It was personally deeply disappointing to read the publication today by my respected, esteemed, even revered think tank, the American Enterprise Instittute (AEI) of a superficial review of the salt and health controversy. Research assistant Sara Wexler properly concluded that FDA regulation of salt was a blind alley, but, instead, she urged "low-sodium campaigners (to) focus their efforts on consumer demand."
This was "think tank lite" at its worst. Both the facts and the analysis were flawed. In fact, the entire article was written to address the wrong problem altogether. This is a worthy subject for a serious AEI analysis, but this wasn't a serious AEI analysis in the proud tradition dating back to Murray Weidenbaum and Chris DeMuth. A sad day.
Where to begin? Let's start with a few facts.
Wexler states the Salt Instittute (and Grocery Manufacturers Association) "have called for voluntary sodium reductions instead of federal regulation." I'll let GMA speak for themselves. The Salt Institute feels that patients should follow their doctors' advice on dietary sodium, but we strongly oppose a general recommendation for sodium reduction. Wexler continues, accurately, to report that the Salt Institute, GMA and the International Food Information Council have concluded that the medical evidence shows "the direct impact of sodium reductin on human health is still unclear." True. That's why we oppose it. Why would we think a "voluntary" program to undertake a major, unjustified health intervention would be appropriate? We don't.
Wexler conflates "blood pressure" and "health risks" regarding dietary sodium. Experts agree salt is related to blood pressure and, indeed, as reported, research at the University of Indiana shows that in a strong majority of people', their blood pressure is unchanged on a low-salt diet while a significant minority actually increase their blood pressure and more has the "desired" fall. But experts do NOT agree that evidence shows that reducing dietary salt actually improves health. In fact, most of the health outcomes studies find no benefit at all and several have found possible risks when people cut back salt. That said, Wexler correctly reports the Salt Institute's support for improving overall dietary quality to improve risks.
Wexler points out there is "confusion" on the issue, but she states that "(t)he biggest problem for industry groups seems to be the lack of adequate demonstrative studies." That's just wrong. First of all, the problem isn't an "industry" problem, it's a "health" problem. The prospect of imposing billions of dollars of additonal cost on American food consumers is not the issue here (though legitimate), the question is whether evidence shows that the proposed major re-engineering of the American food supply has any scientific justification and whether the intended benefit will be sacrificed to unintended consequences. The "confusion" isn't with the evidence. The confusion is caused by those who persist on ignoring the evidence of a lack of a health benefit and suggesting that the "industry" should fund the research to document the government's policy. As an aside, HHS has stonewalled release of key data at every step and fought an attempt by the Salt Institute and the US Chamber of Commerce to force transparency in the process.
Wexler implies FDA's regulation awaits a determination of "(w)hether or not sodium can be linked to high blood pressure." We certainly hope not. And all Americans should hope that FDA should not consider regulations in this area until it can show that 1) reducing salt will improve health and 2) regulating the amount of sodium in individual foods will reduce overall dietary sodium intakes sufficient to achieve a health benefit. Neither has been shown. That's why the US Preventive Services Task Force has concluded there is a lack of evidence for a general salt reduction recommendation.
Wexler seems to consider salt to be just another nutrient, like fat, carbs and sugars, ignoring the fact that it is an essential nutrient necessary for life. As such, the body has redundant systems to ensure an appetite for salt, as discussed as recently as this month's Experimental Physiology and discussed in our blog by both Mort and me . What this suggests is that "consumer demand" will never be the answer.
We won't get the right answer until we start asking the right question: Will a low-sodium diet improve health? We may need to go no further. HHS should fund the controlled trial of this question that will answer this serious question.
Wexler's once-over-lightly piece is fluff. We expected more from AEI.
Less than 20 percent of U.S. adults with high blood pressure eat foods that align with government guidelines for controlling hypertension, a recent study found .
This outcome is no great surprise. The American Heart Association (AHA), the American Medical Association (AMA) and the National Heart Lung and Blood Institute (NHLBI) have all deliberately mislead the public by spinning the results of the DASH-Sodium trial to indicate that most of the blood pressure benefits were the result of salt reduction. It is hard to say if this myth-information was the work of specific individuals within these organizations or the organizations themselves. What is critical, however, is that these organizations have not lived up to their responsibilities and barely promoted the importance of the DASH- or Mediterranean-type diet in reducing cardiovascular disease. Instead, they have adopted the magic-bullet, single nutrient approach and almost exclusively promoted salt reduction as the dietary approach to improve cardiovascular health. That is why so few U.S. adults now follow the DASH diet.
It is time that the credibility of these organizations comes under far greater public scrutiny. The recent disasters of hormone replacement therapy and the disasterous strategy to aggressively drive down blood sugar in diabetes patients are clear examples of our medical establishments doing harm with ill-considered policies and information.
The following graph encapsulates the results of the DASH-Sodium trial:
It is immediately apparent that moving from a regular U.S. diet (blue line) to a DASH-type diet (red line) has a far greater impact on blood pressure than lowering salt consumption. On the regular diet, dropping from the current level of sodium consumption to the recommended daily level of 2,300mg Sodium/day dropped the systolic pressure by an average of 2.1 mm Hg (mercury). However, changing from a regular U.S. diet to the DASH diet, without any changes to sodium consumption, reduced the systolic blood pressure by 5.9 mm Hg, almost three times the drop resulting from the sodium reduction! There is no equivalency here. The move to a DASH diet far exceeds the benefits of salt reduction - there is no comparison. This clearly explains why Mediterranean people enjoy an excellent cardiovascular status despite their high salt consumption, as mentioned in a previous article . With a DASH diet, the impact of sodium on the blood pressure of hypertensives is minimal (and is of no significance to normotensive people - the majority in the population). On top of that, the DASH- or Mediterranean-type diet has myriad other health benefits aside from reducing blood pressure.
Yet, the AHA, the AMA and NHLBI always spin the data to place the majority of the benefits on salt reduction first and then the DASH diet, almost as an afterthought. In lock step, the Center for Science in the Public Interest (CSPI) repeats this in much the same manner.
What a pity that people take their advice!
No wonder we see headlines like, "Not many follow anti-hypertension diet " or "Fewer hypertensives adhering to DASH diet " or "Most With High Blood Pressure Do Not Follow Recommended Diet ". AHA, the AMA and NHLBI must all share in this predictable consequence of myth-direction.
