On January 11 of this year, you announced an ambitious program dubbed the "National Salt Reduction Program." This program was patterned after the Food Standards Agency salt reduction program in the UK, which you characterized as a success. Considering the economic, social and infrastructural problems that New York City faces, you clearly believe that a population-wide reduction of salt intake is a very high priority issue. Yet, the issue of population-wide salt reduction remains deeply mired in controversy. The majority of meta-analyses on the subject do not conclude that population-wide salt reduction is warranted. Some even state that there may be an unintended consequence resulting from such an action.

As you are so devoted to this program, I believe that you should have an opportunity to openly demonstrate the depth of this commitment. It would certainly not be the first time that political leaders have stood up to demonstrate the courage of their convictions. In 1991, in an effort to stave off international criticism regarding Peru's polluted fishery, President Alberto Fujimori dined on local ceviche in front of news cameras to demonstrate his faith in the quality of their fish. It is of no consequence that he came down with cholera the next day - the important thing is he had the courage to stand up for what he believed in.

As a public leader, I feel that you should have the same opportunity and hope that you would demonstrate the same degree of courage. I propose that you go on a 1,500 mg sodium/day diet, as recommended by the CDC and I will maintain my 3,500-4,500 mg sodium/day level for a full month. During that time, we should have our blood chemistry (renin, aldosterone, cortisol, etc.), blood pressure, arterial pulse wave velocity (a measure of arterial stiffness) and urinary sodium levels checked weekly. I would further invite Drs. Larry Apell, Chairman of the Dietary Guidelines Sub-Committee on Electrolytes and Michael Jacobson of the Center for Science in the Public Interest, two individuals who have repeatedly stated that humans do not require more than 500 mg of sodium/day to join in this demonstration by consuming that 500 mg sodium/day for one month as well and undergo the same tests.

Finally, I propose that Dr. Mehmet Oz use his good facilities to manage the clinical tests and report the results on his television program.

Mr. Mayor, I have no doubt that you wish to do what is right. I do as well, however, we are operating from a totally different set of peer-reviewed data. A task as simple as the one I suggest may well resolve this issue to everyone's satisfaction and will set the salt and health debate upon a course that should benefit all citizens.

Yours sincerely,

Morton Satin

Technical Director

Salt Institute

Alexandria, VA 22314

This year has brought an avalanche of salt reduction papers in the medical journals, together with supporting editorials and letters from well-known and influential anti-salt activists. The effort appears to have been coordinated and I would not be at all surprised if WASH (World Action on Salt and Health) and CSPI (Center for Science in the Public Interest) were associated with it.

The rather odd thing is, despite all the published text calling for stronger regulatory action to reduce salt due to all the projected morbidity, mortality and health care costs this would result in, not a shred of actual new evidence was published. The papers published were simply statistical models based upon evidence we know was highly flawed. Obviously, the laudatory op eds and letters that followed were more a show of desperation trying to shore up the flimsy house of cards.

I sent a letter to the Annals of Internal Medicine criticizing the current state of affairs, where leaders in public health policy appear to have become so political that they no longer demand evidence to develop public policy. It is a sorry state of affairs when academics resort to statistical models with fancy nine dollar words instead of simply going out and getting the data which is easily available. The letter can be seen here . Scroll down the page to the letter and click the "more" link to see the full content.

Caught up in this frenzy of scientific folly and compulsion to regulate, New York Assemblyman Felix Ortiz introduced Bill A10129 stating that no restaurant should be allowed to add salt to the food they prepare. I blogged this item and he is apparently rethinking his position coming out with the inevitable statement that he was totally misunderstood by all – that’s not what he meant…..he really meant…..not too much salt…..maybe not on Tuesdays or Thursdays…..only at Happy Hour……or no more rice in the salt shaker…… or something equally stupid!

In fact, Ortiz was highly criticized by Bloomberg for his bill with Bloomberg saying he was only working with manufacturers to gradually reduce salt over time. You know, “slowly, slowly, catchee monkey.” That way no legislation has to be developed and if it all goes south and people start exhibiting signs of cardiovascular illness, metabolic syndrome or stress or reduced cognition or alzheimer’s (all possibilities described in the medical literature), then no one has to take responsibility for it. He can simply say “We were only suggesting salt reduction – it was the industry that actually did it!”

Years ago, when “GAO” stood for “General Accounting Office,” that arm of Congress focused its reviews on how well government agencies were spending taxpayers’ resources. A new GAO report suggests FDA should expend more resources on substances earlier determined to be safe, some, like salt, of proven safety since before the founding of FDA or even the founding of the United States. GRAS has been a prime achievement in wise use of taxpayer monies in that it has allowed the agency to accept substances in foods which had been used safely for centuries, enabling FDA to focus on substances with unproven food safety.

Salt was the original, archetypical GRAS substance.

No one should doubt the safety of salt. The petitioners would have FDA regulate the amount of salt allowed in each serving of food. There is no evidence that this would produce either of the benefits the petitioners assert. No studies have been done that show that those consuming diets incorporating low-salt foods result in lower overall salt consumption. Evidence shows that salt appetite responds to an individual’s physiologic need. Neither is there any controlled trial of whether diets lower in salt or sodium produce better health outcomes. Nearly every one of the few studies that have been done show either no benefit or even increased risk. In fact, the two controlled trials reported to date both show worse outcomes for those on lower sodium intakes.

GAO should go back to serving the taxpayers in assessing whether government agencies are using good judgment in prioritizing limited resources on real problems. The GRAS status of salt is a PR sideshow unworthy diverting FDA from its vital mission of ensuring the safety of America’s food supplies. GAO would be well served to ask why NHLBI continues to fund PR-oriented studies offering computer models of blood pressure impacts of low-salt diets when that question is well-studied and by NHLBI continues to frustrate efforts, including those of the 2005 Dietary Guidelines Advisory Committee, to have the federal government conduct a meaningful controlled health outcomes study of whether lower sodium diets would improve public health. Until that study is done, FDA is right to prioritize its resources to questions where evidence suggests the public will get better bang for its buck.

It remains hard to believe, when the daily newspapers are screaming for action to curtail population sodium intakes, that until this month, only one controlled trial has ever examined the actual health outcomes of salt reduction . Sure, we've seen computer models based solely on blood pressure projections that predict fewer heart attacks and lower cardiovascular mortality. But this fantasy has been "mugged by reality" as the data begin to appear in the peer-reviewed literature.

This month's Clinical Journal of the American Society of Nephrology published the results of a second health outcomes study of low salt diets in a vulnerable population. The first study found low-salt diets caused more hospitalizations and greater mortality among congestive heart failure patients. This new study, by a Chinese research team headed by Dr. Jie Dong, "Low dietary sodium intake increases the death risk in peritoneal dialysis." It's conclusion:

This study revealed that low dietary sodium intake independently predicts the high overall and cardiovascular mortality in dialysis patients.

The researchers suggested a J-shaped curve as described by Dr. Michael H. Alderman in his presidential address to the International Society of Hypertension . Dong et al termed it "another example of 'reversal epidemiologic phenomenon," continuing:

In the case of dialysis patients, harm may outweigh benefit ... Low sodium intake is significantly related to overall and CVD mortality. Sodium restriction did generate undesirable effects in previous studies including increased insulin resistance, activation of the renin-angiotensin system and increased sympathetic nerve activity. ... We reveal for the first time that low sodium intake is not necessarily a good thing....