Historically, aldosterone was considered a hormone released from the adrenal cortex in response to low salt intakes. It was thought to exert its effects solely through mineralocorticoid receptors, thereby causing sodium retention and potassium loss. More recently, however, a much wider role for aldosterone has been recognized.

Research efforts have revealed a host of new pathophysiologic mechanisms associated with elevated aldosterone that could be expected to contribute to the progression of congestive heart failure and sudden cardiovascular death.

More importantly, the recent evidence is based upon research into the actual metabolic mechanisms rather than epidemiological or observational studies, which are generally open to a range of mechanistic interpretations and confounding errors. A growing body of evidence suggests that . The endothelium is the thin layer of cells that line the interior surface of all blood vessels. It serves as the interface between the circulating blood and the rest of the vessel wall. The condition of the endothelium plays a critical role in the regulation of vascular tone, platelet aggregation within the vessel, the adhesion of leukocytes and overall blood coagulation. When the endothelium is not right, as in endothelial dysfunction, it is predictive of future cardiovascular events.

Because low salt diets stimulate elevated aldosterone levels, this phenomenon may very well explain the repeated findings that more people on low salt diets succumb to cardiovascular disease than those on normal or high salt diets, which we reported on previously.

In the past, experimental studies have focused on the pathological effects of angiotensin II, rather than aldosterone, and demonstrated that angiotensin-converting enzyme inhibitors confer significant cardiovascular protection. However, more recently, research has revolutionized our view of aldosterone and its biological actions, and identified mineralocorticoids as important mediators of cardiovascular injury. Elevated aldosterone levels can cause cardiovascular injury without raising the blood pressure, and aldosterone blockers can exert significant protective effects without lowering the blood pressure.

Infants born with a low birth weights tend to have higher aldosterone levels when they are older. This corresponds to recent research, which we previously reported on demonstrating that low birth weight babies are also born with low sodium in their blood serum because their mothers were on low salt intakes.

The current evidence concludes that that a long-term increase in aldosterone production from early on in life is determined by an interaction of genetic and environmental factors, such as diets that are low in salt. This leads to cardiovascular damage in middle age and beyond. These results have been confirmed by at least two other studies, one from Israel and one from Japan, which further state that the current upper limit of 2300 mg sodium per day (6 g of salt), described in the Institute of Medicine Dietary Reference Intakes is insufficient to prevent the triggering of elevated aldosterone levels.

As more and more high quality evidence mounts on the malignant impact of elevated aldosterone levels upon cardiovascular function, it is hoped that the voice of the medical establishment and the new Dietary Guidelines on sodium will take this squarely into account.

As the title suggests, "Aphrodite, sex and salt ," an article just published in the July issue of Nephrology Dialysis Transplantation is wide ranging in its medical and cultural purview.

The article describes "major effects on procreation, gestation and lactation" when humans reduce dietary salt intakes. Bernard Moinier, former staff executive of the European salt association and the French salt association, teamed with Dr. Tilman Drueke to explore neurophysiological mechanisms linking reproductive functions with salt appetite and hormone generation and conclude "a sodium replete state (is strongly related) to fertility and reproductive performance." Of particular note, they point out the hormonal changes that occur related to salt intake during pregnancy and remind us of "a reasonable degree of agreement that salt intake should not be reduced during pregnancy." This is an especially important finding because expectant mothers are the most important target for advice to use iodized salt.

Back in 2003, the Cochrane Collaboration published its evidence-based review of the health outcomes of reducing dietary salt, concluding:

Intensive interventions, unsuited to primary care or population prevention programmes, provide only minimal reductions in blood pressure during long-term trials. Further evaluations to assess effects on morbidity and mortality outcomes are needed for populations as a whole and for patients with elevated blood pressure.

Coming from the inventors of the term "evidence-based medicine," this should have caused reconsideration of the entire approach of universal salt reduction. It also pointed the way to resolving the ongoing conflict among medical experts about whether salt restriction should be part of recommended dietary guidelines: it called for "further evaluations to assess effects on morbidity and mortality outcomes...."

Since then, several new studies have been published on the health outcomes of low-salt diets; they haven't confirmed a benefit.

So the Cochrane Collaboration has re-issued its 2003 Review, unchanged .

Proponents of evidence-based nutrition recommendations should use the 2008 version to counter the statistically-creative, substantively-deficient, blood pressure-centric arguments posited by proponents of the status quo. As this re-publication reminds us, it's time to sweep away opinion-based recommendations and replace them with sceince-based guidelines.

Using as examples the role of salt in combatting lymphatic filariasis and iodine deficiency, the cover story of the June issue of Geotimes devoted six pages to "Salt of the Earth: the pubilc health community employs a mineral to fight infectious disease ." Pointing out that its economy and ubiquity make salt the "ideal vehicle" to fortify with minerals or medications, author Cassandra Willyard concludes: "The saltshaker has become one of the most powerful weapons in the public health arsenal."

The article recounts the pioneering public health efforts to combat iodine deficiency by iodizing salt, quoting Venkatesh Mannar, executive director of the Ottawa-based Micronutrient Intitiative, explaining that salt is the "food that comes closest to being universally consumed." Salt is preferred because "the risk of overdose is minimal because everyone eats a predictable amount."

Building on the success of salt iodization, salt was fortified with other additives, first fluoride to prevent dental caries and then chloroquine to prevent malaria and most recently DEC (diethylcarbamazine) to combat lymphatic filariasis. Willyard featured the World Health Organization's ongoing work with DEC-fortified salt in Haiti and Guyana.

The article also broaches the question of the adequacy of iodine nutrition in the U.S. where substitution of processed foods using plain salt for home-cooked meals using iodized salt has led to a gradual decline in iodine intake levels. Willyard includes the Salt Institute's views, noting "officials may think about adding iodized salt to processed foods, Hanneman says. The important things, he adds, is to keep monitoring."

Choose a few minutes when you want a pick-me-up -- and bookmark the URL for future reference; you'll want to read a new Junk Food Science blog post "Traffic tickets for salt -- does healthy eating mean low salt? "

In a word, "no." But here is author Sandy Szwarc's lead to give you the flavor:

Salt makes food taste good. Therefore, it must be bad for us. Enjoying food means people might eat too much and get fat.

Believe it or not, that is the logic behind beliefs that everyone - from children to adults - should reduce their salt intake as an important part of 'healthy' eating.

Fears of salt have become so widespread, even little kids are being told it's bad for them and given low-salt diets.

She quickly moves to explain why this matters:

But salt is another food ingredient where the science and the voices of medical experts have had a hard time breaking through myths, fears and pop ideologies.

What may seem inconceivable, given the Red Lights being given to salt, is that there is no credible evidence low-salt diets can help prevent heart disease, high blood pressure or premature death. Nor is there any sound evidence to support fears that we're eating too much salt and that high salt diets increase our risks for cardiovascular disease and deaths. Nor can we assume that putting everyone on low-salt diets "can't hurt" and are benign. In fact, the medical research suggests the very opposite.

She continues at length (more than 2,250 words) to explain the NHANES research results from the Albert Einstein Medical College as well as the just-reissued Cochrane Review on "Advice to reduce dietary sodium for prevention of cardiovascular disease." The advice, of course, is: don't bother; there's no evidence of a a heath benefit.

Significantly, Szwarc recounts the multiple risks for those who follow political convention and curtail their salt. Our short post cannot do it justice. You need to read it yourself.

She concludes with this warning:

There are a lot of urban legends about salt, from "salt kills" to "cutting salt can add years to your life." The scariest thing isn't salt, though. It's that scare-based legends and myths, rather than good science, are guiding public health policies, the "nutrition" education being given children, and the public health messages teaching everyone to fear salt. Agendas that are not about health.

We can see why the blog was a finalist for the best new medical blog. Happy reading.

Scotland's youth just received their health "report card " from the World Health Organization. The report was prepared by a Scottish doctor for WHO-Europe and represents rosy health results for Scottish youngsters (among others).

It presents the key findings on patterns of health among young people aged 11, 13 and 15 years in 41 countries and regions across the WHO European Region and North America in 2005/2006. Its theme is health inequalities: quantifying the gender, age, geographic and socioeconomic dimensions of health differentials. Its aim is to highlight where these inequalities exist, to inform and influence policy and practice and to help improve health for all young people.

The report clearly shows that, while the health and well-being of many young people give cause for celebration, sizeable minorities are experiencing real and worrying problems related to overweight and obesity, self-esteem, life satisfaction, substance misuse and bullying. The report provides reliable data that health systems in Member States can use to support and encourage sectors such as education, social inclusion and housing, to achieve their primary goals and, in so doing, benefit young people's health. Policy-makers and professionals in the participating countries should listen closely to the voices of their young people and ensure that these drive their efforts to put in place the circumstances - social, economic, health and educational - within which young people can thrive and prosper.

Yet, within a week, a local paper reported that the government's crusade to re-make Scots' diets will be accelerated. If the kids' "report card" was okay, clearly their parents need some shaping up. Among the new initiatives:

Ministers also want to change the way cooking is taught in the nation's catering colleges by getting young chefs to rely less on salt, sugar, butter and cream, and more on healthy alternatives.

Among the interventions planned is having every worker log in daily using government software to report to the government on his or her personal diet and health situation. The Confederation of British Industry objected.

Iain McMillan, the director of CBI Scotland, said: "I think we will want to look at the detail and we are in favour of promoting health. But it seems that some people are drinking far too much and some are eating far too much and it's everyone else's fault but their own. We need to have far greater regard for the fact that people are responsible for their own welfare. And this seems to be a very heavy-handed approach."

Regular readers will recall the earlier attempt in Glasgow to "lock down" schools at lunch time because students were going off-campus to avoid the "healthy" fare in their cafeterias -- and monitors were to check students' brown bag lunches for nutritional adequacy.

And this from the nation that gave the world the Magna Carta.

Our thanks to Junk Food Science for surfacing the issue.

Returning to an oft-posted theme -- that health and nutrition activists' efforts to demonize all science not funded by (friendly) government bureaucrats leads to politically-correct junk science -- I thought readers might find of interest an op ed piece from earlier this week in the Financial Post , part of the National Post, one of Canda's largest papers.

Author Dr. Beth Whelan, president of NYC-based American Council for Science and Health, decries "the witch hunt against corporate funding of research...." pointing out several recent example of how Health Canada has embraced junk science in order to address alleged health threats. She explains that the

latest unscientific legislation (was) made possible in part by a dangerous prevailing assumption: namely, that anti-corporate claims are by definition "good science" while claims made in defence of industry or new technology - by anyone with the slightest ties to industry - are by definition "suspect science."

She continues:

Ironically, consumers end up paying higher prices as a result of such ostensibly consumer-protecting measures (as products need to be replaced or reformulated) or even end up using less-safe replacement products, such as old-fashioned glass bottles.

Because the insidious de-legitimizing has progressed so far, she laments:

CSPI and others, ignoring decades of productive collaboration between industry and science, can now delegitimize any scientist or scientific conclusion with which they disagree by showing that the scientist or research in question is tied to corporate money.

Our beef is the other side of this coin, namely that the converse of uncritically rejecting any privately-funded research as biased is the uncritical acceptance of publicly-funded research as immune from bias since its sponsors are public agencies. We've seen too many examples of government cooking the books and funding scientists who refuse to divulge their data for independent expert verification.

Economists well understand the perverse incentives that apply when government insists on owning the means of production. Will the public -- and public health practioners themselves -- recognize the perverse incentives inherent in the uncritical acceptance of junk science based on the supposedly-untainted funding from public agencies?

It was just yesterday that we noted the excellent paper, "Redefining Quality--Implications of Recent Clinical Trials ," published in the June 12 issue of the New England Journal of Medicine. Doctors Harlan Krumholz and Thomas Lee challenged their medical colleagues to design medical strategies that affect overall patient health outcomes - not simply isolated risk factors. Reluctantly, we stated that it was unlikely the article would get most of their colleagues to move away from the risk factor fixation.

It did not take long for that unfortunate prediction to be realized. It appeared in the supplement to the article "Cutting salt intake saves lives and money ". The Abstract which appears halfway down the page under the title, "The 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2 - therapy" describes a project to update the evidence-based recommendations for the prevention and management of hypertension in adults. It goes on to state:

"For lifestyle and pharmacological interventions, evidence was preferentially reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field."

The very same crowd that have always protested that a large scale study to determine the impacts of low salt diets on health outcomes would be too costly, turns around and justifies the use of surrogate risk factors as outcomes because there is no data on health outcomes. How duplicitous is that? This approach is precisely what Krumholz and Lee were referring to.

The main article describes a set of model projections that predict the number of cardiovascular events that will be prevented if salt consumption is decreased. Using blood pressure as the sole marker, this is the same sort of mathematical manipulation that resulted in the statements made by the Center for Science in the Public Interest that 150,000 lives per year would be saved by reducing salt. It is difficult to understand how such work can receive any credibility in the face of our achievement of significantly improved cardiovascular and stroke performance, while consuming the same levels of salt we always have.

C'est curieux, n'est-ce pas?

Health outcomes are what matters.

Except to the news media. The Centers for Disease Control and Prevention just issued the latest data from the National Center for Health Statistics. Its news release trumpeted "U.S. Mortality Drops Sharply in 2006, Latest Data Show ." This "news" received as much media attention as last week's announcement that casualties in Iraq are the lowest since 2003 -- in short, a virtual news blackout. To turn around the saw: good news is no news.

For public health practitioners, health outcomes should be the consensus metric. The data show convincingly that 8 of the 10 leading causes of death in the U.S. all dropped significantly in 2006. This continues the trend of the past quarter century and trumps the fact that our aging population would be expected to fare worse; in fact, both the raw and age-adjusted rates reflect the improvement. In just the single past year, deaths due to heart disease dropped 5.5%; strokes, 6.4%; hypertension, 5%. The list goes on. But the media loves negativity and too many advocacy groups have a vested interest in (manufacturing and) peddling a mileau of health threats.

Just a month ago, a prestigious research team published another analysis of federal health outcomes statistics in a well-regarded, peer-reviewed journal examining the comparative health outcomes of Americans choosing low-salt diets compared to those choosing diets unchanged in the amount of salt customarily used over the past century. Mortality in the low-salt group was much higher. Low-salt diets didn't deliver promised benefits; they even may add risk. This wasn't news either. The data undermined the crisis advocates' politically-correct intervention.

We need to get beyond the rhetoric and look at the facts, the data. Clearly, the view through the prism of the media and at least some public health advocates is preventing us from focusing on evidence-based policy decisions.

Today, the field of medicine received a long-needed shot in the arm. In their article, "Redefining Quality--Implications of Recent Clinical Trials ," published in the June 12 issue of the New England Journal of Medicine, Doctors Harlan Krumholz and Thomas Lee challenged medical colleagues to improve their understanding of clinical trial results and to design medical strategies that affect overall patient health outcomes - not simply isolated risk factors.

Quoting study after study, including the ILLUMINATE (Investigation of Lipid Level Management to Understand Its Impact in Atherosclerotic Events) trials to lower LDL and increase HDL cholesterol, the ENHANCE (Effect of Combination Ezetimbe and High-Dose Simvastatin Versus Simvastatin Alone on the Atherosclerotic Process in Patients with Heterozygotes Familial Hypercholesterolemia) trials to reduce LDL cholesterol, the ACCORD (Action to Control Cardiovascular Risk in Diabetes) and the ADVANCE (Action in Diabetes and Vascular Disease) trials to reduce serum glucose levels and the Women's Health Initiative Hormone Replacement Therapy trials all achieved their primary goals. They all reduced the risk factor they were focused on, but in all cases, patients experienced increased cardiovascular mortality. Even though the specific risk factor was reduced, increased numbers of patients died. They were all classic cases of, "The operation was a success, but the patient died."

To quote from the Krumholz and Lee paper,

"A clinical trial is ultimately a test of strategy, and we should not be surprised that different strategies may have different effects on patients beyond their effect on risk-factor levels."

The problem is that this shot in the arm for logic and medical sense is unlikely to be the shot heard 'round the world. While many researchers and practitioners in the medical community have long proclaimed the same advice regarding consideration of risk factors versus overall health outcomes, they appear to be in the minority and are largely ignored by the medical 'establishment.' For decades, the issue of salt and health within the medical community has revolved around the impact of salt on one risk factor - blood pressure. Several eminent physicians and the Salt Institute have long stated that it's not blood pressure that has to be considered, but health outcomes - all to no avail. Despite the fact that evidence demonstrates that more people died on low-salt diets than on high salt intakes, the AMA, NIH, AHA and NHLBI all continued to keep their heads buried in risk factors. It's unlikely that this article by Krumholz and Lee in the NEJM will get them to lift up their heads and see the light.

However, it's good to see that the number of enlightened keep growing.

For the past two years, more than 50 economists under the aegis of the Copenhagen Consensus have been studying the 30 most promising public health interventions to help policy-makers prioritize public health investments. They filed their report today and issued a news release summarizing their findings.

The top three:

1. Combatting micronutrient malnutrition by fortifying foods with vitamin A and zinc.

2. Completing the Doha round of international trade liberalization.

3. Iodizing salt and fortifying foods with iron.

Micronutrient malnutrition ("hidden hunger") is the clear winner with two of the top three "solutions." Fortifying with vitamin A and zinc return $17 for every dollar invested. The benefits of iodizing salt are $9 for every dollar invested.

With the candidates for the Democratic US presidential nomination competing to bash free trade, #2 may gain some political salience. But investing in micronutrient fortification -- including universal salt iodization -- should be high on the public health agenda.

You've probably read press accounts of the attack on environmentalists levied by Czech president Vaclav Klaus at his National Press Club news conference yesterday. Klaus, a renowned economist who has erected a thriving market economy on the ashes of his country's bankrupt communist system, was in town promoting his new book: Blue Planet in Green Shackles -- What is endangered: Climate or Freedom? He also renewed his challenge to former US VP Al Gore to a debate on the issues. He told the crowd:

"The largest threat to freedom, democracy, the market economy and prosperity at the beginning of the 21st century is no longer socialism. It is, instead, the ambitious, arrogant, unscrupulous ideology of environmentalism. Like their [communist] predecessors, they will be certain that they have the right to sacrifice man and his freedom to make their idea reality. In the past, it was in the name of the Marxists or of the proletariat -- this time, in the name of the planet."

Whatever your views on the arrogance or scientific credibilty of the environmental movement, it was Klaus' comments in response to media questions afterwards that caught my eye. Asked why global warming is presented to the public as the overwhelming, consensus position of scientists, Klaus responded, according to John Fund of the Wall Street Journal, explalining that

the careers and funding sources of many scientists now are dependent on 'climate alarmism' and climate alarmists have become an interest group with the power to intimidate into silence skeptical colleagues and public figures. The climate issue, he added, 'is in the hands of climatologists and other related scientists who are highly motivated to look in one direction only.'

Klaus could have been talking about the salt and health issue where anti-salt proponents have tried to convince the public that critics of their views, despite their professional prominence and unassailable credentials, should be ignored and that they, the anti-salt crowd, Not only are major voices in this group funded heavily by the government agency, but careers are enhanced by toeing the government's anti-salt line.

Perhaps Klaus should review The (Political) Science of Salt by Gary Taubes. It would be wonderful to have this courageous national leader tell truth to those in authority on salt and health.

Business speaker/coach Scott Hunter's new book, Unshackled Leadership , makes an initial demand on readers: that they recognize that they live their lives in a paradigm. Their existing beliefs determine their perspective on the world and that those beliefs are unchallenged with regard to their validity or effectiveness. When the paradigm is "truth," all is well, but our beliefs virtually always have "blind spots" or outright errors. Hunter equates the resulting problem to trying to find downtown Chicago with a street map of Detroit.

Hunter goes on, helpfully, to identify various, often "petty," personality flaws as illustrative of the mis-perceptions (my blog co-author, Mort Satin, terms them "myth-conceptions"), but the basic insight is that unless we change our personal pardigms, we cannot change our course in life. He reminds us that Albert Einstein defined insanity as doing the same thing and expecting a different result.

Remodeling a paradigm just doesn't work. It needs to be knocked down and re-built. The entire method of thinking about the events we observe must be changed. To get us started, Hunter suggests:

1. Start noticing what you believe to be "the truth." Be willing to challenge your most deeply held beliefs.

2. See if what you believe is true all of the time. Do you just ignore the facts when you encounter situations which are inconsistent with your beliefs? Maybe your deeply held beliefs are just that, beliefs.

3. Ask what life would be like for you if what you believe was not the truth? Or what would life be like if just the opposite was the truth?

4. Be willing to consider the possibility that you are living in a body of beliefs that are not only not the truth, but not even useful. Your willingness to open your mind and question everything will be an enormously valuable first step to shifting your paradigm.

Using an illustration about salt, we've locked ourselves into a paradigm about salt and health where we believe that only the blood pressure impacts of intake levels of dietary salt have heath implications. As long as we remain immobilized by this perspective, we will be forever frustrated by the evidence that is accumulating that lowering dietary salt may improve blood pressure, but actually increase the risk of heart attacks, strokes and death due to cardiovascular events. Until we reconsider and change our paradigm to accept that there may be multiple effects to reducing dietary salt, we will remain in a state of denial.

It's time to "unshackle" our public health nutrition policy leadership by replacing a flawed paradigm.

Thanks to JunkfoodScience for another gem illustrating tactics of purveyors of junk science. Dietitian Sandy Szwarc describes the case of an attorney attempting to intimidate a housewife/mother-blogger who was defending against charges that vaccinations lead to autism. The attorney's heavy-handedness prompted a New Hampshire judge to demand he account for his charges. His "priceless" response struck Szwarc as "better than a soap opera."

It's not fair and must be some big conspiracy network (with "co-conspirators"), he says (in essence), because she's just a girrrrl. A "mother and housewife" can't possible be smart enough to able to research the internet and medical journals, and write such well-researched pieces. She couldn't just be a concerned mother of an autistic child, somebody had to be helping her, he says, and she must be "either an agent of the defendant or of industry." Therefore, he wanted to find out who she was working for or with. Yes, she must be an industry shill.

The Salt Institute is familiar with this line of attack. On us it goes: Salt Institute spokespersons aren't medical doctors, so they are not capable of either quoting recognized experts or summarizing the results of the scientific studies we call to public attention. After all, they say, what's important is who they represent. Of course, they are reduced to this misdirection because (apparently like the "girrrrl" blogger somehow the messenger makes a better target than the irrefutable message.

Szwarc tells the story with more pizazz. And the blogger's post is even better.

Medical science has made enormous strides since the release of the first national Dietary Guidelines in 1980, but many would agree that the quality of the American diet appears inversely related to these health gains. We've added years to our lifespan and provided the safest, highest quality foods possible yet, as a nation, the quality of our diet has deteriorated. The Secretaries of Health and Human Services and of Agriculture will soon name the next DGAC to define the science base for the 2010 Guidelines. This is the place to fix the problem. We need to establish the new 2010 Guidelines as worthy of the trust Americans hope to place in them as an authoritative source of information about their food choices.

The Secretaries should consider carefully the critical importance of the selection criteria for Committee members. With obesity at historic levels and childhood obesity a near epidemic with grave long-term consequences for our nation, the need for policy guided by expert scientists is clear. No one could deny that the first six DGACs were composed of prominent medical and nutrition experts. There can be no quarrel with the professional, subject matter qualifications of past DGAC members. It's the paradigm that needs changing.

Committees of subject matter experts produce reports with expert opinion. That sounds better than it really is. In the hierarchy of "evidence-based" medicine, expert opinion is the lowest level of evidence. Rigorous data analysis trumps even well-informed opinion. To sort out public confusion and establish consensus authority, we need to move higher on the evidence-based hierarchy. We must do better for the nation. Evidence-based decision-making focuses less on the experts and more on the evidence. While as good they could be, because past DGACs have not followed the best discipline, their reports cannot claim the mantle of evidence-based reviews. We need to change the DGAC process, not just the people on the Committee.

Using a process like the one developed in the 1980s by the Cochrane Collaboration , inventors of "evidence-based medicine," will allow this new DGAC to take the next step in the process and set the standard and grade the evidence before considering the policy analysis. We need this different expertise on the DGAC in order to make the Guidelines reflect the science and become most relevant to Americans' health.

The federal government endorses an evidence-based approach to health policy and the U.S. Preventive Services Task Force (USPSTF) is the model for how the DGAC could adopt the discipline of evidence-based decision-making. Supported by the HHS Center for Outcomes and Evidence and a contracted Evidence-based Practice Center in Oregon which conducts systematic reviews of the evidence, the USPSF makes its recommendations on the basis of explicit criteria. The USPSTF reviews the evidence, estimates the magnitude of benefits and harms for each intervention, reaches consensus about the net benefit for each intervention, and issues a recommendation - from "A" (strongly recommends) to "I" (insufficient evidence to recommend for or against).

The USPSTF process would be the most appropriate and effective model for the DGAC. An evidence-based review will require an evidence-based process; this requires changing the concept of the DGAC which up until now has been compiling expert opinion instead of conducting an evidence-based review.

In a courtroom, judges rely on subject matter experts: witnesses attest to their observations and "expert witnesses" offer their professional opinion. Judges are not subject matter experts; they are process experts. They know what observations and opinions to admit into evidence. They discipline the process. The DGAC has been acting as an "expert witness" instead of a judge. We need a DGAC composed of "judges" - experts in the process of evidence-based decision-making. We need "judges" who have a proven dedication to dispassionate review of the evidence. And we need their report to reflect their conclusions about the quality of the evidence before the policy conclusions and recommendations.