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Investigating the long-term impact of a childhood sun-exposure intervention, with a focus on eye health: protocol for the Kidskin-Young Adult Myopia Study

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Introduction Excessive and insufficient sun exposure during childhood have been linked to serious diseases in later life; for example, insufficient sun exposure during childhood may increase the risk of developing myopia. The Kidskin-Young Adult Myopia Study (K-YAMS) is a follow-up of participants in the Kidskin Study, a non-randomised controlled trial that evaluated the effect of a 4-year educational intervention on sun-protection behaviours among primary school children in the late 1990s. Children who received the Kidskin intervention had lower levels of sun exposure compared with peers in the control group after 2 and 4 years of the intervention, but this was not maintained 2 years after the intervention had ceased. Thus, a follow-up of Kidskin Study participants provides a novel opportunity to investigate the associations between a childhood sun-exposure intervention and potentially related conditions in adulthood. Methods and analysis The K-YAMS contacts Kidskin Study participants and invites them to participate using a variety of methods, such as prior contact details, the Australian Electoral Roll and social media. Self-reported and objective measures of sun-exposure and sun-protection behaviours are collected as well as a number of eye measurements including cycloplegic autorefraction and ocular biometry. Data will be analysed to investigate a possible association between myopic refractive error and Kidskin intervention group or measured sun exposure. Ethics and dissemination The K-YAMS is approved by the Human Research Ethics Committee of the University of Western Australia (RA/4/1/6807). Findings will be disseminated via scientific journals and conferences. Trial registration number ACTRN12616000812392; Pre-results.
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LinghamG, etal. BMJ Open 2018;8:e020868. doi:10.1136/bmjopen-2017-020868
Open Access
Investigating the long-term impact of a
childhood sun-exposure intervention,
with a focus on eye health: protocol for
the Kidskin-Young Adult Myopia Study
Gareth Lingham,1 Elizabeth Milne,2 Donna Cross,2 Dallas R English,3
Robyn S Johnston,4 Robyn M Lucas,1,5 Seyhan Yazar,1 David A Mackey1
To cite: LinghamG, MilneE,
CrossD, etal. Investigating the
long-term impact of a childhood
sun-exposure intervention,
with a focus on eye health:
protocol for the Kidskin-Young
Adult Myopia Study. BMJ Open
2018;8:e020868. doi:10.1136/
bmjopen-2017-020868
Prepublication history for
this paper is available online.
To view these les, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2017-
020868).
Received 28 November 2017
Accepted 1 December 2017
1Centre for Ophthalmology
and Visual Science, Lions Eye
Institute, University of Western
Australia, Nedlands, Western
Australia, Australia
2Telethon Kids Institute,
University of Western Australia,
West Perth, Western Australia,
Australia
3Centre for Epidemiology and
Biostatistics, University of
Melbourne, Melbourne, Victoria,
Australia
4McCusker Centre for Action
on Alcohol and Youth, Curtin
University, Bentley, Western
Australia, Australia
5National Centre for
Epidemiology and Population
Health, Australian National
University, Canberra, Australian
Capital Territory, Australia
Correspondence to
Prof.David AMackey;
davidmackey@ lei. org. au
Protocol
ABSTRACT
Introduction Excessive and insufcient sun exposure
during childhood have been linked to serious diseases in
later life; for example, insufcient sun exposure during
childhood may increase the risk of developing myopia. The
Kidskin-Young Adult Myopia Study (K-YAMS) is a follow-up
of participants in the Kidskin Study, a non-randomised
controlled trial that evaluated the effect of a 4-year
educational intervention on sun-protection behaviours
among primary school children in the late 1990s. Children
who received the Kidskin intervention had lower levels of
sun exposure compared with peers in the control group
after 2 and 4 years of the intervention, but this was not
maintained 2 years after the intervention had ceased.
Thus, a follow-up of Kidskin Study participants provides a
novel opportunity to investigate the associations between
a childhood sun-exposure intervention and potentially
related conditions in adulthood.
Methods and analysis The K-YAMS contacts Kidskin
Study participants and invites them to participate using
a variety of methods, such as prior contact details, the
Australian Electoral Roll and social media. Self-reported
and objective measures of sun-exposure and sun-
protection behaviours are collected as well as a number
of eye measurements including cycloplegic autorefraction
and ocular biometry. Data will be analysed to investigate a
possible association between myopic refractive error and
Kidskin intervention group or measured sun exposure.
Ethics and dissemination The K-YAMS is approved by
the Human Research Ethics Committee of the University
of Western Australia (RA/4/1/6807). Findings will be
disseminated via scientic journals and conferences.
Trial registration number ACTRN12616000812392; Pre-
results.
INTRODUCTION
High levels of sun exposure during child-
hood increase the risk of melanoma in later
life.1 However, a lack of sun exposure during
childhood has been linked to the develop-
ment of diseases such as myopia,2 3 multiple
sclerosis4 and type 1 diabetes mellitus.5
Myopia (near-sightedness) is a common
condition affecting approximately 24% of
20-year olds in Australia.6 The prevalence
of myopia is increasing in many parts of the
world, and current research aims to prevent
the onset or progression of myopia and the
potentially blinding diseases associated with
myopia.6–8 Recent randomised clinical trials
in Chinese school children have shown that
spending extra time outside during the day
prevented the onset of myopia in some chil-
dren2 9; however, it is unknown whether sun
exposure, increased retinal illumination or
viewing of distant objects is responsible for
this beneficial effect.
Between 1995 and 2001, Western Austra-
lian researchers conducted the Kidskin Study,
a 6-year non-randomised controlled trial that
aimed to ‘design, implement and evaluate an
intervention to reduce sun exposure in chil-
dren’10 and thus reduce the risk of melanoma
in later life.10 11 Eligible participants were those
attending their first year of schooling in 1995
at a participating school, all of which were
located within 30 km of Perth. Of the 2528
children invited to participate in the Kidskin
Study, consent was provided by a parent or
Strengths and limitations of this study
The Kidskin-Young Adult Myopia Study participants
were involved in a well-conducted and well-
described interventional trial which successfully
reduced sun exposure for a dened period of
childhood.
Multiple objective and subjective measures of recent
and cumulative sun exposure are collected.
Participants undergo a comprehensive eye
examination with measurement of multiple ocular
parameters.
Most Kidskin participants have not been contacted
for 16 years, therefore, recruitment may be
challenging; however, multiple recruitment
strategies are planned to re-engage participants.
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Open Access
legal guardian for 1776 participants.10 Table 1 provides
an overview of the schedule of the intervention and
outcome measurements in the Kidskin Study.11 12 During
the intervention period between the spring of 1995 and
the summer of 1998–1999, participants were assigned to
a high-intervention, a moderate-intervention or a no-in-
tervention comparison group (hereafter referred to as
high, moderate or control groups) and were examined
at ages 5–6 (baseline), 7–8, 9–10 (end of intervention)
and 11–12 years.10 12 13 The intervention was a specially
designed curriculum that was administered to the high
and moderate groups and replaced the regular sun safety
education curriculum. The Kidskin Study curriculum
was designed to be developmentally appropriate and
skills-based and included both school-based and home-
based activities that were administered in school by the
children’s primary school teacher.13 In addition to the
Kidskin Study curriculum, the high group also received
‘Totally Cool Summer Club’ programme material over
the summer holidays and was offered low-cost swimwear
that protected the trunk, upper arms and thighs. Schools
allocated to the high-intervention group were also given
assistance in implementing sun-protection policies.10 The
control group received the standard Western Australian
health education curriculum over the same period.10
The primary outcome was change in number of mela-
nocytic naevi on the back at the 4-year follow-up. This was
not significantly different between the high, moderate
and control groups at the end of intervention (1999)
and 2-year postintervention (2001) follow-ups. Analysis
of secondary outcomes showed that parents of children
in the high group reported that their child experienced
less whole body sun exposure than that reported by the
parents in the control group at the 2-year and 4-year
follow-ups (1997 and 1999).11 14 Parents of children in
both intervention groups reported that their children
spent less time outside between 11:00 and 14:00 at the
2-year follow-up, but at the 4-year follow-up, only children
in the high group had significantly lower reported time
spent outdoors between 11:00 and 14:00 compared with
the control group.12 14 Measurement of suntan using skin
spectrophotometry showed that children in the high and
moderate groups had a significantly lower level of suntan
at the end of summer than the control group at the 2-year
follow-up.15 However, there was no significant difference
at the 4-year and postintervention follow-ups.12 The skin
spectrophotometer had to be changed between the 2-year
and 4-year follow-ups as it became unserviceable, and
this change in measurement instrument may be a factor
in the lack of an association between measured suntan
and intervention group at the later follow-ups.12 At the
final Kidskin Study follow-up in 2001, 2 years after the
intervention had ceased, there was no significant differ-
ence in suntan or sun exposure between children in the
high, moderate and control groups with the exception of
applying sunscreen to the back, which was more common
in the moderate and high groups.
The size, quality and length of intervention and
follow-up of the Kidskin Study make it unique among
studies of child and adolescent sun protection. Other
sun-protection intervention studies have had mixed
results in reducing sun exposure in participants. Studies
finding no effect of an intervention, lacking a control
group or not longitudinally following the same partic-
ipants have limited usefulness when investigating the
impacts of sun exposure during childhood.16–20 Of the
studies that have successfully reduced sun exposure in the
intervention group compared with the control group, all
have had shorter intervention and follow-up periods than
the Kidskin Study.21–23
Hence, the Kidskin Study provides a novel opportu-
nity to investigate the association between sun exposure
during childhood and the development of potentially
related conditions in adulthood. The intervention study
formed a cohort in which particular groups of participants
had different levels of sun exposure during a well-de-
fined period in primary school. Additionally, participants
had both subjective and objective measurements of sun
exposure recorded at multiple time points throughout
childhood.
The Kidskin Study participants are 27–28 years old in
2017—an age when the prevalence of myopia, a disorder
that predominantly develops in younger life—has gener-
ally stabilised.24 The Kidskin Young Adult Myopia Study
Table 1 Schedule of Kidskin study intervention and data collection
1995 1996 1997 1998 1999 2000 2001
Intervention Spring* Spring Spring Spring
Suntan† Summer‡* Summer‡ Summer‡
Questionnaire Spring Summer‡ Summer‡ Summer‡
Constitutional†§ Winter* Winter Winter
Naevus counts Winter Winter Winter
Adapted from Milne.11
*In Australia, summer is from December to February, autumn from March to May, winter from June to August and spring from September to
November.
†Measured by skin spectrophotometry.
‡Measured at the end of summer immediately after school holidays.
§Constitutional skin colour measured from inner arm.
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Open Access
(K-YAMS) will follow-up participants in the Kidskin
Study, to determine the long-term effects on health
—particularly eye health—of a sun-protection interven-
tion during childhood.
METHODS AND ANALYSIS
Recruitment
The K-YAMS aims to use the established Kidskin Study
cohort to investigate the association between the Kidskin
intervention and the prevalence of myopia in partici-
pants of the Kidskin Study, who are now young adults.
Recruitment for the K-YAMS began in May 2015 and will
be completed by the end of 2018. All participants of the
Kidskin Study are eligible to participate. The expected
follow-up sample size (n ~800) is likely to be too small
to investigate rarer outcomes such as type 1 diabetes
mellitus, but will be large enough to detect differences in
relatively common disorders such as myopia.
While a significant amount of time has passed since the
Kidskin participants were last contacted, approximately
one-third (n=547) of participants responded to a mail
out invitation to provide a saliva sample in 2005; however,
since 2001, the majority of the Kidskin participants have
not been contacted. We are therefore using a variety of
approaches to contact participants including previous
address and telephone or mobile phone details from the
Kidskin Study, Facebook, the Australian Electoral Roll
and snowball recruiting from participants we have been
able to contact, asking them to help spread awareness of
the K-YAMS to their schoolmates.
Data collection
An overview of the measures being collected in the
K-YAMS is given in table 2. The K-YAMS focuses on
myopia and eye health; however, a number of other
broader health measures are also being collected. Partic-
ipants are required to attend a study examination at the
Lions Eye Institute in Perth, Western Australia. Written
informed consent is obtained from all participants prior
to the study examination.
Self-reported data
Participants are asked to complete a questionnaire as well
as a sun calendar at home or during the study visit. Ques-
tionnaire data include current demographics, medical
and ophthalmic history, recent and past sun exposure,
natural hair colour, skin type and skin reaction after sun
exposure. The sun calendar asks participants to report
city of residence and sun-exposure (summer and winter
in categories of ‘less than half an hour per day’, ‘half to
1 hour’, ‘1–2 hours’, ‘2–3 hours’, ‘3–4 hours’ and ‘more
than 4 hours’) and sun-protection behaviours (hat,
sunglasses and sunscreen in categories of ‘never’, ‘less
than half of the time’, ‘half of the time’, ‘more than half
of the time’ and ‘all of the time’) for each year of life from
5 years of age onward. The self-reported calendar data
for the period of the intervention will be compared with
the self-reported and measured data on sun exposure and
sun protection for the intervention period.
Exposure measurements
A variety of objective measures of sun exposure are
being collected to gain a better understanding of each
individual’s past and recent exposure to sun. Skin
photodamage is measured using silicone skin casts
taken from the back of participants’ right hands and
graded on a scale of 1 to 6, as previously described by
Holman et al,25 where grade 1 represents no or little
sun-related skin damage and grade 6 represents severe
skin damage.25 26 Participants will have their back
photographed and the number of naevi counted by a
trained examiner.27 Conjunctival ultraviolet autoflu-
orescence photographs to measure past sun exposure
of the eye are captured using a Nikon D100 camera
(Nikon, Melville, New York, USA) with a B+W 486 UV
IR filter (Schneider Kreuznach, Bad Kreuznach, Rhine-
land-Palatinate, Germany) fitted to a 105 mm f/2.8
Micro Nikkor lens (Nikon). Two Metz 36 C-2 flashes
(Metz, Zirndorf, Middle Franconia, Germany) with 18A
Wratten glass filters fitted over the flash heads are used
as the excitation source. Blood is taken by venepunc-
ture into serum separator tubes. One millilitre aliquots
of serum are frozen at −40°C until the completion of
the study. Liquid chromatography tandem–mass spec-
trometry will then be used to measure serum 25-hydroxy
vitamin D concentration, as a marker of recent sun
exposure, after completion of data collection.
Outcome measurements
Participants have refractive error measurements taken
using cycloplegic autorefraction (Nidek ARK-510A;
Nidek, Japan). Myopia is defined as a spherical
Table 2 Outcome measures in the K-YAMS
Eye and vision
measures
Sun-exposure
measures
Other health
measures
Refractive error
Strength of current
prescribed glasses
Visual acuity
Corneal endothelial cell
count
Ocular motility and
stereoacuity status
Eye colour photography
Ocular biometry
Intraocular pressure
Macular and optic disc
parameters measured
using HRT and OCT
Retinal photography
Sun damage
measured from
silicone skin cast
of back of right
hand
Serum 25(OH)D
concentration
Ocular sun
exposure
(CUVAF)
Self-reported
history of sun
exposure
Height
Weight
Blood
pressure
Naevi count
on back
Naevi count
on right arm
DNA
Self-reported
skin and hair
phenotypes
25(OH)D, 25-hydroxy vitamin D; CUVAF, conjunctival ultraviolet
autouorescence; HRT, Heidelberg retina tomography; K-YAMS,
Kidskin-Young Adult Myopia Study; OCT, optical coherence
tomography.
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Open Access
equivalent 0.50 dioptres (D) (calculated as sphere+½
cylinder). A variety of other eye and vision measure-
ments are collected including visual acuity (ETDRS
chart R; Precision Vision, Woodstock, Illinois, USA),
ocular biometry (IOL master 500; Carl Zeiss Meditec,
Jena, Germany), intraocular pressure (icare TA01i;
icare, Vantaa, Finland), optical coherence tomog-
raphy (Spectralis HRA+OCT; Heidelberg Engineering,
Heidelberg, Germany) and fundus photography
(CF-60DSi; Canon, USA).
Data analysis
The primary analysis of the K-YAMS will test the associa-
tion between spherical equivalent/prevalence of myopia
and intervention group of the Kidskin Study. Linear
and logistic regression models will be constructed to
investigate the impacts of the Kidskin Study interven-
tion on continuous and categorical outcomes, respec-
tively, while adjusting for covariates such as age and
education. Secondary analysis will involve the construc-
tion of further linear and logistic regression models
to investigate the associations between past sun expo-
sure, irrespective of Kidskin Study intervention arm,
and ocular parameters such as spherical equivalent and
axial length, while adjusting for confounding variables.
We will have 99.63% power to detect a difference of
0.50 D of spherical equivalent between the high inter-
vention and control groups with a sample size of 800.
However, if we are unable to meet our recruitment
target, we will still have 96.7% and 87.5% power to detect
a difference of 0.50 D between the high and control
groups with sample sizes of 600 and 400, respectively.
Implications
Australia has the highest skin cancer incidence in the
world; melanoma is the deadliest of the skin cancers
and is particularly associated with childhood sun expo-
sure.28 Incidence rates of melanoma were rapidly rising
in the late 20th century. In the face of this, Australia led
the world in developing sun-protection programmes
to reduce childhood sun exposure. Encouragingly,
the incidence of melanoma in Australia has remained
stable since 2006.28 However, recent evidence suggests
that there may be beneficial effects of sun exposure,
such as preventing onset of myopia, and it is now
essential to understand these effects to find a balance
between excessive and insufficient sun exposure.5 29
Unfortunately, the impact of childhood sun exposure is
difficult to study. First, the effects—both beneficial and
detrimental—can take a long time to manifest so that
either recall of distant events is required for retrospec-
tive studies or long length of follow-up is required for
prospective studies. Second, observational studies of sun
exposure are unable to attribute observed associations
specifically to sun exposure, due to other confounding
factors that often accompany sun exposure, such as
physical activity. Randomised controlled trials can over-
come this issue, but are difficult and costly to run, and
can pose ethical dilemmas, for example, where the
full effects of an intervention have potential adverse
effects on health. In addition, in an intervention study,
it may be a long time before the harmful or beneficial
effects of the intervention are fully appreciated. The
Kidskin Study was a thorough controlled trial that was
completed in 1999 and presents a truly unique oppor-
tunity to immediately begin studying the effects of an
intervention which successfully reduced sun exposure
compared with controls. A difference in myopia prev-
alence across the intervention groups may suggest that
the age period over which Kidskin participants received
the intervention is a key period in the development
of myopia. This age group could then be targeted by
public health campaigns aimed at preventing the onset
of myopia in at-risk children through a controlled
increase in time spent outside. However, the utility of
the Kidskin Study cohort is not limited to myopia, and
further follow-ups could provide crucial information
in examining the effects of reducing childhood sun
exposure.
ETHICS AND DISSEMINATION
Findings from the K-YAMS will be disseminated via publi-
cation in scientific peer-reviewed journals and presenta-
tion at national and international conferences. K-YAMS
participants will also be notified of publications and
provided with a copy where possible. All subjects provide
written informed consent prior to participating in the
study and are made aware that they may withdraw their
consent at any time or refuse any procedure such as
venepuncture or administration of cycloplegic eye-drops.
A trained medical doctor is present during study examina-
tions in the unlikely event of an adverse event occurring.
Contributors GL, DAM, SY and RML were involved in the conception and design
of this manuscript. EM, DRE, DC and RSJ were involved in the conception, design,
implementation, data collection and analysis of the Kidskin Study between 1995
and 2001. DAM, SY, RML and EM were involved in the conception and design of the
K-YAMS. GL was responsible for the initial drafting of the manuscript. All authors
critically reviewed, revised and contributed to the manuscript.
Funding A pilot study of the K-YAMS was funded by a Perpetual Impact
Philanthropy Grant (IPAP2015/0230). The K-YAMS study is funded by a competitive,
peer-reviewed Project Grant from the National Health and Medical Research
Council (1121979). GL receives nancial support through an Australia Government
Research Training Program Scholarship. SY is supported by a National Health and
Medical Research Council CJ Martin Early Career Fellowship. DC is supported by a
National Health and Medical Research Council Research Fellowship GNT 1119339.
RML is supported by a National Health and Medical Research Council Senior
Research Fellowship (#1107343) and a Cancer Australia grant.
Competing interests None declared.
Patient consent Parental/guardian consent obtained.
Ethics approval K-YAMS is approved by the Human Research Ethics Committee of
the University of Western Australia (RA/4/1/6807).
Provenance and peer review Not commissioned; peer reviewed for ethical and
funding approval prior to submission.
Open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
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properly cited and the use is non-commercial. See: http:// creativecommons. org/
licenses/ by- nc/ 4. 0/
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
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Kidskin-Young Adult Myopia Study
focus on eye health: protocol for the
childhood sun-exposure intervention, with a
Investigating the long-term impact of a
S Johnston, Robyn M Lucas, Seyhan Yazar and David A Mackey
Gareth Lingham, Elizabeth Milne, Donna Cross, Dallas R English, Robyn
doi: 10.1136/bmjopen-2017-020868
2018 8: BMJ Open
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... Young healthy community-based adults were recruited from two cohort studies-Generation 2 (Gen2) of the Raine Study [43] and the Kidskin Young Adults Myopia Study (K-YAMS) [44]. Methodology for the eye examinations in both studies have been described previously [43,44]. ...
... Young healthy community-based adults were recruited from two cohort studies-Generation 2 (Gen2) of the Raine Study [43] and the Kidskin Young Adults Myopia Study (K-YAMS) [44]. Methodology for the eye examinations in both studies have been described previously [43,44]. Briefly, for the Raine Study, 2,900 pregnant women were seen at the King Edward Memorial Hospital from May 1989 to November 1991, to whom 2,868 offspring were born, forming the original study cohort (termed "Gen2"). ...
... The eye examination included autorefraction and keratometry (Nidek ARK-510A Autorefractometer [Nidek Co Ltd, Tokyo, Japan]), ocular biometry (IOLMaster v 5 [Carl Zeiss Meditec AC, Jena, Germany]), and SD-OCT imaging Spectralis HRA+OCT [Heidelberg Engineering, Heidelberg, Germany]) [43,44]. Autorefraction was taken at least 20 minutes after instillation of one drop of 1% tropicamide. ...
Article
Purpose: Changes in retinal thickness are common in various ocular diseases. Transverse magnification due to differing ocular biometrics, in particular axial length, affects measurement of retinal thickness in different regions. This study evaluated the effect of axial length and refractive error on measured macular thickness in two community-based cohorts of healthy young adults. Methods: A total of 2160 eyes of 1247 community-based participants (18-30 years; 23.4% myopes, mean axial length = 23.6mm) were included in this analysis. Macular thickness measurements were obtained using a spectral-domain optical coherence tomography (which assumes an axial length of 24.385mm). Using a custom program, retinal thickness data were extracted at the 9 Early Treatment of Diabetic Retinopathy Study (ETDRS) regions with and without correction for transverse magnificent effects, with the corrected measurements adjusting according to the participant's axial length. Linear mixed models were used to analyse the effect of correction and its interaction with axial length or refractive group on retinal thickness. Results: The raw measures (uncorrected for axial length) underestimated the true retinal thickness at the central macula, while overestimating at most non-central macular regions. There was an axial length by correction interaction effect in all but the nasal regions (all p<0.05). For each 1mm increase in axial length, the central macular thickness is overestimated by 2.7-2.9μm while thicknesses at other regions were underestimated by 0.2-4.1μm. Based on the raw thickness measurements, myopes have thinner retinas than non-myopes at most non-central macular. However, this difference was no longer significant when the corrected data was used. Conclusion: In a community-based sample, the raw measurements underestimate the retinal thickness at the central macula and overestimate the retinal thickness at non-central regions of the ETDRS grid. The effect of axial length and refractive error on retinal thickness is reduced after correcting for transverse magnification effects resulting from axial length differences.
... The Kidskin Study was initially established to investigate the effects of sun exposure during childhood (age 5-12 years) on development of melanocytic naevi, a marker of melanoma risk. The KYAMS focussed on eye health in young adulthood (25-30 years of age) but used data on sun exposure collected during the Kidskin Study to investigate the long-term effects of childhood sun exposure on myopia (near-sightedness) [4]. ...
... The KYAMS investigated the effect of childhood sun exposure on myopia in young adulthood. Participation in the study involved a 2-to 3-h eye examination at the Lions Eye Institute in Perth, Western Australia [4]. All participants of the Kidskin Study who had not withdrawn consent were eligible to participate in the KYAMS. ...
Article
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Background: Recent changes in communication technologies, including increased reliance on mobile phones and the internet, may present challenges and/or opportunities to re-engaging inactive study cohorts. We evaluate our ability to recruit participants for the Kidskin Young Adult Myopia Study (KYAMS), a follow-up of the Kidskin Study. Methods: KYAMS participants were recruited from the Kidskin Study, a sun exposure-intervention study for 5-6 year-olds running from 1995 to 1999 with most recent follow-up in 2005. From 2015 to 2019, the KYAMS used mail-outs, phone calls and social media to contact Kidskin Study participants. Multivariable logistic regression was used to identify variables associated with successful contact of a Kidskin Study participant or family member and KYAMS participation. Results: Of 1695 eligible participants, 599 (35.5%) participants (or a family member) were contacted and 303 (17.9%) participated in the KYAMS. KYAMS participation was more likely in those who participated in the 2005 follow-up (odds ratio [OR] = 5.09, 95% confidence interval [CI]: 3.67-7.06) and had a mobile phone number on record (OR = 2.25, CI: 1.57-3.23). Of those contacted, participants who were the first point of contact (OR = 4.84, CI: 2.89-8.10) and who were contacted by letter in the first (OR = 6.53, CI: 3.35-12.75) or second (OR = 5.77, CI: 2.85-11.67) round were more likely to participate in the KYAMS, compared to contact by landline phone. Conclusions: We recruited approximately one-fifth of Kidskin Study participants for the KYAMS. Participants were more likely to participate in the KYAMS if they were contacted directly, rather than through a family member, and if they were contacted by invitation letter. Trial registration: ACTRN12617000812392.
... The Kidskin Young Adult Myopia Study [KYAMS; details previously published 26 ] is a follow-up of the Kidskin Study, a non-randomised controlled trial that aimed to reduce sun exposure in children through a sun exposure-intervention. In 1995, the Kidskin Study enrolled 1776 children attending their first year of school (aged 5-6 years) in the Perth metropolitan region, Australia. ...
Article
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Myopia (near-sightedness) is an important public health issue. Spending more time outdoors can prevent myopia but the long-term association between this exposure and myopia has not been well characterised. We investigated the relationship between time spent outdoors in childhood, adolescence and young adulthood and risk of myopia in young adulthood. The Kidskin Young Adult Myopia Study (KYAMS) was a follow-up of the Kidskin Study, a sun exposure-intervention study of 1776 children aged 6–12 years. Myopia status was assessed in 303 (17.6%) KYAMS participants (aged 25–30 years) and several subjective and objective measures of time spent outdoors were collected in childhood (8–12 years) and adulthood. Index measures of total, childhood and recent time spent outdoors were developed using confirmatory factor analysis. Logistic regression was used to assess the association between a 0.1-unit change in the time outdoor indices and risk of myopia after adjusting for sex, education, outdoor occupation, parental myopia, parental education, ancestry and Kidskin Study intervention group. Spending more time outdoors during childhood was associated with reduced risk of myopia in young adulthood (multivariable odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69, 0.98). Spending more time outdoors in later adolescence and young adulthood was associated with reduced risk of late-onset myopia (≥ 15 years of age, multivariable OR 0.79, 95% CI 0.64, 0.98). Spending more time outdoors in both childhood and adolescence was associated with less myopia in young adulthood.
... Wearable detectors have been developed to record light intensity and time outdoors, and even track the patterns of outdoor activities, including HOBO light meters, Nike+ Fuel Band, and others. Other measures have been used to estimate exposure to natural light such as conjunctival ultraviolet autofluorescence and skin photodamage, but these are more appropriate when measuring the cumulative light dosage or UV exposure [50,51]. ...
Chapter
Full-text available
Given the prevalence of myopia has been increasing significantly across the world, especially in East Asia, great challenges have been raised for myopia correction and the management of pathological myopia. Delaying the onset of myopia will likely reduce the prevalence of myopia as well as high myopia in school-aged children. Prevention of the onset of myopia is therefore an important priority. This chapter focuses on the clinical strategy to prevent or delay the onset of myopia among school-aged children, summarizing the interventions currently available, including increased time outdoors, reduced near work, latest optical interventions, eye exercises of acupoints, and takes a glance at future perspectives.
Article
Full-text available
Purpose: To describe the thickness profiles of the full retinal and outer retinal layers (ORL) at the macula in healthy young adults, and associations with best-corrected visual acuity (BCVA). Methods: In total, 1604 participants (19-30 years) underwent an eye examination that included measurements of their BCVA, axial length, and autorefraction. The retinal thickness at the foveal pit and at the nine Early Treatment of Diabetic Retinopathy Study macular regions (0.5-mm radius around the fovea, and superior, inferior, temporal, and nasal quadrants of the inner and outer rings of the macula) were obtained using spectral-domain optical coherence tomography imaging. A custom program was used to correct for transverse magnification effects because of different axial lengths. Results: The median full retinal and ORL thicknesses at the central macula were 285 µm and 92 µm. The full retina was thinnest centrally and thickest at the inner macula ring, whereas the ORL was thickest centrally and gradually decreased in thickness with increasing eccentricity. There was no association between axial length and the full retinal or ORL thickness. Increased thicknesses of the full retina at the central macula was associated with better BCVA; however, the effect size was small and not clinically significant. Conclusions: This article mapped the full retinal and ORL thickness profile in a population-based sample of young healthy adults. Translational relevance: Thickness values presented in this article could be used as a normative reference for future studies on young adults and in clinical practice.
Article
Purpose To describe the central choroidal thickness (ChT) in a large sample of young adults with the aim of establishing a normative ChT profile reference in this demographic cohort, and explore its association with best-corrected visual acuity (BCVA). Design Cross-sectional study Methods From a single-center, 741 young adults (19−30 years, 49% male) were recruited to undergo a comprehensive ophthalmic examination, including BCVA measurement, autorefraction, ocular biometry, tonometry, and spectral-domain optical coherence tomography (SD-OCT) imaging. The enhanced depth imaging mode on the SD-OCT was used. The main outcome measure was the central macular ChT (0.5mm radius around the fovea). The ChTs at the inner (between 0.5 and 1.5mm radius) and outer macular rings (between 1.5 and 2.5mm radius) were additionally measured. Results Median central macular ChT was 370μm (interquartile range= 312−406μm). The choroid was thickest at the superior, inferior, and central macular regions (370−373μm), and thinnest nasally at the outer macular region (median=256μm). Decreased central macular ChT was associated with younger age, female sex, non-Caucasian ethnicities, and myopia (p≤0.013). There was a significant association between better BCVA and increased central macular ChT (p<0.001), after adjusting for age, sex, ethnicity, and ocular measures. This relationship was only apparent in eyes with central macular ChTs <300μm (p=0.019) and absent in eyes with ChTs >300μm. Conclusions The central ChT of young adults was 370 μm. There was a significant association between worse BCVA and thinner choroids below a threshold of 300μm, raising the possibility that ChT could be predictive of visual function.
Article
To examine the impact of sun exposure on human health, accurate measures of past sun exposure are required. We investigated how young adults’ recall of childhood sun-related behaviours compares with parent-reported measures collected during childhood. The Kidskin-Young Adult Myopia Study (KYAMS) is a follow-up of the Kidskin Study, a sun-protection intervention study conducted from 1995-2001. KYAMS participants, aged 25-30 years, reported time in sun, and use of hat and sunscreen, for each year from ages 5-26 years (n=244). Using weighted kappa, we assessed agreement between these data and corresponding variables derived from the Kidskin Study parent questionnaires completed when KYAMS participants were aged 6-12 years. Ordinal logistic regression was used to test the association between self-reported sun-behaviours and corresponding parent-reported data. We found slight agreement between self-reported and parent-reported data for all sun-behaviour measures except hat use at 12 years. KYAMS recall of time in sun at 8-12 years was not associated with Kidskin Study parent-reported responses after adjustment for current time in sun. Recall of higher hat and sunscreen use was associated with higher parent-reported hat and sunscreen use (OR[hat]=1.37, 95% CI: 1.16, 1.62; OR[sunscreen]=1.23, 95% CI: 1.03, 1.48). However, KYAMS self-reported data were unable to predict corresponding parent-reported responses. Group data from retrospective recall of sun-related behaviours may be of limited value in studying the relationship between sun exposure and health outcomes; however, individual data are likely of little use.
Thesis
Fragestellung: Ist es sinnvoll im Kindesalter restriktiv einen UV-Schutz für die Augen anzuwenden, obwohl UV-Strahlung eine schützende Wirkung für das Entstehen einer Myopie hat? Einleitung: Die Myopie ist eine typischerweise durch Längenwachstum des Augapfels verursachte Fehlsichtigkeit mit stark steigender Prävalenz in den letzten Jahrzenten. UV-Strahlung hat auf die Haut und die Augen eine Vielzahl negativer Auswirkungen. Nebst der akuten Photokeratitis sind Pinguecula, Pterygium, Plattenepithelneoplasie, Katarakt, AMD und maligne Melanome chronische Veränderungen. Andererseits bremst UV-Strahlung das Fortschreiten des Augenlängenwachstums. Modellrechnung: Mittels dem evidenzbasierten Modellrechner kann das Risiko einer Myopie und deren Stärke anhand des Jahrgangs, der Sonnenschutzanwendung, der familiären Prädisposition, der Zeit im Freien und des Bildungsgrades berechnet werden. Gelegentlich angewandter Sonnenschutz hat gegenüber häufig angewandtem Sonnenschutz einen Schutzfaktor für die Myopieentstehung von 1.03. Das grösste Risiko einer Myopie kommt von der familiären Prädisposition. Diskussion: Zeit im Freien hat einen grossen hemmenden Effekt auf die Myopie, Sonnenschutzanwendung nur einen leicht Fördernden. Zudem hat Sonnenschutz einen stark hemmenden Effekt auf UV-bedingte Augen- und Hauterkrankungen. Auf Sonnenschutz der Augen zu verzichten, um eine Myopie zu verhindern oder im Fortschreiten zu bremsen, scheint unvernünftig.
Article
Purpose of review: Myopia refers to a refractive state of the eye that can predispose to visually significant ocular disease. The prevalence of myopia is increasing worldwide. Researchers internationally have been investigating methods to slow down its progression to prevent sight-threatening complications. In this article, we perform a review of the current literature discussing interventions for preventing pediatric myopic progression. Recent findings: Various interventions, including lifestyle modification, optical methods, and pharmacologic approaches, have been proposed to help control myopic progression. Increasing time spent outdoors can help prevent myopia onset, but has a clinically questionable effect on progression of myopia. Contact lenses that reduce peripheral retinal hyperopic defocus represent a new area of research and may hold promise as an effective intervention in myopia control. Orthokeratology shows moderate reduction rates in myopic progression whereas atropine drops, even at low doses, show the most impressive effect on slowing myopia. Summary: Atropine eye drops, followed by orthokeratology lenses, are the most effective in slowing down axial elongation and myopic progression. Guidelines for use and the target populations for such interventions have not been well established and more research is warranted in these areas. Treatment should be tailored to each patient.
Article
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Importance: Myopia has reached epidemic levels in parts of East and Southeast Asia. However, there is no effective intervention to prevent the development of myopia. Objective: To assess the efficacy of increasing time spent outdoors at school in preventing incident myopia. Design, setting, and participants: Cluster randomized trial of children in grade 1 from 12 primary schools in Guangzhou, China, conducted between October 2010 and October 2013. Interventions: For 6 intervention schools (n = 952 students), 1 additional 40-minute class of outdoor activities was added to each school day, and parents were encouraged to engage their children in outdoor activities after school hours, especially during weekends and holidays. Children and parents in the 6 control schools (n = 951 students) continued their usual pattern of activity. Main outcomes and measures: The primary outcome measure was the 3-year cumulative incidence rate of myopia (defined using the Refractive Error Study in Children spherical equivalent refractive error standard of ≤-0.5 diopters [D]) among the students without established myopia at baseline. Secondary outcome measures were changes in spherical equivalent refraction and axial length among all students, analyzed using mixed linear models and intention-to-treat principles. Data from the right eyes were used for the analysis. Results: There were 952 children in the intervention group and 951 in the control group with a mean (SD) age of 6.6 (0.34) years. The cumulative incidence rate of myopia was 30.4% in the intervention group (259 incident cases among 853 eligible participants) and 39.5% (287 incident cases among 726 eligible participants) in the control group (difference of -9.1% [95% CI, -14.1% to -4.1%]; P < .001). There was also a significant difference in the 3-year change in spherical equivalent refraction for the intervention group (-1.42 D) compared with the control group (-1.59 D) (difference of 0.17 D [95% CI, 0.01 to 0.33 D]; P = .04). Elongation of axial length was not significantly different between the intervention group (0.95 mm) and the control group (0.98 mm) (difference of -0.03 mm [95% CI, -0.07 to 0.003 mm]; P = .07). Conclusions and relevance: Among 6-year-old children in Guangzhou, China, the addition of 40 minutes of outdoor activity at school compared with usual activity resulted in a reduced incidence rate of myopia over the next 3 years. Further studies are needed to assess long-term follow-up of these children and the generalizability of these findings. Trial registration: clinicaltrials.gov Identifier: NCT00848900.
Article
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Purpose To determine the association between ocular sun exposure measured by conjunctival ultraviolet autofluorescence and myopic refractive error in young adults. Design Cross-sectional study Methods Setting: Population-based cohort in Western Australia Study population 1344 mostly white subjects aged 19-22 years in the Western Australian Pregnancy Cohort (Raine) Eye Health Study Observation procedures Cycloplegic autorefraction, conjunctival ultraviolet autofluorescence photography, participant questionnaire Main Outcome Measures Prevalence of myopic refractive error (spherical equivalent less than -0.50 diopters) and area of conjunctival ultraviolet autofluorescence in mm2 Results There was an inverse relationship between myopic refractive error and ocular sun exposure, with more than double the prevalence of myopia in the lowest quartile of conjunctival autofluorescence than the highest quartile (33.0% vs 15.6%). Median area of autofluorescence was significantly lower in myopes than non-myopes (31.9mm2 vs 47.9mm2, p<0.001). These differences remained significant after adjustment for age, gender, parental history of myopia and subject level of education. The use of corrective lenses did not explain the lower conjunctival autofluorescence observed in myopes. Conclusions In this young adult population, myopic refractive error was inversely associated with objectively measured ocular sun exposure, even after adjustment for potential confounders. This further supports the inverse association between outdoor activity and myopia.
Article
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Context High nevus density is a risk factor for cutaneous malignant melanoma. Melanocytic nevi originate in childhood and are largely caused by solar exposure.Objective To determine whether use of broad-spectrum, high–sun protection factor (SPF) sunscreen attenuates development of nevi in white children.Design Randomized trial conducted June 1993 to May 1996.Setting and Participants A total of 458 Vancouver, British Columbia, schoolchildren in grades 1 and 4 were randomized in 1993. After exclusion of nonwhite children and those lost to follow-up or with missing data, 309 children remained for analysis. Each child's nevi were enumerated at the start and end of the study in 1996.Intervention Parents of children randomly assigned to the treatment group (n=222) received a supply of SPF 30 broad-spectrum sunscreen with directions to apply it to exposed sites when the child was expected to be in the sun for 30 minutes or more. Children randomly assigned to the control group (n=236) received no sunscreen and were given no advice about sunscreen use.Main Outcome Measure Number of new nevi acquired during the 3 years of the study, compared between treatment and control groups.Results Children in the sunscreen group developed fewer nevi than did children in the control group (median counts, 24 vs 28; P=.048). A significant interaction was detected between freckling and study group, indicating that sunscreen use was much more important for children with freckles than for children without. Modeling of the data suggests that freckled children assigned to a broad-spectrum sunscreen intervention would develop 30% to 40% fewer new nevi than freckled children assigned to the control group.Conclusions Our data indicate that broad-spectrum sunscreens may attenuate the number of nevi in white children, especially if they have freckles.
Article
Purpose: To investigate the association between serum vitamin D levels and myopia in young adults. Methods: A total of 946 individuals participating in the 20-year follow-up of the Western Australian Pregnancy Cohort (Raine) Study were included in this study. Ethnicity, parental myopia, and education status were ascertained by self-reported questionnaire. A comprehensive ophthalmic examination was performed, including postcycloplegic autorefraction and conjunctival UV autofluorescence photography. Serum 25-hydroxyvitamin D₃ (25(OH)D₃) concentrations were determined using mass spectrometry. The association between serum 25(OH)D₃ concentrations and prevalent myopia was determined using multivariable logistic regression. Myopia was defined as mean spherical equivalent ≤ -0.5 diopters. Results: Of the 946 participants, 221 (23.4%) had myopia (n = 725 nonmyopic). Myopic subjects had lower serum 25(OH)D₃ concentrations compared to nonmyopic participants (median 67.6 vs. 72.5 nmol, P = 0.003). In univariable analysis, lower serum 25(OH)D₃ concentration was associated with higher risk of having myopia (odds ratio [OR] for <50 vs. ≥50 nmol/L: 2.63; confidence interval [95% CI] 1.71-4.05; P < 0.001). This association persisted after adjustment for potential confounders, including age, sex, ethnicity, parental myopia, education status, and ocular sun-exposure biomarker score (adjusted OR 2.07; 95% CI 1.29-3.32; P = 0.002). Conclusions: Myopic participants had significantly lower 25(OH)D₃ concentrations. The prevalence of myopia was significantly higher in individuals with vitamin D deficiency compared to the individuals with sufficient levels. Longitudinal studies are warranted to investigate whether higher serum 25(OH)D₃ concentration is protective against myopia or whether it is acting as a proxy for some other biologically effective consequence of sun exposure.
Article
Purpose: The aim of this study was to investigate the effect of outdoor activity during class recess on myopia changes among elementary school students in a suburban area of Taiwan. Design: Prospective, comparative, consecutive, interventional study. Participants: Elementary school students 7 to 11 years of age recruited from 2 nearby schools located in a suburban area of southern Taiwan. Intervention: The children of one school participated in the interventions, whereas those from the other school served as the control group. The interventions consisted of performing a recess outside the classroom (ROC) program that encouraged children to go outside for outdoor activities during recess. The control school did not have any special programs during recess. Main outcome measures: Data were obtained by means of a parent questionnaire and ocular evaluations that included axial length and cycloplegic autorefraction at the beginning and after 1 year. Results: Five hundred seventy-one students were recruited for this study, of whom 333 students participated in the interventional program, and 238 students were in the control school. At the beginning of the study, there were no significant differences between these 2 schools with regard to age, gender, baseline refraction, and myopia prevalence (47.75% vs. 49.16%). After 1 year, new onset of myopia was significantly lower in the ROC group than in the control group (8.41% vs. 17.65%; P<0.001). There was also significantly lower myopic shift in the ROC group compared with the control group (-0.25 diopter [D]/year vs. -0.38 D/year; P = 0.029). The multivariate analysis demonstrated that the variables of intervention of the ROC program and higher school year proved to be a protective factor against myopia shift in nonmyopic subjects (P = 0.020 and P = 0.017, respectively). For myopic subjects, school year was the only variable significantly associated with myopia progression (P = 0.006). Conclusions: Outdoor activities during class recess in school have a significant effect on myopia onset and myopic shift. Such activities have a prominent effect on the control of myopia shift, especially in nonmyopic children. Financial disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Article
Background: To report the natural, longitudinal history of shifts in refractive errors in different age groups in a large western European cohort over at least 5 years in the same patients. Methods: The electronic database of a large regional clinic containing 225,000 patients was searched for records of patients with a follow-up of at least 5 years, excluding all patients who had received any surgical interventions in any eye. This search retrieved 15,799 patients aged 3 months to 79 years (median 37.8 years) with refractive follow up of at least 5 years (mean 8.8 years) and no surgical interventions. Differences in spherical equivalents (sum of sphere +1/2 cylinder) and cylinder between first and last visit in the same patients in only the right eye were calculated, and used as the measure of refractive shift. Subsequently differences in change between the right and left eye were also determined. Results: Refractions were found to be mostly stable from 25 to 39 years (n = 3,155 right eyes), with 50% of these patients not changing their refraction. In patients aged 20-24 (n = 825 right eyes), only 39% of the refractions remained stable, whereas 49% experienced a myopic shift. In the age group 40-69 years (n = 6,694), 40-45% remained stable, with an increase in hyperopic shifts. Eighty-five percent of all patients had bilateral symmetric shifts, and 61% showed stable cylindrical values. Conclusions: This report documents clinical relevant changes in spherical equivalents in all age groups within 5 to 10 years in the largest examined European cohort. Refractive surgery patients in particular should be selected accordingly, and be informed about the physiological changes which might still occur during their lifetime.
Article
Objective:To evaluate a school-based intervention in terms of reducing children's sun exposure and improving their use of sun protection measures. Methods:‘Kidskin’ is a five-year, school-based intervention study in Perth, Western Australia, of a cohort of children who were five or six years old in 1995. The study involves three groups: control, ‘moderate’ and ‘high’ intervention. Children in the control schools received the standard health curriculum; those in the intervention schools received a multicomponent intervention, including a specially designed curriculum. Children in the high intervention group also received program materials over the summer holidays and were offered sun-protective swimwear at a low cost. After two years, parents completed a questionnaire about their child's sun-related behaviour. Results:Children in the intervention groups — especially the ‘high’ group — were reported to have had less sun exposure. This involved covering the back more often, spending more time in the shade when outdoors and wearing a style of swimsuit that covered the trunk. There was also evidence that children in the intervention groups spent less time outdoors in the middle of the day. There was little difference between groups in the wearing of hats or sunscreen. Conclusions:Our school-based intervention improved children's sun protection, but had little effect on specific behaviours that have already been vigorously promoted. Implications:School-based prevention campaigns would benefit from focusing on sun protection using clothing and shade, and reducing sun exposure in the middle of the day. There may be little potential to improve hat and sunscreen use.
Article
Objective: This paper presents the results of the evaluation of measured suntan and parent-reported sun exposure in participating children after 2 years of the Kidskin study, a 5-year school-based sun protection intervention undertaken in Perth, Western Australia (1995–1999). Methods: The study involves three groups: a control, a moderate, and a high intervention group. Participants were 5 or 6 years of age at the beginning of the study. Control schools received the standard Health Education curriculum, while intervention schools received a multicomponent intervention including a specially designed curriculum. Children in the high intervention group also received program materials over the summer vacation and were offered sun-protective swimwear at low cost. At the end of the second summer, suntan was measured and parents completed a questionnaire about their child's sun-related behavior. Results: Children in the intervention groups – especially the high group – were less tanned at the end of the summer; this effect was greater for the back than for the forearms. These children were also reported to have received less sun exposure and made greater use of sun protection measures. Conclusion: Intensive school-based interventions can reduce tanning and reported sun exposure in children.
Article
To examine whether past and recent sun exposure and vitamin D status (serum 25-hydroxyvitamin D [25(OH)D] levels) are associated with risk of first demyelinating events (FDEs) and to evaluate the contribution of these factors to the latitudinal gradient in FDE incidence in Australia. This was a multicenter incident case-control study. Cases (n = 216) were aged 18-59 years with a FDE and resident within one of 4 Australian centers (from latitudes 27°S to 43°S), from November 1, 2003, to December 31, 2006. Controls (n = 395) were matched to cases on age, sex, and study region, without CNS demyelination. Exposures measured included self-reported sun exposure by life stage, objective measures of skin phenotype and actinic damage, and vitamin D status. Higher levels of past, recent, and accumulated leisure-time sun exposure were each associated with reduced risk of FDE, e.g., accumulated leisure-time sun exposure (age 6 years to current), adjusted odds ratio (AOR) = 0.70 (95% confidence interval [CI] 0.53-0.94) for each ultraviolet (UV) dose increment of 1,000 kJ/m(2) (range 508-6,397 kJ/m(2)). Higher actinic skin damage (AOR = 0.39 [95% CI 0.17-0.92], highest grade vs the lowest) and higher serum vitamin D status (AOR = 0.93 [95% CI 0.86-1.00] per 10 nmol/L increase in 25(OH)D) were independently associated with decreased FDE risk. Differences in leisure-time sun exposure, serum 25(OH)D level, and skin type additively accounted for a 32.4% increase in FDE incidence from the low to high latitude regions. Sun exposure and vitamin D status may have independent roles in the risk of CNS demyelination. Both will need to be evaluated in clinical trials for multiple sclerosis prevention.
Article
Few developers of school-based health education programs actively involve the primary and secondary target audience in their program’s development. Kidskin was a sun protection intervention study involving a cohort of 1,776 children recruited from 33 primary schools in Perth, Western Australia. A formative evaluation to develop the Kidskin sun safety classroom and home education program for grades 1 to 4 children and their families was conducted. Process data collected from teachers revealed high levels of satisfaction with the program with the majority agreeing that the activities were developmentally appropriate, effective and enjoyable for students. Mailouts to students’ homes, reinforcing sun safety messages, were used to successfully reach most students and their families during the summer school holidays.