Questions for Jeffrey Sachs

March 31, 2014

On Econtalk, Russ Roberts recently interviewed Jeffrey Sachs, author of The End of Poverty and head of the Millennium Village Project (MVP). I enjoyed it but thought Roberts was too easy on Sachs. Here’s what I wished he had asked:

Your book, The End of Poverty — did you get anything wrong?

What mistakes have you made with MVP?

You say Nina Munk [author of The Idealist] chose a non-representative village. [Sachs said that Munk spent her time in the only village in "a war zone."] Did you tell her that? If not, why not?

Munk was on your side when she began reporting, but changed her mind. Why is that?

Why was the project set up in such a way that evaluation is difficult? Why not pick ten villages and randomly select five for treatment?

You say the MVP project is successful because people are copying it — but those people are government officials. Is it plausible they are copying it because they see it as a good way to make money for themselves or improve their career? You must know many worthless medical treatments have been widely copied. Is this your best evidence of success?

No doubt your employees have often told you what you wanted to hear rather than the truth. What’s an example? What have you done to get honest assessments of how things are going?

What did you learn from Nina Munk’s book?

Roberts says he didn’t ask Sachs certain questions because there wasn’t enough time.

More Cereal Fiber, Much Less Heart Disease

March 30, 2014

In Vitamin D and Cholesterol: The Importance of the Sun (2009) by David Grimes, an excellent book, I came across a 1977 study of healthy middle-aged men. The researchers measured their diet and watched them from 1966 to 1976. The question: What diets were associated with better health? There turned out to be associations with cholesterol (lower better) and systolic blood pressure (lower better), but these were less interesting than two strong dietary associations. One was between energy intake and heart disease. Men in the lowest third of energy intake had 23 cases of heart disease; men in the highest third had 7 cases. That’s probably due to exercise: the more you exercise the more you eat. We already know exercise is good.

The other association was with cereal fiber. Men in the lowest third of consumption (2-7 g/day) had 25 cases of heart disease; men in the highest third (8-34 g/day) had 5 cases. (A Wasa cracker has about 2 g cereal fiber.) You might dismiss this as healthy-person bias: healthy people do many healthy things, such as eat fiber. However, there was no association of heart disease and fiber from fruit and nuts. They’re healthy too. “The advantage of a diet high in cereal fibre cannot be explained [by us],” said the authors.

Later studies have found the same thing. For example, a 2006 review reached a similar conclusion: “There is an increasing body of evidence, including that from prospective population studies and epidemiological observational studies, suggesting a strong inverse relationship between increased consumption of wholegrain foods and reduced risk of CVD.” A study of health-conscious people — to reduce healthy-person bias — found a similar association: “Persons who habitually ate wholemeal bread had a lower mortality from cerebrovascular disease.” A 2002 review and a 2013 review provide even more evidence for the association.

Shant Mesrobian has emphasized the importance of fiber for health. Whereas paleo gurus usually say grains are bad. Here, for example, are “10 reasons to avoid grains”.

Teaching Histology: Lessons for Other Teaching?

March 29, 2014

Edward Edmonds is an histologist at the Albany Stratton VA Medical Center, Albany, New York. He has been an histologist since 2002. Previously he worked at the Landstuhl Regional Medical Center, Landstuhl, Germany, the Ehrling Bergquist Hospital Offutt AFB, Nebraska, and the Armed Forces Institute of Pathology (now Joint Pathology Center), Washington D.C.

Recently he left an interesting comment on this blog: Read the rest of this entry »

Larger Lesson of “We Were Wrong about Saturated Fat”

March 28, 2014

My sister sent me a link to an article (“Butter is Back”) by Mark Bittman, the New York Times food columnist, about a recent review that found saturated fat didn’t cause heart disease. I told my sister I had clicked on the link but had forgotten to read the article.

My sister was incredulous. How could you not want to say “I told you so”? she wondered. (In a 2010 talk I questioned the danger of butter.)

Here is the relevant passage, according to my sister:

A meta-analysis published in the journal Annals of Internal Medicine found that there’s just no evidence to support the notion that saturated fat increases the risk of heart disease. (In fact, there’s some evidence that a lack of saturated fat may be damaging.) The researchers looked at 72 different studies.

I told you so. But this part interests me more:

No study is perfect and few are definitive. But the real villains in our diet — sugar and ultra-processed foods — are becoming increasingly apparent.

Uh-huh. The experts were staggeringly wrong about saturated fat…but they couldn’t possibly be wrong about “sugar and ultra-processed foods”. That makes no sense, but that’s what Bittman wrote (“increasingly apparent”). To me, what is increasingly apparent is that nutrition experts shouldn’t be trusted.

I don’t know what “ultra-processed foods” are but I am beginning to believe the experts are utterly wrong about sugar, too. As far as I can tell, sugar in the evening improves sleep — by a lot, if you get the details right — and nothing is more important than good sleep. If you have read The Shangri-La Diet, you already know that sugar alone cannot have caused the obesity epidemic. It is more complicated than that.

Assorted Links

March 27, 2014

Thanks to Alex Chernavsky.

“Why Fuss About Paleo Life?”

March 26, 2014

dearime asks:

Why do people fuss so much about paleo life? The population has grown so much since that it’s easy to believe that we’ve evolved a long way from then.

Jared Diamond wrote a paper about rapid evolution on an isolated island. When modern (factory) food was introduced to the island (in the 1940s?), there was a very high rate of diabetes, presumably due to the new food. Since then, the rate of diabetes on the island has gone way down, although they still eat modern food. Diamond took this to be due to evolution (people with diabetes-resistant genes had more offspring), supporting dearime’s point of view.

After the first Ancestral Health Symposium, Melissa McEwen commented how unhealthy many of the top people looked. On the other hand, Tucker Max commented how healthy the attendees looked in general. I agree with both observations. A paradox.

When I was an assistant professor, and wanted to sleep better, I believed wondering about paleo life was unhelpful because (a) we knew so little about it and (b) it must have differed in thousands of ways from modern life. Should I spend an hour trying to find out about paleo life and/or what paleo gurus recommend for bad sleep? Or should I spend an hour trying to find out how ordinary people have improved their sleep? My answer was the latter. I ignored paleo life.

Looking into how ordinary people improved their sleep did help. I eventually reached a non-trivial conclusion: Eating breakfast made my sleep worse. No paleo guru had said that — I had been right to ignore them. Yet it made evolutionary sense. Cavemen did not eat breakfast, I was pretty sure. (No refrigerators.) After that I paid more attention to what evolutionary thinking would suggest. This led to several discoveries: the effect of faces in the morning on mood, the effect of standing on sleep, and the Shangri-La Diet. It is incredibly hard to discover big new experimental effects (such as the effect of morning faces), especially in fields you know little about (my specialty in psychology was animal learning, not mood, sleep or weight control). I was impressed.

The effect of bedtime honey (more generally sweets in the evening) on sleep emphasizes the paradox or puzzle or whatever you call it. I found out about the honey effect by paying attention to what works. No paleo involved. Stuart King told me it improved his sleep. Here are three reasons to look at ordinary experience and avoid paleo theorists: 1. It turned out to help. 2. It’s a huge effect and very easy. 3. Paleo theorists have said the opposite: avoid carbs, avoid sugar. If you followed their advice, you would do the opposite of what helped Stuart and me. On the other hand, I increased my belief in the effect because it made evolutionary sense: 1. It makes sense of why we like sweets. 2. It makes sense of why our liking for sweets goes down when we are hungry (surely due to an evolved mechanism). 3. It makes sense of why we eat sweets more in the evening (presumably due to an evolved mechanism that makes sweets taste better in the evening).

The short answer to dearime’s question is that, in my experience, it is incredibly hard to learn anything about health. There are so many possibilities and evolutionary thinking helps choose among them — decide which to take the trouble to test.

Treat Everyone As Smart, Capable and Motivated?

March 25, 2014

A Vancouver drug center has started an unusual program: alcoholics bottle homemade beer.

The Drug Users Resource Centre, the Downtown Eastside non-profit famous for housing Canada’s first crack pipe vending machine, is also behind what may well be North America’s first program teaching severe alcoholics how to brew their own beer and wine.

Now the alcoholics just do bottling but the people behind the program intend to expand it to include other parts of the beer-making process, such as fermentation.

What’s interesting is that they are not treating severe alcoholics as passive or disabled — as recipients of treatment. At least not entirely.

This program reminds me of several things. Geel, a town in Belgium, treats people with mental illness as valued caregivers. Zeynep Ton says low-level retail employees should be treated as people who can learn many jobs, give good advice to both customers and management, make good use of free time, and so on. I treat my students as people who want to learn — who do not need to be scared into learning by threat of a bad grade — and are capable of inventing their own assignments.

Is there a general lesson to be drawn from these examples? (All are complicated, in spite of brief descriptions.) Could it be a good idea — as a default — to treat those you deal with as smart, capable and motivated? It is no great leap to treat alcoholics as motivated to make beer but it is a slight leap to treat them as capable of making beer. Is the next step is to treat them as smart?

What if doctors, before they saw a patient, told them: Please search the Internet for possible remedies. Bring a list of the ones you want to consider to our meeting. Is that crazy? The slightly subtle point is this may make the doctor happier.







Why Do Sweet Foods Taste Good? The Importance of a Simple Observation

March 23, 2014

Stuart King writes:

I was very hungry today at dinner and the thought of sweet food wasn’t appealing at all, but after filling up on some rice, chicken and coconut cream curry I immediately had ice cream and chocolate slice [= what Americans call a brownie], which had had no appeal 15 minutes or so before!

An everyday observation that anyone can make. Studies have shown what Stuart noticed: When you are hungry sweet foods are unappealing. This is why dessert is eaten after the rest of the meal.

The main way that psychologists explain an experimental effect — choose between explanations — is by finding out what makes the effect larger or smaller. For example, discovery of what makes learning more or less (what increases or decreases the effect of one learning trial) is the main way psychologists have chosen among different theories of learning. Different theories predict different interactions.

Why do we like sweet foods? The usual answers are that sweet foods are a “good source of energy” and they provide “quick energy”. But these explanations do nothing to explain what Stuart noticed. If sugar is a good (= better than average) source of energy, we should eat it before other foods (average sources of energy) when we are hungry (hunger signals lack of energy). The opposite is true. You may not want to call it a “contradiction” but there is no doubt the conventional view does not explain what Stuart noticed. Of course many nutrition experts, such as Weston Price, are/were entirely sure sugar is unhealthy.

As a tool for choosing among theories, Stuart’s observation is especially good because (a) it is very large (sweets go from unappealing to appealing) and (b) paradoxical (eating calories should make all calorie sources less appealing).

If you have been reading this blog, you know I explain Stuart’s observation by assuming that we need sugar in the evening to sleep well. Sugar (sucrose, fructose, glucose) eaten in the evening increases blood glucose, which increases glycogen. During sleep, glycogen becomes glucose, which the brain needs to work properly. Evolution shaped us to like sweet foods after a meal so that we will eat them closer to when we sleep. (The value of replenishing glycogen close to bedtime also explains why we eat sweet foods after dinner more than after breakfast or lunch.)

I can’t think of another case where what experts say is so out of line with what’s easily observed. For example, I’m sure cholesterol doesn’t cause heart disease, but there is no everyday observation that supports my belief.

I can’t think of another case where what experts say is so out of line with what’s easily observed. For example, I’m sure cholesterol doesn’t cause heart disease, but there is no everyday observation that supports my belief.

If sugar is helpful for sleep, why is it associated with diabetes? My guess is that sugar is almost always consumed in foods that taste exactly the same each time — what in The Shangri-La Diet I called ditto foods. For example, soft drinks. Ditto foods with sugar, because they have a strong precise CS (smell) and a strong fast US (calorie signal), produce an especially strong smell-calorie association. Such an association raises the body fat set point, thus causing obesity. Obesity causes diabetes. It’s also possible that eating sugar during the day — at the wrong time — hurts sleep. Maybe sugar during the day raises insulin and thus reduces the conversion of sugar to glycogen. Less glycogen causes bad sleep, bad sleep causes diabetes. My blood sugar levels clearly improved when I started eating sweets in the evening — opposite to what the sugar-diabetes link would predict.

Assorted Links

March 22, 2014

Thanks to Casey Manion.

Assorted Links

March 21, 2014

Thanks to Melody McLaren.

Cheap Accurate Home HbA1c Test

March 20, 2014

Walmart sells a kit for home measurement of HbA1c (brand name ReliOn) that costs $9 and provides results by email. It’s sold only at Walmart. I have been paying $30 for the same measurement at a test center (about 30 minutes away). If you use insurance, copay might be $15. Without insurance, a doctor’s office test might cost $90. The reviews suggest the test has roughly the same variability and average as a lab test. A few people had trouble getting enough blood on the dots but at $9 there is plenty of room for repeat testing.

My blood sugar improved when I started to walk an hour per day and when I started intermittent fasting (eating about half as much as usual every other day). I noticed the effects with blood sugar tests but frequent HbA1c tests (say, once/week) would have been much better.

Diabetes has become an enormous problem in China, where 10% of adults have Type 2 diabetes, roughly the same as in America. Americans often think obesity causes diabetes but this doesn’t explain why smoking — which makes people thinner — is associated with diabetes. People get diabetes who don’t smoke and aren’t fat. Whether anyone who walks an hour/day gets diabetes is less clear.

Thanks to Shant Mesrobian.

Truth to Power: Eric Lander’s Reddit AMA

March 19, 2014

A year ago, Eric Lander, who identified himself as “President and Founding Director of the Broad Institute of Harvard and MIT [and] one of the principal leaders of the Human Genome Project, directing the largest center in the international project” did a Reddit AMA (Ask Me Anything). One of the questions did not go as expected:

Question As an advisor to the President, what is being done or do you think will be done to increase the attractiveness of students finishing PhD programs in science?

Lander We need to shorten the time for getting a PhD and for a first faculty job. Young people should get out into the scientific world early, when they have lots of fresh ideas. We should encourage grants to young scientists and should encourage them to take big risks. When you’re taking big risks, science is amazingly fun.

The response to this answer was very negative.

With all due respect, this is a ludicrous statement. . . The true problem is the way in which you fund science. You fund projects and proposals. In order to get these projects funded, the preliminary data has to be essentially the whole project being done. Then you fund at a 6% percent line. It leads to cronyism in the peer review process and a general sense of despair in scientists. How about you radically change the funding system for PIs?

I too am disappointed with Dr. Lander’s response to possibly THE most important question here regarding training basic scientists.

Do you truly believe this? . . . There is no reason to encourage more students to go into science if there is not enough government funding to support their careers.

Alas, this is not important. It just pleased me that someone questioned Dr. Lander’s absurd claims, which he makes often. “We should encourage young scientists to take big risks”. Yes, I agree, does he really believe this? Do he really believe that someone coming up for tenure should take big risks?

Heart Emergencies by Appointment at Mt. Sinai Hospital

March 18, 2014

A recent Bloomberg News article looked into why Mt. Sinai Hospital in New York did a very large number of heart procedures, making its cardiologists very well-paid. One reason, the journalists discovered, is that patients had been told to lie:

On a pair of representative Sundays in 2012, 10 patients told ER workers they’d been instructed to arrive there before their cath-lab appointments, according to internal hospital correspondence. Two of them said they’d been coached to say they were having acute symptoms of heart disease, according to the exchanges.

Even more remarkable, the journalists found, was that many patients had cardiology appointments before they showed up at the emergency room:

Certain patients who showed up at Mount Sinai Hospital’s emergency room on Sunday mornings stood out [because] they already had appointments. Each was scheduled for a procedure at Mount Sinai’s catheterization lab, where cardiologists thread wires and tubes into blood vessels to detect disease and insert cardiac stents. The New York hospital’s cath lab has regularly scheduled such emergencies-by-appointment, according to three doctors and another medical professional, all of whom said they had direct knowledge of the practice.

Larry Husten, a medical columnist at Forbes, argues that this is an example of a widespread problem.

The Wisdom of Google: “Dessert”, “Honey” and “Fruit” Closer to “Dinner” than “Breakfast” or “Lunch”

March 16, 2014

I have blogged many times that bedtime honey improves sleep. I learned this from Stuart King, an Australian musician. He also pointed out we eat dessert with dinner more than with other meals. which others who have described the honey effect have not said. The dessert observation suggests that other sweets, not just honey, improve sleep. After I repeated the dessert observation, a friend said I of all people should know it isn’t universal. The Chinese don’t eat dessert, she said. Yes, I said, but where I lived in Beijing there seemed to be lots of sweets eaten in the evening, and lots of street vendors selling fruit in the evening. Read the rest of this entry »

Assorted Links

March 14, 2014

Thanks to Steve Hansen.

“Dawn of Genomic Medicine”

March 13, 2014

According to the headline of a Yahoo News article, “the dawning of the age of genomic medicine” is upon us. There has been little impact of genomics but “that is finally changing,” says Julie Steenhuysen, the author of the article.

I was curious how this would be argued. Here’s how:

Sambrookes had been very athletic as a young teen, but as she matured, she noticed a heaviness in her legs. By age 20, running left her tired. At 40, she needed a pacemaker, just like her mother did at that age.

“I started thinking there is something to this,” said Sambrookes, now 56, who lives in Michigan City, Indiana.

After some dead ends, she found McNally, who cast a wide net, testing for more than two dozen genes that could account for Sambrookes’ heart and muscle problems.

The culprit turned out to be a mutation in a gene called Lamin that causes Limb-girdle muscular dystrophy. The disease can cause weakness and wasting of the muscles between the shoulders and knees. The mutation can also cause electrical disturbances of the heart.

McNally recommended Sambrookes replace her pacemaker with an implantable cardiac defibrillator that could protect against sudden cardiac death.

That proved to be the right call. Last August, Sambrookes’ heart stopped three times. Each time, the defibrillator shocked her back to life.

“She literally tried to die three times,” McNally recalls of her patient. “It still takes my breath away.”

Because someone recommended a pacemaker be replaced with a defibrillator, genomic medicine is a good idea. The benefits of genomic medicine must remain elusive if you have to use such a poor example to support it.

Assorted Links

March 12, 2014

Thanks to Patrick Vlaskovits.

Nick Szabo is Satoshi Nakamoto, the Inventor of Bitcoin

March 11, 2014

There were many funny things about Leah Goodman’s claim in Newsweek that a California engineer invented bitcoin. One was her observation that he put two spaces after a period — just like the inventor of bitcoin. Another was her observation that his relatives said he was “brilliant”, without giving any examples. His brilliance had remained perfectly hidden – until now. A third was her conclusion that he was obsessed with secrecy and distrusted government – just like the inventor of bitcoin (according to her). Felix Salmon was quite wrong when he said there are some very strange coincidences and the pieces of her argument “fit elegantly together”. Actually, her argument is worthless from top to bottom. Salmon was right, however, when he said that the engineer’s English shows he couldn’t possibly have invented bitcoin. As Salmon says, Goodman ignored this itty-bitty problem.

Who is the inventor of bitcoin? I’m sure it’s Nick Szabo, a former law professor at George Washington University. This idea first surfaced a few months ago in an anonymous blog post based on textual analysis. Szabo used certain phrases in the original bitcoin description far more than a bunch of other possible candidates. That is real evidence. The hypothesis that Szabo is the inventor passes several other tests as well: Read the rest of this entry »

Human Papilloma Virus and Cervical Cancer

March 10, 2014

After I say that Nobel Prize in Medicine is usually given for research of little or no proven value, one counterexample I’ve heard is the 2008 prize for the discovery that cervical cancer is caused by the human papilloma virus (HPV). This should allow us to reduce cervical cancer via vaccination.

There are several things wrong with this example:

1. The predicted improvement has not been observed. The average age at which a woman is diagnosed with cervical cancer is 48 years old. To assess the effect of HPV vaccination — usually given to young girls — on cervical cancer you need to wait thirty years. Thirty years haven’t passed. The history of medicine is full of examples where treatments that supposedly worked — such as tonsillectomies, given to millions — when tested turned out to not work. The history of medicine is also full of examples where supposedly wonderful treatments (e.g., frontal lobotomies) turned out to have side effects so bad the treatment was stopped.

2. Cervical cancer is not a big source of death. In the United States, it kills perhaps five thousand women per year. Heart disease kills hundreds of thousands of people per year; so do all forms of cancer taken together. And pap smears, which cost little, actually work. “Cervical cancer is 100% curable if detected early,” says one website.

3. Because pap smears work well, it isn’t clear there is room for improvement. To find out you’d want to compare two groups: (a) pap smears plus HPV vaccination and (b) pap smears alone.

4. It isn’t clear the vaccine will work, even if HPV infection does cause cancer. There are at least 100 varieties of HPV; the vaccine protects against two. Does vaccination against two varieties increase infection by other varieties (because different viruses compete for the same niche)? Hard to rule this out. Again, there are many examples in medicine where actually helping people turned out to be far harder than experts had predicted, even when the initial idea wasn’t nonsense. An example is the oncogene theory of cancer, which also has a Nobel Prize associated with it.

In summary, not a counterexample.

The Coming Reunification of Korea

March 9, 2014

A few years ago, a Korean friend of mine spent a college year abroad in Tanzania. In South Korea, access to information about North Korea on the Internet was blocked. In Tanzania, it wasn’t. Impressed by what she learned, she cut-and-pasted some of it into an email to her sister.

After she sent the email, she remembered that in South Korea it was illegal to cut-and-paste from a website. She called her mom to tell her sister not to read the email. The message was successfully conveyed and her sister deleted the email without reading it.

In the last year, however, the South Korean government has changed its policy and is now trying to educate citizens about life in North Korea. Information is no longer blocked. Now and then people escape. They are put on show and tell about North Korean life many times. The intention is to prepare for the coming reunification. Special committees have been formed to discuss how to solve the anticipated problems.

We are used to hearing about the advantages of dividing one country into two, but my friend had no trouble explaining why the South Korean government wanted reunification. One reason was that the war with North Korea was very expensive. Another was that families had been divided. A third was that since North Korea has nuclear weapons, reunification will mean that South Korea has them. (My friend had not read a certain newspaper article the day she said that.) This article suggests that the real reason cannot be said out loud. It is that reunification will allow South Korea to take advantage of the land and people freed by the collapse of North Korea.

“What have you learned from the reunification of Germany?” I asked.

“There will be chaos for a long time,” she said.