Sad to the bone: sun deprivation places residents in jeopardy. Some facts on remedying the problem. (Feature Article).

As we age, we shrink in stature, our bones become brittle, our muscles weaken, and lethargy, apathy, and depression rule our emotions. Because these signs are seen commonly in the elderly, they almost assume the status of "normal" as does use of medication to treat them. Most medication, though, only treats symptoms. For those residing in assisted living facilities or nursing homes, while medication might make residents easier to manage, it does nothing to solve the ultimate cause of these problems: a mismatch between the biologic needs of individual residents and their current living environment. That mismatch can leave them "sad to the bone."

The "ABCs" of Sunlight

Bone loss, muscle weakness, and depression have a common origin in ultraviolet B (UVB) radiation deprivation. Yes, deprivation: inadequate exposure to UVB radiation--the type of radiation we are warned about by dermatologists. Ultraviolet radiation, the invisible portion of sunlight, occurs in three types: A, B, and C. Type C radiation is very deadly but is not an important concern because the ozone layer blocks all of it from hitting the earth. Type A is involved in aging effects on skin, and type B is associated with sunburn. It is widely known that overexposure to UVB radiation can cause skin cancer, but it is also true that underexposure to UVB radiation is just as harmful, maybe even more harmful, to our overall health.

Exposing unprotected skin to UVB radiation sets in motion a cascade in which the initial (prohormone) form of vitamin D, found in the skin, is converted to an intermediate form (25-hydroxyvitamin D) in the liver, and then is converted in the kidneys where it becomes the active hormonal form (1,25 dihydroxyvitamin D). This latter form regulates calcium balance, suppresses tumors, and interacts with numerous tissues in the body, including those in the brain. Individuals who receive little or no exposure to UVB radiation are at risk of having inadequate blood levels of vitamin D, which is associated with bone disorders (including osteoporosis); hypertension; cancers of the prostate, breast, and colon; muscle weakness; and depression. Instead of disorders of aging, these should be considered disorders of environmental deprivation.

Food for Thought

You might be thinking, "Surely residents can get enough vitamin D from their diet and supplements." Unfortunately, this is probably not the case, for three major reasons. First, it is almost impossible to get enough vitamin D from diet alone unless one eats sardines or other fatty, oily fish every day (Table 1). Second, vitamin D supplements, at least in the United States, generally come bound to other vitamins or minerals, such as calcium. Therefore, getting enough vitamin D through supplementation could mean getting excessive amounts of other vitamins or minerals, which could cause other health problems. It is possible, although difficult, to overdose on vitamin D via supplementation; however, it is not possible to overdose on vitamin D via UVB radiation exposure.

Finally, even if it appears (based on the Dietary Reference Intakes [DRI] or Recommended Daily Allowance [RDA] levels of vitamin D) that an individual is obtaining sufficient vitamin D via diet and/or supplementation, such is not the case. Those recommendations are too low, being based on amounts needed to maintain vitamin D levels at the low end of what is considered to be the normal range of variation. This range is based on analysis of apparently healthy individuals living in the United States or Europe, rather than on the optimal levels of vitamin D found in healthy individuals residing in equatorial zones or those who work outside (e.g., lifeguards) during the summer months in the northern latitudes (Tables 2 and 3). Based on these optimal levels, most individuals residing in the United States (not just assisted living or nursing home residents) are probably suffering from vitamin D deprivation.

A Penny of Prevention

Although you cannot compensate for a lifetime of UVB radiation/vitamin D deprivation, changing the current environment can reduce and modify the effects of that deprivation. You might be wondering what this will cost, but what are the costs associated with staff downtime and turnover? What are the costs associated with resident injuries, or with making sure medications are taken properly? The cost of providing vitamin D supplementation of 1,000 IU (International Units) per day for an individual is probably less than $2 per month, and providing adequate exposure to UVB radiation each day might cost even less.

The best method for ensuring that residents maintain adequate blood levels of vitamin D is to get them outside into the sunlight. Achieving "appropriate" levels of UVB exposure involves balancing between activating the vitamin D system and preventing the burning associated with skin cancer.

Although the folk belief is that 15 or 20 minutes a day of exposing unprotected skin to the sun is enough to maintain adequate levels of vitamin D, there are several problems with this concept.

First, this notion is based on research involving light-skinned infants who were exposed to the sun during the summer months, wearing minimal clothing and no hat. As we age, our ability to produce vitamin D via skin exposure to natural sunlight gradually decreases. Compared to infants, the elderly have a much-reduced ability to produce vitamin D in this manner.

Second, this folk belief ignores the needs of those whose skin color is darker. Melanin, the skin-coloring pigment, blocks UVB radiation penetration. The darker the skin color, the less UVB radiation is able to penetrate the skin to activate the vitamin D system. Very dark pigmentation is equivalent to wearing a sunscreen of SPF 15 (UVB radiation is blocked by a sunscreen of SPF 8).

Third, in the northern climates of many major U.S. cities (e.g., New York, Boston, Chicago, Minneapolis, San Francisco, Seattle), UVB exposure is available only from about late March through late October. Even if adequate vitamin D levels are achieved from skin exposure during the warm weather months, it is probable that the levels will be inadequate by February or March, if not earlier.

Because of these factors, it is quite possible that all residents and most staff members in an assisted living or nursing home facility are vitamin D deficient, except for those who are very light skinned and spend a significant portion of each day between 10:00 a.m. and 3:00 p.m. outside exposing unprotected skin to direct sunlight.

What Can Be Done?

An individualized plan of action specifying the proper amount of UVB radiation exposure and/or vitamin D supplemeI-0AXV-2003FEB25-1-30

Byline: Brian DeBose and Jabeen Bhatti, THE WASHINGTON TIMES

Two D.C. Council members are expected to introduce a bill next week that would tax commuters from Maryland and Virginia on incomes they earn in the District, saying residents from those states benefit from city services, but don't pay for them.

D.C. Council members Jack Evans, Ward 2 Democrat and chairman of the Committee on Finance and Revenue, and Adrian M. Fenty, Ward 4 Democrat, said they will introduce the "Commuter Tax Act of 2003" March 4. The measure would amend D.C. law and impose a tax on salaries and wages earned by nonresidents.

"What is not fair is to get a service and not pay your fair share for it," Mr. Evans said in a written statement.

Under the proposed measure, a commuter whose taxable income is under $10,000 would be taxed 0.5 percent; a commuter with a taxable income between $10,000 and $40,000 would be taxed 1 percent, and those with a taxable income above $40,000 would be taxed 2 percent.

The commuter tax on individuals' incomes would be offset by a full credit on their own state's tax returns, the council members said.

All 13 members of the council say they will support the measure.

Rep. Thomas M. Davis III, Virginia Republican and chairman of the House committee that has authority to override legislation passed by the D.C. Council, said through a spokesman yesterday that almost every member of the regional congressional delegation opposes a commuter tax.

Mr. Fenty noted that Maryland and Virginia tax the incomes of D.C. residents who work in their cities, but refuse to allow the city to do the same, which he said "is really thievery."

"My residents who work in Virginia - and Maryland does it, too - pay a portion of their income to Virginia, and yet Tom Davis runs around saying a commuter tax will never happen in the District," Mr. Fenty said.

"They are concerned they will be hit by a $500 million tax credit for their residents."

Mr. Fenty and Mr. Evans said the universal principle of taxation is the primary right to tax income where it is earned.

Louisville, Ky., Philadelphia, Detroit, Cincinnati and Cleveland have levied commuter taxes that range from 1.45 percent to 4 percent on nonresidents. New York City saw its 30-year-old tax repealed by the state legislature in 1999. New York Mayor Michael R. Bloomberg is trying to get a new commuter tax instituted - at a rate six times higher than that of the repealed tax.

Two-thirds of all income earned in the District is earned by nonresidents and 57 percent of all real property located in the District is not taxable because it is owned by the federal government.

Since the District can tax only one-third of income earned in the city, D.C. residents are taxed at higher rates than other jurisdictions.

The tax rates range from 6 percent to 9.3 percent in the District, from 2 percent to 5.7 percent in Virginia and from 3.2 percent to 7.76 percent in Maryland, the council members said.

The higher tax rates borne by D.C. residents are a consequence of many individual taxpayers leaving the city, further shrinking its tax base.

The measure is the latest attempt by D.C. officials to address a structural imbalance in the city's finances. But every attempt to institute a "commuter tax" has failed so far.

Already, Rep. Albert R. Wynn, Maryland Democrat, said yesterday he has long opposed any measure that would take money from the very commuters that make such a huge contribution to the District's economy.

Mr. Wynn added that a commuter tax would not foster regional cooperation, but instead might encourage counties to impose reciprocal taxes on D.C. residents who work in their jurisdictions.

Delegate Eleanor Holmes Norton, the District's nonvoting Democratic representative, is again pushing a measure that would send 2 percent of the federal taxes paid by commuters to the District's treasury. Because Congress has traditionally blocked commuter-tax measures, Mrs. Norton is seeking alternatives, an aide said.