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Sun For Sja

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Sun For Sja

  1. 1. Adequate sun exposure is essential for optimal health George Jelinek Professor of Emergency Medicine University of Western Australia
  2. 2. Overview <ul><li>The controversy </li></ul><ul><li>Background </li></ul><ul><ul><li>Sunlight and UV light </li></ul></ul><ul><ul><li>Vitamin D </li></ul></ul><ul><li>The evidence </li></ul><ul><li>Conclusions and recommendations </li></ul>
  3. 3. The messages <ul><li>A lot of data but simple messages: </li></ul><ul><li>Vitamin D deficiency due to inadequate sunshine is an epidemic in the West </li></ul><ul><ul><li>Population calcium supplementation has resulted and is unnecessary </li></ul></ul><ul><li>Avoiding the sun makes us sick </li></ul><ul><ul><li>Most of us need more sunlight to be really well </li></ul></ul>
  4. 4. The controversy <ul><li>Growing debate about public health messages regarding sun avoidance* </li></ul><ul><li>Growing burden of disease related to inadequate vitamin D </li></ul><ul><ul><li>Without sun, there would be no life on earth: why continue regarding sunlight as poison? </li></ul></ul><ul><ul><ul><ul><ul><li>* Lucas RM, Ponsonby AL. Ultraviolet radiation and health: friend and foe. Med J Aust 2002; 177:594-8 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ness AR, Frankel SJ, Gunnell DJ, et al. Are we really dying for a tan? BMJ 1999; 319:114-16 </li></ul></ul></ul></ul></ul>
  5. 5. Changing mainstream opinion <ul><li>‘ The paradox of Vitamin D deficiency emerging as a public health issue in sunny Australia’* </li></ul><ul><li>‘ It is no longer acceptable to assume that all people in Australia receive adequate Vitamin D from casual sunlight exposure’+ </li></ul><ul><li>‘ Vitamin D deficiency is now recognised as an epidemic in the United States’^ </li></ul><ul><ul><ul><ul><ul><li>* Ebeling PR. Megadose therapy for vitamin D deficiency. Treating the paradox of an important emerging public health problem. Med J Aust 2005;183:4-5 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>+ Nowson CA, Diamond TH, Pasco JA, et al. Vitamin D in Australia. Aust Fam Phys 2004;33:133-138 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>^ Holick MF. The vitamin D epidemic and its health consequences. J Nutr 2005;135:2739S-48S </li></ul></ul></ul></ul></ul>
  6. 6. Background <ul><li>Sunlight composition </li></ul><ul><ul><li>Mixture of infrared, visible and ultraviolet </li></ul></ul><ul><ul><li>Ultraviolet comprises UVA, UVB, UVC </li></ul></ul><ul><li>UVB </li></ul><ul><ul><li>Only about 5% </li></ul></ul><ul><ul><li>Acts on skin to form vitamin D </li></ul></ul>
  7. 7. Formation of vitamin D <ul><li>Amount of vitamin D formed depends on: </li></ul><ul><ul><li>Area of skin exposed to sunlight </li></ul></ul><ul><ul><li>Length of time exposed </li></ul></ul><ul><li>Upper limit of 10 000-15 000 IU after which no more produced </li></ul><ul><ul><li>This takes all over exposure for 10-15mins at midday on a spring day </li></ul></ul><ul><ul><li>Skin makes about 1 000 IU a minute for 15 mins then no more </li></ul></ul>
  8. 8. Vitamin D <ul><li>Main action is to increase absorption of calcium from gut and deposition in bone </li></ul><ul><li>More recently found that vitamin D has profound effects on immune system </li></ul><ul><li>Other effects on muscle, balance, mood </li></ul><ul><li>Impossible to get adequate amounts from diet alone </li></ul>
  9. 9. Effects of vitamin D deficiency <ul><li>Calcium effects </li></ul><ul><ul><li>Ricketts, osteoporosis, fractures </li></ul></ul><ul><li>Hypertension, depression, weakness, falls# </li></ul><ul><li>Immune effects </li></ul><ul><ul><li>Increased incidence and severity of autoimmune diseases and cancers* </li></ul></ul><ul><ul><ul><ul><ul><li># Bischoff HA, Stahelin HB, Dick W, et al. Effects of vitamin D and calcium supplementation on falls: a randomised controlled trial. J Bone Miner Res 2003;18:343-51 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>* Ponsonby AL, McMichael A, van der Mei I. Ultraviolet radiation and autoimmune disease: insights from epidemiological research. Toxicology 2002; 181-182:71-8 </li></ul></ul></ul></ul></ul>
  10. 10. Diseases from low vitamin D <ul><li>Cancers* </li></ul><ul><ul><li>Digestive tract cancers </li></ul></ul><ul><ul><ul><li>Esophageal, gastric, colon, rectal </li></ul></ul></ul><ul><ul><li>Breast and reproductive system cancers </li></ul></ul><ul><ul><ul><li>Breast, cervical, endometrial, ovarian, vulva </li></ul></ul></ul><ul><ul><li>Urogenital cancers </li></ul></ul><ul><ul><ul><li>Bladder, kidney, prostate, renal, testis </li></ul></ul></ul><ul><ul><li>Other cancers </li></ul></ul><ul><ul><ul><li>Gallbladder, laryngeal, pancreatic, Hodgkin’s lymphoma, non Hodgkin’s lymphoma </li></ul></ul></ul><ul><ul><ul><ul><ul><li>* Grant WB. Ecologic studies of solar UV-B radiation and cancer mortality rates. Recent Results Cancer Res 2003; 164:371-7 </li></ul></ul></ul></ul></ul>
  11. 11. US UV exposure
  12. 12. Breast cancer
  13. 13. Colon cancer
  14. 14. Diseases from low vitamin D <ul><li>Autoimmune disorders </li></ul><ul><ul><li>Multiple sclerosis, rheumatoid arthritis, insulin dependent diabetes, SLE </li></ul></ul><ul><li>Bone disorders </li></ul><ul><ul><li>Ricketts, osteoporosis, osteomalacia, fractures, poor fracture healing </li></ul></ul><ul><li>Mood disorders </li></ul><ul><ul><li>Depression, seasonal affective disorder (SAD) </li></ul></ul><ul><li>General health </li></ul><ul><ul><li>High BP, CHD # , irritable bowel, Crohn’s disease, falls, muscle weakness </li></ul></ul><ul><ul><ul><ul><ul><li># Grimes D., Hindle E., and Dyer T., Sunlight cholesterol and coronary heart disease. QJM 1996; 89;579-589 </li></ul></ul></ul></ul></ul>
  15. 15. MS prevalence WW2 veterans at entry into armed forces by latitude
  16. 17. Seasonal variation in Vitamin D levels versus no of new MS lesions
  17. 18. Current vitamin D ranges <ul><li>Current mod/severe deficiency: <25nmol/L </li></ul><ul><li>Current mild deficiency: <50nmol/L </li></ul><ul><li>Lots of evidence that this range too low* </li></ul><ul><li>Even at these levels, large proportion of population has low levels </li></ul><ul><ul><ul><ul><ul><li>* Vieth R. Why the optimal requirement for Vitamin D(3) is probably much higher than what is officially recommended for adults. J Steroid Biochem Mol Biol 2004; 89-90:575-9 </li></ul></ul></ul></ul></ul>
  18. 19. Vitamin D deficiency <ul><li>In hostels and nursing homes </li></ul><ul><ul><li>80% of women </li></ul></ul><ul><ul><li>70% of men* </li></ul></ul><ul><li>In Geelong women </li></ul><ul><ul><li>30% in summer </li></ul></ul><ul><ul><li>43% in winter# </li></ul></ul><ul><ul><ul><ul><ul><li>* Flicker L, Mead K, MacInnis RJ, et al. Serum vitamin D and falls in older women living in residential care in Australia. J Am Geriatr Soc 2003;51:1533-38 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li># Pasco JA, Henry MJ, Nicholson GC, et al. Vitamin D status of women in the Geelong Osteoporosis Study: association with diet and casual exposure to sunlight. Med J Aust. 2001;175:401-5 </li></ul></ul></ul></ul></ul>
  19. 20. Target blood range <ul><li>Check levels in autumn when level lowest </li></ul><ul><ul><li>Aim for at least: 70nmol/L if well </li></ul></ul><ul><ul><li>100-140nmol/L if sick </li></ul></ul><ul><ul><li>Probably up to 200nmol/L really optimal* </li></ul></ul><ul><ul><li>Evidence that 135-225nmol/L normal in sunny countries where these diseases rare </li></ul></ul><ul><ul><ul><ul><ul><li>* Grant WB,Holick MF. Benefits and requirements of Vitamin D for optimal health: a review. Altern Med Rev 2005; 10:94-111 </li></ul></ul></ul></ul></ul>
  20. 21. Current vitamin D recommendations <ul><li>RDA now 200IU to prevent deficiency </li></ul><ul><ul><li>Equivalent to about 6 seconds all over sun in Perth summer at midday! </li></ul></ul><ul><li>Where these diseases uncommon blood levels at least 100-140nmol/L </li></ul><ul><ul><li>4 000IU/day gives level of 100nmol/L </li></ul></ul><ul><ul><li>10 000IU/day gives level of 140nmol/L </li></ul></ul>
  21. 22. Is Vitamin D toxic? <ul><li>Current ‘LOAEL’ is 2 000IU per day </li></ul><ul><ul><li>10 000IU per day perfectly safe* </li></ul></ul><ul><ul><li>Only published toxicity is from >40 000IU/day </li></ul></ul><ul><li>Potential toxicity relates to high calcium </li></ul><ul><ul><li>Currently much work on vitamin D analogues to get immune effect without calcium effects </li></ul></ul><ul><ul><li>Flawed thinking: nature provides the balance </li></ul></ul><ul><ul><ul><ul><ul><li>* Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr 1999; 69:842-56 </li></ul></ul></ul></ul></ul>
  22. 23. Benefits of high normal vitamin D levels <ul><li>Not only prevents ricketts, osteomalacia, osteoporosis, autoimmune diseases, cancer, hypertension, depression* </li></ul><ul><li>Prevents complications of these diseases, such as osteoporosis from inactivity, falls (49% drop), fractures, muscle weakness# </li></ul><ul><li>Eliminates the need for Ca supplements: population Ca supplementation unnecessary </li></ul><ul><ul><ul><ul><ul><li>* Deluca HF, Cantorna MT. Vitamin D: its role and uses in immunology. Faseb J 2001; 15:2579-85 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr 2003; 89:552-572 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li># VanAmerongen BM, Dijkstra CD, Lips P, Polman CH. Multiple sclerosis and vitamin D: an update. Eur J Clin Nutr 2004 </li></ul></ul></ul></ul></ul>
  23. 24. How to get adequate vitamin D <ul><li>Diet alone not enough </li></ul><ul><li>Simplest and cheapest is adequate sunlight </li></ul><ul><li>Probably also helpful in other ways besides vitamin D (melatonin, etc) </li></ul><ul><li>Supplements </li></ul>
  24. 25. Recommendations: sunlight <ul><li>10-15mins sunlight all over (in speedos) </li></ul><ul><li>3-5 times a week </li></ul><ul><li>More in winter, less in summer </li></ul><ul><li>Get it while exercising if too cold </li></ul><ul><ul><li>Blocked by glass </li></ul></ul><ul><ul><li>Passes through water </li></ul></ul>
  25. 26. Risks of adequate sunlight <ul><li>Probably none! </li></ul><ul><li>Risks are from excessive sunlight </li></ul><ul><ul><li>Various skin cancers </li></ul></ul><ul><ul><li>But, for every melanoma prevented by sun avoidance we incur about 6.6 internal cancers* </li></ul></ul><ul><ul><li>Adequate Vit D probably prevents melanoma# </li></ul></ul><ul><ul><ul><ul><ul><li>* Grant WB. Ecologic studies of solar UV-B radiation and cancer mortality rates. Recent Results Cancer Res 2003; 164:371-7 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li># Garland FC, White MR, Garland CF, Shaw E, Gorham ED. Occupational sunlight exposure and melanoma in the U.S. Navy. Arch Environ Health 1990; 45:261-7 </li></ul></ul></ul></ul></ul>
  26. 27. bom.gov.au
  27. 28. May 2005 ANZ osteoporosis recommendations for sun exposure <ul><li>Melbourne summer: ‘6-8min of sun at 10am or 2pm on hands, face and arms’* </li></ul><ul><li>Melbourne winter: ‘25mins of sun at midday on hands, face and arms’* </li></ul><ul><ul><li>Very similar to mine except only 15% of body exposed: 6-7 times the dose with mine for optimal effect: clearly considered safe exposure </li></ul></ul><ul><ul><ul><ul><ul><li>* ANZ Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia. Vitamin D and adult bone health in Australia and New Zealand: a position statement. Med J Aust 2005;182:281-5 </li></ul></ul></ul></ul></ul>
  28. 29. Recommendations: supplements <ul><li>4 000IU per day if no sun </li></ul><ul><li>Up to 10 000IU per day </li></ul><ul><li>Single megadose if levels low is very safe </li></ul><ul><ul><li>Up to half a million units if severe </li></ul></ul><ul><ul><ul><li>Single dose of 600 000IU raised levels to 73nmol/L for people with levels <12.5nmol/L* </li></ul></ul></ul><ul><ul><ul><ul><ul><li>* Diamond TH, Ho KW, Rohl PG, Meerkin M. Annual IM injection of a megadose of cholecalciferol for treatment of vitamin D deficiency. Med J Aust 2005;183:10-12 </li></ul></ul></ul></ul></ul>
  29. 30. Getting the supplements <ul><li>Vitamin D3 unavailable in Australia </li></ul><ul><li>Don’t try to get it from cod liver oil (vitamin A toxicity) </li></ul><ul><li>Ostelin R 1 000IU available on prescription but vitamin D2 (synthetic), doesn’t work as well as D3 </li></ul><ul><li>Try www.healthau.com for 5000IU capsule </li></ul>
  30. 31. Final recommendation <ul><li>Enjoy your time in the sun! </li></ul>

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