Sunday, November 05, 2006


What pros and cons will fill the media? In general, the debate swings between two extremes. Advocates for the ban present evidence that trans fats clog arteries, cause death and cost billions in tax dollars in medical care each year. Civil libertarians accuse advocates of promoting a nanny state - that is, an intrusive government that dictates the minutia of how people may live under the guise of taking care of them.

The push to legally prevent individuals from having a french fry "their way" is likely to prevail.if not in New York, then elsewhere - and soon. It is too potent a mixture of dire health alerts, politics and ethical judgements. If so, it will prevail over two values that have defined the American character: personal freedom and rugged individualism.

Compared to Europe, America is relatively new to "nanny" measures. For example, the right to educate your own children (homeschooling) is illegal in many European nations like Germany, but commonplace in America.

Traditionally, the question of what you choose to eat has been discussed outside the American framework of politics and ethics. Generally speaking, American politics and ethics have not dealt with how you prepare french fries, but with how you relate to other people; do you lie, defraud, or physically harm others. Nutrition might have been a health concern and a discussion in classrooms, but it did not stir political and ethical interest within the broader society. Personal eating preferences were considered just that: personal preferences.

Society has changed in several ways. For one thing, both public and private health care have become increasingly expensive, with both taxpayers and insurance premium payers subsidizing the so-called bad health choices of others. In consequence, the general public feels a greater right to prevent others from making bad health decisions at their expense. Thus, if studies prove that trans fats clog arteries and cause heart disease and premature deaths, then calls for legislation often follow. Such calls ignore several factors.

First, although trans fats may very well pose the health dangers claimed, medical studies in general are notoriously unreliable. The July 2005 issue of the Journal of the American Medical Association (JAMA), contained an article by Dr. John P. A. Ioannina entitled "Why Most Published Research Findings Are False." It reviewed "all original clinical research studies published in three major general clinical journals or high-impact-factor specialty journals in 1990-2003," each of which had been "cited more than 1000 times" in subsequent literature. In short, it reviewed 'the best'. 32 percent of the studies were subsequently refuted; 44 percent could not be validated; 11 percent remained unchallenged and, so unvalidated.

Moreover, even a reliable study does not always establish causality. An excellent and non-hysterical exposition of true death risks is provided by Bernard Cohen, Professor Emeritus of Physics at the University of Pittsburgh, in his 1991 "Catalog of Risks" (large pdf). Cohen uses solid statistical definitions and methods to evaluate the probable loss of life expectancy (LLE) from various activities. He also answers such nontrivial questions as "premature by how much" and "compared to what?" For example, the LLE from jogging is "1.7 days per year." Cohen balances that against the fact "jogging is usually viewed as a measure of preventing heart disease" which has a far higher LLE; this makes jogging beneficial overall. Trans fats are unlikely to be nutritionally beneficial, but whether using them in cooking should be outlawed is a different issue entirely.

Unfortunately, in past decades, food has become a political and ethical flash point, with voices of reason being shouted down. Accusations have taken over. If you eat meat, then you violate animal rights. Feed your child sugar and you are guilty of abuse. Buy inexpensive food from Wal-Mart and you are complicit in labor exploitation. The United Nations has suddenly switched from alarm bells about starvation to ones about obesity.

Food is the new political chic; eating is the new morality. Unhappily, this trend is why I think trans fats bans are likely to succeed In North America. "What's the big deal?" readers may ask. "We're only talking about a french fry." Well, viewed from one perspective, words are only 'puffs of air,' but that doesn't diminish the importance of free speech. The idea of government micro-managing personal choice and freedom down to the level of a french fry is a very big deal.


The tired doctor problem

Sadly, regulations against overworking doctors may mean no doctor at all for many patients

When I was working on my PhD my wife would ring me from work. She wanted me to come and pick her up from the hospital because she was too tired to drive home. I was happy to do that. But I started to wonder. If my wife was too tired to drive - a relatively simple and straightforward task - how could she be alert enough to care safely for patients?

That question was the impetus for a personal journey and a research program looking at working hours and fatigue over the next 15 years. At the time the answer to this question seemed self-evident - how can the traditional 36-hour shifts be safe? Surely it must compromise patient safety. We wouldn't let a truck driver or a pilot operate a vehicle for more than 12 hours. How can we possibly let our doctors provide continuous patient care for 36 to 48 hours? After years of research and a lot of soul searching, I have come to the conclusion that the answer is not simple or obvious.

There is no doubt that doctors have traditionally worked long hours, and 24- to 36-hour shifts are part of the way we train them. The long shifts are, anthropologically speaking, most probably an initiation ceremony or rite-of-passage. They demonstrate one's dedication and commitment to patients and the "elders" of the profession. Despite a clear lack of evidence, extended working hours continue to be justified using the rhetoric of patient safety, continuity-of-care and the need for relentless experience.

There is also no doubt that the research data on the effect of extended working hours was unequivocal, and confirmed what we all knew only too well from personal experience. Tired people don't perform as well as alert ones and extended working hours result in reduced attention, poor decision-making and mood changes that potentially compromise patient safety. This line of research probably reached its zenith in a paper published in the journal Nature in 1997. This paper showed that the cognitive and psychological effects of a single night of sleep loss were broadly comparable to the effects of moderate alcohol intoxication, equivalent of 0.05 per cent blood alcohol level. Given that many of our doctors worked up to 48 hours with little or no sleep, the conclusion was obvious - long working hours impaired performance and should be restricted in the interest of patient (and doctor) safety.

Over the past seven or eight years there has been a lot of discussion of this paper and the implications for policy and regulation on doctors working hours. In much of the English-speaking world we have seen significant pressure to use the recent research on sleep loss and cognitive performance to argue for the introduction of working hour restrictions. Recently, the US medical profession has recommended a nominal 80-hour maximum working week for junior doctors. Several years ago, the Australian Medical Association introduced a set of "safe working hours" guidelines which have been recently updated. There has been significant community discussion about the importance of reducing or restricting doctors' hours to improve overall patient safety in the community. As a researcher who has been working to raise community awareness of the risks associated with fatigue this would seem an important vindication of a 15-research program.

Unfortunately this is not the case. While I am grateful for the increased community awareness of fatigue-related risk, I am less optimistic about the way regulators and community groups have approached the issue of risk reduction. Indeed, I am reminded of the famous aphorism of H.L. Mencken who once famously noted "that for every complex question there is a simple solution and it is usually wrong!"

I understand the intuitive appeal of their approach. If doctors work excessively long hours they get tired. If we limit doctor's hours we will reduce fatigue-related risk and our hospitals will be safer. Unfortunately it is not that easy. Policy responses need to be formulated in a context beyond the confines of the laboratory. For example, if we restrict doctors' working hours we potentially reduce the supply of medical care to the community. A reduction in available medical care may produce a bigger problem than we set out to solve. In simple terms, sometimes a tired doctor will be better than no doctor at all. In fact, most of the time - since fatigue-related errors are relatively infrequent.

From a strictly scientific perspective, policy-makers need to demonstrate that the reduction in risk associated with restricted working hours is greater than the increase in risk associated with the reduction in available medical care. Until we can do this with a degree of certainty, policy-makers should approach fatigue risk management cautiously and avoid knee-jerk policy responses.



Just some problems with the "Obesity" war:

1). It tries to impose behavior change on everybody -- when most of those targeted are not obese and hence have no reason to change their behaviour. It is a form of punishing the innocent and the guilty alike. (It is also typical of Leftist thinking: Scorning the individual and capable of dealing with large groups only).

2). The longevity research all leads to the conclusion that it is people of MIDDLING weight who live longest -- not slim people. So the "epidemic" of obesity is in fact largely an "epidemic" of living longer.

3). It is total calorie intake that makes you fat -- not where you get your calories. Policies that attack only the source of the calories (e.g. "junk food") without addressing total calorie intake are hence pissing into the wind. People involuntarily deprived of their preferred calorie intake from one source are highly likely to seek and find their calories elsewhere.

4). So-called junk food is perfectly nutritious. A big Mac meal comprises meat, bread, salad and potatoes -- which is a mainstream Western diet. If that is bad then we are all in big trouble.

5). Food warriors demonize salt and fat. But we need a daily salt intake to counter salt-loss through perspiration and the research shows that people on salt-restricted diets die SOONER. And Eskimos eat huge amounts of fat with no apparent ill-effects. And the average home-cooked roast dinner has LOTS of fat. Will we ban roast dinners?

6). The foods restricted are often no more calorific than those permitted -- such as milk and fruit-juice drinks.

7). Tendency to weight is mostly genetic and is therefore not readily susceptible to voluntary behaviour change.

8). And when are we going to ban cheese? Cheese is a concentrated calorie bomb and has lots of that wicked animal fat in it too. Wouldn't we all be better off without it? And what about butter? It is just about pure fat. Surely it should be treated as contraband in kids' lunchboxes! [/sarcasm].

9). For a summary of the weak science behind the "trans-fat" hysteria, see here. Trans fats have only a temporary effect on blood chemistry and no lasting harm from them has ever been shown.


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