April 21, 2004
Mr. Ian Shugart
Assistant Deputy Minister of Health
Health Canada 1124B
Brook Claxton Building, 11th Floor
Tunney’s Pasture
Ottawa, ON K1A 0K9
Canada
RE: WHO Global Strategy on Diet, Physical Activity and
Health
Dear Mr.
Shugart:
The World
Health Assembly will meet next month and provisional agenda item 12.6 would have the WHA
endorse the amended Global Strategy. I
realize that you were not among those who demanded changes in the Strategy when the
Executive Board considered an earlier draft at its meeting in January, but, on behalf of
Canada’s salt industry and, indeed, all Canadians who use our product, that is, all
Canadians, we urge you to consider the flawed science in the April 17th
revision of the Strategy and insist that the current draft be significantly amended.
You are
probably aware that Health Canada’s Laboratory Centre for Disease Control and the
Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and
Control, the Heart and Stroke Foundation of Canada and the College of Family Physicians of
Canada, since your January WHO Executive Board meeting, have published recommendations
very much at variance with the “evidence” offered in support of paragraph 22 of
the Global Strategy that individuals “limit salt.” The Canadian review was based on a true
evidence-based approach as advocated by the Cochrane Collaboration. It recommended that sodium reduction advice be
limited to a minority of Canadians defined to be at “high risk.” The report makes six
lifestyle recommendations to prevent hypertension (salt is number 5) which are:
The recommendations were published in the Canadian
Journal of Cardiology (http://www.pulsus.com/CARDIOL/20_01/touy_ed.htm).
The
Canadian Hypertension Education Program warns that none of these lifestyle modifications
have yet been tested in health outcomes trials and that “long-term follow-up studies
demonstrate that many patients fail to sustain lifestyle changes.” The recommendations are based only on blood
pressure changes and were derived using pre-specified levels of evidence and included
searches of the Cochrane Collaboration databases, the global standards organization in
evidence-based medical decision-making. Lead author Dr. Alexander G. Logan, Mt. Sinai
Hospital/ University of Toronto emphasized in a media statement: “Our process in
Canada tracks the internationally-accepted approach of the Cochrane Collaboration.”
The WHO Report 916, the basis for the
Global Strategy, did not employ an evidence-based approach as defined by the authors of
the concept, the Cochrane Collaboration; rather, they employed an expert panel approach,
selecting 30 experts who, indeed, recommended universal sodium reduction. We applaud our Canadian approach and ask your
support for these recommendations and your resistance to the current approach.
We feel the series of consultations used
to devise the Global Strategy represents a throwback to an era before the dawn of
evidence-based medicine. We can only address
the issues of dietary salt (sodium). Recommendations
on dietary sodium that have been produced by true evidence-based reviews have not
supported universal sodium reduction. Gatherings
of experts, on the other hand, frequently put voice to hoary prejudices. Reviews using the Cochrane discipline represent
sound science. Cochrane reviews have rejected
universal sodium reduction.
Furthermore, there have been only ten
studies addressing the question of whether reducing dietary sodium delivers the health
benefits of reduced heart attacks and strokes, long predicted by models and sustained by
assumptions, but never tested in peer-reviewed science.
The ten studies that have been reported publicly are all consistent (and, I’d
add, an 11th whose preliminary findings I’ve seen though it has yet to be
published). None has identified a population
benefit for reducing dietary sodium. Several
have suggested increased risks. I would
invite your attention to our review of this evidence on our website, http://www.saltinstitute.org/28.html.
The Global Strategy has four worthy
objectives. What is unworthy is the
quality of the science employed. That poor
science, as a direct result, has undermined the quality of the actions recommended in the
Annex.
Paragraph 22 contains five recommendations
regarding diet. The fifth urges limited salt
(sodium) consumption. “Limit” is
vague to the point of being meaningless. All
humans self-limit sodium physiologically without being instructed by WHO bureaucrats or
national health authorities. Worse, the
advice is wrong scientifically, threatens WHO credibility and distracts from important
advice that is needed to improve diets around the world.
Furthermore, to dismiss in a single, short five-word clause perhaps the
foremost global health goal enunciated by WHO’s UN sister organization UNICEF --
universal iodization of salt -- is a travesty. Today’s
papers carried wire service stories about a UN report documenting the threat of
micronutrient malnutrition to more than 80 million people around the world, many of them
vulnerable children. The Global Strategy, by
demonizing salt will deal a harsh blow to the international network dedicated to building
national coalitions to promote sustainable programs of iodized salt. This network has been based in the U.S., but, with
our active support, will relocate to Ottawa next month.
One reason is the strong and consistent support CIDA has provided to
worldwide salt iodization. Fortifying salt
with iodine remains the world’s best hope to protect millions of children each year
against significant mental retardation and loss of mental capacity.
The April 17th Strategy calls
for national policies “to encourage the reduction of the salt content of processed
foods” and restrict advertising “especially to children” of “foods
high in ….salt.” The concept
of reducing the salt content of foods as a means to reduce total individual intake has not
even been tested. Canadian food processors
have produced a myriad of low-sodium foods already. Reducing
the salt concentration in foods has not resulted in reducing population intake levels of
food. Indeed, like livestock and poultry,
human intakes have remained unchanged. We
fatten livestock on low-density sodium diets. If
salt is a food limiter in humans as it is in other animal species, we would risk
encouraging a physiologic inducement to increase the quantity of food intakes. The first principle is “do no harm.” Let those who believe there is a health benefit to
reducing dietary salt provide evidence that reducing the salt content in food will even
result in reductions in sodium intake. WHO
makes no claim of evidence on this point; there is no evidence on this point.
A decade ago, it was difficult to find a
responsible nutritionist who would defend the side of the “good food/bad food”
dichotomy when contrasted with the consensus “good diet/bad diet”
characterization. Only the radical fringe
demonized foods; responsible dietitians recommended that diets be considered holistically. Report 916, and now this Global Strategy, turns a
deaf ear to “good diet” even as it bashes “bad food.” Canada should resist this simplistic and
non-scientific substitution of soundbites for sound science.
We continue to feel that malnutrition is a
significant global challenge. Yes, obesity is too. And
we applaud Health Canada for leadership combating obesity in Canada. But this Global Strategy is as unbalanced as it
is scientifically unsound. The subject
demands urgent attention. The proposal,
unfortunately, risks diverting resources to the wrong targets and jeopardizing the very
goals articulated in the Strategy.
Recognizing that WHO has invested heavily
in this flawed product, we recommend that the WHA amend and approve the Global Strategy. The amendments should confine the recommendations
to promotion of physical activity (e.g. Global Strategy on Physical Activity and Health”)
and charge WHO staff with conducting an evidence-based review on which to base future
recommendations on diet and health, particularly encouraging that review to focus on
health outcomes for any recommended strategies.
Sincerely,
Richard L. Hanneman
President
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