unsportsmanlike conduct

I'm definitely a sports statistics junkie. Maybe this comes from my dad's penchant for setting all the computer passwords in the house to famous baseball players' batting averages. Maybe this comes from my complete inability to perform well at sports, so instead I revel in unimportant factoids.

Either way, I found a story the other day that united my love for sports statistics with health politics. In a survey conducted by National Media, Inc. (conflict of interest possible red flag: this company's a GOP strategy firm), researchers looked at political affiliation of different sports viewers. Check it out:



The researchers also included information about voter turnout and size of viewership for each sport. So for example, while WNBA watchers are the most liberal, they only have a moderate turnout and have a pretty small fan base. Men's golf fans are the most conservative, and although the viewership isn't huge, their voter turnout is easily the highest. And as you might have guessed, overall, sportsfans are mostly republican.

It may not be immediately clear why a GOP strategy firm gives a hoot about the political agenda of sports fans. But here's why: Sports are on TV. Political strategists spend a lot of money on TV ads trying to convince people to vote for so-and-so, to vote against such-and-such issue, etc. With this data, republicans know not to waste their money on buying TV time during WNBA games (although I don't imagine such advertising to cost very much...). Democrats might steer clear of advertising during NASCAR if they can interest more pro tennis viewers.

Now think back to about a month ago, when insurance lobbyists were vehemently advertising against the health reform bill - and community advocates were equally vehement about rallying support for it. All in all, groups on both sides of the issue combined spent well over $200 million in television ads. Even though the people who see these ads during their beloved sports matchups weren't actually the ones who voted on the legislation, you can bet that a good number of them called their Congressmen and Congresswomen after seeing these ads to voice their opinion. And you can bet these ads are going to have an influence on the outcome of the midterm elections in November.

My guess is that we're going to be seeing a lot of political ads this coming September/October/November - certainly not as many as for the presidential race, but probably a good amount will be aired since both House and Senate seats are up for grabs. Even though the bill has been signed into law, many republicans have plans to repeal and debate many of its specific provisions. (But interestingly, even people who were against the bill disapprove of state attorneys general trying to repeal it in court.) GOP strategists will try to make ads that say Congress is too politically lopsided, and that we need more republicans in both chambers. Democratic strategists will try to paint the congress members who voted for the bill as champions who had a role in a historically important reform law. Either way, I can tell you now, the ads are going to be as notoriously rampant and misleading and annoying as ever.

(Speaking of annoying political ads, remember Tim Tebow's terrible pro-life ad during the Super Bowl? GAG. I'd take an angry commercial from Pharma over this any day. Any. Day.)



Everyone should pity us fans of fall sports, for we will certainly be subjected to myriadvertisements. (Play on words alert!) Us poor football fans, especially those living in states whose Congress members voted for health care reform, are probably going to be seeing a lot of attack ad spots against the incumbent democratic official. MLB fans, whose season will be wrapping up just in time for elections, will probably see a good amount of ads from both sides during the playoffs and the World Series; baseball fans are slightly republican, but middle-of-the-road enough for both sides to battle it out during the commercial breaks.

Yes, polticial advertisements can be a great way to engage people in politics, to make them aware of important issues, to share a candidate's views. But most of the time they're filled with half-truths that only obscure the political process. And the voices we hear the most are typically the ones with the most extreme opinions and the ones with the most money. So come fall sports season, I have but two wishes: (1) The Nebraska Cornhuskers will be Big 12 champs and will get to play in a BCS game for the first time since '02, and (2) The ads we all see will be politically honest, fair and informative. And since Nebraska's losing its star DT to the NFL, and since American politics aren't going to be overhauled any time soon, both are unfortunately unlikely.

Ronald McDonald: public health ne'er-do-well, or harmless spokesclown?

Fast food companies are having a rough couple of years. The bad economy took a toll on revenues for almost every major chain. Books like Fast Food Nation and the documentariesSuper Size Me and Food, Inc. have surely been a P.R. nightmare. The recent health reform legislation includes a federal mandate for all chain restaurants to post nutritional information for regular menu items in highly visible spots on the menuboard. (Fun fact: I heard a story on NPR that Starbucks customers had "sticker shock" after learning that their beloved Frappucino had well over 500 calories. In response, Starbucks switched the recipe from whole milk to 2%.)

Rough, right? Well, the hits just keep on coming. Apparently, the advocacy group Corporate Accountability International has called for McDonald's to retire their cartoon spokesclown Ronald McDonald. They say Ronald is a marketing ploy to get kids to eat unhealthy food - and in light of the childhood obesity epidemic, it's unethical for McDonald's to continue to use him to sell Happy Meals. The group held a retirement party in McDonald's homestate of Illinois, and sent "Happy Retirement" cards to McDonald's restaurants all around Chicago.

I wouldn't take this group's efforts too lightly - CAI is kind of a big deal. They're the ones who stomped cigarette spokes-ungulus Joe Camel out of the advertising world. And even though many first believed that a cartoon was harmless, the public ended up siding with CAI's anti-Joe stance. Most now agree that a company that uses a kid-friendly cartoon as a marketing mascot is, intentionally or unintentionally, marketing their products to children. And marketing to children is a real ethical minefield.

So is Ronald McDonald on the same playing field as that malicious dromedary Joe?

Economically, yes. I just read a study that said the national health costs of obesity are about the same as the national health costs of smoking - both hovering around $50 billion per year in medical expenditures.

Magnitudinally, yes. For children between the ages of 2 and 19, 17% are obese. For youth ages 11 to 19, 9% are "established" smokers.

Behaviorally, yes. A recent study published in Nature Neuroscience reports that, like drugs and alcohol and cigarettes, high-fat, high-calorie food is addictive.

When you really think about it, the advocacy group CAI isn't making a real stretch here. Like cigarettes, fast food causes loads of downstream health costs; obesity is much more prevalent than youth smoking; and on top of that, like nicotine, fast food is addictive. Many people say, "One happy meal isn't going to kill you." Well, one cigarette isn't either. It's the fact that people who regularly consume fast food are less able to control their urge to eat (much like people who regularly use cigarettes can't control their urge to smoke). And this is what worries Corporate Accountability International.

McDonald's counters these arguments with two key points. One, Ronald is the spokesperson for the Ronald McDonald House, a very active charity organization. They don't want to lose that branded imagery, which makes sense. Two, they say Ronald is, in fact, an advocate for making good choices and for being physically active and for having good meals with family. (I think this second argument is just one of those things spokespeople say because there's no way to refute this. Yeah, in '05 they "slimmed down" Ronald to say he promotes an active lifestyle. But I'm not sure he could have possibly achieved this on a McDonald's diet alone ... he had to have been cheating on his Big Macs with a Subway sandwich.)

I don't think McDonald's has to send poor Ron off to retirement. I think they just need to use him more as a role model for children to make smart choices - and that means making Happy Meals that are actually nutritious. Apples instead of fries. Grilled chicken sandwiches instead of processed chicken nuggets. Milk - plain milk, not flavored and loaded with sugar - instead of soda. Let Ronald show how much he loves vegetables.

CAI has a point that I think we should make sure McDonald's takes seriously. The analogy between the health effects of the cigarettes Joe Camel peddled and the junk that Ronald sells is hard to deny. Sure, keep Ronald around, but make him serve as a role model for making healthy eating choices. The childhood obesity epidemic is only going to continue to grow if big players like McDonald's don't start thinking creatively about how to change the food environment for consumers and their Happy Mealers.

(Well hey, if nothing else, at least we can sleep soundly knowing that they retired the posse from McDonaldland years ago. I'm not sleeping better because of the lessened threat to childhood obesity - I'm sleeping better because these characters are creeeeepy. *Shudder*)

nudge to eliminate pudge

I just finished the book Nudge: Improving Decisions About Health, Wealth, and Happiness, written by economics professor Richard Thaler and law professor Cass Sunstein, both of the University of Chicago. Lovers of Freakonomics or Blink will definitely appreciate Thaler and Sunstein's look into the field of behavioral economics. In one sentence, Nudge is about why people make the decisions they make and how policy can "nudge" people into making better choices.

I realized that the ideas in this book are the theoretical basis for many disease prevention government public health programs. These programs are attempts to improve "choice architecture" - that is, many public health initiatives attempt to redesign the context in which people make choices about their health behaviors in order to improve the chances that people will make the most healthy choice possible (while still giving people freedom of options).

Here's one of Thaler & Sunstein's examples of "nudges":

"[Nudging] is a relatively weak, soft and nonintrusive type of paternalism because choices are not blocked, fenced off, or significantly burdened. If people want to smoke cigarettes, to eat a lot of candy, to choose an unsuitable health care plan, or to fail to save for retirement, libertarian paternalists will not force them to do otherwise - or even make things hard for them. ... [Libertarian paternalists] are self-consciously attempting to move people in directions that will make their lives better. They nudge." (pg 11-12)

I can't stress enough how great this framework can be for public health professionals. We don't want to force people to make a certain health choice - we want to make it easier for people to make good choices, we want to provide incentives for people to make these types of choices, we want people to have as few barriers as possible. What we don't want to do is penalize those who make "the wrong" choices, because taking away someone's choices to behave as they wish infringes on personal liberties.

How about a more concrete example of public health "nudging"?

Like every other man and woman in America, I absolutely adore Michelle Obama. She's young, beautiful, and smart as hell. And, like many of the First Ladies before her, she has taken a national-level role in promoting a cause: encouraging Americans to improve nutrition and increase physical activity. Last week she spoke at the Grocery Manufacturer's Association, calling for major food manufacturers like ConAgra, Kraft & General Mills to reinvent the products that they sell in grocery stores - especially those products that are marketed toward children.

Michelle is asking these food producers to chance the choice architecture for people who shop in grocery stores and restaurants, especially for parents shopping for their kids. Children are drawn to food that's marketed to them during youth television programming, or that's marketed to them by colorful, cartoon packaging. But the food kids gravitate toward are *overwhelmingly* some of the most unhealthy food in the store. Margo Wootan, of the non-profit Center for Science in the Public Interest in Washington, said, "If companies were marketing bananas and broccoli, we wouldn't be concerned. But most marketing is for sugary cereals, fast food, snack food and candy."

The idea here is that childhood obesity has become such a national epidemic because of the availability and affordability of unhealthy food that children want to eat. Michelle is, first, trying to encourage these manufacturers put less salt, fat and sugar in the food marketed to children. Secondly, Michelle is calling for these companies to make labels less confusing for the average shopper - many foods with the word "healthy" on the box aren't. Hopefully, the changes for which Michelle is advocating will (1) make children want to eat food that's better for them, and (2) make it easier for parents to pick out and purchase the healthy food options.

There's an important but subtle point in all of this. Michelle is not trying to ban unhealthy food. People can still go to the grocery store and buy their kids donuts if they wish. But if healthy food is marketed to children, and parents can easily understand the nutritional value of the food they're purchasing, they just might be persuaded to put the donuts back and buy some fruit instead. No options are being eliminated - certain options are simply being nudged.

From start to finish of the book, I began to look at public health news with these "nudge" concepts. I think this book could be incredibly important for professionals and students in this field, because it made me understand from a theory-based perspective how public health programs should influence behaviors: through conscious structuring of a people's choice architecture to "nudge" them towards healthy decision-making. Loved the book. And I think anyone in a policy role (or aspiring to be in one) should give it a read.

(And a special shoutout to Brian Merry, second-year public health student, who let me borrow Nudge. Sorry about the coffee stains in Part IV ... turbulence + coffee from the flight attendant = minor spillage.)

reducing your carbon footprint? don't drink outside the box

As if wine needs another reason for us to love it, here's one more: Boxed wine is good for the environment.

This week's New York Times wine blog rekindled my love for all things boxed wine - it's cheaper, it stays fresh longer, and despite the reputation of Franzia and other similarly low-quality wines, there is actually a pretty good selection of high-quality wines that just happen to have bag-in-box packaging. There's a box of cheap sangria in my fridge right now, and it brings me great happiness - it may not be Moet et Chandon, but it's palatable both financially and gustatorily. As one blogger puts it, "Boxed wine may be short on charm, but it is long on practicality." Pretty much the only reason bottled-and-corked wine is so popular today is because of the perception that these wines are finer. Glass packaging may actually be bad for the product - glass allows light through which may degrade the wine, and the cork can seep into the liquid which can taint the flavor.

But my favorite pro-box argument is that boxed wines have a smaller carbon footprint that bottled wines. How exactly, do you ask? Through three main routes:

(1) Less gasoline emissions due to cheaper transportation. Boxed wines weigh less per liter of liquid than bottled wines (cardboard is lighter than glass). Also, greater quantities of boxed wine can fit in cargo areas due to their rectangular and easily-stackable shape, whereas bottled wine is fragile and oddly-shaped, making it difficult to ship. More wine for less gas means fewer carbon footprints!

(2) Cardboard and glass are both recyclable - but it is oftentimes more difficult to locate glass recycling facilities. Also, neighborhood recycling collectors sometimes won't pick up glass because it's too dangerous for the collectors. Cardboard, in most cases, is easier to deal with recycling-wise.

(3) When you open a bottle of wine, you have to finish it within about 48 hours. When you open a box, you've got at least a month. People are more likely to toss out day-old bottled wine due to spoilage - thus, boxed wine can reduces burden created by waste.

Let's not forget that boxes and bottles both contain wine - and while the product may not be identical in flavor, their ingredients are pretty similar. And the health-promoting effects of these ingredients are pretty well-publicized, when consumed in moderation. Because boxed wines are generally less expensive, this allows a greater number of people - of a greater range of income - to benefit.

Boxes do have their environmental drawbacks - the plastic bag inside the boxes is usually not recyclable, and more labor is needed to assemble these boxes (which corresponds with greater manufacturing emissions). But these are tradeoffs which, in the long run, may not outweigh the pro-box arguments.

So would it really be so outrageous to suggest that policymakers subsidize American wine manufacturers who box their wines? In a few years, America will probably be the biggest wine producer in the world, so it's important to think about how this global industry operates. We're trying to be a more environmentally responsible nation, and if there were incentives to try and change the perception of boxed wines, more wineries would box better-quality wines, quality sellers would keep more boxed wines in stock, and more consumers would switch to this packaging style. A decade or so ago nobody with class would even dream of drinking beer out of a can - but breweries knew it was an easier format to ship, and aluminum was easier to recycle. Eventually people came to allow cans to be an acceptable packaging (even New Belgium's Fat Tire is now sold in cans!). Maybe the boxed wine revolution needs a little subsidizing - or just a subtle policy push - in order to get rolling.

Oh, and technically, the most environmentally prudent way to consume wine would be to have your own glass jug and fill it up yourself at local wineries. No cross-country transportation, reusable container, and support of the local business economy. While it's a great idea, not everyone lives near a winery, and I'm not even positive if the owners allow this kind of transaction. I've personally filled up a growler at Lazlo's, a local microbrewery back in Nebraska. Maybe I'll try my luck with the jug at Bishop's down the road.) But it's how many families get their wine in France, and maybe U.S. wineries can accommodate (or at least publicize that they accommodate!) this technique soon.

the ugly side of snow days

The issue: School closings and snow days

The vocab: Snow days are usually perceived as fun and as a respite from the daily school grind - but for some kids who rely on the school's resources, snow days aren't so quaint

The Northeast has been battling record snowfall for the past two weeks - hundreds of flights were cancelled, car accidents abounded, and almost every school from Virginia to Maine was closed for days. (Well, except for Yale, which hasn't declared a snow day in more than 30 years.)

One thing a lot of us don't think about is the public health trade-off schools make when declaring snow days. School is usually cancelled in the name of student and staff safety - that is, fewer automobile/bus accidents and less exposure to dangerously low temperatures. But there are health risks associated with not being in school, too.

Besides the inconvenience to parents who have to find a last-second babysitter, and besides the inconvenience to teachers whose lesson plans are disrupted, there are negative effects that students must face if school is cancelled. As discussed in stories from both MSNBC and the Newark Advocate, many elementary, middle and high school students rely on free breakfast and free/reduced-price lunch - and their family may not be prepared to provide these meals when their children are unexpectedly home for a few extra meals.

Here in New Haven, most schools were closed at least two days these past couple of weeks. And most of the schools in town have about 60% of their students on the free and reduced-price lunch program. While schools often have a bad rep for the quality of their cafeteria lunch menus, this may actually be the most nutritious meal some kids get that day. In order for a school to participate in the program and receive subsidies from the Federal government, cafeteria food must meet certain nutritional guidelines - with limits on calories and fat, and requirements for vitamin content.

So what can families do when they unexpectedly have another mouth (or so) to feed? In Philadelphia and D.C., where schools were apparently only open one day all of last week, food pantries were either (1) closed due to the inclement weather or (2) running low on food because of the unusually high demand.

Some school administrators in Evansville, Indiana - a midwest town that's no stranger to frequent winter school closings - started a pilot program last week, where kids who were brave enough to trek to one of two local schools could still get a free lunch. (It's unclear whether they had to be eligible for the federal free/reduced-price lunch program, or if just anyone under 18 could roll in.) If a State of Emergency is declared in the city this back-up program would close as well. But when school is closed for several days straight, chances are the city won't be in a snow emergency the entire time - and due to the efforts of this school district kids will have at greater access to nutritious meals in otherwise tough times. And it does put kids at risk - if the weather's bad enough to close schools, it's probably at least mildly perilous to get to school to take advantage of the program. But at least it's a resource that families can use if food options are running low.

Snow days should be fun - it shouldn't be a stressful time where parents have to worry if they're going to be able to feed their kids. The government already has a free/reduced-price lunch program for eligible kids to use during the summer - they should maybe expand this they way schools in Evansville did, so on unexpected closures kids can have access to nutritious food ... and then go play in the snow like kids should be doing!

[And now for your non-public health side note ... while googling Connecticut cafeteria policy, I came across a story about a 55-year-old cafeteria worker in Danbury who got put in jail after getting in a food fight with a fifth-grader. God Bless Connecticut.]

olympians' most dreaded foes: cold and flu

The issue: Olympians' health while competing in Vancouver this month.
The vocab: Banned performance-enhancing substances ... in the International Olympics Committee's eyes, cold and flu medications are equivalent to doping.

The Olympics are always wrought with controversy over alegations of performance-enhancing substance abuse. While the summer games tend to have higher rates of offenders, the winter games aren't immune from illegal performance enhancement. In Turin's 2006 games only one athlete was busted for using a banned substance. But back in 2002 when Salt Lake City was host, seven competitors were caught - including four medalists, all of whom had to forfeit their prizes.

The International Olympic Committee surely prides itself on rigorously ensuring fair competition through frequent testing and harsh consequences.

But has anyone thought about the negative side effects of such stringent substance bans on the athletes in Vancouver this month?



The New York Times came out with a story today about Olympians' battles with their harshest competitors - The Common Cold and The Flu. Athletes have the triple whammy that increases their susceptibility to illness:

1. Being around millions of people, and being in close quarters with fellow athletes in Olympic Village, increases the chance of transmission.
   
2. Intense physical activity suppresses the immune system, decreasing the body's ability to fight off cold and flu.


3. Athletes aren't allowed to take many of the everday cold and flu meds because of the IOC's strict rules against banned substances. Some cold and flu remedies contain stimulants just like the ones in banned amphetamines - in smaller doses, yes, but still detectable via routine drug testing.

Dr. P. Gunnar Brolinson is a team physician at the Vancouver games, and is the author of a 2007 article published in Clinics in Sports Medicine about the immune-suppressing effects of rigorous exercise. In the NYT article, Brolinson says, "The biggest reason for poor performance at an internation, multisport games is a respiratory infection."

So what we have here is a public health tradeoff - do the risks of acquiring a cold or a flu outweigh the risks of allowing these medications?

Until drug testing becomes sophisticated enough to distinguish between a small dose of cold/flu medicine and a true banned substance, Olympians will have to deal with the regulations by becoming more proactive in preventing illness. Vancouver is literally giving away flu vaccines. Over 40% of the city's residents have been vaccinated, and the Canadian Olympians have set a stellar example for their colleagues, with more than 80% of the Canadian team receiving vaccines throughout the flu season. And I suppose you could go one step further like U.S. cross-country skier James Southam, who admitted to carrying a hospital mask in his carry-on bags just in case one of his co-riders was looking under the weather. But recall the reports from the beginning of the swine flu epidemic: there's doubt that hospital masks protect casual wearers all that much. (Plus it makes you look like a massive dork.)

And what if, despite preventive efforts, a cold or flu begins to emerge?

Old school remedies are the answer, in this case. Lozenges, ibuprofen and antibiotics (if necessary) are perfectly fine. Some Olympians are actually spokesmen for anti-cold remedies - U.S. speedskater (and much hunkier without his ridiculous soul patch) Apolo Ohno has an ad for DayQuil/NyQuil. Both of which are allowed by the IOC.



While it may be tricky for athletes to stay cold- and flu-free during the Vancouver games, the winner of the public health tradeoff is clear: The IOC would much rather risk athletes getting sick than risk allowing athletes an unfair competitive advantage.



[An aside... Chuck Klosterman wrote a fairly famed essay about the Olympics back in 2004 for Esquire magazine. Not public health related, sadly. But as always with this guy, it's a fascinatingly convoluded and hilarious read.]

avatar & james cameron's (inadvertent?) health policy commentary

The issue: James Cameron's interpretation of the future of healthcare

The vocab: Health insurance coverage for veterans

So I finally got around to seeing Avatar. And yes, it was visually stunning and a technical masterpiece and so on. I'll let the reviewers and The Academy do the fawning - for there is health policy subtext to be analyzed.

The protagonist is Jake Sully, a former Marine who was paralyzed from the waist down (which is presumably a war injury). Jake had agreed to travel to the distant planet Pandora and gather information on Pandora's indigenous people for the U.S. military unit stationed there - in return for his intel, the unit's Colonel promised to pay for spinal surgery that would enable Jake to use his legs again. Being the good public health student (read: dork) that I am, I turned to my friend sitting next to me and exclaimed:

"So James Cameron is saying that in 150 years, even though the technology had been invented to reverse paralysis, an injured war vet doesn't get enough health insurance coverage for spinal surgery???"

OK, yeah, the point of the movie is to blow you away with the visuals and submerge you in the blatant environmental commentary - but I got preoccupied for a while with this insurance coverage bit. But then I realized, I don't actually know what the current state of health coverage is for those on active duty and veterans.

When someone is on active duty, they receive insurance through the Military Health System. Those who are honorably discharged are then shuffled over to Veteran's Affairs insurance (or to their employer's or private insurance, if they opt). According to the Veteran's Affairs benefits site, there are two types of benefits: ones for service-connected disabilities (i.e., those that occurred during active duty), and ones for nonservice-connected disabilities. Sully was a victim of the former. He'd definitely be getting some monthly compensation, somewhere between $123 and $2,673, depending on what his "level of disability" was assessed to be. But I can't figure out from the VA's website if his insurance would cover expensive spinal surgery several years after the injury was suffered.

I suppose that's an interesting weakness to point out in and of itself - it's pretty impossible for the average person to easily scroll through veterans' benefits package and actually understand what to expect. For example, the site states that veterans receive a monthly stipend based on percent disability, but it doesn't explain (or link to a site that explains) how percent disability is determined. Part of the Senate's proposed health bill calls for the creation of an Internet site that clearly lists healthcare options and comparisons of benefits packages. Maybe the VA should set an example.

Speaking of health reform, let's look into how the recent healthcare overhaul talks could affect veterans - are we dooming our nation's future vets to unaffordable healthcare services and inadequate coverage for vets with service-related disability? Are we setting the stage for Jake Sully's predicament?

Probably not. First of all, I'd like to think that if doctors in the future are able to reverse paralysis, the VA would be extremely eager to help vets with war injuries (and I'd bet that taxpayers would gladly help share the costs). And secondly, according to The White House Blog, Obama's 2010 budget includes "the largest single-year increase in funding for the Department of Veterans Affairs in three decades, and significantly expands coverage, extending care to 500,000 more veterans who were previously excluded."

So do I buy James Cameron's depiction of a future where a disabled war veteran can't get paralysis-reversing surgery?? Nah. I don't think Congress or taxpayers would stand for it. And I don't think the VA will ever shrink the benefits package - it can really only grow. While the movie is grounded in fantasy and science fiction and imagination, it's simply not believable that Jake Sully wouldn't have health coverage in a non-Cameronsian (read: possible) future.