The following is a press release from The American Academy of Dermatology. I do not agree with some details but the broad position contains valuable guidelines. While dermatologists naturally regard themselves as authorities on the skin and its lesions, they do only represent the medical dermatological perspective, they are human and do make errors of judgement and many other equally well qualified professionals would take issue with one or more points in their position outlined below. Nevertheless, there are some things below I encourage you to think about.
In recent weeks, many news reports have focused on the potential health benefits of vitamin D. This news coverage has led to the incorrect perception that you have to intentionally seek the sun or an artificial source of ultraviolet (UV) radiation in order to get the health benefits that vitamin D may provide.
"Any individual or organization advocating intentional sun exposure as the preferred means of obtaining vitamin D is doing a tremendous disservice to the public," said dermatologist Barbara A. Gilchrest, M.D., professor and chair of the department of dermatology at Boston University School of Medicine. "Vitamin D is critical to healthy bones, and some research now suggests that maintaining higher levels than traditionally believed to be sufficient may offer additional health benefits. However, if you are concerned about getting enough vitamin D, the safe way to obtain it is through diet or oral supplements."
But many myths about vitamin D abound, leaving the average American confused over the contradictory messages. These myths can lead people to increase their risk of developing skin cancer, one of the most common cancers.
"While the potential benefits of vitamin D are still unknown and more scientific studies need to be done, we do know without a doubt that overexposure to UV radiation — from either natural or artificial sources (sun or tanning beds) — causes skin cancer," Dr. Gilchrest said. "It’s important that people understand the facts about UV radiation and vitamin D so that they can make informed choices about their health."
Myth: People who use sunscreen are at risk of having a vitamin D deficiency.
Fact: Even when used correctly, sunscreen with a Sun Protection Factor (SPF) of 15, the minimum recommended by the American Academy of Dermatology (Academy), deflects or absorbs 93 percent of the sun’s UVB rays and allows 7 percent to penetrate skin where the energy may produce vitamin D — or permanent damage. Indeed, because the same wavelengths of UV radiation produce both vitamin D, sunburn, DNA damage, and skin concerns, you cannot separate the wanted from unwanted effects.
Recent reports indicate that although the public may be using sunscreen, it is being incorrectly applied, used far too sparingly, and is therefore not as effective as it should be, usually well less than half as effective. "The average person requires one ounce of sunscreen, enough to fill a shot glass, to adequately cover the exposed areas of the body," advised Dr. Gilchrest. "However, the majority of people don’t use enough sunscreen to receive the level of protection that is indicated on the package. Many people also fail to apply sunscreen at least 15-30 minutes before going outdoors in order to allow it to be completely absorbed into the skin, and they neglect to re-apply it every two hours or after swimming."
Many studies have measured "normal" vitamin D levels in regular sunscreen users, even among those also practicing extreme sun avoidance because of high skin cancer risk. Although some authorities now suggest that these "normal" levels should be higher to achieve optimal health in the general population, all authorities agree that even the highest recommended vitamin D levels can safely and readily be obtained exclusively from oral supplements of up to 1000 IU of vitamin D daily, depending on age and diet.
Myth: If spending a little time in the sun allows the skin to produce vitamin D, then the more time, the better.
Fact: Maximum production of vitamin D occurs after brief exposure to UV radiation. The exact amount of time depends on many factors including geographic location, time of day, time of year, and skin type. However, for a fair-skinned person in Boston or New York, at Noon in June, it is 2-5 minutes. After this, any additional vitamin D that your body produces will not be stored for future use, but instead will be converted into inactive compounds. In contrast, UV damage to DNA and other skin components continues at the same rate as long as the UV exposure continues, so additional exposure will only increase your risk of developing skin cancer and premature aging.
"Most people, especially fair-skinned Caucasians, get more than enough incidental sun exposure to manufacture the vitamin D they need, so there is no reason to intentionally seek the sun," Dr. Gilchrest said. "Without a sunscreen, a fair-skinned child or adult will maximize the skin’s vitamin D production while running a brief errand or standing briefly in the yard. Even with a sunscreen, spending a total of 30 minutes outdoors over the course of the day will likely achieve this maximum. Even the most enthusiastic sun exposure advocates acknowledge that such exposure three times a week is quite enough."
Myth: The only way you can get vitamin D is through sun exposure.
Fact: If you are concerned that you’re not getting enough vitamin D, there are safe and effective ways to obtain it without intentionally exposing yourself to the sun. Both milk and orange juice are fortified with vitamin D and oral supplements are available over-the-counter. Additionally, foods that are good sources of vitamin D include salmon, tuna, sardines, eggs, beef liver and Swiss cheese.
"Vitamin D does not need to be produced from UV radiation to be effective. Don’t be misled into thinking that sunlight or tanning beds are better sources of vitamin D than foods or supplements. The only thing for which they are better is increasing your risk of developing skin cancer," Dr. Gilchrest said.
Myth: More people will be diagnosed with breast, colorectal and lung cancer due to vitamin D deficiency than will be diagnosed with skin cancer due to exposure to UV radiation.
Fact: In 2006, approximately 500,000 people will be diagnosed with breast, colorectal or lung cancer, according to the American Cancer Society. In contrast, this year more than one million people will be diagnosed with skin cancer. Among women ages 20 to 29, melanoma, the deadliest form of skin cancer, is the second most common form of cancer.
"The cause-and-effect link between UV exposure and the great majority of skin cancers is uncontested," said Dr. Gilchrest. "Whether more vitamin D would have reduced their cancer risk is far from proven. For example, a recent randomized, double-blind controlled study of more than 36,000 post- menopausal women performed by the Women’s Health Initiative and published in The New England Journal of Medicine showed that daily vitamin D supplementation for at least seven years did not reduce their risk of developing colorectal cancer. This is telling because indirect evidence linking vitamin D levels and sun exposure to prevention of colorectal cancer was stated by vitamin D advocates to be stronger than for any other cancer."
"I would advise anyone who is confused by conflicting reports of the health benefits of sunlight, whether in conjunction with vitamin D production or otherwise, to remember that nearly 8,000 people will die from skin cancer this year and UV radiation is the most preventable risk factor," Dr. Gilchrest said.
Professor Barbara Gilchrest
I’m calmer these days. A few years ago, I was angry about the epidemic of vitamin D deficiency and the millions of needless deaths, somehow thinking I wasn’t getting the word out. Now I plug along, knowing the truth will prevail, regardless of what I do, knowing we need decades, not months, for the work ahead. As the poet, Patmore, said:
I knew a backlash against vitamin D was coming. This month, Professor Barbara Gilchrest of Boston University fired the first broadside.
J Am Acad Dermatol. 2006 Feb;54(2):301-17. Epub 2006 Jan 4.
I’m happy the paper didn’t upset me that much, although, like anything that you don’t agree with, it was difficult to read carefully. Scientists, experts, physicians, and advocates should always read opposing views carefully, less they get drunk on their own whiskey.
Professor Barbara Gilchrest is the same Boston University academic who turned me livid eighteen months ago when she fired Professor Michael Holick for writing a book. Holick’s book simply questioned current dermatology dogma that sunlight is evil and she fired him: Boston University’s version of academic freedom.
Dr. Gilchrest and Dr. Deon Wolpowitz wrote an attack on vitamin D and sunlight. The two authors have something in common: neither had ever published a peer-reviewed paper about vitamin D (just search PubMed). Nor did the article get much press. Reuters picked it up, but few other news outlets.
Supplements not sun best for boosting vitamin D
As an aside, Dr. Gilchrest is one of the invited speakers at the upcoming 13th Annual Workshop on Vitamin D in Victoria, British Columbia, from April 8-12, 2006. Professor Tony Norman and Professor Roger Bouillon, both giants in the vitamin D field, organized this meeting. Tickets are going fast. The conference is at the gorgeous Fairmont Empress, a historic hotel one should experience at least once in your life. Be warned, this is a conference for scientists. Most of the presentations are technical, just the work that needs to be done to better understand vitamin D.
However, mixed in with the highly technical papers are some very useful clinical papers. Heike Bischoff-Ferrari, Hector Deluca, Edward Giovannucci, Robert Heaney, Bruce Hollis, Jo Ellen Welsh, Susan Whiting, and others usually present their data in ways educated lay people can understand. I was sorry to see that Michael Holick, Cedric Garland, and Reinhold Vieth were not invited to speak — sorry because Holick is the giant of the field, Garland because of his recent incredible paper on vitamin D and cancer, and Vieth because he started the current vitamin D revolution.
At first, I was upset (not livid) to see Dr. Gilchrest invited to speak at a vitamin D conference. However, the more I thought about it, the more I realized this is academic freedom at its best. One of the harshest critics of sun exposure, Dr. Gilchrest, invited to a conference where many of the attendees are staunch advocates of sensible sun exposure. I respect her for coming. I only hope that Professor Norman will invite Professor Michael Holick to debate her. Now that would be a free exchange of ideas!
Getting back to her paper, the most depressing thing about it was the emails I got from vitamin D experts, who complained it is useless to write a rebuttal to the Journal of the American Academy of Dermatology. That journal will not print any view that opposes their dogma that God was confused when she created sunlight, another blow against academic freedom.
After reading Professor Gilchrest’s paper twice, I found so many inaccuracies that I can’t list them all. Some of the errors are basic. Professor Gilchrest, cholecalciferol is not previtamin D; it is vitamin D. Professor Gilchrest, vitamin D is not in the “superfamily of steroid hormones that includes vitamin A and thyroid hormone,” its receptor is in that family. Professor Gilchrest, vitamin D is not a steroid hormone; it is a prehormone. Professor Gilchrest, vitamin A is not a steroid hormone; it has a retinol base, not a sterol one. Professor Gilchrest, thyroid hormone is not a steroid hormone; it has a tyrosine base, not a sterol one. When she makes basic mistakes on freshman biochemistry, how can readers trust her interpretation of scientific studies with immense medical and social consequence?
Her first argument is sunlight and sunbeds kill people, mainly due to malignant melanoma. However, she failed to cite the two biggest and best studies! A large, multi-center European study, perhaps the best one ever done, “found no association between melanoma and risk factors related to UV exposure such as sunbed use, sunbathing, or number of weeks of holidays in sunny areas.” The authors actually found sunbeds were associated with a small decreased risk for melanoma! They also found that sun bathing and sunburns were not associated with melanoma. Fair skin and the number of moles were the major risk factor for melanoma, not sunbeds or sunshine. They even found some evidence of decreasing risk with increasing sunbed use, concluding “The observed decrease in risk (of melanoma) with increasing use (of sunbeds) suggest either a protective effect or could be explained by recall bias with cases under reporting their true exposure.”
Eur J Cancer. 2005 Sep;41(14):2141-9.
Actually, recall bias (errors due to what patients tell researchers they remember), as the authors admit, will likely skew the results the other way. Patients with melanoma are more likely to report sun exposure or sun bed use in an “effort after meaning.” That is, humans tend to explain their problems by falsely remembering factors they believe might explain their melanoma.
Gilchrest also ignored another recent large European study looking at melanoma and sun/sunbed exposure. The British authors concluded, “This case-control study of melanoma did not find that exposure to natural or artificial radiation was significantly associated with an increased melanoma risk in the population overall.” Although they found ten or more sunburns and exposure to sunbeds for individuals with fair skin yielded significant but small melanoma risks, they found no overall risks. “The fact that no dose response was found for hours and years of exposure to sunbeds, even in young subjects, suggests that the use of sunbeds . . . is unlikely to be a major environmental risk factor for melanoma.”
Eur J Cancer. 2004 Feb;40(3):429-35.
After she ignores the two best, biggest, and most recent studies of melanoma and UV light, she argues sunlight is largely responsible for the 8,000 melanoma deaths per year. It is more likely that the current epidemic of melanoma, like many other cancers, is partially due to vitamin D deficiency. Vitamin D is such a stellar anti-carcinogen, doing everything an ideal anti-neoplastic drug should do, it is likely that dermatologists’ advice to melanoma patients — avoid the sun at all costs — is actually killing patients. A recent large multi-center trial (another one Professor Gilchrest ignored) looked at the effects of ongoing sun-exposure in melanoma patients. “Sun exposure is associated with increased survival from melanoma.”
J Natl Cancer Inst. 2005 Feb 2;97(3):195-9.
Professor Gilchrest then argues that the health benefits of vitamin D beyond bone disease are unproven. She explains that controlled interventional trials using vitamin D are rare, which is true. However, it is also true that science never proved that low fat diets prevent heart disease or stroke with good controlled interventional trials. The lack of good interventional trials did not prevent modern medicine from advising low fat diets — uselessly it seems.
JAMA. 2006 Feb 8;295(6):655-66.
New York Times, February 8, 2006: Low-Fat Diet Does Not Cut Health Risks, Study Finds
In implying physicians should not act until scientists conclusively prove a point, Professor Gilchrest misses the point. Sometimes physicians must act before scientists conclusively prove a point. Physicians can’t wait. Scientists can wait. Physicians are obligated to perform a risk benefit analysis based on available data and treat their patients accordingly. If a new therapy is risky (like a new cancer chemotherapy with numerous side effects), then physicians should only use the drug on patients facing death. If the therapy or advice is safe (drink eight glasses of water a day), it can be recommended although I dare the reader to find a single controlled interventional trial showing eight glasses of water a day does anything other than increase bottled water sales.
Unlike advising a low fat diet (assuming one warns against trans-fats and excess omega 6 consumption), advising people to avoid the sun is risky advice. Why is it risky? First, it is unnatural advice for a species that evolved in the sun. Second, it goes against mammalian instincts, as any pet owner will verify. Third, it goes against human instincts — the sun draws humans to it — and such instincts evolved for a reason. Finally, it goes against a large body of data that associates both sun exposure and low latitude with reduced incidence of many diseases. Thus, sun avoidance is risky advice and physicians should dispense it only after science has conclusively proven the benefits outweigh the risks.
Consider the advice of the Lancet Editorial Board, commenting on a petition to set aside public land for nude sunbathing! “On first consideration, the idea of a community of people deliberately practicing nudity, especially with public encouragement, strikes the average person as ridiculous. . . But the discovery that the rays of the sun on the skin exert a beneficent effect on health has done something to undermine these prejudices.”
Naked and unashamed [editorial]. Lancet 1932;1:688.
Granted, the Lancet proffered this advice in 1932, when organized medicine knew the health benefits of sun exposure and before dermatologists scared us out of the sun. Whatever you think of the government sponsoring nudist colonies, you should know that the best physicians in the 20′s and 30′s routinely recommended sun exposure for a wide variety of diseases; many of the same diseases have now been associated with vitamin D deficiency.
J Am Acad Dermatol. 2003 Jun;48(6):909-18.
Professor Gilchrest goes on to say, “No trail data support the conclusion that vitamin D supplementation in the absence of concomitant calcium supplementation is effective in preventing falls.” I guess she did not have time to read Sato’s recent study that showed a 59% reduction in falls with ergocalciferol supplementation alone.
Cerebrovasc Dis. 2005;20(3):187-92. Epub 2005 Jul 27.
She then cites five “high-quality epidemiological and observational studies,” which “do not support a role for vitamin D in preventing cancers.” The problem is that two of her studies are reviews, both of which call for better studies. Two others found the opposite of what she claimed. For example, the first study she cited concluded, “Calcium supplementation and vitamin D status appear to act largely together, not separately, to reduce risk of colorectal adenoma recurrence.”
J Natl Cancer Inst. 2003 Dec 3;95(23):1765-71.
The other “negative” study she cited actually concluded, “This trial cohort provides some evidence that calcium and vitamin D may be inversely associated with adenoma recurrence.”
J Nutr. 2005 Feb;135(2):252-9.
Professor Edward Giovannucci recently reviewed the evidence and concluded, “Recent studies add more support to a potential role of vitamin D on risk of colorectal cancer, but suggest that intakes higher than customary are required if solar ultraviolet-B exposure is low.”
Curr Opin Gastroenterol. 2006 Jan;22(1):24-9.
Professor Gilchrest also cited a prostate cancer study as negative, which actually showed protective effects for those with mid range vitamin D blood levels, while showing increased risk for those with high and low levels. She failed to point out the author of this study accepted Vieth’s explanation that high levels put one at risk because such patients do not maintain them throughout the year. Vitamin D levels fall precipitously in the autumn and winter, triggering even lower intracellular levels. It appears that falling levels may be as dangerous as low levels.
Int J Cancer. 2004 Jan 1;108(1):104-8.
Int J Cancer. 2004 Sep 1;111(3):468; author reply 469.
Then she makes another mistake, but I have made it myself. She says humans make all the vitamin D we can make in the first few minutes of sun exposure then we can’t make anymore. Although we make a lot very quickly, production continues to rise with sun exposure –up to about 50,000 units after four minimal erythemal doses (if you stay in the sun four times longer than it takes your skin to begin to turn pink). In 1982, Adams proved that by measuring levels after steadily increasing artificial UVB exposure into the sunburn range. Increased melanin in the skin (suntan) and other factors will eventually block such robust production.
N Engl J Med. 1982 Mar 25;306(12):722-5.
She also fails to mention the role vitamin D may play in preventing cardiovascular disease (potentially a greater lifesaver than preventing cancer), a topic recently reviewed by Zittermann.
Br J Nutr. 2005 Oct;94(4):483-92.
She goes on to say that if science eventually proves that vitamin D is important, then supplementation, not sunshine, is the answer. That is risky advice. How does she know all the sun does? She correctly thinks that sun exposure increases the risk of non-melanoma skin cancers and ages the skin. She incorrectly thinks sun exposure is the major risk factor for melanoma.
She overlooks the benefit side of the safe sun exposure equation. The sun provides vitamin D, which looks as if it may help protect humans from most of the diseases of civilization. What else does the sun do? Before I told someone to avoid the sun, I would wait until science completely understood the relationship between the sun and humans. Until then, supplementation in the colder months, moderate safe sun exposure in the warmer ones, and visits to the dermatologists should you develop signs of skin cancer, is the safest advice. Remember, non-melanoma skin cancers are mostly a nuisance, unless you ignore them. I have a few frozen every year. I thank my dermatologist and them go out to celebrate, knowing that long ago science associated non-melanoma skin cancers, a marker for sun exposure, with a reduced risk of dying from internal cancers.
Apperly FL. The relation of solar radiation to cancer mortality in North America. Cancer Res 1941; 1:191-5.
The Vitamin D Newsletter, January 18, 2003.
She then points out that misapplied sunscreen lotion, and thank God most people misapply it, will not block vitamin D production in the skin. However, she misinterprets Matsuoka’s classic paper which not only showed properly applied sunblock prevents vitamin D production, but showed casual exposure of the arms and face will only produce minimal amounts of vitamin D. That is an important point, because some say casual exposure of the arms and face is sufficient. It is not for many people. Furthermore, does it make sense to expose those parts of your body with the highest cumulative lifetime radiation burden to additional radiation? When I go in the sun, I cover my face and hands but expose as much of the rest of my body as prudence dictates.
J Am Acad Dermatol. 1990 May;22(5 Pt 1):772-5.
Towards the end of the paper, she makes some excellent points. “Recent reviews have summarized an impressive amount of data showing that hypervitaminosis D from diet (and I infer supplements from her context) is more a theoretic concern than a reality.” Good for her! I guess she read your paper Reinhold? As Reinhold Vieth once said, “Worrying about vitamin D toxicity is like worrying about drowning when you are dying of thirst.” Everyone should read the paper that started the vitamin D revolution. (By the way, Reinhold Vieth’s seminal paper is now free to download thanks to the American Journal of Clinical Nutrition)
Am J Clin Nutr. 1999 May;69(5):842-56.
She also competently discusses a pet peeve of mine. Casual sun exposure won’t work in the winter at many latitudes; it won’t work for African Americans, the aged, and certain cultural groups who veil their skin. Supplementation is critical for many people. Although she sees no reason to strive for natural blood levels (around 50 ng/ml, year around), she correctly points out that casual sun exposure will not protect our most vulnerable populations from vitamin D deficiency. Professor Heaney and Professor Hollis have both recently warned us that vulnerable patients may have to take more than 2,000 units a day – especially in the winter – to prevent deficiency.
J Steroid Biochem Mol Biol. 2005 Oct;97(1-2):13-9.
J Nutr. 2005 Feb;135(2):317-22.
At the end of her paper, a paper filled with inaccuracies, selective references, and apparent ignorance of the melanoma literature, she surrenders. She grudgingly admits vitamin D is probably important and the issue needs moreattention, even obliquely taking the Food and Nutrition Board to task for not raising guidelines.
However, she doesn’t discuss potential liability for dermatologists – an important omission for her dermatology readers. What will happen to dermatologists who promulgate sunphobia without taking steps their advice doesn’t induce vitamin D deficiency? Dermatologists in England have already provided the expert opinion needed in a court of law. After reviewing the role vitamin D plays in cancer prevention, including prevention of malignant melanoma, they concluded: “It would seem mandatory to ensure an adequate vitamin D3 status if sun exposure were seriously curtailed, certainly in relation to carcinoma of breast, prostate and colon and probably also malignant melanoma.”
Br J Dermatol. 2002 Aug;147(2):197-213.
Eighteen months ago, after she fired Professor Michael Holick, I was livid. I sent her a registered letter , threatening to file complaints with the AMA’s Council on Ethical and Judicial Affairs for violating the Principles of Medical Ethics, and with Board of Registration in Medicine of the Commonwealth of Massachusetts for dispensing harmful medical advice. I also threatened to run ads in Boston newspapers to find patients who had developed life-threatening cancers due to her sunphobe advice, patients who could sue her should she not educate herself about vitamin D. After I calmed down, and after Michael Holick calmed me down, I didn’t do any of these things.
Now I’m looking forward to hearing her speak in Victoria at the 13th Annual Workshop on Vitamin D . Even with all the mistakes in her paper, I think Professor Gilchrest has come a long way in the last eighteen months.
Then again, so have I.
John Cannell, MD
The Vitamin D Council
9100 San Gregorio Road
Atascadero, CA 93422
For the record:
This detailed response to Professor Gilcrest’s comments in the official AAD press release was referred to the AAD with an invitation to reply with a clarification of their position. I received an automated acknowledgement of my email from Jennifer Allyn, the Acadamy’s senior public relations specialist but have as yet received no further communication.
Peter
________________
Dr Peter Tylee
Editor
You can find a more informed reply to Professor Gilcrest here
http://www.vitamindcouncil.com.....ry2006.pdf
Note this link is to a PDF document. You may wish to right-click and download the file. [Editor]