Self-centered Syllogism: Bad in public health, bad anywhere

I recently met someone who had seen a couple of my blog posts, was interested in public health, and asked a few interesting questions. My answers – or, really, comments – were things I have said and written about before, but his questions forced me to put them together, and in my opinion, the issues bear repeating.

The first question he asked was “why do we put so much emphasis on smoking but not on alcohol? After all, smoking never caused someone to beat their children or spouse, or to drive impaired and have an accident, or get into a bar fight and beat, shoot, or stab someone else.” That is true, and it raises the issue of the impact of substance abuse on the individual versus on the society (although second-hand smoke causes a lot of deaths). But the real answer is the incredible mortality caused by smoking. The CDC page identifies tobacco as the cause of nearly a half-million deaths in the US annually. While the data is from 15-20 years ago, and (hopefully) the mortality rate from tobacco has decreased as its usage has decreased, this is an astonishing statistic. Deaths from tobacco exceeded the total of deaths from alcohol, plus illegal drugs, plus accidents, plus homicides, plus suicides. It remains, even as smoking has decreased, a major health problem. The CDC says, “Tobacco is the leading cause of preventable mortality in the United States”. It was, therefore, the focus of public health efforts because of its tremendous impact on mortality.

However, of course, alcohol is also a major problem, causing both death and severe morbidity (bad outcomes besides death). It is, as my questioner noted, highly associated with violence against both family members and strangers, with automobile deaths, with homicide and not-homicide violence. It also, of course, kills people who use it, from diseases such as cirrhosis and heart disease as well as many cancers that are more common in heavy drinkers. We all have heard someone who did something very bad (commit violence against family members or strangers, have a car wreck, etc.) say “It was the alcohol. I wouldn’t have done it if I were sober”. But they were not sober, they had been drinking, and probably had often been.

The American Addiction Centers alcohol.org estimate that 88,000 people die from alcohol-related violence and abuse and accidents. The site also notes that “The American Society of Addiction Medicine notes that between 28% and 43% of violent injuries, and 47% of homicides, alcohol has been estimated to be involved.” That is a lot, and it could be an underestimate, but it is the closest I can get to quantifying the attributable risk for violence from alcohol. The concept of “attributable risk” in public health can be understood as the percentage of “bad outcome X” that would go away if “risky behavior Y” went away. This is different from the amount that it increases an individual’s risk; some behavior “Y” may increase your risk a lot but, because it is relatively uncommon, account for less attributable risk. Examples include asbestos and lung cancer (very high increase in risk but a lower percent of cases, compared to smoking). Or, looking at it inversely in terms of what disease a risk factor causes, smoking and lung cancer vs. heart disease. Smoking increases the risk of lung cancer more than it does heart disease, but because heart disease is so much more common, the attributable risk from smoking, the number of lives that would not be lost if people didn’t smoke, would be more from heart disease than lung cancer. An example of “smaller percentages of larger numbers can be greater than larger percentages of smaller numbers”.

So what did I say about alcohol? He identified the fact that there is a very large industry of alcohol manufacturers and sellers, which have great influence. I noted that there was (is) also a great industry of tobacco manufacturers and sellers. He said that in addition to the manufacturers, there were also many businesses, restaurants and bars whose existence depended on the sale and use of alcohol. The current emphasis we see in “alcohol reform” is “don’t drink too much”, a common “PSA” from alcohol manufacturers. The implicit message, however, is “do drink!”.

I think most of the members of our society, including many of those still smoking, recognize that any amount of smoking is bad for you, and more is worse, but I do not think that the same is true for alcohol use. The general attitude, even among medical and public health professionals, seems to be “a lot of drinking is obviously bad, for you and for others, but a little – like I do – is not.” What could be wrong with a couple of beers? A couple of glasses of wine? Especially if you’re not driving? Aren’t there studies that show a little red wine is good for you?

There are such studies but they are dated, poorly done, and wrong. Pretty much, while more is worse, there is no amount of alcohol consumption that is good for your health, and any amount is somewhat bad. We disparage those who use other drugs (heroin, cocaine, crack, meth, even still cannabis) for entertainment, but much of our society is actually built around alcohol as the “social lubricant”. Restaurants, bars, parties. Family events like weddings and funerals. Most of such entertainment revolves around alcohol. Perhaps the only place where alcohol is not the key component of “having fun” would be at an AA meeting! This issue is seriously joined by Holly Whitaker in her book “Quit Like a Woman: The radical choice not to drink in a culture obsessed by alcohol”.

The key here is that so many people drink (if “responsibly”, by which they usually mean “not too much” and “not when driving”) that they have to justify themselves by saying it is OK. I call this the “Dirk Gently Phenomenon” from Douglas Adams’ book “Dirk Gently’s Wholistic Detective Agency”. The lead character, who dies on the first page, was a millionaire who made his money by essentially developing syllogisms that took you from the data you had to the conclusion you had foreordained (his biggest client was the US Department of Defense). This is pretty much what we do in lots of areas, including alcohol use; we decide on what we want the answer to be and then look for evidence that supports it.

My new friend noted his son had been in a public health program a few years ago when the big emphasis was on obesity and its health effects. I nodded, but it not so much any more. Obesity has big health effects, yes, but it is also easy to disparage people who are overweight. This is a manifestation of another common tendency among people (including among health professionals): to be critical of people who do (or don’t do) things that come easily to you to do or not do, and conversely minimize the significance of the negative behaviors that you do (or don’t do). If you are naturally thin and have an no difficulty keeping weight off, it is easy to criticize those who are overweight. However, if you like your fancy wine or craft beer or expensive single-malt scotch, you don’t think drinking is such a bad thing. Or, for that matter, being self-righteous.

Public health is good and important. In the US, it is grossly underfunded compared to individual medical care (about 1% of health care dollars). But, like much of medicine it is also subspecialized. To a large degree, public health researchers go where the money is available for grants – in obesity, or smoking, or violence prevention, etc., and become specialists in that area. It is (or should be) different in primary care. As a family doctor, I can measure and counsel you on your blood pressure, but I cannot ignore your diabetes or lung disease and just refer you to another specialist. Similarly, while public health specialists “do obesity” or “do child seats”, this is not an option for the family physician. I need to help you to stop smoking, but cannot ignore that you need to use a seatbelt. Or get vaccinated. Or would have a greater probability of better health outcomes if you lost some weight. Or did not drink so much. Or at all.

Judging others for doing (or not doing) what we find it easy to not do (or do) and minimizing the damage caused by what we ourselves do is a big logical flaw, as is the “Dirk Gently” fallacy. They are not attractive, appropriate, or helpful or good for anyone, and are especially dangerous coming from medical or public health professionals.

Gangster capitalism and our health: In the US and in the World

There has been a lot written about capitalism. Karl Marx, for example, wrote a multi-volume study of it just about 150 years ago, and since then a lot of the writing has been about what he wrote, supportive and critical. There is no question that it has remained the dominant economic system in the world; it is the linchpin not only of Western “democracies” and totalitarian fascist states but also ostensibly Marxist governments like China. While capitalism has both its defenders and detractors, it is interesting to me that the defenders spend little time defending the amazingly deleterious effects that it has on the quality of life (and even existence of life!) of people, the environment, war, and (to the point of this blog) health.

The problem is that, in pursuit of profit, industries will do and have done almost anything, with no moral compass or conscience, and, worse, with no concern for future generations or the planet. Some of the most obvious and egregious examples in the US at this time include their (largely successful) lobbying of the current administration to roll back on rules to ensure clean air and water and the overall environment so that they (in this case, extraction industries like oil and mining) can further increase their unconscionable profits without worrying about the damage it does. So we have mining and extraction in and near our national parks (“near” is important; air and water do not respect boundaries!), scaling back of national monuments so extraction can take place, poisoning of the water through leaks in oil pipelines (such as Keystone), and poisoning of the air we breathe when fossil fuels are burned. Oh yeah, and the increase in global warming which has already permanently altered the climate and will eventually wipe out life on earth (starting with the lowest lying areas) if nuclear war doesn’t first.

Our health and safety is also constantly at risk from aggressive efforts by corporations to increase their profits. This can take the form of producing unsafe products either because it saves money (e.g., dangerous child toys) or costs a lot to not do (e.g., not having lead in our water or asbestos in talcum powder), or by making important and beneficial (and hopefully safe) medications unavailable to many people because of incredible price increases (for the tip of the iceberg, see “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016). We of course know about the ongoing – and largely successful efforts – of the tobacco industry to increase their profits by promoting a product that kills 400,000 people a year in just the US (mainly from cancer and heart disease), including through promoting it to children (e.g., the cartoon character “Joe Camel” – see Fischer et al, “Brand Logo Recognition by Children Aged 3 to 6 Years: Mickey Mouse and Old Joe the Camel”, JAMA 1991;266(22):3145-3148, December 11, 1991).

One of the most vicious and insidious efforts to compromise our health in the interest of profit has been carried on for more than a half-century by the sugar industry. For decades, under the table, sugar producers funded scientific research into the negative effects of a high-fat diet while ignoring the almost-certainly more detrimental effects of a high-carbohydrate, especially simple carbohydrate – sugar – based diet. Soda pop became the national beverage with incredible impact on the rate of obesity, in the US and internationally. A 12-oz can of Coca-Cola® has 140 calories, so what about that 40oz fountain drink at the convenience store? A 2-liter bottle has 812 calories. That’s a lot. So most health professionals, like doctors, tell people to not drink it, or not very much of it. This is, however, competing against the messaging of the industry, which pushes it a lot, and gets the cooperation of many nutritionists through the use of – wait for it – money! I have written about the corruption (or conflict of interest, to put it nicely) of health organizations like the American Academy of Dietetics and Nutrition (AADN) and the American Academy of Family Physicians being funded by Coca-Cola® and other sugar purveyors and having their ads on their websites (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). The ads are no longer there, but you can read about the AADN at the fooducate blog, and if you search sugar on the current AADN website, you will find some pieces on limiting sugar, but as many on the potential risks of artificial sweeteners (which, whatever your beliefs,  the FDA rules as safe) and fats.

Of course, as with the case of tobacco, efforts to limit the sugar market in the US (such as Mayor Michael Bloomberg’s failed attempt to limit the size of sugary sodas in NYC), have led the industry to branch out and increase its efforts to profit in the rest of the world, particularly the developing world. While many countries can be targeted, the biggest markets, China, India, and Mexico, have received special attention. The NY Times has an important exposé  on January 9, 2019, ‘Research details how junk food companies influence China’s nutrition policy”, citing work published in BMJ (“Making China safe for Coke: how Coca-Cola shaped obesity science and policy in China”) and the Journal of Public Health Policy (“Soda industry influence on obesity science and policy in China”) on the role of the International Life Sciences Institute (ILSI):

…a worldwide organization with a Washington headquarters, funded by many of the biggest names in snack foods, including Nestlé, McDonald’s, Pepsi Co. and Yum! Brands as well as Coca-Cola. It has 17 branches, most of them in emerging economies like Mexico, India, South Africa and Brazil, and promotes itself as a bridge between scientists, government officials and multinational food companies.

But in China ILSI is so well-placed that it runs its operations from inside the government’s Centre for Disease Control and Prevention in Beijing. In fact, when asked to comment on the studies, the ministry emailed a statement not from a government official but from ILSI’s China director.

Thus China’s health policy, which almost entirely focuses on exercise like “Happy 10 minutes” (good for you!) and ignores the dangers of high-calorie sugar-laden foods for obesity (and there is excellent evidence that diet is probably about 80% of the issue, with exercise critical for the other 20%).

There are those who will argue that it is not capitalism itself, but “unfettered capitalism” that is the problem. There is a lot of truth to that. The blind pursuit of maximal profit with no attention at all to the negative impacts on the world around them is not a necessary part of any profit making endeavor. Indeed, the “Wealth of Nations” by Adam Smith cautions strongly against this sort of excess, and “the only responsibility of business is to make profit for its stockholders” guru Milton Friedman sort of assumed that they wouldn’t do it.

But they do, and “unfettered” – or corporate gangster capitalism – is what is running the world. And it is not good for our health.

Keeping immigrants and all of us healthy is a social task

The Health Toll of Immigration, by Sabrina Tavernise in the May 19 New York Times, documents the decreased life expectancy and worse overall health that accompany immigration to the United States. Focusing on Mexican immigrants in the border city of Brownsville, Texas, but drawing on data about other ethnicities and even time periods, the article provides convincing data that descendants of people who immigrate from Mexico and other, poorer, countries, have, in general, worse health, greater rates of obesity and diabetes, and shorter life expectancies than their parents or those who stayed. The numbers are impressive:  “A 2006 analysis by Gopal K. Singh, a researcher at the Department of Health and Human Services, and Robert A. Hiatt, a professor of epidemiology and biostatistics at the University of California, San Francisco, found that immigrants had at least a 20% lower overall cancer mortality rate than their American-born counterparts. Mortality rates from heart disease were about 16%  lower, for kidney disease 18%  lower, and for liver cirrhosis 24% lower.” It seems to get worse for later generations; “Elizabeth Arias, a demographer at the National Center for Health Statistics, has made exploratory estimates based on data from 2007 to 2009, which show that Hispanic immigrants live 2.9 years longer than American-born Hispanics.”

Some, perhaps most, of this is related to the prosperity of the US, and the easy availability of cheap, high fat, high sugar, high calorie food. One woman, who came to the US at 26 and has since developed diabetes, says she was amazed at seeing hamburgers as big as dinner plates; “I thought this really is a country of opportunity! Look at the size of the food!” Grueling work hours, both parents working (when both are here) make time for preparation of healthful food scarce, and more cash in their pockets allows the purchase of tasty-but-bad-for-you fast food. In addition, there is evidence of increased smoking and drinking as immigrants move into the US underclass, a group particularly targeted by marketing efforts for these substances of abuse.

Traditional diets for most people, including Mexicans, are based on food that is grown or found wild (vegetables, cactus) or bought in bulk (rice and beans). These are high fiber and low in empty calories. Robert Valdez, from the Department of Family and Community Medicine and Economics at the University of New Mexico, is quoted as saying “All the things we tell people to do from a clinical perspective today — a lot of fiber and less meat — were exactly the lifestyle habits that immigrants were normally keeping.” There is some evidence that there may be a genetic predisposition to diabetes in some Latinos, particularly Mexicans, as there is in American Indians; after all, Mexicans are largely a mestizo people with much Indian “blood”. Of course, these observations may be related; the natural diet of native peoples did not provide the environmental  factors (high calories, obesity) needed to trigger clinical diabetes, and so the genes for this did not “die out” as readily as in other groups. The same model is seen in South America; the remote Xingu Indians of the Amazon now have extremely high rates of diabetes where it never existed before the introduction of “white” food (used to refer to the color of the food as well as of the people who introduced it).

The other big factor is physical activity. While many immigrants work in physically demanding jobs, the prevalence of physical activity is not as great as for those living on farms in Mexico. One man talks about losing 75 pounds motivated by the image on the wall of his grandfather, who is 93 and still rides his bicycle every day. Yet, 4 of the 6 siblings of the grandson are obese and have diabetes. Another immigrant talks about walking in her early years in the US and feeling so conspicuous (“a bean in rice”) that she was afraid people would think she was here illegally. This has also been described in African-Americans moving from the agricultural (and very poor) South to a more prosperous, but sedentary, life in the North, and in most families a generation or two removed from farms, whatever their ethnicity. Concepts of what is “enough” food, what is a “good” breakfast or dinner for our children, did not change as quickly as lifestyles did. Our culture does not require physical activity as part of daily life the way farming, including subsistence farming, did, but we fed our children the same number of calories as we did (if we were prosperous farmers) or would have liked to, or more, because it is more easily available. Indeed, these changes are not limited to the US; things are changing for the worse (in terms of health) in Mexico as well; citing the fact that up to 40% of the rural diet in Mexico comes from packaged foods, “Researchers are beginning to wonder how long better numbers for the foreign-born will last.”

These are all factors in the “social determinants of health” – how we eat, how we exercise, how poverty grinds us down and how marketing of harmful substances like tobacco, alcohol, and high-sugar foods take their toll at even greater rates on the poor. This is not to romanticize rural poverty, of people, including children, having to do excessive physical labor in order to survive and thus burn up more calories than they consumed, or to minimize the difference between a rural/farming life which provided enough income to supply those calories and those in which malnutrition claimed lives and health. It is, rather, to point out that some of these terrible conditions ironically protected the health of its victims. This has been observed in the past; beri-beri occurred more in wealthy Chinese who ate hulled white rice than in the poor who ate the rice with hulls that contained the thiamine. In England in the early 20^th century alcoholic cirrhosis was a disease of the rich who could afford highly-taxed spirits, while workers drank watered beer. The image of the wealthy many as obese – and suffering from gout, "The disease of kings1" (all that high-protein food) persists in cartoons.

Dr. Arias, cited above, observes that the health status of immigrant families “…may indeed improve as they rise in socioeconomic status, which in the United States is strongly correlated with better health.” Of course, there is no guarantee that longer time in this country will cause a rise in socioeconomic status; the last decade shows a persistent decrease in the socioeconomic status of most Americans, despite a “recovery” measured by Wall St. stock prices. The answer is not to regress to rural poverty, but it is to address these social determinants. It is to build towns that encourage walking and other physical activity. It should be to make fresh, healthful food widely available. It should involve education in schools about healthful eating, not undercut by junk food available in machines. It should limit advertising for poisons such as tobacco and alcohol. It should make clean air and water a priority, and ensure everyone has access to good health care.

 It should be a no-brainer, but in the politics of the US today, it may not be. Charles Blow in his May 18, 2013 column “Resonance Resistant”, notes that “We all know that anything with ‘social’ in its name activates the conservative gag reflex.” This is crazy; we are social beings. We can do better, and we should.

Weight and class: who is obese and why should we care?

One of the things that people are most fixated upon, in both the health arena and in society at large is weight. In popular culture, weight is a major issue. Celebrities are (mostly) thin; when they are not, and look like more of the regular people who are around us, they are seen as unusual. Diet books and “fad” diets abound as do classes to help us exercise. Issues of body image are major stressors for adolescents in particular, and health problems like anorexia are all too common. And, yet, an increasing number of Americans are obese, and health problems that are certainly associated with obesity – notably, but not only, Type II diabetes – are rapidly growing.

There is a major class association with weight; as income and class go down, prevalence of obesity goes up. Perhaps ironic compared to earlier centuries, when being heavy was associated with money – that is, the ability of the person to afford all that food – and poor people were starving. But if ironic, it is serious; the abundance of cheap, high-calorie foods in our society mean that poor people are not denied the opportunity to have lots of calories, but the stressors of poverty that affect all aspects of social life are still there, creating obesity as just one more problem to be confronted (or not).

In this context, a recent article in JAMA by Katherine M. Flegal and colleagues has garnered a lot of attention. “Association of All-cause mortality with overweight and obesity using standard Body Mass Index Categories: A systematic review and meta-analysis”[1], reviewed 97 studies with over 2.8 million people and encompassing 270,000 deaths, and performed a meta-analysis (a set of statistical techniques that allows accounting for studies that are somewhat different in design and have different numbers of people). The results were that people whose body mass index (BMI, a ratio of weight to height) was in the “overweight” range (25-30) had lower all-cause mortality than those in the “normal” range (18.5-25). In fact, the all-cause mortality rate was no higher for those in the range of “grade 1 obesity” (30-35) than for those in “normal” weight range. However, it was higher for those with grade 2 obesity (35-40), grade 3 obesity (>40) and for all obesity taken together (>30). In addition, unsurprisingly, the “hazard ratios” for mortality were greater for the same BMI when heights and weights were self-reported rather than measured (suggesting people under-estimate or under-report their weight, which would mean their BMIs are actually higher than reported).

This is not, of course, really new news, since all of the studies reviewed had been previously published. There was already a sense among many in the medical field that people at the “low end” of overweight (say 26-27) might be as least as healthy (have as low a mortality risk) as those at the low end of “normal” (18.5-25).  Heymsfield and Cefalu, in their editorial commenting on this study, “Does body mass index adequately convey a patient’s mortality risk?”,[2] say “Persons with a BMI between 18.5 and 22 have higher mortality than those with a BMI between 22 and 25. Placing these persons in a single group raises the mortality rate for the normal weight group. The average resulting from combining persons in the lowest mortality category (BMI of 22-25) with those who have greater mortality (BMI of 18.5-22) might explain why the NHLBI category of normal weight has an observed mortality similar to class 1 obesity (BMI of 25-30).”

If people with a BMI of 18.5-22 have a higher mortality rate than those with a BMI of 25-30, why, for goodness sakes, is 18.5-25 considered “normal”. For reference, a 5’4” person with a BMI of 18.5 would weigh about 108lbs, at a BMI of 22 it would be 128lbs, at 25, 145lbs, and at 30, 175lbs. For a person who is 5’10”, the weights at the same BMIs would be about 129, 152, 174, and 207. I think most people would not think that the lower range was normal except for models and marathon runners (hey, I’m overweight and would like to lose about 10-15 pounds of fat, but I think I’d be pretty sick before I lost the 60 lbs needed to get me to 22! My son was heavy when he developed Type I diabetes as a young adult, and went from a BMI of about 32.5 to about 21; let me tell you, he looked bad!), but the real question is “what are the healthiest ranges to be at”? This is what official recommendations should be based on, and it is clear from the work reported by Flegal and colleagues that this is not the case for the current numbers.

The relationship between adiposity (presence of significant amounts of excess fat) and risk for many diseases is well-established; the relationship between adiposity and BMI less well so. Variables include amount of muscle mass (not a risk factor but leading to greater weight-for-height), sickness (people who lose weight as a result of disease), and overall body structure. I tried to find out where these ranges come from, but have, so far, been unsuccessful. I found the references to the “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults”, put out by an expert panel in 1998, but at least their “Executive Summary”^[3] does not reveal the source of how the “normals” were derived; they are just asserted. 

Obviously, this is going to be controversial. Paul Campos’ op-ed piece in the NY Times on January 3, 2013, “Our absurd fear of fat”, makes many of the same points I have, but letters generated in response range from those lauding it and saying people (especially children) should be taught to be proud of their bodies, to those arguing it minimizes the health dangers of obesity. What is clear, though, is that the fixation on “ever thinner” that exists in much popular culture has no place in health discussions. The JAMA article strongly suggests that our standards for “normal”, “overweight” and “obese” BMI are too low, although not irrelevant. It calls our attention to a tendency to other similar areas in which health professionals have adopted uni-dimensional disease markers and driven them even lower, to result in poor health outcomes for many. Recent examples include blood sugar (or its related value, hemoglobin A1c), blood pressure, and cholesterol. Studies that held everything else equal found benefit in lower values, so experts kept driving down the definitions of normal and desirable for these tests. Unfortunately, not everything else is equal. Pushing the desirable hemoglobin A1c level of people with diabetes to 5% instead of 6% led to a lot of morbidity from hypoglycemia; lowering cholesterol goals led to toxicities from drugs; lowering blood pressure goals to poorer functioning and greater mortality in some populations, especially the elderly. Most people don’t exercise regularly, but rather than lauding all efforts to exercise, “experts” keep raising the bar for how often, how long, and how intense exercise should be.

So let’s get back to class, and its associated characteristics. It is time for health professionals to recognize that they are also social service professionals and members of a society whose broad policies have a much more profound impact upon health than small numbers variation in BMI, blood pressure, cholesterol, and blood sugar. We need to treat, as well as support and encourage, people at the extremes whose health is at risk, but we shouldn’t fall prey to definitions that name more people as diseased and needing interventions and distract us from the real business at hand.

Which is creating a more just, fair, equitable and safe society.

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[1] Flegal KM, et al., “Association of All-cause mortality with overweight and obesity using standard BMI Categories: A systematic review and meta-analysis, JAMA Jan 2 2013;309(1):71-82

[2] Heymsfield SB, Cefalu WT, Does body mass index adequately convey a patient’s mortality risk?” JAMA Jan2 2013;309(1):87-88.

[3] Expert panel, “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary”, Am J Clin Nutr, 1998;68:899-917.