Human Nature: Science, Technology, and Life.

Ambulances for the Ample

Everywhere you look, fat people are being charged extra. More for plane seats. More for health insurance. More, in the form of reduced incentive payouts, under proposals for Medicare and Medicaid.

Now, more for ambulance service.

We've talked about ambulances before. Along with toilets and coffins, they're part of a global size upgrade for bigger bodies. And it's expensive. Heather Hollingsworth of the Associated Press does the math:

Transporting extremely heavy people costs about 2 1/2 times as much as normal-weight patients. It takes more time to move them and requires three to four times more crew members, who often must use expensive specialty equipment. ... [One] unit in Topeka recently spent about $10,000 to retrofit an ambulance with equipment that accommodates patients weighing up to 1,600 pounds. Ambulance services with helicopters also are creating larger patient compartments and adding stronger gurneys. Sales of specialized lift systems nationwide are expected to reach $193 million by 2012, up from $75 million in 2004, according to EMS Insider, an industry newsletter. The sale of specialized stretchers is expected to nearly double to $50 million in 2012.

Now there's a movement to pass on the costs. Hollingsworth reports:

Ambulance companies say it's time for insurance providers, Medicaid and Medicare, or patients themselves to begin paying the added costs, which are cutting into their razor-thin profit margins. In the past, ambulance companies often absorbed the extra expense of serving the obese. Now they are adding charges similar to those already imposed on intensive-care patients, people requiring multiple medications and patients on ventilators.

The surcharge is significant. In several cities, ambulance services are billing nearly double for anyone over 500 pounds. In raw numbers, that's around $500 to $700. Fat-rights activists say the extra fees are discriminatory. The president of one group tells Hollingsworth, "Ambulance services are a critical public service and should accommodate the needs of all of those who require them at a fair cost."

I don't have a quick answer to this problem, but maybe we can start to think it through. First, we need to decide whether privately operated ambulances are, as the fat-rights spokesman says, a public service. It seems pretty clear, for example, that private airlines can make you pay double if you don't fit in a seat. Do ambulances have to play by nicer rules because medical services are inherently public? If so, shouldn't the public reimburse them?

Second, to the extent that fat is an issue of personal responsibility, does that really apply to ambulance service? Nobody's going to lose weight so they can save $700 on their next ambulance trip. To the extent that motivation can overcome obesity, the reason people are going to lose weight is to stay out of the hospital altogether.

Third, if you think fat people should bear the extra cost of transporting them, what does that say about your overall views on insurance for preexisting conditions? The health-care reforms being debated in Congress would bar insurers from excluding people with pre-existing conditions. The argument is that people aren't responsible for such conditions and shouldn't be priced out of the insurance market on account of them. Therefore, we would socialize their extra cost. Is that OK with you? If so, to the extent that obesity is genetically or environmentally induced, shouldn't we treat it the same way?

Big Brother Is Watching Your Weight

When the government tells insurers what they can or can't do, it's easy to restrict outcome-based incentives for weight loss. Why let those nasty, greedy companies charge people more for being fat? But the public sector is a different ballgame. When taxpayers fund wellness incentives, they're entitled to see results. So don't expect the government to protect fat people from outcome-based incentives while footing the bill for health care. The more it pays, the more results it will demand.

More here.

Mini Soda: The New Light Cigarette?

You'll drink Coke mini for the same reason you already drink Coke: to sate your addiction. And if you don't get enough "sparkle" from the smaller can, no problem. Just open a second 7.5-ounce can, and you'll get 20 percent more sparkle than you used to get from a 12-ounce hit.

You'll also get 20 percent more calories. But you'll feel better about yourself, because now you're practicing "portion control" and "a healthy lifestyle." Just like you felt better about smoking light cigarettes.

More here.

The Fresca Rebellion

It's the left that's turning conservative. Well, not conservative, but pushy. Weisberg put his finger on the underlying trend: "Because Democrats hold power at the moment, they face the greater peril of paternalistic overreaching." Today's morality cops are less interested in your bedroom than your refrigerator. They're more likely to berate you for outdoor smoking than for outdoor necking. It isn't God who hates fags. It's Michael Bloomberg.

More here.

Minicows

A few weeks ago, I noticed an article in the Los Angeles Times about "minicows." "In the last few years, ranchers across the country have been snapping up mini Hereford and Angus calves that fit in a person's lap," wrote reporter P.J. Huffstutter. "Today, there are more than 300 miniature-Hereford breeders in the U.S., up from fewer than two dozen in 2000. And there are about 20,000 minicows, compared with fewer than 5,000 a decade ago ..."

Huffstutter explains the animals' virtues. Mini-Herefords "consume about half [the feed] of a full-sized cow yet produce 50% to 75% of the rib-eyes and fillets, according to researchers and budget-conscious farmers," he notes. "Farmers who raise mini Jerseys brag how each animal provides 2 to 3 gallons of milk a day." Grass-fed minicows also "reached their mature weight faster, so they could be sold for meat sooner."

I was all set to write about minicows as the latest human manipulation of animal genetics. Then I realized that I had it backward. According to Huffstutter:

Minicows are not genetically engineered to be tiny, and they're not dwarfs. They are drawn from original breeds brought to the U.S. from Europe in the 1800s that were smaller than today's bovine giants, said Ron Lemenager, professor of animal science at Purdue University in West Lafayette, Ind. ... Big cows emerged as a product of the 1950s and '60s, when farmers were focused on getting more meat and didn't fret as much about the efficient use of animal feed or grasslands. "Feed prices were relatively cheap, and grazing lands were accessible," Lemenager said. "The plan was to get more meat per animal. But it went way too far. The animals got too big and eat so much."

In a way, this makes minicows even more fascinating. We did manipulate cows' genes for our purposes. We adapted them to our environment: plentiful land and feed. But then our environment changed. It became better suited to natural cows—or, more accurately, cows that were the product of human manipulation up to a century ago—than to the artificial cows of the last 50 years. So artifice unraveled itself. We went back to the original gene pool. Except that now, having becoming used to oversized 20th-century cows, we call the modern offspring of their ordinary-sized predecessors "minicows."

Cows aren't the only animals we can shrink. Two years ago, when parents of a disabled girl "attenuated" her growth through surgery and hormones, I argued that

economic and ecological forces are going [that] way. Smaller people consume fewer resources, live longer, and are cheaper to transport. They can fit in a Hyundai. Forty-five years ago, if you were 6 feet tall, you couldn't fly in a NASA space capsule. Now, you can barely fly coach. Blessed are the short, for they shall inherit the earth.

That's certainly the argument for minicows. They fit the latest "trend in farm efficiency—the move to ranchettes, smaller operations run by families or small groups of workers," Huffstutter writes. Today's ecology and economics demand smaller livestock.

The same is true of people. We're getting too fat for our planet. Many of us no longer fit old-fashioned toilets, ambulances, or coffins. Yet we've become so accustomed to our new size that only 15 percent of obese people now recognize themselves as obese. Fearing the economic consequences, governments around the world are groping for measures to restore us to our previous size. If they succeed, I wonder what we'll call the thin people of tomorrow. Minihumans, anyone?

Wide-Body Aircraft

Good news for fat fliers and the passengers who sit next to them: We may be heading toward a compromise involving wider seats.

Two months ago, when United joined other carriers in requiring oversize fliers to buy two seats, I argued that this binary policy was unnecessary. A better model is the extra leg room United sells to tall passengers:

Why shouldn't fat people have a similar option? Most of them don't need two seats side-by-side any more than we long-legged guys need two seats front-to-back. Like us, they just need a few extra inches. ... If United can swap out a row of three normal coach seats for two wide ones, two fat people should be able to buy those seats for an extra 50 percent instead of an extra 100 percent. That's the simplest nonbinary solution. But if the flight is full, or if swapping out a seat row is too difficult, here's an alternative: Let other passengers sell part of their seat width to those who need it.

In today's Wall Street Journal, one flier says he's open to the sale idea: "If people are so large or overweight that they can't get the armrest down, then these people should be required to sit elsewhere, pay for an additional seat or pay me for the part of my seat they are spilling into." But the wider-seats option is less embarrassing and should be easier to implement. And the Journal's Scott McCartney reports interest from both sides:

Frequent travelers and advocates for the obese would like to see airlines offer a few rows of wider coach seats and charge extra—just as they do with rows of expanded legroom. Instead of six seats across a typical single-aisle plane, why not have four or five seats and charge 50% extra on a coach fare? ... "We're willing to pay for what we are rightfully using," says Peggy Howell, spokeswoman for the National Association To Advance Fat Acceptance. ...  "What we really need are seats half-again as wide," she says. ... United, which offers extra legroom in "Economy Plus" rows to frequent fliers and customers who pay extra, says it will review the wide-seat idea.

Substituting a two-seat row for a three-seat row, at a 50 percent premium per seat, is a no-brainer. If the airline wants to require that such rows be purchased whole and with plenty of advance notice, those are reasonable conditions. It shouldn't be too hard to make each extra-wide seat purchase conditional on a second purchase to fill out the row. On flights with four seats across the middle, a three-seat row could be substituted. On smaller planes with only two-seat rows, wide fliers would have to buy an extra seat. And if extra leg room is necessary, sell it the same way it's already sold to thin people.

This plan shouldn't take long to resolve or implement. Airlines and obesity interest groups just need to sit down and work out the deal. Preferably in comfortable seats.

The Surgical War on Fat

Look out, fat folks. As we learn more about the intractability of your condition, the good news is that people may stop expecting you to diet or exercise your way to a thinner body. The bad news is, they may start expecting you to go under the knife.

More here.

Fat and Plane Seats

United Airlines has just implemented a tough policy for fat people: If you're too big to fit in a coach seat on a full plane, you'll have to pay for a first-class seat or two adjacent coach seats. And if those options are sold out, you'll be bumped from the flight.

I have a better idea: I'll sell you part of my seat.

More here.

The Tax War on Soda

The food police are closing in on their next target: a soda tax.

Writing in the New England Journal of Medicine, they propose a penny-per-ounce excise tax on "sugared beverages." That's nearly $3 per case. Why so much? Because this tax, unlike the petty junk-food taxes of yesteryear, is designed to hurt. Its purpose is to discourage you from buying soda, on the grounds that soda, like smoking, is bad for you.

More here.

No Tears for Salt

First they came for the cigarettes. Then the soda. Then trans fats. Then fast food. Now salt.

Reuters brings the news from across the Atlantic:

Alarmed by high death rates from strokes in Portugal, deputies from the ruling Socialist party submitted a bill to parliament Friday to slash the use of salt in bread ... The bill calls for salt content to be cut to a maximum of 14 grammes per kg, or by about 25 percent, introducing fines of up to 5,000 euros ($6,435) for exceeding this. ... Socialists have the majority of seats in parliament and the bill is likely to pass without a hitch.

Yes, the socialists. Cue Rush Limbaugh.

The rationales are the same ones we've already used to legislate against trans fats and fast food. Saving lives:

According to the Portuguese Society of High Blood Pressure, a reduction of salt intake by one gramme a day on average would save 2,650 lives per year.

And saving money:

The document links excessive salt consumption to high blood pressure, which in turn causes strokes, generally reduces life expectancy and means high medication costs for the state.

We don't have a viable Socialist Party in the United States. But could salt restrictions happen here? Sure. Little more than a year go, the FDA held a hearing to consider regulating salt as a food additive. Proponents argued that we eat too much salt, that reductions could save 150,000 lives a year, and that we could lower health-care expenses.

Then, a few months ago, New York City health commissioner Thomas Frieden, with the asserted support of health departments in other cities, summoned food-company executives to the mayor's residence and urged them, in concert, to cut the salt content of high-sodium foods by 25 percent in five years, and then to cut the same percentage again in the next five years, for a total reduction of nearly 50 percent. He told the New York Times, "If there's not progress in a few years, we'll have to consider other options, like legislation."

Can Frieden and his allies deliver on the legislative threat if the food industry doesn't cooperate? I don't know. In some ways, the more interesting question is what happens if the industry does cooperate. The plan is essentially collusion between the government and an all-encompassing alliance of corporations. The aim is to deprive consumers of the targeted food item, beyond a specified limit, through "quiet, mass reduction." Frieden's team calls it "stealth health":

He wants to get most of the major food and restaurant companies to do the same thing at the same time ... Key to the plan is a gradual reduction in sodium levels. The theory is that if the salt disappears slowly enough, consumers will not notice. Dr. Sonia Angell, director of cardiovascular health for the city, said: "We've created a whole society of people accustomed to food that is really, really salty. We have to undo that."

I'm supposed to be a raving libertarian. But I like the collusion plan. My six-year-old daughter is a total salt fiend (she's been that way since birth, unlike my son), and even she couldn't finish the can of Progresso vegetable soup she requested for lunch yesterday. Why? Because it has 990 milligrams of sodium—41 percent of the recommended daily allowance. So I poured out the "broth" and substituted hot water, and she gave it the thumbs-up. That's how salty the soup was: The vegetables alone made water taste like broth.

Corn chips are the same way. The number of grocery stores near us that offer unsalted chips has dwindled to one. But that's what I keep in the house, so our kids are used to it. A month ago, we were served Fritos on an airline flight, and we could barely stand them. That's what happens when you dial down the salt volume in your life: You start to notice how absurdly oversalted most prepared foods are.

Dr. Angell is right: Today's unhealthy salt levels have been commercially manufactured. It's now much harder to escape salt than to find it. And nobody's talking about taking away your table salt. If you want to dump 990 milligrams into your soup, it's your funeral.

So here's to you, Dr. Frieden. I hope you and your captains of industry get away with your hush-hush salt-fixing scheme. I want to see whether people really miss all that sodium, or whether they get used to a saner level and don't miss a thing. And I want to see whether we can pull this off without legislation. I'll keep quiet about it if you will.

Portly Johns

Humans are getting bigger.

Not taller or stronger, sorry. Just fatter. We're gaining weight and taking up more space. And that means the entire industry of things designed to fit, hold, transport, and dispose of us has to upsize. Starting with toilets.

Agence France Presse has the latest from Australia:

The standard strength of toilet seats is slated to triple, after the national safety watchdog Standards Australia found the maximum unsupported weight capacity of 45 kilogrammes was not enough. Toilet seats will soon have to pass flex and rigidity tests at 150 kilogrammes—"a precautionary measure to accommodate the increasing size of humans," a Standards spokeswoman said.

If your toilet was designed in the era of smaller humans and breaks under the stress of the new normal weight, don't fret. We can get you to the hospital, thanks to bigger emergency vehicles.

The Royal Flying Doctors, Australia's iconic outback air ambulance, is the latest service to supersize, announcing last month that it was seeking larger aircraft to cope with heavier patients. ... The planes will join a fleet of "mega lift" road ambulances already in use in New South Wales. ... More than 1,500 patients have been transported by the special ambulances since 2002, and the number is growing. ...

And if you don't make it to the hospital in time, we'll take care of your corpse,

with the standard coffin size growing from 18 inches (46 centimetres) across the shoulder to 20 inches. Most coffin-makers now stocked a range right up to 32 inches—once considered a "custom order," said [the director of the Australian Funeral Directors Association]. Crematoriums were upgrading their ovens to expand door widths closer to 100 centimetres (40 inches) and gone were the days of a "standard" grave, he said.

So, if you failed to burn off some of that extra fat when you were alive, no worries. We'll burn it off after you're dead. Or we'll put you in an extra-wide burial plot with a matching headstone to help future paleontologists reconstruct the era of wide-body humans.

The World Is Fat

Did you stuff yourself at Thanksgiving? Do you feel stupid about it? Do you wonder what the hell you were thinking as you went for that second helping of pie, your belly already swollen with turkey and cranberry sauce?

I'll tell you what you were thinking: the same thing your ancestors thought. They were suckers for fat, sweets, and extra helpings, too. The difference is, back in their day, those urges were healthy. You're not weaker or more gluttonous than they were. You just live in a different world—a world of cars, McDonald's, and corn syrup.

If you want to understand this mismatch between your genetically inherited tastes and your industrially inherited world, go pick up a copy of Barry Popkin's new book, The World Is Fat. (The title is a play on Tom Friedman's The World Is Flat.) I've written about Popkin before. He's an astute analyst of what's causing the obesity epidemic.

If you're like me, you grew up worrying about people starving in other countries. Your mom would tell you things like, "Eat your food. There are kids going hungry tonight." But hunger, as a global threat, is now dwarfed by overweight. According to Popkin, the population of obese and overweight people worldwide—1.6 billion—is now twice as large as the population of malnourished people.

This isn't the first time dietary changes have radically reshaped the human body. Popkin reports that average height shrank by about 4 inches during the Agricultural Revolution, apparently because previously diverse diets narrowed to a few crops. Then, as diets diversified again during the Industrial Revolution, average height in Europe and the United States regained 2 to 4 inches.

But Popkin's most important insight is that today's reshaping of our species—getting fat—is a result not of bad habits but of good habits that lost their context. During our ancestors' evolution, he explains,

To help us survive as a species, we developed preferences for sweet and fatty foods. ... Sweet foods provided nutritional balance to our diet, and they helped us survive during periods when animal foods were scarce. Sweet foods also provided the glucose needed to fuel our brains. At this time, however, sugars were only found in fruit. Because there are nine calories of energy in each gram of fat ... consuming as much fat as possible would have helped our hunter-gatherer and hominid ancestors to get an adequate amount of calories.

So, when you reach for that second helping of pie, you're doing what nature intended but in a world so radically transformed that nature's previous dictates no longer make sense. You're experiencing the disjunction between the rapid pace of technology and culture on the one hand and the slow pace of evolution on the other. Your body hasn't caught up to your world.

I'm a big fan of Popkin's theory for two reasons. First, it's consistent with the evidence. And, second, it's consistent with Human Nature's first law: Bad things happen because, initially, they're good. So, check out Popkin's book. Or if you're still not sold, start with a short overview of his argument. Bon appétit!

Cut the Salt

Happy Thanksgiving. Here's a request to those of you who are cooking today: Go easy on the salt.

In case you haven't heard, salt is the latest target of the health police. First smoking, then fat, now salt.

In the case of smoking, I'm with the health cops all the way. As one country after another has banned indoor smoking, I've been fist-pumping. When the health crusaders turned to fat, I celebrated again. Trans fats? Don't need ‘em. Soda? Disgusting.

But then they banned new fast-food restaurants in south L.A, and I freaked out. Cigarettes are industrial and nutrition-free, I figured. Trans fats and soda are artificial, too. But burgers and fries? The cooking's modern, but meat and potatoes are basic. They're food. You can't do that to food.

What happened to calories and saturated fat is now happening to salt: Public-health groups are clamoring for regulation, the FDA is holding hearings, and industry is adapting. Here's the latest from Reuters:

Burger King said on Wednesday it would limit sodium to 600 milligrams or less in all of its Kids Meals advertised to children younger than 12. ... McDonald's Corp already prepares its children's meals with less sodium. Its four-piece Chicken McNuggets Happy Meal ... has 390 calories and 570 milligrams of sodium. ... Burger King's currently advertised Kids Meal is its first to meet the new criteria. ... The meal has 340 calories and 505 milligrams of sodium.

That's still too much salt, but it's a start. And I'm with the health cops on this one. Salt is different from meat and potatoes. It's food, but it's also an additive. It's great that industry is reducing it voluntarily. If industry doesn't move far enough and the health cops want to restrict salt in prepared food, I won't cry. You can always add more salt from a shaker or from takeout packets.

Here's my pitch to the burger joints: Thanks for letting us choose whether to leave out the lettuce and tomatoes. Do the same with salt

Contrarianism in Context

Impressive cluster of contrarian research in today's batch: Coffee can help prevent Alzheimer's; trans fats can be good for you; fat kids have fewer cavities; and the alleged benefits of drinking lots of water are unfounded. I love reports like these. I've flagged and commented on lots of them in the previous Human Nature news roundups. Part of it is that I just enjoy contrarianism. Part of it is that discoveries like these expose our overconfidence about what we know. Biology is enormously complex. Sometimes extra weight is bad for you; sometimes, at death's door, it can save your life. We vilify and prohibit alcohol as a sin, then discover it can help your circulation.

But I don't want to let the mischievous fun of medical contrarianism obscure reality. The reason why studies like these are surprising and intriguing is that they generally run against the grain of biology. By and large, trans fats are horrible for you. Relying on coffee instead of sleep for daily energy is dangerous. And even if being fat somehow improves your kid's dental health, the damage done to the rest of his body isn't worth it.

When you see a report about the benefits of booze or chocolate, always remember that the reason it's worth a headline is that these things, in their usual form and consumed quantity, are generally unhealthy. Not a very entertaining takeaway, I admit. But true.