This is no joke. Good news used to be a cause of celebration. Too often, today, it conjures up worry and concern as we sophisticates "know" it must be "too good to be true." Sometimes, actually, it really is just plain good news. We need to learn better how to appreciate our blessings, our progress.
Last week, several stories illustrated the point.
In Canada , researchers reported on a study that showed that the rate of coronary heart disease incidence is decreasing. The authors -- and the media -- played the story that CHD increased by 10.5% from 1994-1995 -- while leaving unreported that the population of Canada increased by 12.5% over the same time span. Good news/bad news.
Also last week, the British Medical Journal reported that over the past 20 years, CHD in the UK has fallen 61% in men and 56% in women. Celebrate? No, the authors -- and the media -- emphasized that the rate of decline seems to be slowing, a cause for concern.
North Atlantic polemicist Brendan O'Neill, writing in Spiked , pointed out just-released U.S. Census data showing that within a decade Americans over 65 will outnumber those ages 5 and under for the first time in history. He makes my same point: why not celebrate that more of us are living longer (and better) rather than complain about the "burden" of golden-agers?
It may be hard sometimes to see that "every cloud has a sliver lining," but we certainly can do a better job in appreciating what we have and the progress we have made in so many ways. Every cloud is not a nimbus cloud. The bad news is that we're losing our ability to appreciate good news. That's no joke.
The Canadian Medical Association Journal (CMAJ) this week carried a story, released widely in the media, implying drastic slippage in Canadians' cardiovascular health status. Douglas S. Lee and colleagues on the Canadian Cardiovascular Outcomes Research Team reported that, from 1994 to 2005, 19% more Canadian men suffered from heart disease (and 2% more women). They conclude: There is an increasing prevalence of heart disease and risk factors for cardiovascular disease in Canada."
Everyone would love to report that no Canadians suffer heart disease, of course, but the researchers report nearly all groups in Canadian society suffering "significant" increases in heart disease and the "risk factors" which predict adverse health outcomes. Trouble is: that's not what their data really showed.
The Canadian population is split nearly evenly between males and females (49.6%/50.4%) so the 19% increase in heart disease among men and 2% among women comes out to about a 10.5% population average increase over the 12 year period. But Canada's population during those years grew from 29 million to more than 32.6 million, an increase of 12.5%. So, actually the rate of heart disease in Canada has actually continued to improve. Two years ago, our Salt and Health (pdf 500.04 kB) newsletter displayed these figures graphically (see Figure 5).
It's unfortunate that journalists didn't look deeper than the news release and author-prepared abstract for the real story.
The authors are concerned about trends in recognized risk factors that run directly counter to the pattern in heart disease incidence. Diabetes, hypertension and obesity are all on the rise, though, regarding obesity, Canada seems the reverse of most other developed societies where obesity is more common in lower socio-economic groups; that trend is exactly reversed among Canadians.
The authors' primary concern is that risk factors among the young are a cautionary finding for future trends, but they give short shrift to the dramatic and long-term gains that their study documents.
Earlier this week, the National Institute of Aging released "Tips for Older Adults to Combat Heat-Related Illnesses " noting that the "risk of heat-related problems increases with age." That's a timely warning as summer's sweltering days lie immediately ahead. While timely, the advice is incomplete and incomplete for the reason of ensuring the advice is politically-correct -- if not medically correct.
Older people need to heed the warning. They are at extra risk of hyperthermia as the NIA warns. And, in fairness, buried in the release is the notation that low-salt diets "may increase their risks."
Rather than include any action steps to heat-threatened seniors to safeguard their salt (and total electrolyte) intakes, however, NIA contents itself with advice to consume water and fruit/vegetable juice. Replacing fluids without replenishing electrolytes (like salt) can be fatal to those suffering hyperthermia, leading to hyponatremia. Every summer, thousands die not appreciating that hydration is critical and proper hydration requires attention to electrolyte balance.
The American Medical Assocation's JAMA journal examined the situation in women and documented the importance of salt therapy:
Chronic hyponatremia is a common clinical problem in the elderly, particularly among women. Mortality is substantial. It is now well accepted that acute symptomatic hyponatremia (hyponatremic encephalopathy) can result in death or permanent brain damage. While failure to institute active therapy (intravenous [IV] sodium chloride) in such patients may lead to increased morbidity, IV hypertonic sodium chloride therapy is both safe and effective in preventing hyponatremic brain damage.
Seniors would be well advised to take NIA's warnings seriously, but take the agency's remedial advice with a grain of salt.
Show me the money!
Reuters reported on Monday July 20, that two years after New York City declared war on artificial trans fats, nearly all the city’s restaurants had successfully cut the artery-clogging fats from their menus, according to city health officials. Artery-clogging fats? The story went on to say that trans fats have become notorious because they not only raise so-called "bad" LDL cholesterol, but also lower levels of so-called "good" HDL cholesterol. In 2006, before the health department ban, half of New York City's restaurants were using trans fats. By November 2008, less than 2 percent were, according to Dr. Sonia Y. Angell and her colleagues at the Department of Health in their article in Annals of Internal Medicine .
What they could not say was how this initiative actually helped the citizens of New York. The presumption is that ridding the food supply of trans fats will definitely improve the cholesterol levels of millions of people. Improving the cholesterol levels should result in reduced cardiovascular disease, but has it ? Since most New Yorkers eat in restaurants, often several times a week, there should be a significant decrease in the number of people that will have heart attacks and die - right? That is what everyone is after - right? And certainly with all the modern statistical tools we have available and with a precise knowledge of the exact date that the trans fat ban went into effect, we must be able to demonstrate the health benefits that accrued from the New York ban. Surely we can be spared the lame “cardiovascular disease is multifactorial, therefore we can't really tell if the ban worked" excuse. The fact is there are no metrics in place to measure what should have been the primary goal of the ban. The people behind the ban were arrogant enough or insensitive enough to dispense with the trivialities of actually determining if their initiative really accomplished anything. There is nothing in place to "Show me the money!"
For 1500 years, the world believed in 'spontaneous generation' simply because the Greek philosophers said it was so. Francis Bacon, often referred to as the father of the scientific method, didn't buy it and effectively said, "Show me the money!" Credibility has to be based upon evidence.
The scientific integrity of this country and its institutions is declining because we are associating credibility with institutions rather than with evidence. We accept notions without demanding evidence. It may well be that there is spontaneous generation and that New York's citizens have actually benefitted from the trans fat ban, but until there is objectively-obtained evidence to confirm this, the only ones who have really benefitted are those individuals and institutions who have garnered free publicity. Consumers should be served a lot better than that!
The New York Times archive yields this 60-year-old headline (February 20, 1949): "CITY STOPS THE SALE OF SALT SUBSTITUTE ; But Mustard Says No Deaths Have Been Reported -- Public Warned of Danger." The study reports how the NYC Health Department withdrew approval of the very best taste-alike salt substitute ever known: lithium chloride. The City Health Department was interested in salt reduction apparently (the City noted that lithium chloride was being "used widely as a substitute for common table salt"); but just as apparently, didn't do their homework. Lithium chloride may taste like salt -- and no other salt substitute has been found that matches its taste -- but it's a deadly toxin and the substance administered to execute death row prisoners. As we've told the NYC Department of Health: first do no harm (pdf 53.83 kB) . We didn't realize they'd already been put on warning.
A week ago, a blogger blatantly misrepresented "facts" from the Salt Institute. Within hours we filed a comment correcting his blog post. Comments on his site are "moderated," however, and, now a full week later, he has declined to post the badly-needed correction. I cannot let its inaccuracy pass without response.
Mr. Weck writes "Food Trends 2009: Food Business Resource's complete food trends guide 2009" and on July 9 posted "Easy on the salt ." He told his ostensible food service industry audience:
With all the talk of sodium and heart disease, I have a hard time even picking up a salt shaker anymore without grabbing my chest, gasping for air and seeing my life flash before my eyes! It’s no wonder Americans have grown increasingly fond of salt. According to American Salt Institute, “Salt intake has increased by 50% over a period of 15 years beginning in the late 1980’s.” If that’s not impressive, I don’t know what is!
Mr. Weck misquotes us; no one associated with the Salt Institute has ever made such a representation. It's a total fabrication.
Americans have always been "fond of salt," but we are eating the same amount of salt today that they ate in the late 1980s. Indeed, we have eaten the same amount for more than a century. Before the early 1900s, we lacked instrumentation to make accurate measurements. True, we get the salt from different dietary sources -- far more from foods prepared by others and far less from foods we prepare ourselves at home -- but the amount of sodium, for which we have accurate measures, is about 3,400 mg/day. All that doesn't come from salt; most nutritionists calculate that about 10% of it occurs naturally in the foods we eat. Thus, the average American is consuming about 7.9 grams of salt per day today.
Mr. Weck warns: "As the public becomes increasingly aware of this issue and the severity of its consequences if ignored (i.e. heart disease, stroke, kidney disease, high blood pressure, obesity, ad infinitum), the entire food industry is going to be in a heap of trouble." He confesses his own employer promotes low-salt foods. Since the evidence fails to show adverse health outcomes from current salt levels (any blood pressure impact is canceled by offsetting changes in other risk factors like rising insulin resistance, plasma renin activity and increased aldosterone production) and since all evidence suggests that salt appetite is regulated by unconscious brain directives, not conscious decisions, it may be that Mr. Weck's company may be "in a heap of trouble" when Americans begin to realize that companies touting low-sodium foods to tap politically-correct salt avoidance stand accused of fomenting fears to promote a hidden agenda of increasing Americans' food intakes. While salt intake levels remain unchanged, our consumption of calories trends steadily upward.
Perhaps I should have more patience and empathy for someone whose feeble cardiovascular condition induces chest pains simply by picking up a one- or two-ounce salt shaker. Such a rare condition deserves medical attention; it separates Mr. Weck from healthy Americans.
"Everyone" knows that blood pressure (BP) is an important risk factor for heart attacks and strokes. There's solid evidence. And "everyone" knows that interventions to lower BP will improve these health outcomes. Or will they?
A new Cochrane Review concludes: "Aiming for blood pressure targets lower than 140/90 mmHg is not beneficial ." In their study, published July 8, Drs. J.A. Arguedas, M.I. Perez and J.M. Wright conclude:
High blood pressure (BP) is linked to an increased risk of heart attack and stroke. High BP has been defined as any number larger than 140 to 160 /90 to 100 mmHg and as a result this range of BPs has become the standard blood pressure target for physicians and patients. Over the last five years a trend toward lower targets has been recommended by hypertension experts who set treatment guidelines. This trend is based on the assumption that the use of drugs to bring the BP lower than140/90 mmHg will reduce heart attack and stroke similar to that seen in some population studies. However, this approach is not proven.
This review was performed to find and assess all trials designed to answer whether lower blood pressure targets are better than standard blood pressure targets. Data from 7 trials in over 22,000 people were analysed. Using more drugs in the lower target groups did achieve modestly lower blood pressures. However, this strategy did not prolong survival or reduce stroke, heart attack, heart failure or kidney failure. More trials are needed, but at present there is no evidence to support aiming for a blood pressure target lower than 140/90 mmHg in any hypertensive patient.
The Cochrane Collaboration invented the discipline of substituting "evidence-based" decisions for the opinions of doctors . We have recommendations on all sides of various medical issues and these Cochrane Reviews try to separate the sheep from the goats, identifying recommendations based on expert opinion as opposed to those based on scientific data.
I was reminded of an extended conversation I had more than 20 years ago with two of the world's foremost advocates of universal sodium reduction, the husband and wife team of Jerry and Rose Stamler. I asked the Stamlers whether the BP target for intervention was the "normal" 120/80. Jerry responded, no it should be lower. I pressed: 110/70? Jerry: lower. 100/60? Jerry: lower. 90/50? Lower. I tried the query from the other direction, noting that a corpse had 0/0 BP but was hardly "healthy." Jerry's final response was that any intervention that could lower BP was healthier and that practical limits on the amount that people could lower would represent both the minimum achievable BP and the healthiest BP.
The data in this study demolish that expert opinion.
For years "everyone" has known that having the entire population reduce its intake of dietary salt would reduce the rates of heart attacks and strokes. An earlier Cochrane Review of "Advice to reduce dietary salt for prevention of cardiovascular disease ," however, found no evidence supporting this platitude, though the fable continues to enjoy popularity among some experts despite the absence of confirming data.
Award-winning investigative journalist Gary Taubes described the situation in his "The (Political) Science of Salt " where he pointed out that while the data for universal salt reduction were eroding confidence in the theory, advocates of the intervention were becoming more strident and vocal. Said Taubes:
The dispute over salt, however, is an idiosyncratic one, remarkable in several fundamental aspects. Foremost, many who advocate salt reduction insist publicly that the controversy is a) either nonexistent, or b) due solely to the influence of the salt lobby and its paid consultant-scientists. Jeremiah Stamler, for instance, a cardiologist at Northwestern University Medical School in Chicago who has led the charge against salt for 2 decades, insists that the controversy has "no genuine scientific basis in reproducible fact." He attributes the appearance of controversy to the orchestrated resistance of the food processing industry, which he likens to the tobacco industry in the fight over cigarettes, always eager to obfuscate the facts. "My considerable experience indicates that there is no scientific interest on the part of any of these people to tell the truth," he says.
While Stamler's position may seem extreme, it is shared by administrators at the NHBPEP and the NHLBI, which funds all relevant research in this country. Jeff Cutler, director of the division of clinical applications and interventions at NIH and an advocate of salt restriction for over a decade, told Science that even to publish an article such as this one acknowledging the existence of the controversy is to play into the hands of the salt lobby. "As long as there are things in the media that say the salt controversy continues," Cutler says, "they win." Roccella concurs: To publicize the controversy, he told Science, serves only to undermine the public health of the nation.
After interviews with some 80 researchers, clinicians, and administrators throughout the world, however, it is safe to say that if ever there were a controversy over the interpretation of scientific data, this is it. In fact, the salt controversy may be what Sanford Miller calls the "number one perfect example of why science is a destabilizing force in public policy." Now a dean at the University of Texas Health Sciences Center, Miller helped shape salt policy 20 years ago as director of the Center for Food Safety and Applied Nutrition at the Food and Drug Administration. Then, he says, the data were bad, but they arguably supported the benefits of salt reduction. Now, both the data and the science are much improved, but they no longer provide forceful support for the recommendations.
This was written a decade ago. We've learned a lot since then. We have the Cochrane Review finding inadequate science to support general salt reduction. And now we have a new Cochrane Review that the approach of experts to treat lower and lower BP levels can be classified as expert opinion, not scientific fact.
What we need is more reliance on scientific data and less on the opinion of scientific experts. We need more confidence in the scientific method and more humility by many who profess to embrace its results. In the area of salt and health, including blood pressure, the role of overall dietary quality, the role of hormones, insulin resistance, etc.
In 2007, the poet Ted Sheridan wrote "The More We Learn, the Less We Know For Sure ." In our present circumstance, these humbling observations strike home. But they're hardly new. In the last century, Albert Schweitzer observed: "As we acquire more knowledge, things do not become more comprehensible, but more mysterious." And far earlier, Lao Tsu rendered this enduring reminder: "To know that you do not know is the best."
It all leads back to the core principle: primum non nocere, "first, do no harm ." Confining our interventions to those with solid evidence avoids unintended consequences. Pride is one of the Seven Deadly Sins.
Candidate Obama pledged to confine his self-predicted tax increases to fund his campaign promises to the top 5% of taxpaying Americans (i.e. "the rich" who he said earn more than $250,000 -- the top 5% of earners earn one-third total earnings and pay 57% of federal taxes -- a rather "progressive" structure). Without wandering around the issues of funding for Social Security and Medicare, discussion on Capitol Hill these days about new taxes on foods shows just how hollow can be such populist campaign rhetoric.
I remember how in my home state of Wisconsin, enactment of a sales tax was conditioned on exemption from the tax for food and pharmaceuticals, "the basics." Good lobbying? Sure. But the concept was to avoid imposing further regressivity in the tax code.
Currently, Congress is only considering a tax on soft drinks. Surely, we'd concede that Coke and Pepsi aren't essential foods. Their nutritional value isn't their selling point. So the new food tax is being promoted to promote health -- to make this "bad" food more expensive and inhibit its consumption, ostensibly to prevent obesity. Economic incentives do work. Whether they would reduce obesity is another matter. It may be that it's just a power trip for those newly installed running the government and the next "nibble" in imposing "society's" values on us as individuals and that this is a slippery slope into extending that tax to other politically-incorrect foods.
But consider a further point: the very people who rail against "the rich" would promote this tax that would largely be paid by the "non-rich."
The Congressional Research Service estimates that 96.4% of the tax would be paid by people earning less than 250,000 and 70.6% by those earning less than $91,297. Hardly confined to the rich.
Perhaps if such taxes worked to combat obesity, decision-makers might be tempted to "soak the poor" to pay for predicted healthcare cost savings, but the two states that have such taxes on soft drinks (West Virginia since 1951 and Arkansas since 1992) aren't encouraging examples (WV is the nation's 5th most obese state; Arkansas, 6th). The soft drink folks point out that soft drink sales are actually down 9.6% in the past eight years (they don't say why, but probably more people drinking water) -- but that obesity in this period is up 2.5%.
William F. Shughart II, writing in the San Jose Mercury News June 24 (article # 1148414) predicted popular resistance and noted the nations' first "food tax" provoked the Whiskey Rebellion put down by armed troops led by George Washington. A stronger parallel might be the French gabelle which cost King Louis XVI his head in the French Revolution.
The Salt Institute is, among other things, a "health advocacy organization" trying to adhere to a fair statement of the science in an attempt to advance the public interest -- in this case, better health outcomes.
We're not alone, of course. There are many "health advocacy organizations" all calling for quality science harnessed to promote public health. Five with "well-oiled publicity machines" are highlighted in a July 6 article, "Whose side are health advocacy groups on" by the Los Angeles Times' "healthy skeptic," Chris Woolston. Woolston, unfortunately, betrays her own bias, leaning heavily on the Center for Media and Democracy, described as "a Madison, Wis.-based nonprofit organization that published PR Watch, a quarterly newsletter that tracks advocacy organizations and PR groups." Wikipedia points out that CMD is run by an "environmenalist writer and political activist" and has been accused by one of the groups under analysis as "a counterculture public relations effort disguised as an independent media organization." So, consider the source.
Among the "well-oiled publicity machines," naturally, is the Center for Science in the Public Interest, described neutrally as providing "reliable information" that CMD says "keeps them honest." Let me repeat, consider the source.
For years, the Salt Institute has been touting the findings of a 2004 study by Dr. Ashima Kant on "Dietary Patterns and Health Outcomes
." We've argued that
no single nutrient can explain the effect of diet on health (pdf 216.70 kB)
the diet provides context to food choices (pdf 405.43 kB)
. Healthy diets have predicted positive health outcomes and that's the advocacy position taken by the Salt Institute
. We've pointed to clear evidence that the best marker for a "quality diet" is potassium consumption
Dr. Kant has a new study, "Patterns of recommended dietary behaviors predict subsequent risk of mortality in a large cohort of men and women in the United States ," Kant concludes (see Table 2) that potassium and calcium are strongly related to overall dietary quality. No surprise there. What about sodium? A month earlier, another study of adherence to US Dietary Guidelines found that those consuming "better" diets actually consumed more salt (even though that diminished their overall diet quality score). So, Kant's findings would offer useful comparison.
Kant reported lots of nutrient variables including energy, energy from fat, alcohol, fiber, folate, Vitamins C and E, and carotene in addition to calcium and potassium. But not sodium.
Could it be another "inconvenient truth"?
Using data from the National Center for Health Statistics, National Academy of Sciences and the Bureau of Labor Statistics, Timothy Dall, et. al. of The Lewin Group documented that reducing calories by less than 5% would produce economic benefits of about $100 billion. Adopting the most anti-salt interpretation of the medical evidence (i.e. Ignoring evidence that sodium reduction would produce no net health benefit), the authors found that reducing salt by more than double that amount (>12%) would yield benefits of $5 billion. Dall declared: "One of the most revealing finding was just how big an impact of 100 calories less per day can have compared to the more modest benefit of sodium reductions." (And, he failed to note that the sodium reduction was two-and-a-half times more severe than the curtailed calories).
Put another way, using the Dall analysis, reducing calories by less than half the magnitude being advocated for salt reduction would put national economic savings at $243 billion a year.
ConAgra's diet foods reduce both calories and sodium, but as Dall concedes: "Although many adults could benefit from cutting back on both sodium and calories, the return on investment for long-term health is clearly greater for calories."