Category Archives: Heart Disease

Alcoholism: A Family Scourge

I miss my father. He should be around to be granddad to my wonderful boys, helping me raise them to be good men. But he’s not around, dying far too early, from alcoholic cirrhosis of the liver. Only in his mid-60’s, he was a wonderfully warm-hearted man with a deep belly laugh, very much the average-guy Martin Crane to my Frasier Crane-like stuffiness. But he was also an alcoholic who slowly drank himself to death.

I have countless fond memories of us over the years, but I also have nightmare memories of holding his hand as he died in the hospital, in a coma, his skin yellow and lungs filled with fluid as his kidneys and liver finally gave up from the years of toxic abuse. These are memories that no child should have — but so many do.

My father

Why is alcoholism such a scourge to society? When compared to many other common diseases such as heart disease, alcoholism has a much more devastating social effect — not just on that person, but also their family, who painfully watch for years, helplessly, as their loved one slides into decline. Yes, many diseases are terrible and affect others; smoking can cause secondhand smoke diseases to family members. But alcoholism is a sad disease, and it’s those bad memories that really haunt families of alcoholics — memories of being afraid as we weave across wintry roads as dad drives home tipsy; memories of mom crying as dad refuses to hand over the car keys; memories of watching his belly get bigger and his memory weakening as his liver starts to fail.

So as we honor Alcohol Awareness Month this April, I’d like to use this opportunity to spread the word about alcoholism, hopefully to help a few people out there.

The first step, as anyone in 12-step programs will tell you, is to admit there may be a problem. If you’re not sure, just answer these four simple questions:

  1. Have you ever felt you needed to Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

If you’ve answered “yes”  to 2 or more, then you indeed may have a problem with alcoholism and may already be causing liver damage. These questions above are called the “CAGE questionnaire” and are used by doctors as a screening tool for alcoholism.

What If You May Be Alcoholic?

First of all, congratulations if you’re honest enough to admit you may have a problem. Secondly, you need to know that you are not alone, and many people and organizations can help you:

  • Your family doctor can check out your liver and kidney health.
  • Some newer medicines, like naltrexone, may actually help you quit drinking; your doctor can discuss these with you.
  • Twelve step programs such as Alcoholics Anonymous aren’t for everyone, and there’s contradictory evidence as to how effective they are. But for many recovering alcoholics, they’ve been a source of strength, all over the world. You can find a list of AA sites in the US here.
  • Psychologists and psychiatrists can help you in many ways, from quitting drinking to processing underlying stresses and depression, to fixing family and job problems related to your drinking.

    dad on the twins second birthday
    My dad with us, at 2 years old. That’s me on the right (I think)

My Dad’s Legacy

Clearly, living through my dad’s illness has had a profound influence on me as a doctor, and I do find myself drawn to these patients. I’m sure it’s partly an effort to make up for what I couldn’t do for my own dad.

But despite all the pain of those later years, my strongest memories are the good ones. I will always remember his laugh, and to this day I vividly remember how he could light up a room. I’d like to end with a poem from Ralph Waldo Emerson, which we used at his wake:

To laugh often and much;
to win the respect of intelligent people
and the affection of children;
to appreciate beauty;
to find the best in others;
to leave the world a bit better
whether by a healthy child,
a garden patch, or a redeemed
social condition; to know even
one life has breathed easier
because you have lived.
This is to have succeeded.

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!

Chinese Spring Festival Eve: As Unhealthy As Thanksgiving?

Next week’s Spring Festival will already be my sixth 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.

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.

Red Meat: Not So Good For Your Heart. Here’s More Proof

Red meat cow cardiac disease

A couple years ago I wrote a post discussing data showing how some red meats are bad for your heart; now a major new study again confirms this concept. This huge study from the Harvard School of Public Health analyzed data from 2 studies which followed 120,000 people over 20 years. They found that the more red meat people ate (especially processed meats) the more people died from heart disease. Here’s a nice summary from the very cool Meatless Mondays website:

…They discovered just one 3-ounce serving of red meat daily (about the size of a deck of playing cards) was associated with a 13% greater chance of dying over the course of the study. What’s more, participants who consumed daily servings of processed meats like hot dogs and bacon were at 20% higher risk of mortality. As the amount of meat consumed increased, so did the risk of death.

Conversely, replacing beef and pork with a serving of nuts, legumes, whole grains or low-fat dairy seemed to improve longevity. Nut consumption was linked to a 19% lower risk of dying during the study, whole grains with a 14% reduction, and beans and dairy with a 10% decrease in mortality.

“Any red meat you eat contributes to the risk,” An Pan, a postdoctoral fellow and lead author of the study told the LA Times, “If you want to eat red meat, eat the unprocessed products, and reduce it to two or three servings a week,” he said. “That would have a huge impact on public health.”

Dr. Dean Ornish, a UC San Francisco researcher and author of an editorial that accompanied the study in the Archives of Internal Medicine, agrees, suggesting that red meat lovers can reduce their risk by cutting meat one day a week. “Something as simple as a Meatless Monday can help,” he said. “Even small changes can make a difference”

I discuss this article on my March 14th weekly radio interview on EZFM’s Beijing Hour. Paul and I also discuss a Xinhua news report discussing the lastest campaign to decrease the massive overuse of antibiotics in Chinese hospitals.

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.

High Cholesterol Hits Home…



I’m in America right now, visiting my family for the first time in over a year. I’ve been having a wonderful time with them – right up until my older brother casually told me how, a year ago, his cholesterol was checked for the first time and “something was high, like I think my triglycerides were over 800, and my good cholesterol was low, and my total was over 300. Something like that…”

Well, that certainly perked up my ears. My oldest brother had cholesterol problems at such dangerously high levels (normal TG is under 150) that he was a “walking heart attack risk” before the age of 50. Needless to say, I picked up my jaw off the floor and had a long brother/doctor heart-to-heart discussion with him about how serious this was. I even showed him his cardiovascular risk score (from and showed him how he has a 12% risk of having a heart attack or a stroke in the next 10 years (normal risk is ~5%; mine is 1.5%; anything over 10% worries us docs). I’m not exactly sure how that doctor last year let him get out of his office without medicines or strong warnings, but it doesn’t really matter now; I have no intention of letting my only older brother depart from this world prematurely.

One important point for my readers is that for many of you, as well as for my brother, lifestyle changes only take you so far. Honestly, even if my brother spent 3-6 months losing 10 kilograms and having a hardcore low-fat diet, his levels still would be higher than normal, certainly still high enough to be laying down that artery-clogging cholesterol plaque in his heart and brain. Many people cling to this noble idea that lifestyle changes will help a lot, and they absolutely do and should be a part of anyone’s treatment, including when on prescription meds. But for a great many of us, medicines are inevitable. That’s not a bad thing at all! It’s just the hard draw of our genetic makeup. This idea is called epigenetics, a very trendy and exciting research term: our genetic makeup determines a lot about which diseases we get, but our environment can dramatically effect how severe, or how quickly, we develop those pre-programmed diseases. In my brother’s case, he likely has a genetic weakness for cholesterol, especially triglycerides, but his decades of a typical American diet clearly makes his condition worse than it could be.

That’s why cholesterol-lowering medicines for many of us are not only inevitable but essential. The prescription statins such as Lipitor have been remarkably effective for tens of millions of people, and they literally can cut your risk of heart attacks and strokes more than 50%. But another take-home message is that a few natural medicines can also really help many of us. The best evidence is for omega-3 fatty acids as well as niacin, but fiber and other natural products also help a bit.


I’ve written a lot about omega-3, a natural fatty acid which is found in all the fatty fish, especially salmon, mackerel and sardines. The healthiest way to get this is to eat those fish as often as possible, at least twice a week. If that’s not too practical, all pharmacies carry fish oil supplements.
If you do decide to take it, and if you can tolerate the fishy aftertaste, there are some key facts:

  • LOOK CLOSELY AT THE FINE PRINT. Sure, it may say “1000mg fish oil”, but we’re not interested in that. We want to know the TOTAL AMOUNT OF OMEGA 3 (DHA and EPA) – which is usually only a third of the total oil amount! So the key is to look at the nutrition label to see how much TOTAL omega 3 it has — again a combination of DHA and EPA. Usually, your 1,000mg of fish oil only has about 360mg of omega-3. That means, if you need to take 1 gram a day of omega 3, you need to take 3 capsules. (Shoppers tip: in the US, the megastores Costco and Sam’s Club have big bottles of higher-strength, and enteric-coated, softgel capsules. I always stock up at Costco when I go home).
  • For general low cholesterol issues, people should usually take 1 gram a day of the omega 3.
  • For more severe cholesterol problems (such as my brother), usually 2-3 grams a day of omega 3 is recommended. That means some of you may need to take ~8 pills a day, if you can tolerate them.
  • Don’t forget that omega-3 is mostly beneficial for triglycerides; it can lower TGs by 23-45%. It is NOT very effective for lowering total cholesterol, and it actually raises LDL a bit, which may surprise many of you. But it also raises HDL, the “good cholesterol”, by a similar amount – thus canceling out the bad effect on LDL (we think). To be most effective in my brother’s case, he would need to take a lot, at least 2 grams – but 4 grams is even better, if he can tolerate it.

Another natural treatment for cholesterol, niacin, is actually a simple over-the-counter mineral which is quite cheap. Niacin is quite effective for some types of high cholesterol but isn’t commonly used – mostly due to the side effects and liver problems. Here are some important points:

  • Niacin is great for lowering triglycerides, at high doses >1,500mg daily. It lowers triglycerides by 20% to 50%.
  • Niacin decreases LDL-C by about 5% to 25%.
  • It’s excellent for increasing HDL-C. It increases HDL-C by up to 35%.

But side effects of niacin are very common, and many people cannot tolerate this for too long. The most common problem is headaches and a flushing reaction people get after taking their medicines, almost like a hot flash. This can range from barely noticeable to intolerable. Some tricks to avoid the side effects are to take a baby aspirin 1/2 hour before your niacin, and also to buy the extended-release and not the immediate-release niacin. The most concerning — but rarer — side effect is liver toxicity; you should not start niacin by yourself without first getting your liver function tested by your doctor. And your doctor can help you choose which niacin is best. The extended-release pills have less flushing and headache effects but they also increase the risk of liver toxicity.
Niacin can also increase glucose levels, so diabetic or pre-diabetic persons should discuss this issue with their doctor before starting niacin.
One great thing about niacin is price – the OTC versions can be as cheap at $10 a month. But then you also cannot guarantee that the doses are totally accurate; in some cases, it’s still better to get the prescription versions. If you have insurance, it’s probably best to get it from your doctor, or at least get their recommendation as to which, if any niacin, you should take.

As for prescription medicine, my brother’s triglycerides are best treated with prescription fenofibrate, usually called Tricor in most countries. This medicine has a long track record and is, by far, the top choice that doctors would use in this case – much more than niacin, for example. Fenofibrate lowers TGs over 50%, and it also lowers LDL and raises HDL. Thus, it’s a potent triple-benefit for people with seriously high triglycerides. But since he’s currently waiting for his health insurance to kick in (welcome to America!), there’s nothing at all wrong with now starting omega-3 supplements right now, and perhaps niacin if he gets his liver tests first. There’s also a bunch of fiber supplements and others that work a bit: here’s a nice graph from the Natural Medicines Database article on natural ways to lower cholesterol:

natural medicines to lower cholesterol
natural medicines to lower cholesterol

So I’m now heading back to China, at least feeling a bit better that I could help my brother out. The hardest part – lifestyle changes and weight loss – will be up to him.