Kicking off today, Sun Awareness Week (12-18 May) is the start of the British Association of Dermatologists’ (BAD) summer-long campaign to encourage everyone to protect their skin from sun damage and skin cancer, the most common cancer in the UK. ...
Kicking off today, Sun Awareness Week (12-18 May) is the start of the British Association of Dermatologists’ (BAD) summer-long campaign to encourage everyone to protect their skin from sun damage and skin cancer, the most common cancer in the UK.
There are several types of skin cancer, with melanoma and non-melanoma skin cancers being the most common. Melanoma develops from melanocytes, cells in deeper layers of the skin that give skin its colour. Non-melanoma skin cancers, such as basal and squamous cell carcinoma, develop from cells known as keratinocytes found in the outer layer of the skin. Simple steps like using sunscreen, avoiding sun in the middle of the day, wearing sun hats, and reducing the amount of direct sun exposure can lower your risk of both.
Recent research from the BAD journals—British Journal of Dermatology, Clinical and Experimental Dermatology, and Skin Health and Disease—offers new insights into preventing, diagnosing, and treating melanoma and non-melanoma skin cancers. Here are some highlights:
Why sunscreen matters
Using sunscreen every day is one of the best ways to stay safe. The sun gives off ultraviolet (UV) rays that harm your skin and raise skin cancer risk, and regular use of high-SPF sunscreen can protect you. Sunscreen comes in many forms, like creams, lotions, sprays, and sticks. Apply it 15-30 minutes before going outside. Reapply every 2 hours, or after swimming or intense physical activity.
Sunscreen prevents skin cancer and premature ageing (called photoageing), but it’s good to know the facts. A recent narrative review found possible downsides of using sunscreen, like allergic skin reactions and concerns about endocrine disruption. Some ingredients, like preservatives and fragrances, may cause allergic skin reactions, though evidence suggests these reactions are rare. Concerns about hormone effects are low, as sunscreen stays mostly on the skin’s surface.
Photoageing: a key concern
UV rays don’t just increase skin cancer risk—they also age your skin early, causing wrinkles and spots. A recent survey across 17 countries found that people often worry more about photoageing than skin cancer. So, talking about photoageing in sun awareness campaigns could motivate more people to engage in sun protective behaviours.
A digital sun protection campaign for healthcare workers
Researchers from University of Limerick Hospital Group in Ireland tried a new digital campaign to promote skin cancer awareness among hospital staff. Their study found that staff became more positive about sun protective behaviours after the campaign, showing that digital tools could work for everyone in encouraging sun protection.
Figure from Emma Porter et. al, ‘The Impact of a Novel Digital Sun Protection Campaign on Sun-Related Attitudes and Behaviours of Healthcare Workers: A Prospective Observational Study’, Skin Health and Disease, Volume 4, Issue 6, December 2024, https://doi.org/10.1002/ski2.256
Better sun habits, better outcomes
Campaigns like Sun Awareness Week make a real difference. A study from Austria found that people who improved their sun protection habits after being diagnosed with melanoma lived longer, showing that these behavioural changes can save lives.
Global melanoma trends
A population-level study across 162 countries found that melanoma diagnoses are rising over time, but death rates are steady or growing slowly. This may be related to improved screening and awareness programs for melanoma. However, this may be compounded by melanoma overdiagnosis, with some cases caught early that may not have been deadly. Researchers are still exploring this complex phenomenon.
Melanoma and gender
Men and women face different melanoma risks. This study from Australia found that, on average, women are often diagnosed with melanoma years earlier than men, especially on the torso and for thinner melanomas. Their findings suggest that sex-tailored approaches to melanoma control could improve prevention and care.
Sun safety policy in primary schools
As per the World Health Organization, school sun protection programmes may be the key to skin cancer prevention. This study carried out an online survey of primary schools in Wales to understand their sun safety policies and practices. Of 471 schools that responded, only 183 enforced their policy. Those who did not have a policy were ‘not aware of the need’ (34.6%); ‘need assistance with policy or procedure development’ (30.3%); or ‘not got around to it just yet’ (26.8%).
Skin cancer and blood cancers
This study in the Netherlands found that patients with blood cancers have a higher risk of developing skin cancers across their lifetime. This means that targeted awareness campaigns for sun protection are vital for this patient population.
Diabetes drugs and skin cancer
In this systematic review, the authors found that drugs for type 2 diabetes, especially metformin, may lower risk of non-melanoma skin cancer. This is good news for people with type 2 diabetes who are worried about developing skin cancer.
This Sun Awareness Week, we are urging everyone to prioritise sun protection to prevent skin cancer and premature skin ageing. Check your skin regularly and see a doctor if you notice any new or changing moles or other skin lesions.
Join the #SunAwarenessWeek conversation and share your sun safety tips! You can explore the latest research from the BAD journals here.
Ultra-processed foods are industrial formulations typically containing ingredients not commonly used in home cooking, such as hydrogenated oils, high-fructose corn syrup, flavour enhancers, and emulsifiers. Examples of these types of foods include chips, soft drinks, instant noodles, ice cream, chocolate, biscuits, ready-to-eat meals, sausages, burgers, chicken and fish nuggets, sweet or savoury packaged snacks, and energy bars.
These foods, and the ingredients they contain, are designed for convenience and long shelf life,and to enhance palatability, but often come at the cost of nutritional value.
Now, a groundbreaking study, led by Monash University, has shed light on a particularly alarming consequence – the acceleration of biological ageing.
Biological age refers to how old a person seems based on various molecular biomarkers, compared to chronological age, which is the number of years a person has lived.
A person’s biological age is a relatively new way of measuring a person’s health, and can be traced back to 2013, when geneticist Steve Horvath developed the epigenetic clock, which measures DNA methylation levels. DNA methylation is a process that modifies the function of genes.
A second generation of epigenetic clocks was developed a few years later that incorporated environmental variants such as smoking or chronological age. Among these was the PhenoAgeand GrimAge clocks.
As well as diet, biological age can be influenced by genetics, general lifestyle, and environmental factors, and it can differ significantly from chronological age.
A person with a healthy lifestyle may have a biological age younger than their chronological age, while poor lifestyle choices, such as a diet high in UPFs, can accelerate biological ageing.
The Monash University study, published in the journal Age and Ageing, was led by nutritional biochemist Dr Barbara Cardoso, a senior lecturer in the University’s Department of Nutrition, Dietetics and Food. It involved 16,055 participants from the United States aged 20-79, whose health and lifestyles were comparable to those in other Western countries such as Australia. The study used the PhenoAge clock to assess biological ageing.
It found a significant association between increased UPF consumption and accelerated biological ageing. For every 10% increase in UPF consumption, the gap between biological and chronological age widened by approximately 2.4 months.
Participants in the highest UPF consumption quintile (68-100% of energy intake in their diet) were biologically 0.86 years older than those in the lowest quintile (39% or less of energy intake in their diet).
Dr Cardoso said the findings underlined the importance of eating as many unprocessed and minimally-processed foods as possible.
“The significance of our findings is tremendous, as our predictions show that for every 10% increase in total energy intake from ultra-processed food consumption there is a nearly 2% increased risk of mortality and 0.5% risk of chronic disease over two years,” she said.
“Assuming a standard diet of 2000 calories [8500 kilojoules] per day, adding an extra 200 calories of ultra-processed food, which roughly equals an 80-gram serving of chicken bites or a small chocolate bar, could lead to the biological ageing process advancing by more than two months compared to chronological ageing.”
The study used data from the US National Health and Nutrition Examination Survey (NHANES) 2003-2010. Diet quality was assessed with the American Heart Association (AHA) 2020 and the Healthy Eating Index 2015 (HEI-15).
The association between UPF intake and biological ageing remained significant after adjusting for diet quality and total energy intake, using the above data as a baseline.
This suggested the association could be due to other factors such as lower intake of flavonoids or phytoestrogens, which occur in natural foods such as fresh fruit and vegetables, or higher exposure to packaging chemicals and compounds formed during food processing.
“Adults with higher UPF tended to be biologically older,” the study found. “This association is partly independent of diet quality, suggesting that food processing may contribute to biological ageing acceleration. Our findings point to a compelling reason to target UPF consumption to promote healthier ageing.”
The results also support earlier research linking UPF consumption to ageing markers such as telomere length (a shorter telomere length is a sign of cell ageing), frailty, cognitive decline, and dementia.
Dr Cardoso said while the study participants were from the US, the relevance of the findings apply to Australians too – on average, ultra-processed foods represented almost 40% of total energy intake among Australian adults.
She said given the global population continued to age, demonstrating the adverse effects of UPFs reinforced the need for dietary-focused public health strategies to prolong a healthy lifespan.
“Our findings indicate that reducing ultra-processed foods in the diet may help slow the biological ageing trajectory, bringing another reason to target ultra-processed foods when considering strategies to promote healthy ageing,” she said.
Mechanisms behind UPFs and ageing
Mechanisms by which UPFs may accelerate biological ageing include:
Nutrient deficiency: UPFs are often low in essential nutrients such as vitamins, minerals, and antioxidants, which are crucial for maintaining cellular health and preventing oxidative stress.
Chemical additives: Many UPFs contain artificial additives and preservatives that may have adverse effects on health, including promoting inflammation and disrupting metabolic processes.
Packaging chemicals: Exposure to chemicals from food packaging, such as bisphenol A (BPA), has been linked to various health issues, including accelerated ageing.
Practical steps to reduce UPF intake
To mitigate the adverse effects of UPFs, individuals can take several practical steps:
Increase whole foods: Emphasise whole, minimally processed foods such as fruits, vegetables, whole grains, nuts, and seeds in your diet.
Read labels: Be mindful of food labels and avoid products with long lists of unfamiliar ingredients.
Cook at home: Preparing meals at home allows for greater control over ingredients and cooking methods.
Limit convenience foods: Reduce reliance on ready-to-eat meals and snacks, opting instead for healthier alternatives.
This work was carried out in collaboration with senior author Euridice Martinez Steele, from the University of Sao Paulo (Brazil), Daniel Belsky, from Columbia University (US), Dayoon Kwon, from the University of California at Los Angeles, Priscila Machado, from Deakin University, and Junxiu Liu, from Icahn School of Medicine at Mount Sinai (US).
Many criminal investigations, including “cold cases,” do not have a suspect but do have DNA evidence. In these cases, a genetic profile can be obtained from the forensic specimens at the crime scene and electronically compared to profiles listed in criminal DNA databases. If the genetic profile of a forensic specimen matches the profile of someone in the database, depending on other kinds of evidence, that individual may become the prime suspect in what was heretofore a suspect-less crime.
Searching DNA databases to identify potential suspects has become a critical part of criminal investigations ever since the FBI reported its first “cold hit” in July 1999, linking six sexual assault cases in Washington, D.C., with three sexual assault cases in Jacksonville, Florida. The match of the genetic profiles from the evidence samples with an individual in the national criminal database ultimately led to the identification and conviction of Leon Dundas.
How the statistical significance of a match obtained with a database search is presented to the jury should, in my view, be straightforward but, given the adversarial nature of our criminal justice system, remains contentious. One view is that if the profiles of the evidence and a suspect who had been identified by the database search match, then the estimated population frequency of that particular genetic profile (equivalent to the Random Match Probability in a non-database search case) is still the relevant statistic to be presented to the jury. The Random Match Probability (RMP) is an estimate of the probability that a randomly chosen individual in a given population would also match the evidence profile. The RMP is estimated as the population frequency of the specific genetic profile, which is calculated by multiplying the probabilities of a match at each individual genetic marker (the “Product Rule”).
An alternative view, often invoked by the defense, is that the size of the database should be multiplied by the RMP. For example, if the RMP is 1/100 million and the database that was searched is 1 million, this perspective argues that the number 1/100 is the one that should be presented to the jury. This calculation, however, represents the probability of getting a “hit” (match) with the database and not the probability of a coincidental match between the evidence and suspect (1/100 million), the more relevant metric for interpreting the probative significance of a DNA match. Although these arguments may seem arcane, the estimates that result from these different statistical metrics could be the difference between conviction and acquittal.
There are many different kinds of DNA databases. Ethnically defined population databases are used to calculate genotype frequencies and, thus, to estimate RMPs but are not useful for searching. The first DNA searches were of databases of convicted felons. In some jurisdictions, databases of arrestees have also been established and searched. These searches have recently been expanded to include “partial matches,” potentially implicating relatives of the individuals in the database. This strategy, known as “familial searching,” has been very effective but contentious, with discussions typically focused on the “trade-offs” between civil liberties and law enforcement. In some jurisdictions, the “trade-off” has been between two different controversial criminal database programs. In Maryland, for example, an arrestee database (albeit one specifying arraignment) was allowed but familial searching was outlawed. Familial searching has been critiqued as turning relatives of people in the database into “suspects.” A more accurate description is that these partial matches revealed by familial searching identify “persons of interest” and that they provide potential leads for investigation.
Recently, searching for partial matches in the investigation of suspect-less crimes has expanded from criminal databases to genealogy databases, as applied in the Golden State Killer case in 2018. These databases consist of genetic profiles from people seeking information about their ancestry or trying to find relatives. Genetic genealogy involves constructing a large family tree going back several generations based on the individuals identified in the database search and on genealogical records. Identifying several different individuals in the database whose profile shares a region of DNA with the evidence profile allows a family tree to be constructed. The shorter the shared region between two individuals or between the evidence and someone in the database, the more distant the relationship. This is because genetic recombination, the shuffling of DNA regions that occurs in each generation, reduces the length of shared DNA segments over time. So, in the construction of a family tree, the length of the shared region indicates how far back in time you have to go to locate the common ancestor. Tracing the descendants in this family tree who were in the area when the crime was committed identifies a set of potential suspects.
The DNA technologies used in investigative genetic genealogy (IGG) are different from those typically used in analyzing the evidence samples or the criminal database samples, which are based on around 25 short tandem repeat markers (STRs). The genotyping technology used to generate profiles in genealogy databases is based on analyzing thousands of single nucleotide polymorphisms (SNPs). With the recent implementation of Next Generation Sequencing technology to sequence the whole genome, even more informative searching for shared DNA regions can be accomplished. (Next Generation Sequencing of the whole genome is so powerful that it can now distinguish identical (monozygotic) twins!)
Investigative genetic genealogy (IGG) has completely upended the trade-offs and guidelines proposed for familial searching as well as many of the arguments. Many of the rationales justifying familial searching of criminal databases, such as the recidivism rate, and the presumed relinquishing by convicts of certain rights do not apply to genealogical databases. Also, the concerns about racial disparities in criminal databases don’t apply to these non-criminal databases either. In general, it’s very hard to draw lines in the sand when the sands are shifting so rapidly and the technology is evolving so quickly. And it is particularly difficult when dramatic successes in identifying the perpetrators of truly heinous unsolved crimes are lauded in the media, making celebrities of the forensic scientists who carried out the complex genealogical analyses that finally led to the arrest of the Golden State Killer and, shortly thereafter, to many others.
It’s still possible and desirable to set some guidelines for IGG, a complex and expensive procedure. It should be restricted to serious crimes. The profiles in the database should be restricted to those individuals who have consented to have their personal genomic data searched for law enforcement purposes. With the appropriate guidelines, the promise of DNA database searching to solve suspect-less crimes can truly transform our criminal justice system.
As we welcome 2025, we reflect on the milestones and achievements that shaped Health Affairs Scholar in 2024. Among the highlights, we introduced our first Calls for Papers, focusing on the critical topics of: Global Aging, Intersections of Social Policies and Health, and Policy Options for the 340B Discount Program. These ongoing series continue to invite submissions, fostering meaningful discourse on pressing policy issues.
The journal also launched its inaugural Featured Paper Series, Health Workforce Issues and Challenges in the Post-Pandemic Era, with contributions from each of the nine federally funded Health Workforce Research Centers. Building on this momentum, three additional Featured Paper Series are set to publish in 2025, each exploring distinct, timely topics and supported by different sponsoring organizations. The papers below kick-off two of these series, with the introduction to the third series on Emergency Room Care coming soon.
In addition to these exciting new initiatives, we’re pleased to share that the journal is now indexed in the Web of Science, as well as PubMed Central, The Directory of Open Access Journals, and Google Scholar.
As we look back on a successful year, we also want to highlight the top ten most read papers published in 2024. These papers reflect some of the timeliest issues of 2024, including contraceptive access and use in the post-Dobbs era, mapping pharmacy deserts across the country, prior authorization burdens and solutions, and much more.
In this brief report, Megan Kavanaugh and Amy Friedrich-Karnik examine the broad impact the overturning of Roe v. Wade has had on contraceptive access and use. The report highlights decreased access to quality contraceptive care across four states and emphasizes the need for evidence-based policies and programs to better support people’s contraceptive needs in the post-Dobbs era.
Medicaid Section 1115 demonstration waivers offer states the opportunity to pilot coverage for nutrition-based services to address health disparities. Erika Hanson and coauthors provide insight into the evolution and current landscape of food-based initiatives supported by these demonstrations across 19 states.
Sayeh Nikpay and coauthors quantify the return on investment for interventions focused on combating food and housing insecurity, emphasizing the role these estimates play in encouraging future investment by health plans and other private actors in the health care space.
Salpy Kanimian and Vivian Ho explore the rising gap between health insurance costs and wages, highlighting the role hospitals play in driving premiums. Between 2006 and 2023, hospital price index rose faster than insurance premiums, and hospitals consistently maintained high profit margins than insurers.
Yashaswini Singh and colleagues explore the often rapid turnover of private equity investments in physician practices. Their analysis reveals that private equity firms increase affiliated practices by 595% on average in just three years, raising concerns about the long-term sustainability of care and workforce investments.
Rachel Wittenauer and coauthors use pharmacy address data and Census Bureau surveys to map pharmacy deserts across the United States. Their findings show that 4.7% of Americans in both rural and urban communities live in these deserts, demonstrating an urgent need to improve access to pharmaceutical services.
Nikhil R. Sahni and colleagues examine the perceived challenges related to prior authorization processes and the barriers that impede the adoption of automated solutions including the use of artificial intelligence.
Anti-obesity medications have garnered significant attention for their effectiveness, but their high price poses a major challenge to accessibility. Using a policy simulation model, David Kim, Jennifer Hwang, and Mark Fendrick evaluate the impact of an economical weight-maintenance program after weight loss plateau as an alternative to continuous medication use.
A policy inquiry by Danielle Poulin and coauthors provides recommendations for policymakers to address the persistently high rates of infant and neonatal mortality in Ghana, despite efforts to improve financial accessibility to care. The authors suggest that a systems approach is needed to minimize barriers to pre- and post-natal care, including investment in medical facility and transportation infrastructure, increased workforce development, and improvement in claims reimbursement.
A national survey of US physicians reveals that most view working with physician assistants and nurse practitioners as positively impacting their clinical practice. Physicians in medical schools and with higher incomes were particularly likely to report benefits, while those in specialties with higher women’s representation had lower ratings.
An extraordinary breakthrough of modern medicine occurred in 2005 when the FDA approved ropinirole for the treatment of restless legs syndrome (RLS). With the first drug ever approved for this misery-inducing condition, patients finally had a highly effective treatment with relatively few side effects. Nearly 20 years later, ropinirole and its cousin pramipexole are among the most prescribed treatments for RLS, and they have been considered first-line therapy for over a decade.
Restless legs syndrome is an unpleasant sensation, typically described as an intense urge to move, that worsens later in the day, is provoked by holding still, and improves while moving. It can affect people of all ages, but it gets more common around middle age. For people with this condition, life can become unbearable. They are unable to sit long enough to enjoy a meal or watch a movie. Taking a flight or a long car ride is torture. Having an effective treatment like ropinirole and pramipexole was beyond a miracle for patients with severe symptoms.
Ropinirole and pramipexole fall under the drug category of dopamine agonists. This means that these drugs stimulate dopamine receptors in the brain. While it was known long before 2005 that dopamine-related drugs could improve RLS symptoms, those drugs had unacceptable risks. The two new dopamine agonists—which were joined in 2008 by a third drug, rotigotine—were considered much safer, and doctors who treated RLS flocked to them. Dopamine agonists were how RLS was treated. Problem solved, apparently.
Another extraordinary event is taking place in 2024, though. Dopamine agonists are not only being removed as first-line treatment for RLS, new guidelines by the American Academy of Sleep Medicine place dopamine agonists on the “do not use” list. This complete about-face is a result of years of observing that dopamine agonists are not the RLS saviors they were once thought to be. In fact, they have almost certainly caused even more suffering.
Dopamine agonists have two major problems: augmentation and impulse control disorders. Augmentation occurs when consistent use of a dopamine agonist starts to make RLS symptoms worse. This might manifest as patients having symptoms earlier in the day or having symptoms in other body parts, such as the arms.
Dopamine agonists are not the RLS saviors they were once thought to be.
Augmentation is thought to be the result of the brain shutting down its own natural dopamine production to rely more and more on the pills to stimulate dopamine receptors. As a result, patients require higher or more frequent doses to achieve the same degree of relief. Eventually, even those doses don’t provide relief, and the suffering starts to spread throughout the day. These drugs are particularly insidious because each time the dose is increased, patients feel better. Temporarily. If they try to decrease their dose, they feel worse. Essentially, patients become dependent on these drugs; they’re addictive.
The only treatment for augmentation is to stop the offending medication. Dopamine agonists must be weaned off, and the process can be brutal: insomnia, severe pain, anxiety, depression, thoughts of suicide, and more. When it’s over, though, the RLS symptoms are inexorably better.
The elevated doses of dopamine agonists that patients with augmentation often take can also cause a highly destructive condition called impulse control disorders (ICDs). ICDs are a form of compulsive behavior in which patients find it difficult or impossible to stop doing things that are harmful to them. The most common ICDs related to dopamine agonists are eating, shopping, gambling, and pornography consumption. Patients with a gambling ICD, for example, might spend 24 straight hours at a blackjack table. Those with a shopping ICD might start buying gifts they can’t afford for all their friends and family members just because an advertisement came on TV. The financial and social losses incurred by these patients can be massive, and many of them have no idea that their RLS medication is the cause.
With decades of experience, it became clear to physicians treating RLS that dopamine agonists were a seductive enemy to RLS patients. Exposing patients to the risks of augmentation and ICDs could no longer be justified, and they are no longer recommended for daily use. If patients do take dopamine agonists, the doses must be kept low, and ideally, used only sparingly for situations likely to trigger the RLS, like a long flight.
Fortunately, there are highly effective alternatives to dopamine agonists now. The most important treatment, bar none, is iron. A low level of iron in the brain is a very common cause of RLS and a very treatable one. Successful treatment of RLS begins with ensuring adequate levels of brain iron. After that, first-line drug therapy is now gabapentin, a drug originally approved for seizures that is highly effective for RLS, along with its related drug gabapentin enacarbil and their counterpart pregabalin. The other highly effective class of medications for RLS is opioids, including methadone and buprenorphine. Dipyridamole, a drug that used to be used to help prevent strokes, is starting to be used for RLS now. And earlier this year, a nerve stimulator band worn below the knees entered the American market for a drug-free treatment option. Each of these therapies can be considered for the treatment of RLS.
It is crucial for doctors and patients to understand the risks of dopamine agonists, including augmentation and ICDs. There are many alternatives to help this long-suffering group of people without the threat of making them worse over time. Patients who suffer with RLS should know they need not suffer forever.
