Unhealthful News 120 - Banning use of food stamps for soda - can all of the arguments on both sides be wrong?

The New York Times ran an exclusive article about the New York mayor's proposal to forbid the use of food stamps for purchasing sugar sweetened beverages (soda and such).  The story read like a trial balloon to test out the arguments for and against (i.e., it looks like it was planted with a pet reporter or newspaper by a politico – presumably Bloomberg's office – to see how people would react before moving forward).  The funny thing is that pretty much none of the arguments presented in that article on either side of the issue seems valid.
 “This initiative will give New York families more money to spend on foods and drinks that provide real nourishment,” Mr. Bloomberg said in seeking federal approval.
Um, no.  It is not possible for a rule that only prevents someone from doing something to "give" them something.  If Bloomberg wants to make the argument that it forces people to spend more money on other products (or, more diplomatically, leaves them no choice but to spend more money on those products), then fine.  But if he has to claim that it gives people something he is (a) dishonest and (b) not very confident that the truth will win the day.
Food stamp benefits are paid for entirely by the federal government, and the city is seeking permission from the Agriculture Department to test its proposal in a two-year project. Because the proposal would define “food” more narrowly than federal law and regulations, food industry groups have unleashed a barrage against it.
Again, no.  Whatever happens, it will not change anyone's definition of food.  Opponents do not like the law because it would directly cut into sales of their products a bit and would probably set precedents for other actions that would cut a lot more.
President Obama, whose position on the New York plan is unclear, is in an awkward situation. The Agriculture Department, historically averse to restricting the use of food stamps, has said, “There are no bad foods, only bad diets.” ….  But Mr. Obama has set a goal “to solve the problem of childhood obesity within a generation,” and his wife, Michelle, is waging a high-profile campaign to promote healthy eating. The Web site of Mrs. Obama’s childhood obesity initiative even urges Americans to “drink less soda or sugar-sweetened drinks.”
Really?  Obama is going to personally intervene in this matter?  He does not have time to fight for a stimulus plan to help tens of millions of suffering Americans, or to figure out how to have a more enlightened way to deal with innocent (they have not been proven guilty) prisoners at Guantanamo, or even to provide a decent health financing plan, but he is going to get so involved in this that he cannot distance himself from it.  Just great.

And what about this list of facts makes it awkward?  It is common knowledge that the USDA says "there are no bad foods" because their primary constituents include the meat and corn industries, makers of bad foods, and not consumers.  There is no reason the President needs to yield to this conflict of interest if he does not want to.  As for the website recommendation, there are a lot of things that are recommended for health that are in no way enforced by government action.  Where is the awkwardness in leaving this one of them?
Opponents say that many factors, besides soft drinks, contribute to obesity.
You would think that the opponents of this could muster some good arguments.  But if this article is to be believed then this is their lead argument.  The logic is equivalent to saying, "many factors besides sleeping air traffic controllers contribute to plane crashes, so let's not do anything about it."
Moreover, they say, imposing restrictions on food stamps would require retailers to reprogram computers and embarrass some customers at the checkout counter.
I suspect there is not a food-stamp-accepting store in existence that does not sell some items that are not eligible for food stamps, so they are already asking for some cash from food stamp customers.  Even if customers feel bad about using food stamps or somehow feel bad about being asked for cash, these do not change, so where is the new embarrassment?  As for reprogramming, if anyone is using a cash register computer system that cannot be changed to handle this using one data upload that presumably the government could provide (the SKUs or other identifying series information of all the products included in the change), then I would guess that they are already committing food stamp fraud (at least unintentionally), so probably would not care too much. 

I cannot fathom how these pass for the arguments against the policy.  My only theory is that these are the fake arguments cooked up by the policy proponents to make the opponents look like they have no valid arguments.  As I said, the article does read like a planted trial balloon, and so is probably testing arguments Bloomberg is worried about, not the best arguments that could be made.  One more source of disinformation for serious readers of the health news to beware of.
Eighteen members of the Congressional Black Caucus recently urged the Obama administration to reject New York’s proposal. The plan is unfair to food stamp recipients because it treats them differently from other customers, they said in a letter to Agriculture Secretary Tom Vilsack.
Still not even making a close pass near reality.  This rule would actually treat food stamp recipients slightly more similarly to other customers, requiring them to pay cash for something that everyone else is already paying for.  Is the Black Caucus's reasoning that if food stamps can buy anything then it is unfair for them to not buy everything?  If so, why are they not protesting the fact that they cannot be used to buy prepared deli foods, beer, or greeting cards?

The article goes on to offer and answer:
While Coca-Cola and PepsiCo are among the largest contributors to the nonpartisan Congressional Black Caucus Foundation, a research and education institute, caucus members say their positions are not influenced by such contributions.

Not much face validity in that claim.  On the other hand, the fact that it showed up in the article again reads like a plant, with the planters trying to preemptively discredit what could be phrased as a legitimate concern.  The legitimate version appears below, which the previous version might have been intentionally made to sound dumb.

One public health professor type was quoted as saying,
the government spends hundreds of millions of dollars a year buying beverages that have been linked to risks for obesity and diabetes. These conditions cost the government and taxpayers billions of dollars a year in costs paid by Medicaid and Medicare.
The article still lacks a legitimate argument for a policy change.  Even if the "costing taxpayers" claims that are made so casually turn out to be completely true (as opposed to the claims about the health effects of smoking causing a net cost for the government which are false), this still does not justify the policy.  Show of hands out there – who wants to live in a country where "it saves the government money" is considered a sufficient justification for a restrictive policy decision?

Also interesting is that the San Francisco Chronicle runs a "ask Marion Nestle" column, which just happened to address the question of food stamps and soda on the same day as the NYT trial balloon story.  Coincidence?  It seems unlikely.  But then again, why would the people planting the NYT story set it up so that someone else's brief column could present the issue and the best real arguments on both sides better than their story (please read it if you are interested in the topic).  I can only guess there was a leak about the story and she took the opportunity to preempt it.

Nestle is an academic and probably the most well-known critic of U.S. food business and nutrition policies (or at least the most well known honest, intelligent and respectable critic – there are a few just science aficionados who are better self-promoters than she is, although she is pretty good).  She happens to be one of the authors I referred to in yesterday's UN who wrote the call for papers for article about how to change the behavior of the food industry.  But do not mistake her for the typical "health promotion" or anti-tobacco academic; she has worldly political views, but she is honest and does good analysis, not junk science.  Nestle manages to make a better case than the Black Caucus did (or at least were reported to have done), explicitly noting that the restriction could be seen as condescending to the poor.  In light of that she admits ambivalence about the Bloomberg proposal, but has come to support it.

Unfortunately, her articulate and though-out arguments strike me as dangerously close to invoking the "denormalization" concept from anti-tobacco.  That was the campaign that started out as "let's get people to stop thinking that smoking is an inevitable part of social interaction and getting through the day" and morphed into "let's convince everyone that smokers are evil and that seeing smoking should be as socially unacceptable as seeing someone get raped".  Nestle makes a good case, but a good policy that flirts with a proven-dangerous process is seldom a good idea.  This might be what some of the opponents are trying to say, but not doing a very good job of getting it into the papers.

The best part of the whole story, though, was the reader question that Nestle was answering in her column.  It read:
Q: When I see people in grocery stores using food stamp benefits to buy sodas, I get upset. Why does the government allow this?
It is just so sad that she did not answer the question as asked with:  "Because the government has no magic power to keep people like you from getting upset when your urge to force others to live how you want them to creates emotional turmoil.  Perhaps you should see a counsellor about that."

Unhealthful News 119 - Adamance and conflict of interest (part 1)

It is a bad day for news, thanks to the oh so pretty wedding of the heir to the system that made Old Europe the source of most of the worst bloodshed the world experienced for about half a millennium.  (For anyone who is interested in my further anti-royalist snark – not that you should be – see my comment on this post.)  So, lacking news, today I will do a meta – instead of writing about health research and reporting, I am writing about something that affects health research and reporting.  It is something that comes up so often, and is pretty clearly even less well understood than confounding.  Several commentaries that bring up the concept of highly adamant opinions and how they relate to conflict of interest have crossed my screen this week, so I will concentrate on those.  I have written a lot on this topic, so I am picking just a few themes, continuing this post in UN121, and planning to revisit the topic later series.

The most important thing to understand is that the phrase "conflict of interest" is not just jargon.  It has its natural language meaning:  Someone has two different interests and they create conflicting motives.  One interest is about worldly outcomes, and is venal or is a narrow special interest that is not universally shared, and the other is the ideal of presenting disinterested and dispassionate scientific analysis.  It is actually often the case that someone is not really motivated by the latter of these at all, feeling no hesitation to unabashedly serve their worldly goals, in which case the phrase refers to the conflict between their actual interest and the interest they are supposed to have.

So, someone doing a study to figure out whether "Big Food" is really causing children to eat badly has an obligation to try to report what the data shows, shooting for the ideal of being a disinterested scientist.  (The term "objective" often gets used, but that is actually a very bad choice of words – objective science cannot exist, while disinterested science is rare in worldly sciences, but theoretically possible.)  But if a researcher is a dedicated activist against Big Food, already convinced that there is problem, it will be quite the challenge to not let that influence the interpretation.  Even when someone in that situation does their best to be unbiased there are blind spots (to borrow a phrase from this recent NYT op-ed that looked at ethical questions related to COI).

On the other hand, not every adamant opinion leads to a conflict of interest.  Jacob Sullum just posted this observation about how two anti-Big Food activist academics published a call-for-papers at a journal, looking for "articles considering how to change the behavior of the food industry".  Sullum slams the authors for portraying their particular personal morality on this controversial topic as if it were a matter of science or the only possible view of the public interest.  At this point, it might be tempting to accuse such advocates-cum-scientists of having a COI, as some authors (not Sullum) have done.  But I would argue that they neither exhibit much COI nor are creating it with their call for papers.  They are not calling for studies that support the claim that the food industry's behavior should be changed – that would clearly create a terrible COI (of the type that is typical in anti-tobacco and other areas that are more politicized than food).  Rather, they lead with their goal and look for support for how to pursue that change; so long as their premises, motives, and goal are not secret (it would be hard for them to avoid disclosing those even if they wanted to), there is no COI or disclosure problem.  The legitimate criticism, then, takes forms like Sullum's, about the adamance itself and how it is directing the science priorities, not that it is corrupting the science.

Being an advocate for a particular worldly goal and writing an advocacy piece in favor of it is not a conflict of interest.  It is a perfect alignment of interests – no conflict there.  Moreover, being a paid advocate for a particular position is no more a conflict of interest than is being an unpaid advocate.  Why would it matter?  In theory, a paid advocate might not really believe in the cause they are advocating, unlike an unpaid advocate, but it is difficult to see why this would matter when interpreting their claims.  A conflict does arise if, instead of trying to make the case for one's side of an argument, an advocate-author claims to be presenting a balanced analysis of the dispute or claims to be speaking for the "public" or the only possible goal someone could have. 

Money matters occasionally, and under a few circumstances is arguably the strongest source of COI, though it is not the most common source as is generally implied.  Money is primarily a problem when someone is employed by an entity with a particular position.  A rarer but potentially far more problematic case is when someone has a major financial investment (e.g., owning relevant intellectual property) that is affected by the outcome of a study.  In both of these cases, it is difficult to imagine the author being able to completely overcome the COI if writing about whether a particular scientific conclusion or view (the one that they are employed to support, or stand to make a lot of money from) is justified.  If they were studying something based on the assumption that their preferred view is true (e.g., why it is true; how to act, given that it is true, as in the case of the food advocates; etc.), then they should be fine.  Someone who is employed in "tobacco control" can be trusted to make the best arguments in favor of more tobacco control policies (more's the pity that the published arguments are so lame).  But vanishingly few tobacco control advocates have the intellectual discipline and honesty to analyze whether, all things considered, tobacco control efforts are improving the world (I cannot recall ever seeing a respectable example of that).

Anti-tobacco activists recently became agitated upon learning that British American Tobacco quietly provided financial support for UK retailers' campaign to fight the proposed ban on all in-store displays of tobacco products.  But for activists to portray this as some improper "conflict of interest" debases the term, changing its meaning to simply "there is financial support for a position I and my friends personally disagree with".   If a tobacco company (or an anti-tobacco advocacy group, private or governmental; or a retail lobbying group) expends resources to support a particular goal, they are simply acting in their interests – no conflict.  It is only COI if they claim to be acting for the common good or disinterested science that they start promising scientific disinterestedness.  If BAT, hypothetically, commissioned a study about the effects of display bans, there would be a challenging COI to deal with.  Similarly, when activists who are intent on demonizing tobacco use claim there is scientific support that display bans have a public health benefit, their obvious COI must be considered in interpreting their claims (and their persistent failure to disclose that COI needs to be recognized as reflecting their overall level of honesty).  Their interest in the demonization creates the incentive for them to misrepresent the health science.

In short, adamantly believing in a position, for whatever reason, whether one's salary depends on it or not, does not create a COI for many analyses related to the position, and certainly not with explicit advocacy for the position.  However, the COI is a challenge for analyses of whether the position is valid.  Interestingly, the adamance itself may create more credibility problems for honest readers than the COI.  I will take that up in Part 2.

Unhealthful News 118 - How to take an unconfounded result and introduce confounding

Thanks to a tweet from @cjsnowdon I found this study in which the researcher showed a month-of-birth effect for anorexia risk (high if born in March-June, low if September-October).  The results were pretty strong and cannot be explained by confounding, and measurement bias seems extremely unlikely.  So as odd as it might seem, the effect seems to be real.

Highly technical point:  The test statistics they report are probably wrong (in the sense of being dishonest, though probably out of ignorance of honest methodology rather than lying) because they pretty clearly fished around to pick the most extreme time period.  Notice that Mar-Jun is four months but Sep-Oct is two, and you can be sure they did not specify their protocol to be "we will pick which of the four month periods, running Mar-Jun, Jul-Oct, or Nov-Feb, has the highest rate and which two month period, starting with Jan-Feb, has the lowest.  But I am sure they calculated their error statistics based on the assumption that they did exactly that.  So their results are biased upward a bit and their confidence intervals are too narrow.  I will make it a project to try to write up a version of this that fills in some details but is still widely understandable – I will post it when I manage.

Because the most sensible claim is basically "something about being born in a particular month" has an effect, there is literally no way for there to be confounding or reverse causation.  It cannot be that some unknown factor is causing both the ostensible cause and the observed effect (the most common source of confounding) because the "something about" conceptualization means that whatever that unknown factor is, it is actually captured in the broad phrasing of the causal factor.  Also, it is obviously impossible for someone's characteristics later in life to go back and affect their birth month.  So, in the spirit of yesterday's UN and my efforts to explain that there is no rigid hierarchy of study types, this correlation must be causation.  When people say that randomized trials (RCTs) are always better than any other study design, they are saying (though they often do even not understand enough to know this is what they are saying) that any systematic confounding is replaced by random confounding.  But the birth-month study is actually better than a RCT even for this one thing that favors RCTs:  There is no confounding, random or systematic.  Thus, the relationship must be causal.

Ah, but the tricky part is figuring out the causal pathway.  Unfortunately, the researchers did not seem to understand that this is a challenge and simply declared,
These results indicate that environmental risk factor(s) are operative during gestation or immediately after birth and their identification will be important for disease prevention strategies.
Really?  They apparently did not understand the "something about being born in a particular month" concept and managed to re-introduce confounding where none existed before by restricting the causal claim to "the physical act of coming to term in particular months and being a newborn in particular months" causes anorexia.  Unlike the claim that just trusts in what the data actually shows and must be right, this one makes huge assumptions and therefore is reasonably likely to be wrong.  If, for example, being conceived in a particular month is the actual cause of anorexia (maybe it is related to birth order, for example, or parents' SES), then under the authors' claim the result is actually due to confounding:  both the ostensible cause (being a newborn in a particular month) and the effect would be caused by an underlying common cause, and not otherwise related to each other.

The funniest part of all of this – at least to me – that in the BBC article about this, one of the authors declared,
However, our study only provides evidence of an association. Now we need more research to identify which factors are putting people at particular risk.
Allow me to just say, nonononononono NO NO NO!  Come on people, this is really not that difficult.  While it is never possible to prove than an association is causal, this study provides overwhelming evidence of causation (so long as you do not gratuitously introduce claims about why and stick with the "something about" that the data actually supports), not "only association".  There is almost no conceivable epidemiologic study that could provide better evidence of causation.  Now you need to figure out why there is causation.  The situation does not warrant some weaselly "more research blah blah which factors blah blah" that might be at home in some other study like the one I looked at yesterday.  I am somehow reminded of barely-literate star athletes awkwardly reciting the interview script after a game: "it was a team effort", "I could not have done it without….", and "the fans have been great".  You would like to think that someone working at a research university could do better than than reciting a pretend self-deprecating script while parading in front of the admiring national news rreporters. 

(And why did this highly technical study produce news coverage like scoring the winning goal? It is not as if the result is big enough to change anyone's behavior.  I guess that is a topic for another day.)

Of course, we do want to know why birth month is causing anorexia.  Thus we would not fault the researchers for positing a theory.  But that is not what they did.  They not only declared what particular aspect of birth month was causing the outcome, but they absurdly claimed "these results indicate".  But the results they report absolutely do not indicate that.  The results indicate what I wrote ("something about…"), but not the specific causal mechanism.  Other information would be needed to support their claim.  The BBC interview provided better support than their results.  The author noted that other very different psychological diseases have similar birth-month patterns, which tends to support the biological claim.  Nevertheless, I would wager on a social theory rather than a biological one.

My conception-date hypothetical may seem a little far-fetched but there are lots of alternatives.  The more promising ones to explore have to do with who is a bit older and younger when they first enter a school grade where the social pressures that cause anorexia start to manifest.  Keep in mind that anorexia undoubtedly has biological causal factors, but it is predominantly a social phenomenon.  Surely everyone has read the example, popularized by Malcolm Gladwell in Outliers, that professional hockey players who grew up in Canada are much more likely to have been born early in the year.  The explanation is that youth leagues form based on calendar-year birth cohorts, so the kids born in January are older, stronger, and more practiced than their contemporaries.  This would not matter by the time someone got to the NHL except for the fact that it matters a lot when someone is six years old, and the better players get more attention, and so become even better, and so play in better leagues as they move up the ladder, which makes them a bit better still, and so on.  Such a positive feedback loop seems less likely for anorexia, so the results would not be as dramatic.  But some story like that seems at least as plausible as a biological factor resulting from being a newborn in summer rather than winter manifests in a socially-constructed behavioral disorder. 

And surely the researchers must have read Outliers.  Even if you see that book, as some critics do, as just-so stories that rip off the clever ideas of other researchers without giving them due credit, it is still a must-read.  Kind of like The Spirit Level.  (That link is a plug for Snowdon's takedown of that book as a s/o for giving me this great example.)

Unhealthful News 117 - Exercise is good for six-year-olds, but not because of this study result

A new study had researchers looking into the back of the eyeballs of over a thousand Australian six-year-olds and found that those who watch more television or engage in less outdoor sports have narrower capillaries there.  The alarming conclusion that was reported is that since narrower blood vessels are associated with cardiovascular disease in adults, that this means that watching more TV or doing less exercise for six-year-olds means that they will be at greater CVD risk.

If the conclusion is simply that less exercise and more television viewing are probably associated with poorer cardiovascular health, then it is undoubtedly right.  But we kinda knew that already.  If the conclusion is something more specific about the meaning of this particular study, then we have a really serious problem of epistemology.

I will set aside the question of how well habits of six-year-olds predict future behavior and focus on some other problems with the reasoning of the study authors and the reporters who blindly transcribed their claims.  The most important of these is that correlation does not necessarily mean causation.

You have no doubt read that observation before.  Unfortunately, most of the time you read it, it is just being used as weasel words by someone who does not like what a study suggests about causation (e.g., cigarette companies forty years ago protesting that the overwhelming correlation between smoking and lung cancer, which was pretty obviously causal, does not mean that smoking causes cancer because it is just correlation).  Occasionally the statement is used by a study's authors themselves if they are looking for an excuse to not really stand up for what their study shows.  Other times it is used by observers who are not intent on discrediting the study, but are trying to make themselves seem like knowledgeable reviewers of the science by pretending there is some simplistic bright-line hierarchy of study types such that "more research of the right type is needed" to show causation (regular readers will be aware of the fact that this mostly just shows their lack of knowledge).

But correct statements are not made incorrect because the ignorant or venal misinterpret them.  In many cases we observe correlations and have good reason to believe they are causal, and absent the presentation of any affirmative reason to believe otherwise, the causal conclusion is warranted.  In other cases, there are so many other compelling explanations for the correlation that a causal conclusion without further information is foolish.  Sometimes we are somewhere in between.  For example, if we observe that roofers have an elevated risk for skin cancer, it seems safe to conclude it is causal (with a causal pathway that passes through sun exposure).  If they have a very elevated rate of liver cancer, it is plausibly causal, and we should look into chemicals they are using.  If they have a higher rate of diabetes, we might consider looking at their dietary patterns or ethnicity.

The implicit causal claim in the present case is: (a) the behaviors cause narrow capillaries; (b) that narrowness is associated with CVD in adults so either (b1) the narrowing causes the CVD or (b2) whatever is causing it causes CVD and that "whatever" is being caused by the six-year-olds' behaviors (and is, in turn, causing the narrowing that we observe).  I can think of twenty different stories that explain the observations without supporting that full causal pathway.  E.g., adult narrowing of blood vessels is caused by CVD, not the other way around; narrow blood vessels in adults cause CVD, but children who use their eyes on televisions just have effects in their eyes that  do not affect this; physically unhealthily people (or even just children) have narrower blood vessels and also eschew outdoor sports, which causes CVD via some other pathway; and so on.

The headlines mindlessly repeated the causal claims even though the same reporters would probably have mindlessly reported the claim "oh, but this is just correlation, not causation" in some other case where causation is the only compelling explanation.  USA Today reported "Couch-potato kids could be risking their hearts", the New York Times reported it in their "Risks" series, and some more sensationalistic sources included the whole causal claim in their headline, like "TV Causes Heart Risks in Children".  Funnier were the ones who reported headlines that told us nothing that was not already obvious, but still managed to imply the study showed results that it did not, like "Watching Television Could Be Harmful for Kids".  That is just about as simultaneously obvious and misleading as the usual stating that correlation is not necessarily causation.

To further put the study's naive claims in perspective, here is a pretty good analogy in terms of the many flaws in the causal conclusion:  Having darker skin is associated with an increased chance of imprisonment.  Kids who spend lots of hours in front of screen have lighter skin, while those who do more outdoor exercise have darker skin. 

Let's break down the implications of the analogy:  There is no reason to assume that the mechanism that causes narrowing/darkening among screen users is the same one that causes the association with CVD/imprisonment.  Darkening from tanning has no relationship with the association of race and imprisonment; it is a completely different phenomenon though it still involves darker skin.  Even when race is a step along the causal pathway (or a proxy for one) between screen and outdoor activity and health outcomes – e.g., kids in poor urban neighborhoods have no place to safely play outdoors – the implied causal path is still wrong.

The point is, when causation seems like the only plausible explanation for a correlation, it is a reasonable conclusion.  When other explanations seem comparably compelling, it is not.  Instead, efforts should be made to identify the other explanations (well-educated epidemiologists know how to do this; >95% of those publishing epidemiology do not) and test them in ways that discriminate the different explanations (which is something that scientists know how to do).

There are a few obvious questions to ask.  Is there something special about looking at TV (the study looked at other screen use but did not find such interesting results) or do bookish six-year-olds have the same narrowing?  If the type of sedentary activity matters, the implications are different.  Similarly, does indoor exercise have the same effect as playing outdoors.  We are talking about activities that directly affect the eyes, after all, and a measurement in the eyes.  Maybe there is nothing important about that confluence and it is all about overall vascular health, but maybe not.  Do we even know if narrow blood vessels in kids predicts adult CVD?  In a field that was more serious than epidemiology or health reporting, these questions would have been at least mentioned.

In fairness to the professor who is the senior author of the study, he was quoted in the NYT as being cautious about interpreting the results.  Apparently he has not taught this wisdom to his student / advisee / employee who was the first author of the paper, though, who was quoted in the USA Today article basically making the full causal claim.

Finally, as a subtle technical point, one that I could pick up even without doing a careful analysis of the study, I noticed that the authors chose to divide the kids into thirds based on level of outdoor sporting activity, comparing the top third to the bottom, while they divided the TV watching into quarters, again comparing the top to the bottom.  This is always a sketchy methodology, since the extreme groups in population studies like this pick up all the extreme people (e.g., the kids who hardly ever go outside and watch TV all day, perhaps causing huge genuine health problems that only exist at the extreme, or perhaps caused by major non-lifestyle health problems that keep them from being able to play outside).  But even beyond that standard error(!), the change of what fraction the group was divided into is very suspicious and suggests that they made choices that gave them more dramatic results.  If this is really the case then something is very wrong since the less extreme comparison (top third to bottom third) would produce a less dramatic result than the more extreme (top quarter to bottom) if there were really a trend.  If the comparison that should produce a larger contrast does not, then we should be very suspicious of even the claimed correlation.

In summary, there is no doubt that exercise is better for cardiovascular health than being sedentary.  It is plausible that this manifests in vascular size in adults, though it is not clear to me that we know how way the causation runs (though it might be clear to those who both understand causal inference and are expert in the subject matter).  That the same thing happens in six-year-olds is plausible, though far from obviously true, and the new study might be seen as lending a bit of support to that claim though it has major limitations.  As for whether this effect in kids has any bearing on adult health, this is purely speculative at this point.

So exercise – both your body and your reasoning ability.

Unhealthful News 116 - Yesterday's non-news about e-cigarettes

I found a great UN example today, but it was a bad health and productivity day, so writing this post for the THR blog was most of my productivity for the day.  So just a few words now about the news reporting that relates to that one, and I will save the more interesting one tomorrow.

The quick background is that the US FDA announced yesterday that it would regulate electronic cigarettes according the rules used for tobacco products instead of the rules for medicines, as they had wanted.  The latter would have effectively banned e-cigarettes, but manufacturers took them to court, and the court required they do what they just announced they are doing.  For a bit more background, you can read my other post at the link, and for more background still, you can follow the links from that.

Every reporter seemed to have either missed or ignored the fact that this was not a choice by FDA, but something the court had required, and that there was really no information provided about what the critical implementation details will be.  It was kind of an inkblot test for the reader, with e-cigarette supporters typically reading in better news than can be assumed.  Despite that, the Associated Press story by Michael Felberbaum did a nice job of explaining the matter.  Covering the pertinent facts for someone to basically understand the matter, without hype, too much hyperbole, or too many unsubstantiated scientific claims.  It was one of the better short health news stories I have read in a while. 

Extra credit goes to the Philadelphia Inquirer, whose version of the AP story left out the flawed attempt to explain why e-cigarettes are much less harmful than smoking, because they do not contain "the more than 4,000 chemicals found in cigarettes".  You get used to seeing nonsense like that from anti-tobacco propaganda, but it is pretty lame when news reporters decide to gratuitously throw it into stories.  Here is a hint about counting chemicals:  There are pretty much as many of them as you want to count, if you keep looking hard enough, in most any complex natural substances like tobacco, kale, salmon, children, etc.  Also, the counts of thousands of measured and named chemicals refer to the smoke, which has different properties from the cigarettes themselves.  The New York Times version cut out much of the useful material and left that in.

The Los Angeles Times made the mistake of writing their own story, and dredged up the discredited attacks on e-cigarettes that FDA launched as part of their legal strategy.  The Winston-Salem Journal, which often delves more deeply into tobacco-related stories than any other paper, focused on the reactions of various partisans in a way that was probably cryptic to anyone unfamiliar with the topic.  Most of the television news reports cut for length by leaving out the fact that this was fait accompli, implying it was a policy-changing decision.  This is actually what a lot of my expert colleagues did also, interestingly enough.

As far as I could find, no reporter seems aware of how little the FDA announcement told us about what will really happen (see my THR post for my take on that), other than there will be no immediate ban.  But I get the impression that no one they talked to made any effort to explain to them how uncertain the matter still is, so it is hard to blame them.  In this case, it is not so much that we need a more skeptical press corps, as I often scream, but that we need more skeptical pundits.  The only such analysis I noticed came from two small San Francisco newspapers which suggested (as I did) that this paves the way for treating e-cigarettes like cigarettes in all ways.  Because of recent policy debates there, they focused on including e-cigarettes in place-specific smoking bans.  While this obviously does not logically follow from the FDA policy (the rule is that e-cigarettes will be regulated as tobacco products, many of which are smokeless, not as producers of smoke) it seems like an inevitable rhetorical path.

Bottom line: It really is interesting to see so much reporting about a "groundbreaking" "decision", some of which included some genuinely good background information, without actually seeing any news reporting.

Unhealthful News 115 - Goals are not predictions; sometimes they are not even goals

Numerous headlines over the past few days have reported that the US will/could/should/is expected to have inflexible indoor smoking bans everywhere in the country by 2020, or some variant on that theme (here are some examples).  The thing is that this is merely some people's goal, and contrary to many of the reports, there was no study supporting the claim.  Moreover there was not even anything "newsworthy", since there was not even any change in the arbitrary goal.

So what generated the "news"?  There was a simple matter-of-fact report in Morbidity and Mortality Weekly Report (MMWR), CDCs weekly blog.  It is actually a newsletter that predates blogging, but these days the most useful way to think of it is as a blog, to avoid confusing it with a journal or even a carefully-edited periodical.  The report was about the enactment of indoor smoking bans from 2000-2010, and it seemed to be just fine for what it was.

But it also included the tangential observation that the US government's "Healthy People 2010" goals included enacting exception-free nationwide indoor smoking bans in any space where someone is employed, which did not happen.  So the wish was just carried over to "Healthy People 2020" and the report said this "is achievable if current activity in smoke-free policy adoption is sustained nationally and intensified in certain regions, particularly the South".  Yeah, that warrants headlines about 2020 being the time to expect nationwide laws – an arbitrary date from an old list of goals combined with a report that simply recounts past events and has no forward-looking analysis.  But wait, there is a one-sentence assertion by a random group of analysts working at CDC, so stop the presses.  This is what passes for health news.

(Someone looking for a more interesting story might focus on how the US government goal was to enact these laws, but they failed and are now wondering if it can be done ten years later.  For those not familiar with the US system, the explanation is simple:  Most laws are controlled by state and local governments and not all of them share the feds' goal.  The beauty of federalism is that different states and localities can try out different policies, and if they are really important, people can vote with their feet.  Of course, the feds have a habit of thwarting this system in many cases where variety and local freedom is useful and, indeed guaranteed by the Constitution.  Perhaps the confidence in the 2020 goal should be read as the federal government hinting it will withhold funds to force all states to adopt the "right" laws, the usual tactic for ignoring the rights of the states under the Constitution.  Reporting that would be a much more interesting and genuine news story.)

That one phrase from the report that is quoted above was not all that was written.  As with many MMWR reports, the analysts' useful information is accompanied by an "Editorial Note".  This one, like many such notes in MMWR, is longer than the actual study report.  Like I said, it is a blog, not a journal or even really the technical report series it is supposed to be.  The editorial waxes about how the existing laws are "remarkable public health achievements" though the data to support that claim is pretty sketchy.  More important, the editorial makes clear that whoever was writing does not consider sufficient laws that allow for any exception whereby consenting adults can gather and smoke, and suggests that restrictions on smoking at home should be added to the goals.

I am not writing this to comment on the anti-tobacco extremists and slippery slopes – there has been plenty written about those.  Rather, this story is a reminder that for any issue with political implications, the health press often take a break from being overly-credulous science reporters and instead become typically-credulous policy reporters.  That is, they report whatever someone in a position of power asserts as if it were information, and report government goals, no matter how extremist, naive, or unpopular, as if they were god-given.  There are few Americans who would insist that if some states chose to allow well-ventilated smoking sections in bars or casinos, or refuse to force old men at the American Legion (a private club for military veterans) to relive their days in Korea by going out into the snow to smoke, that this would be a terrible thing.  And it seems like there is a good chance that some states will allow at least some such exceptions, thwarting the inflexible CDC goals, if they are not blackmailed by Washington. 

I suspect that the debate on this matter will have matured enough by in 2021, or perhaps even become largely moot, so that we will not see a spate of naive stories about how the goal will be met by 2030.  But given the anti-tobacco activist enclaves of the government and the quality of the press corps, I am not willing to rule out the possibility.

Unhealthful News 114 - Krugman takes on some unhealthful news

Paul Krugman has written several posts in the last week about medical financing, including his New York Times column about how medical spending requires limits/choice/rationing and how medical patients are quite dissimilar from people in their role as consumers of ordinary goods.  He pointed out in his blog that this was basically reminding us of something the great Kenneth Arrow wrote in 1963.  I suspect that readers in most of the world understand that these points go without saying, which is why the government needs to exert substantial control over medical financing and, by extension, limits on spending.  But in the US the the debate goes on about whether or not we are going to do anything remotely rational about medical financing.  (For those interested in other recent Krugman writings on the topic, they are here, here, here, and here – I understand that links from blogspot let you into nytimes pages even if you have used up your free articles for the month.)

To summarize, the most important reason that patients do not act as normal consumers – probably obvious to anyone who thinks about it, a category that clearly does not include about half of American commentators on the subject – is that they are not paying most of the bill.  This is because if they had to do so for anything other than routine care, they would not be able to afford it, so insurance of some sort is needed, and there is no getting around how that prevents normal consumer decision making.  A second reason is that the "consumers" seldom have the knowledge and confidence to make a decision, and often are in no condition to think straight, so someone else (neither the patient nor the payer) is also making the decisions.

As for the need for some kind of rationing, it is not possible for us to provide everyone with every beneficial medical treatment, a category that includes a lot of expensive treatments that will probably fail, but might offer a little benefit.  We understand this for most goods, but the thing about medical care (this is my claim, not Krugman's) is that until recently the total cost of all beneficial treatments for anyone who might benefit from them was quite small.  Moreover, during a brief period that included the formative years of most current American pundits, we were rich enough to afford all of those treatments for everyone in rich countries.  That odd situation has changed.  But our usual method for rationing consumer goods – making people choose what they want, constrained by what they can afford – does not work, so someone has to make the decision.  It can be private insurers who are looking for any excuse to not pay for something, or it can be – gulp! – government.

Rationing is tough, but it would be better if we acted like adults and recognized that it was necessary, and best to do it in some sensible way.  I had a conversation this morning with someone who is on Medicare (for those who do not know, that is America's efficient, popular, tax-funded socialized medicine, available to everyone assuming they survive their lack of health insurance and reach age 65).  She told me about how she and her husband were constantly getting calls from companies trying to sell them (which means deliver for free and bill Medicare) motorized wheelchairs, anti-sleep-apnea machines, and various other boondoggles.  She also recounted tales of oncologists making a fortune by selling the in-office chemotherapy delivery that they themselves chose to recommend over other options.  I was aware of the latter of these but had not realized how bad the former had gotten.

Anyway, the point is not that much of American medical care is making a few people rich at the expense of people who just need basic care – that is not a very impressive insight.  What Krugman's posts and that conversation got me thinking about is how badly backwards the entire system is when people are allowed to buy, at the expense of their insurance (government provided or otherwise), an electric scooter if they can get some scamming medic to declare that they have a medical need, but they cannot buy (to pick just three examples I have written about recently) soda in various public buildings, or caffeinated alcoholic drinks, or electronic cigarettes if the FDA has its way.  The latter are legitimate consumer decisions where someone can understand the ramifications and make a choice about how to expend their money (and time and perhaps their thin waist or even a few hours of long-term memory if they so choose).  We would not all make the same choices, but that is the beauty of functioning free markets:  we do not have to agree and no one has to understand why.  The same is not true for medical care, where someone often has to figure out how to choose for everyone.

The point is that it is not just offensive to liberty that "health promotion" busybodies (not to be confused with real public health advocates) try to restrict consumer choices about food, drugs, etc. and bastardize the epidemiologic science in the process.  But since they often do so in the name of reducing medical expenditures, it is downright insulting (and bastardizes the economic science).  People are told they must not smoke or otherwise enjoy nicotine because the resulting health costs increase government expenditures (which is not actually true, but let's run with it for now).  But the aforementioned medical device companies and oncologists cost the system orders of magnitude more, but are allowed to keep acting the way they do.  The burden is put upon the rest of us, and the victims are blamed.

Krugman waxes about how, because of the aspects of the relationship that are simply beyond the standard merchant-consumer interaction, medical providers have to be something more that just profitable producers, how they have to have super-human ethics and heroism.  But, you know, I am not seeing that happening anytime soon after a few decades of this "consumer" attitude.  The wheelchair makers are certainly not headed in that direction, and the millionaire oncologists probably did not choose that specialty because all the positions as a desperately-needed general practitioner in an under-served rural area were taken.  So the only hope for reigning in these costs is – again, gasp! – aggressive government intervention.  But this does not make it all right for the government to intervene to alter people's private possibly-health-affecting choices via any method other than education, suggestion, and perhaps a bit of nudging.  More pointedly, the embarrassment of those in power over the government's failure to have enough ...um... let's say fortitude to stand up those who are getting rich providing needlessly expensive medical care – let alone the embarrassment of those who are providing that needlessly expensive medical care – is a pathetic motive (though one with understandable self-interested as well as pscyhological motives) for blaming consumers for the uncontrolled costs.