Exercise while you work

I just got something new: a laptop desk that attaches to a treadmill. I tried it out yesterday, and it works great. It’s a little hard to type while I’m using it, but it works OK if I slow the treadmill down a bit. When I’m just reading, I can push it up to quite a brisk walking pace.

I gave it a go for an hour yesterday morning, and another hour yesterday afternoon, and I like it a lot. It’s a great way to avoid sitting in one place all day while I work. I may try some speech-recognition software as an alternative to typing, which, if it works well, might let me spend more time on it.

The treadmill might be a little noisy to use during conference calls, but those seem ideal times to get an extended period of walking in. I’ll have to try it, and see how that goes.

So far, with limited use, I can say that I really recommend it for anyone who works from home and sits at a desk all day!

Sleep and work

In a recent TED talk,^[1] Arianna Huffington comments on the importance of getting enough sleep.

Because the essence of leadership is being able to see the iceberg before it hits the Titanic. And we’ve had far too many icebergs hitting our Titanics. In fact, I have a feeling that if Lehman Brothers was Lehman Brothers and Sisters, they might still be around. While all the brothers were busy, you know, just being hyper-connected 24/7, maybe a sister would have noticed the iceberg because she would have woken up from a seven-and-a-half- or eight-hour sleep... and have been able to see the big picture.

This prompts me, in a round-about way, to talk about having worked from home for almost two years, now.

Since I left IBM at the end of February, 2009, I haven’t worked in an office — I’ve been working at home for 22 months. There are both advantages and disadvantages to that situation. I miss some of the structure of going to the office, but mostly I miss the people.

I miss the specific people I used to work with, of course, but, more broadly, I miss seeing people and getting the social interactions in the work environment. I miss having coffee and tea with people, having lunch with people, having people stop in my office and having an opportunity to stop into theirs. Sharing a laugh with a colleague, batting around an idea, or just hearing about his weekend for a few minutes personalizes the work experience in a way that seems important.

I’m still in communication with colleagues constantly, of course, through email, instant messaging, and telephone. Having an IM window pop up that says, Hi, Barry. Do you have a few minutes to talk about [some topic]?, or Hey, did you have a good weekend?, does have similarities to the in-office visit. But it’s not really the same, and I do miss doing that face to face.

On the other hand, my job requires a lot of time reading, writing, and thinking, and I don’t miss the interruptions that come with the office environment. That very visit by a dear colleague can, when it comes at an inconvenient time, dislodge critical thoughts and derail a writing session. Sometimes, one has an ephemeral idea in one’s head that’s flowing onto the paper phosphor, and even a brief distraction will ruin the subtle wording that was happening in the head, before it ever makes it to the hands. It’s nice to have the quiet and privacy, and to know that I can maintain it as long as I need to, uninterrupted.

But what I really do not miss is the commute, and actually going into the office. I’m saving over an hour a day of entirely wasted time. And my commute, a half hour or so each way, is much less than that of some. I got to listen to the radio — NPR, usually, except when they were begging having a membership drive — so that was something, but it didn’t really count for much. I just considered the drive to and from work a necessary annoyance, and a complete waste of time.

So I save the hour a day, and I also save the fuel for the car — about a gallon and a half a day, 7.5 gallons a week... at current local prices that’s nearly $25 a week — and the wear and tear, as well. But what I didn’t expect is that I save wear and tear on myself.

It’s not just your car that’s stressed by a drive to work; you get the effects as well. It pushes the stress up. And getting up to go to the office can get in the way of getting enough sleep. That part surprised me. It’s only an hour of time, and my days almost always had some down time, so I would never have thought that going to the office was making me sleep less (or less well). But between the time saved and the stress saved, I am getting more sleep and feeling more rested than I have in many years.

The effects are clear to me. I feel better, and I think I work better. I can keep my mind on things more effectively, I don’t have an afternoon low period, and I’m happier.

Ms Huffington is right: get enough sleep, and don’t get caught in the I need less sleep than you do! macho trap.

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^[1] This is a good opportunity to throw in a plug for TED, which, in case you don’t already know, has a bunch of wonderful talks, all by good speakers and all short enough that they won’t cut into your time too much. Many of them are worth watching.

Follow-up on placebos

I wanted to do a follow-up to Friday’s post about a ridiculously flawed study of the effect of placebos. I have two follow-up points.

Point 1: The study is not blinded, but that is not a problem, as I see it. There are two types of blinding used in studies:

1. Blinding relative to the subjects: the subjects don’t know which group they’re in (and sometimes don’t know specifically what’s being studied). This reduces the influence of the subjects’ expectations and biases on the results.
2. Blinding relative to the researchers: the researchers don’t know which group a given subject is in. This reduces effects that the researchers’ behaviour toward the subjects will have on the results.

For this study, the whole point was not to blind it to the subjects. And since the subjects are either being treated or not, there’s nothing to blind relative to the researchers, either. The problem with the study isn’t the lack of blinding, but the bias that the instructions to the subjects provides.

Point 2: I see a reasonable way to evaluate what these researchers want to evaluate, which fixes the bias problem — or, more accurately, which makes that bias part of the study itself. It involves what I’ll call half blinding relative to the researchers.

Get, say, 300 subjects, and divide them into three groups of 100. Group A gets no treatment, just as one group got in the existing study. Groups B and C each get identical bottles labelled PLACEBO. Each bottle contains identical pills. Each bottle contains an instruction sheet that only the subjects see, and each subject is told to read his sheet and not to discuss with anyone what it says.

The instruction sheets for group B would say, This bottle contains placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.

The instruction sheets for group C would say, This bottle contains placebo pills made of an inert substance, like sugar pills, that have no effect whatsoever. They will not affect your symptoms in any way.

Now, if groups B and C have similar results, we can legitimately say that placebos have their effect even when the subjects know they’re getting them. But if, as I suspect, group C has results comparable to those of group A, then what we’ve shown is that telling people the placebos are effective is the same as not calling them placebos — setting up the expectation of effectiveness is what gives the results.

If you want to call that mind-body self-healing processes, that’s fine with me. Well, almost fine: it’s not healing; it’s symptom relief. That your mind can help you feel better is no surprise. But it’s not going to heal your cancer, repair your liver damage, or kill viruses. Unless, perhaps, someone can show, with a properly designed study, that it can.

Someone’s high on placebos

On Wednesday, this paper, published in PLoS ONE, hit the popular news in the medicine/science category, with articles such as this one from MedPage Today and this, from Reuters. The headlines are consistent, implying that the study has shown that the placebo effect works even when patients know that they’re getting placebos.

From the MedPage article:

While this may seem counterintuitive, the results suggest that physicians don’t have to resort to deception to harness the power of the placebo effect, Kaptchuk explained in an interview.

Conventional wisdom says that in order for a placebo to work you have to convince the patient that they are taking a real drug, he told MedPage Today.

However, the brain appears to respond to placebo in a way that conditions like IBS are susceptible to, Kaptchuk noted.

Counterintuitive, indeed, and enough so that it merits some serious scrutiny. My first thought was that the headlines are misrepresenting the study and the claims of the researchers, a common problem in the reporting of research in the popular press. But it seems that they are, indeed, reporting exactly what the researchers are saying, here.

I’ll note that the paper appears in a Public Library of Science (PLoS) journal, rather than in some other, more respected medical journal (such as NEJM or BMJ). I’ll also note that the lead researcher, Ted Kaptchuk, is associated with Harvard’s Division for Research and Education in Complementary and Integrative Medical Therapies, a connection the press just puts forth as Harvard, downplaying the fact that he does complementary medicine.

Those aren’t reasons to ignore his research or his results, of course. But they are points that should make us ask questions. On the other hand, we should ask questions with any study; that’s what science is about.

Now, the study is on IBS, which is a very subjective, catch-all condition of unknown etiology. They mention in the article that they expect this effect to work also with conditions such as fibromyalgia and chronic pain — also subjective conditions of unknown etiology — and depression and anxiety, more highly subjective stuff. And the study itself is entirely subjective, using self reporting exclusively, and not measuring anything.

That could be OK. If we’re looking for cures, we need to measure; if we’re looking for symptom relief, well, if you think you feel better, then you feel better. Where I have to scratch my head, though, is in wondering what their hypothesis was.

When you go into a study, you go in with a hypothesis, which your study might support or disprove. Even if it seems like you’re just wildly trying any drug that might work, you have a hypothesis: This drug might work. What’s the hypothesis, here? Placebos might work even if the patients know they’re placebos, is a valid hypothesis, I suppose, but to whom would it occur to even try that?

The answer shows up in the study: it would occur to people who think they can show mind-body self-healing processes. OK... again, a valid thing to consider. But that’s where we get into some problems.

We start with some very typical problems with medical studies... again, from MedPage:

Limitations of the trial included a relatively small sample size, too short duration to examine long-term effects, and the possibility of self-selection bias in that the trial may have selectively attracted IBS patients interested in mind-body interventions.

Many, many studies are too small, too brief, and suffer from various sorts of selection bias, and this one is no different. But to get the real kicker, we have to go into the paper itself and see how the placebos were presented to the patients:

Patients were randomized to either open-label placebo pills presented as placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes or no-treatment controls with the same quality of interaction with providers.

Read that again. The patients were not told just that they were getting placebos. They were not told that what they were getting is an inert substance with no medical effect. They were told that what they were getting has been shown in clinical studies to produce significant improvement in IBS symptoms.

In other words, these pills are having exactly the same placebo effect as is well documented in pretty much every other medical study that involves placebos. And, to put the point forth directly, far from making this deception-free, they are deceiving the patients in the same way patients are deceived in every other administration of placebos.

Let’s line it all up:

1. You recruit people who have a condition that makes them feel horrible, that no one can tell them the cause of, and that no one has effective treatment for.
2. You give them a pill and you tell them that this has been shown to provide significant improvement for their condition.
3. They report that the pills did, indeed make them feel better.
4. You claim that you did not deceive them, because you told them they were getting placebos.

Bullshit. Whether or not you put the label placebo on it, you told them they were getting effective treatment. That biased the outcome, and the result should be no surprise to anyone. And it says... nothing. This study is worthless garbage.

Can you be “pro-life” when there's no life there?

The Ridger, pointed out an item in the Washington Post magazine section, citing a particular section. The article is by a religion writer called Julia Duin, and it describes her bus ride from New York to D.C. for the Stewart/Colbert rally at the end of October. She talks with a number of folks on the bus, along the way.

But Ms Duin is a writer, not a reporter, and her story isn’t an attempt at unbiased reporting, but a piece that includes her opinions — sometimes strongly. Here’s the part that The Ridger noted, where Ms Duin is talking with her seatmate, Robert Woudenberg, a 46-year-old man from Rockland County, just across the river from me:

[...] But I decline to argue with Woudenberg about this, as the conversation soon shifts to his 21-month-old daughter, whom he dotes on. Before she was born, I learn, there was another pregnancy. Doctors told Woudenberg and his wife that the fetus had no heartbeat, and she was advised to abort.

Why couldn’t you have at least allowed your child to live out its short life in the womb? I ask.

I have strong feelings on this, not just because of my faith but because of a 2009 article I wrote about a Silver Spring organization called Isaiah’s Promise, which encourages women with problem pregnancies to bring their babies to term. The women I had interviewed told me that doing so was less traumatic than aborting the babies would have been.

Woudenberg responds with a line I often hear: that if an unborn child has some kind of abnormality, it’s best to abort him or her sooner and let the mother get on with her life. He argues that my position is a minority one; I say it’s the more compassionate one for the mother, for whom an abortion is an added trauma, and for her helpless child, for whom nine months in the womb will be the only life he or she knows.

I talked this over with a sonographer who does ultrasounds on pregnant women. She spends all day, every work day, looking at babies in utero, mostly with good news for the mothers, sometimes with sad. Here’s an approximation of her response to the above:

No, no, that doesn’t make sense at all. There’s no grey area here. Dead [she extends her left hand]. Not dead [she extends her right hand]. A fetus with no heartbeat is dead [she waves her left hand]. That’s it: it’s dead. There’s no life for it to live out, in the womb or anywhere else. It doesn’t know anything, it’s not enjoying being in there, it’s not growing (in fact, it will probably atrophy if it’s left inside), it’s not kicking or moving around. It’s not alive.

This woman is confusing a problem pregnancy, perhaps a congenital defect that will result in the baby’s death soon after birth... with a fetus that’s dead now. It’s not a problem pregnancy; there is no pregnancy any more. And removing it isn’t an abortion. Abortion is terminating a pregnancy; this has already terminated.

Indeed. It’s certainly a valid choice for a woman to make, if she wants to leave her dead fetus inside her for a while, until her body expels it. If she feels that will be less disturbing to her, less traumatic, than having a doctor help remove it, that’s fine. But there’s no sense in which she’d be doing it for her unborn child. Her unborn child is dead, and that’s a terrible thing for her to have to face. If softening it in some way helps her... good.

We don’t know how far along the pregnancy was — perhaps Mr Woudenberg didn’t say, or perhaps Ms Duin just prefers to leave that out to help make her point, just as she does by referring to the helpless child as he or she. The heartbeat should first have shown up at 6 weeks, so it could have been lost any time after that. The current standard for viability is 24 weeks. And, of course, full term is 40 weeks. If it died after 24 weeks, we’d consider it a stillbirth. But no matter what, it’s not a helpless child.

It’s dead.

Ms Duin is a religious-fanatic, nonsensical moron, looking to try to preserve some sense of life and sentience for an erstwhile being that has none of either to preserve. And insisting that it’s the right thing to do. And berating a man who probably still feels horrible about having lost his first child before it was born, expecting him to share her delusional fantasy of a happy baby soul floating contentedly inside its mother.

I continue to be puzzled that we accept such fantasy from otherwise thinking adults, that we actually encourage and praise such magical thinking, and that we publish garbage like this in reputable media.

Managed cardio care

My doctor — general practitioner — recently did a routine referral, sending me to a cardiologist for a stress test, because, well, I’ve reached the advanced age of 53 and haven’t had one, and I have a family history of heart problems. Results first, lest anyone be alarmed: everything is fine, and they have a baseline for future testing if it’s needed.

Specifically, I had a stress echocardiogram. A sonographer attached about a dozen electrocardiogram leads to my chest to monitor my heart, then took very cool pictures of my heart at rest, using ultrasound imaging. The focus, here, was on the blood flow to the heart muscle. The cardiologist came in, and they put me on a treadmill, monitoring all the while. Every three minutes, the treadmill sped up and increased its steepness. They’re looking for me to get to my target heart rate and stay there or above for bit.

The target heart rate is a strange thing, by the way, as it’s rather arbitrary. You figure your maximum heart rate by subtracting your age from 220, as though 220 were a magic number, and magic things happened to you at each birthday. Anyway, that puts my maximum at 167. The target rate is then 85% of that, 142 for me.

After 10 minutes or so on the treadmill, they turned it off and had me lie back on the table as quickly as I could, so the sonographer could repeat the ultrasound pictures with my heart working hard. They can then compare the before and after pictures to see if there are problems with the blood flow under stress. As I said above, there weren’t.

As you might imagine, given that I’m occupying a sonographer for some 45 minutes and a cardiologist for 15 or 20 minutes, and using an exam room, an ultrasound imager, a treadmill, a heart monitor, and so on... it’s not an inexpensive test. I got my insurance information, the explanation of benefits, the other day.

The cardiologist billed $1750 for the whole procedure. But here’s the interesting part: the insurance company discounted that by about $1240. That’s the amount that the doctor agrees to eat, as a cost of participating in this insurance plan, and that brings the amount that he actually gets for the procedure to about $510.

Let’s go over that again: he bills $1750, but accepts just $510, by agreement with the insurance company.

And that brings up a question: Who pays retail? That is, who, if anyone, actually winds up paying $1750 for that procedure?

If everyone with insurance pays a discounted fee, then it would have to be the uninsured people who pay the full one. But that doesn’t make sense: the uninsured are generally the ones least able to afford the full fee. And I’m told that doctors will routinely negotiate discounted fees for people without insurance.

What I get from this is that the full fee is actually an inflated one that’s designed to draw a higher discounted amount from the insurance company. Something like, Ask for $1500, hope for $1000, be happy with $500. Most of us have seen that sort of thing in other contexts.

But what does it say about managed care? Is it really keeping costs down, or are doctors just compensating by pushing their asking price up, requiring more pre- and post-procedure consultations — bringing in hundreds of dollars for spending ten minutes with the patient to explain the procedure, something that could be done with a leaflet the vast majority of the time — and using other techniques to keep the money coming in, in the face of more scrutiny by the insurance companies?

It seems to me that, in the end, the consumer isn’t winning here.

People like to have paid sick leave. Imagine.

Here’s another unsurprising result of a poll, reported a couple of weeks ago in the New York Times:

Most Americans Support Paid Sick Leave, Poll Finds

[...]

The survey of 1,461 randomly selected people found that 86 percent of respondents favored legislation that would guarantee up to seven paid sick days a year, while 14 percent opposed such legislation.

According to the survey, which was released on Monday, 69 percent of respondents said paid sick days were very important for workers, with 78 percent of women compared with 61 percent of men saying paid sick days were very important. Sixty-four percent of respondents who described themselves as strong Republicans said paid sick days were very important as a labor standard, compared with 85 percent of those who identified themselves strong Democrats.

Americans overwhelmingly view paid sick days as a basic labor right, said Tom W. Smith, a senior fellow at the National Opinion Research Center and director of the study, Paid Sick Days: Attitudes and Experiences.

The other unsurprising thing is what people do if they don’t have paid sick leave: they go to work sick. That is, they’re more likely to go to work sick than people who do get paid sick leave, but there is a surprise here after all: the margin isn’t what one might think. Only 55% of those who have to eat the day themselves say they’ve gone to work with a contagious illness — that means that 45% always stayed home, despite not being paid for the day — and 37% of those who have paid sick leave went to work sick anyway.

I have to conclude that our work culture encourages going to work sick, even when you might infect others. People might fear staying home for a number of reasons. Perhaps they worry that their employer will think they’re faking it, goldbricking. Maybe they’re concerned about work piling up, meetings missed, authority undermined, and so on. Some workplaces give awards for no absenteeism, without thinking of the effect that has on legitimate absences — and the consequences of having contagiously ill employees at work.

Of course, lack of paid sick leave makes that worse, giving us more workers infecting others, more sending their kids to school sick (and having them infect teachers and other kids), more using hospital emergency departments because they can’t make appointments with their regular doctors during working hours. All of this costs money — a lot of it — but it’s less obvious than the direct cost of giving the paid leave in the first place.

We need not to look to the false economies, not try to save money on the obvious things and wind up spending it on more illness and more health-care costs.

Failure to seek (and see) common ground

The people who oppose abortion and those who support the right to decide what to allow to grow in one’s body have few, if any, places to compromise. If I want to allow a woman to terminate an unwanted pregnancy and you consider that to be the killing of a baby, we can’t meet in the middle. There’s no common ground there.

There is, though, common ground elsewhere, if we look for it. Essentially, no one favors abortion, in that no one thinks it’s a beautiful thing that people should do regularly. Both sides of the abortion issue want to reduce the number of abortions. One side wants to reduce the number to zero, but the other side also wants it reduced, not by legislating it away, but by reducing the need for it.

That’s where we should all be putting our efforts: on something on which we can agree, and on which we can work together.

If we work on ways to reduce the number of unwanted pregnancies, we’ll reduce the number of abortions. We’ll still have a fight about the ones that are left, but we’ll have accomplished something good, and everyone will be happier.

That’s the point at which my mind starts to boggle: I see the anti-abortion side not only failing to take action to help in that reduction, but actively impeding efforts toward it. Many want abstinence-only education, and refuse to teach young, sexually-active potential mothers and fathers how to prevent pregnancy. Many refuse to use contraception, and won’t allow its use in their families. Many work to block the availability of contraception to others.

Such is the case for a new morning after pill, ulipristal acetate, which can prevent pregnancies up to five days after intercourse, compared with three days for levonorgestrel (marketed as Plan B), and which is more effective than the alternative drug. The right-wing anti-sensibility groups are, predictably, rallying against approval of the new drug, called ella:

With ulipristal, women will be enticed to buy a poorly tested abortion drug, unaware of its medical risks, under the guise that it’s a morning-after pill, said Wendy Wright of Concerned Women for America, which led the battle against Plan B.

Plan B prevents a pregnancy by administering high doses of a hormone that mimics progesterone. It works primarily by inhibiting the ovaries from producing eggs. Critics argue it can also prevent a fertilized egg from implanting in the womb, which some consider equivalent to an abortion.

Women who were truly concerned for America would see the need to prevent unwanted pregnancies in their daughters, and would understand that abstinence-only education doesn’t do that. Instead, though, these people hold onto the ludicrous concept that two cells that happen to have united are now, though still microscopically small, a person, and must be given every protection available. They maintain that anything that interferes with the process of forming a viable human, once a penis has touched a vagina, is wrong.

And, of course, holders of those sorts of moral views don’t find it sufficient to hold the views themselves; they must impose them on everyone.

In doing so, they are actually increasing the number of abortions that will be performed. Yet they know they’re right, and they’ll fight to the ends of the Earth to force the rest of us to comply.

Their intransigence amazes me, but what also amazes me is how easily the rest of us can let them beat us down. If they want to work with us on common ground, that’s great, and I’ll welcome it. Otherwise, we need to be as vocal as they are; we need to stop allowing fanatics to tell us what to do.

Calorie counts

The elementary school where I play volleyball has some new signs up in the gym, presumably for a class lesson they’ve started. Each sign depicts two foods and one common calorie count.

From this, we’re given to understand that a plate of rice and beans and a plate of lo mein each have the same number of calories (I forget the numbers, and I didn’t write them down). A Big Mac and a plate of fish and vegetables are 600 calories each. A hot dog matches up with a salad, and a cupcake is in some way equal to a bowl of fruit. Doughnut, or bagel and cream cheese? Machts nicht.

I don’t know how the lesson goes, but I do hope they give a strong message that calories don’t tell the whole story. I’d hate to see a kid come out of this eating more cupcakes, or opting for a hot dog or a Big Mac instead of a salad or fish and vegetables.

Anyway, yesterday at lunch time I took a walk to the local post office — about a mile and a half each way — and decided to stop for a Caesar salad at a chain restaurant near the post office. In New York, most chain restaurants are now required to show calorie counts on their menus, and as I browsed the menu I thought about the signs in the school gym.

It’s not surprising, of course, that restaurant food tends toward the high-calorie side, but some of what’s there is eye-opening.

What really struck me was that almost every appetizer on the menu came in at well over 1000 calories — I think one was around 800, the lightest of the bunch, and one was 2500. These are appetizers. They’re meant to get you started.

Yes, they’re also meant to be shared, but here: suppose you and a companion order the spinach and artichoke dip (about 1500 calories or so; this one isn’t exact) to share, and then you each get the Fiesta Lime Chicken — a moderate choice, somewhere around yellow or green on the health spectrum — at 1230 calories. That brings you right to 2000 calories, which is a full day’s allocation, and that’s just for dinner (assuming you drink water or iced tea, and forgo dessert; we won’t even think about adding dessert to this). You skipped breakfast and lunch that day, right?

I’ve often joked that “appetizer” seems to be an American idiom that means “fried stuff”. The spinach and artichoke dip isn’t fried, of course, but that’s little consolation — note that it’s full of cheese, but that’s not part of the name (it’s all marketing, you know). And most of the other appetizers are: chicken wings, fried zucchini sticks, onion rings... fried cheese.

Again, calories aren’t everything, but the appetizers are also loaded with fat and salt, items that aren’t (yet?) listed on the menu. But you can get it from the chain’s web site:

Spinach and Artichoke Dip: ~100g fat (~25g saturated, 1.5g trans), ~2300mg sodium
Fiesta Lime Chicken (including sides): 67g fat (16g saturated, 1g trans), 4390mg sodium

4400 mg of sodium in the chicken platter! So in addition to the 2000 calories you and your companion would each eat, you’d each be sucking down about 110 grams of fat and an unbelievable 5550 mg of sodium. That’s almost two and a half days worth of sodium (recommendation is under 2300mg/day). And at 9 calories per gram, the fat makes up 990 calories of your meal. That’s almost 50%, and the U.S. Food and Drug Administration recommends getting less than 35% of your calories from fat [reference].

OK, we’re all curious: if you do go for dessert, you’ll have to get the Triple Chocolate Meltdown, of course (what else?). It’s actually not bad, as the desserts go: 810 calories, 46 grams of fat (no trans), and 530 mg of sodium. Share it. Or realize that it’s your calorie allocation for tomorrow’s lunch.

Oh, and my Caesar salad? Not too bad: 410 calories, 29 grams of fat (no trans), 820 milligrams of sodium. Too much salt, but otherwise OK. But don’t think that the salads are healthful, diet meals. The full-sized Oriental Chicken Salad has 1310 calories, 93 grams of fat, and 1470 mg of sodium. And the Santa Fe Chicken Salad is about the same in calories and fat, but has an amazing 3420 mg of sodium.

Eat well....

How about the Grapefruit and Avocado diet?

Last week, there was a small item in the New York Times science section, Science Times, answering the question, “Other than celiac disease, is there any reason to avoid gluten in the diet?” There are reasons other than celiac disease for people to be intolerant of gluten, a protein in wheat and some other grains, but, as the Times item says, evidence is just not there to support health benefits of a gluten-free diet if you are not one of those affected.

Despite that, the gluten-free diet has become a fad, with all sort of claims from general well-being, to anti-cancer properties, to autism prevention behind it. None of the claims are supported by science, only by folk tales, by books and magazine articles and self-help lecturers.

But, of course, when you start talking about fad diets, you’ll get the faddists coming out of the woodwork. And so we have a letter to the editor, from a California reader:

Rather than casting doubt on the people who take on the economic, social and other hardships associated with a gluten-free diet, The New York Times should use its public platform to applaud them for taking responsibility for their health and encourage doctors to take a professional interest in what they can learn from these earnest patients.

— Tracy Haughton, Mill Valley, Calif.

Sigh. No.

Rather than believing quietly whatever bullshit people come up with, the New York Times should be using its public platform to cast doubt on that which has no evidence. And doctors should be looking at things that really work, and taking a professional interest in what they can learn from studying the real effects of foods and drugs. There’s no value in paying much attention to some vague story about how Aunt Gertrude took on the economic and social hardships of a fad diet, and her arthritis feels much better now.

People should take responsibility for their own health, and that includes eating properly. But before we start arbitrarily removing things from our diets — or, if you like, as we try removing them — we should be pushing for real studies of the effects, not accepting anecdotes and fuzzy science.

Demise of the bake sale?

We seem to have a series on education this week, and today’s entry looks at what used to be an institution in learning institutions: the bake sale. A policy panel of the Department of Education in New York City has unanimously approved a policy change that will ban the sale of home-baked cakes, brownies, and cookies, but will allow the sale of Pop-Tarts, packaged cookies, and Doritos.

In what is truly a WTF? move, the city is attempting to ensure healthier foods available for purchase — the rules specify maximum calorie counts, maximum fat levels, and such, and ban homemade items because “it’s impossible to know what the content is, or what the portion size is.”

And, yet, it simply seems ludicrous to forbid dad’s zucchini bread and mom’s cranberry cookies, but to allow Pop-Tarts and Chips Ahoy. A kid won’t be able to buy a mini-loaf of multigrain health bread, but can snag four bags of Doritos.

Yes, that makes sense.

Ms. Puccini, whose children attend the Children’s Workshop School in the East Village, said the regulation appeared to be a “blatant attempt by food companies such as Pepsi-Cola and Kellogg’s to reap enormous profits at the expense of our children” — an opinion shared by many of the more than 200 readers who commented on an In the Schools item on City Room this week outlining the policy. Ms. Puccini added that the school should focus on eliminating the high-fructose corn syrup in many cafeteria items.

Indeed. The Department of Education should not be trying to regulate this stuff. It needs to look to make its mark elsewhere.

It’s abstinence only that’s the problem

I’ve really been trying not to think of Ross Douthat as an idiot, but it’s been hard. When he replaced Bill Kristol as the token conservative on the New York Times op-ed team, I knew it had to be an improvement, and it has been so. His columns are sometimes good. Unfortunately, I still too often, when I read them, find myself smashing nose-first into a wall of ideas that were conceived with blinders on.

His latest column is a good example. His basic point is a reasonable one to debate: Should we have national standards for how to teach kids about sex, or should we defer to local sensibilities? Your answer to that will depend upon whether or not you think that there’s an objective “best method” that transcends local mores, and that letting the locals decide will cause problems for kids in areas where they would choose to deviate too far from what’s best.

Mr Douthat thinks there is not such an objective “best”, and that’s a fair conclusion. The problem is how he got there.

From his column, “Sex Ed in Washington”:

Liberals hated almost everything about George W. Bush’s presidency, but they harbored a particular animus toward a minor domestic policy priority: abstinence-based sex education. The abstinence effort accounted for about a hundred million dollars in a trillion-dollar budget, but in the eyes of many critics it was Bushism at its worst — contemptuous of experts, careless about public health and captive to religious conservatism.

Indeed, with a spotlight on the “careless about public health” part. It was shown over and over not to work, and it has been once again with new numbers recently reported: teen pregnancy went up in 2006, and “liberals” blame abstinence-only education.

For what Mr Douthat thinks of that, let’s go back to his column:

The new numbers, declared the president of Planned Parenthood, make it “crystal clear that abstinence-only sex education for teenagers does not work.”

In reality, the numbers show no such thing. Abstinence financing increased under Bush, but the federal government has been funneling money to pro-chastity initiatives since early in Bill Clinton’s presidency. If you blame abstinence programs for a year’s worth of bad news, you’d also have to give them credit for more than a decade’s worth of progress.

No. No, no, no, no.

Because, yes, Bill Clinton funded abstinence education as well. Forty years ago, my parents and my school taught abstinence. We have been teaching teens and pre-teens not to have sex until they’re older and emotionally, socially, and financially ready ever since we figured out what causes pregnancy. The problem is not that we teach abstinence.

The problem occurs when we teach only abstinence. The problem shows up when we fail to prepare children with information on how to protect themselves when they, despite the moral values we’ve instilled in them, fall victim to a natural urge that’s more powerful than a locomotive.

When I was young, alongside the lessons that told us to wait were lessons about pregnancy and sexually transmitted diseases, lessons about condoms, IUDs, and contraceptive pills, lessons about what to look for and when to go see a doctor. These lessons did not confuse us, did not give us mixed signals, and did not chip away at the moral framework our families and communities were passing on to us. We understood the priorities — but we had a backup plan, for when things went awry.

And that’s the point — contrary to what Mr Douthat says, teaching abstinence with a backup plan does work, and has been shown to, through the years. What fails is the policy of teaching abstinence only.

Now, we can still have the debate about whether communities should be forced into one lesson plan or another through federal policy. But let’s frame it properly, and not dismiss a major part of the argument out of hand by misrepresenting it.

The Massachusetts vote, and the health insurance bill

Perhaps you’ve heard that the Democrat who ran a bad campaign to finish out the late Senator Kennedy’s term lost to the Republican who ran a better campaign. Perhaps you’ve also heard the knells telling us that this signifies the end of the world as we know it. To hear it from some, all opportunity for getting anything done in the Senate is over.

At the very least, it’s common knowledge that health-care reform is in trouble. The New York Times tells us in its headline that “Democrats Regroup on Health After Losing Seat”, and the headline that article had on the RSS feed was more dire: “Democratic Defeat Imperils Health Care Overhaul”.

So, wait, let’s take a step back and look at it again.

First, the “filibuster-proof majority” was a myth to start with. The Democrats relied on “Independent” Joe Lieberman for that, and it’s been clear for some time that he is not on their side. Far from assuring the power to push legislation through, that just enabled Senator Lieberman to muscle things around, at the expense of the Democratic Party.

Second, a filibuster-proof majority is a fragile thing that’s of questionable value. With some exceptions, if an issue is touchy enough that they have to worry about a filibuster, making sure that all the Democrats are signed up to break it requires so much waffling on the substance of the bill, so much damaging compromise and dilution that what they wind up getting through has little left. Indeed, that’s what’s happened with the health-insurance reform bill (it’s about health insurance, not health care), already making it so thin that it looks like a homeopathic remedy.

These are where attempts to be “bipartisan” go: trying to please everyone means that in the end, we please no one, really.

The effect that the seating of Scott Brown as the new junior senator from Massachusetts will have is not that anything will be derailed, not that all negotiations will break down, and not that the health insurance bill — which Senator Brown has promised to vote against — will founder, but that those with a vision of reforming health insurance may have to make some changes to get it through.

This can actually be their opportunity to make positive changes, as they recognize that they no longer need to coddle the fringe elements who recognized where the situation put them and threatened to kick sand in their faces.

They can now come back with something that will make 52% of the Senate more happy, rather than settling for one that 59% can tolerate.

And if a filibuster comes, then let it. Senator Reid can say, “OK, if you want to talk, talk. We have time. The Senate is now in session 24 hours a day, seven days a week, until we sort this out. Have at it.” And it will last until enough voters in some of the less conservative places (such as Massachusetts) put pressure on their senators to stop getting in the way and go back to getting things done.

A filibuster on this bill will delay things for a short time. But in the end, I’d rather have a better law that took a few extra weeks than some junk that’s of little long-term value,^[1] but that allowed our politicians to say “Mission accomplished.”

Sadly, I have no confidence in the Senate Democrats to make this happen.

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^[1] That’s not to say that I think the proposed legislation is useless; it clearly has some useful points to it. It will help some people a lot, and everyone a little. It’s just that it’s had some very important points cut out of it, and the problem is that it still doesn’t accomplish what we need: health care for all Americans. Just cover everyone.

Volunteer Ambulance Corps

I tried a new adventure this week: I did a ride-on shift with the Ossining [NY] Volunteer Ambulance Corps. Some background:

I play volleyball with a paramedic at the O.V.A.C., and when I was at IBM I worked with two volunteer Emergency Medical Technicians (EMTs). I’d often said that I admire people who do that sort of thing, devoting their time to helping people. When I told my volleyball teammate that I’d been laid off, she suggested that it might be an opportunity to look at something completely new... like taking EMT or Paramedic training.

The idea struck a spark, but it took a few months for me to get around to setting up a ride-on, where I’d really get to see what they do.

For those who don’t know the difference: EMTs have a relatively brief training period, and are only authorized for basic life support (BLS) tasks: CPR, giving oxygen, splinting, that sort of thing... and, of course, transport. Paramedics have significantly more training, and they can perform advanced life support (ALS) tasks, such as running IVs, giving certain medications, and using the defibrillator. Ossining has two ambulances — one with two EMTs and one with an EMT and a paramedic — and a “fly car” — an SUV that a paramedic goes alone in.

The protocol at Ossining is that whenever possible, either both ambulances or the two-EMT ambulance and the fly car go to a call. That ensures that there’s a paramedic there, so ALS is available. And if the paramedic decides that ALS isn’t necessary, the EMTs take care of the situation and, if necessary, the transport, leaving the paramedic available for the next call.

On my day, we had an extra EMT with us, one who is just finishing his paramedic training. I rode in the “bus” with my paramedic friend and two EMTs.

The shift started at 8 A.M., but it wasn’t until a little before 10 that we got our first call. After that they came pretty steadily, with just short gaps... six calls for us, all told (and a couple of calls we didn’t go to because we were busy — the fly car took those).

The calls varied in scope:

1. A worker felt strange, enough so that the crew called us. The paramedic asked some questions, did some basic exam. Blood pressure high, nothing else obvious. EMTs transported him to the hospital.
2. A woman cut her leg. EMTs cleaned and bandaged it, no transport needed.
3. A man with a history of emphysema complained of shortness of breath. Nothing immediately urgent, so EMTs gave oxygen and transported him.
4. A woman fainted at her workplace. Vitals were normal when we got there, but paramedics gave her a saline IV and we took her to the hospital. Very nice (new) emergency department. Not crowded, not hectic.
5. A woman was in an auto accident, complaining of neck/back pain. No ALS needed, but the other bus was busy, so we transported her.
6. A man thought he was having a heart attack at his workplace. He looked pale and ashen when we arrived, high blood pressure and tachycardia (rapid heartbeat). Paramedics gave him aspirin, nitroglycerin, and saline, monitored him (EKG, BP, oxygen level) in transit — his stats went back to normal.

And that was the day. No traumas, nothing very challenging,[1] but a variety of things that let me see these folks in action.

Two things struck me, in particular. The one I completely expected is that the paramedics and EMTs are well trained, competent, and effective. The area covered is small enough that we were just a few minutes from every call. Everyone knew just what to do, and did it with confidence.

The other thing was less obvious: they have a practiced, easy “bedside manner”. One of the most important parts of what they have to do is to make the patients feel calm, safe, and relaxed. Think about it: you’ve collapsed at work and the ambulance has come for you! You’d have to be agitated, frightened. And the EMT talks with you calmly, the paramedic has a soothing manner with you. It’s OK. We’ll get you to the doctor, and you don’t need to worry. I could see the difference that made.

I’ve asked my volleyball teammate to let me know when the next EMT class is. I’m going to learn to do this, as part of giving back to the world.
 

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[1] I actually felt a little odd at the start of the day, in that I knew that if we didn’t get any calls I’d wind up spending the day watching dumb stuff on TV... but that it was kind of weird to hope that a few people would get sick or injured so that my day would be more interesting.

Health care: U.S. vs Canada

About a year and a half ago, former Canadian Prime Minister Kim Campbell was on the Brian Lehrer Show on WNYC, the local public radio station here in New York. Among other things, the topic of health-care coverage came up (listen at 30:10 into the audio), and Ms Campbell said, as part of her answer, “It’s interesting, because there are all sorts of myths here about Canadian health care, and I can’t answer all of them now, but the point is that the system is rational and it is accountable to the public.”

At the time, I wished I could contact Ms Campbell and get her list of myths. But now another Canadian — this time, Rhonda Hackett, a clinical psychologist now living outside of Denver — has written an article about Canadian health-care myths, published a few weeks ago in the Denver Post.

Read the article; it makes a number of things very clear. Allow me to summarize some points that one gets from Ms Hackett’s list:

United States: 31% of health-care money goes to overhead (paperwork, company salaries & profits, and so on).
Canada: 1% of health-care money goes to overhead.

United States: 17% of the gross domestic product (GDP) is spent on health care.
Canada: 10% of the GDP is spent on health care.

United States: Less than 85% of the population is covered, and many of those have inadequate coverage. The U.S. has many “hidden” costs when uncovered people go to emergency facilities in order to get health care.
Canada: 100% of the population is covered through the normal system.

United States: Insurance companies often overrule doctors’ health-care decisions.
Canada: Your doctors are the only ones who make your health-care decisions.

United States: 14.4% say they have unmet health-care needs.
Canada: 11.3% say they have unmet health-care needs.

United States: You have to find a doctor who’s in your health insurance plan.
Canada: You go to any doctor.

United States: Doctors are private businesses; they do not work for the government. Their fees are reimbursed by the health insurers.
Canada: Doctors are private businesses; they do not work for the government. Their fees are reimbursed by the government, which acts as the health insurer.

Ms Hackett finishes with a story of her aunt, who’s waited 14 months in Canada for elective knee-replacement surgery. The wait may sound bad, until you realize that she will get her new knee next month. In the U.S., she could not have afforded it, ever.

Further, according to Ms Hackett, Canadians do not pay significantly higher taxes, overall.

Health care: cover everyone

Not wanting to worry about burying the lede, I’ll put it right out here: I’ve been saying for a long time that when we reform health insurance in the U.S., we need to make sure that everyone is covered. Not that everyone can afford it, not that everyone can buy it if they want to... because those result in not everyone being covered.

Like other first-world countries, like Canada and Japan and the United Kingdom and Sweden and France and Germany and the Netherlands, we just need to take care of our people. We need universal health coverage that people don’t have to think about. You need to see a doctor, you see a doctor... and it’s covered. You never see a bill. You don’t have to argue with someone about the treatment your doctor recommended.

That said, let’s back up and listen to NPRs report on Tuesday afternoon about Healthy Howard, a plan in Howard County, Maryland, which is meant to provide cheap coverage for all the uninsured residents of the county.

What a great idea! If the country won’t do it, the state can. If the state doesn’t, well... the county is giving it a shot. For a very small payment — between $50 and $85 per person per month, they’ll give you a whole bunch of medical coverage. It’s a wonderful deal.

But here’s the thing: out of around 10,000 adults who ought to be getting this, fewer than 600 have applied for it.

Yow!

They attribute some of this to lack of awareness, and they’re working on that. But they cite two other reasons:

Reason 1:

Beilenson attributes the low numbers to the "young invincibles" in their 20s and 30s who think they’re going to live forever.

Reason 2:

“The costs are somewhat problematic, even though it’s very reasonable: $50 to $85 per person per month — far less than insurance,” Beilenson says. “Nonetheless, it is something, and for a lot of people who are having trouble holding jobs during this recession or have lost their jobs, economics plays some part of it.”

Even the cheapest health care program will strike some low-income working families as too costly.

And there it is, in black and white: some people don’t think they need it, and some aren’t willing (or able) to pay for it, however “affordable” it may be.

And when those people get sick, they’re in trouble, because they lack preventive care, and because they turn to hospital emergency departments instead of using the health-care system the way it was designed to be used. And the rest of us are affected too.

Now, when I first heard the item on NPR, I thought that Dr Beilenson, Howard County’s health commissioner, was heading there:

But the paltry enrollment figures have also confirmed Beilenson’s belief in the need for a reform that isn’t even on the table in Washington.

Indeed: universal coverage is not anything that any politicians are discussing. None of the front-runners in the 2008 election talked about it. No one working on legislation now is talking about it. Everyone’s afraid of considering it, afraid that someone will accuse them of supporting socialized medicine, as though that were a fate worse than... well, worse than not being covered. Having doctors work for the state is one way to achieve this, but it isn’t the only way.

But Dr Beilenson was about to cross that line, yes, and suggest universal coverage?

Well, no:

“I am 100 percent convinced that if we are going to have comprehensive affordable quality coverage for all and spread the risk amongst the entire population, you have to have individual mandates,” he says.

That means people would be required by law to have health insurance, something President Obama campaigned against.

We aren’t learning anything from this stuff, we really aren’t. The answer isn’t to require people to buy health insurance. The answer is to provide it for them, as part of the package of benefits they get from living in the United States. Howard County is proving that, right there on NPR.

How much is that tiramisu in the window?

Readers outside the New York City area might not know about the city’s relatively new regulation, under enforcement for about seven months now, that requires most chain restaurants to display calorie counts on their menus. Though the law’s been controversial and under appeal, its enforcement means that places like McDonald’s and Starbucks — within the New York City limits — now have to tell you the calorie count, along with the price, of Big Macs, eggs McMuffin, bagels, scones, and slabs of banana bread.

One appeal, a major one, has just been settled:

In a victory for New York City’s campaign against obesity, a federal appellate court on Tuesday rejected the New York State Restaurant Association’s challenge to the city’s 2007 regulation requiring most major fast-food and chain restaurants to prominently display calorie information on their menus.

Enforcement of the rule began in July 2008, with the appeal continuing. But the ruling on Tuesday, by the United States Court of Appeals for the Second Circuit, eliminates, for now, lingering uncertainty over the rule.

“This is good news for everyone,” said Dr. Thomas R. Frieden, the city’s health commissioner. “Nearly all chain restaurants are now complying with the law. Consumers are learning more about the food before they order, and the market for healthier alternatives is growing. We applaud the court for its decision, and we thank the restaurant industry for living by the rules.”

My view, as a resident of Westchester County, who usually drops in at Starbucks, Borders, and other cafés outside the city, is that this is an excellent law that makes a real difference... and I see why the restaurants don’t like it.

You see, out here in the blissfully ignorant suburbs, I’m happy to order my coffee with a side of scone. Because a “scone” isn’t like, say, a cookie or a piece of cake. Those are loaded with sugar and fat, and all; but a scone is a healthier alternative. And it dunks nicely into that cup of Joe.

And then, of a weekend, I sometimes wander into Metropolis to go to an art museum, say, or an event sponsored by the New York City Skeptics. When I stop for a coffee then, there are two numbers under that scone, and it’s hard to tell, at first, which one is the price and which the fat+carb index. The latter wins, at well over 450; the price is still less than that.

Here’s the thing: when I see that, when I look at that number, I don’t order the scone. I realize that I don’t want to use around ¼ of my calories for the day that way. And it’s not that I count my calories with any rigour; I don’t. It’s that the number whacks some sense into my head. It makes me realize that getting that scone — or, at various other places, the piece of cheesecake or the tiramisu — is stupid and unnecessary.

And, consequently, it encourages these places to have smaller alternatives. In place of something that could feed the entire tribe wandering through the Sinai, I can get a smaller morsel, something where the cents and the calories are each around, say, 100.

The law works. It doesn’t tell me what I can’t have. It just tells me what I need to know to decide what I really want.

Brain damage in football players

Examinations of the brains of six deceased former National Football League players have shown damage indicating chronic traumatic encephalopathy, a degenerative condition caused by repetitive head trauma:

Using techniques that can be administered only after a patient has died, doctors have now identified C.T.E. in all six N.F.L. veterans between the ages of 36 and 50 who have been tested for the condition, further evidencing the dangers of improperly treated brain trauma in football.

“It’s scary — it’s horribly frightening,” said Randy Grimes, who played center next to McHale on the Buccaneers for several years. “I’ve had my share of concussions, too. More than my share. My wife says I have short-term memory loss. It’s really scary to think of what might be going on up there.”

News flash: getting your head battered about for years... is not good for your brain. Who knew?

Well, actually, technically, we still don’t know. This isn’t a controlled scientific study, and doctors on the NFL payroll remind us of this, and tell us that as far as they know, if your head gets kicked in every few games, there’s no cumulative effect as long as it’s “managed properly” each time.

Now, I’m usually among the first to look critically at incomplete, flawed, or hasty studies, and to question judgments made with insufficient evidence. I often point out when questionable conclusions are drawn from such evidence. And it’s absolutely true that this needs to be studied more in order to be sure of what’s going on.

But there’s another set of points here: the suspected cause is so closely connected to known causes of the condition, the damage is sufficiently severe that quick action is warranted, and a properly controlled study would take too long to carry out and would be ethically questionable. Let’s look at each of those:

1. We know that repeated brain trauma brings on CTE. We know these players are suffering repeated brain trauma. What we don’t know is whether prompt and correct treatment of the individual traumas is enough to ward off long-term damage, as the NFL doctors claim, so we don’t know that the players’ concussions are the cause of their CTE pathology.

   But we’re not talking about wondering whether the players’ diet of, say, more red meat than the average person is what’s causing the encephalopathy. If that were the question, I’d agree that the data don’t support it. We’re talking about a known connection, for which I think the existing data is sufficient cause to take action, pending more study.

2. As Lisa McHale says in the article, “We’re not talking about turf toe — we’re talking about a significant brain injury that has huge implications in terms of people’s health.” The fact that this is addressing a very serious, debilitating, non-reversible condition means that taking action even before studies are completed is warranted.
3. Because the condition develops over many years, and because even after it develops it’s degenerative over many more years, a controlled study would take decades to complete. What’s more, since they can only be sure of what’s happened post mortem, the decades would stretch out into the lifetimes of the studied players. It could well be fifty years or more before a properly controlled study could produce results. And the ethics of leaving players untreated for suspected brain pathology are questionable, to say the least.

Sure, study this more, by all means. But there’s enough evidence here as it stands to require action now, from an ethical point of view, even before further study.

Sunday morning

A SIDS study

The idea of babies dying in their sleep, unexpectedly and without explanation, frightens and horrifies us. Of course, the idea of adults dying that way does too, or should... but when it’s babies, few-month-old bundles of cuteness and love, we find it especially jarring. So we give it a name — SIDS, Sudden Infant Death Syndrome — and we grope for explanations, trying to find out what the problem is and to stop it.

One problem with doing that is, of course, that we’ve just given a name to something vague. We may talk of a SIDS “diagnosis”, but it’s not so in the same sense as “liver cancer”. A diagnosis of SIDS means, “Your baby died, and we don’t know why,” a non-diagnosis, really. We assume that there are enough cases that are from the same cause that we can isolate at least one cause of at least some cases.

But it makes studying it difficult. And, of course, making it more difficult are other factors, such as the relative infrequency of SIDS and the fact that there are serious ethical issues preventing many of the ways medical issues are typically studied.

The result is that the studies we have are anecdotal, and we’re using a trial-and-error approach to it. Or better to call it a trial-and-progress approach, because progress has been made: there was a 56% reduction in the incidence of SIDS between 1992 and 2003.

There’s a recent study, published in the Archives of Pediatrics & Adolescent Medicine that adds itself to the mix. Unfortunately, one needs a subscription to read it, so I have to go by the news articles, which are notoriously spotty on reports of scientific studies. The New York Times says this, for example:

Since 1992 the rate of SIDS deaths has dropped by more than half, to about one death per 2,000 live births from 2.4 per 1,000. The decline is linked to a national “Back to Sleep” campaign that promotes putting babies on their back instead of their stomach, which has been shown to lower the risk of sudden death.

That’s a reduction from .24% to .05%. In what sense is that merely “more than half”? I suspected that it’s an error, and that at least one of the numbers is wrong.

Checking other reports turns up that the Times article tried to normalize the numbers and made an error in the process: it should have said 2.4 per 2000, not 1000. So the correct numbers are .53 SIDS deaths per 1000 live births in 2003, and 1.2 per 1000 in 1992, .053% vs .12% eleven years earlier.

Putting that in other terms, it means that in 1992 the rate was one SIDS death in about 833 live births, and in 2003 it was one in about 1887. We’ll come back to this after looking at what WebMD says about the study:

One theory is that SIDS is caused by the buildup of carbon dioxide when infants with inadequate sleep arousal responses re-breathe exhaled air trapped by bedding or proximity to other sleeping family members.

With this idea in mind, Li and colleagues from the research division of the California-based managed health care group Kaiser Permanente hypothesized that increasing airflow near a sleeping baby would help protect against sudden infant death syndrome.

To test the theory, they interviewed the mothers of 185 babies who died of SIDS in Northern California and Los Angeles County from 1997 to 2000. The average length of time between the SIDS death and the interview was 3.8 months.

The mothers of 312 children matched for age, area of residence, and socioeconomic and ethnic background to the SIDS victims were also interviewed.

Sleeping in a room with an open window was found to reduce the risk of SIDS by 36%, while sleeping with a fan in the room was associated with a 72% reduction in risk.

And the NY Times adds that the benefits of a fan along with the previously identified “safe sleeping environment” are “not statistically significant”, though there’s a 16% reduction in risk. How can that be?

It’s that statement that really points out what the problems with this sort of study are, and where its limitations lie. Let’s go back to the numbers I computed earlier: in 2003 you’d have to look at 1887 live births to statistically expect one SIDS death.

The researchers interviewed parents of 185 SIDS victims in the late 1990s. Even if we assume that the rate of death was 1 in 1000 then (somewhere between the 1992 and 2003 rates), that means we’d need 185,000 live births to expect that many SIDS deaths. If we looked at 18,500 live births, we’d expect to find only 18 deaths — still enough to do statistics on this. With 1,850, two deaths would be against the odds.

But that’s still six times the number of survivors they actually looked at.

If you talk with only 312 parents of living children, even if they had ignored all the “safe sleeping environment” recommendations, even if that group had the 1992 death rate applied to it, you’d only expect a 37.5% probability of a single SIDS death.

That means that things have to be pretty glaring before they have any statistical significance with a sample that small, and even then I wouldn’t call it a “reduction in risk”. At best, we can say that there’s a correlation — but we have to be careful about confusing correlation with cause.

So, should we be running fans in babies’ rooms when they sleep? Sure, it seems harmless and there’s some small indication that it might help. Mostly, it needs more study, but the only way to study it is to recommend it, have parents do it widely for a few years, and then see what happens to the SIDS rate by, say, 2011.

We’ll get there... but until we can actually confirm causes of this, it’s going to remain difficult to study and hit-and-miss to prevent.