Association analysis of Suboptimal health Status: a cross-sectional study in China

Introduction

Suboptimal health status (SHS) is the “third state” between health and disease, carrying the characteristics of transformation from health to disease. According to a 2013 global survey by the World Health Organization (WHO), only 5% of people could be classified as truly healthy, 20% were sick, and people in SHS was accounted in 75% of people (Ma & Zhu, 2013). In addition to acquired immunodeficiency syndrome, hazards that result from SHS have been recognized in the medical field as being of top concern in the 21st century (Zhao, 2006). If SHS is properly handled, the human body can be transformed into a healthy state, or turn the disease the other way around (Chen et al., 2014). It is therefore of significance to explore the factors influencing SHS for its prevention and intervention.Many individuals may not be aware that they are suffering from SHS. For instance, a 1998 study with 6,000 asymptomatic “healthy people” indicated that 72.8% of these people were in the “suboptimal health status” range (Liu & Li, 2001) . The identification of SHS is the key to preventing the deterioration of an individual’s health status. SHS can reportedly be measured objectively using the microbiome (Sun et al., 2020), telomere length (Alzain et al., 2017), plasma stress hormones (Yan et al., 2018), plasma metabolites (Wang et al., 2020), glycan (Adua et al., 2019a; Adua et al., 2019b; Wang & Tan, 2019), ideal cardiovascular health metrics (Wang et al., 2017), and traditional Chinese medicine (Wang & Yan, 2012; Wang, Russell & Yan, 2014). However, these objective measures are not easily accessible, and may sometimes not be obvious, especially when people feel uncomfortable and are without abnormal symptoms. Self-rated assessment using a questionnaire has been shown to be widely applicable for assessing SHS, with the first Chinese study on suboptimal health measured using a questionnaire being published in the English literature in 2009 (Yan et al., 2009).

In China, the Sub-Health Measurement Scale (SHMS V1.0) (Xue et al., 2019a; Xue et al., 2019b; Xue et al., 2019c; Xu et al., 2012; Xie et al., 2016; Lu et al., 2013), suboptimal health status questionnaire (SHSQ-25) (Yan et al., 2011; Adua, Roberts & Wang, 2017; Kupaev et al., 2016; Hou et al., 2018; Anto et al., 2019; Adua et al., 2019a; Adua et al., 2019b) and Chinese sub-health scale (CSHES) (Xu et al., 2012) have been widely used for assessing SHS. However, unlike other questionnaires, the SHMS V1.0 assesses of the physical, mental, and social aspects of SHS, which is in accordance with the concept of health proposed by the WHO in 1947.

With the rapid urbanization in China in recent years, the lifestyle and living environment of urban residents have changed substantially (Chen et al., 2017a; Chen et al., 2017b). However, urbanization is a double-edged sword for urban residents’ health (Li et al., 2016). On the one hand, to some extent, urbanization has improved the health benefits of urban residents due to easier access to health care services and knowledge than that available to the rural population. On the other hand, risk factors, such as air pollution, having an unhealthy diet, living a sedentary lifestyle and the life pressure (Miao & Wu, 2016) of chronic diseases were increased for urban residents. The first SHS study that involved urban Chinese population indicated (Yan et al., 2012) that SHS was associated with risk factors of chronic diseases and contributed to the development of them. Previous studies have shown that lifestyle behaviors are some of the most important contributing factors including smoking, alcohol consumption, irregular breakfast habits, malnutrition, lack of exercise, and sleeping problems (Lolokote, Hidru & Li, 2017; Chen et al., 2017a; Chen et al., 2017b). Drinking, inadequate breakfast, sleep quality and negative event experience have been reported to be significantly associated with suboptimal health for urban residents (Xie et al., 2016). The environment can also greatly influences one’s overall health (Messer, Maxson & Miranda, 2013). As such, SHS can be aggravated by both air pollution (Kelly & Fussell, 2015) and noise (Clark & Paunovic, 2018).

Despite all the above, previous studies on the association factors of SHS for urban residents have only investigated specific aspects, especially external factors, such as lifestyle and environmental factors. Internal factors, such as personality characteristics, and health consciousness have rarely been studied. Materialist dialectics holds that the development of things is the result of both internal and external factors: that the external cause influences the development of things through internal factors. Thus, this study attempts to determine the factors associated with internal factors, such as personality characteristics and health consciousness, and external factors, such as lifestyle and environmental factors, among urban residents in China with suboptimal health.

Materials and Methods

Results

The SHS incidence rate of urban residents in the five investigated provinces and cities in China was 66.7%. The average age of these urban residents was 41.56 ±16.14, of which 2640 (48.4%) were men and 2820 (51.6%) were women. The descriptive analysis and comparison by gender are presented in Table 2. Females were more likely to be divorced and widowed, have a monthly household income per capita less than ¥5000/month, have a higher body mass index, be a nonsmoker, have never exposed to secondhand smoke, not drink alcohol, have breakfast every day, bask in the sun less than three hours a week, occasionally do physical exercise, fall asleep before 11 p.m. (day/week) every day, live together with family, have parents who practiced disciplining, live with plentiful greenery, live in a harmonious neighborhood, have access to adequate fitness facilities, have access to adequate medical and educational resources, have a positive life attitude, have a low adverse quotient, have few interests and hobbies, have a swallowing rage and suffering in silence and anxious and irritable personality, and often attend health training and lectures.

Discussion

This study was the first to systematically investigate the influencing factors of SHS from the aspects of demographic information, lifestyle behaviors, environmental factors and internal factors with a sample of Chinese urban residents at the national level. A total of 23 variables were significantly associated with SHS, of which 12 were significantly associated with males and 14 with females. All these variables that were significantly associated with SHS were from demographic information, lifestyle behaviors, environmental factors and internal factors, which thereby indicates that the association factors were widespread, not only demographic information and external factors, such as lifestyle behaviors and environmental factors, but also internal factors.

Regarding demographic information, age was significantly associated with SHS in all participants. However, association with SHS was not found between men or women. For all urban participants, especially males, whose registered permanent residence was in an urban area, it was found that there people were not easily prone to suboptimal health. This finding was in line with the actual real-life situation in society that rural–urban migrant workers have greater life stress and work stress than do urban-native residents (Cui et al., 2012). Education level was found to be significantly associated with SHS in all participants, especially in males, with having a higher education level leading to an easier chance of developing SHS. This might be due to high-pressure jobs and working longer hours than people with lower educational levels (Schieman & Glavin, 2011). Women who ate divorced and widowed have been reported to have a 82.5% higher risk of developing SHS compared with married women. Compared with men, divorced women have an increased risk of living in poverty and being a single parent (Leopold, 2018); being widowed may severely restrict women’s ability to access financial, affective, informational, or physical resources, which in turn may affect health outcomes (Perkins et al., 2016). Previous studies have reported a significant association between income and health. Studies in the United States have pointed out that the effect of income on health tapers off at around the median level of income (Knaul et al., 2006; Arsenijevic, Pavlova & Groot, 2013). Our findings are in line with these studies in the United States. We also found that women whose monthly household income per capita was between ¥5,000 and ¥7,500 were not prone to developing SHS compared with those whose income was less than ¥2,500.

Concerning lifestyle behaviors: The impacts on health exerted by secondhand smoke are self-evident (Iloh, 2017). In the present study we investigated the same association of exposure to secondhand smoke with suboptimal health in males. The risk of detection rate of suboptimal health was increased when exposure to secondhand smoke was more severe. Alcohol drinking also plays a significant role in the etiology of many acute (Rehm et al., 2010) and chronic diseases, and can cause a major burden to the population’s health ,accounting for 4% of disability adjusted life years worldwide (Whiteford et al., 2013). Alcohol consumption can increase the risk of SHS by 37.4% in females. However, no significant association was found between alcohol consumption and SHS in men. This difference between males and females may be explained by the cause for drinking. Drinking in Chinese culture can be classified mainly as social drinking, which is an actively usually widely accepted in men than women (Cochrane, 2003). In our study, we found that bad eating habits were associated with SHS in both males and in females. These bad eating habits that were investigated included irregular eating, poor dieting, overeating, partial or picky eating, high intake of salt, eating spicy food, and usually eating snacks instead of regular meals and etc. Eating salty food is not good for the health and may increase the risk of incidence of stomach cancer (Park et al., 2016). While having an unhealthy diet or overeating can induce heavy gastrointestinal burden and go against one’s overall health (Janssen, 2010). Meanwhile, spending a prolonged amount of time online may cause backache, neck, finger, wrist, and arm pain, as well as emotional fluctuation, tension and anxiety, fatigue and other SHS symptoms (Karacic & Oreskovic, 2017). In traditional medicine, the time past 11 p.m. is considered to be the time for organ detoxification, and a need for deep sleeping (Li & Li, 2017). Going to bed before 11 p.m. and having enough hours of sleep are important for the strengthening of the body’s resistance and immunity (Chen, 2012). We investigated whether there is a significant association with falling asleep before 11 p.m. and SHS, and for those who can’t could not fall asleep before 11 p.m. whether these people had a higher risk of developing SHS. We found that spending time more than five hours a day online increased the risk of SHS by 66.8%.

As to environmental factors, males and females with good relationships with their parents during their growth period were less susceptible to SHS, which is consistent with the findings of several previous studies (Xue et al., 2019a; Xue et al., 2019b; Xue et al., 2019c). More attention should be paid to the relationship between parents and children when proceeding with family education to allow for the protections of children’s health and growth. Good air quality is closely associated with optimal health, and the present study showed that women who live with good air have a lower risk of attaining suboptimal healthy. However, this association was not found in males. Living in crowded conditions showed negative association with SHS in males, but not in females. This might be because living in crowded conditions comes with foul air, disturbing noise, and tension, which impose strains and harm to people’s physical and mental health (Gibson et al., 2011). We found that living in a harmonious neighborhood and having access to adequate fitness facilities were all associated with SHS in females, not in males. Harmonious neighborhoods brings with them a safe and mutually supportive living environment, which is good for both physical and mental health. A study has shown that higher perceived neighborhood disorder was significantly associated with a higher level of total health service usage among those with lifestyle illnesses (Martin-Storey et al., 2012). The popularization of community fitness facilities has provided residents with convenience in accessing and undertaking fitness programs and helps to ease residents to participate in fitness programs, especially for those with weak fitness awareness; the popularization of such facilities is an important component of the Healthy China 2030 plan (Li, 2018). Both male and female patients whose health was affected by the two-child policy had higher risk of developing SHS. A major concern after the implementation of two-child policy has been the acute shortage of pediatricians and paediatric nurses in China, which has worsened over the past decade (Han, Hu & Wang, 2014). Therefore, for parents with lower incomes and who work in high-pressure working conditions, the demand for a newborn child will inevitably bring more anxiety which is not good for the health (Ren et al., 2015).

Lastly, on internal factors, adverse quotient,( also known as setback business or counter business), refers to people’s ability to resolve and withstand setbacks, usually the more one is able to bear such setbacks, the higher the adverse quotient is (Zhao, 2016). In our research team’s previous study, it was found that the higher the adverse quotient, the lower the risk of suboptimal health (Xue et al., 2019a; Xue et al., 2019b; Xue et al., 2019c). In the present study, we found that a high adverse quotient was a protective factor against SHS in both males and females. Participants (both males and females) with more than three kinds of interests and hobbies had a lower risk of developing SHS compared with those with less than three interests and hobbies. People with a wide range of hobbies have been reported to be less likely to have mental health problems, and their physical to be better than those with less interests and hobbies (Hirosaki et al., 2009). Furthermore, the findings of our group’s previous research indicated that the personality and SHS were related, and that those urban residents with a personality pertaining to swallowing rage and suffer in silence, inpatience and aggressiveness have significantly lower scores than those of urban residents with a mature and steady character (Xue et al., 2019a; Xue et al., 2019b; Xue et al., 2019c). Hence, the development of a mature and steady personality may have a positive effect for improving health. This study also exhibited the same findings in both males and females.

The protective effect of high attention to one’s health with SHS was found in all participants, not between females nor in males. The protective effect of effective health promotion induced by leading a leisurely lifestyle with SHS was found in both males and females. The forms of leisure and its corresponding effects are of great significance for fatigue reduction and health recovery (Kubo et al., 2013). Proper recreational activities were contributed to health promotion, and enhance the quality of life and health outcomes.

Conclusions

Through this large cross-sectional study of Chinese urban residents, we found that SHS was significantly associated with demographic information, lifestyle behaviors, environmental factors and internal factors, both in males and females. Our study supports propositions regarding the benefits of controlling both internal and external factors in preventing suboptimal health.

Supplemental Information