1. Sunlight skin cancer and bones: Making sense of “mixed” messages Seeta Durvasula Centre for Developmental Disability Studies University of Sydney seetad@med.usyd.edu.au CDDS Centre for Developmental Disability Studies

2. 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

3. 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

4. “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

5. 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

6. 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

7. classical non classical Pancreatic  cells

8. What is Vitamin D Deficiency? (Position statement, 2005)  Defined by serum Vitamin D level  Mild Vitamin D deficiency –  25 (OH) vitamin D level - 25 – 50 nmol/L = Insufficiency  raised parathyroid hormone level  Moderate Vitamin D deficiency 12.5-25 nmol/L  Severe Vitamin D deficiency< 12.5 nmol/L

9. 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

10. 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

11. 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)

12. 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)

13. Prevention of Vitamin D deficiency in general population  Diet  200IU if 70yrs (US Food &Nutrition Board) <100 IU/day  Most Australians get <100 IU/day  Sun exposure = 1/3 Minimal Erythema Dose (MED)  To Reduce fracture risk in elderly – 1000IU day

14. 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

15. Recommended sun exposure times (mins) for 1/3MED for moderate fair skin RegionDec-Jan July-Aug at 10 am or 2pm Auckland6-830-47 Christchurch6-949-97 Cairns6-7 9-12 Brisbane6-7 5-19 Adelaide5-725-38 Perth5-620-28 Sydney6-826-28 Melbourne6-832-52 Hobart7-940-47

16. 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

17. Mixed messages?  Sun protection – prevent skin cancer  Sun exposure – prevent vitamin D deficiency

18. 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 http://www.cancer.org.au/content.cfm?randid =299825

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

28. 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