1. Malinow MR, Duell PB, Hess DL, et al. Reduction of plasma homocyst(e)ine levels by breakfast cereal fortified with folic acid in patients with coronary heart disease. N Engl J Med 1998;338:1009-15. 2. Savage DG, Lindenbaum J, Stabler SP, Allen RH. Sensitivity of serum methylmalonic acid and total homocysteine determinations for diagnosing cobalamin and folate deficiencies. Am J Med 1994;96:239-46. 3. Herbert V. Making sense of laboratory tests of folate status: folate requirements to sustain normality. Am J Hematol 1987;26:199-207. [Erratum, Am J Hematol 1988;28:134.] 4. Brattstrom LE, Israelsson B, Jeppsson JO, Hultberg BL. Folic acidan innocuous means to reduce plasma homocysteine. Scand J Clin Lab Invest 1988;48:215-21. 5. Santhosh-Kumar CR, Deutsch JC, Ryder JW, Kolhouse JF. Unpredictable intra-individual variations in serum homocysteine levels on folic acid supplementation. Eur J Nutr 1997;51:188-92. To the Editor: The editorial by Oakley (April 9 issue) 1 downplaying the role of dietary modification and advocating routine multivitamin supplementation for the U.S. population illustrates the confusion that exists with respect to the use of nutrient pills as research tools as opposed to an effective public nutrition measure. Furthermore, it contributes to the worrisome U.S. trend toward the medicalization of public nutrition. Nutrient-containing capsules are ideal vehicles for testing diet-health hypotheses, following double-blind, randomized clinical-trial designs. Public nutrition measures in response to these trials should be based first and foremost on dietary recommendations. When diet alone may be insufficient, as for example, in cases of iron deficiency during pregnancy, then carefully targeted supplementation becomes a reasonable option.The New England Journal of Medicine Downloaded from nejm.org on May 11, 2018. For personal use only. No other uses without permission.Copyright © 1998 Massachusetts Medical Society. All rights reserved.
· August 13, 19 98The New Eng land Jour nal of Medicine Folic acid supplementation as a public nutrition measure for the prevention of neural-tube defects 2 or heart disease is unwarranted. Contrary to what is implied in the editorial, it is quite possible to obtain recommended intakes of folate or folic acid daily through dietary means, particularly now that flour-based products are fortified with folic acid. Oakley indicates that we have no conclusive evidence on which to base food-based recommendations because studies have used folic acid capsules. The plausibility of this is low, since dietary folate is likely to offer the same benefits as those derived from synthetic folic acid.Oakley's position has major flaws. First, he bases recommendations for the whole United States on studies conducted in samples with unique biomedical, demographic, socioeconomic, and cultural characteristics. Second, there is not a single published randomized trial to support the folic acid-heart disease argument being made. Third, he advocates the use of higher doses for fortificati...
