Although the headline of today's Wall Street Journal misleads readers into thinking it focuses on blood pressure, WSJ blogger Shirley S. Wang makes it clear that her focus is on whether new medications "prevent heart attacks and death any better than an old-fashioned diuretic." Referencing a new report about the ALLHAT study in the Archives of Internal Medicine , she calls for a focus on the health outcomes of various interventions.

I responded for the salt industry:

ALLHAT was an important step for another reason not yet discussed in this thread: rather than focus on the "risk factor" of blood pressure, it addressed the truly important question of whether the intervention (in this case anti-hypertensive drugs) achieved the expected health outcomes benefit. Too often we've confused "risk factors" with absolute risk. It is the event -- the heart attack the stroke, i.e. cardiovascular health and mortality -- that should concern us individually and be the focus of our public health policy.

I am president of the Salt Institute, the industry association of salt producers. We monitor the medical literature and participate in the public health debate. ALLHAT provides important information to physicians who make recommendations to their patients. Likewise, as an exercise in focusing on the health outcomes of a recommended intervention, ALLHAT is a proper model for our public health decision-making as well. Regarding salt, for example, the question should not be "will salt reduction improve blood pressure?" Blood pressure is the "risk factor" and there are other risk factors (e.g. insulin resistance, plasma renin activity, sympathetic nervous system activity, etc.) which are affected by reducing dietary salt. As in ALLHAT, we should be asking: will this intervention improve health outcomes? Will reducing dietary salt improve actual risks of heart attacks and strokes? Will cutting back salt improve cardiovascular (and all-cause) mortality?

If you think you know the answer, I'd suggest that answer isn't "politically correct" and invite you to review the issue on our website at http://www.saltinstitute.org/28.html or access a comprehensive list of the studies of this question at http://www.saltinstitute.org/healthrisk.html .

We have recommended to the Department of Health and Human Services that it conduct a controlled trial of the health outcomes of reduced-salt diets using the ALLHAT rationale and modeled on a recent study, the Trials of Hypertension Prevention, which demonstrate both the ethics and the study protocol appropriate to determine whether those who encourage general salt reduction are likely to improve public health.

There are many biomarkers pertinent to diet and disease, Roger Clemens and Peter Pressman explain in the January issue of Food Technology . All biomarkers should

"indicate the biological plausibility of a diet-disease relationship, improve the assessment of relative risk, and serve as surrogate endpoints,"

the authors explain. Biomarkers include blood pressure, serum glucose, serum triglycerides. Some are better indicators than others. There is a "critical need for markers that distinguish the clinically meaningful stages of … pathology," they state, decrying the "simplistic model" that fails to predict outcomes accurately. They warn:

"The food industry, in its effort to provide more-healthful choices in the functional foods arena, must consider more-illuminating biomarkers that punctuate the much larger and exquisitely complex constellations o factors representing our emerging knowledge of the progression of disease states.

"As we examine the mechanisms of disease progression and the role of diet in augmenting health, it becomes paramount that we realize fundamental processes. …

"… our task will be ideally to select a biomarker that serves both as intervention target and as "barometer" of intervention efficacy and health status or of disease progression. …

"… we are engaging a clear priority on health promotion and disease risk reduction.

"Along with this movement is the absolute ethical and legal requirement that we scientifically support any health claims …."

Thus, the choice of a marker is key and, they add,

"when specifying a biomarker, it is important to understand how it fits with nutritional exposure or intake, time frame, sampling, specimen collection, storage, the model system under study…, biologic variation, and the analytic quality control."

Unmentioned by Clemens and Pressman is the growing awareness of the inadequacy of blood pressure as a reliable biomarker for cardiovascular risk. Increasingly, we understand that not only are multiple processes and interactions taking place with regard to dietary sodium intake and that individuals vary widely in their response, but that how we attempt to change surrogate biomarkers can be a clear indicator of the result. We need to focus on the hard disease outcomes and then look back to see which surrogate biomarkers offer value predicting adverse outcomes. Until then, take two doses of humility and see me in the morning.

Chicago boasts more Polish residents than Warsaw and now it's hijacking a salty secret from Eastern Europe - salt caves or salt rooms. A recent Chicago Tribune article notes a suburban restaurant featuring a relaxing, spa-like respiratory restorative salt cave inspired by one the owners visited on a trip to Poland - as well "Chicago's first dining room encased in Black Sea salt." The owners also converted one of their salt caves into a small dining room.

Other Chicago-area spa's have salt "breathing rooms" to restore mind and body. Patrons claim "30 to 60 minutes in a salt-covered room can help relieve stress, cure a hangover or even improve respiratory health." Don't miss the video .

The UK Food Standards Agency just commissioned a research contract to study the impact that front-of-pack nutritional labeling has on people's food choices. The goal of this project is to gain an insight into the way in which consumers approach purchasing decisions. Of course, the ultimate goal is to assist consumers in making healthier choices.

The problem is that consumers will be considering labels on individual foods and, as a result, evaluating the merits of products outside the context of the whole diet. The project will look at shoppers' understanding of the main types of front-of-pack nutrition labels used in the UK (traffic lights, Guideline Daily Amounts, and traffic light color-coded GDAs) and how they use them. What the project will not even attempt to determine is how consumers incorporate the front-of-pack nutritional labeling information into the context of their whole diet on a daily basis - which is, of course, the most important change because that is how we derive our nutrition on a daily basis.

The program has the unfortunate potential to focus on the means of communicating information and bits of data while ignoring the greater importance of perspective and context. In other words it has the potential of ignoring the forest by focusing on individual trees.

As an example, a consumer could come across a mayonnaise, or a salad dressing preparation which, by itself, would require a red light on the label. If, however, that dressing encourages the consumer to eat a serving or two of healthy cruciferous vegetables, what decision should the consumer make? Avoid the dressing and the vegetables? Certainly not!

But that is a conclusion one might make if the dressing is taken out of the context of the whole diet. An unintended consequence resulting from a focus on one tree rather than the forest.

It will be interesting to see the results of this research, which will be hopefully available by the end of 2008.

Often when the decibels rise and the tone turns shrill it's akin to a stock market contrarian's moment of vindication. Sometimes it seems that politically-correct conventional wisdom can never be changed. But it can.

The American Academy of Pediatrics which had been advising mothers of infants with a family history of allergies to avoid cow's milk, eggs, fish, peanuts and tree nuts while breast-feeding has taken a fresh look at the science and updated its advisory conceding that there's no good evidence for avoiding certain foods during pregnancy, using soy formula or delaying introduction of solid foods beyond six months.

So, dogma can be changed. Hang in there, those of you who've joined our seemingly-lonely effort to combat the unscientific demonization of salt.

An Associated Press story quoted Dr. Scott Sicherer of Mount Sinai School of Medicine's Jaffe Food Allergy Institute in New York City, one of the authors of the revised AAP policy statement:

They say, 'I shouldn't have had milk in my coffee. I've been saying, 'We don't really have evidence that it causes a problem. Don't be on a guilt trip about it.'

Of course, for Americans 2008 is a political year with a new president to elect. But while the electorate seems to be tiring of political polarization already, some lobby groups are becoming more assertive. Since New Year's day, the American Medical Association, has displayed a feisty combativeness urging its members to pressure Congress to pursue a path antithetical to the approach recommended by the U.S. Preventive Services Task force and endorsed by the Salt Institute. We'll have to wait and see if the AMA membership supports this campaign or returns to a more science-based approach to public health policy.

The January 14 edition of amednews.com, the AMA online newsletter, editorialized "Time to pinch off the salt " with the explanatory subtitle "The AMA calls on the FDA to revoke salt's 'generally recognized as safe' status to allow more regulation of sodium in food." The editorial liberally quotes AMA vice president for science, quality and public health Stephen Havas, who has almost single-handedly radicalized the AMA strategy on salt restriction.

About the same time, AMA issued a news release, not mentioning salt, but calling for Congress to pursue an aggressive assault on risk factors for cardiovascular disease. The AMA's January 11 release announced:

American Heart Association President Daniel W. Jones, M.D. urged Congress to pass legislation to help Americans control their risk factors for cardiovascular diseases. With obesity, hypertension, diabetes and other risk factors on the rise, the association is calling on elected officials to support measures that focus on research and prevention.

"Risk factors, such as unhealthy weight, poor diet, smoking and diabetes could undercut many of the gains we've made to reduce cardiovascular disease deaths," said Jones, vice chancellor, University of Mississippi Medical Center. "We must ratchet up efforts to convince policymakers that a strong and sustained investment of government resources is essential."

The association's 2008 Health Policy Agenda addresses risk factors through legislation and initiatives that would combat the obesity epidemic, curb tobacco use, particularly among children, increase funding for medical research and prevention and reduce health disparities.

This year alone, cardiovascular diseases will cost Americans an estimated $449 billion in lost productivity and medical expenses. Treatment costs for cardiovascular diseases are expected to rise 64 to 84% by 2025. Stroke treatment alone is projected to exceed $2 trillion by 2050.

While the AMA's specifics are a bit extreme, the concept of extending the effectiveness of "research" and "prevention" enjoys as much support today as "motherhood and apple pie" did of yore. The Salt Institute joins that chorus. We'd add, however, that federally-funded research should be available for independent confirmation and used to support government policy only if findings can be replicated. And, while we strongly support the prevention of cardiovascular disease and its resultant heart attacks and strokes, we are less sanguine concerning prevention of "risk factors" as semantacist Dr. Jones has stretched the term. How do you prevent age, for example, the surest predictor of cardiovascular events and deaths? How about being an African-American, another powerful "risk factor"?

The proper focus of public health policy is to prevent disease, extend life and improve the quality of that life. A focus on "risk factors" presupposes that they can be modified as part of our public health efforts. Some "risk factors" cannot be modified. Others, like "salt sensitivity," as recently as a decade or two ago were thought to be immutable and unchangeable and are now properly understood to be the product of deficiency intake levels of other nutrients, in this case, calcium, magnesium and potassium; correct those deficiencies (as with the DASH Diet) and the "salt sensitivity" disappears. So, the proper policy focus should not be on "risk factors" but on the effectiveness of HOW we try to modify those risk factors .

Again, salt is illustrative. Blood pressure is a risk factor for CV events and mortality. Few would deny that. But HOW blood pressure is modified is what's important, not the raw number itself. Blood pressure is not the disease, it is the symptom, the "risk factor" for CV disease, myocardial infarcts and strokes. Treating the symptom is not prevention. It may even make the underlying condition worse and increase the risk of an event rather than prevent it. That's what we discovered when scientists started examining the question of whether cutting salt (a "risk factor") would yield in actuality the "prevention" benefits predicted by mathematical models such as those used by Dr. Havas and the AMA. It turns out, they don't. In a long string of "health outcomes" studies , no pattern of a health benefit is correlated to diets lower in salt. It turned out that other "risk factors" such as insulin resistance, plasma renin activity and sympathetic nervous system activation were also affected by reducing dietary salt. These "risk factors" increased the risk of salt reduction, proving, once again, that HOW we seek to modify "risk factors" is more important than announcing a campaign focused only on change.

In this political year, we've heard virtually all the presidential candidates call for significant "change." Let's be reminded that the specifics of what should be changed and how it should be changed are as important as lamenting our current situation. That's as true in public health nutrition policy as it is in presidential politics.

Nobody is arguing that we should shift from prioritizing prevention and accept the projected $2 trillion cost of treating strokes, but let's focus our efforts on preventing heart attacks and strokes, not waste our money on "risk factors." Proven interventions identified by the U.S. Preventive Services Task Force specifically exclude general salt restriction as having no proven benefit. The president of the International Society of Hypertension used his presidential address a year ago to make the same point: let's focus on health outcomes, not intermediate "risk factors." That's the way we see it too.

I have never figured out who said "confession is good for the soul," but she was right. And a confession is in order tonight. Four days ago, I succumbed to the very sin I've decried publicly so often in the blogosphere: the sin of bestowing credibility, even endorsing results of a medical study whose conclusions support one's own worldview. It's natural. Understandable. But, sans apology and full repentance, nigh unto unforgivable.

Still, we learn from our experiences. As I humbly recant the ill-considered, cyber-published product of my passion, I hope I can be granted not only absolution, but insight into the difficulty others may likewise be experiencing when jumping quickly to endorse a "politically correct" end result without regard to the quality of the "science" employed to reach that result.

Four days ago I celebrated a new study, declaring with exuberance :

Today's publication in PLoS Medicine of a massive (20,244 persons) 14-year mortality study, showed that four simple interventions -- increasing fruits and vegetables, becoming physically active, not smoking and consuming no more than moderate amounts of alcohol -- increased lifespan by 14 years.

Kay-Tee Khaw et al report that "the trends were strongest for cardiovascular causes." It's time we got serious about promoting the DASH Diet and stopped diverting resources to interventions like salt reduction which have been endorsed by experts but are unsupported by actual scientific evidence.

My enthusiasm and endorsement of the DASH Diet remain intact, but my respect for the Khaw study is gone. Having now read the January 10th post by Sandy Szwarc on her Junkfood Science blog , I am hoist on my own petard. My admonition to "get serious" about the science underlying nutrition recommendations is exposed as pure self-righteous cheerleading. Not to excuse my excesses, but as Ms. Szwarc points out:

Within hours this week, television newscasters, as well as some 500 published articles - for scientists, medical professionals, nursing professionals, business professionals and consumers - were all reporting the same interpretation of this study. The script was provided by the publication's press release: "4 health behaviors can add 14 extra years of life."

Thank you, Sandy, for your very relevant reminder:

Simply making extraordinary statements about a study, however, does not make them true - no matter how much we might want them to be. And who wouldn't want to believe that by doing just four easy things we could add 14 years to our lives?

After reviewing the methodology, Szwarc cuts to the chase:

Their key finding, which has not been reported, was they were unable to find a tenable correlation between any of the health behaviors and mortality: all-cause, cardiovascular disease, cancer or any other cause of death. The relative risks all hugged either side of 1 - null findings. (emphasis in original) …

In other words, reports of higher relative risks associated with not engaging in four healthy behaviors were based on 49 people, 0.2% of the cohort. But the absolute (actual) risk of dying differed only 0.2% between those doing zero and those doing all four healthy behaviors (0.25% and 0.05%, respectively). (emphasis in original)

This is just the kind of book-cooking that we've prided ourselves on exposing here at the Salt Institute. And it stands exposed - at least in this instance - as that proverbial pride that goeth before a fall. Mea culpa. Note to self: pay attention to details. Look at the "p value." Beware author bias. May I learn patience and sympathy for others of you who ascribe authority to a medical study that "sounds right" because it confirms what one is predisposed to believe. May I find the discipline to "walk the talk" and insist to myself as I've admonished others to insist on quality science, eschewing the authors' news releases and the funding agencies' "spin."

Let us sinners go forth together seeking truth.

Almost 30 years after the UN International Year of the Child , 2008 is shaping up to be a banner year focused upon improving the health of our children through the provision of nutritional information and recommendations for improvements to their lifestyle.

It seems a bit odd to be referring to lifestyle improvements for children; after all, don't children do what they've always done?

Wrong!

The lifestyles of children have changed dramatically and most of these changes are not positive for their health. Eating a breakfast bar during the morning bus commute to school is OK but it is not the same as sitting down at the kitchen table, having breakfast and then marching off to school. Playing the Wii game for a few hours a day in front of the widescreen is a lot of fun, but it is not the same as running your heart out chasing a soccer ball. Not the same for a child's mind nor a child's body.

Having a pizza delivered, with double everything and cheese product extruded into the crust might be great to order one night, but unless someone insists that everyone take a 5 km run afterwards, the extra calories have only one unflattering place to go. Do that or something similar a few times a week and you are beginning to talk about some pretty serious caloric and nutrient imbalances.

Maybe referring to children's lifestyle issues is not such a bad idea, after all.

The recent GMA Industry Health and Wellness Report highlights the goal of reducing obesity rates and encouraging healthy lifestyles for children. Not only do children have to be encouraged to pursue a fully balanced diet as shown in MyPyramid , but they should be taught the simple concept of energy balance and encouraged to do far more aerobic physical activity to keep their weight in check and their metabolic processes toned up.

In a recent paper entitled, "Children's diets: looking at the bigger picture ", Charlotte Musgrove, a nutrition scientist at the British Nutrition Foundation in London states that previously, the main focus was to provide enough energy and nutrients to meet the needs of a growing child. However, today there is a stronger emphasis on making sure that children are having a varied and balanced diet, and an active lifestyle. Of particular interest, is the finding that the message to eat at least five portions of fruit and vegetables a day appears to be gaining ground. Although many children are still not consuming the recommended amount of fruit and vegetables, their intakes have increased over recent years. In 2000, children were on average eating only 2 portions of fruit and vegetables a day. One in five children did not report eating any fruit, and three in five children did not report eating any green leafy vegetables over an average week. Between 2001 and 2004, average intakes of fruit and vegetable portions per day increased slightly, with boys consuming 2.5 portions per day, and girls consuming 2.6. Data from 2005 shows the average number of daily portions of fruit and vegetables eaten was 3.1 (for both boys and girls) and there was an increase in the proportion of children eating five or more portions per day (Health Survey for England 2005 ). Good news, but still a long way to go.

Together with the balance of nutrients from the rest of the diet, with physical fitness programs to ensure their bodies are kept in tune and a social environment where they can flourish with support and mentoring, our children will thrive in good health.

Slowly, slowly, we are moving away from the single, silver bullet solutions to children's health problems, because although they seem easy and they have made many rich and famous - they don't work - they never have. Life is just not that simple. It's the whole diet as part of the whole lifestyle that will direct us to good health for our children.

Everything should be made as simple as possible, but not simpler - Albert Einstein

Anyone promoting the addition or reduction of any single nutrient as the key solution to children's diseases is little different from the snake-oil salesmen of days gone by.

The problem is, they sold an awful lot of the stuff.

This week's (January 5th) National Journal cover story, "Data Bomb ," set off reverberations in my mind. The article recounts the release of grossly-misleading data immediately prior to the 2006 Congressional elections that exaggerated tenfold the number of deaths in Iraq; the study fed popular disillusionment with U.S. engagement in Iraq and contributed to capture of both houses of Congress in the elections several weeks later. The study was produced by the Johns Hopkins School of Public Health. The researchers, it turned out, were anti-war activists, though they claimed their errors didn't reflect their political views.

Bad memories. Six years earlier, researchers from the Johns Hopkins School of Public Health published misleading statistics in the DASH-Sodium trial - and refused to release further statistical calculations that would likely have unmasked their charade. Again, the Johns Hopkins researcher was an activist, a member of the lobby group World Action on Salt and Health (WASH). Again, the incompletely-reported and misleading research was instrumental in an important policy decision - to establish a Daily Recommended Intake level for sodium and a Dietary Guideline supporting reduced salt intake. Even worse, this time, despite the incontrovertible conflict represented both by his WASH lobby group membership and heavy involvement in the research itself, the researcher was installed as chair of the DRI project committee and the Dietary Guidelines subcommittee where he blocked consideration of the full data from the study.

Putting the National Journal aside, I plunged into an editorial in the journal of another advocacy organization, reading an editorial entitled "Eat your fruits and vegetables, but hold the salt ." The editorial writer acknowledged his funding support from the same federal agency that had funded DASH-Sodium for a study he has underway exploring the effects of the "DASH Diet" on individuals with isolated systolic hypertension. I expected little comfort, but hoped that, perhaps, the editorial would confess the over-interpretation of the results (as had an earlier article in 2005 where a DASH-Sodium investigator revealed that in six of the eight subgroups - subgroups that represented a large majority of the public - the reported findings were statistically insignificant even though the authors described them as valid.

All these discussions of DASH-Sodium have attempted to portray the DASH Diet as salt-reduced and demonstrating benefit from lower sodium intakes. This has been frustrating to those of us - including the salt industry - who have strongly endorsed the DASH Diet because it does not reduce salt and the blood pressure effect is produced by the fruits, vegetables and dairy products - not the salt. But the federally-funded PR juggernaut rolls on.

In the editorial, Dr. Paul Conlin of Harvard University's Brigham and Women's Hospital, indeed, endorsed salt reduction and noted a study of blood pressure in chimpanzees supported increased intakes of fruits and vegetables, two of the triumvirate of "good" foods in the DASH Diet. But note the caveats Conlin incorporates into his conclusions:

Elliott et all have provided new information, albeit in chimpanzees, showing that long-term salt restriction in the setting of a diet rich in fruits and vegetables produces sustained reductions in blood pressure. These data are relevant to humans but should be approached with caution and respect for the sample size, the lesser effects when adjusted for key factors, and the inability to add knowledge on the health and/or cardiovascular benefits of salt restriction beyond blood pressure lowering. Major next steps include …confirming that eating such a dietary pattern provides unquestioned health benefits. (emphasis added)

Last year, other WASH advocates took an important step forward in conceding the validity of health outcomes measures instead of controversial statistical extrapolations based solely on blood pressure (ignoring other metabolic changes that occur in salt reduction). As one observer sagely observed, their embrace of health outcomes in a Finnish study "backfired" when the data showed that improvements in Finns' cardiovascular health lagged their European and North American peers. Still, anti-salt advocates have claimed it would be "immoral" to ask study subjects to consume "normal" levels of salt since they "know" it is unhealthy. The Conlin editorial cedes the point, admitting that such a study is not only feasible and moral, but needed to "add knowledge on the health and/or cardiovascular benefits of salt restriction beyond blood pressure lowering" and confirm "that eating such a dietary pattern provides unquestioned health benefits." Those benefits - projected to be improved cardiovascular outcomes like less heart attacks and cardiovascular disease - have not been confirmed in the several studies that have examined them.

The Salt Institute has called for a controlled trial of whether there is any health benefit from reducing dietary sodium. Now, even those who support salt reduction for blood pressure lowering are beginning to see that this isn't the right question and are embracing our view of the need for a new study.

Perhaps those bad memories of incomplete data reporting by Johns Hopkins' researchers can, indeed, be relegated to history and not the basis of public policy.

Two child specialists issue a timely reminder in the December 22 issue of the British Medical Journal . Indianpolis-based Rachel C Vreeman, a fellow in children's health services research, and Aaron E Carroll, an assistant professor of pediatrics, remind physicians not to be taken in by myths perpetuated in medical science:

Physicians understand that practicing good medicine requires the constant acquisition of new knowledge, though they often assume their existing medical beliefs do not need re-examination. ...

Even physicians sometimes believe medical myths contradicted by scientific evidence.

The prevalence and endorsement of simple medical myths point to the need to continue to question what other falsehoods physicians endorse.

Examining why we believe myths and using evidence to dispel false beliefs can move us closer to evidence based practice.

Let's face it, doctors are busy people. Reading all the latest journals -- and, particularly, the methods sections that often contain the key statistical manipulations -- is a virtually insurmountable task for GPs or area specialists like those serving our children. Take, for example, an aricle on salt and blood pressure in children published in the Journal of Human Hypertension in September 2007 by anti-salt war chief Graham MacGregor and his associates. MacGregor et al reported that

An increase of 1g/day in salt intake was related to an increase of 0.4 mm Hg in systolic and 0.6 mm Hg in pulse pressure....The consistent finding of our present analysis of a random sample of free-living indiviudals with that from controlled salt reduction trials provides further support for a reduction in salt intake in children and adolescents.

That's the item that may have caught readers' attention and, if so, it would have perpetuated another myth -- that salt was important to the blood pressure of children. Don't blame the journal, however; the editors commissioned an editorial to attempt to keep the story straight -- and they continue to make that editorial available as their top-listed Featured Article. In that corrective editorial , fomer International Society of Hypertension president Michael H. Alderman explains:

Specifically, a difference in salt intake of 1 g was associated with a 0.4 mm Hg rise in blood pressure. However, the significance of this relationship disappeared after correction for energy intake. ...

Regrettably, the current report provides little information regarding other associations to blood pressure or variations in other characteristics that might be associated with variations in sodium intake. For example, stature and physical maturation are associated with blood pressure. Bigger children may be muscular or pudgy. Children who exercise vigorously may have large energy (and sodium) intakes, and be taller and leaner than youngsters who have the same body mass index and different life styles. Cooper et al. postulated that the strong link of creatinine to blood pressure might reflect muscle mass and perhaps be a marker of body size. This, in turn, might be the most powerful determinant of blood pressure in children-more important than age or sodium. Perhaps, the best measure of growth and development available here is mid-arm circumference. The strong arm to blood pressure correlation may reflect muscle mass and suggests that diets high in energy (and therefore, among other things, sodium) may be conducive to physical maturation, along with a slightly higher blood pressure. In short, if this were the causal pathway, then higher pressure might even be a desirable sign in children.

Dietary intake is complex, and to characterize it on the basis of one element may well oversimplify any assessment of its value. For example, given the high correlation of energy with virtually all other nutrients, it is possible that those consuming more sodium (and energy) had more satisfactory consumption of other important dietary elements-both known and unknown. In any event, blood pressure is not the only measure of the health of children. The British Survey of Young People probably includes, in addition to physical and physiological data, information on other social, economic and developmental characteristics whose explanation might well inform our understanding of the relation of blood pressure, diet, health and development in these youngsters. Of note, He et al. also provide some other interesting information. For example, they note that 18-year-old British residents, in 1997, were consuming 2.6-g of sodium per day. That was similar to levels found in Chicago a decade earlier, and falls within the range of adult sodium intake seen world-wide in most countries and suggests that, a decade and 2 ago, these near adults were within that range.

It is also interesting to note that measures of discretionary sodium use did not correlate with blood pressure. This supports the Cochrane Collaboration conclusion that there was not sufficient evidence for a general dietary recommendation to reduce sodium intake. (emphasis added)

Medical myths can cause real damage. With regard to children, it seems that once corrected for caloric intake, there is no association of blood pressure and salt intake, but there IS a strong association of calories (and salt) with healthy development of children. Perhaps the biggest myth is that diet is less important than its component nutrients. Don't let your pediatrician get duped or pass on medical mythology.

Or should we title this: "Get government out of the bedroom ... and the kitchen"?

Don't miss the "Brave New Diet" op ed piece by Sally C. Pipes in today's Washington Post . To give you a flavor, she points out that basketball superstar Kobe Bryant and undefeated New England Patriot's QB Tom Brady -- to say nothing of "Hollywood hearttrobs" Brad Pitt, Matt Damon, Tom Cruise and George Clooney" -- are all "fatties." They're overweight using today's metrics. Besides some useful facts on government games-playing on the obesity issue, the political insight about dietary guidelines is particularly timely -- and planned -- for this holiday season with its parties and feasts. Ms. Pipes notes that

"underlying this ["common political refrain that America faces a childhood obesity epidemic"] is the premise that we're helpless before gingerbread cookies and honey-roasted hams -- unable to resist these and other foods and incapable of putting down our forks. We can be cured, it seems, only by government intervention such as the banning of trans-fats and sodas from public schools.

But is it the food, or is it us? Is it a proper role of government to tell us what we can or can't eat?

She poses some questions she'd like answered "[b]efore we let Uncle Sam into our kitchens, at school or at home" and concludes:

People make choices. And government should protect -- not restrict -- the freedom to make those choices so long as we're not harming others.

While we may not always like the choices others might make, it is essential that we all have the freedom to choose for ourselves. Once we accept the idea that the Nanny State should step in when it's "for our own good," we've taken a very big step down the road to something like the scene painted in George Orwell's "1984" -- when citizens wake each day to mandatory exercise classes on the Telescreen.

Most of us would prefer to choose for ourselves whether to exercise or have an extra helping of apple pie. And if we gain an extra pound over the holidays -- so what? That's why we have New Year's resolutions.

How can it be that Americans are living longer and healthier lives than ever before and yet dying in unprecedented numbers from chronic diseases? Are we confusing risks of proxy conditions for real risks of adverse health events?

Successful people live in the present, but they think seriously about the future. They invest themselves and their resources to make tomorrow better than today and to cushion the inevitable bumps in life's road. Through learned precept or harsh experience, they know that "an ounce of prevention is worth a pound of cure." They've also learned to count their blessings along the way, to temper their worry about the future by appreciating the good fortune they've enjoyed.

We use the same thought process to fashion public health policy. As a society, we have never been healthier nor longer-lived, yet these hard-won achievements are tempered with recognition that many amongst us and elsewhere in the world live Hobbesian lives. We recognize the fragility of our personal health and the imposing shadow of chronic disease in our lives and in our families. We invest ourselves, sometimes wisely, sometimes not, in quests to improve our diet and fitness and otherwise protect our health and that of our loved ones. We crave security in matters inherently uncertain. We sacrifice to prevent potential threats, often accepting taxes and social regimentation, believing that using a seatbelt or getting a flu shot is a reasonable trade-off against injuries in car crashes or a flu pandemic.

Just as we do as individuals, as a society we accept risk trade-offs, but we do it based on our belief that these risks have been fairly described. While each of us has a unique set of risk tolerances, the entire calculus is undermined if the information fed into this vast social "brain" is compromised by poorly-understood data limitations or manipulated by unseen parties with special interest bias.

Not to say that these choices are easy. We are beset, as individuals and citizens, with media coverage of emerging science which often seems conflicting. We hear blaring warnings about health threats and advocates' impassioned appeals for action on divergent strategies based on different diagnoses. It's confusing.

Take, for example, two recent "authoritative" pronouncements. In the new publication from the Department of Health and Human Services (HHS), Health, United States, 2007, a compendium of more than 150 tables reporting data from the Centers for Disease Control and Prevention, as we reported earlier :

Life expectancy is at an all-time high. Females live longer than males, but a baby born in 1900 would live until 1948 (men) or 1951 (women) -- 48 and 51 years, respectively. Boomers born in 1950 will live, on average until 2015 (men) or 2021 (women) -- 65.5 and 71 years, respectively). The new report predicts children born in 2004 will live until 2079 (men) and 2084 (women) -- 75.2 and 80.4 years respectively. We take it for granted, but it's big news. And good news.

Children are healthier. In just the past quarter century, the number of children who died before age 14 has been cut in half -- in half! (since the mid-20th century, the rate has been cut 80%). Youth and teens are 60% less likely to be in "fair" or "poor" health. Almost as good as Ivory Soap, 98.2% of our children are healthy.

Adults are thriving, too. Despite our aging population, the percentage of all people in "fair" or "poor" health has dropped in a decade by more than 10% -- from 10.4% in 1991 to 9.2% in 2005. Physical limitations have also been dropping, from 13.3% to 11.7% over the past eight years while age-adjusted vision- and hearing-impairment, over the same period, have improved a remarkable 65% (dropping from 10% to 3.5%).

Mortality continues to decline. The new figures confirm those we reported earlier this year in comparing the U.S. with Americans' steady salt intakes with mortality figures in Finland which compromised its health improvements as it reduced its population's salt intake. Overall, age-adjusted mortality for all of the leading causes of death are in decline -- cut in half since 1950. In just the past 14 years, deaths from the leading cause, heart disease, have dropped by a third. Deaths from the second-leading cause, cancer, have fallen 14% and the third, stroke, by a whopping 72% (with no reduction in dietary salt). The key is age-adjusting. If we don't die of something in our youth or early adulthood, we reach old age where we (all, eventually) die of "old age" ailments like respiratory infections or Alzheimers's. In fact, the biggest risk of dying is getting old.

But, just as we were feeling that perhaps all the doom and gloom of rising health costs and millions without health insurance, was a manageable challenge, The Partnership to Fight Chronic Disease, a new national coalition of business and labor groups, issued its "Policy Platform" declaring that "rising rates of chronic health problems pose a significant and unsustainable burden on the U.S. health care system" and called for Americans to display "a willingness to enact policies that help Americans better prevent and manage chronic illnesses." The Platform calls on the presidential candidates to "highlight common-sense reforms." Pointing out that 77% of U.S. healthcare costs are due to chronic disease, it cites (other) CDC figures showing two-thirds of American children will develop diabetes leading to "lower life expectancy than their parents." Scary stuff. The Platform throws around a lot of numbers, too, such as alleging that obesity costs society $200 billion a year.

Head-scratching time. What about the other CDC figures that show that overweight Americans are actually healthier than their thinner fellow-citizens ( 1 2 3 4 )? You may remember: the ones CDC issued as revisions to their earlier obesity alert .

Now, let's accept that the people making these analyses are most likely fair-minded advocates for their views. The first thought in sorting this out is the correct one: consult the data; a close reading of the studies may help explain the discrepancies and where the authors of various studies may have claimed more than their data show. There is another possibility, however.

While there is general consensus that preventing cancer or heart disease is better - and likely less expensive - than caring for the victim after a malignant tumor is discovered or a heart attack occurs, the differing statistical worldviews as described in Health, United States, 2007 and the PFCD Platform may come down to how risk is defined.

Take the seat belt example. Unrestrained car drivers and passengers are clearly at greater risk of injury or death than those who "buckle up for safety." We'd never, knowingly, combine the two groups to determine the average risk when the documentation of the very different risk profiles is available.

Transfer that thinking to the question of the risk of high blood pressure. About 20% of Americans have high blood pressure, hypertension. And hypertension is responsible for about 16% of heart disease. The 20% with high blood pressure include, of course, those whose current blood pressure exceeds the defined minimum 140/90 mmHg. But the calculation also includes all those whose blood pressure would have been at the "hypertension" threshold except that they took medications or made lifestyle adjustments to lower their blood pressure. Those who managed their blood pressure (like those with seat belts), surely have a lower risk. Unlike the seat belt example, however, they are all lumped together: "once a hypertensive, always a hypertensive." The group that modified its blood pressure should be considered a separate, lower-risk group. By lumping them together, we inflate the number of people identified at risk and targeted for public health concern.

Better data would, thus, help us understand why we continue to have a large number of people with hypertension while at the same time we have achieved fantastic reductions in the rate of heart disease. Hypertension is often "sold" as a disease when it is, rather, an indicator, a marker, an intermediate variable. We are concerned about heart attacks, strokes and mortality. When it comes to treating this surrogate marker, we must never lose track of the real objective: improving health outcomes, not modifying "risk factors" - especially one that explains only one-sixth of the problem. The body is complex and its systems, redundant and interconnected. Simple solutions may make great headlines, but they don't change the "medical facts of life."

So, as we marshal our resources and prioritize our public health targets, let's keep in mind that efforts to prevent chronic disease must be assigned using real-world data. We can prevent high blood pressure, but if the side-effects (e.g. increased insulin resistance, elevated plasma renin activity, etc.) impose unanticipated costs, we need to prevent heart attacks using the best weapons we have. And those weapons are proven. They include medications. They may include lifestyle interventions like weight control and fitness. They don't include salt reduction for the general population.

The Food and Drug Administration recently asked for comments on what new reference values the agency might use to calculate the percent daily value (DV) on the Nutrition Facts and Supplement Facts labels and what factors the agency should consider in establishing such new reference values. The Salt Institute provided a comprehensive response addressing the questionable value of this type of labeling to consumers.

The Salt Institute strongly support the provision of objective scientific information to consumers in a manner that will help consumers can make informed choices. Currently, nutrients are labeled in isolation - not in reference to thief role in the whole diet. While placing the impact of individual nutrients into context with our "whole diet" is a complicated task, this is how nutrients are metabolized on an ongoing basis. Lacking a complete knowledge of how individual nutrients impact upon each other in the overall diet, the question remains as to whether the consideration of nutrients in isolation for the purposes of informing consumers is truly a functional benefit to them. While no one doubts that this data provides information, it can compromise perspective by taking nutrients out of their 'holistic diet' context.

Based upon the results of the DASH diet and the most recent results on the positive impact of vegetables on the diet, we are not certain that the establishment and dissemination of a DV is of particular benefit to consumers. Salt consumption is self limiting because of taste and despite the outcry regarding our current levels of consumption, our cardiovascular performance is significantly better than that of Finland - the only country that has significantly reduced its salt consumption by 40-50% in the last 30 years. If a DV is felt to be absolutely necessary, it is certainly not in anyone's interest to reduce it any further than its current level.

The news media's been reporting a paper in The Lancet this past week that purports to "prove" that salt produces chronic disease mortality, killing 8.5 million persons around the world. As the headline writers penned, that would be a serious condition, indeed, if it were true. But a closer look shows the authors engaged in the same statistical sleight-of-hand that was on display at the FDA hearing a couple weeks ago.

No matter how you quantify the enormous costs associated with chronic disease and, in this case, heart disease, the key to assessing the veracity of the numbers associated with salt is the linkage. Simply put, there is none. It's manufactured -- it exists only as the product of a mathematical model that assumed that lower salt diets WILL lower population blood pressure AND that lowering BP in this way WILL produce the lower incidence of CV death. GIGO's the term for it; garbage in, garbage out.

In fact, the authors cite one of two studies of salt reduction in Finland. The study they don't report is the health outcomes of Finand over the year it reduced its citzens' salt intake. Absent any control, the numbers show improvement, but compared with other countries over the years, Finland lagged behind those countries that did NOT reduce salt .

That The Lancet would choose to publish this reflects the policy preference on the author, not a substantive contribution to public health nutrition policy.

When the federal government set up its program to ensure the safety of American foods, it recognized that some ingredients had been used safely for years -- for some, for centuries and for a few, like salt, for millennia. They prioritized their resources and accorded these proven-safe ingredients recognition as Generally Recognized as Safe (GRAS). The decision was reviewed and affirmed in 1982. The process is about to be re-run.

Arguing that salt affects blood pressure, a number of advocacy groups endorse removing GRAS from salt and having FDA set food-by-food limits on salt content on the assumption that this would produce lower sodium intakes and lower blood pressure. Defenders of GRAS for salt (SI, food manufacturers, some health groups and prominent hypertension researchers, argue that blood pressure is an "surrogate" risk factor -- and not a very good surrogate at that! There are other surrogate candidates to predict chronic disease risk: insulin resistance, plasma renin activity and more. Salt affects them as well. Salt's defenders -- like the Salt Institute -- have insisted the right test isn't blood pressure, but rather actual disease outcomes like heart attack incidence or, better still, mortality rates.

FDA is conducting a hearing Nov. 29th to air the controversy with prominent proponents of both views delivering oral testimony to an FDA panel in College Park, MD.

The Salt Institute will be testifying, renewing its call for a controlled trial of the health outcomes of low-salt diets and challenging FDA to help fund the study. Read the news release or the full testimony .

For a good review of the issues, see JunkFoodScience's story "The good-bad salt debate gets a hearing at the FDA ."