# 28. Don’t harm your body just to change its appearance This section covers several methods people use to alter their appearance: fasting, taking pills, getting injections, and undergoing surgery. They all share one thing in common: the decision to use them is usually driven by comparisons with others. Yet the costs are borne entirely by the individual, and many of those costs are irreversible. We make no judgment about anyone’s personal choice regarding how they want to look — that is a matter of personal preference. What we do address is this: for the same end result, how much greater is the risk when people follow unregulated paths — buying products online, using services at beauty clinics, or increasing dosages on their own — compared to following medically supervised routes that involve prescriptions, qualified professionals, and follow‑up care? Our assessment focuses on actual physical consequences such as blindness, hospitalization, and death. In addition, illegal cosmetic procedures can lead to serious criminal liability. ### 1. Do not use extreme dieting, fasting, or self-induced vomiting to control weight; if you want to lose weight, focus on exercise instead - Cost: No cost at all. In fact, it saves money you would otherwise spend on weight-loss products. - In plain terms: People with anorexia nervosa have a mortality rate roughly 5.9 times higher than their peers. Over a period of one year, 5.1 out of every 1,000 individuals in this group die. One in five of those who die commit suicide. The root cause of this is dieting: a three-year study of students at 44 secondary schools found that girls who engaged in severe dieting were 18 times more likely to develop eating disorders than those who did not diet. If you want to manage your weight, increase physical activity rather than cutting food intake to the point of hunger. - Benefit: This conclusion comes from a combined analysis of 36 studies that tracked a total of 166,642 person-years of data on individuals with anorexia nervosa. Their standardized mortality ratio was 5.86, meaning their mortality rate is about 5.9 times higher than that of the general population. As noted above, 5.1 deaths occur per 1,000 person-years, and roughly one-fifth of these deaths are suicides. For bulimia nervosa, the standardized mortality ratio is 1.93, and for other eating disorders it is 1.92 — both values are roughly 1.9 times higher than those of the general population. Another study conducted in 44 secondary schools in Victoria, Australia, followed 14–15-year-old students for three years, with six rounds of assessments during that time. It found that 21.8 new cases of eating disorders occurred per 1,000 person-years among girls; girls who dieted severely were 18 times more likely to develop such disorders than those who did not, while those with moderate dieting habits had an 5 times higher risk. After adjusting for prior dieting habits and existing mental health issues, factors such as BMI, physical activity levels, and gender no longer predicted the development of eating disorders. The authors concluded that for adolescents, using exercise rather than diet restriction to manage weight appears to lower the risk of developing eating disorders. - Evidence grade: A - Sources:Arcelus J et al. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. ；Patton GC et al. (1999). Onset of adolescent eating disorders: population based cohort study over 3 years. BMJ. - Notes: The term “severe dieting” here refers to long-term food intake that is far below the body’s actual needs; it does not include skipping a single meal or foregoing late-night snacks. If you or someone you know exhibits symptoms such as self-induced vomiting, feelings of guilt after binge eating, or an inability to stop weighing oneself, it is recommended to seek help from a psychiatrist or a clinical psychology department at a general hospital. This is a medical condition with established treatment methods, and it is not a matter of lacking willpower. For information on the relationship between BMI and mortality, please refer to Section 2, Item 32, which discusses long-term weight ranges rather than weight-loss methods. ### 2. Two things to check before getting injections, thread lifts, or surgery: does the facility’s license list “medical aesthetics,” and is the practitioner a licensed attending physician? - Cost: There is no cost involved. Checking these two documents takes only a few minutes. The clinic should display its “Medical Institution Practice License” in the lobby. A doctor’s qualifications can be verified via the health authority’s online registry of licensed physicians. - In plain terms: Any procedure that involves needles, surgery, or medical devices — meaning anything that breaks the skin or enters the body — is considered medical treatment. Such procedures may only be performed at facilities whose licenses explicitly list “medical aesthetics,” and only by registered attending physicians. Performing them in beauty salons, private studios, or hotel rooms is illegal medical practice: in serious cases, offenders face up to three years in prison; if they cause injury, three to ten years; if they result in death, more than ten years. - Benefit: Article 2 of the “Administrative Measures for Medical Aesthetic Services” defines medical aesthetics as “the use of surgery, drugs, medical devices, and other invasive or traumatic medical techniques to repair and reshape a person’s appearance and body contours.” In simpler terms, any procedure that breaks the skin or introduces needles or devices into the body qualifies as medical treatment. Articles 8 and 24 stipulate that a facility must first obtain a “Medical Institution Practice License” and be approved for medical aesthetic services before conducting such procedures; if “medical aesthetics” is not listed on the license, the practice is prohibited. Article 11 requires attending physicians to hold valid licenses and be registered; those performing cosmetic surgery must have at least six years of relevant clinical experience, cosmetic dentistry five years, and cosmetic traditional Chinese medicine or dermatology three years each. Article 20 mandates that patients receive written explanations of indications, contraindications, risks, and precautions prior to consent. Article 336 of the Criminal Law criminalizes illegal medical practice — performing injections, surgery, or treatment without proper licensing. Penalties range from up to three years imprisonment for minor offenses to three to ten years for causing injury, and more than ten years for resulting in death. - Evidence grade: A - Sources:卫生部 (2002). 医疗美容服务管理办法（卫生部令第 19 号，第二条、第八条、第十一条、第十六条、第二十条、第二十四条）. ；全国人大 (1997). 刑法（第三百三十六条）. - Notes: Article 16 of the same regulations further specifies that medical aesthetic procedures may only be conducted at licensed medical aesthetic facilities or at hospitals/clinics with designated medical aesthetic departments. Therefore, performing injections at a patient’s home or in a private studio already violates regulations. Article 20 also requires parental consent for minors undergoing such treatments. Routine beauty services such as facials, massages, or nail care fall outside this regulatory framework; however, any procedure involving needles or surgery remains classified as medical aesthetics. ### 3. Facial fillers should avoid the bridge of the nose, glabellar area, and forehead — and never opt for unregulated clinics just to save money - Cost: No cost at all. You simply choose a different injection site, or skip the treatment altogether. - In plain terms: Between 2015 and 2018, 48 new cases of partial or total vision loss following filler injections were reported worldwide. The nose was the most common site of complications, accounting for 56.3% of cases; followed by the glabellar area at 27.1%, the forehead at 18.8%, and the nasolabial fold at 14.6%. Hyaluronic acid was used in over 80% of these cases. Only 20.8% of patients regained full vision, while 16.7% saw partial recovery; the rest remained visually impaired. Nearly 20% also developed complications affecting the central nervous system. Currently, no single treatment has been proven consistently effective for reversing these effects, so prevention remains the only reliable option. - Benefit: Data compiled from all published case reports worldwide show that from January 2015 through September 2018, 48 new instances of partial or complete vision loss occurred after filler injections. The nasal region accounted for 56.3% of incidents, followed by the glabellar area at 27.1%, the forehead at 18.8%, and the nasolabial fold at 14.6%. Hyaluronic acid was identified as the filler material in 81.3% of cases. Skin changes appeared in 43.8% of patients, while central nervous system complications arose in 18.8%. Ten patients (20.8%) fully recovered vision, eight (16.7%) partially recovered, and the remainder did not improve. Researchers concluded that treatment approaches varied widely across studies, and no single method has been demonstrated to reliably restore vision. - Evidence grade: B - Sources:Beleznay K et al. (2019). Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature. Aesthet Surg J. - Notes: These figures were derived by manually tallying each reported case across medical journals. They reflect only the number of patients experiencing complications, not the total number of injections performed; thus it is impossible to calculate the exact probability of blindness per injection. The B rating reflects this limitation. Reputable clinics naturally employ standard risk‑minimization practices: mapping vascular pathways beneath the injection sites, using blunt‑tip needles instead of sharp ones, administering small amounts of filler while slowly withdrawing the needle, and keeping hyaluronidase on hand. All these steps must be carried out by trained physicians — which is precisely why unregulated providers should be avoided. Before proceeding, verify that the clinic holds proper licensing and that the attending physician is qualified, as outlined in Section 2 of this chapter. ### 4. Don’t buy weight‑loss pills, coffee, candies, or “enzymatic plums” that promise rapid results - Cost: Zero. In fact, you’ll save the money you’d otherwise spend on these products. The hard part is accepting that there’s no such thing as “losing several pounds in a week.” - In plain terms: The illegal ingredient most often found in these products is sibutramine. Originally a legitimate weight‑loss medication, it was banned in China in 2010. One large trial enrolled nearly 10,000 participants who took the drug for an average of over three years. Compared with placebo, users had a roughly 30% higher risk of non‑fatal heart attacks and a 36% higher risk of non‑fatal strokes; the overall adverse‑event rate was 11.4% versus 10.0%. Over three years, the drug only produced an extra 1.7 kg of weight loss. By the time tests detect the substance, you’ve already consumed it. - Benefit: The SCOUT trial involved 9,804 participants aged 55 or older who were overweight or obese and had cardiovascular disease or type 2 diabetes. They were randomly assigned to receive sibutramine or placebo for an average of 3.4 years. The primary endpoints were several predefined adverse events: non‑fatal myocardial infarction, non‑fatal stroke, cardiac arrest with successful resuscitation, and cardiovascular death. The incidence rates were 11.4% in the drug group versus 10.0% in placebo, giving a hazard ratio of 1.16 (95% CI 1.03–1.31, P = 0.02). In other words, treatment raised the risk of any such event by roughly 16%, with the true increase likely ranging from 3% to 31%. Non‑fatal heart attacks occurred in 4.1% vs 3.2% of participants (HR 1.28, 1.04–1.57), a 30% relative rise; non‑fatal strokes appeared in 2.6% vs 1.9% (HR 1.36, 1.04–1.77), a 36% increase. Cardiovascular and overall mortality did not rise. On average, the sibutramine group lost only 1.7 kg more than placebo. Based on safety concerns, China’s former State Food and Drug Administration ruled in October 2010 that the benefits of sibutramine did not outweigh its risks, ordering cessation of its production, sale, and use; both sibutramine and phenolphthalein are prohibited in foods and dietary supplements. - Evidence grade: A - Sources:James WPT et al. (2010). Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects. NEJM. ；天津市市场监督管理委员会. 警惕部分食品中违法添加「盐酸西布曲明」和「酚酞」. - Notes: SCOUT enrolled high‑risk individuals already suffering from heart disease or diabetes; it does not prove that healthy young people would experience the same effects. Because it’s impossible to identify who is truly low‑risk, regulators opted to withdraw the drug entirely. Another common illicit additive is phenolphthalein, originally a laxative whose chronic overuse can disturb electrolyte balance and provoke arrhythmias. How to tell a legitimate product from a fraudulent one: genuine weight‑loss medicines are prescription drugs whose approval numbers can be verified at pharmacies or hospitals. Products marketed as “coffee,” “candies,” “plums,” or “meal replacements” that promise rapid weight loss should, by definition, have no therapeutic effect; any such effect indicates illegal adulteration. The original wording of State Food and Drug Administration Order No. 432 [2010] can be cross‑checked on provincial regulatory websites; the phrase “risks outweigh benefits” and the statement “production, sale, and use were halted in October 2010” appear verbatim there. A total of 412 participants took part in the trial, underscoring its large scale. ### 5. Do not use anabolic steroids (“muscle‑building injections” or “oral pills”) to build muscle - Cost: There is no cost involved; you even save money on medication. The hard part is accepting that muscle growth will be slow. - In plain terms: A Danish study followed 545 men who tested positive for anabolic steroids and compared them with 5,450 age‑matched controls. Users had a three‑fold higher risk of death, and the median number of hospital visits per year was 0.81 versus 0.36 for controls. More than 10 % of steroid users developed acne, gynecomastia, or erectile dysfunction. In China these drugs are prescription‑only, and any source selling them illegally is breaking the law. - Benefit: The Danish researchers matched each steroid user with a control of the same age. The original cohort comprised 545 men whose androgenic steroid tests were positive between 2006‑01‑03 and 2018‑03‑01; they were paired with 5,450 controls. An additional validation used 644 refusers and 6,440 controls. Results showed a three‑fold increase in mortality among users (HR = 3.0; 95 % CI 1.3–7.0). The median yearly number of hospital visits was 0.81 versus 0.36 (P < 0.0001). Median means that half of the users had more visits and half fewer; such a low P‑value indicates this difference is highly unlikely to be random. Acne, gynecomastia, and erectile dysfunction each affected over 10 % of users – at least one in ten – a rate far above that of controls (P < 0.0001). The validation cohort yielded the same findings. Article 7 of China’s Anti‑Doping Regulations states that all substances on the prohibited list are strictly controlled; no entity may produce, sell, import, or export them illegally. The same regulation designates anabolic agents and peptide hormones as prescription drugs, meaning they may be obtained only with a doctor’s prescription; “anabolic agents” is the official term used in legislation. - Evidence grade: A - Sources:Horwitz H et al. (2019). Health consequences of androgenic anabolic steroid use. J Intern Med. ；国务院 (2004). 反兴奋剂条例（国务院令第 398 号，第七条、第九条）. - Notes: This is an observational study, not a randomized trial; steroid users may also engage in other risky behaviors, so the three‑fold risk increase may not be attributable solely to the drugs. The true effect size likely falls between 1.3 and 7.0. However, visible side effects such as acne, gynecomastia, and erectile dysfunction are less prone to bias. Legally these products are termed “anabolic agents”; any product described with that phrase contains them. Ordinary protein powder or creatine does not fall under this category. A problem is that some products marketed as “muscle‑building powders” or “nutritional supplements” may contain hidden steroids while claiming rapid results. The screening method is the same as for weight‑loss products (see item 4: avoid any weight‑loss drug promising quick results). Legitimate drugs are prescription‑only and carry verifiable approval numbers; any product sold as a “muscle‑building supplement” that promises results within weeks is probably adulterated. ### 6. If you need weight-loss medication, get a prescription from a doctor — don’t buy it from online shops that ship it without one - Cost: A single doctor’s visit plus a round trip to the clinic. This costs just a few dozen yuan and takes half a day. - In plain terms: By regulation, prescription drugs must be sold only with a valid prescription, and pharmacies must keep that prescription on file for at least five years. Online sellers of prescription drugs must also have a genuine prescription and verify the buyer’s identity. So when you see an online shop that doesn’t require a consultation or a prescription and ships the product right away, there are only two possibilities: either the product isn’t actually the drug it claims to be, or the shop is breaking the law. In either case, no one can be held responsible for dosage or contraindications if something goes wrong. Those few dozen yuan you spend on a doctor’s visit buys you exactly this protection. - Benefit: The “Measures for the Supervision and Administration of the Quality of Drug Operation and Use” require retail pharmacies to follow a classification system that separates prescription drugs from over-the-counter ones. Under this system, one category requires a doctor’s prescription, while the other can be bought without one. Pharmacies must sell prescription drugs only with a prescription, keep it on file for at least five years, and post notices when no pharmacist or other qualified pharmacy staff member is on duty; otherwise they may not sell prescription drugs at all. Prescription drugs may not be sold from open shelves where customers can pick them up on their own. Article 9 of the “Measures for the Supervision and Administration of Online Drug Sales” stipulates that any online sale of prescription drugs to individuals must be backed by a verified, authentic prescription and must use real-name registration. Article 10 requires that risk warnings be clearly displayed on every product page. Before a prescription is verified, no product description may be shown and no purchase option may be offered — in other words, there should be no “Buy Now” button on such pages. Article 8 further states that drugs under special government control may not be sold online at all; this includes vaccines, blood products, narcotics, psychotropic drugs, toxic drugs for medical use, radioactive drugs, and precursor chemicals used to make illicit drugs. None of these may be sold online. - Evidence grade: B - Sources:国家市场监督管理总局 (2023). 药品经营和使用质量监督管理办法（总局令第 84 号）. ；国家市场监督管理总局 (2022). 药品网络销售监督管理办法（总局令第 58 号，第八条至第十条）. - Notes: The legal provisions can be checked word for word, but no study has ever quantified exactly how much safer it is to take prescription drugs versus buying them without one; therefore this evidence rating is recorded as “difficult to quantify,” resulting in a grade B. This rule applies to all prescription drugs, not just weight-loss medications. The same regulations govern steroids and sex hormones, as mentioned in items 5 and 7 of this section. When a patient truly needs medication to manage weight, a doctor first evaluates their BMI, any other medical conditions, and possible contraindications before deciding whether and which drug to prescribe. This professional judgment cannot be replaced by any online purchase. ### 7. Sex hormone therapy should only be used when prescribed by a doctor and with regular follow‑up; do not buy it online and do not adjust the dose on your own - Cost: Regular doctor visits and blood tests are required. Over a year this can cost several hundred dollars and take up several half‑days of your time. - In plain terms: This section does not discuss whether hormone therapy is appropriate, only how to use it safely. A study followed transgender individuals for about four years. Transgender women taking estrogen had a noticeably higher rate of venous thrombosis than age‑matched controls — 4.1 extra cases per 1,000 people in two years and 16.7 extra cases per 1,000 in eight years. Such risks must be monitored through long‑term follow‑up, and that monitoring only happens when a clinician checks you regularly. When people buy hormones online and adjust doses themselves, there is no one to provide that oversight. - Benefit: Researchers examined electronic medical records from Kaiser Permanente, a large health‑care system. They identified 2,842 transgender women and 2,118 transgender men, with average follow‑up periods of 4.0 and 3.6 years respectively. Each participant was matched to roughly ten cisgender controls based on birth year, race, clinic location, and enrollment date — resulting in 48,686 cisgender men and 48,775 cisgender women. Compared with cisgender women, transgender women showed more venous thromboembolism: 4.1 extra cases per 1,000 people after two years (95% CI 1.6–6.7) and 16.7 extra cases after eight years (6.4–27.5). Compared with cisgender men, the numbers were 3.4 (1.1–5.6) and 13.7 (4.1–22.7) respectively. Rates of ischemic stroke and myocardial infarction were similar across groups. The differences were more pronounced among transgender women who started hormone therapy during the study period. Evidence for transgender men was insufficient to draw conclusions. The authors concluded that “these results may indicate a need for ongoing vigilance regarding the vascular side effects of estrogen in transgender hormone therapy.” - Evidence grade: A - Sources:Getahun D et al. (2018). Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study. Ann Intern Med. ；国家市场监督管理总局 (2022). 药品网络销售监督管理办法（总局令第 58 号，第九条）. - Notes: The researchers acknowledged a limitation: they could not determine how many participants obtained hormones outside the health‑care system, so the data on actual medication use are incomplete. This limitation actually underscores why regular medical follow‑up is essential. The study only examined vascular events; it does not address whether hormone therapy should be used or what its overall benefits are — those questions require different evidence. The same principle applies to any use of sex hormones, including birth‑control pills, menopausal hormone therapy, and testosterone replacement. Anyone who buys hormones online, adjusts doses based on internet advice, and never monitors blood clots or liver/kidney function is at risk primarily because there is no medical oversight. In China, the proper route is to consult an endocrinology department or relevant specialist at a licensed medical institution for evaluation, prescription, and follow‑up. 〔17〕 ### 8. If the feeling of “being unattractive” has reached the point where you constantly check your reflection and obsess over changes, get a body image assessment before considering surgery - Cost: A single visit to a psychiatrist or clinical psychologist costs only a few dozen yuan. The real challenge is making that appointment before scheduling any surgery. - In plain terms: When we combine data from 33 studies, we find that 15.04% of people seeking cosmetic surgery meet the criteria for body dysmorphic disorder — a condition where a flaw barely noticeable to others becomes a major source of distress. Among dermatology patients seeking cosmetic treatments, the rate is 12.65%. In both groups, over 70% are women. Surgery can alter facial features, but it cannot break the cycle of constant self‑scrutiny and dissatisfaction; this often leads to repeated operations. Spending a modest amount on an initial evaluation can help determine whether you fall into this category, guiding your decision about surgery. - Benefit: A comprehensive review of those 33 studies shows that the prevalence of body dysmorphic disorder among cosmetic surgery patients is 15.04%, with individual study estimates ranging from 2.21% to 56.67%. Roughly 15 out of every 100 patients fit this description, though some studies report as few as 2 or as many as 57. The average age of these patients is 34.54 ± 12.41 years, and 74.38% are female. Among dermatology patients, the rate is 12.65%, with study figures ranging from 4.52% to 35.16%; their average age is 27.79 ± 9.03 years, and 76.09% are female. Researchers recommend that plastic surgeons and dermatologists proactively screen for this disorder and coordinate care across specialties. - Evidence grade: B - Sources:Ribeiro RVE (2017). Prevalence of Body Dysmorphic Disorder in Plastic Surgery and Dermatology Patients: A Systematic Review with Meta-Analysis. Aesthetic Plast Surg. - Notes: The reported prevalence varies widely — from 2.21% up to 56.67% — because different studies use distinct questionnaires and populations. Thus we can only conclude that this condition is fairly common and warrants screening; the 15.04% figure should not be taken as an exact statistic. This is why it is graded B. Importantly, most people seeking cosmetic treatments do not have psychological issues; only a small subset — those whose preoccupation is persistent, interferes with work or social life, and leads to repeated surgical attempts — are at risk. Warning signs include spending excessive time each day inspecting or concealing a body part, avoiding social interactions or photos, and constantly fixating on new areas after previous corrections. 〔13〕