Human Limits

The massacre of first graders in Newtown, Connecticut along with other recent mass shootings is going to re-start the discussion on gun-control and violence in the United States.   When people ask me what I think about these topics, I tell them to read the books by Lt. Col. Dave Grossman, who is both a paratrooper and Ph.D. psychologist and wrote the classic book “On Killing” in the 1990s.  Grossman essentially predicted and explained how and why these tragedies happen.   Grossman also has a website on “killology” that offers resources to prevent and deal with these catastrophes.   Here are some caveats I have gleaned from following Professor Grossman’s work over the years.

• Many of us are far removed from death and killing by modern society.   We have never killed anything, butchered the meat we eat, seen a person die either slowly at the end of life or violently in an accident or conflict.
• Without direct experience what we know about death and violence comes to us indirectly via the media.  So we experience a false version of violence via cartoons, in action movies or video games for example.   Whatever the source, it is a caricature of real violence and death.   This experience of pseudoviolence also sends us messages about the role of violence in problem solving (e.g. kill the bad guys) and personal empowerment.
• Most humans are extremely reluctant to kill and have to be trained or desensitized to do it.   Grossman sees parallels between video games and techniques used to train soldiers to kill in combat.   These are classic psychological conditioning paradigms designed to reward a specific behavior and overcome inhibitions.

When you add all of the above together and put real firepower – assault weapons, high capacity ammo clips, and specific types of bullets — in the hands of an unbalanced person you can get a volatile mix that ends in tragedy.  Here is a link with statistics on the larger issue of gun deaths in the United States.   Gun deaths are almost as common as traffic fatalities.  Clearly we should be able to come up with laws and regulations that protect the rights of hunters and sportsman but at the same time limit gun violence and gun deaths in the U.S.   Through regulation we have reduced yearly traffic deaths by about 40% and deaths per passenger mile driven by about 90% since WW II.   With a little common sense and we could probably do the same for gun deaths in the U.S. in a way that protects the rights of responsible citizens to own weapons.   Whatever you think about gun control, the work of Dave Grossman offers real insight into the magnitude and many facets of the problem exemplified by Newtown.   I urge you to read his work so you can contribute to the discussion in a thoughtful way.

Why there is so much political gridlock in Washington related to the country’s finances?

It is pretty clear that there are plenty of policy solutions out there.   Here is information from the Peter G. Peterson Foundation Solutions Initiative.   This comes from a program in 2011 that asked six think tanks across the political spectrum to suggest approaches to the long term financial challenges facing the United States.   So, the first thing everyone needs to recognize is that there are plenty of ideas out there.

Then why are our political leaders having so much trouble finding middle ground, compromising and “cutting a deal”?   The standard arguments go something like this:

• The country is more polarized than ever so there is little middle ground.
• There are not enough moderates in either party who can cross party lines to make a deal happen.
• There is a media echo chamber so that each side has their position constantly reinforced.
• The current political leaders lack the political and negotiating skills that were once common in Washington that made deals possible.

I have another take and it comes from brain scanning studies and what parts of the brain are activated in people who are interested in politics.   A technique called functional MRI is used in these studies.  Here is a summary of the results from one such study:

“Using functional magnetic resonance imaging (fMRI), we scanned individuals (either interested or uninterested in politics based on a self-report questionnaire) while they were expressing their agreement or disagreement with political opinions….Behavioral results showed that those political opinions participants agreed with were perceived as more emotionally intense and more positive by individuals interested in politics relative to individuals uninterested in politics. In addition, individuals interested in politics showed greater activation in the amygdala and the ventral striatum (ventral putamen) relative to individuals uninterested in politics when reading political opinions in accordance with their own views. This study shows that having an interest in politics elicits activations in emotion- and reward-related brain areas even when simply agreeing with written political opinions.”

The take home message for the authors was that:

“…..increased amygdala activity in individuals interested in politics for political opinions in accordance with their views may be related to an increased emotional intensity associated with the sense of belonging to a social group and/or the importance of their beliefs to constructing a positive sense of self.”

If you think about these results and the explanation above, perhaps they explain why it is so hard to compromise and negotiate.   Activation of emotional parts of the brain might make it hard to get past your own world view.  There are other interesting findings about how brain structure differs in conservative vs. liberals and how they process political information differently.

Finally, motivated reasoning is a term used to describe biased information processing when people have an emotional stake in the outcome.  It is interesting to note that there is also brain imaging evidence to suggest that political thinking activates specific areas of the brain involved in motivated reasoning distinct from the areas involved in cold or unbiased reasoning.

Based on the ideas presented above it seems to me the issue in Washington is Brainlock and not Gridlock.   I wonder if there are training programs or other techniques that politicians and pundits on both sides could use to increase their mental flexibility.

The obesity epidemic and what to do about it has been a major focus of this blog.   Plug in OBESTIY to the key word search tool and a large number of links show up on many elements of the obesity problem.  Except for the ideas that exercise can modulate the negative health consequences of obesity, limit the impact of obesogenic genes, and play a key role in helping real biggest losers, there is not a lot of good news on the obesity front.

However, there were reports earlier this week that childhood obesity is dropping in some cities in response to comprehensive nutrition and physical activity programs.   Here is a link to a longer report from the Robert Wood Johnson Foundation.   The report concludes:

“Growing evidence suggests that strong, far-reaching changes—those that make healthy foods available in schools and communities and integrate physical activity into people’s daily lives—are working to reduce childhood obesity rates. More efforts are needed to implement these types of sweeping changes nationwide and to address the health disparities gap that exists among underserved communities and populations.”

There are also new ideas about how social media might be able to help fight childhood obesity.  This is an important idea because evidence from the Framingham Study shows that weight gain in our friends is a critical risk factor for weight gain in us!   They followed social connections between and among about 12,000 people for over 30 years and found that:

“Discernible clusters of obese persons (BMI>30) were present in the network at all time points, and the clusters extended to three degrees of separation. These clusters did not appear to be solely attributable to the selective formation of social ties among obese persons. A person’s chances of becoming obese increased by 57% if he or she had a friend who became obese in a given interval.”

The idea is that the same social forces that make obesity “contagious” might also be used to make healthy choices and behaviors contagious.   There is also increasing evidence that food pricing strategies (e.g. sugar and fat taxes) will work to improve nutrition and combat obesity especially in low socio-economic groups.  This is important because these groups have been relatively resistant to other public health efforts directed at obesity.

When you look at the data and ideas described above and discussed previously, it seems to me we need to do the following to turn the obesity epidemic around:

• Adopt the strategies outlined in the Robert Wood Johnson Report nationally.  Like smoking, if we stop obesity early in life it will pay off in middle age.
• Develop comprehensive programs to promote physical activity.  Some of this is about urging people to exercise more.  Some of this is about urban design and planning to make the world friendlier to physical activity.   Most of us live in places that are car friendly but not walking or biking friendly.  This is critical because weight loss is hard and physical activity can prevent weight gain, help with weight loss, and blunt the negative health consequences of obesity.
• Increased public education programs.
• Interventions that increase the cost and/or reduce the portion size of obesogenic foods like sweetened beverages.   This would include so-called sin taxes.
• Use social networking tools to define what is normal and reduce the “contagious” elements of obesity.  They could also be used to increase the contagious elements of fitness and normal body weights.

Summary:  the news on obesity is not all bad and strategies that work are beginning to emerge.   If they are applied widely over the next 20 or 30 years perhaps the obesity epidemic can be stopped.   It is a matter of both our individual and collective cultural will power.

The recent deaths of the legendary jazz musician Dave Brubeck just short of his 92nd birthday, and the great Brazilian architect Oscar Niemeyer at 104 got me thinking about the relationship between creativity and longevity.   These men were among the most creative people of the last 100 years and they remained productive and engaged into old age.   Was there a connection?

In a U.S. Veterans administration study on personality traits, aging and mortality in 1349 men, a 1 standard deviation increase in markers of creativity was associated with a 12% reduction in mortality risk.   The figure below is from a study on personality traits and all-cause mortality in the Edinburgh Artery Study which included 1035 subjects in their 60s or older who took a personality survey in the middle 1990s.  It shows that the subjects who scored highest on markers of openness to new experiences, which is one element of creativity, had much higher survival rates than people who scored lower.

 The authors of conclude:

“During follow-up, 242 (37.1%) men and 165 (24.6%) women died. For the whole sample, there was a 28% lower rate of all-cause mortality for each 1 standard deviation increase in openness and an 18% lower rate of all-cause mortality for each 1 standard deviation increase in conscientiousness. In men, the risk of all-cause mortality was 0.63 for a 1 standard deviation increase in openness and 0.75 for a 1 standard deviation increase in conscientiousness. In women, none of the personality domains were significantly associated with all-cause mortality. Well fitting structural equation models in men (n = 652) showed that the relationships between conscientiousness and openness and all-cause mortality were not substantially explained by smoking, or other variables in the models.”

These observations are certainly consistent with life stories of Brubeck and Niemeyer.   It is also interesting to note that the protective effects of openness and creativity seem to be more pronounced in men.  They also seem to interact with conscientiousness which can be seen as an ability to take good care of yourself by paying attention to your health.  As more research on personality and healthy aging emerges it will be interesting to see if these divergent results for men and women are confirmed.   It will also be interesting to learn if we can train people to be more open and creative to promote healthy aging.   Last week I reviewed the data on what happens when elite endurance athletes remain highly active into their 80s, and in earlier posts I have reviewed the positive effects of physical activity and exercise on longevity.   Maybe fitness and exercise interact with openness and creativity because older fit people are able to try new things and live in what might described as a bigger and more stimulating world.

Enjoy the classic video clip below from the 1960s showing the Brubeck and band playing his signature composition “Take Five”.   Brubeck is on piano and Paul Desmond is playing the sax.

click here if needed for video

Today’s post is brief and shows data on health care costs and physical activity in Medicare patients from about 10 years ago.

The figure shows average annual total health care costs for adults over age 65 who had either worked for General Motors or were spouses of former GM employees.    The subgroups in the figure are based on body mass index (a marker of obesity) and also those who were inactive (0/wk), active 1-3 times per week and active more than 4 times per week.   Over 40,000 people were involved in the study.   For each body mass index subgroup, health care costs were lower and there seemed to be a dose response effect.   In other words the most active people had lower costs than the moderately active people who had lower costs than the least active people.

While this data is interesting and certainly suggests that more activity equals lower health care costs, there are limitations.  For example, perhaps the most active people were simply healthier to begin with and as a result could be more active.   In future posts I will explore what is known about the effects of interventions that promote physical activity on overall population health and also health care spending.

A number of recent posts have focused on what might be called the “geopolitics” of healthcare and the Federal budget in the United States and offered analysis and ideas about how things like sin taxes and insurance plans might incent healthier behavior.   Today I want to get back to human performance and elite athletes, topics that were covered in detail last summer during the Olympics.   The twist here is that I want to talk about elite 80 year old endurance athletes.

In an amazing scientific paper, scientists from Ball State University in Indiana, along with collaborators in Sweden, found 9 elite cross-country skiers (including an Olympic Champion) who had remained highly physically active and trained throughout life.   On average these individuals had VO₂  max values of 38 ml/kg/min.  This is a value similar to that seen in sedentary men in their teens and twenties.   It is also a value about 80% higher than the values seen in sedentary 80 year olds.   VO₂ max is a marker of the ability of the heart and lungs to deliver oxygen to exercising muscles and also the ability of the muscles to use oxygen.   A simple analogy is that VO₂ max somewhat similar to a measure of horse power for a car.   With more horse power you can do more!

Below is a figure from the paper.   The key point is that a VO₂ max value of about 15 is required to be functionally independent and that the untrained octogenarians were likely drifting downward toward that value, while the athletes had plenty of reserve and extra capacity.    Another key point that my colleague Jill Barnes and I made in an editorial on this paper is that while the high values in the athlete’s likely had a component of “natural ability” or “genetics”, it should be possible for highly active regular guys in their late 70s and 80s to have VO₂ max in the high 20s or lower 30s, or about twice the value needed to remain independent.

This paper raises a lot of questions about things like what kept these men motivated to stay so active throughout life.  It will also be interesting to see what the data in older women looks like as more women participate in endurance sports throughout life.    While there is no fountain of youth, the data in these older elite athletes is just another example of what lifelong exercise can do.

Depending on who you believe any long term solution to the fiscal issues confronting the United States will include revenue increases of 800 billion to 1.6 trillion dollars over the next 10 years.   From what I can tell almost all of the discussion about how to raise that revenue focuses on what the well-off will pay.   Will their income tax rates be higher, will their deductions be lower, and will the tax code be revamped so that things like capital gains are taxed at a higher rate?  As someone interested in public health it seems to me that the revenue, and more importantly behavioral changes, associated with sin taxes should be considered in this debate.

• The Congressional Budget Office estimates that nearly 80 billion dollars could be generated over the next 10 years by increasing the tobacco tax by about 50 cents per pack.
• Obesity researchers and economists from Yale and the University of Illinois Chicago have modeled the effects of a 1 cent per ounce tax on sugary beverages and estimated that nearly 20 billion dollars per year could be generated (200 billion over 10 years).
• The alcohol tax as a percentage of the total cost of various forms of alcoholic beverages is much lower than it was in 1980.  If the alcohol tax was 30% of the pretax value of the beverage (it is currently about 10%),  a study by the Cato institute estimated that federal revenues would increase by 25 billion dollars per year (250 billion over 10 years)
• Demark recently repealed their so-called fat tax.   It was generating about 200 million per year in taxes on high fat foods for the Danes.   Extrapolate that to the U.S. which has about 60 times the population of Denmark and you get about 12 billion in revenue per year or 120 billion over 10 years.

All of this adds up to about 650 billion dollars of increased revenue over ten years.   Additionally, there is pretty good evidence that smoking rates, health problems associated with excessive drinking, and perhaps even obesity rates might fall if these taxes were enacted.      For example a 10% rise in cigarette prices typically reduces consumption by 4%.  The sugary beverage tax is estimated to reduce consumption by about 24%, and the alcohol tax is estimated to reduce consumption on the order of 10%.   These behavioral changes would likely have positive effects on health care spending over time. There are also economic arguments about improved productivity and increased spending in other parts of the economy that would flow from things like less smoking and drinking.

One of the major arguments against sin taxes is that they fall disproportionately on the poor.  However, the counter argument is that the positive behavioral changes associated with these taxes would probably disproportionately benefit the poor in terms of improved health over time and more money to spend on other things.   This is especially important because policies that promote positive behavioral health changes in the poor have been difficult to implement and results have been marginal in many cases.

The figure below is from an article on health disparities in 8 socioeconomic groups in the U.S. and shows the role of common behavioral factors in disease burden (for the record I would argue that they grossly underestimated the effects of physical inactivity).  These factors are typically higher in the socioeconomic and racial groups with the worst overall health and lowest life expectancy.  Increased taxes on tobacco, alcohol and foods contributing to obesity would clearly help reduce the burden from the top four or five causes.

As the article notes:

“Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.”

That having been said, I would argue that sin taxes should be attractive to liberals concerned about racial and socioeconomic disparities for statistics like life expectancy and other measures of overall health.

Sin taxes should also be attractive to conservatives who typically espouse a preference for policies that promote personal responsibility.   Sin taxes would also help address the current conservative narrative about makers and takers because the increased taxes would tend to fall hardest on states that receive excess federal funds relative to the taxes they pay…..what might be described as “taker” states.

The changes in tax policy that will be made in the coming years have the chance to make things fairer, simpler, more transparent, and perhaps spur economic growth.   The ideas outlined above have the added advantage of improving public health, raising revenue, and perhaps driving health care costs down in the longer run.  Sin taxes also have the opportunity to address both liberal and conservative policy goals, so shouldn’t they be part of any solution designed to put our financial house in order?

There has been a lot of discussion about things like soda taxes to reduce unhealthy behaviors and address the obesity and diabetes epidemic.   The idea is that as prices rise, sugary drink consumption will fall and this will have an impact on obesity and diabetes and ultimately reduce some of the upward pressure on health care costs.   Along these lines, Denmark implemented a “fat tax” for high fat food items a few years ago but recently reversed the tax for a number of reasons.   Importantly, the fat tax in Denmark was not around long enough to determine if it would have any impact on public health.   By contrast it is pretty clear that cigarette taxes have contributed to reductions in smoking rates.

Another idea out there is to ask people to pay differing health insurance premiums for what might be called “behavioral” risk factors that are subject to personal choice and changes in behavior.  For example, smokers would pay more for their health insurance than non-smokers.   The question is how far to take this approach.   In some insurance plans there is a move to charge people more for obesity, high cholesterol, hypertension, and diabetes (this would be in addition to higher charges for smokers).   The plan would then lower rates or offer rebates as people with “controllable” risk factors addressed their issues and got “their numbers” under control.   In other words, if they lost weight, took their blood pressure, cholesterol and/or diabetes medication etc., their costs would go down.  The plans are controversial but there is at least some evidence that they work.   In the long run this should improve the health of plan members and reduce health care spending over time.  For example Safeway reported:

“…the proportion of employees classified as obese declined by five percentage points, while the proportion who were overweight declined by one percentage point. Meanwhile, 40 percent of workers and spouses who failed the blood pressure test in 2008 passed in 2009, 30 percent of former smokers registered as tobacco-free, and 17 percent who failed the cholesterol test in 2008 passed in 2009.”

Absent in the discussion is rating people based on their physical fitness.  As an exercise advocate this makes sense to me because exercise is a powerful modifier of other health risk factors.

My take is that a large fraction (estimates are in the 60-90% range) of our health and the diseases we get have major behavioral components.   We also know that only a limited number of people follow key health guidelines and practice what might be described as personalized preventive medicine.   Should those of us who do follow the guidelines subsidize insurance premiums for those who don’t?   That having been said, I think insurance plans that reward personal responsibility are essential to improve public health and reduce health care expenditures –a potential win-win for us all.   Premiums schemes that encourage personal responsibility are probably only one part of a comprehensive plan to address lifestyle related diseases, but it seems to me the more messages we send people about the importance of personal responsibility for their own health the better.