Medical science is evolutionary. We learn as we go and adjust our remedies as we better understand the problems we confront. Guidelines for medical practicioners and for consumers can help us make intelligent choices, but their credibilty can be jeopardized if they stray from recounting the scientific data into the minefield of promoting the policy preferences of the expert scientists who draft the guidelines.

We can and should preserve the credibilty of guidelines by injecting them with a healthy dose of humility.

Scientists have developed a system to grade the guidelines based on the quality of the evidence supporting the advice. The process is as valuable for clinical advice given in the doctor's office as it is for general population advisories such as the Dietary Guidelines for Americans.

The February 25 issue of the Journal of the American Medical Association contains an important article by Pierluigi Tricoci et al which grades the evidence underlying the joint cardiovascular practice guidelines of the American College of Cardiology and the American Heart Association. The results were important in their own right. Authors from Duke University and the University of North Carolina agreed that most of the guidelines are based on "lower levels of evidence or expert opinion" and disturbingly documented that "(t)he proportion of recommendations for which there is no conclusive evidence is also growing." Nearly half (48%) of the guidelines were based solely on expert opinion, not data. And, an icreasing percentage of guidelines are not based on "Class I" evidence but more on "Class II" which are supported by "conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment." Fully 41% of the ACC/AHA guidelines are based on contentious Class II evidence.

The authors called for a more evidence-based approach.

We agree. The background discussion of the paper should be required reading for all expert groups preparing guidelines. After all, at least the ACC and AHA report that their recommendations are based on "Level of evidence C" -- expert opinion, the lowest level of evidence after "Level of evidence A: recommendations based on evidence from multiple randomized trials or meta-analyses" or "Level of evidence B: recommendations based on evidence from a single randomizd trial or nonrandomized studies."

In contrast, the process of preparing the Dietary Guidelines for Americans is purely "Level of evidence C: recommendation based on expert opinion, case studies, or standards of care." Sure, the experts select evidence of quality scientific studies, but the process is inverted: their cited literature follows the experts' conclusions (level C) rather than drive the process (levels A and B).

In an accompanying editorial , Terrence M. Shaneyfelt and Robert M. Centor opine:

Current use of the term guideline has strayed far from the original intent of the Institute of Medicine. Most current aticles called "guidelines" are actualy expert consensus reports. ...

The overreliance on expert opinin in guidelines is problematic. All guideline committees begin with implicit biases and values. However, bias may occur subconsciously and, therefore, go unrecognized. Converting data into recommendations requires subjective judgments; the value structure of the panel molds these judgments.

While many focus on direct financial conflicts of interest as the motivating bias of experts, Tricoci et al dig a bit deeper:

Recommendations based only on expert opinion may be prone to conflicts of interest becaue, just as clinical trialists have conflicts of interests, expert clinicians are also those who are likely to receive honoraria, speakers bureau, consulting fees, or research support....

The list could be much longer and include career and other professional advancement considerations.

The overall message is one of humility and restraint. Don't over-interpret the evidence and fit the evidence to desired policy options. That's what robs guidelines of credibilty and leaves practicioners and the general public whip-sawed with conflicting advice.

For guidelines on dietary salt, the lesson is that we need to adhere more faithfully to an evidence-based approach embodied in the approaches of the international Cochrane Collaboration and the U.S. Preventive Services Task Force, both of which have concluded there is insufficient evidence to justify a population guideline on salt intake levels. That's a "Class I, Level of evidence A" conclusion we should incorporate.

The article and editorial are timely for two reasons:

1. One of the authors, Dr. Robert Califf of Duke University, is reportedly a top contender to become the new Commissioner of Food and Drugs in the Obama Administration and
2. The Dietary Guidelines Advisory Committee has just begun a periodic reassessment of the Dietary Guidelines.

Our vote is for Dr. Califf to head FDA and for a new measure of data-driven humility in rendering dietary advice on Americans' eating habits, converting the Guidelines from expert opinion to a true evidence-based product.

George Will's column today, "Bon Appetit ," his reader-voted best column so far this year, explores the thesis of Stanford University/Hoover Institution fellow Mary Eberstadt that human appetites for food and sex are polar opposites. Intriguing speculation.

The argument runs that a half century ago, people were uptight about sex and casual about their diets while today the reverse is true.

Surely we'll all accept that humans are hard-wired to consume food and enjoy sex, both are essential to our survival as a species. But Will's (and Eberstadt's) thesis that social mores are the driving force in determining the level of indulgence -- the appetite -- may be misplaced. At least for food.

Research published a year ago in Experimental Physiology -- and being studiously ignored by today's dietary morality enforcers -- shows that, at least in the case of "salt appetite," consumption of given dietary intake levels is an unconscious process driven by the brain, not a conscious behavioral choice by consumers.

Theories are stimulating. Data are controlling. That's why human physiology trumps dietary guidelines and why Americans (and others around the world) are eating the same amount of salt today as they did a century ago -- before the food police arrived on the scene to render assistance.

John Tierney's Science column in yesterday's New York Times , is yet another reminder of the problems we're having sorting out scientific fact from scientists' opinion. Tierney takes his cue from the new book, The Honest Broker , by Roger Pielke, Jr. who asks: can scientists be honest brokers? Pielke's concerned that scientists are "jeopardizing their credibility while impeding solutions to problems."

Tierney notes how Pres. Obama's new Energy Secretary and National Science Advisor have both made extremely radical "scientific" doomsday predictions (e.g. no farms in California by the end of the century and a billion deaths from climate change-induced famines by the year 2020, respectively) and recounts Pielke's analysis that scientists think they have two roles: pure researchers or experts providing evidence for political decisions:

A scientist can enter the fray by becoming an advocate for certain policies, like limits on carbon emissions or subsidies for wind power. That’s a perfectly legitimate role for scientists, as long as they acknowledge that they’re promoting their own agendas.

But too often, Dr. Pielke says, they pose as impartial experts pointing politicians to the only option that makes scientific sense. To bolster their case, they’re prone to exaggerate their expertise (like enumerating the catastrophes that would occur if their policies aren’t adopted), while denigrating their political opponents as “unqualified” or “unscientific.”

“Some scientists want to influence policy in a certain direction and still be able to claim to be above politics,” Dr. Pielke says. “So they engage in what I call ‘stealth issue advocacy’ by smuggling political arguments into putative scientific ones.”

When experts disagree, too often the result is name-calling, not resort to hard scientific data.

We've seen that in spades in the discussion of salt and health policy. We need to elevate science to its proper role in sorting out facts, not muddy the waters with expert opinion self-proclaimed as "science."

Put another way, as it is titled in an editorial in February's PLosMedicine: "An unbiased scientific record should be everyone's agenda ." Absolutely.

Recognizing that authors and publishers have built-in biases, the editorial identifies five problem areas:

1. "Journals generally have policies regarding declaration of competing interests by authors. Similarly, editors’ political and scientific views, personal relationships, and professional and financial interests can all conceivably interfere with the objectivity of their decisions."
2. "So much has been published relating to the damaging nature of commercial competing interests that it is tempting to ignore the influence of non-commercial interests in research. Yet publications can be influenced by the desire to promote an idea, or a research program, rather than a commercial product."
3. "All contributors to the debate agree on one thing: a transparent declaration of author contributions is an essential requirement. As part of such a transparency policy, editors can therefore ensure that the individuals responsible for essential roles in research (such as designing the project, carrying out analyses, and writing the paper) are actually named, and their roles and competing interests made clear in the publication."
4. "Many journals now have policies requiring, or recommending, the submission of original protocol documents before papers reporting the results of clinical trials are peer reviewed....these policies enable verification of the study’s prespecified objectives and analysis plan, and require clear description of any subsequent changes."
5. "Editors have an important role to play in encouraging authors to value their results, irrespective of the study’s outcome. For example, in an attempt to impress editors with the importance of a study, authors may overemphasize an intriguing post-hoc subgroup analysis, or may avoid stating that a well-conducted trial was inconclusive in its primary outcomes. Editors can help combat this problem by emphasizing to authors that their data are still publishable if overstated conclusions are appropriately toned down."

We stand with the editors who conclude:

Peer-reviewed publication is the final, essential step in any research project, providing legitimization and credit for the work that has been done. It is the responsibility of everyone involved to ensure that the published record is an unbiased, accurate representation of research. We recognize that today there are many, and increasing, pressures on authors and journals to bias this record. If this pressure is not resisted, journals may increasingly become closer to works of fiction telling the stories dictated by various lobbies rather than works of science. We hope that PLoS Medicine’s efforts, and those of many other journals, to promote full transparency will ultimately lead to a more rigorous and unbiased knowledge base.

A study just published in Hypertension documents that continuous activation of the renin-angiotensin system impairs cognitive function in mice. In humans, low-salt diets reliably predict increased activity of the renin-angiotensin system. The body produces these neurohormones when it senses inadequate salt intake -- and that "inadequacy" is far, far above the IOM's "adequate intake" level for sodium. Low-salt dieters can be assumed to have continuously high renin-angiotensin activity levels.

Other studies have suggested low-salt diets may produce mental impairment. This could be the mechanism.

All this is in addition to the contributions of iodized salt, the consensus solution to overcoming the most easily-prevented, but still-widespread cause of mental retardation: iodine deficiency

Several years ago, the massive Women’s Health Initiative examined the health outcomes of hormone replacement therapy (HRT) where post-menopausal women received supplemental estrogen. “Everyone” knew it was safe and it made logical sense: after menopause, women didn’t produce estrogen so, “of course,” replacing the hormone would make them healthier and live longer lives.

Only it didn’t.

Results of the trial showed clearly that many women died from the treatment. Surprise. The embarrassed NIH quickly shut off that portion of the trial and doctors were warned that what “everyone” knew was the right treatment regime was, in fact, endangering the lives of their patients.

The Salt Institute has cited the incident as a “learning experience” for public health policy-makers: that sometimes the most obvious and popular health nostrum turns a cropper so prudence dictates reserving population health interventions to those that have been tested in controlled trials. HRT never had been tested before it was rushed into practice. “People are dying. We can’t wait,” cried advocates.

Well it’s happened again. Same study. Different health outcome. A study published in the New England Medical Journal February 5 found increased incidence of breast cancer in HRT-treated women “suggesting a cause-and-effect relation between hormone treatment and breast cancer.”

Coming close on the heels of two studies done in Italy that found Coronary Heart Failure patients receiving salt-reduced diets (because for the past century “everyone knew” they work or at least cause no harm) suffered massively greater mortality than those on regular salt diets, the new HRT study drives home the point made repeatedly by the Salt Institute: we need a controlled trial of the health outcomes of low-salt diets. We should not ask the population to be the guinea pigs as we did the women in the Women’s Health Initiative.

Elsewhere we report the news that the European Union is cracking down on food health claims, approving only 9 of the first 43 evaluated and imposing stricter-than-FDA standards, usually based on "convincing" evidence from human clinical trials.

We applaud EFSA for its professed objective of preventing unproven health claims on food labels that would further confuse consumers in making informed dietary choices. To do the job right, EFSA has addressed one critical element: reliable, high quality data should be required to support approved health claims. There is a second crucial standard EFSA should also address: health claims should be based on disease outcomes, not intermediate variables, risk factors or biomarkers -- hard outcomes like disease-caused events or mortality.

On the first point, data quality, the key is to adopt a process like "evidence-based" medicine as defined by the Cochrane Collaboration: first set the standard for quality before looking at what the evidence might be; that's exactly the opposite of what the US Dietary Guidelines Advisory Committee is doing in its expert-based review (which it also calls "evidence-based").

For the second point, the key is to stop looking at "indicators" and "risk factors," recognizing that there are often multiple and conflicting bodily processes affected by any single nutrient. Not only is a carefully controlled trial needed to isolate those effects, but its is their combined totality that concerns us: does the intervention improve health, extending healthy lives, or just change one risk factor (ignoring others)?

With regard to salt, the implications are enormous. The Cochrane Review on health outcomes of salt-reduced diets finds insufficient evidence of improved health to justify a population advisory (as has the US Preventive Services Task Force). That much is clear, though ignored by diehard salt reductionist activists like WASH and its most vocal advocate, Dr. Larry Appel. It is the second question that will prove pivotal for EFSA if it hews consistently to the high standard it professes. For salt, the proper measure is cardiovascular health. Not blood pressure. Not insulin resistance. Not neurohormonal activity. All of these are risk factors. Some "improve" in some people when they reduce salt. Others impose additional risks when salt is reduced. It is the net effect -- the health outcome -- that is important.

In the US, FDA has wandered off into the health policy wilderness on this point. Its health claim (whatever one's view of its scientific rigor, the subject of another discussion) is for "hypertension," a risk factor, not "cardiovascular health" (or heart attack incidence, another "hard outcome"). FDA could just as well approve a health claim that diets with today's salt intake levels protect insulin resistance and warn consumers of the fact that salt-reduced diets endanger our ability to metabolize glucose properly, setting up low-salt dieters for diabetes and metabolic syndrome. For FDA to follow the professed EFSA approach, it should replace a "salt and hypertension" health claim with one for "salt and cardiovascular health" -- but then, of course, back to point one, quality of evidence, there would be insufficient evidence to support such a claim.

The challenge for EFSA is to resist the blandishments of the salt reduction lobbyists who claim to "know" that their computer-modeled extrapolations of blood pressure changes due to salt intake levels represent true health outcomes. EFSA should insist not only on good quality science, but on evidence that an intervention (or food) will actually improve HEALTH.

Okay, it's still early, but Junk Food Science has raised the bar in its report this week on "Who decides what you can eat? Sating on salt ." Read it all. Twice.

Noting that New York City has announced a campaign to reduce dietary salt in the Big Apple, nurse-blogger Sandy Szwarc laments that the "significance of this initiative may have been lost on media" and capsulizes why people should care:

It deserves to be out in the open, though, because the best science for nearly half a century — including the government’s own findings on examinations reflecting 99 million Americans; more than 17,000 studies published since 1966; and even a recent Cochrane systematic review of the clinical trial evidence — fails to support the hypotheses that salt reductions offer health benefits for the general public. Cochrane’s reviewers specifically concluded that such interventions are inappropriate for population prevention programs.

It’s not just that the salt reductions being proposed will be costly programs that won’t be of much help to people, but that they could hurt people. Even more troubling, the public health messages in this new campaign appear to be most targeting minorities, fat people, the elderly and poor.

Szwarc sums the NYC campaign quoting from the New York Times : “Dr. Frieden says a quiet, mass reduction in sodium levels — stealth health, they like to call it around the department — might be more effective.” She then continues to skillfully excoriate the city health department's scientific summary: "None of these claims can be scientifically supported," she declares.

She then explains how heart disease rates are improving, how population blood pressure has been unchanged over the past 20 years and how salt usage, also, has not increased over the past 20 years. Then she turns to health outcomes, summarizing the findings by a team at the Albert Einstein Medical College who studied the biggest and best federal government database, the National Health and Nutrition Examination Survey (NHANES):

The lowest sodium intakes — the 1500 mg/day that the New York health department says everyone should be eating — were associated with an 80% higher risk of cardiovascular disease compared with those consuming the highest salt diets. The lowest salt intakes were also associated with a 24% higher risk of all-cause mortality. Clearly, low-salt diets are not associated with lower risks for the general population. Conversely, the Albert Einstein researchers were unable to show that even the highest salt intakes were associated with increased risks for developing cardiovascular disease or high blood pressure or for premature death.(emphasis in original)

She explores the "unintended risks" of low-salt diets, the many scientists who question universal salt reduction and queries: "What is it all about?" answering:

As the New York City-led nationwide low-salt initiative is clearly not founded on a true health crisis, on the medical evidence, or on proven health interventions for the primary prevention of high blood pressure or heart disease, what might it really be about?

As the New York Times pointed out today, the target is going after packaged foods and chain restaurant meals. Reducing salt to levels unpalatable to their consumers appears to primarily be about getting people to eat less of foods these public officials don’t think people should eat or others should sell.

Szwarc rarely deals with salt. She's been a consistent and effective proponent of evidence-based health decisions on a broad range of nutrition issues. Her insights earned Junk Food Science "silver medal" runner-up recognition for the best medical/health issues blog for 2008. This could vault her to "gold" in 2009!

President George W. Bush's first director of his White House Office of Information and Regulatory Affairs (OIRA), Harvard professor John Graham, exercised an activist role in promoting better science in federal decision-making. President Obama's OIRA choice, another Harvard professor, Cas Sunstein, could do the same.

Graham directed the Harvard Center for Risk Analysis. Sunstein has been on the faculty of the Harvard Law School and directs its Program of Risk Regulation. He taught earlier at the University of Chicago and is the author of a recent book, Nudge.

A devout liberal who writes for New Republic regularly, he also advocates some positions (judicial minimalism and support of such Bush nominees as now-Chief Justice John Roberts, among them) that have worried left-leaning environmentalists like Chris Mooney, author of the anti-Bush diatribe The Republican War on Science. Mooney admits he's impressed with Sunstein's intellect. "I'm interested to hear whether any environmentalists are going to be rattled by this choice. Sunstein is an ingenious scholar, and continues the whole "best and brightest" motif of the Obama administration...Important question: Will he roll back the Bush administration's overuse of the Data Quality Act?"

Good question. Our concern was that, after Graham’s departure, the Bush Administration failed to push the Data Quality Act far enough. But Sunstein is a believer in behavioral economics and its contention that the theoretical assumptions of law and economics should be modified by new empirical findings about how people actually behave. This might lead to the kind of confident assumption that government policy manifestos to change Americans’ diets will trump human physiology. Stay tuned.

Perhaps you saw the headlines like "salt reduction benefits go beyond blood pressure." We did, so we read the study by Kacie Dickinson et al, "Effects of a low-salt diet on flow-mediated dilation in humans ." The study of 29 overweight and obese Australians in this month's American Journal of Clinical Nutrition is being portrayed as yet another reason to reduce dietary salt.

Not so fast. We recognize that there are many changes that occur when dietary salt is reduced, some well understood (e.g. renin, aldosterone, insulin resistance, blood pressure), others less so. So it may be that this study adds to our understanding.

Keep in mind one key finding: "There was no correlation between change in FMD (flow-mediated dilation) and change in 24-h sodium excretion or change in blood pressure. No significant changes in augmentation index or pulse wave velocity were observed."

As we push for risk factors of risk factors, let's not lose sight of the other competing mechanisms that are activated by lowering dietary sodium and reaffirm our commitment to examining the sum total, the net outcome of all these interventions in terms of cardiovascular health.

Forecast for New York City: flurries. While many New Yorkers may worry more about whether salt is being used to keep their streets safe, city health commissioner Thomas Frieden is concocting a plan to put less of it in their diets.

Today's New York Times carries a story by Kim Severson, "Throwing the book at salt " which describes Frieden's effort to reduce salt in packaged foods and restaurant meals with an aim to reduce salt intake by 25% over the next five years. He's talked to the food industry (mentioned) and the Salt Institute (unmentioned) and warns: "If there's not progress in a few years, we'll have to consider other options, like legislation."

Severson continues to point out the campaign will be "difficult for Dr. Frieden, both practically and politically."

It's actually more difficult than Frieden and his cardiovascular advisor Sonia Angell imagine. Severson quotes Angell presuming that salt intake is a matter of taste: "We've creatd a whole society of people accustomed to food that is really, really salty. We have to undo that." The plan is for "stealth" reductions in the salt content of processed foods "based on one in the United Kingdom (where) targets for sodium reduction will be set for certain food categories."

All this in blithe ignorance of the evidence. Well, not really ignorance, self-deception. Last week, the Salt Institute met with Dr.Frieden and his senior staff and laid out the problems he's facing, none of them "political" but all "practical" since the campaign is based on pseudo-science. The Institute confirmed its representation in a letter, as usual, posted on its website . The letter warns that Frieden's disregard of the science amounts to "using the citizesn of New York as a grand experiment of this generally-believed but as-yet untested hypothesis."

The Institute told Frieden that sodium-reduced diets raise the blood pressure in a significant number of people and will increase in most people insulin resistance, sympathetic nervous system activity and activate productin of renin and aldosterone, well-demonstrated to increase their risk of teh very cardiovascular events your program is intended to reduce." Bottom line: "Salt reduction may actually increase the risk of a significant portion of those New Yorkers who adopt your recommendations since teh lower sodium intake stimulates these known physiologic factors for heart attacks, congestive heart failure and metabolic syndrome."

The Institute lamented the predictable but "unintended consequences" since the medical literature is discovering more and more adverse impacts of salt reduction. "Since it is your mandate to improve the public health of the citizens of New York, we remind you that it si these physiological facts, not political policies that will ultimately determine health outcomes," the Institute warned.

Frieden's campaign also ignores strong evidence that the UK model has been a total waste of money and has achieved no sodium reduction and that medical evidence shows that humans' salt appetite is "hard-wired" in the brain, not a behavioral choice. Unmentioned in the letter was a new study released just yesterday showing that the "human brain makes snap decision on fat content" -- the headline on a new study in NeuroImage .

NHLBI scientists and their taxpayer-funded university researchers released a follow-up study for the important Trials of Hypertension Prevention trial . The authors claimed "a higher soidum to potassium excretion ratio is associated with increased risk of subsequent CVD (cardiovascular disease)." Headline writers fell in line.

A summary analysis of the article published in the January 12 Archives of Internal Medicine would have been more accurate had it stated: There was no statistically significant relationship between sodium excretion and cardiovascular risk and even the reported non-significant association evaporated when the researchers adjusted for known confounding factors. A "p-value" (calculating the likelihood that the reported association was accurate) is usually considered valid when it is 0.05 or less, meaning a 95% chance that the result is accurate. The sodium:blood pressure "p-value" for men was 0.49 and for women 0.98. This means that there was only a 51% chance of a valid relationship between sodium among men and a miniscule 2% chance in women. Hardly the conclusion drawn by the authors or the headline writers.

With the Dietary Guidelines for Americans up for review, we can hope the process deals more with data than headlines. But don't hold your breath.

Salt is so basic to our existence we often forget its life-saving role as an essential nutrient; consider oral rehydration therapy which has saved millions of lives, particularly in Africa. But salt is not only essential to life, it plays a key role combatting mental retardation; consider the enormous achievement of iodized salt.

New York Times columnist Nicholas D. Kristof does just that. In today's paper, he reviews the enormous paybacks of salt iodization, "Raising the World's I.Q ."

Salt does have a real downside, Kristof admits -- "it's so numbingly boring, few people pay attention to it or invest in it. (Or dare write about it!)." I guess we here at the Salt Institute are so insensate we didn't realize that salt was boring or unworthy of attention so count us among the few.

Thankfully, Kristof is one of the few as well. With his proselytizing, perhaps the few will become many.

Although the study was conducted in an at-risk population being treated for congestive heart failure (CHF) and, therefore, not directly comparable to healthy populations, yet another study has found reduced-sodium diets creating health risks.

A study by an Italian research team led by Salvatore Paterna and Pietro Di Pasquale on "Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure " in the October issue of Clinical Science asks: "Is sodium an old enemy or a new friend?"

Friend, according to the data. Lowering dietary sodium stimulated plasma renin activity (PRA) and aldosterone production.

The normal-sodium group had a significant reduction, P less than 0.05, in readmissions. BNP values were lower in the normal-sodium group compared with the low sodium group (685±255 compared with 425±125 pg/ml respectively; P

When PRA and aldosterone levels are high, multiple studies have shown subjects have significantly higher incidence of heart attacks and cardiovascular mortality.

Thus, the study concluded: "a normal-sodium diet improves outcome, and sodium depletion has detrimental renal and neurohormonal effects with worse clinical outcome in compensated CHF patients."

The 2010 Dietary Guidelines Advisory Committee has begun its five-year review of the science behind the government's recommendations for U.S. food consumers -- all of us!

In its latest Salt and Health newsletter, the Salt Institute examines "The Evidentiary Foundation of our Dietary Gudelines " and finds that foundation is built on sand, not rock. The article recounts a 2007 review of the process by the Institute of Medicine of the National Academy of Sciences which confirmed that the scientific review of the diet and disease data was based on the opinions of respected authorities -- the lowest level of evidence -- rather than on controlled trials of dietary interventions. That review drew on a New York Times Magazine story on "Why can't we trust much of what we hear about diet, health and behavior-related diseases?" The Salt Institute endorses an "evidence-based" approach as opposed to the "opinion-based" recommendations produced in the current process.

It appears that we finally have something that we can agree upon with the Center for Science in the Public Interest (CSPI) . According to a recent article prepared by Merrill Goozner of the at CSPI, and repeated by Marion Nestle in her blog , nearly half the new 2010 Dietary Guidelines Advisory Committee's 13 members have taken funding from the food and pharmaceutical industries. Of common interest is the Chairperson of the Committee, Dr. Linda van Horn, professor of preventive medicine at the Northwestern University Feinberg School of Medicine in Chicago. We are not aware of any conflict of interest involving research funding, however, during the first public meeting of the DGAC, Dr. van Horn recalled an experiment that she had done as a graduate student, which she stated proved without doubt that children who were fed reduced salt diets ended up abhorring the typical salt levels in many foods. Thus, she revealed the personal bias she brings with her as she assumes the chair of a committee tasked with the 'objective' evaluation of all the data on salt and health to be used as a base for future recommendations.

It is interesting to note that CSPI, Marion Nestle, and the preponderance of professionals in the medical community choose to define conflict of interest almost exclusively in terms of funding received from outside (particularly industry) sources. What they seem to totally ignore is the overwhelming bias resulting from personal ego, and a lifelong investment in a particular point of view on a subject. Such an all-consuming passion usually results in a conflict of interest greater than any motivated by research funding. Clinical researchers who have promoted a particular theory for decades are very unlikely to change their minds easily. Many brazenly belong to advocacy groups that publicly espouse their positions. How can they be expected to objectively evaluate data that may make decades of their investment worthless? Yet, there they are - fully prejudiced by preconceived positions - and placed in a position of public trust to make objective evaluations.

Thus, we have one of the greatest hypocrisies in modern medicine - biased researchers sanctimoniously pointing their fingers at the 'conflicts of interest' of others.

Physician, heal thyself.

As we pointed out in an earlier article, the chairman of the sub-committee for Fluid and Electrolytes for the 2010 Guidelines is Larry Appel. Dr. Appel is one of the world's most outspoken anti-salt advocates and is listed as a member of World Action on Salt and Health (WASH) , an advocacy group whose singular aim is: "to achieve a reduction in dietary salt intake around the world." In their justification for salt reduction , WASH focuses almost exclusively on hypertension to the virtual exclusion of all other risk factors and biomarkers responsible for overall health outcomes. They systematically ignore all data (including the Cochrane review and its latest reissue - ) as well as the most recent evidence that demonstrates the net negative health outcomes from reduced salt diets. How any member of such an advocacy group could possibly be selected (much less lead) what is supposed to be an objective advisory group is quite astonishing and black mark on the Institute of Medicine as well as our National Academy of Sciences under which it operates. It is not as if the IOM were unaware of this conflict of interest. They simply choose to ignore it, confident in the belief that they can pass anything off as legitimate science.

And why not? When has the medical establishment ever been called out, no matter how egregious their behavior or advice has been? How many people marched on the IOM or the AMA offices to protest the countless deaths resulting from the hormone replacement therapy fiasco. When it comes to medicine, people suffer silently - and the establishment gets a free pass.

Such hypocrisy does not bode well for the future of objective medical science in this country.