Category Archives: Nutrition

Losing Weight: Evidence-Based Advice

In my sixteen years of family medicine, I think the most frustrating disease I treat is obesity. It’s frustrating because as a doctor I feel great compassion for these patients, trying so hard to lose weight, and yet I feel almost shameful that as a primary care physician I can’t offer much in terms of medicines to help. And now that I’m back in the USA after ten years in China, I’m very concerned that America’s struggle is even worse, with more than two thirds overweight or obese. So now, driven to seriously tackle this epidemic, I’ve scoured the literature for the most up-to-date, evidence-based advice on losing weight. Please feel free to print and share this.

Surgery

Let me jump right in to perhaps the most controversial point: I think that many, many more people should consider weight loss surgery. It literally is the most effective way not only to permanently cause weight loss, but it also literally can put diabetes in remission, lower your overall death rates, and lower your heart disease risks. A huge percentage of people can stop taking diabetes medicines after surgery. Don’t believe me? Feel free to read up on it, including a 2015 meta-analysis from JAMA, and the Cochrane library review from 2014. There are three major options:

  • Sleeve gastrectomy: This involves stapling off much of the stomach, leaving around 25% of the stomach. Average weight loss is 56%. This is now the most popular of the three.
  • Roux-en-Y gastric bypass: This is the most radical surgery, with the most complications, but also the most effective, with a weight loss up to 67%
  • Adjustable gastric banding: This involves putting a flexible silicone band around the top of the stomach, which essentially limits intake of food and makes you feel full with less food. The average weight loss for this is 44%, less than the other surgeries, and is now less commonly done.

Of course there are risks to these surgeries, and weight loss is disappointing for many afterwards. But in general, this is a far, far better option than the usual lifestyle struggles leading to maybe 10-20% loss at the most, with many gaining the weight back, and still having diabetes and other diseases. In fact, a recent 5-year study comparing weight loss surgery to lifestyle interventions showed a clear winner in the surgery group, with far more people losing much more weight, as well as putting diseases like diabetes in remission — totally stopping insulin injections and diabetes pills.

I seriously hope many people, especially in the high-risk categories, make an appointment with your local bariatric surgery teams and just talk with them, to discuss your options. If you’re in my Swedish system here in the Seattle area, you can sign up for their weight loss seminar and hear them out.

In terms of who should consider bariatric surgery, the current recommendations are:

  • Everyone — and I mean everyone — with a BMI (Body Mass Index) over 40, even without any other medical conditions, should consider bariatric surgery.
  • Anyone with a BMI 30-40 with diseases such as diabetes, high blood pressure, high cholesterol, sleep apnea, or severe arthritis, can also greatly benefit. Insurance companies usually would cover it if your BMI is over 35.

Do you know your BMI? A BMI over 25 is overweight, over 30 is obese. Here’s a calculator:

[bmi_calculator]

Prescription Medicines

My second main point, and perhaps even more controversial among physicians, is that prescription medicines can also help with weight loss. There now are four prescriptions and one OTC supplement which actually are FDA approved for weight loss, and these expanding choices are encouraging for us family physicians on the front lines. Most work by decreasing your hunger urges. All have side effects, of course, and weight loss varies from 7-12% on average, and people often regain the weight after stopping. But since even a 5% reduction in weight loss can greatly help reduce risks for diabetes, heart disease and arthritis, I think these are definitely worth considering, and I’m using more and more of these in my practice. I strongly suggest interested people (and doctors) read the 2016 meta-analysis in JAMA, comparing all five. The summary graph is here:

JAMA-weight-loss
Source: JAMA. 2016;315(22):2424-2434

The take-home message from this review is as follows:

  • The medicine phentermine/topiramate (Qsymia) is the most effective at weight loss, with side effects in the middle of the pack. This is currently my first choice for many. But one side effect is severe: birth defects, so all younger women have to take birth control and get monthly pregnancy tests while on this.
  • The combo medicine naltrexone/bupropion (Contrave) was less effective than Qsymia, with more side effects, and also some debate about its safety with heart disease.
  • The OTC medicine orlistat (Xenical/Alli) is the least effective, but has relatively fewer severe side effects (stomach issues), and also is the only one available without a prescription. You take it with each meal, and it decreases fat absorption.
  • The diabetes medicine Liraglutide (Saxenda) is second most effective for weight loss, but has the most side effects. But it’s certainly a great option for those who have type 2 diabetes.
  • Lorcaserin (Belviq) has the least side effects but was second to last in effectiveness.

Who’s a candidate for these prescription medicines? The FDA says that anyone with a BMI over 30, regardless of any illnesses, and also those with BMI 27-20 with risks (the usual ones mentioned above) could benefit from trying these medicines, at least for three months to see if you can get to 5% weight loss. If you do, great! Keep going! Hopefully your insurance will cover the cost (many do not).

Besides these medicines, I should also mention metformin. This common prescription medicine for type 2 diabetes also has the great side effect of weight loss, and while the overall loss is less than 5% in the studies, and thus is not FDA-approved for weight loss, it’s still a fantastic first choice for pre-diabetic people who are overweight. The famous Diabetes Prevention Program showed how even after ten years, the overweight group who took metformin 850 mg twice a day had an impressive 18% reduction in developing diabetes. (That’s impressive, but not nearly as impressive as the 34% risk reduction in the group that stuck to lifestyle changes: weight loss of 7%, 150 minutes a week of exercise, and diets focused on fewer calories and less fat.)

Diets

And now we finally arrive at the third controversial issue: diets. There’s so much overwhelming confusion out there, but I like to simplify it a lot by saying that it’s not so much what you eat, but how much you eat. In other words, calorie restriction is key. If you want to lose a pound a week, you need to eliminate 500 calories each day. This is basic biochemistry. (check out your specific needs using my weight loss calculator at the top right of this article). If you can do this daily calorie restriction, especially by decreasing simple carbs, great! Keep going!

But there’s an interesting newer option you may have heard about, called intermittent energy restriction (IER; the 5:2 diet). This has been trendy since 2013, with a BBC documentarybest selling book, and a British study showing how a twice a week regimen of cutting your calories (especially carbs) had similar or better results for insulin resistance and body fat than the group that followed daily calorie restriction. When we fast, even if only for 12-16 hours (nothing between dinner and lunch the next day), insulin resistance improves and fat starts to get reabsorbed. A recent review of all IER studies showed that the evidence for IER is promising — but still premature to fully endorse, with much more to learn about which pattern is most ideal, as well as long-term effects. Also, people who aren’t overweight and are trying this actually have a lot more side effects than benefits.

Otherwise, in terms of “diet”, it’s just overwhelming out there for people searching for the “right one”. An excellent review article this year does detail quite convincing evidence that a low-carb high-fat Atkins-style diet not only reduces the hunger urge, but also has clear benefits in insulin resistance, cardiac markers, and weight loss. The DASH diet really does help to lower blood pressure and weight, and the Mediterranean diet also seems to help with heart disease and some weight loss.

But again, the main issue for all of this diet talk is to focus not on food categories, but food quantity. It’s simple biochemistry: you have to have less energy intake to lose weight. Or you could increase energy output, which leads us to:

Exercise

For decades, the usual doctor spiel is to get 150 minutes a week of moderate exercise. But that hasn’t really translated into any meaningful changes nationally, has it? So here’s where another trendy (uh oh) regimen is gaining popularity, mostly because the growing research is impressive. It’s called High Intensity Interval Training (HIIT), and it basically means you go all out for 30-60 seconds on any activity, getting to maximum exertion, then take a few seconds break, then do another all-out effort, etc etc. You do this 15 minutes tops, twice a week only (typically). Check out an example in the image below from a New York Times article about a 7-minute workout, which I also blogged about in my New York Times column in China. This HIIT routine is great because it requires zero fancy equipment, and you can do it absolutely anywhere. Click here to access the online workout app.

The 7 Minute Workout. Source: New York Times

Supplements, Diets and Herbals:

This topic is actually less controversial for me, mostly because there’s an easy answer: most of those supplements have almost no hard evidence that they work well. I’m not confident enough about recommending any of the trendy ones, and that includes CLA, chromium, 5-HTP, and garcinia. I’m sure many of you are already taking some of these. You’re welcome to read the evidence, including some excellent supplement reviews by the Natural Medicines Database (paid);  The Encyclopedia of Natural & Alternative Treatments (free); The Cochrane Library; and The National Center for Complementary and Integrative Health (NCCIH).

Personally I’d much rather have my patients focus not on supplements but on calorie restriction. I’d also rather give them one of the prescription medicines above, which all have more evidence than any supplement.

If you must choose a supplement, at least you could try that OTC Orlistat with meals. And you could also consider soluble fiber such as blond psyllium. Used especially for constipation, it also helps lower cholesterol, control diabetes a tiny bit, and also help a bit with weight loss. You’d take it with food, and it absorbs fat from that meal. In fact, it’s now recommended that Orlistat users also take blond psyllium with each dose of Orlistat, as it prevents some of those unfortunate gastric effects.

Yogurt is also one of my favorite recommendations, not just for the way the probiotics help our microbiome and immune system, but also because the literature shows that yogurt helps to manage weight loss and waist circumference. I actually prefer higher fat than the low fat versions, and adding fresh fruit to non-sweetened yogurt is a great way to start your day. Add a pack of instant oatmeal, microwaved with soy milk, and you’ve got a healthy and filling breakfast.

Stand Up!

Did you know that sitting all day at work literally is harmful to your health? Recent data, including this 2015 meta-analysis of sedentary lifestyles, shows that the more you sit, the higher your risks for heart disease, obesity, diabetes and overall death rates. I just ordered a standing desk for my office! Here are more tips on how not to be a couch potato.

Use Smaller Plates

Americans definitely have suffered “portion distortion” over decades, as sizes for all types of food creep up and up. Remember how soda machines used to carry 12 ounce cans, and now all have 20 ounce bottles? How about a small popcorn at the movies? If we can’t control these external factors, at least at home we can control portion size, and one interesting step is to replace all of your usual large dinner plates with smaller plates, like the appetizer or salad plates. Recent studies, including the 2016 meta-analysis, do show that when people switch to smaller plates, they actually eat less. How easy is that?

Keeping It Off

It’s actually not super hard to lose weight — it’s keeping it off that’s the problem for most. Unfortunately, that’s a totally normal problem because our “hunger hormones” ghrelin and leptin reset to a new balance when we gain weight, and when we lose that weight, that hormone imbalance doesn’t reset well to the lower weight, and it thinks “I’m starving!” and compels you to eat more. Some tips to control this include healthy carbs, fiber, yogurt and protein (and not a high fat diet). Also, getting a good night’s sleep literally helps to reset those hunger hormones (that’s one reason why people with sleep apnea are at risk for gaining weight).

And for those who are in the higher obese categories with BMI over 35 or 40, gastric bypass surgery actually can permanently improve some of that hunger urge. How? Removing the top of the stomach in these surgeries removes the stomach tissues that secrete grehlin; less grehlin = less hunger signals = less eating = weight loss. That’s another important reason why I urge people to consider weight loss surgery.

My Bottom Line

After writing this article, I personally feel much more empowered as a doctor to help my patients lose weight. There are a lot more options than I had realized, and I’m definitely giving all of my overweight patients this article, and I look forward to working closely with my patients to help them lose weight in a healthy and permanent way. And hopefully I’ve helped you, as well!

Good luck!

COMMON COLD REMEDIES: WHAT HERBALS WORK?

Isn’t it humbling that we have no cure for the world’s most common illness? Yes, the common cold, globally the #1 cause of sick days and doctor visits, still stampedes across the world, blissfully immune to any Eastern or Western prescriptions. As a family doctor, I’m always a bit frustrated that I can’t offer much to these patients, at least in terms of Western allopathic medicines. So, I decided to scour the literature again to see if any new research has shown benefits from herbals and supplements. And the good news is yes: there may actually be a couple of supplements which can help you get better, quicker. Here’s my advice below. (Please note that this research is for treating, and not preventing, colds and flu.)

Evidence-Based Literature Search

When it comes to supplements and natural therapies, I use only a tiny handful of resources that I consider trustworthy. All are certified by the Health on the Net Foundation as sources of trustworthy medical information. All these sites would review only the best, most unbiased research, which usually means the gold standard of all research: placebo-controlled, randomized controlled trials. I strongly recommend that everyone use HONCode’s search engine anytime you’re looking for medical advice, especially regarding supplements. For example, you’ll never see the anti-vaccine snake-oil salesman Dr. Mercola on their list. Here are my favorite medical resources, and their evaluations of therapies for the common cold:

Cold_symptoms_cdc
A graphical image and time line for cold symptoms. Note how the cough is always the last to improve…

Let’s break it down into the supplements that have the most evidence:

  • Zinc: This seems to have the most support, especially higher doses (>75 mg daily) of lozenges containing zinc gluconate or zinc acetate. Some good studies show reduction in cough, runny nose, headache, sore throat and overall time of illness. But side effects are common, especially nausea and a bad taste in the mouth. Also, definitely do not do the zinc nasal sprays, which have clear evidence to permanently cause loss of smell. The data suggests you should stick with lozenges and not pills. I see a few brands of logenzes up to 30 mg each, which at three times a day would help. I see a few popular brands with only 5 mg zinc each, which seems far too low to work. I wouldn’t advise using these for children.
  • echinaceaEchinacea: This is probably the one you’ve heard about, and the evidence is encouraging — but not totally clear. Some “double-blind, placebo-controlled studies have found that various forms and species of echinacea can reduce the symptoms and duration of a common cold, at least in adults. The best evidence is for products that include the above-ground portion of E. purpurea rather than the root.” But it’s very difficult for me to recommend a proper dose, as studies have used multiple regimens via drops, pills and teas, also using many types of echinacea, as well as different combinations of root and plant. Here’s a useful list of test results from ConsumerLab showing which brands in the USA have proper amounts of the herb.
  • andrographisAndrographis peniculata: An Indian herb very popular in Ayurvedic medicine and now in Europe, I think this actually has some good evidence.  A handful of double-blind, placebo-controlled have shown benefit in reducing the duration and severity of cold symptoms, especially cough. An excellent meta-analysis of herbals from Germany showed significant improvement in severity and duration of a cough, especially via liquid formulation. The usual dose seems to be 48-500mg of the andrographolide aerial parts, usually divided three times a day. You can find a good list of andrographis brands on iherb.com. I keep reading about a Swedish patented combination with eleutherococcus and sambucus (Kan Jang Plus), but I don’t see it sold anywhere in the USA.
  • pelargonium-409238_960_720.jpgPelargonium sidoides (Umckaloabo): This is an interesting herbal, very popular in Europe and perhaps should be more popular here in the USA. That same German meta-analysis I mentioned above found strong evidence that it helped with cough, fevers, and sore throat — including for children as young as one year old, although the German independent Institute for Quality and Efficiency in Health Care says it shouldn’t be used for children under six years. The Cochrane Library also reviewed this herb and concluded, “P. sidoides may be effective in alleviating symptoms of acute rhinosinusitis and the common cold in adults, but doubt exists.” As with andrographis, the liquids and syrups were better than tablets. I see on iHerb a series of pelargonium products called Umcka with good reviews.
  • Probiotics: Probiotics actually have pretty good evidence that taking them for months, especially over the winter, can markedly improve both the frequency and the severity of colds — for kids and for adults (as does vitamin D). That’s great news! But for symptom relief during a cold, the evidence is much more scant. I couldn’t find one good study for this; none of the groups above recommend probiotics as treatment.
  • Vitamin C: Here’s another super popular supplement, which many people swear by. But again the evidence isn’t conclusive, and the few studies that do show a benefit show only mild improvement. Still, at least it seems safe for adults and children, and evidence is even stronger as a preventive during the cold seasons.

cold-1974481_960_720

My Bottom Line

For immune boosting,  don’t forget the most important advice: get a good’s night sleep; eat a lot of anti-oxidant foods; and stay well hydrated.

In terms of supplements, I think it’s appropriate for adults (not kids) to try some of the above supplements — and the sooner, the better, within 24 hours of your symptoms starting.

For what it’s worth, here’s my plan for myself and my wife the next time we get a cold: we’re going to continue our usual vitamin C + zinc bursts, usually using Airborne effervescent tablets, three times a day. Emergen-C and Wellness Formula also are similar, all three with a ton of vitamin C, some zinc and an assortment of herbals, many of which are mentioned above. I’m also adding andrographis 400mg twice a day and also pelargonium; and I’ll continue doubling up on my probiotic supplement, despite the lack of evidence. (One small note: last week my wife tried andrographis for the first time and had a horribly itchy rash for days. I was fine.)

In general, for children, I’m still hesitant about using any of these herbals for children under 6 years old, and I remain cautious about what I use with my own kids, both under 4 years of age. I still like probiotics during a cold, and I’m a big fan of honey for cough for all ages above one year, which studies show works better than any OTC syrup. I’m encouraged with the European studies using pelargonium and also ivy/primrose/thyme syrups, some of which are partially included in American brands like Zarbees. For more age-specific advice, please look at the recommendations in my previous article about curing a cough.

What herbals and supplements have you used? Please leave comments below.

Diabetes: An Avoidable Lifestyle Choice

I’ve been a family doctor for fifteen years, and one of the more dramatic changes I’ve noticed is a big spike in the incidence of prediabetes and diabetes, in all age groups. I had worked in China for ten years until last summer, and all us family doctors at my Beijing clinic weren’t surprised at all with the 2013 paper published in JAMA confirming the frightening reality in China: more than half of all adults in China now are prediabetic. Even worse, 11.2% have diabetes, giving China the dubious distinction of having the highest prevalence of diabetes in the world — higher than in the USA, an extraordinary statement given the far higher rate of obesity in the USA. As tomorrow, March 22  is American Diabetes Alert Day, I felt a timely urgency to share my advice on how to avoid this disease – or at least to slow it down.

It helps me to think of diabetes as a modern lifestyle disease, mostly caused by all developing countries’ gains in weight, less physical activity, and changes in diet. Diabetes now is a global pandemic. Tens of millions of people have diabetes, and many people are undiagnosed because they’ve never been tested. There are two types of diabetes, and type 2 diabetes accounts for 90 to 95 percent of diagnosed diabetes in adults.

Prediabetes concerns us doctors because it means you are at extremely high risk of developing diabetes in the next few years. Studies show that a prediabetic person has a 25% risk of developing diabetes within three years, and a majority within ten years. The greatest risk factor by far is overweight and obesity. Having a BMI under 23 is ideal, and a BMI of 25 increases your lifetime risk of diabetes by 600%. A BMI of 30 increases your risk by 4,000% — that’s 40 times the risk! That’s an extraordinary number which should worry us all, since in the USA over two thirds of adults are overweight and over a third are obese.

But here’s the good news: the crucially important message for everyone is that you have great control over whether or not you develop full diabetes. You should think of prediabetes as an early warning sign by your body, a major wake up call that whatever you’ve been doing to your body isn’t too healthy. Most people with prediabetes fit one or more of these three major risk factors: body mass index (BMI) over 25; lack of enough exercise; and unhealthy food choices as well as portion sizes.

So let’s say that you’re one of the many people who has prediabetes: what can you do right now to help? If you follow the three lifestyle steps below, you can lower your risk more than half! One of the most important public health research studies ever, the Diabetes Prevention Program, proved that lifestyle changes worked better than pills in reducing progression to diabtes. Lifestyle changes lowered a prediabetic person’s risk by 58% over three years — much better than the 31% improvement with a daily pill (metformin).

So what are these magic steps? Without further ado:

  1. Lose weight. Weight gain and obesity are the top causes of type 2 diabetes, and losing weight is now proven to be the most effective prevention. In the DPP study, the goal was to lose at least 7% of your body weight. Your goal should be to lose 5-10% of your body weight.
  2. Exercise. Exercise may not directly cause much weight loss, but exercising muscles absorb sugars much more effectively. This is why exercising is crucial to help control sugars, both in a prediabetic as well as in diabetics. How much exercise is enough? We usually recommend 150 minutes a week of moderate exercise, but any amount is better than nothing. Also, as I mentioned in an earlier column, shorter, more intense workouts can help as much as moderate exercise.
  3. Proper diet. Healthy food choices also are crucial to control your sugars. One of the most common misperceptions about diabetes and prediabetes is that it’s “a sugar problem” and you must cut down on sweets and desserts. The bigger culprit are total starches — pastas, breads, rice and potatoes. In all these cases, processed versions are never as healthy as the originals.

Here are a few quick tips on nutrition:

  • Brown is always better than white: Processed white bread and flour have lost all the nutritious fiber which helps regulate your bowels as well as your sugar spikes after a meal. If you love your carbs, at least try to switch to whole wheat pastas, breads and rice.
  • Portion control: Total calories are also important, as most likely you are taking in a bit more than you realize. These extra calories will get deposited as fat, which leads to more risk of diabetes.
  • Cut back on sodas, beer and juices: All of these are empty calories, full of processed sugars which stress out your liver and pancreas. These unhealthy carbs, especially in sodas, are a major cause of obesity and diabetes in both children and adults.

Type 2 diabetes is partly genetic, so no matter how healthy you are, it still may be inevitable. But these above steps are always good advice for all of us. Another great thing about these healthy life changes is that they also dramatically reduce your risk of heart disease, many cancers, and early deaths from all causes.

Don’t get discouraged — you have control over the next steps!

 

This post was originally published on my new blog atMyFamilyHealthGuide.com. Please follow my new blog! (and my Facebook page

Safe Salmon in China? Yes!

 

I love the unique taste of salmon, which is fortunate for me as it’s truly one of nature’s superfoods. Salmon is packed with heart-healthy omega-3 oils EPA and DHA, protein and vitamin D and also is low in dangerous metals such as mercury. I oftentell people to eat oily fish such as salmon at least once a week to dramatically decrease their risk for heart disease. A 2006 review study in JAMA  shows that a daily dose of only 250-500 mg of omega-3 fatty oils can lower your risk of sudden death from heart disease by 36%, and from all-cause mortality by 17%; more than 500 mg daily actually provides very little extra benefit. And as 100 grams (3 ounces) of farmed salmon has over 2 grams of omega-3 (more than wild salmon has), even one serving a week may be enough because the healthy oils can remain in our tissues forweeks. This is all great news, right? But when I tell my patients in Beijing this fantastic news, they usually reply the same way: “I’d love to eat more fish here, but I never know which store I can trust.”589px-Salmon_sashimi

When my wife and I first arrived in Beijing nine years ago, we first bought our fish and other meat from the large international supermarkets Carrefour and Walmart, mostly because we assumed (for better or worse) that these stores would have superior quality control and safety standards, especially with imported foods. And that worked well for many years, especially as these markets slowly started to sell more organic options. Later on, we discovered the German-run Metro 麦德龙 hypermarket, and we immediately switched almost all our meat and produce purchases there, due to their outstanding logistics and traceable food chain. In other words, we trust them, and trust is a really big deal here in China. Metro’s salmon is mostly from farmed ponds in Faroe Island, a very safe area in the north Atlantic which is antibiotic-free and also certified by the non-profit Aquaculture Stewardship Council (ASC). Ikea, just up the street from Metro, also has an impressive selection of imported frozen salmon from Scandinavian waters, again all certified by the ASC or MSC (Marine Stewardship Council), and at very reasonable prices. Both stores sell their salmon for ~60-70 RMB/500g. So for those of you who don’t trust your fish in Beijing: there’s my answer.

omega-3 Fatty Acid Fish Safety Doses
Comparison of omega-3 and mercury levels in various fish

We still love Metro and Ikea but our #1 choice now for salmon is the monthly group buy, called GroupBuyByBianca, organized by the staff formerly from the Chef Too restaurant. Once a month they’ll trek to Beijing’s wholesale fish market; choose farmed salmon from Norway, Canada, or Faroe Island; de-bone and vacuum pack and then deliver to your door in chilled containers. It’s a fantastic service, and we usually get half a salmon every couple of months which we store in our freezer. Bianca and the team also sell imported cod and other meats in season. To sign up and order, follow their WeChat ID “GroupBuyByBianca” or email [email protected]. The cost depends on market prices but recently is usually ~45RMB/500g plus 10% and a flat 65 RMB processing fee.

Our other newer options for buying fish and meat are again online. The first is the wonderful local organic farm TooToo, which I’ve mentioned before as a very trustworthy, internationally certified local organic farm with a terrific distribution chain, easy online payment, professional delivery service and unbeatable value of organic produce. It’s an awesome resource for Beijingers — plus their website at tootoo.cn has English and Chinese! You can buy 200g bags of Norwegian salmon for 36-50 RMB each. Besides salmon, they now offer a large selection of meats from many different sources — check out their long list of imported fish here. We’ve had particular success with shellfish from Europe — mussels from Scotland and shrimp from Ecuador were delicious.

 

Where? Cost (RMB) per jin Notes
Ikea 69/500g ASC certified, Atlantic
Metro market 60-70/500g ASC (Faroe Island: Bakkafrost)
Carrefour market 128/500g Faroe Island
Jingkelong market 78/500g
Tootoo.cn online store 90/500g (36 RMB/200g) Norway
Group Buy by Bianca ~70/500g (~95/kg+10% + 65RMB) Farmed: Faroe Island, Norway or USA
April Gourmet 123/500g (245/kg) Norway

 

Besides TooToo, there are now a bewildering number of players in China selling foods online via apps and websites, with ridiculous amounts of investments from all the big internet players and finance companies. One such store my wife uses often is called yiguo (易果) at yiguo.com. We liked them initially for their imported fruits but they also have a decent selection of meat, including a special section for imported beef. Other large sites like yihaodianWomai and JD.com’s grocery store are notable because they both have their own supply chains and distribution centers, which in theory could provide consumers better quality and more traceable products (with quicker deliveries, I’ve noticed). Amazon China also has their own online grocery store. All of these e-markets carry a big selection of imported foods of all types, far more than you would ever see in any local market.

Many expats get their salmon and meat from the small international markets such as April Gourmet or Jenny Lou’s, and that’s fine of course, and it’s certainly convenient for many on the way home from work. I just think the prices can be a lot higher than other options (see the comparison chart below), and I also worry about low sales volumes in small markets in terms of food safety. Many people also buy salmon at local markets like the popular Sanyuanli market, but I personally feel they have extremely inadequate food safety there; most vendors’ meats sit in the open air at room temperature, uncovered, on wooden slabs, with flies buzzing around. Do I really need to break down how many violations of basic food safety I just mentioned in that one sentence? I wouldn’t recommend buying meat from any market anywhere in the world if it’s sitting at room temperature for more than two hours.

ikea-salmon
Notice the ASC certification label…

Besides making your own salmon, eating in restaurants is definitely the next best option. All you sushi lovers can easily get your weekly omega-3 fix with even a few slices of salmon. Beijing is blessed with plenty of excellent Japanese restaurants and salmon dishes. Our favorite sushi place is a small Japanese market called yuqing (鱼清) just next to Yotsuba along the Liangma canal waterfront across from the Four Seasons Hotel; you can choose your raw fish from their shelf and the chef will prepare it right there for you to eat in the store.

What about the big percentage of readers who take a daily supplement of fish oil, including myself? This indeed has been long recommended even by the American Heart Association, but unfortunately the most recent studies, much larger than earlier studies, disturbingly show very little benefit from the supplement. There must be something else besides omega-3 in the actual fish that provides the heart-healthy benefit. Anyway, when my supply runs out, I won’t be continuing that anymore.

So there you have it; I hope I’ve convinced some of you that healthy fish = healthy heart. And for Beijingers, it’s not nearly as hard as you may have thought to add safe salmon into your diet, even at a reasonable price. For those of you in China out of the tier one cities or not near a good market, now there are plenty of online options to get salmon delivered right to your door. If you’re really worried about trust, sustainable fishing, and seafood free of chemicals and antibiotics, just stick with vendors that have ASC, BAP or MSC certification stickers on the fish packaging — Ikea and Metro would be your safest bets.

In terms of general value, here’s a nice graph from the JAMA review showing relative money spent on different types of fish to get your daily 250 mg of omega-3:

Estimated Costs of Consuming the equivalent of 250 mg/d EPA + DHA From Fish

 

Have A Happy — and Healthy — Chinese New Year

Asian Family Having Breakfast Before Husband Goes To Work

This week’s Spring Festival will be my eighth here in Beijing, and Spring Festival Eve is always one of the highlights of my year. My wife and I spend a wonderful evening with our Chinese in-laws, and all two dozen of us will gorge for hours on endless rounds of dumplings and snacks, drink all types of alcohol and juices, and happily shout at the TV screen as another awful performer lip syncs yet another tacky ballad.  Just before midnight we will all rush to the rooftop and spend the next hour in awe at the lightshow and sound spectacular coming from every corner of Beijing. It’s difficult to describe to people back in the US just how impressive Spring Festival is. It’s like a combination of American Thanksgiving, Christmas and the Fourth of July — only much, much more intense, and lingering for a couple weeks, fading away with one last blast on Lantern Festival.

Chinese New Year Spring FestivalOne of the major connections, unfortunately, between Chinese Spring Festival and the American holidays is the habit of ending these festive days slightly heavier and more unhealthy than when we started. So let’s continue another annual tradition: news media filled with warnings by nerdy doctors like myself lecturing their readers to not have any holiday fun. So I now shall try the difficult task of balancing health advice while not ruining your party. I could just say “everything in moderation!” and send you on your way to the supermarket, but I would like to make a couple points first. So please bear with me, and I’ll reward you with a cookie at the end. Or maybe just a sticker.

I think it’s important to step back a bit and make sure everyone realizes that the main killers and causes of disability across both China and the USA are cardiovascular disease, especially heart attacks and strokes. And for many reasons, the situation in China is more serious, according to the World Bank’s fascinating report from 2011 regarding the global burden of disease in China. They report that the average Chinese person can expect to live only 66 “healthy years” (years free from disease and disability), which is ten years less than in some leading G-20 countries. Strokes, in particular, have “the largest health and well-being impact on an individual.

I find these statistics alarming, but in my talks with my Chinese patients, most have no idea about this data. Nor do they know about the report’s other warnings that Chinese eat an astonishingly dangerous amount of salt every day, more than 12 grams on average, which is more than twice the recommended maximum amount. The World Bank calls excess salt, “by far, the most prevalent modifiable risk factor for non-communicable disease in China.” Too much salt is one of the major causes of high blood pressure and strokes, and lowering salt intake across China would probably be one of the quickest and most cost effective measures that public health groups could tackle. Most of this salt comes from processed foods such as instant noodles as well as the incredible variety of sauces in China.

How does all this tie in to Spring Festival Eve?  The great majority of us survive the holiday fun just fine, but what I mostly worry about are the well documented spikes in heart attacks and strokes after classically large meals such as American Thanksgiving and Chinese Spring Festival Eve. Emergency room doctors in both countries report spikes in patients during these holidays, for a multitude of illnesses mostly traced back to indulgence with food and drink. Many of these high salt foods are eaten in abundance during the Spring Festival revelries. A large dose of salt can easily raise your blood pressure and lead to strokes and heart attacks in those of us at most risk for heart disease. Also, this salt infusion makes all of us retain water, which inevitably leads a few people into congestive heart failure, heart attacks and strokes.

One of the great tragedies of these holiday parties is that all of us are trying to relax and have a great time with our families and loved ones, and the last thing we want to do is to ruin the party. Therefore, some people may actually be having a heart attack during the meal, and they will ignore the pain so as not to upset the others, trying to wait until after the party is over to get some help. Another group will feel the chest pain but mistake it for a stomach problem such as indigestion or heartburn, and they will show up the next day in the doctor’s office or the emergency room with “really bad heartburn” which actually is a half-day old heart attack.

Family enjoying Chinese meal in traditional Chinese clothing

So if you have to absorb just one party-pooping take-home message from me today, it’s this: if you feel pressure or pain around your left chest during the party, especially if this pain radiates into your jaw or left arm, please do not ignore it until the next day. I’m deadly serious: if you truly are having a heart attack, then you need to be having emergency treament at your local hospital within 90 minutes to three hours, otherwise your survival rate starts to drop dramatically. Time is crucial with heart attacks, and your heart’s muscles are being starved of oxygen and need treatment ASAP, otherwise the muscle tissue may die forever — and so may you. Trust me, your relatives would much rather have you ruin the party and stay alive than be the life of the party now but dead tomorrow.

OK, everyone, go have fun! Here, have some more Coke with your third plate of dumplings. Don’t worry, these ones are vegetarian.

Perhaps I should have stopped earlier when I told everyone the horrible cliche, “everything in moderation”, because that actually is the obvious answer to avoiding this above dilemma. Hopefully the people cooking the holiday foods can try to use healthier oils and lower salt sauces, especially soy sauce, which is probably the easiest to find. And maybe the host can put out their smallest kitchenware, since it’s been proven many times that people eat less and feel more full when they use smaller plates, bowls and cups.

Otherwise, the rest is up to each of us and our self control when faced with bounty. I’d like to add some tips from my family medicine colleage Dr Liang Lijun (梁立筠), who also has a masters degree in nutrition and public health:

On the day of a big evening gathering, wake up at a reasonable time, eat a satisfying breakfast, and exercise so that you are not so hungry by dinner time. If you really want to be health-conscious, survey the table, choose a colorful palette of foods to eat, and try to eat the healthier foods first. This way you leave less room for oily, rich foods that are sure to tip the bathroom scale. Also, be wary of drinks, which can contain a lot of hidden calories. Try to make sure you prepare some tea (flower tea is best) to drink, or choose wine over cocktails and beer. And, perhaps most importantly, eat slowly, pause often to enjoy the conversations flowing around you, and do your best to remove yourself from the table when you’re full.

I will be the first to admit that I’m terrible at self control, and it takes me weeks to work off the excess holiday weight — an increasingly losing battle. And if I added up my total calories from my usual Thanksgiving meal, I’d probably have a heart attack just from the sticker shock. But I hope some of these recommendations can help some of you to take action, ensuring that you continue to enjoy Spring Festival with your loved ones for many more years.

 

This article is a reprint from 2013 — with Chinese versions on my New York Times column and my book. Happy new year!