May 18, 2004

Dr. Muhammad Nasir Khan
President
57^th World Health Assembly
Geneva, Switzerland

 RE:  WHO Global Strategy for Diet, Physical Activity and Health

Dear Dr Khan:

As you assume your new duties as President of the WHA, we encourage you to consider the needs of developing countries like Pakistan with regard the Global Strategy for Diet, Physical Activity and Health that will be considered Wednesday afternoon.

The Global Strategy is not described as a strategy to combat nutrition excesses; it is a general strategy on diet and health.  The Global Strategy claims it is about making “healthy choices regarding nutrition and health.”  As such, it totally fails to address the critical nutrition deficiencies of many WHA member states.  Its adoption virtually guarantees that public health attention will shift towards addressing health problems associated with nutrition excesses and undermine the momentum we have been able to build, in Pakistan, throughout South Asia and in Africa, especially, towards addressing and correcting the deficiency intake levels of critical vitamins and minerals.  The PR will devastate those programs unless the April 17 draft Global Strategy is changed.

The Global Strategy needs to be balanced between dietary excesses and dietary deficiencies.  No one doubts that excesses demand attention.  But we have not completed the job on correcting deficiencies.  Let’s not allow our enthusiasm to address excesses decapitate our efforts to overcome serious damages inflicted by nutrition deficiencies.

Two weeks ago, over the objections of the PAHO regional director who defended the Global Strategy, a regional meeting of 22 Latin American countries, sponsored by WHO and UNICEF in Lima, Peru to re-advocate iodizing salt to eliminate Iodine Deficiency Disorders, adopted a consensus statement calling for such balance in all dietary guidance.   Others committed to eliminating micronutrient malnutrition are also concerned.

Although the WHO Executive Board expressed concern at its January meeting that the Global Strategy needed further attention, the April 17^th version of the Global Strategy has not made the significant improvements suggested.  And, the problems are deeper and broader than just the unbalanced focus on nutrition excesses.

You should be aware that the problems in science in the November 27^th draft Strategy that drew fire, further evidence suggests the salt recommendation, at least, is far from a consensus statement.  In February, Health Canada and four Canadian medical associations produced population recommendations regarding intakes of dietary sodium.  Like the Cochrane Collaboration, the Canadian recommendations were the product of an evidence-based review of the evidence.  And, again like the Cochrane Collaboration, the new Canadian recommendations rejected a policy of universal sodium reduction (that is, they rejected the conclusions of WHO Report 916, the basis for the Global Strategy).  Instead, the advice to reduce dietary sodium was directed to a “high risk” subgroup. 

The Salt Institute is committed to quality science.  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.

Furthermore and with regard to salt, 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.  None has identified a population benefit for reducing dietary sodium.  Several have suggested increased risks. 

Paragraph 22 of the Global Strategy contains five recommendations regarding diet.  The fifth urges limited salt (sodium) consumption.  That advice is wrong scientifically. Thus, it 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.  This Spring, we had been encouraged with the momentum to eliminate VMD – vitamin-mineral deficiencies – generated by a UNICEF report documenting the threat of micronutrient malnutrition to more than 80 million people around the world, many of them vulnerable children, and most of them in developing countries.  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.  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 17^th 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.  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 unbalanced and unscientific Global Strategy, turns a deaf ear to “good diet” even as it bashes “bad food.”  The WHA should resist this simplistic and non-scientific substitution of soundbites for sound science.

We hope you agree that malnutrition is a significant global challenge. Yes, obesity is too.  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 you exercise your leadership with the WHA to have the delegates either send the Global Strategy back for further staff work to improve its balance or to amend and approve the Global Strategy by calling it the “Global Strategy on Physical Activity and Health” and stripping out the “diet” recommendations for further discussion.  The WHA, we respectfully submit, should 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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