Rather than join in a constructive debate on the policy options based on scientific evidence, anti-salt activists continue to finger-point at personalities and "special interests" to divert public attention to the fact that scientific studies do not identify an improved health outcome from reducing dietary salt.
The latest blast, typified in today's Washington Post , attributes the controversy to economic interests including "Big Salt" -- the Salt Institute. I've submitted this response to the Post:
"Big salt"? As president of the Salt Institute: thanks for the compliment. A few years ago, Gene Weingarten's Below the Beltway profiled the Salt Institute as a prime example of the notion that even the smallest and most insignificant interests have a not-for-profit organization (see http://www.saltinstitute.org/pubstat/beltway.html) . But that's another matter.
The article says "Too much salt is bad for you, right?" By definition, "too much" is, well "too much" ergo "bad."
But who's to say that the amount of salt Americans eat (and we're very average around the world) is "too much"?
I guess it depends on who you ask. The Cochrane Collaboration, inventors of "evidence-based medicine" feel there is no evidence supporting a population intervention. So, too, does the U.S. Preventive Services Task Force, guardians at the HHS of the "evidence-based" approach to public health nutrition policy.
This is an enduring debate among scientists. While we don't fund research due to our modest means, we've seen the debate transform itself from the old debate: will lowering salt help a significant number of people reduce their blood pressure? to a new, better line of inquiry: will reducing dietary salt lower the risk of heart attacks and improve health outcomes?
Surprise. When the question is framed in terms of health outcomes, the answer is clear: none of the studies show a population benefit by reducing dietary salt. Some show increased risk. The president of the International Society of Hypertension published an article earlier this year, using a massive HHS database, and found 37% greater mortality among those following the Dietary Guidelines' recommedation.
We've reviewed the controversy on our website, http://www.saltinstitute.org/28.html and comment regularly on our blogs http://www.saltinstitute.org/rss/health-other/ and http://www.saltinstitute.org/rss/saltsensibility/ . We are a very transparent organization and you can also find all our public statements on this issue online at http://www.saltinstitute.org/advocate.html .
Dick HannemanPresidentSalt Institute
This may be David and Goliath, but we're not Philistines, in Webster's terms: "disdainful of intellectual values."
Carefully coordinated, even choreographed, the anti-salt campaign launched another publicity barrage today, announcing that the UK CASH (Consensus Action Against Salt) has been superseded by WASH, the World Action Against Salt. CASH experts (Dr. Graham MacGregor, et al) will be in Paris tomorrow and Friday, having persuaded the World Health Organization to host a one-sided symposium on salt to build pressure for action. The announcement was made in foodnavigator.com .
Meanwhile, the science is unchanged, trending against WASH as public health agencies consider whether their earlier focus on the blood pressure effects of salt reduction should remain the scientific focus or whether, as advocated by the presidents of the International Society of Hypertension and American Society of Hypertension, the focus should broaden to consider whether reducing dietary salt will improve public health .
Researchers from the University of California at Berkeley argue in an article published yesterday in the British Medical Journal recommending the "Parachute approach to evidence based medicine ," that there are times when it is unethical to wait for controlled trials of a health intervention. People die before the intervention is tested, they say, citing as their most impressive evidence the case of Oral Rehydration Therapy (ORT). They explain:
In 1980 childhood diarrhoea was killing an estimated 4.6 million children annually. Treatment with an intravenous drip is life saving but requires health facilities. Studies from 1977 onwards showed that infant diarrhoea could be treated with oral rehydration. The World Health Organization initiated a highly successful programme of oral replacement therapy in 1981 after it became obvious that the treatment saved lives and no alternative home based treatment was possible. Randomised controlled trials were later conducted in health facilities, confirming that oral replacement therapy was as effective as intravenous therapy. The initiation of large scale programmes for oral replacement therapy before the randomised trials meant that by 2000 there were three million fewer deaths from diarrhoea annually.
Treating diarrhea with a mixture of salt, sugar and water has, indeed, saved millions of lives. The authors advocate the "parachute" principle, explaining:
Evidence based medicine and randomised controlled trials are not synonymous. The parachute approach can be the most appropriate, especially in situations of high mortality and low resources, when a simple intervention can have a large impact. Randomised controlled trials are essential in many other settings and they have defined many life saving strategies and corrected some important mistakes. They are often needed when mortality has reached a low level because new treatments require large investment for relatively small improvements in therapy that may be difficult to distinguish.
All that may be well and good, but BMJ has also editorialized that they feel confident in recommending universal sodium reduction. Perhaps a caveat is needed before we call in the airborne assault on salt. In the case of ORT, the small scale studies produced strong consensus of a health benefit. While there is no such concensus that reducing salt would reduce blood pressure to a meaningfull degree, because the effect is so heterogeneous, the UC-Berkeley authors and BMJ editorial staff should be chastened by the consensus of the observational studies of low-salt diets -- there is no benefit in terms of reducing heart attacks or reducing mortality.
Let's not "parachute" in to reduce dietary salt -- at least until the clouds clear and we can see the landing area.
Used to be all dietitians would chant the mantra of varied diets where all foods could find a place. "We need to focus on the question of "good diets" and "bad diets," they'd say, and avoid labeling individual foods as "good foods" or "bad foods."
The science is unchanged, but the mantra is gone. When nutrition experts gather these days, they're shaking their heads and wringing their hands: the public doesn't "get it." While consumers pretty well understand the concepts of the dietary guidelines, they don't buy into them in terms of personal eating decisions. What to do?
Demonize foods, say some like the Center for Science in the Public Interest which has pushed the "good food/bad food" dichotomy for 30 years. Make people feel that the foods they eat are poisoning them. Ostracize foods with "bad" nutrients and limit diet choices to "good foods" with plentiful "good" nutrients.
The food industry is buying into the "good foods/bad foods" story too -- for marketing reasons. Food companies want to deliver what their customers want. If you can put a "healthy" label on your foods, it makes a difference in product placement and sales -- if you can make it taste good!
A new study reported by the European Food Information Council sums up this way:
There is widespread interest for nutrition information on food packages. Consumers generally understand the link between food and health, and many are interested in using information about the nutritional properties of the food they eat. However, the degree of interest differs between consumers and varies across situations and products. In addition, it can conflict with other interests in food, notably taste, traditional eating, and indulgence.
Consumers like the idea of simplified front-of-pack information but differ in their liking for the various formats. These include health logos, 'traffic lights', GDA-based systems and energy labels. Differences can be related to conflicting preferences for ease of use, being fully informed, and not being pressurised into behaving in a particular way. For example, many consumers like colour coding, but some regard reds and greens on food products as too coercive.
Most consumers understand the most common signposting formats in the sense that they themselves believe that they understand them and they can replay key information presented to them in an experimental situation.
There is still virtually no insight into how labelling information is, or will be, used in a real world shopping situation, and how it will affect consumers' dietary patterns.
The real question is will food buyers follow the red-yellow-green stoplight the same way they follow traffic speed limits -- by applying their own judgment in the absence of an officer writing speeding tickets? As EUFIC points out: "There is still virtually no insight into how labelling information is, or will be, used in a real world shopping situation." Are we ready to buy another set of unintended consequences?
The latest issue of Food Technology, the foundation publication of the Institute of Food Technologists has an article in the Food, Medicine & Health section devoted to the issue of salt and hypertension. The knee-jerk response by certain regulatory agencies to very limited and inconclusive evidence is highlighted along with the dangers of developing policies based on the vocal opinions of a few commited anti-salt advocates. The authors, Clemens and Pressman, go out of their way to remind us that that hypertension is not a discrete disease nor is it a clinical end point, but rather a multifaceted risk factor steeped in myth-information and too-often passed off as a proxy for cardiovascular disease - a misleading representation.
More articles like this one, in widely circulated journals pointing will get rid of the hype and reduce the tension in the whole hypertention debate.
As Mort blogged earlier this morning, the Salt Institute gets calls constantly from the media. In an exchange yesterday with another Chicago area reporter writing on salt and health, I drew an analogy that may help explain the basic point of the Salt Institute's advocacy on salt and health. See what you think.
We argue that the relevant question that should be asked with regard to a public health advisory to reduce dietary sodium is "Will cutting salt intake improve health?" Instead, some frame the question as "Will cutting salt improve blood pressure?" They aren't the same thing. When you cut salt, you "buy" all the consequences, intended and unintended, that are triggered as the body recognizes it is consuming less salt.
I likened public confusion on the issue with the current flap over national security policy. Those who characterize our national security challenge as combatting terrorism have a very different worldview from those who define our challenge in terms of our engagement in Iraq. It's not a matter of patriotism; it's a matter of focus and context.
In the war against cardiovascular mortality, some would test our weapons systems for their impact on overall health and mortality; others would focus on the specific problem of blood pressure. Without doubt, blood pressure is related to cardiovascular health, but it is one of several important "theaters." It's important to identify specifically and correctly our rules of engagement before we sally forth to meet the enemy. We want to avoid any "friendly fire" casualties.
Unfortunately, experts lack consensus over the right questions to ask in both challenges: national security and cardiovascular health.
I received an interesting call the other day from a correspondent preparing story for the Chicago Tribune. She had heard from an author that so little salt was consumed in Finland that there was actually no word for it in the Finnish language. This struck me as rather odd because the Finns are known to consume among the highest levels of salt in the world. How could that be possible without having a word for the world's favorite condiment? Might a typical conversation around the kitchen table go something like this?
Olga, this soup is perfect, you added just the right amount of white stuff and pepper. Would you mind passing the white stuffine crackers, they go perfect with this soup.
Oh, I'm glad you like it Paavo, guess what's up next?
Don't tell me it's my favorite, white stuff herring or perhaps some of your excellent white stuff pork and beans? Olga, my darling, you are really the white stuff of the earth.
Sounds ridiculous, doesn't it? In fact, it didn't take long to set the record straight. The word for salt in Finland is suola. Another urban legend destroyed!
Sometimes you have to take some authors with a pinch of suola… or white stuff!!
The news of discovery of four salt men in Chehr Abad mine was last reported on July 27 in SaltSensibility . They are among the very rare mummies formed as a result of natural conditions. Samples of these salt men were sent to Oxford and Cambridge for genetic studies and DNA analysis. Today, the director of the archaeological team working at the Chehr Abad Salt Mine announced that a group of Oxford archaeologists expressed interest in being part of the study team working at the mine site.
There are 14,000 known uses of salt and I've just run across one I hadn't heard before, but it may be on the list already. I'm in Prince Edward Island for the annual meeting of the Transportation Association of Canada and here learned among the local lore of a means by which the Prohibition-era bootleggers avoided interdiction of their off-shore deliveries: by using salt. The bootleggers would weigh-down barrels of rum with blocks of salt and pitch them over the side of their ships at the appointed delivery point; then, depart, perhaps hotly pursued by the Coast Guard. Their land-based confederates would wait until the salt blocks dissolved enough to release the buoyant rum barrels and then row out and retrieve them when no Coast Guard was around. Let's hope someone has developed a means to thwart this tried-and-true method of clandestine "importation."
The American public is unaware that expectant mothers are ingesting only about three-fourths of a key nutrient required for proper fetal brain development according to an NIH-funded public opinion poll conducted by Opinion Research Corporationa and publicized by The Solae Company .
And after reading this news report, Americans still won't know the crucial importance of adequate iodine nutrition for pregnant women and infants since the article is about choline. NIH has done nothing to publicize the need for improved iodine nutrition, but its sister agency, the Centers for Disease Control and Prevention has tracked a decline in the iodine status of the American diet including a fourfold increase in pregnant women consuming less than the World Health Organization's minimum acceptable levels of iodine.
A major source of dietary iodine, of course, is in iodized salt.
In August 28 comments to Environment Ontario , the Salt Institute articulated principles it favors for inclusion in pending legislation to improve drinking water source protection in the Province of Ontario. Salt Institute president Richard L. Hanneman noted that the four Ontario salt production plants all operate under federal and provincial permits and recommended that source protection be integrated into the existing permitting program or, alternatively, that the new responsibilities and capabilities of regional conservation authorities include granting permits to avoid duplication. He noted the great strides that Ontario governments have made in improving their road salt management practices in recent years and recommended that the conservation authorities be encouraged to support implementation of the national Road Salts Code of Practice as the best management requirement for drinking water source protection against contamination from road salts.
It seems everybody wants to visit a salt mine. Small surprise, that. Cargill Deicing Technology is capitalizing on that interest to earn some valuable industry PR as this article in today's Cleveland Plain Dealer shows.
My "in" box is filling up today with news on salt and exercise, interupting (and affecting) my final edits on a story on salt and obesity. First, CBS Radio News medical consultant Dr. Gabe Mirkin wrote calling my attention to his "August" article (all senses of the word) "Why You Need Salt During Exercise " followed closely by an article filed today by Ivana Bisaro, "See Salt: You Need More Sodium Than You Think ." The Bisaro article was perfect for hot August days, reminding us of the new guidelines presented by the American College of Sports Medicine calling for replacing 500-700 mg of sodium and 3/4 to 1 liter of fluid for every hour of exercise. ACSM warns to pay special attention to getting enough salt if your sodium intake is less than 3,000 mg day (US average = 3,500 mg, but some recomend 2,300 mg, below the ACSM warning level). The US Dietary Guidelines call for a half hour of at least moderate exercise a day beyond normal activities. When it's hot outside, you may need even more than the 250-350 mg of sodium called for by the ACSM.
House Energy and Commerce chair Joe Barton (R-TX), the committee's ranking minority member John Dingell (D-MI), oversight subcommittee chairman Ed Whitfield (R-KY) and Rep. Bart Stupak (D-MI) have called on the National Institutes of Health to come clean on conflicts of interest at the agency. The Los Angeles Times reported that the letter is focused on the activities of NIH cancer researcher Dr. Thomas J. Walsh and involves his receipt of corporate support and his appearance at regulatory hearings related to his corporate sponsors.
The effort remains the tip of the larger iceberg. Current regulations address the issues of financial conflicts with for-profit organizations, but conflicts of interest inherent in both funding and professional advancement growing from support by NIH itself is a big (perhaps, bigger) concern because its subtlety has the same effect: determining policy that may support private interests and agendas more than the public good.
In previous posts, I've noted that concern for investigator bias is a serious threat to the integrity of medical research -- and public confidence in the results. It's getting to the point of "piling on" for the Wall Street Journal and the editor-in-chief of the Journal of the American Medical Association to add their strong voices to the crescendo of the chorus.
But it's a lot like the future funding for Social Security: everyone recognizes a serious problem, but sometimes the remedies suggested are half-measures that will surely only paper-over the fundamental problem.
Last Friday, the Wall Street Journal ran a story "Simply Disclosing Funds Behind Studies May Not Erase Bias " about how researchers would likely deal with toughened disclosures of financial ties to for-profit firms. Tuesday, Catherine DeAngelis, JAMA's editor-in-chief weighed in with a powerful salvo in "The Influence of Money on Medical Science ." Of course they're both right. Bias is a cardinal sin and must be stamped out.
Unfortunately, the remedies being discussed are focused narrowly on bias from a for-profit funding source. They ignore the bias based on funding from a non-profit or government source, though that influence can be even more pernicious because the public is gulled into believing the sponsors genuinely represent the "public interest." The truth is, there are policy and bureaucratic biases fully as important as taking money from a drug company or medical device manufacturer.
Sure, let's deepen our concern -- but let's widen it as well!
