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The Fat Subsidizing The Obese
Jacob Sullum digs into the flabby thought about the recent Medicare decision to pay for obesity treatments. An interesting point for any best friend/epidemiologists who happen to be in the neighborhood (and we do miss you from our current Parisian neighborhood, despite its other obvious merits). Oh yes...on to that point:

We don't really know whether taxpayer costs are higher, on balance, than they would be if everyone were thin.

In the case of smokers, economic analyses indicate that taxpayer savings from less health care in old age and fewer Social Security payments (because of shorter life expectancies) outweigh the costs of treating tobacco-related diseases. Something similar could be true of obesity.

And then, this:

Even if the government starts to treat the condition of being overweight as a disease, it does not mean the behavior that makes people overweight is a disease as well. Gonorrhea is a disease, but promiscuous, unprotected sex is not.

At the anthropology and evolution conference I attended, J. Dee Higley, of the NIH Animal Center/Nat'l Institute Of Alcohol and Alcoholism, presented alcoholism as a disease, and links it to low levels of serotonin. His talk was fascinating -- and explained why impulsitivity caused by low serotonin might have had evolutionary payoffs. Some of the potential reasons, as Higley saw them:

*Calories in times of famine, if you're impulsive, youre more likely to try some new food.
*Increased Resources impulsivity might lead you to migrate earlier, potentially staving off starvation in a played-out locale.
*Sex impulsive types are more promiscuous -- and thus more likely to pass on their genes.

While I have no reason (and not much ability in the covariate/regression analysis department) to dispute Higley's findings on serotonin, I do dispute his "alcoholism is a disease" contention.

Sure, somebody might have a biological propensity toward alcoholism, but is addiction really a disease -- or, as Stanton Peele believes -- a choice, for short-term gratification over long-term goals? Higley refused to consider the question when I asked it after his discussion (presenting it as "Stanton Peele's approach"), and he simply resummarized his findings about serotonin levels in the primates he studied -- which I understood the first time around, thank you very much.

I wasn't surprised at his total unwillingness to investigate another point of view -- or so much as acknowledge the existence and work of Stanton Peele. That's one thing that's really frustrating about hanging around people of a particular academic discipline; for example, sociologists (who tend to think the evolutionary psychologists are morons for insisting that the differences between men and women are biological, not cultural -- despite a mountain of data screaming "biology!" as well as obvious physical differences visible to anyone who is not legally blind).

Unfortunately, there's an almost feverish push, amongst many university profs and researchers, to keep away any thoughts other than the most catholic in one's own field. There's also an unfortunate tendency to turn up one's nose at practical application of research data -- like these examples of evolutionary psychology and anthropology data applied to regular people's lives:

*by me, in my column, using Devendra Singh's waist-to-hip ratio findings to advise women to always wear clothes that show off their waist (or give the illusion that they have one), and referring to research by Buss, Shackelford, and others to advise men to stop behaving like neutered kittens, per the deluded feminists.
*by Albert Ellis-trained psychologist Nando Pelusi, who sometimes applies evolutionary psychology to help his patients understand the biological reasons behind their problems; ie, if you understand that you have a biological propensity to drink, you might not feel so ashamed about it...which doesn't mean you still don't need to reorient yourself to long-term goals over your propensity to impusively call any time "Miller Time."

Gee, you, as a university researcher, might make a difference in a regular person's life with your research? How intellectually down-market!

Silly, huh?!

UPDATE: Stanton sent me this link to a page on his Web site (which wasn't working yesterday). Here's an excerpt:

Change is natural. You no doubt act very differently in many areas of your life now compared with how you did when you were a teenager. Likewise, over time you will probably overcome or ameliorate certain behaviors: a short temper, crippling insecurity.

For some reason, we exempt addiction from our beliefs about change. In both popular and scientific models, addiction is seen as locking you into an inescapable pattern of behavior. Both folk wisdom, as represented by Alcoholics Anonymous, and modern neuroscience regard addiction as a virtually permanent brain disease. No matter how many years ago your uncle Joe had his last drink, he is still considered an alcoholic. The very word addict confers an identity that admits no other possibilities. It incorporates the assumption that you cant, or wont, change.

But this fatalistic thinking about addiction doesnt jibe with the facts. More people overcome addictions than do not. And the vast majority do so without therapy. Quitting may take several tries, and people may not stop smoking, drinking or using drugs altogether. But eventually they succeed in shaking dependence.

Kicking these habits constitutes a dramatic change, but the change need not occur in a dramatic way. So when it comes to addiction treatment, the most effective approaches rely on the counterintuitive principle that less is often more. Successful treatment places the responsibility for change squarely on the individual and acknowledges that positive events in other realms may jump-start change.

Including, perhaps, irrational belief that there's a god, and that god is helping keep you away from the drinkie. As Stanton notes, however, AA doesn't work for everyone. I actually think it's not such a good thing, except for people who'd be in a steel drawer at the morgue without it, because it focuses on the sympton ("Whatever you do, don't drink!"), not the underlying issue leading you to overdrink.

Posted by aalkon at July 25, 2004 8:33 AM


"Gonorrhea is a disease, but promiscuous, unprotected sex is not."

Through the careful application of evidence-based treatment guidelines, health care providers can persuade sluts and drunks to stop having fun, once and for all. To get paid for their work, providers have to diagnose the slutty and drunken behavior as pathological. Any diagnosis must correspond to a unique "ICD-9 code" from the International Classification of Diseases, 9th edition. There are more than 10,000 codes in that manual (one of them, I believe, refers to musculoskeletal injuries that result from hauling it around). Physician representatives such as the American Psychiatric Association aren't necessarily working in the name of Scientific Progress when they lobby to have yet another code added to the manual. Their primary goal is to get insurance companies and government programs to reimburse physicians for working with drunks and sluts like us.

The treatment goal for anyone with a serious substance abuse problem is to quit drinking and/or drugging. Like Amy, I think the disease model is unconvincing. But if conceptualizing substance abuse as a disease helps some people change their destructive behavior, I'm not going to bust their chops for a lack of theoretical or scientific rigor.

Posted by: Lena Cuisina, Policy Analyst and Girl Epidemiologist at July 25, 2004 9:51 PM

I agree that the disease model for substance abuse and chemical depedency is unconvincing. However, at this time it's probably the best we've got. To characterize the difficulities faced dealing with such a problem by calling it simply a "choice", as Mr. Peele does, minimizes the very real issue of developing effective treatment programs to help individuals with "lifestyle diseases" such as substance abuse, obesity, smoking, alcoholism, etc..

The controversy over nomenclature seems to revolve more around religious (gluttony, alcohol abuse, etc. as sin or moral failure) and political (is taxpayer money going to fund treatment) issues, rather than a pure scientific discussion of whether or not chemical dependency fits the "disease model".

The problem is further exacerbated by the insinuation of Alcoholics Anonymous (AA) and the "12 Step Program" into virtually every major rehab program (around 90 %) in the US. This has served to legitimize the concept that you need god to get, and stay, sober.

Very few treatment concepts run contrary to AA beliefs, with Narconon (linked with the Scientology Church) and Jack Trimpey's Rational Recovery (which is vehemently anti-AA) being the two major exceptions I am aware of.

I prefer to think of "lifestyle diseases" as mental health problems, which is what they are bascically classified as at this time, being defined thus in the psychiatric DSM Manual. Perhaps this is a matter of semantics, but we don't tend to think of individuals with depression as having a "disease" but rather a "mental health disorder". Psychiatric classifications have always been somewhat of a "soft science" based on the high degree of subjectivity involved, and the fact that the "disorders" are basically defined in terms of their deviations from human norms. And "normal" is pretty subjective these days anyway. The point is, this classification system is clearly the best we have at this time.

Finally, I know whereof I speak, having spent time in the belly of the beast (with apologies to Mr. Trimpey). As someone who is both a physician, and has spent 3 months in residential rehab for substance abuse, I feel uniquely qualified to comment on these very pertinent issues.

If we toss aside the religious and political contentions, a few things are clear. No matter how much debate there is with regards to "personal choice", overcoming a hardcore addiction, whether it be to drugs, alcohol, cigarettes or food, is very difficult even when the individual recognizes there is personal responsibilty involved. Physical dependence makes the situation even worse. It often takes some type of professional help, and this can vary from simple therapy to detox to long term residential rehab, to become free of an addiction.

For chemical dependency, long term (from 30 days to 6 months) residential rehab is emerging as one of the best treatment options. Cost, not effectiveness, is the huge issue surrounding this concept.

As someone who is required to attend AA meetings, but actually enjoys and benefits from them, I will not digress into a lengthy discussion on the merits and foibles of the AA program. As an agnostic, I agree with Amy completely about the difficulty in using the AA program because it supposedly relies on god to keep you sober. There is clearly a need for quality long term treatment programs that do not rely on religious concepts of a supreme deity and the 12 Steps.

In the end, it's not whether you still call yourself an alcoholic after 20 years of sobriety, or call yourself cured after one month, it's the recognition that returning to a hardcore addiction likely will lead to the proverbial "jails, institutions or death."

Posted by: Jeff R at July 27, 2004 11:19 PM

Addiction is a tough thing to live with! It is very important to do the "day by day" style of living to keep yourself straight and healthy!

Posted by: alex at August 26, 2004 2:18 AM