Tanning beds – a Legalized Cancer causing agent

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Kudos to Nova Scotia for taking a bold step in December of 2010 that continues to evade other Canadian politicians Nova Scotia Act to regulate Tanning Beds .  The restriction on permitting minors to access tanning beds came into force in May of 2011.  Recently California has followed suit, and that will likely mean other provinces and jurisdictions may pay attention. At times these social experiments may not be successful and founded in political ideology, conversely it was California that led the nation in addressing the health consequences of tobacco use.   It might be surprising that Nova Scotia was first, it should not be surprising that California has taken a serious charge at addressing sun exposure issues.  

Melanoma is the most severe of the skin cancers.  While survival rates have improved over the last 4 decades, the incidence rate of primary melanoma has increased 4 times in males, and 2 ½ tmies in females, and continues to increase Melanoma in Canada.  Mortality has creeped up to perhaps twice the rate in males and remained constant in females. As non-melanoma skin cancers are not reportable, there are no good statistics.  What we probably know is that for each case of melanoma there are about 60 cases of non-melanoma skin cancers, in total affecting some 75,000 Canadians annually.  

The main cause of skin cancer is ultraviolet irradiation.  Of course, most radiation exposure comes from the sun, however man’s ingenuity has replicated our solar source and marketed under the terms of “tanning beds” and “sun lamps”.   Yes, users of tanning salons do appear to be at least 30% more likely and in some studies as much as 4 times the risk of developing melanoma – and that likely extends to other skin cancers as well. 

The risk for skin cancers and melanoma is greatly increased when exposures occur earlier in life.   How many times have you heard the messages on slip, slap, and slop, or other refrain reminding of the importance of protecting ourselves and more importantly our children from the sun’s rays?  How well do you comply with this solid advice? Canadians have certainly not embraced the messages as well as our Australian friends who already have the highest global rates.  

Tanning beds produce the equivalent UV radiation exposure to at least 6 times longer of high intensity summer sun.  A typical 20 minutes of that bronzing glow is the same as lying still on the beach for 2 hours. 

Nova Scotia and California are only addressing the highest risk use of tanning beds, namely amongst minors.   The subtle inaccuracy in the limited restriction is the failure to adequately warn all users of the carcinogenic risks of using tanning beds or sun lamps – such would be the norm for other cancer causing agents. 

PEI, BC and Ontario have been testing the tanning waters but seem to be shy of wading in, and perhaps are suffering from cold feet.   Time to re-shine the light on the subject and push those provinces forward, start advocating in other provinces, and finally ignite a solar flame under PHAC and Health Canada who have tip toed around the subject on both use of tanning salons by minors and proper warning messages for adult users of these carcinogenic devices.

Health-evidence.ca - Hat's off to another brilliant Canadian contribution to knowledge synthesis

I once heard the definition of a public health specialist, was "someone who was an expert on any health topic within 15 minutes". Those who have been in the field can likely relate to the cold calls from the public, media or politicians wanting immediate answers on some obscure issue and briefing notes yesterday on items of importance.

Knowledge synthesis and brokering have become the latest information management tool. The actual number of medical journals in circulation probably is a best guess, but in 2004 it was about 9000, and that had doubled in the previous decade. Keeping abreast of the literature would be more than a full time job. Managing this new knowledge is becoming a specialty in of itself.

Not surprising the vast majority of health care practitioners will begin a literature search by using a general Internet Search engine like Google. Wikipedia has become the default generalists starting point for gleaming information on new health topics and surprisingly sufficient in many cases.

There are more sophisticated approaches to literature searching which should form a basic skill set for practitioners. Databases like Medline and CINAHL provide rapid search engines for primary literature, leaving the reader with the daunting task of synthesis. Inserted between the primary literature and the lay superficial assessment have developed two layers of knowledge synthesis. The first was the meta-analysis, or attempt at quantifying multiple similar studies to improve the precision of an estimate. The second being the systematic reviews undertaken by a variety of agencies, the most notable being the Cochrane Collaborative reviews.

Within Canada, there is a synthesis site that brings together information from a variety of synthesis processes – lets call it a meta-synthesis. Reviews are rated on quality before being posted to provide some assessment of the confidence that the reader should ascribe to the quality of the synthesis review. You should become familiar with Health Evidence.ca

 http://health-evidence.ca/articles/show/21720 showing no effects of any trials to date and workplaces http://health-evidence.ca/articles/show/21746 showing some effects. Preventive efforts directed in childhood and youths for avoiding criminal behavior showing some benefit http://health-evidence.ca/articles/show/21675 . There is a nice article demonstrating that it appears that yoga is a somewhat effective intervention for stress reduction – I’ll leave it you to try to find the review.

Some recent gems

Obesity reduction efforts in schools

 http://health-evidence.ca/articles/show/21767 . We all need to be aware not only of the synthesis materials, but also the messages that they carry as others will undoubtably be reading the same literature and this finding is contrary to what would currently be considered best practice.

The one that public health professionals should look at carefully is a review of efforts of collaboration between health agencies and local governments which does not show any added benefit over standard services

http://health-evidence.ca/ and well worth bookmarking.

Aboriginal Health equity – remedying a century of wrongdoing

“To have and to hold the same to Her Majesty the Queen/His Majesty the King, and Her/His successors forever”.   Is the wording used in the Treaties which define the integral part of Canadian heritage and established the foundation of the defining relationship between Aboriginal peoples and those that now share this land.  It is a contract and both parties are bound by the contents.  The reference to “successors” on the above line reflects the duties of non-Aboriginal persons in Canada as Her Majesty is/was the agent on behalf of the Canadian peoples.

Seven of the treaties were signed between 1871-1877.  Four more were signed up to 1921. There are a smattering of other agreements that were entered into over the years but do not carry the weight of the above treaties.  A full list can be found buried in the Aboriginal and Northern Affairs website Canadian treaty documents and history.   Most tribes of Central Ontario and the provinces to the east are not covered by formal agreements.  Much of BC not covered by the treaties though a more formal treaty process began in 1990’s, slightly earlier for the Nis’gaa who signed a formal treaty in 2000. The Inuit are not formally covered by treaty, nor are Metis peoples. 

In Treaty 6 there is an onus on “Her Majesty” to provide a “medicine chest”, whose purpose was likely originally intended to reflect the limited medical options available in 1876.    The interpretation and application of the medicine chest clause has become an important part of defining Aboriginal peoples in Canada and given the tremendous advancements in medical science in the last century, what constitutes the basket of services is open for debate. At no point should Aboriginal peoples be denied the same health benefits available to non-Aboriginal persons.

The additional health benefits provided certain indigenous people through interpretation of the Treaties are provided to all First Nations and Inuit peoples, but not Metis (the province of Manitoba has extended certain benefits to Metis peoples). The extent of, and the interpretation of what constitutes the medicine chest is the foundation for the multilayered, jurisdictionally complex and at times perverse national approach to Canada’s most embarrassing health inequity.  The inequity is confounded by the efforts of the Canadian government through the late 1800s and at least the first half of the 20^th century to constrain Aboriginal identity.  The inequity is clearly identifiable in reviewing inequalities of determinants of health in issues such as through the limitation of movement of Aboriginal persons off reserve, Indian hospitals and residential schools. 

There are innumerable papers, documents, reports, theses, and dissertations which have described and dissected the health status of Aboriginal peoples.  I have selected one at random for currentness and national perspective.   National Collaborating Centre on Aboriginal Health - Inequalities and social determinants albeit that some of the data is dated.    Many provinces, territories or health regions have issued health status reports of Aboriginal populations.   No shock to anyone that they clearly describe the burden of additional death, disease and injury shouldered by Aboriginal peoples throughout Canada.

The good news is that gains are being made.   In only the eloquent language of the epidemiologist, “there is evidence that the inequity is being reduced”.   While both Aboriginal and non-Aboriginal populations are getting healthier, the rate of health improvement amongst Aboriginal peoples is faster.  At some point decades in the future, there is hope that the lines may finally meet.  Bolstering this improvement are the collective efforts to support First Nations and Aboriginal groups in repatriating ownership of responsibility and self-determination.  Not a downloading, but an honest attempt to recognize that self-empowerment is a critical element in personal and population health promotion and improvement.  

Perhaps amazingly, this is occurring despite the obstructive efforts of the reigning political ideologists.  Perhaps the concept of off-loading the problem may be appealing for other ideological reasons.  Empowerment is however integral to re-establishing the wellbeing of our traditional inhabitants. Irrespective, hats off to the Canadian government for supporting the move forward, kudos to many of the provincial governments who have recognized the future investment benefit, bravo to Aboriginal leaders who are willingly accepting the challenge, and thanks to public health workers at a local level across the country who are facilitators, catalysts, cheerleaders and change agents in this developing success.  It is not yet time to celebrate, but it is time to begin to recognize the selfless efforts of so many in a country to right the wrongs of a century. 

Thanksgiving has its roots in the neighbourly celebration of European settlers and Native Americans coming together.   May a reflection of our history and current efforts reignite that joint celebration of cultures.  Happy Thanksgiving to all.   (for non-Canadian readers, Thanksgiving is celebrated the second Monday of October rather than the American tradition of the fourth Monday of November – such is one plight of living in a colder climate)

Alcohol and the public's health - Bottoms up!!

Nova Scotia took a brave step in 2007 with the release of the provincial alcohol reduction strategy  Nova Scotia alcohol policy .  Ontario slipped an alcohol policy into a broader drug strategy.  Alberta senior agencies called for one, I’ve not seen anything yet.  BC did an updated report in 2008.  

Conversely both Australia Australia alcohol reduction strategy  and England UK strategy for alcohol reduction have national alcohol reduction strategies. 

The first question might be why don’t we have more provincial strategies, or a national strategy.  We are good at describing the impact that alcohol has on the public’s health.  We haven’t been very good about owning the problem and seeking solutions.

Of course alcohol brings with it that subtle and slight health protective benefit.  Not insignificant, and certainly difficult to recommend abstinence as the healthiest option. Hence we have by default, a harm reduction policy in Canada towards alcohol.  I hope that the Prime Minister’s office (PMO) reads this, as harm reduction is such a obscene term that perhaps it might incite some radical action to eliminate alcohol consumption. Though, unlikely the PMO would take on the Molsons, Labatts, Vincor, Seagrams, or a host of other producers of Canada’s finest in beer, wine and spirits.

Given the contribution to founding stability in the Canadian economy afforded by Canadian distillers during the US prohibition years, we should be grateful.  Economic vitality has been founded in small volume breweries, estate wineries and a growing interest in small volume distillates. 

Canada’s alcohol and drug consumption use monitoring survey Canada alcohol and drug use monitoring survey   is a rich resource on alcohol and drug use consumption in Canada for the past few years.   Statistics Canada produces rich data on alcohol consumption, but in typical fashion does not present it for intellectual consumption – there is a good tabulation of regional comparisons posted to Wikipedia Wikipedia version of Statistics Canada data.  For long term trends, the BC centre of addiction research has good data regionally that compare nationally.  The graph is reproduced below, the most notable finding is that alcohol consumption continues to rise at about 1% increase per capita per year.   Not the right direction to be going to if there existed an alcohol reduction strategy as Australia and UK have.

Speaking of reduction strategies, kudos to Obama and our cousins to the south for their updated drug control strategy.  An enlightened effort that perhaps can show Canada the need for a more balanced approach.  Given the US went so far to the right on the War on Drugs, coming back to reality is welcomed, can we learn from this experience?  White House US drug strategy 2011    

Marijuana – "Smoking hot" harm reduction guidelines.

Given the last few blogs focused on obscurely released hidden national public health gems, the release of the safe cannabis consumption guidelines in the Canadian Journal of Public Health Sept/Oct edition has gotten much more attraction and interest. (unfortunately you either have to wait for your mailed copy, figure out how as a subscriber you can access the current edition on-line, or wait until the current edition is archived and available to the general public) 

Combined with the INsite court decisions, the focus on harm reduction and learning to work with the problem instead of ignore it is a clear message that is being transmitted.   If I can believe what the media are reporting, the receptivity to the harm reduction messages at the senior levels of government is lacking.  The war on drugs is to be fought with major artillery and at a cost of lives, rather than through intelligence and diplomacy.  

There is not much in the guidelines that common sense would not suggest, but finally someone has the good sense to write down what common sense should look like.   CPHA abstract of cannabis guidelines  .   The actual article (when or if you can find it) goes into details on known effects of cannabis and is a very good review of the current understanding of the science.  It is worth reading for updating an understanding of one of the most commonly used psychotropic drugs in the country.

One in 10 Canadians has used cannabis in the last year, one in three young adults.  The report does focus on the evidence that cannabis is not an innocuous drug and use at a young age, frequent use, use before driving are all associated with significant health risks.  The risk in pregnancy is not known leading to an appropriate precautionary recommendation to abstain throughout pregnancy and some evidence of potential negative consequences like lower birth weights. 

There is evidence that the stimulatory effects of cannabis are associated with an almost 5 times increase in the risk of myocardial infarction during the hour after inhalation.   Psychotic episodes are more likely to occur amongst cannabis users where family history of psychosis exists. The risk for motor vehicle collisions after consuming cannabis is increased, though not as much as for alcohol impairment.  There is also evidence that earlier age of onset of use is associated with multiple negative outcomes.

Canada desperately needs a comprehensive strategy to address psychoactive drug use.  There are excellent examples of “four pillar” strategies in prevention, treatment, harm reduction and enforcement that lay solid foundations.   Enforcement currently devours 75-80% of most four pillar strategies, and is known to be the least effective of the interventions.  How to rebalance these efforts is a national challenge.  Regrettably it is unlikely that the “Harper” government will recognize as the politically smart direction.  

Meanwhile, efforts to reduce harm and increase knowledge of the effects should be welcomed whole heartedly.  Thanks to Dr. Benedikt Fisher from Simon Fraser for leading this initiative. 

Mental Health Promotion – Protecting our sanity.

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Found - Another important national monograph, supposedly released March 2011 – and seems to be getting some circulation finally now.   Mental Health Promotion and Mental Illness Prevention  in Canada looking specifically at value for money for certain types of mental health programming.  Why these gems remain hidden and waiting to be uncovered is a major mystery. 

The first tirade for today is the continuing expectation that prevention and promotion activities demonstrate money saved for the money expended.  This is not the expectation for other health services, in fact if health services were measured by this metre stick, most health services would be eliminated. 

The second tirade is the continuing expectation that the only benchmark for prevention and promotion interventions is randomized trials.  Yes they provide the best evidence when they are available.  The inherent literature biases inserted into decision making when research methodologies are complex, interventions can’t be clearly isolated, populations are the unit of outcome and not  individuals – all contribute to shortcomings in evidence, not necessarily shortcomings in effectiveness.  Work needs to be done on clarifying how this evidence is incorporated and respected.

Tirades aside, perhaps not surprising, the best mental health promotion and prevention evidence comes from childhood and adolescents situations.  The school setting affords the opportunity to limit extraneous variables and control the therapeutic setting leading to better quality research.   If you speak to clinicians, they would have told you that focusing attention on schools makes more sense anyway. 

The document does do justice in several areas.  First Mental Health is an underresourced, understudied and less evidence based sector than other parts of the system.   The report makes these conclusions admirably.  The conclusion is that we need to expect the same sense of rigour from Mental Health professionals, that may be challenging as there are decades of isolation and ostracization to overcome, and the health system is not a very patient patient. 

One key area identified in the conclusions is the need to meld language and not utilize similar terms to describe different issues.   John Last, the grandfather of Canadian public health, has led the effort to standardize epidemiological and public health terminology globally.  Prevention has three levels, primary, secondary and tertiary.   Health promotion takes its definition from the Ottawa Charter.  As the fields have expanded you will find reference to quaternary prevention, primordial prevention, and now mental health promotion that attempt to carve out niches for their language.   Credit to the monograph for placing so much emphasis on clarifying the differences between mental health promotion and illness prevention activities.  

The best part of the document is the clarity by which the outcomes that extend beyond the realm of mental health professionals are identified and measured.   Worth the look just to learn from the methodologies and appreciate the approach to trying to insert rigorous evaluation into a field that seems resistant.

Obesity - a big problem with bigger political implications

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It’s a growing problem, the battle of the bulge. And it is not a pretty sight. 

Taken as any other public health problem, it has some interesting contexts.   We all need to eat, and obesity is the result of having eaten too much.   Such a high proportion of the population do not have a healthy weight, only 45% of women and 31% of men.   Taking public health issues back to the basics, the first step is to describe the problem. Obesity in Canada Obesity in Canada  is a publication released in June with so much fanfare that I only just discovered the link while surfing the PHAC website and I can find no record of any media release of its announcement.    Perhaps the communications department is a bit too thin. 

While Canada is substantively smaller than our cousins to the south, obesity rates of 25% and continuing to grow are unacceptable. 

There is lots of great information in the publication.   Epidemiologists doing what they do best, describing the problem in minute detail.  It is reference material that many will find useful in helping tackle the problem.  That is where the challenge begins.  Despite the largeness of the dilemmia, effective interventions are hard to grasp onto. 

There are several thrusts that are required, and need to be kept distinct.

1.      Preventing the expansion of the problem

2.      Managing those with increased weight problems

This is not an all or nothing issue like tobacco, or even as graduated a challenge as controlling alcohol.  We all consume calories during the day, and usually through multiple meals.  Cutting back is just not that simple – no doubt most of us have tried with varying success and more often not. 

The simpler issue may be to prevent the problem.  Of course, lets torture our children into behaviours that we ourselves struggle to adopt.   Eliminate the sugary drinks, increase the physical exercise, support them in adopting healthy habits while we sit back and chug another cola.   While we know we need to do something, and I fully support the need to do something, we really don’t know what will be effective in the long term.

Worse still is that our ability to intervene to support persons who are over their ideal weights is even less clear.   Physical activity, while an important supplement to weight reduction, has not yet been shown to be sustainable in supporting healthy weight loss.   Dietary manipulation seems the logical solution, yet debates rage about low fat versus high fat versus healthy fat.  Low carbohydrates versus low sugars with complex carbohydrates.  High protein, low protein. Its no wonder that the diet industry is estimated to be worth nearly $600 Billion dollars globally annually (okay, for those who would like to see their purses and wallets fattened, here is ‘healthy’ growth).  The Canadian market likely comes in at about $4-5 Billion annually.

Almost perversely, the best evidence for successful weight loss and maintenance is in bariatric (weight reduction) surgery.  Given many surgical procedures lack good evidence of their effectiveness, it is the irony that here is one which has been reasonably well documented for those with extreme weights.

Of course, in the face of evidence to change public policy like limiting certain foods, reducing portion sizes, engineering foods with less calories, increasing prices of poor quality high calorie foods etc.  all of which will more than likely be vehemently opposed by the food industry (they have effectively shut down efforts to reduce salt content of processed foods).  “Big Sugar” is the growing term similar to “Big tobacco” and “Big Pharma” to represent these vested interests. 

The absence of clearly effective approaches in the face of industry opposition must cause political reluctance.   Obesity reduction strategies have been in the works in some provinces.  They are usually couched in either a diabetes prevention strategy, or a childhood obesity strategy but full strategies do not seem to see the light of day because of the implications on the food industry.  

Perhaps we need to exercise a bit and find out why comprehensive obesity strategies have not been released, and the PHAC report just “showed up” with no fanfare.   It’s a heavy subject and public health has rarely shied away from difficult problems.  Time to step to the plate.