No doubt the UK's anti-salt publicity machine was feeling pleased with their success in generating headlines for a recent piece that suggested that infants need to cut their salt in half. That is, until junkfoodscience called their bluff.
We don't know if blogger-nurse Sandy Szwarc knew anything about the multi-million pound British anti-salt ad campaign featuring "Sid, the Slug," a cartoon reminder of one of the 14,000 beneficial uses of salt -- to kill slugs. Szwarc suggests the public "pour salt on it" -- the study in question. As she laments:
Such extraordinary claims require extraordinary evidence. Does this study hold up?
This study is said to be the "first ever meta-analysis of salt reduction studies in children." And it epitomizes every caveat of these types of studies. MacGregor and He "developed a strategy" of their own design to look for words in several databases and through reference lists at the end of articles to find studies of salt reduction in children. They only used studies published in English and of the 33 they found, decided to use 10 on children for this report. The studies all had different designs, with only one being a double-blind trail and only 9 were randomized; the studies varied in length from 2 weeks to 3 years; compliance with salt reductions appeared poor in two of the studies; we have no information on the racial/ethnic mix of the children and if it is representative of the general population; and only 3 measured 24-hour urinary sodium levels - which the researchers admitted is "the only accurate way to assess dietary salt intake." Simplifying what they did next, they pooled the data on blood pressures and net changes in salt intake, and used statistics to estimate the changes as needed to fill in missing data. Then, they applied two computer models to plot the results and more statistical analyses to reach their findings.
What they reported was that cutting salt intake by 42% reduced systolic blood pressures in the children by 1.17 mmHg. Most parents and children would consider such a salt reduction - nearly in half - to be extreme; while most doctors would debate the clinical significance of a mere 1 point reduction in blood pressure. Taking blood pressures in young children is an imprecise task at best and the children in these different studies were also at varying stages of development, with corresponding variable changes in blood pressures over the study durations, according to their growth and size.
The researchers stated that the "physiological need for salt intake in children has not been studied," but concluded anyway that "current salt intake in children is unnecessarily high and is very likely to predispose children to develop hypertension later."
They went on to declare that these results "provide strong support for a reduction in salt intake for children. [And] if continued, may well lessen the subsequent rise in BP with age and prevent the development of hypertension. This would result in major reductions in cardiovascular disease."
Their press release promised possible "massive population health gains."
·But this study did not examine a single child.
·It conducted no clinical research to learn how much salt is needed or might be harmful for children.
·It offered no clinical evidence to know if a lower blood pressure reading of 1 point means anything for children's health or is maintained as a child grows.
·It offered no proof that a blood pressure reading during childhood has any bearing on adult blood pressures or heart disease.
·And worse, it didn't follow a single child to see if there were any health effects from the salt restrictions they are recommending.
In other words, this study offered no clinically meaningful evidence, only speculations. ...
Shouldn't we have something tenable to go on before experimenting on an entire generation of children? I suspect most parents would think so.
She notes approvingly the award-winning expose of games-playing by the anti-salt crowd as documented in Science magazine and recent research showing that low-salt diets may be creating additional risk .
Beginning in 2007, the American Journal of Hypertension will have a new Editor-in-Chief, replacing its founder, Dr. John Laragh, a Time magazine cover story subject for his breakthrough work on blood pressure and heart disease. Laragh will be succeeded by Dr. Michael Alderman who has just completed his stint as president of the International Society of Hypertension.
In his parting editorial, Dr. Laragh says:
It is a pleasure for me to announce that Dr. Michael Alderman will replace me as Editor-in-Chief of the American Journal of Hypertension effective January 1, 2007. Dr. Alderman is a world-renowned epidemiologist who is unique among his peers because he has been especially interested in asking pathophysiologic questions in performing his population trials. This penchant led him to demonstrate, in a classic eight-year trial of 1717 hypertensive worksite employees, that the height of the entry ambulatory plasma renin level was directly related to the subsequent occurrence of a myocardial infarction (MI). At the same time, he found that no MI's occurred in the 251 patients who had low entry plasma renin levels. This led Alderman to do a confirming follow up study showing that dietary salt-depleted hypertensives with consequent higher renin values and lower urinary sodium values had proportionally higher heart attack rates than did those who ate more salt, and therefore had progressively lower renin values.
Dr. Alderman's research rightly questions the popular wisdom of unselectively advising salt avoidance for all hypertensives, and for all normotensive people, - a popular public health strategy which will surely chronically raise all of their plasma renin values and may have other unintended adverse consequences. Furthermore, this research has clearly reaffirmed the existence of only two mechanistically different types of long-term hypertension, each one of which is caused and sustained by either a body sodium (plasma and ECF fluid-volume) excess or instead by a plasma renin-angiotensin excess. This construction is supported by evidence that the hypertensive states caused by a body salt excess or a plasma renin excess are each quite selectively correctable respectively by giving a natriuretic drug or instead an antirenin antihypertensive drug.
The American Council for Science and Health (ACSH) has struck another blow for science and sanity. ACSH president Elizabeth Whelan's column yesterday, "Are Foods 'Addictive' ?" laments the tactic of critics of "Big Food" who try to make customers the victim of a conspiracy -- unable to protect their interests (in this case, their health) and, unstated but implied, requiring protection through more government intervention. Not so fast, Whelan says.
The word "addiction" is used very loosely today -- as when people claim they are "addicted" to exercise, chocolate, or the Internet. But addiction is a medical term referring to compulsive, habitual use of a substance that has physiological effects but is not necessary for survival. Addictive substances produce tolerance (meaning that it takes an increasing amount of the substance to produce the desired effect) and physical dependence -- and unpleasant symptoms of withdrawal if use is discontinued. The nicotine in cigarettes fits all these criteria. Food does not.
There have been claims that eating high-fat or high-sugar foods overactivates drug-like substances in the brain called endogenous opioid peptides, leading to food cravings, overeating, and obesity. Food, it is argued, causes an increase in neurotransmitter levels just as addicting drugs do. Some animal experiments may support this idea, but other animal data and human observations do not. If overeating were induced through an opioid-like mechanism, one might expect that opioid-antagonists would be useful in treating overeating, but they are not.
If this sounds familiar to salt-interested readers, it should. More than 20 years ago the Center for Science in the Public Interest (CSPI) conflated salt with cocaine -- "another white powder we snort" -- and labeled salt addictive. This past summer, critics accused "Big Salt" of heading a "conspiracy" as we tried to mobilize resources for a definitive controlled trial of the question of whether the amount of salt in a person's diet is related to their health outcomes, particularly to cardiovascular mortality. We have only observational studies addressing this question to date and they tend to suggest just the opposite of our current policy. Existing studies show no health benefits for reducing dietary sodium and several have identified heightened risk.
Fortunately, over these past 20 years, we've seen serious scientists express revulsion and reject this fear-mongering. The Cochrane Collaboration grew from a core of concerned research scientists at Oxford University to become first the inventor and then a worldwide force for "evidence-based" medicine (now everybody claims their product is "evidence-based" even when they stray from the Cochrane Collaboration's evidentiary rules). Now groups like ACSH and blogs like JunkScience and Junkfoodscience have taken up the watchdog role protecting the public against those who would pervert science to advance their policy objectives.
"Reactionary." That's the word that best captures the loud defense of the status quo in science. And, as the old saw goes about courtroom strategy for lawyers: If you have the law, argue the law; if you have the facts, argue the facts; if you have neither the law nor the facts argue at the top of your lungs. Perhaps the humor offers an insight into why institutional defenders of the status quo in medical science have turned up the volume in condemning high quality new science that challenges the conclusions of their earlier, often lower quality conclusions.
One of the best new blogs I've read in months examines this phenomenon in two posts this weekend. Junkfoodscience.com , in "Say it isn't so - Part 1 " looks at the Women's Antioxidant Cardiovascular Study (WACS), noting:
It is predictable. A flurry of press releases and articles appear everytime a major study is released that debunks "pop science" - what everyone "knows" to be true - and threatens the research or agendas of special interests. These stories attempt to confuse us, spin the science, or restate the beliefs more emphatically. Many times, they even claim to have new research supporting their position, when they don't!
Registered Nurse Sandy Szwarc, RN, BSN, CCP, pointed out that WACS
followed nearly 16 other major clinical trials released earlier - including the Heart Outcomes Prevention Evaluation (HOPE), Atherosclerosis Folic Acid Supplementation Trial (ASFAST), and the Norwegian Vitamin Trial (NORVIT) - all firmly demonstrating no benefit of folic acid or vitamin supplementation in heart disease, and that lowering homocysteine levels does not translate to real-life reductions in heart disease. And more importantly, has no effect on the most important end point of all: death.
As a Medscape review noted, the clinically measureable evidence is overwhelmingly consistent.
Immediately, the institutional status quo leaped into action, papering the media with the contrary story, to wit (from Reuters):
Folic acid can cut heart attack risk: experts
Can taking folic acid supplements reduce the risk of heart disease and stroke? British researchers believe it can. After analyzing evidence from earlier studies, a team of scientists in Britain said on Friday there is enough research that shows folic acid lowers levels of the amino acid homocysteine and reduces the odds of cardiovacular [sic] disease.
Now, I"m not going to wander from the confines of salt and health to comment on the benefits of folic acid supplementation; there are plenty of experts to thrash that out. What seems worth mentioning, however, is the tactic of the defenders to deflect serious consideration of the WACS and the other 16 studies. And you can read in more detail on Junkfoodscience.com. Szwarc describes how David Wald, a colleague of Malcolm Law, well known for his low-quality "meta-analyses" of the blood pressure effects of salt restriction, for context, launched a high-volume attack on the mounting number of clinical trials using older, lower-order observational studies he had done reaching the contrary conclusion (his news release implied the studies were new and of superior quality).
In today's "Part two ," Szwarc turns her attention to the same phenomenon in the current debate over obesity. Anyone who challenges the orthodoxy that obesity is the root cause for virtually all nutrition related medical conditions has a hard time having their voice heard. Again, it's not a primary issue for our focus, but the process of defending the status quo is frighteningly consistent. As she explains:
Nothing compares to the all-out, massive, well-organized efforts to preserve the "obesity crisis" that began last year after senior research scientists inside the CDC's National Center for Health Statistics exposed the war on obesity - begun by their own director of the CDC, Julie Gerberding, and Secretary of Health and Human Services, Tommy Thompson - as a grossly exaggerated and fabricated scare campaign.
She continues:
the study, looking for correlations between weight and premature death that had been created to lay the foundation for billions of dollars in government and industry "obesity" initiatives, and popular with an enormous throng of marketing and political interests all using the "obesity crisis," had been derived from poor data and had flagrant methodological flaws. How bad was it? It didn't even account for aging, the single biggest risk factor for death, in its computer model!
But, back to the story of tactics used to defend the status quo. Szwarc explains:
Within hours of the release of this potentially devastating study in the Journal of the American Medical Association, special interests - notably, doctors from Harvard School of Public Health, along with the American Cancer Society, American Heart Association and the CDC - quickly rallied press conferences and media releases to deny and spin the findings and attempt to discredit them in the minds of the credulous public. They made noises about it failing to consider smoking, of reversing causality and attributing higher deaths among thin due to the fact they are sick or old, and of not considering the long-term effects of obesity. These spin doctors assumed, correctly, that the media would simply repeat their assertions and not a single reporter would go to the actual study to realize they were nonsense.
Flegal and her associates had analyzed the data in a myriad of ways and had accounted for smoking, chronic diseases and preexisting health problems, involuntary weight loss, and long-term obesity ... and each time the results were the same.
Reporters who'd read the journals where this controversy had been raging could have learned that the "obesity is deadly" studies done by researchers from Harvard, the American Cancer Society and CDC that were being so vehemently defended, had looked at self-reported data from select groups of people that weren't representative of the population and had excluded nearly 90 percent of the deaths in their analyses to get the results they wanted. Among other such studies, you'll find all sorts of other shenanigans.
Let's not blame the media entirely. As much as we should hope reporters would ask the tough questions and look critically at the evidence itself and not just accept what one side of an issue says it means, the real -- and largely hidden -- story here is the enormous lengths that defenders of the status quo have gone to dredge up lower quality studies or those focused on only one portion of a broad problem to emphasize their argument. And the volume! Turn down the hyperbole. Let's discuss science and get that right; then we can turn our attention to getting the policy right to build on that science.
The same process has been playing out in the salt and health issue. Investigative journalist Gary Taubes won the top award from the National Association of Science Writers for his article "The (Political) Science of Salt " appearing in the prestigious magazine Science.
We all need to pay attention to these tactics. Thanks, Ms. Szwarc.
A news analysis, with this title, by Denise Grady published in yesterday's New York Times should be required reading by the nation's public health nutrition community. Grady points to public health campaigns that "have drilled that message into the national psyche." Her example: angioplasties and coronary stents. She could have been talking about salt. She continues:
Ideally, treatments, operations and diagnostic procedures should be thoroughly tested before they come into routine use. Bu that is not always the case. ...
Some treatments -- like opening a closed artery -- appeal so strongly to common sense that it becomes irrestible to go ahead and use them without waiting for scientific proof that they are effective. ...
As the treatments start to catch on, people assume they must work, and it becomes difficult or impossible to study them in the most definitive way -- by comparing treated patients with an untreated control group. If most people think a therapy works, who wants to be the control? Doctors may balk at controlled studies, too, calling it unethical to withhold the treatment from patients in the control group.
Grady recognizes that her example is just that, a single instance of a widespread phenomenon of pseudo medical advice lacking "gold standard" testing through randomized trials to prove improved health outcomes -- just as is the case now with encouragement to reduce dietary salt.
And today's news that FDA has (once again) approved silicone breast implants suggests that FDA understands the need to revisit arguments based on Chicken Little pseudo-science. Responding before controlled studies confirm the problem can compound the ultimate solution by creating controversy as medical experts learn the earlier "fix" is wrong, but the public has already been indoctrinated on the basis of the premature "solution."
Grady reminds us:
Medical history is strewn with well-intended treatments that rose and then fell when someone finally had the backbone to test them, and the scientific method trumped what doctors thought they knew.
Hormone treatment after menopause, which works for symptoms like hot flashes, was widely believed to prevent heart disease and urinary incontinence. But carefully done studies in recent years have shown that hormones can actually make those conditions worse.
Stomach ulcers were once attributed to emotional stress and too much stomach acid, and were treated with surgery, acid-blocking drugs and patronizing advice to calm down. Then, in the 1980s, two doctors who were initially ridiculed for proposing an outlandish theory proved that most ulcers are caused by bacteria and can be cured with antibiotics.
For decades, women with early-stage breast cancer were told that mastectomies offered them the best chance of survival. But in 1985, a large nationwide study showed that for many, a lumpectomy combined with radiation worked just as well.
"As a nation, we're not doing ourselves any favors by going after the next new thing without doing the studies," said Dr. James N. Weinstein, chairman of orthopedic surgery at Dartmouth and a researcher at its Center for the Evaluative Clinical Sciences, which studies how well various medical and surgical procedures work.
When established treatments turn out to be useless, or worse, harmful, Dr. Weinstein said, "everybody's going to lose trust in the system."
With regard to salt, the FDA and NHLBI may have succeeded in brainwashing the public, but, ultimately, science will prevail. Government pronouncements don't change physiology. The essence of the scientific method is that current "knowledge" is bombarded with new facts and new analytical methods as they are developed and, guess what, the old orthodoxies are often overturned or modified.
What we need to sort out the controversy among medical experts regarding dietary sodium is a controlled trial of the health outcomes of various levels of dietary sodium. We need to know if lowering the average population sodium intake will save lives or put our population at higher risk of heart attacks and cardiovascular mortality as the latest studies have found.
Tunnel vision is described as the loss of peripheral vision resulting in a constricted circular tunnel-like field of vision. This week has seen a rash of newspaper articles on salt and hypertension in children that precisely reflects that idea. Stemming from the work of MacGregor and He of St. George's University of London and published in the November issue of Hypertension, a number of journalists have parroted the view that reducing salt intake is the single most important path to the future health of all people. Their research, found that a significant reduction of salt intake in children will bring down their systolic and diastolic blood pressures by as much as 1 millimeter of mercury each.
Dr. MacGregor has long espoused salt reduction as the silver bullet for hypertension and has published a number of books: The salt-free diet book; The Low-salt Diet Book; and Salt, Diet and Health: Neptune's Poisoned Chalice, on this issue. Like other researchers focused on reduction of salt consumption as the one answer to hypertension, he believes that research results contrary to his own are tainted by industry or the international salt conspiracy. Since the drop in blood pressure in this study was found to be small, the authors rationalized it by speculating that if it was extended into adulthood, it would have major public health implications in preventing cardiovascular disease in the future. Speculation comes easy to those with committed views, however, as Samuel Johnson once said, "When speculation has done its worst, two and two still make four."
No one doubts the lifelong health benefits of eating more fruits and vegetables as recommended in the government's 5 a Day program or following the principles of the DASH diet for those concerned with hypertension. Rather than extolling the virtues of consuming more fruits and vegetables as the most effective and enduring path to improved health and reduced hypertension for people of all ages - MacGregor and company cannot get away from their singular focus on salt - a constricted, tunnel-like point of view. Could it be because a small amount of salt makes bitter vegetables so much more palatable for everyone, particularly youngsters and would result in far greater benefits (see, And Now For Something Completely Different.. .)? That might contradict everything they stand for.
And herein lies the problem. Scientists who are committed to a single idea can be very damaging. Francis Bacon, the father of modern science insisted that knowledge had to derive from dispassionate scientific experimentation, rather than the musings and speculations of philosophers. Zealots committed to a single idea are, almost by definition, incapable of objective science - neither in the design of proper experiments nor in the interpretation of results. The danger is that they parade around under the mantle of science and will never recognize their own bias. We see this everywhere - advocacy groups proclaiming to pursue science in the public's interests, yet subjectively pick and choose selective bits and pieces of data to serve the objects of their advocacy. Believing in science means practicing science and that means being objective. It leaves no room for individuals committed to a single idea and any information or advice that they develop must be treated with the intellectual reserve and caution it deserves - particularly when it come to the health of our children. Journalists should understand this before they serve as a vehicle for the dissemination of myth-information.
I love this story in Burt Prelutsky's Townhall column today of the above title. We can all agree that our public health authorities, as well as our personal doctors, should avoid harming us with their interventions "on our behalf." But that really is setting the bar too low, isn't it?
I'm reminded of the furor a decade ago when the first studies began appearing examining whether reduced-salt diets actually delivered the improved health outcomes long forecast based on blood pressure models. They didn't. The first study, in fact, in 1995, found in a New York City medical practice, that diagnosed hypertensive patients who consumed low-salt diets actually had a 430% greater incidence of a heart attack than those on regular levels of salt intake. Of course the study had flaws, but it was what it was; and what it was was a wake-up call for The Establishment to re-examine its advocacy of reducing dietary sodium/salt. The National Heart, Lung and Blood Institute leaped into action, commissioning both internal and external research on the subject and produced consistent results: their research, they proclaimed, demonstrated that there was no elevated risk of reducing dietary sodium. Unstated, their research also clearly showed that there was no benefit of the reduced-salt diets. No matter. Their advocacy persisted, despite subsequent studies showing risk in the U.S. and Scottish populations. Still, today, one hears low-salt advocates claiming that while not everyone could conceivably benefit by reducing dietary salt, "at least no one could be harmed." We are unpersuaded and have called for a controlled trial of the health outcomes of low-salt diets, but, in the meantime, shouldn't we be a bit more concerned about the lack of efficacy? As Prelutsky says:
The first principle of the Hippocratic Oath, which all physicians are sworn to abide by, is: Do no harm. I don't want to be regarded as a nitpicker, but, as standards go, I'd say that's a pretty measly one.
Do no harm?! For crying out loud, Boy Scouts at least have to be prepared. Soldiers are expected to be all they can be, and while I think we'd all agree that's pretty vague as to specifics, the basic tone suggests that courage and self-sacrifice could well be part of the job description.
And although I don't know it for a fact, logic would dictate that being a member of the 4-H Club would at the very least require feeding the chickens, slopping the pigs, and washing one's hands before sitting down at the breakfast table.
I mean, what if something that inconsequential was the first principle of other occupations? What if accountants had to be admonished not to round off numbers to the nearest zero, and bus drivers were told to really knuckle down and not run into any lampposts? How would you like it if chefs graduating from culinary academies were handed their diplomas, their puffy white caps, and a friendly piece of advice from the dean along the lines of "Remember, arsenic is not a condiment"?
How about barbers? Would it put your mind to rest if you discovered that the first principle in their handbook was a reminder that they're not matadors, and it's not recommended that they take home a bagful of ears at the end of the day?
This is not to say that we should all stand around and ridicule physicians simply because the Mafia apparently has slightly higher expectations of its members than the AMA has. While we can all agree that the doctors' motto leaves something to be desired, things could be a lot worse. Take criminal defense attorneys. Please, as Henny Youngman used to say.
The Public Health Advocacy Institute (PHAI) held its annual meeting last weekend in Boston and, according to the Chicago Tribune ,, agreed to "increase threats of litigation (against) food companies to improve the fare they offer. The group did not name the companies targeted with "tobacco-style litigation" seeking "huge fines" against (the) corporations."
Less adulatory is the description of the group by the consumer watchdog group ActivistCash.com . Says the group's website, PHAI
is a lawsuit lounge where food cops and trial lawyers swap strategies to litigate away consumers' food choices. Located in Boston with a board composed of faculty members from the Northeastern University School of Law and Tufts University School of Medicine, PHAI's goal is to attack food makers through lawsuits. Along the way, it is creating the next huge payday for trial lawyers, who are trying to demonize popular foods by using their template for attacking tobacco.
Self-interested or not, the threat is the latest in a barrage of charges that the food industry is trying to undermine the health of its customers. A nummber of reporters are in obvious sympathy. We'll see how the general public responds.
Is the "silly season" of US elections spilling over into anti-salt advocacy? Latest news release: longstanding anti-salt zealots in Finland assert that salt is responsible for the burst in global obesity.
In an article in Progress in Cardiovascular Diseases , Drs. Heikki Karppanen and Eero Mervaala assert that their study "refutes the frequently repeated claims that a comprehensive salt reduction would not produce any overall health benefits, or would even increase diseases and shorten the life span."
The Salt Institute has made the argument frequently (and, apparently, someone is listening!) that observational studies of health outcomes fail to identify population health benefits at levels common in the North American diet -- and advocating a controlled trial of reduced salt diets to determine whether they decrease heart attacks and cardiovascular mortality.
We still think that's the right question, but this claim that low-salt diets "would be a powerful means against obesity" is just over the top. Of course, if we made foods so unpalatable as to stop people from eating as much (as has been done with less-than-happy results in geriatric institutions) we might be able to link salt and body mass, but to assert that
The increased intake of salt, through induction of thirst with increased intake of high-energy beverages has obviously remarkably contributed to the increase of obesity in the United States.
with no evidence adduced to support the allegation is irresponsible.
The authors specifically cited Salt Institute statistics of U.S. salt sales saying that salt intake had increased "more than 50%" over a recent 15 year period. In response, I wrote Dr. Karppanen:
Your concern with increased salt intakes is obviously misplaced. While salt intakes in the U.S. have increased in the past 15 years, they track population increases. The U.S. population is 300 million today. We've added 50 million in population in those years. I know population growth is something a bit foreign to your part of the world, but we've experienced a lot of immigration and natural population growth. Even so, our latest figures show food salt sales growth up 41%, not "over 50%" and while greater than the population growth, this does not account for US food salt which is exported in US processed foods, salt used in food processing and wastage. The better metric, as I'm sure you agree, is 24-hour urines and those in study after study show that baseline salt intakes per capita are unchanging generation after generation.
Of course, correlation is not causation, but to correlate salt intake with the rise in obesity ignores evidence that those on higher salt diets are actually leaner than other Americans. Just as obviously, the longest-lived national population in the world, the Japanese, have much higher salt intakes than Americans. Your "obvious" correlation of salt intake and thirst and obesity makes interesting headlines, but sorry science.
The Finns claim salt reduction is responsible for increasing the life span of their compatriots by 7-8 years over the past one-third century. Let's keep in mind, Romans lived to an average age of 28. The Yanomamo people of the Brazilian jungles who are touted as low-salt-consuming models for our diet live only into their 30s. A century ago, Americans lived only 48 years on average while a century later we live 77 years on average. If Finland's medical and nutrition improvements parallel Americans, 7-8 years additional longevity over the past 30 years is just average, nothing to crow about -- nor to try to assign causation when none can be adduced from ecologic data.
Unfortunately, while preposterous charges amongst American politicians will likely abate after November 7th, there is no apparent reprieve from the anti-salt crowd.
Today's Washington Post reports a survey of medical researchers at the National Institutes of Health showing that two in five are looking for other jobs as a direct result of the Administration tightening-up conflict-of-interest regulations to prevent them from outside consulting.
Of the NIH personnel who supervise outside contract research, many fewer are exploring an exit. The Post notes they have fewer outside consulting opportunities.
We'd observe that the conflict-of-interest regulations don't go far enough in preventing in-house scientists from commisioning studies to deliver "evidence" for agency policy choices. Now that we've destroyed the myth that government-paid scientists are without blemish or bias, let's take the next step and get some independent review of the contract science by such means as reinvigorating the Data Quality Act.
One need not allege scientific fraud to be concerned over documented -- even confessed -- evidence that NIH-funded researchers have cooked the books on major research that supports the policy direction favored by the government. An investigative report in today's New York Times Magazine , "An Unwelcome Discovery" by Jeneen Interlandi, reports the scientific fraud perpetrated by Dr. Eric Poehlman of the University of Vermont in his studies on hormone replacement therapy after menopause, supported by the National Institutes of Health with results confirming that agency's policy choices. Dr. Poehlman is now in jail.
Given that the media regularly give government-funded researchers a free pass on conflict of interest and virtually indict researchers for receipt of drug company or food company funding, the case is instructive. I'd note that the Salt Institute has no horse in this race; we report on peer-reviewed science, but we do not fund the research.
Interlandi explains why the Poehlman story matters:
The scientific process is meant to be self-correcting. Peer review of scientific journals and the ability of scientists to replicate one another's results are supposed to weed out erroneous conclusions and preserve the integrity of the scientific record over time. But the Poehlman case shows how a committed cheater can elude detection for years by playing on the trust - and the self-interest - of his or her junior colleagues.
. . . .
The length of time that Poehlman perpetrated his fraud - 10 years - and its scope make his case unique, even among the most egregious examples of scientific misconduct. Some scientists believe that his ability to beat the system for so long had as much to do with the research topics he chose as with his aggressive tactics. His work was prominent, but none of his studies broke new scientific ground. (This may also be why no other scientists working in the field have retracted papers as a result of Poehlman's fraud.) By testing undisputed assumptions on popular topics, Poehlman attracted enough attention to maintain his status but not enough to invite suspicion. Moreover, replicating his longitudinal data would be expensive and difficult to do.
"Eric excelled at telling us what we wanted to hear," Matthews, Poehlman's former colleague, told me. "He published results that confirmed our predisposed hypotheses." Steven Heymsfield, an obesity researcher at Merck Pharmaceuticals in New Jersey, echoed Matthews's sentiments and added that Poehlman's success owed more to his business sense and charisma than to his aptitude as a scientist.
"In effect, he was a successful entrepreneur and not a brilliant thinker with revolutionary ideas," Heymsfield wrote me via e-mail. "But deans love people who bring in money and recognition to universities, so there is Eric."
At his sentencing hearing, Poehlman took responsibility for his actions, but between the lines, he seemed to be placing some blame on the system that requires principal investigators to raise money for their research through government grants.
"I had placed myself, in all honesty, in a situation, in an academic position which the amount of grants that you held basically determined one's self-worth," he told the court in June. "Everything flowed from that." With a lab full of people dependent on him for salaries, Poehlman said he convinced himself that altering some data was acceptable, even laudable. "With that grant I could pay people's salaries, which I was always very, very concerned about."
He continued: "I take full responsibility for the type of position that I had that was so grant-dependent. But it created a maladaptive behavior pattern. I was on a treadmill, and I couldn't get off."
Interlandi quotes NIH spokesperson Sally Jean Rockey on the lessons to be learned. Rockey
said that lost grant money was not the only, or even the most significant, cost incurred. "Science is incremental," she said, explaining that most scientific advances build on what came before. "When there's a break in the chain, all the links that follow that break can be compromised." Moreover, she said, fraud as extensive as Poehlman's would inevitably lead to further erosion of the public's trust in science. Poehlman's sentence, she said, should send a clear message to the scientific community and the public at large that fraud would not be tolerated.
The story is a tragedy at several levels, of course. Besides landing him in prison and utterly wasting $2.9 million in NIH taxpayer investment, the Poehlman fraud misdirected medical advice given to thousands of post-menopausal women. Further research has shown dramatic health risks for Hormone Replacement Therapy -- another expensive case where a plausible theory was undone by controlled health outcomes studies.
Again, recounting this tragic story is not an underhanded way of alleging scientific fraud on the part of the NIH and its cadre of university researchers. It does illustrate quite clearly, however, that effective safeguards to ensure research integrity are lacking. It should cause all of us to be concerned about the potential for analytic bias by researchers whose funding (and career health) are determined by a government agency with an unswerving policy proclivity.
In the case of the health impacts of dietary salt, NIH-funded researchers have generally lined up behind their funding agency's policy conclusions. NIH has protected the researchers it's funded against having to make their data available for independent professional review required under the federal Data Quality Act. Again, without alleging fraud, could it be that the policy bias of the federal funders has allowed another intervention, like Hormone Replacement Therapy, to be promoted to the public without the scientific rigor of a controlled trial?
Indeed, there has been no controlled trial of the health outcomes of dietary salt despite the vocal advocacy of salt reduction based on extrapolations of blood pressure data as if that was the only metabolic impact of cutting dietary salt. Could this story be parallel to the Poehlman one? Interlandi points that Poehlman "had derived predicted values for measurements using a complicated statistical model. His intention, he said, was to look at hypothetical outcomes that he would later compare to the actual results."
Let's be charitable: if public health policy is to be based on "predicted values" of health benefit derived from a "complicated statistical model" as has been the case built for reducing dietary salt, perhaps it's time for HHS to heed our call for a controlled clinical trial of the cardiovascular outcomes (mortality and the incidence of heart attacks and strokes) of the pet NIH theory that cutting salt will save lives. Let's see the evidence.
Despite massive public education efforts and ubiquitous nutrition labeling, consumers don't appreciate the caloric impact of their portion choices and, if they exercise, self-righteously overcompensate by increasing their food intake. So concludes Cornell University professor Brian Wansink, as reported in today's New York Times . (free registration required)
He found that while most people think they make only 15 food decisions a day, they are really making more than 200. And his research with college students show a wide variety and many unexpected bases for these decisions. He takes shots at those "at 30,000 feet" who call for changes in the food system, school lunches and farm policy and he pans "nutritionists and diet fanatics" who beat-up on individuals for "bad" food choices. His approach is a series of practical habits to chip away at calorie intake.
Dr. Wansink's research took no cognizance of salt intake, but his conclusions invite a salt-related question. Among the unrecognized, even unconscious, food choices may be an inherent salt appetite. Perhaps a future study.
A story in today's Washington Post introduced the concept of "Big Salt" -- ostensibly, the Salt Institute is a powerful political force in Washington (see earlier post). Later in the day, I had a chance to read another story that quotes another expert: "Salt is big."
What a difference between the stories.
Peggy Townsend's "Salt Rocks " story in the August 30 Santa Cruz Sentinel (yes, I'm a bit backed up because of travel) makes the point that gourmet salts are all the rage despite a few naysayers like Robert Wolke:
Chemistry professor and author of the book "What Einstein Told his Cook," Robert Wolke told the Associated Press that mineral concentrations in salt are so small they don't contribute any meaningful taste to food. No matter how "unprocessed" gourmet salt companies say their products are, the act of evaporation - whether by wind, sun or machine - purifies out most minerals. And while someone might be able to tell the difference between certain salts when tasted raw, the flavors fade to nothing when added to food.
A salt-using chef begs to differ:
Michael Rech, executive chef at the California Culinary Academy, says no one will taste the difference if you use fleur de sel in the water you are using to cook rice.
But use it in pate or foie gras "and you get this all-around flavor of salt which you don't get from an iodized salt," he says. And, when you want to set out salt for a dinner party, nothing is better than a small bowl of blushing pink Himalayan salt or stunning red Hawaiian salt crystals.
"All you need is a pinch of the gourmet salts," says Jennifer Jones, who owns Jones and Bones food and kitchen shop in Capitola. "It's like a good olive oil or a balsamic vinegar."
Jones, who carries 13 kinds of salts and offers free salt tastings, says customers have long sought out the fleur de sel but with the popularity of rubs and brining are now branching out even further to flavored salts like fennel salt and truffle salt to enhance their dishes.
People are dusting lavender salt on scrambled eggs and sprinkling truffle salt into mashed potatoes. They're brining fish in Hawaiian sea salt and rubbing salt seasoned with cranberry, rosemary and orange oil into turkey or chicken.
"Salt," says Jones, "is big."
That's the kind of "Big Salt" we like to talk about.
It was somewhat of a surprise to read the Washington Post's latest conspiracy theory - it must be the influence of the Da Vinci Code.
No one has ever disputed the impact of salt on blood pressure, nor for that matter has anyone ever disputed the impact of the myriad stresses we routinely encounter on blood pressure. There is, however, a great debate on whether these impacts per se lead to negative health events.
Hypertension is not a proxy for death, nor is it a surrogate for cardiac disease. Yet the anti-salt lobby ask us to believe it is, without the benefit of any scientific data. They rely exclusively on epidemiological studies using hypertension as an end point, ignoring all other variables. They rely on the famous Intersalt Study (Brit. Med J., v. 297, July, 1988) which compared per capita salt consumption to blood pressure in populations around the world. What they did not do was compare salt consumption to longevity. Using the same Intersalt data on salt consumption and the US Census Bureau data on life expectancy across the world, the resulting curve draws the inescapable conclusion that those populations which consume the most salt live the longest! No joke, no fudging figures - those populations which consume the most salt live the longest.
Of course, there are many other factors involved in longevity just as there are many other factors associated with blood pressure, but it still remains that the more salt a population consumes, the longer they live.
Indeed, one of the most outspoken and effective British anti-salt advocates, when confronted with data from Japan, whose citizens are amongst the highest per capita salt consumers in the world and also have the longest lifespan, dismissed this simply by stating that they would probably live even longer if they didn't eat so much salt. Some analysis, some science, no?
Before we all go around hoisting placards claiming Bland is Grand, let's consider the science and the data a bit more carefully.
Rather than join in a constructive debate on the policy options based on scientific evidence, anti-salt activists continue to finger-point at personalities and "special interests" to divert public attention to the fact that scientific studies do not identify an improved health outcome from reducing dietary salt.
The latest blast, typified in today's Washington Post , attributes the controversy to economic interests including "Big Salt" -- the Salt Institute. I've submitted this response to the Post:
"Big salt"? As president of the Salt Institute: thanks for the compliment. A few years ago, Gene Weingarten's Below the Beltway profiled the Salt Institute as a prime example of the notion that even the smallest and most insignificant interests have a not-for-profit organization (see http://www.saltinstitute.org/pubstat/beltway.html) . But that's another matter.
The article says "Too much salt is bad for you, right?" By definition, "too much" is, well "too much" ergo "bad."
But who's to say that the amount of salt Americans eat (and we're very average around the world) is "too much"?
I guess it depends on who you ask. The Cochrane Collaboration, inventors of "evidence-based medicine" feel there is no evidence supporting a population intervention. So, too, does the U.S. Preventive Services Task Force, guardians at the HHS of the "evidence-based" approach to public health nutrition policy.
This is an enduring debate among scientists. While we don't fund research due to our modest means, we've seen the debate transform itself from the old debate: will lowering salt help a significant number of people reduce their blood pressure? to a new, better line of inquiry: will reducing dietary salt lower the risk of heart attacks and improve health outcomes?
Surprise. When the question is framed in terms of health outcomes, the answer is clear: none of the studies show a population benefit by reducing dietary salt. Some show increased risk. The president of the International Society of Hypertension published an article earlier this year, using a massive HHS database, and found 37% greater mortality among those following the Dietary Guidelines' recommedation.
We've reviewed the controversy on our website, http://www.saltinstitute.org/28.html and comment regularly on our blogs http://www.saltinstitute.org/rss/health-other/ and http://www.saltinstitute.org/rss/saltsensibility/ . We are a very transparent organization and you can also find all our public statements on this issue online at http://www.saltinstitute.org/advocate.html .
Dick HannemanPresidentSalt Institute
This may be David and Goliath, but we're not Philistines, in Webster's terms: "disdainful of intellectual values."
