Category Archives: New York Times

This is my collection of articles from the New York Times China edition, where I had a health column during 2013-2014. My articles are translated into Chinese from the originals here. The Chinese versions are found above under 《纽约时报》中文网撰稿

What’s The Best Bedtime For Kids?

baby sleeping on big pumpkin

A good night’s sleep is crucial for all of us, but especially for children. My Alex is now 17 months old and is pretty good with his routine, being put to bed at 8 pm and usually waking up around 7:30 am. Along with a nap or two, he easily gets his recommended 12 hours a day of sleep. But our upstairs neighbors’ toddlers are bouncing on our ceilings until at least 10 pm most nights. Many Chinese parents tell me their child goes to bed at 9, 10 or even 11 pm — much later than the typical children of my expat and American colleagues. What explains this cultural difference, but more importantly — is either one healthier for a child?

One study from 2005 confirmed my personal observations that Chinese children not only go to sleep later than American children, they also wake up earlier. This comparative survey showed that Chinese children in elementary school sleep a full hour less than American children (9.25 vs. 10.2 hours); more worrisome were the Chinese children’s complaints of daytime sleepiness.

The main issue isn’t so much what time your child goes to bed: more importantly is their total amount of daily sleep, including naps (which very few children over five years take). Sleep research has shown that preschool-aged children need 11-12 hours, while school-aged children need at least 10 hours, and teens need 9-10 (infants need 16-18, and adults need 7-8). If your five year old is going to bed at 9:30 and waking up at 6:30 and already no longer takes naps, then their 9 hours a day of daily sleep isn’t enough for their long term health.

One of the main problems with insufficient sleep is the daytime sleepiness, an obvious consequence of not sleeping enough. A fascinating series of tests in children in China just published this year showed that insufficient sleep and daytime sleepiness both lead to worse school performance. Most of these children went to bed at 9-9:30 am and almost all got up at 7 am, causing a daily sleep debt of 1/2-1 hour for many children. While that may seem like a small amount, like any debt, it must be paid back, and most children cannot recover all of this lost time by sleeping late on weekends. Over time, this cumulative sleep deficit causes problems with attention spans, motivation, and also achievements on tests. Researchers hypothesize that the brain’s prefrontal cortex, which processes attention, creative processing, motivation, and abstract reasoning, is especially vulnerable to poor sleep. They conclude that “our results provide a cautionary tale for the practice in Chinese society that children spend a lot of time on studies even with the sacrifice of sleep time.”

One good bit of news from the same study describes how delaying school start times even by just a half hour can significantly improve sleep duration and daytime sleepiness. In their interventional study with six primary schools in Shanghai, delaying school openings from 7:30 to 8 or 8:30 gave the children almost an hour of extra sleep — and more importantly, less complaints of daytime sleepiness. This fits with studies in other parts of the world and supports the growing movement, led by pediatricians, to delay school opening times to 8:30 am. Just doing this could allow better sleep and improved test scores for all students!

Besides school performance, poor sleep also leads to an increased risk of overweight and obesity in children (as well as adults). A 2007 meta-analysis of 36 studies across the world showed a strong, independent association between short sleep duration and weight gain in children, which continues into adulthood. One study of 500 adolescent twins in Anhui, China showed an association between less sleep and more weight gain. Another survey of over 4,000 children in rural northeast China found that obese children were more likely to have insufficient sleep (less than 7.5 hours, including naps). While this isn’t a cause-and-effect, the association certainly is worrisome. There may actually be a physiological base to this, as research shows that inadequate sleep causes changes in the hormones which control appetite. Less sleep leads to less leptin and more grehlin, which increases our instinctive hunger reflex. Since the obesity rate in Chinese children is rising alarmingly, I think all parents at least should consider proper sleep in this context.

I can’t control the noisy kids upstairs, but in my own home I’m happy that we’ve taught Alex good sleep patterns, and we have plenty of leeway for 8:30 or 9 pm times if needed, all the way until his teen years. And when we choose schools we would definitely consider later start times as a positive factor.

 

Can E-Cigarettes Save Your Life?

secondhand smoke electronic cigarettes
One of the most challenging patient encounters for any family doctor is a discussion with long term smokers about quitting. Not because we don’t realize how bad smoking is — of course both doctor and patient know it’s a deadly habit. But it truly is very difficult to quit, no matter what we doctors say or offer. We try this and that, and patients quit and often restart, and the cycle of addiction continues. That’s why any new treatment that can really help the world’s smokers — who include more than half of all men in China – to quit smoking would be a medical miracle.

Enter the electronic cigarette, the battery-powered contraption that allows people to smoke tobacco-free, by vaporizing liquid nicotine and other additives. Though they still account for just a tiny sliver of the market in most countries, e-cigarettes have begun to explode in popularity over the last couple of years, including in China, where the vast majority of e-cigarettes are assembled. The controversy surrounding the product has erupted in turn. Are they a miracle, or a mirage? Any casual reader of the news knows that there’s a massive worldwide debate among doctors and public health experts regarding e-cigarettes. Many experts argue passionately they should be made available to all. Others say that the potential health risks have yet to be fully understood and that they should be treated just like a regular cigarette, to be regulated or even banned pending further study. I stand in the pro-e-cigarette corner — for now, at least — provided the production, distribution and marketing of the product is properly monitored and regulated.

The first job of a doctor is to “do no harm”, and can we reliably say that electronic cigarettes do no harm? There is far from a medical consensus on this, and the World Health Organization finally added their input just this month in their new report, calling electronic cigarettes an “evolving frontier filled with promise and threat for tobacco control.” They find “currently insufficient evidence to conclude that e-cigarettes help users quit smoking or not.” They also strongly urge regulations to protect children, including severe restrictions on advertising as well as any flavoring or packaging which is proven to be attractive to children.

I do agree that e-cigarettes do present some potentially serious reasons for concern. Children can accidentally drink the nicotine liquid they contain, causing serious stomach problems, even though responsible parents already know that any potentially harmful chemicals should always be locked away from children. I’m also worried that more and more teenagers are starting to think that e-cigarettes are cool, especially based on the advertising. More than 260,000 American youths who had never smoked a cigarette before tried e-cigarettes in 2013, according to a U.S. Centers for Disease Control and Prevention study published in August, up more than three-fold from about 79,000 in 2011. But a reassuring new survey from the UK’s public health charity Action on Smoking and Health (ASH) shows that the vast majority of children trying e-cigerettes also are smoking regular cigarettes, and 98% of children who have never smoked at all have still never tried an electronic cigarette.

Many critics of e-cigarettes have focused on this potential problem with children, but the fact remains that right now, tens of millions of chronic smokers worldwide are at great immediate risk of health problems. Here in my family medicine practice, when I have a patient in front of me with a 30-year history of smoking a pack a day, I am acutely aware that this person has just crossed a very dangerous medical milestone. Such 30-pack-year smokers have such a greater risk for cancers, heart disease and all-cause mortality that the US Preventive Service Task Force now recommends that all such smokers get an annual chest CT to look for lung cancer . I have a professional and ethical obligation to try everything to save this person’s life, and I would recommend that they try any means possible to quit — including e-cigarettes.

Girl Holding Traditional And Electronic Cigarette

The anti-e-cigarette crowd will often say that data on the health effects is poor, and it’s true that until recently there were few strongly designed studies. But now there are a couple of better studies called randomized controlled trials, and we should re-examine our previous stances based on this new, firmer evidence.

The first, called the ECLAT study, was published in the scientific journal PLOS ONE in early 2013. It followed 300 smokers in Italy for one year, giving them three months of different nicotine doses of e-cigarettes. None of these smokers initially were interested in quitting smoking. At the end of the twelve month study, 13% of the higher-dose group had quit, compared to 9% from the lower-dose group and 4% from the placebo group. Also, the great majority of quitters (73%) were no longer using their e-cigarettes, which I find a reassuring argument against those who fear that smokers will replace one addiction with another.

An even better research trial was the ASCEND study, published by the medical journal Lancet late last year, which finally gave us data comparing e-cigarettes to nicotine patches, a commonly used therapy to help people quit smoking. In this randomized controlled trial of 657 smokers in New Zealand, 7.3% of the e-cigarette users stopped smoking at 12 months, a better result than the 5.8% in the nicotine patch group (and 4% in the placebo group). Nicotine patches are notoriously unhelpful for most of my patients, and this study suggests that e-cigarettes may be more useful than patches, which should be welcome news to all doctors on the front lines of this battle against smoking.

Besides those two trials, a few review articles published in these last few months also add much needed intellectual weight to this important debate. One review just published last July in the medical journal Addiction concluded that e-cigarettes “are likely to be much less, if at all, harmful to users or bystanders” than cigarettes. Another systematic review just published last March concluded that, “electronic cigarettes are by far a less harmful alternative to smoking and significant health benefits are expected in smokers who switch from tobacco to electronic cigarettes.”

In terms of public health impact, I generally agree with the recent comments from the European Journal of Public Health, stating in an editorial that ” it is simply too early to know” exactly how effective or safe are e-cigarettes. But they also stress in a quote: “As nicotine addiction expert Professor Michael Russell wrote in 1976, ‘people smoke for the nicotine but they die from the tar’. E-cigarettes deliver the nicotine without the tar, as their use involves no combustion. Common sense therefore dictates that e-cigarettes are significantly less harmful than cigarettes, and for the individual smoker who cannot or does not want to quit, there is little doubt that switching to e-cigarettes will be beneficial.”

If we limited use of e-cigarettes only to smokers trying to quit, then we could probably save many of the six million annual deaths worldwide from smoking. However, I am very uncomfortable with e-cigarette companies’ aggressive marketing campaigns on TV and other mass media, often targeted to youth, trying to make them hip and cool. It brings to mind the infamous Joe Cool advertising campaign from 1987-97 which attracted many new smokers to the Camel brand, and made Joe Camel as recognizable as Mickey Mouse among six year old children. If a certain percentage of people who never considered smoking suddenly try an e-cigarette and then move on to real cigarettes (the “gateway drug” theory), then the long-term risks could outweigh the benefits.

Because of this, I do think that governmental health authorities should regulate the marketing as well as availability of e-cigarettes, particularly as it concerns minors. I think they should be locked up right next to the nicotine patches on the shelves in all pharmacies, with proof of age over 18 required to purchase them. And I certainly think almost all types of advertising should be banned, as well as limits on the kid-friendly flavoring and coloring. But I don’t think regulation should go overboard, by requiring a prescription for it, for instance. I also feel it’s counterproductive to ban e-cigarette use in all public places, but perhaps for now such bans aren’t totally unreasonable, as we wait clearer data on risks.

I should disclose here that I am an occasional fan of smoking mini-cigars, and last year I bought an electronic pipe for myself, mostly to satisfy my craving for the nicotine rush without reaching for a real cigar. So I can personally empathize with a smoker’s addiction, and I understand firsthand why e-cigarettes can be successful in a way that a nicotine patch will never be: they still allow you that habitual sensation of smoking — holding, puffing, seeing the smoke — without nearly the same severe health risks to yourself and to others nearby.

Some people argue that you’re replacing one addiction with another, and I have two things to say to that: first, the trial above proves that only a small percentage of quitters continue to use e-cigarettes. Second, and more importantly: I would much rather have any smoker hooked on nicotine via an e-cigarette than from continuing to burn tobacco. Again, I can’t stress this enough: nicotine itself does not cause cancer or any chronic lung or heart disease. ‘People smoke for the nicotine but they die from the tar’, as Dr. Russell said four decades ago.

Let’s go back to my title, “can an e-cigarette save your life?” If you’re a smoker for many decades and you now switched completely to e-cigarettes, then yes, you may have just saved your life. If only 10% of all smokers in China switched to e-cigarettes, that could save countless thousands of lives every year.

If a series of new studies comes along that proves that long term risks actually are worse than benefits, then I will reassess my position. But for now, I will continue to endorse this therapy to my patients. I believe it would be unethical not to.

 

Chinese translation of this article is available in my health column in the New York Times China edition

UHT Milk: Is It Safe — and Nutritious?

uht

When I moved to China eight years ago, I was quite shocked at seeing milk in small boxes piled high on store shelves — at room temperature! With expiration dates longer than six months! How could this be safe — and nutritious? Like most other Americans, our milk was bought and sold at refrigerator temperatures, and kept fresh only for a week or so.

One of the greatest public health advances in the modern world is pasteurization. All milk must be sterilized after being delivered from the cow (or sheep or goat), mostly to kill dangerous bacteria and spores that otherwise can seriously harm and even kill people. To kill the pathogens, milk is exposed to high heat at specific lengths of time — this is called pasteurization, named after the famous 19th century French scientist Louis Pasteur. Heating not only kills pathogens but also slows down spoilage, which is triggered by other sets of bacteria.

Pasteur’s heating technique doesn’t kill all bacteria, which is why it must be kept cool and used within a couple of days after opening. Normal pasteurization heats milk to around  70 – 75 °C for 15 seconds, — but the newer technique heats at up to 150 °C for 5 seconds. This is why it is called ultra-high temperature (“UHT”) milk, which is what you see written on these cartons. At such a temperature, all harmful pathogens, including spores, are killed, as well as the enzymes which could spoil the milk, which is why you can keep at room temperature for months. The milk also goes directly into the container after heating, which eliminates possible contamination.

Pouring milk in the glass on the background of nature.

But what about nutrition — surely this higher temperature must destroy vitamins and other molecules? While there are some very minor changes, all of the major governmental and nutritional sites I’ve seen, including the US CDC; the European Union; and New Zealand all state the same essential facts, summed up by the US CDC: “all of the nutritional benefits of drinking milk are available from pasteurized milk without the risk of disease that comes with drinking raw milk.” And while I’ve read reports that milk’s enzymes are damaged even more with UHT processing, as the US CDC again summarizes, “the enzymes in raw animal milk are not thought to be important in human health.” 

Most Europeans will find my initial hesitancy of UHT milk quite amusing, as it’s become the popular choice in most EU countries for many years. In China, almost all milk in stores is still the traditional pasteurized milk sold from the chilled containers, with UHT mostly still only available as imported brands in expat and upscale supermarkets. Fortunately, this UHT milk is now easily available on all major shopping websites for home delivery anywhere in China.

I have many patients and online readers, both expat and local Chinese, who are desperate to find quality milk sources ever since the melamine scandal of 2008 — especially for their children. My response to all is that UHT milk is a great choice — especially imported, and why not get organic as well!  Such milk certainly is a far better choice for toddlers than toddler formula, which has no medical indication from any pediatric groups anywhere for its preference over milk.

I drink imported organic UHT milk mostly as a food safety precaution, but I also feel very reassured that my toddler son and family are all drinking milk 100% free of pesticides, heavy metals and growth hormones, from cows fed on grass in healthy organic farms. Given all the constant uncertainly here with food safety scandals, why not have some peace of mind with your milk?

 

Fatherhood, Year Two

dadbaby
As I celebrate my second father’s day as a dad, I’ve been thinking more and more about my own father, who died over ten years ago. When I travel back home to Boston I always drive down the spartan Cape Cod highway to the Veterans Cemetery. I will sit on the crisply cut grass by his gravestone, admiring the blue skies, soaking up the sun and feeling the breeze through the trees. I’ll update him about my wild adventures in China, but I think he already knows.  I know he and my Alex would get along swimmingly, and I’m sure he’s as proud of me as he’d always been. And then I choke down that ache of longing, dust off his stone and make the lonely drive back, wishing he were still here.

As I remember my dad, I think about the importance of fatherhood and how signally important it is for me to raise my children as best I can. My father did the best he could, a very typical father at the time, focused more on providing than nurturing. Somehow he worked three jobs to provide for his wife and four children under the age of five. We four have used our parent’s relaxed, unconditional love as bedrock to develop our own life path and rhythm. Some took a longer time to figure out that path, including me, but as a late bloomer I’m pretty darn happy with what I’ve already accomplished in my life.

 

AlexDadClinic

As I now think about fatherhood and the differences not just between American generations but also cultures in China and the USA, I find research on fatherhood quite fascinating. I recently read last winter’s CDC National Health Statistics Report, Fathers’ Involvement With Their Children, reviewing the amount of time that fathers spend with their children. I found it reassuring that most American fathers were quite hands-on, a more modern approach than in my father’s time. Among fathers living with children younger than five, 98% played with their children, 90% bathed, dressed or diapered them, and 60% read to them at least several times a week. These numbers have increased from their earlier 2002 survey. I fit into this hands-on dad category, and it’s a very conscious decision on my part. My career path at this time absolutely is secondary to ensuring that my children’s first years are as nurtured and guided as they can.

Now that I’ve immersed in Chinese culture for almost a decade, and especially now as a first time father, I’ve wondered more and more whether I can combine Eastern with Western “best practices” of fatherhood, such as I’ve tried to do with medicine. But are there any true differences, or are they just superficial anecdotes from my limited viewpoint here in our first tier economic bubble of Beijing? And if there are true differences, is either “better” than the other?

twins_second_birthday

I found a couple of excellent review articles to shed light on this, including Parenting and fatherhood in urban China—a sociological perspective  from 2009 and Fathers in Chinese culture: from stern disciplinarians to involved parents, from last year. They both have similar points: the incredible changes in Chinese society over the last half century have also affected fatherhood. Both articles mention how it’s impossible to generalize about one stereotypical “Chinese dad” because parenting in China differs between economic groups and regions, as well as urban versus rural fathers. But they agree that the traditional Confucian-infused emphasis on total subservience to daddy (filial piety) has mellowed to a more nuanced fatherhood. Some studies commented on the increasing amount of dads (and moms) who take on roles as friends with their child, partly due to the one child policy. Also, many homes are now a nuclear family of two parents and one child, and no longer the traditional three generations living together (san dai tong tang), which may lead to more father-child intimacy. One Shanghai study from 2003 revealed how the more educated fathers were more involved with domestic chores and playing with their children.

 

with_3_kids

So is there a “better” way of fathering, gleaned from an East-West comparison? Actually no, I can’t really say that there is an obvious difference now — not anymore. But what does seem clear from the literature is that the old-fashioned fatherhood approaches from both cultures — distant and stern, provider and not nurturer — wasn’t the best way. A 2006 review from the U.S. Children’s Bureau makes clear the large body of evidence which shows how more emotionally involved and affectionate fathers, especially at younger ages, raise children who develop a higher IQ, better social connections, better grades and fewer behavior problems.

So I will continue to practice my own quirky fatherhood style, and I personally much prefer the more modern authoritative style versus the older authoritarian model based on Confucian principles. I agree with Confucius that “the father guides the son” — but let’s not forget about daughters, of course. I also agree when he says, “as a father, he rests in kindness.” There’s another famous Confucian quote, “in filial piety, there is nothing greater than reverential awe of one’s father.” Well, I can immediately think of at least a handful of things that are greater than that: growing up self confident; having a core of integrity; showing automatic respect and politeness to all others — I could easily go on.

GandpaAlex

 

Do I want my son to lovingly gaze on his hero-dad for eternity? Of course I do. But I’ll settle for respect, honest conversations and warm affection into his teen years and adulthood. I suppose ending phone calls always with an “I love you, dad” also would be really cool. I can’t control that, but I certainly will always be telling him I love him, at any age, no matter how uncomfortable it makes him, and no matter what he’s done.

I already know I will have a perfect Fathers Day 2014, with Alex at 16 months. We will do our usual routine of me holding him in the baby carrier while I make breakfast, then we all walk along the tree-lined streets to our child development center where he will joyfully play, tumble and laugh with half a dozen other toddlers. Afterwards, we will all take well-deserved afternoon siestas. I can’t think of a better way to spend that or any other Sunday. Well, actually I can — I wish his grandpa were here, in person and not just in spirit.

AlexMeBookSigning

Bike Helmets in China: A No-Brainer

bike helmets safety children chinaDo you or your children bike to work or school? Here in Beijing, a lot of us are fortunate to live close enough to their schools and offices that walking or biking could be an option. I bike to my hospital every day and I love it. But many others choose not to, for various reasons. Hopefully some readers can be inspired by the annual May 7th Walk and Bike To School Day and reconsider their commuting options, at least for one day of the year.  This public health promotion, sponsored by the US Department of Transportation, has two main goals: to encourage healthy exercise as well as to educate about proper bike safety. Walking and biking are great ways to keep kids in shape, especially amidst our modern world’s worsening epidemics of obesity and diabetes. In China, childhood obesity and diabetes is increasing at an alarming rate.

Many parents are worried about road safety and air pollution, and your kids certainly need to know the bike “rules of the road“, especially if you are riding in the street and not in a bike lane. These include:

  • Ride single file and in the same direction as cars.
  • Ride to the right side of the road, but far enough from parked cars to avoid any car doors that suddenly open.
  • Obey traffic laws. Follow all traffic signs, signals, and lane markings.
  • Be predictable. Ride in a straight line, not in and out of cars. Use hand signals.

Regarding air pollution and biking, a handful of studies have directly compared health benefits of biking versus driving to school or work, and found much greater health benefits than any risks from air pollution or road accidents. The largest study followed 67,000 Shanghai women for five years and showed clear benefits from bicycling, leading to less heart disease, cancers and deaths. Other studies from Europe have also shown this, but as Shanghai’s air pollution is more relevant for us here in China, it’s very encouraging that local research shows that exercise and bicycling still have clear health benefits.

Besides road safety, a proper bike helmet is crucial for protecting yourself in an accident, especially with car collisions. The foam padding in a helmet can absorb most of the impact in a collision, minimizing potential injuries especially to the brain. Compared to helmeted cyclists, unhelmeted cyclists are twice as likely to sustain a brain injury or head injury; and four times more likely to die from their injury. Helmet use is recommended by all the major health organizations, including the World Health Organization, the American Academy of Pediatrics and the American Medical Association.

The other key to this puzzle is proper fit of a bike helmet, as yet another quick glance around tell us shows many people, including kids, with helmets perched up too high, or worse — not even strapped down. Make sure your kids know the basics of a proper fit:

  • Put your helmet flat on your head. If it moves when you shake your head, you need to tighten your helmet or get a smaller one.
  • Eyes: The helmet should sit low on your forehead – two finger widths above your eyebrows.
  • Ears: With the helmet buckled, the straps should meet just below the ears.
  • Mouth: When buckled, you should be able to fit no more than two fingers between the buckle and chin.
  • Finally, take the yawn test: a big yawn should tighten the mask down. If it doesn’t, it’s not tight enough.

I’ve bought a few brands of helmets for myself and now also for my one year old son, and I know how confusing it is to buy a safe brand with a good reputation. In the USA, every helmet must have safety approval by the Consumer Product Safety Commission, and every helmet must have this CPSC sticker inside as proof. You may also see other certification stickers inside your helmet, including EN 1078 or EN 1080, which are the European Union safety standard. For more research, you can find specifics on safe brands at websites including the Bicycle Helmet Safety Institute and ConsumerSearch. You should resist the urge to buy the most expensive helmets, assuming they are safer: the BHSI performed their own tests and found that a $10 helmet and a $200 helmet achieved the same safety results.

We all know from a quick glance around our streets that a distressingly small amount of riders actually wear helmets, including children. It’s such a tragedy to have any child die from a preventable bike accident! What can we do to increase the use of bike helmets in our communities? Firstly, I believe we all need to be role models for others, especially our children. That means we adults always wear a bike helmet, and our children will model our good example. Secondly, a Cochrane review of studies has shown that public health campaigns in communities can help increase awareness, and giving away helmets or providing coupons can greatly help increase the percentage of people wearing them.

My Alex is still too young even to go to school, but I’m already teaching him safety habits with his own bike helmet as he rides with us. He initially hates it, but once he sees mommy and daddy wearing one as well, he eventually calms down and we all have a lovely time exploring our local hutongs via bike. Very soon, he will be walking or biking to his local school, escorted by his daddy. I already know that will be much harder on me than on him.