The American Journal of Medicine published an article this week showing the utter failure of 30 years' efforts to improve the healthfulness of Americans' lifestyle habits. The findings suggest policy-makers need to be much humbler and likely less strident in their efforts to "improve" diet and other lifestyle choices. The current approach just isn't working.
In "Adherence to healthy lifestyle habits in US adults, 1988-2006," Dana King and colleagues at the Medical University of South Carolina use the government's own NHANES database to demolish the notion that advice to maintain a healthy weight, get more exercise and eat more fruits and vegetables are effecting positive change in Americans' behavior. The only "dietary" advice that's being followed is that more people are drinking alcohol -- and many would dispute that getting more people to drink alcohol is a national health priority (even on that, excessive drinking increased among non-Hispanic whites; only Hispanics slightly moderated their excess intake. But larger percentages of all groups began drinking (this was seen as a positive health development). Smoking incidence was unchanged (although Hispanics' smoking increased).
The number of obese Americans increased from 28% to 36%. Those exercising 12 times or more per month declined from 53% to 43%. And fruit and vegetable consumption plummeted from 42% to 26%. Those adhering to all five major lifestyle recommendations was cut nearly in half, dropping from 15% in 1988 to 8% in 2006. Unexamined were other minor advisories like curtailing salt intakes -- which also are unchanged over the period -- but, in this case, unchanged is an improvement over the five major recommendations where siginificant slippage continues.
The observation period began right after implementation of the 1980 Dietary Guidelines. With public acceptance levels like this, the Dietary Guidelines are looking like investments in Chrysler and General Motors. Where's the outrage? We've instilled concern, even fear, about eating. The public is convinced that the advice they've been given will make them healthier. But, as pretty as the model appears on the showroom floor, nobody's buying it.
We need to "stimulate" fresh approaches to our approach to the Dietary Guidelines for Americans to "bailout" our failed attempts for the past 30 years.
Government advisers in the UK are making menu recommendations in order to cut out what they deem to be “high carbon” foods. The Committee on Climate Change has evaluated the methane produced by burping sheep and cows and the carbon footprint of many foods and has pronounced that citizens must change their eating habits.
“Changing our lifestyles, including our diets, is going to be one of the crucial elements in cutting carbon emissions,” said David Kennedy, chief executive of the Committee on Climate Change.
The Carbon Trust, a government-funded firm, is working with food and drink companies to determine the carbon footprints of products.
I am relieved to note that chocolate has a smaller footprint than chicken. But common sense and time spent on farms leads me to question their assertion that lambs burp more than cows. Yes, believe it or not, government bureaucrats are spending money to determine whether sheep burp more than cows.
If about now you are wondering if this is satire or serious, a Saturday Night Live skit or truly a story from the Times, you may wish to read this absurdity for yourself .
It appears there is no end in sight to the quest for government control over what we eat.
Perhaps because of its English origin, the image of a primrose path leapt to mind when I read about the UK's Food Standards Agency this week announcing a second round of "more challenging" sodium targets for British food manufacturers. The theory is that if people eat foods lower in sodium they will lower their overall sodium intake. The theory's beguiling simplicity is easy to embrace rather than the "steep and thorny way" of rigorous science.
William Shakespeare immortalized the expression in Hamlet where Ophelia warns her brother Laertes against succumbing to libertine indulgence, the feel-good path, if you will. Rather, she suggests, he practice what he's preached to her ("reck not his own rede"). Groups claiming to represent good science in pursuit of noble social causes should heed Ophelia's advice to "reck their own rede" and put science foremost.
Do not, as some ungracious pastors do,
Show me the steep and thorny way to heaven,
Whilst like a puffed and reckless libertine
Himself the primrose path of dalliance treads,
And recks not his own rede.
Hamlet, act 1, sc. 3, l. 47-51
The image of this enjoyable garden pathway, so easy to traverse, but ultimately leading to misery, not heavenly bliss, is the modern reading of Shakespeare's dialogue. Most people would think of the primrose path as being a path ease and pleasure; the easy path out of a hard situation. It implies that those taking the enjoyable stroll down the path do so in ignorance, and those who lead others down the primrose path deserve condemnation for misportraying the journey as easy, since it will not lead to the desired destination and leave the travelers in a desparate situation.
So it is with the new FSA targets. Remember, the objective isn't to have an enjoyable stroll through food choices, the idea is to use those choices to reach the goal of improved health.
We don't subscribe to the notion that healthy diets must be filled with unpalatable choices; just the opposite. But a quality diet, especially in society today, isn't a primrose path where choosing the foods that look, smell and taste best are always the best for you. FSA has persuaded food manufacturers to reduce the salt level of their foods; that was the first round of targets. Food companies were eager to please and removing a portion of salt seemed like a stroll in the garden. Now comes the second round. Tougher targets. Challenging to technologists. Closer to the line on food safety.
Worse, although British consumers have played along and added more low-sodium foods to their shopping baskets, the British diet has the same amount of salt in it that it had 20 years ago (and, probably a good deal longer than that). The Intersalt Study published in the British Medical Journal in 1998 confirmed sodium intakes of about 150 mmol Na; the same as it is today (and in the middle of the same consistent intake range that has endured ever since we've had the technology to measure it).
Small wonder that FSA feels it needs a second round of tougher targets. It has made no progress to date. Food manufacturers should be warned that if they haven't recognized their situation as a classic "primrose path" they will eventually make the connection. Perhaps it will be the still more agressive targets of round three or round four. To paraphrase the expression: "Beatings will continue until morale improves." Targets will continue to tighten until public health responds.
Guess what? Public health IS responding, FSA just doesn't recognize the response. They are looking for sodium intakes to fall. Ain't gonna happen. But if they looked at total food intake, they'd find that the sodium-calorie ratio IS responding to their stimulus. Britons are choosing more low-sodium foods, but their intakes take their marching orders from their unconscious brain, not their conscious behaviors. They are following their hard-wired salt appetite and just eating more calories to get the salt their brains are signaling they need.
The "brains" at FSA are wrong. The brains in our bodies are, by design, right. Taking the easy primrose path and foresaking the "steep and thorny" path of scientific integrity is the wrong path. Thanks, Ophelia. I'm sure her father, Polonius, would endorse her pre-trip advice to his son Laertes just as he added his own: "To thine own self be true." Let's be true to the science and shun the primrose path.
Many government public health agencies recommend universal salt reduction. Unfortunate. Unjustified. But true.
In the past couple weeks, however, nutri-fascists have been spewing forth wild and scary allegations about the "toxic" level of dietary salt. Their fact-free rants may have cost them their customary agency support. At least one agency has said "enough" and issued a fact sheet that their population intakes are normal.
In fact, Food Standards Australia New Zealand went the extra step to explain that 95% of the residents Down Under are consuming less than 8.5 grams of salt daily. The statement was prompted by local WASH agitators who claimed Australians were "regularly" consuming 40 grams of salt per day. The release notes there are no recorded invidividual intakes over 26 g/day much less the 40 g/day whopper. FSANZ had to speak out publicly attempting to save their scientific credibilty (something about which WASH seems unconcerned).
The head of the Aussie WASH group was quoted in FoodNavigator saying: "The real question is whether government will take on industry." Actually, the real question is whether government will take on those who would frighten the public with irresponsible charges that their current salt intakes are poisonous. At a news conference a week ago the U.S. counterpart group, Center for Science in the Public Interest (CSPI) claimed highly-salted restaurant meals are excessive, even poisonous.
More and more evidence is being published about how moderate -- and stable -- population salt intakes are around the world. Activists have claimed high and rising salt intakes. Neither is true.
A couple months ago, the European Journal of Clinical Nutrition published a study of salt intakes in Denmark. The study of a representative sample of the Danish population found population sodium exactly those found in the U.S. (148 mmol Na) and the UK (149 mmol). In Denmark, the population consumes 147 mmol. Interestingly, the study by Anderson et al adjusted the male average (182 mmol) and female average (122) for caloric intake and reported:
no difference was found if total salt intake was measured per energy intake. No significant difference was found between sexes regarding intake of household salt, and neither the educational level nor the age was associated to either total salt intake or intake of household salt.
I guess the citizens of the U.S., U.K., Australia and Denmark didn't get the WASH talking points. If these activists continue to play fast and loose with the evidence, perhaps more public health agencies will be forced to issue statements like that from FSANZ as they try to preserve their credibility.
Today’s Wall Street Journal reports a recent study on “The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors ” published online by the Public Library of Medicine. With scientists from major institutions and high powered statistical techniques, the study addresses the public health burden of a dozen “modifiable dietary, lifestyle, and metabolic risk factors” including dietary salt. Putting aside evidence that salt intake may not be “modifiable,” the authors tip off readers as soon as Table 1, footnote h that they’ve failed to take advantage of their opportunity to address this important question of mortality related to salt intake.
The footnote reads:
The effect of reduction in salt intake on SBP and the effect of subsequent decline in SBP on the relevant disease outcomes, were estimated at the individual level to account for possible correlation between salt intake and SBP.
Actually, there’s no need to read any further. The authors confine their concern for dietary sodium to extrapolated “benefits” based solely on blood pressure, totally ignoring both the two published studies of a randomized trial of the health outcomes of reducing dietary sodium and the entire literature of observational health outcomes studies which does not support the conclusion that SBP is the only relevant variable in determining disease outcomes. The authors term blood pressure a “disease outcome,” further weakening their credibility as examiners of mortality.
Even employing a fundamentally and fatally flawed methodology, they employ high powered statistics to examine the same question addressed earlier in the week by the Center for Science in the Public Interest which claimed salt caused 150,000 American deaths each year. This study puts the figure about 35,000 – wrong, but underscoring how fast and loose CSPI and NHLBI have been in playing with these projections.
Unfortunately, as has become the pattern, journalists pick up the news release and run with the story line. For example, Daniel Akst in the WSJ story reports:
Too many of us appear to be bent on slow-motion suicide. Consider smoking; if we could get every American to stop, we'd save 467,000 lives annually. Solving high blood pressure (much of it arising from unhealthy lifestyles) would save 395,000. And if we could get everyone to slim down to an appropriate body weight, we'd save 216,000 lives.
Great headlines. Lousy science.
Generals are often accused of preparing to fight the last war, not recognizing that events have moved on. The grand strategy of reducing the global burden of chronic diseases should remain our mission, to be sure, but we need to understand whether we’re using the right weapons in our battlefield tactics. The “last war” mentality is represented in the simplistic, one-size-fits-all campaign against blood pressure. Now we know there are many ways to reduce blood pressure. Some improve health; others, don’t. We used to bleed patients to improve their health. That certainly reduced their blood pressure. And many died. We used to urge pregnant women to reduce salt intakes; today that would be medical malpractice. Some interventions work to advance our mission of improving human health, other well-intended tactics have proved counterproductive, creating “unintended consequences,” like the 37% greater cardiovascular mortality among Americans consuming (recommended) low-salt diets. Think of salt reduction as waterboarding. Extreme, for sure. Some would argue unethical. But, bottom line, ineffective and possibly counterproductive.
Headlines across the country , and the world , alerting the public that the DASH Diet reduces the rate of heart failure. As champions of the DASH Diet for the past dozen years, we feel vindication. It was distressing, therefore, to read the authors’ news release declaring their study provides support for salt reduction among the dietary improvements. It doesn’t. Actually, it’s just the reverse.
"High blood pressure is always of concern because it has the potential to lead to major adverse events, including strokes, heart attacks and heart failure," explains senior author Emily Levitan, ScD, a research fellow in the Cardiovascular Epidemiology Research Center at BIDMC. She and her coauthors, therefore, hypothesized that the DASH diet (short for Dietary Approaches to Stop Hypertension) would also reduce a woman's risk of heart failure through its blood pressure lowering effects as well as its secondary effects on cholesterol and other heart-disease risk factors. The DASH diet, which has been shown to lower blood pressure in randomized clinical studies, is plentiful in fruits, vegetables, low-fat dairy products and whole grains. "These foods are high in potassium, magnesium, calcium and fiber, moderately high in protein, and low in saturated fat and total fat," explains Levitan.
So far, so good, but a news release referenced by Cardiology Today continues:
Emily Levitan, ScD, a research fellow at Beth Israel Deaconess Medical Center, said the women’s diet did not have to exactly mirror the DASH diet to have a benefit. “Very few of the women we looked at had diets that shared all aspects of the DASH diet,” she said in a press release. “But we found that the closer they were, the lower their risk of HF.
“This suggests that making even moderate adjustments to your diet to include more fruits, vegetables, whole grains and low-fat dairy products, and less salt and sugar and less red meat and processed meats, can help improve cardiac health,” she said.
Levitan ignores her own data. Like previous studies that have shown higher quality diets are not lower in salt, this new study does the same. The original DASH Diet, of course, held salt constant to eliminate the possibility that its results might be confounded by salt reduction. The ensuing DASH-Sodium trial added a salt reduction intervention and its (salt reductionist) authors refuse to divulge the data for analysis, but what has been reported suggests any salt effect applies only to a small number of people , at most. But this new study found the DASH Diet – high in fruits, vegetables and low-fat dairy products – had double digit changes to typical diets in terms of fat, saturated fat, cholesterol (all down) and potassium, calcium, magnesium and fiber (all up). That’s what you’d expect. The salt intake was virtually unchanged (<2%). The study also reports that the “high quality” NHLBI diet, which does recommend reduced salt intakes, had the same magnitude double-digit changes to fat, saturated fat (both down) and potassium calcium, magnesium and fiber (all up) and, in addition, recorded double digit increases in protein and sodium. Repeat, a double digit increase in sodium, not a cut. This was the actual diet of those adhering most closely to the recommended diet.
So, this further evidence confirms exactly the opposite point the authors’ report: the Archives study shows no link of reduced-salt diets with heart failure rate.
Until a year ago, that would have been surprising. Until last year, heart failure patients were routinely placed on low-salt diets. “Everyone” knew low-salt diets would be medically helpful. Except that “everyone” was wrong. The first-ever clinical trial of the health outcomes of low-salt diets was done among congestive heart failure patients . Guess what? Those on the low-salt diets had far worse health outcomes . They died and were re-admitted to the hospital much more frequently. A year later, you’d think researchers who found no association of salt intake with heart failure would have referenced the only two studies on this very point. Peer reviewers missed it.
Unfortunately, most of the reading public did too, according to the media play of the authors’ news release.
Newspaper reports from around the country have reported the warning which the FDA delivered to General Mills over its claims regarding the cholesterol-lowering benefits of Cheerios. The concern was that the claims being made about the cholesterol-lowering ability of Cheerios gave the indication that the product possessed almost drug-like qualities when, in fact, its ability to lower cholesterol was far more limited. In other words, anyone who is on statins or any other type of cholesterol-lowering therapy should never consider the claims as a justification to replace them by eating Cheerios.
Perhaps the strangest press release came from the newsroom of CSPI . They applauded the FDA for taking action against misleading and exaggerated health claims on foods. This statement came exactly one day after a news conference in which CSPI representatives Michael Jacobson and cohorts claimed that salt was toxic and that our current levels of consumption are prematurely sending countless Americans to their graves. Talk about exaggerated health claims!
CSPI has long been known for their wildly exaggerated and factually baseless tales of terror in the food industry. The organization's current fantasy is salt consumption. Ignoring all the data indicating that our cardiovascular disease performance has improved dramatically over the last 30 years; that countries which consume the most salt have the best cardiovascular figures; that the famous Mediterranean diet contains 30-40% more salt than the typical American diet; and that, even for salt sensitive people, significant reductions in salt consumption results in clinically non-significant reductions in blood pressure, they continues to rant of impending doom to anyone who will listen. The problem is that many do listen, but either cannot discern fact from fancy or are unwilling to do the follow-up research to verify the CSPI statements.
Dietitians are in consensus: diets are important. Individual nutrients, specific foods or single meals need to be considered as part of a person’s dietary pattern before they rise to the level of health significance.
For years, it’s been annoying to see the creeping acceptance of the contrary view, embracing a “good food/bad food” dichotomy based on the obvious fallacy that any food or any meal raises or lowers the likelihood of good or bad health outcomes. Groups like the Center for Science in the Public Interest (CSPI) take this wrong road right to the very end; their membership solicitations try to frighten the gullible into shunning “10 foods you should never eat.” Truth is: all of these foods can be part of a healthy diet. Not only is the variety of nutrients, foods and meals important, but examining dietary patterns allows consideration for the complex nutrient interactions that take place when we eat.
We’ve known the importance of healthy diets for centuries. Five years ago, Dr. Ashima Kant documented how dietary patterns (not foods, not meals) are related to chronic disease outcomes (JADA , 2004;104:615-35). Now, just in time for the 2010 revision of the Dietary Guidelines for Americans, two studies published in the past month offer further support to reversing the slide into the “good food/bad food” fallacy. Both employ rigorous scientific methodology to reach their conclusions. And those conclusions are:
- With regard to coronary heart disease there is “strong evidence of a causal link between CHD and dietary patterns ” with cohort studies demonstrating the protective effect of vegetables, nuts and monounsaturated fatty acids and three defined dietary patterns that incorporate these elements: the Mediterranean Diet and what Dr. Andrew Mente and colleagues at McMaster University call the “prudent” and “high quality” dietary patterns. On the other side, the current “western diet” and diets with high glycemic loads create health risks. Of these, only the Mediterranean Diet has been proven effective in randomized controlled trials. Think about all the dietary recommendations – and, even more, recommendations on various foods or types of meals – that are advocated constantly but which lack a foundation in medical science.
- Using dietary recall to evaluate dietary quality is difficult, so a simple surrogate indicator, a biomarker, would be a valuable aid to determine if our individual – or our population – diets are meeting our quality objectives. And now such a boimarker has been validated . That marker is urinary potassium. The higher the urinary potassium, the better the diet. Given that sodium is the electrolyte that’s been accorded the most emphasis (on food labels, in advertising, etc.) the researchers also examined urinary sodium as a marker of diet quality. They found sodium to be a poor surrogate for overall dietary quality (despite the fact that the model included a sodium component whereby higher sodium intakes would be “unhealthy” so that modeled disadvantage was overcome by other dietary factors). Dr. Mente, this time with a team at Toronto’s Mount Sinai Hospital, conducted the analysis. They concluded that “a single 24-h urinary K+ measure is a clinically valid, simple, and inexpensive ($10.00 in Canada) test of overall diet quality.”
So, when you hear CSPI or some other do-good advocate suggest that eating a particular food or avoiding another is good for you, take it with a grain of salt. If they tell you that meals with too much of any nutrient (sodium, certainly, but also fat or some other target of opportunity) is bad for you, tell them to read the science first.
The Mediterranean Diet, the only one proven in controlled trials to actually improve health, has about 30% more salt than the average American diet today. Perhaps coincidentally the only randomized controlled trial of the health outcomes of a low-salt diet was also done in Italy. It confirmed that low-salt diets not only failed to deliver expected health benefits, but actually placed those cutting back on salt at additional risk.
Perhaps the quality science pushing forward our understanding of the importance of dietary patterns and overall diet quality will displace the loud, but scientifically-unsupported calls to cut out this nutrient or that, forego eating traditional and tasty foods and avoiding meals that don’t pass muster with the food police.
At the bottom, I'll fill-in-the-blanks (asterisks), but see if you don't see how accurately this reports the situation when the Salt Institute and US Chamber challenged HHS with a Data Quality Act petition on the DASH-Sodium study.
* Suit Says Law Requires Federal Agencies To Use Sound Science
Appeal Argues Statements on ** Must be Accurate
On April 14, the federal Ninth Circuit Court of Appeals heard arguments from * on why such federal agencies as Health and Human Services (HHS) and the Food and Drug Administration (FDA) must correct the inaccurate information they disseminate about **.
In late 2007, a lower court accepted the government's contention that there is no right to judicial review under the Data Quality Act, effectively reducing the law a friendly request, without ruling on the merits of *'s claims.
Arguing on behalf of *that the laws Congress passes have consequences that federal agencies cannot ignore was noted legal scholar Alan Morrison, who founded Public Citizen's Litigation Group and taught administrative law at Stanford. "Citizens have a right to expect the government to be transparent and to use the best available information for policy decisions," said Morrison. "Unfortunately, so far, the government has been anything but transparent and has failed to produce any evidence for its policy statements on **."
While the law says federal agencies must rely on sound science when disseminating information to the public, the petition filed by * in October 2004 marked the first serious test of the Data Quality Act, which was passed by Congress in 1999. After more than two years of delay by the federal government that culminated in a refusal to act on the petition, * filed a lawsuit in February 2007 asking the courts to direct the agencies to comply with the law.
The respected magazine Science published an editorial on the case that year, claiming that HHS had "violated its own DQA guidelines."
At issue are such statements as "there have been no studies that have scientifically assessed **"We welcome the Obama Administration's recently stated commitment to making policy decisions based on science, not politics," said ____, Chief Counsel with *. "This case is designed to ensure that the federal government's policy on ** is not politically motivated."
On March 9, 2009, President Obama issued a memorandum to the heads of executive departments and agencies stating that, "The public must be able to trust the science and scientific process informing public policy decisions," and calling for "transparency in the preparation, identification, and use of scientific and technological information in policymaking."
During oral arguments, attorney for the government told the three-judge panel that there were simply too many facts in the world to require the government's statements about them all to be accurate.
We'd only note that we think our Salt Institute v. Leavitt was the "first serious test of the Data Quality Act," but, otherwise this newsletter from *Americans for Safe Access (ASA) about **medical marijuana reads like a sequel to our attempt to compel HHS to comply with the DQA and make available replicable data it was using for policy decisions and (mis)portraying on its website.
We hope ASA fares better than we did. The appeals court in our case upheld, in the language of the ASA newsletter, "the government's contention that there is no right to judicial review under the Data Quality Act, effectively reducing the law (to) a friendly request without ruling on the merits." Good luck.
Every day, we learn more and more about the metabolism of salt and mechanism of its role in maintaining balance or homeostasis within our circulatory system. Some of the most interesting work continues to come from a Europe-wide collaborative group based in Germany. Their latest work entitled, “Macrophages regulate salt-dependent volume and blood pressure by a vascular endothelial growth factor-C–dependent buffering mechanism,” was just published online by Nature Medicine .
This new data provides valuable insights into the role of the mononuclear phagocyte system (MPS) cell and lymphatic function in the context of maintaining intracellular Na+ homeostasis. Cells of the mononuclear phagocyte system (MPS) are found in large numbers in every organ of the body, where they contribute to innate and acquired immunity and fluid balance. When rats are fed high salt diets, the extra accumulation of sodium ions that occurs in excess of compensating water results in local hypertonicity or increased pressures that provokes a tissue-specific regulatory cascade, with the macrophages releasing vascular endothelial growth factor-C (VEGF-C) which acts protective protein to maintain a constant intracellular volume. This mechanism then restructures the existing lymph capillary network and to manage this increased pressure.
The researchers conclude that the complex MPS-derived secretion of VEGF-C in states of sodium-induced intracellular hypertonicity functions to moderates blood pressure.
Their findings move the prevailing view of the salt volume–blood pressure relationship from a simpler two-compartment model to a more dynamic three-compartment model in which the interstitial (intracellular) spaces in tissues feature as a separately regulated space that also relies on tissue-specific mechanisms to maintain internal osmo- or pressure regulation.
While we caution that this work was done with rats -- and at experimentally huge salt intake levels to demonstrate the mechanism -- and, therefore, has no human health policy implications at this point, the study usefully reveals how complex a system we have evolved to manage and balance all components of our diet.