to the editor: I especially appreciated the point made by Hark and Deen¹ in their recent review of nutrition screening in American Family Physician—that family physicians should find the time to address nutrition and dietary behavior issues within the context of an office visit. Physicians must take advantage of every opportunity to educate and improve the nutritional behavior of their patients. Unfortunately, the section on folates in this article missed an opportunity to emphasize prevention of birth defects and infant mortality and morbidity through vitamin B supplementation.

Each year in the United States, about 4,000 pregnancies are affected by neural tube defects. In 1992, the U.S. Public Health Service recommended that all women of childbearing years consume 400 μg per day of the B vitamin folic acid to reduce the risk of these defects.² More specifically, in 1998, the Food and Nutrition Board of the Institute of Medicine recommended that all women of childbearing age consume 400 μg per day of synthetic folic acid from fortified foods or vitamin supplements in addition to natural food folate.³ The body can more easily absorb synthetic folic acid than natural food folate. It is crucial to provide this advice to all women of childbearing age, because an estimated 50 percent of all pregnancies in the United States are unintended.⁴ The neural tube closes during the first month of pregnancy, before many women even know they are pregnant; thus, it is important that an adequate amount of folic acid be in a woman's system before conception.

In 1998, the March of Dimes launched a $10 million, multi-year campaign to increase awareness among women about the importance of folic acid, and to inform women about how they can consume the required 400 μg per day by following a healthy diet and taking a daily multivitamin. The goal is to reduce serious brain and spine defects in the United States by at least 30 percent by the year 2001. The campaign includes professional education, community outreach programs, new material, advertising and publicity.

So yes, I agree that each office visit should be used advantageously for nutritional education, but physicians should always provide complete information—especially when it can prevent thousands of severe birth defects.

in reply: We completely agree with Dr. Mattison's comments about the important issue of the prevention of neural tube defects. While we believe that primary care physicians should discuss the issue of folic acid supplementation with all women of child-bearing years, space considerations in our article did not allow us to pay attention to specific issues of importance at different stages of the life cycle. We appreciate Dr. Mattison's thoughtful comments and believe that conversations regarding preventive issues related to specific nutrients should be conducted in the context of a conversation about patients' usual dietary intake and other health maintenance behaviors.