Which APAC nation has the healthiest lifestyle?

According to the World Health Organisation, 6 of the 10 top causes of death are non-communicable diseases (NCDs) — that is, diseases that are not infectious and take a long time to develop.

While it's true that uncontrollable factors like genetics and the environment can play a role in developing these types of illnesses, leading a healthy lifestyle is still the best way to reduce your chance of developing an NCD.

With November being the month to bring awareness to non-communicable diseases like diabetes, lung cancer and Alzheimer's, we wanted to see which APAC nations lead the healthiest lifestyles.

Using the World Health Organisation's indices for alcohol and tobacco use and biological factors like obesity, blood pressure and cholesterol we were able to find out which nation is on track to reduce their risk of developing some of the world's most common and dangerous illnesses.

Key findings

• Singapore and Australia ranked as the 1st and 2nd healthiest nations out of 12 APAC countries analysed
• The Philippines and Thailand ranked last at 11th and 12th places respectively, due to above average alcohol & tobacco consumption and heightened biological risk factors.
• Non-Communicable Diseases (NCDs) have a greater impact on poorer nations, which tend to have a greater risk of premature death due to NCDs, even in nations that lead healthier lives than their wealthier counterparts.

1. Healthiest nation in APAC: Singapore

Singaporeans lead the healthiest lifestyles due to their 3rd lowest alcohol and smoking scores. Despite an above average proportion of Singaporeans indulging in excessive drinking on certain occasions, their total alcohol consumption per capita is the 3rd lowest out of the countries analysed (just 2 litres of pure alcohol per person annually).

Singaporeans also have the lowest prevalence for alcohol use and dependence disorders of 1.1 per cent and 0.5 per cent, respectively, out of the non-Muslim majority countries. This healthy attitude towards alcohol seems to have paid off for Singapore.

The Years of Life Lost (YLL) due to alcohol is just 1 year, on par with Malaysia and Indonesia that tend to have low alcohol consumption in general due to their religious practices. Singapore's alcohol-attributable fraction (the proportion of a health outcome that's caused by alcohol) is also below average for cancer and liver cirrhosis.

Singaporeans also have below average tobacco use rates (16.5 per cent vs. average of 22.82 per cent), which greatly reduce the nation's overall risk for diseases like heart disease, lung cancer, stroke and cancer.

In terms of biological risk factors like obesity, high blood pressure & cholesterol and inactivity, Singaporeans also have some notable metrics. For instance, the prevalence of obesity (BMI > 30) and high blood pressure is below the regional average. 

However, despite Singaporeans leading overall healthier lives than their APAC counterparts, there's still room for improvement. For instance, Singapore has one of the highest levels of non-HDL cholesterol (11-14 per cent above the optimal level of 3.37 mmol/L ), which increases their risk for heart diseases.

Singaporeans also have one of the highest rates of physical inactivity (36.5 per cent vs. 31.62 per cent average), which may stem from a myriad of factors including long working hours at sedentary jobs, pre-existing conditions and modern conveniences.

2nd healthiest nation in APAC: Australia

Australians lead the 2nd healthiest lifestyles, due to their extremely low tobacco consumption and a healthy biological risk score.

In fact, Australians have the 2nd lowest tobacco use prevalence, which already helps reduce the nation's risk of many cancers, stroke and heart disease.

Australia also has fairly healthy cholesterol and blood pressure levels, which suggests that there is a lower risk for cardiovascular diseases compared to other nations.

Metric	Score
Alcohol Risk Score	8.75
Tobacco Risk Score	2.00
Biological Factors Risk Score	5.13
Final Ranking	2

However, as far as vices go, Australians consume above average levels of alcohol compared to other nations. Not only is alcohol consumption per capita above average, but Australians also binge drink more often than their APAC counterparts — 39.2 per cent were estimated to indulge in heavy drinking on occasion, compared to the regional average of 22.31 per cent.

This level of alcohol consumption has been causing serious effects on Australian health. For instance, the percentage of cancer and liver cirrhosis deaths attributable to alcohol consumption in Australia is above the average out of the countries analysed.

This is especially important to note as these diseases typically arise from heavy chronic use of alcohol — contradicting Australia's below average alcohol dependence and abuse rates. Another area for improvement is Australia's obesity rate.

An estimated 30.4 per cent of Australians have a BMI greater than 30, making it the 2nd more obese nation in APAC, although it's worth pointing out that obesity rates vary widely within the country.

3rd healthiest nation in APAC: China

China is the 3rd healthiest nation on our list, due to its citizens having one of the best biological risk factor scores.

Of note, China has the most active citizens out of the countries analysed—only 14.1 per cent of the population doesn't get enough physical activity.

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China's population also has the 2nd healthiest non-HDL cholesterol levels and below average rates of high blood pressure. This suggests that, at least in terms of diet and physical activity, China's citizens lead relatively healthy lifestyles compared to those of other nations on our list.

Metric	Score
Alcohol Risk Score	6.75
Tobacco Risk Score	10.00
Biological Factors	4.22
Final Ranking	3

On the other hand, alcohol consumption in China is fairly close to the regional average, as is the occasional binge drink, dependence and use disorder rates.

Interestingly enough, the percentage of cancer deaths that can be attributed to alcohol is below average, which means that despite average alcohol consumption rates, there are other carcinogens that carry heavier weight in cancer-related deaths.

China also has an above average population of smokers (24.7 per cent), which suggests a population at an increased risk of certain NCDs like lung cancer, chronic obstructive pulmonary disease (COPD) and stroke compared to countries that have similar biological and alcohol metrics but smoke less.

4th healthiest nation in APAC: Japan

Japan is the 4th healthiest nation, due better than average scores for alcohol, smoking and biological factors. It has one of the lowest levels of obesity (just 4.4 per cent of the population has a BMI equal or greater than 30), and levels of unhealthy cholesterol is only slightly increased for men and is below the maximum healthy level of 3.37 mmol/L for women.

While Japan does consume more alcohol than average, data shows that it's more so during occasions, rather than through chronic dependence. For instance, while 28.7 per cent reported drinking heavily in one sitting in the past 30 days, levels of alcohol dependence and abuse are below average.

However, as we saw with Australia, binge drinking in Japan may be at unhealthy levels, as alcohol contributes to 2 years of healthy life lost and alcohol's contribution to cancer and liver cirrhosis deaths is above average out of the nations analysed.

Metrics	Rank
Alcohol Risk Score	5.50
Tobacco Risk Score	5.00
Biological Factors Risk Score	6.88
Final Ranking	4

Other areas for improvement are physical activity, smoking and blood pressure. Japan has high levels of inactivity and tobacco use is still quite common (roughly 22 per cent of the population uses tobacco, most of whom are men).

Japan also has the largest population of people with raised blood pressure. This is a critical issue as high blood pressure is one of the greatest risk markers for NCDs.

Unfortunately, Japan's problem with high blood pressure may be difficult to treat. While blood pressure can be reduced by eating clean, reducing stress and being active, Japan still prioritises long working hours. In Japan's case, this prioritization of work over health ends up having deadly consequences .

5th healthiest nation in APAC: Vietnam

Vietnam is the 5th healthiest nation on our list due to having one of the lowest biological factors risk scores. Its obesity rates are the lowest out of the countries analysed, only 1 in 4 people don't get enough physical activity (compared to the average 1 in 3) and non-HDL cholesterol levels were below average (though still slightly above the healthy range).

Since obesity and high cholesterol can in part be attributed to diet, we can assume that part of the healthy lifestyle comes from the traditional Vietnamese diet. Coupled with most jobs centered in labor-intensive sectors like mining, agriculture and service, Vietnam's high ranking may in part be attributed to cultural and socioeconomic conditions.

Metric	Score
Alcohol Risk Score	8.00
Tobacco Risk Score	8.00
Biological Risk Score	5.00
Final Ranking	5

However, Vietnam scored just above average for alcohol and smoking, which indicates that despite a relatively healthy populace, Vietnam struggles with vices more so than the other countries on our list. For instance, Vietnam had the 4th highest alcohol consumption per capita of 8.7 litres of pure alcohol per person annually.

Furthermore, Vietnam had one of the highest alcohol use disorder and dependence rates (5.4 per cent and 2.9 per cent, respectively).

However, only 14.4 per cent of Vietnamese citizens reported an episode of heavy drinking on occasion, compared to the regional average of 22.31 per cent, which may suggest that Vietnam's alcohol consumption comes mainly from those struggling with alcohol dependence rather than social drinkers.

Tobacco use was also relatively high in Vietnam, at an estimated 23.9per cent of the population, most of whom are males. Overall, data suggests that a change of habit through awareness and taxation on alcohol and cigarettes will be crucial in reducing Vietnam's risk of developing NCDs.

Philippines & Thailand lead the riskiest lifestyles

Philippines and Thailand came in 11th and 12th, respectively, due to their above average scores for all 3 metrics measured.

Among the 12 countries in APAC we analysed, the Philippines has the highest recorded total alcohol consumption rate at 10.5 litres per person per year, and one of the highest rates of alcohol dependence and use disorders.

This unfortunately heavy alcohol use leads to an equivalent of 4 healthy years of life lost, in addition to above average rates of cancer and liver cirrhosis deaths attributed to alcohol. Filipinos also use more tobacco (24.3 per cent), have higher cholesterol levels and have one of the lowest physical activity rates (roughly 40 per cent of people don't get enough physical activity compared to the average 32 per cent).

However, it's worth pointing out that the Philippines actually has very low rates of obesity compared to other nations (just 6per cent compared to the 11per cent average) and low rates of high blood pressure.

Country	Alcohol Risk Score	Tobacco Risk Score	Biological Factors Score	Final Ranking
Singapore	3.75	3.00	6.38	1
Australia	8.75	2.00	5.13	2
China	6.75	10.00	4.25	3
Japan	5.50	5.00	6.88	4
Vietnam	8.00	8.00	5.00	5
Indonesia	1.25	12.00	6.50	6
South Korea	11.00	6.00	4.75	7
Malaysia	2.50	4.00	9.50	8
New Zealand	8.25	1.00	8.25	9
India	7.25	11.00	4.88	10
Philippines	6.50	9.00	7.63	11
Thailand	7.50	7.00	8.38	12

Thailand consumes more alcohol than the regional average and has one of the highest rates of alcohol use disorders (5.4 per cent of the population). Thailand's tobacco use also hovers around the average, with roughly 1 in 5 people using tobacco products.

Furthermore, despite being a fairly active nation, Thailand has above average obesity rates and one of the highest rates of elevated blood pressure and raised cholesterol out of the countries analysed. However, in the case of both nations, the relatively risky lifestyles aren't due to ignorance but more so because habits are hard to change and resources may be limited.

Indeed, a recent study showed that most Filipinos are aware of the risks associated with vices like smoking, but cite stress, lack of time and funds as the main reasons for smoking. Thankfully, both countries have acknowledged the danger of their NCD risk and are currently taking steps to encourage healthy habits.

Poorer nations have higher NCD mortality, despite seemingly healthier lives

It would seem like the wealthier a nation is, the healthier its citizens are due to better education, healthcare spending and funds to pursue healthy habits.

While the correlation between GDP per capita and health is moderate, there are several cases where poorer nations have healthier citizens than richer nations (ex: Vietnam and Indonesia ranked higher than New Zealand and South Korea). Why is this? First, a nation may be inadvertently healthy through cultural reasons.

This is seen with Muslim nations that prohibit alcohol, which effectively eliminates alcohol as a risk factor. Second, nations that have large portions of their population in physically active jobs like agriculture will have a larger portion of their citizens meeting physical activity recommendations without trying.

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On the other hand, as a nation becomes wealthier, we can see people moving towards sedentary white-collar jobs, fast food and occasional indulgence in vices to reduce stress.

However, while wealthier nations may sometimes be less healthy, poorer nations have a hard time dealing with the burden of disease despite how low their risk factors may be.

For instance, the chance of dying between the ages of 30 and 70 from the main 4 NCDs (cardiovascular disease, diabetes, cancer and chronic respiratory disease) is 9.3 per cent in Singapore but 17.1 per cent in Vietnam, despite both countries ranking in our top 5.

The reason for this may be two-fold. The first and major reason is that poorer nations may have limited healthcare access. Treatment of chronic diseases like cancer and heart disease can cost thousands of dollars per year which may be too much for the average citizen to bear in certain countries.

In fact, we found that the strongest negative correlation (-0.85) exists between premature death due to an NCD and total healthcare expenditure per capita, suggesting that unless a country has a quality, affordable healthcare system, the perceived health of the individual matters much less when it comes to living a long, healthy life.

The second reason could be that poorer nations may have a higher rate of chronic issues that greatly impact overall health. For instance, developing nations have higher rates of substance abuse as people contend with poor living conditions.

Comparatively, wealthier nations have lower rates of smoking and alcohol dependence and instead indulge in the occasional binge drinking session — still risky, but less so.

Additionally, despite being active through work and a healthy diet, industrial development and risky jobs may expose citizens in developing nations to carcinogens that have greater adverse effects compared to the health benefits of being active and eating well.

Methodology

Since many NCDs can be prevented by leading a healthy lifestyle like not smoking or drinking alcohol, the goal of this study was to explore which nation leads the least riskiest lifestyle by analysing factors that are in the control of the individual.

To find out which nation had the healthiest citizens, we look at 3 major risk and behavior categories: alcohol consumption, tobacco use and biological factors that can be caused by poor diet and exercise habits (obesity, high blood pressure).

All data was provided by the World Health Organisation for the latest available years (2016-2018), was age standardised and based on adult populations (15 years and over) when possible.

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Due to the scope of the study, uncontrollable factors like genetics and pollution were not considered, although we do recognise their importance in contributing to disease.

We scored metrics from 1 to 12 (1 being most healthy and 12 being least healthy) and used a weighted scale to create more realistic rankings. The weight was distributed based on the effect the metric had on health (also known as Disability Adjusted Life Years).

According to the WHO, alcohol's global impact on health is 4.5 per cent, tobacco's is 4.1 per cent, and the combined biological factors we measured is 10.1 per cent. Since these rates were the only ones considered in our study, we scaled them to 100 per cent, resulting in a weighted average of 24 per cent for alcohol use, 22 per cent for tobacco use and 54 per cent for biological factors.

Lastly, we want to acknowledge that the relative health of a nation is complex and constantly evolving. Due to this, our study is not intended to advise on policy issues. For more information about the metrics we used, please find the in-depth explanations of each category below.

Alcohol factors

To measure a country's alcohol use, we looked at 4 metrics: Recorded and unrecorded alcohol consumption per capita (a more accurate measure of alcohol use in a country), 12-month prevalence of alcohol dependence, 12-month prevalence of alcohol use disorders and the percentage of people who indulged in heavy drinking in the past 30 days.

We scored each country's metric from least to worst and averaged the scores to get their final alcohol risk factor score. We also looked at the number of years lost due to alcohol as well as alcohol-attributable fractions (AAF) for cancer deaths and liver cirrhosis.

AAF is a measure that shows the percentage of a health outcome that is caused by alcohol. While the latter 2 metrics weren't included in the rank, they were useful in helping us understand how alcohol impacted each nation.

Category Rank	Country	Total Alcohol Consumption/Capita^	Heavy Episodic Drinking (per cent)^^	Alcohol dependence (per cent)^^^	Alcohol use disorders^^^
1	Indonesia	0.60 L	6.40 per cent	0.70 per cent	0.80 per cent
2	Malaysia	0.90 L	9.10 per cent	1.10 per cent	3.00 per cent
3	Singapore	2.00 L	32.20 per cent	0.50 per cent	1.10 per cent
4	Japan	8.00 L	28.70 per cent	1.10 per cent	3.40 per cent
5	Philippines	6.90 L	12.10 per cent	2.90 per cent	5.30 per cent
6	China	7.00 L	23.60 per cent	2.30 per cent	4.40 per cent
7	India	5.50 L	17.00 per cent	3.80 per cent	4.90 per cent
8	Thailand	8.30 L	16.80 per cent	1.80 per cent	5.40 per cent
9	Vietnam	8.70 L	14.40 per cent	2.90 per cent	5.40 per cent
10	New Zealand	10.60 L	35.20 per cent	1.30 per cent	4.00 per cent
11	Australia	10.50 L	39.20 per cent	1.50 per cent	4.40 per cent
12	South Korea	9.70 L	33.00 per cent	5.50 per cent	13.90 per cent

Smoking factors

To look at which country had the largest smoking population, we looked at the age-standardised estimated tobacco use.

Tobacco use included smoking and non-smoking usage, which helped us get a holistic picture. Since Vietnam wasn't included in the WHO's database for this metric, we looked at the latest figures provided by the government.

Category Rank	Country	Rate of Tobacco Use
1	New Zealand	14.80 per cent
2	Australia	16.20 per cent
3	Singapore	16.50 per cent
4	Malaysia	21.80 per cent
5	Japan	21.90 per cent
6	South Korea	22.00 per cent
7	Thailand	22.80 per cent
8	Vietnam	23.90 per cent
9	Philippines	24.30 per cent
10	China	24.70 per cent
11	India	27.00 per cent
12	Indonesia	37.90 per cent

Biological factors

Biological factors are another important role in determining the likelihood of someone developing an NCD.

For this metric, we looked at modifiable risk factors that are largely determined by a person's dietary and exercise habits like obesity rates, inactivity rates, the percentage of people with high blood pressure and mean high non-HDL cholesterol (aka the "bad" cholesterol). Non-HDL Cholesterol was measured as the departure from the healthy levels of 3.37 mmol/L.

Category Rank	Country	Obesity Rate^	Insufficient Physical Activity Rate	Raised Blood Pressure^^	Increase of Non-HDL Cholesterol Above Healthy Levels^^^
1	China	6.6 per cent	14.1 per cent	20.6 per cent	0.2per cent (M); -2.0per cent (F)
2	South Korea	4.9 per cent	35.4 per cent	13.2 per cent	5.4per cent (M); -1.3per cent (F)
3	India	3.8 per cent	34.0 per cent	23.5 per cent	-3.6 per cent (M); -6.5 per cent (F)
4	Vietnam	2.1 per cent	25.4 per cent	22.2 per cent	2.7 per cent (M); 3.6 per cent (F)
5	Australia	30.4 per cent	30.4 per cent	18.9 per cent	-2.1 per cent (M); -7.8 per cent (F)
6	Singapore	6.6 per cent	36.5 per cent	16.7 per cent	13.9 per cent (M); 11.1 per cent (F)
7	Indonesia	6.9 per cent	22.6 per cent	22.0 per cent	5.2 per cent M); 11.2 per cent (F)
8	Japan	4.4 per cent	35.5 per cent	26.7 per cent	4.7 per cent (M) ; 4.4 per cent (F)
9	Philippines	6.0 per cent	39.7 per cent	19.0 per cent	17.2 per cent (M) ; 21.3 per cent (F)
10	New Zealand	32.0 per cent	42.4 per cent	20.1 per cent	2.3 per cent (M); -2.8 per cent (F)
11	Thailand	10.8 per cent	24.6 per cent	25.0 per cent	19.8 per cent (M); 17.5 per cent (F)
12	Malaysia	15.3 per cent	38.8 per cent	20.6 per cent	24.3 per cent (M); 23.9 per cent (F)

While each of these metrics were measured as separate from each other, it is important to note that they are all intertwined.

Inactivity is believed to be a direct link to not just NCDs, but also plays a role in obesity, high cholesterol and high blood pressure. Similarly, obesity is linked to high blood pressure and high cholesterol.

This article was first published in ValueChampion.