Tag Archives: health

Yo, how big is that yogurt bucket?

People don’t know how much they’re eating.

A recent experiment found that people eat more when the container is larger, even when the portion size is not. They gave Belgian college students a container of M&Ms and parked them in front of a TV, with some cover story. The students were randomly assigned to three groups, medium-portion/small-container, medium-portion/large-container, and large-portion/large-container. These were the results: The ones who got the large container ate more, whether it was full or not (the difference between the two wasn’t significant). These kinds of experiments continuously suggest that distractions, distortions and other apparently irrelevant information and events routinely have large effects on people’s eating practices (here’s an extensive review). One infamous study showed that even people served 14-day-stale popcorn at the movies ate 34% more when it was served in a large container. In an earlier popcorn study, researchers found that people given large containers not only ate more, but were less able to report how much they ate. They concluded:

When a food is eaten from a large container, it appears easy to lose track of how much one eats. Even if the food were to taste relatively unfavorable, eating it from a large container may cause one to overeat because they lose track of how much they have consumed.

About that yogurt tub All this occurred to me when I visited one of our many local Frozenyo franchise outlets. It’s a self-serve frozen yogurt place where you pay one price by weight no matter what you put in your bucket. The trick that impressed me is the bucket — there is only one size, and it’s very large. But you can’t judge how big it is because there’s nothing to compare it with — no sizes or prices on the wall, no mini cup for kids — just one stack of identical buckets. So the person who posted this picture on Yelp probably thought she had a reasonable size serving, since the thing is barely half full:

There are three possible ways to judge your self-served serving size. You can go by the tub (“I filled it half way”), you can go by the person next to you (“sheesh!”), or you can look at the cartoon penguins on the wall:

How much is the penguin eating? I took home one of the buckets, and measured the volume of water it holds: 18 ounces. In comparison, a standard kid-sized serving bowl, the kind some people use to give their kids ice cream at home, holds 12 ounces:

An innocent child used to half a bowl of ice cream — in the bowl on the left — might be pretty steamed if you served her this:

According to the serving size information on the back wall of Frozenyo, I think that’s about 1.5 servings, or 150 calories of the nonfat variety, before toppings. The penguin’s overflowing bowl is 5.0 servings. With no toppings that’s 500 calories. If you pile it with M&Ms, sprinkles, hot fudge, Captain Crunch, coconut topping and fresh kiwis, who knows. It’s not really that many calories to consume — the same number as a single slice of banana bread at Starbucks.

But the point is you don’t know how much you’re eating. One Yelp reviewer cautioned that you can get a stomach ache after eating at Frozenyo, because “your eyes are bigger than your stomach.” I think it’s because the dump-truck sized delivery vehicle you eat it out of is bigger than your stomach.

But most reviewers love it for the individual control over serving size and toppings, and the reasonable price ($.39 per ounce by weight, or $5-$6 for a typical load).* I think it’s a winning business model, with low labor costs, because all you need is one person to pour the mix into the machines and another to weigh the tubs and swipe credit cards. According to the company’s ambitious map, there are still 46 states with “territory available.”

If I were them, I would increase the bucket size by 5% per year. I doubt anyone would notice.

* Paging George Ritzer: it’s the irrationality of rationality.

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Incarceration’s contribution to infant mortality

A recent study in the journal Social Problems by sociologist Chistopher Wildeman shows that America’s practice of mass incarceration may be exacerbating both infant mortality in general and stubborn racial inequality in infant mortality in particular.

Drawing on recent literature by himself and others, Wildeman spells out the case for incarceration’s negative effect on family economies, including: lost earnings and financial contributions from fathers, the expensive burden of maintaining the relationship with an incarcerated parent, and the lost value of the incarcerated parent’s unpaid labor. All of those costs may take a toll on mothers’ health, which is the primary cause of infant mortality.

In addition, family members of incarcerated parents may contract infectious diseases, experience significant stress, and lose support networks — all taking an additional health toll.

Sure enough, his analysis of data from the Pregnancy Risk Assessment Monitoring System confirms that children born into families in which a parent has been incarcerated are more likely to die in the first year of life. The association may not be causal, but it holds with a lot of important control variables.

Does this increase racial inequality? Probably, because parental incarceration is so concentrated among Black families, as Wildeman and Bruce Western reported previously (my graph of their numbers):

To make the connection to racial inequality explicit, Wildeman moves to compare states over time, on the suspicion that incarceration could increase infant mortality rates, and racial inequality in infant mortality rates. That could be because concentrated incarceration undermines community support and income, people with felony records often are disenfranchised (so the political system can ignore their needs), and the costs of incarceration crowd out more beneficial spending that could improve community health.

The results of a lot of fancy statistical models comparing states show that:

the imprisonment rate is positively and significantly associated with the total infant mortality rate, the black infant mortality rate, and the black-white gap in the infant mortality rate.

It’s an impressive article on an important subject, one that thankfully is attracting more attention from good scholars.

I previously reported on Wildeman’s work on how the drug war affect families, here.

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The disparate lives of fifth graders

A new study of about 5,000 fifth-grade students in the three public school districts shows wide disparities by race/ethnicity in a number of important health practices and outcome measures. The study, published in the New England Journal of Medicine, showed unadjusted disparities and then attempted to account for them statistically with common control variables, such as family socioeconomic status and school characteristics.

Here is a breakdown of some of the indicators (my graph):

On all but alcohol consumption (remember these are fifth graders), the white students showed advantages over Black and Latino students. In the subsequent analysis, the authors showed what amount of the disparity was accounted for by the different control variables. Here is their graph illustrating the findings:

It shows, for example, that about 10 points out of the 20-point difference between Latinos and Whites on the frequency of reporting fair or poor health is accounted for by their control variables. For Black children, about four points out of the eight point difference is accounted for. (These gaps would likely be larger if private school students were included.)

Determining the causal story behind these disparities is interesting and important, however it is most important to realize that at the descriptive level these represent major disparities in the lived experience of young children who are blameless.

It is interesting to note that some of these practices and outcomes speak to parenting practices, which has been the subject of a growing literature in recent years. However, after Annette Lareau reported that parenting practices in her study differed more by social class than they did by race, class has been the focus of much of this research. For example, although I did not see it, a study by Jessica McCrory Calarco at Indiana University, presented at the annual meeting of the American Sociological Association last week, looks very interesting. She used observation and interviews and found stark differences between middle-class and working-class parent-child interactions. From the press release:

Working-class parents, she found, coached their children on how to avoid problems, often through finding a solution on their own and by being polite and deferential to authority figures. Middle-class parents, on the other hand, were more likely to encourage their kids to ask questions or ask for help.

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Study shows home births are not as safe. So?

There’s an interesting example of how to interpret scientific results — and draw policy implications from them — from the world of birth practices and safety.

The subject of the debate is a major new study from the British Medical Journal. The study followed more than 60,000 women in England with uncomplicated pregnancies, excluding those who had planned caesarean sections and caesarean sections before the start of labor. They compared the number of bad outcomes — from death to broken clavicles — for women depending on where they had their births.

One comparison stands out in the results. From the abstract: “For nulliparous women [those having their first birth], the odds of the primary outcome [that is, any of the negative events] were higher for planned home births” than among those planned for delivery in obstetric units. That is, the home births had higher rates of negative events. The difference is large. Here’s a figure to illustrate:

The error bars show 95% confidence intervals, so you can see the difference between home births and obstetric-unit births is statistically significant at that level. These are the raw comparisons, but the home-versus-obstetric comparison was unchanged when the analysts controlled for age, ethnicity, understanding of English, marital or partner status, body mass index, “deprivation score,” previous pregnancies, and weeks of gestation. Further, by restricting the comparison to uncomplicated pregnancies and excluded all but last-minute c-sections, it seems to be a very strong result.

But what to make of it?

In their conclusion, the authors write:

Our results support a policy of offering healthy nulliparous and multiparous women with low risk pregnancies a choice of birth setting. Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome.

But in what way do the results “support a policy”? The “higher risks” they found for planned home births are still “uncommon,” by comparison, with those in poor countries, for example. But the home birth risk is 2.7-times greater.

The Skeptical OB, who is a reliable proponent of modern medical births, titled her post, “It’s official: homebirth increases the risk of death.” She added some tables from the supplemental material, showing the type of negative events and conditions that occurred. Her conclusion:

“In other words, any way you choose to look at it, no matter how carefully you slice and dice the data, there is simply no getting around the fact that homebirth increases the risk of perinatal death and brain damage.”

I guess the policy options might include include whether home births should be encouraged, more regulated, covered by public and/or private health insurance, banned, penalized or (further) stigmatized.

Home birth seems safer than letting children ride around unrestrained in the back of pickup trucks, which is legal in North Carolina — as long as they’re engaged in agricultural labor. On the other hand, we have helmet laws for kids on bicycles in many places. And if a child is injured in either situation, hopefully an ambulance would take them to the hospital even if the accident were preventable.

In other words, I don’t think policy questions can be resolved by a comparison of risks, however rigorous.

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Warning: What do smokers Google?

If I ran the Federal scary anti-smoking image warning program, I might show smokers the list of health-related terms that show up most in the states with the highest cigarette smoking rates.

The Google Correlate tool is showing the great potential for using Internet search activity to investigate layers of behavior and meaning behind other observable social phenomena, such as race/ethnic composition, health behavior, and family patterns. Today’s example is smoking.

If you take the smoking rates by state, and throw them into the Google Correlate hopper, you can see the 100 search terms that are most highly correlated with that reported smoking behavior. That is, the terms that are most likely to be used in high-smoking states and least likely to be used in the low-smoking states.

Is the result just a lot of noise? Maybe, but I don’t think so. Here are the smoking-related terms in the top 100:

  • camel no 9
  • cigarette coupon
  • cigarette coupons
  • marlboro coupons
  • my time to quit
  • safe cigarettes
  • stopping smoking
  • time to quit
  • fire safe cigarettes
  • ways to stop smoking

So that’s good for face validity — a list of random search terms isn’t likely to have all those smoking terms on it.

But after the smoking terms, the thing that jumps out is the health-related terms. We know from the Google flu tracker that people search for their symptoms. So these caught my eye.

Here is a screen shot of the first page of results:

I selected “stages of copd” as the term to map. The map on the left is the smoking rates; the one on the right is the relative frequency of searches for “stages of copd.” That is, chronic obstructive pulmonary disease, a nasty disease the most common cause of which is smoking.

Here is the complete list of health-related terms among the top-100 correlates with smoking rates:

Lymph node swelling, which is implicated in the jaw and neck searches, most often reflects infection — which smoking causes.

How strong are the connections? They’re not the strongest I’ve seen on Google Correlate. The “stages of copd” search is correlated with smoking rates at .77 on a scale of 0 to 1. It’s not uncommon to find correlations of .93 (which is the relationship between “quiche” and “volvo v70 xc”).

But considering the smoking rates come from a sample survey (the National Survey on Drug Use and Health) which includes random error, and states are somewhat arbitrary geographic units, that correlation seems pretty high to me. Here’s the scatterplot:

What is the correlation causality story here? I can’t say. But the simplest explanation is that these are the terms smokers (and maybe those who know or care for them) are most likely to Google relative to non-smokers — not that they are the most common searches smokers do, of course, but the searches that differentiate them from non-smokers. The simplest explanation is the best place to start.

I like this list of conditions because in my experience smokers sometimes have the attitude of “you have to die of something.” But it’s not just the chance of dying that smoking increases – it’s a lot of possible forms of suffering along the way.

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Breastfeeding promotion here and there

We have just concluded another annual World Breastfeeding Week, and the U.S. Centers for Disease Control has a new report on how well hospitals are promoting breastfeeding. The results show progress in the direction of public health objectives, but the distribution of services is very unequal. Here’s the background:

Childhood obesity is a national epidemic in the United States. Increasing the proportion of mothers who breastfeed is one important public health strategy for preventing childhood obesity. The World Health Organization and United Nations Children’s Fund (UNICEF) Baby-Friendly Hospital Initiative specifies Ten Steps to Successful Breastfeeding that delineate evidence-based hospital practices to improve breastfeeding initiation, duration, and exclusivity.

The CDC did a survey of obstetric hospitals and birth centers in 2007 and 2009, and found progress on some of the Ten Steps (click on the image to read the labels):

Just as compliance on the Ten Steps is uneven, so too is the percentage of births at the top-rated “Baby-Friendly facilities” by state:

The CDC estimates that 4.5% of all U.S. babies are born at “Baby-Friendly facilities.”

Finally, the CDC report is linked to a Report Card for states, which shows how well each state is doing in terms of breastfeeding outcomes, as well as “process indicators,” which measure some of the policy supports in place in each state, such as child care center regulations, state health department workers tasked with promoting breastfeeding, and the number of lactation consultants.

To look under the cultural hood a little, I loaded the national Maternity Practices in Infant Nutrition and Care (mPINC) scores for each state into Google Correlate to see what Google searches are most highly correlated with breastfeeding success and failure at the state level. The Google tool gives the 100 most correlated searches, and they are mostly cooking terms, including 8 references to Martha Stewart or Julia Child, Epicurious, and highbrow recipes like “pumpkin lasagna” and “asparagus prosciutto.” So, that’s kind of fun to know but not really useful.

Surprisingly relevant, however, was the high prevalence of searches for “Nutrition Action” and “Nutrition Action Healthletter,” which both were correlated at .84 or higher with the mPINC scores across states. That is a newsletter put out by the Center for Science in the Public Interest, which actively promotes — among other things — breastfeeding policies intended to improve health and nutrition. Here are the maps showing where mPINC scores are higher and more people Google the Nutrition Action Healthletter:

This does not mean the relationship is causal, of course. But it appears that the places were CSPI resonates are also those that do a better job of promoting breastfeeding. Hopefully, this will further motivate the social science of search behavior.

Anyway, as I noted last year, breastfeeding rates are strongly associated with the race/ethnicity and education level of mothers:

This may be because of working conditions or other demands on time, mothers’ health, or other factors — but it might also reflect the failure of public health and education programs to inform many mothers about the importance of breastfeeding and support their efforts to breastfeed. Public health promotion of breastfeeding can help extend its health benefits, but to do that will require sustained state-supported efforts.

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Do explicit, enforceable policies matter?

Yes.

The Supreme Court’s decision in the Dukes v. Wal-Mart case, Justice Scalia acknowledged that Wal-Mart’s many local managers had a lot of discretion in their personnel decisions, even though the company had a written policy against gender discrimination (who doesn’t?). But he gave the company credit for a vague policy and let it off the hook for a systematic pattern of disparity between men and women. So, when does a toothless, vague policy over wide discretion lead to a bad outcome, and is failing to prevent it the same as causing it?

A path-breaking sociological analysis of organizational affirmative action outcomes has shown that the companies that successfully diversify their management are most likely to have policies with teeth – where accountability is built into the diversity goal. In light of the Wal-Mart case, this led to a rollicking debate about how to think about “corporate culture” versus policies, and when to blame whom, legally or otherwise – which even divided sociologists.

Smoking in the movies

Here’s an interesting, at-least-vaguely related case. Positive depictions of smoking in the movies are widely understood to be harmful. Yet, smoking is also glamorous, artistic, and popular – representing both anti-adult rebellion and maturity. So, what to do? The Centers for Disease Control, in the always-riveting Morbidity and Mortality Weekly Report, has published a fascinating report on this topic. They report the number of tobacco incidents* in top-grossing, youth-rated (G, PG, PG-13) movies, and divide them between those that implemented an anti-tobacco policy and those that didn’t — helpfully cutting the movie industry roughly in half — and provide a simple before-and-after tabulation:

From 2005 to 2010, among the three major motion picture companies (half of the six members of the Motion Picture Association of America [MPAA]) with policies aimed at reducing tobacco use in their movies, the number of tobacco incidents per youth-rated movie decreased 95.8%, from an average of 23.1 incidents per movie to an average of 1.0 incident. For independent companies (which are not MPAA members) and the three MPAA members with no antitobacco policies, tobacco incidents decreased 41.7%, from an average of 17.9 incidents per youth-rated movie in 2005 to 10.4 in 2010, a 10-fold higher rate than the rate for the companies with policies. Among the three companies with antitobacco policies, 88.2% of their top-grossing movies had no tobacco incidents, compared with 57.4% of movies among companies without policies.

The difference is dramatic, as indicated by this image about the images. (Because I turned the columns into cigarettes, this is not just a graph, but an infographic):

The policies provide what may be an ideal mix of accountability and responsibility, short of a simplistic ban.

[The policies] provide for review of scripts, story boards, daily footage, rough cuts, and the final edited film by managers in each studio with the authority to implement the policies. However, although the three companies have eliminated depictions of tobacco use almost entirely from their G, PG, and PG-13 movies, as of June 2011 none of the three policies completely banned smoking or other tobacco imagery in the youth-rated films that they produced or distributed.

Maybe this formula is effective because there already has been a strong cultural shift against smoking — as strong, even, as the shift against excluding women from management positions?

Graphic addendum (disturbing image below)

Whether smoking in movies actually encourages young people to take up smoking is of course a not a settled issue — especially on websites sponsored by tobacco sellers, as seen in this ironic screen-shot from Smokers News:

One reason to have an explicit policy is that it’s easy to assume viewers will see through the glamour to the negative outcomes. “Surely no one will want to be like that character…” But people – maybe especially young people? – have an amazing capacity to celebrate selectively from the characters they see. I have learned from experience that, in children’s stories, even those who get their comeuppance in the end still manage to emerge as role models for their bad behavior. So maybe some people want to relive this from Pulp Fiction…

…and aren’t put off by this:

*”A new incident occurred each time 1) a tobacco product went off screen and then back on screen, 2) a different actor was shown with a tobacco product, or 3) a scene changed, and the new scene contained the use or implied off-screen use of a tobacco product.”

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