I receive email alerts from MedPageToday online. Here’s the headline for a recent alert:
Stroke Rounds: Less Educated Smokers at Higher Stroke Risk
The article is about a large observational study conducted in Denmark. The conclusions drawn by both the investigators and the reporter approach head-bang-on-desk levels of mushy thinking. Let’s take a look:
The combination of a low level of education — a marker of socioeconomic status — with smoking appears to increase risk of stroke, especially in men, according to one of the first studies to analyze social inequality and stroke risk.
Social inequality and stroke risk? Someone is studying that? That had me scratching my head already. Turns out the study was funded by something called the Danish Cancer Society Commission of Social Inequality in Cancer. (And as Dave Barry would say, I am not making this up.) I don’t know why the Social Inequality division of a national cancer society is mucking around in the field of social inequality in stroke risk, but apparently they felt the need. Anyway …
In a pooled cohort of more than 68,000 people, lower education and current smoking led to 134 (95% CI 49-219) extra cases of ischemic stroke per 100,000 person-years in men, the authors wrote.
“The combined effect of low education and current smoking was more than expected by the sum of their separate effects on ischemic stroke incidence,” wrote Helene Nordahl, MS, PhD, of the University of Copenhagen, and her co-authors online in Stroke.
So don’t smoke unless you have a college degree, which apparently will provide you with some protection against strokes.
This particular example of the impact of socioeconomic position on risk was “quite interesting and novel” and “the most surprising finding of our study,” Nordahl told MedPage Today.
The impact of socioeconomic position … you know where they’re going with this, right? They’re going to make a case that smokers with less education are having more strokes because of their lower socioeconomic status – and by gosh, someone (meaning the government) needs to do something about it.
Overall, the combination of exposure to smoking, low level of education, and hypertension on ischemic stroke was associated with 566 extra cases among men and 438 among women, compared with those who had no exposure to the three risk factors.
I’m not sure how you avoid exposing yourself to a low level of education, but I suppose refusing to respond to the greeter at Wal-Mart could help.
“In order to reduce social inequality in stroke we need to challenge disparities in unhealthy behaviors, particularly smoking,” Nordahl told MedPage Today.
Yeesh … I hope the goal of reducing social inequality in strokes doesn’t find its way to the United States. Given the crowd currently running Washington, the result would be more strokes among wealthy people.
The social differences in risk of stroke have been a topic of interest for health research for a number of years, Nordahl told MedPage Today.
So let’s talk about those social differences. Normally when studies like this are conducted and published in the U.S., reporters assume people lower on the socioeconomic ladder have worse health outcomes because of inferior healthcare. The unfairness of U.S. medicine and all that. If only we had a socialized system where everyone is equal, by gosh, we wouldn’t see these disparities.
I remember reading an article along those lines awhile back in our local socialist rag – excuse me, local newspaper. The article pointed out that people living in Williamson County (where I happen to live) have lower rates of heart disease, cancer, etc., and suggested perhaps we need to find a way to move more poor people here so they’ll be healthier. Clearly those well-to-do folks in Williamson County are enjoying superior healthcare. Oh, the unfairness of it all.
But wait … this study about stroke and social inequality was conducted in Denmark, which already has socialized medicine. Since the researchers couldn’t blame inferior healthcare, they seem determined to blame “exposure” to a low level of education. Must be the education disparity, ya see.
It’s the same problem we see over and over with conclusions drawn from observational studies: researchers and reporters can’t seem to grasp that the data is nothing more than the result of comparing different kinds of people — and I’m not just talking about health-related studies. Fuzzy-thinking conclusions about cause-and-effect have led to mistaken beliefs about education as well. (The Denmark study researchers seem determined to pull off the unusual feat of engaging in fuzzy thinking about both health and education.)
I remember reading about the relationship between income and education in a book about economics. (Sorry, don’t remember which one.) The author noted that people who earn college degrees have higher incomes than those who don’t, and people who earn degrees from an Ivy-League school have much higher incomes. Most people assume this means going to college will raise your future income, and going to an Ivy-League college will seriously raise your income. Cause and effect. So let’s make sure everyone goes to college, and we’ll end poverty. (Just ask all those kids taking on $100,000 in student-loan debt to get a degree in Art History.)
But as the author explained, those correlations don’t prove cause-and-effect at all. As he recounted in the book, it occurred to some researchers that perhaps people who attend Ivy-League schools have significantly higher incomes because they’re smart enough to attend an Ivy-League school. There is, after all, a very strong correlation between IQ and income.
So the researchers went out and found thousands of people who had been accepted into an Ivy-League college but, for one reason or another, decided not to attend. Guess what? On average, they were just as financially successful as people who earned degrees from Ivy-League schools. In other words, if you’re smart enough and hard-working enough to be accepted into Harvard, you’re probably going to do very well in life – even if you choose to attend a state university instead.
To a large extent, the same goes for the correlation between a college degree and a higher income. Yes, there are many high-paying jobs you’d probably never get without attending college – good luck landing a job as a CPA without a degree – but according to the author of the book on economics, people who earn college degrees end up with higher incomes largely because they have higher IQs and more discipline on average than people who don’t attend college.
In other words, they’re different. I’ve written before about what Dr. Mike Eades calls adherers vs. non-adherers. (I think of them as conscientious people vs. people who don’t give a @#$%.) As Dr. Eades pointed out years ago, adherers regularly end up with better health outcomes. In drug studies, for example, the adherers get better results than the non-adherers even if they’re in the placebo arm of the study. That means it’s not the drug making the difference. Perhaps they just take better care of themselves in ways the study investigators don’t measure. Perhaps their lives are less of a mess, so they’re less stressed.
One factor that separates adherers from non-adherers is the degree to which they are motivated by possible future consequences. Adherers plan ahead and act accordingly. Non-adherers are more likely to live for today. I can think of all kinds of ways being motivated by future outcomes would cause an adherer to think and act differently:
- That soda would taste good, but I don’t want to become fat and diabetic.
- Those French fries smell awesome, but the broccoli would be better for me.
- There are a lot of good shows on TV, but I need a good workout more than I need entertainment.
- I’d like to go hang out with my friends, but I need to study so I can get good grades and get into a good school.
- I’d love to own that new car, but I need to save more money to invest or use to start my own business.
- Yeah, he’s hot as all get out, but he doesn’t seem to have any kind of work ethic and would probably be a lousy provider if we got married and had kids. Pass.
You get the idea. Compared to non-adherers, adherers are more likely to take care of themselves, so they’re healthier. They think about long-term consequences, so they study and get better grades, probably go to college, are more willing to defer fun and gratification now if it means a higher income later, so they end up better off financially.
Then they move somewhere pleasant where the homes are bigger and more expensive – like Williamson County, for example. The local schools end up being highly ranked because the smart adherer children of the smart adherer parents study and do their homework and pay attention in class.
Then researches and reporters notice how those well-to-do people have better local schools and lower rates of heart disease and cancer and stroke, and they think they’ve spotted social inequality that might need a government cure.
