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What’s The Secret to Long Term Expat Happiness?

After six and a half years here in Beijing, I can comfortably say that I have joined the ranks of the long term expats. I’ve seen many friends and patients come and go. But I’m still here with my wife, and now with my new son Alex. And despite all those constant stressors from environmental scandals, bad traffic and all too rare perfect weather, we continue to have a satisfying adventure here. What’s our secret? And is there a common thread, some survival skill, which separates long term expats from those that leave earlier?

Happiness index

No matter where you are in the world. if you want to thrive in your community you need happiness. If you’re happy, you stay. If you’re unhappy, you move along. I think the main secret to expat happiness in Beijing is a healthy attitude, open mind, and deep social connections. Our minds are powerful mediators of our physical health, and to survive in Beijing’s often harsh environs you definitely need a tolerant and malleable frame of mind. Otherwise, a buildup of stress or unhappiness will inevitably wear down your immune system and lead to illnesses as well as chronic problems such as heart disease. This is why a successful long term expat comes to terms with those stressors and rides them out, like a luxury boat on a choppy river.

I asked one of our psychologists, Dr Rob Blinn, what he thought was the secret to long term expat happiness for both kids and adults:

Several meta-studies in the past few decades have shown that neither health nor wealth are predictive of happiness.  What is predictive is the breadth and depth of social connections.  This is true for kids as well as adults.  I think this is the most important tip I have.  The people who do well here seem to have lots of close friends.   They also seem to know when to ask for help or support when they are struggling.

I’ve always found relaxing activities such as yoga, tai chi or a massage to be powerful tools for relaxing and resetting my balance. Yoga, especially, has well researched benefits on happiness and relaxation as well as treating anxiety and depression. All of these activities are readily available in Beijing. A good, inexpensive massage surely is one of the best perks of living here!

Another key for long term happiness here is to really connect with your community of local Beijingers. If you’re always in an expat bubble and especially don’t learn Chinese, you’re much more likely to suffer that “Lost in Translation” ennui and never really understand the charming side of local Beijingers. The best way to explore Beijing is on a bike! Our favorite activity in Beijing is to bicycle through the hutongs inside second ring, randomly taking turns and discovering new gems each time. Beijing is at its most charming after dinner as everyone socializes outside, and you can have a fun and rewarding social experience joining everyone as they sing and dance on every street corner and park.

Physical health is crucial for long term happiness. Exercising the recommended 90-150 minutes a week; getting a good night’s sleep; not letting stress take over your life; eating a balanced diet; drinking in moderation and no smoking; not getting overweight — all these lifestyle basics are helpful anywhere to thrive.

The number one tip again: be social! And have a wonderful time!

(This article was originally printed in the current edition of Beijing Kids magazine, where I am a contributing editor. You can click here to read the rest of my BeijingKids “The Doc Is In” columns.)

School Pollution Domes: Let The Building Boom Begin

Here in Beijing we have a residential area near the airport called Shunyi, which is essentially a collection of uber-suburban villa complexes surrounded by corn fields and the ever-dwindling scattered village. You can sip your Starbucks coffee and almost convince yourself you’ve never left your American suburb — except you just paid twice as much, and there’s no decaf brew. The saving grace of this ersatz community is their collection of excellent private schools. One of these, Dulwich College Beijing, recently built an enclosed dome over a new sports field. Nearby, their competitor International School of Beijing just recently finished building two enormous domes over a huge swath of their outdoor playing fields. Last week I had the honor of giving a speech at ISB’s opening ceremony for this Fitness and Tennis Center, and I was blown away by its sheer scale and technical specs. Both of these are really just enclosed outdoor arenas, which many schools in America already have, so what’s the big deal? The big deal is that these aren’t just to keep off the rain and snow: these are pollution domes, replete with massive air scrubbers to filter out the smog. Both can easily keep the AQI levels safely under 25, even in the midst of the recent mind boggling pollution spikes over 600.

International School of Beijing Fitness and Tennis CenterIt’s no secret that the air pollution levels in Beijing are high quite often, and many parents are extremely nervous about health effects on their children. In my six years working in Beijing as a family medicine doctor, I’ve also become quite concerned, especially after digging through the research. I’ve been alarmed mostly by the well publicized results from the USC Children’s Health Study. In this research, kids from 4th to 12th grade in smoggy Los Angeles were followed for over nine years. The results showed a worsening of lung function in those children from the most polluted school districts. Their follow up study was equally concerning, showing lingering changes to these same lungs even at 18 years of age, when most lung development is completed. In other words, this lung damage could be permanent. It’s important to be a bit cautious here, as their lab findings, while statistically significant, may never become clinically significant to those students. But the main worry still remains risks to their long-term health and increased mortality as adults. Given these and other studies, I think it’s not just prudent to take action, it is in fact morally obligatory for local schools to protect their students.

I’ve been pushing this issue on my blog for a few years now, and a few school principals have been miffed at me after their battles with concerned parents, who often are waving my articles in their faces. I have no qualms being such a gadfly, although I rather like to picture myself as a pied piper, luring the children to greener pastures and bluer skies.

Because of all of this increased pressure from many angles, many private schools in Beijing over the last couple years have created action plans for air pollution, setting up activity cutoffs at set points of the Air Quality Index, obsessively followed every hour via multiple websites and smartphone apps. For example, an AQI around 250 would probably cause all outdoor sports and recess to be cancelled that day. While that AQI number may seem extraordinarily high to many, it happens so frequently here that the ISB students almost developed cabin fever last year, having been forbidden to play outside on thirty five days. So the school decided to build two enormous domes over huge sections of their outdoor playing fields and tennis courts. Now, when Shunyi’s AQI hits those higher trigger points, schoolkids at Dulwich and ISB no longer have to stare longingly out the windows into the smog; they can play sports and have recess inside these domes.

While I’m actually quite happy that these schools have done this, I’m also disturbed by the implications of schools building “pollution domes.” When I first saw the ISB dome rising over their sports fields, my first reaction was, “what the heck am I doing living in such a polluted city that schools have to think of such solutions?” Before Beijing, I called Sonoma county my home, and air pollution was a nonexistent issue there. Every day I had the rare honor of commuting past gorgeous vineyards on my drive to my Guerneville clinic, watching hot air balloons rising majestically in the pristine morning air. The only issue with air pollution was the occasional wildfire, and fog had none of the ominous euphemisms it has here.

My second major reaction to these domes was great unease over the clear implications of wealth and privilege. How fair is it for a handful of children to be protected from “beyond index” air pollution while hundreds of thousands of local kids in public schools are still running around outside? Should we be building domes for all schools? And how far should local schools go with protection, given limited budgets? Does a school ensure their students’ long term health better via MERV-13 rated HVAC filters or a low salt, soda-free lunch menu?

While those above implications still disturb me, I must admit that if I were choosing a school for my child, and School A and School B’s major academic criteria were equal, environmental programs such as action plans and pollution domes could definitely be my deciding factors. I think this could actually be a serious promotional advantage for a school in areas similar to Beijing, and I wouldn’t be surprised at all to start seeing a competition between schools as to who can offer the cleanest air and the fewest skipped days of outdoor recess.

But while it’s easy and obvious for Beijing parents to obsess about the inescapable grey days, I think many lose focus on other major health issues. In the big picture of a child’s health, factors such as obesity, nutrition and lack of exercise can be far more important than the risks of air pollution. For example, one could argue that no exercise at all may be worse than exercise outside on a bad day. And since exercise is so much more a factor in health than pollution, then isn’t lack of exercise due to cancelled outdoor recess indeed a serious concern? I think so, which is why I’m hesitant but ultimately supportive of steps such as pollution domes. Since it reportedly will take many, many more years for our local air to get significantly cleaner, perhaps these stopgap measures are indeed warranted. I wish we didn’t need these types of debates, but now that it’s out there, and “up” there, I say go for it. Let the building boom begin.

Dulwich Sports Dome
Dulwich Sports Dome

A Chinese version of this article was published in my column in the New York Times Chinese edition, available here. This is an updated version of my Beijing Kids column last year.

Which Lifestyle Choice in China Will Kill You First?

Happy Elderly Seniors Couple Biking

If the tooth fairy gave you 10,000 RMB every year in China that you could only spend on your health, what would you buy? Would you get an air purifier? How about a gym membership; an organic delivery service; a daily massage — what would you choose? Perhaps it’s best to rephrase the question, “what gives my health the most bang for the buck?” In order to answer that, one needs to know which lifestyle choices are harmless fun and which are unhealthy.

Air Pollution : A Lifestyle Choice? 

Many in China, both local and foreign, would instinctively say that air pollution is their greatest threat to health, but is it really? Let’s make a slight intellectual leap and say that exposure to air pollution is a lifestyle choice; in other words, a modifiable risk factor. I know that breathing is of course involuntary, but most of my readers do have a choice whether or not to live here in China. If you accept this admittedly disturbing assumption, you can then compare this always dreaded “risk factor” to much more mundane risks we all encounter — such as obesity, smoking, lack of exercise, poor diet and other lifestyle choices.

We can clarify lifestyle choices even further into what the American Heart Association calls the four ideal health behaviors:

  • not smoking
  • not being overweight (body-mass index (BMI) <25 kg/m 2)
  • physical activity at goal levels (>150 minutes a week of moderate exercise)
  • diet that includes three or more servings of fruits and vegetables daily.

The AHA also lists three ideal health factors, including total cholesterol <200 mg/dL, systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg, and fasting plasma glucose levels <100 mg/dL.

How many of these seven metrics do you pass? Don’t feel too guilty, as only 1 percent of the AHA’s test group of 7,622 persons passed all seven. But here’s the clincher: compared with individuals who didn’t meet any of these seven measures, those with five or more had a 78% lower risk of all-cause mortality and an 88% lower risk of death from diseases of the circulatory system. That’s impressive, no? But it’s much more interesting to find out exactly which of these ideal goals is most efficiently beneficial. Plus, how do they compare to air pollution?

Yoga Near Lighthouse

It’s All About The Relative Risks

I’m a data junkie, and I find hard numbers very comforting in the midst of my hectic “medicine is art” family medicine clinic. My favorite tool to compare health outcomes is the relative risk; this compares the ratio of a disease’s prevalence from a health exposure as compared to non-exposure. It’s simple division: divide numerator (exposure) by denominator (no exposure) and you have your ratio, your “RR”. Any RR over 1 signifies a positive risk, and under 1 is a “negative” risk, i.e. a benefit. Let’s use air pollution and smoking as initial examples. As I mentioned in my controversial post earlier this year, a day in Beijing is comparable to smoking 1/6 of a cigarette, which for many of my readers was scandalously low, almost heretical to their predisposed belief systems.  Sorry, true believers, but you can crunch the numbers yourself from Dr C Arden Pope’s sudy. From this study, we can calculate relative risks of lung cancer for air pollution, smoking and secondhand smoke:

  • Air pollution (from American Cancer Society and Harvard Six Cities studies): 1.14-1.21 relative risk
  • Air pollution in Beijing: 1.49 RR
  • Secondhand smoke victims: 1.21-1.28 RR
  • Smoking 3 cigarettes a day: 5.6 RR
  • Smoking half a pack a day: 7.7 RR
  • Smoking a pack a day: 12.2 RR
  • Smoking two packs a day: 19.8 RR

As the numbers show, “light” smoking of only 3 a day is far more deadly than living with Beijing’s air pollution. Since writing that article last winter, I’ve achieved a certain catharsis on this issue, and my personal obsession with air pollution has mellowed from debilitating to professionally curious. I’m now more concerned with the much less glamorous lifestyle choices that bedevil all developing societies, all eagerly latching onto the “Western” lifestyle and quickly picking up both the best and the worst of such lifestyle.

I’m particularly worried about obesity, the great pandemic of our times and an astonishingly pervasive crisis in my homeland, the USA. When I make my annual visit home on Boston’s south shore, I’m truly shocked just how large are the average American adult and child. Having spent six years outside of America, I can peer back with increasing impassivity and state that Americans simply don’t realize the true state of this public health disaster. One of my all-time favorite public health graphs, taken from data from a 1999 NEJM review article, shows the relative risks of increasing weight on coronary heart disease, diabetes, high blood pressure and kidney stones.

Right now, more than half of Americans are technically overweight, with a Body Mass Index (BMI) of 25, the threshold crossing from “normal” to “overweight”. This BMI of 25, now the new normal in the US, increases your lifetime risk of diabetes sixfold, and your risk of high blood pressure doubles. And that’s only at the mildly overweight group; the 35% of Americans who are technically obese, with a BMI over 30, have at least a forty-fold increased risk of getting diabetes. Obesity also raises your risk of cancers; in one study of obesity and cancers, the relative risk of death was 1.52-1.62 in the heaviest group (BMI over 40).

Shanghai Skyline in thick Fog

My 10,000 RMB Each Year Goes To…

When we discuss the global burden of disease, there isn’t anything very different anymore about China compared to most other countries. Chinese people are already dying from the same chronic diseases as the developed countries, and people here need to follow the same common sense lifestyle precautions as anybody else does.

I meet many patients who spend extraordinary amounts on imported air purifiers, whose markup is so sinfully exorbitant the distributors should be publicly flogged. But a great many of these patients are mildly overweight, or “walk” for exercise, or have only a couple servings of vegetables a day. I hope some of these same people can realize that they’re focusing their energies and their money on the wrong issue. Same goes for kids; if parents are fighting over Blueair versus IQAir for the nursery, but their child is already at 99% weight, then their pediatrician needs to have a serious discussion with them about prioritizing. And heaven forbid if you’re even a “light” smoker; please just sell the damn air purifier, return your gym membership, and go pick up a prescription of varenicline!

As for me, with my 10,000 RMB annual play money? I’m already maxed out on those pricey imported air purifiers at home, although the replacement filter cost certainly adds up (again at extortionary markups). And I’m a bit self-satisfied that I pass all three of the AHA’s ideal health factors. As for their ideal behaviors, I don’t smoke, so I’m down to the weight and exercise issue — the banes of our modern civilization. My BMI hovers at 24-25 but my waistline is starting to strain a bit at my perennial size 33 waist. Perhaps I can blame Beijing’s hard water for the pants shrinking in the wash? No, I must admit that I am slowly losing the weight battle, as are most fortysomething men. I also am skilled at hypocrisy, preaching eloquently to my patients about needing their 150 minutes a week of moderate exercise yet equally poor at following my own wise words.

So this year, I’ve locked up my wonderfully fun electric bike and now pedal to the hospital most days, even now, during Beijing’s biting winter. My exercise is now part of daily life and not a “chore” like trudging guiltily to the gym. As for getting the weight down, I’ve started to make my own morning coffee so I won’t be tempted by a Starbucks muffin to go with their Christmas toffee latte (hold the whipped cream).

My health risks are relatively small (knock on wood) so my goals are fairly modest — and very inexpensive as well. I’m way under my 10k RMB stipend, so I’ll use the rest of that money for the creature comforts you can get only in China: two hour massages; three hour KTV sessions; all-day soaks in Beijing’s local hot springs. It’s those little things in China, those cumulative and inexpensive perks, that truly soothe the soul. In China, as anywhere else, mental health is just as crucial as physical health.

A Chinese version of this article was published in my column in the New York Times Chinese edition, also available here on my site.

Top Ten Parenting Posts of 2012

It’s hard enough being a parent anywhere, but adding China-specific hassles could give anyone a headache. Here are my favorite parenting posts from 2012:

Parenting articles 2012 Cough Syrups For Kids: Do Any Work Well? — Short answer? Not really. Better answer: honey!

Make Your Own Yogurt! — It’s a superfood breakfast, fun to make, and gives you control of food choices in China.

All I Want For Christmas Is A Pollution Dome — Here are my thoughts on ISB’s new covered gym. What does this say about our society?

Probiotics: The New Black — Kids on antibiotics should also be taking probiotics.

TCM and Kids: Which Therapies Are Safe — And Effective? — Here’s my review of the literature.

Pain Relief For Kids: A Guide To Proper Dosing — It’s all too easy to overdose, especially with Tylenol syrups.

Soft Drinks + Kids = Bad Idea — There is zero redeeming value to any soda!

Dehydration From Gastro: Are Sports Drinks and Sodas Safe? — No, most are not very ideal and may be harmful. I explain why.

Breathing Clean in Beijing: Let’s Separate Fact From Fiction — Is our air like a pack-a-day smoker? Not even close. Find out more.

Should Doctors Fire Parents Who Refuse Vaccines For Their Children? — Some doctors have started doing this; here’s my take.

You can also peruse my archives of Children articles here.