Culture War, Obesity and the New Puritans

I almost forgot I’m a blogger. Nah, not really, but it’s been difficult to keep up lately. I write longer posts, and want to take care to do the homework, so that I’m not producing something that’s misleading. For example, take this recent post by Paul Campos over at Lawyers, Guns and Money. Paul objects to the idea that public health measures involving promoting changes in lifestyle, specifically with what we eat or drink, might help reduce health care costs, or as he says it:

[i]n any case the notion we can cut health care costs significantly by getting people to drink less soda and eat fewer Doritos is unsupported by any evidence.

Riffing off of a post by Matthew Yglesias, Campos also makes lifestyle intervention – public health matters an outpost in the culture war, putting those of us who are interested in the social benefits of exercise and healthy eating into the bin of “cultural Puritanism. We’ll put aside for a moment the point that equating “puritan” with someone who disapproves of pleasure is a bit of historical misdirection. You can even find some evidence for his point that long-term health care costs are driven by old age and not lifestyle choices.

Last year, RIVM published a study modeling lifetime health care costs for cohorts of obese people, smokers and “healthy living” folks, defined as non-smokers with BMIs between 18.5 and 25. The results were that annual health care costs were highest for obese people earlier in life, until age 56, and were highest for smokers in later years. However, the overall highest lifetime health care costs were for the healthy-living folks. Life expectancy from age 20 is reduced by 5 years in obese people and 7 years in smokers. Healthy-living people live on to incur greater medical expenses, more than compensating for the expenditures related to smoking or obesity.

So, I should start smoking again and eat like this to do my part to control health care costs. However, before you shout “gotcha”, take a look at the commentary traveling along with this article. Compare a lean and obese population with the same age and sex distribution, and the latter will have greater health-care costs throughout life. So during the productive adult years of your life, when you should be spending money on other things, such as books, vacations and family, your're spending it on health care. There are other costs associated with obesity such as absences from work and lost productivity, in addition to health care costs. In the UK, these extra costs are estimated to be about four times as great in obese than in lean people.

The problem in the health care debate that no-one seems to want to talk about is that people want to live forever, and it in those years at the end where the health care costs are highest. However, living longer shouldn’t be the goal, rather maximizing the number of years free of disease burden. For me at least, I’d rather not be clomping around on knee or hip replacements, being treated for diabetes or putting up with erectile dysfunction.

Holding ED at bay. . . ok, now we’re getting to why I really pay attention to exercise and what I eat. I’m so transparent. See you in the gym.

We Need Biomarkers

As desirable as the idea sounds, we might have to finally admit to ourselves that reducing human exposure to toxic substances by curtailing their use isn’t working. There are a lot of good initiatives out there in green chemistry, and there’s REACH, but these are years in the future before they start having any effects on really reducing human exposure. The time factor bites here; there’s a progression from research initiative and legislation to regulatory programs and enforcement, pilot testing, redesign and startup of new production plants, and distribution of the new toxic-free products through the supply chain – a process that requires many years. Existing products, such as polycarbonate plastic baby bottles or computer cases with polybrominated diphenyl ether (PBDE) fire retardants, may remain in use for many years even after production and sale of them ceases, providing a continuing source of exposure. Once exposure ceases, additional time passes before human body burdens decline; the amount of time depends on the persistence of the substance in the environment and in the human body.

Bisphenol-A is metabolized rapidly in humans, and body burdens should decline quickly, once we get around to removing it from food and beverage containers. However, even with nearly a decade of intensive scientific study, we still haven’t been able to come to a decision of whether or not bisphenol-A poses a threat to human health that warrants its replacement in plastics. PBDEs will be with us for generations, even if we eliminated all of them from all products today, because of their persistence in soil, water and the foodchain. A concerted effort has been made over the past 15 years to reduce dioxin exposures, which has resulted in decreases in body burdens. The question remains as to whether that effort has been sufficient – we still don’t have an accepted assessment of dioxin health risks.

Note this doesn’t mean “giving up” on clean production. Elimination of high-toxicity substances and substitution with lower toxicity materials is always the first choice in reducing human exposures (next in the hierarchy are engineering controls, personal protective equipment and lastly, administrative controls). Adhering to good design philosophy, and attempting to use smaller quantities of lower toxicity materials along with lower amounts of energy, should remain an objective for all types of manufacturing. But at the same time, we shouldn’t kid ourselves that clean production is going to have a measurable effect on human exposure to toxic substances anytime in the near future. It would be helpful if we had a robust set of biomarkers of toxicity in humans.

Regardless of where you fall on the “yes they do”/”no they don’t” continuum about environmental chemicals causing cancer, you have to admit that the National Academy of Sciences nailed the problem when it said last year:

Many cancer patients are diagnosed at a stage in which the cancer is too far advanced to be cured, and most cancer treatments are effective in only a minority of patients undergoing therapy. Thus, there is tremendous opportunity to improve the outcome for people with cancer by enhancing detection and treatment approaches. Biomarkers will be instrumental in making that transition.

Even further, the NAS’s report on cancer biomarkers says, “. . .recharacterization of disease in pathophysiological terms via the use of biomarkers is the key to the future of medicine.” Wow. If true, biomarkers taking off could really move the “war on cancer” out of the slash and burn (i.e. surgery and chemo/rad) mentality to something more sublime, less painful and scary and probably more effective in protecting health and improving quality of life.

Postscript: A companion post is in preparation that talks more about what are biomarkers and what we can do with them, beyond saying they are early indicators of processes or events in the body that might in the future lead to disease.

Vegetables and Sex

No, that’s not what I’m talking about, you kinky people. . . .

It’s one of those indisputable bits of knowledge that you need to eat enough fruits and vegetables to stay healthy. There are perhaps two basic ways you could go about promoting more fruit and vegetable consumption:

Harass people with boring, gloomy statistics such as:

- Up to 2.7 million lives could be saved annually with sufficient fruit and vegetable consumption.
- Low fruit and vegetable intake is among the top 10 selected risk factors for global mortality.
- Worldwide, low intake of fruits and vegetables is estimated to cause about 19% of gastrointestinal cancer, about 31% of ischaemic heart disease and 11% of stroke.

OR



Now, that’s what I call social marketing.

(Image courtesy of Copenhagen Wholesale Markets)

Flotsam and Jetsam II – Spectator at a Health Care Debate

Many of the passing events during my blogging hiatus I had observed while lurking over at Scienceblogs. For example, there was this little call-and-response between Revere and Orac about whether or not drug quackdom extends to pharmaceutical manufacturers, whether or not physicians serve as “pharma shills” and other associated whatnot concerning drugs. I come down on Revere’s side in this matter; further evidence offered by Revere of how Big Pharma marketing practices are perverting the concept of evidence-based medicine are with this post concerning another side effect associated with the use of Viagra. Just an aside: now, I’m pleased that because of erectile dysfunction, that at least on TV, you get to hear something about middle-aged guy sexuality. But it was painful to watch the “Viva Viagra” ad, with the middle-aged garage band guys singing about their limp wieners. The problem with prescribing PDE inhibitors is that erectile dysfunction can be a symptom for some major underlying lifestyle health problems. This makes me wonder if the physicians prescribing Viagra are also prescribing lifestyle changes for their middle-age male patients. Sex is better when you’re fit, but spinach, olive oil and gym memberships don’t generate revenue for pharmaceutical companies. While Viagra is evidence-based and pharmacologically active, it is still being marketed in a manner designed to strip mine the assets (either through their insurance or personally) of unhealthy people, without accomplishing any other preventive health benefit beyond the ability to get laid once in awhile. I think the “quacks in business suits” argument applies here.

Soft Drinks: and You Worry About the Benzene?

Consumption of sugar-sweetened beverages, and in particular, carbonated soft drinks may be a key contributor to the current epidemic of overweight and obesity. High-fructose corn syrup, a principal ingredient in these beverages has been suggested as a cause of the increased incidences of obesity and metabolic syndrome in the US. sugar-sweetened soft drinks contribute more than 7 percent of Americans’ calories, making them the largest single source of calories in the US diet. They contribute to the erosion of tooth enamal and dental caries. Consumption of caffeine and phosphoric acid in colas may have an adverse effect on bone mineral density in older women. Consumption of sugar-sweetened foods, including sweetened beverages and soft drinks, are being investigated as risk factors in pancreatic cancer. As if that isn't enough, Coca-Cola has been studied as a possible animal carcinogen.

With all of that, what is it that people worry about? Trace levels of benzene formed from the reaction of sodium benzoate and ascorbic acid. While I'm pleased that action is being taken to get a carcinogen out of the food supply (though the term "food" applies very loosely to sugar-sweetened beverages and soft drinks), I question the wisdom of being concerned about the benzene at all; there's more than enough evidence to persuade a reasonable person that drinking sugar-sweetened beverages, and particularly carbonated soft drinks is a really bad idea for your health. If you sat down and did the math, you might find that the cancer risks from the benzene exposure are probably trivial by comparison.

Pediatric Environmental Health Tools from the Physicians for Social Responsibility

The Physicians for Social Responsibility have a nice page of environmental health information on their web site. First among these is a Pediatric Environmental Health Tool Kit that combines a reference guide and "anticipatory guide" for health providers with educational materials for parents on preventing chemical exposures that can affect infant and child health. According to PSR’s web site, the tool kit is endorsed by the American Academy of Pediatrics.

The Reference Guide, a four page table of information on several chemical substances of concern for pediatric health, provides reasonable introductions to each substance. However, as with any document that provides an extremely tight summary of hazard information, some useful information is left out, such as what levels of exposure in the body or environment are of concern. It’s an inevitable result of the process of producing a readable summary, and it may be useful to also point health providers to the next layer of detail about specific chemicals, such as the resources provided by ATSDR, including ToxFAQs and the toxicological profiles.

The Anticipatory Guidance Pocket Card is a handy item that:

. . . fits in a large pocket for handy use during a well child visit. The topics on the pocket card are both developmentally appropriate and take advantage of “teachable moments.” For example, at a newborn visit, the provider will naturally discuss infant feeding. Exchanging mercury thermometers for safer digital ones is another easy step that a provider can mention at an early visit. These flexible guidance points provide clinicians with an age appropriate menu of choices to discuss during routine visits.

The advice on it is linked to various development stages. For example, advice during prenatal development includes “avoid eating fish high in mercury or PCBs/dioxins”. Advice for parents with newborns includes “encourage breastfeeding” and “avoid polycarbonate bottles which may leach plasticizers”. There are also safety tips covering carbon monoxide detectors and smoke detectors, encouragement to avoid pesticide use, as well as mention of indoor air pollutants including radon and molds, lead exposure, childhood poisoning prevention, prevention of overexposure to sunlight, healthy eating, TV watching, physical activity, noise exposure, and tobacco use and substance abuse. It’s more of a checklist, without any details on what to do regarding each of these hazards, and presumably the pediatrician provides the specifics during wellness visits. About the only omissions I observed were that it doesn’t mention brominated fire retardants and allergens that could provoke childhood asthma; I call these out because previous studies suggest that carpet dust can be a reservoir for both BFRs and allergens, which should trigger a reminder regarding vacuuming carpets.

However, the 4 page paper “Key Concepts in Pediatric Environmental Health” does include mention of BFRs and asthma. This paper also highlights childrens’ vulnerabilities to toxic substances based on their higher rates of exposure and lesser-developed metabolic defense mechanisms. It mentions the influences of food choices and the built environment on health, setting the stage for preventing childhood obesity. It also focuses on preventing exposure pathways in the built environment, mentioning dust as an exposure medium for pollutants (PCBs, BFRs and lead) and allergens. Other topics addressed in this paper include body burden and breast feeding, “acceptable risk” (or as the paper states it, the declining threshold of harm) and higher risk communities, with low-income or minority populations who experience higher levels of exposure to air pollutants or other hazardous substances.

The most important feature for me is the statement in the paper that “[p]hysicians can protect their pediatric patients by taking environmental/occupational histories of parents and caregivers, and offering appropriate recommendations”. Again, I feel that physicians can be provided with more information regarding the appropriate recommendations, but overall this paper as advertised discusses the “key concepts”.

For the parents, there is a fact sheet “Rx for Prevention”, which goes through the hazards and prevention steps at different developmental stages, and refrigerator magnets and posters with prevention messages. PSR also sponsors training events around the country for health providers.

On a little more political note, PSR also provides a “Prescription for a Secure and Healthy World”, focusing on issues of ending dependence on foreign oil, global climate change and proliferation of nuclear weapons. It contains an online petition that PSR will send to members of Congress, and a resource guide. Another feature of the “prescription” is the “Comprehensive Briefing Book on Key Environmental Health Issues”, addressed to the members of Congress, but a good source of talking points for anyone on fifteen key environmental health issues.

Memo to Ezra Klein: How Not to Cite a Health Study

Question for Ezra Klein. Why are you getting your health data from the Cato Institute? It was headache-making for me to read the progression from a rather limited study. . .

Rational decision-makers will take into account forecasts of longevity and quality of life in making their work and savings decisions. Public policy must account for this as well. Every additional year of life after age 65 is associated with about $15,000 of social security and medical care spending, and years spent disabled result in substantially greater medical spending than years spent without disability. . . .

. . . to one sweeping generalization . . .

Americans are getting healthier in spite of a little extra flab.

. . . to another. . .

Americans are actually becoming substantially healthier, even as our waistlines expand.

Let’s first review the quantitative results from the Cutler, Glaeser and Rosen study, and then look at where the authors might have overstated their conclusions a bit based on those findings. First, the results (from the summary):

For the population aged 25-74, the 10 year probability of death fell from 9.8 percent in 1971-75 to 8.4 percent in 1999-2002. Among the population aged 55-74, the 10 year risk of death fell from 25.7 percent to 21.7 percent. The largest contributors to these changes were the reduction in smoking and better control of blood pressure.

So, there’s a reduction in overall mortality, and it might be related to people smoking less and better blood pressure medication (I’m fairly sure people aren’t controlling their blood pressure better using exercise and diet. . . ). However, the authors don’t make clear how this translates to:

Examining these factors as a whole, we show significant improvements in the health risk profile of the U.S. population between the early 1970s and the early 2000s. Reduced smoking, better control of medical risk factors such as hypertension and cholesterol, and better education among the older population have been more important for mortality than the substantial increase in obesity.

Reduction in mortality doesn’t translate directly to “significant improvement in the health risk profile”. For example, the authors didn’t go into why they feel we’re getting healthier if the overall prevalence of diabetes is increasing over time, and if we’re spending more to treat it. I have to wonder if Ezra and the Cato Institute are implying that we’re getting healthier because we spend more money to keep at bay a lifestyle-related chronic degenerative disease. Shades of Mad Hatter economics. . . .

While the underlying purpose for the study isn’t mentioned in the paper, it is interesting to note that it was funded by the Social Security Administration. I have to wonder if it’s intended to figure out how much of an impact there’s going to be to the Fund from the reduced mortality. For example, the Centers for Disease Control have reported:

At least 80% of seniors have at least one chronic condition, and 50% have at least two. These conditions can cause years of pain, disability, and loss of function. About 12 million seniors living at home report that chronic conditions limit their activities. Three million older adults say they cannot perform basic activities of daily living, such as bathing, shopping, dressing, or eating. Their quality of life suffers as a result, and demands on family and caregivers can be challenging.

And, the introduction of the Cutler, Glaeser and Rosen study does state:

Every additional year of life after age 65 is associated with about $15,000 of social security and medical care spending, and years spent disabled result in substantially greater medical spending than years spent without disability.

So, is the Cutler, Glaeser and Rosen study is one piece of information about the impact of increased longevity on social security and medical spending? The study doesn’t really say that, but it’s not an unreasonable inference. But it is a broad overstatement to say the Cutler, Glaeser and Rosen paper is evidence that we’re getting healthier even as we get fatter.

It’s no surprise to me that the Cato Institute would go there. However, I am surprised that Ezra Klein would fall for it.

New York State’s Going to Get Healthy

This week, New York state Governor Eliot Spitzer today announced the initiation of a program make New York the healthiest state in the nation. This is going to be accomplished through a comprehensive disease prevention program.

“For years, the health care debate has focused almost exclusively on institutions that deal with various health problems, such as HMOs, hospitals and nursing homes,” Governor Spitzer said. “By shifting focus to the prevention of disease, we can significantly improve public health and help bring exploding health care costs under control.”

AAAUUGH, I can’t see – I was just hit by something blindingly obvious.

As the writer of an environmental health blog, it is very gratifying to hear the announcement of a state sponsoring a disease prevention program. I wish them luck. It’s something that probably needs to be done. Healthcare reportedly is 16 percent of the economic output of the country, A good chunk of that expense is avoidable suggesting that most people apparently can’t or won’t manage disease prevention on their own. All the Presidential candidates are vaporing about the broken healthcare system – principally from the perspective of how to fix health insurance, though disease prevention and quality of life just don’t seem to enter into the political discussion.

I hope the state of New York can make disease prevention interesting and compelling. There’s something so liberal, earnest and dull about public health. Water treatment and smoking cessation isn’t nearly as entertaining as catching criminals or blowing up terrorists. I wonder if part of the appeal of neocon philosophy has been that sowing war and chaos are more fun than behaving responsibly and spreading civilization, especially if you’ not the one fighting in the war, and you’re on the winning side. Candidates for political office also try to appear tough on crime or strong on national defense, not public health. Telling voters that you’re going to be tough on Type 2 diabetes just makes you look weird.

New York State’s agenda is ambitious, and appears to hit all of the high points:

- New public health campaigns targeting cancer, diabetes, obesity, asthma, stroke and heart disease and depression;

- A new program requiring Body Mass Index reporting in schools;

- New legislation requiring healthier school lunches;

- New anti-smoking initiatives, including aggressively promoting tobacco cessation treatment to all Medicaid, Child Health Plus and Family Health Plus enrollees;

- Expanded access to cervical cancer vaccine;

- Enhanced programs to combat HIV/AIDS in minority communities;

- A directive that all state agencies make the elimination of trans-fat a condition of future food service contracts;

- A new program to improve the quality of provider skills in mammography interpretation, colorectal screening and infection control;

- Implementation of a prenatal/postpartum home visitation program for high-risk communities;

- Expanded use of incentives to encourage physical fitness by state employees;

- Expanded childhood lead poisoning prevention efforts;

- Creation of a new Pollution Prevention Institute in the Department of Environmental Conservation to assist businesses in reducing the use of toxic chemicals;

- A new “Green Cleaning” initiative that will help reduce exposure to harmful chemicals in state facilities, schools and worksites; and

- Administrative directives encouraging the use of non-toxic pest control at state facilities, schools and other institutions.

In addition to these disease prevention and environmental measures, the agenda also includes a concerted effort to address infection control in hospitals and nursing homes and other institutions. This effort includes stockpiling of anti-viral medications and public health emergency preparedness exercises across the state.

Funding for the initiatives is reportedly more than $200 million. The governor’s 2007-2008 budget proposal also includes expansion of a program to provide affordable health insurance coverage to the uninsured in the state.

Expect the usual conservative wingnut blogger allusions to food fascism and anti-smoking Nazism. Some of the wingnuttery have even directly compared health promotion advocates to the Nazis.

An agenda is one thing – implementation is another. There will need to be some out-of-the-box thinking to keep this from turning into another juiceless, marginally effective government program. One possibility might be to give it a social marketing spin. There’s more on social marketing as a tool for health communications here and here. I’ve written before about a program sponsored by New York City that appeared to be working for helping diabetics manage their diet, exercise and meds, that is, before the clinics went out of business. More money to be made in amputations than nutritional counseling. . . . Anyway, the story in the New York Times chronicled a client of the program, who was slipping back into her high-risk habits, without the support system provided by the clinic. Perhaps these clinics were providing a social network beyond the medical supervision. Maybe there will be a few dollars to start them back up again, Governor Spitzer?

No Word on Prevention

This just seems to be the time to talk about carcinogens and cancer. The New York Times today discusses the problem of diminishing returns with drugs used for treating cancer. Few drugs are being marketed, have been very expensive to produce and test, and provide few of the expected benefits. Better methods for imaging and diagnosis are needed (X-rays in particular are identified as having questionable accuracy). The problem has been chalked up as an obsolete drug development process.

For example, the FDA just approved Nexavar, a drug described by its developer Bayer as the first approved treatment for advanced renal cell carcinoma in more than a decade. Nexavar has been shown to double the progression-free survival in patients with advanced RCC. Before getting too excited about that news, it’s important to note this meant the median progression-free survival doubled from 84 days (with the placebo) to 167 days (with Nexavar).

When you factor in the more common side effects, skin rashes, diarrhea, and hypertension, on top of the additional three months of life, you start to wonder how worthwhile Nexavar really is, in the overall quality of life department.

Also, not a word about prevention in the Times article. Maybe Sam Epstein has a point about the cancer orthodoxy.