Thanks to an expensive and extended PR campaign, most Americans know that blood pressure is an important indicator of their cardiovascular health. Higher is not better. But a new survey Web-published recently discovered that 75% of adults with high blood pressure are not at all familiar with another "number" that may be even more important in determining their chances of a stroke or heart attack. Only one in four has any inkling of the function and critical role of the body's renin system, even though 89% of those surveyed told the pollsters they wanted to understand what was causing their high blood pressure. Medical News Today reported the survey results.

Many things impact blood pressure. And lower BP isn't always better, though the greater public health risk is the high and rising number of people with above-normal BP. Salt is among those factors. So is renin. Renin? That's what three-fourths the respondents said. Only 2% said they were very familiar with the role the renin system plays in their body, though one quarter (25%) consider themselves at least somewhat familiar. Ominously, even after respondents were given descriptions about the role the renin system plays in the body, only 23% were able to correctly describe it (by regurgitating the information they had just received. No wonder so many people uncritically embrace the proposition that lowering dietary salt will improve their health. They just don't understand what's going on in their bodies.

Renin is a key regulator of BP. It's a proteolytic enzyme produced in the kidney that plays a major role in the release of angiotensin which the body secrets to tighten up blood vessels to keep BP up if the body senses it is falling to an unhealthy level. Many anti-hypertensive drugs block renin activity.

Renin levels are associated with a 430% increase in heart attack incidence according to a study published back in 1989. Fifteen years earlier, the foremost investigator into renin's role, Dr. John Laragh, landed on the cover of Time magazine for his pioneering work. But that was more than 30 years ago and the government's PR blitz on salt has buried those insights.

What does this have to do with salt? Salt reduction triggers elevated levels of renin. Didn't read that on the NHLBI website, huh? It's true. Reducing intakes of dietary sodium prompts the kidneys put crank up their production of renin, increasing your odds of a heart attack. The government knows this (I personally notified FDA Commissioner David Kessler back in 1989), but it's another "inconvenient truth" it prefers to ignore. It is one of the "unintended consequences" of salt reduction that, in sum total, negate any health benefit of lowering dietary salt to reduce BP.

Well, now at least you can add yourself to the 23% who are at least "somewhat familiar" with the crucial BP role of renin.

The survey was sponsored by Novartis Pharmaceuticals Corporation and conducted by Harris Interactive. It included more than 2,400 US adults ages 18+ of whom more than 700 reported elevated blood pressure. In releasing survey results, RealAge.com declared: "The results of this survey reinforce the need for education, particularly around the renin system. Targeting the renin system is a key to regulating blood pressure. Our hope is that by helping the public better understand the physiology of high blood pressure, we can motivate those with the condition to adapt a healthier lifestyle and ask their physicians about treatment options that target a key source of blood pressure."

Everyone knows prevention is better than remediation. That's true of removing snow and ice from roadways, preventing mineral deposits on hot water appliances or avoiding personal accident or injury.

In health, that translates to preventing disease or treating the afflicted. In our national healthcare debate, everyone's for prevention as much as everyone is for "reform." With trillions of dollars at stake, we should be asking ourselves whether it's true that "an ounce of prevention is worth a pound of cure." Is prevention cost-beneficial and, if so, is all prevention justified or should our prevention efforts be targetted where they'll deliver the biggest bang for our bucks? Time magazine made prevention its cover story this week, summarizing the issue:

As the cost of health care continues to climb (60% of U.S. bankruptcies in 2007 were due to medical costs), the health of our nation is not getting any better. Heart disease remains the No. 1 killer of Americans (as it has been for all but a few years since 1900), our collective waistline continues to bulge, diabetes rates march ever higher, and after steadily declining in recent decades, the smoking rate among high schoolers is leveling off. The U.S. boasts the best cutting-edge medicine in the world, yet 75% of our health-care costs are attributable to chronic, preventable diseases. In all, about 40% of premature deaths in the U.S. are caused by lifestyle choices — smoking, poor eating and inactivity.

But while prevention — intervening in patients' lives before they get sick — has long been part of the medical lexicon, programs to educate and encourage patients to adopt healthy behaviors have never truly been embraced. Ours is a system that rewards pills and procedures and nurtures a clinical culture in which the goal is primarily to fix what goes wrong. "I never saw a well patient in my life," says Cosgrove of the years he spent as a heart surgeon. "They were all sick. We are in the sickness business. We need to get into the health business." This idea is at the heart of how President Obama wants to reform health care in America; he argued that the U.S. medical system is designed to provide disease care rather than health care. In a letter to Senators drafting health-care-reform legislation, Obama cited the [Cleveland Clinic] as a model: "We should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country," he wrote.

...

Will prevention work? And will our health system finally embrace the strategy over prescriptions and procedures? We don't have many other options. Prevention is a timeless idea, one our species has always practiced: pioneers preserved food to prevent starvation in the winter; modern workers invest in 401(k)s to prevent destitution when they're older. Applying the same ethos to medical care ought not be that hard — especially since the country's health, economic and otherwise, may depend on it.

In fact, the President is personally modeling as well as cheerleading the prevention effort. Capitol Hill newspaper Politico carried a story earlier this month by Carrie Budoff Brown entitled "Coach Obama: Shape up now." Brown points out that the prevention push is controversial ideologically ("To some, it smacks of a 'nanny state on steroids'"), noting that Obama has imported into the senior ranks of his Administration "officials who, in their previous jobs, outlawed trans fats, banned public smoking or required restaurants to proivde a calorie count with that slice of banana cream pie." She warns: "Obama needs to (avoid) coming across as a public scold or killjoy." She quotes a frustrated David Harsanyi, a Denver Post columnist and author of the book Nanny State: How Food Fascists, Teetotaling Do-Gooders, Priggish Moralists and Other Boneheaded Bureaucrats Are Turning America Into a Nation of Children, saying: “If you care about the sorts of things I do, then you are going to be losing big-time for the next four to eight years,”

Obama's effort is more than ideology, however, Brown continues. The major argument is that prevention will save money.

The public health community has worked intensively in recent years to build a body of evidence in support of the very initiatives Obama and lawmakers are now embracing. They frame the issue as one of money: Chronic diseases account for 75 percent of the nation’s $2 trillion in medical costs, according to the Centers for Disease Control and Prevention. And if the government encourages healthful lifestyles, it could slow the rising cost of health care, though the exact savings are debatable.

Yes, prevention IS debatable. Earlier this year, Rutgers economics professor Louise B. Russell addressed the subject in an article in Health Affairs, "Preventing Chronic Disease: An Important Investment, But Don’t Count On Cost Savings." Dr. Russell explained:

Over the four decades since cost-effectiveness analysis was first applied to health and medicine, hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them. Medications for hypertension and elevated cholesterol, diet and exercise to prevent diabetes, and screening and early treatment for cancer all add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving.

Russell's been quoted a lot recently as the healthcare debate heats up. She told Janet Adamy of the Wall Street Journal that many previous government prevention efforts aimed at costly chronic diseases have had little success in reducing illness or costs: "It is not going to cut costs. We already do a lot more prevention than other countries. We are not healthier." Adamy's report continues:

[Russell's] findings don't question the benefits of a healthy lifestyle, and many preventive measures are effective. The problem is that when testing becomes too widespread, or heavy investments are made in monitoring people with chronic diseases, the rewards often fail to match the costs.

...

The Congressional Budget Office, in a December report, concluded that greater use of preventive care would at best generate modest reductions in costs over 10 years, and might even result in increases.

One reason cost savings are hard to achieve, according to Prof. Russell, is that much of the money spent on disease prevention goes for people who aren't going to get sick anyway. Also, people have trouble making difficult lifestyle changes, such as taking up regular exercise or eating healthier food.

A report published in the New England Journal of Medicine last year examined 279 spending ratios in published studies of health-oriented prevention measures, and another 1,221 on treatments for people who were already sick. Some measures clearly saved money, like screening men in their early 60s for colorectal cancer.

But the report concluded that most preventive measures reviewed didn't save money. For instance, screening all 65-year-olds for diabetes would cost $590,000 for every healthy year of life it adds over just screening people that age with high blood pressure.

Medicare has conducted seven pilot programs in the past decade testing the theory on some of the most costly chronic diseases. Each showed little if any cost savings or measurable improvement in patients' health.

So prevention isn't the magic pill that "everyone" believes it to be. But what I'd call "smart prevention" certainly should play a central role in addressing our national health needs. Smart prevention has two principles: 1) it's evidence-based, not playing to the crowd and, 2) it's selective, focused on interventions and individuals or tightly-defined groups who will benefit. [By that standard, of course, universal salt reduction would be abandoned as a policy].

Dr. Russell would seem to endorse this approach. Her Health Affairs article avers:

Prevention can be a cost-effective, sometimes cost-saving, component of managing established chronic conditions. For example, at $16 per person (1995 dollars), or about $25 today, vaccination against pneumococcal pneumonia reduces medical spending for adults ages 50-64 with congestive heart failure, chronic lung disease, and diabetes, and other chronic conditions...

But, she concludes:

Over the past four decades, hundreds of sutides have shown that prevention usually adds to medical spending. ... 80 percent add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving."

Thanks for the reminder that a bit more humility and a lot less hyperbole are needed concerning prevention.

It's now clear: I lack the patience to await the full four parts of a powerful new series of posts on Junk Food Science before sharing it with Salt Sensibilty readers. They're too good to wait. They examine the subject: “Paradoxes – Compel us to think.” So far, two posts: Part One and Part Two . Sandy Szwarc introduces the quest to “separate science from ideology” (phrase from JAMA ) as follows:

We may know, intellectually, that correlations can never show causation, but when a correlation seems to confirm a reason we believe, it’s very easy to find ourselves falling for the fallacy, anyway, and to not even consider other explanations. We may call our belief “common sense” or what “everyone knows,” without realizing that we’ve come to believe it simply because it’s all we ever hear. It may never even occur to us to question an axiom — especially if we never hear about the evidence which contradicts or disproves it.

Her primary focus remains obesity as we may remember since I've often blogged on her relevant posts. Nevertheless, many of the observations pertain equally to the salt and health controversy. She notes that “The obesity paradox wouldn’t be a paradox at all, for example, if the public had been hearing objective reports of medical research all along.” How true for salt. I've just been participating in an online discussion at Toronto's Globe and Mail that well illustrates the pervasive retreat to unexamined acceptance of asserted medical “truths.”

Understanding the limitations of the scientific method employed is crucial. She observes:

(E)pidemiology has become a vehicle to find associations between every aspect of our everyday lives or our physical features and risks for some feared disease. And it’s being misused to convince us that our diets and lifestyles or appearances are the cause of ill-health. Blame, guilt and fear are the bread and butter of health marketing. That’s why carefully controlled epidemiological studies that find no link — those null studies that rarely get reported — are especially valuable. If there’s not even a strong link between two variables, then a variable can’t possibly have a causal role. Null studies tell credible scientists, and should tell us, to move on and stop worrying about that.

Among the reasons all this matters, she offers as an example the question of exercise. “Everyone” knows exercise is good for us. I feel better when I'm in shape and when I exercise. Of course. Common sense. But there are always unintended consequences. In this case, she provides data from the Centers for Disease Control and Prevention (CDC) that, next to the common cold, sports and exercise injuries are the leading cause of doctor's visits. That doesn't mean: don't exercise. It means, weigh the evidence ( and, probably, engage moderately). Federal data confirm that 488 million work days are impaired by sports injuries and that baby boomer sports injuries cost $18.7 billion in 1998.

Bottom line, she concludes in Part One:

Scientists understand the importance of testing hypotheses about causes and effects — and balancing overall benefits over risks — using carefully designed randomized, controlled clinical trials and measuring hard clinical outcomes. Yet, every randomized, controlled clinical trial of “healthy lifestyles,” as popularly defined, has failed to significantly reduce premature deaths from all causes or to prevent chronic diseases of old age.

Part Two continues to bust obesity-related myths, in this case: that obese individuals have worse health outcomes. “Everyone” believes that, too. Common sense. She offers the Helsinki Businessmen Study as a confounding input. The conclusion:

The only statistically significant inverse correlations to the men’s BMIs were with diabetes and hypertension — but they didn’t affect the men’s mortality rates, perhaps because, as we’ve seen, heavier people with both conditions have lower health complications compared to slender people with those conditions. Other popular myths weren’t supported in this study, which also won’t surprise regular readers who’ve followed the research. The men who gained weight as they aged and those who lost weight to achieve a normal weight had identical rates of developing diabetes, and the same cholesterol levels and blood pressures , as they aged.

Once again, the conclusions track closely with how the salt and health debate was sidetracked into the blind alley of a solitary focus on blood pressure. See the parallel:

Time and again in randomized clinical trials of pharmaceuticals and other medical interventions, we’ve seen the importance of examining confirmed clinical endpoints — with all-cause mortality the most important — rather than surrogate endpoints. Not understanding risk factors and believing that these surrogate health indices are measures of health and future disease has been the greatest way the public been led to believe that weight loss is beneficial, even when it’s not supported in well controlled studies looking at actual clinical outcomes and mortality.

The only difference here is that there have not been repeated RCTs on salt reduction – only a dozen or so observational studies, though they have suggested our uncritical acceptance of the salt hypothesis has been erroneous. It matters not only because we waste time, effort and expense pursuing the wrong remedy, but because the fallacious intervention can actually create health risks. Take the obesity case again:

German epidemiologists, examining 13,362 middle-aged adult men and women in the European Prospective Investigation into Cancer and Nutrition-Potsdam Study, for example, found that fat people who had normal blood pressures prior to weight loss had a nearly 7-fold increased risk of developing essential hypertension during the following two years after weight loss, and those whose weight yo-yoed had a 4.29-fold increase in hypertension.

And, referencing Dr. Thorkild Sorensen at the Institute of Preventive Medicine in Copenhagen from an article in the International Journal of Obesity:

It’s been argued, he summarized, that weight loss does not equal improvement in health and longevity, that staying fat is safer than weight fluctuations, and dieting has negative psychological effects. “In summary, we still do not have conclusive evidence that weight loss has overall beneficial effects.”

She wraps up Part Two with a warning:

The possible healthfulness of natural weight gain with aging, however, is a paradoxical idea in popular media. People may never think to question their beliefs about the deadliness of fat and benefits of weight loss when they never hear anything different.

The importance of research finding seeming paradoxes is that it make us think, question and not be afraid to learn where the evidence might really take us.

Echoes of the salt and health debate. We need to change our paradigm and become evidence-based.

Prominent food scientists, including a member of the federal Dietary Guidelines Advisory Commmittee (DGAC), reported to the IFT last week on the process underway to revise the Guidelines. Dr. Fergus Clydedale of UMass, the lone food scientist on the 2005 DGAC, and Dr. Roger Clemens of USC, the token food scientist on the 2010 DGAC, painted a bleak picture of the use of science and understanding of food technology. Clemens noted he has been relegated to food safety issues and, implied, kept at a distance from nutrition issues.

Clydesdale and Clemens addressed the IFT session on "The evolution of dietary guidance: Lessons learned and new frontiers."

Covering the session, BakingBusiness.com quoted Clydesdale saying: "A food scientist should not be regulated to just food safety on the Dietary Guidelines, and there should be more than one." The report continued:

Dr. Clydesdale said technology has helped society in many areas. He said he doubted people would like to go back to using typewriters or that teachers would like to go back to using chalkboards.

"We’re not going to go back to 78 r.p.m.s (records)," he said.

Dr. Clydesdale said he wondered why people do not embrace technology in the food system. He said he wondered why people wanted to cook the way people did 100 years ago.

The Dietary Guidelines could use input on how food science technology may help meet the Guidelines goals, Dr. Clydesdale said.

We'd prefer an evidence-based approach rather than the DGAC's current expert opinion process. Apparently so do the experts.

A recent study in the American Journal of Clinical Nutrition by Fumiaki Imamura et al examined adherence to the 2005 Dietary Guidelines for Americans to determine how compliance related to coronary artery disease outcomes. Their conclusion: some Guidelines are more important than others.

In fact, they documented that the salt Guideline doesn't work at all. Women who had better overall quality diets actually were LESS compliant on the salt (reduction) Guideline. The lowest third in terms of Dietary Guidelines compliance consumed much less than the recommended 2,300 mg/day sodium while the upper two-thirds in terms of overall dietary compliance actually consumed 12% MORE SODIUM. (table 3).

Considered as a whole, the authors concluded:

No significant association was identified between the DGAI as a measure of diet consistent with the 2005 DGA and narrowing of coronary arteries after a mean 3.3 year follow-up period in post-menopausal women with established cornonary artery arthersclerosis.

The study found that "no womeno[of the 224 in the study] reported complete adherence to all dietary recommendations" consistent with other studies. On the other hand,

not all components have an equal weight in describing diet-disease relations....not all dietary recommendations are equally related to disease progression. Our findings highlight the need for the development of more sophisticated approaches to the assessment of dietary recommendations on disease progression and other chronic disease outcomes.

Amen.

A former National Heart, Lung and Blood Institute employee, DebbieN, blogging on Slow Food Fast , showed her true colors earlier with her "Salt Rant" post. She has now opened a discussion about the science underlying her former agency's support for universal sodium reduction.

DebbieN's post "Misunderstanding Salt Research: Bon Appetit's Shamfeul 'Health Wise' column" yesterday doesn't fully avoid the name-calling and attempted intimidation that has characterized past attempts to suppress discussion of the science. She lashes out at John Hastings, author of a skeptical piece in Bon Appetit , noting that as "a former editor of Prevention and health column contributor to O, the Oprah Magazine, is someone you'd expect to be reasonably accurate in reporting health research findings." But she at least continues through her rant to address some meaningful issues. Would that the Dietary Guidelines Advisory Committee did the same, but that's another post.

Yesterday, I posted comments on DebbieN's post, but her blog is moderated and she has not seen fit to approve my comments. Even without reading her original post, you can get the flavor of her representations. In my signed comment, here's what I said:

Your post provides so many "targets of opportunity."

John Hastings posed the right question: if an intervention modifies one of many risk factors but does not modify health risk (or even worsens that risk) then we should reconsider advice to follow that recommendation. But let me skip ahead first.

I am president of the Salt Institute. We do not "demonize salt moderation." We endorse moderate salt intake recommendations as were part of the Dietary Guidelines until 2000 when they abandoned "moderation" in favor of specific (lower) intake levels.

Studies of health outcomes of those lower levels show 20-37% greater cardiovascular mortality among those reporting they consume the lower, recommended levels -- these data from the editor-in-chief of the American Journal of Hypertension. See a discussion on our website at: http://www.saltinstitute.org/Issues-in-focus/Food-salt-health and http://www.saltinstitute.org/Articles-references/References-on-salt-issues/SI-references-on-issues/SI-references-on-food-salt-health-issues .

It is the proponents of "moderate" low-salt diets who are misleading the discussion by claiming that a 60% reduction in salt is "moderate." A 60% reduction is not only not "moderate" -- it is unsustainable in free-living subjects.

The health outcomes question CAN be studied. NHLBI has already proved the protocol -- the Trials of Hypertension Prevention -- only it measured the wrong outcome (BP not CV mortality).

The DASH Study you mention is very important for the blood pressure argument (but not for health outcomes). Its findings, however, are that for those with high blood pressure, the systolic BP fall on the DASH Diet was 11.4 mmHg. When hypertensive subjects were put on a diet with 60% less salt, their SBP declined 11.5 mmHg. Thus, the "DASH effect" is 11.4 mmHg and the "salt effect" is 0.1 mmHg.

I could go on, but read the website and, even better, read the referenced medical journal articles to better understand the scientific controversy that John Hastings had the courage to describe.

The Spring issue of Salt and Health (pdf 318.77 kB) is published The misuse of the word “toxic” by media, some medical doctors and CSPI is examined within the context of long standing accepted definitions and parameters of the term. Concrete examples are illustrated in regards to replacing a natural substance, sodium chloride, with complex industrial chemicals such as: 5-ribonucleaotides, L-lysine, L-arginine, lactates, mycosent, MSG and trehalose. This newsletter leaves the reader to more intelligently ponder what health implications of such a broad-based replacement of salt with an arsenal of untested synthetic chemical products could possibly do to an unsuspecting population.

An article in Politico , a widely read DC paper, recently warned that President Obama and Congress are ramping up to impose a new era of public health activism unlike anything ever seen.

Michael Jacobson of CSPI gushed about the opportunities presented by this president, saying, “He has expressed more interest in preventing diseases and promoting health than any previous president. It is not a breath of fresh air. It is a tornado…This is really a rare opportunity to make progress on so many issues.” Jacobson’s favorite issue appears to be population-wide salt reduction.

According to Politico the president is “filling top posts at Health and Human Services with officials who, in their previous jobs, outlawed trans fats, banned public smoking or required restaurants to provide a calorie count with that slice of banana cream pie.”

In fact, many people were nervous after former NYC Public Health Commissioner Thomas Frieden was named director of the CDC. Frieden led the charge against trans fats, soft drinks and salt in the city. And Joshua Sharfstein, a new deputy commissioner at the FDA, created a Salt Task Force to study the “impact of excessive salt intake” in Baltimore, ignoring the scientific data which debunks the premise of population-wide salt reduction.

This doesn’t clearly divide along partisan lines. Some conservative members of Congress want to prohibit “junk food” under the federal food stamp program. While SI actively promotes a quality diet and certainly wouldn’t encourage anyone to eat “junk food” as a diet staple, we realize the slippery slope of bureaucrats deciding what is and is not junk food.

According to the Center for Consumer Freedom: “Get ready, because the ‘nanny state on steroids’ is going national.”

If you're not regularly reading the blog Junk Food Science , you're missing some good stuff. Today's post is another gem: "Seeing the evidence: tighter control of blood sugars in type 2 diabetics " isn't about salt, but as poet-philosopher George Santayana famously observed: "Those who cannot learn from history are doomed to repeat it." There's an important lesson here.

In this case, blogger Sandy Szwarc reviews a recent meta-analysis of the health outcomes of high quality trials of interventions more tightly controlling blood sugars . Forget for a moment the literature showing that low-salt diets increase insulin resistance , the point is the process of substituting well-publicized, lower quality studies as summarized by expert "consensus" for reliance on the available quality data. That is a pattern we've seen in the salt and health controversy as well. The blog's well worth reading, but, bottom line, Szwarc summarizes:

To this day, no sound clinical study has ever shown that treating type 2 diabetics to achieve even lower blood glucose levels provides added benefits that outweigh the harms. Treating a number that is a symptom of a disease doesn’t mean the disease process has been changed. Lowering health indices in elderly patients to match those of healthy 20 year olds doesn’t mean their risks will be lowered to those of 20-year olds again. And minimizing the risks associated with extremely high lab values doesn’t mean that “how low can you go” is better for patients.

Busy medical practitioners rely heavily on experts’ assessments of research findings, but those assessments are fraught with biases. As Dr. John P. Ioannidis, M.D., at the University of Ioannina School of Medicine in Ioannina, Greece, and with the Institute for Clinical Research and Health Policy Studies at Tufts-New England Medical Center, Tufts University School of Medicine in Boston, cautioned : “Empirical evidence on expert opinion shows that it is extremely unreliable.” As we also see time and again, the analyses and conclusions made by study authors and industry experts often differ from what the data actually shows. Bias doesn’t always come from financial conflicts, but can come simply from a belief in a popular scientific theory. It can lead even medical professionals to see only what supports a theory: confirmation bias .

Myths can take on lives of their own even in medicine unless we look objectively and carefully at the evidence. Only with unbiased discussions can we ever hope to turn evidence-based medicine into evidence-based medicine.

Pray for poetic philosophy -- and hard data.

The American Journal of Medicine published an article this week showing the utter failure of 30 years' efforts to improve the healthfulness of Americans' lifestyle habits. The findings suggest policy-makers need to be much humbler and likely less strident in their efforts to "improve" diet and other lifestyle choices. The current approach just isn't working.

In "Adherence to healthy lifestyle habits in US adults, 1988-2006," Dana King and colleagues at the Medical University of South Carolina use the government's own NHANES database to demolish the notion that advice to maintain a healthy weight, get more exercise and eat more fruits and vegetables are effecting positive change in Americans' behavior. The only "dietary" advice that's being followed is that more people are drinking alcohol -- and many would dispute that getting more people to drink alcohol is a national health priority (even on that, excessive drinking increased among non-Hispanic whites; only Hispanics slightly moderated their excess intake. But larger percentages of all groups began drinking (this was seen as a positive health development). Smoking incidence was unchanged (although Hispanics' smoking increased).

The number of obese Americans increased from 28% to 36%. Those exercising 12 times or more per month declined from 53% to 43%. And fruit and vegetable consumption plummeted from 42% to 26%. Those adhering to all five major lifestyle recommendations was cut nearly in half, dropping from 15% in 1988 to 8% in 2006. Unexamined were other minor advisories like curtailing salt intakes -- which also are unchanged over the period -- but, in this case, unchanged is an improvement over the five major recommendations where siginificant slippage continues.

The observation period began right after implementation of the 1980 Dietary Guidelines. With public acceptance levels like this, the Dietary Guidelines are looking like investments in Chrysler and General Motors. Where's the outrage? We've instilled concern, even fear, about eating. The public is convinced that the advice they've been given will make them healthier. But, as pretty as the model appears on the showroom floor, nobody's buying it.

We need to "stimulate" fresh approaches to our approach to the Dietary Guidelines for Americans to "bailout" our failed attempts for the past 30 years.

Government advisers in the UK are making menu recommendations in order to cut out what they deem to be “high carbon” foods. The Committee on Climate Change has evaluated the methane produced by burping sheep and cows and the carbon footprint of many foods and has pronounced that citizens must change their eating habits.

“Changing our lifestyles, including our diets, is going to be one of the crucial elements in cutting carbon emissions,” said David Kennedy, chief executive of the Committee on Climate Change.

The Carbon Trust, a government-funded firm, is working with food and drink companies to determine the carbon footprints of products.

I am relieved to note that chocolate has a smaller footprint than chicken. But common sense and time spent on farms leads me to question their assertion that lambs burp more than cows. Yes, believe it or not, government bureaucrats are spending money to determine whether sheep burp more than cows.

If about now you are wondering if this is satire or serious, a Saturday Night Live skit or truly a story from the Times, you may wish to read this absurdity for yourself .

It appears there is no end in sight to the quest for government control over what we eat.

Perhaps because of its English origin, the image of a primrose path leapt to mind when I read about the UK's Food Standards Agency this week announcing a second round of "more challenging" sodium targets for British food manufacturers. The theory is that if people eat foods lower in sodium they will lower their overall sodium intake. The theory's beguiling simplicity is easy to embrace rather than the "steep and thorny way" of rigorous science.

William Shakespeare immortalized the expression in Hamlet where Ophelia warns her brother Laertes against succumbing to libertine indulgence, the feel-good path, if you will. Rather, she suggests, he practice what he's preached to her ("reck not his own rede"). Groups claiming to represent good science in pursuit of noble social causes should heed Ophelia's advice to "reck their own rede" and put science foremost.

Do not, as some ungracious pastors do,
Show me the steep and thorny way to heaven,
Whilst like a puffed and reckless libertine
Himself the primrose path of dalliance treads,
And recks not his own rede.
Hamlet, act 1, sc. 3, l. 47-51

The image of this enjoyable garden pathway, so easy to traverse, but ultimately leading to misery, not heavenly bliss, is the modern reading of Shakespeare's dialogue. Most people would think of the primrose path as being a path ease and pleasure; the easy path out of a hard situation. It implies that those taking the enjoyable stroll down the path do so in ignorance, and those who lead others down the primrose path deserve condemnation for misportraying the journey as easy, since it will not lead to the desired destination and leave the travelers in a desparate situation.

So it is with the new FSA targets. Remember, the objective isn't to have an enjoyable stroll through food choices, the idea is to use those choices to reach the goal of improved health.

We don't subscribe to the notion that healthy diets must be filled with unpalatable choices; just the opposite. But a quality diet, especially in society today, isn't a primrose path where choosing the foods that look, smell and taste best are always the best for you. FSA has persuaded food manufacturers to reduce the salt level of their foods; that was the first round of targets. Food companies were eager to please and removing a portion of salt seemed like a stroll in the garden. Now comes the second round. Tougher targets. Challenging to technologists. Closer to the line on food safety.

Worse, although British consumers have played along and added more low-sodium foods to their shopping baskets, the British diet has the same amount of salt in it that it had 20 years ago (and, probably a good deal longer than that). The Intersalt Study published in the British Medical Journal in 1998 confirmed sodium intakes of about 150 mmol Na; the same as it is today (and in the middle of the same consistent intake range that has endured ever since we've had the technology to measure it).

Small wonder that FSA feels it needs a second round of tougher targets. It has made no progress to date. Food manufacturers should be warned that if they haven't recognized their situation as a classic "primrose path" they will eventually make the connection. Perhaps it will be the still more agressive targets of round three or round four. To paraphrase the expression: "Beatings will continue until morale improves." Targets will continue to tighten until public health responds.

Guess what? Public health IS responding, FSA just doesn't recognize the response. They are looking for sodium intakes to fall. Ain't gonna happen. But if they looked at total food intake, they'd find that the sodium-calorie ratio IS responding to their stimulus. Britons are choosing more low-sodium foods, but their intakes take their marching orders from their unconscious brain, not their conscious behaviors. They are following their hard-wired salt appetite and just eating more calories to get the salt their brains are signaling they need.

The "brains" at FSA are wrong. The brains in our bodies are, by design, right. Taking the easy primrose path and foresaking the "steep and thorny" path of scientific integrity is the wrong path. Thanks, Ophelia. I'm sure her father, Polonius, would endorse her pre-trip advice to his son Laertes just as he added his own: "To thine own self be true." Let's be true to the science and shun the primrose path.

Many government public health agencies recommend universal salt reduction. Unfortunate. Unjustified. But true.

In the past couple weeks, however, nutri-fascists have been spewing forth wild and scary allegations about the "toxic" level of dietary salt. Their fact-free rants may have cost them their customary agency support. At least one agency has said "enough" and issued a fact sheet that their population intakes are normal.

In fact, Food Standards Australia New Zealand went the extra step to explain that 95% of the residents Down Under are consuming less than 8.5 grams of salt daily. The statement was prompted by local WASH agitators who claimed Australians were "regularly" consuming 40 grams of salt per day. The release notes there are no recorded invidividual intakes over 26 g/day much less the 40 g/day whopper. FSANZ had to speak out publicly attempting to save their scientific credibilty (something about which WASH seems unconcerned).

The head of the Aussie WASH group was quoted in FoodNavigator saying: "The real question is whether government will take on industry." Actually, the real question is whether government will take on those who would frighten the public with irresponsible charges that their current salt intakes are poisonous. At a news conference a week ago the U.S. counterpart group, Center for Science in the Public Interest (CSPI) claimed highly-salted restaurant meals are excessive, even poisonous.

More and more evidence is being published about how moderate -- and stable -- population salt intakes are around the world. Activists have claimed high and rising salt intakes. Neither is true.

A couple months ago, the European Journal of Clinical Nutrition published a study of salt intakes in Denmark. The study of a representative sample of the Danish population found population sodium exactly those found in the U.S. (148 mmol Na) and the UK (149 mmol). In Denmark, the population consumes 147 mmol. Interestingly, the study by Anderson et al adjusted the male average (182 mmol) and female average (122) for caloric intake and reported:

no difference was found if total salt intake was measured per energy intake. No significant difference was found between sexes regarding intake of household salt, and neither the educational level nor the age was associated to either total salt intake or intake of household salt.

I guess the citizens of the U.S., U.K., Australia and Denmark didn't get the WASH talking points. If these activists continue to play fast and loose with the evidence, perhaps more public health agencies will be forced to issue statements like that from FSANZ as they try to preserve their credibility.

Today’s Wall Street Journal reports a recent study on “The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors ” published online by the Public Library of Medicine. With scientists from major institutions and high powered statistical techniques, the study addresses the public health burden of a dozen “modifiable dietary, lifestyle, and metabolic risk factors” including dietary salt. Putting aside evidence that salt intake may not be “modifiable,” the authors tip off readers as soon as Table 1, footnote h that they’ve failed to take advantage of their opportunity to address this important question of mortality related to salt intake.

The footnote reads:

The effect of reduction in salt intake on SBP and the effect of subsequent decline in SBP on the relevant disease outcomes, were estimated at the individual level to account for possible correlation between salt intake and SBP.

Actually, there’s no need to read any further. The authors confine their concern for dietary sodium to extrapolated “benefits” based solely on blood pressure, totally ignoring both the two published studies of a randomized trial of the health outcomes of reducing dietary sodium and the entire literature of observational health outcomes studies which does not support the conclusion that SBP is the only relevant variable in determining disease outcomes. The authors term blood pressure a “disease outcome,” further weakening their credibility as examiners of mortality.

Even employing a fundamentally and fatally flawed methodology, they employ high powered statistics to examine the same question addressed earlier in the week by the Center for Science in the Public Interest which claimed salt caused 150,000 American deaths each year. This study puts the figure about 35,000 – wrong, but underscoring how fast and loose CSPI and NHLBI have been in playing with these projections.

Unfortunately, as has become the pattern, journalists pick up the news release and run with the story line. For example, Daniel Akst in the WSJ story reports:

Too many of us appear to be bent on slow-motion suicide. Consider smoking; if we could get every American to stop, we'd save 467,000 lives annually. Solving high blood pressure (much of it arising from unhealthy lifestyles) would save 395,000. And if we could get everyone to slim down to an appropriate body weight, we'd save 216,000 lives.

Great headlines. Lousy science.

Generals are often accused of preparing to fight the last war, not recognizing that events have moved on. The grand strategy of reducing the global burden of chronic diseases should remain our mission, to be sure, but we need to understand whether we’re using the right weapons in our battlefield tactics. The “last war” mentality is represented in the simplistic, one-size-fits-all campaign against blood pressure. Now we know there are many ways to reduce blood pressure. Some improve health; others, don’t. We used to bleed patients to improve their health. That certainly reduced their blood pressure. And many died. We used to urge pregnant women to reduce salt intakes; today that would be medical malpractice. Some interventions work to advance our mission of improving human health, other well-intended tactics have proved counterproductive, creating “unintended consequences,” like the 37% greater cardiovascular mortality among Americans consuming (recommended) low-salt diets. Think of salt reduction as waterboarding. Extreme, for sure. Some would argue unethical. But, bottom line, ineffective and possibly counterproductive.

Headlines across the country , and the world , alerting the public that the DASH Diet reduces the rate of heart failure. As champions of the DASH Diet for the past dozen years, we feel vindication. It was distressing, therefore, to read the authors’ news release declaring their study provides support for salt reduction among the dietary improvements. It doesn’t. Actually, it’s just the reverse.

Lead author Emily Levitan et al, explains about the findings published in the Archives of Internal Medicine , as reported by Science Daily :

"High blood pressure is always of concern because it has the potential to lead to major adverse events, including strokes, heart attacks and heart failure," explains senior author Emily Levitan, ScD, a research fellow in the Cardiovascular Epidemiology Research Center at BIDMC. She and her coauthors, therefore, hypothesized that the DASH diet (short for Dietary Approaches to Stop Hypertension) would also reduce a woman's risk of heart failure through its blood pressure lowering effects as well as its secondary effects on cholesterol and other heart-disease risk factors. The DASH diet, which has been shown to lower blood pressure in randomized clinical studies, is plentiful in fruits, vegetables, low-fat dairy products and whole grains. "These foods are high in potassium, magnesium, calcium and fiber, moderately high in protein, and low in saturated fat and total fat," explains Levitan.

So far, so good, but a news release referenced by Cardiology Today continues:

Emily Levitan, ScD, a research fellow at Beth Israel Deaconess Medical Center, said the women’s diet did not have to exactly mirror the DASH diet to have a benefit. “Very few of the women we looked at had diets that shared all aspects of the DASH diet,” she said in a press release. “But we found that the closer they were, the lower their risk of HF.

“This suggests that making even moderate adjustments to your diet to include more fruits, vegetables, whole grains and low-fat dairy products, and less salt and sugar and less red meat and processed meats, can help improve cardiac health,” she said.

Levitan ignores her own data. Like previous studies that have shown higher quality diets are not lower in salt, this new study does the same. The original DASH Diet, of course, held salt constant to eliminate the possibility that its results might be confounded by salt reduction. The ensuing DASH-Sodium trial added a salt reduction intervention and its (salt reductionist) authors refuse to divulge the data for analysis, but what has been reported suggests any salt effect applies only to a small number of people , at most. But this new study found the DASH Diet – high in fruits, vegetables and low-fat dairy products – had double digit changes to typical diets in terms of fat, saturated fat, cholesterol (all down) and potassium, calcium, magnesium and fiber (all up). That’s what you’d expect. The salt intake was virtually unchanged (<2%). The study also reports that the “high quality” NHLBI diet, which does recommend reduced salt intakes, had the same magnitude double-digit changes to fat, saturated fat (both down) and potassium calcium, magnesium and fiber (all up) and, in addition, recorded double digit increases in protein and sodium. Repeat, a double digit increase in sodium, not a cut. This was the actual diet of those adhering most closely to the recommended diet.

So, this further evidence confirms exactly the opposite point the authors’ report: the Archives study shows no link of reduced-salt diets with heart failure rate.

Until a year ago, that would have been surprising. Until last year, heart failure patients were routinely placed on low-salt diets. “Everyone” knew low-salt diets would be medically helpful. Except that “everyone” was wrong. The first-ever clinical trial of the health outcomes of low-salt diets was done among congestive heart failure patients . Guess what? Those on the low-salt diets had far worse health outcomes . They died and were re-admitted to the hospital much more frequently. A year later, you’d think researchers who found no association of salt intake with heart failure would have referenced the only two studies on this very point. Peer reviewers missed it.

Unfortunately, most of the reading public did too, according to the media play of the authors’ news release.