ReportWire

Tag: population level

  • BMI Won’t Die

    BMI Won’t Die

    [ad_1]

    If anything defines America’s current obesity-drug boom, it’s this: Many more people want these injections than can actually get them. The roadblocks include exorbitant costs that can stretch beyond $1,000 a month, limited insurance coverage, and constant supply shortages. But before all of those issues come into play, anyone attempting to get a prescription will inevitably confront the same obstacle: their body mass index, or BMI.

    So much depends on the simple calculation of dividing one’s weight by the square of their height. According to the FDA, people qualify for prescriptions of Wegovy and Zepbound—the obesity-drug versions of the diabetes medications Ozempic and Mounjaro—only if their BMI is 3o or higher, or 27 or higher with a weight-related health issue such as hypertension. Many who do get on the medication use BMI to track their progress. That BMI is the single biggest factor determining who gets prescribed these drugs, and who doesn’t, is the result of how deeply entrenched this metric has become in how both doctors and regular people approach health: Low BMI is good and high BMI is bad, or so most of us have come to think.

    This roughly 200-year-old metric has never been more relevant—or maligned—than it is in the obesity-drug era. BMI has become like the decrepit car you keep driving because it still sort of works and is too much of a hassle to replace. Its numerous shortcomings have been called out for many years now: For starters, it accounts for only height and weight, not other, more pertinent measures such as body-fat percentage. In June, the American Medical Association formally recognized that BMI should not be used alone as a health measure. Last year, some doctors called for BMI to be retired altogether, echoing previous assertions.

    The thing is, BMI can be an insightful health metric, but only when used judiciously with other factors. The problem is that it often hasn’t been. Just as obesity drugs are taking off, however, professional views are changing. People are so accustomed to seeing BMI as the “be-all, end-all” of health indicators, Kate Bauer, a nutritional-sciences professor at the University of Michigan, told me. “But that’s increasingly not the way it’s being used in clinical practice.” A shift in the medical field is a good start, but the bigger challenge will be getting everyone else to catch up.

    BMI got its start in the 1830s, when a Belgian astronomer named Adolphe Quetelet attempted to determine the properties of the “average” man. Using data on primarily white people, he observed that weight tended to vary as the square of height—a calculation that came to be known as Quetelet’s index.

    Over the next 150 years, what began as a descriptive tool transformed into a prescriptive one. Quetelet’s index (and other metrics like it) informed height-weight tables used by life-insurance companies to estimate risk. These sorts of tables formed “recommendations for the general population going from ‘average’ to ‘ideal’ weights,” the epidemiologist Katherine Flegal wrote in her history of BMI; eventually, nonideal weights were classified as “overweight” and “obese.” In 1972, the American physiologist Ancel Keys proposed using Quetelet’s index—which he renamed BMI—to roughly measure obesity. We’ve been stuck with BMI ever since. The metric became embedded not only in research and doctor’s visits but also in the very definitions of obesity. According to the World Health Organization, a BMI starting at 25 and less than 30 is considered overweight; anything above that range is obese.

    But using BMI to categorize a person’s health was controversial from the start. Even Keys called it “scientifically indefensible” to use BMI to judge someone as overweight. BMI doesn’t account for where fat is distributed on the body; fat that builds up around organs and tissues, called visceral fat, is linked to serious medical issues, while fat under the skin—the kind you can pinch—is usually less of a problem. Muscularity is also overlooked: LeBron James, for example, would be considered overweight. Both fat distribution and muscularity can vary widely across sex, age, and ethnicity. People with high BMIs can be perfectly healthy, and “there are people with normal BMIs that are actually sick because they have too much body fat,” Angela Fitch, an assistant professor at Harvard Medical School and the president of the Obesity Medicine Association, told me.

    For all its flaws, BMI is actually useful at the population level, Fitch said, and doctors can measure it quickly and cheaply. But BMI becomes troubling when it is all that doctors see. In some cases, the moment when a patient’s BMI is calculated by their doctor may shape the rest of the appointment and relationship going forward. “The default is to hyper-focus on the weight number, and I just don’t think that that’s helpful,” Tracy Richmond, a pediatrics professor at Harvard Medical School, told me. Anti-obesity bias is well documented among physicians—even some obesity specialists—and can lead them to dismiss the legitimate medical needs of people with a high BMI. In one tragic example, a patient died from cancer that went undiagnosed because her doctors attributed her health issues to her high BMI.

    But after many decades, the medical community has begun to use BMI in a different way. “More and more clinicians are realizing that there are people who can be quite healthy with a high BMI,” Kate Bauer said. The shift has been gradual, though it was given a boost by the AMA policy update earlier this year: “Hopefully that will help clinicians make a change to supplement BMI with other measures,” Aayush Visaria, an internal-medicine resident at Rutgers Robert Wood Johnson Medical School who researches BMI’s shortcomings, told me.

    Physicians I spoke with acknowledged BMI’s flaws but didn’t seem too concerned about its continued use in medicine—even as obesity drugs make this metric even more consequential. BMI isn’t a problem, they said, as long as physicians consider other factors when diagnosing obesity or prescribing drugs to treat it. If you go to a doctor with the intention of getting on an obesity drug, you should be subject to a comprehensive evaluation including metrics such as blood sugar, cholesterol levels, and body composition that go “way beyond BMI,” Katherine Saunders, a clinical-medicine professor at Weill Cornell Medicine, said. Because Wegovy and other drugs come with side effects, she told me, doctors must be absolutely sure that a patient actually needs them, she added.

    But BMI isn’t like most other health metrics. Because of its simplicity, it has seeped out of doctor’s offices and into the mainstream, where this more nuanced view still isn’t common. Whether we realize it or not, BMI is central to our basic idea of health, affecting nearly every aspect of daily life. Insurance companies are notorious for charging higher rates to people with high BMI and lowering premiums for people who commit to long-term weight loss. Fertility treatments and orthopedic and gender-affirming surgery can be withheld from patients until they hit BMI targets. Workplace wellness programs based on BMI are designed to help employees manage their weight. BMI has even been used to prevent prospective parents from adopting a child.

    The rise of obesity drugs may make these kinds of usages of BMI even harder to shake. Determining drug eligibility by high BMI supports the notion that a number is synonymous with illness. Certainly many people using obesity drugs take a holistic view of their health, as doctors are learning to do. But focusing on BMI is still common. Some members of the r/Ozempic Subreddit, for example, share their BMI to show their progress on the drug. Again, high BMI can be used to predict who has obesity, but it isn’t itself an obesity diagnosis. The problem with BMI’s continued dominance is that it makes it even harder to move away from simply associating a number on a scale with overall health, with all the downstream consequences that come along with a weight-obsessed culture. As obesity drugs are becoming mainstream, “there needs to be public education explaining that BMI by itself may not be a good indicator of health,” Visaria said.

    In another 200 years, surely BMI will finally be supplanted by something else. If not much sooner: A large effort to establish hard biological criteria for obesity is under way; the goal is to eliminate BMI-based definitions once and for all. Caroline Apovian, a professor at Harvard Medical School, gives it “at least 10 years” before a comparably cheap or convenient replacement arises—though any changes would take longer to filter into public consciousness.” Until that happens, we’re stuck with BMI, and the mess it has wrought.

    [ad_2]

    Yasmin Tayag

    Source link

  • Somehow, the Science on Masks Still Isn’t Settled

    Somehow, the Science on Masks Still Isn’t Settled

    [ad_1]

    For many Americans, wearing a mask has become a relic. But fighting about masks, it seems, has not.

    Masking has widely been seen as one of the best COVID precautions that people can take. Still, it has sparked ceaseless arguments: over mandates, what types of masks we should wear, and even how to wear them. A new review and meta-analysis of masking studies suggests that the detractors may have a point. The paper—a rigorous assessment of 78 studies—was published by Cochrane, an independent policy institution that has become well known for its reviews. The review’s authors found “little to no” evidence that masking at the population level reduced COVID infections, concluding that there is “uncertainty about the effects of face masks.” That result held when the researchers compared surgical masks with N95 masks, and when they compared surgical masks with nothing.

    On Twitter, longtime critics of masking and mandates held this up as the proof they’d long waited for. The Washington Free Beacon, a conservative outlet, quoted a researcher who has called the analysis the “scientific nail in the coffin for mask mandates.” The vaccine skeptic Robert Malone used it to refute what he called “self-appointed ‘experts’” on masking. Some researchers weighed in with more nuanced interpretations, pointing out limitations in the review’s methods that made it difficult to draw firm conclusions. Even the CDC director, Rochelle Walensky, pushed back against the paper in a congressional testimony this week, citing its small sample size of COVID-specific studies. The argument is heated and technical, and probably won’t be resolved anytime soon. But the fact that the fight is ongoing makes clear that there still isn’t a firm answer to among the most crucial of pandemic questions: Just how effective are masks at stopping COVID?

    An important feature of Cochrane reviews is that they look only at “randomized controlled trials,” considered the gold standard for certain types of research because they compare the impact of one intervention with another while tightly controlling for biases and confounding variables. The trials considered in the review compared groups of people who masked with those who didn’t in an effort to estimate how effective masking is at blunting the spread of COVID in a general population. The population-level detail is important: It indicates uncertainty about whether requiring everyone to wear a mask makes a difference in viral spread. This is different from the impact of individual masking, which has been better researched. Doctors, after all, routinely mask when they’re around sick patients and do not seem to be infected more often than anyone else. “We have fairly decent evidence that masks can protect the wearer,” Jennifer Nuzzo, an epidemiologist at Brown University, told me. “Where I think it sort of falls apart is relating that to the population level.”

    The research on individual masking generally shows what we have come to expect: High-quality masks provide a physical barrier between the wearer and infectious particles, if worn correctly. For instance, in one study, N95 masks were shown to block 57 to 90 percent of particles, depending on how well they fit; cloth and surgical masks are less effective. The caveat is that much of that support came from laboratory research and observational studies, which don’t account for the messiness of real life.

    That the Cochrane review reasonably challenges the effectiveness of population-level masking doesn’t mean the findings of previous studies in support of masking are moot. A common theme among criticisms of the review is that it considered only a small number of studies by virtue of Cochrane’s standards; there just aren’t that many randomized controlled trials on COVID and masks. In fact, most of those included in the review are about the impact of masking on other respiratory illnesses, namely the flu. Although some similarities between the viruses are likely, Nuzzo explained on Twitter, COVID-specific trials would be ideal.

    The handful of trials in the review that focus on COVID don’t show strong support for masking. One, from Bangladesh, which looked at both cloth and surgical masks, found a 9 percent decrease in symptomatic cases in masked versus unmasked groups (and a reanalysis of that study found signs of bias in the way the data were collected and interpreted); another, from Denmark, suggested that surgical masks offered no statistically significant protection at all.

    Criticisms of the review posit that it might have come to a different conclusion if more and better-quality studies had been available. The paper’s authors acknowledge that the trials they considered were prone to bias and didn’t control for inconsistent adherence to the interventions. “The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect,” they concluded. If high-quality masks worn properly work well at an individual level, after all, then it stands to reason that  high-quality masks worn properly by many people in any situation should indeed provide some level of protection.

    Tom Jefferson, the review’s lead author, did not respond to a request for comment. But in a recent interview about the controversy, he stood by the practical implications of the new study. “There’s still no evidence that masks are effective during a pandemic,” he said.

    Squaring all of this uncertainty with the support for masking and mandates early in the pandemic is difficult. Evidence for it was scarce in the early days of the pandemic, Nuzzo acknowledged, but health officials had to act. Transmission was high, and the costs of masking were seen as low; it was not immediately clear how inconvenient and unmanageable masks could be, especially in settings such as schools. Mask mandates have largely expired in most places, but it doesn’t hurt most people to err on the side of caution. Nuzzo still wears a mask in high-risk environments. “Will that prevent me from ever getting COVID? No,” she said, but it reduces her risk—and that’s good enough.

    What is most frustrating about this masking uncertainty is that the pandemic has presented many opportunities for the U.S. to gather stronger data on the effects of population-level masking, but those studies have not happened. Masking policies were made on sound but limited data, and when decisions are made that way, “you need to continually assess whether those assumptions are correct,” Nuzzo said—much like how NASA collects huge amounts of data to prepare for all the things that could go wrong with a shuttle launch. Unfortunately, she said, “we don’t have Houston for the pandemic.”

    Obtaining stronger data is still possible, though it won’t be easy. A major challenge of studying the effect of population-level masking in the real world is that people aren’t good at wearing masks, which of course is a problem with the effectiveness of masks too. It would be straightforward enough if you could guarantee that participants wore their masks perfectly and consistently throughout the study period. But in the real world, masks fit poorly and slip off noses, and people are generally eager to take them off whenever possible.

    Ideally, the research needed to gather strong data—about masks, and other lingering pandemic questions—would be conducted through the government. The U.K., for example, has funded large randomized controlled trials of COVID drugs such as molnupiravir. So far, that doesn’t seem to have happened in the U.S.  None of the new studies on masking included in the Cochrane review were funded by the U.S. government. “The fact that we never as a country really set up studies to answer the most pressing questions is a failure,” said Nuzzo. What the CDC could do is organize and fund a research network to study COVID, much like the centers of excellence the agency has for fields such as food safety and tuberculosis.

    The window of opportunity hasn’t closed yet. The Cochrane review, for all of its controversy, is a reminder that more research on masking is needed, if only to address whether pro-mask policies warrant the rage they incite. You would think that the policy makers who encouraged masking would have made finding that support a priority. “If you’re going to burn your political capital, it’d be nice to have the evidence to say that it’s necessary,” Nuzzo said.

    At this point, even the strongest possible evidence is unlikely to change some people’s behavior, considering how politicized the mask debate has become. But as a country, the lack of conclusive evidence leaves us ill-prepared for the next viral outbreak—COVID or otherwise. The risk is still low, but bird flu is showing troubling signs that it could make the jump from animals to humans. If it does, should officials be telling everyone to mask up? That America has never amassed good evidence to show the effect of population-level masking for COVID, Nuzzo said, has been a missed opportunity. The best time to learn more about masking is before we are asked to do it again.

    [ad_2]

    Yasmin Tayag

    Source link

  • It’s Gotten Awkward to Wear a Mask

    It’s Gotten Awkward to Wear a Mask

    [ad_1]

    Last week, just a couple of hours into a house-sitting stint in Massachusetts for my cousin and his wife, I received from them a flummoxed text: “Dude,” it read. “We are the only people in masks.” Upon arriving at the airport, and then boarding their flight, they’d been shocked to find themselves virtually alone in wearing masks of any kind. On another trip they’d taken to Hawaii in July, they told me, long after coverings became optional on planes, some 80 percent of people on their flight had been masking up. This time, though? “We are like the odd man out.”

    Being outside of the current norm “does not bother us,” my cousin’s wife said in another text, despite stares from some of the other passengers. But the about-face my cousin and his wife identified does mark a new phase of the pandemic, even if it’s one that has long been playing out in fits and starts. Months after the vanishing of most masking mandates, mask wearing has been relegated to a sharply shrinking sector of society. It has become, once again, a peculiar thing to do.

    “If you notice, no one’s wearing masks,” President Joe Biden declared last month on 60 Minutes. That’s an overstatement, but not by much: According to the COVID States Project, a large-scale national survey on pandemic-mitigation behaviors, the masking rate among Americans bounced between around 50 and 80 percent over the first two years of the pandemic. But since this past winter, it’s been in a slide; the project’s most recent data, collected in September, found that just 29 percent have been wearing masks outside the home. This trend may be long-standing on the population level, but for individuals—and particularly for those who still wear masks, such as my cousin and his wife—it can lead to moments of abrupt self-consciousness. “It feels like it’s something that now needs an explanation,” Fiona Lowenstein, a journalist and COVID long-hauler based in Los Angeles, told me. “It’s like showing up in a weird hat, and you have to explain why you’re wearing it.”

    Now that most Americans can access COVID vaccines and treatments that slash the risk of severe disease and death, plenty of people have made informed decisions to relax on masking—and feel totally at ease with their behavior while paying others’ little mind. Some are no longer masking all the time but will do so if it makes others feel more comfortable; others are still navigating new patterns, trying to stay flexible amid fluctuating risk. Saskia Popescu, an infectious-disease epidemiologist at George Mason University, told me that she’s now more likely to doff her mask while dining or working out indoors, but that she leaves it on when she travels. And when she does decide to cover up, she said, she’s “definitely felt like more of an outlier.”

    For some, like my cousin and his wife, that shift feels slightly jarring. For others, though, it feels more momentous. High-filtration masks are one of the few measures that can reliably tamp down on infection and transmission across populations, and they’re still embraced by many parents of newborns too young for vaccines, by people who are immunocompromised and those who care for them, and by those who want to minimize their risk of developing long COVID, which can’t be staved off by vaccines and treatments alone. Theresa Chapple-McGruder, the public-health director for Oak Park, Illinois, plans to keep her family masking at least until her baby son is old enough to receive his first COVID shots. In the meantime, though, they’ve certainly been feeling the pressure to conform. “People often tell me, ‘It’s okay, you can take your mask off here,’” Chapple-McGruder told me; teachers at the local elementary school have said similar things to her young daughters. Meghan McCoy, a former doctor in New Hampshire who takes immunosuppressive medications for psoriatic arthritis and has ME/CFS, has also been feeling “the pressure to take the mask off,” she told me—at her kid’s Girl Scout troop meetings, during trips to the eye doctor. “You can feel when you’re the only one doing something,” McCoy said. “It’s noticeable.”

    Read: Mask mandates are illogical. So what?

    For Chapple-McGruder, McCoy, and plenty of others, the gradual decline in masking creates new challenges. For one thing, the rarer the practice, the tougher it is for still-masking individuals to minimize their exposures. “One-way masking is a lot less effective,” says Gabriel San Emeterio, a social worker at Hunter College who is living with HIV and ME/CFS. And the less common masking gets, the more conspicuous it becomes. “If most people met me, they wouldn’t know I was immunocompromised,” McCoy told me. “There’s no big sign on our foreheads that says ‘this person doesn’t have a functioning immune system.’” But now, she said, “masks have kind of become that sign.”

    Aparna Nair, a historian and disability scholar at the University of Oklahoma who has epilepsy, told me that she thinks masks are becoming somewhat analogous to wheelchairs, prosthetics, hearing aids, and her own seizure-alert dog, Charlie: visible tools and technologies that invite compassion, but also skepticism, condescension, and invasive questions. During a recent rideshare, she told me, her driver started ranting that her mask was unnecessary and ineffective—just part of a “conspiracy.” His tone was so angry, Nair said, that she began to be afraid. She tried to make him understand her situation: I’ve been chronically ill for three decades; I’d rather not fall sick; better to be safe than sorry. But she said that her driver seemed unswayed and continued to mutter furiously under his breath for the duration of the ride. Situations of that kind—where she has to litigate her right to wear a mask—have been getting more common, Nair told me.

    Masking has been weighed down with symbolic meaning since the start of the pandemic, with some calling it a sign of weakness and others a vehicle for state control. Americans have been violently attacked for wearing masks and also for not wearing them. But for a long time, these tensions were set against the backdrop of majority masking nationwide. Local mask mandates were in place, and most scientific experts wore and championed them in public. With many of those infrastructural supports and signals now gone, masking has rapidly become a minority behavior—and people who are still masking told me that that inversion only makes the tension worse.

    San Emeterio, who wears a vented respirator when they travel, recently experienced a round of heckling from a group of men at an airport, who started to stare, laugh, and point. Oh my god, look at what he’s wearing, San Emeterio recalls the strangers saying. “They clearly meant for me to hear it,” San Emeterio told me. “It didn’t make me feel great.” Alex Mawdsley, the 14-year-old son of an immunocompromised physician in Chicago, is one of just a handful of kids at his middle school who are still masking up. Since the start of the academic year, he’s been getting flak from several of his classmates “at least once a week,” he told me: “They’re like ‘You’re not gonna get COVID from me’ and ‘Why are you still wearing that? You don’t need it anymore.’”

    Alex’s mother, Emily Landon, told me she’s been shaken by the gawks and leers she now receives for masking. Even prior to the pandemic, and before she was diagnosed with rheumatoid arthritis and began taking immunosuppressive drugs, she considered herself something of a hygiene stan; she always took care to step back from the sneezy and sniffy, and to wipe down tray tables on planes. “And it was never a big deal,” she said.

    Read: Put your face in airplane mode

    It hasn’t helped that the donning of masks has been repeatedly linked to chaos and crisis—and their removal, to triumph. Early messaging about vaccines strongly implied that the casting away of masks could be a kind of post-immunization reward. In February, CDC Director Rochelle Walensky described masks as “the scarlet letter of this pandemic.” Two months later, when the administration lifted its requirements for masking on public transportation, passengers on planes ripped off their coverings mid-flight and cheered.

    To reclaim a mask-free version of “normalcy,” then, may seem like reverting to a past that was safer, more peaceful. The past few years “have been mentally and emotionally exhausting,” Linda Tropp, a social psychologist at the University of Massachusetts at Amherst, told me. Discarding masks may feel like jettisoning a bad memory, whereas clinging to them reminds people of an experience they desperately want to leave behind. For some members of the maskless majority, feeling like “the normal ones” again could even serve to legitimize insulting, dismissive, or aggressive behavior toward others, says Markus Kemmelmeier, a social psychologist at the University of Nevada at Reno.

    It’s unclear how the masking discourse might evolve from here. Kemmelmeier told me he’s optimistic that the vitriol will fade as people settle into a new chapter of their coexistence with COVID. Many others, though, aren’t so hopeful, given the way the situation has unfolded thus far. “There’s this feeling of being left behind while everyone else moves on,” Lowenstein, the Los Angeles journalist and long-hauler, told me. Lowenstein and others are now missing out on opportunities, they told me, that others are easily reintegrating back into their lives: social gatherings, doctor’s appointments, trips to visit family they haven’t seen in months or more than a year. “I’d feel like I could go on longer this way,” Lowenstein said, if more of society were in it together.

    Americans’ fraught relationship with masks “didn’t have to be like this,” Tropp told me—perhaps if the country had avoided politicizing the practice early on, perhaps if there had been more emphasis on collective acts of good. Other parts of the world, certainly, have weathered shifting masking norms with less strife. A couple of weeks ago, my mother got in touch with me from one such place: Taiwan, where she grew up. Masking was still quite common in public spaces, she told me in a text message, even where it wasn’t mandated. When I asked her why, she seemed almost surprised: Why not?

    [ad_2]

    Katherine J. Wu

    Source link