Mort Satin and I today filed a letter (pdf 103.06 kB) with the Dietary Guidelines Advisory Committee lamenting their decision to convert a public meeting next week into a webinar with no face-to-face interaction. We told the DGAC:

This runs directly counter to the Administration’s encouragement of greater transparency. We earlier registered our continued disappointment that the Committee has turned its back on another Administration commitment – to improve the process in considering science. By not pre-defining quality standards for inclusion in the evidence-based review process being utilized, the Committee invites the same kind of selective, expert opinion criticisms leveled at earlier panels.

Our letter registered process concerns on several issues:

1. Failure to upgrade to a true evidence-based process as recommended by the Institute of Medicine, the U.S. Preventive Services Task Force and the Cochrane Collaboration.
2. Failure to insulate against the prejudicial policy bias of DGAC leaders. We pointed out how the 2000 Guidelines had reversed course on its recommendations for fat when they determined "the recommendation to lower fat intake had been ill-advised and might actually create harm." With leaders pre-judging the issue, the DGAC will find it difficult to ease the salt guideline to reflect the failure of scientific studies to identify a health benefit.
3. Some DGAC members seem to equate salt "disappearance" data with human consumption, but government and university research shows that between 27% and 50% of foods are wasted and many food technologies using salt do not result in that salt ending up in the final product. We offered as examples of "wastage" that 80-90% of salt in koshering meats, 60-80% used in cheese curing, 80-95% used in processing frozen vegetables, 75-80% used in canning, 75-80% used in preparing pickles, sauerkraut and olives, 60-75% used in salting fish and 85-90% used in home cooking water for pasta, vegetables, etc. is discarded after the food is prepared and not ultimately ingested. Overall, we estimated 30-50% shrinkage.
4. We reminded Committee members that any successful replacement of salt in food products would require massive use of salt substitute chemicals with long chemical names that consumers might find problematic since none have been tested in the huge amounts that would be ingested if large-scale salt replacement was achieved.

Today's Wall Street Journal carried a story on "Why we need less sodium." While the question may provoke different opinions, I'm reminded of the observation that everyone is entitled to their own opinion, but nobody is entitled to their own facts.

The article collects oft-repeated myths, perpetuating public confusion. Consider:

• Americans consume the average amount of salt of societies around the world. The article states we consume "15 times" too much. The National Academy of Sciences says humans can survive on 500 mg. But good health requires more.
• The article states that salt intake has increased “50% since the 1970s.” The truth is that per capita salt intakes haven't increased at all. Not since the 1970s and not in the past century. That’s a total fabrication.
• Thus, the implication is that we eat too much salt. That is unfounded. Those with the best health outcomes consume salt at current levels. At the government’s “recommended” 2,300 mg level, cardiovascular mortality is actually higher, more than a third greater (37%), according to the federal government’s own National Health and Nutrition Examination Survey.

National policy should be based on more than opinion and that there should be a controlled trial to establish whether reducing dietary salt improves health. Evidence-based groups like the government’s U.S. Preventive Services Task Force and the Cochrane Collaboration which invented the concept, have concluded that there is insufficient evidence to ask everyone to reduce salt. Unfotunately, the article doesn't even hint at the controversy among expert scientists.

Elsewhere we cover the first rigorous examination of possible causal links between diet and heart disease . The study appeared in the April 13 edition of the American Medical Association's Annals of Internal Medicine . Its authors are with McMaster University in Hamilton, Ontario, the Canadian epicenter of "evidence-based medicine."

The authors provide context noting: "The relationship between dietary factors and coronary heart disease (CHD) has been a major focus of health research for almost a half century." The vast literature with discordant results, however, "has generated confusion among health care professionals, policy makers, and the population at large who are interested in this information to aid them in CHD prevention strategies."

The study sets the standard for evidence-based reviews and is entirely different from the approach being utilized right now by the U.S. Dietary Guidelines Advisory Committee which is utilizing the old traditional "expert panel" approach. Referencing the 2005 US Dietary Guidelines (and equally applicable to the ongoing 2010 revision process), the authors lament:

....little direct evidence from RCTs supports these recommendations. In come cases the RCTs have not been conducted, and RCTs that have been conducted have generally not been adequately powered or have evaluated surrogate end points rather than clinical outcomes. Despite this lack of information evidence-based recommendations derived from cohort studies have been advocated. This is cause for concern because dietary advice to limit the intake of a certain nutrient (i.e. dietary fat) may result in increased consumption of another (i.e. carbohydrates), which can have adverse effects on CHD risk factors. Moreover, without large prospective studies in which multiple health outcomes are evaluated, recommendations to modify a dietary component may decrease teh likelihood of one chronic disease (i.e. CHD) at the cost of increasing another (i.e. cancer)

The authors conclude that there is

strong evidence of a causal link between CHD and dietary patterns. Population-based cohort studies have demonstrated the protective effect of a quality diet against CHD and all-cause mortality. ...Dietary patterns have the advantage of taking into account the complex interactions and cumulative effects of multiple nutrients within the entire diet....

This study should become required reading for the Dietary Guidelines Advisory Committee which seems to be retreating both from objective science and transparent process. As these authors note: "Our study has a number of strengths because we undertook several measures to minimize bias" (which it proceeded to discuss). In contrast, the DGAC appointed an anti-salt zealot, a member of the rabidly anti-salt WASH advocacy group, to chair its salt subcommittee. So much for "measures to minimize bias."

Oh, and by the way, the study found

strong evidence of a causal relationship for protective factors including intake of vegetables, nuts and monounsaturated fatty acids and Mediterranean, prudent and high quality dietary patterns, and harmful factors, including intake of trans-tatty acids and foods with a high glycemic index or load and a western dietary pattern. Among these dietary exposures, however, only a Mediterranean dietary pattern has been studied in RCTs and significantly associated with CHD.

If trhat sound like what regular readers of the Salt Institute's Salt and Health newsletter have been reading about in recent years, particularly about the true nature of evidence-based reviews , how those standards are perverted in the US Dietary Guidelines process and the importance of dietary patterns , we hope that's because we, too, try to be evidence based -- but we cannot claim the exemplary rigor of these researchers who clearly practice what they preach.

The latest trend exposed by the NPD Group’s 23^rd Annual Report on Eating Patterns in America , is the focus on adding healthful ingredients to diets, rather than limiting food items. The percentage of adults supplementing their diets with beneficial ingredients such as whole grains, fiber, antioxidants and Omega-3 fatty acids has been increasing since 2005. According to NPD, a market research firm, the percentage of consumers trying to eliminate trans-fats, cholesterol, sodium, caffeine, sugar and carbohydrates has declined drastically since the late 1980s and early 1990s.

According to NPD’s report, the number of dieters reporting that they are adhering to a low salt diet has decreased significantly since 2001, when 5.4% indicated they were on a low salt diet. In 2008, only 3.4% of dieters reported adhering to a low salt diet.

Despite the efforts of the “food police” and alarmists who focus on single dietary items rather than whole diets, it appears that an increasing number of Americans are taking a more common sense approach to their overall diets. Bombarded with a constant barrage of mixed messages regarding nutrition perhaps they are getting back to the basics that most of us heard at the dinner table growing up: “Eat your vegetables so you will grow big and strong.” “Don’t eat too many cookies or you will get fat.” Note that our parents didn’t say, “Eat only vegetables” or “Don’t eat ANY cookies”. Yet public policy makers often take extreme approaches that make our parents look like they were complete pushovers.

Ultimately a vast body of data supports what our parents told us. We should eat a well balanced diet rich in vegetables, fruits, whole grains, low-fat dairy and lean meats. There is not one magic ingredient in our diets to make us healthy and there is not one “poison pill”. Or as my grandmother would say, “All things in moderation.”

A new publication in this week's Annals of Internal Medicine illustrates the importance of distinguishing evidence-based reviews from more political conclusions by expert groups as employed, for example, in the creation of the US Dietary Guidelines or the World Health Organization's diet recommendations. Andew Mente, et al released "A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart Disease ." They followed an examplary procedure, defining how they would analyze the evidence before actually digging into the subject content of any of the studies. First they identifed 5,705 medical journal articles on diet and heart disease. They then applied pre-established rules on their strength, consistency, temporality (exposure before outcome) and coherence, and then considered biological gradient, experimental evidence, specificity (avoiding multiple risk exposures), biological plausibility and the avoidance of analogy. These comprise the rigorous Bradfor Hill Criteria for Assessing Causation.

The "blind" screening process netted 146 prospective cohort studies and 94 randomized controlled trials that were then analyzed to answer the question: what does medical science tell us about diet and heart disease? The results of the study, in the authors' words:

Strong evidence supports valid associations (4 criteria satisfied) of protective factors, including intake of vegetables, nuts, and "Mediterranean" and high-quality dietary patterns with CHD, and associations of harmful factors, including intake of trans–fatty acids and foods with a high glycemic index or load. Among studies of higher methodologic quality, there was also strong evidence for monounsaturated fatty acids and "prudent" and "western" dietary patterns. Moderate evidence (3 criteria) of associations exists for intake of fish, marine -3 fatty acids, folate, whole grains, dietary vitamins E and C, beta carotene, alcohol, fruit, and fiber. Insufficient evidence (2 criteria) of association is present for intake of supplementary vitamin E and ascorbic acid (vitamin C); saturated and polyunsaturated fatty acids; total fat; -linolenic acid; meat; eggs; and milk. Among the dietary exposures with strong evidence of causation from cohort studies, only a Mediterranean dietary pattern is related to CHD in randomized trials.

Some interpreted the finding as disappointing because the evidence found only a limited number of dietary causes of heart disease -- unlike the huge number of alleged relationships read about in the newspapers almost daily. As USA Today summed it up: "What we know for sure about diet and what protects the heart is a relatively short list." The Systematic Review validated the Salt Institute's dietary advocacy: a quality diet embodying the Mediterranean Diet without regard to any concern about salt intake is the best thing for heart health. No evidence implicated salt as a cause of coronary heart disease.

Rather than disappointment, we should cheer the conclusion that "evidence supports a valid association of a limited number of dietary factors and dietary patterns with CHD." Since we've been largely unsuccessful in changing Americans' dietary patterns, having greater agreement on a limited number of interventions that are proven effective sounds like a real breakthrough to us.

Dr. Steven R. Covey, management guru, teaches as one of his "Seven Habits" to "begin with the end in mind." The key here is that the focus of science and health is the end of preserving the integrity of the science by rigorously following quality scientific methods. The "end" is not finding evidence to support a pre-determined policy preference. Thank you, doctors, for this outstanding reminder that process can determine outcomes and that data-driven conclusions are far more valuable than expert opinion.

Stay tuned to see how the experts on the Dietary Guidelines greet this study.

Mort Satin, Director of Technical and Regulatory Affairs at the Salt Institute addressed the Institute of Medicine 's Committee on Strategies to Reduce Sodium on March 30 at their 2nd Information-Gathering Workshop . He cautioned the Committee to use great caution and to read all the peer-reviewed scientific and medical literature before making any recommendation for a population-wide reduction of salt intakes. He stated that "you cannot simply reduce salt - salt has to be replaced or enhanced with something else and once you begin to modify flavor profiles, you embark on an endless journey of adding nuances and counter-nuances to correct off-flavors or dis-functionalities introduced by the previous additive, until you are left with a cocktail of complex industrial chemicals in the final food product. The very concept of replacing salt with an arsenal of synthetic chemical that have never been tested for their interactions and toxicities at the levels they are projected to be consumed at, if they replace salt, is highly questionable. It is no different than replacing animal fats with trans fats or cane sugar with the several unpronounceable industrial chemicals we call sugar replacers today. All these chemical replacers distort the consumer’s perspective and promote greater overall consumption of food. Sooner or later, a fuller understanding of their toxicities will be revealed, and it is this Committee that will have to bear the responsibility for the ill-conceived strategy that prompted their widespread adoption."

You can read the full statement here (pdf 98.90 kB) .

Will President Obama's actions match his lofty rhetoric? He has charted an ambitious course. He is pursuing nuclear disarmament while North Korea launches ICBM missles. He's ended the "War on Terror" and apparently extending U.S. civil rights to law-breakers like the Somalian pirates. At home, he's promised the biggest spending program in history while being able to cut the deficit by half, all paid for by raising taxes on just 5% of American taxpayers. Lofty -- and oft-lauded -- rhetoric. A lot of these issues won't be sorted out in the near term.

Another rhetorical flourish, however, will be tested this coming Tuesday, April 14, in a federal appeals courtroom in California . Pres. Obama has promised major changes in his Administration to reform the way the federal government uses science . This was to include the Freedom of Information Act and other changes to federal policy to ensure that public policy follows the science. "Restoration" of scientific integrity resonated during the campaign. Now comes the acid test: a court case on the Data Quality Act.

The issue is medical marijuana . That's not a Salt Institute issue. The Salt Institute's issue is the statute being tested: the Data Quality Act (DQA). Signed into law by President Clinton, the DQA affirms that no federal policies will rely on scientific data that does not meet certain quality standards, among them that the data are available for independent verification.

Unfortunately, during the last Administration, the Department of Justice controverted the intent of the law and convinced a federal appeals court in the 4th district in the case, Salt Institute v. Leavitt , that the Data Quality Act was not judicially reviewable. The bureaucracy would determine for itself if its data followed the statute's strict requirements. The government had been asked to produce for independent review rudimentary statistical analysis of the DASH-Sodium study which it was using as justification for the 2005 Dietary Guidelines. Not wanting to divulge the information, the Department of Health and Human Services denied a DQA petition from the Salt Insitute and the U.S. Chamber of Commerce and refused to reconsider it on appeal. The court decision to leave the matter with the agency totally neutered the statute and, doubtless, contributed to the Adminstration's alleged arrogance in subverting science.

Now comes the DOJ again to court in a case that many Obama partisans support -- opening up use of medical marijuana. The argument is made that the government has no compelling data to deny states the right to allow the practice. Will DOJ on Tuesday adopt the stance of the former Administration that "Uncle Sam knows best" what data should be allowed into the policy discussion? Or will the new Obama DOJ implement the lofty ideals espoused by the President that scientific integrity be restored and only high quality data be the basis for federal policy.

The larger issue was captured in a "Power and Control " blog today by"M. Simon of Rockford, IL" noted in today:

It would seem that the Federal Government and Congress have not been keeping up. Justice Clarence Thomas got it right in a medical marijuana case (Raich) when he said

"Congress presented no evidence in support of its conclusions (that marijuana has no medical value - ed.) , which are not so much findings of fact as assertions of power," and Thomas concludes: "Congress cannot define the scope of its own power merely by declaring the necessity of its enactments."

So, who's in control? President Obama with his ideals? Or the federal bureaucrats who seek to avoid accountability by thwarting the Data Quality Act and its lofty, laudable requirements that federal policy follow the science. It doesn't take a new law. We hope it doesn't take a "Saturday Night Massacre" at the Justice Department to make the right moral choice.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Well, it's about time!

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

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

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

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

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

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

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

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

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

and

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

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

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

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

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

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

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

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

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

Amen.

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

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

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

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

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