First, a declaration of bias: I really don't believe in the "good foods"/"bad foods" dichotomy. For me, it's diets that matter. They matter a LOT, but individual food choices need a dietary context to explain a health impact. OK. That's said.

Yesterday, ePerspective from Food Technology Magazine published an important opinion column by Prof. Nancy Cohen, head of the UMass nutrition department: "Guiding America to healthier food choices? " Pity the poor consumer, it laments, confronted with "tens of thousands of products to choose from" in fashioning a healthy diet. The column notes that the federally-mandated Nutrition Facts label is increasingly supplemented with front-of-package (FOP) labels often bearing simplified symbols for good foods and bad foods. It points out a further feature is an online service that provides consumers information about the environmental performance, energy use, labor policies and social performance of the food manufacturer -- all available on the consumer's cell phone. It continues:

With all of this information available, will consumers make healthier choices? That remains to be seen. Little research has been conducted on whether FOP or at-shelf labeling will result in consumer diets that are more nutrient-dense or lower in calories. In an effort to increase diets with high nutrient ratings, will consumers consume diets that are lower in nutrients or beneficial food components that are not included in the rating system? With a variety of rating schemes in the marketplace, will consumers become more confused? Will the addition of the environmental and social dimensions simplify the decision-making process, or make it more complex? How will the consumer diet be affected by the presence of the environmental and social dimension? For example, will a consumer choose a product with more calcium, but with a low rating for labor practices?

While rating systems and labeling are designed to increase healthful food choices, they do not take into account three major factors in a consumer food decision: price, taste and convenience. Thus, consumers still need to factor in their own formulas for product choices.

I attended a liberal arts school where the educational emphasis was on learning how to think, not learning facts. The distinction is much like distinguishing education from training. We need facts, sure. Absolutely essential. The Nutrition Facts label probably gives us all -- or more -- than we need. What we need more is a sounder grounding in nutrition science, educating ourselves in how our food choices ultimately become our diet and how that process works. Until then, consumers will see ads and labels that appeal to the lowest common denominator making claims that may be "true" without consumers being able to tell if the claims should mean anything to them.

We need better consumer education, not traffic lights or number or letter codes telling us how healthy any particular food will be. Wholesome foods are healthy in a balanced quality diet. As the ePerspective reminds us, there is little research on the link between consumer label-driven food choices and overall dietary quality.

A generation ago, cartoonist Walt Kelly's opposum character Pogo famously observed, paraphrasing Admiral Perry's victory announcement from Lake Erie: "We have met the enemy and he is us." Labels can only get us so far, we need to improve American's basic understanding of nutrition and health to provide context for our consumer food choices.

The high rate of gastric (stomach) cancer in Japan has been cited by salt reduction activists as a rationale for cutting Americans’ salt intake, despite the fact that the Japanese consume nearly twice the level of U.S. consumers and the conclusion of the American Cancer Society that normal North American salt levels are not a cancer risk on this side of the Pacific.

Cancer researchers also agree that eating more fruits and vegetables has a protective effect against cancer. The DASH Diet, high in fruits vegetables and dairy products, is considered a high quality diet and is the diet endorsed by the Salt Institute. The DASH Diet does not curtail normal salt use.

Researchers and nutritionists further agree that Americans need to eat more vegetables; current intakes are significantly lower than recommendations.

With all that as prologue, consider the findings of an article in the April 1 edition of the journal Cancer Prevention Research . Animals infected with H pylori, the precursor of gastric cancer, were fed a diet high in broccoli sprouts decreased gastric inflammation and bacterial colonization. Broccoli is a natural chemoprotective agent preventing bacteria-induced oxidative stress of the stomach lining.

President George H.W. Bush (Bush 41) famously detested broccoli. He disliked its bitter taste. So do kids. Tests at The Ohio State University confirmed children find broccoli nearly unpalatable unless – here’s “the commercial” – unless it’s salted . The salt masks the bitterness of broccoli and encourages people to eat it.

So, eat your (salted) broccoli. It’s good for you.

Thus reads the headline of this week's NY Times article that captures, perfectly, the ongoing controversy over salt reduction. After composing this post, in a hotel room in Peoria, IL, I realized that Mort had been working on the same thought. So here's my take (read Mort's below ). Interestingly, in January, I forecast we'd already read the "best blog of the year " that just happened to be on this same subject. Now, I guess, we've read the "best MSM story of the year" on salt and health.

We couldn't summarize the issues any better than NYT Science editor John Tierney:

Suppose you wanted to test the effects of halving the amount of salt in people’s diets. If you were an academic researcher, you’d have to persuade your institutional review board that you had considered the risks and obtained informed consent from the participants.

You might, for instance, take note of a recent clinical trial in which heart patients put on a restricted-sodium diet fared worse than those on a normal diet. In light of new research suggesting that eating salt improves mood and combats depression, you might be alert for psychological effects of the new diet. You might worry that people would react to less-salty food by eating more of it, a trend you could monitor by comparing them with a control group.

But if you are the mayor of New York, no such constraints apply. You can simply announce, as Michael Bloomberg did, that the city is starting a “nationwide initiative” to pressure the food industry and restaurant chains to cut salt intake by half over the next decade. Why bother with consent forms when you can automatically enroll everyone in the experiment?

And why bother with a control group when you already know the experiment’s outcome? The city’s health commissioner, Thomas R. Frieden , has enumerated the results. If the food industry follows the city’s wishes, the health department’s Web site announces, “that action will lower health care costs and prevent 150,000 premature deaths every year.”

But that prediction is based on an estimate based on extrapolations based on assumptions that have yet to be demonstrated despite a half-century of efforts. No one knows how people would react to less-salty food, much less what would happen to their health.

Dr. Frieden has justified the new policy by pointing to the “compelling evidence” for the link between salt and blood pressure . It’s true that lowering salt has been shown to lower blood pressure on average, but that doesn’t mean it has been demonstrated to improve your health, for a couple of reasons.

First, a reduced-salt diet doesn’t lower everyone’s blood pressure. Some individuals’ blood pressure can actually rise in response to less salt, and most people aren’t affected much either way. The more notable drop in blood pressure tends to occur in some — but by no means all — people with hypertension , a condition that affects more than a quarter of American adults.

Second, even though lower blood pressure correlates with less heart disease, scientists haven’t demonstrated that eating less salt leads to better health and longer life. The results from observational studies have too often been inconclusive and contradictory. After reviewing the literature for the Cochrane Collaboration in 2003, researchers from Copenhagen University concluded that “there is little evidence for long-term benefit from reducing salt intake.”

A similar conclusion was reached in 2006 by Norman K. Hollenberg of Harvard Medical School. While it might make sense for some individuals to change their diets, he wrote, “the available evidence shows that the influence of salt intake is too inconsistent and generally too small to mandate policy decisions at the community level.”

Tierney continued, explaining how the recent randomized trial of health outcomes of low-salt diets for congestive heart failure patients documented the unexpected conclusion that:

Those on a low-sodium diet were more likely to be rehospitalized and to die, results that prompted the researchers to ask, “Is sodium an old enemy or a new friend?”

Tierney's point is that the new anti-salt campaign of NYC health commissioner Thomas Frieden is sailing into the wind of emerging research and the gale of scientific controversy. Will Frieden trim his sails, tack into the wind ... or capsize?

Well, it's about time!

The two articles in yesterday's New York Times science section, "Hold the Salt? " and "Public Policy That Makes Test Subjects of Us All " by John Tierney finally brought the goods home!

Taking the trouble to do a comprehensive review of all the evidence available, Tierney writes how the New York City Health Commissioner, Thomas R. Frieden's salt reduction initiative is based more on political expediency than scientific merit.

We applaud this journalist who took the time and trouble to do the research showing that the alarmists' predictions that current salt consumption patterns result in 150,000 premature deaths per year is not based on scientific data but merely a trumped up estimate based on extrapolations based on assumptions that have never, to this day, been proven. Up until now most journalists who never did their homework, misinformed their readers by always assuming it was a fact. Tierney set the record straight and quite rightly says, "No one knows how people would react to less-salty food, much less what would happen to their health."

The article goes on to say that the population's response to reduced salt intakes is heterogeneous and makes the valid point that some individual's blood pressure actually rises as a result of lower salt intake. Tierney goes on to quote the recent Cochrane Collaboration meta-review that concluded that there was little evidence for any long-term benefits of salt reduction. He also referred to two very recent studies that have shown that congestive heart failure patients who are put on low sodium diet (the gold standard in most medical practice) were much more likely to die or be rehospitalized than those placed on regular salt diets. Tierney also made reference to the recent University of Iowa study in rats demonstrating that salt was an essential component to dispel depression and enjoy normally pleasurable activities.

The author ended by stating what we have long believed at the Salt Institute. Policies that end up arbitrarily placing people on a restricted salt regime will effectively put consumers into one of the largest clinical trials ever carried out, without their knowledge or consent.

The American Public Health Association has been among those we've contested when they abandoned an outcomes- and evidence-based approach to public health nutrition. So it seems fair to compliment APHA when it gets it right. This week, APHA released its 2009 Agenda for Health Reform . It contains six "critical changes" to achieve "health improvement." (It also contains five recommendations for health care delivery, beyond our balliwick).

We hope APHA examines its previous program recommendations against these critical priorities and abandons, for example, its past advocacy of universal sodium reduction as inconsistent with its new policy priorities. The six "critical changes" include four goals we share, but would accord a lower priority: 1) investing more in prevention program "that have been proven to prevent disease and injury and improve the social determinants of health," 2) investing more to address "the chronic underfunding of the nation’s public health system," 3) improving programs "to reduce disparities in health," and 4) requiring "an annual report to the nation that holds the system accountable for achieving agreed upon health goals and outcomes. The federal government should develop appropriate standardized measures and health status indicators, along with methods for collecting, reporting and analyzing such data." We like the outcomes focus of #4; it almost rises to the higher priority we'd accord to APHA's other two "critical change" recommendations.

We hope the Obama Administration seriously addresses the other two recommendations which are:

Account for the real cost savings and cost avoidance of preventive and early intervention services at the individual and community levels through more accurate fiscal scoring methods. The Congressional Budget Office (CBO ) and the Office of Management and Budget (OMB ) should be directed to develop and implement methods to more accurately score the costs savings associated with community-based and other prevention programs.

and

Require methods to assess the impact federal policies and programs have on public health. Health is intricately tied to community design and directly affected by policies and programs across various sectors, including housing, transportation, environment, land use, agriculture, labor, education, trade and the economy. Therefore, health reform legislation should require a health impact assessment for all new federal policies and programs.

"Real cost" savings can only be determined by an examination of health outcomes of an intervention. We cannot support the APHA's call for a health impact on the vast array of policies -- at least as a priority recommendation -- but let's start with an assessment of policies intended to improve health. We are woefully light on real-world assessment. These two recommendations surely tie together. If we can assess real outcomes, we will better target our interventions and realize "real cost savings."

To exemplify these points, consider, naturally, the question of efforts to reduce population salt intakes. What "real cost savings" can be realized? We've seen the scary numbers produced by computer projections from models developed by salt reduction advocates. But consider the data. Three studies of the federal government's National Health and Nutrition Examination Survey have found those on the "recommended" levels of salt intake suffer between 20% and 37% greater mortality. The only two health outcomes randomized clinical trials of salt-reduction documented that high-risk congestive heart failure patients treated with low-salt diets died more often and more quickly and were readmitted to the hospital more frequently than those consuming regular amounts of salt. And evidence is now available that there exists in the human brain a "central regulation of sodium appetite " more powerful than conscious food choices which helps explain why salt intakes have been unchanged for a century and are unlikely to be modified by calls to substitute low-sodium foods for our normal diet.

So we join with APHA in endorsing new emphasis on examining actual health outcomes, not computerized models, and the real cost savings we can expect by properly targeting our interventions, abandoning those that aren't evidence-based or likely to deliver theorized benefits.

Bias in medical research isn't confined to financial matters, a recent Washington Post op ed explained. Dr. David A. Shaywitz , a former Harvard University endocrinologist and stem cell researcher, reminds

University research is not a pure enterprise; its researchers have feet of clay and are subject to an array of professional biases.

Consequently, our myopic obsession with industry conflicts of interest may have the unintended consequence of distracting us from some of the more important sources of prejudice and concern.

He might have included government researchers, either on-staff or on-the-research-dole. There are many conflicts and motivations for researchers to publish and interpret junk science. In many ways, the publications can be career-enhancing -- unless discovered and exposed. Writes Shaywitz:

Researchers are unlikely to become less self-serving -- just as reporters are unlikely to become less opportunistic in their hunt for news. Ultimately, it is up to each of us to develop a more skeptical ear, to approach received wisdom cautiously and to pay more attention to data than to narrative.

Amen.

Mail online, a UK popular website associated with the Daily Mail, recently ran an excellent article by journalist Jerome Burne on the work published in January, 2009 by Dr. Paul Welton and his group at Loyola University in Chicago.

Burne stressed the study suggested that by concentrating on the effects of salt on blood pressure we could be missing the bigger picture. That's because salt doesn't affect blood pressure on its own; it does so only in concert with another mineral - potassium. To go one step further, it should also be understood that by focusing on blood pressure alone we are missing the far more important issue of overall health outcomes. Of course, for some, blood pressure may indeed be an issue, however, health outcomes are paramount for everyone.

On the issue of blood pressure itself, the research indicated found that there was no significant difference in the risk of heart disease whether patients had been eating a lot or a little sodium. What did reduce the risk, however, was the ratio of sodium to its counter-balancing mineral potassium. Concuming more potassium tipped the balance in favour of reducung blood pressure for those who may be sensitive.

Burne went on to review evidence from the British medical Journal showing that cutting back on salt may help those taking medication for high blood pressure, but held no clear benefits for everyone else. He also referred to the excellent research carried out at the Albert Einstein College of Medicine in New York showing no benefit and perhaps harm accruing from salt reduction. Finally, Burne stressed the importance of DASH-type diet as being one of the most effective ways of improving cardiovascular health.

Obviously, we need many more journalists delving more deeply into the issue of salt and health.

Yesterday's Politico had an interesting article suggesting "A lesson for Obama from the other Roosevelt ." Bush White House aide Daniel M. Price extracted a quote of Theodore Roosevelt from historian Edmund Morris' TR biography, Theodore Rex . Roosevelt responded to a journalist who suggested that popular opinion favored nationalizing American railroads instead of Roosevelt's tack of increasing regulation; TR said:

Here is the thing you must bear in mind. I do not represent public opinion: I represent the public. There is a wide difference between the two, between the real interests of the public and the public’s opinion of those interests. I must represent not the excited opinion [of some], but the real interests of the whole people.

A parallel leapt to mind, probably because I spent yesterday in a meeting with medical scientists and nutrition experts. Many public health nutrition groups and the federal government have used "expert consensus" as an argument to support a public policy of encouraging everyone to eat less salt. Expert opinion mirrors public opinion in this case; the federal government has spent tens if not hundreds of millions of dollars "educating" the public and public opinion is that dietary salt is consumed in "excess" amounts. As in TR's apt distinction, however, there is a "wide difference between this expert/public opinion and the public's true interest.

The public cares about improving health. It cares about the quality of the evidence underlying public policy. And for good reason: physiology trumps expert opinion. Whether the experts get it right or not, the body is going to do "its thing" by responding to changing conditions. So it is with the science concerning dietary salt.

While some groups prescribe salt reduction, the inventors of "evidence-based medicine," the Cochrane Collaboration , finds insufficient evidence to recommend a population-wide lowering of dietary salt. The Cochrane Review, "Advice to reduce dietary salt for prevention of cardiovascular disease ," concluded: "There was not enough information to assess the effect of these changes in salt intake on health or deaths."

Policy should reflect the needs of the public, not public opinion. However that may play out in President Obama's efforts to stabilize the U.S. financial system, it's a sound prescription for healthy public nutrition policy.

In a new editorial commentary published today by the American Heart Association , John B. O'Connell MD points out that the AHA's new guidelines for managing heart failure patients are "eminence-based," not evidence-based. Nice turn of phrase, that.

It turns out that the guidelines include 24 recommendations. Only one is level of evidence A. O'Connell continues:

Although some have called such recommendations "eminence-based," until there are randomized controlled clinical trials to justify the recommendations, the quality of expertise on the panel and their collective experience justifies consensus recommendations.

The increased focus on quality of evidence underlying recommendations is refreshing, even if it reminds us of just how uncertain are the foundations of many "consensus" recommendations. Certainly salt reduction falls in that category.

Small amounts of a well-known white powder should be ingested daily to prevent coronary heart disease, the federal US Preventive Services Task Force (USPSTF) reiterated in a March 17 article in The Annals of Internal Medicine .

No, the white powder, in this article, isn't salt, it's aspirin. The USPSTF reiterated its 2002 finding that men over age 45 and women over age 55 should take aspirin. The recommendations receive the top "A" grade for strength of evidence supporting the recommendation.

USPSTF does have a recommendation on that "other white powder" (no, not THAT one!) -- salt. USPSTF concludes: "There is insufficient evidence to recommend for against counseling the general population to reduce dietary sodium intake....

That's what USPSTF concludes for aspirin-taking advice when men and women reach 80.

If we believe in evidence-based health recommendations, let's not pick and choose. Let's take our daily aspirin...and our daily salt!

Newspapers and websites around the country are reporting a story coming out of the American Heart Association's Cardiovascular Disease Epidemiology and Prevention annual conference in Palm Harbor, Florida yesterday. Medical researcher Dr. Kirsten Bibbins-Domingo, an assistant professor of medicine and epidemiology at the University of California, San Francisco, reported that if Americans cut just one gram of salt from their daily diet, there would be 250,000 fewer new cases of heart disease and more than 200,000 fewer deaths over a decade.

This dramatic statement was not the result of any clinical trials or observed data but rather the product of a computer simulation called the Coronary Heart Disease Policy Model. Many such statistical models are available and were the subject of a systematic review in 2006. The conclusion of this review stated that

"…few Coronary Heart Disease Policy Models have been calibrated, replicated or validated against minimum quality criteria. Before being accepted as a policy aid, any model should explicitly include a statement of its aims, assumptions, outputs, strengths and limitations."

Despite this, most media devoted to food and health report this study without any qualifications - as if it were fact and not the consequence of speculation and assumption. It's little wonder that in his book "Life on the Mississippi" Mark Twain wrote:

"There is something fascinating about science. One gets such wholesale returns of conjecture out of such a trifling investment of fact."

Over the last number of years we have heard, seen and read about hundreds, of medical breakthroughs and pending calamities that vanished into thin air after a short period, never to be heard from again. Most of these were based on conjectures and assumptions that never panned out, yet, the media, consumer advocates and the medical establishment latched onto them without any reference to the quality of data - as if they were proven fact.

It's a pity that there isn’t a requirement to have all public statements regarding health, conform to a minimum level of evidentiary quality. At the very least, there should be a system established so that consumers will be informed of the level of evidence behind any health-related public statements or claims. After all, the consumer advocacy movement, followed by the medical establishment, was the first to insist on food labels so that consumers would be better informed as to what they were getting for their money. Why shouldn’t the same sentiment govern the public statements consumers get concerning our health, so that they can judge their value and trustworthiness?

The Salt Institute has long extolled "performance-based" policies. For roadways, "performance management" means policy driven by outcomes measured in terms of safety and reliability in moving people and goods from point A to point B. For dietary salt, we've called for "performance-based" policies driven by health outcomes: a person's salt intake should be driven by the health consequences of that person's dietary salt intake. The goal is safe, reliable and efficient roads and longer, healthier lives.

University of California-Berkeley law professor Stephen D. Sugarman authored an op ed piece in today's San Francisco Chronicle urging what he termed "performance-based regulation" of dietary salt intake. He called for a "cap and trade" system as has been widely debated as a means of curbing America's carbon emissions.

Sugarman should stick with law. He clearly doesn't understand physiology, economics or history.

His argument goes off-track early when he posits that consumers are helpless victims of food processors. To him, consumers are unable to determine how much salt they're eating despite widespread use of nutrition labels. Since a major portion of the salt Americans ingest comes from processed foods, the clear answer for Sugarman is to regulate salt consumption by "imposing financial penalties" on food manufacturers. Specifically, "we could demand that large retailers cut the total amount of salt in food they sell." Retailers like Wal-Mart would then demand "its food providers to reduce the salt they add to their products, reducing the volume of salty products it sells (by raising the price, providing smaller or less attractive shelf space), introducing and promoting less-salty or salt-free alternatives, given Wal-Mart customers more information about the salt they're consuming, and more." Trouble is: that's hardly creative. That's what's happening now here in North America and in the UK. And it's not working.

Food procesors have used a "stealth" approach to paring back the salt content of food products. They put their salt alternative products at eye level on grocery shelves and relegate "round cans" to shoetop shelves. They've introduced an enormous array of "low-salt" or "salt free" products. They've provided consumer education materials going far beyond federally-mandated nutrition labels. And they've watched as salt intake continues unabated.

The problem lies not with the food manufacturers, but with the customers. And customers "know" they want to cut back on salt. Some assiduously count milligrams of sodium towards a target based on a "daily reference value." To no avail. Why not? Physiology. Economics. History.

Human salt intakes are unchanged over the past century. When humans have access to salt, they consume it in a predictable and fairly narrow range of about 2,300 - 4,600 milligrams sodium a day. We know this because for many years medical scientists have studied various health concerns and routinely extracted 24-hour urine specimens. Those numbers and unchanged over many decades. Nor are humans unique: livestock and poultry, like humans, need salt to live and each species has developed its own predictable, narrow range of intakes -- the phenomenon is well understood by animal nutritionists.

Why it should be so has been more elusive, but even that conundrum is yielding to scientific assault. A February 2008 Experimental Physiology article on "Central regulation of sodium appetite " explains how our brains control salt intake. Appetite is what counts. Not taste. Not politically-correct menu choices. Not even the cost or quantity of the food. Americans eat a diet far less dense in sodium compared to calories than they used to -- perhaps because consumers have the tools and the motivation to try to reduce salt. They just cannot behaviorally control a hard-wired, neurally-mediated appetite. Sugarman suggests food manufacturers and retailers can "reduce the flow of slat in ways that best satisfy consumer preferences." But all "preferences" are not conscious choices. Salt appetite is not a conscious consumer choice.

Thus, the economics is all wrong. "Demand" is not elastic at all. It's fixed. You can reduce the amount of salt per serving and all that you'll produce is consumption of more servings. Taxing Wal-Mart for the amount of salt it sells would be impossible to control; would you have Wal-Mart tell its customers to buy their food elsewhere because they had used up their allotment?

And history gives no comfort either. Recognizing this inelasticity of demand -- the physiologic requirement expressed as salt appetite -- many countries throughout history have monopolized the salt trade and taxed it heavily. The French gabelle triggered the bloody French Revolution. China's imperial salt tax funded much of the country's rule, from dynasty to dynasty. India won independence in no small part based on Gandhi's adroit exploitation of indefensible British "protection" of salt production.

Sugarman admits he has no idea how much cutting salt would lower blood pressure. Of course, that's the wrong question. If he's interested in "performance" it's not blood pressure by health outcomes he should be championing. He says he seeks "a big step in a healthier direction, and performance-based regulation is the most promising way to get there."

We agree, Mr. Sugarman, but you need to learn a bit more about what performance really means. A performance-based intervention would improve health. Salt reduction won't.

Sanitary and phytosanitary measures are applied to protect human or animal life from risks arising from additives, contaminants, toxins or pathogenic organisms in their food. The World Trade Organization (WTO) Agreement on Sanitary and Phytosanitary Measures (SPS) restricts the use of unjustified measures for the purpose of trade protection.

The aim of the SPS Agreement is to ensure that regulatory measures are not misused for protectionist purposes and do not result in unnecessary barriers to international trade. In particular, measures to protect health must be based on the analysis and assessment of objective and accurate scientific data. Standards are developed by leading scientists in the field and governmental experts on health protection and are subject to international scrutiny and review.

If national requirement results in a greater restriction of trade, a country may be asked to provide scientific justification. The Agreement checks unjustified discrimination in the use of sanitary and phytosanitary measures, particularly if they are in favour of domestic products. In a trade dispute regarding a sanitary or phytosanitary measure, the normal WTO dispute settlement procedures are used, and advice from appropriate scientific experts can be sought.

If regulations are set arbitrarily, they could be used as an excuse for protectionism. The Agreement on Technical Barriers to Trade tries to ensure that regulations, standards, testing and certification procedures do not create unnecessary obstacles and are based upon sound scientific information. Because a large portion of dietary sodium enters the food supply through processed foods, sodium reduction programs in the UK and Canada are directed at reducing the salt content of these products. While most consumers and policy-makers perceive processed foods to be convenience foods made by large scale manufacturers, a great many well-known traditional foods customarily considered to be high quality, healthy products are also processed and contribute significantly to the dietary sodium we consume. Examples of such foods can be found in the range of epicurean foods imported from Italy, for example. Hard cheeses such as Parmesan and Pecorino ; semisoft Sardos and softer blue cheeses such as Gorgonzola ; olives, anchovies and capers; Parma ham, smoked prosciutto and Italian dry-cured salamis and sausages and Baccalà (salted cod) all have been traditionally produced for centuries. They are all known internationally and are produced to exacting standards of identity.

These traditional Italian foods have a high salt content that has characterized their quality and international acceptance. In a personal comment a senior US FDA staff member once made to me, he indicated that for close to a century, all imported ham from around the world had been analyzed for Trichinella spiralis infection and Parma ham was the only product where this infection was never detected. He attributed this fact to the salt levels used in traditional Parma ham production. For more than 350 years, Parmesano Reggiano, considered to be the King of Cheeses , has been artisanally made by small manufacturers in the Parma region. They are so tied to tradition that they still measure the products temperature by the Réaumur scale - a temperature scale developed during the Renaissance period that stopped being popular elsewhere by the end of the 18th century. To cure their fresh cheese, they immerse the huge rounds in saturated sea salt baths (some of which have been in continual operation for more than 100 years - you can see beautiful 4-5 inch wide salt crystals sitting on the bottom of these crystal clear baths). The only changes these manufacturers have made in the process during the 20th century was to convert to sophisticated digital temperature controls (still using the Réaumur scale) and to use more expensive recrystallized sea salt to improve the products’ flavor.

Although these specialties are staples in the Italian diet and are high in salt, the Italian population continues to have amongst the very best cardiovascular statistics in the world. In fact, the per capita consumption of salt in Italy and other Mediterranean countries is considerably higher than in North America or the Northern Europe, yet their cardiovascular performance is far superior.

If, in the course of executing a sodium reduction program, such as we currently see in Canada and the UK, restrictions are placed upon the salt contents of classes of foods, many of which may have long-established standards of identity, such an action may be perceived by exporting countries as an artificial technical trade barrier and institute a dispute settlement procedure at the WTO. For example, an exporting country, such as Italy, may well claim that it was never conclusively demonstrated that, for the majority of the population, salt reduction has any significant health benefits. In such an argument, Italy can point to its own excellent cardiovascular performance as proof that higher salt consumption does not have any negative impacts on health.

Such a dispute would likely be adjudicated by FAO (Food and Agricultural Organization of the United Nations) an institution that routinely relies on risk assessment criteria drawn from the broadest base of scientific information. This review would not be restricted to the impact of salt on blood pressure alone, but would extend far beyond to cover other health biomarkers and risk factors as well. In carrying out this review, the FAO convenes a panel of experts that are chosen for their objectivity and expertise in making evaluations based on the preponderance and quality of scientific evidence.

During an open session of the Canadian Multi-stakeholder Working Group on Sodium Reduction held in Ottawa on February 19, I described every aspect of the salt and health debate that such a working group would analyze. It was clear to the assembled audience, that if a thorough and objective analysis were carried out on all the data available that the panel of experts would overwhelmingly conclude that salt reduction in the food supply will be a strategy destined to failure and, worse, that it may hold the potential for unintended consequences that may cause harm to a significant portion of the population. We have seen this all before when consumer advocates and the medical establishment put the fear of fat into the minds of the public. In short order, the market was swamped with every form of no fat and low fat foods imaginable a phenomenon considered by many to have ushered in the current epidemic of obesity.

It is human nature to continually want to improve things. In a great many cases, when our knowledge was sufficient and the universe unfolded as expected, our efforts led to social, material and medical advances that have stood the test of time. In other cases, rather than delivering the expected benefits, these innovations led to unintended consequences that plagued us for long periods before we discovered the true nature of their effects and dispensed with them. One of the areas of interest that has seen a great many of these dilemmas has been the field of food and nutrition.

The ancient Greeks and Romans discovered that when they coated the interiors of their copper or bronze cooking pots with lead, many of the food and beverages they prepared tasted much better. Nowhere was this more evident than in the preparation of acidic products such as wines. Popular recipes of the day called for the boiling of the must from grapes in lead-lined vessels in order to prepare a liquid additive that would enhance the color, flavor and shelf life of wine. The resultant sweet, syrupy liquid was called “sapa”.

Sure, they could have added natural honey as they had for centuries, but this new development was considered a real advancement. What actually happened when they boiled the must in lead vessels was a reaction between the acetic acid from the grape ferment and the lead of the pot to form a compound called lead acetate. Lead acetate is also called ‘lead sugar’ because it is so sweet and it made wine more tasty.

What they did not know was that lead sugar was toxic - not the acute toxicity that could be detected immediately - but the chronic toxicity which often evades immediate notice. Thus, the unintended consequence of lead poisoning ushered in an epidemic of morbidity and mortality that lasted for more than 1500 years before being discovered . Unbelievably, this new development in taste contributed significantly to the downfall of Rome, because more than two thirds of the leading Roman aristocrats who served between 30 – 220 C.E. including all the Roman Emperors, were most likely victims of lead poisoning .

In the current rush to replace salt (sodium chloride) in our diet with chemicals that mimic its taste, we may be seeing "déjà vu, all over again." Salt replacement is a very complex task because nothing quite duplicates its taste perfectly. For example, not only does potassium chloride have a considerably lower taste intensity, but it has a large bitter component that has to be compensated for. To get over the bitterness, chemicals such as 2,4-dihydroxybenzoic acid have to be added. But it doesn't stop there because the low-level of salty taste inherent in all the proposed salt replacers require that they be enhanced through the employment of chemical enhancers such as inosine 5-monophosphate, disodium guanylate, glycine monoethyl ester, ornithyl-β-alanine, L-arginine or (N-(1-Carboxethyl)-6-hydroxymethyl-pyridinium-3-ol) commonly known as alapyridaine.

In the past, these industrial chemicals have been approved as additives with the understanding that they would be used in minute amounts within our foods. However, if they are to be used to replace salt throughout our food system we will consume a lot more of them than ever anticipated. Unless long-term chronic toxicity testing of these chemicals is carried out, we may very well be exposing ourselves to the unintended consequences that have befallen humankind in the past. In fact, it is strange that consumer advocacy groups such as CSPI have not questioned their use more closely.

Of course, in more recent history, we have seen the good intentions of trying to eliminate all forms of fat in our diet. Unfortunately, good intentions may not have been enough, because we are now coming to realize that the whole genre of no fat, low fat and reduced fat foods may have contributed significantly to the epidemic of obesity we now see all around us.

Before we go grabbing at another dietary gold ring, it may be prudent to get all our knowledge in place if we want the universal to unfold as it should.

German bakers are up in arms, reports Judy Dempsey in the Feb. 26 NY Times .

European Union officials have offered to sit down with German bakers in an endeavor to defuse the latest uproar over proposed regulations from Brussels.

Echoing a recent furor over legislation dictating the size, shape and texture of fruits and vegetables, German bakers have criticized a proposal that would force a change in the salt content of their products.

The anger of the bakers — who condemned the bureaucrats in Brussels as “taste police” — seems to reflect a rising resentment of the European Union by a country that has long been among its biggest supporters.

The bakers' association declared:

“What the E.U. is doing amounts to stupid interference. ... “The E.U. is trying to change the way we bake our bread, change the way we market it — and of all things, change the taste of our bread. And all this is taking place just months before we go to the polls to elect a new European Parliament. This is exactly the kind of interference and overregulation by Brussels that annoys citizens and even makes the E.U. unpopular.”

This is noteworthy on two counts:

1. Until now, food companies in Europe and North America acted like lapdogs of the food police, failing to challenge the fundamentally-flawed science behind "healthy" food definitions and taking the stance that food manufacturers can avoid being tarred for destroying their customers' health by rolling out new "healthy" foods; and
2. The bakers' lobbying group, the Central Association of German Bakeries, has developed a new line of defense: preparing low-salt breads as the EU wants is energy inefficient, "undermining its goal of improving energy efficiency." The article quotes a Bavarian bakery spokesperson declaring: "We are being asked to change our recipes by reducing the level of salt. But that means we will have to bake the bread for longer and use more energy."

We don't know the validity of the energy efficiency argument, but it's heartening that food companies are awakening to the insatiable bureaucratic appetite for regulating personal dietary choices.