home remedies and foods, as well as a few safe over-the-counter (“OTC”) medicines. The most important goal is to stay hydrated, as you can quickly lose a lot of water from vomiting and diarrhea. You shouldn’t only drink water because it doesn’t really replenish your body’s needed salt and sugars, which is why the best options are the Oral Rehydration Salt packages available in local clinics and pharmacies. Those of you who are nauseous and throwing up can try the usual safe pregnancy options for nausea, such as ginger and vitamin B6. If you start to feel too dehydrated, or especially if you feel a change in your baby’s movements, you should immediately see your doctor.
The OTC medicine that most people commonly use to stop diarrhea — loperamide, AKA immodium — isn’t recommended for pregnancy, especially if you have bloody diarrhea. Some safer OTC items to slow down diarrhea include Medilac-S, which is a capsule of “good” bacteria; and Smecta, a charcoal-based powder which can also clear infections more quickly and is not absorbed in your body.
Of course, it’s better not to get gastro in the first place, so pregnant women should take special care with food hygiene. Specific recommendations include:
- not allowing frozen food from the shop to defrost on the way home;
- cooking all meats and eggs fully;
- thorough washing of vegetables;
- separating cooked and raw foods on different cutting boards;
- not reheating foods more than once;
- and washing hands frequently while preparing food.
To prevent the more serious listeria infection, specific foods to avoid include:
- refrigerated pate;
- processed and cold meats including hot dogs unless reheated to steaming hot;
- unpasteurized dairy foods and soft cheeses;
- and cold, raw or smoked seafood.
Those of you with an ayi should make sure that she understands the Five Keys to safer food; the World Health Organization has a great handout in Chinese which you can print or read to her. It is available at http://www.who.int/foodsafety/publications/consumer/5keys/en/
|Read more Women’s Health posts below and here in Children or Women’s Health:|
Case study: A 45 year old woman eats leftovers of sushi and salad (1 day in fridge). Two days later, she has diarrhea, stomach cramps, gas, and vomiting…
Literally, gastroenteritis means “inflammation of the stomach”. This is the treaded traveler’s diarrhea, also known as Turista. It is an infection of the stomach tract, usually from contaminated food. In developed countries, this is usually caused by a virus and not treated with antibiotics. But in developing countries such as China, it’s much more commonly caused by bacteria, or also a parasite. This is why many travel doctors recommend antibiotics (but not always).
Why So Common?
This is usually a hygiene problem; the food got contaminated somewhere along the chain:
- in the field (farm animal feces)
- during shipping and storage (not temperature controlled)
- during preparation (hand washing, cross contamination, not cooked well)
- during serving (cook, server, fellow diners sharing utensils)
Bacteria : Common symptoms include diarrhea (>3 loose stools per day); nausea; vomiting; cramps; no appetite. Less common are fever, blood in stool. Serious symptoms include dehydration. The usual course: starts within 2 weeks of ingestion. Lasts 1-4 days
Unfortunately, no matter how obsessive-compulsive you are, you have a good chance of eventually developing traveler’s diarrhea. A recent study compared these fastitious types with more casual travelers (the ones that would still eat ice cubes, etc) — and lo and behold, both groups got equally infected! I actually find this comforting; we should all relax just a bit while traveling.
But of course, it is best to follow some common sense rules:
- Hand washing: this is crucial for everyone, not just the cooks. It is especially important after using the toilet. Far too many Chinese toilets still do not have proper soap and towels, so I always carry around Purell-style alcohol gel. The gel kills germs much more effectively — and much quicker — than soap and water. Keep one in your bag, on your desk at work…
- At home: fruits and veggies — anything that can be peeled, should be! I would not assume that an imported apple would be any safer than local product; there could be pesticides on those, and they traveled long and far to get here. Better to be safe. Leafy greens, especially spinach, should be washed well. I highly recommend the Veggie Wash citrus spray, found in most expat markets. This natural spray kills most bugs and also helps wash off pesticides. As for meats and fish, make sure you cook it well — after inspecting it, and of course after washing your hands.
- Restaurants: Even a 5-star can have infected foods, if the busboy or chef didn’t wash their hands properly. Also, look for the Beijing Health Department sanitation ratings at the front door. It’s usually a big blue sign with letters on it; A is top, B is ok. If you see C or D, then maybe you should think twice before entering.
- Street food: buyer beware! For obvious sanitary reasons, the food here is riskier. Food poisoning is also much more common, especially in the summer months. If any food is left out in the heat for only one hour, the bacteria start multiplying. And where is the cook’s bathroom, or fridge, or cutting boards? Something to ponder…
- Lomotil is the best choice to slow down non-serious diarrhea (aka not bloody). This medicine will slow down diarrhea for almost everyone. But some people don’t like the feeling, and it doesn’t make the infection go away quicker.
- Smecta – charcoal. This powder is usually taken for 3 days; it helps to firm up the stool and also decreases the overall severity a bit — if you can tolerate the taste. There’s a new strawberry flavor for kids and queasy adults.
- Medilac-S: this is “good bacteria”, a powder you put in water 3 times a day. It helps replenish your stomach with healthy bacteria, and also improves overall symptoms and length. Good stuff. Also has a kids version Medilac-Vita.
Nausea: ginger (jiang) is great in any form for nausea and stomach cramps. Mints usually also work well, as do salt crackers. Doctors can prescribe stronger medicines.
It’s important to realize that if you can’t keep any foods down, just drinking water is not enough to stay hydrated; you need salt and sugar as well. The salt packets are best for infants; mild diarrhea in adults usually can be handled with some type of clear broth soup (chicken soup with ginger; miso; wonton), or Pocari Sweat-type bottled waters. Be aware that some juices make your diarrhea more watery.
When To Go To The Doctor
In Your Travel Kit
The second worse problem, when traveling and developing diarrhea, is not to have medicine ready! It’s always a good idea to throw some basics into your carry-on:
- Lomotil (aka immodium) – most important, especially to get you through a long flight
- Antibiotic – it’s not a bad idea to carry either ciprofloxacin or azithromycin. Your doctor will need to prescribe this.
- Others: Smecta (charcoal); medilac; bismuth (Pepto-Bismol)
I created a simple slide show about gastroenteritis, which you can watch full-screen below by clicking on the Menu button:
(Most of this text is a reprint from a year ago here…)
The summer always brings a lot of stomach infections, but fortunately there are a lot of easy ways to treat it — without a visit to the doctor. Below is a slide show on gastroenteritis: the symptoms, treatment, and prevention. It is the compliment slide show to my Illness article on gastro.