Category Archives: Food safety

Diabetes: Healthy Lifestyle Choices Are Key

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 this epidemic spreads,  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 diabetes. 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!

Barbecue and Cancer: Let's Review The Risks

Summer is in full swing, and many of us are enjoying one of life’s favorite past times — eating barbecued foods. Who can’t resist ears of corn, or a burger or hot dog? I certainly can’t, and have no intention of stopping — but I am now more careful about what and where I eat barbecue , as well as how I prepare it.  Why? That’s because I was too darn curious; while I was watching the smoke rise from the grill at my favorite Japanese teppanyaki restaurant, I googled “barbecue + cancer” on my iPhone and found quite a lot of research discussing this issue.  Unfortunately, it’s true: barbecuing many animal proteins, as well as from any smoke, definitely can create unhealthy chemicals, the most dangerous of which are called heterocyclic amines, which are officially listed by the FDA since 2005  as cancer-causing agents. So I’ve decided to ruin all of your late summers and tell you the scary details. OK, it’s not that bad — but there are some basic facts which can help you decrease your risk, as well as increase your nutrition.

One trusted source is from the Harvard Health Letter, which in 2007 wrote this nice summary about barbecue’s risks:

When meat is cooked at high temperatures, amino acids react with creatine to form heterocyclic amines, which are thought to cause cancer. That’s why cooking meat by grilling, frying, or broiling is the problem. Grilling is double trouble because it also exposes meat to cancer-causing chemicals contained in the smoke that rises from burning coals and any drips of fat that cause flare-ups. How long the meat is cooked is also a factor in heterocyclic amine formation; longer cooking time means more heterocyclic amines. Depending on the temperature at which it’s cooked, meat roasted or baked in the oven may contain some heterocyclic amines, but it’s likely to be considerably less than in grilled, fried, or broiled meat.

Marinating meat is often suggested as one way to cut down on the formation of heterocyclic amines, but the evidence that marinating helps is mixed. The Harvard Health Letter suggests some other tips that may make grilled meat safer to eat:

  • Cook smaller pieces: They cook more quickly and at lower temperatures.
  • Choose leaner meat: Less fat should reduce flames and therefore smoke.
  • Precook in the microwave: Doing so for two minutes may decrease heterocyclic amines by 90%, according to some research.
  • Flip frequently: That way, neither side has time to absorb or lose too much heat.

Another good source, the USDA’s Food Safety and Inspection Service, has this to say:

Does Grilling Pose a Cancer Risk?
Some studies suggest there may be a cancer risk related to eating food cooked by high-heat cooking techniques as grilling, frying, and broiling. Based on present research findings, eating moderate amounts of grilled meats like fish, meat, and poultry cooked — without charring — to a safe temperature does not pose a problem.

To prevent charring, remove visible fat that can cause a flare-up. Precook meat in the microwave immediately before placing it on the grill to release some of the juices that can drop on coals. Cook food in the center of the grill and move coals to the side to prevent fat and juices from dripping on them. Cut charred portions off the meat.

Yet more fascinating data, backed up by studies, came from the Cancer Project website’s page on barbecue risks. Among their findings:

Cancer Project nutritionists determined that many commonly grilled foods contain alarmingly high levels of HCAs. This table lists the five foods containing the highest levels.

The Five Worst Foods to Grill

Food HCAs ng/100g*
Chicken breast, skinless, boneless, grilled, well done 14,300 ng/100g2
Steak, grilled, well done 810 ng/100g3
Pork, barbecued 470 ng/100g4
Salmon, grilled with skin 166 ng/100g5
Hamburger, grilled, well done 130 ng/100g3
*100g portion equals about 3.5 ounces grilled


Safer Alternatives for Grilling
Other foods produce undetectable levels or negligible concentrations of HCAs when they are grilled. These include soy-based veggie burgers, veggie brochettes, and portabello mushroom “steaks.” These healthy vegetarian alternatives are also low in fat and cholesterol.

And yet other sites, including the New York Times, mention tantalizing research from lucky lab techs at Livermore, who reportedly found that certain marinades dramatically decreased the carcinogen production. But I’m still trying in vain to see these original studies, so I cannot comment too much on that.

The Bottom Line

I think there’s certainly enough evidence about HCA and PAC compounds to make hard-core barbecuers take note, and perhaps follow some basic changes. My major changes:

  • Pre-zap more of my meats in the microwave  for 2 minutes
  • Focus on less charring and less smoke
  • Use more lean meats
  • Use more marinade and sauces
  • Barbecue more veggies (corn, roasted bell peppers, portabello, onions…awesome!)

Meatless Mondays — Can You Handle It?

meatless mondayI love meat. Looooove it. I would never consider going full vegan. At least, I’ve always said that, until…

…until a couple weeks ago when I was in Carrefour’s meat section, doing my usual food shopping. For some strange reason, I kept staring at this messy pile of plucked chickens, with small tufts of hair still sticking out here and there. And then I looked around at the other displays: the pig heads, the huge piles of cow spines and ribs — and suddenly it all seemed so, well, inhumane. The raw depravity of it is so blatant here in Chinese markets (I live in Beijing), and I actually prefer the sheltered ignorance from my American sanitized supermarkets, where you are so separated from the slaughterhouse that you completely lose touch with the process of farm-to-table. In American markets, you would never, ever see a head or eyes on any meat, even on most fish. I much prefer not to have my dead meat staring back at me, thank you very much.

So I am now facing a typical liberal’s guilt/dilemma: humans are biologically adapted to be meat-eaters, but with modern food technology we no longer have to eat meat. And it is more and more clear that humanity’s appetite for meat has a massively negative impact on our environment. And I am also increasingly uncomfortable with most livestock farms’ depraved living conditions, as well as the way most animals are killed, which obviously involves pain. There are also clear health reasons for avoiding the most common cow meat, as this red meat has been shown to lead to more heart disease and other illnesses (I’ve mentioned a few of these studies before).

So, I’ve made a personal decision to cut back on meat — not totally, just a bit for now, and let’s see how things go. I chose first to stop eating meat on Mondays after I discovered one website, called Meatless Mondays, which started as a public health campaign from Johns Hopkins. They ask people to not eat meat on Mondays as a not-too-intrusive way for all of us to start thinking more about the negative impacts of eating meat. They also have a good collection of PDF toolkits for communities and schools. I think one day a week is easy for all to do, and I think this is a healthy debate for all of us to consider. What do you all think? Who wants to join me?

meatless monday poster

Pregnancy and Food Poisoning: What’s Safe To Treat?

pregnancy gastroenteritisGastroenteritis — diarrhea caused by bacteria from our foods — peaks in the summer but can occur all year. Pregnant women should be especially choosy about where and what they eat, since a bad bout of “gastro”, while usually not serious for mom, can sometimes cause serious problems for her baby. Most infectious causes don’t directly affect your baby, but specific bacteria like listeria and salmonella can directly cross the placenta and cause harm. You should see your doctor quickly if you have more severe symptoms such as fever, bloody diarrhea, dehydration, or any changes in fetal movement.

Fortunately, those more severe cases are not common, and most pregnant women can get through those uncomfortable days with simple home remedies and foods, as well as a few safe over-the-counter (“OTC”) medicines. The most important goal is to stay hydrated, as you can quickly lose a lot of water from vomiting and diarrhea. You shouldn’t only drink water because it doesn’t really replenish your body’s needed salt and sugars, which is why the best options are the Oral Rehydration Salt packages available in local clinics and pharmacies. Those of you who are nauseous and throwing up can try the usual safe pregnancy options for nausea, such as ginger and vitamin B6. If you start to feel too dehydrated, or especially if you feel a change in your baby’s movements, you should immediately see your doctor.

The OTC medicine that most people commonly use to stop diarrhea — loperamide, AKA immodium — isn’t recommended for pregnancy, especially if you have bloody diarrhea. Some safer OTC items to slow down diarrhea include Medilac-S, which is a capsule of “good” bacteria; and Smecta, a charcoal-based powder which can also clear infections more quickly and is not absorbed in your body.

Of course, it’s better not to get gastro in the first place, so pregnant women should take special care with food hygiene. Specific recommendations include: not allowing frozen food from the shop to defrost on the way home; cooking all meats and eggs fully; thorough washing of vegetables; separating cooked and raw foods on different cutting boards; not reheating foods more than once; and washing hands frequently while preparing food. To prevent the more serious listeria infection, specific foods to avoid include: refrigerated pate; processed and cold meats including hot dogs unless reheated to steaming hot; unpasteurized dairy foods and soft cheeses; and cold, raw or smoked seafood.

Produce & Pesticides: Which Are Worst?

Do you know which produce has the most pesticides? The website, sponsored by the Environmental Working Group, has a Shoppers Guide to Pesticides which you can download as a PDF. There is also a nice, free iPhone/iPod Touch application called Dirty Produce, which also lists the Dirty Dozen and Clean 15. I find the iPhone app really useful while shopping for groceries, as it helps me decide whether a certain veggie should always be organic or could I get away with the regular version.

For example, below is their list of Top Ten Dirtiest Produce. I would always try to buy these organic, and I would still be cautious in washing and scrubbing:

1 (worst) Peach 100 (highest pesticide load)
2 Apple 93
3 Sweet Bell Pepper 83
4 Celery 82
5 Nectarine 81
6 Strawberries 80
7 Cherries 73
8 Kale 69
9 Lettuce 67
10 Grapes – Imported 66

Gastroenteritis: What You Need To Know

Case study: A 45 year old woman eats leftovers of sushi and salad (1 day in fridge). Two days later, she has diarrhea, stomach cramps, gas, and vomiting…

The Basics

Literally, gastroenteritis means “inflammation of the stomach”. This is the treaded traveler’s diarrhea, also known as Turista. It is an infection of the stomach tract, usually from contaminated food. In developed countries, this is usually caused by a virus and not treated with antibiotics. But in developing countries such as China, it’s much more commonly caused by bacteria, or also a parasite. This is why many travel doctors recommend antibiotics (but not always).

Why So Common?

This is usually a hygiene problem; the food got contaminated somewhere along the chain:

  • in the field (farm animal feces)
  • during shipping and storage (not temperature controlled)
  • during preparation (hand washing, cross contamination, not cooked well)
  • during serving (cook, server, fellow diners sharing utensils)

The Symptoms

Bacteria : Common symptoms include diarrhea (>3 loose stools per day); nausea; vomiting; cramps; no appetite. Less common are fever, blood in stool. Serious symptoms include dehydration. The usual course: starts within 2 weeks of ingestion. Lasts 1-4 days

Parasite: Parasite infections are usually much more subtle and slower onset than other infections; you may have slight cramps and bloating with occasional loose stools, which sometimes last for many weeks. A fever is uncommon. Dehydration is also rare, but if a child has a parasite for months, they could experience weight loss, fatigue and poor school performance.


Unfortunately, no matter how obsessive-compulsive you are, you have a good chance of eventually developing traveler’s diarrhea. A recent study compared these fastitious types with more casual travelers (the ones that would still eat ice cubes, etc) — and lo and behold, both groups got equally infected! I actually find this comforting; we should all relax just a bit while traveling.

But of course, it is best to follow some common sense rules:

  • Hand washing: this is crucial for everyone, not just the cooks. It is especially important after using the toilet. Far too many Chinese toilets still do not have proper soap and towels, so I always carry around Purell-style alcohol gel. The gel kills germs much more effectively — and much quicker — than soap and water. Keep one in your bag, on your desk at work…
  • At home: fruits and veggies — anything that can be peeled, should be! I would not assume that an imported apple would be any safer than local product; there could be pesticides on those, and they traveled long and far to get here. Better to be safe. Leafy greens, especially spinach, should be washed well. I highly recommend the Veggie Wash citrus spray, found in most expat markets. This natural spray kills most bugs and also helps wash off pesticides. As for meats and fish, make sure you cook it well — after inspecting it, and of course after washing your hands.
  • Restaurants: Even a 5-star can have infected foods, if the busboy or chef didn’t wash their hands properly. Also, look for the Beijing Health Department sanitation ratings at the front door. It’s usually a big blue sign with letters on it; A is top, B is ok. If you see C or D, then maybe you should think twice before entering.
  • Street food: buyer beware! For obvious sanitary reasons, the food here is riskier. Food poisoning is also much more common, especially in the summer months. If any food is left out in the heat for only one hour, the bacteria start multiplying. And where is the cook’s bathroom, or fridge, or cutting boards? Something to ponder…



  • Lomotil is the best choice to slow down non-serious diarrhea (aka not bloody). This medicine will slow down diarrhea for almost everyone. But some people don’t like the feeling, and it doesn’t make the infection go away quicker.
  • Smecta – charcoal. This powder is usually taken for 3 days; it helps to firm up the stool and also decreases the overall severity a bit — if you can tolerate the taste. There’s a new strawberry flavor for kids and queasy adults.
  • Medilac-S: this is “good bacteria”, a powder you put in water 3 times a day. It helps replenish your stomach with healthy bacteria, and also improves overall symptoms and length. Good stuff. Also has a kids version Medilac-Vita.

Nausea: ginger (jiang) is great in any form for nausea and stomach cramps. Mints usually also work well, as do salt crackers. Doctors can prescribe stronger medicines.

Dehydration: This is the #1 problem with diarrhea; thousands of children die needlessly every year in poverty-stricken regions worldwide due to lack of access to simple rehydration salts. You can buy these packets in clinics (Oral Rehydration Salts) and keep in the house or while traveling.
It’s important to realize that if you can’t keep any foods down, just drinking water is not enough to stay hydrated; you need salt and sugar as well. The salt packets are best for infants; mild diarrhea in adults usually can be handled with some type of clear broth soup (chicken soup with ginger; miso; wonton), or Pocari Sweat-type bottled waters. Be aware that some juices make your diarrhea more watery.
Healthy foods: Try salt crackers to get some basic nutrients. Leafy steamed greens with garlic and vinegar are great — and on every Chinese menu. Soups and rice broth (zhou) are a good start.

When To Go To The Doctor

Most gastro is easily managed at home with OTC medicines and a bit of TLC. If your diarrhea or vomiting is severe, or you feel dehydrated, or have a very high fever, you should see your doctor. But overall, for the average gastro, there’s nothing wrong with waiting a few days. And no, you don’t automatically need antibiotics. Even if it is bacterial, much of the time your body’s immune system can handle it just fine. A general rule — diarrhea for one week (7 days), even if mild, is probably not viral and needs evaluation.

In Your Travel Kit

The second worse problem, when traveling and developing diarrhea, is not to have medicine ready! It’s always a good idea to throw some basics into your carry-on:

  • Lomotil (aka immodium) – most important, especially to get you through a long flight
  • Antibiotic – it’s not a bad idea to carry either ciprofloxacin or azithromycin. Your doctor will need to prescribe this.
  • Others: Smecta (charcoal); medilac; bismuth (Pepto-Bismol)

Slide Show

I created a simple slide show about gastroenteritis, which you can watch full-screen below by clicking on the Menu button: