bearing blog

Home care.

Megan McArdle has a piece on healthcare cost-cutting and hospitalization stay-length:

If you've been wondering about the rather light posting schedule, here's most of the explanation: two Saturdays ago, my mother's appendix burst.  It was a lengthy, draining saga that fouled up a rather full writing schedule.  We just brought her home from the hospital today; she'll be staying with us while she finishes a course of IV antibiotics.  Luckily, we're both writers with a great deal of flexibility about where we can work, and we have a spare bedroom, and the means to purchase a bed for her to stay on.

...Hospital costs were a huge political issue throughout the 1970s.  Jimmy Carter unsuccessfully tried to pass price controls, but ultimately, the government settled on a system that paid a fixed reimbursement for a given class of problem, rather than just paying the hospital for however long they'd care to keep patient. (A system known as Diagnostic Related Groups, or DRGs).  The length of hospital visits dropped like a stone--from an average of 7.5 days in 1980 to 4.8 today.  Most of that change was accomplished by 1995.

I know all the reasons why this is a good idea.  Hospital days are unbelievably expensive.  And hospitals are not fun places to be.  They're noisy and the amenities aren't too great.  They're also a great place to pick up a hospital acquired infection--and hospitals are the primary vectors for really nasty drug resistant bacteria.

 

But it's hell on the families--the web is full of people who are at their wits end because the hospital just dumped Mom on them even though Mom can't really walk or use the toilet.

...One way to think about it is that we made a policy choice to save money by turning family and friends into parahealth professionals.  In my case, I think that's the right choice: I'm happy to take care of my mother, and I understand the cost pressures that made this desirable.

 

  The problem is, most people didn't participate in that choice.  There was no public debate over whether we should send elderly patients home in terminal condition to families with no training as health workers.  We just said "let's cut hospital costs!" and everyone said "Yay!" and then some folks in a back room decided that this was the way to do it. 

 

So "one way to think about it" is that lately we have "made a policy choice to save money by turning family and friends into parahealth professionals."  Another way to think of it is that, long ago, we made a policy choice to spend money -- and ostensibly to provide better care -- by professionalizing convalescent, hospice, and recovery care, which used to be done (for better or worse) by family members.

 

This doesn't purport to be an argument for or against insurance coverage of longer hospital stays, just a musing on some unintended consequences.

 

I have no doubt that a lot of people would be better off cared for by hospital staff than by family members.  And many people have no one to care for them at all.  

 

But I think it's worth remembering that "sickroom care" was once a natural part of homemaking, and families used to have the skills to care for relatives who were suffering from a wide variety of ailments.  We're talking about something that is a lost art, not an impossible art.  Old homemaking manuals used to have chapters about it (here's one); sometimes even cookbooks would.  There was one around the house when I was a child -- heaven knows where it came from -- and I used to read the "sick room" chapter with fascination -- how to clean and sterilize a bedpan and wrap it in a neat package of clean newspaper to keep it read y for use, and the importance of giving the patient as much privacy as possible (even if that is only turning your face casually away) while he or she uses it;  how many visitors are appropriate; what to do with infectious garbage; how often to change the sheets; how to avoid bedsores.

 

Homemaking manuals don't seem to have this chapter anymore.

 

 It seems pretty obvious that when people grow to expect professionals to do the work of caring for the sick, both the recovering and the dying, then that work is no longer seen as the proper expertise of loved ones.  Either it is above them (and doctors and professional nurses should do it) or it is below them (and health care techs and janitors should do it).  

Maybe one way to lower costs, and improve care at the same time, is to invest in caregiver support rather than hospital stays.  

Is it better that hospital care be available?  Obviously so, at least for many cases.  It's hard, though, not to see some parallels to the home birth movement.  Sometimes people choose to forgo technology, professional health care workers, and a sterile environment, because they have an alternative:  human hands, loved ones who (unprofessionally) love them and desire the best for them, and a familiar home environment.  When it becomes the norm to professionalize a caregiving environment, surely a great many people have better outcomes (especially those who do not have the alternative) -- but there are also a large class of people who won't really have "better" outcomes and who will have lost out on a real opportunity for human connection, human relationship building, the experience of relying on others or of caring for others because that's what human beings do.

Maybe we need a home convalescence movement, or a home hospice movement, the way we have a home birth movement.   (If that's so, then we could use some "midwives:"  experienced and caring, but not necessarily professionally trained and licensed, women and men whose passion is to help people help themselves in their own homes.)  It's surely not for everyone, but it could well be -- for more people than realize it.

UPDATE:  Oh goodness, a McArdle-lanche.  Welcome to my hastily-tossed-off post.  You may be interested in other posts partly inspired by discussions at Megan's blog, many of which are in my weight loss category.  There is also politics (lately material about the HHS contraception mandate) and homeschooling.

A more interesting statistic about Catholics and birth control.

In one sense, statistics about "who does what" are irrelevant.   The fight to overturn the HHS mandate forcing insurers and/or employers to cover contraception is a fight about religious freedom, and it really doesn't matter how many people use contraception and how many employers object to paying for it directly or indirectly.  

It is, after all, religious minorities -- groups of people who adhere to beliefs that are unusual in the wider society -- who require the most protection and who desire the most accommodation in the civil structure.  If your philosophical beliefs and practices are common, ordinary, and widespread -- such as making time for worship on the weekends, or eating only non-animal foods, or giving presents to your children on a quiet, at-home Christmas morning -- we can assume that there is some accommodation for them built right into the fabric of society, since some of your co-believers will have helped put that society together.  Indeed, if we look around we see that many jobs (though not all) are available which leave room for weekend worship, that Christmas is a day when few people (though not without exception) have obligations outside the family, that vegetarianism is largely accepted and that many eating establishments offer meatless items year-round.

If you're a member of a religious minority, though, you occasionally may ask for, and legitimately receive, accommodations written into the law.  Laws like the 1993 Religious Freedom Restoration Act, which prohibits the federal government from burdening a person's exercise of religion unless it demonstrates that it does so in furtherance of a compelling government interest AND  is the least restrictive means of doing so.  The mandate doesn't further the government's interest (which is stated to increase "access" to contraception, and that has been shown not to be a problem) and it's not the least restrictive means (which would be something like a rider that an employee can purchase) and so the 1993 law, enacted during the notoriously right-wing Clinton administration, almost certainly renders the HHS mandate illegal.  

But it's obvious that the media is happy to wave this "98 percent of Catholic women use birth control" statistic around because someone thinks  it matters, or that it will matter if enough people hear it.  I think the idea must be something along these lines: Few Catholics consistently obey the Church's teachings, therefore we can make the nation think that it isn't a "real" or sincere religious belief that deserves accommodation.

If that's the case, then there is a lot of misdirection going on.  Because of course the freedom that is being infringed here is not the freedom to refrain from taking contraceptive pills or being sterilized.  (The government had to stop forcing people to contracept and be sterilized some time ago... must have been back in the dark ages... oh wait, it was 1981.)

No, the freedom being infringed is the freedom not to buy pills and sterilization for other people who want them.  So perhaps a much, much better thing to ask is:  "How many Catholic employers and insurers either cover contraceptives in their employee insurance plan or directly pay for them for their employees?"

Oops, now we have a conundrum.  Because if the number is small compared to the general population of employers and insurers, well then, there just might be something to the argument that Catholic employers and insurers have a real and sincere religious belief that precludes them from paying for other people's contraceptives.  And if the number is similar or large compared to the general population of employers and insurers, well, then, what exactly is the problem that needs to be solved by forcing them?  

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But even the question of "how sincere is this religious belief" is misdirected.  There is no test for sincerity in the Clinton-era law protecting the free exercise of religion against the federal government.  

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Here is a pair of recent statistics that you may find interesting.  (Via Red Cardigan, who herself found it via Get Religion).  

Of U. S. Catholics:

•  Fraction who say they attend Mass once a week or more:  22%. 
•  Fraction who say they agree that using artificial means of birth control is wrong:  22%.

(The first statistic is from CARA, a Catholic think tank.  The second is from a recent CNN poll.)

Only twenty-two percent of people who call themselves Catholics are going to Mass once a week.  This number is, of course, disturbingly low.  Recall that weekly Mass attendance is, in the Catholic faith, compulsory (though allowances are made, on the honor system, for duties and conditions that interfere with the obligation).  

Often, when you wish to define who is and who isn't a "practicing" Catholic, weekly Mass attendance is used as a reasonable proxy.  It's a practice that is required by the Church, it is relatively easy to measure, and it is public.  It is debatable whether this is the best proxy, but it is at least convenient.

The same proportion of Catholics agree with the teaching against artificial birth control.

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Let's do a little calculation with estimates using data from the Pew Forum.   Nearly 24% of the U. S. population is Catholic.  Twenty-two percent of that is 5.3% of the U. S. population.  This is only a little bit more than the number of people (4.7%) who belong to non-Christian religions, who, I think most reasonable people agree, deserve careful attention to their religious accommodations because their minority status places them at the margins of public discourse.  Just as unpopular speech is the speech that most needs protection, uncommon exercises of religious belief are those that most need accommodation.

We are a religious minority.

It is not what we would choose, but it is the reality we live in.

 

Book review, part 2: Glucose and willpower.

(Part 1 of my review of  Willpower:  Rediscovering the Greatest Human Strength by Roy Baumeister and John Tierney is here)

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Sometimes, at the end of what feels like a long day, or a long mental effort, I have a feeling that I often describe as "brain-fried."  I've been struggling not to yell at the kids, I've been thinking about a blog post I need to write, I've been trying not to procrastinate the million things I need to do, and I have an inexplicable craving for things like mashed potatoes or chocolate -- and solitude.  Tierney and Baumeister use a different term, but I immediately recognized it.  They call it "ego depletion," and it is the state of having used up all your willpower.

Yes, "used up."  Here are what they have to say about it, based on the research described in the book:

1. Resisting temptation is only one way we use willpower. Three others are

• controlling display of emotion or emotional outburst; 
• making decisions; 
• and performing physical tasks that require skill, e.g., balancing speed and accuracy.

2.  You have a limited supply of willpower. Repeated effort at any of the willpower-using activities depletes it.  After trying to control yourself for long enough, you lack the self-control to do any of them.  It becomes more difficult to restrain your displays of emotion, to think about decisions you have to make, to practice your skills, or -- yes -- to resist temptations and urges.

3.  It's trying to control yourself, not succeeding, that depletes willpower.   Even if you give in, you're left with less willpower to work with.

4. When your blood glucose levels drop, your willpower depletes faster.  

5. Accordingly, raising your blood sugar (i.e., by consuming food) restores your willpower supply.  The fastest way to do this is, of course, easily digestible carbohydrates, but protein and more-healthful, more-slowly digestible carbohydrates also work, albeit more slowly.

6. At low glucose and low willpower, your brain turns its effort to other things.  It keeps working and consuming fuel at the same rate, but it gives up on the willpower-consuming activities.

7.  One of the things it turns to is trying to get you to raise your blood sugar.  Hello, carb cravings!

Tierney and Baumeister point out the obvious "Catch-22" for people who struggle with food cravings here:  You need willpower in order not to eat, and you need to eat in order to have willpower.  

Just as obvious is that, if what they are saying is true, then folks with impaired glucose tolerance -- insulin resistance, hypoglycemia, diabetes and prediabetes (even, they suggest, premenstrual syndrome!)  -- will frequently be in a state of (relatively) impaired impulse control and decisionmaking skills.  

We can get a little overfocused on overeating here at bearing blog.  Remember that impulse control applies to a lot of different areas of life (and indeed Tierney and Baumeister mention many):  drinking and drug abuse, procrastination, violent outbursts, child discipline, studying and schoolwork, performance at a variety of difficult tasks.

I have to go now (procrastinating long enough) but I'll post again with more insights about willpower, not so glucose related, and then try to tie them into some practical tips for behavioral change.

Book review, part 1: Willpower: Rediscovering the Greatest Human Strength.

This past week I finished reading Willpower:  Rediscovering the Greatest Human Strength by Roy Baumeister and John Tierney.  I recommend it.  

As nonfiction goes, it's a fairly light and quick read, and interesting:  I would rank it with Brian Wansink's Mindless Eating in the pop psychology genre.  Like those Wansink describes, some of the psychological experiments that Tierney and Baumeister recount (most of which were designed and executed by others) are interesting and creative.  Interesting, creative, and cruel:  I really, really felt bad for some of the experimental subjects, who had to do things like

1. first, fast for many hours
2. then, hungry, be ushered into a waiting room filled with the smell of baking cookies
3. sit next to a bowl of freshly baked chocolate chip cookies and be told "Those aren't for you, here, have one of these nice crunchy radishes instead"
4. finally be given "intelligence tests" which consisted of puzzles that, in fact, had no solution, the point being to measure how long the subjects sweated over them before they gave up trying.

The book also includes material gleaned from a handful of celebrities, either from interviews or from excerpts from memoirs.  Not sure why they had to be celebrities, but they do make for interesting stories.  How Drew Carey looked at his messy desk, said "Shit, man, I'm rich," and hired David Allen (of Getting Things Done) to work with him as a personal organizer for a year.  How Eric Clapton stopped drinking, and speculations as to how AA's "abandon yourself to a higher power" thing can work even for atheists.  How performance artist Amanda Palmer maintained composure as a living statue, standing perfectly still for three hours a day even in the face of people trying to anger or amuse her, and how it affected her for hours afterward.  There's also a historical discussion of Henry Stanley (he of "Dr. Livingstone, I presume?") and how his memoirs hint that he could maintain discipline -- both of himself and of the men under his command -- through truly horrific conditions.

But the real gem of Willpower is the insights it suggests from research, some of which are surprising -- but which explain a lot.  I hinted at this in a blog post I wrote  about sticking to your resolutions, which drew on an article written by Tierney, and also you can see a New York Times review of the book here which summarizes it pretty well.

Before getting into the specific insights, though, let's talk about the problem posed by the very idea of "willpower" itself.   Some people, to be blunt, believe there is no such thing, pointing to various research findings that convincingly show that we are so often driven by forces of which we are not conscious.  Others are wary of bringing up the possibility because it smacks so much of blaming people for the situation they find themselves in, which may largely be because of forces outside their control.  

In the obesity research world, there is a lot of evidence out there that "lack of willpower" is not the root reason for much of the obesity problem.  Take Gary Taubes's two books, Good Calories, Bad Calories (I reviewed it here) and Why We Get Fat (I reviewed it here, here, here).  Both of them make a very convincing case that intractable obesity is caused by a biochemical vicious cycle that is triggered by exposure -- maybe even as early as in utero! -- to a diet of sugars and other refined carbohydrates.   The cravings and the difficulty resisting them are both products of broken hormonal signals, according to this model, and so you simply cannot say that obesity can be "fixed" through application of willpower alone to resist the temptation to overeat.  From Good Calories, Bad Calories:  "Though the traditional response to the failure of semi-starvation diets to produce long-term weight loss has been to blame the fat person for a lack of willpower... [some] have argued that this failure is precisely the evidence that tells us positive caloric balance or overeating is not the underlying disorder in obesity."

So let's stipulate for the purposes that this is true:  our decisions to give in, or not to give in, very often come from unconscious processes, or biochemical urges, or explicable impulses.  How do Tierney and Baumeister deal with that?  And the answer is that they  do it through a careful -- and useful -- definition of the terms "will" and "willpower."

The will is to be found in connecting units across time.... Will involves treating the current situation as part of a general pattern... You must treat (almost) every episode [of temptation] as a reflection of a general need to resist these temptations.

That's where conscious self-control comes in, and that's why it makes the difference between success and failure in just about every aspect of life.

The way I read it is this:  We may have no conscious and immediate control over the impulses that overtake us, the urges and cravings and temptations.  They may come from our environment or from chemical signals inside us.  And we may have little conscious and immediate control over the strength of our resistance against those impulses:  once the impulse has begun, if we are "caught out," there may be little we can do to fight against them.  

 

But we do have power to predict the impulses that may overtake us in the future, and we can take steps to prepare.  We can shape our environment so that they meet us on a battleground we have chosen, or we can avoid meeting them at all.  We can also whip ourselves into shape so that we have a better chance at resisting even if we are surprised by our impulses.

That is where the "will" part of "willpower" comes in.

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In a future post, I'll list some of the insights from the book that resonated with me.  Some of them, I met with a sense of recognition, as a general form of the specific insights that I discovered for myself during my weight loss and subsequent struggles with maintenance.  Finally, I'll discuss how I think people can harness these insights to hammer out a plan of action for personal change.

(I think I can write with some conviction and experience about how to harness willpower to overcome the specific fault of gluttony.  What I'd really like to do, though, is figure out how to harness it to overcome faults I'm still mired in.  Maybe, through continued writing about gluttony, I can see a way to draw analogies that will create a map to escape from those other faults as well.)

 

Well, this is a timely article: How to stick to your resolutions.

I was talking to Mark this evening about trying to nail down the general principles of behavioral change -- not the list of "handy weight loss tips," but the general principles that I've followed to choose my new, permanent habits and to make them stick.  

All right, I'm fessing up:  I've been tossing around the idea of putting these disconnected eating-and-exercise blog posts into a longer and more organized form.  What I'm not yet sure about is focus:  gluttony?  personal change in general?  willpower defeating?  straight-up weight loss?

Anyway, I was amused tonight to encounter this article from the NYT's John Tierney, "Be It Resolved," which is very much like the sort of thing I was envisioning writing.

IT’S still early in 2012, so let’s be optimistic. Let’s assume you have made a New Year’s resolution and have not yet broken it. Based on studies of past resolutions, here are some uplifting predictions:

1) Whatever you hope for this year — to lose weight, to exercise more, to spend less money — you’re much more likely to make improvements than someone who hasn’t made a formal resolution.

2) If you can make it through the rest of January, you have a good chance of lasting a lot longer.

3) With a few relatively painless strategies and new digital tools, you can significantly boost your odds of success.

Now for a not-so-uplifting prediction: Most people are not going to keep their resolutions all year long. They’ll start out with the best of intentions but the worst of strategies, expecting that they’ll somehow find the willpower to resist temptation after temptation. By the end of January, a third will have broken their resolutions, and by July more than half will have lapsed.

They’ll fail because they’ll eventually run out of willpower, which social scientists no longer regard as simply a metaphor. They’ve recently reported that willpower is a real form of mental energy, powered by glucose in the bloodstream, which is used up as you exert self-control.

Well, that explains a lot.  Dieting is hard because low blood sugar depletes your willpower!  

But this is the paragraph in the article that really resonated with me (emphasis mine):

One of their newest studies, published last month in the Journal of Personality and Social Psychology, tracked people’s reactions to temptations throughout the day. The study, led by Wilhelm Hofmann of the University of Chicago, showed that the people with the best self-control, paradoxically, are the ones who use their willpower less often. Instead of fending off one urge after another, these people set up their lives to minimize temptations. They play offense, not defense, using their willpower in advance so that they avoid crises, conserve their energy and outsource as much self-control as they can.

This.  This.  A thousand times this.  Using willpower sucks, so you have to exert it in advance.  So much of what worked for me is about this very principle.

The article goes on to give a somewhat outlandish anecdote and then from it derives some strategies that ring very true to me:

• Set one clear goal at a time
• Precommit (like Odysseus lashing himself  to the mast, remove your options to break your resolution)
• Be accountable to someone else, and plan to pay a real penalty if you don't reach your goal
• Keep track of how you are doing
• Don't overreact to a lapse by saying "what the hell" and figuring the day's already ruined
• Tell yourself you can have some later (rather than swearing off pleasures for good)
• Reward yourself, or find reward in your actions, often.

I will have to spend some time thinking about this -- but maybe the first step is to read the book about willpower that is referenced in the article.

Negotiation and gender.

I'm really intrigued by Megan McArdle's description (okay, it's third-hand, hence the multiply nested blockquotes) of a study on gender norms in negotiation situations:

[MEGAN McA.]: One of the reasons that women are paid less than men is that they don't negotiate.  The advice that follows is usually, "Well, negotiate!"  But in fact, women don't negotiate for very good reason, as Kevin Drum points out:

[KEVIN D.] I apologize for sticking around, but there's a reason. I've run into this before myself, and have always told women "Just ask! The worst that can happen is that they say no." But that's not actually the case. Here's a bit of research on the subject:

 

Their study...found that women's reluctance [to negotiate] was based on an entirely reasonable and accurate view of how they were likely to be treated if they did...."What we found across all the studies is men were always less willing to work with a woman who had attempted to negotiate than with a woman who did not," Bowles said. "They always preferred to work with a woman who stayed mum. But it made no difference to the men whether a guy had chosen to negotiate or not."

 

[Back to MEGAN McA.] When I was in business school, I learned about a case that had been run experimentally.  I may hash some of the details, but the gist is that half the classes that used it read about "John" facing a tough management problem, while the other half read about "Jane" facing the same problem.  No detail other than the names had been changed.

But what a difference a name makes!  "John" was a strong, thoughtful leader making tough choices about what was best for his group.  "Jane" was a headstrong bitch who was wildly overstepping her authority and generally making a mess of things.

No woman is unaware of these dynamics. 

Let's see if I can sum this up correctly -- negotiation is in reality a riskier game for women to play, so they act in their own interest by doing it less often (or perhaps less directly).   Instructing women to negotiate, then, perhaps may meet with one measure of success (more women will attempt to make gains by negotiating) but maybe will be repaid by biteback (some may be "punished" for the effort).  

I would really like to write about this subject from personal experience because it intrigues me, but I am spectacularly disqualified to comment on my own ability to negotiate or on my response to other people negotiating, as I have historically been an opinionated yet socially awkward introvert with a fixation on facts rather than feelings, probably somewhere on the Asperger's spectrum, and am therefore among the "no" women whom McArdle says are "unaware of these dynamics."

As the commenters on the thread take the time to point out, it would be a mistake to assume that the hostility toward women who negotiate is conscious and overt.  It would also be a mistake to assume that it's primarily men who unconsciously punish women who attempt to negotiate; probably women and men both do it.    

One thing I find particularly fascinating is the notion of a person who lacks natural social gifts, or who is hampered by prejudices around them, creating sets of rules to mitigate the situation.  That is, deliberate behaviors that attempt to create the social interactions that we imagine a truly successful or powerful or gregarious or friendly person can conjure up naturally and without having to think about it.  Ways to manipulate people!

(Kind of analogous to a colorblind person imposing a rule on herself to always dress in basic black with a single colorful accessory.)

One commenter writes,

I had read the study Drum references before, and after I saw it I started using two strategies that work well so far: (1) When I'm disagreeing with a man who has a moderately to very high opinion of himself, I smile while I disagree. (2) If I'm giving a presentation with a man, and he speaks first because of the way our presentation is structured or something, I take a step in front of him to address the group.

Small body language things, not threatening, that still allow me to be assertive without offending anyone's subconscious. It's not the way it should be, but it works: I have good relationships with and respect from co-workers and management in a majority-male environment.

Boy, I could have used a lot of tips like this in my past life.   There's no need that they have to be laden with judgments about which sex is friendlier or more open or more assertive and whether that's better or whatever, or whether our expectations are good or bad.  It seems not unreasonable just to accept that human nature is what it is, and many cultural forces are what they are, and women and men live (typically) under different sets of unconscious expectations and have therefore evolved (typically) different common strategies to meet their goals.  Encouraging women and men to adopt each other's apparently successful strategies will likely backfire when it turns out that the unconscious expectations in the environment are not so mutable.

Thoughts?

Secrets of Feeding a Healthy Family review part 3: Some good stuff.

In the last two posts (#1 and #2) about Secrets of Feeding a Healthy Family by Ellyn Satter, I pointed out problems and inconsistencies I perceived in the book.  Now I want to write more about things I found helpful or that I  particularly liked.

The book has an odd structure.   From the title, you might guess that it's mainly about how to feed children.  But that's only what the middle section of the book is about.  The subtitle is a little more descriptive:  How to Eat, How to Raise Good Eaters, How to Cook.   

I suspect with this title, the book is trying to set a trap.  Parents will pick the book up hoping that it will help them get their picky eaters to eat, or maybe hoping that they can curtail a junk-food habit.  And then, perhaps, they will discover that part of the problem is that they (the grownups) have unresolved food issues -- maybe even eating disorders -- themselves, and that before they can teach good food-acceptance and food-choosing skills to their children, they will have to work on their own issues.

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That first part -- "How to Eat" -- is aimed at people who really don't know how to feed themselves, or who have such awful emotional issues around eating that they do not possess the skills to eat normally, or who suffer from eating disorders.   It's not a comprehensively long section, but I think it contains some good stuff. 

As I wrote before, Satter comes from the "accept your body at the weight it is" school of weight-writers, and one of her chapter titles is "Eat as much as you want."    I do not share the fatalistic "you can't lose weight and you shouldn't try" attitude, and I think "Eat as much as you want" is correct only as long as your "want" is in conformity with the requirements of your body, duties, and state in life.  But we have to have our priorities right, and changing one thing at a time is often best; and if you lack the most basic skills of feeding yourself, or suffer from a clinical eating disorder, or experience terrible emotional reactions to food and eating -- as, apparently, do many of the people that Satter works with -- then probably you need to put healing first, and shelve concerns about weight or even the advanced topic of gluttony until you've mastered simply feeding yourself.  

Indeed, I suspect that Satter's focus comes from being used to working with people whose weight problem is not their biggest problem, and for whom over- or under-eating is a symptom of an underlying disorder.    Just to give you some perspective:   Her anecdotes include

• a woman who required weeks of therapy to muster the courage to taste a strawberry
• a man who felt guilty about consuming a single bite of anything that wasn't bland,  
• and a woman who thought it was obscene that her seven-month-old liked eating.    

For these folks, worrying about weight or gluttony would be counterproductive.

Still, for those of us who aren't quite so far gone, and who understand that "acknowledging a moral fault" isn't the same thing as "descending into a spiral of negative emotions and self-hatred," speaking of "gluttony" can be helpful.   In myself I found that gluttony, as a moral fault, was inextricably bound up with physical and psychological problems.  Physically, I had to reconnect with my sensations of hunger and satiety, as Satter recommends; once I'd done so I was less enslaved by gluttony, but even to take that first step required resisting gluttonous impulses -- that first step, in other words, was a moral victory.    And preceding that was a desire to be freed from the impulse-pleasure cycle, a desire that can only have been put in my heart by God.   Psychologically, I continue to struggle with the impulses of bulimia; I have the most success when I acknowledge a spiritual and moral component to that struggle.  We should never be surprised that the mind, the body, and the will are entangled, and that all three need to be taken together as a united whole.

To that end, Satter's book contains tools and ideas that can help someone who's trying to release herself from the hold of gluttony.  Here are some that I find especially powerful:

•  The idea that "eating competence" can be broken down into a set of discrete skills which can be individually learned.
• The idea that food needs fall into a hierarchy, and that more-fundamental needs should take priority over less-fundamental ones.  
•  A good description of "normal eating."
• Tips for being satisfied at meals.
•  The idea that "food acceptance" (the opposite of pickiness) can be broken down into a set of discrete skills which can be individually learned.
• A technique for learning to recognize the signals of hunger and satiety.
• Tips for learning to eat at meals (instead of grazing) and for organizing successful family meals.
• A philosophy for dividing responsibility for children's nutrition between the parent and the child at various ages. 

All of these are good, and I'll write more about them in subsequent posts.

 

Review part 2 of Secrets of Feeding a Healthy Family: Virtue and restraint.

(Part 1 here)

So there's a couple of turns of phrase in Ellyn Satter's Secrets of Feeding a Healthy Family that sets off red lights and sirens for the likes of me.

The first one is "Shun Virtue."  Yes, you heard that right:  shun virtue.  It even appears in the index:  "Virtue, shunning, 20."

The second one is "Restraint is profoundly unrealistic."  "The research is clear that restrained eating profoundly disrupts eating attitudes and behaviors" (okay, that's circular) "as well as destabilizes body weight."

Let me first give you an idea of the grain of salt you need to tuck into your cheek here.  Note that she does not say that the research is clear that restrained eating causes, or even is associated with bad outcomes -- only that it's associated with weight instability, which in turn is associated with bad outcomes.  And although the heading "Restrained Eating" in the appendix (pp. 240-241) is followed by a column and a half of text with citations, only a couple of these are actually about so-called "restrained eaters."  Just one of those looks well-supported to me, and I'll write more about that one further down.

But more to the point, how can we take anyone seriously who says "shun virtue" and "restraint is unrealistic?"  I'm automatically suspicious of the "restraint is unrealistic" line, because in my experience it's often the backbone of an entire philosophy of existence, life, and education -- a philosophy which I utterly reject.   It comes too often with advice to "do what feels good", justified by the assertion that self-control is inherently damaging, and that our pent-up frustration will find an outlet in psychological problems or some kind of binge.  We Catholics are certainly familiar with analogous philosophies in sexual matters, no?
 
I'm not saying that Satter espouses a "do what feels good" philosophy, or even that she's incorrect in suggesting that "restrained eaters" really do tend to binge as a reaction to their restraint (more on that later -- I think the evidence is that some of them do).  I'm just saying that the twin phrases "shun virtue" and "restraint is unrealistic" make me instantly skeptical.

But maybe the problem is one of defining one's terms.  Obviously Satter's not setting out to write a book about virtue and vice.  She's not, then, using the term "virtue" and "restraint" in the same way that we are -- they aren't theological jargon, but some jargon of her own.  So what does she mean?

A quote:

When I helped Wesley learn to feed himself in a more positive and nurturing way, I encouraged him to have regular meals.  This brought us right up against his well-developed pattern of freaking himself out with the food rules, and together we apprehended him again and again when he went chasing off after the food rules and neglected to provide himself with foods he enjoyed.  When his eating became chaotic, we traced it to his out-of-control virtue.  You understand the dilemma of the overdeveloped conscience if you order broiled fish when you really want it fried, and then give in to cheesecake when the dessert tray comes around.  If you truly enjoy broiled fish, you will have to come up with some other example of out-of-control virtue, but the point stands:  If you can't give yourself permission to eat the foods you enjoy, you will have to rely on impulse to get them.

She's using the word "virtue" to mean something it never means in ordinary usage:  something bad.  Can real virtue get "out of control" and become bad?  I think not, although we can misunderstand what behaviors are required for the practice of virtue (and become prudish when we intended to be modest, for example).  So -- this is an error on her part, and it sounds to me like she's unfamiliar with the language of virtue -- or else she would choose a different word.   (Note too the reference to an "overdeveloped conscience."  No such thing.  You can have a perverted conscience, though, which is what she really means:  a conscience that tells you good things are bad.)

What Satter means for the reader to shun is food scrupulosity:  excessive rule-following coupled to self-judging with respect to the rules.  She calls this "virtue." I hope it does not reflect upon her opinions about people who really do try to be virtuous in the correct sense!

That takes care of "virtue."  Now, how about "restraint?"  What does she mean by a "restrained eater" or an "unrestrained eater?"

Helpfully, she includes a side box with a definition of "restrained eating."

As originally defined, restrained eating is trying to get yourself to eat less food or less-desirable food than you really want in pursuit of thinness [or health]."

• Imposing absolute limits:  so many calories, so many helpings.  Going by portion sizes or a food pattern. 
• Making yourself hurdle:  "I have to eat this before I can eat that."
• Avoiding certain foods...
• Limiting your menus to drab, uninspiring foods
• Trying to fill up on low-fat, low-calorie, "healthy" food
• Trying to eat only low-carb...
• Substituting low-calorie butter, margarine, or salad dressing for the real thing in order to save calories.
• Asking yourself "Do I really need that?"

This is what she means whenever she talks about "restraint."  She clearly doesn't mean all kinds of self-control, because (while she recommends "self-trusting" eating) she does make recommendations that require self-control or self-discipline, and even an imposed outside structure.  For example:

•  She advocates eating as part of regular meals and snacks -- not grazing.
• She offers techniques for learning to like new foods through controlled exposure.  (Some of us find it hard to believe you might need self-discipline to get yourself to eat more of something, but indeed you do.)
• She advocates "tuning in" and "staying in touch with your feelings of hunger and eagerness to eat" while eating -- mindful eating.  She even advises, "That takes effort."  In other words, she advocates slowing down and paying attention.  
• She even gives an excruciatingly detailed technique for learning to notice hunger and satiety signals, right down to how long to chew a mouthful of food.  If that isn't controlled, I don't know what is!

 
It's pretty clear that she thinks *her* messages are all about trust and not control or restraint, but I'm not buying that the distinction is all that clear.  (Similarly, she writes lots of stuff about how children need to be free to take as much or as little of a food as they want -- but when you get right down to it, even she says that children should only be given one helping of bread lest they fill up on it!  And she even advocates making "rules" -- her word, not mine -- about Halloween candy.  Gasp!  Rules!)

So.  What does her "unrestrained eating" have to do with gluttony?  When she says "get rid of restraint," is she inviting us to be gluttons?

What's usually cited as Aquinas's "definition" of gluttony is really more of a classification of gluttonies (too much, too soon, too eagerly, too pickily, too expensively).  I made a stab at defining gluttony here:  gluttony abhors the restraints on food that are necessary according to our state in life.  Restraints are placed on us by a number of different requirements:  charity, obedience, resources, physical health, religious or ethical duties, and manners, among other things.  If you can't stand to make your food intake conform to these requirements, you might be a glutton.

It's really clear from reading Satter that with her term "restrained eating" she doesn't mean to condemn any of the restraints I mention above -- except those we perceive we need for physical health and especially thinness.  For example, she strongly emphasizes table manners, and demonstrates sensitivity to food budgets or cultural differences in food traditions.  

As far as I can tell, though, she completely ignores a distinction between our real physical constraints and our perceived ones, and condemns as dangerous "restrained eating" any self-control in pursuit of help.  

Can she really mean this?  I assume, for instance, that she wouldn't advocate ignoring the restraints placed upon people by allergies, autoimmune diseases, or endocrine diseases like diabetes -- even though these involve eating "less" or "less-desirable" food "than you really want" in the pursuit of "health."   A diabetic simply cannot eat as much as he or she wants of whatever he or she wants.  And conditions like diabetes really do exist on a spectrum from healthy to pre-metabolic syndrome to metabolic syndrome to pre-diabetes to full-blown diabetes, itself on a continuum of severity.  So somewhere along the line, a person has to be aware that food choices affect health, and a little bit of "restraint" won't kill you.  But by ignoring the constraints placed on people by real physical disorders, she loses the opportunity to clarify when restraint is appropriate.

So I mentioned above that there was one thing about the dangers of restraint that made sense to me.  Here's the one thing she writes that looks plausible to me based on the citations, and that I'm willing to believe on her authority, given that she works with people who suffer from eating disorders:

Rather than overeating per se in response to stressors, restrained eaters suspend restraint:  They stop undereating.  Then, because restraint has been violated, rather than simply eating enough to satisfy hunger, they go on to overeat.

That sounds really familiar.  The term she uses for this pattern is "restraint and disinhibition."  And I think what it comes down to is this:  Following rules won't cure gluttony all by itself.  The tendency is still there.

And she may be right about this.  On the other hand, the problem may also be that the rules are poorly designed.  I tend to think that she doesn't really think all rules are bad; she just won't call the good rules "rules."  More on this another time.

Secrets of Feeding a Healthy Family" review part 1: What I learned from reading the appendices first.

So I finally gave up on reading Ellyn Satter's Secrets of Feeding a Healthy Family forwards, and started reading it backwards instead, starting with the appendix.  I'm not sure why, but I found that easier -- maybe I just wanted the details first.  Also, I was kind of curious what kind of publications the author cited.  

It seems that many of her publications appear in The Journal of Nutrition Education and Behavior, which is not a periodical I am familiar with.  This is the journal of the Society for Nutrition Education, an educational and advocacy organization.  So, more of an education journal than a nutrition-science journal.   Skimming through the abstracts, I see a lot of papers that are trying to answer the questions:  How do the messages that people hear influence the food choices they make?   How do people learn about nutrition?  What really helps people make positive changes?

All these are good questions to ask, especially if you are a parent, an educator, or a blogger who likes to write motivational posts about healthy, temperate eating.  It's worth noting that this is not the same question as "what food choices should I make to be physically healthier" or "how do I lose weight."

 I get the impression that Satter's area of expertise is in "how to teach children to eat well," "how to understand eating," "how to make positive choices," "how to navigate the confusing mix of food messages that we're all immersed in"  or "how to correct certain eating disorders."  Her focus isn't in biochemistry or in nutrition science:  "what kind of fat is best for you" or "how many calories should a person eat." 

But you wind up with a little bit of overlap, because Satter does have definite ideas about what kinds of positive change are most important, and that winds up getting presented as "make this kind of change first, save that other kind of change for later."  Which sounds a little bit like "this is what you should eat."  But it's not, actually, that kind of advice.  

So I guess I learned something useful from starting with the appendices after all.  This book is, among other things, about setting priorities for change to more positive eating.   And when it comes to priorities, Satter places nutritional content of the food considerably lower than the emotional context of the food.   So, for example, it's much more important to her that families eat regular meals together than, say, what those meals are made of.

+ +  +

Mark has a fair amount of exposure to food, nutrition, and food-marketing research, and is skeptical about sweeping claims drawn from studies that demonstrate correlation but not causation.  So, for example, take Appendix B, "What the Research Says about Meals."  Satter presents a whole string of data, citing twenty different sources, that shows strong associations between regular family meals and good outcomes in children and adolescents.  And then she concludes the appendix with this:  

The evidence is compelling... the day-to-day routine of structured, sit-down family meals and snacks reassures children that they are loved and that they will be provided for -- nutritionally and in all other ways.

Well, no.  The evidence actually is that children who have regular family meals tend to be healthier and do better and school and things than children who don't -- possibly because regular family meals are a marker for success, not a cause of it.  "When you start advising people to make a change, you'd better be sure that it's causation and not just correlation," warns Mark.  Now, I tend to think about many interventions-correlated-with-good-stuff, "Why not try it and see if it works?" but then, I'm biased towards thinking that something like family meals are a good end in themselves.  

Mark has a point:  If you start telling people that they should eat regular family meals together, you're telling a big chunk of the population, "You don't parent your children right... the way you do it is wrong... you might be to blame if your children have problems later."  These messages aren't without consequence, especially for the people who don't go on to make the recommended changes because of hardship or conflicting desires or whatever.  And if in fact family meals don't cause good outcomes, well, then your advice didn't actually help anyone.

So, there's a bit of a grain of salt to take the advice with:  correlation, not necessarily causation.  On the other hand, many of Satter's readers may desire things like regular family meals for their own sake, whether or not it makes the children better-behaved, smarter, or fitter.  And there's some advice in here about how to do it, even if you don't know how.  Believing that making some of these changes might help your family's physical and emotional health could provide some useful motivation.   

Another sweeping statement shows up in Appendix D, "BMI Mortality, Morbidity, and Health:  Resolving the Weight Dilemma."  After presenting some data that demonstrates what we already know (it's hard to lose weight) and what many people don't know (overweight isn't as strongly associated with bad health as a lot of people think it is), she goes on to advise:

[Weight loss] can't be achieved anyway... instead of trying for weight loss, focus on improving your health behaviors.  Establish goals that can be achieved:  

• Develop and maintain eating competence.
• Develop sustainable patterns of activity.
• Learn to feel good about yourself, just as you are.

She clearly believes that weight loss can't be achieved.  I'm all for developing eating competence, for learning to fit exercise into your life, and for getting rid of unhelpful negative thought patterns, but I don't like the "it's hopeless" attitude toward permanent weight loss.    

But in one sense she's correct that weight loss can't be achieved directly.   A weight loss "goal" isn't a real "goal" because it's not something you can decide to reach.  You can't exactly choose to lose weight.  What you can choose to do is change your behavior, and that might help with the weight loss you hope for, or it might not.  Desiring behavior change for its own sake is something I've written a lot about.   A behavior goal -- unlike a weight-loss goal -- is something that can be achieved merely by choice.  And such behavior goals include eating well and getting exercise.

("Learn to feel good about yourself just as you are," though... I'm having trouble finding any evidence that this is associated with better outcomes.  This sounds like touchy-feelyism to me.  And why should I work hard to develop eating competence or sustainable activity -- why should I try to improve anything at all about myself -- if I "feel good about myself just as I am?"  No, better to remain always aware of our shortcomings and always ready to work on them.  But this is obviously a philosophical difference, not a difference in expertise, between her and me.  I think it's an error to claim that science supports this kind of "should" philosophy -- either hers or mine.)

Because it's late, I'm going to stop here, even though there's more to be said about the appendices.  I'm particularly interested in what she has to say about "restrained eating," something she says is associated with bad outcomes.  A fair question:  Is "restrained eating" as Satter defines it the same as eating temperately?  Is "unrestrained eating" as Satter defines it the same as eating gluttonously?  Or is the unrestrained-restrained axis orthogonal to the temperance-gluttony axis?  Tune in later and I'll think out loud some more.

Anti-boy bias.

So there's some discussion going around about the AP story on the newest government study to show that young people are having less sex.

The thing I noticed about the article, though, is it's yet another example of  the all-too-common media pattern:

1.  Social scientists discover a trend.

2.  If the trend says anything about females, the reporter must leave readers with the impression that it says something good.

3.  If the trend says anything about males, then it must say something bad about them.

This survey found that, compared to 2002, rates of sexual experience among young men and young women have fallen.  So that's a good sign, right?

Well, it is if you're a high  school girl.  Learn from the AP's example:

"It's not even on my radar," said 17-year-old Abbey King of Hinsdale, Ill., a competitive swimmer who starts her day at 5 a.m. and falls into bed at 10:30 p.m. after swimming, school, weight lifting, running, more swimming, homework and a volunteer gig working with service dogs for the disabled....

She is on the junior board for Robert Crown Center for Health Education, a nonprofit organization that teaches sex ed to students in the Chicago area.

She sees sex, alcohol, smoking and drugs as distractions to her goal of getting a college scholarship in swimming, she said.

What a stellar example we have in Miss King, no kidding.

 On the other hand, if you're a guy, the reason you aren't getting laid is, likely, because you're too busy playing video games:

[Washington, D. C. based sex educator Yvonne Fulbright] suggested that some young men aren't making time for relationships.

"Some guys, at the end of the day, they'd rather channel their energy into music, playing their guitar or playing computer games," Fulbright said. "That's immediate gratification. People forget it takes work to woo somebody and keep her happy."

Yes, that's it.  Teen boys and young men aren't having sex as frequently because they prefer immediate gratification.   

I wonder why they didn't give us a concrete example of a young man who exemplifies the trend, preferring to speculate about stereotypes.  Pattern recognition, I mean.