Know Your Risks

The Oxford English Dictionary defines “risks” as a situation involving exposure to danger or the “possibility that something unwelcome or unpleasant will happen.” Knowing your risks is important when considering what can be done to stay healthy, live longer, and have a good quality of life.

Let’s start with the example of exposure to the sun’s rays and note the risk factors associated with no exposure, modified and intelligent, and excessive exposure. There are so many factors to consider, including the susceptibility of an individual when exposed to the sun, the dosage of UVA and UVB rays, and the length of exposure—both long term as well as short term. The risks are skin damage and accelerated skin aging, melanoma, non-melanoma skin cancers, sunburn and blistering of the skin, and retinal damage to the eyes.

Interestingly, a recent article in the Journal of Medicine (April, 2016) noted that there are equal risks to health when comparing no sun exposure to sun exposure plus smoking. How can this be? It is because when we consider risks, we often have to match them against benefits. In this case we know that vitamin D is made in the body by exposure to UVB light (utilizing your serum cholesterol) and has a tremendous influence on development of skin cancer, as well as other aspects of health. For example, in emerging industrial England, rickets was rampant among the many young children who worked in factories and had no chance to play outside in the sun. This is because they were deficient in sunshine-generated Vitamin D. The solution was giving factory workers a teaspoon of cod liver oil daily, which supplemented their vitamin D.

This risk/benefit relationship is seen today when dark-skinned people who live at more northern latitudes (i.e., Europe or the northernmost American states) have a higher rate of cancers than light-skinned people because the darker pigment blocks the entry of UVB rays. It is also seen with non-melanoma skin cancer, and more sun exposure produces more vitamin D, but the UVA part causes aging changes of the skin, and UVB is partly ionizing radiation which causes DNA mutation and subsequent skin cancers.

These risks can be modified by using more shade, sun protective hat and clothing, and eating a highly nutrient diet with vitamins A, D and C, and phytochemicals (antioxidants). Fair-skinned Europeans living at lower latitudes with more sunshine have a higher rate of melanoma and skin cancer. Another factor is that melanoma is increased in incidence with recreational sun exposure and decreased with long-term daily occupational exposure. With smaller long-term doses, the skin develops a protection factor, which quadruples the time of safe exposure.

In the Women’s Health Initiative Study, women who took vitamin D and calcium had the same incidence of skin cancer but decreased risk of melanoma. Lower vitamin D levels (<20) are seen with an increase in the thickness of melanoma tumors, but childhood sunburn, long-term sun exposure, or skin sun damage were not associated with this.

To compound this issue, other factors which influence the development of all cancers, including melanoma and skin cancer, are related to genetic tendency, lighter skin, blue/green eyes, and lower immune status. So in order to reduce risks and increase benefits of sun exposure, you should know your family history, not get much sun exposure if you have fair skin, protect critical areas from sun damage by using sunscreen, maybe wear sun protective clothing and a hat, take vitamin D, monitor your vitamin D serum levels, and try to get small cumulative amounts of sun exposure when needed. All of this will reduce risks and increase benefits.

Another health area where we should know our risks of disease or death is cardiovascular disease. If you take a low-dose aspirin each day and have had a heart problem or heart surgery, the risk of death by coronary occlusion is lower. But if you do not have any heart problems, the risk of dying or severe gastric bleeding equals the risk of coronary occlusion, and therefore aspirin has no value. In this group, however, if you add cancer to the equation, we know that prophylactic aspirin reduces the risks of colon cancer and prostate cancer by a significant amount—as much as 40 percent.

One area of controversy is whether or not to take statins for prevention of heart disease and more recently stroke, the number 1 and number 4 killers in the U.S. New guidelines note that 33 million in the U.S. are at a 25 percent higher risk for myocardial infarction and stroke and could benefit from statins. However, the new guidelines now include women over 60 who smoke and black males with increased blood pressure, as well as a history of heart attack, stroke, angina, and artery disease. All over 21 with LDL over 190 are also included, as well as all type 1 and type 2 diabetics.

This is all well and good, but a caloric restricted diet, exercise, preventative aspirin or BP treatment as required, and careful exam intervals, could improve the parameters which are indicative of possible impending problems. Also, the long-term effect of statins may not be known, and muscle pain or damage, liver damage, increased diabetes type 2, digestive problems, and neurological problems may be a sequela of them. One thing is obvious, that a lot of people have to take statins for many years for even a small percentage of them to benefit from taking these drugs.

In this and all other instances of evaluating risk/benefit ratios, you must consider all of the facts, discuss them with your doctor, and look up all questions that you may have by going to the internet. You can be the guardian of your own health and lower your risks for heart disease, stroke, and other diseases as well. If you want to know the risks of taking a certain medication or having a surgical procedure, simply ask Google or Google Scholar. Ask in the same words you would use to ask your doctor and the answer will usually be immediate and clearly understandable.

Dr. James Carraway is a plastic surgeon at the Cosmetic & Plastic Surgery Center of EVMS. Call 757-557-0300.

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James H. Carraway, M.D.

Dr. James Carraway is a full-time academic and practicing clinical plastic surgeon.  He is Director of the Cosmetic & Plastic Surgery Center of EVMS, is board certified in surgery and plastic surgery, and is a fellow of the American College of Surgeons.  Dr. Carraway has been teaching and practicing for 30+ years and has been director and chairman of residency training programs and fellowship programs in plastic surgery.
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