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The new AJPM blog is a forum for professional discussion of the issues raised in the articles we publish and in selected perspective we solicit from leading authorities in prevention, public and population health.
We invite you to read the posts below and join the conversation.
Skin cancer affects people of all ages and races, and it most often develops on the areas of a person’s skin most exposed to the sun—exposure to ultraviolet (UV) radiation and a history of sunburn are risk factors. According to the American Cancer Society, there are about 3.5 million diagnoses annually of skin cancer, more than the new diagnoses of breast, prostate, lung, and colon cancers combined.
It is estimated that one in five Americans will develop skin cancer in their lifetime, yet it is chiefly a lifestyle disease, and is preventable. In addition to the usual precautions when outdoors, a really good idea is to stay away from indoor tanning salons.
Two articles on the dangers of indoor tanning appear in the current issue of the Journal. The first, Preventing Skin Cancer Through Reduction of Indoor Tanning: Current Evidence, provides a brief review of the evidence linking indoor tanning to skin cancer, why people use indoor tanning devices, and things to consider when developing strategies to reduce indoor tanning. This information sets the context and background for the companion paper in this issue, Strategies to Reduce Indoor Tanning: Current Research Gaps and Future Opportunities for Prevention, which
summarizes highlights from a meeting of experts convened by the CDC in August 2012 to explore ways to reduce the use of indoor tanning devices.
The August meeting at the CDC came hard on the heels of their May morbidity report, Sunburn and sun protective behaviors among adults aged 18-29 years—United States, 2000-2010.
The CDC report found that although some sun protective behaviors, including shade and sunscreen use and wearing long clothing to the ankles, have increased in recent years among adults, the prevalence of sunburn in 2010 remained high (50.1%), especially among whites (65.6%). Previous data have indicated that most U.S. adults aged 18–29 years do not regularly engage in protective behaviors when outdoors in the sun, and approximately half have experienced sunburn in the past year.
The implications for public health practice are that provision of shade and sunscreen in recreational settings and clinical counseling of younger adults are promising strategies for creating environments and social norms that facilitate sun protection and sunburn prevention in this population.
Recent recommendations from the International Agency for Research on Cancer, a subsidiary of the World Health Organization, state, “Policymakers should consider enacting measures, such as prohibiting minors and discouraging young adults from using indoor tanning facilities, to protect the general population from possible additional risk for melanoma.”
The American Academy of Dermatology Association, Environmental Protection Agency, Food and Drug Administration, Indoor Tanning Association, National Cancer Institute, and the National Council on Skin Cancer Prevention, have each made recommendations regarding the use of tanning devices—from requiring parental consent for minors to banning all use by children under age 18.
Currently California and Vermont ban the use of tanning beds for all minors under 18, and at least 33 states regulate the use of tanning facilities by minors. Eighteen states require operators to limit exposure time to manufacturers’ recommendations and provide eye protection. Along with requiring parental permission for minors, Arizona also requires public schools to provide education about risks to developing skin cancer. For a list of current laws see, Indoor Tanning Restrictions for Minors: A State-by-State Comparison, compiled by the National Conference of State Legislatures.
Fortunately, there are some easy tips to help prevent skin cancer. The Mayo Clinic has a new public service announcement airing this month that offers the following tips:
- use sunscreen
- skip tanning beds
- seek shade
- get spots checked.
I’d also like to see fedoras back in style, and swank supper clubs where we can stay out of the sun.
—Michael Lytton, AJPM Blog Editor
May 15 marked the end of the 3rd and final round of AJPM’s Childhood Obesity Challenge. In the scientific publishing world, creative ideas with the potential to transform health and health care but not yet backed by volumes of data, are often dismissed. Consequently, at the AJPM’s 2010 Strategic Planning Meeting it was agreed that the Journal would strive to be a conduit of innovation for clinical practitioners and policymakers. The following year the Childhood Obesity Challenge was launched, sponsored by the Robert Wood Johnson Foundation’s Pioneer Portfolio.
The Challenge was an online competition encouraging proposed solutions to childhood obesity, not only from academia, but also from sectors such as industry, small businesses, social entrepreneurs, and media providers. In addition to receiving cash prizes for at least three judge-selected entries in each round, the first-place submissions were featured in the print and online editions of the AJPM.
“The concept of speeding promising information to both practitioners and policymakers underpinned the competition; having that information come from arenas outside the typical academic or government settings was the icing on the cake,” said Jill Waalen, Deputy Editor of AJPM and the Co-Principal Investigator on the project. And the response was very gratifying. The Challenge website had a total of 239,355 page views and 67,671 site visits during the course of the three challenges.
The three rounds of competition received 141 entries. “With Round 1 of the Challenge, we had a broad focus and attempted to capture any type of solution with the potential for the largest reach, “ said Kevin Patrick, AJPM’s Editor-in-Chief. Round 2 sought submissions aiming at innovative policies, as well as strategies for getting those policies adopted and applied to schools, institutions, municipalities, or other organizations. Round 3 concentrated on interventions for children and their families delivered in clinical settings, or involving partnerships between clinics and communities.
A glance at the winning selections reveals the broad range and high caliber of innovative thinking.
Decision support tools included a caloric calculator that presented energy balance at the population level on a daily basis. The tool, by synthesizing the best existing evidence on approaches that hold the promise, will make it easier for decision-makers in a broad range of roles—policymakers, teachers, administrators, community leaders, parents—to compare the relative impacts of making changes to local, state, or federal policies. Another winning submission included decision support tools in the electronic health record, such as alerts delivered to pediatric clinicians at annual patient visits.
Entries focusing on environmental factors included design guidelines for school architecture to provide optimal healthy eating spaces, and another offered a plan to transform popular neighborhood streets and avenues to boost children’s activity levels and consumption of healthy food.
A food education proposal deployed a nationwide team of AmeriCorps service members in public schools to directly focus on healthy eating, and two submissions addressed afterschool settings. One initiative produced three guiding principles that address nutrition and physical activity in out-of-school (OST) environments, and encouraged the country’s leading OST organizations to integrate the principles into their policies. A second winning idea leveraged professional development training and technical assistance to achieve afterschool physical activity and nutrition programs and policy changes.
Exceptional proposals for local government action included a model ordinance to help communities set a healthy baseline for retail outlets that sell foods and beverages. Another described formal collaboration between a healthcare provider and a municipal community center to offer patients the opportunity to learn cooking skills and get exercise, neither of which was possible in the clinic setting. A first-ever joint use agreement between the clinic and the city parks and recreation department complemented healthy lifestyle interventions provided by an interdisciplinary team during monthly patient and family visits.
A healthcare team was also central to a project to provide group medical visits for obese and overweight Latino children. During interactive sessions at health centers, a team consisting of a doctor, a nutritionist, and a promotora (community health worker) discuss nutrition, physical activity and stress with the children and their families, and help them develop weight loss action plans.
To see details of these, and all other entries, visit the Challenge archives at: ajpmchallenge.calit2.net.
The last week of April was World Immunization Week, sponsored by the WHO and its worldwide partners. More than 180 countries, territories, and areas marked the week with activities including vaccination campaigns, training workshops, round-table discussions and public information campaigns. In conjunction, here in California, the Department of Public Health promotes National Infant Immunization Week (NIIW) and Toddler Immunization Month (TIM), annual observances that highlight the importance of routine immunizations for children younger than two years of age.
March was also the 50th anniversary of the first steps in the development of a vaccination for mumps. For the occasion, a New York Times article celebrated the superhero of vaccinations, Maurice Hilleman, an American microbiologist who developed over 36 vaccines, more than any other scientist. Of the 14 vaccines routinely recommended in current vaccine schedules, he developed seven: those for measles, mumps, hepatitis A, hepatitis B, chickenpox, meningitis, and pneumonia. He is often credited with saving more lives than any other scientist of the 20th century. He unquestionably deserves his own wing in the preventive medicine Hall of Fame.
In 1988, Hilleman received the National Medal of Science, the nation’s highest scientific honor. In his lifetime (he died in 2005), he also received: the Prince Mahidol Award from the King of Thailand for the advancement of public health; a special lifetime achievement award from the World Health Organization; the Mary Woodard Lasker Award for Public Service; and the Sabin Gold Medal. Robert Gallo, co-discoverer of the virus that causes AIDS, said “If I had to name a person who has done more for the benefit of human health, with less recognition than anyone else, it would be Maurice Hilleman. Maurice should be recognized as the most successful vaccinologist in history. “
The use of vaccines to protect, or “immunize” people of all ages against disease is one of the world’s most powerful tools in public health. Immunization is a highly successful and cost-effective preventive intervention, averting between 2 and 3 million deaths every year. From infants to senior citizens, immunization protects against diseases such as diphtheria, measles, pertussis (whooping cough), pneumonia, polio, rotavirus diarrhea, rubella, and tetanus.
Global vaccination coverage is improving: 130 countries have been able to administer all three primary doses of the DPT vaccine to 90% of children younger than 1. And the benefits of immunization are increasingly being extended to adolescents and adults, providing protection against life-threatening diseases such as influenza, meningitis, and cancers (cervical and liver).
Yet even now an estimated 22 million infants are not fully immunized with routine vaccines, and more than 1.5 million children under 5 die from diseases that could be prevented by existing vaccines. There remains an urgent need to better communicate the health benefits of vaccination and the dangers of not immunizing children.
Priority needs to be given to strengthening routine vaccination globally, especially in the countries that are home to the highest number of unvaccinated children (India, Nigeria, and Indonesia). Particular efforts are needed to reach the underserved, especially those in remote areas, in deprived urban settings, in fragile states, and strife-torn regions.
The Global Vaccine Action Plan (GVAP) is a roadmap to prevent millions of deaths through more equitable access to vaccines. Countries are aiming to achieve vaccination coverage of ≥90% nationally and ≥80% in every district by 2020.
An encouraging example is Haiti, which has recently introduced the pentavalent vaccine, a combination vaccine designed to protect children from five dangerous diseases. Haiti is among the countries in the Americas with the highest child mortality rates, caused mainly by acute respiratory infections like pneumonia, diarrheal diseases, anemia, and chronic malnutrition. The “five-in-one” pentavalent vaccine protects children from diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenzae type b (Hib), which causes pneumonia and meningitis.
For Further Reading:
For a link to related AJPM articles, you can go to AJPM Collections: Immunizations
As the graphic details of what occurred one night at an alcohol-fueled party in Steubenville, Ohio come to light, coaches, educators, parents, and youth across the country are asking what can be done to prevent this kind of violence? And why didn’t one of the other young people at the party that night do something? A significant challenge in violence prevention is helping youth to build skills and language they need to stand up and speak out when they witness abusive behavior among their peers.
Futures Without Violence’s Coaching Boys into Men (CBIM) is a research-tested violence prevention program that equips high school athletic coaches to talk with their male athletes about the importance of building healthy and respectful relationships. Administered over the course of a typical athletic season, the CBIM curriculum is easily integrated into coaches’ schedules. The curriculum guides coaches on how to build character and promote positive bystander behavior (skills to interrupt peers’ abusive behaviors) in young men through teamwork, sportsmanship, integrity, and respect. Young male athletes are the focus of the program because of their potential to be leaders in their school communities. Athletic coaches play an influential role in the lives of many young people and are uniquely poised to positively influence how they think and behave when it comes to their relationships.
In our randomized controlled trial conducted in 16 high schools in California with over 2000 athletes and 170 coaches, at the end of the sports season, the athletes receiving the program (compared to athletes receiving regular coaching) reported greater intentions to intervene, increased recognition of what constitutes abusive behaviors, and more frequent reports of intervening as positive bystanders when witnessing peers’ abusive behaviors. In the 1-year follow-up (reported in AJPM), the male athletes who received the program reported less abuse perpetration and fewer behaviors that support or condone violence among their peers compared to athletes in the comparison group. Stated another way, the athletes in the comparison group had an increase in abuse perpetration during the course of the year and also reported more instances when they laughed or went along with peers’ disrespectful or harmful behaviors. CBIM represents a chance to foster a different kind of culture in school communities—one that values respect, integrity, and nonviolence over abuse and disrespect.
While the findings from the research study are promising, the real challenge for our work in violence prevention is how to bring this easy-to-implement program to schools, athletic departments and coaches across the country. Our research team, in partnership with Futures Without Violence, continues to work with schools and violence prevention organizations to identify ways to engage coaches and support program implementation.
As tragic incidents like the Steubenville rape case gain national attention, more and more community leaders are taking a stand against violence. Using sports as a platform for social change, CBIM engages male role models and provides them with tools they need to talk with boys about building healthy relationships. The message is simple: athletic coaches can teach their young athletes that violence never equals strength. The challenge is how best to implement and sustain this program in local communities.
In keeping with the nation’s obsession with education testing, let’s take a peek at the just-released research report from UNICEF: Innocenti Report Card 11, Child Well-Being in Rich Countries: A Comparative Overview.
The Report Card presents the latest available overview of child well-being in 29 of the world’s most advanced economies. Its purpose is to record the standards achieved by the most advanced nations and to contribute to debate in all countries about how such standards might be achieved.
As moral and pragmatic imperatives, the need to promote the well-being of children is widely accepted. Failure to protect and promote the well-being of children is associated with increased risk across a wide range of later-life outcomes such as impaired cognitive development, lower productivity and earnings, antisocial behavior, drug and alcohol abuse, higher levels of teenage births, and a higher incidence of mental illness.
The case for national commitment to child well-being is therefore compelling both in principle and in practice. And to fulfill that commitment, measuring progress in protecting and promoting the well-being of children is essential to policy-making, to advocacy, to the cost-effective allocation of limited resources, and to the processes of transparency and accountability. In that spirit, let’s take a look at the report card.
Five dimensions of children’s lives have been considered in the UNICEF report card: material well-being, health and safety, education, behaviors and risks, and housing and environment. In total, 26 internationally comparable indicators have been included in the overview.
How are we doing?
Sad to say, the U.S. ranks 26 out of 29 rich countries in the latest UNICEF comparative review of child well-being. We were dead last in 2001 and find ourselves there again in 2010. (The 10-year record is a limited overview, ranking only 20 countries because comparable data for the dimension of housing and environment was not available for all countries at the beginning of the decade.) Finland and the Netherlands led the child well-being rankings in both 2001–2002, and 2009–2010. Canada is ranked 17th and has not changed its position in the past decade.
The U.S. ranks in the bottom third in all dimensions of child well-being—material well- being (26th), health and safety (25th), education (27th), behavior and risks (23rd), and housing and environment (23rd).
We score well on a few indicators: lowest alcohol abuse by young people, 2nd in children reporting exercising for at least an hour a day; 4th in both smoking rate for young people and children eating fruit every day; and 5th in levels of air pollution.
We’re in the middle of the pack for the following indicators: family affluence, educational achievement, children involved in fighting, and young people reporting being bullied.
We score poorly on: relative child poverty rate; child poverty gap; infant mortality; birthrate; preschool enrollment; participation in further education; overweight; teenage births; cannabis use; and, homicide rates. The U.S. also ranks in the bottom third of rich countries on the children’s life satisfaction survey.
In the language of our sacred school report cards, “skills are below grade level in most areas; progress is inconsistent; [Uncle Sam] does not have positive attitude or eagerness to improve; not participating and sharing well in class activities; not demonstrating self-responsibility, social interaction and group dynamics (listening well, showing interest in learning).
A better understanding of the report card is obtained by the relative comparison. For example, while the Netherlands retains its position as the clear leader, and is the only country ranked among the top five countries in all dimensions of child well-being, the bottom four places in the table are occupied by three of the poorest countries in the survey, Latvia, Lithuania and Romania, and by one of the richest, the United States. Overall, there does not appear to be a strong relationship between per capita GDP and overall child well-being. The Czech Republic is ranked higher than Austria, Slovenia higher than Canada, and Portugal higher than the U.S.
Finland is the only country with a relative child poverty rate of less than 5% and heads the comparative rankings by a clear margin of more than 2%. The U.S. is in the bottom third of the 29 countries, with a child poverty rate of 23.1%. In terms of the child poverty gap—the distance between the national poverty line and median incomes of households below the poverty line—we join the handful of countries that has allowed the gap to widen more than 30%. Here in the U.S. the child poverty gap is 37.5%.
The percentage of overweight children rose in 17 countries over the decade, with the sharpest rise in Poland, where it doubled. Childhood obesity levels are more than 10% in all countries except Denmark, the Netherlands, and Switzerland, but only Canada, Greece and the U.S. have childhood obesity levels higher than 20%. The U.S. had the highest proportion of children overweight at both the beginning and end of the decade, reaching almost 30% by 2009–10.
It is never pleasant to get a bad report card, but dismissing the news is unhelpful. As tempting as it might be to angrily dismiss a child’s poor report card as unfair, in error, or using the wrong measures, we know such evasions are counterproductive. And it’s certainly no use to allege that such report cards are irrelevant on the grounds that “my kid can beat up your kid any day of the week.”
Make no mistake, monitoring the level of children’s well-being is important: the exercise not only takes stock of how well off children are, but also reminds governments and societies around the globe of their obligations toward children and points them toward areas where improvements could and should be made. We can do better.
Our next look at report cards will be U.S. Health in International Perspective, from the National Academies Press. Stay tuned.
— Michael Lytton, AJPM Blog Editor
For Further Reading:
Anda RF, Butchart A, Felitti VJ, Brown DW. Building a Framework for Global Surveillance of the Public Health: Implications of Adverse Childhood Experiences. Am J Prev Med 2010;39(1)93-8.
Butchart A. Epidemiology: The Major Missing Element in the Global Response to Child Maltreatment? Am J Prev Med 2008;34(4S):S103-5.
Issues surrounding physical fitness testing have been around for more than 50 years in the U.S. Members of our group have conducted research in schools related to childhood and youth physical fitness for more than 30 years. Key issues that we have investigated include the reliability and validity of health-related physical fitness measures. Since the development of childhood and adolescent physical activity guidelines in1994 (Sallis et al.) and then the 2008 USDHHS Physical Activity Guidelines for all Americans, interest has been refocused toward assessing physical activity behaviors in schools, communities, and home environments. Measuring physical fitness (the outcome) is often easier than measuring physical activity behaviors. Significantly, we report that children who meet national physical activity guidelines have increased odds of achieving healthy physical fitness results on a nationally recognized health-related, criterion-referenced fitness assessment, the Fitnessgram®, a component of the Presidential Youth Fitness Program (PYFP) conducted by the President’s Council on Fitness, Sports and Nutrition. The PYFP is a “comprehensive school-based program that promotes health and regular physical activity for America’s youth.” Conducting research in schools can be described as “messy business” when having to work with and around teachers, students, parents, and administrators. Some specific challenges we faced included: test administrators who are not trained to administer tests, trying to help the educators with retesting because of incorrect protocol, and teachers/coaches making comments about students during the measurement process. We implemented more specific procedures after witnessing questionable testing procedures. While these challenges and additional ones related to scheduling, classes, weather, teachers, administrators, and parents, can sometimes be obstacles to school-based research, the development of good relations between researchers and school-based personnel helped move the science of physical education forward as we attempted to measure behaviors and objectively measured physical fitness outcomes.
— James R. Morrow, Jr., PhD
University of North Texas
A bit like the old adage, “gravity isn’t just a good idea, it’s the law,” there is reason to suspect that food isn’t just necessary, it’s addictive.
And therein lies the conundrum: The diet high in fat, sugar and salt is unhealthy, but it sure tastes good. Fat and sugar are two of the most pleasurable elements of the diet in terms of taste preferences, a fact not lost on the transnational food corporations who are tempting us with their processed delights. Clearly part of the obesity challenge is to provide more varied and tasteful diets, that along with increased activity levels, will help to reduce the prevalence of obesity, adult-onset diabetes and cancer related to nutrition and exercise.
In late February the New York Times published an article by Michael Moss titled The Extraordinary Science of Addictive Junk Food. Moss won a Pulitzer Prize in 2010 for his reporting on the meat industry, and the article was adapted from his subsequently published book Salt Sugar Fat: How the Food Giants Hooked Us. In a nutshell, Moss says that it’s not just a matter of poor willpower on the part of the consumer and a give-the-people-what-they-want attitude on the part of the food manufacturer, but rather a conscious effort—taking place in labs and marketing meetings and grocery-store aisles—to get people hooked on foods that are convenient and inexpensive. The processed food industry knows that big profits require a sustained effort in both marketing and science, and Wall Street punishes those who let margins slip in the name of health.
Moss’s book discusses the armies of food scientists and technicians, psychologists, and marketing teams that are fully engaged in optimizing food sales. They are locating the “bliss point,” avoiding “sensory-specific satiety,” maximizing crave, and formulating products to deliver that sugar, fat, and salt that they have helped the limbic brain yearn for.
It’s not an encouraging read. As one reviewer lamented, “we’ve eaten like a nation of impulsive teenagers, happy to pay for a diet of carnival food. Our adolescent food culture fell hard for the romance of industrial perfectibility and the “convenience doctrine”: the proposition that easy should define good in American eating.”
Is government regulation the answer? Could social costs (externalities) somehow be quantified and assigned to the responsible parties? This would likely result in significant price differentials between healthy and unhealthy food, thereby making better dietary choices more “economically palatable.” But the lower-priced alternatives must also taste good (be equally addictive).
I asked Mr. Moss if he thought government regulation was necessary, and if highly palatable foods could ever compete with diets high in sugar, fat and salt. His reply is guardedly optimistic:
I’m struck by how many of the food scientists and marketers that I interviewed for the book now have regrets about their work on behalf of the processed food industry, and are eager to make amends, or as one former Coca-Cola president put it to me, to account for his “karmic debt.” These are very smart, resourceful people who know what it takes to create and market products that are sure winners in the grocery store, and they believe that the food giants’ path to truly healthier food is not merely reducing this or that, as in creating lower sugar or lower fat versions of their mainline products. Rather, they speak of the need for Manhattan-style projects, with the best and brightest engaged in creating — from the shelf-up, so to speak — truly new products that are nutritious, reasonably priced and tasty without compelling us to overeat. Why not invent a breakfast cereal made from nuts, and not sugar? Or tomato sauce made from great tasting tomatoes, instead of sodden ones needing sweeteners? Or research to make fresh fruits and vegetables less expensive to grow, rather that putting all our scientific effort and subsidies into making corn and soy so cheap? This will sound expensive and risky to the food giant CEOs, who are closely attuned to their revenue projections and Wall Street’s oversight. But if consumers raise their voices loudly enough, and through their purchases act on the growing concern worldwide about what we put into our bodies, then the food giants will respond in the only way that we can expect them to respond: by being companies that make money by selling product that people will buy. We could wait a long time for the food giants to adopt ethics that put consumer health over profits. Prodding them to profit from new products that will promote better health could show some swift results.
For a link to related AJPM articles, you can go to AJPM Collections: Diet and Obesity.
— Michael Lytton, AJPM Blog Editor