Archive for the 'health' Category

Fitness, Health, Risk

February 8, 2010

Popular discourses on fitness, health and risk are filled with confusion, misunderstanding, and sometimes willful ignorance. Let this quick post be your guide to sorting out the three concepts.

Fitness. Generally speaking, fitness is capability to perform a certain task. Therefore, “fit” is fairly useless as a descriptor, because it does not specify what the person in question is fit to do. “Are you fit?” can always be answered with “fit for what?” There exist many “fitness” standards – for cardiovascular fitness, strength, flexibility, and so forth. Arguably, the bare minimum of fitness is being fit enough to sit on the couch without keeling over and dying. However, neither this nor any other fitness standard gives a good estimate of health, more on which below.

Health. Unlike fitness, health is a state of being, generally understood as a state in which the body is not suffering from disease. Depending on your relationship with postmodernism, you can add qualifiers such as “socially constructed disease,” etc. “Being healthy” is somewhat more informative than “being fit,” although again the operationalization of health varies considerably. In some cases, health is summarized as just a handful of measures, while in others, it is used to mean the state of the entire body. Using the latter maximal definition of health, or some approximation thereof, we can evaluate fairly accurately whether an individual is healthy (in fact, medical professionals do this daily with their patients), but unfortunately we may not be able to ascertain an individual’s risk for future problems.

Risk. Unlike health or fitness, risk does not reside within the individual. In discussing the risks of developing future health problems, it is important to clarify two points. First, what is the outcome for which risk is being computed? Second, is the risk to be computed as is, or net of other effects? The importance of the first question is self-evident: risk for early mortality is quite different from risk for chronic diseases, which is quite different from risk for low self-reported health. The importance of the second question is more elusive. Risk can be computed simply by correlating a predictor variable with an outcome variable: this is “as is” risk. This basic correlation can be controlled for confounding factors – gender, socioeconomic status, health behaviors, and age, to name a few – yielding (theoretically) the true net effect of the predictor on the outcome. For example, the “as is” risk of mortality is greater among underweight people relative to “normal weight” people (using standard BMI categories), but controlling for factors such as smoking and disease explains this association and results in a much smaller “net” risk. Risk, by its nature, cannot be computed from a single case. It requires referencing studies of large and representative samples to make a well-validated estimate. By the same line of logic, risk cannot be assessed from either fitness or health without appealing to robust statistical findings.

The final point to keep in mind is that these three concepts carry very different standards of proof. At one extreme, “fitness” for a task can be proven simply by doing that task. At the other extreme, the estimated risk of a certain outcome for a given person is always open to revision by newer and more sophisticated definitions and analytical techniques, but cannot be “tested” through personal anecdote. Beware when discussants switch concepts to down- or up-shift the standard of proof to their own advantage.


The Bones of an Idol

December 16, 2009

Health care reform is starting to look as sickly as the health care system it is supposed to fix. First, the public option vanished quietly a week ago. That was supposed to be OK, because Senate Democrats introduced the Medicare expansion which was supposed to cover more previously uninsured people, anyway – and have a greater chance of making it into the law books. Now the Medicare expansion is on the chopping block, too. What, then, is left of health reform?

The exact answer is likely to shift from day to day with the ebb and flow of Congressional politics, but the rough outline is this. First, the individual mandate is alive and well. Americans are required to have minimal health insurance, or else pay a fee. Second, the insurance exchanges are poised to become the biggest change to how consumers buy insurance. In these exchanges, consumers would be able to shop for health insurance much as employers can shop for company-based health insurance today. Third, a number of new regulations for health insurance companies have endured so far in the proposed bills: for example, requiring coverage for pre-existing conditions or capping differences in premiums or coverage by age or by salary. Fourth, as Jamelle writes today, there are “dozens of small measures and experiments aimed at controlling costs while also improving outcomes.”

Substantively, I am afraid, health care reform is falling apart. I have written before on the conflict between expanding health insurance coverage and cutting costs. The problem with health care reform used to be that it tried to do both – aggressively expand coverage while promising to cut costs. The problem with health care reform today is that it will probably do neither. Let’s look at the pieces still standing:

1. The individual mandate. Without further reform, an individual mandate only serves to drive the uninsured into a broken market. Even with generous subsidies, an individual mandate alone props up the status quo by giving insurance companies more customers without giving them incentives to change the way they do business.

2. The insurance exchange. Any insurance exchange. An insurance exchange presumes either that (A) the existing market works fine, or (B) the competitive pressures from the exchange’s creation will be so great as to make the existing market work better. (A) is untenable as a premise for insurance reform. (B) is an odd proposition, because insurance companies already compete to some extent. The exchange-based competition is only a question of degree. While it is a libertarian article of faith that more competition is always more better, actual evidence on competition’s effect on efficiency in the health insurance market is mixed in its implications for the insurance exchange.

3. New “fairness” regulations for the insurance market. These involve highly uncertain tradeoffs between cost containment and increased coverage, as I discussed here.

4. The “small experiments.” These are just that – small experiments, not far-reaching reform. They may well point the way to future improvements in the provision of health insurance and health care, but their place in a reform bill is auxiliary by definition.

To be fair, no reform bill will ever come with the guarantee that costs will be reduced or coverage will be expanded. The modern incarnation of health care reform began as a mishmash of policy proposals, which taken together may well have achieved some improvement over the status quo. Then, the legislative process got to work, axing parts of health care reform when it became politically expedient to do so. The bill that will eventually pass will contain the last policies standing, rather than the best policies to achieve the stated goals.

I consider this a natural outcome of the way we have been talking about health care and health reform. I remember passing a street demonstration this summer where people chanted and held signs to the effect of “Health care reform now!” Well, what kind of reform? Making all doctors wear Mickey Mouse ears on the job would reform health care, but probably not in the way these protesters had in mind. From the very outset, we had committed ourselves to talking about health reform either as all things that are good, or as the worst thing in the whole world. “Health care reform” became a mirror which reflected our personal ideas of what we thought reform should or should not look like. Because the actual bills failed to rally around a single proposal – “insurance exchanges now!” or “Medicare expansion now!” – their details became mere inconveniences in a larger ideological battle between Left and Right.

If this was still a policy debate, I would have suggested that we try to at least agree on a single goal to pursue for now – but pursue doggedly, until it is achieved. Cost control – through regulation, tort reform, or any other possible means – might be one such “compromise goal.” Unfortunately, the struggle over health care reform has ceased to be about achieving either lower costs, increased coverage, or any other substantive policy goal. It has become (or maybe it always was) about flexing political muscle. The credibility of President Obama and Congressional Democrats, and, by extension, electoral success in 2010, are what’s really at stake. So I wouldn’t be surprised, once the administration succeeds in getting a “health care reform” bill through Congress, if the result will bear only faint resemblance to the promises of efficient health care provision and equitable access to health insurance.

What Passes for Food

September 22, 2009

I have no real content to post, so here’s a link to an interesting blog, Food In Real Life, billing itself as:

Preaching truth to packaging. Pictures of packaged food, cooked to specifications, compared to the photo on the box.

Two things to think about:

1. How few of the packaged foods depicted look like what’s on the package (or, in the case of fast food, on the menu board). We travel through a world of delectable images but disappointing products, speaking of which…

2. How few of the package pictures – to say nothing of the actual foods – actually look like real food that might be put together using familiar ingredients. Some entries are less offensive in this regard (the rice, for example), but others are grade-A frankenfoods (Jeno’s pizza, Pop-Tarts).

One take on these images states the obvious: that we are trained and acclimated to eating the foods that we do, for better or for worse. No one is born with a genetic craving for Pop-Tarts, or, for that matter, a Pringles addiction. (Cos even they admit – once you pop, you can’t stop.)

The equally obvious corollary to this point, however, is anathema in certain circles. For all the fanfare around “intuitive eating,” (aka “eating when you’re hungry, stopping when you’re full”) the approach makes no sense in a world where eating for one’s health has been entirely cleaved from eating by one’s instincts. Anyone who has ever craved soda, or chips, or instant noodles, or, hell, any of the foods featured on FoodIRL, understands this on some level: in the present food environment, our eating instincts often lead us away from food and towards “food-product.”

And so, many people live their lives oscillating in an unhealthy Catch-22: when they eat intuitively, their eating is as disordered as the food culture at large; but when they try to “order” their eating, they end up with overly-restrictive, insufficiently-nutritious diets. If there is a way out from this, it will necessarily include curtailing to some extent our eating instincts, bent as they are towards unhealthy (and at times even unsatisfying) choices – but it cannot be so severe as to rob us of the pleasure and utility of food.

How Obamacare Might Increase Costs

September 9, 2009

For those of you following at home, the President gave a big speech on health care reform tonight. Specifically, he argued for a plan composed of three major planks:

First, …. it will be against the law for insurance companies to deny you coverage because of a pre-existing condition. As soon as I sign this bill, it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies – because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.

[Second,] We will [create] a new insurance exchange – a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices. … For those individuals and small businesses who still cannot afford the lower-priced insurance available in the exchange, we will provide tax credits, the size of which will be based on your need.

[Third, U]nder [this] plan, individuals will be required to carry basic health insurance – just as most states require you to carry auto insurance. Likewise, businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers.

If I may sum up these points, Obama is essentially proposing to

1. Extract more value out of insurance policies, by expanding who, what, and how much is covered,
2. Improve accessibility to individual insurance policies, including a nonprofit, self-sustaining public option, and
3. Mandate that every American carry health insurance.

It’s a good plan for extending health insurance coverage to all Americans, which in itself is a worthy goal. But I am much more skeptical of its effect on health care costs. Health care reform has been billed as including powerful cost-cutting measures. But before we pour our faith into arcane budget estimates, we would do well to remember a few ways in which this plan may end up costing us more, not less, than our current (broken) system.

  • If you have insurance, you may end up getting less services for more money. This would directly contradict Obama’s promise, but it’s a reasonable possibility. Under this reform plan, insurance companies will no longer be able to save money by dropping customers or limiting their coverage. On paper, they would not be allowed to charge customers more, and would have to raid their profit margin to come up with the difference. But in practice, they will almost certainly try to get the money from customers somehow – directly through higher premiums, or indirectly through government subsidies.
  • If you don’t have insurance, you will get it (public or private, subsidized or not), and might therefore increase your utilization of health care. If people who today are being denied health care because of insurance shenanigans get the care they need, they might be healthier for it, but this care won’t come free.
  • Even if you get insurance but don’t increase your utilization of health care, you would still be paying for insurance. You might not use your new policy, but you would still be paying for it. That’s less money in your pocket, more money in the national health care expenditures column.
  • Not all of these cost increases are necessarily bad. Of course it will cost money to provide un- and underinsured Americans with lifesaving (or even just life-enhancing) health care. Of course everyone who can should pitch in to spread out the risk of ill health. If the economic times were good and (dare I dream) the federal government were running a surplus, I would gladly ignore all these factors. However, given a runaway national debt and a shaky economy, we simply cannot afford health care reform that costs more money than it saves. I have a hard time believing that Medicare and Medicaid waste and inefficiency are so great as to equal the costs of insuring the 45-some million uninsured Americans and providing improved health care for everyone.

    There are ways to improve health insurance coverage while tackling the fundamental inefficiencies of the market. I proposed one half-baked and politically unfeasible specimen a while back. In any case, if we cannot have health care reform that both expands coverage and reduces costs, then let us at least be candid about this limitation and the need for further reform. It wouldn’t have sounded as good in his speech, but President Obama would have been prudent to acknowledge that he will likely be far from the last President trying to reform a costly and inefficient health care system.

    Why Food Snobbery Is a Tough Sell

    August 1, 2009

    Writing for the Times,* Michael Pollan laments the (de-)evolution of televised cooking, and ends, as always, on a prescriptive note:

    The question is, Can we ever put the genie back into the bottle? Once it has been destroyed, can a culture of everyday cooking be rebuilt? One in which men share equally in the work? One in which the cooking shows on television once again teach people how to cook from scratch and, as Julia Child once did, actually empower them to do it?

    Let us hope so. Because it’s hard to imagine ever reforming the American way of eating or, for that matter, the American food system unless millions of Americans — women and men — are willing to make cooking a part of daily life. The path to a diet of fresher, unprocessed food, not to mention to a revitalized local-food economy, passes straight through the home kitchen.

    According to Pollan, there once was a beastie that roamed this great land freely, showing up at American homes every day for breakfast, lunch, and dinner. Its name was “Real Scratch Cooking,” and it brought joy to the heart of every man, woman, and child. Then, some evil corporations came along, and with a few engineering tricks and a little TV showmanship, convinced Americans to banish Real Scratch Cooking from their lives. And that, in a nutshell, is why Americans are so fat and unhappy nowadays.

    Now, why would Pollan spin such a fanciful tale? First, I will delight you with an obscure and irrelevant literary reference:

    It could be said that there was no one like Michael Pollan in the whole Republic. The Republic valued his services. He was of great use to it. But, for all that, he remained unknown, though he was just as skilled in his art as Chaliapin was in singing, Gorky in writing, Capablanca in chess, Melnikov in ice-skating, and that very large-nosed and brown Assyrian occupying the best place on the corner of Tverskaya and Kamerger streets was in cleaning black boots with brown polish.

    Chaliapin sang. Gorky wrote great novels. Capablanca prepared for his match against Alekhine. Melnikov broke records. The Assyrian made citizens’ shoes shine like mirrors. Michael Pollan was a food snob.

    See, Pollan has a vested interest getting us (back) into Real Scratch Cooking, because, as an inveterate food snob, he would love nothing more than to have his particular brand of snobbery validated by others. Oh, he may be a well-meaning snob, earnestly convinced that doing things his way (or, really, his and our ancestors’ way) is good and right for everyone. But the only thing that would explain his “my way or the highway” approach to Americans’ cooking eating habits is regular snobbery, not overwhelming concern for the public good.

    An analogy to Pollan’s writing comes immediately to mind: he is to food as a less profane Mark Rippetoe would be to fitness**. Oh, the two might motivate beginners in their respective fields to dig deeper, and even rope in some gen-u-ine newbies (fresh meat?), but their simple, authoritarian pronouncements – “cook food from scratch” and “squats and milk,” respectively – adapt terribly to the education of the masses.

    We can see proof of this in the comments section on the Pollan piece. There, some Times readers offer legitimate pushback:

    Cooking, like everything else, requires practice and repetition. If you cook fairly elaborate meals regularly and don’t exercise like an Olympian there’s a good chance you’re going to get unhealthily fat. Some people also may not be as thrilled by the effort of cooking and clean up as seems to be assumed. There’s a world of difference between the lovely fantasy of the beautiful, trim, industrious woman removing the baking bread from the oven and serving it to her gorgeous, always-appreciative family and the reality.


    I believe this article overlooks one factor that heavily affects the time people spend cooking, especially single young people: It’s often not economical to cook certain types of food if you work irregular hours and/or don’t have a family. Besides the time factor (which is significant), it’s sometimes hard to justify spending $50-100 on the ingredients for a meal that will only feed one person, when I can go to a restaurant and get the same meal for a fraction of the cost.

    Or even,

    I think the whole “foodie”/locavore/annoying Alice Waters” culture which shows disdain for the Food Network types contributes to the lack of cooking in this country. It’s great to know how to cook a “from scratch” meal and I enjoy doing it because I love cooking. However, some others who can cook well often seem to look down on those who assemble meals or buy takeout for whatever reason.

    I’ve seen them in action. I’ve seen them get invited over to people’s houses and then sneer to me (because they know I can cook) about the green-bean casserole and the parmesan from the green can on the pasta and how the host served Trader Joe’s wine instead of the good wine they, the great cooks, brought as a gift.

    I quote these comments at length not only because I agree with their arguments, but also because they come from (presumably) a variety of people, and not just one crotchety blogger. To intellectuals and foodies and intellectual foodies Pollan’s snobbery may hold truth and comfort, but below this rarefied realm, the fetishism of Real Scratch Cooking has only a shaky appeal.

    Lest this post be elongated even further, here is a list of just a few reasons why exhorting the American people to return to Real Scratch Cooking may be a bad idea:

  • Cooking takes time. This is the stupidest possible objection to cooking from scratch, but it holds immense purchase on our habits. It is stupid because it is so obvious – of course doing something well takes time – but it is still a legitimate objection: many Americans are not willing or not able to sacrifice hours out of their day to cook from scratch what they could cook or obtain otherwise.
  • Cooking takes money. In theory, cooking can be cheaper than eating out or relying on prepackaged or “nearly-ready-to-eat” foods. In reality, cooking entails many hidden and not-so-hidden costs that can quickly outweigh the nominal savings. For example, a half-pound of roast beef from the deli might cost $5; an equivalent quantity of steak might cost only $3. But to realize this savings one must avoid the following expenditures: the cost of other ingredients (oils, marinades), the cost of tools (grills, skillets, roasting pans), and the cost of excess raw ingredients, should the steak not come in a handy .500 lb package.
  • Cooking takes skill. Sure, practice makes perfect, but going from zero to kitchen hero is a process that would entail a good deal of unsavory errors and frustrating pitfalls. Asking people who don’t know how to cook to learn Real Scratch Cooking is much like asking people who have never learned to walk to qualify for the Boston Marathon.
  • Cooking takes motivation. Let’s face it – not everyone fantasizes about spending precious leisure time in front of the stove, or, as the first comment above notes, picking and cleaning up after dinner. Some people just aren’t going to be interested in labor-intensive forms of cooking no matter how much Pollan and his disciples might browbeat them. There are compelling reasons why cooking from scratch might be enjoyable, but there are many equally compelling reasons why people might just not want to do it.

    These are but a few of the possible objections to Pollan’s adoration of Real Scratch Cooking. Others include, but are not limited to: the false equation of home cooking with healthy eating; the elitism of asking people to turn cooking and eating into a hobby; and the lack of any suggested alternatives for people who may not want or be able to pursue the foodie lifestyle as prescribed.

    If we shouldn’t lecture people to drop everything they’re doing and get started on their “Real Scratch Cooking” re-education, then what message should we be disseminating about cooking, food, and their intersection? I believe the answer lies somewhere short of all-out Pollan-esque snobbery, but far beyond the laissez-faire approach of, say, the Intuitive Eating folks. Particularly, to have mass appeal and mass applicability, food manifestos should strive to offer a good-better-best continuum of food practices. For example, starting the day off with cereal and milk instead of a box of donuts is good; frying a couple eggs to serve with toast is better; and cooking a delectable omelet is best – or some such progression. This principle can be applied to all aspects of eating and (maybe even) cooking: an easy option just about anyone can try; a superior option requiring just a bit more time, money, skill, and motivation; and a very good option that would also be most difficult to execute. The downfall of advice that has its roots in snobbery – as does Pollan’s advice to return to Real Scratch Cooking – is that is addresses only the last category, giving the majority of people, who are unwilling to go to those lengths, neither aid nor comfort.

    * Link via the U.S. of Jamerica.
    ** I owe the comparison to the Brass Tack.

  • Beaten to the (HFCS-sweetened) punch

    July 15, 2009

    The Brass Tack just went right ahead and blogged New Yorker’s review of recent fat-themed books before I could get to it. I even had the article bookmarked and everything! Anyway, I guess that releases me from having to summarize the review myself:

    People have gotten fatter in the past few decades not because the nation’s willpower has suddenly been sapped by pod people, but because calorie-dense food has become much more abundant, and because humans are always easily manipulated psychologically by supersizing and the like.

    As Elizabeth Kolbert, the review’s author writes, this is a wee bit problematic:

    Type 2 diabetes, coronary disease, hypertension, various kinds of cancers—including colorectal and endometrial—gallstones, and osteoarthritis are just some of the conditions that have been linked to excess weight. (Last month, the Times reported that gout, once considered a disease of royalty, is, as the population gets fatter, making a comeback among the middle class.) It has been estimated that the extra pounds carried by Americans add ninety billion dollars a year to the country’s medical spending. No credible estimates exist for global costs, but, Delpeuch and his co-authors write, “Obesity is inescapably confirming itself as one of the biggest drains” on national health-care budgets.

    So far, we’ve heard about a variety of ways in which the obesity epidemic might be mitigated: through the tax code, through education, and even through better urban planning, to name a few. (e.g. discussions here and here.) As Brass Tack points out, these well-known initiatives may or may not be enough for the U.S., but to reduce and prevent obesity worldwide something else is needed. Here is where our takes on the situation diverge.

    As the Brass Tack writes, technology is the missing ingredient:

    The only real solution would be to make protein and vegetables competitive with grains in terms of price. If we could make in vitro meat cost-effective, one day a skinless chicken breast might be as cheap as an order of fries. (And factory-grown meat doesn’t torture animals.) We’d also need to really et aquaculture off the ground. And we’d need a new green revolution for non-starchy vegetables so they could be harvested more cheaply and watered with less. It’s going to take a whole lot more than a rooftop garden to do this.

    Now, her piece is titled “Obesity and economics,” and so my dissent may as well be titled “Obesity and sociology.” Because, for all the economic and technological factors that have gone into fueling the obesity epidemic, these factors have only been the “how.” The “why” of obesity stems from culture, and specifically the culture of food: what is food, when and how and with whom it should be eaten, and so forth. Basically, if people didn’t recognize fast-food french fries as food, it wouldn’t matter how cheap McDonald’s could sell french fries for, because the demand would just not be there. On a broader scale, people eat as they do because of a mix of old customs, new marketing, and timeless peer pressure – and, yes, because technological and economic developments have enabled them to eat so.

    So what’s the point of this – if you will – sociological take on obesity? Even if we remove the enabling factors – cheap corn, “supersize” portions, urban “food deserts”, total ignorance of nutrition – we will still be left with the root cause of obesity: the desire for a certain (and incidentally unhealthy) diet. And that means, so long as a caloric surplus is available, people will continue to get fat(ter). And that’s the good news; the bad news is that “food culture” is much more difficult to manipulate on a national scale than tax rates or commodity costs.

    Absorb what is useful

    June 4, 2009

    I don’t know if President Obama is big on kung fu movies, but he certainly seems to live by Bruce Lee’s dictum. In a departure from his campaign literature, Obama now says he is “receptive to Congressional proposals that would require Americans to have health insurance and oblige employers to share in the cost.” The Times has more:

    The president said he was open to proposals for “shared responsibility — making every American responsible for having health insurance coverage, and asking that employers share in the cost.” … “If we are going to make people responsible for owning health insurance, we must make health care affordable,” Mr. Obama wrote. “If we do end up with a system where people are responsible for their own insurance, we need to provide a hardship waiver to exempt Americans who cannot afford it.” …

    Mr. Obama’s letter affirmed his support for creation of a new government-sponsored health plan. “I strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans,” he wrote. “This will give them a better range of choices, make the health care market more competitive and keep insurance companies honest.”

    Now, the three remaining supporters of Clinton’s 2008 Presidential campaign might be excused for foaming at the mouth a little. Then, Hillary Clinton promised an individual mandate to have health insurance, Massachusetts-style. Meanwhile, Obama’s plan called for a weak employer mandate, in which some but not all employers would be required to provide or help pay for health insurance. As of this writing, Obama seems to be moving away from this (most likely) less-effective policy and toward the individual mandate.

    There’s just one nagging little thing. Extending health insurance to more people costs money, and the prospective individual mandate lite, in which people are required to get insurance through the myriad private companies or a government plan does little to cut down these costs, either for consumers or for providers. It is trivial to show that unless insurance companies can effectively discriminate against high-risk consumers, the best insurance plan is one in which everybody is enrolled. Short of this drastic ideal, the more people are enrolled in a given plan, the cheaper that plan is per person on both the supply and demand sides, assuming enrollment is uncorrelated with risk. So a good way to equitably lower the cost of health insurance would be to enroll as many people as possible – regardless of risk – in a single plan. This would also have the benefit of cutting down on per capita administrative costs and duplicated overhead costs.

    How does Obama’s plan (or intentions) measure up to this ideal? By letting – nearly encouraging – consumers who are already insured to keep their current health insurance, it does nothing to lower costs for the policies of the insured (which greatly outnumber the uninsured). By allowing the uninsured to sign up for a government plan, it creates just another small insurer saddled with all the problems of the rest of the market. Finally, by encouraging some of the uninsured to seek health insurance on their own, it leaves them vulnerable to the steep premiums that rationally must be charged of individuals purchasing insurance solo.

    A real solution to the problems of American health insurance – bloated administrative costs, underinsurance, high prices – could lie just one radical policy away. If we take as constraints the ideas that 1. Americans will not accept the complete bulldozing of the private insurance market, and 2. there is no guarantee that a government-run program will be more efficient than a private one, there still remains a reasonable policy option that combines wider coverage with lower costs and room for market-driven innovation.

    Consider this: a basic government insurance plan, with mandatory participation, and a deductible-copay system similar to but more benign than existing private policies. This plan would extend basic coverage to everyone, including perhaps most preventative procedures, some ER visits, and limited consultation with specialists, among other things. It would not aspire to provide full health coverage to its enrollees – only coverage for procedures with positive externalities or those which most often bring needless financial strain upon low-income families – and would be priced accordingly. Everything else – prolonged hospital stays, expensive treatments, frequent trips to the doctor – could then be covered by supplemental insurance, which consumers could obtain from anyone. Such a dual-layer system would provide universal, low-cost (but limited) health insurance, without completely turning the health insurance sector into an arm of the government.

    “They can stuff their [food] credentials, ’cause it’s them that take the cash”

    March 22, 2009

    You know virtuous food (i.e., local/organic/sustainable or some other euphemism of the day) is doing well when Times articles about it move from the Fashion & Style section to Business. Saturday’s article chronicles the new momentum virtuous food – particularly organic food – has acquired thanks to a bit of White House boosterism. Andrew Martin writes:

    Mr. Hirshberg and other sustainable-food activists are hoping that such actions are precursors to major changes in the way the federal government oversees the nation’s food supply and farms, changes that could significantly bolster demand for fresh, local and organic products. Already, they have offered plenty of ambitious ideas.

    For instance, the celebrity chef Alice Waters recommends that the federal government triple its budget for school lunches to provide youngsters with healthier food. And the author Michael Pollan has called on President Obama to pursue a “reform of the entire food system” by focusing on a Pollan priority: diversified, regional food networks.

    Still, some activists worry that their dreams of a less-processed American diet may soon collide with the realities of Washington and the financial gloom over much of the country. Even the Bush administration, reviled by many food activists, came to Washington intent on reforming farm subsidies, only to be slapped down by Congress.

    The plot is familiar: intelligent foodies and farmers are trying to improve America’s diet with the help of a few Washington mavericks, only to be stymied by Congress and the evil agribusiness/food industry lobbyists which control it. Even the cast is familiar, at least on the pro-virtue side: Alice Waters. Michael Pollan. Mr. Hirshberg.

    Wait–Mr. Hirshberg? That’s Gary Hirshberg, chief executive of Stonyfield Farm. Mr. Hirshberg, according to Martin’s report, is fired up about changing the system:

    Back in Anaheim, Mr. Hirshberg, the head of Stonyfield Farm, said he, too, is optimistic that change is at hand. But he reminded the small crowd that the organic industry remains a “rounding error,” roughly 3 percent, of the overall food and beverage business.

    “We’re at the starting line,” he says. “This is our job, our government. We’ve got to take it back.”

    Do it, Mr. Hirshberg! Take back the government in the name of … multinational corporations. As Andrea Whitfill wrote last week in AlterNet, Stonyfield Farm is mostly owned by the Danone conglomerate, and Hirshberg happens to sit on the board of Dannon U.S.A. So is that talk about “taking back” the government in the name of virtuous food change from within, or clever marketing to sell Danone’s higher-priced yogurt?

    In fact, Mr. Hirshberg’s Stonyfield Farm is not alone in pushing virtuous product while being owned by a distinctly non-virtuous company. It seems that just about every organic or virtuous brand consumers are familiar with has been snapped up by large corporations. Take virtuous cereal brands, for example.

    “Cereals, like milk, are one of the primary entrance points for use of organics,” said Lara Christenson of Spins, a market research group for the natural products industry, “which is pretty closely tied to children — health concerns, keeping pesticides, especially antibiotics, out of the diets of children. These large firms wanted to get a foothold in the natural and organic marketplace. Because of the mind-set of consumers, branding of these products has to be very different than traditional cereals.”

    These corporate connections are often kept quiet. “There is frequently a backlash when a big cereal package-goods company buys a natural or organic company,” Christenson said. “I don’t want to say it’s manipulative, but consumers are led to believe these brands are pure, natural or organic brands. It’s very purposely done.”

    A little more digging shows that General Mills owns Cascadian Farm; Barbara’s Bakery is owned by Weetabix, the leading British cereal company, which is owned by a private investment firm in England; Mother’s makes it clear that it is owned by Quaker Oats (which is owned by PepsiCo); Health Valley and Arrowhead Mills are owned by Hain Celestial Group, a natural food company traded on the NASDAQ, with H.J. Heinz owning 16 percent of that company.

    Whitfill has more examples, and Allison Kilkenny has pictures. Virtuous cereal, virtuous drinks, virtuous snacks, virtuous dairy products – much of what’s on the shelf at your grocery store is made by Big Food (-owned) companies far, far removed from what most of us envision when we think about how virtuous food is (should be) produced.

    So what’s the big deal? Food activists have been telling us that the best way to get the food market to change is to vote with our money, spending more of it on smaller quantities of “good” food. Now we find out that the main channel through which we consume virtuous food – brand-name packaged foods – diverts our monetary votes to the coffers of the same companies we are trying to “punish.” That is not, in itself, the end of the world – or even of food activism. It may still be the case that virtuous food, in its most common forms, is better for us than other offerings from the parent Big Food firms. It may still be the case that corporate warriors such as Mr. Hirshberg will effect real “change from within” in the conglomerates they serve. It may still be the case that we can support virtuous causes by giving our money to one division of Unilever over another. Yet whatever may happen, it is definitely time for food activists to drop the “holy crusade” rhetoric in which organic/local/sustainable is the banner of the good, and “corporate” is the mark of the evil, and never the twain shall meet.

    Sometimes a risk factor is just a risk factor

    March 18, 2009

    Possibly the least controversial statement to have come out of the Fat Acceptance and Health at Every Size movements is the idea that obesity is not a death sentence – in other words, that not every fat person is one calorie away from heart failure, diabetes, and the many other diseases linked (often tenuously) to obesity. Now, mainstream medicine is starting to accept this. As reports,

    One of Canada’s top obesity doctors says it’s time to stop recommending weight loss for everyone who meets official criteria for obesity. Dr. Arya Sharma says being obese doesn’t necessarily doom people to poor health and that weight loss recommendations should be targeted at those most at risk because of medical problems.

    Many people who meet the body mass index criteria for obesity “are really not that sick at all,” says Sharma, chairman for cardiovascular obesity research and management at the University of Alberta and scientific director of the Canadian Obesity Network. “It’s not unusual to find someone come into your practice whose BMI is 30 or 32 (technically obese). This might be someone who is physically active, who is eating a good healthy diet. If you followed the guidelines to the letter you would be prescribing obesity treatment when there’s really no reason to do that, because they’re not medically obese.” …

    His appeal comes as evidence begins to mount that a significant proportion of fat people are metabolically healthy. One in every three people who are obese — and half of those who are overweight — may be resistant to fat-related abnormalities that increase their risk of cardiovascular disease, according to new research from Albert Einstein College of Medicine in New York. … In [that] study, nearly 17 per cent of obese men and women possessed not one of the heart or metabolic abnormalities the researchers considered.

    On the one hand, this is fairly obvious stuff. Many fat people remain fat despite leading a healthy lifestyle; and many thin people remain thin despite doing everything “wrong” with their diet and/or exercise. There has never been a perfect correspondence between (over)weight and health, and it’s about time the public discourse on obesity acknowledged that basic fact.

    On the other hand, it may be premature to dismiss the effects of obesity on populations’ health. In the Albert Einstein College study mentioned by the article, 83% of obese participants had at least one heart or metabolic “abnormality” that may have been linked to obesity. Now, this absolutely does not imply that these 83% were sick because they were fat, or that the sample is representative of any larger population. However, it does raise the question of whether fat people (not all of whom are in poor health) are disproportionately sicker than thin people.

    Instead of a conclusive answer, I have some tangentially-related old data to share. In 1993, the CDC’s Behavioral Risk Factor Surveillance System survey asked a large, nationally-representative sample of American adults to report their general health, height, and weight, among many other things. This crosstabulation shows the relationship between respondents’ classification as obese (by their BMI) and respondents’ self-reported general health status.

    Health Crosstab

    A vast majority of obese (and non-obese) respondents reported their health as “good” or better. However, comparing the two BMI categories suggests a strong correlation between obesity and worse self-reported health. For instance, obese respondents were twice as likely as non-obese ones to report their health as “poor,” and half as likely to report their health as “excellent.” This relationship persisted in three-way crosstabs controlling for sex, race, education, and income.* While this analysis was carried out on unweighted cases, weighting the data set by a product of poststratification and design weights did not alter or weaken this relationship.**

    The table raises as many questions as it answers. It appears true that in 1993, obese people were more likely to report being in poor health than non-obese people. However, one must ask:

  • Has this relationship persisted over time?
  • Does this relationship persist under different statistical methods?
  • To what extent does this relationship exist because obese respondents perceive their obesity as a health problem, independent of any diseases it may cause?
  • By extension, does this relationship persist when controlling for body image?
  • If the relationship is robust in various years, under various methods of analysis, and while controlling for body image, then what causes obese respondents to be more likely to self-report poor health?

    As this (overly) simple analysis suggests, the effect of obesity on the public health is not a closed case. While many people classified as obese lead healthy lives and suffer from no diseases, it remains to be seen whether the obese are still more disposed to be in poor health than the non-obese, and what (if any) maladies of the former are actually caused by their obesity.
    Read the rest of this entry »

  • No percentage for Truth is given because the Daily Value has not been established

    March 13, 2009

    Jacob Gershman, a man who eats Cocoa Pebbles for dinner, reports on the latest trick food manufacturers have used to make sugary cereal (and similar foods) seem healthy:

    The fiber in Cocoa Pebbles comes from a little-known ingredient called polydextrose, which is synthesized from glucose and sorbitol, a low-calorie carbohydrate. Polydextrose is one of several newfangled fiber additives (including inulin and maltodextrin) showing up in dairy and baked-goods products that previously had little to no fiber. Recent FDA approvals have given manufacturers a green light to add polydextrose to a much broader range of products than previously permitted, allowing food companies to entice health-conscious consumers who normally crinkle their noses at high-fiber products due to the coarse and bitter taste of the old-fashioned roughage. These fiber additives serve dual purposes—they can serve as bulking agents to make reduced-calorie products taste better, such as the case with Breyers fat-free ice cream, and carry an added appeal to consumers by showing up as dietary fiber on food labels.

    With the First Lady exhorting Americans to eat healthy and nutritious foods, many may turn to the nutrition facts label to help them distinguish between virtuous and non-virtuous grub. Since 1994, the Nutrition Labeling and Education Act (NLEA) has ensured that this scientific-looking chart appears on nearly all foods Americans consume. However, as Pebbles-gate and other food crises show, the NLEA may have lulled consumers into a sense of false security about knowing what is in their food.

    Some of the most severe food crises in recent months have occurred because of ingredients that were not on the label. The discovery of Salmonella contamination in countless batches of peanut butter could not have been foreshadowed by consumers reading “S. enterica – 300% DV” off of the nutrition facts label. Similarly, the melamine with which food products have been adulterated in China would have shown up on the label as nothing more suspicious than a few extra grams of protein. However, the problems of the nutrition facts label go beyond mere omissions. By evaluating all foods on a short list of uniform criteria, the label fosters two dangerous attitudes: seeing all (or most) foods as interchangeable, and evaluating the virtue of foods on just one or two of the nutrients the label lists.

    Nutrition facts labels are often used with the idea that comparing two foods is as simple as comparing their labels. Now, when one is crafting a diet based on macronutrient ratios, sodium limitations, or micronutrient requirements, the information on nutrition labels can be useful, accurate, and relevant. But what about other aspects of food quality, safety, wholesomeness, sustainability, or even taste? Diet Coke boasts that it is 99% water, and the labels of the two are indistinguishable; meal replacement bars are available which mimic – on the nutrition facts label – a meal made with real, pronounceable ingredients; and Cocoa Pebbles now come with added fiber to emulate either granola or actual pebbles. In each case, the marketing pitch for the processed food is how it is nutritionally similar to unprocessed foods people might consume instead. Meanwhile, the nutrition facts labels on the processed foods give consumers no way to place these claims in their proper nutritional and environmental contexts.

    In theory, consumers can decide what to eat based on some ideal balance of Vitamin C, calcium, and cholesterol – three nutrients which appear on the nutrition facts label. In practice, however, much of the attention consumers devote to reading nutrition labels gravitates to just two nutrients: fats and carbohydrates. Many fad diets carve out their niche by coming up with a new way to restrict the intake of either fats or carbs. This page offers a much more detailed, if somewhat curmudgeonly description of the myths and dangers of such diets. In short, consumers seldom use all the information provided on the nutrition facts label to make food choices, tending to focus on two or three – sometimes even one – nutrients and ignoring the rest.

    Nutrition facts labels on food may well have changed the way America eats. Armed with precise knowledge of just a few attributes of each food, we are able to approach our diet as a simple linear programming problem. When that gets too time-consuming, we can take the shortcut to a healthy diet by merely checking if a food is low-fat or low-carb. The end result is that the well-meaning NLEA has created artificial demand for artificial foods. This suggests that future food policy should not only attempt to give consumers more information, but should also seek to summarize that information in ways that more accurately reflect the values – nutritional and perhaps also environmental – of the foods we are asked to buy.