Sunday, November 20, 2016

Public Health Strategies Part 2: Personal Responsibility

If you find one of the ideas in these posts on public health strategies objectionable consider waiting before jumping to conclusions because I may address your concerns in a later post

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.  In this post I’ll discuss the strategy of personal responsibility, which I thought fits nicely into the libertarian right quadrant.  This is because personal responsibility is a key value of the political right, and because personal responsibility is a strategy that maximises individual freedom and ultimately limits the influence of government and others

It’s tempting to blame what’s called the obesogenic environment (which is a decent point I'll discuss later) and ‘evil corporations’ for the rise in obesity and other chronic diseases across the globe.  Similarly, because free will cannot exist, one could justify playing the victim, that they are not personally responsible for the bad things that happen in their life including their poor health behaviours and health status, that they are a victim of being born to the wrong parents and living in an obesogenic environment

As discussed in the previous post, even though free will does not exist there is value to society and us as individuals to emphasise a belief in personal responsibility.  We have plenty of options to make healthy or unhealthy lifestyle choices; we all know the basics of what to do to improve our health (that whole foods are on average healthier than highly processed foods and that getting enough exercise and sleep are important); and no one has a gun to our heads forcing us to make the wrong choices.  The blaming of business is not really appropriate (except when they distort science and engage doctors/dieticians for hire) as businesses cannot force us to purchase their products (unlike government), but instead they are reacting to what consumers want when they decide to open more stores and make more products (supply and demand).  In addition, there should come a time when people realise that although playing the victim may give you an excuse and sympathy in the short-term, but in the long term others will become desensitised to the strategy such that it no longer has the same effect, and is ultimately unproductive as your problem will remain until you take active steps to fix it.  In this respect, holding yourself and others personally responsible is more empowering than wallowing in self-pity

The efficacy of personal responsibility as a public health strategy is difficult to assess.  Some people may argue that it’s the status quo and so is failing as a public health strategy.  However, I don’t think this is completely true

1) Taking personal responsibility for your health isn’t as incentivised as it could be.  Most Western countries have some degree of universal healthcare, health insurance, subsidised pharmaceutical drugs, and government funding into the basic sciences that can lead to drug development.  These policies and institutions mean that individuals and not completely financially responsible for the costs of poor health resulting from poor lifestyle choices, and the financial costs are instead shouldered by others to varying degrees in the form of more taxes, or from funding being taken away from other public services.  Under such conditions it would be expected that individuals would be less motivated to prevent and treat diet and lifestyle diseases themselves by improving their diet and lifestyle

2) Our society’s narrative on ageing and chronic disease is one that emphasises an inevitability of chronic disease and the role of bad luck, rather than personal responsibility.  I think some of this narrative is to protect against blaming and shaming when people are at their most vulnerable, but it has the unintended consequence of fostering a belief that humans are broken and creating a sense of hopelessness

So the potential of personal responsibility as a public health strategy is not likely to be realised in a society that has universal healthcare, social norms against personal responsibility and a pessimistic attitude towards ageing and chronic disease.  So the strategy of personal responsibility should be coupled with: (1) a major change in universal healthcare, or at least the addition of a mechanism that incentivises people not getting lifestyle diseases/adopting good health choices (focus of the next post I have planned); and (2) a change in society’s narrative of chronic disease to one that empowers people

The second point illustrates a weakness with personal responsibility as a public health strategy.  Which is that it requires that people either know or have readily available access to the knowledge that will allow them to make the healthy lifestyle choices that will dramatically reduce their risk of chronic disease or in other cases treat or reverse existing diseases.  Some of this knowledge is already widely known, but most people don’t know about even well supported interventions (such as very low calorie diets for type 2 diabetes, vitamin K2 for osteoporosis, and higher protein diets for fat loss and sarcopenia) and there will almost certainly be more options available that no one knows yet until more research is done

Sunday, November 13, 2016

Implications of not having Free Will

In the previous post I briefly challenged the idea of free will.  In philosophy, hard determinism states that current events are determined by previous events and therefore free will cannot exist.  That any thoughts or actions we take are the result of the interaction between earlier environmental factors and our genetics.  And those earlier environmental factors in turn are the result of the interaction between even earlier environmental factors and our genetics.  You can ultimately go back with this chain of causality (infinite regression) to a point where we have not yet been born.

Hard determinism is very difficult to argue against, but some philosophers argue that even though current events are determined by previous events (determinism), the fact that we have choice on a practical level means that free will exists.  This position is called soft determinism or compatibilism and can only work by changing the definition of free will.  You could describe this version of free will as functional or practical free will, as opposed to what could be called ultimate free will that is the topic of this post

The case against free will has been made stronger from recent neuroscience research, showing that our conscious awareness of having made a decision occurs after our brain unconsciously makes the decisions [1] [2].  So in a sense, both conscious decision making and free will are illusions

Rather than being an academic point, I think the absence of free will has several important implications.  In the previous post I used the absence of free will to question whether it was appropriate to blame someone for their behaviours and health status, but there are more important issues than this.  This content is going to be quite different to my usual blog posts, but I think these are ideas worth mentioning regardless

Personal Responsibility

In the strictest sense, a not having free will means that we cannot be personally responsible for our actions and so any praise and criticism is not deserved.  However, it’s still important for the functioning of society to emphasise personal responsibility and praise and criticise the behaviours of others as if they were personally responsible.  This is purely because of the positive consequences of doing so, the negative consequences of not doing so, and the fact that none of us have a gun to our head forcing us to act in a certain way (functional or practical free will)

Imagine the following scenarios:

  • Someone does poorly on their job and when questioned about it states that they are not responsible for their poor performance
  • A driver runs over a pedestrian with their car, and in court claim they are not personally responsible for running the pedestrian over
  • A student studies hard for a test and does well on it.  The student receives no praise from the teacher who decides the student is privileged for being white/Asian and being middle/upper class
  • An entrepreneur finds a gap in the market, takes risks and works hard to start and build their business, and they end up making a lot of money.  Despite selling people products they want and increasing jobs, an angry mob claims conflates inequity with inequality and demands 90% of the entrepreneur’s income

In each scenario the person cannot strictly be held personally responsible for their actions, but each scenario demonstrates the importance of: (1) emphasising personal responsibility regardless of its truth; and (2) using praise and criticism to encourage good behaviour and discourage bad behaviour, even if life isn’t fair, the world isn’t a true meritocracy, and the praise and criticism isn’t deserved.  You would want other people to hold themselves personally responsible for their actions, other people would want it of you, and you would want society to be based on it and the encouragement of good behaviour and discouragement of bad behaviour

The alternative is a bleak world, but one that is close to the utopia of social justice warriors.  It would be a socialist world where people would have little incentive to work hard or create value.  The opposite would be true as people would be incentivised to take as much as possible from society while doing as little work as possible, claiming that their unique set of genes and environmental factors resulted in them having great needs and little ability*.  The perceived merits of each person and the criminal justice system would be perverted by what Thomas Sowell calls cosmic justice.  The purpose of the criminal justice system will no longer be to deter crime and prevent repeat offences to protect the innocent.  Instead it will focus on the criminal and apply the law unequally to people from groups with current or historical privileges or oppressions to the detriment of the public.  This will raise tensions between races/sexes/etc because the ‘privileged’ group will be resentful of the special treatment of the 'oppressed' group, while the ‘oppressed’ group will be fed a false narrative of victimhood at the hands of the privileged.  People who disagree with this ideology won’t receive the same concessions.  They will uniquely be held personally responsible, labelled as evil, and silenced in the name of progress because the end always justifies the means

* Capitalism is been criticised as a system based on based on greed.  I agree, but capitalism incentivises co-operation and creating value for others, whereas socialism is a system based on sharing, but one that actually incentivises greed

Divine Justice

For this section just an FYI, I’m an atheist

This brings me to what I think is the most important implication of not having free will by far.  Many religions have a concept of an afterlife and that pleasantness or unpleasantness of which is determined by your actions while you’re alive.  This is judged by an omniscient deity in the Abrahamic religions (Judaism, Christianity, Islam) or by karma in Eastern religions such as Hinduism and Buddhism.  I’ll call this divine justice

Many aspects of religion can be interpreted to have had functions that provided a net benefit to society in some way at some stage.  For example, the Abrahamic religions have a very strong emphasis on hygiene and cleanliness and this was likely a cultural adaptation against infectious disease at a time before the germ theory of disease.  Similarly, the belief in an afterlife and in divine justice could have been a cultural mechanism to strongly encourage or discourage certain behaviour and provide consolation for the suffering experienced in life.  This could be cynically interpreted as a means to keep the general population complacent with authoritarian regimes and the massive inequalities in those ancient societies

Belief in an afterlife and divine justice may have been helpful earlier, but I think that these beliefs are ultimately responsible for some of the major problems in the world at the moment, which is why I’m writing this section

The Abrahamic religions have a belief in the same deity, who is believed to be omniscient, just, and merciful (they believe this deity possesses many other qualities, but these are ones relevant to the topic).  They also all include a belief in free will, an afterlife and divine justice.  Belief in free will is a necessary premise for belief in divine justice, and in the absence of free will, the belief that their deity possesses those qualities contradicts the belief that divine justice will affect the quality of the afterlife

Since free will cannot exist, therefore we cannot strictly be personally responsible for our actions.  An omniscient, just, and merciful deity could not possibly condemn someone to purgatory or hell based on the actions they made in life as these actions are a product of the genetic and environmental cards they were dealt.  For such a deity, divine justice would be an infinite regression back to the first cause – the big bang (or whatever came before that) or the deity creating the universe – and everyone would have to be judged as neither good nor evil and deserving no different treatment regardless of whether they were a sociopath or a saint.  It would take an exceptionally unjust, unmerciful and sadistic deity to condemn someone to an eternity of suffering for the crime of being born to the wrong parents, in the wrong place, at the wrong time

Therefore not having of free will - combined with a belief in an omniscient, just, and merciful deity - undermines the religious beliefs and practices (but not faith in a deity) one would ordinarily not partake in, but does so to appease their deity and increase their chances of a better afterlife.  Knowing this would have the effect of freeing people from any religious practices that don’t improve your life or the lives of others (because you don’t need religion to be a good person).  Most importantly, not having free will undermines a basis for religiously motivated violence/terrorism outside sectarianism (whether it’s holy war, delivering gays from sin, just killing infidels, etc) and the politicisation of religion, all because it cannot matter in the eyes of an omniscient, just, and merciful deity

Sunday, October 23, 2016

Public Health Strategies Part 1: Blaming and Shaming

In the previous post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.  In this post I’ll discuss the rationale and efficacy of the strategies of blaming and shaming, which I thought both fit nicely into the authoritarian right quadrant.  This is because of the emphasis on personal responsibility in these strategies, which is a key value of the political right, and because of the authoritarian nature of blaming and shaming others*

The strategies of blaming and shaming are ones I thought of later, after I noticed that none of the strategies that initially came to mind fit nicely into the authoritarian right quadrant.  I think this is due to blaming and shaming not really being that commonly discussed as public health strategies, probably because so many people find it abhorrent, and also because I haven’t been the recipient of either, as they are generally just applied to people who are overweight and obese

It’s worth noting that blaming and shaming are so rarely applied to other health conditions largely caused by poor diet and lifestyle and so rarely applied to unhealthy behaviours when the individual is not overweight or obese.  Blaming and shaming may be quite specific to overweight and obesity because it is visible unlike other costly chronic diseases, it’s easier to jump to the conclusion of a character defect (gluttony and sloth) and perhaps because it triggers something in our brains like a sense of unfairness (they are having more than their fair share)

Even though I bundled blaming and shaming together they are actually two different strategies both with slightly different rationales and outcomes

* However, this doesn’t mean that blaming and shaming others are strategies that are exclusive to the authoritarian right. In fact, these days I see shaming being more commonly used by the authoritarian left (social justice warriors)

Rationale of blaming

The rationale of blaming is that individuals are ultimately responsible for their behaviour, and consequently responsible for their health status.  That holding other individuals responsible for their health behaviours and health status is both a statement of fact and more likely to result in behaviour change and health improvements than not taking personal responsibility for their health behaviours and health status

However, there are many factors beyond an individual’s control that can strongly influence their health behaviours and health status:

·         To start from the beginning, individuals cannot be held responsible for the genes they inherit, and the particular set of genes can strongly influence behaviour and health outcomes.  Genetics are a strong predictor of obesity for example [1]*
·         Next is that the health status of the parents at conception, the health status of the mother during pregnancy and breastfeeding, and the child’s environment during the early years all strongly influence an individual’s health later in life.  In fact there is a whole field of study called the developmental origins of health and disease (DOHAD) [2]
·         And finally is the environment the individual is in, including the influences from the family, factors that go with socioeconomic status, obesogens, etc (see this map of factors behind the obesity epidemic)

In fact, when you think about it, our behaviour and thoughts are entirely due to our genes and environment, both of which we ultimately have no control over, and thus free will cannot exist (a little more on this later).  This all begs the question of whether it is appropriate to blame someone for their behaviours and health status, or whether these things are merely a product of circumstances that are ultimately beyond an individual’s control

* Although the extremely low prevalence of obesity and other chronic diseases in western populations 100 years ago and in hunter gatherers and other non-industrialised societies indicates that it’s extremely rare for genetics to be a sufficient cause of chronic disease

Efficacy of blaming

Since the strategy of blaming is like a soft form of shaming and has an appeal to personal responsibility, the efficacy of blaming is related to both of those strategies and so should be covered when discussing the efficacy of those strategies.

Rationale of shaming

The rationale of the strategy of shaming has two components that are outlined well in this paper [3]:

·         Individuals are not sufficiently aware of their poor health behaviours and poor health status or are not sufficiently aware that their poor health status
·         ‘Soft’ public health strategies, like self-regulation of the food industry and education, haven’t worked and so ‘hard’ public health strategies, like taxation, bans and social coercion (such as shaming) are necessary to improve health and reduce healthcare costs

Both the rationales of shaming depend on other people being negatively affected by someone else’s health status, and consequently their health behaviours.  This is generally because of the costs imposed on the public health systems, but could also similarly develop if an individual’s poor health was negatively affecting a company’s productivity or the productivity of a country, particularly if that country is very collectivist or is being economically or militarily threatened.  Without such conditions, resorting to such antagonistic measures as shaming is probably just a bullying tactic

The rationales of shaming are actually fairly reasonable:

·         85% of Australians said they were in good or excellent health despite most being overweight or obese, half having a chronic disease, many being on prescriptions and very few meeting targets for diet and exercise [4]
·         ‘Soft’ public health strategies evidently aren’t working

* Given that shaming largely depends on someone’s poor health choices and health status leading to costs on others, it is more difficult to justify shaming someone who pays a large amount of tax (being a net benefit to the public health system) or is a net benefit to society in other ways

Efficacy of shaming

Without looking into this too deeply myself, there seems to be a bit of evidence that fat shaming and body fat stigma on average doesn’t work and has the opposite effect (more calories eaten and more weight gain over time) [5].  This is not too surprising as someone who is overweight or obese is quite aware of that fact, and is reminded of it many times daily without the need for other people to point it out, and that intrinsic motivation works better than extrinsic motivation

Of course, some people can credit fat shaming for at least part of the motivation that started them on successful long-term weight loss.  In addition, if shaming was done in a highly systemic and extremely authoritarian way (think totalitarian government or a fat police instead of a morality police) then I would expect it to work.  But this raises the question of whether the ends justify the means.  The purpose of implementing public health strategies is to ultimately improve quality of life in society, and this can be achieved by improving health and by using money that is no longer needed by the public health system towards other projects that benefit people.  With this in mind, it’s worth asking whether fat shaming to any degree will improve society overall or have the opposite effect

Sunday, September 18, 2016

Values, Politics and Public Health

The prevalence of obesity and other chronic diseases is quite a problem whether you approach this by looking at the burden on medical systems or simply how they adversely affect the quality of life of many people.  Read a comments section (or be a student in a faculty of health) and you’ll find there’s several different approaches being promoted on how to solve this problem.  These can be summarised as:

  • Personal responsibility
  • Education
  • Taxes/subsidies and bans
  • Pharmaceutical drugs 

A recent piece in the Huffington Post argued for taking politics out of obesity but all proposed public health solution are political, and these political positions are based a set of values

The Political Spectrum

The left-right axis in politics is fairly well known.  But beyond economic policies, the characterisation of this spectrum varies widely on which additional issues this spectrum should include.  Some of the problem here is that the traditional ‘left’ and ‘right’ parties often have opposing positions on various social and other issues.  For the purposes of this post I’ll characterise the left-right spectrum as being related to economics and the beliefs about the world and values that underlie the positions.  I think limiting the left-right divide to economics a good way to broaden our political vocabulary beyond ‘left’ and ‘right’ and to have a more nuanced and accurate conversation

Many of the social issues are best placed on an authoritarian-libertarian axis that is included in some political spectrums (see below).  Of course politics goes beyond this.  It’s become very clear in the last year with Brexit and the US election that some of the major political divisions in society are establishment vs. anti-establishment and globalism vs. nationalism and these divisions don’t fit nicely on the left-right spectrum or the authoritarian-libertarian spectrum.  But they aren’t really relevant to public health, which is the main focus of this post

To give an idea of what this looks like and to disclose any potential biases I have, here are my results* from the political spectrum quiz found here.

The 4 quadrants can be fairly accurately characterised as:

Authoritarian Right                 Conservative
Libertarian Right                     Libertarian
Libertarian Left                       Liberal
Authoritarian Left                   Progressive

To give an idea, here are some of the opposing values in these political axes

Big government
Small government
Economic equity (equality of outcome)
Economic freedom (equality of opportunity)
Government regulation of certain markets
Free market capitalism
Globalisation of markets
Social responsibility
Personal responsibility

Big government
Small government
Ends justify means
Means justify ends
Top down solutions
Bottom up solutions
State sanctioned religion or atheism
Secularism and no special treatment of religion

* I’ve taken the test a few times and get pretty much the same result give or take a box.  I actually thought I would be a bit deeper in the libertarian right quadrant, but there were many questions I answered neutral on because there wasn’t enough information

How This Fits Into Public Health

Most of the public health strategies I mentioned earlier fit very nicely into one of those 4 quadrants:

Personal responsibility fits into the libertarian right quadrant.  The emphasis on personal responsibility itself is a key value of the right.  The right is generally against the expense of government funded programs (education) and interference in the free market (subsidies/taxes/bans).  Leaving it at personal responsibility fits the libertarian perspective where your health is just your business – where everyone has a health project and people are free to choice how well they want to do on it.  This would be the opposite of an authoritarian right strategy where you are responsible for your health but is also someone else’s business too

I didn’t initially think of commonly proposed strategy that fits into the authoritarian right quadrant.  An authoritarian right strategy method might be to emphasise personal responsibility with there being good or bad consequences for meeting or failing to meet certain targets.  Something like fat shaming could fall in this category and you can imagine come other scenarios like government mandated weight/health targets (which you’ll probably only see in a very militaristic society, or economically threatened one with universal healthcare).  (Although, to go a little off topic, these days I’m seeing most of the shaming being done by social justice warriors who are without a doubt very deep in the authoritarian left quadrant)

Education fits into the libertarian left quadrant while taxes/subsidies and bans fit into the authoritarian left quadrant.  The left is less inclined to hold people responsible for bad outcomes and shifts the blame towards society.  Both involve some kind of structural change to society to facilitate the desired outcomes.  The division here is that the libertarian side ultimately want individuals to be free to make their own choices without additional costs while the authoritarian side want to exercise government control

The strategy of pharmaceutical drugs doesn’t fit quite so nicely into the political spectrum and doesn’t tap into those key values as much.  Relying on drugs does offload the personal responsibility of adopting a healthy lifestyle, and in many countries the government funds much of the basic science that aids the identification of drug targets and then subsidises the drugs (more left leaning).  Although private business does the rest, and a philosophy of innovating your way out of a problem and using the free market (which isn’t the case) is a very right libertarian one (which can be seen in things like sustainability/climate change as well) 

To finish up, if you disagree with someone politically don’t instantly dismiss their position as ideologically based and think they’re evil.  Everyone has ideologies and many people have similar goals but just disagree on the methods.  They probably just have a different set of values and different experiences to you.  The way to move the conversation forward is by coming out of the echo chambers and having an honest discussion of the advantages and disadvantages of various strategies.  That’s what I’ll attempt to do in some later posts

The 'Thrifty Gene' of Samoa

A recent study conducted a genome-wide association study (GWAS) in 3072 Samoans and found a gene variant of the CREBRF gene that is much more prevalent in Samoans and is strongly associated with higher BMI [1].  The narrative being sold is that this thrifty gene had positive selection in Samoans to help promote storage of fat for periods of food scarcity, like travelling across the Pacific [2]

Unfortunately for the thrifty gene hypothesis (which I’ve previously discussed), the function of CREBRF suggests this gene could scarcely be a worse match for this narrative

The main functions of the endoplasmic reticulum (ER) include Ca2+ homeostasis, the synthesis of proteins and lipids, and ‘folding’ proteins into their tertiary structure.  However, several things (including infection, nutrient stress, oxidative stress, etc) can impair protein folding, leading to an accumulation of unfolded or misfolded proteins and ER stress.  One of the homeostatic responses to ER stress is the unfolded protein response, which attempts to reduce the load on the ER.  If ER stress is prolonged or intense the cell initiates apoptosis [3]

CREBRF stands for ‘cyclic AMP-responsive element-binding protein 3 regulatory factor’ or CREB3 regulatory factor.  CREB3 is part of unfolded protein response [4], while CREBRF is a negative regulator of CREB3, and thus is a negative regulator of the unfolded protein response [5]

This is highly relevant, as endoplasmic reticulum stress is a cause of leptin resistance in diet-induced obesity [6] [7].  Specifically, ER stress increases PTP1B, which mediates the effect of ER stress on leptin resistance [8].  The GWAS paper cites other research showing that knocking out CREBRF lowers body weight in mice and flies [1].  So the chain of mechanisms involved seems to be as follows:

↓ CREBRF > ↑ CREB3 > ↑ homeostatic ER stress response > ↓ ER stress ↓ PTP1B > ↓ leptin resistance > ↓ weight gain

And so for people with the gene variant:

p.Arg457Gln > ↑ CREBRF > ↓ CREB3 > ↓ homeostatic ER stress response > ↑ ER stress ↑ PTP1B > ↑ leptin resistance > ↑ weight gain

The paper provides evidence that the gene variant had positive selection, but that doesn’t explain what outcomes of the gene variant were the source of the positively selection, it doesn’t necessary mean fat storage or that such extreme fat storage as obesity was being selected for.  Going back 100’s of years ago this gene variant doesn’t seem like it would be a problem when ER stress would have been an infrequent transient response to something like infection.  But these days, the average Samoan on a western diet likely has chronic low level ER stress, which leads to higher PTP1B and leptin resistance – and this is being amplified by a weaker homeostatic response

This gene variant fits the certainly fits the outcomes of being thrifty gene, but not the purpose of one.  The thrifty gene hypothesis suggests that overweight/obesity is an evolutionary adaptive physiological condition, whereas this gene variant increases weight by increasing ER stress, a pathological state

Finally, as George Henderson shows below, Samoans were lean and muscular before adopting a western diet.  If you try to explain the leanness by suggesting the picture was taken during a period of scarcity, then why so much muscle mass?  People promoting the thrifty gene hypothesis need to show evidence that ethnic groups who are susceptible to obesity have been overweight during periods of abundance (before adopting a western diet).  Such periods wouldn’t have been uncommon, as we’re talking about tropical Pacific islands, not northern Europe

It’s time for evolutionary medicine to stop looking for reasons why chronic disease may been evolutionary adaptive, and then focus on sources of mismatch