Of course, for Americans 2008 is a political year with a new president to elect. But while the electorate seems to be tiring of political polarization already, some lobby groups are becoming more assertive. Since New Year's day, the American Medical Association, has displayed a feisty combativeness urging its members to pressure Congress to pursue a path antithetical to the approach recommended by the U.S. Preventive Services Task force and endorsed by the Salt Institute. We'll have to wait and see if the AMA membership supports this campaign or returns to a more science-based approach to public health policy.

The January 14 edition of amednews.com, the AMA online newsletter, editorialized "Time to pinch off the salt " with the explanatory subtitle "The AMA calls on the FDA to revoke salt's 'generally recognized as safe' status to allow more regulation of sodium in food." The editorial liberally quotes AMA vice president for science, quality and public health Stephen Havas, who has almost single-handedly radicalized the AMA strategy on salt restriction.

About the same time, AMA issued a news release, not mentioning salt, but calling for Congress to pursue an aggressive assault on risk factors for cardiovascular disease. The AMA's January 11 release announced:

American Heart Association President Daniel W. Jones, M.D. urged Congress to pass legislation to help Americans control their risk factors for cardiovascular diseases. With obesity, hypertension, diabetes and other risk factors on the rise, the association is calling on elected officials to support measures that focus on research and prevention.

"Risk factors, such as unhealthy weight, poor diet, smoking and diabetes could undercut many of the gains we've made to reduce cardiovascular disease deaths," said Jones, vice chancellor, University of Mississippi Medical Center. "We must ratchet up efforts to convince policymakers that a strong and sustained investment of government resources is essential."

The association's 2008 Health Policy Agenda addresses risk factors through legislation and initiatives that would combat the obesity epidemic, curb tobacco use, particularly among children, increase funding for medical research and prevention and reduce health disparities.

This year alone, cardiovascular diseases will cost Americans an estimated $449 billion in lost productivity and medical expenses. Treatment costs for cardiovascular diseases are expected to rise 64 to 84% by 2025. Stroke treatment alone is projected to exceed $2 trillion by 2050.

While the AMA's specifics are a bit extreme, the concept of extending the effectiveness of "research" and "prevention" enjoys as much support today as "motherhood and apple pie" did of yore. The Salt Institute joins that chorus. We'd add, however, that federally-funded research should be available for independent confirmation and used to support government policy only if findings can be replicated. And, while we strongly support the prevention of cardiovascular disease and its resultant heart attacks and strokes, we are less sanguine concerning prevention of "risk factors" as semantacist Dr. Jones has stretched the term. How do you prevent age, for example, the surest predictor of cardiovascular events and deaths? How about being an African-American, another powerful "risk factor"?

The proper focus of public health policy is to prevent disease, extend life and improve the quality of that life. A focus on "risk factors" presupposes that they can be modified as part of our public health efforts. Some "risk factors" cannot be modified. Others, like "salt sensitivity," as recently as a decade or two ago were thought to be immutable and unchangeable and are now properly understood to be the product of deficiency intake levels of other nutrients, in this case, calcium, magnesium and potassium; correct those deficiencies (as with the DASH Diet) and the "salt sensitivity" disappears. So, the proper policy focus should not be on "risk factors" but on the effectiveness of HOW we try to modify those risk factors .

Again, salt is illustrative. Blood pressure is a risk factor for CV events and mortality. Few would deny that. But HOW blood pressure is modified is what's important, not the raw number itself. Blood pressure is not the disease, it is the symptom, the "risk factor" for CV disease, myocardial infarcts and strokes. Treating the symptom is not prevention. It may even make the underlying condition worse and increase the risk of an event rather than prevent it. That's what we discovered when scientists started examining the question of whether cutting salt (a "risk factor") would yield in actuality the "prevention" benefits predicted by mathematical models such as those used by Dr. Havas and the AMA. It turns out, they don't. In a long string of "health outcomes" studies , no pattern of a health benefit is correlated to diets lower in salt. It turned out that other "risk factors" such as insulin resistance, plasma renin activity and sympathetic nervous system activation were also affected by reducing dietary salt. These "risk factors" increased the risk of salt reduction, proving, once again, that HOW we seek to modify "risk factors" is more important than announcing a campaign focused only on change.

In this political year, we've heard virtually all the presidential candidates call for significant "change." Let's be reminded that the specifics of what should be changed and how it should be changed are as important as lamenting our current situation. That's as true in public health nutrition policy as it is in presidential politics.

Nobody is arguing that we should shift from prioritizing prevention and accept the projected $2 trillion cost of treating strokes, but let's focus our efforts on preventing heart attacks and strokes, not waste our money on "risk factors." Proven interventions identified by the U.S. Preventive Services Task Force specifically exclude general salt restriction as having no proven benefit. The president of the International Society of Hypertension used his presidential address a year ago to make the same point: let's focus on health outcomes, not intermediate "risk factors." That's the way we see it too.