The 2009 Urban Mobility Report by the Texas Transportation Institute documents congestion costs exceeding $87 billion in 2007, more than $750 for every American traveler. All told, congestion wastes 2.8 billion gallons of fuel -- three weeks' worth for every traveler -- an 4.2 billion hours; equivalent to an extra one-week vacation each year. But being stuck in traffic is hardly a vacation. This year's Report tracks a quarter century of traffic patterns in 439 U.S. urban areas from 1982 through 2007.

The Report emphasizes the distinction between “average” and “important” trips as

crucial to understanding the role of the solutions described in the next few pages. Some strategies reduce congestion for all travelers and at all times on every day. Other strategies provide options that some travelers, manufacturers or freight shippers might choose for time-sensitive travel. Some solutions target congestion problems that occur every day and others address irregular events such as vehicle crashes that cause some of the longest delays and greatest frustrations.

To "vehicle crashes," we'd add "snow and ice events."

"Everyone" knows that blood pressure (BP) is an important risk factor for heart attacks and strokes. There's solid evidence. And "everyone" knows that interventions to lower BP will improve these health outcomes. Or will they?

A new Cochrane Review concludes: "Aiming for blood pressure targets lower than 140/90 mmHg is not beneficial ." In their study, published July 8, Drs. J.A. Arguedas, M.I. Perez and J.M. Wright conclude:

High blood pressure (BP) is linked to an increased risk of heart attack and stroke. High BP has been defined as any number larger than 140 to 160 /90 to 100 mmHg and as a result this range of BPs has become the standard blood pressure target for physicians and patients. Over the last five years a trend toward lower targets has been recommended by hypertension experts who set treatment guidelines. This trend is based on the assumption that the use of drugs to bring the BP lower than140/90 mmHg will reduce heart attack and stroke similar to that seen in some population studies. However, this approach is not proven.

This review was performed to find and assess all trials designed to answer whether lower blood pressure targets are better than standard blood pressure targets. Data from 7 trials in over 22,000 people were analysed. Using more drugs in the lower target groups did achieve modestly lower blood pressures. However, this strategy did not prolong survival or reduce stroke, heart attack, heart failure or kidney failure. More trials are needed, but at present there is no evidence to support aiming for a blood pressure target lower than 140/90 mmHg in any hypertensive patient.

The Cochrane Collaboration invented the discipline of substituting "evidence-based" decisions for the opinions of doctors . We have recommendations on all sides of various medical issues and these Cochrane Reviews try to separate the sheep from the goats, identifying recommendations based on expert opinion as opposed to those based on scientific data.

I was reminded of an extended conversation I had more than 20 years ago with two of the world's foremost advocates of universal sodium reduction, the husband and wife team of Jerry and Rose Stamler. I asked the Stamlers whether the BP target for intervention was the "normal" 120/80. Jerry responded, no it should be lower. I pressed: 110/70? Jerry: lower. 100/60? Jerry: lower. 90/50? Lower. I tried the query from the other direction, noting that a corpse had 0/0 BP but was hardly "healthy." Jerry's final response was that any intervention that could lower BP was healthier and that practical limits on the amount that people could lower would represent both the minimum achievable BP and the healthiest BP.

The data in this study demolish that expert opinion.

For years "everyone" has known that having the entire population reduce its intake of dietary salt would reduce the rates of heart attacks and strokes. An earlier Cochrane Review of "Advice to reduce dietary salt for prevention of cardiovascular disease ," however, found no evidence supporting this platitude, though the fable continues to enjoy popularity among some experts despite the absence of confirming data.

Award-winning investigative journalist Gary Taubes described the situation in his "The (Political) Science of Salt " where he pointed out that while the data for universal salt reduction were eroding confidence in the theory, advocates of the intervention were becoming more strident and vocal. Said Taubes:

The dispute over salt, however, is an idiosyncratic one, remarkable in several fundamental aspects. Foremost, many who advocate salt reduction insist publicly that the controversy is a) either nonexistent, or b) due solely to the influence of the salt lobby and its paid consultant-scientists. Jeremiah Stamler, for instance, a cardiologist at Northwestern University Medical School in Chicago who has led the charge against salt for 2 decades, insists that the controversy has "no genuine scientific basis in reproducible fact." He attributes the appearance of controversy to the orchestrated resistance of the food processing industry, which he likens to the tobacco industry in the fight over cigarettes, always eager to obfuscate the facts. "My considerable experience indicates that there is no scientific interest on the part of any of these people to tell the truth," he says.

While Stamler's position may seem extreme, it is shared by administrators at the NHBPEP and the NHLBI, which funds all relevant research in this country. Jeff Cutler, director of the division of clinical applications and interventions at NIH and an advocate of salt restriction for over a decade, told Science that even to publish an article such as this one acknowledging the existence of the controversy is to play into the hands of the salt lobby. "As long as there are things in the media that say the salt controversy continues," Cutler says, "they win." Roccella concurs: To publicize the controversy, he told Science, serves only to undermine the public health of the nation.

After interviews with some 80 researchers, clinicians, and administrators throughout the world, however, it is safe to say that if ever there were a controversy over the interpretation of scientific data, this is it. In fact, the salt controversy may be what Sanford Miller calls the "number one perfect example of why science is a destabilizing force in public policy." Now a dean at the University of Texas Health Sciences Center, Miller helped shape salt policy 20 years ago as director of the Center for Food Safety and Applied Nutrition at the Food and Drug Administration. Then, he says, the data were bad, but they arguably supported the benefits of salt reduction. Now, both the data and the science are much improved, but they no longer provide forceful support for the recommendations.

This was written a decade ago. We've learned a lot since then. We have the Cochrane Review finding inadequate science to support general salt reduction. And now we have a new Cochrane Review that the approach of experts to treat lower and lower BP levels can be classified as expert opinion, not scientific fact.

What we need is more reliance on scientific data and less on the opinion of scientific experts. We need more confidence in the scientific method and more humility by many who profess to embrace its results. In the area of salt and health, including blood pressure, the role of overall dietary quality, the role of hormones, insulin resistance, etc.

In 2007, the poet Ted Sheridan wrote "The More We Learn, the Less We Know For Sure ." In our present circumstance, these humbling observations strike home. But they're hardly new. In the last century, Albert Schweitzer observed: "As we acquire more knowledge, things do not become more comprehensible, but more mysterious." And far earlier, Lao Tsu rendered this enduring reminder: "To know that you do not know is the best."

It all leads back to the core principle: primum non nocere, "first, do no harm ." Confining our interventions to those with solid evidence avoids unintended consequences. Pride is one of the Seven Deadly Sins.

Candidate Obama pledged to confine his self-predicted tax increases to fund his campaign promises to the top 5% of taxpaying Americans (i.e. "the rich" who he said earn more than $250,000 -- the top 5% of earners earn one-third total earnings and pay 57% of federal taxes -- a rather "progressive" structure). Without wandering around the issues of funding for Social Security and Medicare, discussion on Capitol Hill these days about new taxes on foods shows just how hollow can be such populist campaign rhetoric.

I remember how in my home state of Wisconsin, enactment of a sales tax was conditioned on exemption from the tax for food and pharmaceuticals, "the basics." Good lobbying? Sure. But the concept was to avoid imposing further regressivity in the tax code.

Currently, Congress is only considering a tax on soft drinks. Surely, we'd concede that Coke and Pepsi aren't essential foods. Their nutritional value isn't their selling point. So the new food tax is being promoted to promote health -- to make this "bad" food more expensive and inhibit its consumption, ostensibly to prevent obesity. Economic incentives do work. Whether they would reduce obesity is another matter. It may be that it's just a power trip for those newly installed running the government and the next "nibble" in imposing "society's" values on us as individuals and that this is a slippery slope into extending that tax to other politically-incorrect foods.

But consider a further point: the very people who rail against "the rich" would promote this tax that would largely be paid by the "non-rich."

The Congressional Research Service estimates that 96.4% of the tax would be paid by people earning less than 250,000 and 70.6% by those earning less than $91,297. Hardly confined to the rich.

Perhaps if such taxes worked to combat obesity, decision-makers might be tempted to "soak the poor" to pay for predicted healthcare cost savings, but the two states that have such taxes on soft drinks (West Virginia since 1951 and Arkansas since 1992) aren't encouraging examples (WV is the nation's 5th most obese state; Arkansas, 6th). The soft drink folks point out that soft drink sales are actually down 9.6% in the past eight years (they don't say why, but probably more people drinking water) -- but that obesity in this period is up 2.5%.

William F. Shughart II, writing in the San Jose Mercury News June 24 (article # 1148414) predicted popular resistance and noted the nations' first "food tax" provoked the Whiskey Rebellion put down by armed troops led by George Washington. A stronger parallel might be the French gabelle which cost King Louis XVI his head in the French Revolution.

Scientists at the Australian Centre for Plant Functional Genomics and the University of Adelaide and Cambridge University have developed salt-tolerant plants using a new type of genetic modification. The results could impact food production and security, since salinity affects agriculture worldwide.

Soil salinity affects large areas of cultivated land, causing significant reductions in crop yield globally. The sodium toxicity of many crop plants is correlated with over-accumulation of sodium in the shoot. It was previously suggested that the engineering of sodium exclusion from the shoot could be achieved through an alteration of plasma membrane sodium transport processes in the root, if these alterations were cell specific. Current research published in The Plant Cell confirms this. Plants with reduced shoot sodium have increased salinity tolerance. The results demonstrate that the modification of a specific sodium transport process in specific cell types can reduce shoot sodium accumulation, an important component of salinity tolerance of many higher plants.

"Salinity affects the growth of plants worldwide, particularly in irrigated land where one third of the world's food is produced. And it is a problem that is only going to get worse" said team leader Mark Tester, professor at the University of Adelaide.

Tester says his team used the technique to keep salt out of the leaves of a model plant species. The researchers modified genes specifically around the plant's water conducting tissue (xylem) so that salt is removed from the transpiration stream before it gets to the shoot.

"This reduces the amount of toxic salt building up in the shoot and so increases the plant's tolerance to salinity," Tester said.

"In doing this, we've enhanced a process used naturally by plants to minimize the movement of salt to the shoot. We've used genetic modification to amplify the process, helping plants to do what they already do - but to do it much better" he added.

The team is now in the process of transferring this technology to crops such as rice, wheat and barley, said an Adelaide release.

The Salt Institute is, among other things, a "health advocacy organization" trying to adhere to a fair statement of the science in an attempt to advance the public interest -- in this case, better health outcomes.

We're not alone, of course. There are many "health advocacy organizations" all calling for quality science harnessed to promote public health. Five with "well-oiled publicity machines" are highlighted in a July 6 article, "Whose side are health advocacy groups on" by the Los Angeles Times' "healthy skeptic," Chris Woolston. Woolston, unfortunately, betrays her own bias, leaning heavily on the Center for Media and Democracy, described as "a Madison, Wis.-based nonprofit organization that published PR Watch, a quarterly newsletter that tracks advocacy organizations and PR groups." Wikipedia points out that CMD is run by an "environmenalist writer and political activist" and has been accused by one of the groups under analysis as "a counterculture public relations effort disguised as an independent media organization." So, consider the source.

Among the "well-oiled publicity machines," naturally, is the Center for Science in the Public Interest, described neutrally as providing "reliable information" that CMD says "keeps them honest." Let me repeat, consider the source.

New research announced today by the Pacific Institute for Research & Evaluation examines the relative economic costs of vehicle crashes, comparing driver behaviors with roadway surface conditions. Internationally-renowned safety economist Dr. Ted R. Miller and colleague Eduard Zaloshnja determined that 52.7% of highway crashes involve roadway conditions. The crashes were responsible for 22,000 fatalities in 2008.

In terms of social costs, non-use of seatbelts is responsible for $60 billion in costs; speeding, $97 billion; and alcohol impairment, $130 billion. Road condition-related crashes cost the U.S. economy $218 billion. These costs include $20 billion in medical expense, $46 billion in productivity losses and $52 billion in property damage and other resource costs with a further $99 billion in monetized quality of life costs.

The report was commissioned by the Transportation Construction Coalition and timed as Congress weighs the Obama Administration's request last week to pass a stopgap extension of federal transportation programs until after the next election.

Although the TCC advocacy effort is focused only on safety-related roadway construction improvements, a significant opportunity is on the table with the highway authorization bill to upgrade roadway operations. Improved operations can curtail the costs incurred from weather-, incident- and work zone-related crashes -- including winter snow and ice operations.

For years, the Salt Institute has been touting the findings of a 2004 study by Dr. Ashima Kant on "Dietary Patterns and Health Outcomes ." We've argued that no single nutrient can explain the effect of diet on health (pdf 216.70 kB) and that the diet provides context to food choices (pdf 405.43 kB) . Healthy diets have predicted positive health outcomes and that's the advocacy position taken by the Salt Institute . We've pointed to clear evidence that the best marker for a "quality diet" is potassium consumption .

Dr. Kant has a new study, "Patterns of recommended dietary behaviors predict subsequent risk of mortality in a large cohort of men and women in the United States ," Kant concludes (see Table 2) that potassium and calcium are strongly related to overall dietary quality. No surprise there. What about sodium? A month earlier, another study of adherence to US Dietary Guidelines found that those consuming "better" diets actually consumed more salt (even though that diminished their overall diet quality score). So, Kant's findings would offer useful comparison.

Not.

Kant reported lots of nutrient variables including energy, energy from fat, alcohol, fiber, folate, Vitamins C and E, and carotene in addition to calcium and potassium. But not sodium.

Could it be another "inconvenient truth"?

"Healthy Choice" marketer ConAgra Foods announced publication today of a new study in the American Journal of Health Promotion that shows how unbalanced has been the debate on salt reduction.

Using data from the National Center for Health Statistics, National Academy of Sciences and the Bureau of Labor Statistics, Timothy Dall, et. al. of The Lewin Group documented that reducing calories by less than 5% would produce economic benefits of about $100 billion. Adopting the most anti-salt interpretation of the medical evidence (i.e. Ignoring evidence that sodium reduction would produce no net health benefit), the authors found that reducing salt by more than double that amount (>12%) would yield benefits of $5 billion. Dall declared: "One of the most revealing finding was just how big an impact of 100 calories less per day can have compared to the more modest benefit of sodium reductions." (And, he failed to note that the sodium reduction was two-and-a-half times more severe than the curtailed calories).

Put another way, using the Dall analysis, reducing calories by less than half the magnitude being advocated for salt reduction would put national economic savings at $243 billion a year.

ConAgra's diet foods reduce both calories and sodium, but as Dall concedes: "Although many adults could benefit from cutting back on both sodium and calories, the return on investment for long-term health is clearly greater for calories."

Today, the US House of Representatives will vote on a "cap-and-trade" climate change bill embodying the mindset of Al Gore's "inconvenient truth" argument. Thus, today's Wall Street Journal editorial, a last-gasp attempt to deflect the Democrat's legislative steamroller on Capitol Hill, notes that popular skepticism on "climate change" is on the rise around the world. Notably, the argument isn't being framed that "we can't afford it" in troubled economic times; no, the argument is advanced that the science underlying the entire response is flawed: scientific doubts are growing that man-made "greenhouse gas" emissions are a threat. The WSJ attributes the rush to pass cap-and-trade and its multi-trillion-dollar cost-shifting scheme to global warming proponents' foreboding about the concept's eroding prospects.

If the science of global warming is changing, the concept has had prominent skeptics from the beginning. Doubters were overwhelmed by alarmist activists who made dire warnings a favorite media theme. Efforts to secure access to the scientific studies underlying the global warming promotion have been systematically thwarted. Proponents have labeled skeptics as "deniers," affixing them with a popular image akin to those who deny the well-documented Holocaust.

Whatever our personal views on the legitimacy of the science on global warming, there is an eerie parallel process running in the nutrition-and-health debate.

Prominent independent scientists note the absence of evidence for a health outcomes benefit among those consuming low-sodium diets. Questions remain unanswered about the efficacy of reducing and sustaining lower population sodium intakes and, in particular, about the untested hypothesis that substituting low-sodium foods will reduce an individual's sodium intake. Independent analysis of government-funded data is systematically foreclosed. Skeptics are lambasted personally for failing to toe the policy line in a broad pattern of intimidation. And the food industry has resorted to an acceptance of the sodium hypothesis and based its defense on the unfeasibility of some of the remedial policy responses (akin to complaints that cap-and-trade would export American jobs and crush economic vitality). Finally, alarmists press for urgent action with warnings of dire consequences.

The WSJ editorial concludes:

[Climate change opponents] in the U.S. have, in recent years, turned ever more to the cost arguments against climate legislation. That's made sense in light of the economic crisis. If Speaker Nancy Pelosi fails to push through her bill, it will be because rural and Blue Dog Democrats fret about the economic ramifications. Yet if the rest of the world is any indication, now might be the time for U.S. politicians to re-engage on the science.

Those who would stand in the path of cap-and-trade have an uphill fight against a Congressional majority with vigorous White House support. Science hasn't been able to gain traction in the public debate.

The very different scientific issues at play in the salt and health controversy are headed down this same pathway unless we can, as the WSJ says, "re-engage on the science."

One other parallel: Climate, like physiology, responds to immutable laws of nature, whether we understand those principles or not and whether our policy responses anticipate the consequences of our interventions.

So, let's work for re-engagement on the science, greater data transparency and, above all, a focus on the quality of the data upon which our momentous public policy decisions are based.

California's economy is in a shambles and its state government in deep financial distress. One reason, accordng to a Milken Institute study released yesterday by the California Manufacturers and Technology Association is that state policies have made California unfriendly to manufacturing. California is a major salt-producing state.

The report, Manufacturing Still Matters (Manufacturing 2.0) , says manufacturers are the "canary in a coal mine," indicative of basic problems requiring structural solutions. The problems include loss of manufacturing employment, loss of innovation, "an onerous regulatory climate and some of the highest taxes in the United States," and "a reputation for being a state that is unfriendly to business."

Recommendations include rebuilding the manufacturing sector as a foundation for renewed growth.

Canada is currently in the midst of a national initiative aimed at reducing the sodium content of the diets of Canadians. It has appointed a Multi-stakeholder Working Group on Dietary Sodium Reduction (Sodium Working Group) to oversee this process. The compulsion to reduce sodium in Canada is being driven by the international group of advocates belonging to WASH (World Action on Salt and Health) who believe that significant salt reduction will reduce population-wide blood pressure to a point where many thousands of lives will be saved. These assertions are based on the speculations of some blood pressure experts – not on any scientifically derived clinical data. In fact, there are many blood pressure experts who disagree with this notion, but despite this, the Canadian Government has embarked upon a journey that appears to have only one outcome – a reduction in salt consumption.

The Salt Institute has taken part in some of the meetings of this Sodium Working Group and has urged a full consideration of all the scientific evidence and has cautioned prudence in implementing population-wide salt reduction programs since the data on health outcomes clearly does not warrant such an approach.

Today, the Canadian Medical Association Journal published a special report on “National trends in rates of death and hospital admissions related to acute myocardial infarction, heart failure and stroke, 1994–2004, ” by J.V. Tu et al. The report, also covered on “theHeart ” website, states that the rates of death from cardiovascular disease, including myocardial infarction, stroke, and heart-failure mortality rates, have significantly decreased in Canada over a recent 10-year study period. From 1994 to 2004, cardiovascular disease mortality declined 30%, while the rate of myocardial infarction, stroke, and heart-failure mortality decreased 38.1%, 28.2%, and 23.5%, respectively. This precipitous decline has taken place without any reduction in the consumption of salt. In fact, in a recent Salt and Health Newsletter , the Salt Institute compared Canada’s excellent cardiovascular performance over the last 30 years, without salt reduction, to Finland’s – the only country to achieve significant salt reductions during the same time period. The data, taken from the WHO Global Cardiovascular Infobase, shows how much better Canada fared over Finland. This latest report in the Canadian Medical Association Journal confirms this fact

Since Canada has done so well in reducing cardiovascular disease outcomes, it brings the Canadian sodium reduction initiative into serious question. The salt reductionists' dire predictions on salt and cardiovascular heath appear to be incorrect because Canada is doing very well indeed. In fact, today’s report in the Canadian Medical Association Journal states that, despite Canada’s great overall cardiovascular performance, more women than men are dying of cardiovascular disease, particularly elderly women. As it happens, according to a very recent Statistics Canada report, “Sodium consumption at all ages ,” women eat far less salt than men and elderly women in particular, are the one group that consumes the least amount of salt and is closest to the Government’s sodium intake goals – yet their cardiovascular performance is the worst of all Canadians.

Perhaps, it is time for the Government to actually read and respect its own data and acknowledge when it is well off.

Thanks to an expensive and extended PR campaign, most Americans know that blood pressure is an important indicator of their cardiovascular health. Higher is not better. But a new survey Web-published recently discovered that 75% of adults with high blood pressure are not at all familiar with another "number" that may be even more important in determining their chances of a stroke or heart attack. Only one in four has any inkling of the function and critical role of the body's renin system, even though 89% of those surveyed told the pollsters they wanted to understand what was causing their high blood pressure. Medical News Today reported the survey results.

Many things impact blood pressure. And lower BP isn't always better, though the greater public health risk is the high and rising number of people with above-normal BP. Salt is among those factors. So is renin. Renin? That's what three-fourths the respondents said. Only 2% said they were very familiar with the role the renin system plays in their body, though one quarter (25%) consider themselves at least somewhat familiar. Ominously, even after respondents were given descriptions about the role the renin system plays in the body, only 23% were able to correctly describe it (by regurgitating the information they had just received. No wonder so many people uncritically embrace the proposition that lowering dietary salt will improve their health. They just don't understand what's going on in their bodies.

Renin is a key regulator of BP. It's a proteolytic enzyme produced in the kidney that plays a major role in the release of angiotensin which the body secrets to tighten up blood vessels to keep BP up if the body senses it is falling to an unhealthy level. Many anti-hypertensive drugs block renin activity.

Renin levels are associated with a 430% increase in heart attack incidence according to a study published back in 1989. Fifteen years earlier, the foremost investigator into renin's role, Dr. John Laragh, landed on the cover of Time magazine for his pioneering work. But that was more than 30 years ago and the government's PR blitz on salt has buried those insights.

What does this have to do with salt? Salt reduction triggers elevated levels of renin. Didn't read that on the NHLBI website, huh? It's true. Reducing intakes of dietary sodium prompts the kidneys put crank up their production of renin, increasing your odds of a heart attack. The government knows this (I personally notified FDA Commissioner David Kessler back in 1989), but it's another "inconvenient truth" it prefers to ignore. It is one of the "unintended consequences" of salt reduction that, in sum total, negate any health benefit of lowering dietary salt to reduce BP.

Well, now at least you can add yourself to the 23% who are at least "somewhat familiar" with the crucial BP role of renin.

The survey was sponsored by Novartis Pharmaceuticals Corporation and conducted by Harris Interactive. It included more than 2,400 US adults ages 18+ of whom more than 700 reported elevated blood pressure. In releasing survey results, RealAge.com declared: "The results of this survey reinforce the need for education, particularly around the renin system. Targeting the renin system is a key to regulating blood pressure. Our hope is that by helping the public better understand the physiology of high blood pressure, we can motivate those with the condition to adapt a healthier lifestyle and ask their physicians about treatment options that target a key source of blood pressure."

Christian scriptures refer repeatedly to salt. That’s no surprise. Salt has been well-appreciated by people everywhere and throughout time.

We often receive inquiries about these references. These are my thoughts; feel free to add your comments.

Salt references grow from the properties and uses of salt. These functions, historically, produced cultural practices leading to effective symbolism.

Salt is a preservative. It kills bacteria. Thus it retards spoilage and preserves the wholesome purity of foods. In related fashion, salt was the first antiseptic, killing bacteria in wounds. In reference to this function, salt is distinguished from leven or other fermentatives.

Salt affects flavor. The salty taste, of course, is one of the five basic tastes (some would add umami as a sixth), but salt’s flavor role is so much more as a flavor enhancer. It masks bitterness and off-tastes, enabling our palettes to appreciate prepared foods.

Preserving fresh foods equated to permanence and salt came to symbolize covenants. The pure white color symbolizes purity, the absence of contamination, including the contamination of intent in a relationship. Indeed, a “salt covenant” described an enduring, unbreakable covenant, a predictable relationship. Leviticus 2:13 instructed: "Neither shalt thou suffer the salt of the covenant of thy God to be lacking from thy meat offering: with all thine offerings thou shalt offer salt." And in Numbers 18:19 we read: "It is a covenant of salt for ever before the Lord unto thee and to thy seed with thee." Many cultures such as in Russia, prescribe a traditional offering of salt and bread to arriving guests as defining appropriate hospitality.

The desirable taste of salt and of salt-prepared foods has come to symbolize joy and happiness.

One oft-rehearsed verse, Matthew 5:13, produces the most misunderstanding. Christ taught: “Ye are the salt of the earth: but if the salt have lost his savour, wherewith shall it be salted? it is thenceforth good for nothing, but to be cast out and trodden under the foot of men.” Followers of Christ were to be as salt, expunging evil (bacteria) and providing joy in the lives of their fellow men. Chemically, salt does not deteriorate and retains its unique taste (savour) forever. Adulterated, however, and the “savour” is lost and the value destroyed. It becomes unfit for its purposes of preservation or flavoring. The teaching is that followers of Christ are to make choices that preserve their purity and avoid impurities that contaminate their intended role as examples of Christian virtues and the joy they bring.

Salt is good and pure. Salt is the essence of life. Just as salt is an essential nutrient required by the body so must we be like salt. We must avoid losing our “savour” through principle-centered living.

Everyone knows prevention is better than remediation. That's true of removing snow and ice from roadways, preventing mineral deposits on hot water appliances or avoiding personal accident or injury.

In health, that translates to preventing disease or treating the afflicted. In our national healthcare debate, everyone's for prevention as much as everyone is for "reform." With trillions of dollars at stake, we should be asking ourselves whether it's true that "an ounce of prevention is worth a pound of cure." Is prevention cost-beneficial and, if so, is all prevention justified or should our prevention efforts be targetted where they'll deliver the biggest bang for our bucks? Time magazine made prevention its cover story this week, summarizing the issue:

As the cost of health care continues to climb (60% of U.S. bankruptcies in 2007 were due to medical costs), the health of our nation is not getting any better. Heart disease remains the No. 1 killer of Americans (as it has been for all but a few years since 1900), our collective waistline continues to bulge, diabetes rates march ever higher, and after steadily declining in recent decades, the smoking rate among high schoolers is leveling off. The U.S. boasts the best cutting-edge medicine in the world, yet 75% of our health-care costs are attributable to chronic, preventable diseases. In all, about 40% of premature deaths in the U.S. are caused by lifestyle choices — smoking, poor eating and inactivity.

But while prevention — intervening in patients' lives before they get sick — has long been part of the medical lexicon, programs to educate and encourage patients to adopt healthy behaviors have never truly been embraced. Ours is a system that rewards pills and procedures and nurtures a clinical culture in which the goal is primarily to fix what goes wrong. "I never saw a well patient in my life," says Cosgrove of the years he spent as a heart surgeon. "They were all sick. We are in the sickness business. We need to get into the health business." This idea is at the heart of how President Obama wants to reform health care in America; he argued that the U.S. medical system is designed to provide disease care rather than health care. In a letter to Senators drafting health-care-reform legislation, Obama cited the [Cleveland Clinic] as a model: "We should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country," he wrote.

...

Will prevention work? And will our health system finally embrace the strategy over prescriptions and procedures? We don't have many other options. Prevention is a timeless idea, one our species has always practiced: pioneers preserved food to prevent starvation in the winter; modern workers invest in 401(k)s to prevent destitution when they're older. Applying the same ethos to medical care ought not be that hard — especially since the country's health, economic and otherwise, may depend on it.

In fact, the President is personally modeling as well as cheerleading the prevention effort. Capitol Hill newspaper Politico carried a story earlier this month by Carrie Budoff Brown entitled "Coach Obama: Shape up now." Brown points out that the prevention push is controversial ideologically ("To some, it smacks of a 'nanny state on steroids'"), noting that Obama has imported into the senior ranks of his Administration "officials who, in their previous jobs, outlawed trans fats, banned public smoking or required restaurants to proivde a calorie count with that slice of banana cream pie." She warns: "Obama needs to (avoid) coming across as a public scold or killjoy." She quotes a frustrated David Harsanyi, a Denver Post columnist and author of the book Nanny State: How Food Fascists, Teetotaling Do-Gooders, Priggish Moralists and Other Boneheaded Bureaucrats Are Turning America Into a Nation of Children, saying: “If you care about the sorts of things I do, then you are going to be losing big-time for the next four to eight years,”

Obama's effort is more than ideology, however, Brown continues. The major argument is that prevention will save money.

The public health community has worked intensively in recent years to build a body of evidence in support of the very initiatives Obama and lawmakers are now embracing. They frame the issue as one of money: Chronic diseases account for 75 percent of the nation’s $2 trillion in medical costs, according to the Centers for Disease Control and Prevention. And if the government encourages healthful lifestyles, it could slow the rising cost of health care, though the exact savings are debatable.

Yes, prevention IS debatable. Earlier this year, Rutgers economics professor Louise B. Russell addressed the subject in an article in Health Affairs, "Preventing Chronic Disease: An Important Investment, But Don’t Count On Cost Savings." Dr. Russell explained:

Over the four decades since cost-effectiveness analysis was first applied to health and medicine, hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them. Medications for hypertension and elevated cholesterol, diet and exercise to prevent diabetes, and screening and early treatment for cancer all add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving.

Russell's been quoted a lot recently as the healthcare debate heats up. She told Janet Adamy of the Wall Street Journal that many previous government prevention efforts aimed at costly chronic diseases have had little success in reducing illness or costs: "It is not going to cut costs. We already do a lot more prevention than other countries. We are not healthier." Adamy's report continues:

[Russell's] findings don't question the benefits of a healthy lifestyle, and many preventive measures are effective. The problem is that when testing becomes too widespread, or heavy investments are made in monitoring people with chronic diseases, the rewards often fail to match the costs.

...

The Congressional Budget Office, in a December report, concluded that greater use of preventive care would at best generate modest reductions in costs over 10 years, and might even result in increases.

One reason cost savings are hard to achieve, according to Prof. Russell, is that much of the money spent on disease prevention goes for people who aren't going to get sick anyway. Also, people have trouble making difficult lifestyle changes, such as taking up regular exercise or eating healthier food.

A report published in the New England Journal of Medicine last year examined 279 spending ratios in published studies of health-oriented prevention measures, and another 1,221 on treatments for people who were already sick. Some measures clearly saved money, like screening men in their early 60s for colorectal cancer.

But the report concluded that most preventive measures reviewed didn't save money. For instance, screening all 65-year-olds for diabetes would cost $590,000 for every healthy year of life it adds over just screening people that age with high blood pressure.

Medicare has conducted seven pilot programs in the past decade testing the theory on some of the most costly chronic diseases. Each showed little if any cost savings or measurable improvement in patients' health.

So prevention isn't the magic pill that "everyone" believes it to be. But what I'd call "smart prevention" certainly should play a central role in addressing our national health needs. Smart prevention has two principles: 1) it's evidence-based, not playing to the crowd and, 2) it's selective, focused on interventions and individuals or tightly-defined groups who will benefit. [By that standard, of course, universal salt reduction would be abandoned as a policy].

Dr. Russell would seem to endorse this approach. Her Health Affairs article avers:

Prevention can be a cost-effective, sometimes cost-saving, component of managing established chronic conditions. For example, at $16 per person (1995 dollars), or about $25 today, vaccination against pneumococcal pneumonia reduces medical spending for adults ages 50-64 with congestive heart failure, chronic lung disease, and diabetes, and other chronic conditions...

But, she concludes:

Over the past four decades, hundreds of sutides have shown that prevention usually adds to medical spending. ... 80 percent add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving."

Thanks for the reminder that a bit more humility and a lot less hyperbole are needed concerning prevention.

It's now clear: I lack the patience to await the full four parts of a powerful new series of posts on Junk Food Science before sharing it with Salt Sensibilty readers. They're too good to wait. They examine the subject: “Paradoxes – Compel us to think.” So far, two posts: Part One and Part Two . Sandy Szwarc introduces the quest to “separate science from ideology” (phrase from JAMA ) as follows:

We may know, intellectually, that correlations can never show causation, but when a correlation seems to confirm a reason we believe, it’s very easy to find ourselves falling for the fallacy, anyway, and to not even consider other explanations. We may call our belief “common sense” or what “everyone knows,” without realizing that we’ve come to believe it simply because it’s all we ever hear. It may never even occur to us to question an axiom — especially if we never hear about the evidence which contradicts or disproves it.

Her primary focus remains obesity as we may remember since I've often blogged on her relevant posts. Nevertheless, many of the observations pertain equally to the salt and health controversy. She notes that “The obesity paradox wouldn’t be a paradox at all, for example, if the public had been hearing objective reports of medical research all along.” How true for salt. I've just been participating in an online discussion at Toronto's Globe and Mail that well illustrates the pervasive retreat to unexamined acceptance of asserted medical “truths.”

Understanding the limitations of the scientific method employed is crucial. She observes:

(E)pidemiology has become a vehicle to find associations between every aspect of our everyday lives or our physical features and risks for some feared disease. And it’s being misused to convince us that our diets and lifestyles or appearances are the cause of ill-health. Blame, guilt and fear are the bread and butter of health marketing. That’s why carefully controlled epidemiological studies that find no link — those null studies that rarely get reported — are especially valuable. If there’s not even a strong link between two variables, then a variable can’t possibly have a causal role. Null studies tell credible scientists, and should tell us, to move on and stop worrying about that.

Among the reasons all this matters, she offers as an example the question of exercise. “Everyone” knows exercise is good for us. I feel better when I'm in shape and when I exercise. Of course. Common sense. But there are always unintended consequences. In this case, she provides data from the Centers for Disease Control and Prevention (CDC) that, next to the common cold, sports and exercise injuries are the leading cause of doctor's visits. That doesn't mean: don't exercise. It means, weigh the evidence ( and, probably, engage moderately). Federal data confirm that 488 million work days are impaired by sports injuries and that baby boomer sports injuries cost $18.7 billion in 1998.

Bottom line, she concludes in Part One:

Scientists understand the importance of testing hypotheses about causes and effects — and balancing overall benefits over risks — using carefully designed randomized, controlled clinical trials and measuring hard clinical outcomes. Yet, every randomized, controlled clinical trial of “healthy lifestyles,” as popularly defined, has failed to significantly reduce premature deaths from all causes or to prevent chronic diseases of old age.

Part Two continues to bust obesity-related myths, in this case: that obese individuals have worse health outcomes. “Everyone” believes that, too. Common sense. She offers the Helsinki Businessmen Study as a confounding input. The conclusion:

The only statistically significant inverse correlations to the men’s BMIs were with diabetes and hypertension — but they didn’t affect the men’s mortality rates, perhaps because, as we’ve seen, heavier people with both conditions have lower health complications compared to slender people with those conditions. Other popular myths weren’t supported in this study, which also won’t surprise regular readers who’ve followed the research. The men who gained weight as they aged and those who lost weight to achieve a normal weight had identical rates of developing diabetes, and the same cholesterol levels and blood pressures , as they aged.

Once again, the conclusions track closely with how the salt and health debate was sidetracked into the blind alley of a solitary focus on blood pressure. See the parallel:

Time and again in randomized clinical trials of pharmaceuticals and other medical interventions, we’ve seen the importance of examining confirmed clinical endpoints — with all-cause mortality the most important — rather than surrogate endpoints. Not understanding risk factors and believing that these surrogate health indices are measures of health and future disease has been the greatest way the public been led to believe that weight loss is beneficial, even when it’s not supported in well controlled studies looking at actual clinical outcomes and mortality.

The only difference here is that there have not been repeated RCTs on salt reduction – only a dozen or so observational studies, though they have suggested our uncritical acceptance of the salt hypothesis has been erroneous. It matters not only because we waste time, effort and expense pursuing the wrong remedy, but because the fallacious intervention can actually create health risks. Take the obesity case again:

German epidemiologists, examining 13,362 middle-aged adult men and women in the European Prospective Investigation into Cancer and Nutrition-Potsdam Study, for example, found that fat people who had normal blood pressures prior to weight loss had a nearly 7-fold increased risk of developing essential hypertension during the following two years after weight loss, and those whose weight yo-yoed had a 4.29-fold increase in hypertension.

And, referencing Dr. Thorkild Sorensen at the Institute of Preventive Medicine in Copenhagen from an article in the International Journal of Obesity:

It’s been argued, he summarized, that weight loss does not equal improvement in health and longevity, that staying fat is safer than weight fluctuations, and dieting has negative psychological effects. “In summary, we still do not have conclusive evidence that weight loss has overall beneficial effects.”

She wraps up Part Two with a warning:

The possible healthfulness of natural weight gain with aging, however, is a paradoxical idea in popular media. People may never think to question their beliefs about the deadliness of fat and benefits of weight loss when they never hear anything different.

The importance of research finding seeming paradoxes is that it make us think, question and not be afraid to learn where the evidence might really take us.

Echoes of the salt and health debate. We need to change our paradigm and become evidence-based.