It was just yesterday that we noted the excellent paper, "Redefining Quality--Implications of Recent Clinical Trials ," published in the June 12 issue of the New England Journal of Medicine. Doctors Harlan Krumholz and Thomas Lee challenged their medical colleagues to design medical strategies that affect overall patient health outcomes - not simply isolated risk factors. Reluctantly, we stated that it was unlikely the article would get most of their colleagues to move away from the risk factor fixation.
It did not take long for that unfortunate prediction to be realized. It appeared in the supplement to the article "Cutting salt intake saves lives and money ". The Abstract which appears halfway down the page under the title, "The 2008 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2 - therapy" describes a project to update the evidence-based recommendations for the prevention and management of hypertension in adults. It goes on to state:
"For lifestyle and pharmacological interventions, evidence was preferentially reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field."
The very same crowd that have always protested that a large scale study to determine the impacts of low salt diets on health outcomes would be too costly, turns around and justifies the use of surrogate risk factors as outcomes because there is no data on health outcomes. How duplicitous is that? This approach is precisely what Krumholz and Lee were referring to.
The main article describes a set of model projections that predict the number of cardiovascular events that will be prevented if salt consumption is decreased. Using blood pressure as the sole marker, this is the same sort of mathematical manipulation that resulted in the statements made by the Center for Science in the Public Interest that 150,000 lives per year would be saved by reducing salt. It is difficult to understand how such work can receive any credibility in the face of our achievement of significantly improved cardiovascular and stroke performance, while consuming the same levels of salt we always have.
C'est curieux, n'est-ce pas?
Health outcomes are what matters.
Except to the news media. The Centers for Disease Control and Prevention just issued the latest data from the National Center for Health Statistics. Its news release trumpeted "U.S. Mortality Drops Sharply in 2006, Latest Data Show ." This "news" received as much media attention as last week's announcement that casualties in Iraq are the lowest since 2003 -- in short, a virtual news blackout. To turn around the saw: good news is no news.
For public health practitioners, health outcomes should be the consensus metric. The data show convincingly that 8 of the 10 leading causes of death in the U.S. all dropped significantly in 2006. This continues the trend of the past quarter century and trumps the fact that our aging population would be expected to fare worse; in fact, both the raw and age-adjusted rates reflect the improvement. In just the single past year, deaths due to heart disease dropped 5.5%; strokes, 6.4%; hypertension, 5%. The list goes on. But the media loves negativity and too many advocacy groups have a vested interest in (manufacturing and) peddling a mileau of health threats.
Just a month ago, a prestigious research team published another analysis of federal health outcomes statistics in a well-regarded, peer-reviewed journal examining the comparative health outcomes of Americans choosing low-salt diets compared to those choosing diets unchanged in the amount of salt customarily used over the past century. Mortality in the low-salt group was much higher. Low-salt diets didn't deliver promised benefits; they even may add risk. This wasn't news either. The data undermined the crisis advocates' politically-correct intervention.
We need to get beyond the rhetoric and look at the facts, the data. Clearly, the view through the prism of the media and at least some public health advocates is preventing us from focusing on evidence-based policy decisions.
