LETTERS TO THE EDITORS...............................................................................................................................................

not have as much of aneed for identifica-tion symbols at work. However, whose inpractice less than 5 years felt that thiswas an important part of dress. Individu-als in health care agencies and highereducation tended Lobe more favorable topower/authority symbols in dress thanthose in consulting and industry areas.Respondents in higher education tendedto be positive in terms of dress code/policies for dress in health care thanthose in health care agencies, consult-ing, industry and those unemployed.In summary, dietitians who have been

in practice over 20 years tended to bemore positive in their views of formalattire for work. Likewise, those 60 yearsof age or older tended to be more positivetoward formal attire. Those dietitians inthe midrange of age and years of practice01 to 20) were more negative towardformal attire than those younger withfewer years in practice. These individu-als embraced casual dress more thanthose older individuals who entered theprofession when more formal attire wasexpected or the younger individuals whoare still trying to become secure or striv-ing to enter the career. Casual dress forhealth care professionals has an addi-tional element not present in other busi-ness occupations, that of perception ofsafety and competence with clients'physical well-being. This appears to berecognized by dietitians. The groups inthe study that tended not to favor formalattire were Lhose in the midrange of ageand career and those employed in highereducation. This seems to suggest thatdietitians who have direct daily contactwith clients recognize and/or accept theimportanc of projecting an imagethrough their dress of competence andsafety in their knowledge and practice.

DNISPILLMAN, PhD, RDDepartment of physical education,health and sports studies, school ofeducation and allied professions,Miami University, Oxford, OH

References1. BarrettTG,BoothIW.Sartorialeloquence: Doesit exist in the pediatrician-patient relationship?British Medical Journal International. 1994;309(6970) 1710-1712.2. Lehna C, Phoutz S, Peterson TG, Degner K,Grubaugh K,LorenzL,MastropietroS, Rogers LS,Schoettle B,Seck LL.Nursingattire: Indicators ofprofessionalism. Journal of Professional NurSing.1999;15(3):192-199.

346/ March 2002 Volume 102 Number 3

Folie acid fortification: Additionalissues

To the Editors:As we read the article "Folic acid fortifi-cation: Informed mothers, healthy ba-bies" (1) we were impressed with thefacts presented concerning cereal forti-fication. We agree that food manufactur-ers ought to be regulated more strictly intheir folic acid fortification and that di-eLitians should be a leading force in thiseffort. We would like to add some addi-tional information about possible con-tributing factors to neural tube defects(NTDs).First, we wish to comment on the list

of good sources of folate given in thearticle. We agree that the listed foods aregood sources of folate, but they may notbe the most practical source for the gen-eral public, given the eating habits oftypical Americans. Young Americanwomen typically consume only 2 of thefolate-rich foods listed-cold cereal andorange juice. Per mandates of the Foodand Drug Administration, folic acid forti-fication has been required in grains sinceJanuary 1998 (2) so other importantfolate sources include white bread, rolls,and crackers. Also, these foods are forti-fied with synthetic folic acid, which isabsorbed much better than food folate is(3).Second, genetic defects that produce

altered forms of enzymes like cystathione~-synthase, methionine synthase, andespecially 5,1 G-methylenetetrahydro-folate reductase can lead to elevatedlevels of total homocysteine (an aminoacid and by-product of methionine me-tabolism). Elevated homocysteine is in-dicative of inadequate folate intake orabnormal folate metabolism (4), andwomen withhyperhomocysteinemiamayhave an increased need for dietary orsupplemental folate/folic acid.Third, Lhe popularity of low-carbohy-

drate diets may play an indirect role infolic acid consumption and NTDs. Ifwomen following popular fad diets areavoiding high-carbohydrate foods, theymay, in fact, be avoiding folic acid unwit-tingly. Also, we must look at that seg-ment of the population that tends to diet:women aged 15-35 years; this age groupof dieters happens to overlap with theprime childbearing age. Because NTDsarise within the first month of preg-nancy-often before women recognizethey are pregnant-a low-carbohydratediet may deny women the fortified grain

foods they need and will not help toreduce NTDs.We appreciaLe this opportunity to ex-

press our interest in this pressing issue.As future dietitians, we look forward tothe Journal as a leading source of knowl-edge and we look forward to any furthercoverage concerning NTDs.

STEPHANIE MOYAGENIE MclVERJENNIFER SEITERDIANE BAILEYOf the maternal and child nutritionclass, Arizona State University East

References1. McCaffreeJ. Folicacid fortification:informedmothers, healthy babies. J Am Diet Assoc.2001;101:872.2. Foodand DrugAdministration.FoodStandards.Federal Register. 1996;61:8781-8797.3. BaileyLB.New standard for dietary folate in-take in pregnant women. Am J Clin Nutr.2000;71(suppl):1304S-1307S.4. Scholl TO, Johnson WG.Folic acid: influenceon the outcome of pregnancy. Am J Clin Nutr.2000;71(suppl):1295S-1303S.

ERRATUMThe references to Dr Barbara Dennison'sletter to the editor in the November 2001Journal (pg. 1312) were inadvertentlyomitLed. They are:1. DennisonBA,ErbTA,Jenkins PL.Predictors ofdietarymilk-fatintakeby preschool children. PrevMed 2001 (in press)2. What a surprise' MilkSpreading Across theLips of Celebrities [press release]. New York:NationalFluidMilkProcessor EducationProgram;January 11, 1995.The Journal regrets the error.

LETTERS TO THE EDITORS ARE WELCOMELetters may have a maximum of 500words; references should be kept to fiveor fewer. Relevant charts or graphs areacceptable. Letters should be typeddouble-spaced with wide margins. Sub-mission of a letter constitutes permissionfor the American Dietetic Association touse it in the Journal, subject to editingand abridgment. Financial associationsor other possible cont1icts of interestshould always be disclosed. Letters relat-ing to articles published in recent Jour-nal issues have priority. Send four copiesto: The Editor, Elaine R. Monsen, PhD,RD, Journal of the American DieteticAssociation, University of Washington,BOX 353410 Seattle, WA 98195-3410.Letters may also be submitted via e-mailto:ltejada@u.washington.edu.