Paleo

I’m sure there’s plenty about the Paleo diet to recommend it.  My problem with it is that the rationale seems to be so much psuedo-science.  Thus, I really enjoyed this excerpt from Paleofantasy claiming as much and explaining why:

The paleofantasy is a fantasy in part because it supposes that we humans, or at least our protohuman forebears, were at some point perfectly adapted to our environments. We apply this erroneous idea of evolution producing the ideal mesh between organism and surroundings to other life-forms too, not just to people. We seem to have a vague idea that long long ago, when organisms were emerging from the primordial slime, they were rough-hewn approximations of their eventual shape, like toys hastily carved from wood, or an artist’s first rendition of a portrait, with holes where the eyes and mouth eventually will be. Then, the thinking goes, the animals were subject to the forces of nature. Those in the desert got better at resisting the sun, while those in the cold evolved fur or blubber or the ability to use fire. Once those traits had appeared and spread in the population, we had not a kind of sketch, but a fully realized organism, a fait accompli, with all of the lovely details executed, the anatomical t’s crossed and i’s dotted.

To think of ourselves as misfits in our own time flatly contradicts what we now understand about the way evolution works.But of course that isn’t true. Although we can admire a stick insect that seems to flawlessly imitate a leafy twig in every detail, down to the marks of faux bird droppings on its wings, or a sled dog with legs that can withstand subzero temperatures because of the exquisite heat exchange between its blood vessels, both are full of compromises, jury-rigged like all other organisms. The insect has to resist disease, as well as blend into its background; the dog must run and find food, as well as stay warm. The pigment used to form those dark specks on the insect is also useful in the insect immune system, and using it in one place means it can’t be used in another. For the dog, having long legs for running can make it harder to keep the cold at bay, since more heat is lost from narrow limbs than from wider ones. These often conflicting needs mean automatic trade-offs in every system, so that each may be good enough but is rarely if ever perfect. Neither we nor any other species have ever been a seamless match with the environment. Instead, our adaptation is more like a broken zipper, with some teeth that align and others that gape apart. Except that it looks broken only to our unrealistically perfectionist eyes—eyes that themselves contain oddly looped vessels as a holdover from their past.  [emphasis mine]

Also enjoyed this segment on the matter on Quirks and Quarks. Among other things, they discuss the fact that our cavemen ancestors surely weren’t drinking milk from cattle, but that many human populations evolved this ability quite rapidly.

Quick hits

A lot of interesting stuff I’ve been reading lately that I don’t have all that much to say about:

1) Grade inflation is just nuts.  Currently at my alma mater, Duke, fully a quarter of the students have a 3.7 or above GPA.  In my day– class of 1994– that figure was about 3.4 for the top 25%.

2) In theory, I love the idea of attending a Premier League game in England some day.  In practice, sounds kids of crazy.

3) Catholic school in Columbus, OH fires beloved PE teacher after finding out via her mother’s obituary that she has a same sex partner.  Damn this stuff drives me crazy.  Love this quote:

Perhaps six colleagues met Julie over the years, though they probably weren’t the only ones aware of Carla’s sexual orientation. “I’m sure it was surmised: gym teacher, divorced, short hair, didn’t have a bow in it,” Carla said. “Come on.”

4) All of our babies slept in bed with us at some point.  It’s just so much easier and I’m pretty sure we were as safe as could be about it.  I really enjoyed this discussion of the issue, especially the sad fact that pediatricians will not even discuss how to make co-sleeping safer because they are so dead-set against it.

5) Enjoyed this George Packer post on how technology has made our lives better, but there’s not much it can do about inequality.

6) Apparently parents read more to their daughters.  One theory is that its harder to read to boys because they’re more likely to be squirmy.  That one sounds good to me.  This author’s anecdotal N of 1 family (her own) shed no light on the topic at all, but was an interesting review of the issues.  In my family David loved to be read to and so does Sarah, who actually demands it on a regular basis.   I’d like to see more research to help figure out how much of this is about the parents vs. how much is innate differences in young  boys vs young girls.

Teen pregnancy

With the recent discussion of abortion, contraception, etc., I’m reminded of a recent and really good Atlantic piece about the nature of teen pregnancy.  The sub-head gets right to it:

Handing out contraception will only make dents around the edges of the problem. Giving girls a reason not to get pregnant in the first place could go a long way towards solving it.

Basically, getting contraceptives to teenagers (i.e., the Plan B debate) is not the problem.  The problem is convincing at-risk teenagers (i.e., impoverished socio-economic background) that they want to use contraceptives– crazy as that may sound to us successfull, delay parenthood, blog-reading types:

If we really want to combat teen childbearing, we need to present girls at risk of becoming pregnant with an attractive alternative. It is not enough to offer them contraception and to explain to how to use it. We need to convince them that they want to use it; that they and their children will be better off if they wait to become mothers.  [emphasis mine]

Even more challenging: We need that message to be true. This is a much more difficult proposition, but all of the evidence suggests that this is what is required — interventions that change the life trajectory of girls on the path to teen motherhood.

Ummm, I’m pretty damn sure the message is true, though.  Plenty of good evidence on that fact.   That part is actually easy.  So, what do we need to do?

Why don’t these policies [ready access to contraception] have more of an impact? We believe it is because they do not address the fundamental forces that drive most teens to have children. They focus on the immediate precursors to pregnancy, and miss a lifetime of behaviors and decisions that build towards it…

An alternative view [alternative to blaming the teenage brain] — the one we favor — is that teen childbearing is a symptom of living a life full of obstacles. Facing limited education and job prospects, as well as a slim chance of finding a suitable man to marry, some low-income girls simply ask, “Why not have a baby now?” Ethnographic work on young, single mothers supports this theory. So does economic research showing that the financial and social problems teen mothers and their children experience are mostly driven by the mother’s socio-economic background, not her decision to have a baby early in life…

We want to attack the cause — the lack of opportunity so many girls face… In general, improving educational attainment for young women seems to work.

To really drive down rates of teen childbearing, we need young women at risk of becoming teen mothers to see a reason to delay motherhood. They need to believe that they have reason to invest in their futures, and they need a viable way to do so. That is where we need to focus our efforts.

Okay, now that is hard.  But certainly well worth doing.  And we need to very much pay attention to this line of research in how we think about addressing teen pregnancy.  Until then, I still say, more IUD‘s.

Eat more salt!

Okay, not quite, but people really need to get it out of there head that salt is the bad guy.  The evidence that it is not has been accumulating for years.  And now the Institute of Medicine has a comprehensive report about the uselessness of low sodium diets for most people.  From the NYT:

In a report that undercuts years of public health warnings, a prestigious group convened by the government says there is no good reason based on health outcomes for many Americans to drive their sodium consumption down to the very low levels recommended in national dietary guidelines.

Those levels, 1,500 milligrams of sodium a day, or a little more than half a teaspoon of salt, were supposed to prevent heart attacks and strokes in people at risk, including anyone older than 50, blacks and people with high blood pressure, diabetes or chronic kidney disease — a group that makes up more than half of the American population.

Some influential organizations, including the American Heart Association, have said everyone, not just those at risk, should aim for that very low sodium level. The heart association reaffirmed that position in an interview on Monday, even in light of the new report.

But the new expert committee, commissioned by the Institute of Medicine at the behest of the Centers for Disease Control and Prevention, said there was no rationale for anyone to aim for sodium levels below 2,300 milligrams a day. The group examined new evidence that had emerged since the last such report was issued, in 2005.

“As you go below the 2,300 mark, there is an absence of data in terms of benefit and there begin to be suggestions in subgroup populations about potential harms,” said Dr. Brian L. Strom, chairman of the committee and a professor of public health at the University of Pennsylvania. He explained that the possible harms included increased rates of heart attacks and an increased risk of death.

What I found most interesting, which I had not learned before, was just how poor the science was for the low sodium recommendations:

The committee said it found more recent studies, published since 2005 that were more careful and rigorous. Much of the new research found adverse effects on the lower end of the sodium scale and none showed a benefit from consuming very little salt.

Although the advice to restrict sodium to 1,500 milligrams a day has been enshrined in dietary guidelines, it never came from research on health outcomes, Dr. Strom said. Instead, it is the lowest sodium consumption can go if a person eats enough food to get sufficient calories and nutrients to live on. As for the 2,300-milligram level, that was the highest sodium levels could go before blood pressure began inching up.

Also, quite interesting (though not at all surprising) is how harda time people and institutions have in changing their positions and adapting to new sets of facts.  When you’ve been telling the world 1500mg of salt per day maximum !) for years, it’s very hard to admit you are wrong and that the data is pretty clear on that score.  Alas, both the American Heart Association and CSPI which have been scaring far too many people about their sodium intake for years are not backing down.  Now, surely, there are subgroups of American who need to carefully watch their sodium intake, but there’s just no evidence that a low sodium diet is needed for the vast majority of Americans.

Sharing germs

We share utensils, food, you name it with our kids all the time.  I’ve always assumed that we are absolutely sharing bacteria all the time and to think that sharing a fork somehow changes that is ridiculous.  I didn’t realize that members of the public health community had been advising otherwise for years.  Anyway good news (and of little surprise given what I’ve learned about bacteria over the years)– I’m right and they’re wrong.  The NYT story is about cleaning your kids pacifier with your mouth (something I never did– kids weren’t much into binkies, and if it was dirty I didn’t want it in my mouth), but general principles apply:

For years, health officials have told parents not to share utensils with their babies or clean their pacifiers by putting them in their mouths, arguing that the practice spreads harmful germs between parent and child. But new research may turn that thinking on its head.

In a study published Monday in the journal Pediatrics, scientists report that infants whose parents sucked on their pacifiers to clean them developed fewer allergies than children whose parents typically rinsed or boiled them. They also had lower rates of eczema, fewer signs of asthma and smaller amounts of a type of white blood cell that rises in response to allergies and other disorders.

The findings add to growing evidence that some degree of exposure to germs at an early age benefits children, and that microbial deprivation might backfire, preventing the immune system from developing a tolerance to trivial threats.

The study, carried out in Sweden, could not prove that the pacifiers laden with parents’ saliva were the direct cause of the reduced allergies. The practice may be a marker for parents who are generally more relaxed about shielding their children from dirt and germs, said Dr. William Schaffner, an infectious diseases expert at Vanderbilt University who was not involved in the research.

That “generally more relaxed about shielding their children from dirt and germs” certainly applies to me.  And ever-increasing evidence suggsts that it is actually good parenting.  The following was my favorite part:

But Dr. Joel Berg, president of the American Academy of Pediatric Dentistry, said those efforts are misguided, since parents are bound to spread germs simply by kissing their children and being around them. “This notion of not feeding your baby with your spoon or your fork is absurd because if the mom is in close proximity to the baby you can’t prevent that transmission,” he said. “There’s no evidence that you can avoid it. It’s impossible unless you wear a mask or you don’t touch the child, which isn’t realistic.”

I don’t quite want to say that’s just common sense, because I realize common sense can steer you wrong in cases like this, but it seems to be logical based on what we know about bacteria.  Anyway, shared food and utensils will continue in the Greene household.   Though, I should mention that despite our efforts of being lax, all the boys have very mild asthma and they all have hayfever to varying degrees.  In the end, genes will out.

More Medicaid Power

Drum actually posted an explanation of power analysis last night and how it relates to the Medicaid study:

There are several things to say about the Oregon study, but I think the most important one is this: not that the study didn’t find statistically significant improvements in various measures of health, but that the study couldn’t have found statistically significant improvements. It was impossible from the beginning.

Here’s why. The first thing the researchers should have done, before the study was even conducted, was estimate what a clinically significant result would be. For example, based on past experience, they might have decided that if access to Medicaid produced a 20 percent reduction in the share of the population with elevated levels of glycated hemoglobin (a common marker for diabetes), that would be a pretty successful intervention.

Then the researchers would move on to step two: suppose they found the clinically significant reduction they were hoping for? Is their study designed in such a way that a clinically significant result would also be statistically significant? Obviously it should be…

So here’s the question: if the researchers ended up finding the result they hoped for (i.e., a reduction of 16 people with elevated GH levels), is there any chance that this result would be statistically significant? I can’t say for sure without access to more data, but the answer is almost certainly no. It’s just too small a number. Ditto for the other markers they looked at. In other words, even if they got the results they were hoping for, they were almost foreordained not to be statistically significant. And if they’re not statistically significant, that means the headline result is “no effect.”

Now, they didn’t design the Oregon program or they would have insisted upon more numbers for this very reason.  That said, how they probably should have been much more thoughtful about how they brought these findings too light given the inherent problems.

Medicaid, statistical power, and health vs. wealth

The big news for policy wonks last week was a new study of Oregon Medicaid recipients that used a natural experiment to assess the impact of Medicaid.  Short version: No statistically significant” improvement on measured physical health outcomes over two years, but significant improvements in mental health and financial health.  Conservatives have been crowing about how it is therefore pointles to expand Medicaid, as Obama care does.  A lot of really smart responses.  Let’s start with Jon Cohn:

The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses.

That may sound obvious—of course people with insurance are less likely to struggle with medical bills. But it’s also the most under-appreciated accomplishment of health insurance: Whatever its effects on health, it promotes economic security. “The primary purpose of health insurance is to protect you financially in event of a catastrophic medical shock,” [emphasis mine] Finkelstein told me in an interview, “in the same way that the primary purpose of auto insurance or fire insurance is to provide you money in case you’ve lost something of value.” And while only a small portion of people will experience financial shock in any given year, over time many more will—which means many more will benefit from the protection that Medicaid provides.

Damn straight.  Yes, medical insurance keeps my family healthier, but mostly it keeps me out of the poorhouse.

Meanwhile, Chait takes this on as only Chait can:

Okay: The case for Medicaid expansion is not as strong as I had thought. Now for the caveats: The case for Medicaid expansion is overwhelmingly strong. If a study found that puppies survive steep falls at a higher rate than expected, then you could say the case for throwing puppies out of skyscraper windows has marginally weakened, but would remain extremely strong. Indeed, data notwithstanding, either throwing puppies out of skyscrapers or throwing people off Medicaid are both acts of sadism…

We know that Medicaid makes people happier and less poor. We have trouble proving its impact on their physical well-being because proof of the benefits of medicine remain elusive. Unless we want to stop thinking of basic medical care as a life necessity, and we don’t, the case for Medicaid remains unimpeachable.

Meanwhile, Drum and the Incidental Economist take an important look at why Medicaid did not seem to improve outcomes.  Drum:

In fact, the study showed fairly substantial improvements in the percentage of patients with depression, high blood pressure, high cholesterol, and high glycated hemoglobin levels (a marker of diabetes). The problem is that the sample size of the study was fairly small, so the results weren’t statistically significant at the 95 percent level.

However, that is far, far different from saying that Medicaid coverage had no effect. It’s true that we can’t say with high confidence that it had an effect, but the most likely result is that it did indeed have an effect. The table below shows the point estimates. Note also that in all cases, the use of prescribed medication went up, in some cases by a lot.

Here’s the thing, if you are finding 17 and 18% differences but they are not statistically significant at the p<.05 level, it means you just did not have enough statistical power to properly test your hypotheses.  Now, there’s nothing that can be done about that in this case– there were just only so many people– but it does mean that you need to think about this in full context and realize, exactly as Drum suggests, that in all likelihoood Medicaid did improve health outcomes, we’re just not 95% confident.  Kind of like if you gave one treatment to 10 people and 8 improved but only 5 improved in the control group.  Yeah, the treatment probably worked, but there’s just not enough people to give you statistical confidence.  Now, change those numbers to 800 of 1000 and 500 of 1000 and you can be pretty damn sure.  There just weren’t enough people in this study to be pretty damn sure, but in context, the results certainly are suggestive.  And as Chait and Cohn point out, even if there was not any physical improvement (in a narrow two year period), it sure means something to not go bankrupt and to have better mental health.

Quick hits

Lots of interesting stuff I just don’t have the time to get to: 1) Belief in the “Second Coming” of Jesus significantly reduces support for government action to tackle climate change (necessary controls, of course). 2) My hometown of Cary, NC switched over to blinking yellow from solid green for a yield left turn in the past few years.  I don’t feel any safer, but supposedly I am.  Apparently, though, pedestrians are now more at risk. 3) A disproportionate number of the world’s best students are Americans.  Are averages are always getting pulled down due to our inequality and poverty, but at the top, we still rock. 4) Being told that a CFL light bulb is good for the planet makes conservatives less likely to buy it.  How depressing.  Kevin Drum with a nice take on how actually caring about the environment has become an extension of the culture wars. 5) Really enjoyed this piece on how to talk to your child about sexual assault, sexting, etc.  This part especially:

I understand that reluctance: I haven’t talked to my 13-year-old son about Steubenville or the other cases because parties and alcohol aren’t on his radar yet. I don’t want to rob him of his innocence. “I understand that feeling,” Wiseman said. “But that always means the moment of losing their innocence doesn’t happen with you, and they have to deal with it in the moment, and they’re completely unprepared for what to do.” She said I could wait until my son is 14, but probably not much beyond that.

Got it.  David’s 13.  I’m going to get on this. 6) Mother and daughter both injured in Boston marathon bombing.  Good story. 7) Great take on the morons in Congress trying to eliminate NSF social science funding.  Great conclusion:

I have no doubt that Messrs Duncan and Webster’s motivations in offering this bill are not venial or self-serving. I have every faith that they are motivated by a sincere devotion to ignorance, a value they both preach and practice.

8) Cool analysis of age and gender effects on the nature of status updates.  Handy graphical summary from Andrew Sullivan. 9) I think it is great that Bill Gates is funding efforts to make a more pleasurable condom and I agree with this author that the backlash is ridiculous.  It is a simple biological fact that condoms reduce sensation and a socio-cultural fact that many men refuse to use them as a result.  You may not like that last fact, but it’s a reality.  If there can be real progress on the first fact, it might make a real impact on the second.  And that would be great for public health in many places. 10) NPR series of stories on Buried in Grain from back in March.  I got most of these on the radio– they were great.

It’s the prices

Why do we spend so much on health care in America?  Because we charge so much for health care in America?  Why do we charge so much?  Well, that’s complicated, but as much as anything it comes from a lack of a government role.  Hard as it may be for conservatives to accept all those countries with more expansive health care for lower cost due it by using the power of the government to keep prices down.  Truth is, doctors, hospitals, medical device manufacturers, etc., can do quite well and get plenty rich in other countries– just not nearly so rich as in America.  Ezra’s got 21(!) charts on the matter.  Here’s a few:

Now, tell me again we don’t need government involved in prices.  Or that somehow all we need is insurance companies to sell policies across states and this absurdity goes away?  Ummm, no.  National single payer health plan with a global budget?  Yep– that would go a long way.

Map of the day

Health care for the working poor via Medicaid expansion?  Socialism.  An end to liberty.  Health care for poor people?  Let ‘em die– or use the emergency room.  Ugh.  You may notice a pattern here:

Via: The Advisory Board Company

Viral Gastroenteritis 6; Greene family 0

Ugh.  Don’t expect a lot out of me today.

 

People will die

Okay, perhaps a bit hyperbolic, as people die or don’t die due to all sorts of governmental policy decisions– how closely to regulate pollution  traffic and automobile safety, how to deploy our armed forces, etc.  Yet, when you look at the Republicans refusal to allow the Medicaid expansion in this state, rarely is the connection so necessary and explicit.  Roughly half a million North Carolinians who should be getting basic health care– overwhelmingly paid for by the federal, not NC budget– will not be getting that health care due to the choices made by the Republican leaders in this state.  And if you think that access to basic medical care for that half a million won’t affect their mortality and hugely affect their quality of life, I’ve got a bridge to sell you.  Truly, morally appalling.  I’ve got a pretty damn good idea What Jesus Would Do and it isn’t this.  From the N&O:

RALEIGH — A Republican measure to prevent major components of the federal health care law from taking effect in North Carolina will almost certainly be approved after Gov. Pat McCrory endorsed the effort Tuesday.

The new governor had been a wild card after he expressed caution about the fiscal implications of the legislation and declined for weeks to take a position on the broader bill, which would prevent the expansion of Medicaid in 2014 to roughly 500,000 people and prohibit the state from creating an online exchange for private health insurance…

In explaining his stance, McCrory expressed concerns about whether the federal government would pay its share of the cost to expand in light of the budget deficit, which has exceeded $1 trillion in each of the past four years.

That’s just pathetic.  What an utter lie.  There is no doubt whatsoever that the federal government will make good on its Medicaid funding just as it always has when we’ve (almost always) been running budget deficits.  What really kills me is the pathetic hand-wringing of Dr. Idelogue:

Republican state Rep. Jim Fulghum, a retired neurosurgeon from Raleigh, called such uninsured people “an agonizing problem. “If there is a lack of care, I want to provide it – that’s just my nature and anyone’s in this field,” he said.

At the same time, he is concerned about the rising cost of Medicaid, which makes up 15 percent of the state’s $20 billion budget. The $3 billion cost to the state in the 2012 fiscal year compares to $2 billion a decade ago. The federal government pays about two-thirds of the cost for current participants, or about $11 billion.

“It’s a difficult issue to throw good money after bad,” Fulghum said.

Well, I’m glad to know that Fulghum will at least agonize over the considerable human suffering he will in large part be responsible for.  And, if he’s such agony, would it really be so awful to raise revenue to help pay for this, if necessary, into the future.  Now, that’s real agony for a Republican.  And, of course, this business of just blaming it all on ineffective Medicaid.  Does Medicaid have inefficiencies and problems like any other large, complex bureaucratic organization?  Of course.  But it also hugely important– and largely effective– to providing basic health care to millions of Americans.  If the Republicans are so concerned about the damn problems– fix them– don’t deny health care to hundreds of thousands of citizens.  Very many of them who are hard-working in low-paying jobs that don’t offer health care.

And finally, McCrory had done a lot to try and maintain his more moderate image.  At the time of the election, I said the real question would be whether he would follow the extreme elements of his party right off the policy cliff.  Sadly, I think we have our answer.