A study just published by the Journal of Agriculture and Food Chemistry reports on the role of broccoli as a cardioprotector. Broccoli contains high concentrations of selenium and glucosinolates, especially isothicyanate sulforaphane. Both selenium and sulforaphane are shown to protect the heart and the cardiovascular system. Sulforaphane induces the redox regulator protein, thioredoxin, which has a cardioprotective role by reducing oxidative stress.
A clinical study reported that eating fresh broccoli sprouts for a week lowered serum low density lipoprotein levels and a prospective study in Iowa showed a strong association between broccoli consumption and a lowering of the risk of coronary heart disease.
As reported earlier Ohio State University has recently completed organoleptic research indicating that the majority of individuals in three age groups (children, teens and adults) are most likely to eat broccoli when allowed to add sufficient salt to overcome broccoli's natural bitterness.
Here is a clear case of salt indirectly contributing to better heart health.
It is with some dismay that we saw the headline on the UK Food and Drink Federation website, "Salt: Brits Bought 2,000 Tonnes Less in the Past Year ." The article was timed to coincide with "Salt Awareness Week " sponsored by CASH (Consensus Action on Salt and Health) and described the "staggering reduction" in salt consumption which they attributed to the food industry's ongoing efforts to reformulate products to lower salt levels. The staggering reduction amounted to 0.3% which brought forth criticism from CASH chairman, Graham MacGregor, who said
- a fitting rebuttal to an industry that buckled under instead of insisting on food and nutrition policies based on science rather than politics.
It is interesting to note that neither CASH, the UK Food and Drink Federation nor the Food Standards Agency have ever asked that a legitimate health outcomes metric be put in place to show the health benefits to consumers of reducing salt consumption. Are they even interested in measuring the health benefits? Or will they simply follow the example of Finland and reduce salt consumption, then wait a decade or two to find out that their health benefits were reduced? Finland waged a 30-year battle to reduce salt consumption only to discover that there was no health benefit associated with it - on the contrary, their health outcomes performance was not even on a par with their neighbors that did not reduce salt.
The theme of CASH's National Salt Awareness Week , 2008 is Salt and Children. Despite the fact that the most recent National Academy of Sciences Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2004) stated:
"Overall, available evidence on the effects of sodium reduction on blood pressure in children is limited and inconsistent. Hence there are insufficient data to directly set a UL based on expected blood pressure change ."
CASH insists on making reduction recommendations for children. This sort of myth-information based upon statistical manipulation has been commented on earlier.
As was highlighted in a previous article , it is hoped that one day this seemingly inexorable march to misguided policies will halt, so that this issue may be managed by rational thinking and scientific evidence.
I recall an old colleague of mine in the United Nations who kept a sign on the wall behind his desk,
"Don't Just Do Something, Stand There!"
It was his way of trying to get people to think things through thoroughly, before rushing headlong into an intervention.
Legislation on food labeling , recommendations on Daily Values and the Dietary Guidelines are all examples of interventions that would have benefitted from my friend's advice. About the only thing that everyone can agree upon is that they are all largely ineffective and hold scant benefit for the consumer.
In a recent article entitled, "A Call for Higher Standards of Evidence for Dietary Guidelines," Am J Prev Med 2008: DOI: 1016/j.amepre.2007.11.017., authors Marantz, Bird and Alderman make the case that with their weak standards of evidence and tendency to focus on individual nutrients, the national dietary guidelines might actually do consumers a lot more harm than good.
As an example, they used the guidelines developed against the consumption of dietary fat, promulgated in the late 1970s. The authors noted that people were inadvertently led into believing that if they limited their fat intake, they could then go ahead and pig out on carbs - a phenomenon which may have contributed to the current epidemic of obesity and overweight in the U.S.
The flaw in reasoning was that no one believed that the guidelines could cause any harm, therefore only the weakest evidentiary support was needed to promulgate them. Indirect evidence, expert opinions and scientific "reasoning" were the main drivers of the guidelines. After all, they were only guidelines - what could be so bad?
In fact, once published, they took on an aura of credibility that far exceeded any scientific justification. Once promulgated and given the blessing of the medical establishment and the government, they were looked upon by the public, by the media and by teachers no differently than if they had been irrefutably proven by the most rigorous scientific experimentation. And government guidelines don't simply affect one or two of us - we are all influenced by government guidelines.
The authors write that in 2000, the Dietary Guideline Advisory Committee reversed an earlier 1995 recommendation to lower fat intake, indicating that it may have been premature and ill-advised. The Committee stated that "an increasing prevalence of obesity in the United States has corresponded roughly with an absolute increase in carbohydrate consumption."
Marantz et al also point to the advice given on salt intake as another example of the unintended consequences of a seemingly innocuous recommendation, noting that any blood pressure benefits may be trumped by the stream of harmful effects on plasma renin, insulin resistance, sympathetic nerve activity, and aldosterone levels. They further point to a recent finding of no difference in total mortality between randomized sodium-intake groups.
The authors final conclusion for a dietary guideline recommendation reminded me of my dear old friend;
"When adequate evidence is not available, the best option may be to issue no guideline."
Is desire clouding our objectivity or is there an emerging recognition that politically-correct medical science is imposing huge costs on our healthcare system? Junkfood Science led off this week with further coverage of the ethically-compromised ENHANCE trial, asking: "How much more are we spending for medications due to excessive mark-ups, but also for medications that may not provide the clinical benefits they purport?"
Blogger Sandy Szwarc revisits earlier posts (covered by our blog ), pointing out that reliance on a flawed process. We agree. Ignoring evidence-based results as has the U.S. Dietary Guidelines, produces scientifically-flawed recommendations. Just a glimpse of her perspective (which we heartily share):
Amidst all of the congressional hearings and media notice, and amidst the recent infestation of shark lawyers filing class-action lawsuits across the country over alleged cover-ups of the ENHANCE trial results, we mustn't lose sight of the far greater issue in all of this:
"The integrity of the scientific process ... in how drugs are researched and approved, and clinical guidelines are developed." JFS began covering the ENHANCE clinical trial issue last November . This trial provided an opportunity to examine the importance of randomized controlled clinical trials, the gold standards of evidence-based medicine. Sound trial designs that are fair tests include randomization; double-blinding; a placebo control group; control of study data and analysis of study data by bodies independent from drug company sponsors; and primary endpoints that are actual clinical outcomes, such as reduced premature deaths, versus false surrogate endpoints.
On January 17th, "How'd we get here ?" described the foundations of clinical trial evidence for drugs approved by the FDA that have been abandoned, and called into question the use of surrogate measures, like cholesterol, as proxies for actual clinical benefits to lives. When surrogate endpoints are used in order to expedite R & D for new drugs, post-market clinical trials are supposed to follow to provide the FDA evidence that these markers are valid and that the drugs actually save lives. But those studies never seem to come.
… Perhaps this hubbub will lead everyone to question their own assumptions and fears about health risk factors and to look closely at the evidence on cholesterol lowering for prevention of heart disease and whether it extends lives. Perhaps this hubbub will lead everyone to question their own assumptions and fears about health risk factors and to look closely at the evidence on cholesterol lowering for prevention of heart disease and whether it extends lives.
Our issue, of course, isn't cholesterol, but the same dynamic is playing out in the great salt debate. Let's keep the focus on the real issue: will reducing dietary salt improve health? Perhaps we can then realize the health improvements we deserve for the enormous investment society makes in our healthcare system.
Although the headline of today's Wall Street Journal misleads readers into thinking it focuses on blood pressure, WSJ blogger Shirley S. Wang makes it clear that her focus is on whether new medications "prevent heart attacks and death any better than an old-fashioned diuretic." Referencing a new report about the ALLHAT study in the Archives of Internal Medicine , she calls for a focus on the health outcomes of various interventions.
I responded for the salt industry:
ALLHAT was an important step for another reason not yet discussed in this thread: rather than focus on the "risk factor" of blood pressure, it addressed the truly important question of whether the intervention (in this case anti-hypertensive drugs) achieved the expected health outcomes benefit. Too often we've confused "risk factors" with absolute risk. It is the event -- the heart attack the stroke, i.e. cardiovascular health and mortality -- that should concern us individually and be the focus of our public health policy.
I am president of the Salt Institute, the industry association of salt producers. We monitor the medical literature and participate in the public health debate. ALLHAT provides important information to physicians who make recommendations to their patients. Likewise, as an exercise in focusing on the health outcomes of a recommended intervention, ALLHAT is a proper model for our public health decision-making as well. Regarding salt, for example, the question should not be "will salt reduction improve blood pressure?" Blood pressure is the "risk factor" and there are other risk factors (e.g. insulin resistance, plasma renin activity, sympathetic nervous system activity, etc.) which are affected by reducing dietary salt. As in ALLHAT, we should be asking: will this intervention improve health outcomes? Will reducing dietary salt improve actual risks of heart attacks and strokes? Will cutting back salt improve cardiovascular (and all-cause) mortality?
If you think you know the answer, I'd suggest that answer isn't "politically correct" and invite you to review the issue on our website at http://www.saltinstitute.org/28.html or access a comprehensive list of the studies of this question at http://www.saltinstitute.org/healthrisk.html .
We have recommended to the Department of Health and Human Services that it conduct a controlled trial of the health outcomes of reduced-salt diets using the ALLHAT rationale and modeled on a recent study, the Trials of Hypertension Prevention, which demonstrate both the ethics and the study protocol appropriate to determine whether those who encourage general salt reduction are likely to improve public health.
There are many biomarkers pertinent to diet and disease, Roger Clemens and Peter Pressman explain in the January issue of Food Technology . All biomarkers should
"indicate the biological plausibility of a diet-disease relationship, improve the assessment of relative risk, and serve as surrogate endpoints,"
the authors explain. Biomarkers include blood pressure, serum glucose, serum triglycerides. Some are better indicators than others. There is a "critical need for markers that distinguish the clinically meaningful stages of … pathology," they state, decrying the "simplistic model" that fails to predict outcomes accurately. They warn:
"The food industry, in its effort to provide more-healthful choices in the functional foods arena, must consider more-illuminating biomarkers that punctuate the much larger and exquisitely complex constellations o factors representing our emerging knowledge of the progression of disease states.
"As we examine the mechanisms of disease progression and the role of diet in augmenting health, it becomes paramount that we realize fundamental processes. …
"… our task will be ideally to select a biomarker that serves both as intervention target and as "barometer" of intervention efficacy and health status or of disease progression. …
"… we are engaging a clear priority on health promotion and disease risk reduction.
"Along with this movement is the absolute ethical and legal requirement that we scientifically support any health claims …."
Thus, the choice of a marker is key and, they add,
"when specifying a biomarker, it is important to understand how it fits with nutritional exposure or intake, time frame, sampling, specimen collection, storage, the model system under study…, biologic variation, and the analytic quality control."
Unmentioned by Clemens and Pressman is the growing awareness of the inadequacy of blood pressure as a reliable biomarker for cardiovascular risk. Increasingly, we understand that not only are multiple processes and interactions taking place with regard to dietary sodium intake and that individuals vary widely in their response, but that how we attempt to change surrogate biomarkers can be a clear indicator of the result. We need to focus on the hard disease outcomes and then look back to see which surrogate biomarkers offer value predicting adverse outcomes. Until then, take two doses of humility and see me in the morning.
Chicago boasts more Polish residents than Warsaw and now it's hijacking a salty secret from Eastern Europe - salt caves or salt rooms. A recent Chicago Tribune article notes a suburban restaurant featuring a relaxing, spa-like respiratory restorative salt cave inspired by one the owners visited on a trip to Poland - as well "Chicago's first dining room encased in Black Sea salt." The owners also converted one of their salt caves into a small dining room.
Other Chicago-area spa's have salt "breathing rooms" to restore mind and body. Patrons claim "30 to 60 minutes in a salt-covered room can help relieve stress, cure a hangover or even improve respiratory health." Don't miss the video .
The UK Food Standards Agency just commissioned a research contract to study the impact that front-of-pack nutritional labeling has on people's food choices. The goal of this project is to gain an insight into the way in which consumers approach purchasing decisions. Of course, the ultimate goal is to assist consumers in making healthier choices.
The problem is that consumers will be considering labels on individual foods and, as a result, evaluating the merits of products outside the context of the whole diet. The project will look at shoppers' understanding of the main types of front-of-pack nutrition labels used in the UK (traffic lights, Guideline Daily Amounts, and traffic light color-coded GDAs) and how they use them. What the project will not even attempt to determine is how consumers incorporate the front-of-pack nutritional labeling information into the context of their whole diet on a daily basis - which is, of course, the most important change because that is how we derive our nutrition on a daily basis.
The program has the unfortunate potential to focus on the means of communicating information and bits of data while ignoring the greater importance of perspective and context. In other words it has the potential of ignoring the forest by focusing on individual trees.
As an example, a consumer could come across a mayonnaise, or a salad dressing preparation which, by itself, would require a red light on the label. If, however, that dressing encourages the consumer to eat a serving or two of healthy cruciferous vegetables, what decision should the consumer make? Avoid the dressing and the vegetables? Certainly not!
But that is a conclusion one might make if the dressing is taken out of the context of the whole diet. An unintended consequence resulting from a focus on one tree rather than the forest.
It will be interesting to see the results of this research, which will be hopefully available by the end of 2008.
Often when the decibels rise and the tone turns shrill it's akin to a stock market contrarian's moment of vindication. Sometimes it seems that politically-correct conventional wisdom can never be changed. But it can.
The American Academy of Pediatrics which had been advising mothers of infants with a family history of allergies to avoid cow's milk, eggs, fish, peanuts and tree nuts while breast-feeding has taken a fresh look at the science and updated its advisory conceding that there's no good evidence for avoiding certain foods during pregnancy, using soy formula or delaying introduction of solid foods beyond six months.
So, dogma can be changed. Hang in there, those of you who've joined our seemingly-lonely effort to combat the unscientific demonization of salt.
An Associated Press story quoted Dr. Scott Sicherer of Mount Sinai School of Medicine's Jaffe Food Allergy Institute in New York City, one of the authors of the revised AAP policy statement:
They say, 'I shouldn't have had milk in my coffee. I've been saying, 'We don't really have evidence that it causes a problem. Don't be on a guilt trip about it.'
Of course, for Americans 2008 is a political year with a new president to elect. But while the electorate seems to be tiring of political polarization already, some lobby groups are becoming more assertive. Since New Year's day, the American Medical Association, has displayed a feisty combativeness urging its members to pressure Congress to pursue a path antithetical to the approach recommended by the U.S. Preventive Services Task force and endorsed by the Salt Institute. We'll have to wait and see if the AMA membership supports this campaign or returns to a more science-based approach to public health policy.
The January 14 edition of amednews.com, the AMA online newsletter, editorialized "Time to pinch off the salt " with the explanatory subtitle "The AMA calls on the FDA to revoke salt's 'generally recognized as safe' status to allow more regulation of sodium in food." The editorial liberally quotes AMA vice president for science, quality and public health Stephen Havas, who has almost single-handedly radicalized the AMA strategy on salt restriction.
About the same time, AMA issued a news release, not mentioning salt, but calling for Congress to pursue an aggressive assault on risk factors for cardiovascular disease. The AMA's January 11 release announced:
American Heart Association President Daniel W. Jones, M.D. urged Congress to pass legislation to help Americans control their risk factors for cardiovascular diseases. With obesity, hypertension, diabetes and other risk factors on the rise, the association is calling on elected officials to support measures that focus on research and prevention.
"Risk factors, such as unhealthy weight, poor diet, smoking and diabetes could undercut many of the gains we've made to reduce cardiovascular disease deaths," said Jones, vice chancellor, University of Mississippi Medical Center. "We must ratchet up efforts to convince policymakers that a strong and sustained investment of government resources is essential."
The association's 2008 Health Policy Agenda addresses risk factors through legislation and initiatives that would combat the obesity epidemic, curb tobacco use, particularly among children, increase funding for medical research and prevention and reduce health disparities.
This year alone, cardiovascular diseases will cost Americans an estimated $449 billion in lost productivity and medical expenses. Treatment costs for cardiovascular diseases are expected to rise 64 to 84% by 2025. Stroke treatment alone is projected to exceed $2 trillion by 2050.
While the AMA's specifics are a bit extreme, the concept of extending the effectiveness of "research" and "prevention" enjoys as much support today as "motherhood and apple pie" did of yore. The Salt Institute joins that chorus. We'd add, however, that federally-funded research should be available for independent confirmation and used to support government policy only if findings can be replicated. And, while we strongly support the prevention of cardiovascular disease and its resultant heart attacks and strokes, we are less sanguine concerning prevention of "risk factors" as semantacist Dr. Jones has stretched the term. How do you prevent age, for example, the surest predictor of cardiovascular events and deaths? How about being an African-American, another powerful "risk factor"?
The proper focus of public health policy is to prevent disease, extend life and improve the quality of that life. A focus on "risk factors" presupposes that they can be modified as part of our public health efforts. Some "risk factors" cannot be modified. Others, like "salt sensitivity," as recently as a decade or two ago were thought to be immutable and unchangeable and are now properly understood to be the product of deficiency intake levels of other nutrients, in this case, calcium, magnesium and potassium; correct those deficiencies (as with the DASH Diet) and the "salt sensitivity" disappears. So, the proper policy focus should not be on "risk factors" but on the effectiveness of HOW we try to modify those risk factors .
Again, salt is illustrative. Blood pressure is a risk factor for CV events and mortality. Few would deny that. But HOW blood pressure is modified is what's important, not the raw number itself. Blood pressure is not the disease, it is the symptom, the "risk factor" for CV disease, myocardial infarcts and strokes. Treating the symptom is not prevention. It may even make the underlying condition worse and increase the risk of an event rather than prevent it. That's what we discovered when scientists started examining the question of whether cutting salt (a "risk factor") would yield in actuality the "prevention" benefits predicted by mathematical models such as those used by Dr. Havas and the AMA. It turns out, they don't. In a long string of "health outcomes" studies , no pattern of a health benefit is correlated to diets lower in salt. It turned out that other "risk factors" such as insulin resistance, plasma renin activity and sympathetic nervous system activation were also affected by reducing dietary salt. These "risk factors" increased the risk of salt reduction, proving, once again, that HOW we seek to modify "risk factors" is more important than announcing a campaign focused only on change.
In this political year, we've heard virtually all the presidential candidates call for significant "change." Let's be reminded that the specifics of what should be changed and how it should be changed are as important as lamenting our current situation. That's as true in public health nutrition policy as it is in presidential politics.
Nobody is arguing that we should shift from prioritizing prevention and accept the projected $2 trillion cost of treating strokes, but let's focus our efforts on preventing heart attacks and strokes, not waste our money on "risk factors." Proven interventions identified by the U.S. Preventive Services Task Force specifically exclude general salt restriction as having no proven benefit. The president of the International Society of Hypertension used his presidential address a year ago to make the same point: let's focus on health outcomes, not intermediate "risk factors." That's the way we see it too.
I have never figured out who said "confession is good for the soul," but she was right. And a confession is in order tonight. Four days ago, I succumbed to the very sin I've decried publicly so often in the blogosphere: the sin of bestowing credibility, even endorsing results of a medical study whose conclusions support one's own worldview. It's natural. Understandable. But, sans apology and full repentance, nigh unto unforgivable.
Still, we learn from our experiences. As I humbly recant the ill-considered, cyber-published product of my passion, I hope I can be granted not only absolution, but insight into the difficulty others may likewise be experiencing when jumping quickly to endorse a "politically correct" end result without regard to the quality of the "science" employed to reach that result.
Four days ago I celebrated a new study, declaring with exuberance :
Today's publication in PLoS Medicine of a massive (20,244 persons) 14-year mortality study, showed that four simple interventions -- increasing fruits and vegetables, becoming physically active, not smoking and consuming no more than moderate amounts of alcohol -- increased lifespan by 14 years.
Kay-Tee Khaw et al report that "the trends were strongest for cardiovascular causes." It's time we got serious about promoting the DASH Diet and stopped diverting resources to interventions like salt reduction which have been endorsed by experts but are unsupported by actual scientific evidence.
My enthusiasm and endorsement of the DASH Diet remain intact, but my respect for the Khaw study is gone. Having now read the January 10th post by Sandy Szwarc on her Junkfood Science blog , I am hoist on my own petard. My admonition to "get serious" about the science underlying nutrition recommendations is exposed as pure self-righteous cheerleading. Not to excuse my excesses, but as Ms. Szwarc points out:
Within hours this week, television newscasters, as well as some 500 published articles - for scientists, medical professionals, nursing professionals, business professionals and consumers - were all reporting the same interpretation of this study. The script was provided by the publication's press release: "4 health behaviors can add 14 extra years of life."
Thank you, Sandy, for your very relevant reminder:
Simply making extraordinary statements about a study, however, does not make them true - no matter how much we might want them to be. And who wouldn't want to believe that by doing just four easy things we could add 14 years to our lives?
After reviewing the methodology, Szwarc cuts to the chase:
Their key finding, which has not been reported, was they were unable to find a tenable correlation between any of the health behaviors and mortality: all-cause, cardiovascular disease, cancer or any other cause of death. The relative risks all hugged either side of 1 - null findings. (emphasis in original) …
In other words, reports of higher relative risks associated with not engaging in four healthy behaviors were based on 49 people, 0.2% of the cohort. But the absolute (actual) risk of dying differed only 0.2% between those doing zero and those doing all four healthy behaviors (0.25% and 0.05%, respectively). (emphasis in original)
This is just the kind of book-cooking that we've prided ourselves on exposing here at the Salt Institute. And it stands exposed - at least in this instance - as that proverbial pride that goeth before a fall. Mea culpa. Note to self: pay attention to details. Look at the "p value." Beware author bias. May I learn patience and sympathy for others of you who ascribe authority to a medical study that "sounds right" because it confirms what one is predisposed to believe. May I find the discipline to "walk the talk" and insist to myself as I've admonished others to insist on quality science, eschewing the authors' news releases and the funding agencies' "spin."
Let us sinners go forth together seeking truth.
Almost 30 years after the UN International Year of the Child , 2008 is shaping up to be a banner year focused upon improving the health of our children through the provision of nutritional information and recommendations for improvements to their lifestyle.
It seems a bit odd to be referring to lifestyle improvements for children; after all, don't children do what they've always done?
The lifestyles of children have changed dramatically and most of these changes are not positive for their health. Eating a breakfast bar during the morning bus commute to school is OK but it is not the same as sitting down at the kitchen table, having breakfast and then marching off to school. Playing the Wii game for a few hours a day in front of the widescreen is a lot of fun, but it is not the same as running your heart out chasing a soccer ball. Not the same for a child's mind nor a child's body.
Having a pizza delivered, with double everything and cheese product extruded into the crust might be great to order one night, but unless someone insists that everyone take a 5 km run afterwards, the extra calories have only one unflattering place to go. Do that or something similar a few times a week and you are beginning to talk about some pretty serious caloric and nutrient imbalances.
Maybe referring to children's lifestyle issues is not such a bad idea, after all.
The recent GMA Industry Health and Wellness Report highlights the goal of reducing obesity rates and encouraging healthy lifestyles for children. Not only do children have to be encouraged to pursue a fully balanced diet as shown in MyPyramid , but they should be taught the simple concept of energy balance and encouraged to do far more aerobic physical activity to keep their weight in check and their metabolic processes toned up.
In a recent paper entitled, "Children's diets: looking at the bigger picture ", Charlotte Musgrove, a nutrition scientist at the British Nutrition Foundation in London states that previously, the main focus was to provide enough energy and nutrients to meet the needs of a growing child. However, today there is a stronger emphasis on making sure that children are having a varied and balanced diet, and an active lifestyle. Of particular interest, is the finding that the message to eat at least five portions of fruit and vegetables a day appears to be gaining ground. Although many children are still not consuming the recommended amount of fruit and vegetables, their intakes have increased over recent years. In 2000, children were on average eating only 2 portions of fruit and vegetables a day. One in five children did not report eating any fruit, and three in five children did not report eating any green leafy vegetables over an average week. Between 2001 and 2004, average intakes of fruit and vegetable portions per day increased slightly, with boys consuming 2.5 portions per day, and girls consuming 2.6. Data from 2005 shows the average number of daily portions of fruit and vegetables eaten was 3.1 (for both boys and girls) and there was an increase in the proportion of children eating five or more portions per day (Health Survey for England 2005 ). Good news, but still a long way to go.
Together with the balance of nutrients from the rest of the diet, with physical fitness programs to ensure their bodies are kept in tune and a social environment where they can flourish with support and mentoring, our children will thrive in good health.
Slowly, slowly, we are moving away from the single, silver bullet solutions to children's health problems, because although they seem easy and they have made many rich and famous - they don't work - they never have. Life is just not that simple. It's the whole diet as part of the whole lifestyle that will direct us to good health for our children.
Everything should be made as simple as possible, but not simpler - Albert Einstein
Anyone promoting the addition or reduction of any single nutrient as the key solution to children's diseases is little different from the snake-oil salesmen of days gone by.
The problem is, they sold an awful lot of the stuff.
This week's (January 5th) National Journal cover story, "Data Bomb ," set off reverberations in my mind. The article recounts the release of grossly-misleading data immediately prior to the 2006 Congressional elections that exaggerated tenfold the number of deaths in Iraq; the study fed popular disillusionment with U.S. engagement in Iraq and contributed to capture of both houses of Congress in the elections several weeks later. The study was produced by the Johns Hopkins School of Public Health. The researchers, it turned out, were anti-war activists, though they claimed their errors didn't reflect their political views.
Bad memories. Six years earlier, researchers from the Johns Hopkins School of Public Health published misleading statistics in the DASH-Sodium trial - and refused to release further statistical calculations that would likely have unmasked their charade. Again, the Johns Hopkins researcher was an activist, a member of the lobby group World Action on Salt and Health (WASH). Again, the incompletely-reported and misleading research was instrumental in an important policy decision - to establish a Daily Recommended Intake level for sodium and a Dietary Guideline supporting reduced salt intake. Even worse, this time, despite the incontrovertible conflict represented both by his WASH lobby group membership and heavy involvement in the research itself, the researcher was installed as chair of the DRI project committee and the Dietary Guidelines subcommittee where he blocked consideration of the full data from the study.
Putting the National Journal aside, I plunged into an editorial in the journal of another advocacy organization, reading an editorial entitled "Eat your fruits and vegetables, but hold the salt ." The editorial writer acknowledged his funding support from the same federal agency that had funded DASH-Sodium for a study he has underway exploring the effects of the "DASH Diet" on individuals with isolated systolic hypertension. I expected little comfort, but hoped that, perhaps, the editorial would confess the over-interpretation of the results (as had an earlier article in 2005 where a DASH-Sodium investigator revealed that in six of the eight subgroups - subgroups that represented a large majority of the public - the reported findings were statistically insignificant even though the authors described them as valid.
All these discussions of DASH-Sodium have attempted to portray the DASH Diet as salt-reduced and demonstrating benefit from lower sodium intakes. This has been frustrating to those of us - including the salt industry - who have strongly endorsed the DASH Diet because it does not reduce salt and the blood pressure effect is produced by the fruits, vegetables and dairy products - not the salt. But the federally-funded PR juggernaut rolls on.
In the editorial, Dr. Paul Conlin of Harvard University's Brigham and Women's Hospital, indeed, endorsed salt reduction and noted a study of blood pressure in chimpanzees supported increased intakes of fruits and vegetables, two of the triumvirate of "good" foods in the DASH Diet. But note the caveats Conlin incorporates into his conclusions:
Elliott et all have provided new information, albeit in chimpanzees, showing that long-term salt restriction in the setting of a diet rich in fruits and vegetables produces sustained reductions in blood pressure. These data are relevant to humans but should be approached with caution and respect for the sample size, the lesser effects when adjusted for key factors, and the inability to add knowledge on the health and/or cardiovascular benefits of salt restriction beyond blood pressure lowering. Major next steps include …confirming that eating such a dietary pattern provides unquestioned health benefits. (emphasis added)
Last year, other WASH advocates took an important step forward in conceding the validity of health outcomes measures instead of controversial statistical extrapolations based solely on blood pressure (ignoring other metabolic changes that occur in salt reduction). As one observer sagely observed, their embrace of health outcomes in a Finnish study "backfired" when the data showed that improvements in Finns' cardiovascular health lagged their European and North American peers. Still, anti-salt advocates have claimed it would be "immoral" to ask study subjects to consume "normal" levels of salt since they "know" it is unhealthy. The Conlin editorial cedes the point, admitting that such a study is not only feasible and moral, but needed to "add knowledge on the health and/or cardiovascular benefits of salt restriction beyond blood pressure lowering" and confirm "that eating such a dietary pattern provides unquestioned health benefits." Those benefits - projected to be improved cardiovascular outcomes like less heart attacks and cardiovascular disease - have not been confirmed in the several studies that have examined them.
The Salt Institute has called for a controlled trial of whether there is any health benefit from reducing dietary sodium. Now, even those who support salt reduction for blood pressure lowering are beginning to see that this isn't the right question and are embracing our view of the need for a new study.
Perhaps those bad memories of incomplete data reporting by Johns Hopkins' researchers can, indeed, be relegated to history and not the basis of public policy.