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CDDS
Centre for
Developmental
Disability
Studies
Sunlight skin cancer and bones:
Making sense of “mixed”
messages
Seeta Durvasula
Centre for Developmental Disability Studies
University of Sydney
[email protected]
Sun exposure and skin cancer
1920s
– attitudes to sunlight exposure
seen as health promoting
“tanned is beautiful”
In
Australia, sun exposure causes
99% of non-melanoma skin cancers
95% of melanomas (Armstrong, 2004)
So,
strong public health campaigns for
sun protective measures
Sun Protection Measures
Minimise
time in the sun between 11am and 3pm
(daylight saving time);
Use shade wherever you can including trees,
shelters and umbrellas;
Slip! on a shirt made from tightly woven fabric,
with sleeves and a high neck or collar and other
clothing that covers the skin;
Slop! on a broad spectrum water resistant
sunscreen with an SPF rating of 30+; and
Slap! on a wide brimmed hat or legionnaire's
cap, that shades the face, neck and ears.
NSW Health, 1999
“Slip, Slop, Slap”
Slip, Slop, Slap!
It sounds like a breeze
when you say it like that
Slip, Slop, Slap!
In the sun we always say
"Slip Slop Slap!“
Slip, Slop, Slap!
Slip on a shirt, slop on
sunscreen and slap on a
hat,
Slip, Slop, Slap!
You can stop skin cancer say: "Slip, Slop, Slap!"
The Cancer Council Australia
Vitamin D and Bones
Hormone
Necessary
bone health
helps absorb calcium from gut
Beneficial
effect on muscle strength
and balance
Prevention of fractures in elderly
May also have beneficial effects on
some types of cancer
Where do you get it?
(Vitamin D)
In
Australia, 90% from sunlight - UVB
Food - minor source of Vitamin D in
Australia
milk, cheese
margarine
liver
oily fish –sardines, mackerel, salmon
Pancreatic
cells
non classical
classical
What is Vitamin D Deficiency?
(Position statement, 2005)
Defined
Mild
by serum Vitamin D level
Vitamin D deficiency –
25 (OH) vitamin D level - 25 – 50 nmol/L
= Insufficiency
raised parathyroid hormone level
Moderate
Severe
Vitamin D deficiency 12.5-25 nmol/L
Vitamin D deficiency
< 12.5 nmol/L
Vitamin D deficiency
Increase in parathyroid hormone
release of calcium from bones
Reduced bone density
osteomalacia in adults
rickets in children
Increased
fracture risk in older people
Muscle pains, muscle weakness
Linked to falls in older people
Associated with Type 1 diabetes, some
cancers
Causes of Vitamin D deficiency
Inadequate
sunlight exposure
elderly – especially in aged care facilities
immobility
skin covering
Sunlight
less effective
ageing skin
pigmented skin
Diet
– low consumption
Malabsorption and abnormal gut function
How common is vitamin D deficiency?
General
population
43% in young women - Geelong (Pasco et al.
2001)
23% in adult population - SE QLD (McGrath
et. Al, 2001)
Specific
groups at risk
elderly in high level care – 55% (Flicker et al.
2003)
dark skin pigmentation, especially if also
covered/veiled
80% in one study (Grover & Morley, 2001)
People with developmental disability
Studies
mainly in institutionalised
populations on anticonvulsant therapy
47% of people with developmental disability
living in institution in NSW (Beange et al. 1994)
57% of those in a residential facility in SA–
those with poor mobility, difficulty in taking solids
(Valint & Nugent, 2006)
Community living adults - 36% men and 40%
women (Centre et al. 1998)
43% of a clinic population in Sydney – older
people, people with Down syndrome, overweight
(Durvasula et al. 2005 - unpublished)
Prevention of Vitamin D deficiency
in general population
Diet
200IU if < 50yrs; 400IU if 51-70 yrs;
600 IU if >70yrs (US Food &Nutrition
Board)
Most Australians get <100 IU/day
Sun exposure = 1/3 Minimal Erythema
Dose (MED)
To Reduce fracture risk in elderly –
1000IU day
Recommended sun exposure
1
minimal erythema dose (MED) is amount
of sun exposure which produces faint
skin redness
=Whole body exposure to 10-15mins of
midday sun in summer
= 15,000U of vitamin D
Recommend
1/3 MED
= exposing hands, face and arms to of sunlight
on most days
Recommended sun exposure times (mins)
for 1/3MED for moderate fair skin
Region
Auckland
Christchurch
Cairns
Brisbane
Adelaide
Perth
Sydney
Melbourne
Hobart
Dec-Jan
6-8
6-9
6-7
6-7
5-7
5-6
6-8
6-8
7-9
at 10 am or 2pm
July-Aug
30-47
49-97
9-12
5-19
25-38
20-28
26-28
32-52
40-47
Sun exposure in people with
developmental disability
Paucity
of reliable data except for those
physical disability, or those in
institutional care
Possible
other at risk groups
e.g those with challenging behaviour, autism
Note:
Reliance on carers/ support staff
Mixed messages?
Sun
Sun
protection – prevent skin cancer
exposure – prevent vitamin D
deficiency
Not so “mixed”
Risks and Benefits of Sun
Exposure (2005)
Aust. and NZ Bone Society, Osteoporosis
Australia, Australasian College of
Dermatologists, The Cancer Council of
Australia
http://www.cancer.org.au/content.cfm?randid
=299825
Recommendations
Sun protection required when UV index is
moderate or higher (≥3)
Most people achieve adequate Vitamin D
levels through typical day to day activities,
without deliberately seeking additional sun
exposure
summer – expose face, arms and hands to average
of 5 minutes most days of the week outside peak
UV levels
winter, in Southern States – exposure of hands,
face, arms for 2-3 hours over a week
Use of solaria not recommended due to level
of UV exposure
Recommendations
Those
at increased risk of skin cancer
need more vigorous sun protection
practices and should discuss their vitamin
D requirements with their doctor
Those
at increased risk of Vitamin D
deficiency should discuss their vitamin D
status with their doctor
Recommendations – special
groups
Older
adults – if not at high risk of skin
cancer, ensure incidental exposure
Skin
type – dark skin pigmentation,
especially if covered – may need
vitamin D supplementation
What about sunscreen?
Necessary
to prevent skin damage if
prolonged exposure (long enough to cause
erythema) is planned
For
incidental exposure, of less than 10
minutes, may be able to omit sunscreen
short exposures better for vitamin D
synthesis
(Nowson et al, 2004)
What about people with
developmental disability?
Recommendations
as for general
population for prevention of vitamin
D deficiency
i.e. safe sun exposure
But,
need to take into account skin
type/pigmentation, latitude, season,
medication use (anticonvulsants),
mobility
What about people with
developmental disability?
However,
many are at increased risk
of Vitamin D deficiency e.g.
Medications
Limited sun exposure
poor mobility
staffing limitations
challenging behaviour
Therefore,
incidental sun exposure may
not be enough
Recommendations
Vitamin
D insufficiency is common in people with
developmental disability and can only be
confirmed by measuring 25OH D
Either
monitor yearly at end of winter (lowest
values) and treat those < 50nmol/L with vitamin D
supplements
Optimal
calcium intake also needed – diet or
supplements
Message not so “mixed”
Incidental
safe sun exposure where
possible
Check Vitamin D levels and treat if
required
Need further research
Identify those with developmental disability
who are especially at risk
Determine levels of sun exposure in those
living in the community
Management Vitamin D Deficiency
3000
– 5000 IU/day ergocalciferol for 6-12
weeks
50
000 IU cholecalciferol. One tablet monthly
for 3-6 months (NZ only)
Reassess
after 3-4 months of treatment
1000
IU/day of ongoing treatment required for
most patients
Contraindicated
in hypercalcaemia