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?
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).
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.