Something Not Unlike Research

In which I am chastised for arrogance

post by Bill Gardner

Here is a tweet from @jacobgrier in response to my condemnation of smoking that was quoted by Andrew Sullivan:

"Smoking is a vice that benefits no one." -- @Bill_Gardner Oh please. I like it. It benefits me! Arrogant assumption. bit.ly/A07L3a

It's a great tweet: names a culprit, cites a source, states the writer's opinion, gives a cogent reason, and links to a source, all in 140 characters. 

Jacob is a "Mixologist, writer, barista, magician, libertarian." The odd picture to the right is from his blog. It depicts some men consuming drinks through a bone luge -- a drink is being poured down through a hollowed-out bone -- possibly where Jacob tends bar. Kind of like a bong for cocktails. It has an arresting paganism, which I expect is a component of the pleasure. Anyway, Jacob is right, it would be absurd for my to deny that his subjective pleasure in consuming alcohol through an animal (I HOPE) femur can raise his subjective well-being.

I get it about being young, reckless (and male?). I participated in several high risk outdoor sports before I had children, and my life is much richer for it. However, the 'luge' trope is absurd: Binge consumption of alcohol or drugs is at best a degenerate form of adventure; at least in my view, but as Jacob correctly notes, I am arrogant.

But what about liberty? I am not arguing that government should ban bone lugers from employment. My point is that I do not see a compelling argument against employers choosing not to hire them. By extension, we should have no public policies protecting access to employment for smokers (or bone lugers). This is, I believe, consistent with Mill's view that

The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant.

I do want to see smoking go away, and I think social pressure is what makes that happen. ("Social pressure" is not, I think what Mill means by "exercising power".) To that end, I think it is legitimate to ban smoking in public places, and for employers to refuse to hire smokers if they judge that to be in the interest of their firms. 

Having conceded that smoking may benefit Jacob's subjective well-being, can I still say that "smoking is a vice that benefits no one"? I certainly can, if it's understood that benefit refers to the long-term well-being of smokers, and those who depend upon them, rather than immediate subjective well-being. In that sense of benefit, there is nothing to be said for smoking or binge drinking. 

May Employers Ethically Refuse to Hire Smokers?

post by Paul Kelleher

From USA Today:

More job-seekers are facing an added requirement: no smoking — at work or anytime.

As bans on smoking sweep the USA, an increasing number of employers — primarily hospitals — are also imposing bans on smokers. They won't hire applicants whose urine tests positive for nicotine use, whether cigarettes, smokeless tobacco or even patches.

Such tobacco-free hiring policies, designed to promote health and reduce insurance premiums, took effect this month at the Baylor Health Care System in Texas and will apply at the Hollywood Casino in Toledo, Ohio, when it opens this year.

"We have to walk the walk if we talk the talk," says Dave Fotsch of Idaho's Central District Health Department, which voted last month to stop hiring smokers.

When I read a story like this, I always think first of the following passage from Michael Marmot's The Status Syndrome (pp. 68-9):

Here is a more contemporary picture of poverty. In an American city a young woman, let's call her Patty, sits and contemplates her life. She recalls that a researcher, doing a health survey, came to the local grocery store, where Patty works as a cashier, and asked her how much exercise she did. She laughed. Most of the day is spent sitting or standing behind the till. What about exercise at home? She lives in a crowded inner-city tenement building. She won't let the children play on the strip of asphalt nearby. Apart from broken glass, she is worried about the violence in this part of town.

Patty's reverie continues. The children come home from school and ask if they can go swimming. It would certainly relieve the long oppressive hours from Friday night to Monday morning that is the lot of a Single mother with two children. But joining a fitness club had been out of the question. They might as easily have a vacation on the moon. There is the Y. But it is an hour on the bus. With the bus, entry, snacks, and sodas for the kids, the trip would cost $30. A king's ransom, but it would fill a couple of hours at least. Then what? She and the children sit cooped up in their two bedroom apartment going quietly stir-crazy. Not so quietly. The children yell at each other and start to fight again. Patty lights another cigarette.

As she contemplates the week ahead, she thinks that the boy needs new sneakers. Why they have to be the ones with special laces, when he never does them up, is beyond her. Something about all the other kids having them. The girl has been to three different friends for dinner and a sleepover in the last month. She wants friends home to her place. Four children, pizzas all round ... Where is that money going to come from? Patty lights another cigarette. She remembers when she splurged and bought herself a pair of designer jeans. It was Mother's Day before last. Gallows humor of the Single mother to buy herself clothes that she could not afford on Mother's Day.

As she thinks about it, she realizes that the only money she spends on herself is the cigarettes. When she took the children to the clinic the other day, the nurse told her, for the umpteenth time, that she shouldn't be smoking: bad for her health and a bad example for the children. The hell with that, thought Patty, take the cigarettes away and what am I left with? That clinic nurse should try leading my life, and see if she's still worried about lung cancer in thirty years' time. I have enough trouble getting through next week.

Lots of "lifestyle choices" have effects on health care costs. A provocative example I cite in the classroom is a employee's choice to have a child. I don't know how the added costs of this choice stack up to the added costs of smoking; I need to look into that further. But putting the examples side by side makes for a useful thought experiment: do we have the same intuitions in each case about whether it's OK to refuse to hire the potentially health-costly applicant? If not, why not? If it is because having children is a "respectable" choice while smoking is not, then I would urge that we spend more time thinking about passages like Marmot's, as well as all the information we have about how people become smokers and what makes it so hard for them to stop.

I don't insist that these Marmot-inspired thoughts are dispositive. There's of course a lot more to say on this issue. As always, I'd welcome your thoughts and a continued discussion in the comments section.

Social microstructure and health behavior change

post by Bill Gardner

Fighting chronic illnesses and curbing rising health care costs will require that we change health behavior on a population scale. How do we do this? There is lots of smart work on how to use incentives and persuasive health communications to induce people to change. But we also need to understand how change diffuses through a population. 

The importance of the microstructure of your social network for health behavior change was demonstrated in a brilliant set of experiments by the sociologist Damon Centola, reported in Science. By all means, read the whole thing.

What Centola did was create artificial social networks. In each network, each participant is connected to 6 other participants. The network on the left consists of neighborhoods of 6 persons with many connections to each other, and fewer connections to others. On the right, people also have 6 connections, but they are distributed across the population so as not to create clusters. People in the left are close to a small group, but far away from everyone else. People are the right are closer to a randomly chosen population member, but they do not belong to a close group. 

Strangers were recruited to serve at nodes in the network. What they were asked to do was to decide whether to perform a health behavior, specifically to sign up for an online health forum. If a person decided to join, messages were sent to his 6 neighbors informing them of the decision. The question is, given that one person decides to join the health forum, in which network did the behavior spread faster? What he found was

Individual adoption was much more likely when participants received social reinforcement from multiple neighbors in the social network. The behavior spread farther and faster across clustered-lattice networks than across corresponding random networks... My findings show that, not only is individual adoption improved by reinforcing signals that come from clustered social ties but this individual-level effect also translates into a system-level phenomenon whereby large-scale diffusion can reach more people and spread more quickly in clustered networks than in random networks. 

So, changing health behavior is not just a matter of incentives and persuasion. These tools work better if their power is focused, when all your friends change together.

Centola suggests that public health programs target "clustered residential networks," but is this going to work if we are increasingly bowling alone? To my mind the obvious target is the workplace. Workplace wellness programs may work not just because the boss holds the levers, but because workplaces are often the locus of our most important social networks. But where will we be if workplace-based insurance ends, and these programs go away?

The Health Gradient and Health Behaviors

post by Paul Kelleher

In an article purporting to be on the adverse effects of income inequality, but which also spends a great deal of time on status inequality, Sir Michael Marmot is quoted as saying:

When Marmot and his colleagues controlled for lifestyle factors like smoking and lack of exercise in the lower socioeconomic groups, the gradient remained. "Those things accounted for about a third of the gradient," he says, noting that you have to look for the "causes of the causes" — the reasons that the lower classes might be driven to smoke, drink, take drugs or indulge in sweet, fatty foods. "It's now been described the world over," Marmot says.

Many who have read Marmot's work in the past know that it is often reported that the Whitehall Study of British civil servants "controlled for health behaviors," and that the health gradient remained. But follow-up research on Whitehall employees that was published last year seems to conflict with Marmot's original findings. And the conflict appears to trace to different (improved?) ways of assessing the impact of health behaviors on the gradient:

Design, Setting, and Participants Established in 1985, the British Whitehall II longitudinal cohort study includes 10 308 civil servants, aged 35 to 55 years, living in London, England. Analyses are based on 9590 men and women followed up for mortality until April 30, 2009. Socioeconomic position was derived from civil service employment grade (high, intermediate, and low) at baseline. Smoking, alcohol consumption, diet, and physical activity were assessed 4 times during the follow-up period.

Main Outcome Measures All-cause and cause-specific mortality.

Results A total of 654 participants died during the follow-up period. In the analyses adjusted for sex and year of birth, those with the lowest socioeconomic position had 1.60 times higher risk of death from all causes than those with the highest socioeconomic position (a rate difference of 1.94/1000 person-years). This association was attenuated by 42% (95% confidence interval [CI], 21%-94%) when health behaviors assessed at baseline were entered into the model and by 72% (95% CI, 42%-154%) when they were entered as time-dependent covariates. The corresponding attenuations were 29% (95% CI, 11%-54%) and 45% (95% CI, 24%-79%) for cardiovascular mortality and 61% (95% CI, 16%-425%) and 94% (95% CI, 35%-595%) for noncancer and noncardiovascular mortality. The difference between the baseline only and repeated assessments of health behaviors was mostly due to an increased explanatory power of diet (from 7% to 17% for all-cause mortality, respectively), physical activity (from 5% to 21% for all-cause mortality), and alcohol consumption (from 3% to 12% for all-cause mortality). The role of smoking, the strongest mediator in these analyses, did not change when using baseline or repeat assessments (from 32% to 35% for all-cause mortality).

Conclusion In a civil service population in London, England, there was an association between socioeconomic position and mortality that was substantially accounted for by adjustment for health behaviors, particularly when the behaviors were assessed repeatedly.

As Marmot notes, he always thought we need to ask why health behaviors themselves may be distributed in a graded fashion. But this new research seems to support the claim that this is the question. If that's true, it means we should focus much more on health behaviors than the summaries of the original Whitehall studies would have us do.

I would be grateful for pointers to additional research and/or commentary on these points.  

 

Corporate coercion and health behavior: Is it really coercion?

post by Bill Gardner

Yesterday, I summarized a meta-analysis that suggested that corporate wellness programs provide a positive return on investment by controlling employee's health care costs. Today I want to look at whether these programs are coercive.

Ezra Klein raised this concern in his post on the successful Cleveland Clinic employee wellness program:

[C]onsider what [changing health behaviors] actually entails: Changing habits. Breaking addictions. Getting people to the gym. Who wants to hear about any of that from their employer? The clinic, however, didn’t give employees a choice. “First thing we said was we had to make our institution toxin free,” [Cleveland Clinic Chief Wellness Officer] Roizen said. “The biggest toxin we have in the U.S. is tobacco. So we began offering free tobacco-cessation programs to our employees. Then we banned smoking on campus. You can’t even smoke in the parking lot in your car. The first offense you get a warning, and the second you get fired. We fired two high- profile physicians who refused to quit. Then they knew we were serious.”

Klein (see also here and here) noted that

Whether [the Cleveland Clinic's] success is a model for American health care or a preview of a dystopian surveillance state is an open question.

Let's step back, though, and ask what 'coercive' really means. Suppose someone confronts you in the dark with a pistol and says, "Your money or your life." This is coercion. Now suppose you are diabetic and need insulin, but your pharmacist won't give it to you unless you pay for it. In both cases, you are in life-threatening circumstances, unless you give someone money. But in most cases we feel that even though the pharmacist may be pressuring the diabetic, he isn't coercing her. The reason is that we view a threat with a gun as an illegitimate form of pressure, whereas barring dire emergency we believe that pharmacists have the same right to require payment as any other merchant. We distinguish coercive situations from legitimate pressures based on our moral judgments. 

So is what the Cleveland Clinic does coercive? Americans have complex views about what norms employers can legitimately require you to conform to, but in general your employer has wide scope to regulate your behavior. Your boss can require you to be punctual, if that is essential to the functioning of the business. But you can't be discriminated against on the basis of your religion. Your employer can, however, require you to meet a dress code -- unless it's a matter of dress or grooming required by your religion. And so forth. How do we feel about pressure to conform to norms of healthy behavior? My sense is that as people come to understand that unhealthy behavior is a significant business cost, they will increasingly accept employers' monitoring and enforcement of norms about healthy behavior.  

But although I believe Americans would accept Cleveland Clinic style carrots and sticks as part of voluntary employment contracts, they would not accept them if they were imposed by the government. Citizenship isn't voluntary in the way that employment is.

 

 

Positive feedback mechanisms in weight gain

post by Bill Gardner

The Lancet has a superb series on the global obesity epidemic, including an article summarizing the nonlinear dynamics of metabolism that govern weight loss. One key point is that there is a vicious feedback mechanism in weight gain:

increased daily energy intake will result in greater weight gain in the 100 kg man than in the 80 kg man and a greater fraction of the weight change will be body fat

That is, the more body fat you already carry, the easier it is for your body to convert extra calories into additional body fat. The reason is that a kg of fat burns less energy in a given day than does a kg of lean flesh, so as the proportion of lean body fat declines, your body burns energy less intensively. 

The problem is that eating just a bit more than we need seems to give us a feeling of well-being. If you are lean, a small overshoot will produce a small weight gain. As you get fatter though, the small overshoot that signals satisfaction will lead to accelerating weight gains. If I've understood this right, this may explain why it seems to so hard to recover lean weight following large weight gains.

This is clearly a problem at any age, but it really freaks me out thinking about kids. Modest weight gains set them up for worse problems as adults.

 

Living young and reckless

post by Bill Gardner

Reading Aaron Carroll on the consumption of sugared drinks by young males, I had a thought about why the young are reckless with their health -- adolescence is the peak time for initiation of health risk behaviors. There is a lot of work on problems of time discounting and other problems of self-control, which are more severe for adolescents. What occurred to me, though, was a sense in which it is rational to be reckless with your health when you are young.

I have in mind a simple model in which a person holds two stocks of resources that they can expend to obtain well-being: money and health. The person converts these resources into well-being by engaging in activities. Suppose there are two such activities: drinking Coke and eating at world class vegetarian restaurants. Drinking Coke costs very little, but if you consume a lot of it you are spending down your stock of health. Eating at Greens costs a lot of money but little if any health. The young, of course, have seeming limitless health, but little cash. (It is often said that the young think they are immortal, is this what that stupid phrase means?) Consuming Coke is, therefore, much cheaper than gourmet vegetarian food, when we consider cost as including both cash and health. As you age, most of us get more income, while our health dwindles, and high-end vegetarianism becomes increasingly attractive. So it is rational to specialize in health-destroying behaviors when you are young. 

This is obvious, and likely has been written about many times before. The point is just to underscore the challenge of promoting healthy behavior in kids.

Like a cricket match in hell

Kevin Outterson has a great post today on how industries that market junk food to kids are opposing the US federal government's draft guidance on a voluntary program restricting the advertising of unhealthy foods to children. If you are concerned about childhood obesity, read it. My title is from his description of the industry's strategy in this fight:

But lobbyists also play long ball, games that last years, even decades. Like a cricket match in hell.

Specifically,

For more than a decade, the Washington Legal Foundation has filed legal cases and briefs advancing the “commercial speech” theory of the First Amendment, an idea that was unanimously rejected by the Supreme Court in 1942. But today, commercial speech is a profound de-regulatory tool, striking down regulation of tobacco ads, pharmaceutical data mining, liquor stores, and other products. Millions of dollars, invested strategically over many years, is now bearing fruit as judges use “commercial speech” to strike down public health rules.

And now they come for childhood obesity.

So I was curious, and took a quick look at two legal briefs written by well-known law professors, arguing the case for the junk food manufacturers, or the "Sensible Food Coalition," as they style themselves. Several arguments caught my eye.

First, they have a reasonable argument, that there should be no regulation unless there is good evidence that advertising unhealthy food to children contributes to childhood obesity. The authors, however, seem to think that there is conclusive evidence that advertising does not have such an effect. I'm skeptical, and hope to look at the data they cite soon.

What was most striking to me, however, was the preposterously strident civil libertarian tone of these arguments. Federal guidelines on marketing junk food to children are, apparently, the top of a slippery slope to "manipulating citizen behavior through the selective suppression of speech advocating lawful action." Each notes the obvious counter example, which is that the pornography industry is not allowed to market its products to children. I had always thought that such limits on pornographers were a good thing, but Professors Redish and Sullivan offer no reason I can find why we shouldn't similarly free the pornographers from the oppression of tyranny.

 

eHealth technology enhances active self care, but is not a substitute for it

post by Bill Gardner

Here is a cool new eHealth technology: a bone cast with wireless telemetry of muscular activity. It is

threaded with electromyographic (EMG) sensors that track muscle activity around a fracture site. Created by Pedro Nakazato Andrade, a recent graduate of the Copenhagen Institute of Interaction Design, the cast can relay data wirelessly to physicians and physical therapists. It shows how much mobility a patient has in an affected area and how physical therapy and daily activity are affecting the area, allowing clinicians to adjust treatment accordingly.

The key thing this device does is measure "how physical therapy and daily activity are affecting the area." It is not, itself, a device with therapeutic activity. More to the point, it does nothing if you are not doing your physical therapy -- which is most of us. eHealth will fundamentally change health care only in the context of interventions that successfully engage patients in self-care. 

I've overstated the point somewhat. My motivation to adhere to my physical therapy regimin will likely increase if that I know (or at least believe) that that regimin will work. So if the smart cast makes therapy more effective, I'll be more likely to do it.

The problem is that eHealth technology is often presented as if it were a pill: you put it on and you get better. Rather, you put it on, and your self-care becomes more effective. And getting patients to effectively and consistently care for themselves is the hardest problem in chronic care. 

Jimmy Connors was once asked, what are the most effective exercises to improve your tennis?Connors: "The ones that you will actually do."

Are people ready for Personal Health Records?

post by Bill Gardner

A Personal Health Records (PHR) is a record of your medical and health data that you access and maintain yourself. In theory, PHRs should empower patients to better understand and manage their health care. Google Health, however, was unable to build up a sufficient user base to make it viable even for a very well funded and patient company. This may be one reason why:

This week, I talked with Dan Russell, a search anthropologist at Google, about the time he spends with random people studying how they search for stuff. One statistic blew my mind. 90 percent of people in their studies don't know how to use CTRL/Command + F to find a word in a document or web page! I probably use that trick 20 times per day and yet the vast majority of people don't use it at all. "90 percent of the US Internet population does not know that. This is on a sample size of thousands..." 

It may be some time before PHRs can make a significant contribution to population health.