For years, I have gone on record highlighting the benefits of the “Mediterranean” diet . This was no second or third party pitch I was making. Having lived in Italy for almost 20 years, I have ample ‘first-hand’ experience of the diet and its many health benefits. At the same time, it was clear to me that this healthful diet was being misrepresented to fit the agendas of certain individuals and organizations in the health and consumer segments.

There is no doubt that everyone loves a winner and the hands-down favorite diet all around the world promoting good health is the Mediterranean diet, so naturally all the diet talking heads tried to pitch it in their favor. Lots of salads, vegetables and fruits, plenty of grains (bread and pasta), good cheeses, a lot of fish and a small amount of meat – that’s how all the Mediterranean diet promoters characterized it. And there is no doubt, the cardiovascular figures of Mediterranean residents are amongst the best in the world.

But all the pretenders in the medical institutions and the consumer group sector neglected to mention one very important aspect of the Mediterranean diet – it’s very high salt content. That can only mean one of two things. Either, they had no idea of what the diet actually was but pretended they did, or they knew it was a very high salt diet but purposely lied about it because it did not fit their agenda. After all, the urban myth was that high salt diets contributed to cardiovascular disease and if the Mediterranean diet was revealed to be high in salt, it would prove to be very embarrassing to their salt reduction agenda. Either way, it makes me wonder how consumers can still have any faith in the medical establishment when it comes to nutritional advice.

Aside from my personal experience of the food in Italy, there was a highly regarded publication by C. Leclercq and A. Ferro-Luzzi describing the high salt content of the Italian diet (1). This 20 year old paper was just reconfirmed by a recent study of A. Venezia et al, published in the May edition of the European Journal of Clinical Nutrition . And still, the Southern Italians continue to enjoy good cardiovascular health.

And salt is not a bystander to this good health paradigm. A key determinant of good health is the consumption of a sufficient amount of salads and vegetables. These foods contain the bulk of the essential water-soluble micro-nutrients we consume. You don’t get as many water soluble nutrients from any other source in the diet. And it is salt that makes salads and vegetables so tasty. Salt is what encourages a good, well-balanced diet. That is why we evolved to like salt as much as we do – because it keeps us healthy.

The doom and gloom prophets, the food police and the nutrition con artists are all preaching that our diet is killing us. Fortunately, most of us are blissfully unaware of this so we continue to enjoy life and thrive better than at any time in the entire history of mankind – just check out the health statistics on the CDC website .

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(1) C. Leclercq and A. Ferro-Luzzi, “Total and domestic consumption of salt and their determinants in three regions of Italy,” European Journal of Clinical Nutrition, Mar, 45(3), 151-9, (1991).

(2) A Venezia, G Barba, O Russo, C Capasso, V De Luca, E Farinaro, F. Cappuccio, and P Strazzullo, “Dietary sodium intake in a sample of adult male population in southern Italy: results of the Olivetti Heart Study,” European Journal of Clinical Nutrition, 64, 518-524 (May 2010).

In a previous blog "Abolish FSA - Without Delay !" I mentioned that the new UK government was thinking of making major changes to the Food Standards Agency (FSA). Well, today, the UK government has ended speculation about the future of the Food Standards Agency (FSA), announcing that the body will retain its food safety remit but be stripped of responsibility for nutrition policy and labeling.

Under the plans, the Department of Health (DoH) will become responsible for nutrition policy while the Department for Environment, Food and Rural Affairs (Defra) will oversee labeling and food composition policies.

The FSA was known to advance an activist agenda totally driven by misinformation rather than concrete evidence. Their role in nutrition policy will not be missed.

On June 15, 2010, Agriculture Secretary Tom Vilsack and Health and Human Services Secretary Kathleen Sebelius announced that public comments would be accepted on the Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010 (Advisory Report). Individuals and organizations were encouraged to provide written comments and oral testimony could also be provided at a public meeting to be held in Washington, DC, on July 8, 2010 .

I submitted the Salt Institute’s comments (pdf 91.39 kB) that were accepted by the USDA for oral testimony. The oral testimony was well received and was cited in several articles as well as releases issued by other groups .

Aldosterone plays a major role in the maintenance of electrolytes and fluid balance and subsequent blood pressure control. Epidemiological studies that explore the connection between hypertension and cancer have found a higher rate of cancer-related mortality in hypertensive patients that have an elevated level of aldosterone. Recent research indicates that this may be the result of aldosterone-mediated damage to chromosomes and DNA in kidney cells.

For most people, the renin-angiotensin-aldosterone system is activated when our salt consumption drops below current levels. Although cardiovascular issues were always considered to be a possible unintended consequence of salt reduction, this study is one of the preliminary indications that an increase in cancer-related mortality may be a consequence as well. The Salt Institute will maintain a watching brief on the clinical research carried out in this area.

In my recent blog, “Good Tidings ,” I mentioned that Food Standards Agency (FSA) chief executive Tim Smith claimed that the UK has “turned the tide” on salt consumption, basing his case upon the disputed FSA analysis survey showing that average adult salt intakes dropped from 9.5g/day in 2001 to 8.6g/day in 2008. However, there was a strange tone in his public address that led me to believe that something was afoot. I got the impression that, with the new government installed in the UK, the FSA’s chief executive was indicating that they would be cutting their anti-salt campaign, which is which is why I felt that the tide had turned.

Well, there was more news on this front this week. On Monday, July 12, the Guardian wrote that Andrew Lansley, the British Health Secretary indicated that the Food Standards Agency may be abolished entirely. As part of the changes, the FSA's regulatory role – including safety and hygiene –would be reassigned to the Department for Environment, Food and Rural Affairs (Defra) from whence it originally came.

There were the inevitable cries of foul – that the government could not get rid of a much needed watchdog agency , but I for one couldn’t be more pleased. The FSA was the poorest possible model of a watchdog agency and it's about time it was abolished.

The function of a watchdog agency is to make sure everyone is honest – everyone – a hard task to accomplish when the agency itself was dishonest and used taxpayers' money to advance an activist agenda totally driven by misinformation rather than concrete evidence. The agency completely ignored every bit of science that did not support their agenda, as though it didn't exist. They tried to bundle together bits and pieces of poor, incomplete information or opinion and pass it off as a real evidence - talk about putting lipstick on a pig! The FSA became the chief promoters of the big lie on the benefits of salt reduction.

Yes, we may need certain watchdog agencies - not pawns of any interest group, but honest scientists who can objectively evaluate scientific evidence and who have enough backbone and honesty to forgo advancing gratuitous solutions until sufficient evidence is available, rather than giving half-baked advice that will never benefit anyone except themselves.

Speaking to an audience of academics, government officials and World Health Organisation staff at a salt reduction forum in London, the Food Standards Agency (FSA) chief executive Tim Smith acknowledged that UK salt intakes were still well above its target of 6g/day after seven years of vigorous campaigning. He claimed that the UK has “turned the tide” on salt consumption, basing his claim upon the disputed FSA analysis survey showing that average adult salt intakes dropped from 9.5g/day in 2001 to 8.6g/day in 2008. What he didn’t mention to his chosen sympathetic audience was that these figures have been openly disputed as being inaccurate and inconsistent1.

Even if those figure were correct, claiming to have turned the tide when they have only reached 25% of their stated goal in 8 years is reflective of the ‘DON’T BOTHER ME WITH THE FACTS’ ideology that has characterized the anti-salt advocates involved with the salt and health debate. His statement is doubly perplexing coming only a few days two reports by Nielson and Kantar WorldPanel on the retail sales of salt in the UK. Nielson claims an 18% jump in UK retail sales of salt in 2010 (including cooking, table and sea salt) while Kantar WorldPanel claims volumes were up 26.5%! Granted, some of this rise was due to consumers using table salt for home deicing last year, but Nielson also recorded a sharp rise in 2008/09, which could not be attributed to the weather.

So while there is no doubt that the FSA’s strategy of ‘naming and shaming’ companies has coerced many of them to lower the salt in their processed food formulations, have consumers compensated for this by topping up taste with the salt shaker? The neural mechanisms for salt appetite that we have evolved over the eons certainly indicates that this may be the case2. In fact, the Salt Institute has prepared a number of Newsletters on this very subject3, 4, 5. So despite Smith’s claims of turning the tide, the preponderance of scientific evidence appears to disagree with the notion that public policies can supersede our naturally evolved physiological mechanisms controlling our intake and liking of salt4.

Or is it possible that, with the new government installed in the UK, the FSA’s chief executive has signalled that they will be cutting back their anti-salt campaigning, but felt obliged to claim some sort of pyrrhic victory. It certainly seems that way, particularly since he stated how important salt was in preventing microbial growth, toxins and spoilage as well as its critical importance in baking.

It appears that the whole salt and health debate may indeed have seen the “tide turned.”

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1) McCarron, D.A., Geerling, J.C., Kazaks, A.G. and Stern, J.S., “Can Dietary Sodium Intake Be Modified by Public Policy?” Clin J Am Soc Nephrol, 4, 1878–1882, 2009.

2) Geerling, J.C., and Loewy, A.D., “Central regulation of sodium appetite,” Exp Physiol 93: 177–209, 2008.

3) Satin, M., “Aldosterone: unlocking our understanding of cardiovascular risk,” Salt and Health Newsletter, 3(3). Summer, 2008.

4) Satin, M., “Salt Appetite Revisited,” Salt and Health Newsletter, 3(1), Winter, 2010.

5) Satin, M., “Salt Appetite,” Salt and Health Newsletter, First Quarter, 2010.

The impact of salt on health has been reviewed on a number of occasions over the years with mixed results. The latest meta-review of the evidence was commissioned by the German Ministry of Health just last year and concluded that population-wide salt reduction was not justified from a public health point of view. The controversial nature of the evidence will have great significance for international trade if salt reduction policies are ever enacted. This month's Food Technology Magazine features an OpEd I wrote on this issue.

When the World Trade Organization (WTO) was established in 1995, an international agreement on sanitary and phytosanitary measures (SPS) to reduce risks arising from additives, contaminants, toxins, or pathogens in foods took effect. Intimately linked to the SPS is an additional agreement on Technical Barriers to Trade (TBT), signed in the same year and designed to restrict the use of unjustified measures for the purpose of trade protection.

The aim of the SPS and TBT Agreements is to ensure that regulatory actions are not misused for protectionist purposes and don't result in unnecessary barriers to international trade. The intent is to reduce arbitrary decisions by requiring all health protection measures to be based upon an objective analysis of the preponderance of scientific evidence.

Import regulations that fall under the provisions of TBT or SPS Agreements are typically complex and frequently employ standards that create a high hurdle for imports. Exporters, whose own governments do not implement similar standards, find it difficult to understand the logic or need behind the regulations, so an objective evaluation of the science supporting them goes a long way in resolving disputes.

The core strategy of the recent Institute of Medicine (IOM) Committee report on "Strategies to Reduce Sodium Intake in the United States" is the FDA removal of GRAS (generally recognized as safe) status from salt and the regulation of the amount to be added to each food category. Removing the GRAS status of salt and regulating what is an essential nutrient and arguably the oldest and most ubiquitous food additive in the world will be a monumental task and will undoubtedly have enormous consequences for food and food trade around the world.

Several European countries are major exporters of traditional food products to the U.S. Breads, olives, ham, sausages and cheeses--produced through processes standardized centuries ago--are typical examples. These products and processes are so well established that many are protected with geographic origin designations. Not only are products such as Parmesan and Gorgonzola cheeses, olives, anchovies, prosciutto, and pepperoni consumed directly, but they are also key ingredients in many other products such as pizza and pasta dishes.

These traditional products were developed long before refrigeration. Many employ high salt levels for debittering (olives), curing (hard cheeses), mold culturing (blue-veined cheeses), water activity control (black forest and prosciutto hams, corned beef, salamis, etc.), and storage (anchovies, capers, fish roe, salt fish). The intent of the IOM report makes it unlikely that these traditional products will be permitted. While it is impossible to say whether low-salt variations of these products will achieve market success or whether salt replacement additives will themselves come under regulatory analysis for potential health issues, one thing can be predicted with a fair degree of certainty. Regulation of the salt content of foods will be carefully scrutinized regarding its impact as a non-tariff trade barrier.

For exporters of traditional French, Greek, and Italian foods, the health benefits of the high salt content Mediterranean Diet have been acknowledged for centuries. Despite Americans' stable consumption of salt for the past three decades, ischemic heart disease death rates in the U.S. have fallen precipitously. All of the above are rational reasons to invoke the SPS and TBT Agreements to challenge whether the regulation of salt in foods is an arbitrary measure and an unjustified barrier to trade or one supported by the preponderance of scientific evidence.

Supertasters are people who experience taste with far greater intensity over the average. It is estimated that about 25% of the population are supertasters and women are more likely to be supertasters than men as are Asians and Africans. The cause of this heightened response is thought to be due to an increased number of fungiform papillae or taste buds. Although one would think that the taste sensation would be an advantage if it is more sensitive, this is not always the case. An increased response to bitterness may severely limit the range of foods that are palatable. Vegetables have important phytochemicals that are protective of heart disease and cancer risk but their natural bitterness may turn supertasters off.

A potential unintended consequence of population-wide salt reduction has been highlighted in a paper by John Hayes and colleagues from Pennsylvania State University, published in the latest edition of Physiology and Behavior .

Hayes and colleagues examined the response of supertasters to varying amounts of salt in a wide range of foods. As indicated previously, these supertasters make up about 25% of the population and are genetically hypersensitive to bitter tastes, leading them to naturally avoid some vegetables and other foods that taste naturally bitter.

The researchers measured the liking and intake of foods with varying amount of saltiness among 87 healthy adults (45 men).

Supertasters reported greater saltiness in chips and pretzels and soup broth at levels comparable to regular-sodium products. They also found greater sensory enjoyment to growing salt concentration in cheeses (where sodium ions mask bitterness).

Despite adding less salt, supertasters consumed more sodium through food, as salt was more important to preference, both for its salty taste and masking of bitterness. This suggested to the researchers that supertasters appreciate increased salt in food formulations to mask naturally bitter foods particularly vegetables and other foods that may be deemed to be healthy.

The Dietary Guidelines Advisory Committee (DGAC) of the U.S. Department of Health and Human Services and the U.S. Department of Agriculture may increase health risks, including obesity, by ignoring sound science as they announce recommendations to reduce sodium consumption to 1,500 mg per day. It is reckless for the government to risk the health of Americans by relying on substandard levels of evidence and refusing to consider new evidence.

The rationale behind the recommendation is purportedly blood pressure reduction. While no one doubts that a small percentage of our population may experience modest blood pressure declines from salt reduction, it has not been scientifically established that a population-wide reduction will benefit overall health. Research indicates health risks for some on low salt diets, including higher risk of heart attacks. And new research shows that not a single modern society consumes such a low level of salt as that recommended (less than 4 grams of salt per day). This recommendation is essentially an unauthorized massive clinical trial using 300 million Americans as guinea pigs.

Recent research (Can Dietary Sodium Intake be Modified by Public Policy? David A. McCarron, Joel C. Geerling, Alexandra G. Kazaks, Judith S. Stern) involving data collected from more than 19,000 individuals in 33 countries has demonstrated that healthy humans, all around the world, consume sodium within a relatively narrow range (2700 mg- 4900 mg sodium) – a range controlled by a number of physiological mechanisms. The DGAC recommended level of 1500 mg is drastically lower and will result in unintended health consequences if Americans strive to reach the recommended target.

Most nutritionists agree that reduced sodium in food preparations will very likely increase the obesity crisis because individuals will consume more calories just to satisfy their innate sodium appetite and their search for eating satisfaction.

Perhaps the greatest failure of the Dietary Guidelines is their priority focus on single nutrients rather than the whole diet. Concerns over blood pressure would be better addressed if Americans would eat more salads, vegetables and fruits. Italians consume more salt than Americans yet they have better cardiovascular health because they eat a well balanced diet. They use salt to make healthy foods more delicious...without adding calories.

The public comment period on the Dietary Guidelines is June 15 to July 15.

Most salt reduction advocates maintain that we are eating more salt now than ever before in history. They don't have any data to back up this claim, but they were never particularly fastidious about getting real evidence. However, the question of how much salt we ate in the past intrigued me, so I decided to seek out reliable evidence from other sources. It struck me that the military were always meticulous in maintaining and preserving their archives, so I decided to see if I could find out the daily salt rations provided to soldiers over the last 200 years. I hit pay dirt!!

During the War of 1812, the daily salt ration for the Continental army was 18g of salt/day (1).

The United States declared war on England on June 18, 1812 to protest the undue control of the British government over the lives of Americans. Captured US forces were first shipped up to Canada and thereafter crammed into ships for the long, cold voyage to England and the prison camps of Chatham and Portsmouth. Each man was given a daily ration of a pound and a half of coarse bread (8-10 g salt), some boney beef, 9 g of table salt and one or two turnips a week. American prisoners of war described their treatment by the British as "ungenerous, inhuman and unmerited oppression." (2)

The Mexican War ration was established in 1838 and also contained 18g of salt/day.

The Civil War rations enacted by Congress in 1860 and 1861, increased the variety of foods in the ration but maintained the 18g salt/day.

During the Spanish American War very few changes were made to army rations with the exception of a slight increase potatoes and a decrease in wheat flour and beans. Again, the salt ration was kept at 18g/day.

During World War I - the daily army reserve ration included a one-pound can of corned beef containing (10g salt), two 8-ounce tins of hard bread (4g salt), and 4½g of table salt for a combined total of 18½g salt. (3)

During World War II, the salt ration for American prisoners of war in Germany was 20g salt/day and the ration for Italian POWs interred in South Africa was likewise 20g salt/day. (4)

The bottom line is that we are now eating about half that amount of salt.

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(1) Rations: The History of Rations, Conference Notes, Prepared by The Quartermaster School for the Quartermaster General, January 1949.

(2) James Adams, Dartmoor Prison, A Faithful Narrative of the Massacre of American Seamen, to Which is added a Sketch of the Treatment of Prisoners During the Late War by the British Government (Pittsburgh, S. Engles, 1816).

(3) “Special Rations for the Armed Forces, 1946-53", By Franz A. Koehler, QMC Historical Studies, Series II, No. 6, Historical Branch, Office of the Quartermaster General, Washington D.C. 1958.

(4) American Prisoners Of War In Germany, Prepared by Military Intelligence Service War Department, November 1945, Restricted Classification Removed - STALAG 17B (Air Force Non-Commissioned Officers).

Growing up in Montréal was a gastronomic delight. Like most other cities in North America, there was a great variety of ethnic foods, but this city's French flavor seemed to demand more of its restaurants. One day my older brother dragged me over to see a new restaurant that had just opened. It was the city's first pizzeria and he thought that the sign in the window was hilarious. There in all its colorful neon splendor was a large sign that blared "Genuine Italian Pizza - Just like in New York!!" On a smaller printed sign in a corner of the window I read the ingredients: anchovies, capers, mozzarella, prosciutto and then glanced up to my brother for an explanation of each. Real Italian pizza - just like in New York.

Earlier this week, New York Assemblyman Felix Ortiz introduced Bill A10129 stating that “No owner or operator of a restaurant in this state shall use salt in any form in the preparation of any food for consumption by customers of such restaurant, including food prepared to be consumed on the premises of such restaurant or off of such premises.” The penalty for each infraction will be $1,000.

How would such a bill affect New York's famous pizza? Could they still say real Italian pizza - just like in New York? Salt is an integral part of almost every ingredient in pizza. Salt has to be added to the dough in order to condition it so that it will be pliable enough to be stretched, tossed in the air and twirled into a pizza. Omit the salt and the dough will contract back into a ball of tough rubber. Salt has to be added to the tomato sauce in order to moderate the mild bitterness that is normally found in all tomatoes. That is why a slice of fresh tomato tastes so much better with a smidge of salt. Mozzarella, like all other cheese is cured with salt. Both anchovies and capers are packed in salt (at least the best ones are). Salt is also used to cure prosciutto and is the reason that trichinosis has never been found in this type of Italian ham. Can anyone imagine Italian sausages and any type of edible olives made without salt?

Without salt, all dressed would mean a crustless pizza topped with the emperor’s clothes. Is that real Italian pizza? Of course not - so why change it? What's wrong with Italian pizza? Is it making Italians ill? Does pizza give Italians hypertension?

In fact, Italians eat far more salt than we do here. Aside from olives, which can only be consumed if the bitterness is removed by soaking in brine for almost a month, there is Parmesan - the king of cheeses, which happens to be cured for 20 days in saturated salt brine baths, Gorgonzola cheese whose blue mold will only grow in a high salt medium, bacalla or salt cod, bottarga or salted tuna row, and anchovies, capers, salami, etc. etc. etc. Yet, Italians have amongst the best cardiovascular figures in the world because they eat a balanced diet, replete with salads and vegetables. In fact there have been several publications attributing the decline of disease to the consumption of vegetables and fruit. In North America, of course, there is full access to vegetables and fruits, however, our leaders prefer to hype approaches based on magic bullets, such as salt reduction, instead of promoting a balanced diet that every nutritionist knows will be far more effective. Assemblyman Felix Ortiz' bill is just such an example. Had Ortiz looked into the matter a little more deeply, he would have learned that salt is an essential nutrient and that the medical and scientific literature demonstrates that low salt intakes can lead to a cascade of negative health impacts including increased stress, reduced cognition and metabolic syndrome.

But man does not live by pizza alone. How will a ban on salt affect other foods in New York? How would New York's famous deli's such as Katz' or the Stage fare? Pastrami, corned beef and dill pickles will have to go by the wayside - no question. A Reuben sandwich will be no different than a skinless frankfurter without any meat in it. Well, maybe New York can live without deli's.

What about Italian restaurants? There may not be pizza but what about prosciutto e melone? Perhaps that can be changed to melone e melone and be served as a dessert instead as an appetizer? Spaghetti bolognese might work if the bolognese sauce and the parmesan cheese are left out; but plain spaghetti boiled in unsalted water will have to fill both sides of the menu page. You might try Chinese or Japanese foods, but without the vast array of soy-based sauces, what will they taste like? How’s about....Mexican....Tunisian.....Indian....? There must be something? Hmmm....got it! New York will no longer out be dubbed the Big Apple. Henceforth, New York will be known as the Big Boiled Egg.

What does the future hold for New York? Don’t be surprised if you see notices affixed to the walls of post offices declaring, “The authorities are offering a reward of $50,000 leading to the arrest of the owners of Pizza Romano, the illegal restaurant operation that has openly defied Bill A10129. Every time police close in on them, these fly-by-night operators close up shop and open elsewhere. They can be easily identified by the sign in their window, “Genuine Italian Pizza – Just Like in Montreal!!””

The last week has brought a media frenzy to the debate over population-wide salt reduction thanks to the hypocritical and nonsensical campaign by NYC's Mayor Bloomberg and his administration. The Salt Institute has been in the center of the fray as we seek to get fair media coverage from folks who parrot inaccurate sound bites based on faulty science and a political agenda based on a "villain of the day" mentality. We are happy to report we have made great strides in getting out "the rest of the story" as Paul Harvey would say. SI staff appeared on CBS and Fox News, weighed in on approximately 20 interviews with print media and appeared on one national radio show and another large radio show in Miami (NYC's sixth borough).

In addition, the tide seems to be turning as the national sentiment is rejecting the nanny state mentality and seems keen on personal choice and liberty. There has been a shift in reporting on this issue since Bloomberg and company first publicly entertained the notion of population-wide sodium reduction one year ago. Perhaps our favorite editorial in the last week appeared in the Wall Street Journal. Smack is bad, but the crackdown is on salt by Eric Felten does a fine job of pointing out the lunacy of a city which teaches its residents how to properly shoot up heroin, but strong arms food producers into limiting sodium content. We, like Felten, join in a collective chorus of "huh?" John Stossel also did a fine job of making the case against government food nannies in this Fox News segment.

We are encouraged to see many rising up to fight back against nanny state public policy which ignores sound science. Fox News online ran a story "Restaurant chefs boiling over NYC Mayor's salt crackdown." And a new coalition has popped up to fight back: My Food. My Choice. is made up of businesses, restaurant owners and ethnic groups (they see the policy as an attack on ethnic cuisine) and consumers.

Earlier this year a New Jersey startup "food manufacturer," Bon Vivant International , began marketing "NutraSalt an all-natural, low-sodium sea salt," claiming "66 percent less sodium than other salt products."

Well, I guess this "food manufacturer" makes other things than food. Food grade salt is required to have at least 97% sodium chloride. So NutraSalt cannot be food grade salt.

The founder claims: "The product can be sold as table salt and as an ingredient to food-service companies and food makers."

It would be interesting to know which "food-service companies and food makers" are using non-food-grade salt. Inquiring minds want to know.

Scientists generally accept that 24-hour urine samples are the most accurate means of measuring sodium intake -- the "gold standard" for dietary sodium just as randomized controlled trials are the "gold standard" in the hierarchy of levels of evidence.

With that as background, how should we understand the claim by the Heart and Stroke Foundation (Canada) which "revealed" today that "500,000 kilograms of salt have been removed from the food supply in the last four years by companies participating in the Health Check program." HSF's health policy director equated the amount to "20 dump trucks of salt."

On its surface, the claim is that the total food sold over the past four years bearing a Health Check logo contains a half million kilos less salt (that figures to 550 tons of salt). Every year, Canadians consume about 130,000 tons of salt. So over four years, Canadians consumed a half billion tons of salt (520,000). In other words, this effort is claimed to reduce Canadians' salt intake by 0.1%.

But is it true? The claim can only be evaluated if we also know the answers to these questions:

1. Compared to the baseline four years ago, what was the composition of the foods bearing the HSF label? If the quantities and/or configuration of the sales differed, what can be said about the 500,000 gram number? If people, for example, are eating less of these foods (because they don't taste good or cost more) the number is invalid. But even more:
2. Compared to baseline, what other foods are Canadians eating and in what quantities? If they are eating less salt in Health Check foods, are they simply eating that salt in other foods?

No, the entire exercise is entirely bogus.

What we need to test the proposition (and we're all for the test!) is to track the total sodium consumption for a representative sample of Canadians randomized to consume a diet including as much as possible all the Heart Check foods and compare that over a year or two, with those randomized into a control group which eats whatever they want. The outcome would be ascertained by frequent collection of 24-hour urine specimens and the analysis done in blinded fashion.

Evidence suggests that physiology determines sodium consumption, not package labels. If an individual consumes "low salt" foods, they may simply eat additional quantities of food (and extra calories) to satisfy this innate "salt craving" automatically determined by the body to reflect that individual's varying need. That's why research shows such a consistent pattern of salt intake between populations and over time .

Most visible among their food industry peers in claiming "credit" for reducing salt in their product lines, ConAgra Foods and Campbell Soup both have declining customer satisfaction scores from baseline, according to the American Customer Satisfaction Index released today. ConAgra, in fact, finished dead last among the 13 named larger companies (and below the "all others" category).

On a 0-100 point scale in the ACSI, food manufacturers averaged 83 points with Campbell Soup lagging in 12th place with 82 and ConAgra dropping 6 points to 78. Leaders were H.J. Heinz with 89 followed, at 87, by Hershey, Quaker (PepsiCo) and Mars.

ACSI produces indexes for 10 economic sectors, 44 industries, and more than 200 companies and federal or local government agencies. Among all industries , manufacturers earned 81.5. Laggards were newspapers, cable/satellite TV companies and airlines (63 and 64). They, together with telephone companies (69), were the only private sector businesses with customer satisfaction as low as the federal government at 69.

ACSI is sponsored by the American Society for Quality, the University of Michigan's Ross School of Business and Cloes Fornell International.