[Congressional Record Volume 140, Number 21 (Wednesday, March 2, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: March 2, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
           DIETARY SUPPLEMENTS ARE BENEFICIAL TO GOOD HEALTH

                                 ______


                          HON. ELTON GALLEGLY

                             of california

                    in the house of representatives

                        Wednesday, March 2, 1994

  Mr. GALLEGLY. Mr. Speaker, the subject of health care reform seems to 
be the talk of the town these days. While more and more politicians are 
talking about health care reform, one of the trends in our Nation is 
the increasing attention among people toward health consciousness and 
preventative measures.
  Scientific evidence is mounting that one thing people can do to 
promote good health is to consume dietary supplements, and two recent 
articles in respected scientific publications reinforce that view.
  In the December 8, 1993, issue of the Journal of the American Medical 
Association, an editorial appeared concerning the importance of 
adequate vitamin intake. In the past, it was noted that a balanced diet 
was sufficient and that vitamin supplements were not necessary. This is 
no longer the case.
  And in January of this year, the editors of the University of 
California at Berkeley Wellness Letter, published by the university's 
school of public health, said they were now convinced that supplements 
are beneficial as well.
  Proper nutrient intake not only helps prevent disease, but is 
essential to maintaining good health. Unfortunately, most Americans do 
not get even the recommended dietary allowance--RDA--of many nutrients 
from their normal diets and have chosen to supplement their diet with 
vitamins, minerals, and other nutritional substances.
  The scientific evidence continues to mount supporting the importance 
and the necessity of vitamin supplementation. A striking example is the 
relationship between folic acid supplements and the reduction in neural 
tube birth defects. A simple multivitamin of 0.4 mg taken daily by 
women of childbearing age can reduce the risk of neural tube birth 
defects by approximately 70 percent. Neural tube birth defects now 
occur in about 1 of 1,600 pregnancies, resulting in the birth of 2,500 
affected infants each year. Although most survive, many are in need of 
extensive, lifelong medical care, which can have a staggering effect on 
these children and our families.
  Mr. Speaker, I am inserting the editorial from the December 8, 1993, 
issue of the Journal of the American Medical Association, and the 
editorial from the January 1994 issue of the University of California 
at Berkeley Wellness Letter in the Congressional Record.
  The material follows:

  [From the Journal of the American Medical Association, Dec. 8, 1993]

    Homocysteine and Marginal Vitamin Deficiency--The Importance of 
                        Adequate Vitamin Intake

       Apart from calcium and iron requirements, nutrition in 
     general (and vitamins in particular) has traditionally rated 
     only a passing nod in medical school. Physicians in training 
     are typically taught that a ``balanced'' diet is sufficient 
     and that hardly anyone really needs vitamin supplements. 
     although frank vitamin deficiency is now uncommon in the 
     United States, many investigators have long suspected that 
     large segments of the US population are consuming suboptimal 
     levels of several micronutrients; in recent years, compelling 
     evidence has emerged that supports this contention. In 
     national surveys, a substantial proportion of the US 
     population consumes levels of several vitamins that are well 
     below recommended intakes, and recent evidence strongly 
     indicates that such low intakes are associated with serious 
     health consequences. The most striking recent example is the 
     finding that folic acid supplements can reduce the risk of 
     neural tube defects by approximately 70%. That relationship 
     was demonstrated in observational epidemiological studies 
     describing an inverse association with multiple vitamin use, 
     and confirmed by randomized clinical trials. The implication 
     of those studies is that suboptimal consumption of folate 
     exists among at least a subgroup of women of childbearing 
     age. The inverse relationship between consumption of fruits 
     and vegetables and cancer risk, as seen in dozens of studies, 
     further suggests that large segments of our population are at 
     risk of serious disease due to inadequate diets, although 
     cause-and-effect relationship has not been proved. In a 
     recent large prospective study, intake of vitamin A was 
     inversely related to risk of breast cancer, and among those 
     with the lowest intakes from diet, use of supplements 
     containing vitamin A was associated with lower risk. Also, in 
     a recent randomized trial, elderly Canadians given 
     multivitamin, multimineral supplements had half the risk of 
     various infections compared with the placebo group. Two large 
     recent studies found that men and women taking vitamin E 
     supplements of at least 100 IU per day (a level exceeding 
     that found even in good diets) had a 40% lower risk of 
     coronary heart disease.
       In the present issue of The Journal, Selhub and colleagues 
     report on the vitamin status of the elderly participants in 
     the Framingham Study and provide further evidence that 
     suboptimal intake of several vitamins is common, even in a 
     population enrolled in a long-term health survey. They 
     measured intake of vitamins B6 and B12 and folate, 
     their blood levels, and a metabolic marker of suboptimal 
     intake of those vitamins, plasma homocysteine concentration. 
     Their findings are striking. In this population sample, even 
     after taking into account supplement use, about 20% were 
     consuming less than the current recommended dietary allowance 
     (RDA) for folate. More important was the finding that the 
     homocysteine concentration in blood rose with decreasing 
     folate and vitamin B6 intakes (and blood levels). 
     Individuals whose folate intake reached the RDA (200 
     g/d for men and 180 g/d for women) still 
     had elevated homocysteine levels compared with those with 
     higher intake. The homocysteine concentration did not reach 
     its nadir until folate intake approached about 400 
     g/d, a level that was attained by only about 40% of 
     the population. Thus, homocysteine elevations were not 
     limited to a small subgroup with extremely low intake. The 
     findings were strengthened by the close consistency of the 
     results with plasma folate: the homocysteine concentration 
     appeared to increase among those in the lower half of the 
     population classified by plasma folate levels. These 
     observations support the restoration of 400 g/d as 
     the RDA for folate, which was the RDA level until recently.
       Similar findings were observed for vitamin B6. The 
     nadir for homocysteine were not seen until vitamin B6 
     intake approximated the RDA (2 mg/d for men, 1.6 mg/d for 
     women), but half the population had levels lower than this. 
     These findings demonstrate that a large proportion of the 
     elderly do not consume adequate folate or B6 as judged 
     by the RDA standards, or by the impact on homocysteine. As 
     expected in an elderly population, inadequacies in B12 
     levels (also associated with elevated plasma homocysteine) 
     appeared to be more related to absorption than to intake.
       Why should we care about homocysteine? Early studies showed 
     that individuals with very high levels of homocysteine (due 
     to genetic metabolic defects) often died of severe vascular 
     disease in their teens or 20s. More recent work has shown 
     that even moderately elevated levels are associated with 
     increased risk of cardiovascular disease. In the first 
     prospective study, published last year in JAMA, participants 
     in the Physicians' Health Study with homocysteine 
     concentrations greater than 15.8 mol/L (the 95th 
     percentile for controls in that population) had a threefold 
     increase in risk of myocardial infarction compared with men 
     with normal levels, independent of other coronary risk 
     factors. That study was based on a highly selected, low-risk, 
     and generally well-nourished population. In the elderly 
     Framingham population, which is somewhat more representative 
     of the US population, 21% had levels above 15.8 mol/
     L, more than four times the proportion among the physicians. 
     The epidemiologic data are insufficient to distinguish 
     whether the risk associated with homocysteine is limited to 
     those with high levels, or whether there is a graded 
     association across much of the distribution, as with serum 
     cholesterol. In either event, an elevated homocysteine 
     concentration may contribute to a substantial fraction of 
     myocardial infarctions (and perhaps other cardiovascular 
     outcomes) in the United States.
       Several investigators have demonstrated that elevated 
     levels of homocysteine can often be normalized with 
     nutritional supplements, particularly with folate; thus, the 
     associations observed by Selhub et al are very likely to be 
     causal. However, it is not yet clear that reducing elevated 
     homocysteine levels decreases the risk of coronary disease. 
     Thus, observational studies and randomized trials relating 
     intakes of folate and vitamin B6 to incidence of 
     coronary heart disease are needed. Except for the risk of 
     masking vitamin B12 deficiency, which is very small if 
     it exists at all at intakes of less than 1000 g/d, 
     folate doses several times greater than the RDA have no known 
     toxic effects. Hence, randomized, placebo-controlled trials 
     of primary and secondary prevention among persons with 
     elevated levels of homocysteine are quite feasible. Trials of 
     secondary prevention would be simpler because a smaller 
     sample size would be needed (due to the higher risk of a 
     subsequent event) and because a larger proportion of such 
     patients have elevated homocysteine concentrations than the 
     general population. Compared with other treatments and 
     preventives currently being tested, such trials would be 
     simple and relatively inexpensive and would carry a 
     reasonably good likelihood for success. The careful work of 
     Selhub and colleagues underscores the importance of this 
     issue.
       As we await the initiation and completion of such studies, 
     is it appropriate to act on the accumulating evidence? 
     Adequate intake of folate may be important not only in 
     preventing neural tube defects and reducing the risk of 
     cardiovascular disease through its effect on homocysteine, 
     but also in helping to prevent colon polyps, colon cancer, 
     and cervical cancer. The intake of folate, vitamin B6, 
     and some other micronutrients appears to be inadequate for 
     many Americans, and the data from the present study provide 
     further reason for individuals to consume better diets; five 
     servings of fruits and vegetables as part of a good diet 
     would bring the folate and vitamin B6 intakes of most 
     persons to levels adequate to prevent high homocysteine 
     levels.
       However, even though Americans have been told to eat more 
     fruits and vegetables (the best source of folate) for 
     decades, large segments of our population are still far from 
     consuming recommended intakes. Barriers include more than 
     just education; cost, convenience, and hectic lifestyles also 
     contribute. Consuming an optimal level of vitamin B6 is 
     even more complicated as red meat is a major source of this 
     vitamin, but also is an important source of methionine (the 
     metabolic precursor of homocysteine), saturated fat, and 
     cholesterol intake. In recognition of the proven relationship 
     between inadequate folate intake and risk of neural tube 
     defects, the Food and Drug Administration has proposed to 
     fortify flour and rice with this nutrient.
       Given the realities of US diets, uncertainty about the 
     timing and effectiveness of folate fortification, and the low 
     cost and apparent absence of toxic effects of standard RDA-
     level multivitamins, a reasonable argument can be made for 
     recommending such supplements for many individuals. Although 
     the benefits of such supplements have not been proved, except 
     for reducing neural tube defects, physicians must often weigh 
     risks and benefits in the absence of complete information.
       Recommending the use of such supplements should not deter 
     efforts to improve dietary intake of fruits and vegetables, 
     particularly since fiber and other biologically active 
     components of vegetables and fruits, in addition to 
     recognized nutrients, appear to play important functions in 
     maintaining health. Most individuals consuming five servings 
     of fruits and vegetables per day (a minority of Americans) 
     would not benefit from supplement use. Pending results from 
     randomized trials, however, vitamin supplementation at the 
     RDA level may be beneficial for the large segment of the US 
     population not meeting dietary goals, and in particular 
     elderly persons and women of childbearing age.
                                       Meir J. Stampfer, MD, DrPH.

                                      Walter C. Willett, MD, DrPH.

                                  ____


[From the University of California at Berkeley Wellness Letter, January 
                                 1994]

                 Our Vitamin Prescription: The Big Four

       The editorial board of the Wellness Letter headed by Dr. 
     Sheldon Margen, has been reluctant to recommend supplementary 
     vitamins on a broad scale for healthy people eating healthy 
     diets. But the accumulation of research in recent years has 
     caused us to change our minds--at least where four vitamins 
     are concerned. These are the three so-called antioxidant 
     vitamins, plus the B vitamin folacin. The role these 
     substances play in disease prevention is no longer a matter 
     of dispute.
       The antioxidant vitamins are E and C, as well as beta 
     carotene, a plant form of vitamin A. (Beta carotene, one of 
     the carotenoids, is not strictly classified as a vitamin: 
     once thought to be effective only after being converted to 
     vitamin A in the body, it now appears to have important 
     functions of its own.) Acting at the molecular level, these 
     antioxidants inactivate a class of particles known as free 
     radicals. A free radical is a highly reactive atom or 
     molecule that carries an unpaired electron and thus seeks to 
     combine with another molecule. In humans, the most common 
     free radicals are ``activated'' oxygen molecules. Free 
     radicals are natural by-products of many normal processes at 
     the cellular level and are also created by such environmental 
     factors as tobacco smoke and radiation. They can damage basic 
     genetic material, cell walls, and other cell structures, and 
     in the long run this damage can become irreparable and lead 
     to disease. But the antioxidant vitamins help mop up these 
     free radicals before they do their dirty work.
       A high intake of vitamins C and E and beta carotene seems 
     to be protective against many kinds of cancer, including 
     oral, esophageal, and reproductive. They, and in particular 
     vitamin E, may lower the risk of heart disease by reducing 
     the build-up of plaque in coronary arteries. Vitamins C and E 
     seem to play a protective role against cataracts. 
     Antioxidants may even delay some effects of aging. Indeed, we 
     are only beginning to understand the importance of these 
     nutrients and how they work.
       Though not an antioxidant, folacin (also called folic acid 
     or folate) has been shown to prevent certain birth defects 
     (see Wellness Letter, November 1992), and increased intakes 
     of folacin are now recommended to all women in their 
     childbearing years, unless they are absolutely certain of not 
     becoming pregnant. Folacin may also protect against cancer, 
     at least cervical cancer. More discoveries about folacin, 
     too, will undoubtedly be forthcoming.
       Ideally your vitamins should come chiefly or entirely from 
     your diet rather than from pills. Supplements cannot 
     substitute for a healthy diet. There's a simple reason for 
     this: foods supply much else besides vitamins--minerals, 
     fiber, carbohydrates, proteins, and fats, as well as elements 
     we have not yet even discovered. Furthermore, many nutrients 
     require synergy: vitamin C helps you utilize iron, for 
     instance, and vitamin E helps you use vitamin K. But even if 
     you do eat a very healthy diet--and most Americans do not--
     it's unlikely you will get the high levels of folacin and of 
     the antioxidant vitamins many authorities think you need. A 
     recent government survey found that only 9% of Americans are 
     eating the recommended minimum of five servings of fruits and 
     vegetables (rich in antioxidants) a day.
       Optimal doses of these vitamins are still far from agreed 
     on. Dr. Gladys Block of the University of California at 
     Berkeley and other scientists have called for serious 
     national debate on the issues of fortifying more foods with 
     vitamins and recommending supplementation for more groups. 
     The Food and Drug Administration recently proposed that 
     folacin be added to flour, bread, and cereals, which are 
     already enriched with other B vitamins.


                           WHAT YOU SHOULD DO

       The first step is to eat a very healthy diet--at least five 
     servings of fruits and vegetables daily, six to eleven 
     servings of grains, especially whole grains, two or three 
     servings of low-fat or nonfat dairy products, and small 
     servings of meats and fish. In addition, you should consider 
     taking supplements of the antioxidant vitamins and, if you 
     are a premenopausal woman, folacin.

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