Friday, December 30, 2016

Public Health Strategies Part 3: Education

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 education, which I thought fits nicely into the libertarian left quadrant.  This is because this strategy holds a lack of education and empowerment primarily responsible for people not adopting healthy lifestyle behaviours rather than character defects, and then ultimately leaves the adoption of healthy lifestyle behaviours up to individuals once these educational needs are met

Role of Education

In earlier blog posts I discussed how one of the weaknesses of relying on individual personal responsibility is that that strategy depends on individuals having reasonably easy access to reliable information that when implemented would improve their health, substantially reduce their risk of chronic diseases (which I consider as >80-90%), and better treat or even reverse the chronic diseases they currently have

The whole point of improving health is a (reasonable) belief that poor health and chronic disease substantially impairs quality of life, whereas the sacrifices to quality of life in adopting healthy lifestyle behaviours is/should be very small or improves quality of life as early as the day you make them or the following day.  Otherwise, if the costs of adopting healthy lifestyle behaviours exceed the benefits of good health and reducing the risk of chronic disease, then education as a public health strategy is simply one big con

If we assume for the moment that humans are rational creatures, we would therefore make decisions based on objective cost-benefit analyses, and so this shift in favour of healthy lifestyle behaviours in theory should be quite automatic and shouldn’t be too difficult.  However, these analyses depend on our perception on the costs and benefits of various behaviours and our perception is based on our knowledge of the world (perceived cost-benefit).  Therefore, the rationale of education is that providing information regarding the efficacy and implementation of healthy lifestyle behaviours, and the consequences of good health and chronic disease, would shift peoples’ perceived cost benefit analyses in favour of adopting behaviours that improve their health and reduce their risk of chronic disease

You could break down this information to along simple-complex lines and along theoretical-practical lines.  The dietary guidelines are actually a fairly good example of this as they include both a complex 100s of pages long report, and a summary report including how to implement these guidelines.  I’ve included another example of what I’m thinking of below, using the scenario of vitamin K2 for osteoporosis:

Stating that vitamin K2 helps put calcium in bones
RCT evidence with effect sizes, mechanisms
What foods are rich in K2?
Eat X serves of Y
Supplementation, blood tests to measure vitamin K2 status

Health Associations

Here’s the problem, Osteoporosis Australia doesn’t have content on vitamin K2 alongside their content for calcium and vitamin D, and the information they do have only satisfactory checks the simple-theoretical box.  They don’t provide RCT evidence from the vitamin K2 supplementation trials, they say what foods are rich in vitamin K2 but don’t give an indication on how much you should aim for with prevention and treatment (like what they did with calcium and vitamin D), and they don’t inform people on possible blood tests to check for vitamin K2 status.  Osteoporosis Australia also doesn’t have a section for protein (alongside their sections on calcium and vitamin D) which I would think is important considering the popularity of the debunked hypothesis that high protein intake contributes to osteoporosis due to the acid load of protein, despite higher protein intakes actually improving bone mineral density

I’m not targeting Osteoporosis Australia specifically as you could level similar criticisms against just about every other health association.  Many of these health associations provide the earthshattering information that their disease is caused by genes and environment, spread information that is outdated or based solely on observational studies, feature a disproportionate number of recipes for deserts if they have a recipe section, don’t discuss any science beyond the most basic, don’t mention that their disease was historically near absent and near absent in various populations prior to adopting a western diet and lifestyle.  For example, on the Diabetes Australia website you will be told that type 2 diabetes is a progressive disease and see a disproportionate number of recipes for desserts, but won’t be told about superior strategies to manage type 2 diabetes such as a low carbohydrate diet or strategies that have a good chance at reversing type 2 diabetes such as the very low calorie Newcastle diet.  On the Heart Foundation website you will be told that salt is a meaningful factor in the development of hypertension and that saturated fat increases your risk of heart disease, and once again you will see a disproportionate number of recipes for desserts, but you won’t see much on the Mediterranean diet, the PREDIMED Study or the Lyon Diet Heart Study.  On the cancer council Australia website you will be advised to eat a low-fat diet and that red meat increases the risk of colorectal cancer.  You will read about the evils of sun exposure, but won’t be told that vitamin D reduces the risk of other cancers or the possibility of a ketogenic diet potentially improving cancer prognosis.  (I wouldn’t include dietetic associations on this list, as it is clear that their primary goal is to benefit dieticians as a group rather than the health of the general public (they function much like a trade union in this respect))

Suffice to say, I think information regarding health and disease can be substantially improved, and this is a reason why I’ve gone down this path.  I think health associations should:

  • Remove things that aren’t correct
  • Provide information that allows people to increase the number of methods by which they can improve their health and reduce the risk of chronic disease
  • Justify these approaches with evidence, particularly from RCTs
  • Add some clinical information in case that their doctor doesn’t know about the latest research, because otherwise this will be limited to online forums
  • Provide more information regarding the probable causes of disease.  We may not know everything, but we certainly know more than the obvious genes + environment 

Education is not Always Sufficient

That being said, we don’t live in an ideal world where education/knowledge is sufficient to cause behaviour change.  I’m sure each of us could identify at least one area of our lives where this is the case.  But most importantly, it’s clear the education has worked in a sense that people know the basics of a healthy lifestyle (fruit and vegetables are healthy and that soft drink and desserts are not, walk regularly and do some moderate to vigourous physical activity each week, and get enough sleep) and have some understanding of their importance (one could hardly go through life and not be exposed to health information via school and the media at least).  However, that so many people are failing at the basics suggests that simply restating the basics won’t achieve much (the anointed strategy of ‘if it fails, just do the same, but bigger’) and also that education is not always sufficient to change behaviour

Some of the reason for this is that we are wired to be more like instant gratification monkeys rather than deeply logical and rational robots.  In fact this acknowledgement of our own irrationality and impulsivity is something I think that’s missing from health education and education in general*.  Many healthy lifestyle choices require a sacrifice of instant gratification now for a larger payoff in the future.  The way that that health information is presented doesn’t help this as the benefits of a healthy lifestyle is discussed in terms of risk while rarely providing information regarding the magnitude of risk reduction.  Our environment doesn’t help either, as maintaining good health and a healthy weight requires consistently making more effortful and less hedonistic choices such as the purchase of blander and less well marketed foods rather than hyper palatable, high reward and well marketed foods, as well as doing some exercise, meditation or going to sleep when something on the computer or TV is more engaging, etc**

* Something else I think that’s missing from health education is dispelling people’s beliefs that they are healthy when they’re not, although I appreciate that telling people that they’re fat, sick, instant gratification monkeys is a hard sell, but it’s probably necessary.  A recent report found that about 50% of Australians heave a chronic disease and 63% are overweight or obese, but 85% said they were in good or excellent health [1]

** I consider the environment to be the most important factor regarding health.  Remember, I don’t believe in free will, and consider everything to be a consequence of genes + environment, and our genetics haven’t significantly changed in the last few decades.  But I don’t think that a substantial change in the environment (like a regression back to the 1950’s or earlier) is a feasible public health strategy because we want cheap delicious food, labour saving devices and entertainment.  We can make some changes to incentivise healthy lifestyle behaviours (such as a user pays healthcare system and taxes/subsidies) and ban the worst offenders that no one really wants (industrial trans fats).  Beyond that, it’s really up to education and having people create their own micro-environment that promotes health

Targeting the Early Majority

In addition, while it’s probably politically incorrect to say so, some people just don’t care about health, and all the health education in the world isn’t going to change that.  Smoking has had many strategies used against it (education, taxation, bans, stigma, graphic images to invoke disgust, nicotine patches, support for quitting, etc) but people still smoke anyway, much like how people know various crimes are wrong but still commit crime anyway

The following graph is the prevalence of number of healthy behaviours in the US (not smoking, ≥7 hours of sleep, moderate or no alcohol, met physical activity recommendations, normal BMI) [2].  It may not seem too bad, but diet isn’t included, and “76% did not meet fruit intake recommendations, and 87% did not meet vegetable intake recommendations” [3] (similar to “…95 per cent of Australians did not eat the recommended servings of fruit and vegetables” [1]).  There is an explanation for everything, in this case, our high incidence of overweight/obesity and chronic disease.  We are only as good as our weakest link so unless you won the genetic lottery, you will need to do them all

I think you could draw a parallel between the theory of diffusion of innovations (see picture below), the prevalence healthy lifestyle behaviours, and health consciousness and consequently the receptivity to health education/information

Innovators + early adopters = highly motivated by health (4/5 – 5/5).  These people will seek out health information beyond what is provided by health associations.  Public health doesn’t need to target these people, but providing more complex information will make their research more convenient

Early majority = fairly motivated by health (3/5 – 4/5).  These people are fairly receptive to health information but health education may need to be improved to sufficiently inform, motivate and empower them (such as changes suggested here, plus others I haven’t thought of).  Since the theory of diffusion of innovations suggests targeting the early majority and this group is fairly receptive to health information, I don’t think health associations/etc should be too concerned with providing more detail, depth and complexity than the bare minimum

Late majority: not very motivated by health, but not a disaster either (2/5 – 3/5).  Once the early majority has adopted more healthy behaviours and become healthier, and such things have become normalised, the late majority will see that such behaviour change is both feasible and a net benefit to their life.  We might then see a social contagious model of health rather than one of obesity [4]

Laggards = doesn’t really care about health (0/5 – 2/5).  This group can get some rare and awful health scares, but these health scares rarely change behaviour.  Other strategies are probably more productive if you want to improve the health of these people (see next post)

Tuesday, December 27, 2016

Will a User Pays Healthcare System Improve Population Health and Reduce Healthcare Costs?

We have a problem.  In Australia and other Western countries we are spending an increasingly significant amount of our GDP on healthcare [1].  This trend is expected to continue as healthcare spending is increasing at a faster rate than GDP (due to an ageing population and the increasing prevalence of certain diseases such as type 2 diabetes).  This is particularly concerning as Australia is in progressively higher amounts of national debt.  Clearly something needs to change

I find the arguments that ‘healthcare creates wealth’ and that ‘it isn’t necessarily an issue because economies can be flexible’ to be like the ‘broken window fallacy’.  Our ‘sickcare’ system really just patches up broken windows.  There is an opportunity cost in that those resources could be spent on other projects if the window wasn’t broken in the first place.  My aim is to reduce broken windows

As I mentioned in the previous post, the efficacy of relying on personal responsibility (which every public health strategy does to some extent except holding out for miracle drugs and simply banning everything that’s unhealthy) as a public health strategy would be improved if our healthcare systems are structured in such a way that individuals are more incentivised to be in good health.  One way to do this is to have individuals bear more of the financial costs of diet and lifestyle diseases rather than the government

* In 2009-10 Australia spent 9.4% of total GDP on healthcare [2], with 121.4 billion spent on healthcare (~$5,000 per person) [2].  Federal, state and local governments contribute 70% towards healthcare [2], and federal, state and local governments received a combined total of 333.336 billion in tax revenue [3], therefore 25.5% of taxes went towards healthcare in 2009-10

Advantages to a User Pays Healthcare System

There are advantages and disadvantages to more socialised healthcare systems and to user pays healthcare systems.  For this blog post, I’ll just mention some advantages to a user pays healthcare system that has some potential to reduce healthcare costs for most people

Individuals would be more incentivised to improve their diet and lifestyle, rather than face the financial costs of developing and/or poorly managing lifestyle diseases, that could otherwise be prevented or treated through changes in diet and lifestyle.  This would particularly be the case if pharmaceutical drugs for lifestyle diseases were not subsidised through policies like the Pharmaceutical Benefits Scheme we have in Australia (which we seem to be paying too much for [4]).  This will shift cost-benefit analyses in favour of diet and lifestyle, much like how renewable energy would be more cost effective sooner if fossil fuels were no longer subsidised.  For example, someone with type 2 diabetes has a few options: they could either continue what they’re doing and take insulin and Metformin to try and manage their glucose levels; they could simply reduce the amount of carbohydrates they’re eating; and they could try to reverse their diabetes by using the Newcastle diet or other dietary approaches that lead to a short-term spontaneous reduction in calorie intake.  If diabetes drugs and health care associated with diabetic complications becomes more expensive then people will see less value in drugs, while changes in diet and lifestyle (which are more effective anyway) would become more appealing.  As a result, there may be a shift in the culture from popping pills and seeing them as miracle drugs, and more towards a normalisation of healthy diet and lifestyle behaviours.  However, this depends on improving access and dissemination of more than just basic health information such as: the costs and benefits of various pharmaceutical drugs, measured in both relative risk and the number needed to treat; and strategies to prevent and manage many chronic diseases (the focus of the next post)

A major cost for the healthcare system is end-of-life care [5], but quite often end-of-life care prolongs the suffering of the patient, sacrificing quality of life for a few extra months.  Some people would not value it as much as it costs and would prefer to opt out and have that money go toward things they place more value on or toward their families (this should be coupled with voluntary euthanasia).  Similarly, healthcare costs could also be reduced by people opting out of things that offer marginal benefits.  This is basically the idea that individuals are best placed to maximise their utility (↓ money, ↑ value), but standard of care and subsidies distort this

When the cost of something is low (particularly when it’s free) there is a higher demand for it and it isn’t valued as much.  There are obviously many doctor’s visits and hospital admissions that are extremely important, but there are also some trivial ones such as seeing a doctor for the common cold to get a prescription for antibiotics (which won’t work anyway because a viral infection is causing the symptoms)

There are also some minor areas where costs can go down such as lower administrative costs, less bureaucracy, competition driving costs down, being able to shop around for a particular doctor or standard of healthcare, and not needing to see a doctor to get a blood test

In addition, it would remove almost all the rationale for fat shaming or other shaming related to health or health related behaviours


You could hardly discuss the costs of healthcare without talking about health insurance.  In my opinion health insurance, much like other forms of insurance, doesn’t make economic sense in most contexts.  That is because a healthcare system based on health insurance involves the average individual not only covering their costs in the health insurance premiums, but also paying for the overhead costs of running an insurance company, the profit the insurance companies need to make, and the additional admin costs at the doctor’s office.  So not only is the average person not getting their money back, but healthcare itself is made more expensive.  A healthcare system based on health insurance is probably a fair part of the reason why the US healthcare system is much more expensive.  It makes more economic sense, for both the individual and society, for people to self-insure the things they can by saving and investing that money for a rainy day or simply adopting universal healthcare [6]

Some of the contexts where health insurance makes sense include: (1) Where an individual doesn’t have enough capacity to save to self-insure themselves (so insuring your house is more likely to make sense).  (2) If the government subsidises health insurance through income tax concessions (an odd policy that really only benefits middle-upper income earners, who have more capacity to self-insure themselves anyway).  (3) If the government mandates that health insurance companies can’t charge women, older people and people with chronic diseases more (because everything else being equal, these people receive more healthcare on average*).  In this situation your health insurance policy will suffer because young healthy men will refuse to subsidise everyone else and opt out of the system, and only get insured when they’re old and sick.  This will either cause the system to run out of money, increase premiums and/or reduce payments beyond which was previously promised (sound familiar?)

* If you accept this, but you don’t think they should be charged higher health insurance premiums, then do you also think that young men shouldn’t have to pay more for car insurance?

Universal Basic Income

This raises the question of what to do with the extra tax revenue if a user pays health care system is implemented, and also how will low income earners and/or sick people be able to afford healthcare?

With the extra tax revenue, the government could either lower taxes by a quarter or could use that revenue for other projects, and could potentially further reduce total healthcare expenditure by putting money into project that would improve population health.  One possible project is to make public transport free.  There’s a saying in business that you can pick only 2 of the following 3 attributes: fast, good, and cheap.  Public transport is neither, because unless you’re catching a train into the city, driving is faster, cheaper and more pleasant.  Free public transport would at least give it one advantage over driving (cost) while likely being a good form of wealth distribution and improving congestion, population health and the environment

Another option that may addresses both issues well is the implementation of a universal basic income (UBI) or at least one solely for the purposes of a health savings account.  A UBI is basically where every adult citizen receives a regular small parcel of money from the government.  It is attractive to some on the left because of economic security and providing and minimum standard of living, and is attractive to some on the right because it would reduce bureaucracy and current welfare systems can be abused and don’t adequately incentivise employment.  In the future a UBI might become more attractive as there is a great potential for advances in technology leading to more automation and therefore job losses

But how much should the UBI be?  I think it should be set at a level that makes it very difficult to near impossible to live on the UBI alone indefinitely, so that some work is generally necessary.  Some articles mention a UBI of $40,000 per year (~$800 per week or a $20 per hour job) [7], which is simply far too much as it alone would require ~$720 billion (40,000 x ~18,000,000 adults), much more than current tax revenues ($446 billion for 2014-2015 [8]) while providing little incentive to work and causing massive inflation.  With the government spending ~$5,000 on healthcare per person per year, this equates to ~$100 per person per week, but the part of the UBI used for the health can be invested in a health savings account, and total healthcare costs may be reduced as explained above, therefore it may only need to be ~$50-75.  The federal government spends 154 billion on social security and welfare [9], so a UBI for living and healthcare (~275 billion) could be distributed at about $15,000 per year for each adult or ~$300 per week.  At a minimum of $200 for living ($100 maximum going to a health savings account) people won’t be starving in the streets, but won’t be living comfortably on the UBI alone.  The government would then consider the UBI to be part of someone’s income and tax their total income as normal, which addresses an objection to UBI that high income earners really don’t need extra money.  So for people in Australia almost half of the UBI would be taxed for those making over $180,000, compared with 19% being taxed for those making between $18,201-$37,000.  These taxes could go towards disability pensions, people who had a bad accident they couldn’t pay for, and people who lost the genetic lottery regarding health, although if more was needed the UBI might be a bit smaller

The incentive part of a health savings account is that it can be used for family members and whatever is left can become part of your estate (much like the Singapore’s healthcare system [8, 9, 10]).  You could further incentivise good health from the health savings account by allowing a dividend of sorts to be paid yearly based a small proportion of what is left at the end of the year.  But you would want to save most of the health savings account in the event of an accident and because most people receive more healthcare as they get older.  In addition it’s better if this was a system where the health saving account was forced as a default (but something you could opt out of if you signed something that future healthcare is dependent on your ability to pay) because otherwise too many people wouldn’t save for future healthcare (because we are wired to be instant gratification monkeys), much like how superannuation is a somewhat idiot-proof method (but one that’s a tax concession that quite disproportionately benefits high income earners) to have people save for their retirement to avoid the government paying pensions 

I don’t consider myself to be that knowledgeable in healthcare and economics but I think these are some ideas worth considering.  My thoughts on this may change with time as outcomes > ideology and intentions

Sunday, November 20, 2016

Public Health Strategies Part 2: Personal Responsibility

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

I discussed in previous posts that I doubt free will exists, and that I believe the absence of free will is not just an academic issue but that it has some very important implications.  One of these is that the absence of free will is a valid argument against morally blaming people for their health behaviours and health outcomes, as these are a product of their genes and environment.  Ultimately, we can’t choose our personality traits such as conscientiousness, the environment that we grow up in, and our genetic susceptibility to health and disease and so shouldn’t be blamed for that

However, there’s also the risk that this line of thinking goes too far in the other direction.  With the absence of free will, it can be tempting to play the victim and blame your genes, your upbringing and the obesogenic environment.  While this has an element of truth, this mindset is ultimately unproductive.  If your health is impairing your quality of life, what good would it do to ruminate in self-pity that your poor health (or other problem) isn’t your fault and not do anything about it.  While playing the victim may yield some sympathy in the short term, the problem won’t go away and will likely get worse until you take active steps to fix it.  In this respect, holding yourself and others personally responsible is more empowering than fatalism and self-pity

While you can’t change your genes, can’t change the past and have a limited ability to change the broader environment, you can change the way you engage with the broader environment and set up your own microenvironment to support good habits.  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.  Ultimately, your health is in your hands

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 or health insurance, social norms against personal responsibility (a victimhood vs. dignity culture) and a pessimistic attitude towards ageing and chronic disease.  So the strategy of personal responsibility should be coupled with: (1) the addition of a mechanism in healthcare 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 and vitamin K2 for osteoporosis) 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 fair 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 commonly 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 on this spectrum 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 specifically related to public health

Equality of outcome (equity): a focus on health inequalities in outcomes between individuals or demographic groups.  Differences in outcome reflect differences in opportunity
Equality of opportunity (equality): people should have the information and means to make healthy choices.  Afterwards, differences in outcome reflect innate differences in health consciousness
Social responsibility: emphasis on the environment as a factor (or ‘determanant’) in an individual’s or population health
Personal responsibility: adults are responsible for their own health behaviours and should be responsible for the consequences as well

Collectivism: health policies are concerned with demographic groups or the burdens that one places on society
Individualism: aim to improve the behaviour of individuals and also that an individual’s health behaviours are no-one else’s business
Top down solutions: government or other authorities need to be involved to get people to adopt healthy behaviours
Bottom up solutions: people will adopt health behaviours upon seeing success in their social networks

* 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.  Many people have similar goals but just disagree on the methods to get there.  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

Wednesday, July 27, 2016

Why Liver is Likely More Important than Muscle for Pre-Diabetes: Part 2

Muscle is argued to be the primary defect in insulin resistance.  The main evidence for this comes from the presence of impaired insulin signalling and glucose metabolism in people with insulin resistance and type 2 diabetes, and their first degree relatives [1].  Whether you think the contribution of muscle to postprandial glucose uptake is closer to 75% or 30% (see earlier post), it’s a decent contribution.  However, this line of research is limited as similar studies haven’t been done in the liver, since liver biopsies are far more invasive than muscle or fat biopsies (and unfortunately my PhD won’t resolve this)

One of the difficulties with mechanistic research in disease models is that you take a snapshot in time and find several pathologies are present.  The trick then is to figure out what are the possible causes of disease as opposed to the consequences of disease or just unrelated effects.  A method of doing this is to investigate what’s happening at the earliest time points in the progression of disease, rather than drawing conclusions from biomarkers in poorly controlled diabetes

My honours project followed on from a time course study in mice that found the following [1]:

·         Glucose intolerance was present when first measured after 3 days on a high fat diet (HFD)
o   Whole body insulin resistance was present when first measured at 1 week with the euglycemic-hyperinsulinemic clamp (higher glucose infusion rate)
§  This was due to liver insulin resistance  (this wasn’t associated with a defect in Akt activation or inflammation, but with a relatively mild increase in lipid accumulation)
§  Adipose tissue was also insulin resistant, but muscle wasn’t yet
·         Muscle insulin resistance was present when next measured at 3 weeks
o   This was associated with no further deterioration in glucose tolerance, but worsened whole body insulin resistance and increased fasting insulin
·         Glucose tolerance or tissue insulin resistance didn’t worsen even several weeks after the initial defect

This is consistent with other studies in rodents and humans:

·         Liver, but not muscle insulin resistance was present after mice [2] and rats [3] were put on a HFD at 3 days when first measured with the clamp (and associated with liver ER stress [2]).  Muscle insulin resistance was present when next measured at 3 weeks (which was associated with muscle lipid accumulation) [3]
·         Short-term overfeeding (3-7 days) in healthy humans causes hepatic insulin resistance [4] [5] [6] [7] [8], whereas muscle insulin resistance was not present at this point [4] [6]
·         Short term energy restriction almost normalises fasting glucose after 2-7 days, before significant weight loss, and this is associated with improvements in liver insulin sensitivity, but not muscle insulin sensitivity, which improves several weeks later [9] [10]

Since pre-diabetes and insulin resistance develop very quickly in mice on a HFD, one of the hypotheses of my honours project was that the pre-diabetes and insulin resistance would be normalised in a similar timeframe.  This was one of the novel aspects of my honours project, as earlier diet reversal studies in rodents haven’t looked at early points, but instead after 3, 4 and 16 weeks respectively [11] [12] [13].  We found pre-diabetes and insulin resistance was normalised in 7 days after switching mice from a high fat diet to the standard laboratory low fat chow diet.  We didn’t directly measure changes in insulin sensitivity in the liver and muscle, but some evidence suggests it was likely due to changes in liver glucose metabolism rather than muscle:

·         The HFD group had a higher change from baseline in endogenous glucose at 15 minutes, suggesting elevated glucose production between 0-15 minutes.  This was completely normalised in the HFD→CHOW group (figure 3B)
·         The HFD group had higher exogenous glucose at 30 and 60 minutes but not at 120 minutes, indicating a defect in early glucose disposal (15-60 minutes).  As the liver gets first access to glucose, this could suggest a defect primarily in liver glucose uptake that was completely normalised in the HFD→CHOW group (figure 3C and 3E)
·         The HFD group showed evidence of elevated futile glucose cycling in the liver, indicating impaired glucose metabolism, and this was completely normalised in the HFD→CHOW group (figure 3G)
·         While tissue lipid accumulation isn’t always associated with insulin resistance, the HFD→CHOW group normalised 60% of their liver triglycerides (figure 5A) and 32% of their muscle triglycerides (data not shown)

The takeaway from this is not so much that muscle isn’t important, just that it seems that changes in muscle insulin resistance generally occur more slowly and can be sufficiently compensated for by the beta cells or other organs**.  Metabolic changes happen quickly.  Whatever the mechanisms behind the rapid changes in glucose control are they have to be capable of changing quickly.  Lipid accumulation might be too slow and obesity is definitely too slow.  And these mechanisms are more likely to originate in the liver rather than muscle.

If this stuff interests you I strongly recommending reading this review

* Muscle insulin receptor knockout (MIRKO) mice have normal glucose levels and insulin levels, but have elevated plasma triglycerides and free fatty acids [14].  This is in contrast to liver insulin receptor knockout (LIRKO) mice that prior to liver failure have severe insulin resistance and hyperglycemia, but reduced or normal circulating fatty acids and triglycerides [15] [16]

** Also, in figure 1B bellow, note the absence of impaired glucose tolerance and insulin resistance people with duchenne muscular dystrophy, and the profound insulin resistance but normal glucose tolerance of those who were wheelchair bound (WC) 

“With such a severe reduction in muscle mass, glucose intolerance rather than insulin resistance would be the expected consequence. Therefore, the loss of muscle mass in this group is probably unrelated to their insulin resistance. Instead, the inactivity itself, which accompanies the loss in muscle tissue, is probably a major factor in the development of the insulin resistance.” [17]