Category Archives: Public health

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, A Chinese version of this article was published in my New York Times Chinese health column.

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.

Got 3 Minutes? Learn How To Save A Life: The New, Easier CPR

How many of you are terrified at the idea of doing mouth-to-mouth recusitation on strangers? We’ve all seen the doctor TV shows when people drop on the streets from a heart attack, and bystanders start basic life support (hopefully). It’s always a dramatic scene of pounding on the chest and mouth to mouth breathing. Unfortunately, a more real-life scenario involves someone falling down — and a crowd of people watch and do nothing. Well, I’m happy to say that it’s now a lot easier to be a good samaritan and help someone; it’s now official that mouth-to-mouth rescue breaths are not the top priority; the chest compressions are key. More specifically, the previous guidelines of A-B-C (airway — breathing — compression) are now C-A-B (compression — airway — breathing).

What that means is that, when you see someone who needs CPR and you’ve called for help, you start chest compresions first. Don’t stress out about the mouth-to-mouth and getting hepatitis and all that. Just start pushing on their chest as the video below describes — it’s a lot better than nothing, and it may save the life of a loved one.

Here’s a quick 3-minute video from the American Heart Association (with Chinese subtitles) which may save someone’s life. If you cannot see the video below, please click here.


Obesity and Diabetes: How Does Your Country Rank?

It’s no secret that obesity, and its twin sister disease of diabetes, have become epidemics of every modernizing country. I work in a family medicine clinic in China and am now witnessing firsthand the expanding waistlines of Chinese people, as they quickly adopt the “Western” diet. Unfortunately, diabetes is already a scourge here as well. But how does it compare to the US, or to other countries?

You can find out very quickly thanks to a fascinating, interactive graph from the Washington Post, which reviews every major country’s diabetes and obesity rates. They got the data from the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group, which published a series of articles in the Lancet journal. It’s a fascinating chart. For example:

  • Diabetes rates: in 1980 for US men, 6.0%; for Chinese men, 10%. In 2008, for US men: 12.6%, for Chinese men, 9.6%. In the US, there’s a steady progression; in China, the numbers actually improved a while but again are climbing. I’m actually surprised that the percentages in China now are so close already to those in America; awareness of the disease here is much less than in the US. It’s believed that a large percentage of diabetics in China are not yet aware they have the disease.
  • Obesity rates: in 1980, in the US; in 2008 the average BMI for men is 28.5, for women is 28.3. In 2008, for US men is 25.5, women 25.0%.  For China, in 1980 for men, 21.6, women 21.9; in 2008, both are 22.9. (a BMI 25-30 is considered overweight, and over 30 is obese).

With the obesity rates, again the trend in the US is a very scary climb upwards; in China, the rate is rising much slower.

How does your country fare? Click here and find out. You can also go straight to the interactive graphs from the Collaboration Group. it takes a while to load, but their data is much richer and also includes blood pressure and cholesterol.

Sunscreen SPF over 50? It's Now Banned

How many of you simply must have the strongest sunscreen? How many Americans are paying premium markups for SPF 70, 90 — or higher? Starting next summer in the United States, you will no longer be able to buy any sunscreen with a rating over 50. This is due to last week’s ruling by the FDA, which also has mandated a special “drug label” be put on the back of each package describing specifics such as actual waterproof time and active ingredients. I think this is a positive step for American consumers, as it filters out the marketing hype regarding any SPF over 50. It also catches up with the EU and many other countries, which have already banned any SPF over 50. But first, let’s review the U.S. FDA’s new rules:

Q4. What are the main points of the new Final Rule?

A. The new final rule includes the following requirements:

Broad Spectrum designation. Sunscreens that pass FDA’s broad spectrum test procedure, which measures a product’s UVA protection relative to its UVB protection, may be labeled as “Broad Spectrum SPF [value]” on the front label. For Broad Spectrum sunscreens, SPF values also indicate the amount or magnitude of overall protection. Broad Spectrum SPF products with SPF values higher than 15 provide greater protection and may claim additional uses, as described in the next bullet.

Use claims. Only Broad Spectrum sunscreens with an SPF value of 15 or higher can claim to reduce the risk of skin cancer and early skin aging if used as directed with other sun protection measures. Non-Broad Spectrum sunscreens and Broad Spectrum sunscreens with an SPF value between 2 and 14 can only claim to help prevent sunburn.

“Waterproof, “sweatproof” or “sunblock” claims. Manufacturers cannot label sunscreens as “waterproof” or “sweatproof,” or identify their products as “sunblocks,” because these claims overstate their effectiveness. Sunscreens also cannot claim to provide sun protection for more than 2 hours without reapplication or to provide protection immediately after application (for example– “instant protection”) without submitting data to support these claims and obtaining FDA approval.

Water resistance claims. Water resistance claims on the front label must indicate whether the sunscreen remains effective for 40 minutes or 80 minutes while swimming or sweating, based on standard testing. Sunscreens that are not water resistant must include a direction instructing consumers to use a water resistant sunscreen if swimming or sweating.

Drug Facts. All sunscreens must include standard “Drug Facts” information on the back and/or side of the container.

Choosing a sunscreen from the hundreds on your store’s shelf is always confusing, and most of us fair-skinned types would naturally choose a higher SPF. But as the FDA mentions, there is no good scientific evidence that any SPF over 50 offers a higher protection against skin cancers. And the American Academy of Dermatologists only mentions that “regardless of skin type, a broad-spectrum (protects against UVA and UVB rays), water-resistant sunscreen with a Sun Protection Factor (SPF) of at least 30 should be used year-round.” They don’t mention anything over 30 as being more useful. Why not?

The main reason is that any SPF over 30 provides only incremental extra blockage of the sun’s harmful UVA and UVB rays. Let’s look at the actual protection (The math is easy, just divide 1 over the SPF number, then (1-x)x100=percent blocked):

  • SPF 2 blocks 50%
  • SPF 15 blocks 93%
  • SPF 30 blocks 97%
  • SPF 50 blocks 98%
  • SPF 70 blocks 98.6%
  • SPF 90 blocks 98.9%

As you see, any SPF over 50 is already blocking 98%, and anything after that is providing minimal extra benefit. People may argue that 99% is still better than 98%, especially those super-fair skinned or with high risks of skin cancers. I personally use year-round protection with a Neutrogena Ultra-Sheer Dry Touch SPF of 45 as I am a pasty Irish-American with a family history of deadly melanoma cancers. Neutrogena, like many companies, also has a line of SPF 55, 70, 85 — even 100. But again, those will be banned starting next summer.

I think the main take-home points are crucial:

  • Everyone of all skin types should always use sunscreen at all times of year, at least on the face. In the winter, I like to use an aftershave which also has SPF protection (only 15, but a lot better than nothing as it blocks 93%)
  • Nothing is totally “waterproof”, and now the labels must show actual “water resistance” minutes — which would never be more than 120 minutes
  • Don’t worry too much about not getting enough vitamin D because of the sunscreen; the Academy of Dermatology believes that everyone can get enough vitamin D via foods. I personally am not convinced of this, especially in the winter, and I prefer to supplement with vitamin D each day.
  • Indoor tanning beds are not considered safe and still lead to skin cancers, especially for children and teens.

You can read more information about sunscreens from the Academy of Dermatology’s FAQ on sunscreens; they also have a recent position statement supporting use of sunscreens with SPF 30+ at all times of the year.

Just What Is A "Harmless" Radiation Dose? And Why is the EPA's Radiation Website So Unfriendly?

The US Environmental Protection Agency’s Daily Data Summary continues to say that the “EPA’s RadNet radiation air monitors across the U.S. show typical fluctuations in background radiation levels. The levels detected are far below levels of concern”; also mentioning that, “as the Nuclear Regulatory Commission has said, we do not expect to see radiation at harmful levels reaching the U.S. from damaged Japanese nuclear power plants.” I suppose we will have to take their word for it; I find their RadNet map totally indecipherable, with their Google map offering me gibberish such as “Gamma Energy Range 2 Gross(CPM)” and other such user-unfriendly information. Where’s the real-world context or graphing to keep the raw data in perspective? Where’s the conversion to sieverts, or to rem — to anything that we simple folk can grasp? I find it interesting that here in Beijing, where I currently work, the radiation information is more accessible than in the US. For example, the Chinese Ministry of Environmental Protection has been publishing data twice a day, along with a graph, showing tiny amounts of radioactive iodine over many cities in China. The MEP’s press release from yesterday says “there was no need to take protective measures”  as “the levels of radioactive material were below one-hundred-thousandth of the natural background radiation.” Here is their latest graph published online as well as in most newspapers (this latest English version is from March 28):

Radiation exposure china march 29
Radiation exposure china march 28

I will discuss the graph in detail in a minute, but here’s the top question on everyone’s mind: what radiation dose actually is harmless, and at which dose should we worry? So here’s my take on it, and I think the illustration at the bottom of this article is a wonderfully easy way to think about this issue (thanks to Olivia Lee for this image link).

Firstly, I think we all know by now that radiation exists naturally in our environment, from many natural sources such as deep space rays as well as natural radon seeping into our basements. I’ve seen numbers that 10 microsieverts a day is the average normal background dose (a bit higher living in higher altitudes). Annually, we get about 3.65 millisiverts of background radiation exposure. The word “sievert” has been thrown around the news a lot; a sievert is the scientific measure of absorbed radiation. “Microsievert” means 100,000th fraction of a sievert (printed as uSv); “millisievert” = 1,000th fraction of a sievert (printed as mSv). In America, the measurement system is rem and not sievert; one sievert equals 100 rem. The EPA estimated means the average annual radiation dose per person in the U.S. is 620 millirem (6.2 millisieverts).

So let’s compare our normal daily dose of radiation (10 microsieverts) to some common items, in increasing order of dose (data mostly from the EPA):

  • Dental x-ray: 5 microsieverts (0.5 millirem)
  • Airplane flight NY-LA: 40 microsieverts (4 millirem)
  • Chest x-ray: 100 microsieverts (10 millirem)
  • Mammogram: 300 microsieverts (30 millirem)
  • Chest CT: 5.8 millisieverts (0.58 rem)
  • Radiation worker annual dose limit: 50 millisieverts (5 rem)
  • Lowest one year dose clearly linked to increased cancer risk: 100 millisieverts (10 rem)
  • EPA dose limit for workers in emergency situations: 250 millisieverts (25 rem)
  • Dose causing radiation poisoning: 400 millisieverts (40 rem)

Let’s think about this for a minute; a chest x-ray, which most people wouldn’t think twice about, is about 2 days normal exposure. A chest CT gives you over a year’s dose; this is quite a large dose which many doctors now realize could be contributing to new cancers, especially when CTs are done during annual “routine” health physicals. (this is a whole extra topic…)

OK, Let’s Get Back To Japan…

Now let’s use this new info and first go back to that confusing graph above showing readings in China: the graph’s units are in uGy/h; the helpful wikipedia article mentions that 1 sievert = 1Gy. (Technically  1Sv = Gy*w, a weighting factor, but this is where my physics brain hit the wall…) So, this means that the graph is reading microsieverts per hour. All of the graph’s readings are around 0.1 microsievert per hour; multiply that by 24 hours in a day and you have 2.4 microsieverts per day, which as we noted above, is far below the normal daily dose of 10 microsieverts. So yes, it does seem to be true that the current radiation exposure is “harmless”. Of course, no dose of radiation is 100% harmless — even “normal” background radiation is a risk for cancers (did you know that radon inside homes is the #2 natural cause of lung cancer?) Also, I should stress that I am no physics whiz and I may be doing this calculation incorrectly, especially regarding this weighting factor; any expert can feel free to correct me in the comments section below. But the finding is consistent with the reassuring messages from both countries’ agencies.

What About In America?

As I already mentioned, I don’t even see basic information like sieverts or rem from anything on the EPA website; is there another website I am missing that does this? If not, then I think that things can be vastly improved at the EPA’s website, which is supposed to be the final say on such matters. People right now are very anxious and starved for helpful, practical information, and the EPA website is not offering that. They do have a very good collection of pages explaining radiation in general, including information for schools as well as this handy image showing relative doses and health:

US EPA Relative Doses From Radiation Sources
US EPA: Relative Doses From Radiation Sources

However, right now people need more immediate data with simple explanations: I think a visual graph would be enormously helpful which converts their raw data to sieverts or rem, along with a sidebar-type graph to keep it in perspective, similar to the above image or another very helpful (but not “official”) radiation dose chart that I mentioned earlier. You can click on it for a closer look:

Radiation Dose Chart
Radiation Dose Chart