June 7th, 2011

_The End of Overeating_, David Kessler

Published by Rodale. (<-- I could say a lot, but I decline.)

First, there are a couple David Kesslers out there writing books. This is the pediatrician/FDA Kessler, not the writes-about-dying Kessler.

Amazon has a sale on 600 mainstream published ebooks for .99, 1.99, 2.99. I think Amazon is trying to convince publishers that they can move enough additional product at lower price points to make up for the lower price points. A lot of the books involved have been out for a few years and some of them appear to have not moved as well as their publishers might have expected them to (e.g. this book is also available as a "bargain book").

This particular book is about food/health policy and thus exactly the kind of book I would ordinarily love to read. However, I declined to buy it for over two years, because I was pretty sure I wasn't going to enjoy it. And I was right. In the interests of identifying the rhetorical "bones" of the book, I skimmed.

Kessler spends the first portion of the book arguing that in the 1980s, adult Americans started gaining weight in a way that they had never done previously. A certain segment of adult Americans was gaining a disproportionate amount of that weight. The next chunk of the book is devoted to understanding how this segment of adult Americans differs from other adult Americans, and how it isn't just poor impulse control (that is, not just a willpower deficit). Having spent time understanding the psychology and biology of this group of people and deciding that it isn't actually possible to identify whether they are this way due to heredity or biology, he explores how in the 1980s and later, our environment became increasingly obesigenic. His focus is on pervasiveness of food and lack of structured eating patterns, portion size increases, etc.

About the point at which you might expect him to say, it's wrong for an industry to exploit a group of people who are innately unable to resist and we should change things again (either go back to a previous way of doing things, regulate industry, blah, blah, bleeping, blah), he instead embarks on a relatively standard CBT approach to establishing new habits as a way of controlling his invented disorder "conditioned hypereating". After motoring through the usual (just saying no isn't enough, you need to have an alternative action to trigger when you encounter a cue; avoid people and places you associate with your addiction, blah, blah, bleeping, blah), he concludes with thinly disguised advocacy for an Atkins style diet (lots of protein -- yet all examples given are animal products and usually flesh -- some vegetables, occasional fruit).

At the very end, he has a list of things we might do to deal with the obesigenic environment: menu labeling, food labeling, PSAs, etc.

That's the structure. Here's what's wrong with the structure.

He set up a very detailed, specific problem (some people in our society cannot resist the temptations that the food industry has sneaked into every corner of our world). He spent a lot of time on the science of this inability to resist. Yet somehow, a very, very typical strategy for self-control is presented as the solution. His "problem" and his "solution" do not match. (You can speculate about which one was wrong. This isn't a guy who is big on nuance, for one thing. That's partly why I started skimming. Any attention to detail just makes him impossible to read at all.)

He spent a handful of paragraphs on exercise, and described exercise as one of the few things which can be as rewarding as food and how it can change the way you see yourself and so forth. In the whole freaking book, he spends a handful of paragraphs on what he himself describes as the best predictor of whether you'll keep weight off once you lose it.

He has bought into the "choice" framework. His few regulatory solutions (menu labeling) suggest that somehow there might _be_ a good-enough choice if we just knew which one it is. I've spent years trying to figure out things to order that satisfy my personal dietary constraints (milk allergic, sodium sensitive, problems with some shellfish, and a few other odds and ends). There are a lot of places where there is genuinely nothing that I can eat at all, and many, many, many places where there is nothing I can order that won't cause me at least some problems. "Choice" frameworks, even with more information, are inadequate (_you_ try to find something low sodium -- let's define it as 1 mg of sodium or less per calorie -- on the McDonald's Menu. Other than the side salad. Good luck.).

There are a lot of other ways to go after this book, this author, and his very, very, very anti-regulatory approach to an extremely serious social problem. I decline.

Don't waste your time or your money.

My sister asked about the pennies thing

http://www.csmonitor.com/Business/2011/0606/2-500-pennies-Is-it-legal-to-pay-a-bill-in-pennies

Her question involved whether the business had to accept the pennies as payment. This article addresses that question. My sister also wanted to know whether this disorderly conduct thing made sense just for paying in pennies. My guess had been that there was more to the story than just paying in pennies -- and in the event, he was apparently huffy and the pennies weren't wrapped. 2500 pennies -- 2500 of a lot of anything big or small -- can make a real mess.

If you attempt payment on a bill using US currency in the US and the person refuses the payment, it turns out to be really hard to use the court system to go after them for nonpayment. This, of course, is a lot different than the examples included in the article (buses only taking change, places refusing hundreds, etc.), in which the person refuses to _sell_ something to you.

Mental Illness and Screening

No, not screening for mental illness.

http://www.psypost.org/2010/12/mental-illness-inadequate-screening-medical-conditions-3046

This isn't precisely what I was looking for, altho it is an example of it.

We are increasingly assessing the quality of health care on a "report card basis". Doctors in particular are pressured to provide care according to "best practice" in particular things that can be enumerated and/or measured. Thus, did you screen for colon cancer when the person turned 50? Did you you prescribe a statin if blood work came back with certain numbers? Etc. As we get better at not killing off (on purpose or inadvertently or through accident or neglect or criminalizing or whatever) people who had mental illness (whether a developmental delay or, as in the study referred to at the link above, schizophrenia or something else), there are more people who are adults eligible for screening services but whose caretakers (parents, generally) have died. Their status may be very ambiguous (receiving social service disability, say, but living somewhat independently) and depending on the kind and degree of impairment, they may not be able to give informed consent to medical procedures such as a colonoscopy. And there might not be anyone who can give consent on their behalf.

This is a problem that is very real, and really distressing to health care providers (I know; I talked to one of them on Sunday about this topic). And we're still at the nag-at-the-doctor-to-do-more-screening stage.

Lame.

One of the most basic rules of medical care is you don't do testing that you are not prepared to take action on. You just get all the risks of the test without any possible benefit. When I consider what went into convincing my walking partner to get a haircut, and the preparation necessary for her to get her wisdom teeth pulled (years, in both cases), I cannot _imagine_ the rationale for trying to line up a colonoscopy for everyone similarly cognitively and emotionally impaired. It just is not worth it. For one thing, you'd never shepherd the person through colon cancer treatment if the test came up positive (which it pretty much won't, and even if it did, we're probably overtreating anyway). You'd just wind up more trials like the obscenity recently perpetrated against the mother who declined to inflict leukemia treatment on her autistic son.

We can do better than this. Fixing the things we think we can fix is NOT a valid "ideal", certainly not valid enough to force it on everyone without contemplating the variability of costs. We need a better model of health care.

_Dear John, I Love Jane_

Subtitled: Women Write About Leaving Men for Women

A collection of essays as described by the title and subtitled, edited by Candace Walsh and Laura Andre with an introduction by Lisa "Sexual Fluidity" Diamond.

I'm never quite sure what I should say about myself when reviewing a book like this. I am a woman married to a man, so the assumption is going to tend to be that I identify as heterosexual and the assumption is wrong. Just 'cause I'm monogamous doesn't mean I'm not still bi- and poly. You don't need to speculate about whether I'm reading this book because I'm Figuring Something Out because I figured all that out a long while ago.

The editors picked a diverse group of contributors: women of color, women in interracial relationships, women born in a variety of decades, in a variety of regions. Women who ultimately identify as lesbian. Women who insist on not being labeled. Women who identify as something they would probably call bisexual, only bisexual has such a bad rep in so many communities and such a lot of silly expectations associated with it that it was rejected out of hand. If I have a complaint about this book, it's that latter: all the women who reject the word bisexual, because they have ideas about what that word means that strike me as every bit as prejudiced and wrong-headed as the prejudices about being lesbian or whatever that they had to get over in order to have any personal integrity, find love, have hot sex, etc.

Good collection, good stories, kind of annoying to slog through all the anti-bi propaganda. _Profoundly_ annoying little epilog at the end by Baumgardner about how "Falling in love with a woman, as a woman, is deeply linked to feminist endeavors". I _hate_ ideas like that. They do a massive disservice to feminism and warp politics and personal connection in ways that damage both.

To be utterly clear, however, I don't think that Lisa Diamond or her idea of "sexual fluidity" should be blamed for the anti-bi propaganda. I was wondering about that, and will probably get her book to find out for sure, but my sense is that she's desperately trying to help women who are getting railroaded from the "you must be straight" camp to the "oh, okay, you must be lesbian" camp when in fact their identity either is genuinely changing at one or more points in their lives (not due to choice!) or their identity is a poor match for either (ditto). That does shine through, ultimately, making this a very worthwhile read. More nuance in coming out stories is a good thing.

A number of the stories involving younger women (born after 1970ish, say) with relatively straightforward lesbian sexual identity sound like classics from a bygone era: they didn't even let themselves know how they felt about women because they were part of a community (Mormon, Evangelical, etc.) which was going to toss them if they didn't put up a very convincing heterosexual front. Poly- is touched upon briefly in one of the younger women's stories, but is part of a community she participates in rather than something she adopts.

For all Baumgardner speculates that "I imagine you may have gotten it in order to support or understand a loved one who has a story similar ... Or, more likely, you are living a story similar to", there's a lot of enjoyment to be found in these stories by anyone who enjoys a good story. Try not to get too bogged down in the politics of it all. (On sale as an ebook for the kindle for .99.)