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:

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.

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• No antibiotics for acute sinusitis infections
• No x-rays of the low back during the first 6 weeks of an injury
  (unless there are obvious “red flag” danger signs)
• No routine ECG during any annual physical for a healthy person
• No DEXA bone scan in healthy women under 65
• No Pap smears for women under 21

These are very common tests and treatments all over the world, but the fact remains that there truly is little proof that these tests help more than hurt most patients. I think this Choosing Wisely campaign is a very important new program that really sheds some evidence-based prudence on what were previously considered de-facto tests. This is a wake-up call for all doctors everywhere, and I welcome the discussion.

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Pistachios are a wonderfully healthy nut, full of healthy, cholesterol-lowering oils and antioxidants. But one uniquely Chinese trait is to bleach the majority of pistachios on the market, as many consumers believe the cleaner, whiter look is more appealing than the original. While the hydrogen peroxide bleach may not by itself be unhealthy, the bleaching certainly removes some of the vitamins such as B1, as well as antioxidant phytochemicals. So please do your body a favor and don’t buy the pure white pistachios with the dull colors; pay a bit more for the slightly darker shell which has the original green nut and deep red/purplish skin.

The same concept applies to mushrooms; local markets are filled with preternaturally, almost luminescent white mushrooms, which again are an obvious sign of unneeded whitening. A mushroom should not naturally be shiny white, like a piece of printer paper; it should be ivory or darker. Some of you may remember the entertaining story in 2010 about a Chinese primary care student who tested store-bought mushrooms and found that 90% had used a fluorescent whitening agent which was considered “not edible”. Maybe not dangerous, but certainly not needed — and given the chronic uncertainties of food safety, why take the risk at all?

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I mention all this because I am concerned that we all are bombarded in our daily environment with potentially toxic chemicals from what we eat, breathe and drink; and I feel we should do everything we can to minimize the potential risks. Plastics, especially BPA, are a clear example of ubiquitous objects which research suggests may carry unintended health effects such as infertility, cancers, heart disease and diabetes. The research isn’t conclusive but I feel it is concerning enough to take action, based on the “precautionary principle”, which states that there is a responsibility to intervene and protect the public from exposure to harm where scientific investigation discovers a plausible risk in the course of having screened for other suspected causes. Also, there is an official position paper from 2009 by the US Endocrine Society which recommends much less exposure to BPA and other “endocrine-disrupting agents”.

With this in mind, some simple things we all can do at home include:

• Switch all your plastic food containers to glass
• Only use plastic cling wrap that says PE on the label.
• With any type of plastic cling wrap, always minimize contact of the plastic with the food to minimize leaching of chemicals, and try not to microwave with the plastic on it. Especially don’t let the plastic sit on top of liquids.
• Always immediately transfer your restaurant leftovers into glass containers at home; many takeaway plastic containers leach dangerous chemicals into the foods. Vinegar, especially, can eat away at the plastic.
• Never reheat your leftovers or eat directly from the takeaway plastic containers, as the leaching effect is dramatically higher.
• If you choose to keep your leftovers in plastic, look closely at the Plastic Coding System (that triangle on the bottom with a number from 1-7 in the middle). It’s better to avoid numbers 3, 6 and 7 and safer to use numbers 1,2,4 or 5
• Try to minimize eating canned food, as the plastic linings also could leach into the food.

Chopsticks hygiene is another big issue in China, both from food safety and environmental angles. When choosing a restaurant, plastic or metal chopsticks are much safer than the reuseable wooden ones, which are very difficult to completely wash of all bacteria and viruses (the same goes for your home’s wooden cutting boards and cooking utensils). Disposable wood chopsticks are far more hygenic but they carry an enormous burden on the environment. My favorite preference is to use my own portable metal chopsticks which unscrew in the middle and collapse into a nice small box to carry around. I now use this exclusively with my lunches at work. I got mine at Muji, but you can find these at many stores.

To sum up, these environmental precautions can be healthy for yourself and your family as well as the environment.

(This article was originally printed in the April 2012 edition of Beijing Kids magazine, in my monthly The Doc is In column)

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The key concept for diabetics is limiting carbohydrates — and that doesn’t only mean sugar. I see many diabetics who think they’re doing well because they’re “cutting back on sweets and dessert”, when the main diabetic culprit in their diet is the starch carbs from rice, pastas and breads.

One popular method of monitoring carbs is the glycemic index. This index is a ranking from 0-100 of how high a carbohydrate raises blood sugar levels after eating. Here’s a graph below showing the basic concept: a healthy food has a low glycemic index, which means the sugar levels in your body peak lower and slower, thus not stressing out your insulin-secreting pancreas. Unhealthy foods have a high glycemic index, where the sugar levels peak very high and very quickly. This stresses out your pancreas to make insulin, and it’s this chronic repeated stress of your pancreas that partly causes it to slowly fail, producing less insulin — and thus causing diabetes.

Glycemic index

Think Brown

Following this GI list of foods, and tracking your foods, can honestly be quite cumbersome. Many believe that patients’ counting their carbs is a more effective tool. But in either case, I have an easy clue for everyone: think brown. Brown food is always better than the equivalent white food. What do I mean? I mean that white foods are quite unnatural; white rice and breads and pastas are finely processed versions of the original grains. And these original grains have the “brown” husks full of vitamins, oils, magnesium, fibers and other nutrients. In other words, brown rice is much healthier than white rice for many more reasons than just lowering risk of diabetes. The glycemic index of brown rice is 55, a bit lower than the 72 for short-grain white rice, which is the most common rice in China. Here’s more data which may convince you: a huge 2010 cohort study showed that switching from white to brown rice can lower your risk of diabetes by 16%. Switching to whole grains lowered risk even better, by 36%. That’s an enormous benefit!

Bread & Pastas: The Same Benefit

The same concept applies to white bread, which is made of finely processed flour and thus has lost its husk of nutrients and fiber. The GI of white bread is 70 (a GI over 70 is considered unhealthy), while whole grain breads have a GI of 51. Pasta, on the other hand, has a much better glycemic index than breads or rices, with a GI range from 43 to 61.

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X-rays are a source of ionizing radiation, which is a potential risk factor for meningioma. Some of the participants in the study received their x-rays many years ago, when radiation exposure from dental x-rays was much higher than it is with new technology today.

The study has some drawbacks that make the link between dental x-rays and meningiomas far from certain. Perhaps most importantly, it relied on participants’ memories about their history of dental x-rays (rather than on dental records themselves). Such studies are subject to a phenomenon that scientists call “recall bias,” when people with a disease may be more likely to look for a cause. This might have caused the meningioma patients in the Cancer study to over-report the number of dental x-rays they received, which could have contributed to the findings. Because of this, the study results can only be considered suggestive of a possible link, and more rigorous studies would be needed to prove it.

Otis W. Brawley, M.D., chief medical officer of the American Cancer Society said, “We need more data before we can even begin to state there is a relationship between dental x-rays and these tumors. Until that research is done, the best advice we can give people is to get dental x-rays when they are necessary and only when they are necessary. The dose of radiation given in a bitewing or panoramic x-ray is lower today than it was two decades ago. Nonetheless, x-rays should be done only when necessary. This is true of all x-ray technology, and it’s the same advice experts would have given without this study.”

On its Web site, the American Dental Association responded to the study with a statement that said in part, “The ADA’s long-standing position is that dentists should order dental X-rays for patients only when necessary for diagnosis and treatment.” The statement also encouraged patients to talk to their dentists if they have questions about their dental treatment.

I think this is a very well-balanced summary of this research, and the take-home message is that almost no healthy person should be getting annual dental x-rays, as the risks likely outweigh the benefits. The American Dental Association’s official recommendations may call for repeat x-rays as frequent as 6 months in the rarer cases of people with severe cavities, but their 2006 review discusses how there’s very little evidence that healthy teeth benefit from routine annual x-rays.

More Podcast Information

You can listen to all my previous podcasts at my podcast archive. You can always listen live to my radio interview each Wednesday around 7:35am Beijing time, on the Beijing Hour program on EZFM 91.5, which is broadcast from 7-8am every weekday by host Paul James. EZFM is the popular bilingual radio station on the China Radio International network, broadcasting here in Beijing and on multiple stations all over the world, as well as live online.

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Recently, the Chinese press greatly expanded their coverage of air pollution. However, there are still quite a few myths and misperceptions about air pollution, which I would like to attempt to clarify below. My ultimate goal is to provide the evidence so that we can make healthcare decisions based on facts, not fiction.

Fact or Fiction: A day of breathing Beijing air is like smoking a pack of cigarettes.

This is fiction. I often hear apocalyptic statements about air pollution, especially the idea that breathing Beijing’s air is like smoking a pack a day. This statement is a bit extreme. I did my own data analysis and found that the total amount of small air particles (PM2.5) we breathe each day is far less than one pack. In fact, it is only 1/6 of one cigarette. This amount of exposure is about the same as secondhand smoke. That finding surprised me, but I think the larger message is that any amount of smoking, even “light” smoking, is far more serious and lethal than living in the heaviest pollution in the world. From this perspective, perhaps Chinese public health would benefit more from drastically reducing smoking rates than from focusing on expensive industrial fixes to lower ambient pollution.

Fact or Fiction: Living long-term in polluted cities shortens life expectancy​.

This is fact, but with many caveats. Living in any city with high air pollution does reduce life expectancy, but every city in the world affects your health in good and bad ways. Living long -term (more than six years) in a city with air similar to Beijing gives you a 32-49% increased risk of pollution-related death than living in a city that has perfectly clean air (check out my analysis here). It’s important to consider the risk in the context of comparing this risk to other cities. For example, residents of Los Angeles have a 16% greater risk, while citizens of Paris and San Francisco have a 20% and 13% greater risk, respectively.

Fact or Fiction: Children’s lungs are more vulnerable to air pollution.

This is an unfortunate fact. The better studies, especially a few from Los Angeles school systems, have shown air pollution can cause small but permanent lung damage to a growing child’s lungs. This is actually my main concern here in China, and I hope all parents take this risk seriously and reduce their children’s risks as much as much as possible, especially ​by buying a good HEPA-certified (HEPA = high-efficiency particulate air) air purifier for their child’s bedroom. These filters, when used in small rooms with the doors closed, can filter up to 99 percent of air particles. I also feel that all school systems should have an air pollution action plan, which limits outdoor activities depending on the hourly Air Quality Index.

Fact or Fiction: Air purifiers are effective in reducing your exposure.

This is a fact, and that’s good news for those of us who feel helpless about air pollution. We tend to focus on the outdoor air quality, but don’t forget that we all spend about 90% of our lives indoors. Indoor air pollution is likely to be about 50-80% of outdoor levels. So while you may feel helpless about air pollution, you still have control over 90% of your exposure. That control mostly involves good quality indoor air purifier systems, whether stand-alone or built into your central HVAC (heating, ventilation and air-conditioning). I consider air purifiers a wise investment. These HEPA filters are rated to filter out more than 99% of all particles larger than 0.3 microns, which covers not only the most dangerous particles but also viruses, bacteria and many dangerous indoor chemicals. I’ve done some real-world testing on a few of the most popular brands and found that all models were extremely efficient in small rooms with doors closed, removing 95-99% of all particles. That means that even on “crazy bad” nights, your bedroom will be a safe oasis. Simply running a good purifier at night automatically decreases your lifetime exposure to pollution by one-third — in any city you live in.​​

To summarize, I’ve lived in Beijing for more than five years practicing Family Medicine, and while I do take air pollution seriously, I feel that my quality of life and overall health are very high here in China. Don’t panic. Acknowledge the facts. And be smart about air pollution.

(Edited by Christina Liao. First published in the American Chamber of Commerce’s China Brief, April 2012 issue.)

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I’ve seen a lot of strange headlines for health articles, but last week I saw two that really stood out for sloppy journalism on top of shoddy research. The first was the Xinhua headline “Popcorn Healthier Than Fruit, Vegetables.” They discussed a research paper presented at a conference (not in a journal) which analyzed the nutritional value of popcorn:

One of the scientists behind the study, Dr. Joe Vinson of the University of Scranton in Pennsylvania, explained that there are more of the antioxidant substances called polyphenols concentrated in popcorn than most fruits and vegetables. One reason is that popcorn only contains about 4 percent water while fruits and vegetables contain up to 90 percent water.

The researchers also find that the hulls of popcorn – the part that everyone hates for its tendency to get caught in the teeth – has been found to have the highest concentration of polyphenols and fibre. They are actually “nutritional gold nuggets,” according to Vinson.

“Popcorn may be the perfect snack food,” said Dr. Vinson. One serving of popcorn will provide more than 70 percent of the daily intake of whole grain needed by an adult.

Vinson warned, however, that how the popcorn is prepared is the key to its healthiness. Air popped popcorn is the best, while microwave popcorn is much worse, as is popcorn made in pot full of oil, butter, and covered with sugar or salt.

Popcorn, in its air-popped form is healthy, but could never fully replace fruits and vegetables due to the other vitamins and nutrients found in them.

So the most important sentence comes at the very last, of course, after the attention-grabbing headline gets you to read the whole thing. I suppose the editing board is just doing their job — to attract readers. And in fact it is a provocative article which, due to the widespread coverage, may get more people to be healthier — but only if they eat air-popped popcorn as a replacement for more unhealthy snacks (such as Oreo cookies, which I confess to adore). And it only applies to air-popped popcorn with essentially no toppings, which sounds painfully, boringly “healthy”. As more balanced articles make clear, the vastly more palatable microwaved popcorns and enormous movie bags oozing with oil are deliciously unhealthy. It’s too bad that in Chinese movie theatres we don’t even get the choice to have lightly salted popcorn, as almost all only have strangely multicolored sweet popcorn.

The other crazy headline this week also comes from Xinhua, which blared that more frequently eating chocolate can help you lose weight. Unlike the above study, this one actually was published in an esteemed peer-reviewed journal – but the paper itself isn’t very robust, only being a cross-sectional questionnaire taken at one point in time. This study design makes it impossible to assess whether chocolate causes weight loss, only that it may be associated with weight loss. This statistical subtlety gets lost to most people, but the distinction is critical. In other words, eating chocolate more frequently possibly may be associated with being thinner but that doesn’t mean the chocolate did it. Worse, the study didn’t break down the results into types of chocolate, so we have no idea whether white, dark or milk was the factor — if there’s a factor at all.

It’s too bad about both of these headlines, as I actually love popcorn at home as a snack — with a tiny bit of oil and some seasoning. I also love dark chocolate and have blogged about this often — but only the dark chocolate is “heart healthy”, and only in small amounts. So the worst outcome for readers would be to eat more movie popcorn and scarf down some white chocolate easter bunnies.

I discuss both of these articles in the March 28 weekly podcast on CRI Radio’s Beijing Hour.

Click on the arrow below to listen to this podcast, or click here.

More Podcast Information

You can listen to all my previous podcasts at my podcast archive. You can always listen live to my radio interview each Wednesday around 7:35am Beijing time, on the Beijing Hour program on EZFM 91.5, which is broadcast from 7-8am every weekday by host Paul James. EZFM is the popular bilingual radio station on the China Radio International network, broadcasting here in Beijing and on multiple stations all over the world, as well as live online.

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It’s getting so bad in parts of America that many pediatricians are starting to fight back in the strongest way possible; a new survey shows that 21% of all US pediatricians have fired families and patients from their practice for refusing to take all vaccines for their children. This certainly may come as a harsh surprise for many readers, and it’s not endorsed by the CDC or the AAP, but I do understand my colleagues’ sentiments and frustrations. I personally have never fired any family for this, nor do I plan to do so, even though quite a few parents in the Beijing community are skeptical of vaccines. I think a better approach is to keep these concerned parents in your “medical home” and keep trying to allay fears, which includes giving them handouts from websites such as the CDC’s outstanding PDF handouts on “Diseases and the vaccines that prevent them”. But if the parents still refuse to give the standard set of vaccines, doctors could get the parents to read the CDC handout about Vaccine Refusals, and then sign the American Academy of Pediatrics “Refusal to Vaccinate” form (PDF here), which details the very real risks they are subjecting their child to, including the increasing risk of getting pertussis or measles from another child.

I understand this is a complicated issue for parents, but in most doctor’s eyes, it’s not complicated, and it’s not a two-sided debate. Most of us feel the evidence is overwhelming in favor of vaccine effectiveness in wiping out polio, smallpox and a handful of other still-deadly diseases, and there are few truly legitimate reasons not to vaccinate. Of course there are some side effects, which were exhaustively reported in the important recent review from the Institute of Medicine, which I discussed last year. Pediatricians and family doctors need to provide concerned parents with the evidence. I strongly feel that if parents still refuse to vaccinate their child despite all the overwhelming evidence, then those parents really need to understand that they are putting their child’s health at risk — and also threatening the health of vulnerable infants and others in their community. Many parents indeed have deeply regretted not vaccinating their child. Here are some sad stories from victims of vaccine-preventable diseases for you to read. You can also read a few sobering articles from the CDC’s “Unprotected Stories” series, including this true story of pertussis (AKA whooping cough, now making a comeback):

“A Preventable Tragedy”: A True Story

Preventing whooping cough—and saving lives in the process—must be a community-wide effort to vaccinate infants, children, adolescents, and adults. Pertussis vaccine has saved thousands upon thousands of lives, but we need to keep up the fight against whooping cough by using vaccines. Here is one family’s story.

On Christmas Eve 2009, Katie and Craig welcomed their daughter Callie Grace into the world. After trying for 5 years to have a child—and suffering several miscarriages—the couple considered Callie their miracle baby. Callie was born 6 weeks early, but she was healthy and strong and came home after only 2 weeks in the hospital.

In January, when she was a month old, Callie developed a soft, dry cough. “It sounded like when a child mimics their parent to get attention. I took her to the doctor,” Katie recalls. The doctor did not find any serious signs of illness, so he sent them home. However, over the next couple of days, Callie’s condition worsened. She continued to cough, and she also became pale, didn’t move around much, and suddenly lost her healthy appetite. Katie took Callie back to the doctor, and while they waited, Callie stopped breathing. A nurse was able to get Callie breathing again, and they were rushed to the hospital by ambulance.
“At the hospital, nurses and doctors flocked to our room,” Katie remembers. “It was truly overwhelming. I was scared and Callie was screaming.” Callie was admitted to the Pediatric Intensive Care Unit, where the staff ran tests to try to find out what was wrong. After a couple of days of monitoring, they started her on antibiotics, while still waiting on test results.

During Callie’s second day at the hospital, she seemed to be doing OK and her parents were hopeful that she’d recover. According to Katie, “Callie was alert and would smile. She kept sticking her feet in the air so we could rub them for her. We never really thought her life was in danger.” But the next night, Callie stopped breathing again. Family members watched helplessly from behind a glass wall as doctors tried for 45 minutes to revive her. Tragically, Callie could not be saved. She was only 5 weeks old. “We never dreamed we’d lose her,” Katie said. “Callie was a more loved, more wanted baby than you’d ever find.”
A few days later, the family found out that whooping cough was the cause of Callie’s death. “We could not believe it,” Katie says, “We were so careful to not expose her to a lot of people. She never left the house except to go to the pediatrician,” Katie says.

The first dose of DTaP vaccine is recommended at 2 months of age but babies are not fully protected until they get all the recommended doses. Callie was too young to even get her first dose of DTaP. Babies need whooping cough vaccination on time, but there’s another important way to protect them. Family members and others who are around babies should be vaccinated—children should be up to date with DTaP, and everyone 11 years of age and older should get Tdap, the booster shot that prevents pertussis.

“Callie could have caught whooping cough from any of the few people that she had contact with—even from someone in the hospital right after she was born. People with even a slight cough might have whooping cough but not know it. I urge everyone to make sure their children have all their DTaP shots on time. I also encourage people to be sure they get the Tdap booster shot,” Katie says. “Getting that shot could save a life.”

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Drive #3: East along the Jingping Highway to marshlands, peach fields and mountains

Everyone knows the airport expressway that goes to the new terminal 3; if you keep going straight on that road instead of taking the terminal exit, you are now on the lovely, quiet Jingping highway (京平高速）. This lovely road breezes past field and then enters hills as it wraps east and then south towards Tianjin. Just past 6th ring is an exit for muyanlu (木燕路); take this northward about 10km to a huge sign on the left for the wetlands of Hanshiqiao（汉石桥水库）. This place has a very nice, large wetlands area which you can explore in a rented boat. You can also rent bikes along the paths and go quite far in back along lovely tree-lined streets along the canal. Plus, their on-site restaurant is surprisingly excellent as well as clean. It’s a very nice daytrip.

If you kept going east along Jingping, you could take an exit into Pinggu city; the entire area around the city is filled with orchards, mostly peaches, and it can be a lovely drive during spring’s blossoms. If you continue along Jingping through the hills and a couple tunnels, you’d pass the lovely Panshan mountain on your left side, one of my favorite mountains. Take the gondola all the way to the top and slowly hike your way down.

Also further up the road is the Hyatt Regency Jing Jin City Resort, a bizarrely huge and ornate hotel in the middle of fields. It’s also a very relaxing, quiet place to spend a weekend, and it’s only 80km from the city.

I’ve blogged about a host of fun Beijing road trips which you can read here:

Within 1-2 Hours Drive:
Yunju Temple & Shidu
Jiufeng National Forest

Within 2-4 Hours Drive:
Baicaopan Mountain & Meadow
Beidaihe & Qinhuangdao
Wulingshan

Within 2-3 Hours Flight:
Dalian
Qingdao

 

 

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