Public Health Report

Category: Other Public Health

We are Just Realizing Nobody Understands Sunscreen


We are in an age of extreme failures of public health communication. Our society is realizing that we don’t know how, or even when, to communicate public health messages. In an era that sees politicians pandering to vaccine deniers,  nutrition research finding butter health-neutral, and myriad other public health crises, it is hard to know what to focus on. Some things, however are easy wins. As The Atlantic’s James Hamblin points out today, proper use of sunscreen might be the easiest cancer prevention tool. But public health officials have dropped the ball, and it has been up to journalists like Hamblin and’s sunscreen crusader Julia Belluz to explain sun damage to the world.

Hamblin’s piece points to a JAMA survey about sunscreen knowledge. Some questions may have been confusingly worded, but only 23% of respondents completely understood that SPF is a measure of protection against sunburn. Hamblin goes on to point out the remarkable fact that the American Academy of Dermatology (AAD) and the FDA manage to disagree on what the letters SPF stand for. AAD calls it “Sun Protection Factor,” and the FDA calls it “Sunburn Protection Factor.”

Hamblin leaves it at that, but it seemed worth delving in to the origin of this discrepancy. It turns out, this difference is due to a rule change in 2007. Here is the FDA’s (vague) justification:

Several comments recommended changing the acronym ‘‘SPF’’ from ‘‘sun protection factor’’ to ‘‘sunburn protection factor’’ because the 33 latter definition is more descriptive of the use of OTC sunscreen drug products and avoids giving consumers the impression of solar invincibility and a false sense of security. FDA agrees. In § 352.52(b) of the sunscreen FM, FDA included only indications for sunburn protection (e.g., ‘‘helps prevent sunburn’’) (64 FR 27666 at 27691). In this document, FDA is proposing to change the word ‘‘sun’’ to ‘‘sunburn’’ in § 352.3(b)(1), (b)(2), (b)(3), and (d) and § 352.52(e)(1)(i), (e)(1)(ii), and (e)(1)(iii).

On the AAD website, it is also explicitly stated that “Currently, there is not any scientific evidence that indicates using a sunscreen with an SPF higher than 50 can protect you better than a sunscreen with an SPF of 50.” Hamblin points out that a 2011 Procter & Gamble study even called for an end to higher ratings, calling them misleading. This translated to a 2011 proposed regulation by the FDA which would make “SPF 50+” the highest allowable claim on packaging, but it does not seem to have gone anywhere since. Notably, the description of this proposed rule change defines SPF as “Sun Protection Factor,” despite being published 4 years after the FDA’s change to “Sunburn Protection.”

The confusion within the FDA over simple terminology is an indication of how well they are able to communicate about sun protection to the public. As in the quote above, the FDA continuously adopts a paternalistic tone in response to proposed simplifications of labeling requirements, insisting that they would make it harder for consumers to understand the products. It is clear, however, that consumers don’t understand the current system. It is likely that SPF, a numbered system with no intuitive association linking the numbers to expected results, should be replaced with another measurement. The FDA, however, is resistant to this idea as well:

Consumers have relied on SPF values for over 30 years and are familiar with this format. Therefore, expressing SPF values as percentages may be confusing. It would imply that the stated percentage of the entire UV spectrum is absorbed by a sunscreen. However, the SPF values only reflect protection against the portion of the UV spectrum that causes sunburn. Additionally, the percentages of UV radiation screened that the submission notes are theoretical.

if SPF values were expressed as percentages, consumers might mistakenly believe that the sunscreen products they are using provide more protection than they really do provide under actual use conditions.

While it’s clear that the percentage proposal would have to be more specific about what the percentage expressed, the FDA’s rebuttal is weak. It is particularly egregious to cite consumers’ familiarity with the current system. It seems the current SPF system is confusing to everyone, even the FDA.

In public health circles, education is regarded as the key to prevention. This usually manifests itself as some form of public outreach. There is no doubt that the public needs to be better educated about sun protection, but changing the SPF system might be the best way to help confused consumers. No method of educating consumers will allow them to make intuitive decisions about sunscreen until there is a labeling system that makes sense.


I’ve chosen the Orlando shooting to open this blog because I think it sets the stage for the discussions I’d like to have, and I think it’s an event that deserves especially cautious interpretation…

Source: Orlando.

Mediterranean Diet Prevents Cancer, Protects Heart and Brain


A trio of new studies of the Mediterranean diet add to growing evidence of incredible health benefits:

A study released yesterday by the University of Ohio indicates that a molecule found in celery and parsley (among other foods), Apigenin, encourages normal cell death through apoptosis, reversing the immortality cancer cells tend to develop.

Another pair of recent publications were released as part of the PREDIMED program, which was designed to “assess the efficacy of the Mediterranean diet in the primary prevention of cardiovascular diseases.”

One PREDIMED study shows that high-risk patients following the Mediterranean diet supplemented with either olive oil or nuts had a significantly lower incidence of major cardiovascular events compared to a low fat diet.

A smaller study in the PREDIMED program indicated that the Mediterranean diets also displayed cognitive benefits in relation to a low fat diet. Significantly lower rates of mild cognitive impairment and dementia were observed in the Mediterranean diet groups supplemented with olive oil or nuts.

Caveat: It should be noted that there is no small amount of bias inherent in all this studying of the trendy Mediterranean diet. On PubMed, a simple search for “Mediterranean Diet” research since January yields 80 results. An identical search for “low fat diet” yields 49 results (this is the diet used as a comparison in the PREDIMED studies because it is commonly recommended by doctors). Another search for the admittedly more obscure “indian diet” gives a single result. Perhaps an Indian diet is the healthier diet; we may not find out until Indian food becomes the next health trend and funding is granted for this research. The key takeaway from these studies is that high vegetable-fat diets have been shown to produce better health outcomes than the standard low fat diet currently recommended for patients with major cardiovascular risk factors.


Data Revolution Overview: Massive Data Access Initiatives in Health and Science Ramp Up


If you work in the health or science sectors, you have probably noticed a flurry of “big data” initiatives. Finding ways to standardize and make accessible the massive amounts of data we accumulate is a growing challenge. Let’s look at some of the recent progress in this area and how we might move forward.

Healthcare has undergone massive policy changes in the last few years, but the data revolution in this field has just begun. 2010’s Affordable Care Act laid the policy groundwork for expanding the use and usefulness of Health Information Technology, notably by encouraging Electronic Medical Records.  Obviously, standardizing health information represents a huge boon to public health research by allowing for easy access to reliable health information. In April, McKinsey & Company released a comprehensive report calling for increased integration of big data into healthcare processes. Notably, they estimate that expansion of current integration trends could lead to a $300-450 billion annual reduction in US healthcare spending, representing a 12-17% overall decrease. On the technological side, the McKinsey report points out that more than 200 new businesses have developed “innovative health-data applications” since 2010. A recent Technorati article confirms the trend of technological innovation brought on by big data, pointing out Samsung’s innovative work with hospitals to create new technology which allows Electronic Medical Records to be better integrated into patient care.

The data revolution is also becoming a greater part of scientific research. With last year’s launch of Obama’s $200 million “Big Data Research and Development Initiative,” the government has accelerated many projects which will allow big data pooling in science. The president’s FY14 budget proposal includes an additional $40 million to expand NIH involvement in the initiative.

As an example of this work, a big step forward was achieved in cancer research last week when the University of Chicago launched “The Bionimbus Protected Data Cloud” to allow for secure access to genetic cancer information from The Cancer Genome Atlas (TCGA). Previously, using  The Cancer Genome Atlas involved weeks of downloading data and additional time setting up methods to manipulate that data. Cloud access to many of the giant data initiatives in the science world will be very helpful to increasing the use of data which is otherwise difficult for researchers to access.

Readers: How can we push smaller research communities to start using more big data methods to standardize and share data? Are you involved with a project that uses big data in an innovative way?

New Research: What Sodium Intake Levels are Healthy?



report by the National Academies’ “Committee on the Consequences of Sodium Reduction in Populations” has found that evidence supports a daily diet which limits daily sodium intake to 2300 mg. Surprisingly, they did not find sufficient evidence to support still lower sodium diets, even in populations at risk for heart disease. In fact, there is some (inconclusive) evidence that low sodium diets may be harmful to those with diabetes, kidney failure, or heart disease

The current US guidelines for sodium intake give an adequate Dietary Reference Intake (DRI) of 1500 mg and an Upper Limit (UL) of 2300 mg, but adult intake levels in the United States average 3400 mg. There is a growing call for increased public health measures to keep America’s runaway sodium intake levels down. 

The focus of the study is on sodium’s direct effect on health outcomes rather than on intermediate biomarkers such as blood pressure, which are a more controversial measure of health impact. The committee refrained from making any direct recommendations of intake ranges due to a lack of data.

Readers, what can we do to prevent the high sodium intake which is the norm in American diets? Have you been recommending low sodium diets to patients?

Read the whole report here.