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Stigmatize the Obese - Even More?

File this one under candidates for Worse Ideas, Ever.  

A so-called bioethics leader, Daniel Callahan, has written an article, that according one source,  argues that 

the public health community can learn from one of the most successful public health campaigns: the anti-smoking campaign. A primary strategy has been to stigmatize smokers, he says, making it clear that their behavior is not only unhealthy for them but is also socially unacceptable. While the public health community has decisively rejected the stigmatization of obesity, Callahan directly challenges that rejection.

In original report, which you can find here, the author proposes "stigmatization lite" to exert social pressure on people by asking overweight folks question like:

If you are overweight or obese, are you pleased with the way you look?
Are you happy that your added weight has made many ordinary activities, such as walking up a long fight of stairs, harder?
Would you prefer to lessen your risk of heart disease and diabetes?
Are you aware that, once you gain a signifcant amount of weight, your chances of taking that weight back off and keeping it off are poor?
Are you pleased when your obese children are called “fatty” or otherwise teased at school?
Fair or not, do you know that many people look down upon those excessively overweight or obese, often in fact discriminating against them and making fun of them or calling them lazy and lacking in self-control?

What I don't follow is that the author fully acknowledges that the overweight are already stigmatized.  Not only to the extremely obese earn lower wages, spend more on health care, and die sooner than normal weight folk, I have yet to see the supermarket tabloids do anything but make fun of even the skinniest celebrity who has put on a few pounds.  Does anyone doubt the clear message our culture sends? Thin is cool, fat is not.  

I don't doubt that a bit more cultural shame (or stigmatization lite) might result in a few pounds being lost.  But, at what cost?  How many pounds would someone need to lose for it to be ethically justifiable to make them feel bad about themselves?  Moreover, why do I have any interest in making someone else feel bad about themselves?    And, as already mentioned, there are already many costs to being obese - why add insult to injury with even more social shame?

What one weights is a complex result of factors related to personal decisions, preferences, technology, genetics, and environmental factors like food prices and availability.  I suspect there are many obese individuals who would say they'd like to weight less, but that's just talk.  I'd like to drive a Porsche.  I don't drive one (and the obese don't weigh less) because life involves constraints and a series of difficult tradeoffs.  So, what's the use in telling me that I'm a loser because I haven't chosen to allocate my salary toward a 911 Carrera Cabriolet?   Perhaps I just need to apply some stigmatization lite to this problem: 

If you drive a Chevy, are you pleased with the way you look in your car?

Are you happy that owning a Chevy has made many ordinary activities, such as driving to work or washing the car in the drive, uncool?

Would you prefer to drive zero to 60 in under four seconds?

Are you aware that, once you buy a Chevy, your chances of every getting a Porsche are poor?

Musings on the Food Safety Modernization Act

We all want safe food.  Right?  It's hard to argue with the intentions behind the new Food Safety Modernization Act (FSMA).  Indeed, when I've asked people on surveys, they almost always say that food safety is one of the most important food issues to them and that they support stricter government rules and government spending on food safety.  

I haven't weighed in much on the FSMA because before now I haven't taken the time to really dig into the meat of the rules.  However, the FDA recently released drafts of the proposed rules, so now is probably as good a time as any to start digging in.

My first thought after reading through the text of the law and the proposed rules is how overwhelming it all is.  Its like trying to read the IRS documents on how to fill out your taxes but even worse.  In this regard, its not any different than many other federal rules, but I suspect most people who say they want more food safety on surveys have never taken the time to read through these things (here is the text of the law; proposed rules are here; or see the 547 page document here).  I agree with a lot of the spirit of what the FDA is trying to do here (in short, firms have to create a "plan" for managing food safety that it is risk based), but if I put myself in the shoes of a food company owner, and tried to read these documents, I think I'd faint.  

Just to given one simple example, one of the proposed rules begins by indicating who the rules apply to, and answering this question is no easy task (we haven't even gotten to a description of what the rules are).  Here is but one exception to the rule: 

The proposed rule would provide a qualified exemption and modified requirements for farms that meet two requirements: (1) the farm must have food sales averaging less than $500,000 per year during the last three years; and (2) the farm’s sales to qualified end users must exceed sales to others. A qualified end-user is either (a) the consumer of the food or (b) a restaurant or retail food establishment that is located in the same State as the farm or not more than 275 miles away. Instead, these farms would be required to include their name and complete business address either on the label of the produce that would otherwise be covered . . . or at the point of purchase.  This exemption may be withdrawn in the event of an active investigation of an outbreak that is directly linked to the farm, or if it is necessary to protect the public health and prevent or mitigate an outbreak based on conduct or conditions on the farm that are material to the safety of the produce.

In other words, if you sell at farmers' markets or to nearby restaurants, you don't have to comply (because apparently you are incapable of selling unsafe food??).  Oh, but we want your name on the produce anyway.  And, if we think it's necessary, we will make you comply anyway, so basically you're not exempt.

At the end of the day, the question is: will the costs of the rule generate more benefits than costs.  And, while I appreciate the FDA's work in trying to answer this question (I've done similar calculations on other topics myself), we have to say: we really don't have a clue.  The agency conducted a regulatory impact analysis (see document 194 here).  In their own words, they:

lack sufficient information to fully estimate the proposed rule’s likely benefits

and they later say that:

. . . quantification of the human health benefits derived from this rule is difficult and complex . . .

One thing that struck me is the actual hard data on how many people are affected by the food safety outbreaks the FSMA is supposed to prevent.  Here is my re-working of one of their tables:

FSMAillnesses.jpg

So, we have a law that will create roughly $1 billion annually (for the first few years) in costs.  And the actual hard evidence we have is that there were 37.5 annual hospitalizations and 1.7 annual deaths from the foods covered by the FSMA.  That's about $27 million in cost for every confirmed hospitalization or $588 million for every confirmed death.  

The authors rightly point out that these illness/death numbers are probably under-estimates of the true number of cases.  But, the extrapolations are - to put it bluntly - wild guesses based on the evidence of a single study.  They do ask:

We seek comment on our assumption that the share of illnesses caused by unknown pathogens that are attributable to food covered by this rulemaking is equal to the share of illnesses caused by known pathogens that are attributable to food covered by this rulemaking.

But I wonder if this is even knowable.  Even more difficult to ascertain is how implementation of FSMA will change the number of annual illnesses.  The impact report does the best it can to cobble together the available evidence, but it is simply sparse, and it often amounts to comparing companies who have already adopted plans like those mandated by FSMA to those who haven't.  But, surely selection is playing a big role here (i.e., the firms adopting food safety plans were already the kinds of companies that were going to have higher food safety than companies who weren't) and comparing these two types of firms does not give a causal impact of FSMA.    

As I said at the onset, the public seems to favor more food safety regulation.  But it sure is messy seeing the sausage being made.  And, I suspect fewer people would want the sausage if they took the time to see its proverbial production process.  

A Casualty of the Drought

I was surprised to learn that Cargill is shutting down one of its large beef processing plants (it processed over 4,500 head daily) in Plainview, TX.  I grew up about 15 miles from this plant (and about 2 miles from a large feedlot that supplies it).  Here is one source on the causes and impacts of the closure:

Cargill Meat Solutions said declining livestock supplies at the plant because of years of drought would force it to shut down operations, putting 2,000 workers out of a job.

I suspect there are those who would rejoice in the closure of a plant that slaughters cattle.  And, I suppose, they have some cause for celebration.  But, I think about all those families who lost jobs (Plainview has about 8,000 jobs, so this plant closure represents about 1/4 of the total work force), the farmers whose cattle now wont fetch as high a price, and the cattle who have to travel farther to reach another packing plant.  

Those aren't reasons to keep the plant open.  Cargill, after all, has to turn a profit to stay in business.  But, it does show how the effects of a drought and high feed prices (also partially due to ethanol policies) have undesirable effects that trickle down and even hit close to home.

The danger of making public policy based on epidemiological studies

Scientific American recently ran an interesting story on antioxidants.  For a while, it seems, experts promoted antioxidants based on epidemiological studies that seemed to suggest they increased longevity.  It is a good thing these experts didn't convince policy makers to subsidize or mandated more vitamins and antioxidants in food years ago (although we do have mandated vitamin D milk and iodine in salt), only to discover this:

Vitamins Kill Epidemiological studies show that people who eat lots of fruits and vegetables, which are rich in vitamins and other antioxidants, tend to live longer and are less likely to develop cancer compared with those who do not.  So it seemed obvious that supplementing diet with antioxidants should lead to better health.  But the results of the most rigorously designed studies do not support that assumption.  Indeed, the evidence shows that some people who take certain supplements are actually more likely to develop life-threatening illnesses, such as lung cancer and heart disease.

There are many epidemiological studies showing correlations across people in the intake of one food (e.g., meat, chocolate, blueberries, wine) and some undesirable or desirable health outcome (e.g., cancer, heart disease, longevity, etc.).  But, it cannot be repeated enough: correlation is not causation.