The Scots' Paradox: Can Sun Exposure, or Lack of it, Explain Major Paradoxes in Epidemiology?

Abstract

Five epidemiological paradoxes that have puzzled epidemiologists for a decade or more can be explained by the UVB–vitamin D hypothesis. The Scots' Paradox is examined in detail as an example. Many subsidiary factors varying over time and place influence the amount of UVB which reaches the skin of individuals and so the amount of vitamin D synthesised, while other factors influence the amount ingested. These factors are plotted leading to a common pathway that ends in vitamin D insufficiency and consequent disease. Examples suggest that the factors interact to increase mortality in Scotland in a way consistent with causation according to the criteria of Bradford Hill. It is suggested that different degrees of vitamin D insufficiency in populations can explain important differences in the health of nations and resolve health paradoxes. The analysis also shows that vitamin D insufficiency is a consequence of industrialisation and, like other consequences of industrial growth, such as water and air pollution, needs to be corrected by public health measures. Direct intervention with use of supplements and fortification of foods with vitamin D can be expected to provide considerable health gains, but progress will be slow until there is greater recognition of the vitamin D health crisis by the public, professionals and politicians. Health professionals need to be trained and motivated to encourage use of supplements, particularly by pregnant and nursing mothers, and infants. The importance of open sunny spaces and clean air that allows full penetration of UVB needs to be recognised by city planners and politicians. New advice and new fashions are needed to encourage maximum exposure of skin to summer sun without burning. Use of sunlamps to boost vitamin D synthesis could be useful.