Category Archives: Cancer

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.

 


This article was originally published in 2014 on my sister blog, myhealthbeijing.com. A Chinese version of this article was published in my New York Times Chinese health column.

Sunscreens Prevent Cancers — And Wrinkles

I’m usually quite proud of my Irish ancestry, but one unfortunate vestige of that heritage is pasty white skin that sunburns quite easily. When my mother was pregnant with me and my twin brother, the doctors discovered a large melanoma on her leg which required immediate surgery. Fortunately everyone turned out just fine, but my family history and skin color certainly put me at higher risk of developing melanoma and other skin cancers. In fact, studies have shown that getting painful blistering sunburns during childhood is a major risk factor for melanomas, squamous cell carcinomas and basal cell carcinomas later in life. This is why it’s up to parents to protect their children from the sun’s harmful effects.

Sunscreen UVA UVB broad spectrumWhat are the essentials for sun protection? For infants under 6 months of age, the American Academy of Pediatrics doesn’t recommend any direct sun exposure, as their skin is especially pale and vulnerable. For most children and adults, a combination of sunscreens, proper clothes, and avoidance of peak times from 10am-4 PM (or following your local UV Index) are the major ways to avoid damage.

How effective are clothes? These should be a first line of defense for all ages, but a plain white t-shirt only has a Sunburn Protection Factor of 7, so you could still burn quite easily through this. Most other clothes, if thicker and darker, would offer a more protective SPF 15 or higher. But I still know all too painfully well that even a dark t-shirt won’t be enough if I’m out all day swimming and playing outside.

This is when sunscreens come in handy. A good sunscreen has been shown to decrease risk for skin cancers, most impressively with squamous cell carcinomas. One Australian study showed a 40% decrease in these cancers when using a broad spectrum SPF-16 sunscreen. The evidence for protection against the much deadlier melanomas actually isn’t so strong, with the best study published in 2010 in the Journal of Clinical Oncology. This randomized controlled trial followed 1,600 persons over 10 years in Australia, a region with the world’s highest rates of skin cancers. Those who routinely used sunscreen had a 73% reduction in invasive melanoma, although the accompanying editorial questions its statistical significance. Still, I agree with their conclusion that, “the question of its efficacy with respect to melanoma prevention should no longer deter scientists or clinicians from recommending sunscreen use…In addition to sunscreen use, excess exposure to ultraviolet rays should be avoided, clothing should be used to shield skin from the sun, and sun-safe environments should be used for outdoor recreation. In addition, sunscreen use should be paired with regular self-examination of the skin.”

Sunscreen also helps prevent wrinkles and aging of the skin, as was just proven for the first time. This study followed 903 Australians for almost five years, and those who used daily broad spectrum SPF-15 had no detectable increase in skin aging.

But what exactly defines a good sunscreen? Right now your local market probably has an entire wall selling dozens of brands in bright plastic, offering a range of SPF and customized for babies, women’s faces, men… on and on, a confusing mess for us consumers. We can cut through a bit of this with the basics:

Buy a broad-spectrum: just because it says SPF-50 or even 70 doesn’t mean it’s wonderful, as the SPF rating system only measures sunburns from UV-B sunlight and not UV-A sunlight. UV-A rays don’t cause your classic lobster-red burn but it is much more sinister, penetrating deeper into your skin layers and causing more subtle and permanent precancerous DNA damage. This is why it’s crucial to buy sunscreen that follows the US FDA’s new rules and literally says “broad spectrum” on the label. This means it contains ingredients covering both UV-A and UV-B

Get SPF 30, and don’t waste your money with SPF-50 and higher: SPF-15 is a good start since it blocks 93% of UVB, but I agree with the American Academy of Dermatology to use SPF-30 as a standard. SPF-50 and above may seem impressive but clinically offer miniscule extra protection over SPF-30. SPF-30 already blocks 97% of UVB and SPF-50 only one percent more, at 98%. In fact, it’s so misleading for consumers that the EU has banned any labels over SPF-50, and the US FDA is also finalizing this long overdue limitation.

Use more than you think is enough: Research has shown a large percentage of us don’t use enough each time we apply it, and thus aren’t getting the proper protection. A typical adult should be using 1 ounce (30 ml) each time for head to toe protection.

Don’t stay out longer: Many doctors are concerned that people, especially children, stay out in the sun longer after applying sunscreen and actually increase their risks for melanomas, forgetting to reapply as directed or not using enough in the first place.

Use it all year: this may surprise many, but the AAD also recommends this. Ultraviolet rays are much weaker during other times of year but can still add up to skin damage. You should at least consider always using a daily facial moisturizer which also has at least SPF-15 and apply on your face, ears and neck. I’ve used daily facial aftershave with SPF-20 since my college days, in winter or in summer.

Sunscreens also have many approved chemicals to choose from, which further confuses your consumer choices. Some groups, especially the Environmental Working Group, claim that two common ingredients in sunscreens, oxybenzone and retinyl palmitate (from vitamin A) are harmful to health and thus should not be included in sunscreens. For example, on their web page describing oxybenzone’s dangers, they state toxic issues with “hormone disruption; reproductive effects and altered organ weights in chronic feeding studies; high rates of photo-allergy; limited evidence of altered birth weights and increased odds of endometriosis in women.” However, not one governmental FDA bans these substances, and no major medical organization agrees with their warnings. The majority of research the EWG cites are done on animals or in test tubes and not on humans, and no major research with humans has shown serious dangers. Both of these chemicals have been, and continue to be, approved as safe by the US, the EU and Canada even after more than 20 years of usage. The American Academy of Pediatrics’ position statement on sunscreens has no specific warning against these or any other FDA approved chemicals for sunscreens. The American College of Dermatology published an updated statement last summer restating their support of these two ingredients.

Fortunately, even if you still remain concerned about these ingredients, there are hundreds of sunscreens available which don’t have either of these and can offer excellent broad spectrum coverage for both you and your children. Oxybenzone isn’t even as effective as other chemicals such as avobenzone, so you could search for that instead. And you don’t need retinyl palmitate because it doesn’t even block sunlight and is only added to allegedly help with photo-aging. The American Academy of Pediatrics specifically recommends products with with zinc oxide or titanium dioxide, as they are physical barriers and don’t get absorbed. If you want more consumer guidance, you can read the independent test results from Consumer Reports or also the sunscreen ingredients guide from Consumer Search, which also reviews natural sunscreens.

Here’s a fun and helpful infographic regarding sunscreens and other summer safety tips, from the folks at Maternity Glow:

 

Rubber Ducky You’re The One — To Cause Diabetes and Cancer?

My boys are now both over two years old, but they still like the occasional chew on their toys, which are mostly made of plastic. Rubber duckies, Lego men, Brio trains — it’s still a ton of fun to put in their mouths if it makes mommy and daddy really mad. I choose my battles with them, but I try to stop them partly because I’m worried about the chemicals in the plastic. Surely, microscopic parts of that plastic must be getting into their systems? One set of bath toys was very typical, made in China but exported to America, from a company vowing they are “safe and dependable”, with standards that “meet and exceed” US laws. What exactly does that mean? What are these laws? Should I be worried? And just how well can I or any parent protect our children from all environmental harms?

When I think about our modern world’s reliance on chemicals and plastics, I’m reminded of what Donald Rumsfeld called the “known unknowns” – we know that we understand almost nothing about the safety of the 80,000 consumer chemicals created since World War II, because they’ve never been required to be tested on humans. As the WHO states in their 2012 report State of The Science of Endocrine Disrupting Chemicals, “the vast majority of chemicals in current commercial use have not been tested at all.

bathtoy

The chief concern is that some of these chemicals are endocrine disruptors, which are chemicals whose molecular structure is similar to our natural hormones. With this mimicry, they can bind to the same receptors that our natural hormones do, thus altering our normal endocrine activities which control  just about every aspect of our health. We are mostly worried about children because these endocrine disruptors could cause permanent damage during our most sensitive growth spurts: while still developing in the womb, and later during puberty. The most notorious example of an endocrine disruptor is diethylstilbestrol (DES), a synthetic estrogen which was given to many pregnant women in the decades after World War II as a treatment to prevent birth complications. But slowly it became clear that many newborn girls of these mothers were getting a rare vaginal cancer, and DES was banned and declared a carcinogenic — but even right now many of these same “DES daughters” are continuing to have reproductive health problems both for themselves as well as in their own children, which means some endocrine disruptors can permanently alter our DNA, affecting generations.

The US Endocrine Society published an even more damning document, their 2015 Scientific Statement on Endocrine-Disrupting Chemicals, which concludes that

…there is strong mechanistic, experimental, animal, and epidemiological evidence for endocrine disruption, namely: obesity and diabetes, female reproduction, male reproduction, hormone-sensitive cancers in females, prostate cancer, thyroid, and neurodevelopment and neuroendocrine systems.

The prestigious JAMA Pediatrics published their own review of endocrine disruptors in 2012, essentially agreeing with the WHO’s assessment that while hard data on humans isn’t very strong, there’s enough concerning data to conclude that “efforts to reduce EDC exposure as a precaution among pregnant women and children are warranted.” Chemicals such as BPA, PVC and phthalates are most often mentioned as causing harm in boys and girls, associated with infertility, obesity, cancers and neurodevelopmental problems such as behavioral issues and a lower IQ.

Plastic ID Codes and Properties. Source: tinyurl.com/o487x9o
Plastic ID Codes and Properties. Click to enlarge. Source: tinyurl.com/o487x9o

So what can we all do to protect ourselves? After all, everything we touch almost literally has plastic as part of it. I’ve found a few consumer groups and blogs that offer helpful advice for worried parents. My favorite is The Soft Landing blog, which has a very useful collection of safer product shopping guides. The Pediatric Environmental Health Specialty Unit also offers similar advice. Here’s a small summary of what most are advising:

  • Try to buy products (especially for babies) that are free of BPA, phthalates and PVC (The Soft Landing website has great blog lists).
  • Switch all your plastic food containers to glass.
  • With the Plastic Coding System, avoid numbers 3, 6 and 7 and try to use numbers 1,2,4 or 5.
  • Consider buying organic produce to reduce exposure to pesticides..
  • If you must use plastic cling wrap, only use PE wrap; minimize contact of cling wrap plastic with the food; and try not to microwave with the plastic on it. Especially don’t let the plastic sit on top of liquids, whether cold or hot.
  • Reduce indoor dust exposure by cleaning carpets and dusty surfaces regularly using a vacuum cleaner with a high-efficiency particulate air (HEPA) filter.
  • Always immediately transfer your restaurant leftovers into glass containers at home, and never reheat your leftovers or eat directly from takeaway plastic containers.

We’ve put most of these into practice in our home, so I feel a bit less stressed about this issue.  And the boys’ bath toys? While The Soft Landing blog reassuringly listed them on their list of safer bath toys, their own company rep emailed me to confirm they are “BPA-free, phthalate-free, and non-phthalate PVC”. So I am letting them munch away — for now. Choose your battles…

Getting Some Sun — Without The Cancer

Did you know that as much as 80 percent of your lifetime exposure to sunlight happens before the age of 18? This early sun exposure slowly causes DNA damage and puts us at risk for skin cancer later on. One of the biggest risk factors for developing melanomas is the frequency of sunburns as a child. In other words, your lifetime risk factors for skin cancer can be largely predicted even before you leave high school!

The obvious solution is to use protective sunscreen or clothes at all ages – but especially in childhood. Most parents are great at protecting babies and toddlers from the sun, but only 25 percent of teens use sunscreen. Appeal to your teen’s vanity by telling them that daily sunscreen use prevents wrinkles; if greasiness is the main “ick” factor, I recommend the Neutrogena line of sunscreens (including the men’s aftershave). They absorb into the skin with a dry, light feeling. Parents should also lead by example by putting on sunscreen every day during the summer months; don’t forget the oft-neglected ears and toes. After all, it only takes 20 minutes to get sunburned in midday.

Parents and teachers can find kid-friendly educational material at SunWise (www.epa.gov/sunwise), a website created by the US Environmental Protection Agency. Studies from countries with thinner ozone layers, such as Canada and Australia, showed that regular use of SPF 30 sunscreen over several years lowered children’s risk of forming moles – an early stage in the development of melanomas. Another study showed a 50 percent drop in melanoma rates among adults who regularly used sunscreen.

However, don’t go overboard with SPF ratings. Supermarkets are now filled with expensive sunscreens outdoing each other: SPF 70, 90, even 100! Is higher better? “Definitely not,” say most doctors, including dermatologists. Any SPF over 50 is overkill and a waste of money; at SPF 30, you’re already eliminating the majority of ultraviolet rays. Last year, the US Food and Drug Administration (FDA) decided to ban any sunscreen labels over SPF 50, forcing manufacturers to simply print “SPF 50+.”

That being said, a bit of sunlight is essential to good health. People who constantly use sunscreen may actually have low levels of vitamin D, which can cause a whole other set of health issues. I generally recommend vitamin D as a supplement for both kids and adults.

 


(This article was originally printed in 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.)

Men, Don’t Forget Sunscreen!

Sunscreen SPF protection skin cancerWe’ve already reached the summer solstice, and the sun is now the strongest it will be all year. So now’s a good time to remind everyone to use sunscreen anytime you go outside for more than 30 minutes. Even if you’re almost fully clothed, you still need to protect your face, ears and tops of your feet. Why? Because these are common “hot spots” for developing skin cancers later in life, including the deadly melanomas. I address my comments mostly to men, as I’ve noticed that men use sunscreens a lot less than women, especially as women are much more proactive in preventing wrinkles and much of their facial moisturizers already contain some SPF protection.

You could definitely argue that men have been ignored by skincare companies and thus we are thus relatively ignorant consumers. There’s some truth to that, but not anymore. Now, the men’s skincare industry has exploded in popularity, so now I am happy to report that there are a lot of men-specific skin products for men at all large markets and pharmacies, including Watsons and all the hypermarkets.

Which takes me to my main point:  everyone should be using sunscreen protection on their face every day, every season, every year. Even in the wintertime, the sun’s exposure on your ears, face and neck can lead to skin cancers, and the rates of these cancers are climbing all over the world. So here’s the perfect solution for men: most of you already shave every day, so why not use an aftershave that includes sunscreen? And then use a bit more of that onto your ears and neck? Bingo — you’re done. Every morning with your usual shave, now you’re greatly protected from the sun and also cutting down on developing wrinkles (an added bonus).

This idea sounds so obvious that you’d think the market would be flooded with such products, yes? Actually, there remain shockingly few aftershaves with SFP protection. The selection in local Chinese markets is still sparse, but my long-term American favorite is now available in China: Neutrogena’s Triple Protect aftershave, with SPF 20. SPF20 is a decent strength, not as good as SPF30 but better than the bare minimum SPF15. This brand is much pricier here than in the US (around 110 RMB, cheaper online) but I still think it’s worth it. I’ve noticed only a couple other local men’s face products with SPF protection, but hopefully the men’s health market will continue to expand.

For more information on sun protection as well as commentary on the raging debate in America about the FDA’s new rules, you can read my article last year, Is Your Sunscreen SPF 50+? Don’t Waste Your Money