Vitamin D and sun protection: The impact of mixed public health messages in Australia

Benefits and Risks of Sun Exposure to Maintain Adequate Vitamin D Levels

Vitamin D is a hormone that can be generated in the skin upon ultraviolet light exposure or ingested through supplementation. Vitamin D deficiency may have numerous deleterious effects on health. Sun avoidance strategies should be avoided due to the unwanted health risks associated with hypovitaminosis D. We present an objective investigation of the benefits and risks of using sun exposure to increase vitamin D levels and how it impacts human health. A review of the literature was conducted using Embase and PubMed to examine the relationship between UV exposure, vitamin D levels, health benefits, and risks. UV exposure is the primary method of boosting serum vitamin D levels, which accounts for numerous health benefits. Higher levels of vitamin D are associated with protection against cancer development, including melanoma. Latitude, season, skin color, and sun protection determine UV absorption and vitamin D production. Public health sun protection guidelines decrease the incidence of skin cancer, but sun avoidance can cause hypovitaminosis D. Serum vitamin D levels less than 16 nmol/L increase morbidity through increased non-cutaneous disease. Sun protection strategies should still be implemented to reduce skin cancer, and sunscreen only minimally lowers vitamin D production. Vitamin D deficiency can increase chronic diseases and cancer, while adequate vitamin D levels can help prevent them. UV exposure and vitamin D production are dependent on many factors. Increasing UV exposure without causing sunburn maximizes vitamin D production.

Vitamin D and Sun Exposure: A Community Survey in Australia

Sun exposure carries both harms and benefits. Exposing the skin to the sun is the main modifiable cause of skin cancers, which exert a considerable health and economic burden in Australia. The most well-established benefit of exposure to ultraviolet (UV) radiation is vitamin D production. Australia has the highest incidence of skin cancer in the world but, despite the high ambient UV radiation, approximately one quarter of the population is estimated to be vitamin D deficient. Balancing the risks and benefits is challenging and requires effective communication. We sought to provide a snapshot of public knowledge and attitudes regarding sun exposure and vitamin D and to examine the associations between these factors and sun protective behaviors. In 2020 we administered an online survey; 4824 participants with self-reported fair or medium skin color were included in this analysis. Only 25% and 34% of participants were able to identify the amount of time outdoors needed to maintain adequate vitamin D status in summer and winter, respectively and 25% were concerned that sunscreen use inhibits vitamin D synthesis. This lack of knowledge was associated with suboptimal sun protection practices. Public education is warranted to prevent over-exposure, while supporting natural vitamin D production.

Attitudes, Behaviors, and Risks of Sun Protection to Prevent Skin Cancer Amongst Children, Adolescents, and Adults

Skin cancer is the most common cancer diagnosis worldwide. Many factors are involved in the development of skin cancers, but ultraviolet (UV) light exposure is the most modifiable. Our lifetime cumulative UV exposure may be a result of poor sun protection practices in childhood and adolescence. Modifying the attitudes and behaviors of children can be done in the classroom, at recreational activities, and at home. A review of the literature was conducted using Embase and PubMed to examine the relationship between attitudes and behaviors as they relate to sun protection strategies. Well-developed, standardized sun protection educational programs are needed to instruct children and adolescents. Individualized counseling from physicians or online programs is needed to help parents increase sun-safe standards for their children. Many young women utilize indoor tanning beds frequently, but many instructional programs increased their tanning bed usage. Time should be allotted at schools, sports practices, camps, and other outdoor activities for sunscreen reapplication. Many parents and children report the media is their primary source of information about sun safety. Media outlets may positively change attitudes and behaviors when reporting about sun safety. Parents and children need individualized programs or counseling to reduce ultraviolet (UV) exposure and increase sun protection. At-risk populations need tailored instruction, but few strategies have worked to decrease UV exposure.

Vitamin D-independent benefits of safe sunlight exposure

This review examines the beneficial effects of ultraviolet radiation on systemic autoimmune diseases, including multiple sclerosis and type I diabetes, where the epidemiological evidence for the vitamin D-independent effects of sunlight is most apparent. Ultraviolet radiation, in addition to its role in the synthesis of vitamin D, stimulates anti-inflammatory pathways, alters the composition of dendritic cells, T cells, and T regulatory cells, and induces nitric oxide synthase and heme oxygenase metabolic pathways, which may directly or indirectly mitigate disease progression and susceptibility. Recent work has also explored how the immune-modulating functions of ultraviolet radiation affect type II diabetes, cancer, and the current global pandemic caused by SARS-CoV-2. These diseases are particularly important amidst global changes in lifestyle that result in unhealthy eating, increased sedentary habits, and alcohol and tobacco consumption. Compelling epidemiological data shows increased ultraviolet radiation associated with reduced rates of certain cancers, such as colorectal cancer, breast cancer, non-Hodgkins lymphoma, and ultraviolet radiation exposure correlated with susceptibility and mortality rates of COVID-19. Therefore, understanding the effects of ultraviolet radiation on both vitamin D-dependent and -independent pathways is necessary to understand how they influence the course of many human diseases.

Barriers towards Sun Exposure and Strategies to Overcome These Barriers in Female Indoor Workers with Insufficient Vitamin D: A Qualitative Approach

The prevalence of vitamin D insufficiency is significant even in tropical countries such as Malaysia. Sun exposure is the primary source of vitamin D for most people due to limited intakes of food containing vitamin D and supplements. This study explored the perception of barriers towards sun exposure and strategies to overcome these barriers among vitamin D insufficient women workers in Kuala Lumpur, Malaysia. Twenty-five female indoor workers with serum 25-hydroxyvitamin D < 50 nmol/L participated in seven focus group discussions (FGDs). Barriers towards sun exposure were lack of accurate knowledge of vitamin D, health concern towards sun exposure, time constraints, desire to have fair and beautiful skin, sedentary lifestyle, indoor workplace, weather, lack of social support, living arrangement, safety concerns, and religious or cultural practices. The improvement strategies were classified into lifestyle changes and workplace opportunity for sun exposure. Public education on safe sun exposure to produce an optimal level of vitamin D is necessary. Future studies should evaluate the effectiveness of sunlight exposure program at workplace for the high-risk vitamin D deficiency group.

Pinterest Homemade Sunscreens: A Recipe for Sunburn

Social media, specifically Pinterest with more than 175 million users, has changed the way people seek and share health information. Recent consumer interest in natural products has led to an increase of shared recipes for homemade products including sunscreen. Homemade sunscreen products are risky because they are not regulated or tested for efficacy like commercial sunscreens. With rising skin cancer rates, the use of effective broadband sunscreen is critical to reduce incidence of skin cancer. This study used directed content analysis to examine how homemade sunscreens were portrayed on Pinterest. Using the search terms, homemade sunscreen and natural sunscreen, researchers sampled every fifth pin to collect 189 relevant pins. A codebook was developed, pilot tested, and used to code pins. Two researchers coded pins and interrater reliability was established at 90%. Of the 189 pins, the majority of pins (95.2%) positively portrayed the effectiveness of homemade sunscreens and 68.3% recommended recipes for homemade sunscreens that offered insufficient UV radiation protection. Sun Protection Factor (SPF) claims were made in 33.3% of pins with a range of SPF 2 to SPF 50. In this sample of pins, 41.8% of pins had been saved by other users ranging from one to more than 21,000 times. Social media is a powerful source of health information. However, this study revealed widespread interest and acceptance of insufficient sun protection information. Pinterest and the interest in homemade recipes for sunscreen present an opportunity for public health professionals to proactively engage on social media. Abbreviations: US: United States; SPF: sun protection factor; USFDA: United states food and drug administration; UV: ultraviolet.

Concerns about vitamin D and sun exposure behaviour among Australians

ISSUES ADDRESSED

Australians' concerns about vitamin D and influence on sun protection were last quantified a decade ago in Queensland amidst media attention on emerging evidence of non-skeletal benefits of vitamin D. Meanwhile these circumstances persist and impact is worth assessing.

METHODS

Measures of concern about vitamin D were included in three recent population-based cross-sectional surveys of Australians' sun-related behaviours during summer months (2010-2011, 2013-2014 and 2016-2017). We analysed characteristics, beliefs and behaviours associated with vitamin D concerns regarding regular sunscreen use among adults in 2016-2017 (N = 3614).

RESULTS

Concerns about vitamin D continued to persist among adults surveyed between 2010-2011 and 2016-2017. Vitamin D concerns regarding the sunscreen use were more common among women, older respondents and adults with skin that tans or is not susceptible to sunburn. Respondents concerned about vitamin D were more likely to exhibit pro-tanning beliefs, scepticism about sunscreen safety and have attempted a suntan. They were also less likely to use sun protection in everyday activities outdoors and less likely to use sunscreen on summer weekends.

CONCLUSIONS

Vitamin D concerns related to sunscreen use remained common among Australian adults. Skin cancer control advocates may be reassured that those with the greatest skin cancer risk (burn only) were less likely to hold these concerns, while the related infrequent sun protection and tanning among concerned adults are problematic. SO WHAT?: Continued education and research is needed to ensure that the general public understand the risks and benefits of sun exposure in Australia.

Tanning benefits, seasonal effects, and concerns about sunscreen: Measuring health beliefs about UV among college students

Objective: To develop and validate a scale measuring health beliefs about UV in cloudy climates that may impact UV exposure behaviors. Participants: Students at a large university in Oregon completed pilot (N = 115) and final (N = 335) scales online March-July, 2016. Five participants underwent cognitive interviews. Methods: Expert feedback, cognitive interviews, and pilot data guided item development and refinement. We conducted factor analysis and invariance testing. Results: The final four-factor model fit well (χ² = 37.97, df = 37, RMSEA = 0.000, CFI = 1.000). HBAU subscales are Sunscreen Toxicity, Seasonal Effects, Health Benefits of Tanning, and Tanning Through the Winter. Invariance testing supported strong invariance across sex and tanning status. Conclusion: The HBAU measures beliefs that encourage UV exposure and discourage protection (eg, the belief that sunscreen ingredients are toxic). This scale will enable more comprehensive measurement of cognitive predictors of UV exposure for student health, clinical, and research purposes.

Relationship Between the ApaI (rs7975232), BsmI (rs1544410), FokI (rs2228570), and TaqI (rs731236) Variants in the Vitamin D Receptor Gene and Urolithiasis Susceptibility: An Updated Meta-Analysis and Trial Sequential Analysis

The relationship between urolithiasis and vitamin D receptor (VDR) gene variants is still under debate according to the available published literature. To assess correlations between VDR gene variants ApaI (rs7975232), BsmI (rs1544410), FokI (rs2228570), and TaqI (rs731236) and urolithiasis susceptibility, we performed the present study through meta-analysis. The PubMed, Cochrane Library, China National Knowledge Infrastructure, EMBASE, Web of Science, and Wanfang databases were searched to retrieve qualified case-control studies. Finally, 31 reports were selected for the present meta-analysis. The results demonstrated that the VDR gene TaqI TT genotype was related to decreased risk of urolithiasis in the overall population (TT vs. Tt+tt: P = 0.011, OR = 0.824, 95% CI = 0.709–0.957). In ethnicity subgroup analysis, we found that the TaqI variant was obviously correlated to urolithiasis risk among Asians and Caucasians (P < 0.05). Additionally, significant urolithiasis risk was identified in adults. However, the FokI, BsmI, and ApaI variants did not have an increased risk of developing urolithiasis. Trial sequential analysis results were on a sufficiently large number of participants and did not require more research to confirm associations. Our research suggested that the VDR gene variant TaqI was correlated with urolithiasis susceptibility and that the t-allele might be the risk gene and T-allele the protective gene in VDR TaqI variant.

Genetic, environmental and biomarker considerations delineating the regulatory effects of vitamin D on central nervous system function

Studies show that vitamin D (vit-D) (25(OH)D), the bioactive metabolite (1,25(OH)2D3) and vit-D receptors (vit-D receptor; protein disulphide isomerase, family A member 3) are expressed throughout the brain, particularly in regions pivotal to learning and memory. This has led to the paradigm that avoiding vit-D deficiency is important to preserve cognitive function. However, presently, it is not clear if the common clinical measure of serum 25(OH)D serves as a robust surrogate marker for central nervous system (CNS) homeostasis or function. Indeed, recent studies report CNS biosynthesis of endogenous 25(OH)D, the CNS expression of the CYP group of enzymes which catalyse conversion to 1,25(OH)2D3 and thereafter, deactivation. Moreover, in the periphery, there is significant ethnic/genetic heterogeneity in vit-D conversion to 1,25(OH)2D3 and there is a paucity of studies which have actually investigated vit-D kinetics across the cerebrovasculature. Compared with peripheral organs, the CNS also has differential expression of receptors that trigger cellular response to 1,25(OH)2D3 metabolites. To holistically consider the putative association of peripheral (blood) abundance of 25(OH)D on cognitive function, herein, we have reviewed population and genetic studies, pre-clinical and clinical intervention studies and moreover have considered potential confounders of vit-D analysis.

Health Beliefs About UV and Skin Cancer Risk Behaviors

Our purpose was to examine the beliefs of college students about UV exposure and sunscreen use and their associations with skin cancer risk and protective behaviors in a cloudy climate. The sample was online survey participants (N = 334) recruited from a large university in Oregon. After fitting an initial measurement model, we fit a structural equation model including Health Beliefs About UV (HBAU) subscales (Health Benefits of Tanning, Seasonal Effects, Tanning Through the Winter, and Sunscreen Toxicity), outcome variables (sunscreen use, indoor tanning, and outdoor tanning), and covariates (eg, tanning and sunscreen use). A minority of participants held the beliefs represented by 3 HBAU subscales, but beliefs about negative health effects of the local weather (Tanning Through the Winter) were common. The measurement and adjusted models provided good fit to the data (χ2 = 143.30; P = .29; df = 136; Root-Mean Square Error of Approximation = .014; Comparative Fit Index = .992; Tucker-Lewis Index = .981). After adjusting for covariates, Sunscreen Toxicity predicted reduced sunscreen use (β = -.12, P = .021), Health Benefits of Tanning predicted outdoor tanning (β = .43, P < .001), and Tanning Through the Winter predicted indoor tanning (β = .31, P = .02). The small sample size, nonresponse rate, and cross-sectional nature of this study mean these findings should be interpreted cautiously. Beliefs about health benefits of sun exposure, the regional weather, and sunscreen safety play a role in skin cancer risk and protective behaviors.

Determinants of Plasma 25-Hydroxyvitamin D Concentrations among Breast Cancer Survivors in Korea

We identified demographic, lifestyle, and clinical factors associated with vitamin D status among breast cancer survivors. The vitamin D prediction model may be a useful surrogate of circulating 25-hydroxvitamin D (25(OH)D) concentrations when this measure was not available. We included a total of 216 Korean breast cancer survivors aged 21–79 years who had been diagnosed with stage I to III primary breast cancer and had breast cancer surgery at least 6 months before enrolment. We used linear and logistic regressions to identify determinants for the plasma 25(OH)D concentrations and vitamin D insufficiency (plasma 25(OH)D concentration < 50 nmol/L). We observed that 48.85% of breast cancer survivors had a plasma 25(OH)D concentration less than 50 nmol/L. We identified the following determinants for plasma 25(OH)D concentrations: time since diagnosis (β = −0.005 for 1 month increment), supplementary vitamin D intake (β = 0.06 for 10 μg/day increment), season of the blood draw (β = 0.35 for summer; β = 0.32 for fall; β = 0.26 for winter vs. spring), smoking status (β = 0.28 for former vs. never), use of any supplement (β = −0.35 for non-use vs. use), and the parity number (β = −0.30 for three or more vs. one) were associated with the plasma 25(OH)D concentrations. In addition to the aforementioned variables, body mass index (BMI) was associated with the prevalence of vitamin D insufficiency. We identified the determinants for the plasma 25(OH)D concentrations among Korean breast cancer survivors. Future studies are needed to investigate the role of vitamin D in the progression of breast cancer among Korean breast cancer survivors.

Knowledge, awareness, attitudes and sources of vitamin D deficiency and sufficiency in Saudi children

OBJECTIVES

To examine the awareness, knowledge, and attitudes regarding vitamin D and its sources among Saudi Arabian children. 

METHODS

One hundred patients (vitamin D-deficient children) and 100 healthy children participated in the study. Participants were interviewed separately on topics including their awareness, knowledge, and attitudes regarding vitamin D using multiple-choice, and short-answer questions. This prospective, cross-sectional study was performed on children and adolescents between January 2011 and December 2011 at the Security Forces Hospital, Riyadh, Saudi Arabia. 

RESULTS

Only 28% were aware of the sources of vitamin D, while 64% of healthy subjects were aware. Similarly, only 50% of patients and their parents knew of the health benefits of vitamin D, while 70% of healthy subjects had knowledge. Hence, our findings agree with previous findings that low levels of awareness and knowledge regarding vitamin D and its sources persist.  

CONCLUSION

Most vitamin D deficient cases were unaware of vitamin D sources. However, half of the patient/parents were aware of benefits of vitamin D. Hence, we recommend that an improved campaign for awareness, knowledge, and attitudes regarding vitamin D and its sources are needed.

The association between beliefs about vitamin D and skin cancer risk-related behaviors

Major health organizations recommend obtaining most of one's vitamin D through dietary sources rather than from sun exposure, given the link between sun exposure and increased skin cancer risk. The purpose of this study is to examine the association between beliefs about vitamin D and skin cancer risk-related behaviors, a topic on which research is limited. We analyzed cross-sectional online survey data collected in the summer of 2015 from 4127U.S. adults aged 18years and older. Overall, 19.7% of adults believed that sun protection would put them at risk of not getting enough vitamin D. However, less than half (43.1%) thought they could get enough vitamin D from dietary sources. Individuals with this belief were more likely to protect their skin when spending time outdoors (71.3%) compared with those who were neutral or disagreed (56.5%; P<0.001). Only 5.1% of adults believed that indoor tanning is an effective way to get vitamin D. Compared to those who disagreed or were neutral, those who thought it was effective were more likely to be outdoor tanners (45.1% vs. 28.5%; P<0.001) and indoor tanners (13.8% vs 1.9%; P<0.001). Beliefs about vitamin D were associated with skin cancer risk-related behaviors. Including information about vitamin D in skin cancer prevention messages may be beneficial.

Epidemic of Vitamin D Deficiency and Its Management: Awareness among Indian Medical Undergraduates

Vitamin D deficiency is prevalent across all age groups in epidemic proportions. The purpose of this study was to acquire a baseline assessment and create awareness among medical students regarding vitamin D. A cross-sectional, voluntary survey was conducted among undergraduate medical students. Data were collected using a questionnaire which assessed the level of knowledge students had with regard to where vitamin D comes from, what it does for health, how much is recommended, factors that affect its levels, and deficiency management. Majority of students were unaware that vitamin D deficiency has attained epidemic proportions. Though bone and skeletal disorders as a complication of vitamin D deficiency were known, a large number were unaware of systemic consequences (diabetes mellitus, cardiovascular diseases, and cancers). Only one-third of respondents were aware of duration and timing of sun exposure required for adequate serum vitamin D levels. However, we observed lack of awareness among students regarding the various biochemical forms, dose, and duration of vitamin D supplementation for treatment of nutritional deficiency. Our study highlighted a lack of knowledge about the importance of vitamin D, worldwide prevalence of vitamin D deficiency, and its management among medical students. Promoting vitamin D health awareness, if replicated across populations, could lead to positive health outcomes globally.

What Do People Know and Believe about Vitamin D?

People have been exposed to a lot of information regarding vitamin D, with evidence suggesting that vitamin D may be involved in numerous health conditions, subsequently creating concerns about vitamin D insufficiency. As a result, what do people really know or believe about this topic? In this cross-sectional study, we assessed vitamin D-related knowledge and beliefs in 59,273 French adults (NutriNet-Santé cohort) using a specific questionnaire. Answers to this questionnaire were weighted according to the French sociodemographic distribution and compared across individual characteristics, using χ²-tests. Physicians and media were identified as key information providers. Participants did not always accurately cite vitamin D sources (e.g., 72% only for sun exposure, fatty fish: 61%) or established health effects (e.g., bone health: 62%–78%). Conversely, they mentioned incorrect sources and health effects for which there is no consensus yet (e.g., skin cancer). These findings were modulated by age/generational and socioeconomic factors. A strong inconsistency was also observed between participants’ true vitamin D status (plasma 25-hydroxyvitamin D concentration) and their opinion about it. This study, the first in Europe with such a large sample, stresses the need for simple and up-to-date supports of communication for the public and healthcare professionals regarding sources and health effects of vitamin D.

Self-Reported Changes in Sun-Protection Behaviors at Different Latitudes in Australia

Sun exposure is the most important source of vitamin D, but is also a risk factor for skin cancer. This study investigated attitudes toward vitamin D, and changes in sun-exposure behavior due to concern about adequate vitamin D. Participants (n = 1002) were recruited from four regions of Australia and completed self- and interviewer-administered surveys. Chi-square tests were used to assess associations between participants' latitude of residence, vitamin D-related attitudes and changes in sun-exposure behaviors during the last summer. Multivariate logistic regression analyses were used to model the association between attitudes and behaviors. Overall, people who worried about their vitamin D status were more likely to have altered sun protection and spent more time in the sun people not concerned about vitamin D. Concern about vitamin D was also more common with increasing latitude. Use of novel item response theory analysis highlighted the potential impact of self-reported behavior change on skin cancer predisposition due concern to vitamin. This cross-sectional study shows that the strongest determinants of self-reported sun-protection behavior changes due to concerns about vitamin D were attitudes and location, with people at higher latitudes worrying more.

Skin Cancer Prevention, Tanning and Vitamin D: A Content Analysis of Print Media in Germany and Switzerland

BACKGROUND

Print media are a major source of health information.

OBJECTIVES

To analyse press coverage related to skin cancer prevention.

METHODS

We conducted a content analysis of print media articles pertaining to skin cancer prevention, solaria and vitamin D published in Germany and Switzerland over a 1-year period between 2012 and 2013.

RESULTS

Overall, 2,103 articles were analysed. Applying sunscreen was by far the most common sun protection recommendation. A considerable number of articles on solaria and vitamin D advocated exposure to ultraviolet radiation to enhance physical appearance and vitamin D photosynthesis, often without mentioning any precaution measures. In total, 26.8% of the articles contained misleading or erroneous statements mostly related to sunscreen use and vitamin D issues.

CONCLUSIONS

Print media can serve as powerful education tools to foster skin cancer prevention. However, misleading or erroneous reports may negatively impact sun-safe behaviour.

Comparing the effects of sun exposure and vitamin D supplementation on vitamin D insufficiency, and immune and cardio-metabolic function: the Sun Exposure and Vitamin D Supplementation (SEDS) Study

Background

Adults living in the sunny Australian climate are at high risk of skin cancer, but vitamin D deficiency (defined here as a serum 25-hydroxyvitamin D (25(OH)D) concentration of less than 50 nmol/L) is also common. Vitamin D deficiency may be a risk factor for a range of diseases. However, the optimal strategies to achieve and maintain vitamin D adequacy (sun exposure, vitamin D supplementation or both), and whether sun exposure itself has benefits over and above initiating synthesis of vitamin D, remain unclear.

The Sun Exposure and Vitamin D Supplementation (SEDS) Study aims to compare the effectiveness of sun exposure and vitamin D supplementation for the management of vitamin D insufficiency, and to test whether these management strategies differentially affect markers of immune and cardio-metabolic function.

Methods/Design

The SEDS Study is a multi-centre, randomised controlled trial of two different daily doses of vitamin D supplementation, and placebo, in conjunction with guidance on two different patterns of sun exposure. Participants recruited from across Australia are aged 18–64 years and have a recent vitamin D test result showing a serum 25(OH)D level of 40–60 nmol/L.

Discussion

This paper discusses the rationale behind the study design, and considers the challenges but necessity of data collection within a non-institutionalised adult population, in order to address the study aims. We also discuss the challenges of participant recruitment and retention, ongoing engagement of referring medical practitioners and address issues of compliance and participant retention.

Trial registration

Australia New Zealand Clinical Trials Registry: ACTRN12613000290796 Registered 14 March 2013.

Think UV, not heat!

BACKGROUND

Australia has the highest incidence of skin cancer in the world, a preventable disease caused primarily by exposure to ultraviolet radiation (UVR) in sunlight. Health promotion strategies play a significant role in sun protection.

OBJECTIVES

To assess the understanding of a population sample as to the time of year that the sun was 'at its most burning' in Melbourne, Australia.

METHODS

A cross-sectional study was performed using questionnaires completed at corporate skin checks, conducted on 668 participants during 2011 to 2013.

RESULTS

Only a minority (n = 82, 12%) gave the correct theoretical answer; the summer solstice or 21-22 December, while another 38% (n = 254) correctly named December and January as the times when the UVR is actually highest. In all, 18% (n = 122) said February was the month when the temperature is hottest and 170 (25%) either mentioned the period May-August when UVR is negligible in Melbourne or had no idea, including saying 'all year round'. There was no significant difference in this knowledge between different age groups.

CONCLUSION

One-quarter of participants did not understand that sunburn was related to high levels of UVR, which occur in summer. Almost one-fifth associated the heat of February with the highest UVR. Understanding these concepts is important for Australians residing in cooler parts of southern Australia, as UVR levels may be high and yet the temperature may be relatively cool. There needs to be more emphasis on UVR in sun awareness campaigns to prompt sun-protective behaviour.

Inflammation and vitamin D: the infection connection

INTRODUCTION

Inflammation is believed to be a contributing factor to many chronic diseases. The influence of vitamin D deficiency on inflammation is being explored but studies have not demonstrated a causative effect.

METHODS

Low serum 25(OH)D is also found in healthy persons exposed to adequate sunlight. Despite increased vitamin D supplementation inflammatory diseases are increasing. The current method of determining vitamin D status may be at fault. The level of 25(OH)D does not always reflect the level of 1,25(OH)2D. Assessment of both metabolites often reveals elevated 1,25(OH)2D, indicating abnormal vitamin D endocrine function.

FINDINGS

This article reviews vitamin D's influence on the immune system, examines the myths regarding vitamin D photosynthesis, discusses ways to accurately assess vitamin D status, describes the risks of supplementation, explains the effect of persistent infection on vitamin D metabolism and presents a novel immunotherapy which provides evidence of an infection connection to inflammation.

CONCLUSION

Some authorities now believe that low 25(OH)D is a consequence of chronic inflammation rather than the cause. Research points to a bacterial etiology pathogenesis for an inflammatory disease process which results in high 1,25(OH)2D and low 25(OH)D. Immunotherapy, directed at eradicating persistent intracellular pathogens, corrects dysregulated vitamin D metabolism and resolves inflammatory symptoms.

Knowledge and attitudes to vitamin D and sun exposure in elite New Zealand athletes: a cross-sectional study

Background

Sun safety and vitamin D status are important for prolonged health. They are of particular interest to those working with athletes for whom for whom safe sun practices maybe limited.

The aim of this cross-sectional study was to describe the attitudes of elite New Zealand athletes to both vitamin D and sun exposure.

Methods

110 elite New Zealand outdoor athletes volunteered to participate in an interview with a trained interviewer. The interviewer asked the athletes questions on their Vitamin D knowledge, attitudes and practices regarding sun exposure as well as their concerns about skin cancer.

Results

Athletes were more concerned about their risk of skin cancer (66%) than their vitamin D status (6%). Although the majority (97%) were aware of Vitamin D and could identify the sun as a source (76%) only 17% could name another source of Vitamin D.

Only 10 (9%) reported always applying sunscreen before going out in the sun. No athlete reported reapplying sunscreen every hour and 25 suggesting that they never reapply sunscreen.

Conclusions

Athletes are concerned about skin cancer however, their use of sunscreen is not optimal suggesting reapplication of sunscreen could be targeted in order to reduce the risk of sun cancer. Awareness of sources of Vitamin D other than the sun may also need to be improved potentially through educational interventions and possibly in conjunction with sun smart messages.

Changes in coverage of sun protection in the news: threats and opportunities from emerging issues

This study aimed to determine whether there have been shifts in news coverage of sun protection issues over a 12-year period in the context of an evolving skin cancer prevention agenda. A content analysis was performed on all relevant articles (N = 552) published in the two metropolitan daily newspapers in Melbourne, Australia, from 2001 to 2012. Coding variables included theme, article type, prominence, spokesperson and topic slant. Articles were collapsed into three 4-year blocks and a series of chi-square analyses conducted to examine changes over time in coverage of topical issues (i.e. vitamin D and sunbeds) and established sun protection themes [i.e. health effects of ultraviolet (UV) exposure, education/prevention, attitudes/behaviour]. Coverage of vitamin D and sunbed issues increased over time and became more positive for sun protection objectives. The proportion of articles reporting on established sun protection themes remained steady over time (range: 36-38%) and there were no changes observed in the way these topics were presented in the news media. These results highlight that potentially competing sun protection issues that emerge over time need not pose a threat to existing skin cancer prevention programmes but instead can provide opportunities to further spread programme messages while increasing credibility.

The influence of sun exposure in childhood and adolescence on atopic disease at adolescence

BACKGROUND

It has been postulated that ultraviolet ray exposure in childhood might influence the development of allergic disease. We examined whether reported sun exposure during childhood or in adolescence is related to the occurrence of atopy or allergic disease.

METHODS

Population-based longitudinal cohort study with sixteen-year follow-up (N = 415). Subjects were recruited at birth as part of an infant health study. The reported daily duration of sun exposure in the summer months was recorded at 8 and 16 yrs of age. Allergen sensitization and the presence of eczema, asthma, and rye grass positive rhinitis were recorded at age 16.

RESULTS

Reported sun exposures of more than 4 h per day during summer holidays in adolescence were associated with reduced eczema and rhinitis but not inhalant allergen sensitization or asthma risk. Thus, higher sun exposure during summer holidays and summer weekends in adolescence was associated with significantly reduced eczema (test of trend p-value = 0.001 summer holidays; test of trend p-value = 0.003 summer weekends) and rye grass positive rhinitis (test of trend p-value = 0.03 summer holidays; test of trend p-value = 0.02 summer weekends). Sun exposure at adolescence or age 8 was not related to inhalant allergen sensitization. There was no association between serum 25(OH)D levels at adolescence with either inhalant allergen sensitization or allergic disease and adjustment for serum 25(OH)D levels did not alter these findings.

CONCLUSIONS

Increased sun exposure during summer holidays in adolescence was associated with reduced eczema and rhinitis risk, independently of measured vitamin D levels but no difference in inhalant allergen sensitization or asthma. The beneficial effects of sun exposure on allergic disease may operate independently from vitamin D or an effect on allergen sensitization.

Trends in North American newspaper reporting of brain injury in ice hockey

The frequency and potential long-term effects of sport-related traumatic brain injuries (TBI) make it a major public health concern. The culture within contact sports, such as ice hockey, encourages aggression that puts youth at risk of TBI such as concussion. Newspaper reports play an important role in conveying and shaping the culture around health-related behaviors. We qualitatively studied reports about sport-related TBI in four major North American newspapers over the last quarter-century. We used the grounded-theory approach to identify major themes and then did a content analysis to compare the frequency of key themes between 1998–2000 and 2009–2011. The major themes were: perceptions of brain injury, aggression, equipment, rules and regulations, and youth hockey. Across the full study period, newspaper articles from Canada and America portrayed violence and aggression that leads to TBI both as integral to hockey and as an unavoidable risk associated with playing the game. They also condemned violence in ice hockey, criticized the administrative response to TBI, and recognized the significance of TBI. In Canada, aggression was reported more often recently and there was a distinctive shift in portraying protective equipment as a solution to TBI in earlier years to a potential contributing factor to TBI later in the study period. American newspapers gave a greater attention to ‘perception of risks’ and the role of protective equipment, and discussed TBI in a broader context in the recent time period. Newspapers from both countries showed similar recent trends in regards to a need for rule changes to curb youth sport-related TBI. This study provides a rich description of the reporting around TBI in contact sport. Understanding this reporting is important for evaluating whether the dangers of sport-related TBI are being appropriately communicated by the media.

Changing the risky beliefs of post-partum women about therapeutic sun-exposure

BACKGROUND

Many post-partum women hold risky beliefs about perceived therapeutic benefits of sun-exposure in the post-partum period and infancy.

QUESTION

Can a maternity hospital based educational intervention reduce the prevalence of such beliefs among post-partum women?

METHODS

In this outcome evaluation of an interventional study, two groups of healthy post-partum women (hospital inpatients) were interviewed, 1-4 days following delivery. The first cross-section (106 women) was recruited prior to in-services for maternity staff; the second (203 women) was recruited after completion of the in-services. Data were compared between the groups.

FINDINGS

More pre-intervention than post-intervention women reported they would expose their baby to sunlight to treat suspected jaundice (28.8% vs. 13.3%; p<0.001) or help his/her skin adapt to the sun (10.5% vs. 2.5%; p=0.003); or use sunlight to manage breastfeeding-associated sore/cracked nipples (7.6% vs. 2%; p=0.026).

CONCLUSION

This simple, effective educational intervention could be implemented in programmes for parents, health professionals and students.

The ABC of vitamin D: a qualitative study of the knowledge and attitudes regarding vitamin D deficiency amongst selected population groups

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.

Agenda-setting effects of sun-related news coverage on public attitudes and beliefs about tanning and skin cancer

The topics and framing of news stories relevant to skin cancer prevention have shifted over time. This study examined agenda-setting effects of such news stories on public attitudes and beliefs about tanning and skin cancer. Content analysis data on 516 articles published in two major daily newspapers in Melbourne, Australia, from 1994 to 2007 were combined with circulation data to generate indices of potential news exposure. Associations between these indices and cross-sectional telephone survey data from the same period on 6,244 adults' tanning attitudes and perceived susceptibility to skin cancer were examined using logistic regression models, accounting for the temporal precedence of news content. Pro-sun protection stories on attitudes and behavior were associated with older adults not thinking a tan looks healthy. Pro-sun protection stories on solaria were associated with less preference for a deep tan among young adults who like to suntan. Stories on vitamin D that were unsupportive of or ambiguous about sun protection were associated with a number of pro-tan attitudes among younger adults. Results indicate news coverage during 1994-2007 served an important agenda-setting role in explaining the public's attitudes and beliefs about tanning and skin cancer. Vitamin D stories appeared most influential, particularly among young adults.

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

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.

Identifying critical sun-protective beliefs among Australian adults

We investigated critical beliefs to target in interventions aimed at improving sun-protective behaviours of Australian adults, a population at risk for skin cancer. Participants (N = 816) completed a Theory of Planned Behaviour belief-based questionnaire and a 1-week follow-up of sun-protective behaviour. A range of behavioural, normative and control beliefs correlated with sun-protective behaviour, with no and only minimal differences observed in correlations between beliefs and behaviour by gender and age, respectively. A range of key beliefs made independent contributions to behaviour; however, the behavioural belief about being less likely to tan (β = 0.09); normative belief about friends (β = 0.20); and control beliefs about forgetfulness (β = -0.14), inconvenience (β = -0.17), knowing I will be in the sun for a long time (β = 0.16) and more fashionable sun-protective clothing (β = 0.13) were significant critical beliefs guiding people's sun-protective behaviour. Our study fills a gap in the literature by investigating an at-risk population for skin cancer and using an established theoretical framework to identify critical beliefs that guide Australian adults' decisions to sun protect. Attention to these critical beliefs will assist health campaigns and interventions aimed at combating the increasing rates of skin cancer for adults.

Sun protection and vitamin D status in an Australian subtropical community

OBJECTIVE

Claims have been made that sun protection may negatively affect vitamin D status, but very few data are available about whether this applies to people in uncontrolled settings.

METHOD

In 1996 we measured 25(OH)-vitamin D concentrations in 1113 adults in Nambour, a subtropical community, who reported their concurrent sun protection behaviours in a skin cancer prevention trial. Estimates were adjusted for time outdoors, vitamin D intake and other factors known to affect vitamin D status.

RESULTS

Persons who tended to stay in the shade had lower vitamin D levels than those who never stayed in the shade (62.5 vs. 68.8 nmol/L respectively, p=0.01), and this association remained in persons who spent less than 50% (p=0.02) but not in those who spent more than 50% of their time outdoors. Wearing a hat, long sleeves, sunglasses and use of sunscreen or umbrella were not associated with vitamin D status after adjustments, including after stratification by time outdoors.

CONCLUSION

Sun protection behaviour to reduce the risk of skin cancer can be maintained without affecting vitamin D serum status, although consistently seeking shade when spending less than 50% of daytime outdoors is associated with lower vitamin D levels.

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.

Sun-seeking behavior to increase cutaneous vitamin D synthesis: when prevention messages conflict

OBJECTIVES

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.

METHODS

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).

RESULTS

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.

CONCLUSION

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.

Prescribing sunshine: a cross-sectional survey of 500 Australian general practitioners' practices and attitudes about vitamin D

This study aimed to assess the attitudes, practices and knowledge of general practitioners (GPs) with regards to vitamin D. A cross-sectional survey of a random sample of GPs stratified by location of practice (rural/remote or metropolitan) and employment status (full-time or part-time) in New South Wales (NSW), Australia was conducted. Of 500 respondents, 58.1% (95% CI 53.8-62.4) reported that up to 39% of their tested patients showed vitamin D deficiency or insufficiency and a further 37.7% (95% CI 33.5-41.9) of respondents said that over 40% of their patients were vitamin D insufficient. Vitamin D supplementation and advice to receive more natural sunlight were the most common ways vitamin D insufficiency was managed (97.1%; 95% CI 95.6-98.6 and 82%, 95% CI 78.6-85.4, respectively). Some gaps in knowledge were identified. Most respondents (64%; 95% CI 59.8-68.2) believed that a person of average sun sensitivity required 10 min of direct sun exposure during summer in peak UV time and a further 21.6% (95% CI 18.0-25.2) believed that people required 30 min of direct sun. A third of respondents (33.1%; 95% CI 29.0-37.2) advised their patients to use sun protection at all times during winter. In general, the attitude items showed that respondents expressed greater concern about vitamin D deficiency than skin cancer. The results reveal some confusion in general practice regarding vitamin D, sun exposure, sun protection and skin cancer risk. Some of the advice that GPs are offering may needlessly increase their patients' risk for vitamin D insufficiency or skin cancer.

Vitamin D status of adults from tropical Australia determined using two different laboratory assays: implications for public health messages

We measured serum 25 hydroxyvitamin D [25(OH)D] levels of ambulatory adults in tropical Australia to determine whether it is appropriate to continue promoting sun-safety in this population. In August 2006 (winter), self-administered questionnaires were completed by 145 Meals-on-Wheels volunteers (49.3% male; mean age 57.8 ± 14.7 years; 76.6% response) from Townsville, Queensland (Latitude 19(o) S). Serum 25(OH)D was analyzed using two common assays. Mean levels were 68.3 (SD ± 18.7; range 26-142) by DiaSorin Radioimmunoassay and 83.0 (SD ± 30.8; range 30-184) by DiaSorin Liaison® one. No participants were 25(OH)D deficient (<25 nmol L(-1)). Nine participants (6.2%) had 25(OH)D levels between 25 and 50 nmol L(-1) (insufficient), by both methods (seven with a BMI ≥ 25). Twenty-eight participants (19.3%) had one result in the insufficient range and the other in the adequate range. Thus, almost all of these free-living adults in tropical Australia had adequate vitamin D levels at the end of winter. There was poor agreement between the two 25(OH)D assays. These results suggest it is appropriate to continue promoting sun-safe messages to the ambulatory Caucasian adult population of North Queensland, which has an extremely high incidence of skin cancer. The lack of agreement between the two assays is a concern. Few doctors are aware of this measurement issue.

The human health effects of ozone depletion and interactions with climate change

Depletion of the stratospheric ozone layer has led to increased solar UV-B radiation (280-315 nm) at the surface of the Earth. This change is likely to have had an impact on human exposure to UV-B radiation with consequential detrimental and beneficial effects on health, although behavioural changes in society over the past 60 years or so with regard to sun exposure are of considerable importance. The present report concentrates on information published since our previous report in 2007. The adverse effects of UV radiation are primarily on the eye and the skin. While solar UV radiation is a recognised risk factor for some types of cataract and for pterygium, the evidence is less strong, although increasing, for ocular melanoma, and is equivocal at present for age-related macular degeneration. For the skin, the most common harmful outcome is skin cancer, including melanoma and the non-melanoma skin cancers, basal cell carcinoma and squamous cell carcinoma. The incidence of all three of these tumours has risen significantly over the past five decades, particularly in people with fair skin, and is projected to continue to increase, thus posing a significant world-wide health burden. Overexposure to the sun is the major identified environmental risk factor in skin cancer, in association with various genetic risk factors and immune effects. Suppression of some aspects of immunity follows exposure to UV radiation and the consequences of this modulation for the immune control of infectious diseases, for vaccination and for tumours, are additional concerns. In a common sun allergy (polymorphic light eruption), there is an imbalance in the immune response to UV radiation, resulting in a sun-evoked rash. The major health benefit of exposure to solar UV-B radiation is the production of vitamin D. Vitamin D plays a crucial role in bone metabolism and is also implicated in protection against a wide range of diseases. Although there is some evidence supporting protective effects for a range of internal cancers, this is not yet conclusive, but strongest for colorectal cancer, at present. A role for vitamin D in protection against several autoimmune diseases has been studied, with the most convincing results to date for multiple sclerosis. Vitamin D is starting to be assessed for its protective properties against several infectious and coronary diseases. Current methods for protecting the eye and the skin from the adverse effects of solar UV radiation are evaluated, including seeking shade, wearing protective clothing and sunglasses, and using sunscreens. Newer possibilities are considered such as creams that repair UV-induced DNA damage, and substances applied topically to the skin or eaten in the diet that protect against some of the detrimental effects of sun exposure. It is difficult to provide easily understandable public health messages regarding "safe" sun exposure, so that the positive effects of vitamin D production are balanced against the negative effects of excessive exposure. The international response to ozone depletion has included the development and deployment of replacement technologies and chemicals. To date, limited evidence suggests that substitutes for the ozone-depleting substances do not have significant effects on human health. In addition to stratospheric ozone depletion, climate change is predicted to affect human health, and potential interactions between these two parameters are considered. These include altering the risk of developing skin tumours, infectious diseases and various skin diseases, in addition to altering the efficiency by which pathogenic microorganisms are inactivated in the environment.

Burden of malignancy after a primary skin cancer: recurrence, multiple skin cancers and second primary cancers

The current paper summarizes relevant recent research on the high risk of recurrence, multiple skin cancers and second primary cancers in the growing number of people with a history of skin cancer; the ultimate purpose is to better assess the burden of malignancy following skin cancer. A number of challenges exist in identifying and tracking both melanoma and non-melanoma skin cancer (NMSC) cases. Most jurisdictions do not routinely track NMSC cases and, even if they do, it is customary to only include the first diagnosis. There are variable rules for counting multiple melanoma cancers, and recurrences are not considered for either major type of skin cancer. Applying insights from recent studies of this issue to Canadian cancer statistics would increase reported diagnoses of NMSC by about 26% and melanoma by 10% in this country. This approach to a fuller assessment of the burden of skin cancers has been called a "diagnosis-based incidence approach" as compared with a "patient-based incidence approach". A further issue that is not usually taken into account when assessing the burden of skin cancers is the 20% to 30% elevated risk of noncutaneous second primary cancers following a primary skin tumour. In summary, individuals with skin cancer are subject to a high risk of recurrence, multiple skin cancers and second primary cancers. This burden should be a special concern in the large and growing pool of individuals with a history of skin cancer, as well as among prevention planners.

[Solaria, vitamin D, and skin cancer]

BACKGROUND

Some researchers have suggested to use an indoor tanning device (solarium) as a vitamin D source for disease prevention.

MATERIAL AND METHODS

The article is based on non-systematic searches in PubMed and ISI, and the authors' experience from epidemiologic research and studies of solarium irradiance.

RESULTS

Vitamin D deficiency is an established risk factor for rickets in children and osteomalacia in adults; and is associated with an increased risk of osteoporosis and fractures. Several studies have found a beneficial role of vitamin D on both incidence and prognosis for other diseases, e.g. cancer, but causal relationships with vitamin D cannot yet be concluded. Sun exposure, our main source of vitamin D, is also an established risk factor of skin cancer. Moderate sun exposure generally provides an adequate amount of vitamin D during summer. Dietary intake of vitamin D is adamant when sun exposure is low. Solarium use seems to increase. Mean irradiance from solariums is higher than that from the summer sun in Oslo; 1.5 times higher for UVB and 3.5 times for UVA . Use of solarium increases the risk of skin cancer and was classified as carcinogenic to humans in 2009; positive health effects are not sufficiently documented.

INTERPRETATION

Recommendations on restricted solarium use should be maintained.

Mass media barriers to social marketing interventions: the example of sun protection in the UK

The role of the mass media in communicating health-related information to the wider population is the focus of this paper. Using the example of sun protection within the UK, we highlight some of the major challenges to raising awareness of steadily increasing melanoma rates and of effective sun protection strategies. The implications of potential barriers to official sun protection messages via conflicting messages in the media are discussed in terms of editorial on sun protection and in the way in which television programme content portrays the issues. Implications for public policy and future research conclude the paper.

Quantification of circulating 25-hydroxyvitamin D by liquid chromatography-tandem mass spectrometry

Hypovitaminosis D is a highly prevalent condition and quantification of serum 25-hydroxyvitamin D3 is accepted to be the most useful marker for the assessment of the individual vitamin D status. Due to the increasing awareness of the prevalence and potential health consequences of hypovitaminosis D, the request numbers for 25-hydroxyvitamin D quantification are growing rapidly in many countries. Automated protein binding assays (based on the use of vitamin D-binding protein or antibodies) for the quantification of 25-hydroxyvitamin D3 are available which enable convenient high-throughput analyses in a routine setting; there is, however, substantial concern about accuracy and analytical reliability of these assays. Several LC-MS/MS methods for the quantification of 25-hydroxyvitamin D3 in serum have been described and in a growing number of clinical laboratories this technology is used routinely for vitamin D monitoring. It is justified to assume that LC-MS/MS enables more reliable analyses of 25-hydroxyvitamin D concentrations compared to protein binding assays. In particular the ability to co-quantify the naturally occurring 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2 which is derived primarily from food fortification is a relevant advantage of LC-MS/MS over protein binding assays. This review describes the background of 25-hydroxyvitamin D measurement, compares published LC-MS/MS methods, discusses problems, strengths and limitations of these assays and compares the application characteristics of LC-MS/MS with those of protein binding assays and HPLC-UV.

Knowledge and attitudes about Vitamin D and impact on sun protection practices among urban office workers in Brisbane, Australia

BACKGROUND

Sun exposure is the main source of vitamin D. Increasing scientific and media attention to the potential health benefits of sun exposure may lead to changes in sun exposure behaviors.

METHODS

To provide data that might help frame public health messages, we conducted an online survey among office workers in Brisbane, Australia, to determine knowledge and attitudes about vitamin D and associations of these with sun protection practices. Of the 4,709 people invited to participate, 2,867 (61%) completed the questionnaire. This analysis included 1,971 (69%) participants who indicated that they had heard about vitamin D.

RESULTS

Lack of knowledge about vitamin D was apparent. Eighteen percent of people were unaware of the bone benefits of vitamin D but 40% listed currently unconfirmed benefits. Over half of the participants indicated that more than 10 minutes in the sun was needed to attain enough vitamin D in summer, and 28% indicated more than 20 minutes in winter. This was significantly associated with increased time outdoors and decreased sunscreen use. People believing sun protection might cause vitamin D deficiency (11%) were less likely to be frequent sunscreen users (summer odds ratio, 0.63; 95% confidence interval, 0.52-0.75).

CONCLUSIONS

Our findings suggest that there is some confusion about sun exposure and vitamin D, and that this may result in reduced sun-protective behavior.

IMPACT

More information is needed about vitamin D production in the skin. In the interim, education campaigns need to specifically address the vitamin D issue to ensure that skin cancer incidence does not increase.

Environmental effects of ozone depletion and its interactions with climate change: progress report, 2009

The parties to the Montreal Protocol are informed by three panels of experts. One of these is the Environmental Effects Assessment Panel (EEAP), which deals with UV radiation and its effects on human health, animals, plants, biogeochemistry, air quality and materials. Since 2000, the analyses and interpretation of these effects have included interactions between UV radiation and global climate change. When considering the effects of climate change, it has become clear that processes resulting in changes in stratospheric ozone are more complex than believed previously. As a result of this, human health and environmental problems will likely be longer-lasting and more regionally variable. Like the other panels, the EEAP produces a detailed report every four years; the most recent was that for 2006 (Photochem. Photobiol. Sci., 2007, 6, 201-332). In the years in between, the EEAP produces a less detailed and shorter progress report, as is the case for this present one for 2009. A full quadrennial report will follow for 2010.