Something Not Unlike Research

Ubel on Bloomberg's Soda "Ban"

post by Paul Kelleher

Peter Ubel writes:

Unfortunately, the Big Gulp ban is a bad idea.

...

Where the trans-fat and soda bans differ, however, is in the coherence with which New York City officials can explain how they draw the line between banned and unbanned goods.

...

Coke and Pepsi are artificially manufactured processed foods, too. And they contain an undeniably harmful substance. But herein lies the problem. The harmful substance is sugar, and the sugar in Coca-Cola is no more harmful than the sugar in apple juice or a milkshake.

This is understandably confusing to the public, who can’t understand why New York City is planning to ban large sodas but not triple-decker chocolate cakes, or why the 280 calories in a 24-ounce Coke are somehow worse for them than the 330 calories in a Starbucks peppermint mocha.

The success of most policies depends upon public support. But incoherent policies are difficult to embrace.

If Mayor Bloomberg were defending his policy in front of the Supreme Court, the justices would be asking him for a limiting principle – a rationale that would help us know where this policy begins and ends. The ban on large sodas doesn’t pass this test.

I think a lot more rides in this case on pragmatic and context-specific considerations than Ubel acknowledges here. Ubel adopts the language of the Supreme Court oral arguments over the ACA when he says that Bloomberg cannot provide a "limiting principle" that explains why large sodas should be banned but not Starbucks peppermint mochas. But I wonder: is there a limiting principle that explains why one can buy Tylenol over the counter but not fentanyl patches? Each one can be very harmful if used improperly, and each works by containing narcotics, just as both soda and milkshakes taste delicious because of their sugar content. This suggests that sometimes pragmatic, context-specific considerations can serve to justify otherwise "incoherent" policies governing the sale of similar substances. A paradigm example of a pragmatic consideration is how likely it is that Tylenol (or soda) will be consumed in degrees that trigger the public's interest. Another example may well be how likely it is that a key demographic--kids and adolescents, e.g.--will overconsume one product rather than another. (Another may concern the degree to which specific consumption patterns negatively impact the already cash-strapped budgets for essential social services.)

I'm not yet saying that the consumption patterns of soda raise do in fact raise pragmatic concerns that render Bloomberg's specific proposal justified in the final analysis. (I need to read more of the empirical work on the issue.) I'm only pointing out that sometimes pragmatic considerations can justify a policy response that can't be neatly expressed in a tidy limiting principle.  

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.