Assessment of lifetime cumulative sun exposure using a self-administered questionnaire: reliability of two approaches

Objectively-Assessed Ultraviolet Radiation Exposure and Sunburn Occurrence

Ultraviolet radiation (UVR) exposure is the primary modifiable risk factor for melanoma. Wearable UVR sensors provide a means of quantifying UVR exposure objectively and with a lower burden than self-report measures used in most research. The purpose of this study was to evaluate the relationship between detected UVR exposure and reported sunburn occurrence. In this study, a UVR monitoring device was worn by 97 parent-child dyads during waking hours for 14 days to measure instantaneous and accumulated UVR exposure. The results showed that the participants' total UVR exposure was associated with reported sunburn after adjusting for Fitzpatrick skin type and geographic location. It was observed that one standard erythemal dose (SED) increase in the participants' daily total UVR exposure was associated with reported sunburn (an odds ratio (OR) of 1.26 with a 95% CI of 1.13 and 1.41, and p < 0.001 for parents and an OR of 1.28 with a 95% CI of 1.12 and 1.47, and p < 0.001 for children). A one-SED increase in the participants' UVR exposure from 10 am to 4 pm was also associated with reported sunburn (an OR of 1.31 with a 95% CI of 1.15 and 1.49, and p < 0.001 for parents and an OR of 1.33 with a 95% CI of 1.12 and 1.59, and p = 0.001 for children). We found that elevated UVR exposure recordings measured by the UVR sensor were associated with reported sunburn occurrence. Future directions for wearable UVR sensors may include their use as an intervention tool to support in-the-moment sunburn prevention.

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.

Cumulative UV Exposure or a Modified SCINEXA™-Skin Aging Score Do Not Play a Substantial Role in Predicting the Risk of Developing Keratinocyte Cancers after Solid Organ Transplantation-A Case Control Study

The risk of keratinocyte cancer is determined by intrinsic and extrinsic factors, which also influence skin aging. Few studies have linked skin aging and UV exposure with the incidence of non-melanoma skin cancer (NMSC). We evaluated signs of actinic skin damage and aging, individual UV burden, and melanocortin-1 receptor (MC1R) variants. A total of 194 organ transplant recipients (OTR) who suffered from NMSC were compared to 194 tumor-free controls matched for gender, age, type of transplanted organ, post-transplantation (TX) period, and immunosuppressive therapy. Compared with the cases, the controls scored higher in all skin aging scores and there were no differences in UV burden except for intentional whole-body UV exposure for specific UV scenarios and periods of life in favor of cases. The number of NMSCs correlated with all types of skin aging scores, the extent of intentional sun exposure, older age, longer post-TX period, shorter interval from TX to first NMSC, and specific MC1R risk groups. Multivariable models revealed a 7.5-fold risk of developing NMSC in individuals with actinic keratosis; 4.1- or 3.6-fold in those with green or blue eyes, respectively; and a 1.9-fold increased risk in the MC1R medium- + high-risk group. In the absence of skin aging contributing to NMSC development, certain MC1R risk types may identify OTR at risk for high tumor burden.

The Association between Self-Rated Health Status, Psychosocial Stress, Eating Behaviors, and Food Intake According to the Level of Sunlight Exposure in Korean Adults

Sunlight exposure has been reported to have various beneficial effects on human health. This study investigated the relationship between self-rated health status, psychosocial stress, eating behaviors, and food intake according to sunlight exposure in 948 adults. Sunlight exposure was classified as less than one hour, less than three hours, and greater than three hours. Of the participants, 49.2% had fewer than three hours of daily exposure to sunlight. Regarding participants exposed to sunlight for less than one hour, the largest response was that they did not engage in outdoor activities on weekdays or weekends, and the rate of being outdoors in the shade on sunny days was the highest in this group at 42.7%. Furthermore, the participants exposed to sunlight for less than one hour had a lower health response than the other two groups, and there were significantly more participants classified in the stress risk group. Regarding eating habits, those with less than an hour of exposure to sunlight frequently ate fried foods, fatty foods, added salt, and snacks, and had significantly lower total dietary scores or three regular meals. Additionally, their frequency of consumption of cereals, milk and dairy products, orange juice, and pork was also significantly lower than the other groups. Thus, it is necessary to provide sufficient guidelines for adequate sunlight exposure and food intake because participants with low sunlight exposure may have low vitamin D synthesis and insufficient food intake.

Assessment of sunlight exposure across industries and occupations using blood vitamin D as a biomarker

Objective

Exposure to ultraviolet (UV) radiation from sunlight induces the production of essential vitamin D, whereas overexposure to sunlight leads to skin cancer. Sunlight exposure has been measured using questionnaires, dosimeters, and vitamin D levels. Several studies have measured vitamin D in the working population; however, these studies were limited to certain occupations such as farmers and construction workers. In the present study, we evaluated sunlight exposure using blood vitamin D as an exposure surrogate across industries and occupations.

Methods

The Korea National Health and Nutrition Examination Survey (KNHANES) is a nationwide study representing the Korean population. We analyzed data from KNHANES between 2008 and 2009. We examined the association between vitamin D levels and pertinent personal, seasonal, residential, and occupational factors. Furthermore, we developed a multiple regression model with factors other than occupational factors (industry and occupation) and obtained residual values. We computed the third quartile (Q3) of the residuals and then calculated the fractions exceeding the Q3 level for each combination of industry and occupation.

Results

Age, sex, body mass index, year, season, latitude, living area, living in an apartment, industry, and occupation were significantly associated with vitamin D levels. Based on the exceeding fraction, the armed forces showed the highest exceeding fraction level of 0.71.

Conclusions

Our results present the high exposure groups to sunlight across industries and occupations. Our results may provide a source for prioritizing occupational groups with a high risk of adverse health effects from sunlight exposure.

Validity of skin blot examination for albumin and nerve growth factor β to detect itching of the skin in Indonesian older adults

AIM

Itching, a common skin disorder, impacts the quality of life of individuals. Itchy skin occurs more with increasing age and the prediction of itchy skin prognosis is necessary to provide good skincare. This study validated biomarkers in skin blotting to identify and measure itching sensation as well as conventional methods to measure skin barrier function.

MATERIALS AND METHODS

From a cross-sectional study conducted in Long-term Care (LTC) facilities in Indonesia itching symptoms were obtained through a questionnaire. Skin conditions were assessed using photographs, stratum corneum (SC) hydration, skin pH, and skin blotting for biomarkers: albumin, interleukin 2 (IL2), nerve growth factor β (NGFβ), and thymic stromal lymphopoietin (TSLP). Association of skin measurements with the presence of skin blotting and trends analysis were conducted.

RESULTS

Altogether, 564 LTC residents (average age, 70 years) participated. The SC hydration, skin pH, albumin, and NGFβ were associated with the presence of itch (p value= <0.001, <0.001, <0.001, and <0.001, respectively). The signal levels of skin blotting biomarkers were higher in itch group than in the non-itch group. Additionally, the higher quantile of SC hydration was significantly associated with a lower intensity level of NGFβ and TSLP (p value = 0.005, 0.003, respectively). The lower quantile of skin pH (better skin condition) was significantly associated with lower albumin, NGFβ, and TSLP (p value = 0.048, 0.035, and <0.001, respectively).

CONCLUSION

The albumin, NGFβ, and TSLP could be a candidate for measurement of itchy skin among older adult with disrupted skin barrier function and local skin inflammation.

Relationship between cumulative ultraviolet exposure and cognitive function in a rural elderly Chinese population

OBJECTIVES

Some researchers have focused on the relationship between vitamin D and cognition, but the conclusions are inconsistent. We estimated cumulative UV exposure could be used to represent the individual's long-term vitamin D status and investigated its association with global cognitive function in elderly Chinese.

METHODS

A total of 641 participants aged 60 years and over were recruited in a rural area of Shenyang, China. All were interviewed to obtain data regarding sociodemographic characteristics and time spent outdoors. Cognitive function was evaluated using the Montreal Cognitive Assessment-Beijing version (MoCA-BJ). Images of skin from UV-exposed (dorsal hand) and UV-protected (inner forearm) sites from each individual were graded by the Beagley-Gibson system. Differences in skin-grade between the 2 sites were used to indicate cumulative UV exposure level. Subjects were grouped in tertiles based on skin-grade differences (<1.75, 1.75-2.74, and ≥ 2.75), representing low, medium, and high UV exposure levels, respectively. The MoCA-BJ score was classified in tertiles as low (<19), middle (19-22), and high (≥23) levels of cognition. Associations between cognitive function and UV exposure were analyzed using ordinal regression.

RESULTS

Skin-grade differences were associated with self-reported time spent outdoors. After adjustment for age, gender, education, BMI, whether living alone, income, diet, hypertension, and diabetes, a high UV exposure level was associated with better cognitive function (odds ratio = 0.643, 95% confidence interval = 0.427-0.969).

CONCLUSIONS

Greater cumulative UV exposure appears to be associated with better cognitive function in elderly adults.

Association of Sun Exposure, Skin Colour and Body Mass Index with Vitamin D Status in Individuals Who Are Morbidly Obese

Vitamin D deficiency is a common issue, particularly in obese populations, and is tested by assessing serum 25(OH)D concentrations. This study aimed to identify factors that contribute to the vitamin D status in fifty morbidly obese individuals recruited prior to bariatric surgery. Data collected included serum 25(OH)D concentrations, dietary and supplement intake of vitamin D, sun exposure measures, skin colour via spectrophotometry, and genotype analysis of several single nucleotide polymorphisms in the vitamin D metabolism pathway. Results showed a significant correlation between serum 25(OH)D concentrations and age, and serum 25(OH)D and ITAC score (natural skin colour). Natural skin colour accounted for 13.5% of variation in serum 25(OH)D, with every 10° increase in ITAC score (i.e., lighter skin) leading to a 9 nmol/L decrease in serum 25(OH)D. Multiple linear regression using age, ITAC score, and average UV index in the three months prior to testing, significantly predicted serum 25(OH)D concentrations (R² = 29.7%). Single nucleotide polymorphisms for all vitamin D genes tested, showed lower serum 25(OH)D for those with the rare genotype compared to the common genotype; this was most pronounced for fok1 and rs4588, where those with the rare genotype were insufficient (<50 nmol/L), and those with the common genotype were sufficient (≥50 nmol/L). Assessing vitamin D status in individuals with morbid obesity requires testing of 25(OH)D, but potential risk factors for this population include natural skin colour and age.

A Model to Predict the Risk of Keratinocyte Carcinomas

Basal cell and squamous cell carcinomas of the skin are the commonest cancers in humans, yet no validated tools exist to estimate future risks of developing keratinocyte carcinomas. To develop a prediction tool, we used baseline data from a prospective cohort study (n = 38,726) in Queensland, Australia, and used data linkage to capture all surgically excised keratinocyte carcinomas arising within the cohort. Predictive factors were identified through stepwise logistic regression models. In secondary analyses, we derived separate models within strata of prior skin cancer history, age, and sex. The primary model included terms for 10 items. Factors with the strongest effects were >20 prior skin cancers excised (odds ratio 8.57, 95% confidence interval [95% CI] 6.73-10.91), >50 skin lesions destroyed (odds ratio 3.37, 95% CI 2.85-3.99), age ≥ 70 years (odds ratio 3.47, 95% CI 2.53-4.77), and fair skin color (odds ratio 1.75, 95% CI 1.42-2.15). Discrimination in the validation dataset was high (area under the receiver operator characteristic curve 0.80, 95% CI 0.79-0.81) and the model appeared well calibrated. Among those reporting no prior history of skin cancer, a similar model with 10 factors predicted keratinocyte carcinoma events with reasonable discrimination (area under the receiver operator characteristic curve 0.72, 95% CI 0.70-0.75). Algorithms using self-reported patient data have high accuracy for predicting risks of keratinocyte carcinomas.

Sun exposure and melanoma survival: a GEM study

BACKGROUND

We previously reported a significant association between higher UV radiation exposure before diagnosis and greater survival with melanoma in a population-based study in Connecticut. We sought to evaluate the hypothesis that sun exposure before diagnosis was associated with greater survival in a larger, international population-based study with more detailed exposure information.

METHODS

We conducted a multicenter, international population-based study in four countries-Australia, Italy, Canada, and the United States-with 3,578 cases of melanoma with an average of 7.4 years of follow-up. Measures of sun exposure included sunburn, intermittent exposure, hours of holiday sun exposure, hours of water-related outdoor activities, ambient ultraviolet B (280-320 nm) dose, histologic solar elastosis, and season of diagnosis.

RESULTS

Results were not strongly supportive of the earlier hypothesis. Having had any sunburn in 1 year within 10 years of diagnosis was inversely associated with survival; solar elastosis-a measure of lifetime cumulative exposure-was not. In addition, none of the intermittent exposure measures-water-related activities and sunny holidays-were associated with melanoma-specific survival. Estimated ambient UVB dose was not associated with survival.

CONCLUSION

Although there was an apparent protective effect of sunburns within 10 years of diagnosis, there was only weak evidence in this large, international, population-based study of melanoma that sun exposure before diagnosis is associated with greater melanoma-specific survival.

IMPACT

This study adds to the evidence that sun exposure before melanoma diagnosis has little effect on survival with melanoma.

Reliability of self-reported sun exposure in Canadian women and estimation of lifetime exposure to vitamin D from sun and diet

OBJECTIVE

To assess the inter-method reliability of the Ovarian Cancer in Alberta (OVAL) survey developed to estimate adult vitamin D exposure from sun and diet for every tenth year, against the longer Geraldton Skin Cancer Prevention Survey (the assumed 'gold standard'). We also estimated total vitamin D exposure using the OVAL survey.

DESIGN

A randomized crossover design to assess the inter-method reliability of sun exposure (OVAL v. Geraldton survey), using intra-class correlation and estimated total vitamin D exposure from sun and diet.

SETTING

Calgary, Alberta, Canada.

SUBJECTS

Randomly selected women (n 90) aged 40-79 years.

RESULTS

The average lifetime sun exposure of 13,913 h (average 411 h/year) from the Geraldton survey was not significantly different from the 13,034 h (average 385 h/year) from the OVAL survey for periods with sufficient UV radiation to stimulate vitamin D production. The intra-class correlation coefficient for average lifetime sun exposure was 0.77 (95% CI 0.69, 0.86); the annual average was 0.60 (95% CI 0.47, 0.74). Estimated vitamin D from diet and supplements increased with age.

CONCLUSIONS

Our OVAL survey reliably estimated adult sun exposure relative to the Geraldton survey, suggesting that assessing sun exposure every tenth year is a reliable and efficient method for estimating sun contributions to lifetime vitamin D exposure.

High residential sun exposure is associated with a low risk of incident Crohn's disease in the prospective E3N cohort

BACKGROUND

Vitamin D insufficiency has been suggested to be associated with high risk of Crohn's disease (CD). In France, where food fortification is limited, the major source of vitamin D is through sun exposure. The aim of this work was to analyze the relationship between residential sun exposure and the risk of incident CD or ulcerative colitis (UC).

METHODS

The E3N cohort consists of women living in France, aged 40 to 65 years and free of major diseases at inclusion in 1990. Among the 91,870 women included in the study, we identified 123 incident cases (45 CD, 71 UC, and 7 indeterminate colitis). To assess residential sun exposure, we used a database containing mean daily ultraviolet radiation (UVR) dose for each French county. The relationship between residential sun exposure and risk of incident inflammatory bowel diseases was explored using Cox models.

RESULTS

Higher levels of residential sun exposure were associated with a significant decreased risk of CD (hazard ratio [HR] for the third versus the first tertile of UVR dose, 0.49; 95% confidence interval (CI), 0.23-1.01; P for trend = 0.04), but not of UC (HR, 1.21; CI, 0.61-2.11). In women with available data on dietary vitamin D intake, we observed a lower risk of CD with higher residential UVR (HR, 0.29; 95% CI, 0.11-0.80; P for trend = 0.01). Dietary vitamin D intake was neither associated with the risk of CD (HR, 0.41; 95% CI, 0.14-1.24; P for trend = 0.14) nor UC (HR, 1.61; CI, 0.61-4.23).

CONCLUSIONS

In this prospective cohort of women, high residential sunlight exposure was associated with decreased incidence of CD, but not UC.

Biologic markers of sun exposure and melanoma risk in women: pooled case-control analysis

A model has been proposed whereby melanomas arise through two distinct pathways dependent on the relative influence of host susceptibility and sun exposure. Such pathways may explain site-specific patterns of melanoma occurrence. To explore this model, we investigated the relationship between melanoma risk and general markers of acute (recalled sunburns) and chronic (prevalent solar keratoses) sun exposure, stratified by anatomic site and host phenotype. Our working hypothesis was that head and neck melanomas have stronger associations with solar keratoses and weaker associations with sunburn than trunk melanomas. We conducted a collaborative analysis using original data from women subjects of 11 case-control studies of melanoma (2,575 cases, 3,241 controls). We adjusted for potential confounding effects of sunlamp use and sunbathing. The magnitude of sunburn associations did not differ significantly by melanoma site, nevus count or histologic subtype of melanoma. Across all sites, relative risk of melanoma increased with an increasing number of reported lifetime "painful" sunburns, lifetime "severe" sunburns and "severe" sunburns in youth (p(trend) < 0.001), with pooled odds ratios (pORs) for the highest category of sunburns versus no sunburns of 3.22 [95% confidence interval (CI) 2.04-5.09] for lifetime "painful" sunburns, 2.10 (95%CI 1.30-3.38) for lifetime "severe" sunburns and 2.43 (95%CI 1.61-3.65) for "severe" sunburns in youth. Solar keratoses strongly increased the risk of head and neck melanoma (pOR 4.91, 95%CI 2.10-11.46), but data were insufficient to assess risk for other sites. Reported sunburn is strongly associated with melanoma on all major body sites.

Multiple indicators of ambient and personal ultraviolet radiation exposure and risk of non-Hodgkin lymphoma (United States)

Recent epidemiologic studies have suggested that ultraviolet radiation (UV) may protect against non-Hodgkin lymphoma (NHL), but few, if any, have assessed multiple indicators of ambient and personal UV exposure. Using the US Radiologic Technologists study, we examined the association between NHL and self-reported time outdoors in summer, as well as average year-round and seasonal ambient exposures based on satellite estimates for different age periods, and sun susceptibility in participants who had responded to two questionnaires (1994-1998, 2003-2005) and who were cancer-free as of the earlier questionnaire. Using unconditional logistic regression, we estimated the odds ratio (OR) and 95% confidence intervals for 64,103 participants with 137 NHL cases. Self-reported time outdoors in summer was unrelated to risk. Lower risk was somewhat related to higher average year-round and winter ambient exposure for the period closest in time, and prior to, diagnosis (ages 20-39). Relative to 1.0 for the lowest quartile of average year-round ambient UV, the estimated OR for successively higher quartiles was 0.68 (0.42-1.10); 0.82 (0.52-1.29); and 0.64 (0.40-1.03), p-trend=0.06), for this age period. The lower NHL risk associated with higher year-round average and winter ambient UV provides modest additional support for a protective relationship between UV and NHL.

Melanoma epidemiology

Melanoma is a complex, heterogeneous cancer that continues to increase in incidence. Multiple studies have consistently identified major host and environmental risk factors for melanoma. Nevi, particularly dysplastic nevi, confer much higher risks than most pigmentary characteristics. Ultraviolet radiation exposure is the predominant environmental risk factor for melanoma. Recently, both rare high risk susceptibility genes and common polymorphic genes contributing to melanoma risk have been identified.