Skin cancer risk, practical realities (local climate and UV intensity, elderly folks who may be less mobile), differing absorption based on skin melanin content, etc.


>Skin cancer risk But, you know, you tell the patient x minutes of exposure at y time of day, so they don't go crazy with it, that shouldn't raise their skin cancer risk in any major way.


I see you have more faith in the general population than most


He is still a student, lets hear his oppinion after 1 month working .


I’m Australian. Suggested sun exposure for sufficient vitamin D in my city (which has a climate like California) varies from a few minutes in the summer to 2-3 hours (multiple times a week) in winter. That’s midday sun. If you can only get out in the morning or evening, you’d need even more exposure. So the the seasonal variation is too large for “x minutes a day” to work. You’d get maybe a month or two where that’s right, and then outside that they’re either crispy fried or vit-D deficient. You’d really have to use a UV weather app specific to your area to dose safely and effectively.


I see you've never lived in a UV index 11+ area


How is this plan going to be more compatible with individuals' schedules than adding a small pill every day??? What about different regions with long winters?? I'm not a doctor and I can understand that the simplest way with any hope of keeping a patient compliant with a treatment plan is going to be the best option.


I think the main point was the lack of discussion towards sun exposure as a treatment for deficiency. Obviously that would not work for every patient for many reasons. The solution of "take a pill, you'll feel better" isn't always the correct solution. You ask how this plan is going to be more compatible with patients, but the real question to ask is what plan out of several plans that we have is going to be most compatible with each individual patients lifestyle.


Yeah, and just tell the overwt pts to stop eating so much. It's that easy!


But it still does?


Daily sun exposure over a long period (especiallly without wearing sunblock) will certainly increase skin cancer


A lot of vit D deficincy is seen in places with long winters. We can go weeks in Minnesota with UV of 0-2, which isn't enough for deficiency treatment.


There is a lot of vitamin D deficiency in very sunny areas as well. In Tucson, I saw more vitamin D deficiency than I ever have in Central Valley, CA


That’s ‘cause it’s hotter than hell and nobody wants to spend time in the sun.


Yep and for people like me, we get burned walking in from the parking lot in peak sun hours.


Between the heat (100+ weather is just around the corner) and the UV (it’s already near the top of the charts now, and will be off the charts soon), people don’t tend to spend that much time in the sun, and if they do, they cover up or lather up in sunscreen. (Sunscreen blocks UVB which is the part required for Vit D synthesis.)


Yeah which is why the argument of "some people don't have enough UV" as the only reason why people don't get vitamin D through the sun is moot. Some places have too much and it is in fact often dangerous to be in the sun in those places.


How was I supposed to get more sun during residency?


Please complete this mandatory module to learn how this is your fault.


Actually, I did that module yesterday, there's no quiz at the end, just a signature, so you can click through without reading.


SHHH DONT TELL THEM THAT. Otherwise we’ll get the ones where every slide is accompanied by a non skippable audio track


Oh god oh god oh god there is no trigger warning on your post!


I found out that if you skip to the last 5 seconds of the track. you still get credit for listening to the entire thing


This hits a little too close to home...


And those ones where you just click through, there is a quiz but you just guess and are right.


OMG, can I please just get the "this is what we changed" version of Universal Precautions? My friend made a T-shirt for the 4 rules of Chemistry that basically summarizes every UP training I've been through. 1. Don't lick it. 2. Don't touch it. 3. Don't breathe it. 4. Don't stick your fingers in the centrifuge.


Oh, at least universal precautions are useful. I get ones on bariatric sensitivity, rules for getting a translator, and where to dispose of drugs and chemo equipment. I'm a fucking lab tech, if I see a patient it's in the cafeteria, and if I see a drug it's in the privacy of my own home.


I am so very tangential to patient care as a research support person. If I'm actually directly involved in patient care it's either because the accident happened right in front of me and I was the first person there with any first aid training or something else has gone terribly, terribly wrong. (I did give some thought to coming back as a phlebotomist but opted not to.)


About the best first aid I could give is using my phone to call for help.


But have you completed a yearly one that teaches you abusing patients, laundering money from the company, and sexually abusing coworkers, and even lesbian nurse sexual encounters during “break” on a couch is against the rules?


Management has provided UV tanning beds in the Resident call room and seasonal affective disorder light boxes (SAD Lamps) so you never need to see the Sun again. this along with the cold pizza in the fridge will make your 24 hour call a wonderful experience to better prepare you for a future in medicine


This made me snort. Thank you for that!


In much of the US, the sun is not a strong enough option to generate vitamin D. It has to do with the intensity of the UV rays at different latitudes. Someone in Minnesota may only get sufficient UV exposure for 2-3 months in the summer. What are they supposed to do in the spring, fall, and winter? [https://www.sciencedirect.com/science/article/abs/pii/S1011134406002491](https://www.sciencedirect.com/science/article/abs/pii/S1011134406002491) edit: included the wrong link


Supplements are low cost, widely available, less time consuming, and more compatible with the schedule of the typical working class person. They're also virtually impossible to overdose on, and have no adverse effects for all practical intents and purposes. Put simply, it's like the holy grail of medical treatment in terms of how simple and effective it is. If it ain't broke, don't fix it


You absolutely can overdose on vitamin D, however.


Just had a pt in the ICU who had been taking 40,000iu of D3 everyday for over 2 years. She was really into CrossFit, and apparently the “nutritionist” at her gym recommended it. Ionized calcium was so high it wasn’t readable, the cut off was greater than 15. We had to do CRRT. Watching her monitor was a lesson in ominous cardiac rhythms. I’ve never seen so many rhythms in one pt.


Sun exposure has a lot of flaws as a supplementation approach. It’s spotty and unreliable since there’s huge variation in how much skin is exposed, for how long, at what strength of light, and there’s obviously huge season and weather variations. It’s legitimately harmful since it’s by far the biggest cause of skin cancer, the biggest cause of aging and wrinkling in the skin, and it can even incite some skin conditions rarely. In addition, there’s a huge habitual, lifestyle, and commitment barrier. You literally have to change the way you live your life in order to get more sunlight. Even the most motivated of people struggle with lifestyle change as an effective treatment, whether it be for diabetes, hypertension, vitamin D deficiency, or whatever else. Take all those flaws and compare it to the alternative. Take a pill every day or week. Boom, done.


One contraindication would be patients whose conditions or medications cause photosensitivity.


Not scientific but anecdotal- seems basically everyone who isn’t on vitamin d is deficient even the farm workers is Southern California who were in the sun all day long. It blew my mind at first, but now I’m just skeptical about it being a useful test outside of a focused workup.


It sounds counter-intuitive, but that's not too surprising. Many of the farm workers here in Southern California wear pants, long-sleeve shirts/sweatshirts, gloves, and hats when working in the fields.


Yep- any people who have actually learned to live with strong sun will know that covering up is the best thing to do to protect yourself, even when it’s very hot.


vitamin D is brought up as a cause and cure for everything, if you look on PubMed


Over the years I’ve become increasingly skeptical of the usefulness and accuracy of vitamin d testing. I live in the literal sunshine state. Our clinic had many, many patients that were sun worshippers that were wealthy and spent literal hours per day “laying out” tanning at the beach or by the pool. Their skin looks like leather but their vitamin d levels range from single digits to the low teens. I am always like HOW THO.


Because it’s a crappy test.


I remember hearing on NPR years ago a study of surfers in Hawaii- so they’re in tropical sun 20+ hours a week in just swimsuits- and how many of them were deficient


Skin cancer.


So the whole world north of latitude 40 N is just going to decamp to the tropics for six months of the year? That's pretty fucking expensive, even if none of the pipes freeze while they're gone. Not to mention accomodation in the southerly latitudes. (Fun fact, excluded the people south of 40 S because I could put them up in my basement) Also, I have heard a rumor that sometimes people have melanin in their skin?




Check a map, sweetie.




It's literally below the mainland of australia. Tassie and the south island and tierra del fuego.






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> sun exposure gives a whole lot of vitamin D and given also that this avenue is entirely free For most people, sun exposure is far from free. They work during sunshine hours, at least during the winter, and the sun is too weak, so you would need to travel south to get any decent amount of sunshine. And there is the whole skin cancer problem. Supplements are cheap by comparison, effective, controllable, nearly side-effect free.


Speaking as a lay person who’s had vitamin D deficiency, it’s probably much like losing weight. There’s a reason I got deficient and a doctor telling me to get out more is not going going to help. Pills on the other hand, I can do those. Injections even better.


You need a UV index of 3+ and adequate sun exposure on enough of your body to actually produce Vitamin D. In areas such as Boston (42 degrees) the conditions for Vitamin D production aren't met at all between October to March, the same is true of everywhere north of there.


I live in an exceptionally sunny climate and am as pale as my Irish ancestry would make you assume. I am always low on vit D because if I don't sunscreen up i turn bright red. even short suncreenless jaunts in the sun don't seem to make a diffference. For whatever reason I don't make it well. Supplements are great.


Just looked it up, 500ct vit d soft gels at Target for $11.75.


The sun is literally free, bro.


The sun is pretty expensive if you live in the north and have to fly south to get any


And get skin cancer in the process


Can I get a UV light filter so I'm only exposed to the good UV rays to make my vitamin D and not the UV rays that cause DNA dimers? /s


UVB is the one produce vit d but it will DIRECTLY change you DNA and get high risk of skin cancer So yeah supplement is the only choice


Sorry, I was being sarcastic/facetious, I do know that the same UV wavelength that catalyzes the vitamin D formation is also the same energy level to catalyze thymine dimer formation.


It's not, though. There is the cost of only working a few months a year, the extra accomodation in the south, etc, etc. and god forbid the pipes freeze while you're gone.


How long are we going to pretend that the Vitamin D reference ranges are of any clinical utility?


I think it's because there's a limit to how much vitamin d your body produces after sun exposure. It might be enough for the day but if you already have a deficiency then that's not closing the gap so you need to get back to a normal level before normal every day sun exposure is enough for the individual.


> Is there some reason that I'm just missing or not aware of? Because "touching grass" just isn't a practical option for people depending on their lifestyle. Vitamin D supplementation is just more reliable and addresses the issue directly.


You're neglecting how much more sun exposure some someone with more melanin needs to produce vitamin D compared to someone who's paler, plus people who live in areas that are frequently cold/cloudy and feasibly can't just rely on sun exposure. As an Arab who lives in the wintery overcast Northeast USA, if someone told me to swap supplementation for more sun exposure I'd laugh directly in their face.


There are also those rare folks with solar uticaria, who are pretty miserable when exposed to the sun.


Anyone who comes up with a way to get any decent majority of people to follow through on any recommended behavior changes of any kind is pretty much guaranteed the Nobel prize.


Many AEDs actively block or compete with Vitamin D absorption in the gut. If I remember correctly, they're not the only class of drugs that do. Also consider bariatric surgery and other gastric issues. Supplements are cheap, covered by insurance even, and they work.


UVA cause aging and UVB cause skin cancer why do we need sun exposure?