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Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement. It is also produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. Vitamin D obtained from sun exposure, food, and supplements is biologically inert and must undergo two hydroxylations in the body for activation. The first occurs in the liver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol. The second occurs primarily in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol [1].
Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts [1,2]. Without sufficient vitamin D, bones can become thin, brittle, or misshapen. Vitamin D sufficiency prevents rickets in children and osteomalacia in adults [1]. Together with calcium, vitamin D also helps protect older adults from osteoporosis.
Vitamin D has other roles in the body, including modulation of cell growth, neuromuscular and immune function, and reduction of inflammation [1,3,4]. Many genes encoding proteins that regulate cell proliferation, differentiation, and apoptosis are modulated in part by vitamin D [1]. Many cells have vitamin D receptors, and some convert 25(OH)D to 1,25(OH)2D.
Serum concentration of 25(OH)D is the best indicator of vitamin D status. It reflects vitamin D produced cutaneously and that obtained from food and supplements [1] and has a fairly long circulating half-life of 15 days [5]. 25(OH)D functions as a biomarker of exposure, but it is not clear to what extent 25(OH)D levels also serve as a biomarker of effect (i.e., relating to health status or outcomes) [1]. Serum 25(OH)D levels do not indicate the amount of vitamin D stored in body tissues.
In contrast to 25(OH)D, circulating 1,25(OH)2D is generally not a good indicator of vitamin D status because it has a short half-life of 15 hours and serum concentrations are closely regulated by parathyroid hormone, calcium, and phosphate [5]. Levels of 1,25(OH)2D do not typically decrease until vitamin D deficiency is severe [2,6].
There is considerable discussion of the serum concentrations of 25(OH)D associated with deficiency (e.g., rickets), adequacy for bone health, and optimal overall health, and cut points have not been developed by a scientific consensus process. Based on its review of data of vitamin D needs, a committee of the Institute of Medicine concluded that persons are at risk of vitamin D deficiency at serum 25(OH)D concentrations <30 nmol/L (<12 ng/mL). Some are potentially at risk for inadequacy at levels ranging from 30–50 nmol/L (12–20 ng/mL). Practically all people are sufficient at levels ≥50 nmol/L (≥20 ng/mL); the committee stated that 50 nmol/L is the serum 25(OH)D level that covers the needs of 97.5% of the population. Serum concentrations >125 nmol/L (>50 ng/mL) are associated with potential adverse effects [1] (Table 1).
* Serum concentrations of 25(OH)D are reported in both nanomoles
per liter (nmol/L) and nanograms per milliliter (ng/mL).
** 1 nmol/L = 0.4 ng/mL
An additional complication in assessing vitamin D status is in the actual measurement of serum 25(OH)D concentrations. Considerable variability exists among the various assays available (the two most common methods being antibody based and liquid chromatography based) and among laboratories that conduct the analyses [1,7,8]. This means that compared with the actual concentration of 25(OH)D in a sample of blood serum, a falsely low or falsely high value may be obtained depending on the assay or laboratory used [9]. A standard reference material for 25(OH)D became available in July 2009 that permits standardization of values across laboratories and may improve method-related variability [1,10].
Intake reference values for vitamin D and other nutrients are provided in the Dietary Reference Intakes (DRIs) developed by the Food and Nutrition Board (FNB) at the Institute of Medicine of The National Academies (formerly National Academy of Sciences) [1]. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and gender, include:
The FNB established an RDA for vitamin D representing a daily intake that is sufficient to maintain bone health and normal calcium metabolism in healthy people. RDAs for vitamin D are listed in both International Units (IUs) and micrograms (mcg); the biological activity of 40 IU is equal to 1 mcg (Table 2). Even though sunlight may be a major source of vitamin D for some, the vitamin D RDAs are set on the basis of minimal sun exposure [1].
* Adequate Intake (AI)
Very few foods in nature contain vitamin D. The flesh of fatty fish (such as salmon, tuna, and mackerel) and fish liver oils are among the best sources [1,11]. Small amounts of vitamin D are found in beef liver, cheese, and egg yolks. Vitamin D in these foods is primarily in the form of vitamin D3 and its metabolite 25(OH)D3 [12]. Some mushrooms provide vitamin D2 in variable amounts [13,14]. Mushrooms with enhanced levels of vitamin D2 from being exposed to ultraviolet light under controlled conditions are also available.
Fortified foods provide most of the vitamin D in the American diet [1,14]. For example, almost all of the U.S. milk supply is voluntarily fortified with 100 IU/cup [1]. (In Canada, milk is fortified by law with 35–40 IU/100 mL, as is margarine at ≥530 IU/100 g.) In the 1930s, a milk fortification program was implemented in the United States to combat rickets, then a major public health problem [1]. Other dairy products made from milk, such as cheese and ice cream, are generally not fortified. Ready-to-eat breakfast cereals often contain added vitamin D, as do some brands of orange juice, yogurt, margarine and other food products. Plant milk alternatives (such as beverages made from soy, almond, or oats) are often fortified with vitamin D to the amount found in fortified cow's milk (about 100 IU/cup); the Nutrition Facts label will list the actual amount.
Both the United States and Canada mandate the fortification of infant formula with vitamin D: 40–100 IU/100 kcal in the United States and 40–80 IU/100 kcal in Canada [1].
Several food sources of vitamin D are listed in Table 3.
* IUs = International Units.
** DV = Daily Value. The U.S. Food and Drug Administration (FDA) developed DVs to help consumers compare the nutrient contents of foods and dietary supplements within the context of a total diet. The DV for vitamin D on the new Nutrition Facts and Supplement Facts labels and used for the values in Table 3 is 20 mcg (800 IU) for adults and children aged 4 years and older [16]. The new labels must list vitamin D content in mcg per serving and optionally list the amount in IUs in parentheses. FDA required manufacturers to use these new labels starting in January 2020, but companies with annual sales of less than $10 million may continue to use the old labels that list a vitamin D DV of 400 IU until January 2021 [15,17]. Foods providing 20% or more of the DV are considered to be high sources of a nutrient, but foods providing lower percentages of the DV also contribute to a healthful diet.
The U.S. Department of Agriculture's (USDA's) FoodData Central lists the nutrient content of many foods and provides a comprehensive list of foods containing vitamin D arranged by nutrient content and by food name. A growing number of foods are being analyzed for vitamin D content. Simpler and faster methods to measure vitamin D in foods are needed, as are food standard reference materials with certified values for vitamin D to ensure accurate measurements [18].
Animal-based foods can provide some vitamin D in the form of 25(OH)D, which appears to be approximately five times more potent than the parent vitamin in raising serum 25(OH)D concentrations [19]. One study finds that taking into account the serum 25(OH)D content of beef, pork, chicken, turkey, and eggs can increase the estimated levels of vitamin D in the food from two to 18 times, depending upon the food [19]. At the present time, the USDA's FoodData Central does not include 25(OH)D when reporting the vitamin D content of foods. Actual vitamin D intakes in the U.S. population may be underestimated for this reason.
Most people meet at least some of their vitamin D needs through exposure to sunlight [1,2]. Ultraviolet (UV) B radiation with a wavelength of 290–320 nanometers penetrates uncovered skin and converts cutaneous 7-dehydrocholesterol to previtamin D3, which in turn becomes vitamin D3 [1]. Season, time of day, length of day, cloud cover, smog, skin melanin content, and sunscreen are among the factors that affect UV radiation exposure and vitamin D synthesis [1]. Perhaps surprisingly, geographic latitude does not consistently predict average serum 25(OH)D levels in a population. Ample opportunities exist to form vitamin D (and store it in the liver and fat) from exposure to sunlight during the spring, summer, and fall months even in the far north latitudes [1].
Complete cloud cover reduces UV energy by 50%; shade (including that produced by severe pollution) reduces it by 60% [20]. UVB radiation does not penetrate glass, so exposure to sunshine indoors through a window does not produce vitamin D [21]. Sunscreens with a sun protection factor (SPF) of 8 or more appear to block vitamin D-producing UV rays, although in practice people generally do not apply sufficient amounts, cover all sun-exposed skin, or reapply sunscreen regularly [1,22]. Therefore, skin likely synthesizes some vitamin D even when it is protected by sunscreen as typically applied.
The factors that affect UV radiation exposure and research to date on the amount of sun exposure needed to maintain adequate vitamin D levels make it difficult to provide general guidelines. It has been suggested by some vitamin D researchers, for example, that approximately 5–30 minutes of sun exposure between 10 AM and 3 PM at least twice a week to the face, arms, legs, or back without sunscreen usually lead to sufficient vitamin D synthesis and that the moderate use of commercial tanning beds that emit 2%–6% UVB radiation is also effective [6,23]. Individuals with limited sun exposure need to include good sources of vitamin D in their diet or take a supplement to achieve recommended levels of intake.
Despite the importance of the sun for vitamin D synthesis, it is prudent to limit exposure of skin to sunlight [22] and UV radiation from tanning beds [24]. UV radiation is a carcinogen responsible for most of the estimated 1.5 million skin cancers and the 8,000 deaths due to metastatic melanoma that occur annually in the United States [22]. Lifetime cumulative UV damage to skin is also largely responsible for some age-associated dryness and other cosmetic changes. The American Academy of Dermatology advises that photoprotective measures be taken, including the use of sunscreen, whenever one is exposed to the sun [25]. Assessment of vitamin D requirements cannot address the level of sun exposure because of these public health concerns about skin cancer, and there are no studies to determine whether UVB-induced synthesis of vitamin D can occur without increased risk of skin cancer [1].
In supplements and fortified foods, vitamin D is available in two forms, D2 (ergocalciferol) and D3 (cholecalciferol) that differ chemically only in their side-chain structure. Vitamin D2 is manufactured by the UV irradiation of ergosterol in yeast, and vitamin D3 is manufactured by the irradiation of 7-dehydrocholesterol from lanolin and the chemical conversion of cholesterol [6]. The two forms have traditionally been regarded as equivalent based on their ability to cure rickets and, indeed, most steps involved in the metabolism and actions of vitamin D2 and vitamin D3 are identical. Both forms (as well as vitamin D in foods and from cutaneous synthesis) effectively raise serum 25(OH)D levels [2]. Firm conclusions about any different effects of these two forms of vitamin D cannot be drawn. However, it appears that at nutritional doses vitamins D2 and D3 are equivalent, but at high doses vitamin D2 is less potent.
The American Academy of Pediatrics (AAP) recommends that exclusively and partially breastfed infants receive supplements of 400 IU/day of vitamin D shortly after birth and continue to receive these supplements until they are weaned and consume ≥1,000 mL/day of vitamin D-fortified formula or whole milk [26]. Similarly, all non-breastfed infants ingesting <1,000 mL/day of vitamin D-fortified formula or milk should receive a vitamin D supplement of 400 IU/day [26]. AAP also recommends that older children and adolescents who do not obtain 400 IU/day through vitamin D-fortified milk and foods should take a 400 IU vitamin D supplement daily. However, this latter recommendation (issued November 2008) needs to be reevaluated in light of the Food and Nutrition Board's vitamin D RDA of 600 IU/day for children and adolescents (issued November 2010 and which previously was an AI of 200 IU/day).
The National Health and Nutrition Examination Survey (NHANES), 2005–2006, estimated vitamin D intakes from both food and dietary supplements [4,27]. Average intake levels for males from foods alone ranged from 204 to 288 IU/day depending on life stage group; for females the range was 144 to 276 IU/day. When use of dietary supplements was considered, these mean values were substantially increased (37% of the U.S. population used a dietary supplement containing vitamin D.) The most marked increase was among older women. For women aged 51–70 years, mean intake of vitamin D from foods alone was 156 IU/day, but 404 IU/day with supplements. For women >70 years, the corresponding figures were 180 IU/day to 400 IU/day [1].
Comparing vitamin D intake estimates from foods and dietary supplements to serum 25(OH)D concentrations is problematic. One reason is that comparisons can only be made on group means rather than on data linked to individuals. Another is the fact that sun exposure affects vitamin D status; serum 25(OH)D levels are generally higher than would be predicted on the basis of vitamin D intakes alone [1]. The NHANES 2005–2006 survey found mean 25(OH)D levels exceeding 56 nmol/L (22.4 ng/mL) for all age-gender groups in the U.S. population. (The highest mean was 71.4 nmol/L [28.6 ng/mL] for girls aged 1–3 years, and the lowest mean was 56.5 nmol/L [22.6 ng/mL] for women aged 71 and older. Generally, younger people had higher levels than older people, and males had slightly higher levels than females.) 25(OH)D levels of approximately 50 nmol/L (20 ng/mL) are consistent with an intake of vitamin D from foods and dietary supplements equivalent to the RDA [1].
Over the past 20 years, mean serum 25(OH)D concentrations in the United States have slightly declined among males but not females. This decline is likely due to simultaneous increases in body weight, reduced milk intake, and greater use of sun protection when outside [28].
Nutrient deficiencies are usually the result of dietary inadequacy, impaired absorption and use, increased requirement, or increased excretion. A vitamin D deficiency can occur when usual intake is lower than recommended levels over time, exposure to sunlight is limited, the kidneys cannot convert 25(OH)D to its active form, or absorption of vitamin D from the digestive tract is inadequate. Vitamin D-deficient diets are associated with milk allergy, lactose intolerance, ovo-vegetarianism, and veganism [1].
Rickets and osteomalacia are the classical vitamin D deficiency diseases. In children, vitamin D deficiency causes rickets, a disease characterized by a failure of bone tissue to properly mineralize, resulting in soft bones and skeletal deformities [20]. Rickets was first described in the mid-17th century by British researchers [20,29]. In the late 19th and early 20th centuries, German physicians noted that consuming 1–3 teaspoons/day of cod liver oil could reverse rickets [29]. The fortification of milk with vitamin D beginning in the 1930s has made rickets a rare disease in the United States, although it is still reported periodically, particularly among African American infants and children [3,20,25].
Prolonged exclusive breastfeeding without the AAP-recommended vitamin D supplementation is a significant cause of rickets, particularly in dark-skinned infants breastfed by mothers who are not vitamin D replete [30]. Additional causes of rickets include extensive use of sunscreens and placement of children in daycare programs, where they often have less outdoor activity and sun exposure [20,29]. Rickets is also more prevalent among immigrants from Asia, Africa, and the Middle East, possibly because of genetic differences in vitamin D metabolism and behavioral differences that lead to less sun exposure.
In adults, vitamin D deficiency can lead to osteomalacia, resulting in weak bones [1,5]. Symptoms of bone pain and muscle weakness can indicate inadequate vitamin D levels, but such symptoms can be subtle and go undetected in the initial stages.
Obtaining sufficient vitamin D from natural food sources alone is difficult. For many people, consuming vitamin D-fortified foods and, arguably, being exposed to some sunlight are essential for maintaining a healthy vitamin D status. In some groups, dietary supplements might be required to meet the daily need for vitamin D.
Vitamin D requirements cannot ordinarily be met by human milk alone [1,31], which provides <25 IU/L to 78 IU/L [26]. (The vitamin D content of human milk is related to the mother's vitamin D status, so mothers who supplement with high doses of vitamin D may have correspondingly high levels of this nutrient in their milk [26].) A review of reports of nutritional rickets found that a majority of cases occurred among young, breastfed African Americans [32]. A survey of Canadian pediatricians found the incidence of rickets in their patients to be 2.9 per 100,000; almost all those with rickets had been breast fed [33]. While the sun is a potential source of vitamin D, the AAP advises keeping infants out of direct sunlight and having them wear protective clothing and sunscreen [34]. As noted earlier, the AAP recommends that exclusively and partially breastfed infants be supplemented with 400 IU of vitamin D per day [26], the RDA for this nutrient during infancy.
Older adults are at increased risk of developing vitamin D insufficiency in part because, as they age, skin cannot synthesize vitamin D as efficiently, they are likely to spend more time indoors, and they may have inadequate intakes of the vitamin [1]. As many as half of older adults in the United States with hip fractures could have serum 25(OH)D levels <30 nmol/L (<12 ng/mL) [2].
Homebound individuals, women who wear long robes and head coverings for religious reasons, and people with occupations that limit sun exposure are unlikely to obtain adequate vitamin D from sunlight [35,36]. Because the extent and frequency of use of sunscreen are unknown, the significance of the role that sunscreen may play in reducing vitamin D synthesis is unclear [1]. Ingesting RDA levels of vitamin D from foods and/or supplements will provide these individuals with adequate amounts of this nutrient.
Greater amounts of the pigment melanin in the epidermal layer result in darker skin and reduce the skin's ability to produce vitamin D from sunlight [1]. Various reports consistently show lower serum 25(OH)D levels in persons identified as black compared with those identified as white. It is not clear that lower levels of 25(OH)D for persons with dark skin have significant health consequences. Those of African American ancestry, for example, have reduced rates of fracture and osteoporosis compared with Caucasians (see section below on osteoporosis). Ingesting RDA levels of vitamin D from foods and/or supplements will provide these individuals with adequate amounts of this nutrient.
Because vitamin D is a fat-soluble vitamin, its absorption depends on the gut's ability to absorb dietary fat. Individuals who have a reduced ability to absorb dietary fat might require vitamin D supplementation [37]. Fat malabsorption is associated with a variety of medical conditions, including some forms of liver disease, cystic fibrosis, celiac disease, and Crohn's disease, as well as ulcerative colitis when the terminal ileum is inflamed [1,3,37]. In addition, people with some of these conditions might have lower intakes of certain foods, such as dairy products fortified with vitamin D.
A body mass index ≥30 is associated with lower serum 25(OH)D levels compared with non-obese individuals; people who are obese may need larger than usual intakes of vitamin D to achieve 25(OH)D levels comparable to those of normal weight [1]. Obesity does not affect skin's capacity to synthesize vitamin D, but greater amounts of subcutaneous fat sequester more of the vitamin and alter its release into the circulation. Obese individuals who have undergone gastric bypass surgery may become vitamin D deficient over time without a sufficient intake of this nutrient from food or supplements, since part of the upper small intestine where vitamin D is absorbed is bypassed and vitamin D mobilized into the serum from fat stores may not compensate over time [38,39].
Optimal serum concentrations of 25(OH)D for bone and general health have not been established; they are likely to vary at each stage of life, depending on the physiological measures selected [1,2,6]. Also, as stated earlier, while serum 25(OH)D functions as a biomarker of exposure to vitamin D (from sun, food, and dietary supplements), the extent to which such levels serve as a biomarker of effect (i.e., health outcomes) is not clearly established [1].
Furthermore, while serum 25(OH)D levels increase in response to increased vitamin D intake, the relationship is non-linear for reasons that are not entirely clear [1]. The increase varies, for example, by baseline serum levels and duration of supplementation. Increasing serum 25(OH)D to >50 nmol/L requires more vitamin D than increasing levels from a baseline <50 nmol/L. There is a steeper rise in serum 25(OH)D when the dose of vitamin D is <1,000 IU/day; a lower, more flattened response is seen at higher daily doses. When the dose is ≥1,000 IU/day, the rise in serum 25(OH)D is approximately 1 nmol/L for each 40 IU of intake. In studies with a dose ≤600 IU/day, the rise is serum 25(OH)D was approximately 2.3 nmol/L for each 40 IU of vitamin D consumed [1].
In 2011, The Endocrine Society issued clinical practice guidelines for vitamin D, stating that the desirable serum concentration of 25(OH)D is >75 nmol/L (>30 ng/ml) to maximize the effect of this vitamin on calcium, bone, and muscle metabolism [40]. It also reported that to consistently raise serum levels of 25(OH)D above 75 nmol/L (30 ng/ml), at least 1,500-2,000 IU/day of supplemental vitamin D might be required in adults, and at least 1,000 IU/day in children and adolescents.
However, the FNB committee that established DRIs for vitamin D extensively reviewed a long list of potential health relationships on which recommendations for vitamin D intake might be based [1]. These health relationships included resistance to chronic diseases (such as cancer and cardiovascular diseases), physiological parameters (such as immune response or levels of parathyroid hormone), and functional measures (such as skeletal health and physical performance and falls). With the exception of measures related to bone health, the health relationships examined were either not supported by adequate evidence to establish cause and effect, or the conflicting nature of the available evidence could not be used to link health benefits to particular levels of intake of vitamin D or serum measures of 25(OH)D with any level of confidence. This overall conclusion was confirmed by a more recent report on vitamin D and calcium from the Agency for Healthcare Research and Quality, which reviewed data from nearly 250 new studies published between 2009 and 2013 [41]. The report concluded that it is still not possible to specify a relationship between vitamin D and health outcomes other than bone health.
More than 40 million adults in the United States have or are at risk of developing osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue that increases bone fragility and significantly increases the risk of bone fractures [42]. Osteoporosis is most often associated with inadequate calcium intakes, but insufficient vitamin D contributes to osteoporosis by reducing calcium absorption [43]. Although rickets and osteomalacia are extreme examples of the effects of vitamin D deficiency, osteoporosis is an example of a long-term effect of calcium and vitamin D insufficiency. Adequate storage levels of vitamin D maintain bone strength and might help prevent osteoporosis in older adults, non-ambulatory individuals who have difficulty exercising, postmenopausal women, and individuals on chronic steroid therapy [44].
Normal bone is constantly being remodeled. During menopause, the balance between these processes changes, resulting in more bone being resorbed than rebuilt. Hormone therapy with estrogen and progesterone might be able to delay the onset of osteoporosis. Several medical groups and professional societies support the use of HRT as an option for women who are at increased risk of osteoporosis or fractures [45-47]. Such women should discuss this matter with their healthcare providers.
Most supplementation trials of the effects of vitamin D on bone health also include calcium, so it is difficult to isolate the effects of each nutrient. Among postmenopausal women and older men, supplements of both vitamin D and calcium result in small increases in bone mineral density throughout the skeleton. They also help to reduce fractures in institutionalized older populations, although the benefit is inconsistent in community-dwelling individuals [1,2,48]. Vitamin D supplementation alone appears to have no effect on risk reduction for fractures nor does it appear to reduce falls among the elderly [1,2,48]; one widely-cited meta-analysis suggesting a protective benefit of supplemental vitamin D against falls [49] has been severely critiqued [1]. However, a large study of women aged ≥69 years followed for an average of 4.5 years found both lower (<50 nmol/L [<20 ng/mL]) and higher(≥75 nmol/L [≥30 ng/mL]) 25(OH)D levels at baseline to be associated with a greater risk of frailty [50]. Women should consult their healthcare providers about their needs for vitamin D (and calcium) as part of an overall plan to prevent or treat osteoporosis.
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 may have 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 [1,51,52]. Studies do not consistently show a protective or no effect, however. One study of Finnish smokers, for example, found that subjects in the highest quintile of baseline vitamin D status had a threefold higher risk of developing pancreatic cancer [53]. A recent review found an increased risk of pancreatic cancer associated with high levels of serum 25(OH)D (≥100 nmol/L or ≥40 ng/mL) [54].
Vitamin D emerged as a protective factor in a prospective, cross-sectional study of 3,121 adults aged ≥50 years (96% men) who underwent a colonoscopy. The study found that 10% had at least one advanced cancerous lesion. Those with the highest vitamin D intakes (>645 IU/day) had a significantly lower risk of these lesions [55]. However, the Women's Health Initiative, in which 36,282 postmenopausal women of various races and ethnicities were randomly assigned to receive 400 IU vitamin D plus 1,000 mg calcium daily or a placebo, found no significant differences between the groups in the incidence of colorectal cancers over 7 years [56]. More recently, a clinical trial focused on bone health in 1,179 postmenopausal women residing in rural Nebraska found that subjects supplemented daily with calcium (1,400–1,500 mg) and vitamin D3 (1,100 IU) had a significantly lower incidence of cancer over 4 years compared with women taking a placebo [57]. The small number of cancers (50) precludes generalizing about a protective effect from either or both nutrients or for cancers at different sites. This caution is supported by an analysis of 16,618 participants in NHANES III (1988–1994), in which total cancer mortality was found to be unrelated to baseline vitamin D status [58]. However, colorectal cancer mortality was inversely related to serum 25(OH)D concentrations. A large observational study with participants from 10 western European countries also found a strong inverse association between prediagnostic 25(OH)D concentrations and risk of colorectal cancer [59].
The largest clinical trial to examine the effects of vitamin D supplements on the primary prevention of cancer in the general population is the newly published VITamin D and OmegA-3 TriaL (VITAL). This clinical trial examined the effects of vitamin D3 supplementation (2,000 IU/day), with or without marine omega-3 fatty acids (1,000 mg/day), compared to placebo for a median of 5.3 years in 25,871 men aged ≥50 and women aged ≥55 with no previous cancer, heart attacks, or strokes [77]. Rates of breast, prostate, and colorectal cancer did not differ significantly between the vitamin D and placebo groups. However, normal-weight participants had suggestive reductions in cancer incidence and mortality as compared to those overweight or obese. In addition, African Americans taking vitamin D had a 23% reduction in cancer incidence. Most participants had adequate serum 25(OH)D levels at baseline; only 12.7% had levels <50 nmol/L (<20 ng/ml). Most participants who took the vitamin D supplements achieved serum 25(OH)D concentrations close to or above 100 nmol/L (40 ng/ml).
Further research is needed to determine whether vitamin D inadequacy in particular increases cancer risk, whether greater exposure to the nutrient is protective, and whether some individuals could be at increased risk of cancer because of vitamin D exposure [51,60]. Taken together, however, studies to date do not support a strong role for vitamin D, with or without calcium, in reducing the risk of cancer [1].
A growing body of research suggests that vitamin D might play some role in the prevention and treatment of type 1 [61] and type 2 diabetes [62], hypertension [63], glucose intolerance [64], multiple sclerosis [65], and other medical conditions [66,67]. However, most evidence for these roles comes from in vitro, animal, and epidemiological studies, not the randomized clinical trials considered to be more definitive [1]. Until such trials are conducted, the implications of the available evidence for public health and patient care will be debated. One meta-analysis found use of vitamin D supplements to be associated with a statistically significant reduction in overall mortality from any cause [68,69], but a reanalysis of the data found no association [48]. A systematic review of these and other health outcomes related to vitamin D and calcium intakes, both alone and in combination, was published in August 2009 [48]. In the recently published VITAL clinical trial (described above in the Cancer section), vitamin D (2,000 IU/day) as compared to placebo, taken for a median of 5.3 years, did not significantly reduce major cardiovascular events (myocardial infarction, stroke, and cardiovascular mortalty) or all-cause mortality in 25,871 middle-aged and older adults [77].
Vitamin D toxicity can cause non-specific symptoms such as anorexia, weight loss, polyuria, and heart arrhythmias. More seriously, it can also raise blood levels of calcium which leads to vascular and tissue calcification, with subsequent damage to the heart, blood vessels, and kidneys [1]. The use of supplements of both calcium (1,000 mg/day) and vitamin D (400 IU) by postmenopausal women was associated with a 17% increase in the risk of kidney stones over 7 years in the Women's Health Initiative [70]. A serum 25(OH)D concentration consistently >500 nmol/L (>200 ng/mL) is considered to be potentially toxic [5].
Excessive sun exposure does not result in vitamin D toxicity because the sustained heat on the skin is thought to photodegrade previtamin D3 and vitamin D3 as it is formed [6]. In addition, thermal activation of previtamin D3 in the skin gives rise to various non-vitamin D forms that limit formation of vitamin D3 itself. Some vitamin D3 is also converted to nonactive forms [1]. Intakes of vitamin D from food that are high enough to cause toxicity are very unlikely. Toxicity is much more likely to occur from high intakes of dietary supplements containing vitamin D.
Long-term intakes above the UL increase the risk of adverse health effects [1] (Table 4). Most reports suggest a toxicity threshold for vitamin D of 10,000 to 40,000 IU/day and serum 25(OH)D levels of 500–600 nmol/L (200–240 ng/mL). While symptoms of toxicity are unlikely at daily intakes below 10,000 IU/day, the FNB pointed to emerging science from national survey data, observational studies, and clinical trials suggesting that even lower vitamin D intakes and serum 25(OH)D levels might have adverse health effects over time. The FNB concluded that serum 25(OH)D levels above approximately 125–150 nmol/L (50–60 ng/mL) should be avoided, as even lower serum levels (approximately 75–120 nmol/L or 30–48 ng/mL) are associated with increases in all-cause mortality, greater risk of cancer at some sites like the pancreas, greater risk of cardiovascular events, and more falls and fractures among the elderly. The FNB committee cited research which found that vitamin D intakes of 5,000 IU/day achieved serum 25(OH)D concentrations between 100–150 nmol/L (40–60 ng/mL), but no greater. Applying an uncertainty factor of 20% to this intake value gave a UL of 4,000 IU which the FNB applied to children aged 9 and older and adults, with corresponding lower amounts for younger children.
Vitamin D supplements have the potential to interact with several types of medications. A few examples are provided below. Individuals taking these medications on a regular basis should discuss vitamin D intakes with their healthcare providers.
Corticosteroid medications such as prednisone, often prescribed to reduce inflammation, can reduce calcium absorption [71-73] and impair vitamin D metabolism. These effects can further contribute to the loss of bone and the development of osteoporosis associated with their long-term use [72,73].
Both the weight-loss drug orlistat (brand names Xenical® and alliTM) and the cholesterol-lowering drug cholestyramine (brand names Questran®, LoCholest®, and Prevalite®) can reduce the absorption of vitamin D and other fat-soluble vitamins [74,75]. Both phenobarbital and phenytoin (brand name Dilantin®), used to prevent and control epileptic seizures, increase the hepatic metabolism of vitamin D to inactive compounds and reduce calcium absorption [76].
The federal government's 2015-2020 Dietary Guidelines for Americans notes that "Nutritional needs should be met primarily from foods. ... Foods in nutrient-dense forms contain essential vitamins and minerals and also dietary fiber and other naturally occurring substances that may have positive health effects. In some cases, fortified foods and dietary supplements may be useful in providing one or more nutrients that otherwise may be consumed in less-than-recommended amounts."
For more information about building a healthy diet, refer to the Dietary Guidelines for Americans and the U.S. Department of Agriculture's MyPlate.
The Dietary Guidelines for Americans describes a healthy eating pattern as one that:
This fact sheet by the Office of Dietary Supplements (ODS) provides information that should not take the place of medical advice. We encourage you to talk to your healthcare providers (doctor, registered dietitian, pharmacist, etc.) about your interest in, questions about, or use of dietary supplements and what may be best for your overall health. Any mention in this publication of a specific product or service, or recommendation from an organization or professional society, does not represent an endorsement by ODS of that product, service, or expert advice.
Updated: March 24, 2020 History of changes to this fact sheet


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There's always been lot of things going on in the Queensryche world and the latest news is that the band is about to release its twelfth studio album DEDICATED TO CHAOS. We had the pleasure to sit down with the bands drum wizard Scott Rockenfield prior to their triumphant performance at this year's edition of the Swedenrock festival. Here are the results of that interesting chat. Read on!
Let's go on to your current thing. There's a new Queensryche album called DEDICATED TO CHAOS out there. Now it's your time to do the marketing thing.
It is time to market DEDICATED TO CHAOS. What do you want to know?
First of all, the last two Queenryche albums have been kind of team albums. How is this new one?
You mean team in terms of different people? It's again a team album. I mean – listen I think we've been making records that way since our first one. Since the early days Queensrÿche was always a team. It was a smaller team. But I think our whole reason for being a band and lasting for so long, is we've been all team players. We all respect each other in the band for what we do. And then through the years, of making records and touring, and just surrounding ourselves with people that we need, whether it's crew guys, for the road and – or working with people, making records, producers, or engineers, or songwriters or whatever it may be. Wherever inspiration comes from I think being a team has always kept us going. Otherwise, I think it gets stale. And I think this record is just another kind of defining moment for that, which is a team situation. A lot of people that we know surround us. Kelly Gray produced the record and engineered and mixed the record for us. And he's been…
Right and Kelly's been a part of the family since the early 80's?
Actually he's been around since high school… So he's actually been around with us for 30 years. So the team just kind of keeps going for us. And we got different crew guys with us, but some guys have still been with us for years and years as well. With this album, it was a kind of the same thing and we did our previous albums. We've used a lot of the same people, the team. Like I said, Kelly Gray was on AMERICAN SOLDIER, he had a big part of producing, engineering, mixing, he was all part of that, wrote some songs with us on that because we go into songs, he's a great guitar player and musician and great ideas. And we have another guy that we've used for many years now since MINDCRIME 2, I think, and then on AMERICAN SOLDIER and this one, a guy named Jason Slater, he's a writer and a producer and kind of part of our bigger team. He lives in LA and we live in Seattle. But he's just kind of become a helpful hand in doing things. And just as you get older and you start doing it, it's just fun to get new inputs and sometimes new inspiration whether it's a suggestion or a player or whatever it maybe. But still that's kind of part of the big team for us.
This time you also have a new member in band?
Right, we have Parker Lundstrom playing guitar, younger kid that's been in with us now for a couple of years and toured with us on AMERICAN SOLDIER and toured last year on some shows that we did in the United States.
Having now such a young guy in the band, does he bring anything new for Queensrÿche?
Well he brings youth that he has. More youth than we have "laughs" I mean he's a kid that we met in Seattle and was surrounded kind of close family friends. And he's just a real dedicated musician. He's a great guitar player and a dedicated musician. And we just realized that the time that we were getting to know him, and he was becoming part of our friendship, that we needed a guitar player who's Mike Stone who we have just prior to that because he's going to move on and going to do his own thing and wanted to focus on that. So Parker was just a good choice. But he brings – that he's excited, he's just enthusiastic to be here and be a part of it. He's a great team player. And he offers great inspiration, suggestion. And it's just real easy to be him.
When you're now seeing him living his own "rock star" dream, does it remind about your own early years when you first made it big time?
Yeah, yeah, yeah. I mean we were like that when we were that age too. It's an exciting time when you're young. And for us it's a different thing now. We get excited in different ways. We have a long history under our belt. And it's a big career for us. It's what we do to make a living. But he's just – gets a chance to live that now, and be a part of it. And he teaches us as I think as much as we can teach him.
I do understand that.
I always learn but I'm old enough to be his father. But I think it works well together. He's a great member of the team and he really blends in well. You know, he's got great tattoos and stuff and he goes out a lot, he has fun every night because he can because he gets over easier. So we get to live by proxy through him "laughs"
I know the feeling "laughs"
It's a lot safer for me "laughs"
This is actually kind of out of question, but when I first heard the new album name, it kind of reminded me Dream Theater's SYSTEMATIC CHAOS?
Right but I've never heard them. I don't know a lot about Dream Theater even though we played together, to be honest "laughs"
Right, what does the DEDICATED CHAOS mean? I mean, is there any deeper thoughts behind the title?
For us, the title was strictly… I think our big reason for the title is just the world we live in, our band world and our lives together for a long. They've been basically chaos. Being in a rock band, and making music and making a career and trying to make a living out of that requires – there's a lot of chaos, it's a lot of stuff, making records, and touring the world, its chaos. And I think current chaos has a lot to do with that with just people in society, social networking, and cell phones. You can't run away anymore, the Internet. Our kids are living that now with their own sell phones. And it's never going to go away. I think that's a lot of chaos. And I'm kind of thinking that's a lot of the inspiration behind the record for us.
How does it like to create new albums when every time the album comes up, there are always some people who keep on saying "Yeah, there is no Chris DeGarmo, it's not going to be any good"?
That's of course – that's fine, they can say that. We make records for ourselves and travel and tour. And Chris, he decided to leave 16, 17 years ago…
Yeah, but some people still don't get over it.
…and that's okay. I mean the majority of people have gotten over it. There's only some that don't. But I don't think it's – it doesn't bother me. It's not for us.
Right and one man don't make a band.
…and it doesn't. And we've had great success ever since. And we're planning bigger shows and touring longer and doing more things than we ever did even back on those days. So we worked hard to get to where we're at. We still got to keep working. This is only beginning this year.
The one special and unique thing what you did on last year were the Cabaret shows.
The cabaret shows, yeah.
Yeah, is there going to be more things like that in the future?
We don't ever know? That was something that we did last year in 2010 because we knew we were going to make a record and rewriting it in doing. But we didn't just want to do that and not get out and play shows. So we kind of started throwing some ideas around about what we could do. And the cabaret came up. Geoff and I went to a dinner theatre, which was kind of like Cirque De Soil, and we liked it so much, we started talking about doing something like that. How could we do that and have fun. And we always do everything just to have fun whether people like it or not. That's really not why we do, we do it because we want to go and have fun. If they wanted to come and enjoy then they do, that's great and we have a great career in that. But that was kind of hit. It was just another way to do something for ourselves and be different and have fun. And I think we weren't able to bring it over to Europe or anywhere else just because it was expensive. We had like peep actors, people…
And it could be really hard to find the suitable places for show like that in Europe?
Yeah, it really is. But hopefully in the future there will be more things like that for Queensrÿche. That was just another way to do something different, you know?
How about making an orchestra album?
We have done some but not a full… but that's all coming. We did a show a couple of weeks ago in Seattle that was with a 50-piece orchestra, and us. And we had Allen White playing drums from Yes, Mike DeRosier playing drums from Heart. And it was a benefit show we did in Seattle, a lot of fun. We did four songs with the orchestra that night. It was a lot of work. But stuff like that is always an option for us to get out and do something deeper. And we'd love to do something like that. Working with an orchestra is really a lot of fun. And I do a lot of that working on music for films, I do film stuff and it's a little different but challenging.
How is your other band, Slaves to The System doing at the moment? Is there anything new in sight?
Yes. We're actually going to try to finish the next one here soon. And Kelly who is working with us, he runs our inter-monitors for us on this tour and mixed the latest Queensryche records, he's going to start working on mixing some new songs that we have in his hotel room. And we all do other things. Geoff's got a wine that he promotes. And we play some shows promoting his wine back at home. It's a little acoustic thing that we do together and I jump in and help him to do that. And that's been a lot of fun. And we just try to do. We just… good work "laughs"
Is Geoff still doing solo shows as well?
Yeah, yeah. We find the time to fill in the gaps and do Queensrÿche and then that.
Scott live at Swedenrock 2011
After you've been doing Queenryche almost thirty years and having all those platinum albums, world tours and so on, what's actually the main goal for you guys at this stage of career?
I actually achieved a goal last year that was a lot of fun which was video games. I like to compose music for movies and stuff, but I got asked to do some music on The Call of Duty black ops video game last year, and then also play all the drums, ride all the drums and play all the drums with the orchestra because they wanted to make it a rock thing. And that's a really big franchise. That game is a huge, huge deal. And so I was really honored when they called me and said, "Do you want to do this?" And I also – I got to compose some extra music for the game that was used all during the game if you play the game. So that was a big thing for me. That was a lot of fun. And it's a hard industry to get into. But that was a nice goal. So I'd like to do more of that. Personally, I'm looking to do more of that. And I got some film scores that I'm being offered this year. Some big action movies that I'm being asked to compose all the music for. And to be honest for me, that's a huge goal for me to get more of that.
A game world, it's a new and different world and there huge goals to reach, I know.
It really is, and it's a lot of fun, and I really enjoy it. And I started doing it, 15, 20 years ago, and got some great – I got a Grammy nomination from my first film that I ever did back in the 90s. So since then, I just wanted to do more. So that's a lot of fun for me. I think everybody has their own goals of that stuff in mid. But as a band, I just think our goals are just to keep making music and planning shows and getting out until they won't have us anymore. When the fans say no because they won't buy our tickets or buy our records or enjoy our music, then it's probably time for us to move on.
I know but like you just said, how long you thing that you could carry on doing Queensryche? I mean, physically there are some limits which are getting closer every day, you know what I mean? Have you ever discussed about the subject between the band members?
You know, we talk about it over glasses of wine now and then. Geoff and I do. And it's really I think more just – I think we'll be able to keep going as long as we can still have an audience that wants to see us because we have to make money doing it, otherwise – I have to make a living somewhere.
Of course, you have to "pay the rent"
Yeah, I got kids going to college and doing all that stuff. So I got to be able to support that. We never knew how long it was going to last when we first started, you know?
Right and there's still Rolling Stones who keep on doing another tour even they're about 70 years old soon.. "laughs" So there's nothing to worry about…
Okay, see there you go. Listen – Allan White from Yes drummer, he lives in Seattle and he's like…
He's like 63 or something?
We hang out and do a lot of things together. Lately, we've been able to do some drum stuff together. He's an inspiration to me. And he's kind of the same way. So we just keep going, you just get through it on, you keep going. It's what we do, if you don't do it, then you got to find something else to do, and that's fine. But you just go until something happens or you can't go anymore. But I think we're okay for right now. So keep going and figure it out as you go.
You already mentioned the game world and the Internet, have you noticed that there are lots of young kids in the audience who come to see you because they've find out about you from that new type of media?
Absolutely. It's a great tool if you embrace it and learn how to make it work for you and keep embracing it. I think you can win and l I think that the ability is really great. There are obviously all sorts of great avenues and mediums with the Internet, and social networking. I mean everything out there, is a whole different world than when you first started. Record companies are few and far between and only signing so many things. They don't throw a bunch of money into careers. And you got to – our legacy has helped us with the record companies, I know. And so there are great avenues. I just think you have to invent and reinvent.
The only difficulty is – how to get your money out from that thing?
Yeah, and that's the biggest issue that has plagued a lot of people and a lot of record labels that don't know what to do with that yet. I think we're working our best as a band to see how we can benefit us. And so far it's working. It could turn – to a corner tomorrow and we have to redesign everything again. But we'll just do it.
Our time seems to be up… The last question… What are your near future plans with Queensryche from now on? I know you're going to Finland tomorrow but then?
Yeah, we're going to Finland tomorrow. We're going to do the show in there again with Judas Priest, we play Judas Priest on the same stage today night, so that'll be a lot of fun. And then in July, we start a tour of all the UK with Judas Priest; it's just us and Judas Priest. So they asked us to come over and do the whole tour with them, three weeks I think in the UK in July. And then July 29th is our first headlining show in New York city. And we do four months in the United Stated headlining. And then we take a break for Christmas and then we go somewhere probably in January again. So it's all starting right out for us.
Didn't you guys tour with Priest earlier as well?
We did – actually we did 2003 I think – 2005, US tour in the summer. So we've been around them for a while. Like I said, they asked us to do this again. They're fun to hang out with.
Okay Scott. Thanks for your time!
No problem.

subset: commoncrawl


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MOUNT PROSPECT, IL -- Exercise walking, which experienced 1.5 percent growth in 2005, remains the No. 1 participation activity surveyed by the National Sporting Goods Association (NSGA). Walking has remained on top since 1990. Data contained in NSGA's annual "Sports Participation – Series I and II" reports, which are now available, shows 86.0 million Americans walked for exercise in 2005.
Swimming, with 58 million participants, an increase of 8.5 percent, regained the No. 2 spot that it had lost in 2002. Camping, which had replaced swimming in the runner-up spot, dropped to fourth (46 million participants, down 16.8 percent) behind exercising with equipment (54.2 million, up 4.0 percent). Bowling rounded out the top five with 45.4 million ( up 3.5 percent).
Classic fitness activities included in the survey showed healthy growth in 2005. The fastest growing fitness activity was weightlifting, which increased 35.4 percent to 35.5 million participants and a spot in the top 10 for the first time at No. 9. Working out at a club ranks 10th with 34.7 million (up 9.2 percent), aerobic exercising, 11th with 33.7 million (up 14.4 percent), and running/jogging 14th with 29.2 million (up 9.5 percent).
"On top of 2004's increases in fitness participation, we're seeing a trend that Americans are taking their health and fitness much more seriously," NSGA Vice President of Information & Research Thomas B. Doyle said. "Five of the top 14 activities in our survey are fitness related, and it shouldn't be too many years before exercise walking becomes the nation's first 100-million-participant activity."


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Rudyard Kipling
Rudyard Kipling (30 December 1865 – 18 January 1936 / Bombay)
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Shillin' A Day
My name is O'Kelly, I've heard the Revelly
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Jerry Sloan, Milwaukee Bucks have met on coaching job
In the category of unemployed Hall of Fame coaches, Phil Jackson has been capturing the large majority of the spotlight in recent weeks.
But while it remains to be seen if the former Lakers and Bulls coach will re-enter the NBA anytime soon, another member of this rarest of clubs may be getting closer to making his return: Jerry Sloan.
According to two people with knowledge of the situation, the former Utah Jazz coach who resigned abruptly in Feb. 2011 has already met with the Milwaukee Bucks about their vacant coaching position and is being seriously considered. The people spoke to USA TODAY Sports the condition of anonymity because of the private nature of the coaching search.
Sloan has been looking for a landing spot for quite some time, but he could be a tailor-made fit for a Bucks situation that has much in common with the Utah job he held for 23 years. Milwaukee's locker room dynamic was shaky from training camp on, and the midseason departure of coach Scott Skiles and insertion of Jim Boylan as an interim did little to change the fact that the Bucks are in need of a coach who will command respect. While Sloan was reportedly being considered by the Brooklyn Nets, a reunion with former Jazz point guard Deron Williams is not on the horizon.
As was first reported by Yahoo! Sports, a person with knowledge of the situation confirmed that the Bucks interviewed Lakers assistant Steve Clifford for the job on Monday. According to various reports, the Bucks have also interviewed former Portland coach Nate McMillan and Houston assistants Kelvin Sampson and J.B. Bickerstaff.


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Story highlights
- Mark Bauerlein: Today's 20-somethings want to stretch out their adolescence
- Bauerlein: We need a comic novel that exposes the habits of "pre-adults" as ludicrous
- He says books have the power to fortify attitudes
- Bauerlein: Only all-out comedy or satire can show that pre-adults' behavior is backward
It seems today that a new stage of life has opened up. Sociologists call it "emergent adulthood," Time magazine termed it "the Twixter years," and author Kay Hymowitz referred to it as "pre-adulthood."
People in this group are over 18, but as they head toward 30 they still act and think like adolescents. They bounce from job to job and relationship to relationship, live with parents at home or in a house with five friends, watch ESPN and play video games (the boy-men) and read "Twilight" and ponder whether he's just not into you (the girl-women), while all of them sprinkle "like" and "'n stuff" and "ya know" in their speech. Adolescence used to be a condition you escaped as soon as you could, but these 20-somethings want to prolong it.
We need to counteract them, to restore embarrassment to adolescent habits, and books are a key weapon.
After all, books have the power to fortify attitudes. For instance, the "Harry Potter" books, a wonderful phenomenon for tweens and early-teens, offered so compelling a world of heroic, beset youth and hostile adults that readers clung to Harry well past the proper age. In fact, quidditch matches have spread to more than 200 college campuses. "Twilight" has had a similar impact, intensifying the ordinary shenanigans of teenagers to luridly high melodrama.
Why grow up when adolescence contains so much romance and suspense? Clinging to such young adult fantasies, pre-adults think that grownup content is a sensation, like "Fifty Shades of Grey," a book so poorly written as to be beyond parody. Only a 14-year-old sensibility could read this passage when Miss Steele first encounters Christian without laughing at the witlessness of the words.
I open the door and stumble through, tripping over my own feet and falling headfirst into the office.
Double crap -- me and my two left feet! I am on my hands and knees in the doorway to Mr. Grey's office, and gentle hands are around me, helping me to stand. I am so embarrassed, damn my clumsiness. I have to steel myself to glance up. Holy cow --he's so young.
Now, who trips over her own feet and falls headfirst to the floor? And the callowness of "Double crap" and "Holy cow" couldn't be more phony. Young women loved it, though. And so did many older women, apparently.
This is bad for our 20-year-olds and bad for our culture. Let us hope, then, that 2013 will unveil a new book about the young, but one that halts the creep of adolescence into adulthood.
Yes, there are several superb recent novels about teens and 20-somethings by talented writers, like Jeffrey Eugenides' "The Marriage Plot" and Gary Shteyngart's "Super Sad True Love Story." But they have too much sympathy for the emerging adult, too much understanding of young love and companionship, to do the work of correction.
It will take an altogether different book to explode extended adolescence; specifically, a frolicking comic novel that submits the interests and longings of pre-adults to whimsy, burlesque and farce. Not gentle humor, but all-out comedy or satire that casts the whole experience and habitat of pre-adults as both ludicrous and avoidable.
Not trite pratfalls that, supposedly, make the characters lovable inept and self-involved, but outrageous (and hilarious) situations such as those in Kingsley Amis' "Lucky Jim" and Philip Roth's "Portnoy's Complaint." Not sensitive and self-aware individuals coping with circumstances that afflict their whole age group, but memorable eccentrics like Ignatius J. Reilly from "A Confederacy of Dunces," whose disdain for all things contemporary highlights the virtues and vices of modern life.
This comic novel will amuse and sell well, for the better elements of our culture and our youth have grown impatient with the travails and aggrandizing of Twixter books, movies, music and TV.
It will serve a larger purpose, too, the same one that motivated satirists from Aristophanes and Juvenal to Swift and Pope to Mark Twain and the creators of "Dr. Strangelove": to curb self-indulgence, deflate pretense, and expel stupidity. To take down a popular genre or a representative figure or a trendy pose, one good belly laugh works better than pages of strict criticism.
H.L. Mencken chided middle-American backwardness at length, but his best weapon was a one-word comic label: the "booboisie." After Sarah Palin's nomination to the 2008 Republican ticket, intellectuals on the left attacked and on the right fretted, but the surest demolition came at the hands of Tina Fey's impersonation. When the catastrophe movies of the 1970s became too theatrical and clichéd, the film "Airplane!" appeared and one could no longer watch the genre with a straight face.
Let's have a comic novel do the same for emergent adulthood.
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SMH: CNN Reporter Calls Chamillionaire "SHHHAMILLIONAIRE" + Cham Won A Itunes Bet & His Dude That Lost Had To Jump Out A Plane!
"DigiJeff" bet Chamillionaire that if his single "Good Morning" became #1 on iTunes he'd jump out a plane & wore the pink shirt for breast cancer awareness.
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text: Enable pop-out video chat, and allow dragging the box anywhere. Obserwuj Nelly 3/11/2018 07:02 Currently, the video chat function is limited only to when you have discord focused, a 'pop out' button would be a really good idea. As well, currently you can only drag the window (While in a chat other than who you're calling) to either the top or bottom right, it'd be nice if you could fix it anywhere on the screen. 5842


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I am the proud owner of ARS Restorations - and OUR primary mission is to provide an exceptional experience for our clients. With over 20 years of experience in commercial roofing, we have helped 100's of building owners with both small and extremely complex projects. We specialize in roof restoration, with an expert team of installers that has made us the "Go To" roof restoration contractor in the state of Missouri.
We emphasize creating a positive atmosphere built on INTEGRITY, RESPECT, COMMITMENT, HONOR, COMPASSION & APPRECIATION.
We understand your commercial roof is one of your most valuable investments. That's why we only believe in using quality materials, meticulous craftsmanship, white-glove communication and hands-on leadership. You can take peace of mind in knowing that you have a contractor that has the expertise and know-how to get the job done right the FIRST time."
~Ashton Withington
NOTE:Your thorough roof inspection will include (drone and IR camera used as needed): photographs, detailed written assessment, potential storm damage discovered, and an easy-to-understand discussion of cost-effective repair or replacement solutions
Up to 50% Cheaper Than A Full Roof Replacement
Restoring your roof with a roof coating can save you up to 50%
Save on labor costs without having to remove your previous roof!
A roof coating can be applied over top of your current roof!
Federal tax rebates & tax credits
Roof coatings can potentially earn you a federal tax credit
Lower your utility bills
Roof coatings are engineered with reflective properties to 'reflect' heat from your building, meaning that it can help keep your building cooler without having cold air escaping during the hotter months! These savings can add up!
Made for the elements
Roof coatings are designed to hold up to Mother Nature. What does this mean for you? The more durable your roof is, the less you have to worry about your roof leaking & having to consistently repair your roof after each significant storm.
How long does it take to replace a commercial roof?
The answer of how long it will take to install your new commercial roof depends on a handful of actors. One of the largest factors is the size of your roof. The larger your roof, the more materials and labor will be required for your replacement, thus requiring a longer installation timeline. Another factor is the type of roof that you have. Does your commercial roof have multiple layers that have to be removed? Other factors are also important, such as what material are you replacing your roof with, what is the scope of the project, etc. Weather is also a factor as sometimes a roof replacement has to be pushed back if inclement weather or rain could impact the roof installation process.
What is the lifespan for a commercial roof?
The lifespan of your new commercial roof can depend on the type of roofing system and material that you have installed. Your roof's lifecycle can also be heavily influenced by local climate and weather. For instance, if several years after your roof is installed there is a massive hail storm, or a hurricane, this can significantly weaken or damage your commercial roof. Other factors also influence the life of your roof, such as the roofing contractor's craftsmanship, and whether or not they adhere to all proper code regulations and manufacturer specifications. Certain roof coatings can have a warranty up to 20-years!
How do I know when it is time to replace my commercial roof?
Not all roofs need to be replaced. Your roof may be a candidate for roof restoration via roof coatings, or roof repairs. However, if your roof is aging, and breaking down from wear and tear, then it may need to be fully replaced. The older a roof ages, it becomes vulnerable to future storm damage. If our technicians are not confident that a roof repair will extend the life of your roof for a reasonable length of time, a full roof replacement may be the only option.
I think I may have storm damage, what should I do?
Our technicians are specialists in identifying flat roof storm damage from both wind and hail damage. Our reps can help you diagnose if those pesky leaks coming into your building are stemming from storm damage, or age. If your roof is suffering from storm damage, we can help pin-point where those leaks are coming from & discuss your options with you if an insurance claim may make sense depending on the extent of the damage.
What should I be looking for in a commercial roofing company?
Your commercial roof is a complex system. It is a valuable investment, and you want a contractor you can rely on. There's a few important things to take into consideration: do they have glowing customer references that can vouch for their work, how much experience do they have in the Missouri market, what warranty do they offer, what is the price of their bid, what is the quality of the materials proposed. All of these points should be factored together. While price is a very large point of consideration when hiring a contractor, price should not be the only consideration. The cheapest option may not be the best option, and long-term could end up being the most expensive option if the roof is improperly installed. Quality and reliability of the contractor should be heavily weighed.
Should I restore or replace my commercial roof?
Not every single low slope, metal roof or commercial flat roof is going to require a full roof replacement - and at the same time, not every commercial roof is going to be a candidate for roof restoration. It can be case by case. Roof coatings can provide tremendous financial savings when compared to a traditional full roof replacement. A roof coating can extend the life of your existing roof without needing to tear off your existing roof, and is much less disruptive. Roof coatings can provide superior waterproofing, financial savings, and even tax credits. After completing a thorough roof inspection, we can discuss whether your roof is a candidate for roof coatings.


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DIY Courses & Trade Courses
Training Centres in Birmingham & Manchester
Welcome to the UK's leading provider of short construction training courses for both DIY and Tradespeople
***Coronavirus Crisis UPDATE ***
We would appreciate your support by taking advantage of our
Advance Booking Offers .
If you are booked on a course, please see the measures we have put in place to reschedule courses, so we can continue to be able to teach you DIY for many years to come. As of Monday May 25th, in line with the Governments guidelines, we are planning to once again start teaching from the 1st June, subject to government approval and the re supply of materials used on our courses.
For details of courses, click on the icons below for more details
Hello to all our past, present and future DIY & Trades students.
Last year, after listening to your feedback, we launched some 1-day courses, such as a Speedskim plastering course, along with an Advanced Tiling Course for underfloor heating and a 2-day Door-hanging course in our completely refurbished training centres.
We've now trained over 12,000 students during the past 13 years, so you can be sure to get the best tuition, use the best materials and have the best experience possible, whilst having lots of fun. Who said learning was boring!
The DIY School courses enable men and women with little or no experience in construction and DIY to learn a comprehensive range of construction skills that are useful, current and in demand, at work or on a home project.
If you're already a tradesperson, you can add new skills without the need to take a long time away from work — something which makes sense when you can't afford to lose business taking time off!
Have a look at our videos to see what the students get up to at The DIY School.
Tiling Courses
Tiling Courses at The DIY School are designed to enable tiling students to tackle the majority of projects in the private & domestic tiling industry or significant DIY tiling projects.
Our Tiling Courses have enabled individuals to set up new tiling businesses; see our Tiling Course Customer Success Stories page for more information.
Fire Officer Matt Birch's first paid tiling job after his Tiling Course
The Tiling Courses cover the skills essential to create a professional tiling finish and provide sufficient skills to build a business around tiling.
The tiling skills that you will cover are considered to be in demand and capable of being taught to a good standard in just 4 days.
The course also acts as a sound foundation to progress from to our Advanced Tiling Course, which provides on the job learning and tiling manufacturer product updates, as well as new tiling product developments.
Read more about our Manchester Tiling Courses and other courses by clicking on the following links:
Top | Tiling | Plastering | Decorating | Bricklaying | Handy Man | Beginners DIY
Plastering Courses
Plastering Courses at The DIY School in Manchester are for men and women looking to tackle the majority of projects they will encounter in the professional domestic plastering industry, such as property redevelopments or significant DIY plastering projects.
The DIY School Plastering Courses enable people to set up new dedicated plastering businesses having made a career change. For existing tradespeople, plastering is an addition to existing skills offered by professionals such as tilers, plumbers, kitchen fitters or electricians.
Matt at work after his Plastering Course
Whilst plastering for many is seen as an "art", The DIY School's Plastering Course teaches the processes that make plastering an easy skill to master, and gives students the skills needed to become independent plasterers running their own businesses.
The Essentials Skills Plastering Course is an ideal starting point from which to build a business around skimming, re-skimming, dry lining, dot and dab, and wall and ceiling repairs, all of which are hugely in demand.
Read more about our Plastering Courses, other courses and book online by clicking on the following links:
Top | Tiling | Plastering | Decorating | Bricklaying | Handy Man | Beginners DIY
Painting, Wallpapering & Decorating Courses
Painting & Decorating Courses at The DIY School in Cheshire enable students to learn the skills with which they will be able to tackle the majority of projects as professional decorators in the private & domestic sector, such as in property development and high-quality home DIY tasks.
With what we call a "tool kit of skills" that includes wall papering, painting and preparation, Decorating Course students will learn the foundations essential to set up successful decorating companies or to tackle significant home decorating opportunities.
Painting & Decorating Course Student after the Decorating Course in Manchester
Because decorating can be time consuming for home owners, demand for good quality decorators is constantly high, making the Decorating Course a great investment in a new career after a redundancy or period of unemployment.
Read more about our Painting, Wall Papering & Decorating Courses and book online by clicking on the following links:
Top | Tiling | Plastering | Decorating | Bricklaying | Handy Man | Beginners DIY
Bricklaying Courses
There are two types of Bricklaying Courses at The DIY School in the North West: Bricklaying Courses for Garden Walls and Bricklaying Courses for Cavity Walls.
These courses have been divided this way as we've learned that most people want to do one type of bricklaying or the other. For those wanting to learn both sets of skills, they can return to add a further two days to their course in order to cover the content of both.
Bricklaying Courses for Cavity Walls & Garden Walls
Unlike with tiling, plastering, and decorating, we are not suggesting that anybody could make a living on the basis of a 4-day Bricklaying Course. Not only is demand for bricklaying much too low, but it is a trade that requires great experience and ability to ensure that plans and building regulations are followed correctly.
4-day Bricklaying Courses at The DIY School are ideal for anyone wanting to tackle smaller projects & larger projects over time. The Bricklaying Courses have also been used by existing tradespeople to add services to their established businesses, such as gardeners, landscapers, conservatory builders and property developers.
Read more about our Bricklaying Courses and book online by clicking on the following links:
Top | Tiling | Plastering | Decorating | Bricklaying | Handy Man | Beginners DIY
DIY Handyman Courses
The DIY Home Handyman Courses appeal to men and women who want an improved understanding of how to fix common DIY faults and problems around the home. The course has been used in conjunction with other courses at The DIY School — including Tiling, Plastering, Decorating and Bricklaying — to enable new handyman businesses to be set up.
Read more about our DIY Handyman Courses and book online by clicking on the following links:
Top | Tiling | Plastering | Decorating | Bricklaying | Handy Man | Beginners DIY
Beginners DIY Tool Use — Hand and Power Tools Courses
Beginners DIY Tool Use Courses have enabled many of our students to take the first step on the DIY ladder. Driven often by the desire to stop relying on others, this beginner course enables students to learn DIY skills that will form the foundation for future Do-It-Yourself independence.
Covering the use of all essential tools, the course covers how to use hammers, nails, screws, screwdrivers, drills, rawl plugs saws, workbenches, chisels and many other everyday DIY tools that may be required around the home.
Introduction to DIY Courses — Kids Come Free!
The Beginners DIY Course acts as a great foundation for follow-on courses, the most popular of which are the DIY Handyman and Decorating Courses.
Read more about our DIY Handyman Courses and book online by clicking on the following links:
Top | Tiling | Plastering | Decorating | Bricklaying | Handy Man | Beginners DIY
Feedback for our courses:
Course content was excellent. It covered all the aspects that I was unsure about. The trainer was always willing to give advice and takes time to explain fully.
John Bridgewood - Plastering Courses - Manchester
The course was above expectation, was flexible with good advice throughout
Max Hatton - Bricklaying Courses - Southport - Cavity Walls
The course was exactly what I wanted, (The trainer) is obviously skilled in his trade and inspires students with his enthusiasm. (Chose us over other local schools having visited others in the area )
Rick Hedley - Tiling Courses - Bolton
Excellent teacher, very knowledgeable and eternally patient. I am more than confident in starting my own project now...in fact I have started already!
Chris Lewis - Plastering Courses - Manchester
At no point during the course did Mike make you feel as though it was something that you couldn't do. A natural trainer and a great personality with it. I was amazed that after just 4 days I could get to the level that I did. excellent course and would highly recommend.
Paul Waterhouse - Blackpool - Plastering Courses - North West
Light hearted, bright, breeze to listen too and in all totally informative. The structure of the course caters for all levels of skill and not once are you put under pressure to keep up.
Andy Turner - Liverpool - Plastering Courses - Merseyside
Mike had a lot of patience and was also very supportive and encouraging
Darren Hatton - Southport -Plastering Courses - Lancashire
Glad that I chose the DIY School as the course was delivered to a really good standard and the staff were really nice.
Monica Thomas - London - Painting & Decorating Courses
Friendly and knowledgeable. Exercises explained clearly and good follow up when doing exercises.
Julian Munro - Painting & Decorating Courses - Blackpool
Superb! Words are not enough. Cannot recommend you highly enough.
Graham Carter - Plastering Courses - Sheffield - The Essentials & Advanced Plastering Courses
Well above my expectations, I could actually do it, amazing. I attended the plastering course because I am renovating my house and wanted to do the plastering myself because of costs. The course gave me all the information I needed and more.
Janet Darragh - Plastering Courses - Bradford.
Excellent Course. I didn't think that I could so much in 4 days.
Jay - Tiling Courses - UK
Very helpful and informative course which has given me the confidence to re-tile my property and possibly take tiling up as a trade. Very friendly and helpful. Always able to answer any questions and point out where I had gone wrong and how to put it right.
David Thomas - Tiling Courses - Leeds
As you know I have just done three courses with you over the last few months (diy, tiling and plastering). I would like to thank all of you for your very patient and professional manner. I thoroughly enjoyed all the courses and have already started putting some of my new found skills to good use around the house. I have to admit that I would never have dreamt that I had it in me – I have always avoided DIY like the plague.
Peter Carling - Isle of Man - Home Repairs, Tiling Courses and Plastering Courses
Very methodical and well structured course. I now feel I have the confidence to skim or a wall or ceiling, dry line or repair defects in plaster work!! Very patient and knowledgeable instructor with a wealth of real world experience. Top Bloke!!
Gary Speakman - Essential Plastering Courses - Lancaster
Excellent! I couldn't believe we covered so much in 4 days. It was great to get down to the practical straight away. We learned so much this way. Mike was fantastic. He was clear, encouraging and fun and truly professional in his role. Thank you.
Heather Gooch - Essential plastering Courses - Yorkshire
Excellent. As you know as an ex head teacher take to heart my comment. Super!
Graham Kellett - Essential Plastering Courses - Derbyshire
Very good. I couldn't even spell DIY this morning. Now I know what is in a tool box and why!
Simon Bate - DIY Tool Use Courses - Merseyside
Basic enough but comprehensive enough. A lot learned in 6 hours. Should be taught in schools!
Sybil Leeman and her teenage son - Lancashire - DIY Tool Use Courses
Very Useful and valuable course from beginners.
Alison Vasey - DIY Tool Use Courses - Hull
Really good intro and demystifies the basics.
Anon - DIY Tool Use Courses - Stoke
You walk in having no idea and leave saying " I will be able to do that now"
Richard Leeman - DIY Tool Use Courses - Staffordshire
Good Instruction
Kendon Macdonald - DIY Tool Use Courses - Birmingham
Warren Fields - Advanced Bricklaying Courses
Super. Made me confident in brickwork
Peter Gaines - Bricklaying Courses - Manchester
A very challenging course but immensely rewarding.
Terry Wiggins - Essential Plastering Courses - Liverpool
The course is intensive but in a fun and relaxed atmosphere
Terry Hill - Essential Plastering Courses - Nort Wales
Very Good
Imran Ghani - Essential Plastering Courses - Chester
Brilliant. Would use & recommend to all.
Martin Hulme - Essential Plastering Courses - Wrexham
Very Enjoyable. Very Informative
Neil Rankine - Essential Plastering Courses - Derby
Excellent! Thoroughly enjoyed & will recommend to anyone interested in doing a course.
Trevor Marchington- Essential Plastering Courses - Nottingham
Thoroughly enjoyable learning. Want to do more. Amazed how much content in the course.
Jude Neli - Painting & Decorating Courses - Manchester
Good fun, informative and very easily absorbed training.
Rachel Lakeland-Fox - Painting & Decorating Courses - Buxton
First Class. Coming Back for the tiling course.
Howard Lockwood - Painting & Decorating Courses - Leeds
Good fun.
Sue Ryder - Painting & Decorating Courses - Manchester
All the essentials in a relaxed atmosphere.
Gill Davidson - Painting & Decorating Courses - London
Lots to do. Well organised and worked out
Paul Doherty - Painting & Decorating Courses - Crewe & Nantwich
Very informative, taught the basics required to create a professional job. -
Andy Warner- Tiling Courses - Manchester
Totally relevant to my need - property renovation. Course content and delivery were spot on. -
Colin Ardron- Tiling Courses - North West
I feel more independent now -
Donna Rees- DIY Home Maintenance Courses - Cheshire
Good atmosphere, easy going, very informative. -
Pete Davies- Essential Bricklaying Courses - Scotland.
Started as a novice, ended up a professional! -
Mark Husband- Essential Plastering Courses - West Midlands.
Excellent course, superb trainer. Would recommend to anyone. -
Stephen Lyth - Essential Plastering Courses - Cheshire
Couldn't believe how good you get in such a short length of time -
Jonathan Mills - Essential Plastering Courses - North Wales.
Excellent 4 days of Training -
Gwyn Owens - Essential Plastering Courses - Merseyside
"A brilliant mother and daughter experience. Both Emma ( 12 years old ) and I thoroughly enjoyed the learning curve"
Dee and Emma Hamilton - Tiling Courses - Hyde.
"Best learning experience I have had in years"
Zeeshan Jameel - Tiling Courses - Bradford.
"Worth every penny. Demystifies trade skills"
Phil Elsey- Essential Bricklaying Courses - Manchester.
"Very useful and great fun too. Could hardly believe how the time flew by"
Vivien Walsh - Home Maintenance Courses - North UK.
"Great, really enjoyed it"
Kate Threadgold - Advanced Plastering Courses - Didsbury
"Here are some pictures of my first paid tiling job."
Paul Pearson - Tiling Courses - Cumbria


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Address: Klagstorpsvägen 135, 295 94 Näsum
Self-picking of assorted fruit.
We have the cultivation of sweet cherries, apples, pears, plums, sour cherries,
We also have a small winery.
As of Sunday, July 12 until August, weather permitting, we have self-picking of sweet cherries and sour cherries daily between the hours of 1PM and 6PM. Blackberries can be picked by telephone ordering fr.om August through November, weather permitting.


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Product Description
Blushing Peonie Pebble 48614-19
A beautiful Range of fabrics designed by Robin Pickens featuring Floral images. The fabrics feature Natural, Pink, Light Green and Grey colours through the range.
Price $25.00 per metre FQ: $6.25
Designer: Robin Pickens . Range: Blushing Peonies
100% cotton 114 cm wide
Theme: Florals
Colour: Grey


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$ 19.95
I'd Rather Live Under The Sea
Please leave size in notes at check out
Tank Tops will be automatically sent during spring and summer
If you need a shirt instead of a tank, please leave in messages.
Headband up to 6yr only
Shorts up to 8yr only
Additional colors for bodysuits and writing are available, please send a message prior to ordering to check availability.
Don't see your size? Ask!!
Made with high quality vinyl
Made in a SMOKE FREE home
Care: Please wash the shirt inside out with cold water on a gentle cycle, and lay flat or hang to dry.
Do not iron the design, it is safe to iron the reverse side of the garment to remove any wrinkling. Just do not directly iron the imprinted image.
Need it sooner? Rush and Shipping Options are available!
Shipping: https://www.etsy.com/listing/286392585/shipping-upgrade-rush-hurry?ref=listing-shop-header-2
Rush: https://www.etsy.com/listing/286391809/rush-order-listing-hurry-custom-design?ref=related-2
►NOTE: Color of photo and actual product may not match exactly due to differences in monitor calibration.
Newborn brand used is Gerber
If desired size is not available substitute will be used
Example: Ordered 3-6 Months 3-9 Months may be used
**items other than bodysuits ordered may extend ship out time**
$ 19.95
Mermaids and Unicorns Are My Favorite IF YOU ARE ORDERING 2T AND UP: Please leave size in notes at check out Tank Tops will be automatically sent during spring and...
$ 19.95
I Can't Walk, I'm A Mermaid Bodysuit This listing is for one, white, bodysuit. IF YOU ARE ORDERING 2T AND UP: Please leave size in notes at check out Tank...
$ 29.95
Are you ready for summer?! Our fringe tanks and dress will add the perfect summer touch to all your beach parties!! IMPORTANT: Tanks start at size 3. Size 3 is...
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