I was recently asked what I would advise the next President to make his number one public health priority.  I said exercise, and here’s why:

Increasing the physical activity of Americans will have tremendous public health benefits, since it will fundamentally help address many conditions that significantly reduce overall public health, including obesity, diabetes, cardiovascular disease, cancer, arthritis, and mental illnesses.  In addition, exercise initiatives can be constructed as public-private partnerships, built collaboratively with a number of advocacy groups, and would require minimal Federal spending.

I was reminded about the importance of exercise when I recently ran across a reference to a December 2006 Archives of Internal Medicine article reporting on a study that found weight loss in overweight 50-60 year old men and women would lead to significant bone loss in the hip and spine if it was accomplished through dieting, but not when exercise was the primary route for the weight loss.

What do you think the next President should make his highest priority for public health?

A couple of months ago I wrote about how one percent of adults in the US get free government health care.  While the statistics in the February Pew study were very interesting (and somewhat shocking), I saw a report in a local Connecticut newspaper (The Day, June 26th) that put a face on these statistics.

The Day’s story was about Jihad Abdulshaheed, a 36-year-old man who had been incarcerated since November 2007.  The judge was prepared to sentence to a one year sentence, and since he had already served at least 50% of his time, under the Department of Corrections guidelines for nonviolent prisoners he could have been released the next day.

However, this is where the story gets very interesting.  The man asked the Judge to hold off his sentencing “because he is waiting for the Department of Correction to schedule his surgery for a groin hernia.”  The newspaper also noted that the DOC’s health care budget for its 23,000 prisoners was $99.3 million.  This works out to a little more than $4,300 per prison.  It seems that finding a way to release this man, and still pay for his hernia surgery would make more sense than keeping him locked up until the DOC can pay for the surgery……. I also wonder about his follow-up care? Where will he get it - in prison or outside?  And how will that be paid for?

This man’s situation and the Pew study illustrates how communicating the essence of a healthcare story can involve statistics, analyses, and anecdotes.  The first two provides a framework if the issue, and the anecdote puts a face on that skeleton.  Each one can be powerful, but together they create a remarkable picture that can change policies, attitudes and actions.

Since I wrote about the importance of Vitaim D a few weeks ago, some new information has come out.

A report was released this week from researchers in Australia about Vitamin D reducing the risk of all causes of death.  The study was in the Archives of Internal Medicine, about their evaluation of 3,258 men and women scheduled to have a angiogram of their heart arteries.  They found that the people who had below average Vitamin D levels had about twice the risks of dying than those with levels in the highest 25% of the group.

While looking for the report of the Austrlian study, I found another study from a group of reserachers in Boston, that looked at 18,225 men who had no diagnosed heart disease.  This study found that during 10 years of follow-up, the men who were deficient in Vitamin D (15 ng/mL) were about twice as likely to have a heart attack as those considered to have sufficient levels of Vitamin D (30 ng/mL).

It may be coincidence that both studies found a 2:1 effect from high/normal v. low levels of Vitamin D, but there seems to be growing interest and consensus that Vitamin D is important for overall health.  What do you think?

The Centers for Disease Control and Prevention released some interesting data yesterday.  They reported that in 2007 an estimated 23.6 million people (7.8% of the total US population) have diabetes.  Of these people, only 17.9 million know they have diabetes, while 5.7 million have not been diagnosed.  The good news is that the percentage of people with diabetes who don’t know it has decreased from 30 to 25% The bad news is that the number of Americans with diabetes is increasing.

Number  of People in the US (in Millions) with Diagnosed Diabetes: 1980- 2005

(from http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm)

How Bad Is a Little Sugar?
As the CDC’s Fact Sheet states, “Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age.” Diabetes causes high blood pressure, heart disease and stroke, and is the leading cause of blindness and kidney failure in adults.  Diabetes – because it affects the small blood vessels – also predisposed people to infections, and can lead to amputations from lack of adequate blood flow.  It also increases the risk of pregnancy complications, and leads to nervous system impairments.

How Many People Have Diabetes Where I live?
The CDC doesn’t have county level data for 2007 yet, but the map below shows the percentage of people with diabetes in counties across the country.  [Note – People in Colorado do have diabetes, but in Colorado the country with the highest incidence of diabetes falls just below the threshold for the second color in the map.]

(from http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx)

What to Do About Diabetes?*
There are lots of good resources of information for patients about diabetes (see below), but without getting into too many specifics, people should talk to their doctors about three different types of things:

1. Testing: Get tested – both for diabetes as well as pre-diabetes, a condition which indicates impaired metabolism of sugar and a higher risk of developing diabetes.
2. Treatment: Get treated if you have diabetes.  Get treated for the diabetes itself and for other conditions that increase the risk of developing the complications of diabetes, such as high blood pressure and high cholesterol.  And be sure to take your medicines as instructed by your physician, and test your blood sugar as they recommend.  If you don’t understand how to take your medicines or have any questions about them, just ask your doctor or pharmacist.  Quality healthcare professionals would rather answer your questions and prevent problems from developing, than have to help you resolve any problems you develop from taking medicines incorrectly.
3. Personal Choices - Eat Right and Exercise: Whether you have diabetes or are at risk for developing diabetes diet is crucial, and exercise and weight loss can help improve diabetes and lowers the risk of developing diabetes and its complications.

Resources About Diabetes
American Association of Diabetes Educators - www.diabeteseducator.org
American Diabetes Association - www.diabetes.org
Centers for Disease Control and Prevention - www.cdc.gov/diabetes
National Diabetes Information Clearinghous - http://diabetes.niddk.nih.gov/ and http://diabetes.niddk.nih.gov/dm/pubs/stroke/#connection

*DISCLAIMER – THIS INFORMATION IS NOT SPECIFIC MEDICAL GUIDANCE, IT IS NOT INTENDED TO DIRECT TREATMENT OR PREVENTION FOR INDIVIDUALS,  AND SHOULD NOT BE SUBSTITUTED FOR ADVICE FROM PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS INCLUDING NUTRITIONISTS, AND DIABETES EDUCATORS.

The focus on Medicare payments to physicians for the last six months has been on the 0.5% increase Congress enacted for the first 6 months of 2008 to replace the 10.1% reduction that would have occurred under Medicare’s Sustainable Growth Rate (SGR) formula. Legislation to continue this rate for the rest of the year failed a required procedural vote in the Senate last week.* This leaves Medicare physician payments after June 30th uncertain – although it is expected that Congress will do something in the next week, or three.

However, beyond the impending Medicare 10.6% reimbursement reduction for all physicians, the Graham Center of American Academy of Family Physicians published a short report on June 13th that expands the analysis to include pending change in how Medicare reimburses physicians in Physician Scarcity Areas (PSAs), and Health Professional Shortage Areas (HPSAs). As the report’s summary table below shows, the PSA 5% reduction would effect about 25,000 primary care physicians and over 7.5 million Medicare beneficiaries. And these payment reductions would be on top of the impending 10.6% Medicare payment reduction.

With the general consensus being that we have a shortage of primary care clinicians, cutting Medicare payments to physicians in underserved areas seems truly unwise. And doing it at the same time that Medicare’s overall reimbursement formula for physicians is being so contentiously debated is really a bad idea.

If the PSA and HSPA programs would benefit by being adjusted to redefine their geographic or other targeted goals, then that should be done as part of comprehensive strategies and plans for improving Medicare’s payment system to ensure Medicare beneficiaries have continued access to physicians – particularly those providing primary care services. Making reductions to the PSA and HSPA programs right now seems like the right and left hands of government don’t know what they are doing.

* This legislation would have also implemented a 1.1% increase for 2009 instead of the SGR formula’s reduction of 5%

Most of what I’ve read and previously written about electronic health records has been about making them work better or getting more clinicians to use them. Security of patients’ on-line data hasn’t been a major topic of concern. I’ve assumed that this was because these concerns had mostly been addressed back in the late 1990s during the development of the Health Insurance Portability and Accountability Act (HIPAA), or because those creating systems to allow medical information to be internet accessible – like those coalitions building dedicated Health Information Exchanges and companies like Microsoft, Google, and BlueCross BlueShield insurance plans – have resolved the security concerns.

Global Cyber-Security
However, I just read the cover story in the May 31st National Journal (”China’s Cyber-Militia”), which made me question these assumptions. The article doesn’t mention healthcare or electronic medical records, but it makes me very concerned because it discusses how Chinese hackers (or hackers working through computers based in China) have been responsible for serious industrial/utility computer breeches, and how government and private sector officials at the highest level are very concerned about this and the trend towards even more cyber-infiltrations.

If I had heard this third-hand I’d be inclined to dismiss it as extremist or Luddite hysterics. But the National Journal is solidly in the mainstream of responsible journalism, and even when their article cites reports from other publications (such as the New Yorker) they reinforce the point with information from other sources and direct interviews with knowledgeable insiders.

Some of the specific points in the article that made me sit up and take notice were:

The February, 2008 blackout affecting 3 million people in South Florida was probably caused by “a Chinese PLA [People’s Liberation Army] hacker attempting to map Florida Power and Light’s computer infrastructure apparently made a mistake. “The hacker was probably supposed to be mapping the system for his bosses and just got carried away and had a ‘what happens if I pull on this’ moment.” The hacker triggered a cascade effect, shutting down large portions of the Florida power grid, the security expert said. “I suspect, as the system went down, the PLA hacker said something like, ‘Oops, my bad,’ in Chinese.”

The article also discusses how the massive August 2003 blackout in the Northeastern US is believed to have been due to Chinese hackers – despite the public explanation that it was caused by overgrown trees in Ohio hitting high voltage lines.

The article even delves into how Chinese hackers are infiltrating corporate computer systems to steal company technology and business secrets, plans and strategies. For example, it includes a security expert’s story about one company’s experience of entering into face-to-face business discussions in China where “the Chinese based their starting points for negotiations on the Americans’ end points.” As Joel Brenner, the US government’s chief counterintelligence officer is quoted in the article, “If you travel abroad and are the director of research or the chief executive of a large company, you’re a target.”

Security of Online Health Records
Two potential weaknesses of utility and corporate computer systems may be because their systems are from third party vendors or were built with older architecture designed before on-line security was a concern. Because the computer systems for electronic health records and information exchanges are being built by the companies who are using them or have ongoing contracts for maintaining them – and are probably being built with newer software architectures – perhaps they are better protected.

The other reason why online health records may be more secure than utility or corporate systems is that hackers probably don’t have the financial or geopolitical incentives to break into medical record depositories. However, I can imagine situations or incentives for groups (aside from pure nihilism) that could change that – butI don’t want to speculate here and give anybody any ideas.

But if one of the great potential values of electronic medical records is having them joined together into Health Information Exchanges, and hackers are apparently able to infiltrate and wreak havoc in sophisticated computer networks, then I hope those developing EMR and HIE systems are really paying attention to security issues. If patients have concerns that their personal information is hackable, this could lead to a tremendous backlash against the use of a technology that should be very valuable for improving the quality of care and reducing the long-term growth in healthcare costs.

The FDA announced today that they have sent letters to 25 companies to stop selling fake cancer cures. That is, things that the companies claim cure cancer, but have never been tested, or approved by the FDA. The FDA has a web-site with more information about this, and a sub-page that lists 125 Fake Cancer Cures.

I know the FDA gets lots of flack for not doing enough - and not doing it fast enough - I applaud the FDA for taking this action, and encourage them to do more because I have found the advertisement and selling of these non-medicines troubling for a long time.

Cancers are serious diseases by anyones definition, and real medical science is making great strides in developing better treatments and cures, and in overall improving the lives of people living with cancer - both through traditional drugs and biologics, as well as with complementary therapies. But those profiting from selling fake medicines are selling false hope.

I would like the FDA go after more of these people who are profiting from selling fake medicines marketed as cures for other diseases and conditions - particularly ones that may be for symptoms of serious conditions. For example, every time I see the plastic-faced grinning guy on TV hawking a non-FDA approved “natural male enhancement” product, I wonder about all the men who may still be too embarrassed to talk to their physician about their erectile dysfunction problem - which unknown to them is being caused by a serious medical problem, like cancer. And of course for men who are buying this stuff who don’t have ED, then it would be nice if they could talk to their physician about therapy to address the route causes of their feelings of sexual inadequacy.

But of course, the FDA currently has insufficient resources to cover all of it’s multiple priorities - which is why Congress and the Administration are discussing how to provide more funding. Until that happens, I hope the FDA continues being vigilant and stops as many of these purveyors of false hope as they can - at least so these people don’t get the idea that because the FDA’s resources are stretched a bit thin, that the FDA won’t bother them.

The Medicare Payment Advisory Commission released its annual report to Congress on Friday. In chapter 2 of its report, MedPAC makes two significant proposals for improving the financial incentives for primary care providers.

Great Incentives for Primary Care Practitioners Not Just Primary Care Services
First, it recommends changing Medicare’s reimbursement system for “evaluation and management” (E&M) services. While last year Medicare increased payments for E&M services, they couldn’t differentiate between types of physicians providing these E&M services, i.e. the Medicare system doesn’t distinguish between a family physician and a cardiologist if they are providing the same type and level of intensity of service.

Therefore, MedPAC recommends that a subset of primary care related E&M services, (e.g. office visits, home visits, long-term care patient visits), provided by clinicians who meet a minimum percentage threshold of a clinician’s total Medicare billing, (and thus would be identified as being “primary-care-focused practitioners”), should receive higher Medicare payments. (MedPAC choose to identify primary care clinicians based upon a percentage of primary care services - rather than specialty designation - because it would be administratively simpler and ensure that the incentives would be directed towards clinicians actually providing primary care services.)

The specific recommendation from the MedPAC report is:

The Congress should establish a budget-neutral payment adjustment for primary care services billed under the physician fee schedule and furnished by primary-care-focused practitioners. Primary-care-focused practitioners are those whose specialty designation is defined as primary care and/or those whose pattern of claims meets a minimum threshold of furnishing primary care services. The Secretary would use rulemaking to establish criteria for determining a primary-care-focused practitioner.

This is a sea-changing proposal in that it seeks to differentiate how Medicare Part B reimburses primary care providers versus subspecialists – and thus makes Medicare Part B payments more granular than was done when the RBRVS system was first installed in the early 1990s. (Back then, the fight was between so-called cognitive and procedural services.) This refinement will enable Medicare in the future to use its payment system as a more managerial tool for shaping the healthcare delivery system to increase the supply and access of primary care practitioners. The need for such changes is evident by the shrinking number of medical school graduates going into primary care:

However, because the proposal is intended to be budget-neutral it explicitly pits the financial interests of primary care practitioners against subspecialists, which means that the subspecialists will not eagerly welcome these changes to Medicare since they would be getting a smaller piece of a same-sized pie. (Note – MedPAC’s analysis shows that using the a cut-off of 65% of primary care services for clinicians to receive a 10% increase in payments for these services, would increase reimbursements for these services by a total of 6.2%, and would require a reduction for all other services of 0.9% to achieve budget neutrality.)

Build a Medical Home
MedPAC’s second proposal to promote more primary care is to increase the number of Medicare beneficiaries with medical homes.

Medical homes are the latest name for initiatives to give patients a single clinical practice or practitioner to ensure that their care is coordinated with the goal of improving the quality of care, and controlling costs by avoiding unnecessary complications and unnecessary testing. Medical homes are particularly important for people with chronic conditions for ensuring appropriate compliance with recommended treatments, disease monitoring and preventive testing. As the MedPAC report states, “Unlike the current fee-for-service (FFS) payment system, which emphasizes treatment for acute conditions and face-to-face care, medical home programs encourage practitioners to coordinate their patients’ care between visits and among providers. In improving care continuity and coordination, medical homes can enhance the role of primary care practice … [and] … increase our health system’s quality and efficiency.”

Medical homes are not new concept, as care coordination has been discussed since the original concept for HMOs several decades ago. Recently they have been promoted by primary care associations, and Medicare will start a medical home demonstration project in January 2009. MedPAC’s proposal builds off of the planned pilot, and would provide additional monthly payments to medical home practices providing the care coordination services. (Signing up with a medical home would be voluntary for Medicare beneficiaries and they would not have to pay any additional co-payments or premiums.)

MedPAC’s specific medical home proposal, which goes beyond the planned pilot project, is:

The Congress should initiate a medical home pilot project in Medicare. Eligible medical homes must meet stringent criteria, including at least the following capabilities:

• furnish primary care (including coordinating appropriate preventive, maintenance, and acute health services) [and medication management]
• conduct care management
• use health information technology for active clinical decision support
• have a formal quality improvement program
• maintain 24-hour patient communication and rapid access
• keep up-to-date records of beneficiaries’ advance directives, and
• ‘maintain a written understanding with each beneficiary designating the provider as a medical home.

Medicare should provide medical homes with timely data on patient utilization. The pilot should require a physician pay-for-performance program. The pilot must have clear and explicit thresholds for determining whether it can be expanded into the full Medicare program or should be discontinued.

MedPAC recommends an enhanced pilot project - rather than a national initiative -because there are administrative and technical factors that still need to be worked out, including, how to structure monthly payments to medical homes, and how to provide medical homes information about services provided to their patients by other providers so they can do care coordinating. The good news proposals for specialist physicians in MedPAC’s is that the pilot is not being proposed as budget neutral, but would cost between $250-750 million over 5 years.

Conclusions
Most experts think these proposals will be effective in improving the healthcare delivery system in the US, and I agree – provided that they are structured and implemented so they actually change the actions of physicians and patients. To be successful they need to change physicians’ practice patterns to focus more on primary care and care coordination, and to change patients’ behaviors so they use their primary care clinicians for more of this care management. In addition, as is reflected in the charts above, these proposals face the logistical challenge of finding enough primary care clinicians to provide these services. These changes will take time - it takes years to alter patient-physician relationships, shift how physicians practice or increase the supply of primary care clinicians – but this is not a reason for further procrastination.

p.s. I’m writing this from the road, so my editing and grammar may be somewhat deficient – my apologies.

The FDA announced yesterday that both the FDA and the European Medicines Association (EMEA) will accept seven biomarker tests for early kidney damage. These animal based tests were developed by a public-private collaborative and will be a voluntary part of the regulatory applications for new drugs. However, it is believed that companies will benefit by doing these test because they will both be able to detect toxicity problems earlier in a drugs development, and enable the approval of more powerful drugs, “because health care professionals could closely monitor patients and halt the drug if early signs of renal toxicity appear.”

“The development of these and other biomarkers can result in important tools for better understanding the safety profile of new drugs,” said Janet Woodcock, M.D., director of FDA’s Center for Drug Evaluation and Research. “We hope these biomarkers will lead to human tests that detect drug-induced kidney injury in people earlier than is now possible, and help health care professionals better manage potential kidney damage from drugs.”

This advanced use of biomarkers represents a quantum leap in our understanding of molecular toxicities and organ damage - these tests detect cellular damage in a matter of hours rather than the actual kidney dysfunction which had occurred over several days by the time the traditional tests of blood urea nitrogen (BUN) and creatinine have become elevated.

The development of these types of biomarkers was also predictable. Over 10 years ago - with prompting by senior industry scientists - I had several discussions with Congressional and NIH staff about the potential value of government support for validating these types of biomarkers. It was important that the government take the lead in developing these tests since all companies would benefit once the biomarkers were validated, and thus the research was beyond the scope of any single company. This reality led to the formation of the public-private coalition to conduct the research to validate specific biomarkers. However, the formation of this consortium is somewhat remarkable because of the structural/cultural barriers between the industry and the regulatory and scientific agencies, and the extreme public scrutiny and criticism of any collaboration between the pharmaceutical industry and its regulatory agencies – no matter how valuable the public benefits.

The development of the kidney related tests is not an isolated advancement. The non-profit organization managing this initiative is working on similar tests for cardiovascular diseases, cancers, and other diseases. Patients and clinicians certainly hope that similar tests are developed quickly for these conditions, and that they will improve the speed and quality of developing and approving new and better medicines.

Accelerating these advancements will depend on how Congress funds the FDA to increase its scientific capabilities and modernize its information technology, as well as how much attention the next President gives to the FDA’s activities - which he should since they touch every American and affect ~25% of the US economy.

Today’s Boston Globe has an article about a study from Children’s Hospital in Boston that explores the high rate of insufficient vitamin D in otherwise healthy infants and toddlers. (12% deficient in vitamin D and 40% with suboptimal levels.) The study also noted that one-third of these children with low levels of vitamin D had pathological bone changes seen on x-rays.

What Does Vitamin D Do?
What the research study did not examine - but the Globe story does mention – is that in recent years there has been extensive investigation and speculation about the role of vitamin D plays in many other areas of health besides strong bones and teeth. For example, the NIH’s Vitamin D Fact Sheet notes that vitamin D may play a role in lowering the risks of certain cancers:

Laboratory and animal evidence as well as epidemiologic data suggest that vitamin D status could affect cancer risk. Strong biological and mechanistic bases indicate that vitamin D plays a role in the prevention of colon, prostate, and breast cancers. Emerging epidemiologic data suggest that vitamin D has a protective effect against colon cancer, but the data are not as strong for a protective effect against prostate and breast cancer, and are variable for cancers at other sites. Studies do not consistently show a protective effect or no effect, however. One study of Finnish smokers, for example, found that subjects in the highest quintile of baseline vitamin D status have a three-fold higher risk of developing pancreatic cancer.

The NIH’s Fact Sheet goes on to note that vitamin D may play a role in preventing diabetes, high blood pressure and multiple sclerosis. A July 2007 review article by Dr. Holick in the New England Journal of Medicine expands upon this information:

The discovery that most tissues and cells in the body have a vitamin D receptor and that several possess the enzymatic machinery to convert the primary circulating form of vitamin D, 25-hydroxyvitamin D, to the active form, 1,25-dihydroxyvitamin D, has provided new insights into the function of this vitamin. Of great interest is the role it can play in decreasing the risk of many chronic illnesses, including common cancers, autoimmune diseases, infectious diseases, and cardiovascular disease.

The fact that vitamin D plays more than one function in the body should not be surprising, since many physiologically compounds serve multiple functions – from neurotransmitters that act in both the GI and CNS systems, to proteins whose breakdown products also have cellular activity. What this points out is that people (and all animals) are not simple biological systems. While I’ll leave a discussion of the exploding field of systems biology for another time, I do want to point out that once we “know” something in medicine it usually means “what we know right now.” As a professor in medical school said “Half of what we’re going to teach you is wrong, we just don’t know which half.” (I think every medical student gets this in some lecture – it must be in the “Medical School Professor’s Crib Notes.”)

So How Much Vitamin D?
This evolving scientific certainty brings us to the question of how much vitamin D people should be getting – and by what route. There is still no academic agreement as to how much vitamin D people should have – although individual needs do depend upon age, gender, skin color, and medical condition (including pregnancy). But there is a growing consensus that most people need more Vitamin D than they are getting.

The three basic routes for getting more vitamin D are supplements, diet, and sun exposure: The latter is somewhat problematic as the rising incidence of skin cancers places greater emphasis on using sunscreen. Supplements are great – particularly for time limited use in select populations like infants who are breast fed. (That was a risk factor in the Children’s Hospital study.) This leaves us with food.

While milk has long been supplemented with vitamin D, milk consumption in adults is very variable – so more foods are being supplemented. Because vitamin D is much more effective when consumed with calcium, vitamin D is increasingly being added to fortified juices, cereals, and now yogurts. In fact, last year, after seeing several articles about the expanding importance of vitamin D (including the NEJM review article) I called Stonyfield Farms to ask why their yogurt didn’t have vitamin D added to it – as did some of their competitors. The person I talked to was very nice, but didn’t have a very convincing answer. However, I recently noticed that Stonyfield yogurts now have added vitamin D. After making this discovery, I found their October 2007 “Moos From The Farm” newsletter that discussed their plans for adding vitamin D to their products over the winter:

Vitamin D in Our Fat Free
When we converted our fat free yogurts to organic on the 1st of this month, we also added vitamin D, which offers a bunch of important health benefits. Vitamin D…

• increases calcium and phosphorous absorption, which decreases the risk of osteoporosis;
• has immune-boosting properties;
• may help to reduce 17 different types of cancer;
• may decrease the incidence of multiple sclerosis;
• helps to maintain optimal muscle strength;
• benefits diabetics and those with hypertension.

We’ll be adding vitamin D to more of our yogurts this winter, so stay tuned!

I would be tempted to say that Stonyfield added the vitamin D as a marketing pitch, but I haven’t seen any ads or labeling changes that now tout, “Now Healthier – With Added Vitamin D!!!,” so I think they did it because it was a good thing to do, they saw the trend towards a greater emphasis on consuming more vitamin D and wanted to be ahead of the movement – and maybe, possibly, perhaps because I called last summer and asked the question.

So while the optimal level of vitamin D consumption is uncertain, taking too much through food seems hard to do. The NIH’s Fact Sheet notes that there doesn’t seem to be any risk of toxicity from too much vitamin D until you get above 2,000 International Units (IUs) per day, and Holick’s NEJM review states that toxicity doesn’t start until you reach 10,000 IU/day. And as the NIH Fact Sheet notes, “High intakes of dietary vitamin D are very unlikely to result in toxicity unless large amounts of cod liver oil* are consumed; toxicity is more likely to occur from high intakes of supplements.” [*Cod liver oil has 1360 IU per tablespoon.]

Talk With Your Doctor and Summertime Eating
So when you’re deciding about what you’re going to eat - or you’re talking with your doctor and other healthcare professionals about diet and its impact on disease risks - think a bit more about vitamin D and how much you’re getting. This is particularly true for people with some medical problems, risks, or who are taking certain medications that can interfere with vitamin D’s actions or calcium absorption. But also remember, while increased sun exposure increases your vitamin D, ice cream - although great in the summertime - unfortunately it’s not a great source of vitamin D, and it has lots of fat and calories. So think of it as a treat and not a vitamin D supplement….. Or maybe just think of it as a “supplemental treat.”

A friend wearing a t-shirt from our favorite dairy on a very cloudy day at the beach.