Yesterday's Politico had an interesting article suggesting "A lesson for Obama from the other Roosevelt ." Bush White House aide Daniel M. Price extracted a quote of Theodore Roosevelt from historian Edmund Morris' TR biography, Theodore Rex . Roosevelt responded to a journalist who suggested that popular opinion favored nationalizing American railroads instead of Roosevelt's tack of increasing regulation; TR said:
Here is the thing you must bear in mind. I do not represent public opinion: I represent the public. There is a wide difference between the two, between the real interests of the public and the public’s opinion of those interests. I must represent not the excited opinion [of some], but the real interests of the whole people.
A parallel leapt to mind, probably because I spent yesterday in a meeting with medical scientists and nutrition experts. Many public health nutrition groups and the federal government have used "expert consensus" as an argument to support a public policy of encouraging everyone to eat less salt. Expert opinion mirrors public opinion in this case; the federal government has spent tens if not hundreds of millions of dollars "educating" the public and public opinion is that dietary salt is consumed in "excess" amounts. As in TR's apt distinction, however, there is a "wide difference between this expert/public opinion and the public's true interest.
The public cares about improving health. It cares about the quality of the evidence underlying public policy. And for good reason: physiology trumps expert opinion. Whether the experts get it right or not, the body is going to do "its thing" by responding to changing conditions. So it is with the science concerning dietary salt.
While some groups prescribe salt reduction, the inventors of "evidence-based medicine," the Cochrane Collaboration , finds insufficient evidence to recommend a population-wide lowering of dietary salt. The Cochrane Review, "Advice to reduce dietary salt for prevention of cardiovascular disease ," concluded: "There was not enough information to assess the effect of these changes in salt intake on health or deaths."
Policy should reflect the needs of the public, not public opinion. However that may play out in President Obama's efforts to stabilize the U.S. financial system, it's a sound prescription for healthy public nutrition policy.
In a new editorial commentary published today by the American Heart Association , John B. O'Connell MD points out that the AHA's new guidelines for managing heart failure patients are "eminence-based," not evidence-based. Nice turn of phrase, that.
It turns out that the guidelines include 24 recommendations. Only one is level of evidence A. O'Connell continues:
Although some have called such recommendations "eminence-based," until there are randomized controlled clinical trials to justify the recommendations, the quality of expertise on the panel and their collective experience justifies consensus recommendations.
The increased focus on quality of evidence underlying recommendations is refreshing, even if it reminds us of just how uncertain are the foundations of many "consensus" recommendations. Certainly salt reduction falls in that category.
Small amounts of a well-known white powder should be ingested daily to prevent coronary heart disease, the federal US Preventive Services Task Force (USPSTF) reiterated in a March 17 article in The Annals of Internal Medicine .
No, the white powder, in this article, isn't salt, it's aspirin. The USPSTF reiterated its 2002 finding that men over age 45 and women over age 55 should take aspirin. The recommendations receive the top "A" grade for strength of evidence supporting the recommendation.
USPSTF does have a recommendation on that "other white powder" (no, not THAT one!) -- salt. USPSTF concludes: "There is insufficient evidence to recommend for against counseling the general population to reduce dietary sodium intake....
That's what USPSTF concludes for aspirin-taking advice when men and women reach 80.
If we believe in evidence-based health recommendations, let's not pick and choose. Let's take our daily aspirin...and our daily salt!
Newspapers and websites around the country are reporting a story coming out of the American Heart Association's Cardiovascular Disease Epidemiology and Prevention annual conference in Palm Harbor, Florida yesterday. Medical researcher Dr. Kirsten Bibbins-Domingo, an assistant professor of medicine and epidemiology at the University of California, San Francisco, reported that if Americans cut just one gram of salt from their daily diet, there would be 250,000 fewer new cases of heart disease and more than 200,000 fewer deaths over a decade.
This dramatic statement was not the result of any clinical trials or observed data but rather the product of a computer simulation called the Coronary Heart Disease Policy Model. Many such statistical models are available and were the subject of a systematic review in 2006. The conclusion of this review stated that
"…few Coronary Heart Disease Policy Models have been calibrated, replicated or validated against minimum quality criteria. Before being accepted as a policy aid, any model should explicitly include a statement of its aims, assumptions, outputs, strengths and limitations."
Despite this, most media devoted to food and health report this study without any qualifications - as if it were fact and not the consequence of speculation and assumption. It's little wonder that in his book "Life on the Mississippi" Mark Twain wrote:
"There is something fascinating about science. One gets such wholesale returns of conjecture out of such a trifling investment of fact."
Over the last number of years we have heard, seen and read about hundreds, of medical breakthroughs and pending calamities that vanished into thin air after a short period, never to be heard from again. Most of these were based on conjectures and assumptions that never panned out, yet, the media, consumer advocates and the medical establishment latched onto them without any reference to the quality of data - as if they were proven fact.
It's a pity that there isn’t a requirement to have all public statements regarding health, conform to a minimum level of evidentiary quality. At the very least, there should be a system established so that consumers will be informed of the level of evidence behind any health-related public statements or claims. After all, the consumer advocacy movement, followed by the medical establishment, was the first to insist on food labels so that consumers would be better informed as to what they were getting for their money. Why shouldn’t the same sentiment govern the public statements consumers get concerning our health, so that they can judge their value and trustworthiness?
The Salt Institute has long extolled "performance-based" policies. For roadways, "performance management" means policy driven by outcomes measured in terms of safety and reliability in moving people and goods from point A to point B. For dietary salt, we've called for "performance-based" policies driven by health outcomes: a person's salt intake should be driven by the health consequences of that person's dietary salt intake. The goal is safe, reliable and efficient roads and longer, healthier lives.
University of California-Berkeley law professor Stephen D. Sugarman authored an op ed piece in today's San Francisco Chronicle urging what he termed "performance-based regulation" of dietary salt intake. He called for a "cap and trade" system as has been widely debated as a means of curbing America's carbon emissions.
Sugarman should stick with law. He clearly doesn't understand physiology, economics or history.
His argument goes off-track early when he posits that consumers are helpless victims of food processors. To him, consumers are unable to determine how much salt they're eating despite widespread use of nutrition labels. Since a major portion of the salt Americans ingest comes from processed foods, the clear answer for Sugarman is to regulate salt consumption by "imposing financial penalties" on food manufacturers. Specifically, "we could demand that large retailers cut the total amount of salt in food they sell." Retailers like Wal-Mart would then demand "its food providers to reduce the salt they add to their products, reducing the volume of salty products it sells (by raising the price, providing smaller or less attractive shelf space), introducing and promoting less-salty or salt-free alternatives, given Wal-Mart customers more information about the salt they're consuming, and more." Trouble is: that's hardly creative. That's what's happening now here in North America and in the UK. And it's not working.
Food procesors have used a "stealth" approach to paring back the salt content of food products. They put their salt alternative products at eye level on grocery shelves and relegate "round cans" to shoetop shelves. They've introduced an enormous array of "low-salt" or "salt free" products. They've provided consumer education materials going far beyond federally-mandated nutrition labels. And they've watched as salt intake continues unabated.
The problem lies not with the food manufacturers, but with the customers. And customers "know" they want to cut back on salt. Some assiduously count milligrams of sodium towards a target based on a "daily reference value." To no avail. Why not? Physiology. Economics. History.
Human salt intakes are unchanged over the past century. When humans have access to salt, they consume it in a predictable and fairly narrow range of about 2,300 - 4,600 milligrams sodium a day. We know this because for many years medical scientists have studied various health concerns and routinely extracted 24-hour urine specimens. Those numbers and unchanged over many decades. Nor are humans unique: livestock and poultry, like humans, need salt to live and each species has developed its own predictable, narrow range of intakes -- the phenomenon is well understood by animal nutritionists.
Why it should be so has been more elusive, but even that conundrum is yielding to scientific assault. A February 2008 Experimental Physiology article on "Central regulation of sodium appetite " explains how our brains control salt intake. Appetite is what counts. Not taste. Not politically-correct menu choices. Not even the cost or quantity of the food. Americans eat a diet far less dense in sodium compared to calories than they used to -- perhaps because consumers have the tools and the motivation to try to reduce salt. They just cannot behaviorally control a hard-wired, neurally-mediated appetite. Sugarman suggests food manufacturers and retailers can "reduce the flow of slat in ways that best satisfy consumer preferences." But all "preferences" are not conscious choices. Salt appetite is not a conscious consumer choice.
Thus, the economics is all wrong. "Demand" is not elastic at all. It's fixed. You can reduce the amount of salt per serving and all that you'll produce is consumption of more servings. Taxing Wal-Mart for the amount of salt it sells would be impossible to control; would you have Wal-Mart tell its customers to buy their food elsewhere because they had used up their allotment?
And history gives no comfort either. Recognizing this inelasticity of demand -- the physiologic requirement expressed as salt appetite -- many countries throughout history have monopolized the salt trade and taxed it heavily. The French gabelle triggered the bloody French Revolution. China's imperial salt tax funded much of the country's rule, from dynasty to dynasty. India won independence in no small part based on Gandhi's adroit exploitation of indefensible British "protection" of salt production.
Sugarman admits he has no idea how much cutting salt would lower blood pressure. Of course, that's the wrong question. If he's interested in "performance" it's not blood pressure by health outcomes he should be championing. He says he seeks "a big step in a healthier direction, and performance-based regulation is the most promising way to get there."
We agree, Mr. Sugarman, but you need to learn a bit more about what performance really means. A performance-based intervention would improve health. Salt reduction won't.
Sanitary and phytosanitary measures are applied to protect human or animal life from risks arising from additives, contaminants, toxins or pathogenic organisms in their food. The World Trade Organization (WTO)
Agreement on Sanitary and Phytosanitary Measures (SPS)
restricts the use of unjustified measures for the purpose of trade protection.
The aim of the SPS Agreement is to ensure that regulatory measures are not misused for protectionist purposes and do not result in unnecessary barriers to international trade. In particular, measures to protect health must be based on the analysis and assessment of objective and accurate scientific data. Standards are developed by leading scientists in the field and governmental experts on health protection and are subject to international scrutiny and review.
If national requirement results in a greater restriction of trade, a country may be asked to provide scientific justification. The Agreement checks unjustified discrimination in the use of sanitary and phytosanitary measures, particularly if they are in favour of domestic products. In a trade dispute regarding a sanitary or phytosanitary measure, the normal WTO dispute settlement procedures are used, and advice from appropriate scientific experts can be sought.
If regulations are set arbitrarily, they could be used as an excuse for protectionism. The Agreement on Technical Barriers to Trade tries to ensure that regulations, standards, testing and certification procedures do not create unnecessary obstacles and are based upon sound scientific information. Because a large portion of dietary sodium enters the food supply through processed foods, sodium reduction programs in the UK and Canada are directed at reducing the salt content of these products. While most consumers and policy-makers perceive processed foods to be convenience foods made by large scale manufacturers, a great many well-known traditional foods customarily considered to be high quality, healthy products are also processed and contribute significantly to the dietary sodium we consume. Examples of such foods can be found in the range of epicurean foods imported from Italy, for example. Hard cheeses such as Parmesan and Pecorino ; semisoft Sardos and softer blue cheeses such as Gorgonzola ; olives, anchovies and capers; Parma ham, smoked prosciutto and Italian dry-cured salamis and sausages and Baccalà (salted cod) all have been traditionally produced for centuries. They are all known internationally and are produced to exacting standards of identity.
These traditional Italian foods have a high salt content that has characterized their quality and international acceptance. In a personal comment a senior US FDA staff member once made to me, he indicated that for close to a century, all imported ham from around the world had been analyzed for Trichinella spiralis infection and Parma ham was the only product where this infection was never detected. He attributed this fact to the salt levels used in traditional Parma ham production. For more than 350 years, Parmesano Reggiano, considered to be the King of Cheeses , has been artisanally made by small manufacturers in the Parma region. They are so tied to tradition that they still measure the products temperature by the Réaumur scale - a temperature scale developed during the Renaissance period that stopped being popular elsewhere by the end of the 18th century. To cure their fresh cheese, they immerse the huge rounds in saturated sea salt baths (some of which have been in continual operation for more than 100 years - you can see beautiful 4-5 inch wide salt crystals sitting on the bottom of these crystal clear baths). The only changes these manufacturers have made in the process during the 20th century was to convert to sophisticated digital temperature controls (still using the Réaumur scale) and to use more expensive recrystallized sea salt to improve the products’ flavor.
Although these specialties are staples in the Italian diet and are high in salt, the Italian population continues to have amongst the very best cardiovascular statistics in the world. In fact, the per capita consumption of salt in Italy and other Mediterranean countries is considerably higher than in North America or the Northern Europe, yet their cardiovascular performance is far superior.
If, in the course of executing a sodium reduction program, such as we currently see in Canada and the UK, restrictions are placed upon the salt contents of classes of foods, many of which may have long-established standards of identity, such an action may be perceived by exporting countries as an artificial technical trade barrier and institute a dispute settlement procedure at the WTO. For example, an exporting country, such as Italy, may well claim that it was never conclusively demonstrated that, for the majority of the population, salt reduction has any significant health benefits. In such an argument, Italy can point to its own excellent cardiovascular performance as proof that higher salt consumption does not have any negative impacts on health.
Such a dispute would likely be adjudicated by FAO (Food and Agricultural Organization of the United Nations) an institution that routinely relies on risk assessment criteria drawn from the broadest base of scientific information. This review would not be restricted to the impact of salt on blood pressure alone, but would extend far beyond to cover other health biomarkers and risk factors as well. In carrying out this review, the FAO convenes a panel of experts that are chosen for their objectivity and expertise in making evaluations based on the preponderance and quality of scientific evidence.
During an open session of the Canadian Multi-stakeholder Working Group on Sodium Reduction held in Ottawa on February 19, I described every aspect of the salt and health debate that such a working group would analyze. It was clear to the assembled audience, that if a thorough and objective analysis were carried out on all the data available that the panel of experts would overwhelmingly conclude that salt reduction in the food supply will be a strategy destined to failure and, worse, that it may hold the potential for unintended consequences that may cause harm to a significant portion of the population. We have seen this all before when consumer advocates and the medical establishment put the fear of fat into the minds of the public. In short order, the market was swamped with every form of no fat and low fat foods imaginable a phenomenon considered by many to have ushered in the current epidemic of obesity.