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1.  Melanoma: prevention and early diagnosis. 
BMJ : British Medical Journal  1994;308(6945):1682-1686.
Over the past two decades there has been a rapid rise in the numbers of people developing and dying from malignant melanoma. Sunlight is the main aetiological factor linked with melanoma. Exposure to the sun is a risk factor that can be modified provided that people are aware of the dangers. Health promotion campaigns can play a part in producing such change. General practitioners and practice nurses have an important part to play in providing those most at risk with information and advice about sensible sun exposure and sun protection measures. Campaigns to reduce delay in diagnosis by a combination of professional and public education have been reported from several centres around the world. The effects of these campaigns in reducing the depth distribution of cutaneous malignant melanoma have sometimes been encouraging, but in other instances have shown little effect. Until there is clear evidence that early detection reduces mortality from melanoma, the opportunistic promotion of early detection may not be cost effective and will fail to reach all sections of the community at risk. At the present time, therefore, the emphasis should be on the primary prevention of skin cancer.
PMCID: PMC2540626  PMID: 8025464
2.  Vitamin D Beliefs and Associations with Sunburns, Sun Exposure, and Sun Protection 
The main objective of this study was to examine certain beliefs about vitamin D and associations with sun exposure, sun protection behaviors, and sunburns. A total of 3,922 lifeguards, pool managers, and parents completed a survey in 2006 about beliefs regarding vitamin D and sun-related behaviors. Multivariate ordinal regression analyses and linear regression analysis were used to examine associations of beliefs and other variables. Results revealed that Non-Caucasian lifeguards and pool managers were less likely to agree that they needed to go out in the sun to get enough vitamin D. Lifeguards and parents who were non-Caucasian were less likely to report that sunlight helped the body to produce vitamin D. A stronger belief about the need to go out in the sun to get enough vitamin D predicted more sun exposure for lifeguards. For parents, a stronger belief that they can get enough vitamin D from foods predicted greater sun protection and a stronger belief that sunlight helps the body produce vitamin D predicted lower sun exposure. This study provides information regarding vitamin D beliefs and their association with certain sun related behaviors across different demographic groups that can inform education efforts about vitamin D and sun protection.
PMCID: PMC3407911  PMID: 22851950
sun exposure habits; vitamin D knowledge; sunscreen use; sun protection behavior
3.  Sun-Seeking Behavior to Increase Cutaneous Vitamin D Synthesis: When Prevention Messages Conflict 
Public Health Reports  2011;126(4):533-539.
The public has long been encouraged to engage in sun-safe practices to minimize exposure to sunlight, the major cause of nonmelanoma skin cancer. More recently, some have advocated unprotected sun exposure to increase cutaneous synthesis of vitamin D as a way to promote health. We assessed the net result of these conflicting messages.
In a cross-sectional survey in 2007, questionnaires were mailed to participants of an ongoing cohort study in Washington County, Maryland. The study population consisted of 8,027 adults (55% response rate).
Thirty percent of respondents were aware that unprotected sun exposure increased endogenous vitamin D levels. Among those who were aware of this benefit, 42% reported going out into the sun to increase vitamin D levels. Sun-seeking to increase vitamin D production did not significantly differ according to self-reported personal history of skin cancer, but was significantly higher among women, older age groups, those with less education, and vitamin D supplement users.
A substantial proportion of respondents reported sun-seeking behavior expressly to increase endogenous vitamin D levels. The message about sun exposure and vitamin D is reaching the general public; however, this finding poses challenges to skin cancer prevention efforts.
PMCID: PMC3115212  PMID: 21800747
4.  Commercially available sun lamps and vitamin D formation 
Postgraduate Medical Journal  1981;57(665):159-163.
Four commercially available, medium pressure mercury sun lamps were used to assess their effects on promoting vitamin D synthesis in the skin. It was found that all the lamps studied had vitamin D synthesizing spectral wavelengths and caused an increase in the serum concentrations of 25-hydroxyvitamin D. However, the ultraviolet and visible irradiance measurements showed that a considerable proportion of the ultraviolet radiation was below 290 nm. It was not surprising, therefore, to find that these lamps caused adverse skin reactions. While a useful rise in vitamin D production can be obtained with these sun lamps, the difficulty involved in avoiding skin reaction limits their usefulness. Such lamps are unlikely to provide a safe practical routine method for the prevention of vitamin D deficiency in the home.
PMCID: PMC2424865  PMID: 7329878
5.  Vitamin D supply: from sun or pill? - Attitudes and recommendation on vitamin D and impact on sun protection practices among German general practitioners evaluated by the network of dermato-oncologists, Onkoderm e.V. 
Oncology Letters  2012;4(6):1392-1396.
Recommendations concerning the intake of vitamin D and/or sunlight exposure in the handling of patients with vitamin D deficiency remain a matter of debate. The present study of the German network of dermato-oncologists (Onkoderm e.V.) refers to an inquiry conducted among general practitioners on this and related issues. Based on 448 answers provided to 10 distinct questions, the consulted physicians recommended vitamin D intake (94% replies) and/or exposure to sunlight (63% replies) in their patients with vitamin D deficiency. An average of approximately 26 min daily unprotected exposure to sunlight at midday in spring and summer was recommended. Nevertheless, 91% of the physicians considered the use of creams protecting against sunlight to be judicious. However, only 54% of physicians considered it worthwhile practice to protect oneself intensively against UV radiation. This study indicates evidence of a reduction in sun protection practices. Yet, approximately 25% of the patients were considered to present vitamin D deficiency and, hence, recommendations to prevent or correct the latter situation should not be ignored. Nevertheless, we consider that there is a need to focus messages regarding sun exposure and for continued sun protection practices. These messages should specifically focus on the vitamin D issue to ensure that the incidence of skin cancer does not increase.
PMCID: PMC3506811  PMID: 23226810
vitamin D; sunlight exposure; skin cancer
6.  Vitamin D and melanoma 
Dermato-endocrinology  2013;5(1):121-129.
Recreational sun exposure and sunburn are causal for melanoma but the risk is strongly genetically determined. Health promotion advice about sun protection should be aimed at susceptible individuals (pale skin, freckles, large numbers of melanocytic nevi and a family history). We discuss here the evidence that sun-sensitive people have lower vitamin D levels and that, in practice, it is very difficult for such individuals to achieve sufficient levels without supplementation in the UK at least. We conclude that melanoma susceptible sun-avoidant individuals should be advised to avoid insufficiency by supplementation.
Vitamin D is anti-proliferative in vitro for some melanoma cell lines. In a large melanoma cohort we have observed that lower serum 25-hydroxyvitamin D2/D3 levels at diagnosis were associated with thicker tumors and poorer prognosis (study as yet not validated). In the UK, melanoma patients commonly have sub-optimal 25-hydroxyvitamin D2/D3 levels at and post diagnosis; we discuss approaches to management of such patients based on some new data from our group.
PMCID: PMC3897580  PMID: 24494045
supplementation; vitamin D serum levels; risk; 25-hydroxyvitamin D2/D3 levels; survival; prevention
7.  Pigmentation and Vitamin D Metabolism in Caucasians: Low Vitamin D Serum Levels in Fair Skin Types in the UK 
PLoS ONE  2009;4(8):e6477.
Vitamin D may play a protective role in many diseases. Public health messages are advocating sun avoidance to reduce skin cancer risk but the potential deleterious effects of these recommendations for vitamin D metabolism have been poorly investigated.
Methodology/Principal Findings
We investigated the association between 25-hydroxy-vitamin D (25(OH)D), skin type and ultraviolet exposure in 1414 Caucasian females in the UK. Mean age of the cohort was 47 years (18–79) and mean 25(OH)D levels were 77 nmol/L (6–289). 25(OH)D levels were strongly associated with season of sampling with higher levels in the spring and summer months (p<0.0001). Light skin types (skin type 1 and 2) have lower levels of 25(OH)D (mean 71 nmol/L) compared to darker skin types (skin type 3 and 4) (mean 82 nmol/L) after adjusting for multiple confounders (p<0.0001). The trend for increasing risk of low vitamin D with fairer skin types was highly significant despite adjustment for all confounders (p = 0.001).
Contrary to previous studies across different ethnic backgrounds, this study within Caucasian UK females shows that fair skin types have lower levels of 25(OH)D compared to darker skin types with potential detrimental health effects. Public health campaigns advocating sun avoidance in fair skinned individuals may need to be revised in view of their risk of vitamin D deficiency.
PMCID: PMC2714459  PMID: 19649299
8.  The ABC of Vitamin D: A Qualitative Study of the Knowledge and Attitudes Regarding Vitamin D Deficiency amongst Selected Population Groups 
Nutrients  2013;5(3):915-927.
Objective: In Australia, vitamin D supply in food is limited, and sun exposure is the main source of vitamin D. However skin cancer risk is high, and the need to gain some sun exposure for adequate vitamin D is challenging public health messages to use protection in the sun. The complex vitamin D public health message may be confusing the public and, in particular, those at highest risk for vitamin D deficiency. This study explored vitamin D and sun exposure attitudes, knowledge and practices of some groups considered at risk of vitamin D deficiency and those delivering healthy sun exposure messages to children. Method: 52 adults participated in six focus groups. Results: Results corroborated with previous research showing low levels of vitamin D knowledge. Individual and environmental barriers to receiving adequate sun exposure were also identified. Conclusions and Implications: The message advocating balanced sun exposure to produce adequate vitamin D needs to be made clearer and be more effectively communicated. Findings provide insights to aid development of appropriate public health messages for safe sun exposure and vitamin D, especially for vulnerable groups.
PMCID: PMC3705326  PMID: 23503169
vitamin D; focus groups; knowledge and attitudes
9.  Vitamin D Deficiency in India: Prevalence, Causalities and Interventions 
Nutrients  2014;6(2):729-775.
Vitamin D deficiency prevails in epidemic proportions all over the Indian subcontinent, with a prevalence of 70%–100% in the general population. In India, widely consumed food items such as dairy products are rarely fortified with vitamin D. Indian socioreligious and cultural practices do not facilitate adequate sun exposure, thereby negating potential benefits of plentiful sunshine. Consequently, subclinical vitamin D deficiency is highly prevalent in both urban and rural settings, and across all socioeconomic and geographic strata. Vitamin D deficiency is likely to play an important role in the very high prevalence of rickets, osteoporosis, cardiovascular diseases, diabetes, cancer and infections such as tuberculosis in India. Fortification of staple foods with vitamin D is the most viable population based strategy to achieve vitamin D sufficiency. Unfortunately, even in advanced countries like USA and Canada, food fortification strategies with vitamin D have been only partially effective and have largely failed to attain vitamin D sufficiency. This article reviews the status of vitamin D nutrition in the Indian subcontinent and also the underlying causes for this epidemic. Implementation of population based educational and interventional strategies to combat this scourge require recognition of vitamin D deficiency as a public health problem by the governing bodies so that healthcare funds can be allocated appropriately.
PMCID: PMC3942730  PMID: 24566435
vitamin D; vitamin D deficiency; 25-hydroxyvitamin D; India; Indian subcontinent; healthy individuals; fortification strategies; supplementation; sun exposure; osteoporosis; fractures
10.  A Pilot Study of the Validity of Self-reported Ultraviolet Radiation Exposure and Sun Protection Practices Among Lifeguards, Parents and Children 
Photochemistry and photobiology  2008;84(3):774-778.
Outdoor recreation settings, such as swimming pools, provide a promising venue to assess UVR exposure and sun protection practices among individuals who are minimally clothed and exposed to potentially high levels of UVR. Most studies assessing sun exposure/protection practices rely on self-reported data, which are subject to bias. The aim of this study was to establish the feasibility of conducting a multimethod study to examine the validity of self-reported measures within a swimming pool setting. Data were collected from 27 lifeguards, children and parents in Hawaii. Each participant filled out a survey and a 4 day sun habits diary. On two occasions, researchers assessed observable sun protection behaviors (wearing hats, shirts, sunglasses), swabbed the skin to detect the presence of sunscreen, and subjects wore polysulphone dosimeters to measure UVR exposure. Overall, observed sun protection behaviors were more highly correlated with diary reports than with survey reports. While lifeguards and children reported spending comparable amounts of time in the sun, dosimeter measures showed that lifeguards received twice as much UVR exposure. This study demonstrated the feasibility of implementing a multimethod validity study within a broader population of swimming pools.
PMCID: PMC3725580  PMID: 18179624
11.  Physician advice on avoiding secondhand smoke exposure and referrals for smoking cessation services 
Tobacco Induced Diseases  2012;10(1):10.
Secondhand smoke (SHS) exposure causes premature death and disease. Eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from SHS exposure, and also contributes to helping smokers quit smoking. Primary health care providers can play an important role in advising nonsmoking patients to avoid SHS exposure, cautioning current smokers against exposing others to SHS, and referring tobacco users to cessation programs.
The purpose of this paper is to examine primary care provider (obstetricians/gynecologists, pediatricians, and general practitioners) advice regarding SHS exposure and referral to cessation programs. Using data from the 2008 DocStyles survey (n = 1,454), we calculated the prevalence and adjusted odds ratios for offering patients advice regarding SHS exposure and referring adults who smoked or used other tobacco products to a cessation program.
The current study found that among a convenience sample of primary care providers, 94.9% encouraged parents to take steps to protect children from SHS exposure, 86.1% encouraged smokers to make their homes and cars smoke-free, and 77.4% encouraged nonsmokers to avoid SHS exposure. Approximately 44.0% of primary care providers usually or always referred patients who smoked or used tobacco products to cessation programs such as a quitline, a group cessation class, or one-on-one counseling.
Findings from a convenience sample of primary care providers who participated in a web-based survey, suggests that many primary care providers are advising parents to protect children from SHS exposure, encouraging patients who smoke to maintain smoke-free homes and cars, and advising smokers on ways to avoid exposing others to SHS. Healthcare providers are encouraged to advise patients to avoid SHS exposure and to refer patients who use tobacco products to cessation services.
PMCID: PMC3434118  PMID: 22748198
Secondhand smoke; Cessation; Physician; Advice and Referral
12.  25-OH vitamin D levels in African American and Caucasian/Hispanic cutaneous lupus subjects 
The British Journal of Dermatology  2012;166(2):372-379.
Because exposure to UV radiation accounts for a significant portion of endogenous vitamin D production, cutaneous lupus (CLE) subjects practicing sun-protective measures are at risk for vitamin D insufficiency. Previous studies have shown light-skinned CLE subjects to have lower serum 25-hydroxy (25-OH) vitamin D levels than normal controls.
To assess the status of vitamin D insufficiency in dark-skinned CLE individuals.
We performed a cross-sectional study comparing serum 25-OH vitamin D levels in 25 CLE and 26 normal African American (AA) age-, gender-, and season-matched subjects in Dallas, Texas. A questionnaire on demographics, medical history, and lifestyle habits was administered to determine factors potentially affecting vitamin D levels. Findings were contrasted to a similar comparison in 26 CLE and 24 age-, gender-, and season-matched normal Caucasian and Hispanic (C/H) subjects.
We found similar 25-OH vitamin D levels in CLE (52.0±18.5 nmol/L) and normal AA subjects (54.8±21.2 nmol/L) (p = 0.62). Almost half of AA subjects in both groups were vitamin D-insufficient. A larger gap in 25-OH vitamin D levels was found in C/H CLE (59.4±21.0 nmol/L) and normal subjects (70.5±27.4 nmol/L) (p = 0.12). Two-way ANOVA analysis demonstrated that skin color (AA vs. C/H) had a significant effect on 25-OH vitamin D levels (p = 0.008), though CLE status (CLE vs. normal) did not (p = 0.13).
Providers are encouraged to address vitamin D insufficiency concerns in all dark-skinned individuals. Future studies should stratify subjects by skin color in determining differences between CLE and normal controls.
PMCID: PMC3265693  PMID: 21966891
African American; cutaneous lupus; skin color; vitamin D
13.  Sun Protection Policy in Elementary Schools in Hawaii 
Preventing Chronic Disease  2004;1(3):A05.
Childhood sun exposure is a major risk factor for skin cancer, the most common form of cancer in the United States. Schools in locations that receive high amounts of ultraviolet radiation have been identified as important sites for reducing excessive sun exposure.
The objective of this study was to determine the prevalence of sun protection policies, environmental features, and attitudes in public elementary schools in Hawaii. Surveys were sent to all (n = 177) public elementary school principals in Hawaii. Non-respondents were called three weeks after the initial mailing. The survey asked about sun protection policies, environmental features, and attitudes toward sun protection. The survey was designed to measure all seven components of Guidelines for School Programs to Prevent Skin Cancer, issued by the Centers for Disease Control and Prevention.
Seventy-eight percent of schools responded to the survey. Only one school had a written school policy. Almost all schools (99.3%) scheduled outdoor activities during peak sun hours. School uniforms rarely included long pants (6.5%), long-sleeved shirts (5.1%), or hats (1.5%). Current policies did not support or restrict sun protection habits. Almost one third of those surveyed were in favor of a statewide policy (28.1%), and most believed excessive sun exposure was an important childhood risk (78.9%), even among non-white students (74.5%).
Results of this study suggest the following: 1) school personnel in Hawaii are concerned about childhood sun exposure; 2) current school policies fail to address the issue; 3) most schools are receptive to developing sun protection policies and programs; and 4) students appear to be at high risk for sun exposure during school hours.
PMCID: PMC1253470  PMID: 15670426
14.  To Be or Not To Be Exposed to Direct Sunlight 
Only small amounts of vitamin D come from dietary sources as it is mainly synthesised in the skin from the ultraviolet B (UVB) fraction of sunlight if the person is sufficiently exposed to direct sunlight. Vitamin D deficiency has been well documented in Oman. The “2004 Oman National Micronutrients Survey” and other recent studies revealed that vitamin D3 stores are low among healthy Omani females of childbearing age and pregnant women. This situation is confusing as Oman is known to be one of the sunniest countries in the world. However, it is known that most Omani women are well covered and for various reasons avoid sun exposure. The article addresses a question about the balance that should be maintained between excessive sun exposure that leads to an increased risk of skin cancer, and healthy exposure that provides sufficient ultraviolet radiation (UVR) to maintain adequate vitamin D levels. In order to avoid vitamin D deficiency, sun exposure or protection messages must be tailored according to different situations, in recognition of the complex combination of personal, cultural and social factors that affect vitamin D synthesis in the skin.
PMCID: PMC3121023  PMID: 21969890
Vitamin D deficiency; 25-hydroxyvitamin D; Sunlight; Ultraviolet Rays; Skin Cancer; Oman
15.  Compliance with Sunscreen Advice in a Survey of Adults Engaged in Outdoor Winter Recreation at High Elevation Ski Areas 
Adults are advised to wear sunscreen with a sun protection factor of 15+, apply it up to 30 minutes prior to sun exposure, and reapply it after two hours to reduce exposure to ultraviolet (UV) radiation in sunlight for the prevention of skin cancer.
This study investigated the extent to which adults comply with sunscreen advice.
A survey was conducted with 4,837 adult skiers and snowboarders at 28 high-altitude ski areas in Western North America in January – April 2001-02. Respondents self reported use of sunscreen, its SPF, time of first application, and reapplication.
Only 4.4% (95% CI=±0.6) of adults were in full compliance with all sunscreen advice. Half (49.8% [95% CI=±1.4]) complied with SPF 15+ advice. Of those wearing sunscreen, 73.2% (95% CI=±1.8) applied the sunscreen 30 minutes before beginning skiing/snowboarding, but only 20.4% (95% CI=±2.0) complied with advice to reapply it after 2 hours. Total compliance was lowest during inclement weather, on low-UV days, by males, and among respondents who believed skin cancer was unimportant and with low sun sensitive skin. It was positively associated with wearing lip balm and hats with a brim.
The sample was predominantly male and of high socio-economic status; the results apply most to winter recreation when UV radiation levels are low, and sunscreen use was assessed by self-report.
While the recommendation to use SPF 15+ sunscreen has reached many adults, the reapplication advice is heeded by few adults and needs to be highlighted in future sun safety promotions.
PMCID: PMC3193866  PMID: 21742410
sunscreen; sunscreen reapplication; adults; outdoor recreation; sun protection; ultraviolet radiation
16.  Reducing ultraviolet radiation exposure among outdoor workers: State of the evidence and recommendations 
Environmental Health  2007;6:22.
Outdoor workers have high levels of exposure to ultraviolet radiation and the associated increased risk of skin cancer. This paper describes a review of: 1) descriptive data about outdoor workers' sun exposure and protection and related knowledge, attitudes, and policies and 2) evidence about the effectiveness of skin cancer prevention interventions in outdoor workplaces.
Data sources
Systematic evidence-based review.
Data synthesis
We found variable preventive practices, with men more likely to wear hats and protective clothing and women more likely to use sunscreen. Few data document education and prevention policies.
Reports of interventions to promote sun-safe practices and environments provide encouraging results, but yield insufficient evidence to recommend current strategies as effective. Additional efforts should focus on increasing sun protection policies and education programs in workplaces and evaluating whether they improve the health behavior of outdoor workers.
PMCID: PMC1995198  PMID: 17686155
17.  Theobald Palm and His Remarkable Observation: How the Sunshine Vitamin Came to Be Recognized 
Nutrients  2012;4(1):42-51.
The seminal discovery that sunlight was important in the prevention of nutritional rickets was made in 1890 by Theobald A. Palm, a medical missionary who contrasted the prevalence of rickets in northern European urban areas with similar areas in Japan and other tropical countries. He surmised that exposure to sunlight prevented rickets. Over the next 40 years his observation led to an understanding of ultraviolet irradiation and its role in vitamin D synthesis. This opened a new era of appreciation for the curative powers of the sun and “the sunshine vitamin”. While Palm’s observations were in some ways obscure, they had a potent effect on the development of photobiology.
PMCID: PMC3277100  PMID: 22347617
vitamin D; nutritional rickets; photobiology; sunlight; UVB wavelength rays
18.  Vitamin D—Effects on Skeletal and Extraskeletal Health and the Need for Supplementation 
Nutrients  2013;5(1):111-148.
Vitamin D, the sunshine vitamin, has received a lot of attention recently as a result of a meteoric rise in the number of publications showing that vitamin D plays a crucial role in a plethora of physiological functions and associating vitamin D deficiency with many acute and chronic illnesses including disorders of calcium metabolism, autoimmune diseases, some cancers, type 2 diabetes mellitus, cardiovascular disease and infectious diseases. Vitamin D deficiency is now recognized as a global pandemic. The major cause for vitamin D deficiency is the lack of appreciation that sun exposure has been and continues to be the major source of vitamin D for children and adults of all ages. Vitamin D plays a crucial role in the development and maintenance of a healthy skeleton throughout life. There remains some controversy regarding what blood level of 25-hydroxyvitamin D should be attained for both bone health and reducing risk for vitamin D deficiency associated acute and chronic diseases and how much vitamin D should be supplemented.
PMCID: PMC3571641  PMID: 23306192
vitamin D; 25-hydroxyvitamin D; vitamin D deficiency; osteoporosis; fractures; cancer; type 2 diabetes mellitus; cardiovascular diseases; autoimmune diseases; infectious diseases
19.  Perceived Relevance of Educative Information on Public (Skin) Health: A Cross-sectional Questionnaire Survey 
Unprotected leisure time exposure to ultraviolet radiation from the sun or artificial tanning beds is the most important environmental risk factor for melanoma, a malignant skin cancer with increasing incidences over the past decades. The aim of the present study was to assess the impact of skin health information provided by several sources and different publishing issues on knowledge, risk perception, and sun protective behavior of sunbathers.
A cross-sectional questionnaire survey was conducted among Austrian residents (n=563) spending leisure time outdoors in August 2010.
Print media, television, and family were perceived as the most relevant sources of information on skin health, whereas the source physician was only ranked as fourth important source. Compared to other sources, information provided by doctors positively influenced participants' knowledge on skin risk and sun protective behavior resulting in higher scores in the knowledge test (p=0.009), higher risk perception (p<0.001), and more sun protection (p<0.001).
Regarding gender differences, internet was more often used by males as health information source, whereas females were more familiar with printed information material in general.
The results of this survey put emphasis on the demand for information provided by medical professionals in order to attain effective, long-lasting promotion of photoprotective habits.
PMCID: PMC3615383  PMID: 23573372
Gender; Health education; Melanoma prevention; Public Health; Skin health promotion; Sun protection
20.  Vitamin D in cutaneous carcinogenesis: Part I 
Skin cancer is the most common cancer in the United States. Exposure to ultraviolet radiation is a known risk factor for skin cancer but is also the principal means by which the body obtains vitamin D. Several studies have suggested that vitamin D plays a protective role in a variety of internal malignancies. With regard to skin cancer, epidemiologic and laboratory studies suggest that vitamin D and its metabolites may have a similar protective effect. These noncalcemic actions of vitamin D have called into question whether the current recommended intake of vitamin D is too low for optimal health and cancer prevention. Part I will review the role of vitamin D in the epidermis; part II will review the role of vitamin D in keratinocyte-derived tumors to help frame the discussion on the possible role of vitamin D in the prevention of skin cancer.
PMCID: PMC3688468  PMID: 23062903
25(OH)D levels; cholecalciferol; supplements; vitamin D; ultraviolet radiation
21.  Primary school sun protection policies and practices 4 years after baseline—a follow-up study 
Health Education Research  2012;27(5):844-856.
Before the 2005 launch of the New Zealand SunSmart Schools Accreditation Programme (SSAP), 242 randomly sampled primary schools completed a mail survey about sun protection policies, practices, curriculum and environment. A 2009 follow-up included 189 (78%) and their mean Total Accreditation Score (TAS = total SSAP requirements met, range 0–12), increased by 0.8 (95% CI 0.5–1.2, P < 0.001) from 7.8 (95% CI 7.4–8.1) to 8.6 (95% CI 8.3–8.9) with evidence changes differed between regions (P = 0.024). The 2009 mean TAS varied by region (range 7.9–9.4, unadjusted P = 0.004, adjusted P = 0.013) with no clear pattern, but likely resource allocation association. TAS of schools acknowledging input from Health Promoting Schools demonstrated a tendency towards being statistically significantly higher by 0.5 (95% CI −0.1 to 1.1, P = 0.082), but statistically significantly higher by 1.1 (95% CI 0.5–1.7, P < 0.001) for schools acknowledging Cancer Society input. Lowest attainment was for the clothing (43%), shade (52%) and curriculum (55%) criteria. Key perceived barriers were cost, particularly of shade and limited support by parents and others. Schools which had not applied for accreditation identified lack of programme awareness and ‘other priorities’ as barriers; further information, better resourcing and training assistance as key needs. Observed positive change justifies increased support to consolidate gains and achieve sustainable universality.
PMCID: PMC3442379  PMID: 22907533
22.  Measured Occupational Solar UVR Exposures of Lifeguards in Pool Settings 
The aim of this study was to measure ultraviolet radiation (UVR) exposures of lifeguards in pool settings and evaluate their personal UVR protective practices.
Lifeguards (n = 168) wore UVR sensitive polysulfone (PS) film badges in wrist bracelets on 2 days and completed a survey and diary covering sun protection use. Analyses were used to describe sun exposure and sun protection practices, to compare UVR exposure across locations, and to compare findings with recommended threshold limits for occupational exposure.
The measured UVR exposures varied with location, ranging from high median UVR exposures of 6.2 standard erythemal doses (SEDs) to the lowest median of 1.7 SEDs. More than 74% of the lifeguards’ PS badges showed UVR above recommended threshold limits for occupational exposure. Thirty-nine percent received more than four times the limit and 65% of cases were sufficient to induce sunburn. The most common protective behaviors were wearing sunglasses and using sunscreen, but sun protection was often inadequate.
At-risk individuals were exposed to high levels of UVR in excess of occupational limits and though appropriate types of sun protection were used, it was not used consistently and more than 50% of lifeguards reported being sunburnt at least twice during the previous year.
PMCID: PMC3728671  PMID: 19572325
lifeguards; occupational UVR exposure; sun protection behaviors
23.  Sun protection advice mediated by the general practitioner: An effective way to achieve long-term change of behaviour and attitudes related to sun exposure? 
To investigate, in primary health care, differentiated levels of prevention directed at skin cancer, and how the propensity of the patients to change sun habits/sun protection behaviour and attitudes towards sunbathing were affected, three years after intervention. Additionally, the impact of the performance of a phototest as a complementary tool for prevention was evaluated.
Randomized controlled study.
Setting and subjects
During three weeks in February, all patients ≥ 18 years of age registering at a primary health care centre in southern Sweden were asked to fill in a questionnaire mapping sun exposure habits, attitudes towards sunbathing, and readiness to increase sun protection according to the Transtheoretical Model of Behaviour Change (TTM) (n = 316). They were randomized into three intervention groups, for which sun protection advice was given, in Group 1 by means of a letter, and in Groups 2 and 3 orally during a personal GP consultation. Group 3 also underwent a phototest to demonstrate individual skin UV sensitivity.
Main outcome measures
Change of sun habits/sun protection behaviour and attitudes, measured by five-point Likert scale scores and readiness to increase sun protection according to the TTM, three years after intervention, by a repeated questionnaire.
In the letter group, almost no improvement in sun protection occurred. In the two doctor's consultation groups, significantly increased sun protection was demonstrated for several items, but the difference compared with the letter group was significant only for sunscreen use. The performance of a phototest did not appear to reinforce the impact of intervention.
Sun protection advice, mediated personally by the GP during a doctor's consultation, can lead to improvement in sun protection over a prolonged time period.
PMCID: PMC3347962  PMID: 21682578
Family practice; phototest; prevention and control; primary health care; skin cancer; sun protection behaviour
24.  Nutritional Rickets 
Nutritional rickets (NR) is still the most common form of growing bone disease despite the efforts of health care providers to reduce the incidence of the disease. Today, it is well known that the etiology of NR ranges from isolated vitamin D deficiency (VDD) to isolated calcium deficiency. In Turkey, almost all NR cases result from VDD. Recent evidence suggests that in addition to its short− or long−term effects on skeletal development, VDD during infancy may predispose the patient to diseases such as diabetes mellitus, cancer and multiple sclerosis. Among the factors responsible for the high prevalence of VDD in developing countries and its resurgence in developed countries is limited sunshine exposure due to individuals’ spending more time indoors (watching television and working on computer) or avoiding sun exposure intentionally for fear of skin cancer. Traditional clothing (covering the entire body except the face and hands) further limits the exposure time to sunlight and, thus, decreases the endogenous synthesis of vitamin D. In Turkey, maternal VDD and exclusive breastfeeding without supplementation were reported to be the most prominent reasons leading to NR. The diagnosis of NR is established by a thorough history and physical examination and confirmed by laboratory evaluation. Recent reports draw attention to the supplemental doses of vitamin D required to achieve a serum 25−hydroxyvitamin D level of at least 20 ng/ml (50 nmol/l) − the serum concentration that is needed to optimize absorption of dietary calcium and to suppress excessive secretion of parathyroid hormone. This type of prevention will also reduce fracture risk as well as prevent long−term negative effect of vitamin D insufficiency.
Conflict of interest:None declared.
PMCID: PMC3005686  PMID: 21274312
Nutritional rickets; Vitamin D; calcium
25.  Sun Protection Preferences and Behaviors among Young Adult Males during Maximum Ultraviolet Radiation Exposure Activities 
This study explores sun protection attitudes, preferences, and behaviors among young adult males participating in an open-field activity with extreme ultraviolet radiation exposure. Male drum corps members (n = 137) responded to survey questions regarding their behavior and willingness to engage in sun protection and barriers to sunscreen usage. A subset of members (n = 31) participated in cognitive interviews exploring various sunscreen products and intervention techniques. Participants were knowledgeable about health risks and protection benefits regarding sun exposure. Generally, males had positive attitudes and normative beliefs about using sunscreen. A barrier to sunscreen re-application was lack of adequate time to reapply sunscreen during the open field activity. Males preferred a towelette application method, but were unfamiliar with its efficacy and proper use. Thus, they were more likely to use the more familiar sunscreen spray. To increase sun protection behaviors and lower skin cancer risk for males participating in open-field activities, breaks must be allotted every 2 h and have sufficient time to allow sunscreen application. Future development and research into delivery systems that rapidly and evenly apply sunscreen may help lower exposure in this population.
PMCID: PMC3774433  PMID: 23912201
sun protection; male adolescent attitudes; primary prevention of melanoma

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