The validated sun exposure questionnaire: association of objective and subjective measures of sun exposure in a Danish population-based sample

Postoperative risk assessment of post-inflammatory hyperpigmentation and the efficacy of delayed prevention following 532 nm Q-switched Nd:YAG laser treatment of solar lentigines: a randomized controlled study

BACKGROUND

Although post-inflammatory hyperpigmentation (PIH) is a common adverse event following laser procedures, studies evaluating its risk remain limited.

OBJECTIVE

To analyze PIH risk after 532 nm Q-switched Nd:YAG laser (QSNYL) treatment for solar lentigines and examine the efficacy of triple combination cream (TCC) for its prevention.

METHODS

In this single center, investigator-blinded, randomized controlled study, participants with solar lentigo either received TCC or emollient from 2 weeks post-QSNYL treatment. The occurrence of PIH was determined by three independent and blinded dermatologists. In vivo skin measurements and sun exposure questionnaires were examined to evaluate the risk of PIH.

RESULTS

A total of 28 patients with 67 solar lentigines were included in the analysis. In the control group, PIH occurred in 55.3% of the lesions. Risk factors for the occurrence of PIH were the increased erythema at weeks 2 (OR, 1.32; p = 0.035) and outdoor activity during 1-5 pm (OR, 8.10; p = 0.038). Treatment with TCC from 2 weeks post-QSNYL treatment significantly decreased the incidence of PIH (31.0% vs. 55.3%, p = 0.048).

CONCLUSION

Post-laser erythema and outdoor activity at the daytime are prognostic factors for the occurrence of PIH. Administering TCC could be considered for the prevention of PIH in high-risk patients.

A photoaging smartphone application to promote sun safety behaviors among youth in late childhood and adolescence

BACKGROUND

Ultraviolet (UV)-exposure behaviors can directly impact an individual's skin cancer risk, with many habits formed during childhood and adolescence. We explored the utility of a photoaging smartphone application to motivate youth to improve sun safety practices.

METHODS

Participants completed a preintervention survey to gather baseline sun safety perceptions and behaviors. Participants then used a photoaging mobile application to view the projected effects of chronic UV exposure on participants' self-face image over time, followed by a postintervention survey to assess motivation to engage in future sun safety practices.

RESULTS

The study sample included 87 participants (median [interquartile (IQR)] age, 14 [11-16] years). Most participants were White (50.6%) and reported skin type that burns a little and tans easily (42.5%). Preintervention sun exposure behaviors among participants revealed that 33 (37.9%) mostly or always used sunscreen on a sunny day, 48 (55.2%) experienced at least one sunburn over the past year, 26 (30.6%) engaged in outdoor sunbathing at least once during the past year, and zero (0%) used indoor tanning beds. Non-skin of color (18 [41.9%], p = .02) and older (24 [41.4%], p = .007) participants more often agreed they felt better with a tan. Most participants agreed the intervention increased their motivation to practice sun-protective behaviors (wear sunscreen, 74 [85.1%]; wear hats, 64 [74.4%]; avoid indoor tanning, 73 [83.9%]; avoid outdoor tanning, 68 [79%]).

CONCLUSION

The findings of this cross-sectional study suggest that a photoaging smartphone application may serve as a useful tool to promote sun safety behaviors from a young age.

Stressful life events and the occurrence of skin cancer

OBJECTIVE

It is widely acknowledged that emotional states can influence skin conditions, yet limited research has delved into the impact of stress on skin cancer development. This retrospective study sought to expand the perspective on skin cancer risk factors by investigating the complex relationship between stressful life events and the incidence of skin cancer.

METHODS

The sample included 268 individuals followed-up in a dermatological clinic, in three groups: Patients who had previously been diagnosed with cutaneous melanoma and are currently in remission (32%), those who had been diagnosed with non-melanoma skin cancer (30%), and a control group who are at risk for skin cancer (38%). Participants filled in questionnaires regarding childhood and adulthood life events, and loss and gain of resources following their subjectively most stressful event in adulthood. Multinomial logistic regression was used to examine the associations of life events with skin cancer occurrence, and mediating and moderating effects of resource loss/gain.

RESULTS

Adverse childhood experiences were associated with melanoma occurrence, with the melanoma group reporting significantly more such experiences compared to the control group (p < 0.001). Resource loss from subjectively significant stressful life events in adulthood partially mediated the association between adverse childhood experiences and melanoma incidence.

CONCLUSIONS

The findings suggest that there may be intricate connections between stress, life events, adaptation to change, and skin cancer, which future research may further unravel. This study underscores the need for a more comprehensive approach to stress management, coping strategies development, and skin cancer prevention in healthcare settings.

Association between dietary inflammatory index and risk of demyelinating autoimmune diseases

Background: Considering limited data on the association between dietary inflammatory index (DII) and demyelinating autoimmune diseases, here, we studied this issue in the early diagnosed patients [e.g., preceding Multiple Sclerosis (MS) diagnosing level (Clinically Isolated Syndrome (CIS), and Radiologically Isolated Syndrome (RIS), MS, and Neuromyelitis Optica Spectrum Disorder (NMOSD)] using a case-control study among the Iranian population. Methods: A total of 291 subjects were selected as the cases (Patients with demyelinating autoimmune diseases including CIS, RIS, MS, and NMOSD, who were diagnosed less than six months before recruitment) and 297 others as controls. A 117-item semi-quantitative food frequency questionnaire (FFQ) was obtained from all of the participants and DII was calculated. Results: After controlling for potential confounders, adherence to a pro-inflammatory diet was associated with a higher risk of demyelinating autoimmune diseases (OR=2.05, 95% CI: 0.51, 3.58), EDSS (OR=2.02, 95% CI: 0.51, 3.53), active plaque (OR=1.90, 95% CI: 0.08, 3.71), higher lesion load (OR=2.11, 95% CI: 0.58, 3.64), LETM (OR=2.19, 95% CI: 0.27, 4.11), higher number of plaques (OR=2.11, 95% CI: 0.58, 3.64), and brain atrophy (OR=2.12, 95% CI: 0.57, 3.67). Conclusion: Our study suggests a possible link between the inflammatory potential of the diet and demyelinating autoimmune disease; however, further prospective cohort studies are needed to draw a causal link on this issue.

Influence of sunlight on the association between 25-hydroxyvitamin D levels and sleep quality in Brazilian adults: A population-based study

OBJECTIVES

This study aimed to evaluate the association of vitamin D with sleep quality during the COVID-19 pandemic and the influence of daily sunlight on this association.

METHODS

This cross-sectional, population-based study among adults stratified by multistage probability cluster sampling was conducted from October to December 2020 in the Iron Quadrangle region of Brazil. The outcome was sleep quality, evaluated by the Pittsburgh Sleep Quality Index. Vitamin D (25-hydroxyvitamin D) concentrations were determined by indirect electrochemiluminescence and a deficiency was classified as 25(OH)D < 20 ng/mL. To assess sunlight, the average daily sunlight exposure was calculated and was classified as insufficient when less than 30 min/d. Multivariate logistic analysis was used to estimate the association between vitamin D and sleep quality. A directed acyclic graph was used to select minimal and sufficient sets of adjustment variables for confounding from the backdoor criterion.

RESULTS

In a total of 1709 individuals evaluated, the prevalence of vitamin D deficiency was 19.8% (95% CI, 15.5-24.9%), and the prevalence of poor sleep quality was 52.5% (95% CI, 48.6-56.4%). In multivariate analysis, vitamin D was not associated with poor sleep quality in individuals with sufficient sunlight. Moreover, in individuals with insufficient sunlight, vitamin D deficiency was associated with poor sleep quality (odds ratio [OR], 2.02; 95% CI, 1.10-3.71). Furthermore, each 1-ng/mL increase in vitamin D levels reduced the chance of poor sleep quality by 4.2% (OR, 0.96; 95% CI, 0.92-0.99).

CONCLUSIONS

Vitamin D deficiency was associated with poor sleep quality in individuals with insufficient exposure to sunlight.

Development and Validation of Vitamin D- Food Frequency Questionnaire for Moroccan Women of Reproductive Age: Use of the Sun Exposure Score and the Method of Triad's Model

This cross-sectional study aimed to develop and validate a vitamin D food frequency questionnaire (VitD-FFQ) to assess vitamin D intake in Moroccan women of reproductive age. Using the method of triads, the VitD-FFQ was validated against seven-day dietary records (7d-FR) and 25-hydroxyvitamin D (25(OH)D) as a biomarker of vitamin D status in 152 women (aged 18-45 years). Participants' sun exposure scores (SES) were assessed using a specific questionnaire (SEQ). Predictors of vitamin D status were identified via linear regression models. Several statistical tests were applied to evaluate the criterion validity of the FFQ against two references methods (7d-FR and the biomarker-serum 25(OH)D). Median (Interquartile range) intakes were 7.10 ± 6.95 µg /day and 6.33 ± 5.02 µg/ day, respectively, for VitD-FFQ and 7d-FR. Vitamin D status was mainly determined by SES (R = 0.47) and vitamin D absolute food intakes derived by the VitD-FFQ (R = 0.56), which demonstrated a more significant prediction ability compared to 7d-FR (R = 0.36). An agreement was observed between the VitD-FFQ and 7d-FR (BA index of 3.29%) with no proportional bias (R² = 0.002, p = 0.54). <10% of participants were incorrectly classified, and weighted kappa statistics showed that VitD-FFQ had an acceptable ranking ability compared to the 7d-FR and the biomarker. The validity coefficient for the VitD-FFQ was high: ρQR = 0.90 (95%CI: 0.89-0.92), and a range from 0.46 to 0.90. Adjustment for the participants' SES and BMI (body mass index) improved the biomarker's validity coefficient (ρRB 0.63 (95% CI 0.39-0.82). Our results indicate that the VitD-FFQ is valid for estimating absolute vitamin D intake in Moroccan women of reproductive age.

Sun Exposure Score and Vitamin D Levels in Moroccan Women of Childbearing Age

Sunlight exposure is an essential source of vitamin D for many humans. However, hypovitaminosis D is a global public health problem. This study aimed to develop and validate a sun exposure score (SES) and correlate it with serum 25-hydroxyvitamin D levels in women of childbearing age. One hundred and sixty women aged 18 to 45 years residing in Meknes, Morocco, were included. A questionnaire estimating the sun exposure score and blood analysis of serum 25-OHD concentration were performed. The questionnaire's reliability and construct validity were evaluated using Cronbach's alpha and factor analysis. Spearman's test was used to assess the correlation between SES and 25-OHD levels. The score's reliability and construct validity were good, with Cronbach's alpha values >0.70 and factorial saturation ranging from 0.696 to 0.948. Serum 25-OHD levels were significantly associated with the total sun exposure score, and all SES domains (Rho was 0.615 (p < 0.0001), 0.307 (p < 0.0001), 0.605 (p < 0.0001), and 0.424 (p < 0.0001) for total SES, indoor exposure domain, outdoor exposure domain, and sun protection practice domain, respectively). In addition, median 25-OHD levels increased significantly when sun exposure was changed from insufficient to sufficient (p < 0.0001). The results suggest that the sun exposure score could be used as a clinical tool to assess vitamin D levels in women of childbearing age.

Impact of Genetic Risk Score and Dietary Protein Intake on Vitamin D Status in Young Adults from Brazil

Given the relationship between vitamin D deficiency (VDD) and adverse outcomes of metabolic diseases, we investigated the interplay of dietary and genetic components on vitamin D levels and metabolic traits in young adults from Brazil. Genetic analysis, dietary intake, and anthropometric and biochemical measurements were performed in 187 healthy young adults (19−24 years). Genetic risk scores (GRS) from six genetic variants associated with vitamin D (vitamin D-GRS) and 10 genetic variants associated with metabolic disease (metabolic-GRS) were constructed. High vitamin D-GRS showed a significant association with low 25(OH)D concentrations (p = 0.001) and high metabolic-GRS showed a significant association with high fasting insulin concentrations (p = 0.045). A significant interaction was found between vitamin D-GRS and total protein intake (g/day) (adjusted for non-animal protein) on 25(OH)D (pinteraction = 0.006), where individuals consuming a high protein diet (≥73 g/d) and carrying >4 risk alleles for VDD had significantly lower 25(OH)D (p = 0.002) compared to individuals carrying ≤4 risk alleles. Even though our study did not support a link between metabolic-GRS and vitamin D status, our study has demonstrated a novel interaction, where participants with high vitamin D-GRS and consuming ≥73 g of protein/day had significantly lower 25(OH)D levels. Further research is necessary to evaluate the role of animal protein consumption on VDD in Brazilians.

Reactivity to UV Radiation Exposure Monitoring Using Personal Exposure Devices for Skin Cancer Prevention: Longitudinal Observational Study

BACKGROUND

Emerging UV radiation (UVR) monitoring devices may present an opportunity to integrate such technology into skin cancer prevention interventions. However, little is known about the effects of using a wearable UVR monitor on adults' and children's sun protection-related behaviors and attitudes (eg, cancer worry and perceived risk). Understanding the potential role of reactivity and seasonal effects will help inform the use of objective monitors in the context of skin cancer prevention research, including intervention studies.

OBJECTIVE

The aim of this study is to examine the potential reactivity associated with a wearable personal UVR monitor, specifically the effects associated with reported sun-protective behaviors and skin cancer-related attitudes, which are often the targets of skin cancer preventive interventions.

METHODS

Child-parent dyads (n=97 dyads) were asked to wear a UVR monitoring device during waking hours for 2 weeks. Participants were asked to sync the device daily with a smartphone app that stored the UVR exposure data. Participants were blinded to their UVR exposure data during the 2-week period; thus, the smartphone app provided no feedback to the participants on their UVR exposure. Participants completed self-report questionnaires assessing sun-protective behaviors, sunburn, tanning, skin self-examination, skin cancer-related knowledge, perceived risk, cancer worry, response efficacy, and intentions to change behaviors over the 2-week period. Linear regressions were conducted to investigate changes in the outcomes over time and to account for the role of the season of study participation.

RESULTS

Regression results revealed that there was a significant decrease over time for several sun protection outcomes in children, including time spent outdoors on weekends (P=.02) and weekdays (P=.008), sunscreen use (P=.03), reapplication (P<.001), and unintentional tanning (P<.001). There were no significant changes over time in children's and parents' UVR exposure, sunburn occurrence, or sun protection attitudes. Season of participation was associated with several outcomes, including lower sunscreen use (P<.001), reapplication (P<.001), sunburns (P=.01), intentions to change sun-protective behaviors (P=.02), and intentional (P=.008) and unintentional tanning (P=.01) for participants who participated in the fall versus the summer.

CONCLUSIONS

The findings from this study suggest that daily use of a UVR monitoring device over a 2-week period may result in changes in certain sun-protective behaviors. These results highlight the importance of identifying and addressing potential reactivity to UVR monitoring devices, especially in the context of skin cancer preventive intervention research. Ultimately, objectively assessed UVR exposure could be integrated into the outcome assessment for future testing of skin cancer prevention interventions.

Time spent outdoors through childhood and adolescence - assessed by 25-hydroxyvitamin D concentration - and risk of myopia at 20 years

PURPOSE

To investigate the relationship between time spent outdoors, at particular ages in childhood and adolescence, and myopia status in young adulthood using serum 25-hydroxyvitamin D [25(OH)D] concentration as a biomarker of time spent outdoors.

METHODS

Participants of the Raine Study Generation 2 cohort had 25(OH)D concentrations measured at the 6-, 14-, 17- and 20-year follow-ups. Participants underwent cycloplegic autorefraction at age 20 years, and myopia was defined as a mean spherical equivalent -0.50 dioptres or more myopic. Logistic regression was used to analyse the association between risk of myopia at age 20 years and age-specific 25(OH)D concentrations. Linear mixed-effects models were used to analyse trajectory of 25(OH)D concentrations from 6 to 20 years.

RESULTS

After adjusting for sex, race, parental myopia, body mass index and studying status, myopia at 20 years was associated with lower 25(OH)D concentration at 20 years (per 10 nmol/L decrease, odds ratio (aOR)=1.10, 95% CI: 1.02, 1.18) and a low vitamin D status [25(OH)D < 50 nmol/L] at 17 years (aOR = 1.71, 95% CI: 1.06, 2.76) and 20 years (aOR = 1.71, 95% CI: 1.14, 2.56), compared to those without low vitamin D status. There were no associations between 25(OH)D at younger ages and myopia. Individuals who were myopic at 20 years had a 25(OH)D concentration trajectory that declined, relative to non-myopic peers, with increasing age. Differences in 25(OH)D trajectory between individuals with and without myopia were greater among non-Caucasians compared to Caucasians.

CONCLUSIONS

Myopia in young adulthood was most strongly associated with recent 25(OH)D concentrations, a marker of time spent outdoors.

Estimating personal solar ultraviolet radiation exposure through time spent outdoors, ambient levels and modelling approaches

BACKGROUND

 Evidence on validation of surrogates applied to evaluate the personal exposure levels of solar ultraviolet radiation (UVR) in epidemiological studies is scarce.

OBJECTIVES

 To determine and compare the validity of three approaches, including (i) ambient UVR levels, (ii) time spent outdoors, and (iii) a modelling approach integrating the aforementioned parameters, to estimate personal UVR exposure over a period of six months among indoor and outdoor workers and in different seasons (summer/winter).

METHODS

 This validation study was part of the EU ICEPURE project and was performed between July 2010 and January 2011 in a convenience sample of indoor and outdoor workers in Catalunya - Spain. We developed linear regression models to quantify the variation in the objectively measured personal UVR exposure that could be explained, separately, by the ambient UVR, time spent outdoors, and modelled UVR levels.

RESULTS

Our 39 participants - mostly male and with a median age of 35 years- presented a median daily objectively measured UVR of 0.37 standard erythemal doses (SEDs). The UVR dose was statistically significantly higher in summer and for outdoor workers. The modelled personal UVR exposure and self-reported time spent outdoors could reasonably predict the variation in the objectively measured personal UVR levels (R² = (0.75, 0.79)), whereas ambient UVR was a poor predictor (R² =0.21). No notable differences were found between seasons or occupation.

CONCLUSIONS

 Time outdoors and our modelling approach were reliable predictors and of value to be applied in epidemiological studies of the health effects of current exposure to UVR.

Sun protection changes among diverse elementary schoolchildren participating in a sun safety intervention: A latent transition analysis of a randomized controlled trial

Children are a priority population for skin cancer prevention as excessive sun exposure in childhood increases the risk of melanoma in adulthood. The complexity of sun protective behaviors has posed measurement challenges for trials testing intervention efficacy. The current study evaluated a sun safety intervention for schoolchildren using latent transition analysis (LTA) to examine patterns of sun protection behaviors over time. A three-armed randomized controlled trial was conducted between 2012 and 2016 with two intervention groups (N = 3368) and an observation-only control group (N = 342) among 4th and 5th graders from 24 public schools in Los Angeles County. Both interventions conditions were grouped and compared to controls. Five self-reported sun protective behaviors were measured at baseline and three-month follow-up: use of sunscreen, long sleeves, long pants, hats, and shade seeking. Participants comprised 3710 schoolchildren, mean age 9 years, 47% female and 69% Latino. At baseline, four patterns of sun protection behaviors were found: children who engaged in 1) all sun protective behaviors; 2) few protective behaviors; 3) protective clothing and shade only; and 4) hats only. Children in the control group were likely to remain in their baseline status or transition to a less protective status at three-month follow-up. By contrast, 30% of children in the intervention group transitioned to a more protective status at follow-up. In this RCT of a sun safety intervention, children in the intervention transitioned to more protective behaviors compared to controls. Using LTA enriches understanding of intervention efficacy by modeling the complexity of sun protection behaviors over time. TRIAL REGISTRATION: School-based Randomized Trial of SunSmart Interventions, ClinicalTrials.gov Identifier: NCT04176237 https://clinicaltrials.gov/ct2/show/NCT04176237?cond=School-based+Randomized+Trial+of+SunSmart+Interventions&draw=2&rank=1.

Sunburn, Sun Safety and Indoor Tanning Among Schoolchildren in Ireland

Objectives: We present patterns of sunburn, sun safety behaviors and indoor tanning bed use in a nationally representative sample of schoolchildren aged 10–17. These behaviors were explored across gender, age, and social class groups.

Methods: Within the Health Behaviour in School-aged Children (HBSC) Ireland study, 10,271 young people (aged 13.54 ± 1.92, percentage girls 53.3%) reported frequency of sun safety behaviors, sunburn, and frequency and circumstances of indoor tanning bed use.

Results: Children frequently experienced sunburn (90% lifetime, 74% last year), and 3% reported never using any sun protection. Applying sunscreen and wearing sunglasses were the most commonly used sun safety measures; other ways of sun protection were less popular. Indoor tanning bed use was reported by around 5%, and a large proportion of users were not advised of any indoor tanning safety measures. Sun safety behaviors varied by age and gender, with some socio-economic differences in tanning bed use. An association was found between frequency of family holidays abroad and sunburn.

Conclusion: Targeted interventions are needed to increase sun safety behaviors and eliminate tanning bed use among children in Ireland.

Novel sunprotection interventions to prevent skin cancer: A randomized study targeting Danes going on vacation to destinations with high UV index

Background

In Denmark, 16,500 cases of melanoma and keratinocyte cancers were registered in 2015, of which 90% could have been avoided by behavioral changes. We aimed to test novel interventions in a randomized design. The interventions targeted Danes going on vacation to high UVI destinations aiming to decrease sunburn by increasing use of sun protection to prevent skin cancer in the Danish population.

Methods

We report a randomized behavioral intervention during May-Dec 2018 with 1548 Danish adults on vacation in 2018 for a period of 1–3 weeks. The study population was population-based and aged 18–65 years. We tested two protection routines against minimal intervention control group (2-by2-factorial design): 1) Avoidance of the sun during peak hours and shade, use of the UV-index and planning of indoor/outdoor activity respectively and, 2) Coverage by increasing use of the hat advice and increasing sunscreen amount by application routine. Outcome was use of protection and sunburn.

Results

There were no differences in sunburn prevalence between intervention and control groups. Protection routine 1 and 2 both increased the overall protection score compared to non-users. Protection routine 1 increased the reported use of shade and decreased time exposed in the sun. Protection routine 2 increased the use of hat and sunscreen amount.

Conclusion

Simple measures can help avoid the majority of one of the most widespread cancers worldwide. Vacations to high UVI destinations is a major influence on the annual Danish UV-exposure. We influenced travelers to protect themselves better and to increase sun protection behavior.

Risk Prediction Models for Melanoma: A Systematic Review on the Heterogeneity in Model Development and Validation

The rising incidence of cutaneous melanoma over the past few decades has prompted substantial efforts to develop risk prediction models identifying people at high risk of developing melanoma to facilitate targeted screening programs. We review these models, regarding study characteristics, differences in risk factor selection and assessment, evaluation, and validation methods. Our systematic literature search revealed 40 studies comprising 46 different risk prediction models eligible for the review. Altogether, 35 different risk factors were part of the models with nevi being the most common one (n = 35, 78%); little consistency in other risk factors was observed. Results of an internal validation were reported for less than half of the studies (n = 18, 45%), and only 6 performed external validation. In terms of model performance, 29 studies assessed the discriminative ability of their models; other performance measures, e.g., regarding calibration or clinical usefulness, were rarely reported. Due to the substantial heterogeneity in risk factor selection and assessment as well as methodologic aspects of model development, direct comparisons between models are hardly possible. Uniform methodologic standards for the development and validation of risk prediction models for melanoma and reporting standards for the accompanying publications are necessary and need to be obligatory for that reason.

Benefit-Cost Analysis of the Danish Sun Safety Campaign 2007-2015: Cost Savings from Sunburn and Sunbed Use Reduction and Derived Skin Cancer Reductions 2007-2040 in the Danish Population

BACKGROUND

Ninety percent of skin cancers are avoidable. In Denmark, 16,500 cases of melanoma and keratinocyte cancers were registered in 2015. The Danish Sun Safety Campaign has campaigned since 2007, targeting overexposure to ultraviolet radiation. During 2007-2015, the key indicators of skin cancer, i.e. sunbed use and sunburn, showed annual reductions of 6% and 1%, respectively.

OBJECTIVES

We aimed to examine the financial savings to society as a result of the campaign reductions in skin cancer cases (2007-2040), and to examine the campaign's cost-benefit and return on investment (ROI).

METHODS

The analysis is based on existing data: (1) annual population-based surveys regarding the Danish population's behavior in the sun; (2) skin cancer projections; (3) relative risks of skin cancers from sunburn and sunbed use and (4) historical cancer incidences, combined with new data; (5) benefits from the avoided costs of skin cancer reductions; and (6) the costs of the Danish Sun Safety Campaign.

RESULTS

The results were based on a reduction of 9000 skin cancer cases, saving €29 million of which €13 million were derived from sunburn reductions and €16 million from reductions in sunbed use. The ROI was €2.18.

CONCLUSION

Skin cancer prevention in Denmark is cost effective. Every Euro spent by the Danish Sun Safety Campaign saved the Danish health budget €2.18 in health expenses.

Association of sunlight exposure with 25-hydroxyvitamin D levels among working urban adult Filipinos

Objectives

To determine the association of different levels of sunlight exposure, measured using the Filipino sunlight exposure questionnaire (SEQ) with 25-hydroxyvitamin D (25-OHD) levels among working urban adult Filipinos.

Methods

Seventy-five adult participants, living and working in Metro Manila, for at least 1 year, were grouped according to their perceived sunlight exposure pattern: low sunlight exposure (mostly indoor work); moderate sunlight exposure (both indoor and outdoor work); and high sunlight exposure (mostly outdoor work). After completion of the self-administered Filipino SEQ, they underwent serum 25-OHD level determination. Strength of correlation between the SEQ scores and 25-OHD levels was computed.

Results

Serum 25-OHD levels generally increased with increasing sunlight exposure levels. The overall Pearson’s correlation between the SEQ scores and 25-OHD levels of the participants was 0.396 (P = 0.001). The correlation for the individual domains was 0.342 for intensity of sunlight exposure (P = 0.003), 0.321 for factors affecting sunlight exposure (P = 0.005), and 0.256 for sun protection practices (P = 0.027).

Conclusions

The sunlight exposure of working urban adult Filipinos, as measured by the Filipino SEQ, has an overall significant, direct and moderate association with serum 25-OHD levels. This Filipino SEQ can serve as a valuable clinical tool for sunlight exposure assessment to identify individuals at risk for vitamin D deficiency.

Sex as a Risk Factor for Solar Ultraviolet Radiation Exposure?-Dosimetry in Danish Outdoor Workers

Solar ultraviolet radiation (UVR) exposure is a known risk factor for the development of skin cancer. Heterogeneity in solar UVR exposure may explain the diversity in skin cancer incidence between men and women. This, however, has not previously been investigated in Danish outdoor workers using UVR dosimetry. The aim of this study was to evaluate sex differences in solar UVR dosimetry in Danish outdoor workers on working and leisure days. A cross‐sectional design was used to collect dosimetry data during the Danish summer season (May to September). Analysis was based on an electronic questionnaire and dosimetry data from 450 outdoor workers (88 women, 362 men). Dosimetry data were reported as standard erythema dose (SED). The daily median SED (Interquartile range) on working days was 1.6 (2.5) in men and 1.5 (2.1) in women while on leisure days it was 0.5 (1.4) in men and 0.6 (1.3) in women. Analysis by multiple linear regression did not show any association between daily median SED and sex on either working or leisure days. In conclusion, solar UVR exposure in Danish outdoor workers did not vary according to sex.

A decade of sun protection in Australian early-childhood services: analysis of cross-sectional and repeated-measures data

Limiting ultraviolet radiation exposure during early childhood can significantly reduce the risk of developing skin cancer, making early childhood a critical time for sun protection strategies. This study aimed to measure sun protection practices utilized in Australian early-childhood services over the past decade and evaluate the impact of Cancer Council Australia's SunSmart Early-Childhood Program. Results are presented from cross-sectional and repeated-measures survey data, completed by directors or other staff at randomly sampled early-childhood services in 2008, 2013 and 2018 (N�=�3243). Most sun protection practices were used by a significantly greater proportion of services in 2018 relative to earlier years, such as requiring the use of sunscreen (98.4%), and sun-protective hats (99.7%) and clothing (88.8%). However, only a small and declining proportion of services (16.3%-22.4%) required the use of specific items of sun-protective clothing. SunSmart program members reported enacting significantly more sun protection practices compared to non-members, while new members showed an increase in the use of those practices relative to services whose status did not change (d�=�0.48). The results demonstrate improvements in sun protection in Australian early-childhood settings, and highlight the benefits and limitations of the SunSmart program.

Can Current Recommendations on Sun Exposure Sufficiently Increase Serum Vitamin D Level?: One-Month Randomized Clinical Trial

BACKGROUND

Lack of sunlight exposure is the primary reason for the worldwide epidemic of vitamin D deficiency. Although recommended sunlight exposure guidelines exist, there is no evidence regarding whether current guidelines are optimal for increasing vitamin D levels among individuals with vitamin D deficiency.

METHODS

Sixty Korean adults aged 20-49 years with serum 25-hydroxyvitamin D (25[OH]D) levels of < 20 ng/mL were randomly assigned to three groups: sunlight exposure (n = 20), vitamin D supplementation groups (n = 20), and daily living (n = 20) for 1 month. The sunlight exposure group had sunlight exposure on 20% to 30% of their body surface areas for 30-60 minutes per day, 3 times a week during the summer season. Vitamin D supplementation was prescribed with 800 IU/day of vitamin D. The serum levels of 25(OH)D were measured at baseline and at 1-month follow-up examinations.

RESULTS

The largest change in serum 25(OH)D was observed among the vitamin D supplementation group (+3.5 ng/mL, P < 0.001). The sunlight exposure group showed a slight increase in serum 25(OH)D level, but the absolute increase was less than one-third that of the vitamin D supplementation group (+0.9 ng/mL, P = 0.043). Only two participants in the sunlight exposure reached serum concentrations of 25(OH)D ≥ 20 ng/mL at follow-up. The daily living group showed no difference in vitamin D levels (-0.7 ng/mL, P = 0.516).

CONCLUSION

Sunlight exposure was not sufficient to overcome vitamin D insufficiency or deficiency in the current study subjects. Effectiveness of current sunlight exposure guidelines among various populations should be reassessed in larger clinical studies.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0002671.

Viruses in Skin Cancer (VIRUSCAN): Study Design and Baseline Characteristics of a Prospective Clinic-Based Cohort Study

BACKGROUND

Accumulating evidence suggests that cutaneous viral infections are risk factors for the development of keratinocyte carcinomas. The Viruses in Skin Cancer (VIRUSCAN) Study, a prospective cohort study, was established in 2014 to investigate the risk of keratinocyte carcinoma associated with cutaneous human papillomavirus and polyomavirus infection and the possible interaction with ultraviolet radiation exposure (UVR).

METHODS/RESULTS

VIRUSCAN incorporates repeated measures of viral infection using multiple markers of infection and quantitative measures of UVR using a spectrophotometer. Participants were recruited between July 14, 2014 and August 31, 2017 at the University of South Florida Dermatology Clinic in Tampa, FL. After excluding 124 individuals with prevalent keratinocyte carcinomas at baseline, 1,179 participants (53.2% women, 46.8% men, all ages 60 years and older) were followed for up to 4 years with routine skin exams occurring every 6 to 12 months. Here, we present the VIRUSCAN Study design, methods, and baseline characteristics, including demographics, sun exposure behavior, quantitative UVR exposure measurements, and cutaneous viral prevalence, for the full study cohort.

CONCLUSIONS

The VIRUSCAN Study will provide critical temporal evidence needed to assess the causality of the role cutaneous viral infections play in the development of keratinocyte carcinomas, as well as the potential interaction between cutaneous viral infections and UVR exposure.

IMPACT

Study findings will be valuable in future development of novel keratinocyte carcinoma prevention strategies.

Validation of a Vitamin D Specific Questionnaire to Determine Vitamin D Status in Athletes

The study objective was to validate a food frequency and lifestyle questionnaire (FFLQ) to assess vitamin D intake and lifestyle factors affecting status. Methods: Data collected previously during the fall (n = 86), winter (n = 49), and spring (n = 67) in collegiate-athletes (Study 1) and in active adults (n = 123) (Study 2) were utilized. Study 1: Vitamin D intake and ultraviolet B exposure were estimated using the FFLQ and compared to serum 25(OH)D concentrations via simple correlation and linear regression modeling. Study 2: Vitamin D intake from food was estimated using FFLQ and compared to vitamin D intake reported in 7-Day food diaries via paired t-test and Bland–Altman analysis. Results: Study 1: Serum 25(OH)D was not associated with vitamin D intake from food, food plus supplements, or sun exposure, but was associated with tanning bed use (r = 0.39) in spring, supplement use in fall (r = 0.28), and BMI (body mass index) (r = −0.32 to −0.47) across all seasons. Serum 25(OH)D concentrations were explained by BMI, tanning bed use, and sun exposure in fall, (R = 0.42), BMI in winter (R = 0.32), and BMI and tanning bed use in spring (R = 0.52). Study 2: Estimated Vitamin D intake from food was 186.4 ± 125.7 via FFLQ and 148.5 ± 228.2 IU/day via food diary. There was no association between intake estimated by the two methodologies (r = 0.12, p < 0.05). Conclusions: FFLQ-estimated vitamin D intake was not associated with serum 25(OH)D concentration or food-record-estimated vitamin D intake. Results highlight the difficulty of designing/utilizing intake methodologies for vitamin D, as its status is influenced by body size and both endogenous and exogenous (dietary) sources.

Postmenopausal hormone use and cutaneous melanoma risk: A French prospective cohort study

Cutaneous melanoma has been suspected to be influenced by female hormones. Several studies reported a positive association between menopausal hormone therapy (MHT) use and melanoma risk; however, previous findings were conflicting. We sought to explore the associations between MHT use and melanoma risk in a prospective cohort of women in France, where a particularly wide variety of MHT formulations are available. E3N is a prospective cohort of 98,995 French women aged 40-65 years in 1990. MHT use was assessed through biennial self-administered questionnaires. We used Cox proportional hazards regression models adjusted for age and skin cancer risk factors. Over 1990-2008, 444 melanoma cases were ascertained among 75,523 postmenopausal women. Ever use of MHT was associated with a higher melanoma risk (hazard ratio (HR) = 1.35, 95% confidence intervals (CI) = 1.07-1.71). The association was strongest among past users (HR = 1.55, CI = 1.17-2.07, homogeneity for past vs. recent use: p = 0.11), and users of MHT containing norpregnane derivatives (HR = 1.59, CI = 1.11-2.27), although with no heterogeneity across types of MHT (p = 0.13). Among MHT users, the association was similar across durations of use. However, a higher risk was observed when treatment onset occurred shortly after menopause (<6 months: HR = 1.55, CI = 1.16-2.07 vs. ≥2 years). Associations between MHT use and melanoma risk were similar after adjustment for UV exposure, although MHT users were more likely to report sunscreen use than nonusers. Our data do not support a strong association between MHT use and melanoma risk. Further investigation is needed to explore potential effect modification by UV exposure on this relationship.

Childhood sun safety at different ages: relations between parental sun protection behavior towards their child and children's own sun protection behavior

BACKGROUND

Sunburns during childhood are strongly associated with development of melanoma in later life. While parents play an important role in children's sun protection, insight in possible shifts in behavioral responsibility from parents towards their children and the possible effect of children's sex is important for targeting sun safety interventions throughout childhood and adolescence.

METHODS

This cross-sectional survey study was conducted among a representative sample of Dutch parents (N = 1053) of children aged between 4 and 13 years old. Questionnaires measured both parental and children's own sun safety behavior during planned (e.g. going to the beach) and incidental (e.g. bycicling) sun exposure situations. Analyses of variance were used to test for age group differences and linear regression models were computed to detect behavioral shifts in executive behavior.

RESULTS

Parents applied all sun safety behaviors (i.e. sunscreen use, wearing UV-protective clothing and seeking shade) more often on younger children, except for supportive behavior (facilitating children's own sun safety behavior), which remained relatively stable over the years. Older children and girls were more likely to execute sun safety behaviors themselves. A behavioral shift was found in wearing UV-protective clothing during planned situations among 11 year old children. For other behaviors, shifts were predicted after the age of 13.

CONCLUSIONS

Older children execute sun safety behaviors more often than younger children, although they still largely depend on their parents' protection. Specific attention for boys in the primary school years, and for both boys and girls in the years adjacent to adolescence is warranted in skin cancer prevention interventions.

Significant Associations Between Sun Exposure and Adiposity Were Not Observed in Breast and Prostate Cancer Patients in a Cross-sectional Analysis

Obesity is a significant health problem worldwide. Exposure to low-dose ultraviolet radiation (like that in sunlight) suppresses the development of obesity in mice; however, the nature of the associations between sun exposure and adiposity is not well understood in humans. The present study characterized cross-sectional relationships between sun exposure and adiposity in a convenience cohort of breast (n = 269; mean age = 58 years) and prostate (n = 78; mean age = 69 years) cancer patients. Participants were enrolled in a 3-month exercise program in Perth, Australia. Self-reported questionnaires measured time spent outdoors (previous week, winter and summer), sex, age, treatment received and physical activity levels. Adiposity measures included body mass index, waist-hip ratio and body fat percentage (measured via DXA). In unadjusted models, greater time spent outdoors across all times was significantly associated with lower waist-hip ratio, while greater time spent outdoors in the last winter was associated with lower body fat percentage, but not when stratified by sex. There were no statistically significant associations between time spent outdoors and adiposity after adjusting for sex, age, treatments received and physical activity. Longitudinal studies in larger populations may elucidate significant associations not found in our study due to the cross-sectional design and power limitations.

Method for Measurements of Terrestrial Ultraviolet Radiation on Inclined Surfaces in Personal Dosimetry Field Studies

Understanding personal ultraviolet radiation (UVR) exposure is essential for the evaluation of the health risks and benefits; however, personal dosimetry could be challenging in large-scale or/and long-term population studies. Alternatively, personal exposure could be simulated using three-dimensional models and lifestyle surveys together with data on a body position with respect to the sun. These models require a real-time input on local environmental UVR. The main challenge in using this method is retrieval of the diffuse irradiance as it requires an often-expensive tracking of solar position. In this study, a hypothesis that UVR measured on a vertical plane in the north direction can be used in the UK as a proxy for diffuse radiation was tested against direct measurements and compared with models based on solar tracker data in Chilton, UK, (51.57°N) in June-July 2018. The statistical analysis over 17 days under all weather conditions showed that for 45° and 90° tilted surfaces the proposed method performed as well as the best of the models based on solar tracker data. A proposed system could offer a portable and low-cost alternative to measurements of diffuse radiation by solar tracking radiometers for spatial distribution of terrestrial erythema effective UVR in population field studies.

Oral contraceptive use and cutaneous melanoma risk: a French prospective cohort study

Cutaneous melanoma has been suspected to be influenced by female hormones. Several studies reported a positive association between oral contraceptive (OC) use and melanoma risk. However, findings were conflicting and data from large prospective studies are lacking. E3N is a prospective cohort of 98,995 French women aged 40-65 years at inclusion in 1990. Exposure to lifetime OC use was assessed in 1992 and through biennial questionnaire updates. To assess the association between OC use and melanoma risk, we used Cox models adjusted for age, pigmentary traits, residential ultraviolet (UV) exposure in county of birth and at inclusion and family history of skin cancer. Over 1992-2008, 539 melanoma cases were ascertained among 79,365 women. In age-adjusted models, we found a modest positive association between ever use of OCs and melanoma risk (hazard ratio (HR) = 1.18, 95% confidence intervals (CIs) = 0.98-1.42), which was reduced after adjustment (HR = 1.14, 95% CI = 0.95-1.38). The association was stronger in long-term users (duration ≥10 years: HR = 1.33, 95% CI = 1.00-1.75) and in women who used high-estrogen OCs (HR = 1.27, 95% CI = 1.04-1.56). Among users, there was an inverse association with age at first use (ptrend < 0.01), but no evidence of an association with age at last use or time since last use. OC use was positively associated with tanning bed use (OR = 1.14, CI = 1.01-1.29), sunburns (ptrend = 0.5) and sunscreen use (OR = 1.13, CI = 1.00-1.28) since age 25. Overall, our findings do not support a strong association between OC use and melanoma risk and suggest intentional UV exposure in OC users, which supports a potential confusion by UV exposure in this relationship.

Development in sunburn 2007-2015 and skin cancer projections 2007-2040 of campaign results in the Danish population

Exposure to ultraviolet radiation is the main risk factor for skin cancer. Denmark has one of the highest incidences of skin cancer in the world. In 2007, a long-term sun safety campaign was launched in Denmark. We have evaluated the effects on prevalence of sunburn and modeled the effects on future melanoma incidence.Sunburn was evaluated by annual cross-sectional surveys representative for the Danish population on age, gender, and region. During 2007-2015, survey data were collected for 33.315 Danes. Cutaneous Melanoma incidences were modeled in the Prevent program, using population projections, historic incidence, sunburn exposure, and relative risk of sunburn on melanoma.The prevalence of sunburn in Denmark was reduced with 1% annually during 2007 to 2015. The campaign is estimated to have reduced the number of skin cancer cases with 664 annually in 2040 and 14.326 totally during 2007 to 2040. If the campaign was terminated in 2015 and sunburn rates return to precampaign level there would be no annual reduction in 2040 while in total the reduction would be 4.024 cases for 2007 to 2040. A continuous campaign until 2040 would yield annual reductions of 2.121 cases by 2040 and a total of 29.729 cases for the entire period.We have showed the value of prevention and the value of long-term planning in prevention campaigning. Sunburn use was reduced significantly during 2007-2015 and further reductions are possible. Consequently, we predict significant fewer skin cancer cases as anticipated.

Determinants of Sunburn and Sun Protection of Agricultural Workers During Occupational and Recreational Activities

OBJECTIVE

The aim of this study was to identify determinants of occupational sunburn in agricultural workers and assess their occupational and recreational sun protection habits.

METHODS

Specific surveys of agricultural workers in Switzerland and France were conducted (N = 1538). Multivariate logistic regressions identified occupational sunburn determinants. Occupational and recreational sun protection habits were estimated and correlated.

RESULTS

One-year occupational and recreational sunburn prevalences were 19.8% and 11.5%, respectively. Occupational sunburn increased with having a recent recreational sunburn, highly sensitive skin, young age, high perceived skin cancer risk, using sunscreen, and not wearing a hat. Correlation between protection habits during work and leisure was substantial (rs 0.5 to 0.7). Skin health knowledge was high and pro-tanning attitude moderate.

CONCLUSION

Potentially modifiable sunburn determinants and suboptimal recreational and occupational sun protection practices were identified in agricultural workers. Refining and tailoring sun protection messages targeting the agricultural sector are needed.

The measurement of time spent outdoors in child myopia research: a systematic review

The purpose of this article is to summarize the methods most commonly used to measure time spent outdoors and provide a comprehensive review of time and activity recording methods with the aim of encouraging the development of new methods. PubMed, Embase and the Cochrane Library were searched from Jan. 1^st, 1990 to Aug. 31^th, 2017. Studies including the following specific terms: "outdoor", "outside", "outdoor activity", "outside activity", "outdoor time", "outside time", and "outdoor AND measurement of time spent outdoors" were considered for this review. In total, three kinds of outdoor time measurements were discussed. Questionnaires have the longest history and are the most thoroughly revised instruments for assessing time spent outdoors, but recall bias is their most substantial drawback. Global positioning system (GPS) tracking can distinguish between indoor and outdoor locations, but its utility is limited due to several factors such as subject compatibility. Light exposure measurement devices are newly emerging, but all of these devices require good subject cooperation. Further efforts and exploration are needed to develop better methods and new tools to record exposure to the outdoors in real time. Moreover, inventing a new device by combining two or more types of devices mentioned above and using the latest technology of en ergy supplementation and autoswitching may make the best use of the advantages and bypass the disadvantages of each tool.

Review on Nonoccupational Personal Solar UV Exposure Measurements

Solar ultraviolet (UV) radiation follows people during their whole life. Exposure to UV radiation is vital but holds serious risks, too. The quantification of human UV exposure is a complex issue. UV exposure is directly related to incoming UV radiation as well as to a variety of factors such as the orientation of the exposed anatomical site with respect to the sun and the duration of exposure. The use of badge-sensors allows assessing the UV exposure of differently oriented body sites. Such UV devices have been available for over 40 years, and a variety of measuring campaigns have been undertaken since then. This study provides an overview of those studies which reported measurements of the personal UV exposure (PE) during outdoor activities of people not related to their occupation. This overview is given chronologically to show the progress of knowledge in this research and is given with respect to different activities. Special focus is put on the ratio of personal exposure to ambient UV radiation. This ratio, when given as a function of solar elevation, allows estimating PE at any other location or date if ambient UV radiation is known.

Reliability and consistency of a validated sun exposure questionnaire in a population-based Danish sample

An important feature of questionnaire validation is reliability. To be able to measure a given concept by questionnaire validly, the reliability needs to be high.

The objectives of this study were to examine reliability of attitude and knowledge and behavioral consistency of sunburn in a developed questionnaire for monitoring and evaluating population sun-related behavior.

Sun related behavior, attitude and knowledge was measured weekly by a questionnaire in the summer of 2013 among 664 Danes. Reliability was tested in a test-retest design. Consistency of behavioral information was tested similarly in a questionnaire adapted to measure behavior throughout the summer.

The response rates for questionnaire 1, 2 and 3 were high and the drop out was not dependent on demographic characteristic. There was at least 73% agreement between sunburns in the measurement week and the entire summer, and a possible sunburn underestimation in questionnaires summarizing the entire summer. The participants underestimated their outdoor exposure in the evaluation covering the entire summer as compared to the measurement week. The reliability of scales measuring attitude and knowledge was high for majority of scales, while consistency in protection behavior was low.

To our knowledge, this is the first study to report reliability for a completely validated questionnaire on sun-related behavior in a national random population based sample. Further, we show that attitude and knowledge questions confirmed their validity with good reliability, while consistency of protection behavior in general and in a week's measurement was low.

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Objectively validated questionnaires tested for reliability/behavioral consistency.

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Strong reliability of the knowledge and attitude items was shown.

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Knowledge about behavioral consistency between questionnaire measurement periods

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A recommendable design for short term evaluation of skin cancer prevention campaigns

Knowledge deficit, attitude and behavior scales association to objective measures of sun exposure and sunburn in a Danish population based sample

The objective of this study was to develop new scales measuring knowledge and attitude about UVR and sun related behavior, and to examine their association to sun related behavior objectively measured by personal dosimetry. During May-August 2013, 664 Danes wore a personal electronic UV-dosimeter for one week that measured their UVR exposure. Afterwards, they answered a questionnaire on sun-related items. We applied descriptive analysis, linear and logistic regression analysis to evaluate the associations between the questionnaire scales and objective UVR measures. Perceiving protection as routine and important were positively correlated with protective behavior. Knowledge deficit of UV and risk of melanoma, perceived benefits and importance of protection behavior was also correlated with use of protection. ‘Knowledge deficit of UV and risk of melanoma and Perceived barrier towards sun avoidance between 12 and 15’ were both associated with increased risk of sunburn. Attitude towards tan was associated to both outdoor time and exposure as well as use of protection, but not to sunburn. The results regarding Knowledge deficit of UV and risk of melanoma associated to UVR exposure and Perceived barrier towards sun avoidance between 12 and 15 emphasize the importance of awareness of melanoma risk and the priority of the skin cancer prevention advice. Shifting activities to outside the suns peak-hours could be an approach for structural and campaign preventive measures. Knowledge of items predicting exposure to UVR, use of protection and sunburn are important for planning of preventive interventions and melanoma research.