Comparisons of Estimated Economic Burdens due to Insufficient Solar Ultraviolet Irradiance and Vitamin D and Excess Solar UV Irradiance for the United States

Association Between Vitamin D Deficiency and Tumor Characteristics in Breast Cancer Patients

Introduction Breast cancer is the most frequent cancer among women worldwide, but there is little literature regarding the effects of vitamin D on breast cancer patients in the Indian population. Hence, this study was planned to determine the correlation between vitamin D deficiency and tumor characteristics in breast cancer patients. Methods This was a cross-sectional study conducted in a tertiary healthcare facility in central India among all newly diagnosed patients with breast carcinoma who had received primary surgery and pathological confirmation. We performed universal sampling and included 50 patients in the study. We excluded patients with insufficient histopathological reports, those unfit for surgery, and those with hepatic or renal failure, metabolic bone disease, malabsorption, or recent consumption of vitamin D (patients who had received oral vitamin D in the preceding two weeks, or vitamin D injection in the preceding six months). Results Among the 50 patients, 86% were vitamin D deficient, with a mean deficiency of 23.54. Vitamin D deficiency is most common in the age groups 41-50 years and >60 years, with the mean age group of 51.49 years. The left side is more involved than the right in vitamin D-deficient patients. Most patients were moderately and poorly differentiated, suggesting a significant association between vitamin D deficiency and tumor differentiation. Almost half the patients were estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (Her-2/neu) status negative with vitamin D deficiency. Vitamin D deficiency was highest in Her-2/neu amplified, luminal A, and B patients. The mean lymph node-positive participants was 4.04, and the mean number of lymph nodes extracted was 15.58 in vitamin D-deficient breast cancer patients. Conclusion The prevalence of low vitamin D status was high among breast cancer patients. There is an association between vitamin D deficiency and tumors with poor prognostic features. Low vitamin D levels were considered a risk factor for ER, PR, and Her-2/neu-negative tumors along with positive lymph node status in breast cancer patients. Vitamin D status is a modifiable risk factor for breast cancer. Thus, it is concluded from this study that vitamin D has a potential role in the prevention of breast cancer, it may reduce its aggressiveness, and its deficiency is associated with an increased risk of breast cancer.

Endogenous Photosensitizers in Human Skin

Endogenous photosensitizers play a critical role in both beneficial and harmful light-induced transformations in biological systems. Understanding their mode of action is essential for advancing fields such as photomedicine, photoredox catalysis, environmental science, and the development of sun care products. This review offers a comprehensive analysis of endogenous photosensitizers in human skin, investigating the connections between their electronic excitation and the subsequent activation or damage of organic biomolecules. We gather the physicochemical and photochemical properties of key endogenous photosensitizers and examine the relationships between their chemical reactivity, location within the skin, and the primary biochemical events following solar radiation exposure, along with their influence on skin physiology and pathology. An important take-home message of this review is that photosensitization allows visible light and UV-A radiation to have large effects on skin. The analysis presented here unveils potential causes for the continuous increase in global skin cancer cases and emphasizes the limitations of current sun protection approaches.

Serum Vitamin D status and VDR (FokI) polymorphism association study in Pakistani females with breast cancer

Background

Breast cancer is most common in Pakistani women at young age compared to West where it is most common after 60 years of age. Variations in genes controlling vitamin D activity would play a role in determining the risk of breast cancer in women at early age.

Purpose

To determine the association of vitamin D receptors (VDR) gene polymorphisms (FokI) with breast cancer risk in Pakistani women.

Methods

FokI polymorphisms were studied through the polymerase chain reaction-restriction fragment length polymorphism technique on blood samples of 300 breast cancer and 300 healthy women.

Results

This study found that circulating level of 25(OH)D3 was significantly lower among breast cancer patients as well as healthy subjects. Patients with large tumor size had significantly lower vitamin D levels. VDR FokI genotypes were significantly distributed (P ≤ 0.00001) in Pakistani women with newly diagnosed breast cancer. A significant association between different FokI genotypes and circulating levels of 25(OH)D3 was found. Patients with FF genotype was significantly (P < 0.0001) associated with higher risk of breast cancer (OR 8.9, 95% CI 0.17-0.45) compared to Ff and ff genotype.

Conclusion

VDR gene FokI polymorphism was associated with plasma vitamin D level and significant differences found in mean serum vitamin D levels between genotype groups of FokI. The study concluded that FokI might be one of the contributors to increase relative risk of breast cancer in Pakistani women.

Vitamin D status and COVID-19 prevention in a worker subgroup in Italy

BACKGROUND

Low levels of vitamin D are widespread in the world's population and associated with sun exposure, genetics, and lifestyles. Office workers in different occupational sectors seem more vulnerable than others. Scientific evidence reports a contribution of vitamin D in resistance to infections, opening to supplementation as a preventive action against pathogens, including SARS-CoV-2.

OBJECTIVE

A pilot campaign in the workplace during the coronavirus 2019 (COVID-19) pandemic was conducted based on the preliminary measurement of vitamin D amount and its integration.

METHODS

A preventive action to contrast the deficiency of vitamin D was offered to a population of 700 bank employees. Vitamin D supplementation was performed between April and June 2021, on workers (n = 139) and showed 25(OH)D serum levels ≤ 30 ng/ml. Demographic, anthropometric and lifestyle information were collected by survey and changes in the serum 25(OH)D amounts were monitored.

RESULTS

The adherence of the target population to the prevention campaign was 21%. 75% of the enrolled workers had low levels of vitamin D. After the intervention, serum vitamin D levels increased (1.28-fold;p = 0.0001) and 80% of the subjects reported optimal values > 30 ng/ml. Only 2.9% reported slight flu-like symptoms, but only 0.7% was confirmed as COVID-19, with respect to a ten-fold higher incidence in the general population.

CONCLUSIONS

Vitamin D supplementation can be achieved by simple and noninvasive approaches and can bring along further insights into health literacy on diet and lifestyles, representing an opportunity to protect the population by the widespread state of vitamin deficiency.

Necessity of daily 1000-IU vitamin D supplementation for maintaining a sufficient vitamin D status

The changes in the serum 25-hydroxyvitamin D (25(OH)D) concentrations after daily 1000-IU vitamin D intake for 3 months (3-month-VD), 6 months (6-month-VD) and then 6-month cessation of vitamin D in-take (6-month-VD cessation) were examined. The serum 25(OH)D levels in 11 male and 16 female subjects were 12.1±3.5 ng/mL at baseline, increased to 27.1±4.7 ng/mL at 3-month-VD, 28.5±5.1 ng/mL at 6-month-VD and decreased to 16.4±4.0 ng/mL at 6-month-VD cessation. The present study suggested that a vitamin D intake of 1000 IU/day is required to maintain the 25(OH) D concentration at 30 ng/mL or higher without vitamin D intoxication. J. Med. Invest. 69 : 135-140, February, 2022.

Solarium Use and Risk for Malignant Melanoma: Many Open Questions, Not the Time to Close the Debate

To shed further light on the ongoing debate whether sunbed use may increase melanoma risk, we have critically assessed the scientific literature that is at present available, focussing on a meta-analysis that we published recently. Our literature search identified several meta-analyses that report a weak association for ever-exposure to UV radiation from a solarium with melanoma risk. However, the quality of studies included in these meta-analyses and the resulting evidence levels and grades of recommendation were very low due to the lack of interventional trials and because of severe limitations of many of the observational studies. The results of cohort and case-control studies published until today do not prove causality, not even by the Hill criteria. The overall quality of these observational studies and the resulting evidence levels are low due to severe limitations (including unobserved or unrecorded confounding), which leads to bias. It must be recognized that in the majority of studies, published to date, many of the confounding factors, including sun exposure, sunburns and skin type, have not been adequately and systematically recorded and adjusted for. We conclude that the many limitations of the individual studies and the resulting low levels of evidence and grades of recommendation do at present not allow postulation of a causal relationship between solarium use and melanoma risk. At present, there is no convincing evidence that moderate/responsible solarium use increases melanoma risk.

A Comparison of Solar Ultraviolet Radiation Exposure in Urban Canyons in Venice, Italy and Johannesburg, South Africa

Urban environments can have high-risk spaces that can provide excess personal sun exposure, such as urban or street canyons, and the spaces between buildings, among others. In these urban spaces, sun exposure can be high or low depending on several factors. Polysulphone film (PSF) was used to assess possible daily solar ultraviolet radiation (UVR) exposure in urban canyons in Venice, Italy and, for the first time in Africa, in Johannesburg, South Africa. The photodegradation of PSF upon solar exposure was monitored at a wavelength of 330 nm by ultraviolet-visible spectrophotometry, and the resultant change was converted to standard erythemal dose (SED) units (1 SED = 100 J m^-2 ). Mean daily ambient solar UVR exposure measured for Venice and Johannesburg ranged between 20-28 SED and 33-43 SED, respectively. Canyon-located PSF exposures were lower in Venice (1-9 SED) than those in Johannesburg (9-39 SED), depending mainly on the sky view factor and orientation to the sun. There was large variation in solar UVR exposure levels in different urban canyons. These preliminary results should be bolstered with additional studies for a better understanding of excess personal exposure risk in urban areas, especially in Africa.

Potential of Skin Microbiome, Pro- and/or Pre-Biotics to Affect Local Cutaneous Responses to UV Exposure

The human skin hosts innumerable microorganisms and maintains homeostasis with the local immune system despite the challenges offered by environmental factors such as ultraviolet radiation (UVR). UVR causes cutaneous alterations such as acute (i.e., sunburn) and chronic inflammation, tanning, photoaging, skin cancer, and immune modulation. Phototherapy on the other hand is widely used to treat inflammatory skin diseases such as psoriasis, atopic dermatitis, polymorphic light eruption and graft-versus-host disease (GvHD), as well as neoplastic skin diseases such as cutaneous T cell lymphoma, among others. Previous work has addressed the use of pro- and pre-biotics to protect against UVR through anti-oxidative, anti-inflammatory, anti-aging, anti-carcinogenic and/or pro-and contra-melanogenic properties. Herein, we discuss and share perspectives of the potential benefits of novel treatment strategies using microbes and pro- and pre-biotics as modulators of the skin response to UVR, and how they could act both for protection against UVR-induced skin damage and as enhancers of the UVR-driven therapeutic effects on the skin.

Association between solar ultraviolet doses and vitamin D clinical routine data in European mid-latitude population between 2006 and 2018

The major source of vitamin D in humans is the ultraviolet radiation-dependent cutaneous synthesis of cholecalciferol; however, low vitamin D status is common in Europe even at mid-latitudes. The UV-radiation that reached the Earth's surface near Milan between May 2006 and December 2018 was retrieved from the TEMIS database and matched with the serum vitamin D levels measured in 30 400 people living in the same area. The results showed a high percentage of insufficient vitamin D levels (measured as 25-hydroxy-vitamin D) throughout the years. During the "vitamin D winter" (November-March) up to 60-90% of the population shows deficient/insufficient (<20-30 ng mL^-1) levels of vitamin D and it is explained by the difficulty in obtaining the recommended UV vitamin D doses. In contrast, the warm season provides plenty of UV-radiation, but still 30-50% of the population shows deficient/insufficient vitamin D levels. The circannual vitamin D variations were less evident in the female groups which, in the cold season, show values higher than the corresponding male groups. An age group analysis explained this difference by the strongly recommended vitamin D intake for post-menopausal women. In conclusion, increasing the medical advice for vitamin D intake is strongly recommended to improve the vitamin D status at European mid-latitudes. Our findings suggest that UV availability alone cannot explain the vitamin D status of the population which instead is likely to be influenced by several other factors related to both the people's lifestyle and their personal characteristics. A desirable vitamin D range considering the time of the year and sun exposure, but also including factors not related to UV-radiation, would probably result in a more accurate diagnosis of the patients' vitamin D status. Despite the relatively large time interval, no evident effects due to climate changes were observed in the vitamin D levels during the almost 13 years of analysis.

Vitamin D and the skin: what should a dermatologist know?

Although first discovered in 1931, vitamin D has seen an increased interest in the scientific community over the past decades, including the dermatology field. Vitamin D promotes calcium and phosphorus absorption; however, the actions of vitamin D are not confined to bone. Indeed, there is now overwhelming and compelling scientific data that vitamin D plays a crucial role in a plethora of cellular function and in extra-skeletal health. Except for fatty fish livers, very few foods naturally contain vitamin D; and the major source of vitamin D comes from skin exposure to sunlight via ultraviolet B. Keratinocytes are unique in the body as not only do they provide the primary source of vitamin D for the body, but they also possess both the enzymatic machinery to metabolize the vitamin D produced to active metabolites. This has been referred to as the photoendocrine vitamin D system. Vitamin D regulates keratinocytes proliferation and differentiation; and plays a role in the defense against opportunistic infections. Multiple factors are linked to vitamin D status; and a growing number of dermatologic diseases has been linked to vitamin D status such as atopic dermatitis, psoriasis, vitiligo, and cutaneous cancers. In this article, we reviewed the potential determinants of vitamin D status, as its implications in dermatologic diseases.

Local In Vivo Measures of Muscle Lipid and Oxygen Consumption Change in Response to Combined Vitamin D Repletion and Aerobic Training in Older Adults

Intramyocellular (IMCL), extramyocellular lipid (EMCL), and vitamin D deficiency are associated with muscle metabolic dysfunction. This study compared the change in [IMCL]:[EMCL] following the combined treatment of vitamin D and aerobic training (DAT) compared with vitamin D (D), aerobic training (AT), and control (CTL). Male and female subjects aged 60–80 years with a BMI ranging from 18.5–34.9 and vitamin D status of ≤32 ng/mL (25(OH)D) were recruited to randomized, prospective clinical trial double-blinded for supplement with a 2 × 2 factorial design. Cholecalciferol (Vitamin D₃) (10,000 IU × 5 days/week) or placebo was provided for 13 weeks and treadmill aerobic training during week 13. Gastrocnemius IMCL and EMCL were measured with magnetic resonance spectroscopy (MRS) and MRI. Hybrid near-infrared diffuse correlation spectroscopy measured hemodynamics. Group differences in IMCL were observed when controlling for baseline IMCL (p = 0.049). DAT was the only group to reduce IMCL from baseline, while a mean increase was observed in all other groups combined (p = 0.008). IMCL reduction and the corresponding increase in rVO₂ at study end (p = 0.011) were unique to DAT. Vitamin D, when combined with exercise, may potentiate the metabolic benefits of exercise by reducing IMCL and increasing tissue-level VO₂ in healthy, older adults.

Calcium and vitamin D in human health: Hype or real?

The incidence and prevalence of vitamin D deficiency are increasing worldwide. It is estimated that over 50% of the world's population have low vitamin D (i.e., hypovitaminosis D; serum levels below 30 ng/mL). In vitamin D inadequacy, human physiological systems work inefficiently. In humans, 80% of the vitamin D is synthesized in the presence of ultraviolet rays from sunlight; for the rest, we rely on diet and nowadays, supplements. The latter becomes important when one is exposed to less than optimal amounts of sunlight, inability to generate vitamin D in the skin efficiently, and/or having conditions that lead to decreased intestinal absorption or increased catabolism of vitamin D. The normal serum 25-hydroxyvitamin D [25(OH)D] level is around 30 ng/mL (75 nmol/L) and the optimal range is between 30 and 60 ng/mL (75-150 nmol/L). In 2011, the Institute of Medicine (IOM) suggested that 600IU of vitamin D is adequate for people below age 71 who are not exposed to sunshine. Although this might be relevant to the ambulatory healthy white Caucasians to achieve serum 25(OH)D level of 20 ng/mL, but it is insufficient for other ethnic groups. Moreover, the IOM recommendations are not suitable for those who live outside North America. Vitamin D requirements are higher during adolescence, pregnancy and lactation, and in many other disease conditions. Most clinicians consider 30 ng/mL as the minimum serum level of 25(OH)D necessary to maintain good health. In the absence of sunlight exposure and with daily oral intake of 600IU vitamin D, very few people would reach serum 25(OH)D level above 30 ng/mL. While an additional daily intake of 1000IU of vitamin D are required for people with lighter-skin color, those with darker complexion and the elderly, require a minimum of 2000IU/day to maintain serum 25(OH)D levels over 30 ng/mL; 5000 IU/day supplement is considered as the safe daily upper limit of supplementation. Vulnerable groups such as the disabled and/or house-bound, obese, with gastrointestinal abnormalities and/or malabsorption syndromes, institutionalized people (e.g., nursing homes, prisons, etc.), and pregnant and lactating women need approximately 4000IU per day for optimal physiological activity. Vitamin D is essential for gastrointestinal calcium absorption, mineralization of osteoid tissue and maintenance of serum ionized calcium level. It is also important for other physiological functions, such as muscle strength, neuromuscular coordination, hormone release, subduing autoimmunity, and curtailing the development of certain cancers.

Can adverse effects of excessive vitamin D supplementation occur without developing hypervitaminosis D?

Vitamin D is a fat-soluble hormone that has endocrine, paracrine and autocrine functions. Consumption of vitamin D-supplemented food & drugs have increased significantly in the last couple of decades due to campaign and awareness programs. Despite such wide use of artificial vitamin D supplements, serum level of 25 hydroxyvitamin D does not always reflect the amount of uptake. In contrast to the safe sunlight exposure, prolonged and disproportionate consumption of vitamin D supplements may lead to vitamin D intoxication, even without developing hypervitaminosis D. One of the reasons why vitamin D supplementation is believed to be safe is, it rarely raises serum vitamin D levels to the toxic range even after repeated intravenous ingestion of extremely high doses of synthetic vitamin D analogs. However, prolonged consumption of vitamin D supplementation may induce hypercalcemia, hypercalciuria and hyperphosphatemia, which are considered to be the initial signs of vitamin D intoxication. It is likely that calcium and phosphorus dysregulation, induced by exogenous vitamin D supplementation, may lead to tissue and organ damages, even without developing hypervitaminosis D. It is needed to be emphasized that, because of tight homeostatic control of calcium and phosphorus, when hypercalcemia and/or hyperphosphatemia is apparent following vitamin D supplementation, the process of tissue and/or organ damage might already have been started.

Vitamin D and the Skin: An Update for Dermatologists

Vitamin D plays a key role in skeletal and cardiovascular disorders, cancers, central nervous system diseases, reproductive diseases, infections, and autoimmune and dermatological disorders. The two main sources of vitamin D are sun exposure and oral intake, including vitamin D supplementation and dietary intake. Multiple factors are linked to vitamin D status, such as Fitzpatrick skin type, sex, body mass index, physical activity, alcohol intake, and vitamin D receptor polymorphisms. Patients with photosensitive disorders tend to avoid sun exposure, and this practice, along with photoprotection, can put this category of patients at risk for vitamin D deficiency. Maintaining a vitamin D serum concentration within normal levels is warranted in atopic dermatitis, psoriasis, vitiligo, polymorphous light eruption, mycosis fungoides, alopecia areata, systemic lupus erythematosus, and melanoma patients. The potential determinants of vitamin D status, as well as the benefits and risks of vitamin D (with a special focus on the skin), will be discussed in this article.

Adequate vitamin D3 skin synthesis versus erythema risk in the Northern Hemisphere midlatitudes

Health-optimum-exposure index (HOEI) is proposed to assess if the prescribed amount of vitamin D₃ (target value) could be synthesized in the human skin without erythema appearance. It is defined as the ratio between the vitamin D₃ quantity received during the maximum allowed outdoor exposure without erythema risk and the target value. Sunbathing is safe for HOEI>1 and 1/HOEI represents a part of minimal erythema dose (MED) necessary to obtain the target value. We examine the following targets: a vitamin D₃ quantity equivalent to 1000 IU vitamin D₃ taken orally, and an optimal vitamin D₃ quantity defined by Krzyścin et al. (2016). The biologically weighted (previtamin D₃ and erythemal) doses from the Northern Hemisphere midlatitudinal stations are analyzed to find HOEI dependence on personal and meteorological factors. HOEI depends mostly on the exposed skin area, person's age, and sun elevation at noon but not on the Fitzpatrick skin phototype. We found that only young adults (<21 yr) could safely obtain vitamin D₃ quantity, which is equivalent to 1000 IU taken orally, almost throughout the whole year. Duration of such exposures appears <1 h only in the warm subperiods of the year (April-September) for a person with minimal erythema dose of 330 J m^-2. Exposing larger part of the body (~30%) enables the oldest persons (>59 yr) to reach 1000 IU target during warm days in spring and summer. The optimal daily vitamin D₃ quantity could only be synthesized only by young adults for about 40-60% of days in the May-August period if they expose at least 1/3 part of their body surface area. Vitamin D₃ supplementation seems to be necessary over the whole year for the oldest persons with daily dosage of ~2000 IU but reduced to ~1000 IU in summer for sunseekers exposing significant part of the body.

Vitamin D levels and influencing predictors in refugee children in Sherbrooke (Quebec), Canada

BACKGROUND AND OBJECTIVE

Suboptimal vitamin D levels and associated complications are on the rise. Vulnerable populations, like refugee children, are further at risk. Studies on the vitamin D levels in refugee children are limited. The primary objective of this cross-sectional retrospective study was to determine the level of serum 25-hydroxyvitamin D (25-(OH)D) in the paediatric refugee population residing in Sherbrooke, Quebec, Canada. The secondary objective was to determine variables predicting vitamin D levels.

METHODS

Refugees under the age of 19 years arriving in Sherbrooke, Quebec, Canada, evaluated by the refugee clinic between March 2013 and April 2014, were included in the study. Vitamin D levels upon arrival and variables including age, sex, body mass index, season of arrival and season of test, ethnicity, previous country of residence and duration of stay in Canada from time of arrival were recorded. The protocol was approved by the scientific and ethics board of respective institutions.

RESULTS

A total of 138 subjects were included in the study from the Middle East, Central Asia and South East Asia, Africa and South America. The mean 25-(OH)D serum value was 55 nmol/L (insufficient). Fourteen per cent of subjects were vitamin D deficient and 64% were vitamin D insufficient as per Canadian Paediatric Society threshold guidelines. Gender (P=0.022), age (P<0.001), latitude (P<0.001) and season of testing (P=0.022) predict vitamin D status.

CONCLUSIONS

This study concluded that refugee children have insufficient vitamin D levels. Gender, age, latitude and season of testing have an impact in predicting vitamin D status.

Ultraviolet radiation and effects on humans: the paradigm of maternal vitamin D production during pregnancy

Current evidence indicates that neonates born of mothers with vitamin D deficiency during pregnancy have greater risk for developing hypocalcemia, rickets and extra-skeletal disorders. Despite the classic knowledge that ultraviolet-B (UVB) exposure is the most efficient way for a future mother to obtain optimal vitamin D concentrations, no current consensus or clinical recommendations exist regarding the duration and timing of UVB exposure for pregnant women. This article offers a narrative review of available data regarding how UVB exposure affects maternal vitamin D production during pregnancy, along with a discourse on clinical implications of this public health issue. Future studies would benefit from adopting UVB exposure estimates to recommend appropriate UVB exposure to pregnant women. Doing so could provide a more holistic and practical approach in managing maternal hypovitaminosis D during pregnancy.

A comparison of the direct medical costs for individuals with or without basal or squamous cell skin cancer: A study from Australia

Objectives:

The composition of the medical costs incurred by people treated for basal cell and squamous cell carcinomas (hereafter keratinocyte cancers) is not adequately understood. We sought to compare the medical costs of individuals with or without keratinocyte cancers.

Methods:

We used national health insurance data to analyze the direct medical costs of 2000 cases and 2000 controls nested within the QSkin prospective cohort study (n = 43,794) conducted in Australia. We reconstructed the medical history of patients using medical and pharmaceutical item codes and then compared the health service costs of individuals treated for keratinocyte cancers with those not treated for keratinocyte cancers.

Results:

Individuals treated for keratinocyte cancers consumed on average AUD$1320 per annum more in medical services than those without keratinocyte cancers. Only 23.2% of costs were attributed to the explicit treatment of keratinocyte cancers. The principal drivers of the residual costs were medical attendances, surgical procedures on the skin, and histopathology services. We found significant positive associations between history of treatment for keratinocyte cancers with treatments for other health conditions, including melanoma, cardiovascular disease, lipidemia, osteoporosis, rheumatoid arthritis, colorectal cancer, prostate cancer, and tuberculosis.

Conclusion:

Individuals treated for keratinocyte cancers have substantially higher medical costs overall than individuals without keratinocyte cancers. The direct costs of skin cancer excision account for only one-fifth of this difference.

Vitamin D, Essential Minerals, and Toxic Elements: Exploring Interactions between Nutrients and Toxicants in Clinical Medicine

In clinical medicine, increasing attention is being directed towards the important areas of nutritional biochemistry and toxicant bioaccumulation as they relate to human health and chronic disease. Optimal nutritional status, including healthy levels of vitamin D and essential minerals, is requisite for proper physiological function; conversely, accrual of toxic elements has the potential to impair normal physiology. It is evident that vitamin D intake can facilitate the absorption and assimilation of essential inorganic elements (such as calcium, magnesium, copper, zinc, iron, and selenium) but also the uptake of toxic elements (such as lead, arsenic, aluminum, cobalt, and strontium). Furthermore, sufficiency of essential minerals appears to resist the uptake of toxic metals. This paper explores the literature to determine a suitable clinical approach with regard to vitamin D and essential mineral intake to achieve optimal biological function and to avoid harm in order to prevent and overcome illness. It appears preferable to secure essential mineral status in conjunction with adequate vitamin D, as intake of vitamin D in the absence of mineral sufficiency may result in facilitation of toxic element absorption with potential adverse clinical outcomes.

Vitamin D deficiency remains prevalent despite increased laboratory testing in New South Wales, Australia

INTRODUCTION

The aim of the present study was to assess the prevalence of vitamin D deficiency and toxicity, the frequency of 25-hydroxyvitamin D (25[OH]D) testing, and 25(OH)D variations with respect to patient gender, patient age and season in New South Wales, Australia.

METHODS

A retrospective analysis of pathology records was performed to ascertain patient age, patient gender, sample collection date, plasma or serum 25(OH)D levels, calcium and parathyroid hormone (PTH) levels, and test numbers between 2001 and 2010. Linear regression with Bonferroni correction was used to calculate and compare age-adjusted mean 25(OH)D levels. Relationships of 25(OH)D with PTH and calcium were tested using Spearman's rank correlation.

RESULTS

25(OH)D testing increased by 730% over the ten-year study period. In 2010, many men (33%) and women (40%) were, to some degree, vitamin D deficient (≤ 50 nmol/L). Vitamin D toxicity was rare, with only one instance noted. 25(OH)D levels correlated positively with calcium and negatively with PTH levels. 25(OH)D levels decreased with age. In 2010, 25(OH)D levels were highest in February and lowest in September/October. Cyclical variation was observed for 25(OH)D levels between 2006 and 2010.

CONCLUSION

We found that vitamin D deficiency was prevalent in both men and women, with a higher prevalence in the latter, despite the substantial increased demand for 25(OH)D testing in our population over the decade. Vitamin D deficiency was associated with elevated PTH levels. Vitamin D toxicity was rare and only observed once during our study period. 25(OH)D levels decreased with age and varied with season, with the highest levels observed in late summer and the lowest in early spring.

Epigenetics of human melanoma: promises and challenges

Melanoma is the deadliest form of skin cancer with rising incidence and mortality rates. Although early-stage melanoma is highly curable, advanced-stage melanoma is refractory to treatment. This underscores the importance of prevention and early detection as well as the need to improve treatment and prognostication of human melanoma. Elucidating the underlying mechanisms of the initiation and progression of human melanoma can help identify potential targets of intervention for prevention, diagnosis, therapy, and prognosis of this disease. Aberrant DNA methylation and histone modifications are the best-established epigenetic mechanisms of carcinogenesis. The occurrence of epigenetic changes prior to clinical diagnosis of cancer and their reversibility through pharmacologic/genetic approaches offer a promising avenue for basic and translational research on human melanoma. Candidate gene(s) or genome-wide aberrant DNA methylation and histone modifications have been observed in human melanoma tumor tissues and cell lines, and correlated to cellular and functional characteristics and/or clinicopathological features of this malignancy. The present review summarizes the published researches on aberrant DNA methylation and histone modifications in connection with human melanoma. Representative studies are highlighted to set forth the current state of knowledge, gaps in the knowledgebase, and future directions in these epigenetic fields of research. Examples of epigenetic therapy applied for human melanoma in vitro, and the challenges of its in vivo application for clinical treatment of solid tumors are discussed.

New perspectives on vitamin D food fortification based on a modeling of 25(OH)D concentrations

BACKGROUND

In Germany, vitamin D intake from food and synthesis in the skin is low, which leads to low 25(OH)D serum concentrations. In contrast to many other countries, general vitamin D food fortification is still prohibited in Germany, although the European Commission published a regulatory framework to harmonize addition of vitamins to foods. Thus the purpose of our study was to develop a vitamin D fortification model, taking into account all vitamin D sources with the goal to fulfill requirements of intake recommendations or preferable 25(OH)D serum concentrations. Finally, the aim was to assess the suitability of different carriers and associated risks.

METHODS

We developed a mathematical bottom-up model of 25(OH)D serum concentrations based on data about vitamin D sources of the German population such as sunlight, food and supplements for all federal states taking seasonal and geographical variations into account. We used this model to calculate the optimal fortification levels of different vitamin D carriers in two approaches. First we calculated required fortification levels based on fixed intake recommendations from e.g. the IOM or the DGE and second based on achieving certain 25(OH)D serum concentrations.

RESULTS

To lift 25(OH)D serum concentration in Germany to 75 nmol/L, e.g. 100 g bread has to be fortified with 11.3 μg during winter, resulting in a daily vitamin D intake of 23.7 μg. Bread seems to be a suitable carrier for base supply. However, overdose risk with a single fortified product is higher than the risk with several fortified carriers.

CONCLUSIONS

With the model in hand, it is possible to conceive vitamin D fortification strategies for different foodstuffs and model its impact on 25(OH)D serum concentrations.

Evidence of overtesting for vitamin D in Australia: an analysis of 4.5 years of Medicare Benefits Schedule (MBS) data

OBJECTIVE

To comprehensively examine pathology test utilisation of 25-hydroxyvitamin D (25(OH)D) testing in each state of Australia to determine the cost impact and value and to add evidence to enable the development of vitamin D testing guidelines.

DESIGN

Longitudinal analysis of all 25(OH)D pathology tests in Australia.

SETTING

Primary and Tertiary Care.

MEASUREMENTS

The frequency of 25(OH)D testing between 1 April 2006 and 30 October 2010 coded for each individual by provider, state and month between 2006 and 2010. Rate of tests per 100 000 individuals and benefit for 25(OH)D, full blood count (FBC) and bone densitometry by state and quarter between 2000 and 2010.

RESULTS

4.5 million tests were performed between 1 April 2006 and 30 October 2010. 42.9% of individuals had more than one test with some individuals having up to 79 tests in that period. Of these tests, 80% were ordered by general practitioners and 20% by specialists. The rate of 25(OH)D testing increased 94-fold from 2000 to 2010. Rate varied by state whereby the most southern state represented the highest increase and northern state the lowest increase. In contrast, the rate of a universal pathology test such as FBC remained relatively stable increasing 2.5-fold. Of concern, a 0.5-fold (50%) increase in bone densitometry was seen.

CONCLUSIONS

The marked variation in the frequency of testing for vitamin D deficiency indicates that large sums of potentially unnecessary funds are being expended. The rate of 25(OH)D testing increased exponentially at an unsustainable rate. Consequences of such findings are widespread in terms of cost and effectiveness. Further research is required to determine the drivers and cost benefit of such expenditure. Our data indicate that adoption of specific guidelines may improve efficiency and effectiveness of 25(OH)D testing.

Vitamin D status at breast cancer diagnosis: correlation with tumor characteristics, disease outcome, and genetic determinants of vitamin D insufficiency

We correlated serum 25-hydroxyvitamin D(3) (25OHD) levels with tumor characteristics and clinical disease outcome in breast cancer patients and assessed the impact of genetic determinants of vitamin D insufficiency. We collected serum from 1800 early breast cancer patients at diagnosis, measured 25OHD by radioimmunoassay (RIA), and determined genetic variants in vitamin D-related genes by Sequenom. Multivariable regression models were used to correlate 25OHD levels with tumor characteristics. Cox proportional hazard models were used to assess overall survival (OS), disease-specific survival (DSS), and disease-free interval (DFI). Lower 25OHD serum levels significantly correlated with larger tumor size at diagnosis (P = 0.0063) but not with lymph node invasion, receptor status, or tumor grade. Genetic variants in 25-hydroxylase (CYP2R1) and vitamin D-binding (DBP) protein significantly determined serum 25OHD levels but did not affect the observed association between serum 25OHD and tumor size. High serum 25OHD (>30 ng/mL) at diagnosis significantly correlated with improved OS (P = 0.0101) and DSS (P = 0.0192) and additionally had a modest effect on DFI, which only became apparent after at least 3 years of follow-up. When considering menopausal status, serum 25OHD had a strong impact on breast cancer-specific outcome in postmenopausal patients [hazards ratios for 25OHD >30 ng/mL versus ≤30 ng/mL were 0.15 (P = 0.0097) and 0.43 (P = 0.0172) for DSS and DFI, respectively], whereas no association could be demonstrated in premenopausal patients. In conclusion, high vitamin D levels at early breast cancer diagnosis correlate with lower tumor size and better OS, and improve breast cancer-specific outcome, especially in postmenopausal patients.

How much vitamin D do we need for skeletal health?

BACKGROUND

Vitamin D is critical for musculoskeletal health and has been implicated in the risk of extraskeletal diseases, including cancer, cardiovascular diseases, and autoimmune diseases, as well as overall mortality. Although numerous studies deal and have dealt with vitamin D deficiency and its consequences, experts cannot agree on the right 25-hydroxyvitamin D levels. This survey aims to shed light on the ongoing vitamin D controversy from different angles.

QUESTIONS/PURPOSES

We discuss the minimum threshold for the 25-hydroxyvitamin D level to guarantee optimal health, why vitamin is D critical to musculoskeletal and extraskeletal functions, and new evidence for the success of prevention measures such as food fortification.

METHODS

We searched PubMed, Google Scholar, and reference lists of articles using several keywords. The most recent search was in February 2011.

RESULTS

While the use of parathyroid hormone as a surrogate measure did not lead to a consensus concerning the required 25-hydroxyvitamin D serum level, the combined analysis of bone mineralization and vitamin D status has established minimum levels of more than 75 nmol/L (30 ng/mL) to guarantee at least skeletal health. An effective measure to approach this status is food fortification, which has been demonstrated by countries such as Canada, the United States, and Finland.

CONCLUSIONS

Given the health economic implications of failure to maintain a balanced vitamin D status, action is recommended to integrate current scientific knowledge on vitamin D into physicians' treatment of patients and governmental policies on food fortification.

Diet, environmental factors, and lifestyle underlie the high prevalence of vitamin D deficiency in healthy adults in Scotland, and supplementation reduces the proportion that are severely deficient

Vitamin D deficiency has recently been implicated as a possible risk factor in the etiology of numerous diseases, including nonskeletal conditions. In humans, skin synthesis following exposure to UVB is a potent source of vitamin D, but in regions with low UVB, individuals are at risk of vitamin D deficiency. Our objectives were to describe the prevalence of vitamin D deficiency and to investigate determinants of plasma 25-hydroxyvitamin D (25-OHD) concentrations in a high northern latitude country. Detailed dietary, lifestyle, and demographic data were collected for 2235 healthy adults (21-82 y) from Scotland. Plasma 25-OHD was measured by liquid chromatography-tandem MS. Among study participants, 34.5% were severely deficient (25-OHD <25 nmol/L) and 28.9% were at high risk of deficiency (25-40 nmol/L). Only 36.6% of participants were at low risk of vitamin D deficiency or had adequate levels (>40 nmol/L). Among participants who were taking supplements, 21.3% had a May-standardized 25-OHD concentration >50 nmol/L, 54.2% had 25-50 nmol/L, and 24.5% had <25 nmol/L, whereas this was 15.6, 43.3, and 41%, respectively, among those who did not take supplements (P < 0.0001). The most important sources of vitamin D were supplements and fish consumption. Vitamin D deficiency in Scotland is highly prevalent due to a combination of insufficient exposure to UVB and insufficient dietary intake. Higher dietary vitamin D intake modestly improved the plasma 25-OHD concentration (P = 0.02) and reduced the proportion of severely deficient individuals (P < 0.0001). In regions with low UVB exposure, dietary and supplement intake may be much more important than previously thought and consideration should be given to increasing the current recommended dietary allowance of 0-10 μg/d for adults in Scotland.

A review of the role of solar ultraviolet-B irradiance and vitamin D in reducing risk of dental caries

Large geographical variations in dental health and tooth loss among US adolescents and young adults have been reported since the mid-1800s. Studies in the 1920s and 1930s noted that vitamin D and ultraviolet-B (UVB) irradiance reduced caries formation, the proposed mechanism being improved calcium absorption and metabolism. This paper reviews the history of studies of dental caries with respect to vitamin D, geographical location and available solar UVB doses. In addition, data on mean dental health rank by state for US servicemen from three periods, 1918, 1934 and 1943, were used in regression analyses with respect to summertime solar UVB doses and an index for mottled enamel, a proxy for natural fluoridation of drinking water, for 1935. There was a significant inverse correlation for dental health rank with respect to solar UVB from doses of 4.0 to 6.5 kJ/m(2) with little change thereafter. Adding data for mottled enamel rates for the states with UvB doses <6.6 kJ/m(2) improved the adjusted R(2) from 0.45 to 0.52. The mechanism whereby UVB reduces risk of dental caries is likely through production of vitamin D, followed by induction of cathelicidin and defensins, which have antimicrobial properties. Serum 25-hydroxyvitamin D concentrations at or above 30-40 ng/ml should significantly reduce the formation of dental caries. It is unfortunate that the UVB and vitamin D findings were not given more consideration in the 1950s as a way to reduce the risk of dental caries when water fluoridation was being proposed.

Holick's rule and vitamin D from sunlight

Holick's rule says that sun exposure 1/4 of a minimal erythemal dose (MED) over 1/4 of a body is equivalent to 1000 International Units (IU) oral vitamin D3. Webb and Engelsen recently commented that the ultraviolet (UV) spectrum used to establish Holick's rule is unknown. They consequently used a spring midday Boston solar spectrum to estimate ample sunlight exposures for previtamin D3 (preD3) at various locations. Literature review found the source upon which this rule is based was a fluorescent sunlamp (FS lamp). The FS spectrum is known and its relative weighting against the action spectra for erythema and the preD3 is significantly different from the solar spectrum used to derive the standard vitamin D effective dose (SDD). The preD3 effectiveness of the solar spectrum per unit erythemal hazard is greater than the FS lamp by a factor of 1.32. Consequently, UV exposure estimates based on Boston reference sunlight, instead of the UV lamp employed in the originating experiments, over estimate UV exposure equivalent to approximately 1000 IU orally by approximately 1/3. This redefinition of SDD impacts risk/benefit assessments of optimal/feasible sun exposure for vitamin D maintenance and the application of Holick's rule to rational public health messages.

Relation between prediagnostic serum 25-hydroxyvitamin D level and incidence of breast, colorectal, and other cancers

The evidence is increasing that higher serum 25-hydroxyvitamin D [25(OH)D] levels reduce the risk of many types of cancer. Ecological and observational studies yield the strongest evidence, with support from studies of mechanisms. A key question is identifying the relation between serum 25(OH)D level and cancer incidence. Meta-analyses of such studies is a reasonable approach to determine the serum 25(OH)D level-cancer incidence relation. This paper reports new meta-analyses for breast and colorectal cancers. Currently, the journal literature offers seven prospective breast cancer and ten prospective colorectal cancer studies that can be used. The data for these studies graphed and compared. Data from some of the studies were multiplied by factors to bring all the studies into reasonable agreement with a tentative dose-response relation. The data were fit with a variety of functions; the best fits were nonlinear functions that tended to asymptotically reach a lower odds ratio at higher serum 25(OH)D levels. These analyses estimated that the 50% reduction in incidence occurs for a value of 78 nmol/L compared with the value at 24 nmol/L for breast cancer, and a value of 60 nmol/L compared with the value at 15 nmol/L for colorectal cancer. Although these results are reasonable, some concern exists that a single serum 25(OH)D level, measured years prior to diagnosis of cancer, does not adequately represent the serum levels for the entire period before diagnosis. Future prospective studies should include more serum 25(OH)D level measurements during the study course.

The relationship between ultraviolet radiation exposure and vitamin D status

This paper reviews the main factors influencing the synthesis of vitamin D, with particular focus on ultraviolet radiation exposure. On the global level, the main source of vitamin D is the sun. The effect of solar radiation on vitamin D synthesis depends to some extent on the initial vitamin D levels. At moderate to high latitudes, diet becomes an increasingly important source of vitamin D due to decreased solar intensity and cold temperatures, which discourage skin exposure. During the mid-winter season, these factors result in decreased solar radiation exposure, hindering extensively the synthesis of vitamin D in these populations.

Critique of the U-shaped serum 25-hydroxyvitamin D level-disease response relation

Previous work has suggested an optimal serum 25-hydroxyvitamin D [25(OH)D] level near 20-30 ng/mL, above which disease risk may increase. Although based primarily on a prostate cancer study in Nordic countries, examples include esophageal, and pancreatic cancer, cardiovascular disease, and all-cause mortality rate. However, these studies apparently are not representative of the findings in the literature for these diseases or disease outcome in general. The prostate cancer study was from Nordic countries and used serum 25(OH)D levels from more than 15 years prior to cancer diagnosis for about half of the cases. Most studies of prediagnostic serum 25(OH)D find no significant correlation with risk of prostate cancer. Many risk-modifying factors for prostate cancer exist that observational studies generally do not include. The esophageal cancer data were from a region of China with high incidence of esophageal cancer. The pancreatic study was conducted on smokers in Finland. Both the esophageal and pancreatic studies are at odds with many ecological and observational studies in various countries. When several studies for cardiovascular disease, and all-cause mortality rate are combined in preliminary meta-analyses, the best fits to the data show a monotonic decrease of hazard ratio with increasing logarithm of serum 25(OH)D. Thus, little support exists for the U-shaped serum 25(OH)D level-disease response relation, and the few studies that do should not be used in forming public health policies regarding vitamin D and ultraviolet-B irradiance.

Critique of the International Agency for Research on Cancer's meta-analyses of the association of sunbed use with risk of cutaneous malignant melanoma

The International Agency for Research on Cancer (IARC) reported meta-analyses of the association of cutaneous malignant melanoma (CMM), finding significant correlations with ever use of sunbeds and first use of sunbeds prior to age 35 years; it did not claim that the associations showed causal links. However, some observational studies in the meta-analysis included individuals in the UK with skin phenotype at increased genetic risk of CMM without adjustment for skin phenotype. Treating the five UK studies separately from the other 14 corrected this oversight. In the original study, the summary relative risk (RR ) of CMM with respect to sunbed use was 1.15 (95% confidence interval [CI], 1.00-1.31). In this study, the similar RR was 1.20 (95% CI, 1.03-1.38). The RR for the five UK studies was 2.09 (95% CI, 1.14-3.84), whereas the RR for the other 14 studies was 1.09 (95% CI, 0.96-1.24). For first use of sunbeds prior to age 35 years, the IARC found a summary RR of 1.75 (95% CI, 1.35-2.36). This study plotted the RRs versus latitude of each study population, with a linear regression analysis carried out for all but the one UK study. The RR increased at 0.077 per degree of latitude and the regression explained 67% of the variance. It is also argued that factors other than sunbed use explain the increasing worldwide trends in CMM. Because solar-UV-simulating sunbeds induce production of vitamin D, the health benefits of their use greatly outweigh any possible risks.

Does an active sun exposure habit lower the risk of venous thrombotic events? A D-lightful hypothesis

BACKGROUND

Venous and arterial thrombotic complications exhibit a seasonal variation, with risk peaking in winter and dropping to a nadir in summer. We sought a possible correlation between sun exposure habits and venous thromboembolism (VTE) events.

METHODS

This was a cohort study comprising 40,000 women (1000 per year of age from 25 to 64 years) who were drawn from the southern Swedish population registry for 1990 and followed for a mean of 11 years. Seventy-four per cent answered an inquiry at the inception of the study (n=29,518), and provided detailed information on their sun exposure habits. Cox regression analysis was used with the presence of VTE as a dependent variable and selected demographics as independent variables. The main outcome was the relationship between VTE and sun exposure habits.

RESULTS

Swedish women who sunbathed during the summer, on winter vacations, or when abroad, or used a tanning bed, were at 30% lower risk of VTE than those who did not. Risk estimates did not change substantially after adjustment for demographic variables. The risk of VTE increased by 50% in winter as compared to the other seasons; the lowest risk was found in the summer.

CONCLUSIONS

Women with more active sun exposure habits were at a significantly lower risk of VTE. We speculate that greater ultraviolet B light exposure improves a person's vitamin D status, which in turn enhances anticoagulant properties and enhances the cytokine profile.

Ecological studies of ultraviolet B, vitamin D and cancer since 2000

PURPOSE

The purpose of this review is to summarize ecological studies of solar ultraviolet B (UVB), vitamin D and cancer since 2000.

METHODS

The journal literature is surveyed and summarized.

RESULTS

The ecological approach has been the primary tool used during the past two decades to extend the applicability of the UVB-vitamin D-cancer theory to include at least 18 types of cancer. Many of these studies were conducted in the United States, which has the advantages of availability of reliable age-standardized cancer incidence and mortality rate data for geographic areas at various spatial resolutions, and an asymmetric solar UVB dose pattern, with higher UVB irradiance in the west and lower in the east, at any particular latitude. In addition, indices for other cancer risk-modifying factors are readily available including those for smoking, alcohol consumption, ethnic background, urban/rural residence, socioeconomic status, air pollution, and in limited fashion, diet. The ecological approach has also been used to identify latitudinal variations in cancer mortality rates in Australia, China, Japan, and Spain, and in multicountry studies. It has been used to investigate the relative roles of solar UVB and dietary factors on a global scale. The ecological approach has also been applied to cancer survival. Studies in Norway and England found that individuals diagnosed with cancer in summer or fall, when serum 25-hydroxyvitamin D levels are highest, had a milder clinical course and longer survival than those diagnosed in winter or spring.

CONCLUSION

These findings provide strong evidence that vitamin D status plays an important role in controlling the outcome of cancer. Support for the UVB-vitamin D-cancer theory is now scientifically strong enough to warrant use of vitamin D in cancer prevention, and as a component of treatment. More research studies would help to explore whether there are benefits beyond the substantial effects that have been observed.

Estimated benefit of increased vitamin D status in reducing the economic burden of disease in western Europe

Vitamin D has important benefits in reducing the risk of many conditions and diseases. Those diseases for which the benefits are well supported and that have large economic effects include many types of cancer, cardiovascular diseases, diabetes mellitus, several bacterial and viral infections, and autoimmune diseases such as multiple sclerosis. Europeans generally have low serum 25-hydroxyvitamin D [25(OH)D] levels owing to the high latitudes, largely indoor living, low natural dietary sources of vitamin D such as cold-water ocean fish, and lack of effective vitamin D fortification of food in most countries. Vitamin D dose-disease response relations were estimated from observational studies and randomized controlled trials. The reduction in direct plus indirect economic burden of disease was based on increasing the mean serum 25(OH)D level to 40 ng/mL, which could be achieved by a daily intake of 2000-3000 IU of vitamin D. For 2007, the reduction is estimated at euro187,000 million/year. The estimated cost of 2000-3000 IU of vitamin D3/day along with ancillary costs such as education and testing might be about euro10,000 million/year. Sources of vitamin D could include a combination of food fortification, supplements, and natural and artificial UVB irradiation, if properly acquired. Additional randomized controlled trials are warranted to evaluate the benefits and risks of vitamin D supplementation. However, steps to increase serum 25(OH)D levels can be implemented now based on what is already known.

Solar ultraviolet irradiance and cancer incidence and mortality

Evidence supporting the UVB/vitamin D/cancer theory continues to mount with little detraction, although there are some inconsistent results, such as some from Nordic countries, with respect to serum calcidiol levels. Also, studies designed and conducted before it was realized that dietary sources are largely inadequate to have a pronounced effect on cancer risk were largely unable to confirm a beneficial role for vitamin D in reducing the risk of cancer. The analysis of the economic burden of solar UVB irradiance and vitamin D deficiencies compared to excess solar UV irradiance for the United States yielded interesting findings. One was that the US economic burden due to vitamin D insufficiency from inadequate exposure to solar UVB irradiance, diet and supplements was estimated at $40 billion to $56 billion in 2004, whereas the economic burden for excess UV irradiance was estimated at $6 billion to $7 billion. These findings are probably still approximately correct, if not on the low side, with respect to vitamin D because of the additional benefits found recently, such as protection against infectious diseases.