Via John Goodman comes a story at LA Weekly reporting that the next released edition of the Diagnostic and Statistical Manual of Mental Disorders might include picky eating, or “Selective Eating Disorder.” One of the lead researchers into the “causes and severity of the disorder” explains it thusly:
She went on to explain that these finicky eaters often reject food not because of taste, but rather because they find the look or smell unappealing or have negative physical or emotional childhood associations with food.
I know I’m only one-eighth of the way to being a medical professional and so might be missing out on something here, but it seems to me that what she’s saying is that sometimes people base their eating decisions on subjective personal preferences about the food in question.
The implication seems to be that if you don’t like a given food for reasons other than taste, you may have a mental illness. I wonder if that covers my avoidance of foods like deep-fried Twinkies for the sake of my health.
Good nutrition, I’m told, is an important part of maintaining good health, staving off chronic disease, and feeling better. Pundits, policy wonks, and the professoriate never tire of telling us this, especially at medical schools. One of the ways in which we as North Americans are to eat better is to increase our consumption of vegetables.
Increasing consumption of produce, especially among poorer demographics who are less able to bear the increased cost of fruit and vegetables relative to less healthy options, is a goal around which there is much government activity, from food stamp subsidies, to state-supported farmers’ markets, to Michelle Obama’s efforts to reduce childhood obesity.
Imagine my surprise, then, to learn that alongside its non-trivial efforts to get Americans (including poorer Americans) to eat more vegetables, the federal government subjects imported vegetables to a 20% tariff.
One hand encourageth healthy eating, whilst the other taxeth the living daylights out of it. Though I must say, this seems like a perfect way to make a dent in some of my classmates’ protectionist tendencies.
Of course, you can make vegetables as cheap as you like, but uptake will be limited unless people like eating them, and don’t have to spend inordinate amounts of time preparing them. And on these criteria, certain elements of the healthy eating movement may have undermined their own cause by focusing on fresh produces and farmers’ markets to the exclusion of another, more convenient option: frozen vegetables. Megan McArdle explains.
And what post about vegetables would be complete without the shocking true story behind Canada’s most successful fake advertising campaign… for broccoli. Having seen those ads, I can only admire their pure marketing genius.
Fun tidbits, health-related and otherwise, from around the ‘tubes:
- How do the media deal with new research? How should the media, or anyone else for that matter, interpret new research? Unfortunately, the New York times only devotes a couple of paragraphs to this first question, but even that is enough to illuminate the complex web of incentives facing those in the science communications industry, and what it means for the science coverage that you see. A blogger at Foreign Policy provides some useful advice in response to the second question.
- The Placebo Journal Blog takes on a proposal to save family practice… by extending the residency to 4 years from 3 (in contrast, FP residency in Canada is 2 years). The comments are harsher than the post itself. A family practitioner blogging at Better Health gives an example of how opting out of Medicare can be win-win for the doctor and the patient. This strikes me as a better option than an extended residency. Even if primary care can be saved, it probably won’t happen soon enough to stave off what could be a massive increase in Emergency Department utilization by newly insured patients as a result of the PPACA.
- File these under “overutilization” for sure: Dinosaur accuses the American College of Obstetrics and Gynecology of “usurping” primary care’s scope of practice with new guidelines recommending OB/GYN visits for younger teenagers; MD Whistleblower blows the whistle on various “pre-emptive” CT scans that are being advertised to patients despite the fact that they don’t do much good for anyone.
- Science-Based Medicine writes a rebuttal to a Slate piece linked to in the last edition of AtM: Why Big Pharma should not buy your doctor lunch. SBM also featured some well-written commentary about new CMS head Don Berwick, touching on his lax attitude towards pseudoscience, and the Central Berwick Paradox of supporting unlimited patient choice and top-down government rationing. Or something like that.
- Via EconThoughts and Megan McArdle, we find a story in the WSJ describing how some unions hire non-union labour to staff their picket lines. Delicious. Less delicious is the story told by House Appropriations Committee Chairman David Obey (D-Wis) of how the White House suggested paying for spending on teachers by cutting food stamp benefits. Does anybody remember who the largest donors to federal Democrats are? I’m having trouble, but I don’t think it’s food stamp recipients.
- TJIC and Coyote Blog talk about “big picture jobs,” adding real value through real work, and what Scott Greenfield would call the “Slackoisie” that is much of my generation (I hope not to fall in with that crowd). We have critiques of recent NY Times letter-writer Arielle Eirienne, Washington Post interviewee “little-miss-altruist Beth Hanley,” and “big-picture jobs” and the people who think they should have one. They use lots of harsh words (well, TJIC does), but honestly… they’re right, painful as it may be for some of my contemporaries (heck, a number of my former classmates) to acknowledge.
- Let’s talk safety. It’s important, right? Important enough to flex some muscle and shut down a business just for the hell of it? Coyote finds that some agencies would say “yes” to that. Toyota and the NHTSA, in a move that didn’t surprise those who cared to think about the issue, announced that virtually all of the so-called “sudden acceleration” issues are attributable to driver error “pedal misapplication.” Whoops. Coyote asks “how safe is safe enough” in the context of dioxin, pointing out that new EPA efforts at regulation are probably superfluous, as is their existing safety standard. Lastly, can we afford to hire government employees to supervise children’s dietary intake? What’s scary is that there are people out there who take the question seriously.
- Doctors aren’t the only ones who deal with emergencies. There is such a thing as a legal emergency as well. Why not regulate emergency legal services in the same we that we do emergency medical care? Of course, like physicians, sometimes lawyers can be breathtakingly, hilariously incompetent.
- Economic mismanagement was a common theme this past week. From EconThoughts we have Obama’s Dirty Dozen; InsureBlog explains how his state is implementing the PPACA’s high-risk pool provision (not very well, it seems). Coyote explains why a government program’s popularity is a terrible metric by which to judge it, just as high corporate profits can sometimes spell bad news for the larger economy.
- Ending on a lighter note, we have an interpretation of Toy Story 3 as a libertarian-inspired parable, and an animation of an orthopedist consulting with an anesthesiologist. “There is a fracture. I need to fix it.“ Hilarious.
As the New York Times, its Prescriptions blog, and the San Francisco Chronicle have been reporting, there’s been a scandal of slightly more-than-minor size involving the UCSF Chancellor’s stock holdings. Dr. Susan Desmond-Hellmann — the oncologist at the head of UCSF’ — disclosed shareholdings in the area of $100,000 in Altria, the company formerly known as Phillip Morris that makes most of its money from tobacco-related products. Since that disclosure, followed promptly by divestment, Dr. Desmond-Hellmann’s holdings in health products/pharmaceutical companies and fast food companies — this time to the tune of millions of dollars — have come to light. The investments were apparently made by a third-party financial advisor without her knowledge, and this advisor has since been instructed to purge her shareholdings in alcohol, tobacco, and firearms manufacturers.
Reading these articles prompted me to consider one of my earliest posts here, in which I argued that there is nothing unethical, unseemly, or untoward about life/health insurance companies holding shares in fast food companies. Does the same argument apply to Dr. Desmond-Hellmann’s holdings?
Yes and no.
In my mind, the most problematic of her stocks are the pharmaceutical and health products companies. These firms are probably vendors or research sponsors at UCSF, or have the potential to be. The Chancellor’s shareholdings in these firms are substantial, and the potential for a conflict of interest is definitely present. As one of the ethicists quoted by the Chronicle points out, recusal from decisions that would trigger this conflict may be all that is required, but continuing to hold the shares certainly creates the appearance of impropriety. While some have pointed out that physician-industry relationships aren’t always eeevvvilll, as others would have us believe, there is a difference between productive collaboration of the sort Dr. Rich discusses and passive shareholding of the sort at question here.
I personally find her other shareholdings to be less objectionable. Alcohol, firearms, soft drinks, and fast food are all legal products that can be used or abused, depending on who is doing the ab/using. I see nothing intrinsically “evil” about them that should force medical leaders to steer clear. Many of these firms (McDonalds, Pepsi, etc.) are also components of major equity indices, and as such may well have been chosen for that reason. It’s highly unlikely that they will be directly involved with UCSF as vendors, donors, or sponsors, though I could be wrong about this. Tobacco, however, doesn’t pass the smell test with me, especially not when we’re discussing an oncologist. Arguably, it’s the only one of the products in question that is inescapably harmful regardless of how it’s used. Of course, I would be remiss if I didn’t point out that there are lots of anti-smoking groups out there who have let their love for tax revenue outweigh their desire to reduce smoking. This doesn’t make Dr. Desmond-Hellmann’s Altria holdings more palatable, in my view. It just places them in the context of “how worse could it be/what company is she in.”
There is a growing obsession with rooting out conflicts of interest in healthcare, often under the rubric of reducing “waste and fraud.” Much of this is a good thing, though as people like Dr. Rich point out, this obsession comes with a risk of harmful side effects. More and more attention seems to be paid to “who owns which shares.” Given that companies like McDonalds, Pepsi, and Altria are major blue-chip companies that are components of the DJIA/S&P 500 — thus likely to be held by many people and institutions — and targets for public health activists, it will be interesting to see how this plays out in the future, and where the line will be drawn for medical professionals who want to be perceived as “ethical investors.”
Fun tidbits, health-related and otherwise, from around the ‘tubes:
- Unconfirmed: 15th century world maps labeled the location of what would later be called “America” with the warning “Here There Be Litigiousness.” WhiteCoat links to an AMA report that looks at key differences between the US medmal system and those of other developed countries, with an eye to what differences may or may not translate into improvement in the US. Great Z’s brings us the details of a case in which drugmakers were found liable for Hep C contracted by patients whose physician reused needles when administering the drug. A guest post at KevinMD gives tips on how to survive a deposition during a medical malpractice case. Edwin Leap reminds us that a large part of being a physician is the ultimate accountability for patient care… and that this accountability has to be compensated.
- Related to accountability is trust. Coyote Blog expresses his confusion about people who distrust large corporations, but don’t extend that same skepticism to government. Hit & Run discusses survey results showing that under-30s trust government to do what’s right in higher numbers than older generations. They also hint that the usual increase in cynicism might not hold for my generation… scary thought. Continuing in the libertarian vein, Megan McArdle explains the difference between liberals and conservatives in terms of the different sets of liberties that they care about (or not). There’s also this short, but entertaining, interview with the mayor of Las Vegas… who is sponsored by a gin brand, apparently.
- The Presidential Cancer Panel recently released a report on environmental carcinogens that set off some minor controversy. Here are reactions from Science-Based Medicine, Reason’s Hit & Run blog (also here), and the Wall Street Journal Health Blog.
- Jason Shafrin at Healthcare Economist runs down the math of running into a terrorist. Bottom line: don’t sweat it.
- Greece and the Euro continue to be in the news: what does it mean for us on this side of the pond? Greg Mankiw links to an article that claims that crises such as that in Greece show that we cannot have democracy, nation-states, and globalization together. Reason talks debt, deficit, inflation, and the future of America’s fiscal situation. On a lighter note, Mark Perry shares a video showing what you can learn about economic communities if you literally follow the money.
- Hit & Run did well this past week, it seems. Here’s another post of theirs arguing that all the nutrition programs in the world won’t work if they don’t take into account the role of values, preferences, and tastes in shaping diet.
- The Health Affairs blog presents a proposal to “Reinvent The Primary Care Workweek.” Importantly, they realize that the quality of the job is at least as important as payment in getting more students to choose primary care fields. Of course, a patient load that small means that you need more people to join the ranks pretty quickly after implementing the model. Seems like a good idea, but we’ll see what happens.
- There was lots of quality blogging about insurance, as well. InsureBlog looks at Massachusetts and finds a classic example of how not to run a health insurance exchange. Prescriptions looks at what the PPACA requires of self-funded employer plans: fortunately, it doesn’t seem to be all that much, given that telling employers how to provide a benefit may well result in them not providing it in the first place (the argument is different with insurance companies). Hit & Run points out that insurance regulation involves lots of tradeoffs, even if the regulation’s proponents don’t want to admit it. Finally, David Williams at the Health Business Blog summarizes InsureBlog’s complaints about an all-too-common situation with college-provided/mandated health insurance: it’s terrible.
- Finally for this week, Scott Greenfield brings us a lengthy, compelling, and disturbing story from the Village Voice that takes an inside look into incentives and operations at the patrol level in New York City’s 81st precinct. From a political/legal/libertarian point of view, it’s frightening. If you insist on putting a health policy lens on it, call it what happens when you implement the ultimate pay-for-performance system alongside the ultimate EMR. Enjoy…
Today, The Economist’s Free Exchange blog mentioned a recent study looking at how children decide between chocolate and broccoli based on the presence or absence of an Elmo sticker. My short version of their short version is that putting the Elmo sticker on the broccoli seems to get more kids to choose it over a chocolate bar relative to a situation in which neither chocolate nor broccoli is adorned with Elmo’s smiling face.
The blogger adds:
Interesting, no? But isn’t the real story here that given the choice between a chocolate bar and broccoli, 22% of children chose broccoli? Surely that means that this study is unreliable, having been based on a skewed sample, no? Because I’m pretty sure that in a representative sample of the population 0% of the children included would opt for the broccoli, correct?
I realize that R.A. is being tongue-in-cheek and probably doesn’t mean anything serious by this, but it got me thinking back to my own childhood relationship with vegetables.
Specifically, I loved them, especially spinach. I grew up in an ethnic minority household, and my mother could prepare pretty much any vegetable in a very, very delicious manner. There was nothing I loved better as a child than my mom’s ethnic minority spinach dish.
This is why I was always puzzled by children’s media (TV, books, whatever else there was in the pre-Internet days) that depicted children needing to be cajoled into eating their Brussels sprouts, broccoli, and spinach. Why would you need to be asked? Spinach (at least as I knew it) was quite possibly the Best Thing Ever, as far as food went. Those other kids, including those depicted in media and those I know in real life, were crazy!
It wasn’t until my high school cafeteria served up boiled, soggy, tasteless spinach that I saw where they were coming from. Even then, though it paled in comparison to the gastronomically enlightened version that my mom made, it wasn’t that bad.
A lot has been written on children’s nutrition and on what can be done to improve it. What children see their parents eating is obviously important, and teaching people to cook nutritious food in interesting ways (so that both the adults and kids will want to eat it) has been touted as a way to improve childhood nutrition. That said, and knowing full well that these factors interact with one another in countless ways, I can’t help but look back to my own childhood and realize that the only inkling I had of the idea that vegetables were something to be disliked came primarily from kids’ books and TV shows.
Where would children learn to hate vegetables if not from their parents’ expectations or from media? I’ve met children under the age of two whose days are made when they get peas with dinner… what are the odds they’ll have to be cajoled into eating vegetables in a few years’ time?
I don’t mean this as advocacy of censorship or regulation of any sort, and I definitely don’t think that changing these expectations is something that can be done overnight, or even something that would solve any problems on its own. I just find it interesting that North American culture, at least as I’ve experienced it, has created such a strong presumption that children “should” hate their vegetables that people rarely think to ask why that should be the case to begin with.
 – I hope it doesn’t matter to you which ethnic minority group I belong to, because I’m not telling! Back to text.
No, we really shouldn’t, recently published misinformed scholarship notwithstanding.
The WSJ Health Blog brings to our attention a gem of a “study” performed by researchers at the Harvard Medical School-affiliated Cambridge Health Alliance.
The article opens with the supposition that “[l]ife and health insurance firms profess to support health and wellness,” then reminds us of the various evils of fast food and of the various efforts at the municipal level to rein in fast food firms. We learn that certain large insurers hold shares in certain fast food firms. The article closes with the claim that insurers should “be held to a higher standard of corporate responsibility,” and thus their only ethical options regarding fast food shareholdings are to 1) divest, or 2) become activist investors and push for “practices consistent with widely accepted public health principles,” possibly even “turn[ing] over their proxy votes to an independent nonprofit organization.”
Is this such a widespread problem? Is this a problem at all? How did they get to this conclusion?
Researchers, “sensing [a] potential disconnect” between insurers “responsibility to share- or policyholders to maximize returns” on the one hand, and “their health-promoting mission” on the other, decided to look at the value of major insurers’ investments in: Jack-in-the-Box; McDonald’s; Burger King; Yum! Brands (mainly Taco Bell, Pizza Hut, and KFC); and Wendy’s/Arby’s. Of these five firms, McDonald’s is a component of both the DJIA and the S&P 500 indices; Yum! Brands is a component of the S&P 500. The study examined the holdings of eleven major insurers who, on aggregate, write life, health, and long-term disability policies in Canada, the US, and the UK.
The results are, in my view, pretty vanilla. The researchers looked at the state of the world on June 11, 2009. Between them, these eleven insurers had positions worth $1.88 billion in the five fast food firms, of which $1.18 billion was McDonald’s holdings and $0.404 billion was in Yum! Brands shares. The current (April 15, 2010) market capitalization of these five companies combined is approximately $101.24 billion; McDonald’s alone has a market cap of $74.41 billion. The article states that, at the time, these eleven insurers together owned shares worth 2.2% of the combined value of the five fast food companies.
(There are some mildly interesting factoids to be gathered by looking at individual insurers: some have large fast food stakes, some have minuscule stakes; some have holdings across all five fast food firms, some only hold shares in one; the three two insurers who write health insurance in the US hold stakes that are minimal relative to the others’; no information is given as to the size of any firm’s total investment portfolio)
The authors suggest three reasons why insurers whose alleged “mission” is to promote health would invest even a dime in these Evil fast food firms. Firstly, the return on investment in these companies might exceed the “potential financial liability associated with their policyholders consuming fast food.” Alternately, insurers might simply be “unaware of the social impact of their investments.” And lastly, the authors suggest that the claims and underwriting sides of large insurers just might not be aware of what their colleagues on the investment side are up to. Holding the shares is just not an option. After all, “”[t]hey’re profiting directly off the people who eat fast food, and if that leads to obesity or cardiovascular disease, they’ll charge you more for premiums if you have some of those conditions,” says Boyd. “They’re making money in either case.”"
Even assuming the objections raised by the insurers about the data’s accuracy are incorrect, let’s see if the researchers’ normative conclusions are justified.
Any insurer’s first priority will be to its shareholders; a legally enforceable fiduciary duty exists between a firm’s management and its owners. Its next priority (or first priority in the case of a non-profit insurer) should be to its policyholders. Specifically, an insurer should uphold its end of any policies that it has written, and should take steps to remain solvent so long as it has policies outstanding.
Nowhere is there an obligation — legal, moral, or otherwise — for life or health insurers to promote health and wellness either among their policyholders or in the community at large. It’s possible that some insurers, particularly health insurers, might find it cost-effective to do so, but it is not within the scope of their obligation to policyholders. A study author claims that insurance ownership of fast food stock amounts to ‘double-dipping.’ Insurers exist to insure against risk (sounds so simple, doesn’t it?). Faced with a riskier prospective policyholder applying for an underwritten product, they will increase the premium to reflect the expected increase in claims paid out to that policy’s beneficiary. To the extent that underwriting differentials are actuarially fair, it doesn’t matter to an insurance company how many Big Macs their policyholders choose to eat, so long as their policies are priced appropriately. If anything, owning fast food shares could be seen as a (vastly inefficient) hedge against unexpectedly increased policyholder obesity from fast food consumption. It’s most certainly not a way to directly profit off of their own customers.
Why would any insurer hold shares of anything in the first place? I can think of two main reasons. The first is unique to life insurance. With universal life insurance or segregated funds, life insurers hold shares on behalf of policyholders. Policyholders may choose to invest the cash value in a number of ways, including in fast food securities. The WSJ blog post quotes a Prudential executive as pointing out that much of their shareholdings could be attributed to these policies and funds. I can think of no policy or ethical reason to prohibit these investors/policyholders from investing in fast food shares, nor do the authors venture one.
The second is common to most insurers: they need someplace to invest their float (the money collected from premiums that do not yet need to be paid in claims). Profits from the float can be good for consumers: insurers can use float profit to offset underwriting losses, and even to maintain looser-than-otherwise underwriting standards or lower-than-otherwise premiums. A vanilla investment strategy might include buying shares of major companies that form part of the Dow Jones Industrial Average or S&P 500 Index… such as McDonald’s or Yum! Brands. I see nothing sinister about it.
Even if insurers were to divest their and their client’s holdings of fast food companies, what effect would it have? Someone else would own the shares and derive profits from them. Instead of profits from those shares being used to reduce the need for premium increases or tighter underwriting standards, they would accrue to someone else. Assuming these shares were held in the first place as part of a profit-maximizing investment strategy on the part of the insurers, this divestment would not serve their policyholders. It’s also hard to see how it serves the larger community in any meaningful way. Buying or holding shares in the secondary market sends no money to the company whose shares are being bought.
In short, this study is much ado about squat.
Life and health insurers have obligations first to their shareholders, then to their policyholders, neither of whom would benefit at all if insurers were to divest from fast food firms. The larger community would receive no benefit from divestment either. Aside from the symbolic value (which would be close to nothing, given the tiny amounts of these companies actually owned by insurers), divestment would do absolutely nothing for the cause of public health.
The larger community, I should add, I include in this analysis only because the authors do. The role of private insurance in managing risk is one that is poorly understood generally, barely acknowledged in the recent health insurance reform conversation, and one that I hope to return to at the Notwithstanding Blog. Generally, however, it does not include improving the health or well-being of the underlying community for its own sake.
Physicians’ organizations spent most of their (limited) political capital during the recent reform conversation arguing for more money for themselves (a goal that I largely agree with), and arguing that ‘more be done for the patients,’ without, in most cases, displaying a serious understanding of the issues involved in the latter. If physicians are to be taken more seriously on these topics in the future, it would behoove them to avoid the pitfalls of understanding that plague this study.
Update (15 minutes later):
I decided to look for information about these investments relative to the insurers’ portfolios. I looked at Manulife and MetLife 2009 Q4 investment fact sheets; it’s unclear how much, if any, of these portfolios are client-directed. Interestingly, MetLife doesn’t seem to offer health insurance, as the study authors claim.
Manulife had an investment portfolio worth C$187.5 billion, including C$9.38 billion in stocks, including $0.1461 billion in shares of McDonald’s and Yum! Brands.
MetLife had an investment portfolio worth $309.3 billion, including $8.66 billion in corporate equity, including $0.0020 billion in holdings of Wendy’s/Arby’s.
I see no reason to believe that the inferences drawn here are inapplicable to the other nine insurance companies in the study.
What this quick number-running tells us is that not only are these insurers’ holdings of fast food shares insignificant in terms of the fast food companies’ market capitalizations, but also in terms of their own portfolios (these two insurers have portfolios an order of magnitude larger than McDonald’s market cap).
Given that there really isn’t anything to be gained from divestiture, this only reinforces the conclusion that this study’s authors are trying to make a capital crime of a traffic violation.
Study citation: “Life and Health Insurance Industry Investments in Fast Food.” Mohan et al. Am J Public Health.2010; 0: AJPH.2009.178020v1
Disclosure: two of the eleven insurance companies studied are Manulife Insurance and SunLife Insurance, which in turn are two of the top 10 holdings of an ETF of whose shares I own a small number. I hope this satisfies the FTC.
 – The authors’ argument is strongest for companies who write health insurance in the United States. Of the 11 insurance companies evaluated, only three two did so. Most of the insurers in question are life insurers, which leads me to think this whole hullaballoo is based on a giant red herring. Private health insurance doesn’t generally cover the “bread and butter” health expenses of Canadians or Britons, and life insurance is a whole other matter entirely, so the authors’ arguments, weak as they are, are barely applicable to their own dataset. Back to text
 – One could argue that someone in the insurance sector should be looking out for the community at large . That may be the case, but it’s not a job to be stuck on private, for-profit insurance, whose existence is a given here. Back to text