In the October 2006 issue of Thyroid, (vol.16, no. 10) , the Public Health Committee of the American Thyroid Association stated that,

"The fetus is totally dependent in early pregnancy on maternal thyroxine for normal brain development. Adequate maternal dietary intake of iodine during pregnancy is essential for maternal thyroxine production and later for thyroid function in the fetus."

They went on to recommend a minimum of 150 µg of iodine supplementation on a daily basis. At the time they suggested that this be best accomplished through the use of vitamin/mineral supplements taken during pregnancy and lactation.

In that same issue Dr. Daniel Glinoer , professor of internal medicine at the University Hospital Saint Pierre, in Brussels, suggested that it would be very worthwhile to consider universal salt iodization as practiced in some countries, rather than the use of supplements. This debate over the best iodine delivery vehicle was highlighted by Dick in his June 12 blog, "Thyroid doctors clash over iodine nutrition for expectant mothers ."

Continuing the debate, in the most recent issue of Thyroid (May 2007, vol. 17, no. 5) , Kevin Sullivan of the department of Epidemiology at the Rollins School of Public Health, Emory University in Atlanta, GA, stresses the importance of ensuring that pregnant and lactating women receive sufficient iodine to prevent irreversible brain damage in infants. He refers to the recent NHANES data indicating that most pregnant women in the US are currently at a borderline level of iodine intake.

Sullivan goes on to make a strong recommendation that iodine fortification should be carried out on all salt concluding that used in food processing. In fact, the Salt Institute is currently discussing this matter internally and with foreign associates to ensure that there is no industry concerns about the universal iodization of salt.

The Salt Institute recently made a strong recommendation to the USDA WIC program that they make a specific effort to ensure that pregnant women and new mothers understand the importance of consuming iodized salt. Up to that point, the WIC program had made no effort to highlight the importance of consuming iodized as opposed to non-iodized salt.

As pointed out in a recent Food Technology 'Perspectives' article, in early 1924, the US salt industry produced and marketed iodized table salt for country-wide consumption. From that moment on, with a simple jiggle of the salt shaker, the US salt industry dispatched the scourges of iodine deficiency diseases - goiter, cretinism, hypothyroid coma and iodine deficiency-induced mental retardation - into the dustbin of Americans medical history. Of course, this practice ia now being adopted on a world-wide basis .

A June 26 story on "Sodium Shakeout: Salt and Health " by Kimberly J. Decker in Food Product Design discussed the salt and health issue, referring to a resolution approved a year ago by the American Medical Association.

"Sodium has been in discussion for many years, and the problem is that it's a very controversial discussion," agrees Markus Eckert, technical vice president, flavors, Mastertaste, Teterboro, NJ. "There have been studies for many years already showing that it can lead to cardiovascular health issues." However, "there have been other published studies that followed subjects on low-sodium diets for several years and found that, actually, the risk for cardiovascular health issues is higher here than for regular diets."

In one such study, published in 2006 in the online version of the American Journal of Medicine (119(3): 275.e7-275.e14), researchers at the Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, studied survey data from the second National Health and Nutrition Examination Survey (NHANES II) and found that, among 7,154 survey participants, those who consumed less than 2,300 mg of sodium per day were actually 37% more likely to have died from CVD. The researchers acknowledged it wasn't a clinical trial, nor did they propose that the results dictate sodium nutrition policy. They did point out that their findings cast some doubt on across-the-board advice to lower sodium consumption.

Decker summarized for her food industry subscribers:

So, following the AMA's 2006 sodium statement, the Institute of Food Technologists, Chicago, offered a voice of reason by noting that we do not now consume substantially more (or, alas, substantially less) salt than we have over the past quarter century. Other food industry organizations, such as the Grocery Manufacturers/Food Products Association, Washington, D.C., and the Salt Institute, Alexandria, VA, issued rejoinders of their own, with the latter's president, Richard L. Hanneman, going so far as to call the AMA's recommendations "scientifically unjustified and a waste of time and money." Ouch.

Ouch, indeed. Thanks to IFT for its efforts to sort out the controversy. Actually, sodium intakes have been generally unchanged not just for the past quarter century, but for the hundred or so years that we've been able to measure intakes with some accuracy. We need a "truth squad" to prevent anti-salt zealots from trying to distract the public health policy discussion from its proper focus on whether lowering dietary sodium would provide any health benefit to the population. There's no evidence on the table that it would, just computer-generated model projections based on flawed assumptions drawn from intermediate variables. Yes, ouch. That hurts all of us.

So much has been written, particularly over the past week or so, about the series of 5-4 votes in the U.S. Supreme Court where President Bush's most enduring legacy is being recorded. While much has been made about the Court's ruling outlawing race-based discrimination and restoring the erosion of political free speech under the McCain-Feingold campaign finance "reform," other less-discussed opinions will have far-reaching impacts on the salt industry.

Perhaps most important among them was the June 25th decision in National Ass'n of Home Builders v. Defenders of Wildlife . The Supreme Court reversed an appeals court ruling that had, in effect, established the Endangered Species Act (ESA) as a super-statute that was given priority when its dictates conflicted with other laws. This grew out of the infamous "snail darter" case thirty years ago that held the ESA "require[s federal] agencies to afford first priority to the declared national policy of saving endangered species." The NAHB ruling examined a conflict of the ESA with the Clean Water Act and the court ruled that the agencies should consult together to resolve the problem, not sacrifice pollution control rules as the preferred outcome. The ESA has been employed regarding solar salt production and this ruling is a step forward for rational (and more flexible) public policy.

One reason MSM journalists are losing their audience is the open secret that much of what is reported as "news" comes pre-packaged in canned stories from various advocacy groups and advertisers. Add that to the herd instinct that produces "PC"-slanted reporting and it's not difficult to poke holes in what we read in the newspapers or see on TV.

Cyber-journalism has the opposite problem. Rather than lemming-like PC stories based on pooled source information like wire services, bloggers and Web authors come in all shapes and sizes of quality and credibility. Who to believe?

When it comes to making sense of the chaos of Internet health reporting, Google is trying to intervene -- to make money and, they hope, to help seekers of quality information pertaining to their precious personal health. Query: will this be another case where the surgery is successful, but the patient dies? Will the choices of the Google censors preserve the essence of scientific inquiry where competing ideas are bombarded with data that either confirms or destroys them? Or will the desire to "help" consumers understand the meaning of medical scholarship excise aberrant findings, leaving only politically-correct interpretations?

We share the concerns of Sandra Szwarc in Junkfoodscience.com :

Search engines have inordinate abilities to censor information by simply making it invisible to searches. It is not uncommon for key documents and papers that don't support government initiatives or special interest agendas to be buried and take extraordinary effort to hunt down, or to disappear from the internet altogether, something anyone who's been researching for any length of time quickly discovers...

Google has just announced that it has created a "Google Health Advisory Council." ... Says Google : "We want to help users make more empowered and informed healthcare decisions, and have been steadily developing our ability to make our search results more medically relevant and more helpful to users."

Screening out "irrelevant" and "unhelpful" information? That sounds like a euphemism for censorship. Look at every name on their new prestigious advisory panel and the interests they represent. Most will be familiar to Junkfood Science readers, as we've examined the soundness of their consumer information RAND Corp., the Cleveland Clinic, the AMA, Robert Wood Johnson Foundation, AARP, Kaiser Foundation Health Plan, Inc., California HealthCare Foundation, and others.

Despite all of the flaws and utter garbage on the net, it's still been the primary way for most people to break through the media groupthink to learn other viewpoints and sounder information. This development could be the beginnings of the world's biggest internet information firewall.

Substituting a Google censor for the rigor of true "evidence-based" analysis would be a clear step backwards. Search engines seeking access to the Chinese market, reportedly, have agreed to censor their search results. That's unfortunate for 1.3 billion Chinese and a disturbing parallel to the new Google Health Advisory Council. What we need in public health policy is more transparency and solid information, not greater opaqueness and opinion. As we blogged recently , the quality of the process is of paramount importance. We need to be able to "lift the hood and kick the tires " of new medical studies, not have a secret censor decide for us what's relevant and what's not.

It would be hard to find anyone or any group today making health policy recommendations who doesn't claim their conclusions are "evidence-based." But since recommendations vary considerably in some areas, such as whether there is a health benefit to reducing dietary sodium/salt, it should be important to all of us exactly how "evidence-based medicine" (EBM) works and how it fits into the overall process of producing health care or health policy decisions.

An interview in the June 19 issue of Health Affairs magazine illuminates the limits of EBM and the shadowy abuses of the term.

Boomers will remember the Sixties when the Cuyahoga River in Cleveland, OH caught on fire; it was that polluted. No more . Still, the notion of water bursting into flame is intriguing and quite visual ( 1 2 ).

Touted by some to be akin to an energy-producing perpetual motion machine, a device developed by John Kanzius, a former broadcast executive with a background in physics, burns salt water using a radio wave machine he originally developmed to kill cancer cells. While testing his machine to see if it desalinized water, the water burst into flame, apparently burning the hydrogen liberated from the water. He claims a 76% efficiency rating and has filed patents for the process using saltwater as an alternative fuel. No doubt it's easier to find saltwater in the ocean than oil under desert sands.

Salt's in the news, whatever direction you look! (make sure you see at least one of the videos ( 1 2 ).

On June 14, the U.S. Chemical Safety Board (CSB) released a safety bulletin warning that some chlorine railcar transfer systems lack effective detection and emergency shutdown devices, leaving the public vulnerable to potential large-scale toxic releases. The Board formally recommended that the U.S. Department of Transportation expand its regulatory coverage to require facilities that unload chlorine railcars to install remotely operated emergency isolation devices to quickly shut down the flow of chlorine in the event of a hose rupture or other failure in the unloading equipment.

Coincidentally, the bulletin raises, yet again, security concerns about transporting chlorine, concerns that are prompting chlorine-using agencies to consider installing on-site chlorinators to avoid spills, releases and becoming a terrrorist target . Mort Satin has reported twice recently on this ( 1 2 ). CSB offered two "incident" reports to underline the seriousness of their concerns:

- June 28, 2004 - The collision of two trains near Macdona, Texas caused a release of liquefied chlorine from one of the train's tank cars. The chlorine vaporized, engulfed the area and led to the deaths of the train conductor and two local residents.

- January 6, 2005 - In Graniteville, South Carolina, a Norfolk Southern train collided with a stationary train, leading to a derailment, and the release of an estimated 120,000 pounds of chlorine. The derailment and resulting chlorine release caused 9 deaths, led to over 500 persons seeking medical treatment for possible chlorine exposure and the mandatory evacuation of over 5,000 residents.

Current bulk chlorine customers receiving chlorine by railcars, barges or tank trucks are in the process of implementing safety guidelines developed by the Chlorine Institute with a deadline at the end of this year. Customers who take delivery in one-ton containers or cyllinders have an additional year to comply.

Junkfoodscience.com has taken the American Heart Association to task for the poor quality of its evidentiary review to support its lifestyle recommendations for women. Writing of the American Heart Association's Evidence-based Guidelines for Cardiovascular Disease Prevention in Women released in May, Sandy Szwarc:

Not one observational study was able to credibly support the AHA heart healthy eating recommendations for women to prevent heart disease or premature death. The only observational study specifically looking at Healthy Eating in accordance with our government's dietary guidelines found no benefit. And finally, the strongest evidence - an actual clinical trial of the heart healthy diet on the primary prevention of heart disease in women, that went on for more than 8 years - found it had no effect on heart disease. Reviews of clinical trials conducted on heart healthy programs to date have found them of doubtful effectiveness, with no effect on mortality. Our beliefs in healthy eating have gone far beyond well-founded advice to eat normally and enjoy a variety of foods in order to prevent deficiencies, fuel our bodies, and for pleasure; to beliefs in special powers of foods as medicines or poisons.

This review looked at the evidence being used to support "evidence-based" recommendations for a heart healthy diet. When we hear the term "evidence-based," most of us probably had a very different picture in our minds.

While the AHA calls for rigorous public policies to implement its preventive guidelines population-wide in order to "combat the pandemic of heart disease in women," how many politicians and healthcare professionals will have taken the time to look at the evidence behind these recommendations? But we will have, and can make a more informed choice about what we want to eat.

This article is the Szwarc's second. The first , published May 2, pointed out:

A major medical paper on primary heart disease prevention admitted that cardiovascular disease risk factors have proven useless for predicting heart disease among our population and that reducing risks factors doesn't translate into reduced clinical disease or fewer premature deaths.

Sounds like our complaints about self-proclaimed "evidence-based" labels need a truth-in-labeling watchdog.

The American Medical Association House of Delegates will gather later this month in Chicago, where it will consider a vast array of resolutions directing their lobbyists in Washington as well as advising their physician members throughout the country.

Resolution 611 deals with "Evidence-Based Policy Development" and would require

RESOLVED, That our American Medical Association House of Delegates resolutions should include, whenever possible or applicable, appropriate reference citations to facilitate independent review by delegates prior to policy development. (Directive to Take Action)

Great idea -- as far as it goes. But evidence-based public health is more than a platitude . Two problems: timing and content.

We can hope that the controversy generated when AMA approved an anti-salt resolution last year might be the genesis of this year's resolution to get serious about basing resolutions on evidence. Evidence-based considerations were missing-in-action last year. Opinion trumped facts. So the timing's bad; it puts the cart before the horse.

The content is also suspect. It's a tepid gesture that will allow any proposer to claim his or her resolution is "evidence-based" merely by including literature citations. That's even worse than what has been passed-off as "evidence-based" policy recommendations by the experts on the Dietary Guidelines Advisory Committee (DGAC). We had recommended the DGAC model their analysis on international "evidence-based" standards. They didn't. Just as everyone wants to be felt to be fair, honest, to say nothing of attractive, witty, etc., self-proclaiming these virtues can often be wildly misleading.

What is "evidence-based" health policy?

Let's give credit where it's due. Back in 1972 A.L. "Archie" Cochrane penned his pathbreaking book, Effectiveness and Efficiency: Random Reflections on Health Services. This is the original textbook on "evidence-based medicine", a term familiar to most doctors and other healthcare professionals today. Cochrane's classic text has had a profound influence on the practice of medicine and on the evaluation of medical interventions. He was the first to set out clearly the vital importance of randomized controlled trials (RCTs) in assessing the effectiveness of treatments, and his work led directly to the setting-up of the Cochrane Collaboration , now a world-wide endeavor dedicated to tracking down, evaluating and synthesizing RCTs in all areas of medicine .

In my reading on the subject, for a recommendation to be evidence-based it should be developed using a structured and rigorous methodology based on a pre-determined set of criteria for grading the strength of any proposed recommendation. Consideration would be limited, most likely, to evidence found in randomized controlled trials and comparative controlled trials identified and synthesized using methods defined by the Cochrane Collaboration. An expert panel should first define evidence of outcomes important to individual subjects and, in aggregate, to the population, by determining the required strength of the evidence considered valid for inclusion in the review. Then, in blinded fashion, the evidence should then be graded against those criteria. The Cochrane methodology is preferred as a means to minimize bias since it outlines an objective and systematic approach to literature search, study selection, data extraction and data synthesis. Anything short of this dilutes the meaning of "evidence-based." To call the AMA approach "evidence-based" is whistling past the park.

Cochrane's home base, Oxford University, hosts a Centre for Evidence-based Medicine which answers the question "What is EBM? by extracting from an editorial in the British Medical Journal back in 1996:

Evidence-Based Medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. There are now frequent workshops in how to practice and teach it; undergraduate and post-graduate training programmes are incorporating it (or pondering how to do so); British centres for evidence-based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and the York Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care; new evidence-based practice journals are being launched; and it has become a common topic in the lay media. But enthusiasm has been mixed with some negative reaction. Criticism has ranged from evidence-based medicine being old-hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost-cutters and suppress clinical freedom. As evidence-based medicine continues to evolve and adapt, now is a useful time to refine the discussion of what it is and what it is not.

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisi ons about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.

Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicabl e to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.

This description of what evidence-based medicine is helps clarify what evidence-based medicine is not. Evidence-based medicine is neither old-hat nor impossible to practice. The argument that everyone already is doing it falls before evidence of striking variations in both the integration of patient values into our clinical behaviour and in the rates with which clinicians provide interventions to their patients. The difficulties that clinicians face in keeping abreast of all the medical advances reported in primary journals are obvious from a comparison of the time required for reading (for general medicine, enough to examine 19 articles per day, 365 days pe r year) with the time available (well under an hour per week by British medical consultants, even on self-reports.

The argument that evidence-based medicine can be conducted only from ivory towers and armchairs is refuted by audits in the front lines of clinical care where at least some inpatient clinical teams in general medicine, psych iatry (JR Geddes, et al, Royal College of Psychiatrists winter meeting, January 1996), and surgery (P McCulloch, personal communication) have provided evidence-based care to the vast majority of their patients. Such studies show that busy clinicians who devote their scarce reading time to selective, efficient, patient-driven searching, appraisal and incorporation of the best available evidence can practice evidence-based medicine.

Evidence-based medicine is not "cook-book" medicine. Because it requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patient-choice, it cannot result in slavish, cook-book approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. Similarly, any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient's clinical state, predicament, and preferences, and thus whether it should be applied. Clinicians who fear top-down cook-books will find the advocates of evidence-based medicine joining them at the barricades.

Evidence-based medicine is not cost-cutting medicine. Some fear that evidence-based medicine will be hijacked by purchasers and managers to cut the costs of health care. This would not only be a misuse of evidence-based medicine but suggests a fundamental misunderstanding of its financial consequences. Doctors practising evidence-based medicine will identify and apply the most efficacious interventions to maximise the quality and quantity of life for individual patients; this may raise rather than lower the cost of their care.

Evidence-based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. To find out about the accuracy of a diagnostic test, we need to find proper cross-sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial. For a question about prognosis, we need proper follow-up studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes the evidence we need will come from the basic sciences such as genetics or immunology. It is when asking questions about therapy that we should try to avoid the non-experimental approaches, since these routinely lead to false-positive conclusions about efficacy. Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the "gold standard" for judging whether a treatment does more good than harm. However, some questions about therapy do not require randomised trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient's predicament, we follow the trail to the next best external evidence and work from there.

Despite its ancient origins, evidence-based medicine remains a relatively young discipline whose positive impacts are just beginning to be validated, and it will continue to evolve. This evolution will be enhanced as seve ral undergraduate, post-graduate, and continuing medical education programmes adopt and adapt it to their learners' needs. These programmes, and their evaluation, will provide further information and understanding about what evidence-based medicine is, and what it is not.

Authors:

David L. Sackett, Professor, NHS Research and Development Centre for Evidence-Based Medicine, Oxford. William M. C. Rosenberg, Clinical Tutor in Medicine, Nuffield Department of Clinical Medicine, Oxford. J. A. Muir Gray, Director of Research and Development, Anglia and Oxford Regional Health Auhtority, Milton Keynes R. Brian Haynes, Professor of Medicine and Clinical Epidemiology, McMaster University Hamilton, Canada W. Scott Richardson, Rochester, USA

The AMA does not welcome "outside" comments (hence this blog), but AMA members may wish to share their thoughts on how their association may be over-reaching by claiming an evidence-based procedure. The contact is Susan L. Hubbell, MD, chair, Reference Committee F, and, again, the proposal is Resolution 611 .

So says Elizabeth Bromstein writing in NOW Magazine (Toronto). "I don't think anybody ever had a heart attack from drinking too much mineral water or vegetable juice," she says, noting that while some think we ingest too much salt, "others say the warnings are way out of whack." So she did her own research and reported:

What the experts say

"Around 1900 we had an average sodium intake of 200 mg a day, and now we have an average intake of 5,000 mg. Sodium has to work with potassium and magnesium, and while our salt intake has increased, our potassium and magnesium intake has gone down. The increase is mostly due to processed foods, but if you eat a diet low in processed foods and high in fruits and vegetables, your salt level is probably fine. Your potassium and magnesium are probably fine as well, and you can add table salt to foods."

AILEEN BURFORD MASON, immunologist and nutritional consultant, Toronto

"In Canada, 25 per cent of people have hypertension, and one in three would not have it if his or her sodium intake were lower. Processors and restaurants are responsible for 80 per cent of our salt intake. We add 10 per cent ourselves, and 10 per cent occurs naturally in food. If we asked restaurants to cut the amount, we'd see a dramatic improvement. Hypertension causes two-thirds of strokes, one-half of all cases of heart failure and one-quarter of all cases of kidney failure and heart attack. Hypertension is one of the major drivers of dementia. There are more effective ways of reducing hypertension than reducing salt, like increasing physical activity, losing weight, getting enough soluble fibre and eating low-fat dairy products."

NORMAN CAMPBELL, professor of medicine, Libin Cardiovascular Institute, University of Calgary

"We know salt is associated with blood pressure, so we concluded that anything we could do to reduce blood pressure would achieve the same risk profile of lower-risk populations, but that hasn't turned out to be true. Some studies even suggest that there may be an increased risk for cardiovascular disease with a reduced salt diet, since it increases insulin resistance and can affect plasma renin activity. Until 12 years ago, we did not look at the net effects [of reducing salt] and only looked at blood pressure. Even then, about a third of the population responded [positively] to salt restriction. What we need is a five-year controlled intervention trial."

RICHARD L. HANNEMAN, president, Salt Institute, Alexandria, Virginia

"Salt is one of those essential elements we need in moderation. There are people who are salt-sensitive. Your intake should depend on your sensitivity level. Salt helps stimulate the kidneys, helps promote fluid metabolism and has a moistening effect. A little bit [taken internally] is good if your skin is very dry. It also has a mild detoxifying effect. In Chinese medicine it is also known as a s oftener for hardened lymph nodes, glands or muscles. It gently promotes bowel regularity. Most importantly, it needs to be kept in balance with potassium. Aside from causing hypertension, too much salt can interfere with calcium absorption and lead to poor bone health. If you have PMS and bloating, it's important to reduce your salt intake as well."

DU LA, naturopath, Toronto

Not to pick a quarrel with experts (especially since Ms. Bromstein kindly denotes me one), but Ms. Mason is just flat-out wrong about salt intakes increasing from 200 mg/day to 5,000 mg/day over the past century. In fact, sodium intakes are virtually the same at about 3,500 mg/day. Dr. Campbell employs the classically flawed extrapolation of blood pressure to heath outcomes; a model rejected by direct health outcomes studies. And the solution to the "bloating" probem identified by Mr. Du is to drink more water, not consume less salt.

That said, the experts also made some important points: Ms. Mason points out any health problem owes to the imbalance of sodium on one side and potassium and magnesium on the other, advising to eat more fruits and vegetables so that your "potassium and magnesiium are probably fine as well and you can add table salt to foods." Balance and moderation: good advice. Though limiting his comments to blood pressure and not health outcomes, Dr. Campbell concedes the same point: "There are more effective ways of reducing hypertension than reducing salt, like increasing physical activity, losing weight, getting enough soluble fibre and eating low-fat dairy products." And Mr. Du agrees: "Salt is one of those essential elements we need in moderation. ... Most importantly, it needs to be kept in balance with potassium."

Thank you, Ms. Bromstein for your reasoned advice. For more on the Salt Institute perspective see our summary and reference citations .

While the Salt Institute has always been quietly aware of its unique influence with policy wonks and lawmakers, we could not quite believe the speed with which our blog was able to galvanize the machinery of government into action. On June 12, only two working days after our Peace Chlor article, Homeland Security Secretary Michael Chertoff, urged all operators of water and waste treatment plants to secure chlorine supplies from terrorists , even though at present they are not required to do so. The July 13 Newsday account indicates that an estimated 3,000 drinking-water and wastewater treatment plants are listed in EPA documents as holding in excess of 2,500 pounds of chlorine gas, according to the Center for American Progress.

Although not specifically mentioned in his announcement, we suggest that the ideas expounded in The Peace Chlor be considered carefully.

The tone and content of the Secretary Chertoff's message, coming so soon after our blog was published leaves us little choice but to assume that Salt Sensibility is continually read at the highest levels of government and when an opportunity arises to act upon our foresight and advice, they do not hesitate to do so.

With that vote of confidence we shall continue providing our considered thoughts on all aspects of salt's benefits to humankind.

Last October, the Public Health Committee of the American Thyroid Association published recommendations on iodine supplementation for pregnant and lactating women in North America. Noting that the World Health Organization had increased its recommended daily intakes to 250 micrograms of iodine daily and that 7.3% of pregnant Americans are ingesting less than 50 micrograms -- the minimum safe level -- the ATA called for all pregnant and lactating women to take iodine supplements of 150 micrograms/day.

Not so fast, says Kevin Sullivan of Emory University, a board member of the International Council for the Control of Iodine Deficiency Disorders. Dr. Sullivan argues in a letter published in the current issue of the journal Thyroid that many women don't take supplements and, even if they started when they learned they had become pregnant, irreversible brain damage may already have been done to their unborn baby. He argued that "all household salt (as well as salt substitutes) and salt used in the food industry" should be iodized. He explained:

The Committee should be applauded for their efforts to prevent irreversible fetal brain damage as a result of iodine deficiency. While an important and useful step, the iodine supplementation during pregnancy recommendation has some limitations. First, currently the Institute of Medicine recommends multivitamins for some groups of pregnant women and the recommended vitamins and minerals do not include iodine, therefore many prenatal multivitamins do not include iodine. The Public Health Committee recommended efforts to encourage manufacturers to include iodine in all vitamin and mineral preparations for use during pregnancy and lactation. Second, many women will not use supplements on a regular basis as has been found with folic acid supplementation. Women who do not use supplements on a regular basis tend to be younger, of lower education, and of certain ethnic/racial groups. In addition, much of the damage caused by iodine deficiency occurs early in the pregnancy, therefore, by the time a woman realizes she is pregnant and seeks prenatal care, damage may have already occurred.

It would seem that the focus of preventing the negative effects of iodine deficiency in the developing fetus should focus on all women of childbearing age. Efforts should be placed on fortification of salt for human consumption as recommended by the International Council for Control of Iodine Deficiency Disorders (ICCIDD ), United Nations International Children's Emergency Fund (UNICEF ), and WHO and implemented in many countries. In the United States, all household salt (as well as salt substitutes) and salt used in the food industry should contain iodine at levels to assure an adequate iodine intake in the vast majority of the population. Through careful study of urinary iodine levels, the iodine content of salt and salt substitutes can be adjusted to assure that there is not too much or too little iodine in the diet, similar to the approach used in Switzerland. To prevent excess iodine intake, the iodine levels in other foods, such as dairy products and bread, may need to be regulated.

Iodizing salt substitutes -- like potassium chloride and "sea salt." Now, THAT's an interesting idea. For a salt industry perspective, see the Salt Institute website or that of EuSalt . The salt industry is part of a global Network for the Sustained Elimination of Iodine Deficiency .

On April 23, USA Today headlined the story, "Chlorine bombs pose new terror risk ." The story began by describing the Homeland Security Department's warning to U.S. chemical plants and bomb squads to guard against a new form of terrorism, namely, chlorine truck bombs. At least five chlorine truck bombs have exploded in Iraq in recent months, resulting in the deaths of scores of people and injuries to many more as a result of breathing toxic fumes. The 150 lb tanks of chlorine used by the terrorist are extremely common and routinely used for the chlorination of municipal water supplies or the disinfection of wastewater.

The Chlorine Institute , which represents the more than 200 companies that produce and distribute chlorine, recently alerted the FBI to several thefts or attempted thefts of the 150-pound chlorine tanks from water treatment plants in California.

These events motivated members of the House Homeland Security Committee, to send a letter to Homeland Security Secretary Michael Chertoff expressing "deep concern" for the potential threat posed by chlorine.

Chlorine gas was among the first chemical weapons to be used as a weapon in modern warfare. On April 15, 1915, German forces released about 160 tons of chlorine gas into the wind near the Belgian village of Ypres. The clouds of the gas drifted into Allied forces, killing some 5,000 soldiers. Two days later, another chlorine attack at the same village killed thousands more soldiers.

Chlorine was first used as a terrorist weapon in 1997, when a serial bomber detonated several chemical bombs containing chlorine across Sidney's eastern suburbs that injured three dozen people. The universal use of chlorine for municipal water treatment, the relative ease with which the ubiquitous chlorine gas tanks can be obtained and the potential to cause massive casualties makes chlorine an uncommonly attractive weapon for terrorists.

Of course, now that Al Qaeda terrorists have had considerable success in chlorine bombing in IRAQ, much greater security will be required when transporting chlorine in future (whether in 150 lb tanks or railroad tanker cars) - not only in Iraq, but around the world.

However, another approach, which would largely eliminate the threat of chlorine as a terrorist weapon requires a simple modification of the current technology of treating water.

For years now, a great many pool owners have invested in chlorine generators which freshly generate chlorine for direct dissolution into their swimming pools. Starting with sodium chloride, a brine is made which then goes through a low voltage electrolytic cell to produce chlorine.

Using the same principal, John Hays, the water plant superintendent for the city of Washington, IA constructed his own electrolytic chlorine generator to serve the million gallon per day water needs for his town. In fact, his design is now under patent review and is the first fully functional municipal class chlorine generator.

John indicated that he began looking at alternatives to chlorine gas for both safety and cost concerns, and electrolytic chlorination seemed to offer the lowest overall cost of capital investment and ongoing operational cost. In a personal communication to the Salt Institute, John indicated that he could now accomplish the same chlorination levels for one third to one quarter the cost of conventional treatments.

On May 10, 2007, NSF International announced that John Hays' Washington, IA water treatment facility was the first to be certified by NSF International to ensure its chlorination system met all national standard requirements.

The Washington, IA chlorine generator uses conventional evaporated salt as it's starting material - a commodity that presents no terrorist hazards whatsoever. In fact, with the relatively small capital outlay and the operational cost-effectiveness, this new system can completely eliminate the threat posed by conventional chlorine stockpiles and distribution, while significantly reducing the costs of producing high quality drinking water. If ever there was a win-win situation, this is it.

Communities across America should be encouraged to use their Homeland Security funds just for this purpose.

It was with great interest that I recently came across an article describing some of Benjamin Franklin's experiments on electricity. Although he was most well-known for his invention of the lightening rod and his work on condensers and batteries, he was never given proper credit for his invention of the process of tenderizing poultry by electrical stimulation.

In correspondence with his English colleagues, Franklin wrote that linking several electrical capacitance jars together allowed him to kill a 10 lb. turkey with a single jolt of high voltage electricity. "I conceit that the birds killed in this manner eat uncommonly tender," he noted.

More than 200 years later, US patents were awarded for "…electrically stimulating poultry carcasses in order to tenderize the poultry meat."

There really isn't very much new under the sun.

Recently, much hue and cry was raised about "enhanced poultry," as if this time-honored brining technique for improving the tenderness of poultry was a new invention of big industry. Brining originated from a method of curing called corning, although it had nothing whatsoever to do with corn. The name comes from Anglo-Saxon times. Meat was cured in coarse "corns" of salt. Pellets of salt, the size of kernels of corn, were rubbed into the beef to keep it from spoiling and to preserve it. It was a means of making tough cuts of beef, particularly briskets, tender prior to storage (since refrigeration was unavailable at the time). Corned beef became such a beloved product that it continues to be made by brining today, even though we all have refrigerators.

As I said, there really isn't very much new under the sun.

Based upon the expected 13.6% increase in population per decade over the next 20 years, most of which will take place in the nation's warm and sunny regions, water is clearly the issue that will dominate our future. Because all U.S. fresh water sources are already committed, plans are moving aggressively forward to put in place the desalination infrastructure to meet our county's needs for the next 50 years. The coastal areas will most likely use seawater as their main raw material source, while the interior of the country will most likely use impaired groundwater or brackish water.

The main technological challenge to desalination is the disposal of residue water that contains three to four times the salt content of the input water. A good deal of this material is currently being pumped into deep wells, but the feasibility of this approach is questionable for the future. A major challenge is the determination of best practices to dispose of or utilize the wastewater streams coming from large- scale desalination operations. This was recently highlighted in a previous blog as well as an article in the April issue of Water Conditioning & Purification Magazine , "A Glass Half Full," by Mort Satin.

In the March SI Report , we suggested that a desalination operation's waste can easily serve as the raw material for another unit operation ("The salt-making/desalination nexus"). Just as former cheese factory waste product, whey, became one of the most highly valued products in the food industry, we speculated that desalination waste streams might prove to be a new source of raw material for the salt industry.

Just this week we see that is exactly what has happened.

Business Wire reported that GE Water & Process Technologies is to design and construct a reverse osmosis seawater desalination plant in South Africa, which will provide 70,000 m3/day of fresh water. In a first, the plant will recover ultra-pure salt from the concentrated brine stream for the production of chlorine, caustic soda, and hydrochloric acid at the refinery.

The $220 million project is part of a larger investment to build a new chlorine refinery in the Coega Industrial Zone, Port Elizabeth, South Africa.

GE's seawater desalination and thermal evaporation technologies will create around 630,000 tonnes of 99.9% pure salt annually. Reclaiming salt from the desalination brine stream will not only improve the overall economics of the refinery project, but also ensure a reliable and locally available supply of high grade salt for use in the refining of chlorine.

This project will provide freshwater to help lessen water scarcity and use the brine waste stream as a valuable raw material for another unit operation.