I clicked on the heart disease algorithm link, and it was just a tweet of screenshots, with no link to the article. I typed in the name of the article into my search bar so that I could read it.
Your commentary about this headline may be correct, but I find it questionable after reading the whole article. The article includes the following paragraph:
Two years ago, a scientific task force of the National Kidney Foundation and American Society of Nephrology called for jettisoning a measure of kidney function that adjusted results by race, often making Black patients seem less ill than they are and leading to delays in treatment.
I find that claim questionable as well, but not in a way that increases my credence in your summary. I clicked through again to an NEJM article mentioned in the NYT article, and it went into detail about how the racial corrections are made. My current belief is now, "this stuff is controversial for seemingly real reasons. Benefits & harms may both be present, and I do not know which way the scales tip." Hardly a slam dunk against the woke menace, which is the impression I had when I first clicked your link.
Am I wrong? Do you stand by your summary? Did you read the article? Do contend that you didn't need to read it?
Perhaps ironically, I didn't read your whole post before commenting. It's possible that you have some appropriate disclaimer somewhere in it, which I missed in my skim. If not though, I want to at least flag this, because I see potential for misinformation cascades if I don't :/
The American Heart Association (AHA) Get with the Guidelines–Heart Failure Risk Score predicts the risk of death in patients admitted to the hospital.9 It assigns three additional points to any patient identified as “nonblack,” thereby categorizing all black patients as being at lower risk. The AHA does not provide a rationale for this adjustment. Clinicians are advised to use this risk score to guide decisions about referral to cardiology and allocation of health care resources. Since “black” is equated with lower risk, following the guidelines could direct care away from black patients.
From the NEJM article. This is the exact opposite of Zvi's conclusions ("Not factoring this in means [blacks] will get less care").
I confirmed the NEJM's account by using an online calculator for that score. https://www.mdcalc.com/calc/3829/gwtg-heart-failure-risk-score Setting a patient with black=No gives higher risk than black=yes. Similarly so for a risk score from the AHA,: https://static.heart.org/riskcalc/app/index.html#!/baseline-risk
Is Zvi/NYT referring to a different risk calculator? There are a lot of them out there. The NEJM also discuses a surgical risk score that has the opposite directionality, so maybe that one? Though there the conclusion is also about less care for blacks: "When used preoperatively to assess risk, these calculations could steer minority patients, deemed to be at higher risk, away from surgery." Of course, less care could be a good thing here!
I agree that this looks complicated.
N=1, but I didn't floss regularly for years, but I found that after I did so it made an enormous difference in my bad breath, to the point of eliminating it entirely for most purposes. Obvious conclusion is that my breath problems were the result of bacterial buildup between my teeth that wasn't getting removed by normal brushing.
I suspect that a lot of tooth-brushing advice is like this: maybe not rigorously studied, but nonetheless upheld by anecdote and obvious physical models of the world.
But yes, working out is mostly unpleasant and boring as hell as we conceive of it and we need to stop pretending otherwise. Once we agree that most exercise mostly bores most people who try it out of their minds, we can work on not doing that.
I'm of the nearly opposite opinion: we pretend that exercise ought to be unpleasant. We equate exercise with elite or professional athletes and the vision of needing to push yourself to the limit, etc. In reality, exercise does include that but for most people should look more like "going for a walk" than "doing hill sprints until my legs collapse".
On boredom specifically, I think strenuousness affects that more than monotony. When I started exercising, I would watch a TV show on the treadmill and kept feeling bored, but the moment I toned down to a walking speed to cool off, suddenly the show was engaging and I'd find myself overstaying just to watch it. Why wasn't it engaging while I was running? The show didn't change. Monotony wasn't the deciding factor, but rather the exertion.
Later, I switched to running outside and now I don't get bored despite using no TV or podcast or music. And it requires no willpower! If you're two miles from home, you can't quit. Quitting just means running two miles back which isn't really quitting so you might as well keep going. But on a treadmill, you can hop off at any moment, so there's a constant drain on willpower. So again, I think the 'boredom' here isn't actually about the task being monotonous and finding ways to make it less monotonous won't fix the perceived boredom.
I do agree with the comment of playing tag for heart health. But that already exists and is socially acceptable in the form of pickup basketball/soccer/flag-football/ultimate. Lastly, many people do literally find weightlifting fun, and it can be quite social.
Re: Canadian vs American health care, the reasonable policy would be:
"Sorry, publicly funded health care won't cover this, because the expected DALYs are too expensive. We do allow private clinics to sell you the procedure, though unless you're super wealthy I think the odds of success aren't worth the cost to your family."
(I also approve of euthanasia being offered as long as it's not a hard sell.)
Wegovy (a GLP-1 antagonist)
Wegovy/Ozempic/Semaglutide are GLP-1 receptor agonists, not GLP-1 antagonists. This means they activate the GLP-1 receptor, which GLP-1 also does. So it's more accurate to say that they are GLP-1 analogs, which makes calling them "GLP-1s" reasonable even though that's not really accurate either.
They decided that this is not a form of evidence they are willing to use, even though African-Americans suffer more heart attacks and strokes even when you control for everything else we know to measure. Not factoring this in means they will get less care.
I... really wish I could still find this surprising. Shocking, horrifying? Sure. But not surprising.
They don’t think about the impact on the lives of ordinary people. They don’t do trade-offs or think about cost-benefit. They care only about lives saved, to which they attach infinite value.
Not sure about infinite, but assigning a massive value to lives saved should be the way to go. Say, $10 billion per life.
Imagine a society where people actually strongly care about lives saved, and it is reflected in the governmental policies. In such a society, cryonics and life extension technologies would be much more developed.
On a related note, "S-risk" is mostly a harmful idea that should be discarded from ethical calculations. One should not value any amount of suffering over saved lives.
Saving up medical and health related stories from several months allowed for much better organizing of them, so I am happy I split these off. I will still post anything more urgent on a faster basis. There’s lots of things here that are fascinating and potentially very important, but I’ve had to prioritize and focus elsewhere, so I hope others pick up various torches.
Vaccination Ho!
We have a new malaria vaccine. That’s great. WHO thinks this is not an especially urgent opportunity, or any kind of ‘emergency’ and so wants to wait for months before actually putting shots into arms. So what if we also see reports like ‘cuts infant deaths by 13%’? WHO doing WHO things, WHO Delenda Est and all that. What can we do about this?
Also, EA and everyone else who works in global health needs to do a complete post-mortem of how this was allowed to take so long, and why they couldn’t or didn’t do more to speed things along. There are in particular claims that the 2015-2019 delay was due to lack of funding, despite a malaria vaccine being an Open Phil priority. Saloni Dattani, Rachel Glennerster and Siddhartha Haria write about the long road for Works in Progress. They recommend future use of advance market commitments, which seems like a no brainer first step.
We also have an FDA approved vaccine for chikungunya.
Oh, and also we invented a vaccine for cancer, a huge boost to melanoma treatment.
Katalin Kariko and Drew Weissman win the Nobel Prize for mRNA vaccine technology. Rarely are such decisions this easy. Worth remembering that, in addition to denying me admission despite my status as a legacy, the University of Pennsylvania also refused to allow Kariko a tenure track position, calling her ‘not of faculty quality,’ and laughed at her leaving for BioNTech, especially when they refer to this as ‘Penn’s historic research team.’
Did you also know that Katalin’s advisor threatened to have her deported if she switched labs, and attempted to follow through on that threat?
I also need to note the deep disappointment in Elon Musk, who even a few months ago was continuing to throw shade on the Covid vaccines.
And what do we do more generally about the fact that there are quite a lot of takes that one has reason to be nervous to say out loud, seem likely to be true, and also are endorsed by the majority of the population?
When we discovered all the vaccines. Progress continues. We need to go faster.
Reflections on what happened with medical start-up Alvea. They proved you could move much faster on vaccine development than anyone would admit, but then found that there was insufficient commercial or philanthropic demand for doing so to make it worth everyone’s time, so they wound down. As an individual and as a civilization, you get what you pay for.
Potential Progress
Researchers discover what they call an on/off switch for breast cancer. Not clear yet how to use this to help patients.
London hospital uses competent execution on basic 1950s operations management, increases surgical efficiency by a factor of about five. Teams similar to a Formula 1 pit crew cut sterilization times from 40 minutes to 2. One room does anesthesia on the next patient while the other operates on the current one. There seems to be no reason this could not be implemented everywhere, other than lack of will?
Dementia rates down 13% over the past 25 years, for unclear reasons.
Sarah Constantin explores possibilities for cognitive enhancement. We have not yet tried many of the things one would try.
We found a way to suppress specific immune reactions, rather than having to suppress immune reactions in general, opening up the way to potentially fully curing a whole host of autoimmune disorders. Yes, in mice, of course it’s in mice, so don’t get overexcited.
From Sarah Constantin, The Enchippening of Medical Imaging. We are getting increasingly good not only at imaging, but imaging with smaller and more mobile and cheaper devices, opening up lots of new potential applications. An exciting time. As Sarah notes more broadly to open the series, making cheaper and better chips is the core tech behind pretty much everything getting continuously cheaper and better, and you should expect continuously cheaper and better from anything that relies on chips.
She also notes that Ultrasound Neuromodulation is potentially very exciting, especially if it can be put into a wearable. We could gain control over our mental state.
Claim that Viagra was significantly associated with a 69% reduced risk of Alzheimer’s Disease. Nice. There are supposed mechanisms involved and everything, the theory being direct brain health effects and reductions in toxic proteins that cause dementia. As opposed to the obvious interaction that Viagra users have more sex than non-users, which might protect against and definitely indicates against dementia.
Experts are, and I quote, warning us ‘not to get our hopes up yet.’
Amazon is now offering medical services, at very low prices. No insurance accepted.
Seems great to me. Yes, if your only optimization target is optimal care and presume that everyone would otherwise get the full product, you will favor vastly more doctor attention, at vastly greater expense. However, if you instead realize that people’s time and money are things that matter to them and to society generally, which also means they will forgo medical consultations and treatments that cost too much of them. And also that we only have so many doctors (thanks AMA!) and thus only so many doctor hours to allocate, so if you waste them where they’re not valuable then someone else misses out, and that we do a lot of that allocation via time rather than price which is even worse. This is all very practical, a lot of people in the spots Amazon is offering a consult would instead have chosen no care at all under our existing system.
Health care would work so much better if we treated it as less sacred and more like Amazon treats its other products.
It’s Not Progress
Economist reports (HT MR) that health insurance providers have a cap on direct profits, so they are buying health providers in order to steer customers to them, then paying those providers arbitrary prices. The incentives were already a nightmare, this makes them that much worse.
An interesting note is that Matthew Yglesias says he thought that this position was the consensus. It is simultaneously the consensus in the sense that people believe it, and also contrarian in the sense that the establishment and public health plan to do it all over again to the maximal extent possible and often act, like they and other cultural would-be authorities do on many things, as if anyone who defies the minority opinion they endorse too loudly is dangerous and terrible.
American Hearth Association releases new clinical tool that removes race as a factor in predicting who will have heart attacks or strokes. They decided that this is not a form of evidence they are willing to use, even though African-Americans suffer more heart attacks and strokes even when you control for everything else we know to measure. Not factoring this in means they will get less care. That doesn’t seem great.
Dylan Matthews makes a convincing case that while deaths of despair and overdose deaths have increased, the bulk of the decline in American life expectancy so far has been due to problems with cardiovascular disease. It is also noted that the decline is focused on the worst-off locations and among high school dropouts, as opposed to being about whether you go to college.
So what matters is whether something in one’s early life is going very wrong. When that happens, we are letting such people down in many ways.
Not that the overdoses don’t matter. We have a rapidly growing, out of control problem with overdose deaths, and it is already having a real impact on life expectancy, and if it continues growing exponentially it will soon be far worse. It is scary as hell.
The right question to ask, as is often the case, is: Is this an ongoing exponential?
It looks exponential. It would be scary anyway since it is already almost 3% of deaths in 2021. What happens if it doubles again in the next decade?
My mind still boggles that asking questions with the intent to learn or prove something requires ‘ethical’ clearance and worries about ‘potential harm’, and people keep endorsing this on reflection, burn it all to the ground.
Yes. A simple safe harbor. If all you are doing is talking to people, or ideally also if you are otherwise doing things humans are allowed to do to other humans without any paperwork or checking for ‘informed consent’ then you don’t need any approvals. Even if you have the federal funding. Ask your questions.
A continuous problem is that the world desperately needs more common sense ethics and well-considered ethical considerations, and also that anyone who uses the word ‘ethics’ almost ever has anything to do with either of these things.
Cost Plus
United Health pushed employees to follow an algorithm to cut off Medicare patients’ rehab benefits, says StatNews, to the tune of our way or the highway. If you want a ‘human in the loop’ the human needs to be able to determine the outcome of the loop. Here, it seems, they did not.
Yes, a lot of the reason Canadian health care is cheaper is that they sometimes tell you they’re not going to give you the surgery and instead suggest you consider assisted dying instead, whereas in America they will operate on you.
Tyler Cowen makes the case for a big push for hospital pricing transparency. As in, we need to insist on this like we insisted on ending the Vietnam War. The current situation is rather dire, as in things like this:
Quite right on all counts. Government has decided for various reasons to intervene massively in the health care payments system, which is a central reason we lack price transparency. We need to use government to fix this, even if we do not use the first best solution of ‘get out of the way,’ and the benefits would be massive if we did fix it.
New Findings
Paper claims working from home has negative mental health effects versus a workplace arrangement, although neither a big effect not anything like not working.
In the context of a pandemic, working from home was probably relatively worse. My model is that the problem comes from isolation. If work was your only contact with the outside world you needed that. If not, you don’t.
Expiration dates are only, like, suggestions, man.
The expiration dates are mandated only for infant formula. That does not mean they are useless, not net useful, or not protective of your health. Expiration dates are highly useful as they mark the relative freshness and remaining time of your items, and they provide reasonable approximations on how long various items can remain edible. Does that make them reliable markers of either spoilage or safety? No. It is a problem when sticklers treat them as gospel, again in either or both directions. I’m still glad they are there.
FDA Delenda Est
Scott Alexander notes that fully abolishing the FDA would require additional adjustments in the system. How would we deal with liability? What if doctors are stupid or fooled by advertising? How would prescriptions work or not work? How would insurance work? He comes down suggesting the FDA have a safety-only pathway for making drugs allowed, and legalization of artificial supplements.
That would be a reasonable practical compromise, but I think you can go a lot further. All these questions have reasonable answers. Prescriptions can continue where a sufficiently high bar is met, likely with a broader range of who can prescribe (e.g. a pharmacist should be fine for many but not all of them, so you don’t need an extra visit.) The other stuff will sort itself out the way it does everywhere else. Inspection agencies, for example, will rise up that do a better job for less money. Probably we do keep an FDA-like agency around for safety certifications due to liability concerns. To the extent other things wouldn’t fix themselves, it would mostly reveal rather than create those additional problems.
Again, I’d be happy to take Scott’s or another similar compromise. I still want to recognize it is far from first best.
The alternative is not abolishing the FDA and having stories like this?
So, yeah. I’ll take my chances with abolition.
Also, the FDA continues to move forward to regulate lab tests. As Alex Tabarrok says, it is vital that we do not let them, although by the time you read this it will be too late for public comment.
Also, why don’t your cold medicines work? Oh right.
Will they finally fix it? I am not optimistic. They did vote 16-0 that there is no evidence that phenylephrine does not work.
If the system were otherwise sane, I would have zero problem with people selling a medicine that does not work. People could make their own choices. Alas, given the say the rest of the system works, permission, like retweets, here is an endorsement, and results in this preventing other actually effective treatment.
Covid Response Postmortem and Paths Forward
As Nate Silver reminds us, the Covid vaccine was the one thing that we know worked to prevent Covid deaths. Red states had 35% higher death rates than blue states once the vaccine was available, but had similar death rates before that despite less stringent countermeasures, so the effectiveness of all other measures remains unclear.
Former NIH director Francis Collins says the quiet parts out loud (1:18 video, worth watching) regarding Covid policy and the public health mindset. They don’t think about the impact on the lives of ordinary people. They don’t do trade-offs or think about cost-benefit. They care only about lives saved, to which they attach infinite value.
I thank him for the clarity. Let this be common knowledge. Then let us never again entrust any future public health decisions to anyone with this ‘public health mindset.’
Instead, public health carries on as if they were right all along, even calling for us to mask up again every so often, and we sometimes see cases such as this one: San Diego State University to require Covid boosters in order to attend. Our colleges never learn, yet we expect them to teach us. What will we do about it?
Some good news on Covid is new claims that vaccination before first infection greatly.
Another good news note that hasn’t been noticed enough:
This was the dog that did not bark. By all accounts, hospitals should have been far more overwhelmed, in ways that caused a lot more degradations in care and many excess deaths. Indeed, health care workers were constantly reporting hellish conditions, being put under unbearable pressures. Yet in the end, at least after the very early days, the center almost entirely held. We never properly thanked or honored those who pulled this off, in any form. Nor have we updated our future anticipations.
House passes ban on toddler mask mandates without a vote after opposition fails to provide any evidence whatsoever that masking toddlers is helpful. Took long enough. Turns out people say things are evidence-based without, ya know, evidence.
Several Republican Congressmen including Rubio told Biden on December 1 to ban travel from China to prevent mystery illness spread. And of course the person posting this was claiming there is no difference between this and lockdowns and this makes Republicans hypocrites. It doesn’t. It does make them wrong, in the sense that such a rule would have accomplished nothing even if the mystery illness had mattered – it is difficult imagine the world where such a ban stops the spread that would have otherwise happened. Luckily, we didn’t ban travel and everything is fine.
Covid Origins
Nate Silver continues to be loud about the ‘Proximal Origins’ paper, the damage it and related efforts to convince us we could assume natural origins of Covid have done to trust in science, and in particular the lack of willingness to admit and call out what happened. He links to this post about it. Things do not look better over time:
The responses attempting to defend natural origin are all essentially ad hominem attacks at this point. The wrong person is advocating, why are you amplifying this bad person and bad theory, you do not know what you are talking about. Never arguments about the facts.
Here is a thread summarizing many pieces of evidence in favor of a lab leak.
If you want to engage with the debate, well, good news, it seems there is an 18 hour recorded debate, a third of which is published, six figures at stake on the outcome and a prediction market on the outcome.
I still am not about to watch hours of that.
The prior should not be low:
If we have almost one confirmed lab leak per year, and given the other circumstances, it would almost be surprising if Covid-19 wasn’t a lab leak.
Was Covid a lab leak? We don’t know. At this point it seems more likely than not.
That statement should drive huge changes in policy. A lot of people should be rethinking quite a lot of things. That is true even if (as I expect) we never know the answer for sure. This is very similar to the question of existential risk from AI. Any reasonable person, given the evidence, should say the lab leak has substantial probability, as does natural origin. Once you think the number is substantial, it does not much matter if your probability of the lab leak is 30%, 50%, 70% or 90%. They should drive most of the same changes in policy, and the same reflections. They won’t.
Imagine how we and you would have reacted if we had known, back in February 2020, that this virus had escaped from a lab. Then ask which parts of that reaction you would endorse on reflection, and which you do would not. Then act accordingly.
The good news is that it likely has succeeded in at least cancelling Deep VZN.
You think this is the worst that can happen? Well, remember that time Australian researchers were actively trying to create a ‘contraceptive mouse virus’ for pest control, which is totally not how any science fiction dystopia stories start, and they instead accidentally created a modified mousepox virus with 100% mortality? Check the linked thread out, because it keeps… getting… worse.
Ban Gain of Function Research
House unanimously votes to defund gain-of-function experiments with potential pandemic pathogens. I would prefer a ban, but unanimous support for at least not paying for it is a great start. Why am I worried this will still not get implemented?
Cause Areas
Reducing third world lead poisoning continues to be a plausible high-value cause area.
Statements like Nathan’s require caution and careful calibration. I very much doubt a billion dollars would put a stop to all the lead poisoning. How much would it reduce such lead poisoning for how many children, with how much impact? I have no idea. I find it likely that $1 billion well-spent on this would be a good use of funds. I also can think of ways one could plausibly spend that money badly, and it ends up wasted or even making things worse.
Seriously, let’s buy out the patent rights and offer these drugs for free to anyone who wants them, what are we waiting for. New EA cause area.
Belarusian comedian hits it big with comedy routine (YouTube, 1:04:00) in which he complains he will die of old age and calls upon everyone to focus on maybe stopping this from happening.
I criticize Effective Altruists for insufficiently high levels of epistemic rigor, because reality does not grade on a curve, but let no one confuse them with governments.
Excellent, I don’t remember seeing a good estimate before, 0.01 seems highly sane. So that’s about three days of life. A very good thing to do, definitely donate blood. Very, very different from three lives in an hour, not even the most outlandish EA earning-to-give and cost-per-life-saved statistics claim anything close to that.
Want to get more people to donate? Yes, you could and should pay them. There is some price at which you’ll get plenty of donations, it will be cheap versus health gains, and those that get the money will be better off.
But also I once again iterate to those in charge of blood donations: By requiring appointments, you are greatly raising the effective cost of donations. If you could take walk-ins, even confirmed right beforehand on the web, I would happy do this much more often. If I have to block out an appointment time days in advance, that’s so much harder.
That change fits well within the ‘ethics’ requirements. All you have to do is provide a place I can walk in on a whim and donate, or go when there is urgent need. I’ll do it.
You know who else you should pay? The head of UK pandemic preparedness.
GLP-1 Has Barely Begun
Wegovy (a GLP-1 agonist) cut the rate of major heart problems in a 17k patient trial – heart attack, stroke, or cardiovascular-related death by 20%. It also cut all-cause mortality by 19%, which I would have led with, with no major side effect issues. Wow.
Market Monetarist thinks GLP-1s are a huge economic deal.
America spends more than 17% of GDP on health care. If GLP-1s reliably cure obesity, and obesity doubles health care costs, and 42% of Americans are obese, the math says that you could in theory reduce health care costs by almost 30%, saving almost 6% of GDP.
That is a huge game, if and only if that spending does not then get reallocated to providing more care to others. If our health spending is determined more by wealth than medical need, as it seems largely to be, most of that would be wasted on additional marginal care of little value.
The actual health benefits, of course, would be very real, including productivity.
I would be cautious attributing too much of the earnings differential to productivity. The beauty premium is real, discrimination against ugly or fat people is rampant, and these are likely to largely be positional effects.
Still, there are obviously large real productivity gains to better health.
There are also big productivity gains to general impulse control. GLP-1 inhibitors help with a wide variety of addictive and unproductive behaviors. My presumption is you would see substantial productivity gains.
How best to think about what Ozempic (another GLP-1 agonist) does?
I think this is one of those places where willpower is a confused concept when you look at it too carefully, but acting like it does not exist or is not important will only leave you far more confused. I find it wise to treat willpower as if it is real.
How much adaptation will we see? It is easy to do the math on every obese person taking Ozempic. It is a lot harder to get that to happen, or anything approaching that.
Ozempic might be driving a selloff in candy and beer stocks, with the caveat that of course one must never reason from a price change.
This is super exciting. As with AI, this part of the future remains highly unevenly distributed, and is orders of magnitude more expensive than it will be soon.
It looks like GLP-1s reduce alcoholism, which on its own is a huge freaking deal.
Does… this… work? Issue hasn’t come up for me in a while:
I mean, I googled ‘Ozempic coupon’ as a test – note that these are very much the opposite of verified – Henry Meds claims to be selling a GLP-1 agonist at $300/month, Calibrate claims even less, GoodRx has modest (~10%) discounts off the bat.
Also does this work? A public service announcement blast from the past.
Matt Yglesias shares his experience losing weight via bariatric surgery. He found it easy to lose weight up to a point, but that past that point he continued to struggle with the same urges to eat more and eat unhealthy and not be active. He’s excited for the GLP-1 inhibitors. One worthy note he makes is that if you have an unhealthy relationship to food, fixing it is (usually, for most people, myself included) not a matter of ‘eat like a healthy person,’ the same way an alcoholic can’t drink like a normal person. You have to do something far more intentional and deliberate, more absolute, more costly, and do it constantly forever. The other is that he sees anticipation that doctors will lecture fat people that they should lose weight as a big barrier to them effectively getting any other treatment for problems their weight makes worse – not only don’t they want to hear it, the doctors often refuse to offer alternative help. Which is terrible, and doctors should of course stop it, especially the not helping with alternatives. Yet we also would be wise to find ways not to generally fool ourselves into thinking that unhealthy weights are healthy.
No One Understands Nutrition
An epic and righteous rant about how much people obsess over vegetables and what is rightfully called morality-based dietary planning. Eigenrobot’s 100-year-old grandfather is literally starving to death because his grandmother keeps insisting on these elaborate ‘healthy’ meal plans that took him hours to consume, when instead it turns out you can just feed the guy stuff like ice cream and he can get it down fine, and obviously that is what any sane person would do in this spot.
My model is that we know four things about nutrition with any certainty:
How important are rules two and three? Great question. We don’t know that.
I’ve been unable to eat fruits or vegetables in most forms for my whole life, unless they are very tiny or heavily processed. My body does not believe they are food and I will literally gag and choke on them. The few ways I can sometimes eat one almost never bring me any joy, only melancholy and sorrow. People constantly worried about this for a long time, and I haven’t been able to fix it. I don’t worry much about this anymore, and you know what? It’s fine.
On rule three, my revealed preference is ‘enough to eat less sugar than I otherwise would, not enough to not eat a lot of sugar anyway.’ I endorse this on reflection.
Model This: Exercise Edition
What are the returns to exercise? Roger Silk does some math, attempting to think like an economist.
His basic model is to assume that we value 16 waking hours per day only, exercise costs time now, and it pays off with additional time in the future. He then asks, if a program of 9 hours gives a 50-year-old the chance to live to 88 instead of 80, what is the rate of return? He finds 5.8%, with returns up to 6.5% for smaller investments, so the marginal return on the final hours is likely more like 4%.
Is that a good investment? As Roger points out, there is no inflation in years. If all things were fully equal, and all that mattered was my personal time discounting, and I thought I ‘lived in normal times’ so to speak so postponing my actions didn’t impact the world nor would the world much change, I would take essentially any positive return.
What key considerations are being ignored in the calculation here?
Also, the real story of people not exercising is pretty damn simple. Mostly true story.
I would take the under on 90% vanity. A lot of working out is for the right reasons. But yes, working out is mostly unpleasant and boring as hell as we conceive of it and we need to stop pretending otherwise. Once we agree that most exercise mostly bores most people who try it out of their minds, we can work on not doing that.
A Bold Stand Against Torture
Well, maybe. From a certain point of view.
Matthew Yglesias takes a stand against dentistry. Well, maybe not quite against dentistry writ large, but against the current regime of dentists being a cartel taking a large cut of every cleaning, not letting others diagnose conditions, and the only insurance available being a product that does not insure one against large dental bills, while not providing evidence for its interventions working.
Studies show, he says, that letting dental hygienists work on their own improves dental health, in addition to improving equality and lowering costs. The mechanism is that if routine dental services cost more, you will consume less of them.
The insurance thing is its own complaint and also pretty weird every time I think about it. In medicine you want to buy medical catastrophic insurance and are forced to also buy coverage on pain of them charging you artificially high prices to punish you. In dentistry, you cannot buy the insurance at all even together with the coverage, only partial coverage of routine costs.
Most interesting is the claim that dentistry is not evidence based.
[comments full of people who don’t trust dentists not to defraud them.]
Matt Yglesias (in his post): Some people, of course, are not that ethical. And even those who are ethical are naturally going to find themselves inclined in the direction of self-interest when dealing with an evidentiary void. William Ecenbarger did a great investigative report for Readers’ Digest years ago where he visited dentists in different cities and asked for their recommendations and got prescribed courses of treatment ranging from $500 to $25,000. One outfit in Philadelphia diagnosed him this way: “Tell me what your insurance limits are, and we’ll proceed from there.”
Back at Vox, I used to work with Joey Stromberg (whose dad is a dentist), who wrote a piece about how “while seeing other dentists, my brother has been told he needed six fillings that turned out to be totally unnecessary (based on my dad’s look at his X-rays) and I’ve been pressured to buy prescription toothpaste and other products I didn’t need.” Aspen Dental appears to have built a whole corporate dental chain around the observation that you can attract patients with low prices and then make it up in volume by prescribing unnecessary treatments.
Yglesias also quotes Ferris Jabr in the Atlantic here:
And perhaps it gets worse? Here’s MF Bloom quoting the AP saying there is no evidence that flossing works. The government seems to have agreed that no one has ever properly researched the question. The AP looked and its findings where that the evidence is “weak, very unreliable” and of “very low” quality. Ouch.
Does flossing do something? It is a physical action, so we can tell that it does literally do something. But does that something translate into better dental health? We do not know. It would be unsurprising to me either way. I can also see why there could be no one party with the incentive to study this properly and find out.