Copyright 2013 American Medical Association. All rights reserved. tions apply to these data. The retail cost for foods may not rep- resent the true costs because food may be purchased and/or con- sumed at restaurants. Details about which specific foods were reported by participants are not included in this analysis; how- ever, other studies have reported that the traditional Mexican diet is richer in fruits, vegetables, and fiber (via corn and beans) and that among Mexican Americans, those with less accultura- tion to the United States are more likely to retain these patterns. 4 It is also not clear whether Mexican Americans purchase the ma- jority of their food through resources that would have been in- cluded in the retail cost database and/or whether food costs in stores that might be more likely to be frequented by Mexican Americans are equivalent to costs in chain stores. Also, these data might not apply to other Hispanics such as Puerto Ricans, Cubans, Dominicans, or Central and South Americans. The data presented in this report should encourage a lively debate about how best to improve the proportion of Ameri- cans consuming diets consistent with DASH. In addition to cost, barriers to adopting DASH include income, education, and cul- tural and family attitudes about DASH foods. 5 The local food en- vironment is also influential; living in areas with few or no su- permarkets or less availability of foods in the DASH dietary pattern has been shown to be associated with worse dietary quality. 6 The national food environment also plays an impor- tant role. The supply of refined grains and fats on a per capita basis exceeds the US Department of Agriculture’s per capita di- etary recommendations, but there is insufficient availability of fruits and vegetables to supply the population with even 5 serv- ings per day, much less the 7 to 9 servings recommended by DASH. 7 Additional research is needed to elucidate the relative importance of food costs compared with other determinants of food choices, such as access or taste preferences, for DASH adherence. Policy makers should consider which changes at the macroeconomic level might be necessary to provide an enhanced food environment, facilitating healthier food choices by the population. For example, modeling studies have suggested that changing the price of healthier foods (eg, subsidies on fruits and vegetables) and taxes and/or reduced subsidies on unhealthy foods (eg, sugars and fats) might lead to beneficial dietary change. 8 National levers that might influence the food supply include federal farm subsidies and the Supplemental Nutrition Assistance Program (food stamps); at more local levels, economic development pro- grams, zoning, and/or tax incentives could be structured in ways that promote access to healthier foods. Municipalities have been pursuing measures such as moratoriums on fast food restaurant permits (Los Angeles) 9 and requiring calorie labeling on menus (New York) 10 ; thus far there is no consen- sus on whether such approaches have made substantial prog- ress in altering food consumption patterns. One need only look at tobacco use, however, to realize that large-scale behavior change over a 20- to 40-year horizon. Alain G. Bertoni, MD, MPH Melicia C. Whitt-Glover, PhD Author Affiliations: Maya Angelou Center for Health Equity, Winston-Salem, North Carolina (Bertoni); Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina (Bertoni); Gramercy Research Group, Winston-Salem, North Carolina (Whitt-Glover). Corresponding Author: Alain G. Bertoni, MD, MPH, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 (abertoni@wakehealth.edu). Published Online: September 2, 2013. doi:10.1001/jamainternmed.2013.9163. Conflict of Interest Disclosures: None reported. 1. Sacks FM, Appel LJ, Moore TJ, et al. A dietary approach to prevent hypertension: a review of the Dietary Approaches to Stop Hypertension (DASH) Study. Clin Cardiol. 1999;22(7)(suppl):III6-III10. 2. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington, DC: US Government Printing Office; 2010. 3. Monsivais P, Rehm CD, Drewnowski A. The DASH diet and diet costs among ethnic and racial groups in the United States [published online September 2, 2013]. JAMA Intern Med. doi:10.1001/jamainternmed.2013.9479. 4. Neuhouser ML, Thompson B, Coronado GD, Solomon CC. Higher fat intake and lower fruit and vegetables intakes are associated with greater acculturation among Mexicans living in Washington State. J Am Diet Assoc. 2004;104(1):51-57. 5. Bertoni AG, Foy C, Hunter J, Quandt SA, Vitolins MZ, Whitt-Glover MC. A multilevel assessment of barriers to adoption of Dietary Approaches to Stop Hypertension (DASH) among African Americans of low socioeconomic status. J Health Care Poor Underserved. 2011;22:1205-1220. 6. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR Jr. Associations of the local food environment with diet quality--a comparison of assessments based on surveys and geographic information systems: the multi-ethnic study of atherosclerosis. Am J Epidemiol. 2008;167(8):917-924. 7. Putnam J, Allshouse J, Kantor LS. US per capita food supply trends: more calories, refined carbohydrates, and fats. Food Review. 2002;25(3):2-15. 8. Eyles H, Ni Mhurchu C, Nghiem N, Blakely T. Food pricing strategies, population diets, and non-communicable disease: a systematic review of simulation studies. PLoS Med. 2012;9(12):e1001353. 9. Sturm R, Cohen DA. Zoning for health? the year-old ban on new fast-food restaurants in South LA. Health Aff (Millwood). 2009;28(6):w1088-w1097. 10. Dumanovsky T, Huang CY, Nonas CA, Matte TD, Bassett MT, Silver LD. Changes in energy content of lunchtime purchases from fast food restaurants after introduction of calorie labelling: cross sectional customer surveys. BMJ. 2011;343:d4464. doi:10.1136/bmj.d4464. COMMENT & RESPONSE Origins of Diagnostic Error To the Editor Singh and colleagues 1 present findings of an elabo- rate and costly program to investigate diagnostic error in pri- mary care. This report and the accompanying Invited Commentary 2 miss the larger significance of the work pre- sented. The very ingenuity and scale of effort required to con- duct this investigation by Singh et al 1 documents the persis- tence in medical practice of the same, pervasive disorder de- scribed by Lawrence L. Weed a half-century ago. 3 Best known as the inventor of the problem-oriented medical record and SOAP (subjective, objective, assessment, plan) note, Weed has labored 60 years to align medical practice with scientific meth- ods. His work culminates in a comprehensive analysis of the disorder in medical practice, identifying its roots in our con- tinued reliance on the physician “as a repository of knowl- edge and a vehicle for information processing.” 4(pX) Far from being “the first step on a path forward,” 2 the work of Singh and colleagues 1 should herald our last missteps on a path of error defined by neglect of Weed’s thought. Letters jamainternalmedicine.com JAMA Internal Medicine November 11, 2013 Volume 173, Number 20 1925 Copyright 2013 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by a Department of Veterans Affairs User on 11/11/2013