Salt has certainly captured a great deal of news in the past 10 days. Since the release of the IOM report on "Strategies to Reduce Sodium Intake ," we have been deluged with countless media reports and numerous requests for interviews. With so much going on, you can't help but wonder how consumers are reacting to all the hype.
It is interesting to examine the reader comments that often follow a news article. The identities of most of the authors who comment are not readily apparent, so it is understandable if their remarks are a bit spirited and sometimes off the point. Many use the occasion to vent their anger and frustration over issues that may not be directly related to salt and health.
As a result, it is sometimes hard to get a sense of how consumers are really reacting to the coordinated attack on salt by our medical institutions and the initiatives under way by many large food companies to reduce the salt content of the products. In other words, how can we tell what's happening where the rubber meets the road?
Two new reports that came out yesterday may give us some insight.
The first was a report in the Food Navigator entitled, "Low-sodium products declined in popularity, says NPD . The NPD Group is a leading provider of reliable and comprehensive consumer and retail information for a wide range of industries. Harry Balzer is vice president of The NPD Group and chief industry analyst specializing on food and diet trends. Balzer and The NPD Group have been tracking the eating and drinking patterns of Americans for nearly 30 years.
The article describes the NPD research, which examined US consumer behavior over the past 30 years and found that, although consumers increasingly say they are concerned about the amount of sodium in their diets, the number of people actually buying products that claim to have low or no sodium has steadily declined. Quoting from the article, “Chief industry analyst at the NPD Group Harry Balzer said: “In my 30 years of observing Americans eating behaviors, there is often a gap between what consumers say and what they do. It’s easier to aspire to a positive behavior than to actually do it."”
The second report was the latest Rasmussen Report just released. The headline read “55% Oppose Government Limits On How Much Salt Americans Consume ." The data from a national telephone survey shows that just 33% of Americans think the government should set limits on how much salt Americans can eat. Most adults (55%) disagree and don't think it's any of the FDA's business. Another 12% are not sure.
It's clear that the huge, coordinated effort by salt reduction advocates around the world have had a very limited impact on the public thus far. That is not to say that the situation will not change, however, we are now getting to a point where some basic truths will start to emerge. In fact, the issuance of the IOM report "Strategies to Reduce Sodium Intake " has transparently revealed what I have been saying for years now – that the IOM fully intends to put the population of the United States into the largest clinical trial ever carried out in history without the knowledge or consent of the people. As stated in their report, a central element of their strategy will be to gradually lower salt intake in stages and then check if any particular stage has demonstrated unintended negative consequences for the population. That is what a clinical trial does! And with very few exceptions the media, which have made the transition from watchdogs to lapdogs, have gone along with it, hook, line and sinker.
We live in interesting times. As you can imagine, the last week was a very busy one filled with numerous television, newspaper and radio interviews. After the IOM press conference to release their report on "Strategies to Reduce Sodium Intake," a key message that we felt was necessary to get out, was the admission on the part of the lead author that the Committee studying the matter never considered the science behind the salt and health issue - but only the strategies required to reduce salt in foods. This was a rather strange admission, since the major part of the IOM Committee consisted of epidemiologists and physicians rather than industry professionals who actually had some knowledge about food formulation. The centerpiece of the IOM 'Strategy' was the recommendation for the FDA to start regulating the salt contents of processed foods and foods prepared in restaurants and foodservice establishments. This would be a dramatic reconsideration of what is an essential nutrient and the oldest and most ubiquitous food ingredient known to humankind. One would expect that a move of this magnitude would be based upon a substantial body of uncontested scientific evidence, but that is very far from the case.
One of the interviewers from a Los Angeles radio station asked me how I might dare to challenge the medical authorities on this matter. I thought it best to ask him for a clarification. Was he referring to the medical authorities that recommended hormone replacement therapy for women and 30 years later admitted that such a strategy had disastrous consequences for women? Or was it the medical authorities that emphatically stated that the consumption of any more than one egg a week would lead to a very ugly and early death from cholesterol-blocked arteries - only to completely recant this advice 20 years later? Or perhaps he was referring to the medical authorities that decreed that frequent PSA measurements were the answer to prostate cancer, only to come out with their most recent recommendations that perhaps it's best not to do PSA tests at all because they can be misleading? Precisely which medical authorities was he referring to? The interviewer admitted that he got the message and dropped the question.
During the course of the actual press conference, I pointed out to the senior author that the impact of salt on health has been reviewed on a number of occasions over the years with mixed results. The latest meta-review of the evidence was commissioned by the German Ministry of Health just last year and concluded that population-wide salt reduction was not justified from a public health point of view. Indeed, it would have been wise for the US to do the same before going ahead with strategies to reduce sodium. Because of the controversial nature in which the evidence has been interpreted, I went on to ask if the international trade implications of salt regulation in food was ever considered in the deliberations of the IOM ‘Strategies’ Committee. The lead author appeared stunned at this question and admitted that the question of trade never entered into their deliberations.
In establishing the Sanitary and Phytosanitary Agreement (SPS) on trade, the United States was one of the leading countries to insist that unjustified measures could not be used to limit trade between countries. Countries would not be able to ban products for public health or safety issues unless it was proven beyond doubt that these measures were fully justified on a sound, scientific basis. For example, because Italians and Greeks have excellent cardiovascular health, exporters of many traditional high salt foods from these countries may find full justification under the World Trade Organization SPS Agreement to declare the regulation of salt in food as a non-tariff barrier to trade and launch an action against the US at the WTO. Since the US has never carried out a large-scale trial on the overall health impacts of salt reduction, and since the sum of evidence remains controversial, the WTO is likely to consider such a complaint valid.
As I said, we live in interesting times.
During the 2008 presidential campaign, candidate Obama complained about how scientists and policymakers in the George W. Bush Administration were perverting the free expression of science. While our choice of examples may have differed, we were in hearty agreement that the government had turned its back on science in the one area we track intensively: science pertaining to salt and health. In fact, the Salt Institute was forced to ask the federal courts to prevent the executive branch from ignoring the data quality standards of the federal Data Quality Act – and the courts demurely determined that the executive branch was immune to judicial oversight in the way it uses scientific data – the final arbiter of its own DQA compliance.
Unsurprisingly, one of President Obama’s early initiatives was to issue, in March 2009, a Memorandum on Scientific Integrity with a promise to have a plan in place to correct the problem by mid-2009. The plan has not yet been released. Examples of impaired integrity in government use of science continue.
One of the most vocal proponents of improving scientific integrity has been Bush-bashing investor George Soros (disclosure: at one time, Mr. Soros was a part-owner of a Venezuelan salt production facility). Soros’ Open Society Institute funded a study to document the threat to scientific integrity within the federal government (“The Scientists in Government Project”) run by George Washington University . The Federation of American Scientists , Government Accountability Project , Scientists & Engineers for America and Union of Concerned Scientists also provided support.
The Project just released its report, Strengthening Science in Government: Advancing Science in the Public’s Interest , and it makes the case that citizens should be very concerned about the integrity of science as portrayed by government scientists. And, we would add: and science controlled and funded by those same government scientists.
The Report takes as its theme Albert Einstein’s observation about the duty of scientists: “One must not conceal any part of what one has recognized to be true.” Tellingly, the Report also quotes a senior manager at the Centers for Disease Control and Prevention (CDC) complaining that “We need supervisors who have the courage to speak up for the science.” (Indeed, when the agency head assiduously leads in the opposite direction).
The Report effectively articulates the challenge:
The (Einstein quote) statement above serves not only as a guiding principle of good science, but as a framework for effective, science-based policy-making. The best public policies are built on a foundation of rigorous data and analyses, widely shared among scientists and the public. The fundamental obligations of a science-based society – advancing the public health, protecting the workforce, safeguarding the environment, developing appropriate energy technologies, defending the nation, and much more – depend on a full and open exchange of ideas, methods, findings, and interpretations.
New scientific knowledge constantly builds on existing scientific knowledge. When information is readily shared, new findings can be analyzed and new hypotheses vetted in an ongoing process that continually generates opportunities for further study and analysis. Science flourishes when scientific ideas are given a fair hearing by colleagues, debated on their merits, tested through replication and further research, and revised in light of new understanding.
Beyond the merits of advancing science, the open exchange of ideas is also cherished because it is concordant with the ideals of a democratic society. Freedom of information is a core belief in the American system.
An analysis of the approach to science taken by the five White House administrations that preceded that of President Barack Obama explains, “It is naïve to believe that scientific findings are the sole determinant of policy . . . Much of the funding, direction and use of American science is determined by the federal government and the political biases of the dominant party invariably influence the decisions that get made.
Policy decisions may be based on science, but they are not purely scientific. Preferences and political considerations shape decisions about regulation, research priorities, service delivery, and program development and evaluation. Nonetheless, the integrity of the science and the validity of the data that informs these decisions must be preserved.
But the report then goes on to explain the "pressures on scientists" employed by government (or hired by government scientists, we'd add):
A "unique challenge" for them is that "they may be expected to represent and advocate for official agency positions, regardless of their personal perspective on an issue. Conversely, they may be barred from presenting conclusions or analyses that are inconsistent with an agency’s stance, even if they are speaking as private citizens."
Okay. We agree on the statement of the problem. And we hope the supporters of the report are sincere. Let’s see if the “solution” is more government-knows-best or whether the new Administration is willing to be measured by the metrics of its lofty rhetoric.
Early indications from CDC on the salt issue haven’t been encouraging, but hope springs eternal.
Last fall, New Yorker science writer and former NY Times correspondent Michael Specter released an important book entitled Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens our Lives . In the NY Times book review, Janet Maslin captured the essence his thesis: "Firing Bullets of Data at Cozy Anti-Science ."
When the IOM produced its report earlier this week on how to implement salt reduction, questions at the news conference about the impacts on health and international trade in processed foods evoked artful non-answers. The authoring panel's chair conceded that the group had not examined the science on whether such a policy would improve public health. And she admitted that the group had not considered how the U.S. would defend its action against the World Trade Organization should FDA be so foolish as to adopt the IOM recommendation.
Though Specter's book deals with a myriad of junk science issues, it is silent on salt. Specter takes jab at celebrity know-nothings like Britain's Prince Charles and targets Dr. Andrew Weil's promotion of vitamin supplements as raising a larger concern -- undermining valid science by equating it with pseudo-science. Says Specter: “The idea that accruing data is simply one way to think about science has become a governing tenet of the alternative belief system....When Weil writes about ‘a great movement toward evidence-based medicine’ as if that were regrettable or new, one is tempted to wonder what he is smoking.”
We expect that a scientist with the appropriate credentials will act like a scientist, not a shaman. But on salt, the quasi-religious fervor has an unstable foundation of pseudo-science and the denialism of the politico-medical establishment -- as rendered in the IOM report -- is, indeed, "hindering scientific progress" and, arguably, "threatening our lives."
Let's "fire bullets of data at the cozy anti-science" behind the IOM report and ask ourselves what data are available to explore the two key questions:
- While salt intake is related to blood pressure, the relationship is heterogeneous and, more importantly, blood pressure is only one of several important health risk factors impacted by changes in salt intake (others being insulin resistance, plasma renin activity, aldosterone production, sympathetic nervous system activity,etc.) so the proper end point is not BP but rather some "hard" end point like cardiovascular mortality or all-cause mortality or incidence of heart attack, etc. Dr. Alderman, former president of the International Society of Hypertension and current editor-in-chief of the American Journal of Hypertension , summarized this argument in a JAMA piece a couple months ago. The only controlled trial of this question showed low-salt diets had worse outcomes. The observational studies are split with most showing no health benefit of reducing dietary salt.
- Any health impact of dietary salt depends not on the amount of salt (sodium) in any particular food, but rather on the amount of sodium in the diet. No studies have been done to establish that persons choosing diets replete with "low-salt" foods instead of those foods with "regular" sodium content are able to reduce and sustain their total sodium intake. On the other hand, evidence by Drs. Joel Geerling and David McCarron have found a physiological signal for "salt appetite" based on the body's need for sodium and that this "need" results in sodium intake levels within a relatively narrow range which is unchanged over time and independent of government dietary guidance.
So, to quote the McCarron-Geerling paper's title: "Can Dietary Sodium Intake Be Modified by Public Policy?" Let's get the evidence before we launch a madcap -- and anti-scientific -- effort to make a massive, untested change in our national diet.
Back to the larger point and in conclusion, this from Kevin Shapiro's review of the Specter book in Commentary magazine:
In Specter’s parlance, “denialists” are those who reject the substantive technological benefits of modern science—medicines and vaccines to treat and prevent illnesses, or techniques to enhance the quality and quantity of agricultural yields. At the same time, they cling to an unsubstantiated faith in the advantages of “natural” alternatives such as vitamins, supplements, and organic foods. The term e-ncompasses a diverse array of quacks and crackpots, ranging from New Age celebrities like Andrew Weil to reactionary patricians like Charles, Prince of Wales. What unites them is a hostility to reason that, when amplified in society, threatens the ability of scientists to pursue real solutions to such problems as disease, hunger, and malnutrition.
Data may be just another “four letter word” to some. And for some advocates, data gets in the way of a good story. That’s what’s been happening as evidence unfolds about the bogus “salt hypothesis” where blood pressure-based computer modeling projecting health benefits from cutting back on dietary salt have been crushed by peer-reviewed studies showing worse outcomes and questioning even the physiologic possibility of modifying salt intakes .
Well, data is happening in other areas, too.
Recently, the American Heart Association journal Circulation published an analysis of 30 million Medicare beneficiaries’ data (repeat, 30 million Americans’ actual experience, not a computer projection). The data clearly documented that (surprise!) heart attack rates are in decline – just the opposite of what computer projections and prominent public health “experts” have claimed.
Dr. Harlan Krumholz of the Yale University of Medicine and principal investigator for the study told the Wall Street Journal that the findings “breathtaking” and attributable to evidence-based prevention strategies. The same results are found in the general population, he claimed.
Of course, the new data came after the fear-mongers’ success in enacting a government takeover of healthcare arguing the current situation was deteriorating. And consider a second point: these same big-government-knows-best “experts” are telling us we have a crisis in salt intake causing, according to recent headlines, a half million heart attacks a year based on their computer projections – when salt intake levels are unchanged over many decades and now we know that heart attack rates are in decline.
As Jeff Stier of the American Council on Science and Health notes: “This isn’t consistent with their storyline that we need more government intervention like fast food bans to keep us healthy.”
So, who to believe? The “experts” or the data?