William McGurn's op ed in today's Wall Street Journal on "Harry Reid's 'Evil' Moment ," brings to mind the ongoing similar campaign to de-legitimize dissent from the orthodoxy of salt reduction. McGurn recalls the mainstream media outrage when U.S. presidents described the Soviet Union as an "evil empire" and North Korea, Iran and Iraq (at the time), an "axis of evil." More recently, when House Speaker Nancy Pelosi accused those opposing President Obama's health care recommendations as "un-American" and Senate Majority Leader Harry Reid following in her train calling those protesting the "public option" health care proposal "evil mongers," the media have been silent about the characterization.
Indeed, it does seem a bit over the top to use the same rhetoric to describe opponents in a domestic American political debate with the same terms as truly "un-American" regimes that employ (or employed) cruel repression as their modus operandi.
What struck me in the McGurn column, is the parallel tactic being employed by proponents of universal sodium reduction in an attempt to deny the controversy among scientists about the scientific underpinnings offered to support having all Americans eat less salt. When the Royal Society of Chemistry conducted a debate in London several years ago, I laid out the evidence amassed by renowned scientists in peer-reviewed medical journals showing the lack of evidence of a health benefit for reduced-sodium diets; my opponent, Dr. Graham MacGregor, eschewed the science and reminded the audience that I was not a medical doctor and my salary was paid by salt producers. When the president of the International Society of Hypertension used his presidential address to decry the misdirection of anti-sodium proponents in focusing on blood pressure rather than health impacts, the mainstream groups pointed out that the Salt Institute has consulted with this acknowledged expert -- even though the consultancy was unpaid -- as if to say that somehow our seeking after the best quality scientific advice and the doctor's proffering his expertise to those dissenting from a view to which he had repeatedly objected is illegitimate.
Just as Americans should recoil from attempts to intimidate debate on legitimate Congressional debate, so should we be concerned at attempts to delegitimize the public health nutrition debate on sodium and health.
The “gold standard” in determining how much sodium you eat is how much you excrete. If healthy, the kidney processes many times over the amount of sodium a person ingests but excretes almost exactly the amount taken in. “Everyone” knows that! All medical studies of dietary sodium are concerned about how to measure intake since sodium isn’t something discrete like a banana or apple; it’s consumed in very small amounts in virtually everything. Dietary recall has become a refined art, but most scientists agree that even the best recall techniques pale in accuracy to measuring urinary sodium – the “gold standard.”
In recent years, however, much like other “truths” we’ve “known” about sodium, our knowledge is becoming a bit less ironclad. The May-June issue of Seminars in Dialysis carries an iconoclastic article by German nephrologist Jens Titze, “Water-free sodium accumulation ” questioning the concept that the amount of steady-state sodium in the body is unchanging. Titze suggests that “large amounts of Na+ can be accumulated” which “provides an extrarenal regulatory alternative in the maintenance of body fluid volume and blood pressure control.” Titze’s conclusion:
The physiology and pathophysiology of body Na+ distribution is more complex than believed. Therefore, clinical concepts based on oversimplified two-compartment models of Na+ balance must be experimentally re-evaluated.
Earlier studies of German astronauts and others have suggested much the same. It’s far too early to jettison our reliance on urinary sodium measurement, but it should remind us that science is ever evolving as we push back the shadows of the unknown.
I’m off to China in a few weeks for a worldwide Salt Symposium. In preparation, I’m auditing a course on Chinese history (“From Yao to Mao” --Tang Yao, not Yao Ming!). One of the study segments compares Confucianism with Taosim and the lesson seems apropos. Confucian thought was very orderly and hierarchical; people should conform to the “known.” Tao thought, to the contrary, is more skeptical, questioning whether we really understand the full nature of anything we think we “know.”
Thus, the “gold standard” of urinary sodium and concept of sodium homeostatis are Confucian and Titze and other skeptics have a Taoist strain.
With regard to our current controversy over dietary sodium, the National Heart, Lung and Blood Institute would represent the Confucian approach of bestowed truth while groups like the Cochrane Collaboration and other skeptics about conclusions being drawn from available evidence, embody a Taoist approach.
All of us, whether we readily accept and revere authority or revel in the flaws inherent in our quest for understanding, should use these small events as useful reminders of the larger need to remain humble and teachable in our approach to life.
The UN Development Program (UNDP) recently published its fifth Arab Human Development Report reviewing the state of affairs in the Arab world. Recently returned from a global meeting on salt iodization in Cairo, I eagerly plumbed the report, particularly Chapter 6 which described nutrition challenges. In that discussion, I found the pattern of the entire report -- and, I hope, a lesson for the rest of the world about the value of competitive ideas.
Chapter 6 on nutrition references iodine deficiency, but fails to make the iodine/brain development connection. It says lack of iodine and other vital nutrients "weaken children's bodies and impair their immune systems" and "reduces productivity." A missed opportunity.
The "missed opportunity" theme pervades the report. Fouad Ajami , professor at the School of Advanced International Studies at Johns Hopkins University, calls the report an "autopsy of the Arab condition," adding:
The first of these reports, published in 2002, was treated with deference. A group of Arab truth-tellers, it was believed, had broken with the evasions and the apologetics to tell of the sordid condition of Arab society—the autocratic political culture, the economic stagnation, the cultural decay. So all Arabs combined had a smaller manufacturing capacity than Finland with its five million people, and a vast Arabic-speaking world translated into Arabic a fifth of the foreign books that Greece with its 11 million people translates. With all the oil in the region, tens of millions of Arabs were living below the poverty line. Little has altered in the years separating the first of these reports from the most recent.
Ajami commends Iranians contesting the announced results of that country's recent presidential election. He would probably find joy in the purple-inked fingers of Iraqi voters as well. But he condemns (democratic, surely, not Islamist) activists in other countries for the ineffective opposition to authority. The lessons he draws are about truth-telling and free public discourse. While lamenting that the powers-that-be have eradicated dissent, he goes one step further, which struck me as instructive in our public health nutrition debate elsewhere in the world, particularly in the US and the UK. He declared:
The simple truth is that the Arab world has terrible rulers and worse oppositionists.
Let me use the contentious salt and health debate to illustrate this transference. In our instant debate, there are those who contend that because salt is related to blood pressure (lowering salt will reduce the blood pressure of some -- and more than the number for whom low-salt diets increase BP) and because populations with lower BP have lower risk of cardiovascular events like heart attacks and strokes, that this "proves" the efficacy of universal salt reduction. Opponents of a population intervention argue that studies of heart attack rates and cardiovascular mortality don't show those on low-salt diets fare better -- often they are placed at additional risk. Moreover, no amount of behavior modification has worked and the latest strategy, coercing the food industry into lowering the sodium density of its products, is untested and flies in the face of research showing that the unconscious brain sets the appetite for sodium.
The "rulers" here embrace the "sodium hypothesis" and endorse sodium reduction. Unfortunately, like the entrenched rulers of the Middle East, they are trying to stifle dissent and deny the legitimacy of the scientific debate. No matter that a recent presidential address to the International Society of Hypertension described the fundamentally-flawed basis for U.S. policy. No matter that the prestigious Cochrane Collaboration , inventors of "evidence-based medicine" finds no basis for the U.S. policy. No matter, even, that the government's own U.S. Preventive Services Task Force agrees that no evidence supports the strategy, the "rulers" press forward. In this regard, they are "terrible rulers," to use Ajami's term.
Worse, where is the opposition? If "the Arab world has terrible rulers and worse oppositionists," are we any better? True, some have decried the assault on sound science (see Taubes, "The (Political) Science of Salt ") and others lament the "nanny state " and "food police " second-guessing individual food choices and steamrolling the food industry on the salt content of its food. But until Kellogg's (html 54.86 kB) recently raised the prospect that the emperor had no clothes, the food industry has largely been content to ignore the science and pump pricier low-sodium foods into the marketplace, fellow-travelers willing to claim the government-bestowed "health" claim in return for their silence on issues of quality science.
Too often we point with disdain at the failings of others when what's needed is a harder look in the mirror. If we want science to guide health policy, we must become "truth-tellers" too.