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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