1. Janet H. Prystowsky, MD, PhD 225 East 64 th Street New York, NY 10065

2.  The sun causes many skin cancers  Sunshine is necessary for vitamin D production  Sunscreen blocks both harmful UV rays AND vitamin D production  Vitamin D deficiency has become common  A new balance is necessary http:i.ehow.com/images/GlobalPhoto/Articles/4725687/sunbather_Full.jpg

3. https://eapbiofield.wikispaces.com/Phototsynthesis+Review+Trey+J

4. http://eucerin.co.uk/media/the_solar_spectrum

5. http://www.wardelab.com/img/reports/sun_skin.gif

6. http://www.solarcsystems.com/images/vitamind.gif Sunscreen

7. http:www.b5media.com/wp-content/uploads/2008/05/sunscreen-nc.jpg VITAMIN D SYNTHESIS All Sunscreens block Vitamin D synthesis BBBB

8. http://www.peoplespharmacy.com/siteimages/are_yousunscre_photo.jpg

9. http://www.arc.org.uk/arthinfo/patpubs/6058/images/6058_3.gif

10. https://www.health.harvard.edu/newsweek/images/latitude-vitamin D.jpg

11. http://skincancer.dermis.net/content/e02factors/index_eng.html

12. http://farm3static.flickr.com/2280/2233193397_9063210935.jpg

13.  Sunscreen use spf > 8  Clothing customs  Latitude  Season  Melanin (Skin type/ Tanning)  Weather/Pollution/Tall buildings http://www.janetprystowskymd.com

14.  Sun exposure/sunburn history  Vacations  Employment  Leisure Activity  Tanning Parlors  Skin Type I and II  Genetics (Family history)  Immune Status  Precancerous lesions http://www.janetprystowskymd.com

15. http:www.cancersa.org.au/cms_resources/images/3-types-of-skin-cancer.gif

16. http:www.virtualmedicalcenter.com/uploads/VMC/Diseaseimages/455_Basal_Cell_Car cinoma_of_the_Skin.jpg

17. http://centralohioskinandcancer.liveonatt.com/images/green/med/squamous.jpg

18. http://64.143.176.9/library/healthguide/en-us/images/media/medical/hw/h9991258.jpg

19.  Seek shade  Use sunscreen spf >30  Protective clothing  Self exam  Follow up with dermatologist  Treat precancerous lesions  Remove suspicious moles  Destroy solar keratoses  Treat with retinoids/5-fluorouracil/imiquimod http://www.janetprystowskymd.com

20.  Ultraviolet B causes sunburn & skin cancer  Ultraviolet B is required to make vitamin D  Sunscreens (>spf 8)block sunburn and vitamin D synthesis  Diet even with food fortification is usually inadequate for vitamin D  Vitamin D deficiency causes rickets, weak bones, immune weaknesses, ?cancer, ?multiple sclerosis, other health problems http://www.janetprystowskymd.com

21. http://www.faqs.org/nutrition/images/nwaz_02_img0208.jpg;http://z.hubpages.com/u /48426_f260.jpg

22. http://rickets.stanford.edu/images/vitamin_D_diagram004-300.jpg

23.  70 % whites, 97% blacks, 90% Hispanics in US had vitamin D inadequacy 2001-2004 according to U.S. National Center for Health Statistics (Arch. Intern. Med. 169:551, 2009)  This is a big increase (about 50%) over levels measured from 1988-1994.  Causes: more time indoors, too little sun and use of a lot of high protection sunscreen www.Bloomberg.com 03-23-09

24.  10 million Americans over 50 have osteoporosis, the most common bone disease-it is a silent condition  34 million are at risk for developing osteoporosis  1.5 million people per year suffer a bone fracture related to osteoporosis  1 in 5 older Americans who suffer hip fracture die within a year of the fracture www.fda.gov

25.  By 2020 half of all Americans over 50 will be at risk of fractures from osteoporosis and low bone mass if no immediate action is taken by  Individuals at risk  Doctors  Health systems  Policymakers  Treatment: calcium, vitamin D, healthy weight, physical activity www.fda.govFDAConsumer Magazine Jan-Feb 2005

26. http://www.interestinglife/Health/images/vitamin%20d.gif

27. http://www.trusttanning.com/images/vitamin_d_sources.png

28. Sun exposure is more efficient than diet to maintain good vitamin D levels. http://www/janetprystowskymd.com

29. Vitamin D Skin Cancer http://www.janetprystowskymd.com

30.  Measure serum 25-hydroxy vitamin D to determine stores  <20 ng/ml means DEFICIENCY  >20 but <30 ng/ml means INSUFFICIENCY  >30-100 ng/ml is NORMAL  Note: >120 ng/ml may occur in patients getting phototherapy (17 treatments over 3 weeks) without toxicity http://www.janetprystowskymd.com

31.  16 adults 23-78 yo (mean 44) were evaluated for vitamin D status in a NYC dermatology practice  All had clinical presentations suggesting risk for vitamin D deficiency  The mean vitamin D level was 19 ng/ml. (Normal is >30. 20-30 is considered insufficient levels.)  The range was <7 to 30.6.(All but one was <30). http://www.janetprystowskymd.com

32.  No tan  No vitamin supplements or erratic intake  Low consumption of milk  Use high spf sunscreen  History of skin cancer (more conscientious about sun protection)  Fatigue http://www.janetprystowskymd.com

33.  Sun exposure/Artificial ultraviolet  Oral supplements  Intramuscular injections  Topical vitamin D (?) http://www.janetprystowskymd.com

34. http:www.fda.gov/fdac/graphics/2005graphics/vitaminD.gif

35. http://www.i-xcel.com/files/imagecache/postdisplay/vitamin+d.jpg 1000 IU Recommended Daily

36. LIVAD Skin Care, LLC www.livadskincare.com 1000 IU Vitamin D 3 in 2 T

37.  Sun exposure: e.g. 15 minutes daily –depends on latitude (no Vitamin D made above 37 o in fall/winter)will provide approximately 1000 IU.  A whole body exposure that gives you a light pink reaction will deliver approximately 10,000 IU. http://www.janetprystowskymd.com

38. http://www.clickforhowto.com/wp-content/uploads/2009/02/suncare.jpg Apply sunscreen to body after 15-30 minutes of sun Apply sunscreen to head and neck and backs of hands before going outside

39.  American Academy of Dermatology feels all vitamin D should be obtained through the diet or supplements—everyone should avoid the sun  My clinical experience shows that many patients have difficulty maintaining adequate vitamin D levels with oral supplements  Conclusion: judicious sun exposure combined with supplements is a reasonable approach http://www.janetprystowskymd.com

40.  Maximum sun protection:  Avoid all sun exposure, always use sunscreen  Vitamin D 1000-2000 IU daily year round  Check Vitamin D blood levels 2 X yearly  Moderate sun protection:  Protect head and neck, and backs of hands with sunscreen/clothing  Allow unprotected sun exposure on arms, legs, trunk for up to 30 minutes; then apply sunscreen  Vitamin D 1000-2000 IU daily October-April (above 37 o latitude).  Check Vitamin D blood levels yearly http://www.janetprystowskymd.com

41.  Skin type I – red-heads/always burn  History of skin cancer or sun abuse behavior  Strong family history of skin cancer  History of precancerous lesions  Dysplastic moles (atypical nevi)  Solar keratoses  Weakened immune status  Organ transplant patients  Chronic lymphocytic leukemia http://www.janetprystowskymd.com

42.  Skin types II-IV  No history of skin cancer, no precancerous lesions, good immune status  No family history of melanoma and minimal history of basal or squamous cell carcinoma  No history of sun abuse (e.g. evidence of significant sun damage, multiple sun-burns, significant tanning parlor use) http://www.janetprystowskymd.com

43.  Test under study checks skin biopsies for abnormally high levels of proteins made by 5 genes that are overactive in melanoma—90- 95% accuracy discerning between benign and malignancy  Misdiagnosis of melanoma is the second most common reason for cancer malpractice claims in the USA (after mistakes in breast cancer diagnosis) Bloomberg News 03/31/2009

44. Dx Tricorder Sensor Volatile organic compounds (VOCs) are released by basal cell carcinomas Monell Chemical Senses Center, Philadelphia, PA in Daily Diagnosis 08-21-2008 VOCs

45.  To prevent vitamin D deficiency, moderate sun exposure +/- supplements is reasonable for most persons.  For persons with a history of skin cancer or “red heads”, stringent sun protection with vitamin D supplements is advised.  When relying on vitamin D supplements check the level checked at least once yearly to ensure adequate intake. http://www.dana.org/uploadedImages/Images/Content

46. http://www.dana.org/uploadedImages/Images/Spotlight_Images/vitD_sun_s.jpg