Advocates contend that the recommendation is justified because sodium restriction has been convincingly proven to lower blood pressure and that this will surely prevent stroke and myocardial infarction. Skeptics argue that modification of this single surrogate end point does not guarantee a health benefit as measured by morbidity or mortality. Instead, they note that salt restriction capable of reducing blood pressure also unfavorably affects other cardiovascular disease surrogates.

Alderman calls for an evidence-based discussion on the policy of universal salt reduction, arguing:

Surrogate markers, such as blood pressure, are not clinical events, but usually are associated with the incidence of subsequent stroke, myocardialinfarction, kidney dysfunction, or heart failure. Multiple randomized clinical trials (RCTs) have established that reduction of sodium intake sufficient to lower blood pressure also increases sympathetic nerve activity, decreases insulin sensitivity, activates the renin angiotensin system, and stimulates aldosterone secretion. The health effects of sodium reduction will be the net of these conflicting effects.

He concludes advising avoiding a rush to judgment:

There are at least 2 paths forward. The rash route is through universal sodium reduction. For countries like the United States, this means changing the diet of all its residents by reducing the sodium content of prepared foods. Despite the heterogeneity of blood pressure response to sodium reduction, advocates of this strategy are confident that known beneficial effects will outweigh known negative effects and that there will be no serious unintended consequences. An alternate, more cautious approach, calls for rigorous, largescale, population-based randomized clinical trials. These trials will likely demand a commitment by thousands of individuals for several years but will result in greater precision and scientific credibility to help answer the question—and vastly smaller risk of human and material resources. In the absence of definitive evidence, both the rash and cautious paths are experimental. Based on what is known, the prudent course of action may well be caution.