Anti-salt zealots display a religious fervor for their cause, trampling scientists who remind them that actual evidence of a health benefit exists only in the end product of elaborate mathematical models extrapolating only blood pressure effects (and even those are often shrouded in withheld statistics preventing replication). There's an arrogance to their advocacy. And a familiarity.
Investigative science reporter Gary Taubes published the lead story in the New York Times Magazine on September 16, asking "Do We Really Know What Makes Us Healthy?" It's the tragic story of well-intended, plausible advocacy of hormone replacement therapy (HRT) for post-menopausal women. The bright promise, the powerful claims and the glittering possibilities all came crashing down a few years ago when it was found that for many if not most of the target audience, the "cure" was killing far more than it was helping.
Taubes called for more "self-doubt" and recommital to the discipline of scientific investigation, foregoing the passion of the righteous objective for the surer cycle of scientific advance -- proposing hypotheses, testing them to discard most of them and then repeating the cycle to refine those who pass muster.
As he pointed out:
While it is easy to find authority figures in medicine and public health who will argue that today's version of H.R.T. wisdom is assuredly the correct one, it's equally easy to find authorities who will say that surely we don't know. The one thing on which they will all agree is that the kind of experimental trial necessary to determine the truth would be excessively expensive and time-consuming and so will almost assuredly never happen. Meanwhile, the question of how many women may have died prematurely or suffered strokes or breast cancer because they were taking a pill that their physicians had prescribed to protect them against heart disease lingers unanswered. A reasonable estimate would be tens of thousands.
In conclusion, Taubes cautions:
All of this suggests that the best advice is to keep in mind the law of unintended consequences. The reason clinicians test drugs with randomized trials is to establish whether the hoped-for benefits are real and, if so, whether there are unforeseen side effects that may outweigh the benefits. If the implication of an epidemiologist's study is that some drug or diet will bring us improved prosperity and health, then wonder about the unforeseen consequences. In these cases, it's never a bad idea to remain skeptical until somebody spends the time and the money to do a randomized trial and, contrary to much of the history of the endeavor to date, fails to refute it.
You can't discern the cankers and the warts at 30,000 feet, but taking in the big picture often helps us understand the motivations that play out as the tangled inconsistencies of daily news stories about health. There are some whose mission in life is to point in alarm at instances where individuals or society comes up short -- where problems mar perfection. These professional and persistent pessimists, in the health arena, would have us focus attention and resources on such interventions as dietary changes ostensibly to effect improved health outcomes, but based only on plausible, but unproven scientific evidence.
A blog today on JunkFoodScience hits the nail on the head:
There's been so much good news recently about the state of our health and that of children. This has clearly distressed alarmists. To keep their gloomy myths alive, they've tried to: A). bury the news and B). convince us that good is really bad.
With people not buying any of that, they've added plan C: scream louder. As Dr Ian Campbell, medical director of Weight Concern, told the BBC news this week: "We are not making enough progress!"
Facts have such a troublesome habit of getting in the way of agendas. Let's look at three major new health reports that all brought good news.
Author Sandy Szwarc points out that the 2006 National Health Interview Survey released recently found 88% of Americans self-report good or excellent health, new figures released this past week from the Centers for Disease Control and Prevention showing strong historic trends of lengthening life expectancies and falling rates of heart disease, and a UNCEF announcement this week that more children are surviving today than ever before in history.
We think the glass is at least half full, and filling steadily.
During our daily review of all legislation related to salt, it was a pleasant surprise to come across the final filing and adoption of the West Virginia division of health nursing home licensure rule that became effective July 1, 2007. The purpose of this legislation was to implement state and federal law governing the licensing, operation, and standard of care in nursing homes located in the State of West Virginia. The goal is to help each nursing home resident attain or maintain the highest practicable physical, mental and psychosocial well-being.
Among the requirements explicitly stated are:
8.15.d. - A nursing home shall provide each resident with: Food prepared with salt, unless contraindicated by a physician's order; and, the salt should be iodized.
Finally, legislation based on the genuine requirements of a person rather than a politically correct interpretation of populist nutrition. Time and time again we have read of the negative effects of low salt diets prescribed to nursing home residents leading to chronic dehydration and hyponatriumia (salt deficiency). Often, these low salt diets lead to other major complications including bone fragility and increased cardiovascular risk. The insistence that the salt be iodized is an additional indication that whoever wrote up this rule did their homework. Bravo!It is refreshing to see that there are still legislators out there willing to take on the responsibility of doing things right.
Perhaps you read the article published this week in the online Journal of Human Hypertension (paid subscription required) by Dr. Graham MacGregor claiming dietary salt was responsible for high blood pressure in children. MacGregor and colleagues claim their results support "a reduction in salt intake for children and adolescents."
Not so fast. Though the media carried the author's conclusions from the study, an accompanying editorial (free) by Dr. Michael H. Alderman, immediate past president of the International Society of Hypertension, in the same edition points out that the entire relationship is due to the fact that those who ate more salt ate more food. Adjusting for caloric intake wiped out the significance of the relationship. Nor was there any difference between the high-salt and low-salt groups in terms of preference for adding salt at the table. Alderman pointed out that those consuming more salt and calories may also have had more adequate intakes of other vital, growth-related nutrients, but that the study did not include these data. Thus, Alderman concludes that the data "support the Cochrane Collaboration conclusion that there was not sufficient evidence for a general dietary recommendation to reduce sodium intake."
Alderman cautioned against following MacGregor's prescription of having children reduce dietary salt.
...randomized clinical trials in adults have shown that lowering sodium intake increases sympathetic nerve activity, reduces insulin sensitivity, increases the activity of the renin-angiotensin system and increases aldosterone secretion.
Do these or other changes occur in children? This is critical because, of course, the health impact of any intervention is the sum total of all its consequences. While I remain an agnostic on that score, I continue to believe firmly that solid knowledge based on evidence of benefit and risk must precede any clinical or public health intervention -- particularly when it comes to dependent children. Good observational studies such as this one generate hypotheses. They need to be tested in clinical trials. Absent such evidence, and absent some pressing public health challenge, therapeutic restraint may be the best and safest way to avoid doing harm.
Alderman may be "agnostic" with regard to his pursuit of an evidentiary basis for an intervention. It's too bad too many proponents of salt reduction seem to advance their arguments with strong faith and religious zeal -- and without scientific basis. We've heard no better argument against the establishment of a state religion.
The U.K. Telegraph reported the story of 110 year old Mary Brown, of Surrey, who attributes her cenetenarian plus status to sprinkling all of her food with plenty of salt . Despite all the negative publicity issued by the Food Sandards Agency's anti-salt campaign , Mary kept to her regular consumption of salt and has lived far beyond the average life expectancy. We wish her continued life and good health.
This is not the first time we hear that salt contributes to continued good health in later years. One Canadian cardiologist wrote us that he felt the low salt diets often prescribed to the elderly led to chronic dehydration and hyponatriumia (salt defficiency). As a result. people became very drowsy and suffered a range of salt-defficiency-related metabolic disorders. Often, this led to instability in walking or standing and a significant jump in the risk of large bone or pelvic fractures - all due to a low-salt diet. The cadiologist in question had been treating patients for 65 years - more than a lifetime of experience. He finishes his letter by saying,
"Spending your golden years in a retirement home with a low-salt diet will convert your last years to a long chronic illness."
Despite her love for salt, 110 year old Mary Brown says, "Everything else should be taken in moderation, except family and friends.
Mort Satin sent in this blog.
This past week saw the announcement of the European Food Safety Authority (EFSA) Scientific Colloquium 9 - Nutrient Profiling for foods bearing Nutrition and Health Claims, to be held from 11 - 12 October 2007 in Parma, a city best known for its fabulous Parma Ham*, as well as the King of cheeses, Parmigiano Reggiano**.
Not surprisingly, the European food agency at the forefront of the nutrient profiling is the Food Standards Agency (FSA) of the UK. Concerned with the rise in obesity, the FSA looked for approaches to nutrition that had the potential to make it easier for consumers to make healthy choices. They argued that it was really the 'imbalance' in the consumption of individual foods that caused health problems, not the overall balance of the diet. It's really not the Mediterranean Diet, it's the fish…or is it the olive oil….the fruits and vegetables….the capers…..truffles…?
In other words, food is considered to be little more than an independent carrier of nutrients. Depending upon the 'balance' of these nutrients, foods would be characterized in a nutrient profile. That not being enough, the profiles would be accompanied by decision signals such as traffic lights that would make it even easier for the consumers to make an "informed" decision. Traffic lights are considered to be useful signals for any being at or above the intelligence of a magpie.
It now appears that, in Europe, this concept has reached a point of no return. The ultimate price that Europe, formerly the global pedestal of fine food, had to pay for nutrition and health claims regulation. The rest will be tedious bureaucracy.
In her landmark book, "The March of Folly," historian Barbara Tuchman defines the characteristics of folly as initiatives that: 1) are contrary to the self-interest of the society pursuing them; 2) are conducted over a period of time, not simply a burst of irrational behavior; 3) are conducted by a number of individuals, not just one deranged maniac and, most importantly; 4) are cautioned by a considerable number of people alive at the time who pointed out correctly why the initiative in question was folly.
In future blogs, we hope to examine the folly of nutrient profiling in detail. If foods were nothing more than carriers of nutrients the future of eating will be little more than a large, perfectly balanced food pill accompanied by a glass of water, and, if you really felt nostalgic, a glass of water and a gelcap of wine concentrate. Good food culture does exist and doesn't require a traffic light to legitimize it. Rather than invent a new model, perhaps it would have been better to copy another neighbor's successful model - but I guess that's not what the sweeping powers vested in public authorities do.
We will also look at the science of nutrient profiling. Our entire base of knowledge for nutrients in foods comes from chemical analysis. To make matters worse, the nutrient profiles reflect laboratory analytical results, not the bioavailability of nutrients in living systems. The impact of one food component upon the other in the gut is never determined for the profiles. Fiber decreases digestibility and consequently bioavailability - how is this factored into the profiles? In fact the profiles never consider indigestibility - a total disgrace from a nutrition science point of view and a matter that would make Dennis Burkitt, discoverer of Burkitt's Lymphoma and one of Britain's most intuitive scientists of the 20th century turn over in his Bisley, Gloucestershire grave.
The nutrient profiles give no indication of the interactions and dynamics taking place in the gut when normal diets are consumed. Dietary regimes incorporate particular food combinations and we have never determined how indigestibility of one component may affect nutrient availability of all other components in the diet. Because the nutrient data tables we use don't relate to this issue at all and, by use of these tables, we incorrectly presume that there is no such interaction - even though not single a nutritionist would agree with this. Thus, the inexorable march of folly rolls along.
*Pig meat profile #4276 (water 50,84%; protein 22,75%; salt 4,84%; fat 21,01%) ** Salt-cured cow milk curd profile #76383 (water 31.98%; protein 36.14%; salt 2.28%; fat 28.6%)