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Brigham and Women's Hospital Division of Preventive Medicine 900 Commonwealth Avenue East Boston, MA 02215-1204
Dear Sir:
We appreciate Seely's proposition that all cereals my not be equal in affecting risk of coronary heart disease mortality. We would like to emphasize 2 main points. First, in a prospective cohort study, we reported an inverse relation between whole-grain consumption and the incidence, not prevalence, of coronary heart disease (1). The difference between prevalence and incidence is subtle but important. Prevalence includes people with coronary heart disease at baseline who may have changed their diet after disease diagnosis. Incidence studies can provide a direct assessment of the association between diet and disease that would not be confounded by factors modified after disease diagnosis (2). Second, the study by Seely can at best suggest a hypothesis to be explored because of important limitations inherent in any such international correlation or ecologic study, including the crude assessment of diet, lack of information on individual diets, and the lack of adjustment for confounding factors including genetic predisposition, environment, and lifestyle practices (3). Seely noted only a few of the many differences between these countries. Large prospective cohort studies with detailed dietary assessment, long-term follow-up, and careful control of multiple confounding factors are better suited to examine diet-disease associations.
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