Be as Healthy as the Wealthy

Social class is simply the best predictor of health. If you could know only one thing about a person and predict that person's health and longevity, you'd ask about social class. It's even more important than family history.

In cases where someone has bothered asking poor people about their health, research confirms the trend: the poorer you are, the less healthy you're likely to feel. That's the finding of a recent Columbia University study. And results of the United States Centers for Disease Control and Prevention's National Health Interview Survey make the case even stronger. In 2006, nearly nine times as many lower-income adults reported being in fair or poor health as affluent adults. Wealth and health go hand in hand.

Here's epidemiologist and author of The Status Syndrome Dr Michael Marmot's way of thinking about it: our society is a gigantic Titanic. First-class passengers on that ship disproportionately survived. In second class, fewer did. Third-class passengers... yikes. Many died before their time. And many of their modern counterparts still do.

The connections between status and health are hugely complex and only partly understood. No matter where you are, money and status make it easier for you to live in a restful place, go out for a Saturday morning jog and buy lean protein instead of fast food. It's more likely you'll enjoy a wide circle of friends, more job opportunities and more control over your schedule. And there's more social pressure to stay away from blood-sucking vices like alcohol, tobacco and drugs.

If socio-economic status tells us so much about health, why didn't we know this? In the past, many researchers felt obliged to avoid questions about socio-economic status when they designed public-health surveys. As a result, they had very little data until about a decade ago. Then the field exploded.

Adler recalls the study that got her hooked. It was one of Marmot's, a landmark British study that scientists refer to by its shorthand, Whitehall I. Whitehall is the wide street in London where many key government departments are located, and the name is synonymous with the British civil service. In 1967, Marmot's team began a huge survey of 18 000 male civil servants. The men were grouped into quadrants based on office hierarchy, with administrators who set policy at the top, followed by executives, clerical workers and finally office messengers at the bottom. All the workers had safe office jobs and high job security. The most surprising finding of the study was that not much about the disparity in health outcomes could be explained away by nasty habits or access to care. And in a follow-up study 25 years later in the Nineties, the men at the bottom were found to be not only unhealthier as a group, but three times as likely to die an early death as the men at the top.

Those results started Adler thinking. What is it about higher social class that matters? How does class affect the body? With that, she switched her field from adolescent risk behavior to class and health. (As she notes, "˜I switched taboos from sex to money.') In 1997 she gathered a dozen like-minded researchers together into the MacArthur Research Network on Socio-economic Status and Health, and became its chairwoman. Since that time, network members have used nearly $9-million in grant money to swop ideas, start pilot studies and tack their questions onto larger, longitudinal studies. Their collective research provides much of the scientific basis for the information you're reading here.

Can you take enough action to save yourself from the ill effects of social class? The researchers can't say for sure. But they'll encourage you to try your damnedest. After all, small lifestyle changes accomplish a lot. A whole lot. They're simple, they're easy, they're appallingly obvious - and they have a stunning impact on longevity and health.

The latest proof comes from a 2008 Cambridge study published in the journal Public Library of Science Medicine, which examined 20 244 men and women, ages 45 to 79, living in the same English county. The researchers gathered baseline data in the mid-Nineties, asking the participants if they engaged in any combination of four common healthy habits: exercise, moderate alcohol use, daily fruit and vegetable intake and abstention from tobacco. Eleven years later, they followed up to see who died in the interim. Result: the people who engaged in none of the healthy behaviors were four times as likely to have died as those who engaged in all four, regardless of social class.

Practicing four simple healthy habits, concluded the researchers, "˜was equivalent to being 14 years younger in chronological age'. Be mindful about one or two things you can't do anything about - your parents, for instance. You can't choose your mother's social class. And low birth weight, which is more common on lower rungs of the ladder, increases the risk of slow cognitive development in early life and heart disease decades later. Socio-economic status even affects physical strength and function. In one British study, men born in 1946 were contacted at age 53 and presented with a few challenges, including this one: close your eyes and stand on one leg for 30 seconds. Sound easy? Less than half of the men were able to do this for longer than five seconds. Disproportionately, their fathers were working-class blokes.

One last caveat: money changes everything, but the trend has a limit. Not a single scientific study has shown that being ridiculously rich will make you ridiculously healthy. Wealth didn't save Donald Trump's hair, for instance. Extra money simply translates into a desire for more stuff, which leads to the need for more money. A golden treadmill, yes, but a treadmill all the same.

With less money and status, all aspects of a healthy lifestyle are harder to achieve - but not impossible. In essence, you can live the good life by acting rich. You don't even have to wear a cravat. The seven lifestyle changes below will help you hit your marks.

Make your Mark

If you can't be rich, settle for famous. In a very cool study out of the University of Toronto, researchers analyzed 72 years' worth of Academy Award winners. They looked up the age at death of actors who won Oscars, and compared that with (1) co-stars of those Oscar winners and (2) actors who were nominated for but never won Oscars.

Amazingly, the Oscar winners lived four years longer than their co-stars and fellow nominees. Stars who won multiple Oscars enjoyed an extra two-year survival boost. That longevity isn't due to a difference in wealth. It's due purely to status.

Researchers are finding out that status is not measured by bread alone. Yes, there's the objective ladder of socio-economic status, which ranks people by annual income, net worth and educational level. But there's also a ladder of subjective social status, on which people rank themselves according to how much respect they are given by members of their peer group or community. And both ladders are valid indicators. Your health is predicted by a combination of the two, says Adler, who pioneered the idea of measuring subjective social status. In one of her studies, the subjective ladder did a better job of predicting heart rate, body-fat distribution and stress responses than the objective measures of socio-economic status did.

Her advice: "˜If you can pick your niche and succeed in that, that's probably going to be good for your health.'

Yes, obesity is bad for you; it leads to type-2 diabetes. And yes, spreading wide is widespread. But like most things, obesity is not spread equally across social classes. The CDC's National Health Interview Survey found the highest 2006 obesity rates in the groups with the lowest income and educational levels.

Let's not blame the victims. It's a sad fact that a proper diet is harder to maintain in poorer neighborhoods, which lack supermarkets and the wide variety of healthy choices they offer, but which have plenty of outlets providing cheap, fattening, fast food. And if you're working two jobs, who has time to cook or schedule exercise sessions?

But your neighborhood isn't the only problem. In one of the most bizarre findings of 2007, Harvard researchers reported in the New England Journal of Medicine that obesity is "˜contagious' - that your friends are making you fat. Indeed, your closest friends influence your weight more than your genes or your family members.

The researchers studied 12 067 interconnected people who had participated in the Framingham Heart Study from 1971 to 2003. They organized them by their social networks and found the big "˜whoa': when a participant's friend became obese, his or her chance of becoming obese increased by 57 percent. (Using data from men only, the risk nearly doubled.) If it's a close friend, your chance of bursting your buttons increases by 171 percent.

Ensure Domestic Tranquility

Where you live shouldn't predict the state of your health. But it does. In one study of 3 617 adults, simply living in a city increased the risk of premature death (by 62 percent) when compared with suburban or small-town life. And of course, living in a disadvantaged neighborhood within that city is really bad for you. What's so bad about the big city? There's more pollution, leading to an increase in respiratory diseases. Also, there's more fear of crime, which results in chronic stress, social isolation, anxiety and depression.

We need to worry about the postmodern killers: jobs with a deadly combination of high demand and low control, high effort and low rewards. Crime-fearing participants in Britain's late-Eighties sequel to the first Whitehall study, Whitehall II, were nearly twice as likely to be depressed as the less-fearful civil servants. And then there's the noise. Noise exposure has been linked to poorer long-term memory, higher stress, sleep deprivation and even heart disease. In 2005, the World Health Organization estimated that long-term exposure to traffic noise in Europe might account for three percent of deaths from heart disease and strokes. Noise at night can create chronic stress, even while you're sleeping because you continue to react to sounds; this can raise your levels of stress hormones.

What's true for real estate investing is also true for your health: better to live in the worst house on a nice block than the nicest house on a bad block. You don't need a mansion to get a good night's sleep.

Back in the day, when Humphrey Bogart lit up on the big screen, everyone smoked. Tobacco use was spread evenly across all social classes. That's no longer true. The class differences are dramatic: in 1995,40 percent of men who were not high-school graduates smoked. Only 14 percent of male varsity grads smoked. And here's the sorry part: those people on the bottom rungs who try to quit are less successful at it than people at the top. It doesn't mean they lack will power; it probably means they're surrounded by more smokers in their daily lives.

Smoking is responsible for the most preventable deaths. And because it has become a low-status behavior, it is a major factor in explaining the different health outcomes of haves and have-nots. So, if by chance you get your hands on a box of good Cuban cigars, don't smoke them. No, no, no. Send them along to us.

Find a Job that Fits

Even though we live in the twenty-I first century, we still carry around nineteenth-century images of workplace health. As in the physical hazards. But fewer of us are miners or shipyard workers or mill workers anymore. We don't worry about black lung. What we need to worry about are the postmodern killers: jobs with a deadly combination of high demand and low control, jobs that require high effort and dole out low rewards. As Adler's MacArthur Foundation report, Reaching For a Healthier Life, puts it:

Jobs that are plagued by time pressure, conflicting demands, low control over how and when tasks get done, worker/management conflict, threats of pay cuts or job loss, and conflicts between family obligations and work requirements can create damaging levels of stress that surface in disease.

The biggest proof of that came from the first Whitehall study, which found that a greater incidence of heart disease at the bottom of the bureaucratic pecking order was due mainly to a lack of job control - that is, limited permission to solve problems and make decisions. Other diseases associated with low job control cited by both Whitehall studies are type-2 diabetes and alcohol dependence. That's no surprise. Men who have a hard time coping with stress tend to turn to alcohol.

But perhaps the most stunning finding from Whitehall II came from 6 000 civil servants who were asked to agree or disagree with this statement: "˜I often have the feeling that I am being treated unfairly'. Those who agreed moderately or strongly were clustered on the lower rungs of the British civil-service system. And by following this group for 11 years, researchers learnt that those who felt the most shabbily treated were 55 percent more likely to have had a heart attack in the interim.

Several small studies in various countries have all confirmed these findings to some extent, says Dr Mark Cullen, a professor of medicine at Yale University. But he thinks the real issue isn't low control; it's psychological stress. "˜It's the burden that matters,' he says. "˜How much they want from you, how fast they want it, how perfect it has to be.' And in his opinion, the amount of stress you feel from your job has a lot to do with whether the job fits you - that is, whether it matches your personality and style and the other demands in your life. Some people actually like low-control jobs, after all - they just want to punch in and punch out. But if you come home at the end of the day feeling angry, alienated and exhausted, maybe you need more than a new job; you need a new line of work. "˜The biggest problems,' says Cullen, "˜are with a misfit.' If you're a misfit, fix it - or you'll die trying.

Call your Favs

Do this: in the next two weeks, call people in at least six of these categories: 1. wife; 2. parents; 3. in-laws; 4. children; 5. other family members; 6. neighbors; 7. friends; 8. colleagues; 9. school chums; 10. fellow volunteers; 11. members of your social or recreational group; 12. religious friends from your church, synagogue, mosque, ashram or cult hideout.

If you run low on minutes, face time is perfectly acceptable. Facebook is not. Do this, and you won't catch a cold. Okay, that's not a guarantee. Put it this way: if your social ties are so frayed that you regularly call three or fewer people on that list, you're three times as likely to catch a cold as someone with a diverse set of social ties, someone who would regularly call or talk to people in at least six of those categories.

A man who is socially isolated has a relative risk of death between two and five times greater than one with better social connections. Why that is, scientists don't know. Social isolation is deadly. In France, the leading cause of death among middle-aged men and women is cancer. In the Nineties, a Harvard study of social integration and mortality among French subjects found that the men who were most isolated were 3.6 times as likely to die of cancer as their well-connected peers.

And, like everything else, social class may play a role here, too. The higher yours is, the less vulnerable you are to loneliness.

Go Back to School

"˜Socio-economic status' is a big, squishy term with several components: the amount of money you earn, the amount of money you have (two different things), your job's prestige and your level of education. But when push comes to shove, the most important predictor of health is your education.

The most convincing evidence comes from Sweden. One study based on the country's 1990 census tracked 25- to 65-year-old adults who died in the ensuing six years and found that each and every step up the educational ladder conferred added longevity. For example: among men who were 64 in 1990, about 14 percent of those with the bare minimum of education had died by 1996. But just six percent of men with PhDs had died.

What was most intriguing was the difference between men with doctorates and the next step down - men who were slightly less schooled, but nonetheless were professionals like lawyers and engineers. The PhDs were surely no richer - but they had a 33 percent lower mortality rate.

The experts come away from these numbers with this conclusion: more education gives you more control over your life. And more control means less stress. So stop watching Law & Order reruns and start thinking about going to night school and earning your law degree, so you can kick butt for real, tough guy.