A Closer Look at the China Study: Fish and Disease

In my last post, I explored what the China Study data says about meat and disease—which turns out to be a far cry from what Campbell reports in his book of the same name. In a nutshell, meat has no statistically significant correlations with any diet-related disease, and actually has a negative correlation with death from all causes and death from all cancers. That means the populations that ate more meat generally had fewer chronic diseases than the populations that ate less of it. While it’s impossible to tell from the China Project alone whether this is because meat was protective of illness or simply corresponded with other helpful factors (like better health care), it does undermine Campbell’s assertion that animal product consumption always went hand-in-hand with disease in the China Project.

(If you’re not sure what the China Study is or why I’ve suddenly made it my life’s purpose to examine every modicum of its data, take a gander at the previous entry for an explanation.)

Of course, the “meat” category doesn’t include fish, eggs, or dairy—so these foods aren’t out of the hot seat yet. In this post, I’ll be looking at fish. Sushi lovers, listen up.

Fish intake in rural China

Among the 65 counties studied in the China Project, fish consumption ranged from zero grams per day to 119 grams per day—a bit over a quarter of a pound. Unfortunately, all forms of seafood (finned fish, shell fish, roe, and so forth) are lumped under the same category, even though these foods tend to have much different nutritional profiles.

Surprisingly, fish had no statistically significant association with mercury intake (correlation of -8).

One thing striking about fish consumption in the China Study is that fish-eating regions have quite a few things in common: These counties tend to have a high population density (correlation +46), citizens overwhelmingly work in industry rather than agriculture (correlation +52 for industry and -53 for agriculture), and folks eat a great deal of processed sugar and starch along with the fish (correlation +58) as well as loads of soybean oil, sesame oil, peanut oil, and cotton seed oil (correlation +61). Infant mortality is low, literacy is high, and beer and liquor are quite popular beverages—especially among men. Although occurrence of heart disease is sparse, the average cholesterol levels are high compared to non fish-eating regions (+45 for total cholesterol, +38 for HDL, and +36 for non-HDL)—which doesn’t exactly support the cholesterol-heart disease connection, but I’ll get to that later.

Unlike meat, fish is quite obviously associated with more industrialized coastal regions—which makes things a little tricky when it comes to untangling variables. Putting nutrition aside for a second, we can see that industry-dominated regions are riddled with chronic diseases that rural regions generally don’t exhibit. According to the China Project data, the variable “Percentage of employed population who are in industry” has the following correlations with disease:

Male lung cancer: +62
Leukemia: +53
Female lung cancer: +47
Liver cancer: +47
Colon cancer: +41
Other heart disease: +40
Death from all cancers: +31
Colorectal cancer: +31
Stomach cancer: +25

Breast cancer: +24
Brain cancer: +21

(On the bright side, they have low rates of infectious diseases, pneumonia, parasites, tuberculosis, and other ailments common in the agricultural regions—indicating better living conditions and perhaps better health care.)

In other words, the folks who eat lots of fish typically work in industry, and the folks who work in industry typically have high disease rates. But is the fish to blame? Or is it one of the other factors associated with industry work, like processed starch and sugar intake or occupational hazards? Let’s find out. Here are the straight-up correlations, not adjusted for the variables that could be skewing the trends.

For the sake of science, I’ll only be focusing on the statistically significant correlations in this post.

NEGATIVE CORRELATIONS (more fish= fewer of these diseases)

Rheumatic heart disease: -43**
Diseases of blood and blood forming organs: -35**
Death from all non-cancer causes: -30*

If we prune away the variables that coincide with fish consumption but that negatively impact health—like processed sugar and starch intake, liquor consumption, soybean oil use, and so forth—I wouldn’t be surprised if some of the other correlations would  reach statistical significance:

Neurological diseases: -23
All diseases: -20
Oesophageal cancer: -19
Cervix cancer: -18
Myocardial infarction and coronary heart disease: -15
Stroke: -15
Hypertensive heart disease: -14

Given the non-China-Project research we have regarding fish, this isn’t too surprising: The omega-3 fats in fish tend to benefit cardiovascular function and work as blood thinners, so it’s no shocker that fish-eating regions have low rates of heart disease. In fact, in 2003, Campbell himself co-authored a paper on the protective effects of fish and DHA as revealed by the China Study data: Fish consumption, blood docosahexaenoic acid and chronic diseases in Chinese rural populations. (Too bad he forgot to include that in his book.)

But that’s only the positive stuff. Now let’s look at the more incriminating side of the fishy coin.

POSITIVE CORRELATIONS (more fish = more of these diseases)

Nasopharyngeal cancer: +56***
Diabetes: +41**
Liver cancer: +34**
Leukemia: +25*

Jeepers! That doesn’t look too good, does it? Positive correlations with several cancers and diabetes, all statistically significant. Could fish be a bona fide health-wrecker, even if it does spare your heart? Let’s take a look at these correlations one by one.

Nasopharyngeal cancer

Nasopharyngeal cancer—or NPC, so I don’t have to keep typing that horrible word—is a type of cancer that occurs at the back of the nose, towards the base of the skull. It’s pretty rare in most of the world: Only about 7 out of every million people get it in the US. The main folks with high rates of NPC are some Chinese populations, the Inuit, and some tribes from North Africa, according to the American Cancer Society.

In the counties studied in the China Project, men generally had between two and twelve times as much NPC as women—indicating that this is gender-biased disease. Since diet didn’t differ severely between the sexes, it’s possible that NPC occurrence is related to a lifestyle practice that Chinese men engaged in more than women (such as drinking or smoking). And indeed, NPC has a correlation of +50 with daily liquor consumption, +40 with daily alcohol consumption, +33 with daily beer consumption, +24 with total tobacco consumption, and +22 with homemade cigarette use.

In looking at NPC factors, something else jumps out at me: The heavy metal cadmium is strongly associated with NPC (correlation of +42). This particular metal is known to contribute to a variety of cancers, including NPC. Although cadmium doesn’t occur naturally in food, eating plants grown in cadmium-contaminated soil—or eating animals that consume said plants—is a surefire way to get it stuck in your body for a few decades. Is it possible the coastal, industry-dominated regions that ate the most fish also had cadmium-contaminated soils? Is it possible certain aquatic regions were also polluted with cadmium, which then accumulated in fish?

First, here’s a graph showcasing the original +56 correlation, using all of the data points for fish intake and NPC.

And here’s a graph using only counties that ate less than 25 micrograms of cadmium per day, as determined by the food composite survey for heavy metals. Some of the now-omitted regions were consuming over 90 micrograms per day, which is considered pretty toxic.


Simply removing cadmium from the equation, we’ve bumped a correlation of +56 down to +14, below the threshold of statistical significance. And get this: That highest data point on the chart, near the “12” grid line, is for the county with the absolute highest use of homemade cigarettes—which not only correlates independently with NPC, but is likely to be a source of cadmium exposure. Coincidence? Perhaps not.

It’s still not clear if cadmium is actually a factor, though, and we’ll never know for sure based on China Study data alone. The American Cancer Society cites infection with the Epstein-Barr virus, consumption of salt-cured foods, and exposure to formaldehyde and wood dust as potential causes of NPC. The China Project data also shows a strong correlation between NPC and tuberculosis, parasitic infection, and peptic ulcers. How are these things related—if they’re related at all? Beats me. I’m no nasopharyngeal cancer expert. But given the prevalence of this disease only in a smattering of places in the world, it’s probably due more to specific food contaminants, certain disease infections, or simply genetics.


Without peeling away any confounding variables, fish has a correlation of +41 with diabetes. That’s pretty high. But given that fish-eating regions also ate above-average amounts of processed sugar and starch (correlation of +58) and also tended to be heavier than most (correlation of +20), we might have a pretty obvious explanation for this sky-high rate. Here’s what our graph looks like using only counties that escaped the ravages of these nutritionally devoid foods, eating 0.5 grams or less of processed sugar and starch per day.

No positive correlation there. Without the influence of processed sugar and starch, the correlation between fish intake and diabetes nosedives from +41 to -5. We’re still in the wobbly land of epidemiological correlations, so we can’t say anything for sure, but it looks like fish itself doesn’t contribute to diabetes. (Unless your fillet of salmon is encrusted with Twinkies.)

Liver cancer

In China, liver cancer—like NPC—is extremely gender biased. In nearly every county, the mortality rates for liver cancer were between two and seven times higher for men than women. Since diet didn’t differ much—if at all—between the sexes, this is a red flag that liver cancer is something related to gender-specific lifestyle habits rather than diet alone.

Indeed, this is one disease that, in the China Study populations, has very little to do with diet: It’s linked pretty blatantly to hepatitis B infection across all counties. This is nothing revelatory, though. The World Health Organization already figured it out:

Hepatitis B is endemic in China and other parts of Asia. Most people in the region become infected with HBV during childhood. In these regions, 8% to 10% of the adult population are chronically infected. Liver cancer caused by HBV is among the first three causes of death from cancer in men, and a major cause of cancer in women.

Dur. Not surprisingly, fish-eating regions not only exhibited high rates of liver cancer, but also had large chunks of the population testing positive for the hepatitis B virus—a correlation of +35, a smidgen higher than the correlation with liver cancer. In other words, it looks like fish-eating regions had a lot of HPV-induced liver cancer, but diet wasn’t the cause.


According to the raw data, fish had a correlation of +25 with leukemia. Is this one legit?

For starters, let’s look at factors that correlate with leukemia in the China Project data. The most significant variable both fish consumption and leukemia have in common is industry work: +52 for fish and +53 for leukemia. (They both share a inverse correlation of -53 with agricultural work.) Could something about industry labor itself be a factor in leukemia occurrence? My spidey senses are tingling.

And look what we have here:

A retrospective cohort study was carried out in 1982–1983 among 28,460 benzene-exposed workers (15,643 males, 12,817 females) from 233 factories and 28,257 control workers (16,621 males, 12,366 females) from 83 factories in 12 large cities in China. … Risk of leukemia rose as duration to exposure to benzene increased up to 15 years, and then declined with additional years of exposure. Leukemia occurred among some workers with as little as 6 to 10 ppm average exposure and 50 ppm-years (or possibly less) cumulative lifetime exposure (based on all available measurements for the exposed work units).

The years cited for this study, by the way, are right around the time the China Study data was collected. How convenient!

Indeed, it seems benzene exposure was a significant problem for some industrial workers in China—the same industrial workers who ate a lot of fish. So is seafood to blame for higher leukemia rates, or could it be occupational hazards like benzene?

Unfortunately, the China Project doesn’t record benzene exposure. And we’re a few decades too late to go track down that data now (if you have a time machine, please contact me). What we can do is clarify the picture by looking at fish consumption and leukemia in counties with low levels of industrial employment. Here’s a graph showing exactly that—using only regions where less than 10% of the population worked in industry:

So there you have it. With industrial work out of the equation, fish no longer bears a statistically significant correlation with leukemia.

In a nutshell:

  • Based on the China Project data, fish may have a protective effect against some forms of heart disease, diseases of the blood, and diseases of blood-forming organs.
  • Fish intake has raw correlations with several cancers and diabetes, but these trends appear to be a result of other factors that accompany fish consumption rather than the fish itself (cadmium exposure, processed sugar and starch intake/high body weight, hepatitis B infection, and benzene exposure). When we tease out these confounding factors, fish loses or reverses its positive correlation with these diseases.
  • No matter what you eat—vegan, vegetarian, pescetarian, or otherwise—be  cautious about cadmium intake, since this metal does appear to cause some cancers and disease.

That’s all for the fish, folks. Next up: eggs and dairy.



  1. I love your posts, Denise, because it is so very rare to find anybody these days who tries to follow the evidence regarding diet and health wherever it might lead. Most people seem to treat diet much like religion. They become linked to some specific dietary cult and then search high and low for anything that supports the belief system they have already decided to embrace.

    I want to know what diet best supports good health in this modern western world. I’m tried vegan, raw, primal and others. Each step is a learning process and it soon becomes evident that no single path has a monopoly on truth.

    Regarding meat and seafood, there is no question whatsoever that we humans ate meat and seafood whenever they could obtain it throughout our evolution. Killing a large animal provides far more food value for the energy expended than any other method of obtaining food. The more advanced humans became in making tools the more they hunted and the more they focused on larger and larger animals.

    So it’s to be expected that eating meat and seafood would not have a detrimental effect on human health. A species simply can’t evolve while eating a certain diet if that diet were harmful.

    But we run into a HUGE problem when we try to apply this lesson to the modern world. The meat and seafood that is available today is nothing like the meat and seafood available to our ancestors. Even back in the day when the data was gathered for the China Study most meat was raised in a fairly natural way. Hogs lived outdoors and rooted for food in addition to eating table scraps. Filsh swam in fairly clean waters.

    But the China of today probably has 10,000 times the industry of the China of 1980. Much of the country is a toxic stew of industrial chemicals. Hogs are raised in feedlots, shrimp are raised in polluted tanks and chicken production is as industrialized as it is in the West. I think it is clear that Colin Campbell cherry picked the data from the China Study in order to support a conclusion that he had already embraced. But, on the other hand, the world has changed so much since then, that I’m not sure that the China Study is even relevant anymore.

    Here in America I believe that you can eat meat and have excellent health as long as you are wealthy enough (and willing to invest enough time) to eat grassfed Bison, and true open range chickens and so forth. But the horrid industrial meat products in the supermarket from genetically engineered animals who are full of hormones and antibiotics and themselves eat a wretched toxic stew of polluted grains and waiste products cannot possibly be healthy.

    This is part of why I”ve decided to be vegan. Not because I believe that meat is inherently unhealthy. But because the meat that is readily available in our society IS extremely unhealthy. In conclusion, purely from a perspective of personal health and nutrition, you can eat meat and be healthy if you are wealthy and dedicated and knowledgeable. But, if you are not wealthy and you want to maximize good health, you are better off just giving up on animal products altogether.

    1. Steve, what a wonderfully insightful comment–thank you so much for taking the time to write this. You raise so many great points. Most of the animal products we have today (scratch that–90% of the items on any grocery store shelf) should barely qualify as food, yet they form the backbone of so many people’s diets. Whether you approach it from an ethical standpoint or a health one, there are no redeeming qualities about factory-farmed animal products saturated with antibiotics and hormones. That stuff doesn’t belong in anyone’s body, and the suffering involved in its production is unjustifiable. If your only option is commercial meat, vegetarian or veganism very well may be the more healthful path.

      I think that as public interest grows in free-range animal products (which, from what I can tell, it slowly but surely is), we’ll see more opportunities for purchasing high-quality animal products at reasonable prices. It’s unfortunate that so many healthy foods are something reserved for the wealthy right now. Someone’s ability to thrive and enjoy great health shouldn’t have a lick to do with what’s in their bank account.

      Thanks again for your comment!

  2. Wow!!! So much data to untangle. Again, thank you for this unbiased look at the China Study. You’re doing a great job at eliminating the variables that obscure the true results. Keep up the great work!

    Steve, I appreciate your comments, too! You make some excellent points.

  3. duh! If Chinese tilapia eat poop and Wal*Mart sells tilapia…..does that mean…Americans poop better.

    “It is the aim of good government to stimulate production, of bad government to encourage consumption.” – Jean Baptiste Say

    If Retail makes NOTHING….and Government makes only MORE DEBT….the only thing that can have a positive affect on communities is Small Business and companies that make stuff.

    The picture of George Washington can float around a town six to eight times before leaving the community but if that dollar is spent inside of a big box store it will leave the same day that it entered.

    Big Box stores like Wal*Mart can take in 200,000 George Washington’s a day and that be a lot of “Liberty” “Pride” “Freedom” leaving town each day.

    And when one figures into the equation America has a six to one trade deficit with China which means five out of every six George Washington’s that go there will never come back unless the US Government sells bonds(debt) this is what those on Jenkins Hill and Wall Street don’t understand when it comes to local banks not having any George Washington’s to loan out in their communities.

    Why is it that people ain’t writing articles about those fifteen cargo ships that pollute as much as 760 million automobiles, T Boone Pickens owning a Texas Water District, Nestle draining the Great Lakes, the disconnect between Coca-Cola and the people of India, Wal*Mart putting less than 5% foreign in their stores in China and Warren Buffett buying a Choo Choo train a few years after Wal*Mart makes a deal on a port in Mexico.

    In 1960 U.S. goods manufacturing produced a $5 billion trade surplus – – 2006 merchandise trade had a $836 billion deficit. Today, for some reason, the world thinks the American consumer needs to support what they make….well, it doesn’t work like that even a fifth grader can figure that out.

    So-call cheaper items only breed cheaper wages and this will go on until the rich of the world carry out the manufacturing of ignorance through out the 182 or so counties that will have a chance to make something.

    I’m just an O’fart with very little book learning but from what I’ve seen over the past sixty five years in this great union of fifty states has shown me that common sense left in the year 63′ and “my sh!! don’t stink” sense as been here every since.

    Sad, those few fat farmers with penmanship of poets holding feather quill pens and writing the American dream has today become nothing more than a page within a history book that a bunch of asinine dipsticks are to lazy and ignorant to teach.

    Over the past 100 years the Federal Debt has gone from $2.6 billion in 1910 to over $14 trillion today….In that time there has only been one 10 year period that the debt has gone down 1920-1930.

    All done by a bunch of elephants and jack@sses acting like turnips. People today still think Clinton balance the budget but anyone knows if they think with an open mind that if the budgets of the Clinton years had been balance the debt would had not gone up.

    America is over $57 trillion in debt and it didn’t get there by people using common sense. If the American people don’t wake-up to that fact within another twenty years they will witness Lady Liberty kneeling to her knees in the Hudson and someone in Tiananmen Square holding that tablet from under her left arm celebrating what is written upon it.

  4. Denise, i am recently a converted pescetarian, with ample amount of raw eggs, fruits, veggies, and unpasteurised cheese thrown in for good measure.

    Your comments about cadmium startled me, and i want to find more info about the cadmium content in different seafood.

    I eat a lot (as in every day) of Chilean farmed mussels, shrimp, scallops, squid, and Alaskan pollock, and one of the criteria for me choosing these foods was, apart from them being quite cheap in the UK, the low environmental impact, low level of mercury, PCB’s and dioxins. However, the site I used to get this info ( http://apps.edf.org/page.cfm?tagID=1521) does not mention cadmium content.

    Can you point me in the right direction for getting more info about specific seafood cadmium content levels?



  5. You actually make it appear really easy together with your presentation but I to find this topic to be really one thing that I believe I might never understand. It kind of feels too complex and very huge for me. I’m looking ahead for your next post, I’ll try to get the hold of it!

  6. I am so happy to come across your article. As a carnivore trying to switch to veganism to help my heart disease, you bring out so many great points. I just finished Dr. Esselstyn, Jr’s book, “Prevent and reverse Heart Disease” and he cites the China Study throughout the book. Nice to see another perspective that you provide here. Thanks so much for your hard work.

  7. Devember 8th 2013
    one must pay particuliar attention to enviromental and consumption inr comparison with Cancer.

  8. This is sure interesting data and would love to get my hands on china study raw data…. One of the major pieces of science not understood by many of these the posts and the Palio diet assumptions; Cancer is an important part of our Biology, it is not necessarily a “disease” or disorder it is intentional.

    Biology, or more specifically Molecular Biology of cancer is well understood. P53 and retinoblastoma data good examples, but 100’s of others have made it clear that we are purposely programed to get cancer and die.. Cancer is an important part of our “biological program” and starts the day we are born. Why ? It’s simple after we have completed reproducing and also raised progeny to reproducing age, often better if food is scarce commodity to eliminate that individual – advantage to lighten the food load of the tribe so they can reproduce ….

    Many things can lead to uncontrolled cell division (i.e. cancer) and it usually happens after we are finished reproducing – it is often age related. For example, many genes seem to break after so many cell divisions. Maybe after so many steaks or fish dinners same thing ? Also many infectious organisms easier to get when we are old can lead to DNA breaks – long long list…

    In other words can not assume just because we have all of the biological machinery to eat and digest a food also means it must be a “safe” food. Death is an important part of our biology, as is also true with all other species on this planet.

    Mice live 2-3 years in the lab, and eating same diet have high incidence of cancer after year 2 and 3. However almost never find a mouse in wild over 1 year of age, they die in wild for other reasons, but DNA program kicks in to make sure die at age 3.

    I like everyone also want to maximize and extend my own life – but am a skeptic that can do that with gimmick diets…. I also doubt that Collin Campbell or the China Study or Wooster MA study can help with that. Wish I had a simple answer “here is what your do” like Campbell or Atkins or 50 others …. I am sure what we eat has major impact on health, but after 200 years of diet science and politics, no one really understands the diet rules or the biology well…… the literature is complex contradictory and just no bon vide credible guidance .

    My hats off to Denise for being so objective, and focused, digging into this epidemiological data is difficult work, very refreshing – she is sui generis; an N-of-1.

    In the end think we all have to use common sense to manage how and what we eat, and become a science experiment with N-of-1, just like Denise and the 88 year old guy who ate 25 eggs a day…….

    This is a good recent review article “How cancer shapes evolution, and how evolution shapes cancer”


    Thanks John

  9. am really glad to come across your survey, which is very helpful for my project.am working on detection of formalin in fish,can you suggest me how to make questionare on how to collect data on the patients regarding their consumption of fish.

  10. It’s a disgrace that when I search for “China study fish” on google, your flawed analysis based on a poor understanding of statistics is the first thing I find.

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