Linking Models of Disability for Children with Developmental ...
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Sunlight skin cancer and bones:
Making sense of “mixed” messages
Seeta Durvasula Centre for Developmental Disability Studies
University of [email protected]
CDDSCentre for Developmental Disability Studies
Sun exposure and skin cancer
1920s – attitudes to sunlight exposure seen as health promoting “tanned is beautiful”
In Australia, sun exposure causes 99% of non-melanoma skin cancers 95% of melanomas (Armstrong, 2004)
So, strong public health campaigns for sun protective measures
Sun Protection Measures
Minimise time in the sun between 11am and 3pm (daylight saving time);
Use shade wherever you can including trees, shelters and umbrellas;
Slip! on a shirt made from tightly woven fabric, with sleeves and a high neck or collar and other clothing that covers the skin;
Slop! on a broad spectrum water resistant sunscreen with an SPF rating of 30+; and
Slap! on a wide brimmed hat or legionnaire's cap, that shades the face, neck and ears.
NSW Health, 1999
““Slip, Slop, Slap”Slip, Slop, Slap”
Slip, Slop, Slap!It sounds like a breeze when you say it like thatSlip, Slop, Slap!In the sun we always say "Slip Slop Slap!“
Slip, Slop, Slap!Slip on a shirt, slop on sunscreen and slap on a hat,Slip, Slop, Slap!You can stop skin cancer - say: "Slip, Slop, Slap!" The Cancer Council
Australia
Vitamin D and Bones
Hormone Necessary bone health
helps absorb calcium from gut Beneficial effect on muscle
strength and balance Prevention of fractures in elderly May also have beneficial effects on
some types of cancer
Where do you get it? (Vitamin D)
In Australia, 90% from sunlight - UVB Food - minor source of Vitamin D in
Australia milk, cheese margarine liver oily fish –sardines, mackerel, salmon
classical
non classical
Pancreatic cells
What is Vitamin D Deficiency?(Position statement, 2005)
Defined by serum Vitamin D level
Mild Vitamin D deficiency – 25 (OH) vitamin D level - 25 – 50 nmol/L
= Insufficiency raised parathyroid hormone level
Moderate Vitamin D deficiency 12.5-25 nmol/L
Severe Vitamin D deficiency < 12.5 nmol/L
Vitamin D deficiency
Increase in parathyroid hormone release of calcium from bones
Reduced bone density osteomalacia in adults rickets in children
Increased fracture risk in older people Muscle pains, muscle weakness Linked to falls in older people Associated with Type 1 diabetes,
some cancers
Causes of Vitamin D deficiency
Inadequate sunlight exposure elderly – especially in aged care facilities immobility skin covering
Sunlight less effective ageing skin pigmented skin
Diet – low consumption Malabsorption and abnormal gut
function
How common is vitamin D deficiency?
General population 43% in young women - Geelong (Pasco et
al. 2001) 23% in adult population - SE QLD
(McGrath et. Al, 2001) Specific groups at risk
elderly in high level care – 55% (Flicker et al. 2003)
dark skin pigmentation, especially if also covered/veiled 80% in one study (Grover & Morley, 2001)
People with developmental disability
Studies mainly in institutionalised populations on anticonvulsant therapy 47% of people with developmental disability
living in institution in NSW (Beange et al. 1994)
57% of those in a residential facility in SA– those with poor mobility, difficulty in taking solids (Valint & Nugent, 2006)
Community living adults - 36% men and 40% women (Centre et al. 1998)
43% of a clinic population in Sydney – older people, people with Down syndrome, overweight (Durvasula et al. 2005 - unpublished)
Prevention of Vitamin D deficiency in general
population Diet
200IU if < 50yrs; 400IU if 51-70 yrs; 600 IU if >70yrs (US Food &Nutrition Board)
Most Australians get <100 IU/day<100 IU/day Sun exposure = 1/3 Minimal
Erythema Dose (MED) To Reduce fracture risk in elderly –
1000IU day
Recommended sun exposure
1 minimal erythema dose (MED) is amount of sun exposure which produces faint skin redness
=Whole body exposure to 10-15mins of midday sun in summer
= 15,000U of vitamin D Recommend 1/3 MED
= exposing hands, face and arms to of sunlight on most days
Recommended sun exposure times (mins) for 1/3MED for moderate
fair skinRegion Dec-Jan July-Aug
at 10 am or 2pm
Auckland 6-8 30-47Christchurch 6-9 49-97Cairns 6-7 9-12Brisbane 6-7 5-19Adelaide 5-7 25-38Perth 5-6 20-28Sydney 6-8 26-28Melbourne 6-8 32-52Hobart 7-9 40-47
Sun exposure in people with developmental
disability Paucity of reliable data except for
those physical disability, or those in institutional care
Possible other at risk groups e.g those with challenging behaviour,
autism
Note: Reliance on carers/ support staff
Mixed messages?
Sun protection – prevent skin cancer
Sun exposure – prevent vitamin D deficiency
Not so “mixed”
Risks and Benefits of Sun Risks and Benefits of Sun Exposure (2005)Exposure (2005)
Aust. and NZ Bone Society, Osteoporosis Australia, Australasian College of Dermatologists, The Cancer Council of Australia http://www.cancer.org.au/content.cfm?randid=299825
Recommendations Sun protection required when UV index is
moderate or higher (≥3) Most people achieve adequate Vitamin D
levels through typical day to day activities, without deliberately seeking additional sun exposuresummer – expose face, arms and hands to
average of 5 minutes most days of the week outside peak UV levels
winter, in Southern States – exposure of hands, face, arms for 2-3 hours over a week
Use of solaria not recommended due to level of UV exposure
Recommendations
Those at increased risk of skin cancer need more vigorous sun protection practices and should discuss their vitamin D requirements with their doctor
Those at increased risk of Vitamin D deficiency should discuss their vitamin D status with their doctor
Recommendations – special groups
Older adults – if not at high risk of skin cancer, ensure incidental exposure
Skin type – dark skin pigmentation, especially if covered – may need vitamin D supplementation
What about sunscreen?
Necessary to prevent skin damage if prolonged exposure (long enough to cause erythema) is planned
For incidental exposure, of less than 10 minutes, may be able to omit sunscreen short exposures better for vitamin D
synthesis(Nowson et al, 2004)
What about people with developmental disability?
Recommendations as for general population for prevention of vitamin D deficiency i.e. safe sun exposure
But, need to take into account skin type/pigmentation, latitude, season, medication use (anticonvulsants), mobility
What about people with developmental
disability? However, many are at increased
risk of Vitamin D deficiency e.g. Medications Limited sun exposure
poor mobilitystaffing limitationschallenging behaviour
Therefore, incidental sun exposure may not be enough
Recommendations
Vitamin D insufficiency is common in people with developmental disability and can only be confirmed by measuring 25OH D
Either monitor yearly at end of winter (lowest values) and treat those < 50nmol/L with vitamin D supplements
Optimal calcium intake also needed – diet or supplements
Message not so “mixed”
Incidental safe sun exposure where possible
Check Vitamin D levels and treat if required
Need further research Identify those with developmental
disability who are especially at risk Determine levels of sun exposure in those
living in the community
Management Vitamin D Deficiency
3000 – 5000 IU/day ergocalciferol for 6-12 weeks
50 000 IU cholecalciferol. One tablet monthly for 3-6 months (NZ only)
Reassess after 3-4 months of treatment
1000 IU/day of ongoing treatment required for most patients
Contraindicated in hypercalcaemia