Wednesday, May 28, 2008

Effects of food subsidies on nutrition in China

In introductory economics in grad school, which I took with Nolan Miller, we read his co-authored paper on why rice is a Giffen good in Hunan, China --- that is, rice is a good for which when price increases, consumption increases as well. Increased rice prices crowd out the more expensive sources of calories, so more calories come from the cheapest source of calories, and rice consumption increases. Likewise, they find that in parts of China where noodles are the basis of the diet, noodles are the Giffen good.

Nolan and Jensen have updated their work now to study whether price subsidies improve the nutrition of the poor in China. They find that the quality of nutrition does not improve with subsidies. Households who are subsidized report consuming less rice, vegetables (mostly cabbage), tofu, and cooking oil, and eat more seafood. They conclude that price subsidies cause people to diversify their diet for taste and enjoyment to the detriment of nutrition.

I have a few comments on the paper.

1. Health is the outcome of interest, and nutrition is an intermediate variable to health. Our understanding of nutrition is incomplete, so there's not much evidence about the extent to which nutritional standards are proxy for health. Even caloric requirements seem more complicated than there being a single ideal number for each person: the studies showing increased longevity from lower caloric consumption may even suggest that caloric minima is the wrong place to look for improving health.

At baseline, median calorie intake was just under 2000 calories for men in Hunan, 350-1200 calories less than the UN FAO requirements. Presumably the men were not losing 3-10 pounds per month as would be expected given this range, and they may have even been healthy to begin with. At baseline they were consuming approximately 50 grams of protein for men and a bit less than that for women, which meets the WHO minimum protein requirements of 0.45 g/kg ideal body weight and many even met the higher 0.8 g/kg USDA standard.

2. Because nutritional standards are necessarily incomplete, variety is considered to be a nutritional good in itself. We continually identify substances that seem important for health, such as omega-3 fat in fish or lycopene in tomatoes. At the same time, The overfed yet undernourished of the US inner cities eat abundant calories and protein, and perhaps even vitamin/minerals from enriched refined grain products. Substances which seem important for health when they are in food do not improve (or even worsen) health when isolated from food, such as beta carotene.

3. Increased diversity of foods at the expense of calories could be a positive outcome, but it's unknown unless the authors followed their results through to health outcomes. Any significant change in caloric intake over the 5 month period would be expected to cause weight loss, which could be easily measured. Protein intake at the beginning seemed adequate, so decreasing it may not have been problematic, but if it were problematic it could affect the height and other measurements of children and/or elderly, which could be measured easily. Self-assessed health measures like the SF-36 could find whether general well-being and depression symptoms changed due to the increased diet diversity and omega-3 fat in fish. For a subsample it could even be feasible to measure strength and aerobic capacity and take blood profiles.

4. The authors conclude that the subjects are diversifying their diets in order to gain utility from their diets at the expense of nutrition, but they don't demonstrate that the diversity has a negative or neutral effect on health. The omega-3 fats in the additional fish that the subjects added to their diet could have improved their lipid profiles and mood, and enjoying food could have improved their appetites and mood. The body's system of weight regulation and nutrition is exceedingly complex, and there seems to be some internal regulation that given the opportunity people take in the nutrients they need under many circumstances. When we're talking about people at the very bottom of the nutritional curve, it's difficult to conclude that these small optimizations such as adding fish could ever be considered negative, especially given lack of physical evidence that their health did not improve.

5. Given that the calories per yuan for rice are so much higher than for fish, we already know that substitution of fish for rice will likely decrease calorie consumption. The quality of the calories and macronutrients could have increased, even if the calories and macronutrients remained the same or even decreased, and that may have real health effects, which were unfortunately not measured, perhaps because they cannot be used in a demand equation.

6. As a side note, I believe that tofu is a complete protein by itself.

Monday, May 19, 2008

_Soul Virgins_ book review

I'm reviewing an evangelical dating book aimed at young adults in order to understand how the evangelical abstinence literature has responded to the academic research on abstinence education and virginity pledges.

I'll put my conclusions up front because the review itself is long: it's as much my comprehensive notes on the book as it is a review for the reader since I don't know if I have any readers.

They do the expected, which is defining sex explicitly and suggesting a sexual ethic which happens to be Dan Savage's, but they also do some things which I would not have expected:

1. Explicitly acknowledging singles' sexualities, acknowledging that many singles are having sex, and criticizing the church for failing to acknowledge the issues and giving simplistic answers.

2. Actively encouraging some sexual behavior within relationships, and discouraging repression. Limited, of course, but encouraging rather than merely condoning is a big step.

3. Condoning masturbation as an appropriate solution to sexual frustration. It's clear from the way that they wrote the section that this view could be controversial among their readership, which may be why only condoning.

They acknowledge that the expectation that adolescents avoid exclusive relationships and not make out until they're ready to consider marriage may not be realistic for most, but ultimately they have to say this in order for their proposed framework to work. Presumably the number of snogging-only relationships people can have is limited, and if they start in adolescence, that will make people more impatient.


Review:

"Soul Virgins: Redefining single sexuality" by Doug Rosenau and Michael Todd Wilson (2006) is a dating book by two evangelical therapists --- one single; one married --- aimed at evangelical young adults which encourages them to develop and act according to their own sexual ethic. While they do impose the expected limits (no sex, broadly defined), I suspect that the emphasis on independent reasoning as well as some of the specifics of their argument may surprise some. The book starts with an anecdote about telling a fellow Christian pastor that they were teaching a "singles' workshop on sexuality", and the reply was, Two hours? "How many ways can you say 'don't'?"

The authors define a "soul virgin" as someone who "seeks to" fulfill an evangelical Christian sexual ethic, decoupling the question from actual sexual experience and emphasizing that effort really matters. Reframing the virginity question lets them deal with readers who have already had sex without making them feel bad, as well as answer the Bearman and Bruckner finding that virginity pledgers may be using oral or anal sex to substitute for vaginal (oddly, they cite only the Washington Post article in the link rather than the J Adolescent Health paper). They acknowledge that much of their readership is currently sexually active: "many of you are already having sexual intercourse or mutual orgasms with your partner." (p. 213), but not until the very end. Through most of the book, they address their advice irrespective of past, "Regardless of whether you are a physical virgin or not, you can commit to soul virginity by choosing to 'hide' or 'separate' the more intimate expressuions of your erotic sexual behaviors (true sex) from this point forward. This process will also practically serve to re-create and restore your sense of sexual worth and integrity. Virginity is ultimately a heart attitude of chastity and purity." (p.71) This sounds repressive to some readers, but see point three below.

Given adolescents' varying definitions of sex and abstinence, they explicitly criticize the legalisms that bring about "Christian hedonism" (i.e., "anything but") and define true sex to include "all intercourse behavior (oral, anal, vaginal) and mutual orgasms" as "biblically inappropriate outside of a committed marital union." They reemphasize in several places that physical virginity is "not the end itself" and "should not be seen as some magical formula for ensuring sexual purity."

Second, this book deals explicitly with the "how far" question by attempting to make the reader think about their sexual ethic. One of the authors said that when he was growing up, the only sexual behavior allowed before marriage was kissing with a chaperone present, and that the legalistic approach was not motivational. They theorize that slogans like "true love waits" won't affect behavior until people understand "how and why it waits." Perhaps influenced by the research of Bersamin et al, that people who make personal virginity pledges to themselves are less likely to have sex, they encourage people to develop internal motivation for the own stop signs. They give some reasons, as well, such as "building character" since resisting outside sexual temptation is necessary within marriage.

They map out a course of relationships of three C's: "connecting" (friendship, casual dating, and what they call "righteous flirting" - flirting that ultimately leaves both better off than when it started), "coupling" (exclusive relationship considering marriage, including sexual behaviors, with substeps "considering" and "committing"), "covenanting" (marriage, sex.)

At the very end of the book, they have a whole chapter whose subtitle is "The proverbial 'how far can I go?' chapter", which begins, "Some of you probably bought this book just for this chapter and even started reading it first!" They then say that the question itself is immature and selfish, and people should instead be thinking about stewardship of their partner, basically (the gay partnered-but-non-monogamous sex columnist) Dan Savage's campsite rule for dating younger people: leave them better than how you found them. "Righteous flirting" seems to fall into this as well. They say that everyone should think about it for themselves, but they suggest that anything covered by a bikini should be off-limits. They encourage couples to talk about sexual boundaries together.

Their ideal stewardship is one couple where a future groom "expressed appreciation that [his future bride] was a more whole woman in her femininity and sexuality" due to her ex-boyfriend, and so invited him to the wedding.

They distinguish between adolescents and adults with respect to appropriate sexual behaviors: since adolescents are not ready for marriage, they reason, they shouldn't be in exclusive relationships and therefore should not engage in "erotic sexual behaviors" limited to exclusive relationships.


Third, they caution readers not to repress their sexuality, and spend more time talking about the dangers of sexual repression than of sexual excess. For example, "A brief word of caution to those who are... currently sexually active: as you choose to become soul virgins, be careful not to simply repress your sexual behavior. ... Alter your lifestyle..., but don't stop all romantic and erotic relating." (p. 73) "Most tend to err more on the side of Christian hedonism, repression is just as dangerous to healthy relationships. We could relate countless stories of couples that go something like this: A couple tries to control their sexual surging by complete repression. They never kiss, hold hands, or even allow their knees to touch while watching a movie. Even the thought of such things is met with internal messages of being 'wrong' or 'dirty' The couple eventually gets married and on their wedding night find themselves alone for the first time with the expectation that they will undress in each other's presence, touch intimately while naked, sleep in the same bed, and experience blissful intercourse. To their surprise, they can't because the scrit in their minds is still saying 'wrong' and 'dirty'. We aren't suggesting that you nee dto 'practice' certain erotic behaviors for your honeymoon... it's extremely important to recognize and honor your erotic desires in Coupling and not just suppress them....To simply ignore or rebuke these desires altogether can reap an unwanted harvest." (p. 203--4)

They don't officially take a position on masturbation, but implicitly say that it is acceptable. I think it's very clever way to potentially broaden their audience. They note that since the Bible doesn't mention masturbation (i.e., the etymology of "onanism" aside, they say the Onan story is not relevant), everyone has develop their own "theology of masturbation". They include this very Buberian imaginary dialogue with Jesus in which he says, "Why do you Christian leaders waste so much time debating masturbation...? Have you considered the hypocrisy of your Christian culture?...What does masturbation mean to you?" They then give several pages of caveats to the accepting of masturbation, including avoiding pornography, "the rampant disease and vice for the average Christian", and the single co-author admits he's addressed the issue in his own life. They seem to criticize secular culture at least as much for hurting women's body images than for pornography.

As is clear from the above passage on masturbation, they don't hesitate to criticize Christian culture, such as for being obsessed with sexual sin and for overemphasizing traditional roles for women. (They also note that everyone is both masculine and feminine, and note that the married author is less logical and more emotional than his wife.) They criticize Christian culture's simultaneous emphasis on abstinence without explaining what is allowed. "The statement 'sex is for marriage -- be abstinent' without any practical explanation of what is meant by itself can send a distrubing underlying message: 'we aren't comfortable discussing what you do with your sexual desires as a single person. If you just abstain from all erotic sexual behaviors, you'll forget you're a sexual being and won't struggle anymore.' Another unspoken message then becomes, 'As a single person you are asexual until marriage --- then you can turn your sexual switch on.' Obviously, single adults are sexual beings and do have sexual desires."



Remaining true to the genre, they have the requisite excruciatingly long drawn-out metaphors, followed by tedious explanations, such as this one comparing sexuality to a laptop. After several paragraphs discussing how Jane got a laptop and her father taught her to use it, it ends, "Jane is coming home again from grad school with excitement --- along with some embarrassment and shame. Her laptop really has changed her life for the better. She remembers, though, that first heart-wrenching experience when she allowed a friend to install some software. It crashed part of the system and affected the functioning of many programs. She also inadvertently got an email virus that she still isn't sure is fully eliminated. Lots of the computer functions seemed so easy when her dad explained them, but now she feels so confused. Her father understood both her excitement and her need for help. Despite her guilt and shame, he was very supportive when she told him about her mistakes, 'Don't worry, sweetheart,' he gently replied. 'Just bring the computer home. I'll teach you more about it and restore it like new.'" (p. 92-3) No comment.

There are a few other memorable lines, such as "Some days of the month, I'm so turned on I whistle back at construction workers." !


Conclusions:

I read the book to understand how the evangelical abstinence literature has responded to the academic findings about abstinence. It seems that they have a few responses.

They do the expected, which is defining sex explicitly and suggesting a sexual ethic which happens to be Dan Savage's, but they also do some things which I would not have expected:

1. Explicitly acknowledging singles' sexualities, acknowledging that most singles are having sex, and criticizing the church for failing to acknowledge the issues and giving simplistic answers.

2. Actively encouraging some sexual behavior within relationships, and discouraging repression.

3. Condoning masturbation as an appropriate solution to sexual frustration. It's clear from the way that they wrote the section that this view could be controversial among their readership.

4. Most importantly, framing the ideal behavior as an average rather than perfection, and acknowledging that the process is dynamic.


They acknowledge that the expectation that adolescents avoid exclusive relationships and not make out until they're ready to consider marriage may not be realistic for most, but ultimately they have to say this for their proposed framework to work. Presumably the number of snogging-only relationships people can have is limited, and if they start in adolescence, that will make people more impatient.

Viewing this book as a cultural artifact is revealing, but the more interesting question is whether it's reasonable for single young adults. Any plan in any book on any domain of life including diet, exercise, psychology, gardening, cleaning, etc. only gets followed to a limited extent, to the extent that it gets followed at all, and all authors realize this. The fact that they make the ideal as an average does make it more attainable.

Of course my question is whether people who consider themselves as implementing this program will lie on surveys about whether they've had sex.

Reframing virginity

The sexual abstinence pledges begun by the Southern Baptists and continued by Catholic and other Protestant churches have frequently been called "virginity pledges". It would be an interesting exercise for someone to trace the evolution of terms for these pledges, however, because I have the sense that the issue is gradually being reframed.

For example, the founder of the purity ball finds the term "virginity" and the idea of a virginity pledge to be too all-or-nothing. The pledges themselves rarely discuss virginity, and in fact the very first TLW did not mention the word at all. The term used in their timeline is "commitment cards," and the term used in the pledge itself is "purity". The evolution of the language used for pledges can examine when the term virginity first started getting used in the context of these pledges, and whether it was leaders, participants, or media members who introduced the word into the discourse.

Even if the movement had been ducking the laden term of "virginity", but they seem to be stuck with it. The theology may put the terms on people's minds, or adolescents' obsession with crossing the line into being an initiate of the behaviors they consider adult such as sex or alcohol use, or American society at large (which did, after all, invent the big lipstick red V on the forehead of first time Rocky Horror attendees). For that matter, many adult virgins over the age of 30 or 35 report feeling incredibly self-conscious until they too have crossed that line, so it's not limited to adolescents.

For whatever reason, then, the pledge movement is stuck with the term virginity and all its connotations, and they have to do something with it. The movement began by encouraging "secondary virgins", in which those who have had sex recommit to not having sex until marriage. The "secondary virgin" term sounds like "second class," and it's still attached to the idea of virginity as the goal, rather than some overall average standard of behavior.

I find it interesting, then, to see a book which reframes the term. "Soul Virgins: Redefining single sexuality" (2006) by two evangelical therapists --- one single; one married --- is a dating book aimed at young adults. They define a "soul virgin" as someone who "seeks to" fulfill an evangelical Christian sexual ethic, decoupling the question from actual sexual experience. It sounds like this term is one that they coined for the book, but it would be interesting if it together with the Purity Ball inventor Wilson actually reframed the discussion in terms of a sexual ethic rather than sexual experience and this laden term, and all its associated terms like "losing" virginity. I review the book at length in the following post.

No matter what they do with the term, they will have to deal with the fact that adolescents and perhaps Americans in general are consumed with the idea of initiation, and avidly use the term virgin, so the reframing may be a doomed cause. The impulse to reframe, though, is itself interesting.

Sunday, May 18, 2008

Religious issues with virginity pledge.

Completely a side point, but it's something that I ran across a few years ago when I started this pledge research and have never remarked upon before.

Many academics believe that early Christianity was a product of rabbinic Judaism. Since rabbinic Judaism strongly opposes vows and pledges, when I started the virginity pledge research I briefly looked at the Christian texts to see what they had to say about vows.

The view at least in the Sermon on the Mount seemed similar to the rabbinic view, that vows were forbidden.

Somehow, though, the US acquired many pledges and vows, such as swearing in for political office, testimony in court, the original alcohol abstinence pledges in the 19th century which also came out of religious movements, and now the virginity pledge.

Purity ball founder opposes virginity pledges as being too all-or-nothing

I didn't notice this in the earlier purity ball coverage, but the founder of the purity ball, a coming-of-age rite for adolescent girls in some evangelical circles, favors abstinence obviously, but opposes virginity pledges.

"We don't do virginity pledges," Lisa Wilson said. "That would be a great consequence, but that's not the point. It's a fatherhood issue of men living in integrity."

Randy Wilson goes so far as to say virginity pledges could be harmful to girls: "It heaps guilt upon them. If they fail, you've made it worse for them," he said. "Who is perfect in this world? One mistake doesn't mean it's all over."



It's fantastic to see diversity within a group portrayed as uniform --- Wilson has worked for the mainstream evangelical organizations, both Focus on the Family and the Family Research Council.

Also, I think it's smart if this signals a move away from the term "virginity." Many on the left criticize pledges for the same reason that he does, and in addition find the term to be distasteful because it evokes the patriarchy, male control of female sexuality, honor killings in the middle east, differential bride price for virgins, rape of young girls out of a virginity fetish, etc. Plus, all the best parodies latch onto the idea of virginity itself.

Framing the balls as being about an average standard of behavior rather than perfection deflects that aspect. Even if adults do not see perfection as the goal, but rather average behavior, adolescents might expect perfection of themselves. We don't have a great deal of information about the sexual habits of pledgers after broken pledges, other than that they may be less likely to use condoms or other birth control.

We do know that the all-or-nothing mentality is pervasive across all human behavior. It's well known that dieters will say, "if I ate two cookies, I may as well eat 10." Psychologists could hypothesize physiological reasons for that mentality: an insulin spike and/or learned conditioning response to one cookie really might be triggered by a single cookie, thus ruining the run of perfection. And many people quitting tobacco prefer cold turkey to tapering off, and perhaps there are physiological reasons for preferring cold turkey there.

So it's great to know that some don't expect perfection, and also interesting to wonder whether adolescents expect perfection for themselves.

Saturday, May 17, 2008

Abstinence education specifics, part 2: young adults

Abstinence education to young adults --- that is, people in and especially after college --- is the main genre I'm looking at because it faces the interesting challenge of how to address a mature adult readership. Some of the differences of opinion over abstinence education seem to be an issue of sheltering vs. not. People even repeat lines to the effect that "Age N is too young to teach about condoms." That is, these people don't object to teaching condoms eventually. They just don't think age N is the right age for it. And certainly that's a view everyone can relate to to some degree: many parents have age benchmarks for various pieces of knowledge. With young adults, there's no question of sheltering. Most have gone to secular colleges, had friends who were sexually active, had multiple opportunities to be sexually active, and have had physical intimacy and chances are have had sex.

Unlike middle and high school students, young adults are also not a captive audience and can be more sophisticated in their critiques. Not only do they have a choice whether to be abstinent, but they have a choice whether to switch to a more progressive church or to stop going to church at all.

Federal abstinence education funds now target up to age 29, so it's also an age group which is policy-relevant.

I'll talk about a couple books in the next post.

How does abstinence education work, part 1

When I started studying virginity pledges, I was surprised at the lack of solid descriptive social science on the subject of pledges.

Even abstinence education had relatively little descriptive work. On the quantitative side, there are lots of small mostly quasi-experimental evaluations of individual programs with mixed findings, the Congressionally-mandated Mathematica evaluation, and a systematic review by Cochrane. There's the Waxman report and a GAO report. But somehow I expected a participant-observer view of abstinence education, in the genre of Boychiks in the Hood about Chasidic Jews around the country or Righteous, a book about evangelical youth cultures around the country, both written by Jews in ironically detached style, incidentally.

Mark Regnerus's sociology on the role of religion in adolescents' sexual decision-making recently came out, and seems to be filling the gap somewhat on abstinence education. I haven't finished reading it yet, but on virginity pledges, he repeats a few recurrent "facts" that aren't strictly true true, such as the 2.5 million virginity pledges signed.

Sideline on the number of virginity pledges: 2.5 million is the number of pledges that the Southern Baptists' True Love Waits (TLW) program has had internationally, as of several years ago (2000, perhaps. The date's on their timeline on their website). TLW do not publish a breakdown by US vs. abroad, and they have no idea how many pledges have been signed total in the overall pledge movement, including other organizations, even including affiliated ministries. They don't seem to make any effort to evaluate them: perhaps they're deontological rather than consequentialist, so any pledge is a good irrespective of what happens afterwards. Silver Ring Thing gives their own estimate of the number of pledges taken at their events, as well as the number of Born Again Christians made. I'm not aware of other organizations' totals, or even how many organizations there are. The TLW website is thorough and media-conscious, and they have a timeline, a list of affiliated ministries, and also a curriculum guide, including a contingency publication to the effect of "So you didn't keep your virginity pledge." That's not what it's called, but it's not far off.

I'm writing a series about abstinence education and especially virginity pledges, just to describe what I've learned about it. There are those who say it is propaganda filled with sexism and deliberately-distorted science, and there are those who say it's responsible and attempts to be as accurate as possible, while staying within the desired values. My bottom line on abstinence education is that I've seen evidence that there is truth to both claims.

People have pulled up lots of propagandist bits, and the ACLU particularly has ferreted out the inappropriately religious content of e.g. Louisiana state's curriculum. I'm sure there are many more propaganda pieces available for mining. One of my favorite misuses --- or, more concretely, the one which bugs me the most --- comes from a misquoting of Jonathan Zenilman's paper on misreporting of condom use, because misreporting is one of my favorite subjects. He found that many people who reported consistent condom use got STDs anyhow, and indeed it's been solidified that it was a problem with reporting: apparently, people don't consider consistently to mean 100% of the time. Plus with the strong pro-condom ethic in the early 1990's, it was strongly anti-normative to report ever not using condoms. Obviously, that's completely irresponsible to conclude against the author's intent that this paper was about how condoms do not protect against STDs.

But the propaganda side is not the only side, and my hunch is that it's a minority. Only extremes make good news. So the abstinence folks repeat the "sex ed is teaching your kids about sex toys and grape jelly" line I mentioned in a previous report, and the comprehensive folks repeat the sexist and inaccurate propaganda lines, as well as any hint they can find that abstinence is harmful, being particularly fond of fire and brimstone lines.

The red-blue divide means that the two sides rarely meet in person, of course.

Monday, May 12, 2008

New virginity pledge research?

I spoke with Time magazine today about virginity pledges. They asked me to summarize my past research, whether virginity pledges decrease sex, affect STDs, or affect the behaviors that adolescents engage in (e.g., substituting oral or anal sex), and for my assessment of the past studies published by Bearman and Brueckner, and also about the unpublished research of Rector. I have a paper on the subject under review, which I mentioned, but I wasn't sure what I could say about it.

She asked for the scientific consensus about virginity pledges and their effect on STDs and perhaps she later asked other outcomes, and these were hard questions to answer. Partly because in many cases there's only one relevant published study, and partly because my research touches on it but I can't talk about my research yet.

Speaking without a set agenda was surprisingly difficult. That is, I could answer her questions easily and I know that I gave valuable background information, but I didn't know whether I was giving her the quotes she needed. I didn't have well-prepared "take home messages" unfortunately.

I was happy that so many questions were easy to answer. E.g., the research which is not peer reviewed is not subject to the same scrutiny as all the other work out there. That was much easier to say than giving my off-the-cuff assessment of the research from my memory of it, especially since my only real comment about it is that I recalled there being more potential for multiple-comparison problems than other similar research, and that's not only speculative, but I have the feeling it's unprintable due to being boring.

Something which I'd never noticed before about journalists was how open-ended her questions were, such as what does it mean about virginity pledges that studies have found that pledgers and non-pledgers have similar STD risks. She asked very specific questions, breaking up the different effects that virginity pledges might have: what's the effect on X, and then later asked about Y. She also asked a few very open questions which allow speculation into how pledgers were thinking, where the answer of course has to be that we don't know what they're thinking, but there's always temptation to veer into speculative territory.

I did underline the seminal nature of the Mathematica Policy Research report on abstinence-only education, and that it was Congressionally-mandated. It sounded like this paper hadn't been part of their research prior to my mentioning it.




I wonder what event brought about this reexamination of virginity pledges, whether it was just the Congressional hearings at the end of April, or whether something else has happened. Something I just noticed is that Heritage's review of past abstinence education studies was released at the same time as the hearings, so there was no time to scrutinize it before the hearing. By contrast, the Cochrane review was published in late 2007, well before the late April hearings.