An open letter to Senator Orrin Hatch

Dear Senator Hatch,

I am the author of two of the approximately ten published papers about the sexual behavior of virginity pledgers. I found that virginity pledgers may lie about their sexual pasts and that they are less likely to use condoms when they do have sex.

Thank you for thinking of my research when you added an amendment for $50 million of Abstinence-Only Sex Education funds to the health reform bill. If the federal government does not fund abstinence education, my research into the sexual behavior of virginity pledgers and evangelical adolescents would lack policy relevance, so I'm truly grateful for this opportunity.

Nonetheless, I have to turn down this generous offer. I have a surfeit of other research topics, and I've moved on with my research. Even most abstinence proponents have moved on with their efforts. Every abstinence proponent I've spoken with, including leading Southern Baptists, seem to accept that their approach to sex education needs to be reworked. The evangelical media's reaction to my most recent paper finding virginity pledges do not work was mild (in the case of Focus on the Family Radio and the Baptist Press) and even favorable (in the case of Christianity Today).

More importantly, as you know, the case against Abstinence-Only Sex Education was definitively made by the Congressionally-mandated evaluation of the program published in 2007 by Mathematica Policy Research.

I consider that perhaps you made this amendment for ironic effect: if your amendment stays in the bill, the Democrats who favor health reform will have to vote for your abstinence funding. If so, your point was made, and I have laughed heartily at the irony. Now you can remove it.

Best of luck in your continued efforts.

Love,

Janet Rosenbaum, PhD

Baptists debate abstinence ... from alcohol

Apparently there's a debate within the various streams of Baptists about whether abstinence from alcohol is still a necessary part of their religion. The anti-abstinence say that alcohol abstinence is a historical remanent of the Temperance/Prohibition Movement 100 years ago and the pro-abstinence say that it's important to draw a firm line so that no one is tempted to get drunk.

I wonder whether they'll be having a similar debate in 100 years about some aspects of sexual abstinence. That's kind-of a naive question.

Bumper sticker of the day

"DON'T DRINK AND PARK: Accidents cause people"

I saw this bumpersticker last night while driving home from a Harvard interviewing workshop. It was just text. Now that I google the phrase, I find some depictions that definitely aren't the classical meaning of "parking."

Condom ads

Condom ads around the world.

My favorites: 1970s style US porn, condoms dancing Bollywood style, and Kenyan Trust-brand condoms covering an umbrella. According to youtube, the Kenyan ad was banned.

Women's recurrent need for self-defense

We had three related stories in the news this week:

• India's women-only train cars, necessary due to extensive harassment and recent increase of women working outside the home;
  
• the murder of a Yale graduate student by a co-worker, which New Haven police emphasize is an issue of workplace violence, not domestic or street violence;
  
• a Hopkins undergraduate's accidental killing of an intruder using a samurai sword.
  

I'm glad that the New Haven police again emphasize that the primary risk to women is the people they know rather than strangers on the street. People have an easier time thinking about self-defense from strangers. Strangers are the least likely attackers, but the line between an attack and a non-attack is brighter, which may be why the Hopkins undergrad was able to take such decisive action; it's obvious that the intruder did not belong there and had already committed a crime. In the case of an acquaintance, it's harder to find the line between minor conflict and potential violence.

According to the National Crime Victimization NCVS survey, 2 million people are the victim of workplace violence on average each year, with homicide being only the extreme of the scale of violence. Workplace violence is the second highest cause of workplace death for women. I wonder how these figures compare with other countries, and what proportion are due to guns, or whether the US is somehow more violent due to inequalities.

Hearing these stories, I've been feeling grateful that my mother took me to a multi-week self-defense class when I was a young adolescent. The class was run by a Chicago organization Chimera that emphasized response possible at each level of escalation, and the realistic responses that women can make to each level appropriate to the situation.

Judging from the murderer's injuries --- "bruises and abrasions on his arms, a mark under his eye, a scratch on his right ear, and a bruise or deep scratch to his chest" --- the victim employed the most common ineffective self-defense tactics. If someone is intent on hurting a woman, the only way for her to stop them is to disable them somehow. Arms and chest are strong, especially on a man, but we learned that even strong people have weak parts and effective self-defense includes poking eyes, striking nose with the palm, using keys as weapons, stomping on tiny foot bones, and dislocating knees.

Of course it's impossible to know what really happened, and everything is much easier said than done especially given the judgement call necessary to realize whether one is really in danger. This attack reminds me to take a self-defense refresher course and makes me thankful that I learned self-defense from an active feminist group as an adolescent so that it became subconscious, reflexive knowledge. I hope that I never find out how well I learned this material.

May her family and fiance be comforted in their loss.

Health reform letter to the editor

I wrote a letter to the editor of a Baltimore Jewish publication. It sounds like they will not publish it, so here it is:

Dear Editor,

As a graduate of both Shaarei Tzedek Medical Center's Schlesinger Institute Medical Ethics program in Jerusalem and Harvard's Ph.D. program in Health Policy, I was excited to see an article on the health care reform debate in this month's WWW because there are certainly Jewish perspectives on the issue. I read it through eagerly but was disappointed that the piece turned out to be boiler-plate rhetoric with a tenuous connection to facts.

For instance, the author says "there is no one in the country who is really uninsured" because everyone can just go to the emergency room and hospitals get reimbursed for that care. This system actually jeopardizes the health of both uninsured patients and hospitals: patients delay seeking care until an emergency, and hospitals go out of business because reimbursement does not directly cover uncompensated care but rather comes indirectly. For instance, a hospital which gives more care to uninsured might make 5% more on hernia operations; unsurprisingly, books do not always balance.

Other claims were irrelevant distractions, such as about end of life care. Government programs already cover the most vulnerable patients such as the elderly, certain terminally ill patients, wounded military members, and veterans through the government insurance program Medicare and government health care provided at Veteran's Affairs (VA) and military hospitals. End of life care is clearly not an issue with these current programs.

Far from ending life, government-provided health care at VA and military hospitals has saved lives in this war that would have been lost in the nation's 9 previous wars. These lives were saved due to comparative effectiveness research, the field funded in the stimulus package for $1 billion that was unfairly maligned by conservative commentators as leading to "death panels." In the 1990-91 Persian Gulf War, 24% of injured soldiers died from their wounds --- the same proportion as in Vietnam and a bit higher than the 19% in the 1898 Spanish-American War and 21% in World War I --- so technology does not seem to be the key factor in reducing wound fatality. In the current wars in Iraq and Afghanistan, only 10% of injured soldiers died from their wounds, largely because of improvements in care delivery (Gawande NEJM 2004). Health services researchers discovered that battlefield stabilization of injured soldiers and rapid movement to US military hospitals reduced wound lethality. The resulting "government interference in the doctor-patient relationship" literally saved twice as many lives as would have been saved by the old system in which battlefield surgeons held onto patients as long as possible rather than moving them through the system.

The Rabbis of the Talmud teach us not to be like the men of Sodom who would say "What is mine is mine and what is yours is yours." Many of us are lucky enough to have secure jobs with stable health insurance, but even giving tzedakah [charity] to pay for the health care of the uninsured is not enough to help the uninsured. Hospitals charge much higher prices to uninsured individuals, while insurance companies have leverage to insist on lower fees. If Sodom had a modern health care system, they could model it on this situation: discounted prices to the rich (health insurance companies) and inflated prices to the poor. Any solution that perpetuates this inequality in pricing between privileged and poor perpetuates the health care system of Sodom.

Prevention is the best medicine, of course. May we all have a new year of health so that we do not personally need the health care system.

Janet Rosenbaum, PhD

Overly conservative statistics and yogurt

Are overly conservative statistics preventing the adoption of low-risk potentially beneficial health care?

It seems like probiotics are being talked about everywhere. We know that "good bacteria" are vital in many cases: babies delivered vaginally versus via c-section, for instance, have better immune function due in part to the bacterial colonization they get on their way out. (Of course, if the mother has chlamydia or other bad bacteria, the babies can get colonized by those too and develop eye infections.) Now that flu is in the air, people are citing studies that certain probiotics can help prevent and shorten flu infection. Probiotics are inexpensive and reasonably harmless: the worst side-effects I've seen attributed to them are the same as placebos such as mild GI distress. Probiotics seem like the canonical case of "can't hurt, could help." Kefir and yogurt are tasty, too.

Recently I ran across an immunologist's summary of the report of a 2005 Yale medical school conference about probiotics, mentioning among other things that probiotics might be able to help a disease a friend has. The hypothesized mechanism makes sense that it would help, so I looked at the Cochrane reviews, a formalized method for summarizing medical literature, and they say there's no evidence. The only studies were so hopelessly small, though, that there's no way to know at this point. So I looked up "probiotics" in Cochrane and got these results showing that there are about 82 abstracts relevant to probiotics. Of the 10 or so that I read, the only ones where Cochrane said there was conclusive evidence was for acute infectious diarrhea.

An interesting case: pediatric antibiotic-induced diarrhea. They noted the effects of missing data: if all the study drop-outs were treatment failure, which seems unlikely, the treatment doesn't work. Immediately after that, they acknowledge that there is almost no downside to the treatment: "Probiotics were generally well tolerated and side effects occurred infrequently." and yet they conclude, "Although current data are promising, there is insufficient evidence to routinely recommend the use of probiotics for the prevention of pediatric AAD."

In other words, there's no downside to using probiotics, but because the overly conservative statistical analysis that counts all treatment drop-outs as failures finds that they don't work, they can't recommend them. There are many reasons why subjects might have dropped out of this study, primarily boiling down to the studies being almost certainly poorly funded and unable to adequately compensate busy parents of sick children needing to catch up on their lives after their children recovered. That caution in counting drop-outs as failures is reasonable in some cases: for instance, if the proposed treatment is invasive or risky. Or in the case of the female condom hearings the commercial sex workers who dropped out of the study could have been the ones for whom the condoms didn't work as well. In this case of probiotics, they're virtually risk free and there's a good reason why parents may have dropped out of the study.

In medical statistics (biostatistics), the methods most commonly used are straight out of a textbook, rules of thumb that apply in general. Obviously context counts and we should be more conservative when there's a risk and less conservative when there's little risk. Biostatistics is not my primary area, but I have helped doctors out with the occasional clinical trial, using the textbook methods because that's what they wanted. There are many better methods that could be used to analyze this data, such as decision theory that accounts for risks, or missing data methods that model the potential outcomes of the study drop-outs. Biostatisticians have no malpractice risks, so there's no reason they couldn't be less conservative in their choice of data analysis methods to account for risk. Somehow the conservatism that US doctors practice under has spread to biostatisticians, though. Until statistics becomes less conservative in their analysis methods, patients may end up missing out on low-risk treatments still being studied.

David Kessler's The End of Overeating

I remember when David Kessler became head of the FDA when I was in middle school. As an MD with a JD, he was a model for combining policy interests with scientific knowledge of health. In my middle school judgement, I found what he said incredibly sensible and just plain smart, and I decided that I should also get an MD/JD so I could grow up to be David Kessler.

Middle school judgements are sometimes exaggerated, but his book The End of Overeating does not disappoint in terms of the breadth of information that it tries to integrate. Kessler combines both human and animal research, frank and sometimes shocking conversations with food consultants revealing the secrets of increasing consumption (e.g., soft drink companies attempting to induce people to drink less water), and a food travelogue to create a compelling story to explain American obesity. For instance, Kessler discusses methods of food manufacture that causes processed restaurant chain food to break down the protein structure of meat and inject marinade so that it can be consumed more quickly than standard meat.

One of his central points is that sugar, salt, and fat combine to make food compelling ("hyperpalatable"), but he treats these elements as if they are interchangeable, but all hyperpalatable foods that he gives as examples have elements with a high glycemic index (breading, sugar, etc.) and the nutrition literature recognizes a distinction between fat and sugar. For instance, rats will overeat on pure sugar, pure fat, and sugar/fat mixtures, but only fat or sugar/fat mixtures increases weight but rats don't gain weight on sugar (one area in which they're clearly different from people --- witness the Snackwells effect which he mentions as well). Rats have few problems discontinuing fat, but discontinuation from sugar causes withdrawal symptoms similar to opioid withdrawal. (Avena NM, Rada P, Hoebel BG. Sugar and fat bingeing have notable differences in addictive-like behavior. J Nutr. 2009 Mar;139(3):623-8. Epub 2009 Jan 28.)

His theory and examples are also disjointed from each other. To bolster his claim that sugar alone is not enough to create hyperpalatability, he describes experiments in which people find skim milk with sugar added unpalatable but really like cream with sugar added, but then he contradicts this theory by describing his own struggles that lead him to eat an entire box of Snackwells fat-free cookies in a short period.

A theory based on macronutrients has extreme limits. While he does talk about flavor with food consultants, he doesn't incorporate flavor into his theory; obviously flavor is complicated. In a few places he says that obviously sugar in the absence of fat isn't a problem because people aren't eating sugar straight out of the bag, not considering that it's not exactly common to see people drinking oil out of the bottle or eating sticks of butter. Flavor is of course the important moderator: people will eat large numbers of meringues, jelly beans, angel food cake, Snackwell cookies, and all sorts of high calorie fat free foods, just as they will eat bacon (and I can't think of any other examples of fatty foods that derive nearly 100% of their calories from fat, to be comparable to jelly beans). An interesting counterpoint would be if he performed experiments in which he tested consumption of food in the absence of flavor, such by wearing noseplugs, as Seth Roberts has experimented with on a small scale.

He makes some strange claims about people historically eating low-fat meat and cites USDA data that people eat more fat than ever before, though other USDA data says that fat consumption has decreased since the 1970s and only sugar consumption has increased.

The book's chapters were short and did not tie together well, so his argument came off as more simplistic and repetitive than if he had written longer chapters that would have necessarily tied his argument together well. Even the short chapters sometimes ended abruptly. For instance, he has a chapter about Cinnabon, the 730 calorie pastry (sidenote: I remember from the only time I had a Cinnabon sometime in middle school that it had 500 calories and being horrified; I decided to check that calorie count again, and in fact now it's 730. Now that 500 calorie cookies are common, Cinnabons had to become 50% larger than before!) He interviews the creator of the Cinnabon and reveals that she had second thoughts about her creation, echoing Cookie Monster's refrain that "cookies are a sometimes food", and that she had created the Cinnabon to be a treat. He adds in a tantalizing last detail that she used to suffer from eating disorders and was unable to distinguish hunger from other needs, but then he ends the chapter abruptly without relating her eating disorder to her second thoughts about having created the Cinnabon.

The chapters about how to resist food are not new and have been covered better elsewhere such as in Brian Wansink's Mindless Eating as well as of course in the literature.



The book does add to the plausible explanations for the rise of obesity in the US, and it's well worth taking an afternoon to read this book. The quotes from food consultants about how to create "irresistible" and multi-layered "eating experiences" ("eatertainment") were especially revealing of the great deal of effort food companies have exerted to produce American obesity.

R Statistics flash mob for Tuesday

Wow, this is too funny.

> From: The R Flashmob Project
>Subject: R Flashmob #2
>
>You are invited to take part in R Flashmob, the project that makes the
>world a better place by posting helpful questions and answers about the
>R statistical language to the programmer’s Q & A site stackoverflow.com
>
>Please forward this to other people you know who might like to join.
>
>FAQ
>
>Q. Why would I want to join an inexplicable R mob?
>
>A. Tons of other people are doing it.
>
>Q. Why else?
>
>A. Stackoverflow was built specifically for handling programming questions.
>It’s a better mousetrap. It offers search (and is well indexed by search engines),
>tagging, voting, the ability to choose the “best” answer to a question, and the ability to
>edit questions and answers as technology progresses. It has a karma system to
>reward people who are happy to help and discourage MLJs (mailing list jerks).
>
>Q. Do the organizers of this MOB have any commercial interest in stackoverflow?
>
A. None at all. We’re just convinced it is the best way to help and promote R. All
>the content submitted to stackoverflow is protected by a Creative Commons
>CC-Wiki License, meaning anyone is free to copy, distribute, transmit, and
>remix the information on stackoverflow. All the content on stackoverflow is
>regularly made available for download by the public.
>
>INSTRUCTIONS – R MOB #2
>Location: stackoverflow.com
>Start Date: Tuesday, September 8th, 2009
>Start Time:
>10:04 AM – US Pacific
>11:04 AM – US Mountiain
>12:04 PM – US Central
>1:04 PM – US Eastern
>6:04 PM – UK
>7:04 PM – Continental W. Europe
>5:04 AM (Weds) – New Zealand (birthplace of R)
>Duration: 50 minutes
>
>(1) At some point during the day on September 8th, synchronize your watch to
>http://timeanddate.com/worldclock/personal.html?cities=137,75,64,179,136,37,22
>
>(2) The mob should form at precisely 4 minutes past the hour and not beforehand.
>
>(3) At 4 minutes past the hour, you should arrive at stackoverflow.com, log in,
>and post 3 R questions. Be sure to tag the questions “R”. See the posting
>guidelines at http://stackoverflow.com/faq to understand what makes a good
>question.
>
>(4) Follow R Flashmob updates at http://twitter.com/rstatsmob
>
>(5) Post twitter messages tagged #rstats and #rstatsmob during the mob,
>providing links to your questions.
>
>(6) During the R MOB, you can chat with other participants on the #R channel
>on IRC (freenode). To do this, install the Chatzilla extension on Firefox.
>Click “freenode” on the main screen. Then type /join #R in the field at the
>bottom of the screen. Then chat.
>
>(7) If you finish posting your three questions within the 50 minutes, stick
> around to answer questions and give “up votes” to good questions and answers.
>
>(8) IMPORTANT: After posting, sign the R Flashmob guestbook at
>http://bit.ly/6F8B2
>
>(9) Return to what you would otherwise have been doing. Await
>instructions for R MOB #3.

Off-topic: Gluten-free blogger dies

David Marc Fischer, the 46 year old author of the most useful gluten-free blog Gluten-free NYC died last month on August 6 apparently from leukemia. His blog was distinctive for giving gluten-free medical and policy news, rather than focussing exclusively on food food food. Also, he sounded like a nice guy who I'd wanted to meet. May his family be comforted in their loss.

Texas wins a prize for high teen births

Texas papers such as the Dallas Morning News and Houston Chronicle are the only papers in the country reporting the results for Texas of a Child Trends teen pregnancy study that is supposed to come out tomorrow. I can only assume that being allowed to break a story early is a reward for their cities' stellar performances: Dallas has the highest proportion of repeat teen births and Houston leads in births under age 15. Of course there is nothing funny about any of this.

The majority are to Latinos. About 95% of Texas schools provide no information other than abstinence to students, a policy supported by white-majority churches such as the Southern Baptist Conference. The lack of information may disproportionately impact Latinos, however, who may come from cultures where sex and birth control are not discussed and may have less access to the internet or other sources of information.