Yesterday in Paris, France, Dr. Tilman Drueke conducted a forum featuring three other scientific experts on various aspects of salt and health. The event was organized by EuSalt, the trade association of European salt producers. An audience of salt producers and news reporters heard presentations by Drueke of Necker Hospital, Paris; Dr. Jens Titze from Erlangen, Germany; Dr. David A. McCarron from the U.S.; and Niels Graudal from Denmark.

Dr. Drueke noted that scientific investigation of the relationship of dietary salt and health outcomes has a distinct "political aspect" and represents an "ongoing hot debate on the pros and cons of a generalized salt restriction." He referenced Gary Taubes' article in Science: "The (Political) Science of Salt ." Drueke declared:

In any case, high blood pressure is nothing more than a surrogate marker of outcome. What is really important is outcome itself. Surprisingly, the medical community has started only recently to examine this issue, namely a possible relationship between salt intake and cardiovascular or all-cause mortality. No prospective randomized controlled trials have been done to address this question. Only observational studies are available and their results led to contradictory conclusions."

He postulated that "the solution...may reside in the notion of salt sensitivity." Salt sensitivity, he explained differs from person to person and for a given person can vary from time to time based on other factors, including diet. He concluded:

"...the main focus on salt restriction is erroneous. In addition, although reducing sodium intake has many effects, either by its own or in interaction with other dietary components, we know nothing about their unintended consequences on human health."

Dr. Titze introduced data that completely call into question the evidence on sodium intakes over the past century. It has been well-accepted, he recounted, that the "gold standard" surrogate for dietary sodium intake is a 24-hour urine specimen, based on the well-understood notion that the body has a fixed store of sodium and daily additions are excreted to maintain sodium balance. He continued:

"Startling data from recent long-term balance studies, where healthy human subjects accumulated large amounts on Na+ without significant changes in their body water content, have challenged this traditional view....Subsequent experiments in animals have confirmed tht large amounts of Na+ can be accumulated without commensurate water retention in the organism."

This, in turn, led to the hypothesis that the skin and skeletal muscle could contain reservoirs of sodium which totally confound previously accepted measures of dietary sodium intake and that "...these Na+ reservoirs might 'buffer' the relationship betwen total body Na+ excess and blood pressure. This hypothesis has been supported in experiments...." This research clearly has major scientific and public health nutrition policy implications.

Dr. McCarron emphasized that evidence shows "that dietary patterns rather than salt should be the focus of public health nutritional recommendations to reduce BP" (blood pressure). He pointed out that the two DASH (Dietary Approaches to Stop Hypertension) studies showed the importance to blood pressure of diets rich in calcium, magnesium and potassium (fruits, vegetables and dairy products), and that the Trials of Hypertension Prevention showed that the blood pressure lowering effect even of significant salt reduction disappears over three years. He noted that

"the intoduction of fruits, vegetables and low-fat dairy (DASH diet) essentially eliminated salt sensitivity even in hypertensive individuals....the DASH-Sodium investigators (and) government agencies, without justification, have used this trial to argue for universal sodium restriction, regardless of blood pressure status....This position has occurred even though numerous meta-analyses and the results of the DASH-Sodium trial itself do not support the conclusions that sodium restriction is effective for normal individuals or for most hypertensive subjects."

Dr. McCarron then warned:

Sodium restriction has a variety of effects beyond blood pressure on other risk factors for CVD. These include weight, insulin resistance, angiotensin II, the sympathetic nervous system, diet quality and physical activity. For each of these risk factors, the preponderance of the evidence indicates that moderate or greater sodium restriction is associated with an adverse impact. Weight control is impaired, insulin resistance increases, angiotensin II levels are raised, sympathetic activity is increase, diet qualityis harder to achive, and maximal exercise capacity may be impaired. None are improved with sodium restriction. Thus, while BP may be decreased in 30-40% of individuals with sodium restriction, the impact on these other CVD risk factors in both salt-sensitive and salt-resistant individuals may offset any potential benefit."

Concluding the Forum, Dr. Graudal reviewed the mass of medical literature for which he has published one of the foremost meta-analyses. He declared:

"The fact is that today supporters of sodium reduction and sceptics do not diasgree about the effect size (BP reduction on reduced salt diets). Furthermore, they agree that sodium reduction can be useful in individuals with elevated BP. The controversial question is: Does an effect of 1-2 mm Hg in normotensive persons justify a general recommendation of sodium reduction in the whole population? The sceptics think not. The supporters think that any small decrease in BP will result inan improved survival and less morbidity. However a recent meta-analysis of the effect anti-hypertensive beta-blockers indicates that this is not necessarily the case....You must have proof and this does not exist, as also shown by a recent review of epidemiological studies which like teh clinical trials could not relate dietary sodium to to cardiovascular disease and death."

Thanks to the organizers of this valuable Forum.

As if we needed further reminder that just because "experts" eyeballed a published study it's methods and conclusions must validate its authors' conclusions, comes an outstanding editorial by Dr. Elizabeth Whelan, president of the American Council for Science and Health in TSC Daily on "From Peer Review to Fear Review ."

Although the article recounts why a recent cancer study is "junk science," the principles have played out in studies involving salt and health as well.

The lesson: look at the quality of the science, not the authors' (or headline-writers') conclusions and don't allow the pedigree of the investigators to give them a free pass to tout their policy preferences. Back to basics!

Research presented this week at the American Society of Hypertension 2007 Scientific Sessions in Chicago, has shown that fewer and fewer people are following the DASH diet. Even though more people are aware of hypertension, investigator Dr Phillip Mellen said the dietary quality of hypertensive adults has deteriorated.

Speculating as to why fewer patients are following the recommendations, Mellen noted that many physicians do not feel adequately trained to implement the DASH diet. More likely, however, is the fact that dietary counseling takes time, and clinicians are still not reimbursed for their counseling labors. "It might be easier to give a prescription than to address root causes," said Mellen.

Dr. Mellen is correct, but he neglects to expand on the role of the American Medical Association on the issue. Instead of prescribing medication as physicians do, the AMA has prescribed the magic bullet of salt reduction as the answer to hypertension.

Of course, the AMA will agree that the DASH diet is useful, but their high priority target is salt reduction. As a consequence, recommendations from the AMA to consume the DASH diet takes a back seat - a distant back seat to salt reduction .

While salt reduction may reduce the single cardiovascular risk factor of hypertension in some sensitive individuals, consumption of the DASH diet reduces all 10 major cardiovascular disease risk factors in all individuals. If a prestigious organization such as the AMA would spend more time and money on promoting the DASH diet, a number of things would occur. Physicians, whose knowledge of dietetics and nutrition is generally wanting, may choose to learn more about balanced diets and may be influenced to spend more time telling their patients about the overall benefits of the DASH diet.

Positive open support for the DASH diet from the AMA may also influence the food industry to develop new products that will allow consumers to consume the 5 - 10 servings of fruits and vegetables recommended each day. The new fusion juices (fruit and vegetable combined) are a perfect example. One glass is the tasty equivalent to two servings and a lot easier to take at breakfast than a bowl full of chopped kale!

With the proper emphasis on balanced diet, the medical community can help millions achieve better health.

As highlighted in one of our previous blogs , the anti-salt campaign being waged in the U.K. by the Food Standards Agency (FSA), has resulted in the removal of saltshakers from school lunchrooms. Telegraph correspondent Paul Eastham reported that this has resulted in students totally avoiding their vegetables while in school. By blindly following the "avoid salt at all costs" mantra, the FSA has effectively prevented young students from enjoying the benefits of vegetable consumption during the school day.

A far more rational approach was advocated by the Alliance for a Healthier Generation, the coalition between Bill Clinton and the American Heart Association. They made it clear that increased salt consumption was warranted whenever consuming foods that delivered essential nutrients, if the salt made these foods more palatable. They based their recommendation on the overall benefit/risk balance.

In order to reduce the level of rhetoric and to begin bringing scientifically-derived data to the issue, the Salt Institute, together with the Center for Innovative Technologies and the Department of Food Science and Technology of Ohio State University organized a series of formal taste panels to determine the impact of different levels of salt on the palatability and acceptability of cruciferous vegetables.

Sample preparation

Broccoli was chosen as the first test vegetable. Two levels of salt, high and medium/low, as well as zero salt were added to cooked broccoli and the participants were asked to rate their preferences. Computerized sensory evaluation software by Compusense was used to evaluate all responses and compile the resulting analysis. Naturally, participants were not informed which samples contained which levels of salt and all sample numbers were randomly generated

This is serious work

The first trial involved 88 students, ranging in age from 9 - 13 years. The students were fully briefed on the procedures and enthusiastically took part in the trials.

A good rinse between samples

The result was a virtual tie in preference between the high and medium/low levels of salt addition, with the zero salt a very distant third. Cruciferous vegetables are very nutritious, but are known to contain bitter components which youngsters are sensitive to. However, a small amount of salt makes these vegetables (together with their nutrients) highly acceptable.

Which one tastes best?

This study, together with future trial will be published in detail in the near future

Josephine Thompson correspondent for the South Wales Echo , asks the one question everyone should be asking. If we are eating too much salt, then why are we living longer? A simple question that deserves an honest answer.

She also goes on to say that she tried the modern version of ready to eat foods (presumably reduced-salt) and "never tasted anything so bland in all her life". A simple observation that food manufacturers should take heed of. They would be far better off listening to the opinions of their paying customers than to agenda-driven activists and civil servants.

A short, honest article from someone unafraid to speak her mind.

Should dietary advice be dispensed nutrient-by-nutrient or in terms of foods being part of dietary patterns? Though many government and advocacy dietary recommendations are expressed in terms of nutrients, the Salt Institute argues for "dietary patterns" in its Spring 2007 Salt and Health newsletter, published today. The Institute explains:

Decades of research in nutritional epidemiology as well as dietary intervention clinical studies have focused on assessing or manipulating the intake of a specific dietary component to determine its role in the development or treatment of a given disease or disorder. Despite the exhaustive effort that has invested in this field of research, it has remained mired in inconsistent and often conflicting results, confusion on the part of the general public, and lack of consensus among the experts.

The public is skeptical of seeming inconsistency between "scientific" studies, the article continues, but there is often a logical explanation.

Nutrients are not ingested in isolation, but as combined constituents of a total diet. Our diets consist of a variety of foods with complex assortments of nutrients and other ingredients, many of which may act on one another synergistically or antagonistically. When the intake of one nutrient is manipulated for study, increased or decreased, the intake and interactions of other components in the diet are likely to be altered.

Properly appreciated, dietary patterns should be the focus of dietary recommendations, the Institute argues, If that happens

We may well be approaching the time when nutrition scientists, policy makers, and the American public can set aside their differences and their skepticism, and sit down together over a meal they can all agree is healthy.

The World Health Organization (WHO) is concerned about the scientific basis of its health recommendations (a concern with WHO we've been vocal in expressing as well). In 2003, the WHO Cabinet recognized the need for process changes to improve the scientific evidence foundation for its policies. Its report appears in today's edition of The Lancet (free registration required).

Authors Andrew Oxman et al note:

WHO's regulations emphasise the role of expert opinion in the development of recommendations. In the 56 years since these regulations were initially developed, research has highlighted the limitations of expert opinion, which can differ both across subgroups and from the opinions of those who will have to live with the consequences. Experts have also been known to use non-systematic methods when they review research, which frequently results in recommendations that do not reflect systematic summaries of the best available evidence.

That's certainly the case in WHO's Report 916 , coincidentally generated in 2003, which selectively cited the literature and reached historically-extreme recommendations regarding dietary salt.

Oxman continues:

Evidence-informed dissemination and implementation strategies are increasingly recognised as a core part of the business of development recommendations.

Unfortunately, the authors found that WHO "almost always" employed the subjective expert committee approach in preference to the systematic review of published evidence. "The guidelines for developing WHO guidelines do not seem to be closely followed...," the report states, neutrally. In fact, they continue:

Although the WHO guideline recommendations are consistent with those developed by other organisations, the actual processes used to develop recommendations at WHO seem to be less rigorous than those of others. None of the directors [note: 23 WHO department directors were interviewed for the research] reported using the guidelines for WHO guidelines and only two reported plans to use them. Few directors reported using processes that were consistent with the guidelines.

Our experience with WHO in Geneva is that developing the nutrition guideline was virtually complete when the staff selected its expert panel; everything subsequent was a sham. With unfortunate results.

In the area of salt, evidence-based organizations like the Cochrane Collaboration and the US Preventive Services Task Force (HHS) have done systematic reviews of the health benefit potential of reducing dietary salt and both agree evidence is lacking to support such an intervention.

Everyone registering an opinion on dietary recommendations claims their advice is "evidence-based," but -- as this WHO study illustrates -- the truth is that governments and advocacy organizations routinely use the lowest form of evidence, expert committees, to formulate recommendations. It brings to mind a verse from the New Testament in the Bible (Matt. 15:8), "This people draweth nigh unto me with their mouth, and honoureth me with their lips; but their heart is far from me."

We need to do more to elevate the place of true evidence-based decision-making in public health nutrition policy through such means as ensuring effective enforcement of the U.S. federal Data Quality Act and opening the rich databases created for federally-funded studies to independent analysis by qualified experts. But, as the authors of this study lamented concerning WHO, achieving this broader objective "will require leadership."

Journalists swarmed Salt Institute technical director Mort Satin after his presentation this week at the Salt Expo staged in Naples, Italy. This first-ever Expo May 3-6 attracted salt manufacturers from Europe, India, and China and other gastronomic suppliers that use salt as an important contribution to the character of their products.

Satin's lecture on salt and health led off a series of presentations on various aspects of salt. Mort provided a comprehensive review of the current "myth information " linking salt to cardiovascular disease explaining how it was incorrect to isolate salt from the rest of the diet and then attribute risk factors to it, He recounted the scientific evidence that repeatedly demonstrated that it was not a risk when part of the balanced diet. His explanation that people consuming the Mediterranean Diet in southern Europe consume 15-20 % more salt than their northern European neighbors, but have half the heart disease and increased longevity because they have a better diet, including much higher levels of fruit and vegetable consumption, attracted significant post-presentation media attention, particularly media from Asia and the Middle East.

The remaining speakers focused on the positive role of salt iodization in reducing iodine deficiency diseases.

A second Salt Expo is planned in San Francisco next year.

We read, daily it seems, of the health risks of this behavior or that dietary factor. In cardiovascular health, we've been lectured for years about the crucial importance of such risk factors as dietary salt in determining society's rate of heart attacks and strokes.

But a recent and insightful post on Junkfoodscience reported May 2nd:

"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."

Prompting author Sandy Szwarc's contrarian comments was publication of new American Heart Association Guidelines for Cardiovascular Disease Prevention in Women which expand the number of "at risk" women being urged to alter their lifestyles to reduce their likelihood of a cardiovascular event. Trouble is, Szwarc explains:

"virtually all heart disease occurs in women without 'risk factors'…these risk factors themselves are problematic … relying on them to predict who will succumb to disease or premature death is insupportable.

"A study just published in the March issue of the Journal of the American Medical Association actually tested the AHA's proposals, among men and women. The METEOR Trial was a randomized, double-blind, placebo-controlled study conducted across 61 primary care centers in the U.S. and Europe. It examined 984 adults, with an average age of 57, who were all considered to have low risk factors for heart disease based on the Framingham Risk Score. Some received the statin, rosuvastatin, and the rest a placebo and after two years the progression of atherosclerosis was assessed by carotid intima-media thicknesses, measured by ultrasound. While the statin reduced LDL-cholesterol by 49% and resulted in small reductions in intima-media thickness, there was no regression of atherosclerosis or change in clinical outcomes."

She continues to explain that NHANES data show 85% of the population has low Framingham scores for risk while 2% have high scores, yet the AHA lumps them together to urge them all to worry about their risk and undertake lifestyle changes or begin taking medications.

"In other words, these risk factors aren't very good measures and we give them more credence than the evidence can support. That doesn't mean we should run screaming into the hills, thinking we're all going die and are all at risk, but that the evidence indicates that our obsession with these popular risk factors and numbers is not especially helpful, healthful or necessary for virtually all of us."

In support of her conclusion, she cites Dr. P.K. Shah, director of cardiology at Cedars-Sinai Medical Center. Shah wrote in the Los Angeles Times on February 28, 2005: "Our traditional risk factors are very weak overall predictors of future risk." She continues:

"The World Health Organization's MONICA project , which is an impressive 10-year study that measured cardiovascular disease mortality and disease incidences and risk factors among 10 million people in 21 countries, was also not included in the AHA evidence review. This study data continues to reveal no statistical connections between reductions in standard risk factors (obesity, smoking, blood pressure or cholesterol levels) and heart disease."

She quotes "the latest Cochrane review of 39 clinical trials conducted in multiple countries over the course of three decades, just updated in August 18, 2006:"

"In many countries, there is enthusiasm for "Healthy Heart Programmes" that use counseling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes, and a sedentary lifestyle. This updated review of all relevant studies found that the approach of trying to reduce more than one risk factor - multiple risk factor intervention - advocated by these Programmes do result in small reductions in blood pressure, cholesterol, salt intake, weight loss, etc. Contrary to expectations, these lifestyle changes had little or no impact on the risk of heart attack or death...

"Recent trials examining risk factor changes have cast considerable doubt on the effectiveness of these multiple risk factor interventions....The pooled effects suggest multiple risk factor intervention has no effect on mortality....

"Risk factor changes were relatively modest, were related to the amount of pharmacological treatment used, and in some cases may have been over-estimated because of regression to the mean effects, lack of intention to treat analyses, habituation to blood pressure measurement, and use of self-reports of smoking. Interventions using personal or family counselling and education with or without pharmacological treatments appear to be more effective at achieving risk factor reduction and consequent reductions in mortality in high risk hypertensive populations. [However], the evidence suggests that such interventions have limited utility in the general population."

The salt and health debate has featured these same issues (e.g. selective citation of the medical literature, defining-down the blood pressure levels defined as "at risk" and, of course, active efforts to persuade the entire population that everyone will benefit by reducing dietary salt intakes.

Let's stick with the facts. And, if we insist on paying attention to blood pressure, for example, as a CV risk, let's also make sure we look at the mortality associated with other risk factors which are modified when salt intake is curtailed: increased insulin resistance and accelerated plasma renin activity, for two, both of which are powerful indicators of adverse CV outcomes.