Are Liberals Repeating The Republican Formula?

Many liberal social media groups that I comment on and am in agreement with on many issues over the past decade are now getting their panties in a twist when I bring up even the slightest descent.

In an effort to be like the Republicans were in the 80's and 90's many liberals are wanting solidarity. They feel they have science on their side but this comes with a cost, especially to the theories they espouse. They are over-stepping their beliefs and reasonable discussions of said theories are blatantly put down.

One particular belief that is common in Liberal circles is that Jesus would support The Affordable Care Act. This is such a silly argument and one I espoused until I thought a bit deeper on the topic. This argument is put forth with the certainty of a scientific fact. It is a ridiculous assumption to posit that Jesus would support a government interventionist approach to the US health care problem.

Let me state clearly that I am whole heartedly in favor of government intervention in social welfare and healthcare because it is best for our society both economically and from a human capital position. My position is also backed up by a lot of research on how social factors influence health, how our economic system creates the high costs of medical treatment, and how they negatively affect minorities at higher rates; where as the Jesus argument is entirely based on the interpretation of a manuscript written in 325 AD, and years after the death of Jesus. That said, I do think other arguments that use Jesus' position on violence are valid. It is abundantly clear he did not advocate violence and much has been written about his position. However, I am not so certain that the story of him healing the blind and giving out food is clear outright support for a government providing health care and social services for its people.

I think liberals enter dangerous waters when they move into these kind of tactics and personally I find this type of argumentative style very off putting. 

A Belated Eulogy for Eleanor

I love studying statistics. They tell us what most people are like most of the time. But like many people, the parts of my life that are the most exciting to me are those that don’t fit well into statistical description.

One such extraordinary part of my life was my friendship with Eleanor. When I met her, she was 85 years old and very sharp. A part-scientist/part-painter with a PhD in English, Eleanor often went for walks and spent a lot of time outdoors sitting on her walker observing nature. It was during her daily jaunts that I began to spend time with her. We immediately hit it off as we discovered that we both had a poetic appreciation of nature, and we both loved art and science.

I met her on my own circuitous journey, which landed me a job as an activity assistant in an assisted-living facility in Mississippi. My wife, a native Mississippian, and I moved there from Seattle after we jumped off of society’s escalator of pre-planned milestones to follow our own personal goals. Within weeks of landing in small-town Mississippi, I was teaching a seated version of Tai Chi to residents of the assisted-living home.

Those classes were well attended, particularly by two residents, Franny, whom I wrote about earlier, and Eleanor. There were many moments that the three of us sat in Eleanor’s room when I felt like I was in a Samuel Beckett play. It was during these occasions that I came to know that Eleanor did not think she “understood” life but sought to understand it, like many of Beckett’s characters. This pursuit of trying to understand life that we shared was probably brought on because of traumas we had each carried like a heavy backpack on a long journey. But they pushed us to explore life and compelled us to share notes about our own unique journeys.

Often this sharing took place in her room where we would sit for hours discussing philosophy, psychology, the arts, and anything that helped us understand the trauma we had experienced. One of the things I loved about Eleanor was that she engaged many people to share whatever they knew about life, and a number of people visited her because of her openness to their experiences. Often others would join in and we would have rich and unexpected conversations.

Some of those discussions included deeply religious people who would tell us their take on the meaning of life, which usually involved heavy dogma. This often disappointed Eleanor and annoyed me, as some people went so far as to claim that my role in her life was to help her find Jesus. Independently, Eleanor and I had come to the conclusion that there is no knowing, only seeking.

Eleanor and I couldn’t relate to those who claim to “know” what life is about, like many religious people and statisticians. I believe as people who had to walk with trauma, she and I didn’t have that feeling of certainty about much in life. We lived in uncertainty and were caught in between statistics and religion.

Five years after Eleanor’s death, I haven’t met anyone quite like her, but I am still carrying my backpack and proudly upholding the values that we shared. I looked up the origin of her name, and of its many possible meanings, the one I think is most suitable to describe her is from the Latin root of the verb lenire, “to soothe or to heal.”

If anyone chooses to write about me after I die, I hope they have as difficult a time as I had in conveying a glimpse of Eleanor.

The Libertarian Endgame

On September 12, 2011, during CNN’s GOP Tea Party express debates, Wolf Blitzer posed a hypothetical question to Republican candidate Ron Paul, asking who should foot the bill for a healthy 30-year-old man who chooses not to buy health insurance and then suddenly ends up in a coma with expensive medical bills? Paul responded that freedom is about taking risks and personal responsibility, and it is not about the government taking care of everybody. Paul is a libertarian and, as such, believes that government should be as small as absolutely possible and only interfere in people’s lives for basic protection from hostile enemies and criminals.

Blitzer then asked, should we just let him die? Some in the audience cheered, “Yes, let him die!”  Many left leaning groups and individuals used this as a glaring example of the hypocrisy of the right. Republicans are a party that claims higher moral ground, conservative family values, and pro-life agendas, and yet at a party debate some verbalized support for a person dying because he couldn’t cover medical bills.

Paul himself said that we shouldn’t let him die, but he offered only altruistic church groups and charities as the solution. In 2012, medical expenses account for 60% of American bankruptcies.  So, leaving this incredible financial burden for church groups and charities to shoulder means that, in reality, many people would die.

The day after the debate, news broke that Paul’s close friend and 2008 campaign manager, Kent Snyder, died of pneumonia at age 49 after accruing more than $400,000 in medical bills. Paul and his staff raised $50,000 towards the bills, but the hospital bill was never paid off. Apparently, libertarians think it is acceptable for the hospital to eat that bill. So they overlook an important point about our medical system: we pay these bills by a back-door financial policy. Hospitals make up for this kind of unpaid bill by the raising the cost of everyone else’s medical care.

This issue is a defining moment for the US because one could easily blame the high costs of healthcare on the Emergency Medical and Treatment and Active Labor Act (EMTALA), which says hospitals that receive taxpayer money cannot refuse care to people. Would libertarians propose getting rid of the EMTALA? Is this the kind of society we want to live in?

One other reason why healthcare costs are high is that the US political system allows corporations to get so powerful that they can steer government policy towards their own interests. Using their monetary influence, they can break down regulation and fix the game in their favor. If, as libertarians believe, government should be small and only used in defense and the like, who will be there to regulate these big corporations when they are in total control? Their default answer is the invisible hand of the market. But even Adam Smith, the great hero of capitalism, extolled the benefits of the invisible hand only when there is a general well being among all citizens. 

I agree that when it comes to government intrusion on lives of its citizens, I think we should look at policies with a libertarian eye and not make a policy without a good reason. However, there is very good reason to provide health care, both for moral reasons, like those above, but also economic ones. The libertarian stance claims that when government gets involved, costs go up. Ron Paul frequently makes this argument in his speeches. I am not sure where their evidence comes from. Data shows instead that healthcare costs are lower in single-payer health systems.

When the ethical and practical reasons for a libertarian position on healthcare crumble, why continue to cling to the hard line?

Social Determinants of Health: is Psychosocial Stress the Primary Determinant and what are the Implications for the Field of Epidemiology?

The evidence linking social factors to health outcomes has been researched since the 1940s (Krieger, 2001). The so-called social determinants of health has generated its own field of research called social epidemiology. The whole field hinges on social constructs or structural hierarchies embedded in human societies that heavily affect health. Psychosocial stress is one such risk factor that has been identified as an explanation for how social factors influence health outcomes. One of the big debates in public health is centered on competing theories of causation for the social determinants of health. This paper is an analysis of what the argument between psychosocial theorists and the neo-materialists says about the future of epidemiology.

One of the largest studies to garner support for the psychosocial risk factor is a case-control study by Rosengren et al. (2004). This large, multicentre study found an association between psychosocial stress and acute myocardial infarction (AMI). The researchers operationalized psychosocial stress by asking questions about eight variables: stress at work, stress at home, general stress, financial stress, stressful life events, locus of control, feeling depressed, and clinical depression. They concluded that the effects of psychosocial stress were independent of lifestyle factors such as socioeconomic status, smoking, and education and that “the size of the effect was less than that for smoking but comparable with hypertension and abdominal obesity”(p. 961).

The three dominant models of causation for the social determinants of health are neo-materialism, psychosocial theories, and the effect modification hypothesis (Jayasinghe, 2011; Marmot and Wilkinson 2001)

The neo-materialists posit that the root cause is the structure of society and the political system, and that the key to solving this problem is through development—providing material needs to people. The psychosocial theory is closer to the biomedical model in that it argues that there is a direct effect on the body’s immune system through the impact of stress from the environment, and that leads to higher rates of mortality. The effect modification hypothesis positions stress as a “risk regulator” (Marmot and Wilkinson 2001). This means that people in low-income groups have higher levels of stress, which in turn causes those people to make poor lifestyle choices, such as smoking tobacco or consuming excessive amounts of alcohol, and thus have poor health outcomes (Lynch et al., 1997).

The heated debate between these differing camps of causal models is both political and methodological in nature. The neo-materialists posit that the major factor is one’s materials or assets and that having a home, car, and computer are proxies for a higher quality of life. Research has confirmed that once one’s basic needs are met, there are significant health improvements(Macleod, et al., 2001; Lynch et al., 1997). Neo-materialists derive a large part of their evidence from studies on the ecological level, which makes it difficult to generalize to individuals. They also argue that the material level is more amenable to change than psychosocial stress, saying that reducing stress throughout the population is difficult if not impossible (Marmot and Wilkinson 2001).

The psychosocial theorists contend that people’s health is more than their material circumstances and, moreover, that understanding the exact physiological mechanisms of action provides a clearer picture of the disease process(Marmot and Wilkinson 2001). The psychosocial variable has proven to be a highly stable measure, albeit sometimes a subjective one. One of the major points of contention is that humans cannot be randomized to treatment groups; therefore we cannot truly ascertain causation because we have to resort to animal models to experiment on. This type of research brings us closer to understanding causal mechanisms, but because humans and primates are vastly different—despite being 98% genetically similar—we cannot fully accept evidence from those studies. However, there has been compelling evidence in primate models that shows conclusively that social hierarchies lead directly to higher levels of stress in those species. Many psychosocial theorists have measured stress objectively with biomarkers such as cortisol and glucocorticoids, which lead directly to atherosclerotic plaque build up, a major risk factor for cardiovascular disease (Sapolsky, 2005). Another argument made by the psychosocial theorists is that social hierarchies embedded within a country mask the neo-materialist’s hypothesis and demonstrate that key components of the psychosocial variable, autonomy and social capital, are the important building blocks to good psychosocial health(Marmot and Wilkinson 2001).

The effect modification hypothesis has strong evidence linking low socioeconomic status (SES) with poor behavioural choices, and some studies have shown that people of low SES are less likely to change their behaviour (Lynch et al,1997). This means that people in low SES groups have higher levels of stress and, due to their low income, cannot afford higher quality foods and health care, which in turn negatively affects their health. Many argue that this blames the individual and is the least productive of all theories(Lynch et al,1997). The criticism here is not so much about methodology as it is about the politically unsavory way it analyzes people.

From a reductionist point of view, the psychosocial theorists have a stronger argument than the neo-materialists because newer technological advances create the possibility that as time advances our abilities to measure will get better and better. According to the hierarchy of evidence, ecological studies are lower ranking, and psychosocial studies command a higher level of evidence. But because it is so difficult to reduce the social determinants of health into neat categories such as education or SES, there is a call from some contemporary epidemiologists for a paradigm shift away from such reductionist searches for causation.(Jayasinghe, 2011; Krieger 1994; Glass and McAtee 2006) Although reductionism works well in identifying strong infectious agents, it is ill-equipped to handle many complex systems like the social determinants of health(Jayasinghe, 2011; Glass and McAtee 2006)

This debate about causation is a digression from the real issue, which is to find workable solutions to issues raised by the social determinants of health. Epidemiology is in a state of transition or stagnation, depending on whether you view the glass as half empty or full. Many epidemiologists seem content to push an outdated model that can’t address many of today’s problems(Jayasinghe, 2011; Krieger 1994; Glass and McAtee 2006) To refocus on problem solving means moving epidemiology from a field distracted by concern with causation and controlling for bias and shifting it instead towards following Kreiger’s assertion that whatever the means of causation, be it direct or indirect, intervening on social determinants such as education and early childhood development should be a high priority in addressing health outcomes (1996).

References:

1.Krieger, N. Theories for social epidemiology in the 21 century: an ecosocial perspective. International Journal of Epidemiology. (2001);30:668-677.
2.Rosengren, A., Hawken, S., Yusuf, S. et al. Association of Psychosocial Risk Factors with Risk of Acute Myocardial Infarction in 11,119 Cases and 13,648 Controls from 52 Countries (the INTERHEART study): Case-control study. Lancet. (2004);364:953-962.
3.Jayasinghe, S. Conceptualising population health: from mechanistic thinking to complexity science [electronic article]. Emerging themes in Epidemiology. (2011). 8:2 http://www.ete-online.com/content/8/1/2.
4.Marmot, M., Wilkinson, R.G. Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. British Medical Journal. (2001);322:1233-1236.
5.Lynch, J.W., Kaplan, G.A., Salonen, J.T. Why poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic life course. Social Science and Medicine. (1997); 44(6):809-819.
6.Macleod, J., Smith, S.D., Heslop, P., Metcalfe, C., Carroll, D., Hart, C.Are the effects of psychosocial exposures attributable to confounding? Evidence from a prospective observational study on psychological stress and mortality. J Epidemiol Community Health. (2001);55:878-884.
7.Sapolsky, R.M.The influence of social hierarchy on primate health. Science. (2005); 308(648); (doi: 10.1126/science.1106477).
8.Krieger, N. Epidemiology and the web of causation: has anyone seen the spider? Social Science Medicine. (1994);39(7):887-903.
9.Glass, T.A., McAtee, M.J. Behavioural science at the cross roads in public health: extending horizons, envisioning the future. Social Science and Medicine. (2006); 62:1657-1671.
10.Krieger, N., Zierler, S. What explains the public’s health?: A call for epidemiologic theory. Epidemiology.(1996);7(1):107-109.

Extreme Diets: Perfect for Reality TV

I wrote my last blog post, Moving towards a whole foods, plant-based diet, after earning a degree in Public Health that focused on chronic disease etiology and prevention. Then I accidentally bumped into a book called The China Study. When I read that book, little did I know I would be thrown into a storm of nutritional chaos theory in which academics are coming to blows over which diets work, how to lose weight, or whether one can even lose weight at all. My professors didn’t even mention this controversy.  Here is my take on this contentious issue.

The basic controversy can be split into two major groups, the “meat is bad” group and the “meat is good” group. Yes, I know it is a bit more complicated than that, but in lieu of writing a dissertation I am simplifying the arguments. Nestled within the “meat is bad” crowd, you have the low fat people, some of whom eat chicken and pork but steer clear of red meats, some vegetarians—which include every imaginable dietary configuration—and the extremists, the vegans. They are pitted against the “meat is good” group, among whom you will find the anti-carb Atkins crowd, the just-plain-carnivorous steak-a-day people, and the ultimate in carnivore, the Paleo-people, some of whom actually run down their own food with spears.

Meat is Bad

First, let’s look at the low fat “meat is bad” crowd. I think it is pretty intuitive that meat feels unhealthy. It is slower to digest, and fat is clearly visible on the product. So it is not too hard to see their basic argument: fat from animals is high in saturated fats, the kind of fat that clogs your arteries, and, putatively, is a major cause of heart attacks. There are many observational studies that support this claim. However, the evidence is highly inconsistent. Two important details often skirted over are that meat has lots of the good fat, too, and that carbohydrates can affect blood cholesterol levels as much as meat.  We also can’t overlook the fact that high consumption of meat is associated with colon cancer. The mechanism is not fully understood, and it could be the nitrates in preserved meats and not the actual meat that causes colon cancer. Also, there are concerns that cows are an inefficient food source because the inputs (feed) outweigh their outputs (meat). So if everyone were a vegetarian, food costs would be lower and the world would be a better place. But the purpose of this paper is to discuss heart disease and obesity.

One troubling flaw in the “meat is bad” argument is that Americans have been eating less red meat and less saturated fat since the low-fat craze of the 1980s, yet obesity has risen to epidemic proportions. It is also a fact that when people switch to a low-fat diet they increase their carb intake. In addition, there is recent research showing that cutting out too much protein lowers lean muscle mass, which is not a good thing.

 

Then there is the issue of dairy. When people become vegetarian, most think they have signed on to a healthier lifestyle when, in fact, they often replace their meat consumption with dairy, in the form of cheese, milk, cream sauces, etc.  India is the country with the highest prevalence of vegetarians. Vegetarianism has been integrated into Hindu religious practices and culture for thousands of years, and people there get most of their protein from lentils and dairy. Yet India has the highest levels of diabetes and obesity in the world.

Then there is veganism. Vegans disavow all meat, dairy, and other animal products, and they are seen as higher up on the dietary purity pyramid. I have eaten in many vegan and vegetarian restaurants. Anecdotally, I find that many of these dishes have high levels of salt and/or sugar. I think this is because evolutionarily our palettes are wired for salty, sweet, bitter, and sour, and our cells need fat to rebuild. So we have evolved to crave these tastes, and when you eliminate one of those tastes, you need to replace it with more of another.  

 

But the real clincher in my questioning of the “meat is bad” perspective comes from the science. In 2010, a thorough meta-analysis published in a prestigious nutrition journal pooled the results of 21 well-regarded studies on saturated fats and health. It showed no significant effect in the relationship between saturated fats and risk of CHD or stroke.  This is definitely a big blow towards the "conclusion" that a low-fat diet is a healthy diet. It also demonstrates how intractable nutritional dogma is because the low-fat diet is still taught in medical schools and health science departments and appears in guidelines used by public schools.

These two dietary choices seem to be based more on romance than evidence, from the health perspective. (I realize there are other reasons, such as ethics and environmentalism, that people choose these diets.) I was never able to put my finger on it until I opened up my undergraduate biology textbook to prepare for a nature walk with my son’s 2nd grade class. I saw an intriguing diagram of the relationship between autotrophs and heterotrophs. An autotroph is any organism that makes its own food, e.g. plants through photosynthesis. Heterotrophs are organisms that cannot do this, which means every animal on the planet has to hunt for food, either by eating the autotrophs or by killing and then eating those who eat autotrophs. Obviously, we are heterotrophs, but we have brains that have adapted a conscience, which means we can see the purity of making our own food and conversely see the pain that killing causes. I believe that some people have a romantic desire for a “pure” diet that appeases their conscience.   

Meat is Good

At the other extreme is the “meat is good” argument, which is based on evidence that our early hominid ancestors began eating meat more than a million years ago and that, from an evolutionary perspective, our bodies have had time to adapt to a diet of meat. In contrast, humans have only been cultivating the land for grains and veggies for the last 11,000 years, which some argue is not enough time for our bodies to have adapted. Thus, it becomes highly unlikely that meat is the cause of our suddenly expanding waistlines. Some archaeologists believe that the adaptation to meat aided in our brains becoming larger.

Bolstering this argument is the fact that many primitive peoples, such as the Hadza and Inuit, have survived on diets of almost pure meat, and they rarely were afflicted with any of the chronic diseases associated with obesity until coming in contact with westernized foods such as refined carbs and sugar. Gary Taubes, author of Good Calories, Bad Calories (GCBC), brilliantly argues that dietary fat is wrongly accused as the culprit in heart disease and points the finger at sugar as the real killer. Taubes’s argument is very convincing. He is backed up by some of the most respected researchers in the field of nutrition who have published papers on taxing and regulating sugar, especially sugar sweetened beverages. Certainly from an evolutionary perspective, for many primitive societies, sugar was a seasonal delicacy and thus its consumption was regulated by nature. That sugar—particularly in drinks like syrupy lattes, white flour, and fried foods—is bad for you is not a contentious issue.

The flaws in the “meat is good” argument lie mostly in the extremes of their position. Look at the way Atkins demands stopping all carbs, at least temporarily, and the diet has produced a processed protein snack market. And although Taubes quietly acknowledges that there are good carbs and bad, his questioning of assumptions that fruit is healthy because no one has ever done a random controlled trial testing its efficacy distracts from his main message and leads people to dismiss his entire argument. Taubes is committed to his position and even posts his diet (bacon, sausage, burgers, and steak daily) and his triglyceride levels on his blog, but the fact that he enlisted a psychiatrist friend to order the tests strikes me as kind of weird.

Then there are the Paleo Diet people who really get into the purity aspect of man the hunter, the meat consumer. To me this position borders on Paleolithic fantasy, with romantic images of man the pure hunter carnivore. Although the idea that our bodies are adapted to eating meat is a valid argument, this camp just takes it to a level of impracticality so glaringly obvious that it’s hard to believe how zealous Paleo people can be. Humans have been genetically modifying food, wild or domestic, since we learned how to control our environment through selection and domestication. So it is impossible to find a truly sustainable Paleo diet on this planet. In addition, there is an unrealistic assumption that there was a homogenized caveman diet. Some Pleistocene era people lived near coasts and some in woodlands. Carbs and grains were certainly available. So again, I see this dietary choice as grasping for an unattainable purity on the other extreme.

Made for TV Confusion and Chaos

I could see people from both sides literally duking it out on the Discovery Channel. It might make for good television when science gets mixed in with zealots fighting over their extreme position, but I am tired of dietary purity and fantasy and I just want the facts. I just want to eat good tasting and healthy meals. So, to me the question really boils down to this: what would you do if suddenly you were diagnosed with coronary heart disease?

One reasonable voice can be found from the author, Richard Wrangham, who wrote the book Catching Fire: How Cooking Made Us Human. He makes a convincing case that cooking food maximized our caloric intake and thus freed humans to develop larger brains. Even Darwin said that cooking was humanity’s greatest discovery aside from language. The Paleo people are correct in that foods that are high in calories and low in nutrients (foods such as fast foods, candies, and frozen meals and that are abundant in obesogenic environments) are nowhere to be found on the African savanna. These are the kinds of foods that our bodies have not evolved to metabolize properly and, unfortunately, they are perfectly suited to our busy lifestyles. Meat is a whole food and it is something we have evolved to eat and digest. But that doesn’t mean eating a prime rib every night is great, and it doesn’t mean root veggies are going to make you fat.

Another way of looking at these extreme positions is seeing where they overlap. Consider a Venn diagram, with an overlapped area (below). This is where both arguments tend to agree on a whole-food diet and both also agree that highly processed foods are not healthy. So really the BIG disagreement is that at one extreme, eating meat is bad and at the other, it is good, with a whole spectrum in between. In this situation, I stick to the center, the overlapped area. Based on current available evidence, controversial as it is, I believe we need to stick to a traditional balanced diet that includes meats and lots of good carbs, such as whole grains, fruits, and veggies.

This validates the Italian-American food values I was raised with. My family believed in eating fresh, whole foods.  There wasn’t a focus on meat, but it was never demonized or romanticized either. I am now inspired to continue with that tradition of making well-balanced, home-cooked meals with fresh ingredients.  We all must find some common ground and admit that using less sugar and salt, very little white flour, limiting alcohol to a drink or two per day, and increasing veggie consumption are the safest bets for health. Personally, I’d stay away from extreme diets, like Atkins, Paleo, and veganism. Many of those diets have some research behind them, and they are not totally implausible, but they always seem to go out further that the evidence suggests. As the prominent scientist Medawar once said, “The intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not.”

Moving towards a whole foods, plant-based diet

I love to cook, and when I say cook, I mean I love Mario Batali and Anthony Bourdain meals, heavy on the meat, fat, and cheese. I never had much of a sweet tooth, but I certainly cannot deny that I crave animal fat. You could put a fresh, homemade chocolate cake in front of me, and not even a taste bud stirs, but make a juicy dish of braised shorts ribs and I become one of those kids in a Mischel experiment.

Recently, my brother and I got into a little argument. We never argue. During a banal phone conversation, he claimed that if everyone turned vegan, the world would be a better place. Being the one with a Master’s degree in health science, I disputed his claim. I threw out some facts, which mostly demonstrated my own bias against veganism.

A few weeks passed, during which time I stumbled across T. Colin Campbell’s book The China Study. The author tells the story of growing up on a dairy farm, drinking milk and eating meat every day, and then coming to the realization that animal-based foods cause cancer, heart disease, and a smorgasbord of chronic diseases.

Campbell was a respected researcher at MIT, and his early research on casein (milk protein) showed that it facilitated cancer tumor production or tumorogenesis in the livers of rats, while vegetable protein suppressed tumor production. He conducted an impressive range of studies on animal models demonstrating that dietary fat from animals, either in milk or meat, facilitated cancer more than leading carcinogens such as aflatoxin. This evidence led him to conduct one of the largest human nutrition epidemiological studies, in China.

This observational study compared lifestyle, dietary factors, and standard biological measures to investigate the amount of influence on all major chronic diseases across most of China, a country with a vast array of regional differences.

One of his major points is that only a small percentage of cancer development can be explained by genetics, while what we eat plays a much larger role, even more than known chemical carcinogenic exposures.

Important findings from the China Study:

1.     High dietary fat is positively associated with heart disease (by increasing bad cholesterol in the blood) 

2.     High animal protein consumption is positively associated with high cholesterol

3.     High animal protein consumption is positively associated with breast cancer

4.     Low animal protein consumption is associated with later menarche in women (through estrogen)

5.     Later menarche is strongly protective against breast cancer

6.     Late menopause is associated with higher breast cancer

7.     Animal protein consumption extends exposure to estrogen because it initiates early menarche and later menopause

8.     Animal protein is associated with many other chronic diseases as well.

If you Google “critiques of the China Study,” you will find some solid, honest criticisms. There is no question that there are some flaws in the study. However, what large-scale, cross-cultural study doesn’t have issues? I myself worked on one in India, and I can say this is a difficult type of study to pull off without flaws. Some of the critiques I read say that Campbell is biased towards a plant-based diet and only looks at studies that confirm his perspective. I think this criticism is off-target. Campbell may very well be biased, but he is totally transparent on every level. There are no hidden deals with the fruit and veggie oligopoly, unlike the meat and dairy industries’ backing of research favorable to them.

Others say he extrapolates too much from his research, and I agree with this to a point. My biggest issues with Campbell's argument are these:

1.     China in the 1980’s had many differences with westernized nations, going well beyond diet alone.

2.     He does an excellent job explaining the pathogeneses of some cancers and casein but I am not clear on other cancers.

3.     World cancer stats from 2002 show India with less incidence, prevalence, and mortality than China. This could be explained by China’s increase in animal protein consumption due to increases in incomes, but incomes in India have risen as well. (Although most Indians are vegetarian, they consume high amounts of milk, cheese, yogurt, and other animal-source foods.) More on this below.

4.     Comparing rural population health to urban population health is problematic.

5.     Western-based questionnaires, although translated, are challenging in a different cultural context. For example, people in China could define some food items differently than people in the US.

Even though I feel there are some over generalizations, the author is very clear about the weaknesses of study designs and provides a breadth of evidence, including randomized trials involving diet. The fact that the author provides so many peer-reviewed studies is a strong aspect of the book.

His advice uses a precautionary principled approach. He notes that one should do some research on plant-based proteins and a few essential nutrients that plants do not provide.  He also points out that diet has a huge effect on one’s metabolism and that in turn affects one’s physical activity. So he is not saying, as some criticize, that all you need to do is change your diet. He says that it is the biggest factor to change and also points out that moderate exercise is necessary.

Another strength of the book is that Campbell provides detailed explanations of why other competing dietary theories miss the mark. More often than not, popular diets do not provide any evidence to check the claims they make. This book’s credibility lies in how Campbell frames his argument using a Hill’s criteria-type of evidence evaluation, which lays out all the mechanisms of actions and pathways, discussing and citing research other than his own, thus adding consistency, coherence, and plausibility to his argument. He doesn’t just present one argument or one pathway like so many dietary theories. Another fact that adds credibility to Campbell’s argument is that the American Cancer Society added their own dietary recommendations, while less stringent about animal-based protein, they recommend increasing vegetable consumption. This is intriguing because the author discusses that they were previously opposed to Campbell’s position regarding any association between diet and cancer. Clearly, Campbell is a pioneer in this area.

His dietary recommendations might be even more extreme than evidence dictates, but as he repeatedly advocates a more safe-than-sorry approach. This is where I feel he is especially refreshing in an area like health and nutrition, where industry has infiltrated every nook and cranny to propagate its agenda, from government agencies to universities. There is so much conflicting information that no one actually knows how much animal protein is too much. So it seems prudent to err on the side of consuming a lot less than the more generous recommendations allow.

Perhaps the biggest question lingering for me is that I would like to see Campbell address India in his analysis. During my own research in India, I conducted a 200-person survey of western fast food eating habits. India is a fascinating case because it is a country of vegetarians, but the disease that claims the most lives is cardiovascular disease (CVD).

For India’s Hindu majority cows are sacred, which changes diets in two ways:  a taboo against killing cows means little beef is consumed, and milk is considered a divine gift so it is consumed whole and is incorporated into many dishes. My longstanding criticism of vegetarianism applies here. Just because someone is vegetarian doesn’t necessarily mean that they eat “healthier.” Lots of junk food is technically vegetarian, and many vegetarians substitute high consumption of dairy products for meat.

Using Campbell’s argument, high dairy consumption could explain high CVD mortality in India. But I am not sure how cancer fits in. I will have to research cancer rates, but I do know that diary consumption in India is at least equal, if not significantly more, than in China. So I am curious if Campbell’s theory of casein as a cause for cancer addresses this inconsistency.

While there may be leaps in some of Campbell’s claims, I have no doubt that diet plays a huge role in health and disease. The associations he has compiled are truly impressive. Equally impressive is the fact that he is not trying to sell his own cookbook or proprietary food system. He lays out very simple, clear guidelines for people to follow to change their diet. It is not some 3-week crash diet but is nothing short of a paradigm shift of typical eating habits.

After reading The China Study, I am definitely decreasing my consumption of animal-based protein (and my family’s, since I do most of the cooking). It will be a slow and demanding process, but the evidence seems clear. Tonight: roasted zucchini, pan-roasted turnips with poppy seeds, and radicchio pancakes. Bon appetite!

Stay tuned for more updates on my dietary paradigm shift, as well as commentaries on the counter position that we owe our great gains in human evolution to a meat-based diet. That claim is important in the Paleo-Diet, the Atkins Diet, and Gary Taubes’s interesting book Good Calories, Bad Calories, which I’m reading now.

How our environment makes us fat

You could walk down the aisle of any place where people gather, like a mall or a Wal-Mart, and hear some remark pertaining to obesity. In fact, weight bias is a popular topic among health researchers. As someone who was obsessed with social psychology as an undergrad, I was not surprised to find the fundamental attribution error (FAE) at the core of this bias. The theory is simply that people often attribute personality faults to other individuals, but they rely on situational or environmental factors to explain their own behavior. In the case of obesity, many people often think of obese people as lazy and not very smart. Many people, especially in the US, think it comes down to personal responsibility.  However, if they themselves were obese they might blame too many hours at the office or too many family obligations for not having time to eat right and exercise, stacking the odds against weight loss.

Just to be clear, humans do make choices, but as the saying goes “genetics loads the gun and the environment pulls the trigger.” People usually make the easy choice. It is easy to blame obese people for their girth, especially in lieu of delving into the complexity of the obesity problem. So we shall dig a little deeper.  

The origin of homo sapiens could be 30,000 years ago or longer. For most of that time we lived in smaller groups, getting our food from hunting and gathering. The agricultural revolution didn’t happen for another 20,000 years. Thus most of our adaptations would have come about for the hunter-gatherer environment. Conservation of energy would have been key to surviving under those conditions. That means we would only use our precious energy if a lion were stalking us or if we were starving. If not, we would sit around and save resources until that lion attacked or food sources dwindled. Humans rarely had to worry about too much food; usually we had too little. Therefore, humans haven’t evolved to become sated. We have no upper limit to our food intake. Have you ever watched an episode of Man vs. Food? Nature was our fitness coach and our dietary regulator.

Add to this a market-driven food system with a laissez-faire governmental approach and you have a recipe for disaster. This is the most supported explanation for the rampant obesity problem facing the world today. How could 60% of human beings on this planet become lazy and fat in just a few generations? And most importantly, when our food system was based on natural cycles the prevalence of obesity was far less. With regards to evolution, our bodies have not had time to adapt to this new and seemingly endless supply of food.

Health researchers use the term “obesigenic environments” to describe environments that foster obesity. These are places that have a high density of fast food outlets, with little access to fresh fruits and vegetables, and with a scarcity of parks and green spaces. So the opportunities for eating healthier and for getting physical activity are decreased. Over the past few centuries, humans have created more and more comfortable environments for themselves, further disconnecting from nature’s regulatory features. Therefore, “fat and lazy” is not truly an accurate description of people who are obese. It gives short shrift to the massive changes humans have brought about during recent history.

If you are obese or know someone who is it might be more productive to take these factors into consideration before making a flippant remark or even blaming oneself for being overweight. By taking this perspective, more opportunities open up to intervene. Our work environments, our food shopping environments, and our neighborhoods all have contributed to our obesity problem, and they are the areas that quite possibly present some solutions. Interventions to built environments have been shown to help people increase their physical activity. By increasing access to fruits and vegetables people will make healthier choices. So instead of making the fundamental attribution error, maybe we should work towards identifying places to change the immediate environment so the easy choice can be the healthy choice.