Sun protection in teenagersBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.a2997 (Published 03 March 2009) Cite this as: BMJ 2009;338:a2997
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Thieden's editorial is remarkable for the number of serious issues
arising therein that are simply left unaddressed.
Thieden highlights a recent study of "sun sails" on the outdoor behaviour
of Australian teenage schoolchildren (1). She fails to consider whether
studies derived from children of Anglo-Celtic origin, living in a region
of exceptionally high solar radiation, provide useful lessons for other
communities worldwide (such as multi-ethnic north west Europe) or merely
constitute an interesting (but non-extrapolatable) experimental model.
Thieden describes the detrimental effects of solar radiation as being
"well known". They are certainly well-publicised, but it is worth
reiterating that the proven effects are acute sunburn, accelerated skin
ageing (keratoses, loss of elasticity, etc), dermal naevi and non-melanoma
skin cancer (2).
Thieden states that the "only" beneficial effect of solar radiation is
Vitamin D photosynthesis. Given that she then goes on to describe a
"widespread global insufficiency of Vitamin D", use of the word "only"
carries echoes of Monty Python's "Life of Brian" ("Well apart from the
aqueduct, new roads, sewage disposal, law & order and public
sanitation, what have the Romans done for us?").
Thieden states that Vitamin D insufficiency is better counteracted by oral
supplementation than by sunlight. She has obviously never tried the
chalky, dyspeptic and constipating Calcium-and-Vitamin-D preparations that
constitute the only widely-available therapy in the UK pharmacopoea.
Unless fortification of foods with Vitamin D is mandated at governmental
level (unlikely given the track record of argument and policy paralysis
over public mass medication with Folic acid and fluoride), oral correction
of the Vitamin D deficiency pandemic is just not going to happen.
Finally, Theiden mistakenly states that the non skeletal benefits of
having optimal Vitamin levels "remain controversial". In fact Vitamin D
insufficiency is associated with type 1 diabetes, multiple sclerosis and
major cancers (oesophagus, breast, colorectal and prostate), not to
mention cardiovascular death and overall mortality. Given the sheer number
and variety of mammalian genes that comprise vitamin D responsive
elements, the existence of widespread extra-skeletal affects of Vitamin D
should come as no surprise (3).
What controversy there is relates to a paucity of decent intervention
studies. Given that oral Vitamin D is cheap (and indeed "solar" Vitamin D
is completely free), there is understandably no incentive for Industry to
fund large scale intervention studies as it has done for statins, etc.
The widespread prevalence of Vitamin D deficiency and its observed
association with life-limiting disease, suggests that these intervention
studies need to be funded and undertaken with some urgency. Until then,
the principle of "primum non nocere" applies, such that blunderbuss sun
avoidance strategies for our children must not be implemented until/unless
we can be reassured that they will not cause an increased future disease
1. Thieden E. Sun Protection in Teenagers. BMJ 2009; 338:a2997.
2. Shuster S. Is sun exposure a major cause of melanoma? BMJ
3. Holick MF. Deficiency of sunlight and vitamin D. BMJ 336:1318-9.
Competing interests: No competing interests
The editorial1 by Elisabeth Thieden stresses the need to devise sun
protection strategies relevant to different subgroups of the population.
The agricultural community is one such subgroup which merits this
attention. The term “farmer’s tan” in certain agrarian societies is
synonymous with the tan which extends from hand to mid-upper arm and from
crown to shirt-line of the neck typically seen in members of the farming
community. However, much skin cancer presents in these very areas as shirt
wearing is often not accompanied by the use of sunscreen and wide brim
Such suboptimal sun protection behavior was confirmed by a recent
study2 of farmers in the West of Ireland. The mean age of the study sample
was 49 years and despite the fact that the mean time spent outdoors per
day was 10.5 hours, nearly two thirds never wore sunscreen while nearly
one half never or rarely wore a hat. Farmers in this study seemed to fall
into one of three categories mirroring previous US data: those heavily
engaged in sun protective behaviors, those using no form of sun protection
and those just wearing hats as a sun protective behavior.3 These results
were surprising and occurred despite a recent targeted sun protection
campaign by the departments of agriculture and health specifically
directed at the 90,000 members of the Irish farmer’s organisation.
However, these findings may just reflect poor sun exposure behaviour and a
lack of awareness of the dangers of the sun among the wider population.
A country such as Ireland is more often associated with rainfall and
turf fires than the sunshine and barbeques we associate with countries
such as Australia where Dobbinson and colleagues conducted their study4.
This is likely to reduce the efficacy of any protection strategy as the
sun appears less frequently and due to latitude radiates with less
intensity for much of the year. In fact, on those rarer days when the sun
does appear, reckless sun exposure behaviour is not uncommon and perhaps
understandable as folk “make hay while the sun shines” to use another
farming metaphor. This is despite the fact that the predominant skin types
in Ireland and the Celtic fringes of Western Europe (type I and II) are
known to increase skin cancer risk and Ireland has one of the highest
rates of malignant melanoma in the world.5 We must continue to devise sun
protection strategies targeted towards farmers and others with high
occupational sun exposure and we should consider the different behaviors
of subgroups of farmers described above when developing tailored messages
aimed at increasing sun protective behaviors.3
1. Thieden E. Sun protection in teenagers
10.1136/bmj.a2997. BMJ 2009;338(mar03_3):a2997-.
2. Mulkerrins L, Glynn, L.G. Sun protection behaviour and awareness among
farmers in the West of Ireland. Western General Practice Training
Programme, Annual Research Meeting; 2008; Galway, Ireland.
3. Silk KJ, Parrott, R.L. All or nothing... or just a hat? Farmers' sun
protection behaviours. Health Promot Pract. 2006;7(2):180-5.
4. Dobbinson SJ, White V, Wakefield MA, Jamsen KM, White V, Livingston PM,
et al. Adolescents' use of purpose built shade in secondary schools:
cluster randomised controlled trial
10.1136/bmj.b95. BMJ 2009;338(feb17_1):b95-.
5. Parkin DM, Bray F, Ferlay J, Pisani P. Global Cancer Statistics, 2002
10.3322/canjclin.55.2.74. CA Cancer J Clin 2005;55(2):74-108.
Competing interests: No competing interests