Tuesday, February 11, 2014

an N of 1

This final post is long, so I've broken it up into several parts. Let me say "thank you" up front to Kerryn for working with me and coaching me, and to the rest of you for your interest and support.

1. A personal story of money and food
2. Health and Food as a signal
3. an N of 1
4. Learning more about being rich than being poor
5. Going forward - More than 100 Minutes.

1. A personal story of money and food

When I tell people my father is a doctor, they often make certain assumptions about how I was raised. Doctors make a really good salary, so obviously money wasn't a concern when you were growing up. But my father finished his residency when I was 15. What that means is that for all of my life up until then, he was in some sort of training, and either not making much money, or not making any money.

My father was forced to drop out of high school and join the Navy. When he came back, he and my mother got married, and had me while he was going to night school to finish get his high school diploma. He started full time undergraduate studies when I was about a year old. It takes many years of schooling and training to become a board certified physician of any sort.

When I was in elementary school, we were poor enough that I not only qualified for free lunch, but free breakfast as well. My mother shopped using food stamps. We had government surplus cheese and other things in the house (it comes in white packages with black writing).

For a time we lived in the servants' quarters of an old estate. My father took care of the grounds and did handy man work on the house to pay for our rent. When that ended, we moved into a public housing project.

Things got better financially as the years went on, and my sister and I could take care of ourselves so that both of my parents could work, and my father started getting paid (typically residents get paid).

But money was always an issue when I was a kid. It was present in every discussion, underlying everything we did, and did not do.

I remember one winter (it may have been more than one), because of the high cost of heating oil, my folks got a kerosene heater that was safe for using indoors. It sat at the bottom of the basement steps (you know, because heat rises). The rest of the house was set at 50 degrees. I remember when I would go to bed, I would lay on my side and clap my hands together between my thighs so that they would warm up. This is how we accommodated money.

When I was 12 I got my first job - delivering the Boston Globe. I've worked pretty much ever since doing one thing or another.

What did I use my money for? Well some of it went to buying stuff my folks couldn't afford or didn't think was worth paying for. Like candy. And soda. And chips. And McDonald's.

The thing is that when I was a kid, I didn't know we were poor. When you're in elementary school, everyone you go to school with is from your neighborhood, so everyone is pretty much the same. I was never hungry. There was always food. And mostly, it was healthy food. My parents always had a garden. My father loved to grow his own food. (I hated the garden - I hated working in it, and I wasn't a fan of vegetables - this was a perpetual source of familial conflict.) There was always food for my friends if they wanted to eat over. There was always talk about our duty to those less fortunate than us, and there was always room at the table.

But there was almost never eating out. And when we did eat out, of course you couldn't have a soda. And don't even look at the expensive stuff on the menu. What was the cheapest? That's likely what you were getting. Dessert was out of the question.

No big deal. Lots of people grow up that way. Many are worse off than that. But buying my own food became a part of my independence. Junk food, that is.

So junk food and eating out were things I developed a taste for early on because they came to be a symbol of abundance to me. And a symbol of rebellion, since my parents tried hard to eat healthily. I've read that your taste for music settles when you're about 14. I think it's likely that tastes of all sorts settle early on, and I developed a taste for sugar and fat that I've been indulging most of my life.

It was money that drove me to join the military. I confess I joined in part for the adventure and in part for the ideals, but a big part was financial independence. I joined the Army National Guard to pay for college because I wanted financial independence. I didn't want my parents to be able to tell me what I should or shouldn't do, especially since they disapproved of my major (philosophy). What can you do with a degree in philosophy? Not much. Other than join the Army. Where people tell you what to do all the time. But at least they weren't my parents.

So money and a rebellious spirit led me to the career I have pursued (which has been great) and to eat the way I have (which has been not so great). I rejected a lot of the advice I heard around me about healthier habits when I was young because my body could overcome all the harmful things I put into it. I also rejected it because health concerns, like the "organic" movement, are so often interwoven with socio-economic identity signals, and I identified more with a working class socio-economic identity than the one I found myself in later on.

2. Health and Food as a signal and as utility

Why do some people drive Corvettes and some people drive BMWs (say a "5 series")? They cost about the same. If you meet an economist at a cocktail party and s/he asks you why you drive one and not the other, you might tell her/him it's because of the handling or the sound or the engine. If s/he is in the mood to be polite, s/he will nod along and act like s/he believes you. But running in her/his mind will be an evaluation of how much of those technical specifications actually matter to you, and how much of your choice was driven by how it makes you look. Owning a Corvette sends a different signal than owning a BMW. Both say something about how much money you have because they are both expensive (relative to, say, the Kia that I drive). So one of the things you are saying by driving one of those cars is "look at me - I have money to waste on a depreciating asset". But clearly driving a Corvette also communicates something about the driver that is quite different than what is communicated by someone driving a BMW sedan. BMW says business, maturity, no-nonsense. Corvette says fast - fast speeds, fast times, a little living on the edge. If you're a banker, you probably drive a BMW. You want people to perceive you as mature and no nonsense. The last thing you want people to think about you is that you live on the edge, because they will be giving you their money, and they don't want you to be living on the edge with their money. The two cars generate what economists call a signal. As social animals, we engage in signaling almost constantly. We do it through the cars we drive, the clothes we wear, the homes we live in, and yes, the food we eat.

When I hear people talking about "organic" foods, and I put scare quotes around "organic" because of my skepticism about the whole field, I do the same kind of evaluation of the speaker as I mentioned above with the cars. How much nutrition education does the buyer of these so-called organic foods have? On what scientific basis do they make the decision to spend upwards of 3 or 4 times as much on these organic foods as they could spend on food not labeled organic? (during the $3 Diet I went shopping for kale and the first kale I found was the organic kale - it was $2.98/bunch. No way I could afford that. Farther down in the produce aisle I found the regular kale - $0.98/bunch. What was the difference? I honestly don't know.) Since the answer almost always becomes apparent relatively quickly - they know less about the difference between "organic" and standard foods from a nutritional perspective than the average Corvette owner knows about her/his car compared to the BMW (or vice versa), I know that the main reason they are eating "organic" is because they want to be seen eating "organic", or be able to tell their friends and acquaintances that they eat "organic". Eating "organic" and "sustainable" is very much about signaling, just like most of what we do in our lives. I haven't done a lot of research on the subject myself, but what I do know is that if there was such a big difference, I wouldn't need to. Why? Because market forces would drive the prices of food produced by dangerous farm practices down such that farmers would not want to use those practices because they wouldn't make any money. The beauty of capitalism is I can rest relatively assured that if the major grocery chain that I shop at carries something, it's probably safe. The reason is that they have a very powerful incentive to be sure that what they carry is safe. HEB, the major grocery chain here in San Antonio, does not want me to take my business somewhere else, which I would do if I believed that they were selling substandard products. So, while I wholeheartedly believe that the CEO of HEB could care less about me personally, I do believe that he wholeheartedly cares about the profitability of his store, and so therefore I can shop fairly blindly.

That isn't to say that in the long run many of the goods that HEB stocks won't kill me. Because apparently that's exactly what was happening. But I can't blame HEB if they carry Ben and Jerry's ice cream. It's up to me not to eat a pint every night after dinner.

One of the things that makes capitalism work so well is that each of us is unique. In fact, capitalism would barely work if we were all homogenous. Not only are we physically different, having different physical and intellectual endowments, as well as endowments of wealth, but we have different preferences. I like Corvettes, you like BMWs. Diversity of endowments and preferences encourages us to pursue different ends - it is the pursuit of different happinesses that creates opportunities for trade. There is little that is more arrogant than to assume that everyone is like you. A view of diversity that is only skin deep is a shallow and ignorant view.

I was talking the other day in a health econ course I am teaching about how some people look at health as a means to an end, while others see health as an end in itself, and then there are lots of people who are somewhere in between. We have limited resources (time is a major one), and it takes resources to create health and it takes resources to create everything else we might want to consume. Of course we are all born with a certain endowment of health - some of us are luckier than others in that regard - but it is a depreciating asset. Our choices add or subtract to our stock of health. People who regard health primarily as a means to an end will target a certain level of health that allows them to maximize doing all of the other things they want to do. Poor health might get in the way of some of those other things, so they take care of their bodies to the degree that it helps them do those other things. These are the people who would prefer to take a pill for cholesterol rather than exercise for an hour every day (which, if we look at the profits of Pfizer - maker of Lipitor - we have a pretty good idea of just how many people have the pill preference). A person who values health as an end in itself would opt for the exercise, and take the pill only as a last resort. But since that person is already likely exercising for an hour a day, it's unlikely they have high cholesterol to begin with (unlikely, not impossible).

For people whom exercise is inherently enjoyable - I have a friend who is an avid bicyclist and rides hundreds of miles a week - they can't understand someone's preference to sit in front of the TV rather than get out and sweat. But the fact is, we have a diversity of preferences in our population. The person who sees health as an end might treat exercise as a means, and only do enough to achieve the level of health they are seeking. All these preferences get a bit confusing! But that's one of the things that makes economics so interesting.

The pursuit of health might also be a signal. It isn't that I really care about health, but I want you to think that I do. So I might engage in activities like exercise or buying organic foods because I want you to perceive me as healthy. Health is hard to see. But a Whole Foods bag is not (and wherever I say, "Whole Foods", feel free to insert your favorite overpriced health food store). So bringing your lunch in a Whole Foods bag is an easy way for you to communicate to everyone who sees you that you are a person who cares about your health. And you have a lot of money to spend on food. In other words, the bag is a signal. For many people it's more important to be seen shopping at Whole Foods and to talk about eating only organics than it is for them to actually be healthier. The degree that these people actually become healthier is a side effect of their activities.

Economists don't like to use squishy words like "happiness" because they like to think of themselves as scientists, so instead they use the word "utility" when they mean happiness (in the Jeffersonian sense). Economists believe that we all generally set out to maximize our utility by satisfying our preferences the best we can. People who really value health will use their resources to increase their health. People who see health as a means to other ends, and those other ends are what gives them utility, will maximize their health to the degree that it enables them to pursue those other ends. People who want to signal that they are healthy will use their resources to generate signals - some of which will actually make them healthy - in order for them to convince the rest of us how healthy they are - which will then maximize their utility. Signalers will prefer to use their resources on activities that have a strong signal (like going to an aerobics class), and will ignore those that do not (like getting a good night's sleep).

I find that there is a large population of people in that third category. They'd rather be watching Oprah and eating bon-bons, but instead they squeeze into spandex and go to the gym where they can be seen exercising and drinking protein shakes. It's these kind of people who piss me off and make me want to eat Ben and Jerry's - preferably in a public place. And it was this kind of hypocritical behavior that as a young person I responded to. I didn't care to be seen trying to be healthy - to the degree that I cared about health, it was primarily as a means to an end.

So I find myself in the second category - valuing health as a means. I hadn't given health all that much thought to this point in my life. I was blessed with good health. I like some exercise activities - but while I don't care for Oprah or bon-bons, I could while away the time eating Ben and Jerry's in front of my computer quite happily. Seeing my weight spike to 198 pounds, and seeing my labs pointing toward an unhealthy future, it was a bit of a wake-up call for me. At the beginning of the experiment, I toyed with the idea of frying everything just to make Kerryn crazy. But sitting in the coffee shop and toying with those rebellious impulses, I could look into the future and see a life where my ability to do other things would be limited by my health. This prompted me to take the 30 days of the $3 diet quite seriously. I see Kerryn as someone who is in the first category - someone who values health as an end. Many of the people I know who get into fields like nutrition or sports medicine are people who appreciate health as an end and not just as a means. Working with people like her is one of the benefits of being in the health field.

3. An N of 1

I have used the word "experiment" to describe my experience, but it was more of an experience than an experiment. Experiment implies a certain level of scientific structure. In particular, it implies that the data is gathered in such a way that it will be generalizable. What Kerryn and I have done here is more of a case study than an experiment. We changed multiple variables - food inputs and exercise - with minimal controls.

When scientists run experiments, they want to see some sort of statistical significance. Statistical significance simply means that if we find a treatment (say, eating on $3 a day) has a positive result, we want to be sure that the positive result would most likely not have simply happened by chance. To make sure that something is not simply by chance, we want to do it many times, or run the treatment on many subjects at once. We call the number of subjects or trials "N". Usually you want your N to be a minimum of 30 if you are looking for statistical significance. What we did here at the $3 Diet was run an experiment with an N of 1. To make this experiment meaningful, we would have had to have had a cohort of probably 60 or more people (depending on the cleverness of the design) willing to go through this process. Some of the participants would have changed their diets without changing their exercise, some would have changed their exercise without changing their diets, and probably some would have done both. With an N of 1 - meaning only I went through the treatment - we can't really generalize and say that the $3 Diet has proven anything in a statistically significant way.

We can say that in this one case:

1) that it is possible to eat a pretty healthy diet on $3 a day. And,

2) that healthy diet, combined with an elevation in exercise will lead to weight loss and improved markers of health (here and here).

Living on $3 a day required completely rethinking the way I ate. The adjustments were hard to make, because food is central to our day-to-day lives, and Kandie and I had previously spent a lot of money eating out. And in addition to going out with Kandie, I was in the habit of spending a lot of money on processed snack food (soda, candy bars, snack cakes, etc.).

The $3 Diet was also challenging because no one else in my house was living with the restriction. Kandie didn't mind the change in food because she appreciated the effort to live healthier, and to be honest, she's been pushing me for years to change the way I eat. But being embedded in a household where everyone else is still eating whatever they had been eating, and being embedded in a society where there is a soda machine around every corner, and most quick food available at convenience stores is both expensive and unhealthy, it was even more difficult.

I could have made it more challenging in a number of ways. While I started each day with $3 and didn't carry over any excess from the previous day, I was able to borrow in a sense from day to day constantly. I only charged myself for what I used - for example, I only charged myself $0.03 for the slice of bread that I had made on a given day, even though the whole loaf was $0.60. People who are really poor face something economists called "borrowing constraints" - which means that they may indeed have a flow of resources - say a job - that would allow them to buy something more expensive than the amount of money they happen to have on hand - but they don't have a means of borrowing against future earnings the way most rich people do by simply using a credit card. This is why you see pawn shops in poor neighborhoods and not in wealthy neighborhoods. Pawn brokers help poor people overcome their borrowing constraints. So even though I didn't allow myself to carry over the resource value from day to day, I did allow myself to carry over resources (which I then charged myself for on the following day).

Especially during the first two weeks being on the diet was mentally exhausting. I was constantly making calculations about what I could afford. It wasn't that hard - but it took time. And it was constant. I would compare it to running additional apps on your phone or additional programs on your computer. My performance on other activities was slowed down because I was thinking about what I could afford. Kandie and I have always liked to go food shopping together because it's a good time to talk, but she got fed up with me after about the second time as I stood in the frozen vegetable aisle comparing prices and trying to figure out price per ounce. She gruffly told me, "It's no fun shopping with you," and walked off.

Not having market resources can be overcome. I did demonstrate that during the experiment. But I only dealt with one market resource limitation - how much I had to spend on food. If I also had to deal with not having a functioning car, and not having certainty about reliable shelter, and not having reliable child care, and so forth, like someone who really would have to figure out how to live on $3 a day, the task would rapidly consume much of my mental processing power.

In order to overcome my lack of monetary resources, I engaged in a lot of what economists call "household production" during the diet. That is, instead of buying goods like bread made by someone else, or whole meals at restaurants, I produced them in my home during the time when I was not engaged in labor market activities (i.e., when I wasn't at work). The result was a low monetary cost, but a high time cost. In other words, I used my time resources to produce goods instead of monetary resources.

From an economic perspective, if you are employed, you are engaged in a trade of your time for money. If you can't trade your time for money, then you should use that time to make the things you need, or make things other people need, and trade those things (but that's getting close to a job again). Sometimes even if you could get a job, it might make more sense to refuse the job (not trade your time) if you can produce more valuable products on your own (such as watching your children or cooking meals for your family) than a job would pay you. For example, if you could only earn the federal minimum wage of $7.25, but you could produce more than $7.25 of value by staying home and cooking a meal, then you should not work that last hour, but instead leave early and go cook dinner.

When you hear discussions of social policy with regard to welfare, you often hear economists point out that the marginal tax rate on the poor is so high that it actually encourages them not to work. The idea is that if you stay out of the work force and collect welfare (or disability), you collect a pay check for doing nothing. But if you start to earn money in the job market, the government very quickly takes away the pay checks it was sending you, making it not worth your while to return to the work force unless you can leapfrog well past minimum wage (which most people who were previously collecting welfare cannot because they lack the skills to do so). One of the things that my experience with the $3 Diet made me realize was that not only should you look at the marginal rates (the trade off of cash) but you should also include the value of household production that can be accomplished if you do not have to sell your time. Policy makers should realize that not only do people who are receiving welfare have to give up the free money, but they have to give up the value of the household production they could have been engaged in. Let's put a dollar figure on that: let's say that welfare paid someone about $15,000 a year in cash benefits, and while they were otherwise unemployed, they were able to generate $3.00 per hour of value in household production (perhaps cooking meals, watching the kids, whatever - $3/hour is pretty minimal). The value of the welfare checks would equal $7.21/hour for a 40 hour work week. Adding on the $3/hour in household production, the person would be generating $10.21 per hour by being unemployed. So in order to justify leaving welfare, that person would have to earn almost 50% more than minimum wage (i.e., more than $10.21/hour). There are additional benefits people on welfare qualify for that often aren't counted because they are non-cash, such as Medicaid. Nevertheless, the missing piece in many of these policy debates appears to me to be the value of household production. Household production also does not show up in any widely used measure of economic productivity - most notably GDP.

Sorry to get wonkish on you - but it's a thing I thought about throughout the experience.

The bottom line: this experience was one individual. To make any sort of generalizations, this experience would have to be repeated with a lot more participants and with more precise controls. Case studies are more useful for raising questions than providing answers. I learned something from the experience - I hope other readers did, too.

4. Learning more about being rich than being poor

I set out on this experience to learn something about being poor. I told you above that much of my childhood I was poor, but that was when I was a kid, and a long time ago. The Army values people who do more than people who talk. We want to see leaders who walk the walk, as it were, and not just talk the talk. So in that spirit I wanted to see for myself what it was like to live on a poverty level of resources. I have already recognized that this experiment did not really subject me to the full challenges of living on a poverty diet because while I reduced the resources I could use for food, I retained all the other benefits of being a relatively wealthy American. I still had a nice safe home, an operational car, access to a nice grocery store, and access to a gym (among other niceties that truly impoverished people do not have).

Ironically in retrospect what I think I realized is that being "rich" (and I use that loosely since I hardly see myself as "rich" in the sense it is commonly used in political conversation) has been harmful to my health, at least in terms of diet. The ease with which I have been able to access high cost food - especially processed and restaurant food - has been detrimental to my health. I was never ignorant about the fact that a Big Mac, fries, and a Coke was an unhealthy lunch choice. But the relative cost of buying a meal from McDonald's vs. taking the time to prepare one myself was so inexpensive that I have indulged far too many times. It doesn't help that my preferences from growing up favored such indulgences as well, associating them with positive values like independence. I've become more focused on how often Kandie and I give the kids fast food during the week when we're all busy - because it's just easier - meaning the relative cost of planning and preparing a meal is higher than the monetary cost of just buying a meal from Sonic (the kids' favorite).

Being nominally rich made making bad choices about diet and health relatively less costly - at least in the short run. I suppose given that I have valued health as a means to an end and not an end in itself, this was actually a rational choice, even in the long run. After all, if I developed excessively high cholesterol levels, I could simply get a prescription for Lipitor (or its equivalent), which would be nearly costless to me because of health insurance, and I could possibly continue engaging in most of the activities I valued.

One of the things I have heard, but now feel it more is this: You are materially rich only to the degree that you do not worry about money. I say materially because of course there is the riches of the spirit. Unfortunately the riches of the spirit do little to keep your belly full.

Coming to this experiment helped me realize that I had set up much of my life so that I did not have to worry about money. Although Kandie and I indulged in eating out quite a bit (me more so than her, since I often bought my breakfast and lunch as well), we always did so in a way that was relatively modest in cost - so that it was not a problem on our income. In fact, I would say that Kandie and I live very modest lives, financially. Nevertheless, money still haunts me from my youth. I suppose it haunts all of us to differing degrees. But many of the choices I have made in my life have been to minimize the amount of time I have to think about money in my personal life (I'm a comptroller and economics professor so I kind of enjoy thinking about it professionally). My personal goal has been to be rich - in the sense I mentioned above - to get to where I don't have to think about money - not to live extravagantly. Taking on the $3 Diet put money front and center in my life again, and I have to say it was not fun.

5. Going forward - commitment

Obviously I am happy with the outcomes we achieved. The experience has raised my awareness about my own health and the choices I am making that contribute to my health. It has challenged some of my beliefs and values, and it has made it clear that I need to change, and I can change.

It's not easy to change. That's why we use commitment devices like joining gyms. Or, in my case, announcing to the world that you are undertaking an experiment.

I'm into the second week now off the $3 Diet and I'm still trying to maintain some of the good behaviors I developed while on the diet.

  • I've still not had a soda. I am drinking some carbonated water, but it's just water with CO2, not soda. I'm hoping to give up soda permanently.
  • I haven't been back to a fast food restaurant, and I'm hoping to swear them off permanently as well.
  • I'm eating a lot more fresh fruit. Even though I'm still trying to cut calories and lose weight, I'm making room in my diet for fresh fruit. I've been chowing down on fresh pineapple, pears, bananas, and blueberries.
  • I'm trying to minimize red meat.
  • I'm trying to eat enough dairy - cottage cheese and yogurt in particular - because calcium and vitamin D haunted me so much during my experience.
So, I'm trying to make the gains permanent. On a related note, Kerryn and I are preparing to launch a new project - a new blog called "More than 100 Minutes."

We describe the theme of the new blog is this:

"More than 100 Minutes" is inspired by the Army Surgeon General's concept that health care providers only get to interact with the average patient for 100 minutes each year. As individuals, we have to fill in the rest of our life space with choices that promote our own health. This blog is about trying to make those good choices.
I'm hoping that by blogging about health - by using some of my processing capacity on an ongoing basis focused on health - that I will gradually transition to a person who values health as an end, and not just as a means. While economists hold that preferences are stable in the short run, we do accept that they can be changed with time. I think if I can get there, if I can make that change, the rest of the decisions won't seem quite so much like sacrifices. We'll see how it goes. That is my real underlying motivation. I think Kerryn wants to do it just to make everyone else healthier - but I'll let her tell you about that on the new blog.

I hope if you've made it this far that you will join us when the new blog goes live soon.


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