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.

The American Dietetic Association has reaffirmed its support for "functional foods," issuing this statement this week:

All foods are functional at some physiological level, but it is the position of the American Dietetic Association that functional foods that include whole foods and fortified, enriched or enhanced foods have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis, at effective levels. ADA supports research to further define the health benefits and risks of individual functional foods and their physiologically active components. Health claims on food products, including functional foods, should be based on the significant scientific agreement standard of evidence and ADA supports label claims based on such strong scientific substantiation. Food and nutrition professionals will continue to work with the food industry, allied health professionals, the government, the scientific community and the media to ensure that the public has accurate information regarding functional foods and thus should continue to educate themselves on this emerging area of food and nutrition science.

ADA also reminds us, pointedly:

The American Dietetic Association defines functional foods as those that “move beyond necessity to provide additional health benefits that may reduce disease risk and/or promote optimal health. Functional foods include conventional foods, modified foods (fortified, enriched or enhanced), medical foods and foods for special dietary uses.”

Curiously missing from the list of examples of functional foods is the first functional food and, arguably, the most important among them: iodized salt . The U.S. began iodizing salt in 1924 and has virtually eliminated the scourge of Iodine Deficiency Disorders, the most preventable cause of mental retardation.

European salt makers and the iodine nutrition community breathed a collective sigh of relief when the European Commission published its latest draft proposal on nutrient profiles used in nutrition label claims. Article 2, paragraph 3 exempts "salt (bearing) nutrition or health claims related to the addition of iodine and/or fluorine."

Somewhat surprisingly to some, Europe as slipped into iodine insuffiency, necessitating increased promotion for the use of iodized salt. The World Health Organization had warned against backsliding on use of iodized salt.

EuSalt led the charge preserving iodized and fluoridated salt and forecasts that the draft will be finalized on April 27.

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.

This is one of those blockbuster stories that is most accurately recounted by quoting the principles' well-considered news release, which follows. A month ago, K+S denied rumors it was in pursuit of US-based Compass Minerals (Compass denied the rumors as well).

This caps a busy day of corporate shuffling as Dow Chemicals closed its acquisition of Morton Salt parent Rohm and Haas while openly shopping the salt business to generate cash to close the deal.

K+S has operated wholly-owned, Clarks Summit, PA-based International Salt, distributing more than 3 million tons of (largely highway) salt which it has imported from its Chilean mine.

Here's the K+S release .

K+S Aktiengesellschaft, one of the world's leading suppliers of speciality and standard fertilizers, plant care as well as salt products, announced today that it has come to an agreement with Rohm and Haas, a wholly owned subsidiary of The Dow Chemical Company to acquire Morton International, Inc. (Morton Salt), one of the leading producers of consumer, industrial and de-icing salt in North America. Closing for the transaction which values Morton Salt at an enterprise value of USD 1.675 billion is expected by mid year 2009 following receipt of the required approvals from antitrust authorities.

“Morton Salt is an excellent opportunity to grow our global salt business”, said Norbert Steiner, Chairman of the Board of Executive Directors of K+S. “It marks another milestone in our strategy towards balanced growth, enhances our profitability and as a result strengthens K+S Group overall, in Europe and Overseas. As one of the leading salt producers, Morton Salt offers us widespread, close-to-customer production sites in the U.S. and Canada and a nationwide distribution network. Through Morton Salt we gain access to new and less volatile de-icing regions. It extends and diversifies our geographic presence and enhances our positions in the North American consumer and industrial salt markets.“

The acquisition of Morton Salt will make K+S the North American and global leader in salt. In 2008, Morton Salt achieved revenues of USD 1.2 billion and EBITDA of USD 270 million. Morton Salt operates 6 rock salt mines, 7 solar evaporation facilities, 10 vacuum pan operations as well as 62 salt stockpiles and 61 distribution centers. Its annual salt production capacity amounts to 13.1 million tonnes. Founded in 1848, Morton Salt has 2,900 employees and is headquartered in Chicago.

The purchase price will be paid in cash. The financing is fully underwritten by Dresdner Kleinwort, Société Générale and Unicredit (HVB). While maintaining a strong and flexible balance sheet, the transaction is consistent with K+S’ acquisition criteria. The acquisition will be clearly EPS accretive from 2010 onwards. “Morton Salt is a profitable business with strong cash flow generation and provides us with operational synergy potential by leveraging the leading salt consumer brand (“The Morton Umbrella Girl”) to its existing product portfolio and by optimizing logistics between Chile, Brazil and North America”, said Norbert Steiner.

“Our business operations are highly complementary and we share a deep understanding of the salt business which will facilitate a smooth integration and deliver immediate benefits to employees, customers and shareholders.

We look forward to working together with an excellent team to realize the growth opportunities that lay ahead”, he added.

K+S and Dow Chemical have carefully analyzed the business combination with respect to potential antitrust and other regulatory considerations and do not foresee any issues in this regard.

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.

The media opines that the Obama Administration's stimulus and bailout packages are reminiscent of the New Deal. Another oft-ignored parallel to that bygone era and its big government response to global economic crisis springs to mind, prompted by a couple recent news items. That parallel is the federal government's retreat from free trade to insular protectionism. Think of the Smoot-Hawley Act of 1930.

Earlier this week, Jeff Stier of the American Council for Science and Health asked in an op ed piece at Forbes.com : "As we enter a trade war with China, are our toxin fears founded?" He continued:

Scaremongering U.S. regulators have been indiscriminately attacking products from China for years, and China recently struck back. Shanghai's equivalent of our Food and Drug Administration investigated baby products made by Johnson & Johnson, echoing claims by a coalition of U.S. activists that the products pose a threat to children because they contain trace amounts of the "carcinogens" formaldehyde and 1,4 dioxane. That China opted not to ban the products is good from both scientific and economic perspectives--and we should learn from this brush with product banning.

He explained that China's investigation was political retaliation, not legitimate scientific concern. "It's just the latest move in a junk-science-exploiting trade war, which plays well at home in each country--but undermines both trade and health," he said. China was retaliating for equally ill-founded scaremongering in the U.S. where the feds declared Chinese-made toys "toxic" because some were found to contain low levels of lead, despite the fact that the levels did not pose a health threat.

The second example was the political payback the Obama Administration afforded the Teamsters Union on March 11 by rescinding a pilot program allowing Mexican trucks to bring their products into the U.S. (instead of using Teamsters-driven U.S. trucks). Mexico retaliated, applying new tariffs on 90 U.S. products with annual sales of about $2.4 billion in Mexico. Time Magazine 's Ioan Grillo calls it "Obama's 'trade war'" and reports:

Down in Mexico, the administration of President Felipe Calderón accused the U.S. of being hypocritical and protectionist. It has a strong case. Under NAFTA, Mexican trucks were meant to be roaming some U.S. roads in 1995 and the width and breadth of the whole country by 2000. However, successive U.S. administrations could not say no to Teamster complaints that Mexican trucks were not fit for the interstates. Finally, both sides agreed on the pilot program to break the deadlock.

Let's not forget our history: The populism of Smoot-Hawley may have had short-term political appeal to "save American jobs," but it widened and deepened the Great Depression. If monetary liquidity is a problem today, let's not compound it by balkanizing trade. China and Mexico are two of our three largest trading partners. What are we going to do next? Disrupt trade with Canada?

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.

American and Canadian salt industry workers logged more hours in 2008 and yet achieved the salt industry’s best-ever worker safety record, the Salt Institute reported today.

The 8.3% increase in industry work-hours resulted from the industry’s year-long all-out rock salt mining effort which produced a record amount of road salt in preparation for the recent, harsh winter,

Salt workers put in nearly 12 million work-hours in 2008 and recorded 99 injuries. Only 21 incidents resulted in time lost from the job. The incidence of recordable injuries fell from 1.97 per 100,000 work-hours to 1.65, a dramatic16.2% improvement and an all-time salt industry safety record.

Morton Salt achieved the best overall company safety record among large companies and Detroit Salt among smaller companies.

Of the 50 U.S. and Canadian salt plants, more than a third, 17, had unblemished safety records last year. <more >

A contemporary art exhibition, "Salt of the Earth ," will be held in a historic church in Salthouse in the UK, which was named after its role in the medieval salt trade. The exhibition features over 50 contemporary artists who are creating new work in response to the theme of 'Salt of the Earth', considering salt's role in culture, history, religion, agriculture, science and culinary matters. The exhibition promises to be an exciting event featuring paintings, drawing, printmaking, film, sculpture, installation and ceramics by some of the leading British artists. This year's curator is Norfolk native Simon Martin from the award-winning, prestigious Pallant House Gallery in Chichester.

Back in December, winter snows paralyzed Seattle, WA when the city, citing concerns with salt in roadway runoff into Puget Sound, failed to use salt to clear city streets. Facing angry citizen reaction, the city recanted and now uses road salt. The mayor, of course, conducted an evaluation; he issued a "B" grade for the city DOT's response actions.

The Seattle Times on March 19 published results of its own independent review "to provide a more complete explanation of why the city was paralyzed by snow and ice for two weeks, even on days when there was no new snowfall." Reporter Susan Kelleher's article "Seattle DOT botched snow response," concluded:

When winter storms rolled over Seattle in December, bringing snow and freezing temperatures to the city, the manager in control of the city's snowplows had no experience directing a major snow response and had put in place as his No. 2 an employee who knew even less on the subject.

Together, Paul Jackson Jr. and Robert Clarke, a former crew chief, orchestrated a disjointed response to the winter weather that left major streets unplowed while Jackson, the man calling the shots, worried aloud about clearing certain streets so the mayor could drive to work, according to interviews with plow drivers and street crews and thousands of department records analyzed by The Seattle Times.

Better training was clearly an issue, beyond salt usage. The article continued:

While the weather was undeniably cold and snowy, interviews and a review of about 2,000 records, including e-mails and detailed reports on how the city deployed equipment and crews, show that transportation managers Jackson and Clarke made questionable calls on staffing and deployment.

Transportation crews described confusion and delays in dispatching plows when the snow first began falling, making it harder to stay on top of the game. Meanwhile, the records show trucks hopscotching around the city, attending to special requests or remaining idle while the city announced it was plowing "aggressively" and clearing main routes that residents swore had yet to see a plow.

Reader comments accepted the analysis and suggest that outrage for bonuses for bailout executives have a West Coast echo.

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?