The Checkout

The Salt Conspiracy

Too much salt is bad for you, right?

This is what federal nutrition guidelines say. Not to mention the National Academy of Sciences and the American Heart Association.

Too much sodium--more than 2,300 miligrams a day or a teaspoon of salt--can lead to high blood pressure, which can increase the risk for heart disease.

But a few months ago, the Journal of the College of Nutrition published a supplement that contained articles questioning the scientific basis for this longstanding recommendation. It might not have made much of splash outside academia, but Integrity in Science Watch, a project of the consumer advocacy group Center for Science in the Public Interest, slammed the supplement, alleging the editor, Dr. Alexander G. Logan, a researcher at Mount Sinai Hospital in Ontario, Canada, was a "paid consultant to the salt industry" and didn't disclose his industry ties.

We've all been told to be dubious of studies paid for by Big Tobacco. Lately, we've learned it's hard to find an expert on depression or schizophrenia who isn't getting paid by Big Pharma. And now, CSPI is telling us, we have Big Salt.

The editors of the Journal of the American College of Nutrition, it seems, let the members of "the sodium committee" of the International Life Sciences Institute choose the editor for the supplement and didn't disclose that to its readers, in violation of its own conflict-of-interest disclosure policies. The articles were also not peer reviewed, according to CSPI.

(No one answered the phone at ACN yesterday. The outgoing message said they're all at a conference in Reno. If I hear from them, I'll be sure to add their comments.)

Reading the ILSI's members list is like taking a trip to the grocery store: Frito-Lay, Kraft, Kellogg and Pepsi. The purveyors of salty foods have an ally in the Salt Institute, an industry trade group, which has frequently cited Logan's work.

Conflicts of interest among medical researchers has become enough of a concern lately that the Food and Drug Administration is in the process of rewriting its guidelines to make it nearly impossible for experts who are paid out of the marketing budget of drug companies to sit on FDA advisory panels.

Of course, this latest spat between CSPI and Logan goes beyond a question of ethics. It's another skirmish in the ongoing War Over Salt.

The American Medical Association wants the FDA to stop considering salt as "generally recognized as safe," an official designation that means it gets little oversight. The Salt Institute is lobbying against this and quoting studies such as the ones that ran in JACN to make its case.

Here's my Modest Proposal: I say they should just let journals take ads from sympathetic sponsors. Just cover the things in logos, the way NASCAR does. That way, everything is out in the open and consumers won't have to work as hard to know where everyone stands.

Instead of getting accused of pulling the wool over people's eyes, JACN should just let Swanson's run an ad for Hungry Man XXL Roasted Carved Turkey dinner--5,410 mg of sodium per serving--next to the article written by Dr. Norman K. Hollenberg of Brigham and Women's Hospital that concluded "the available evidence shows that the influence of salt intake is too inconsistent and generally too small to mandate policy decisions."

Or let Denny's advertise its Lumberjack Slam--4,460 mg of sodium-- next to the study by two doctors at the University of Alabama, that said "careful observations...have revealed only a weak relationship between sodium intake/excretion and blood pressure."

What gets a bigger rise out of you? The effort to regulate salt out of your savories? Or Big Salt?


Epilogue:
I received a return phone call today from Dr. Logan, who vigorously disputes CSPI's claim that he is "a paid consultant" to Big Salt.

He wrote in an E-mail:
As I have stated to you and to all others that ask, I do not hold any research grants nor do I receive research support from the food industry or any salt organization. I am not a member of any speakers' bureau nor do I
accept any honoraria for talks that I give on nutritional or related matters. I hold no ownership in any business related to the food or salt industries. I do not accept fees or honoraria for any consultative advice
that I provide related to nutrition or salt."

CSPI says it based its terminology in part on a meta-analysis of salt research that Logan co-authored and published in a 1996 issue of the Journal of the American Medical Association. The study was funded in part
by $100,000 from Campbell's Institute for Research & Technology, which has ties to the soup company of the same name.

Logan acknowledged the grant from Campbell's and further responded: "I disclosed any perceived conflicts of interest related to our article in JAMA published in 1996 and my presentation in California in 1997. Both
disclosures were made voluntarily and are in the public domain.

CSPI spokesman Jeff Cronin said JACN should have done what JAMA did. "The point of the exercise is to encourage medical journals to publish conflicts of interest, not to demonize someone."

By Annys Shin |  October 5, 2006; 7:00 AM ET Consumer News
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Comments

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I love salt. And I have high blood pressure. The thought of giving up salt makes me want to cry. I'm fiercely hoping that the BP is weight related so if I lose some, I can keep my salt. Big Salt doesnt scare me - where I can I sign up?

Posted by: Alison | October 5, 2006 8:43 AM

What a way to rub SALT in the wounds of the FDA! I'm worried that the honest AMA folks could wind up a-SALT-ed. I love the way you SEASON your article with humor. It's sad though, to see corruption everywhere...

Posted by: Chris | October 5, 2006 8:50 AM

What gets a bigger rise out of you? The effort to regulate salt out of your savories? Or Big Salt?

Both.

Low sodium diets can easily be had by those who want them.

Yet another industry has chosen to subvert so-called scientists with outright bribes. There is a word for those who do certain things for a fee. It applies to those on street corners as well as those in white lab coats.

Posted by: Steve | October 5, 2006 8:54 AM

I suppose that there are always those that work hard on making the boundary between advertising and reporting blurry. But, when I first heard of Big Salt some months ago, I was astonished. Their efforts are so transparent! It's amazing that they can make any headway.

Posted by: Keith | October 5, 2006 10:14 AM

I actually have very, very unusually low blood pressure so I have to say the high sodium content in foods doesn't really have any negative effect on me. If anything, it's positive.
However, I do think it's unethical to publish a "scientific" study of any kind where the facts are misrepresented for personal gain. That's not science, that's marketing. When these falsifications are in medicine, I think the people involved should be sited for malpractice. They forgot they should "do no harm".

Posted by: Salt??? What about science? | October 5, 2006 12:20 PM

Hard to believe Swanson's and Denny's sell single meals with 4 to 5 teaspoons of salt in them! On the other hand, that explains why any normal human is able to finish such a meal. It's been known for eons that salt stimulates the appetite; eating salty foods creates the urge for mare salty foods. So on top of everything else, in the long run, salt makes you fat - which compounds the blood-pressure issue.

So to Alison: losing some weight, if that's your goal, can improve your overall health including BP. A moderate amount of sodium won't hurt you and is something your body needs. But if you don't moderate your salt intake, losing weight will be extremely difficult.

Posted by: Salt Schmalt | October 5, 2006 12:36 PM

I agree that SALT, and any other commercial entity should not be allowed to fund "scientific studies." Period. Making them disclose the identity of the company/entity funding the study is not good enough, as many people do not read the fine print at the end of the article.

BTW, I grew up without salt, and so did my husband. We don't even have a salt shaker! Yes, people like us exist and thrive.

Posted by: Cathy | October 5, 2006 12:37 PM

"Big salt"? As president of the Salt Institute: thanks for the compliment. A few years ago, Gene Weingarten's Below the Beltay profiled the Salt Institute as a prime example of the notion that even the smallest and most insignificant interests have a not-for-profit organization (see http://www.saltinstitute.org/pubstat/beltway.html). But that's another matter.

The article says "Too much salt is bad for you, right?" By definition, "too much" is, well "too much" ergo "bad."

But who's to say that the amount of salt Americans eat (and we're very average around the world) is "too much"?

I guess it depends on who you ask. The Cochrane Collaboration, inventors of "evidence-based medicine" feel there is no evidence supporting a population intervention. So, too, does the U.S. Preventive Services Task Force, guardians at the HHS of the "evidence-based" approach to public health nutrition policy.

This is an enduring debate among scientists. While we don't fund research due to our modest means, we've seen the debate transform itself from the old debate: will lowering salt help a significant number of people reduce their blood pressure? to a new, better line of inquiry: will reducing dietary salt lower the risk of heart attacks and improve health outcomes?

Surprise. When the question is framed in terms of health outcomes, the answer is clear: none of the studies show a population benefit by reducing dietary salt. Some show increased risk. The president of the International Society of Hypertension published an article earlier this year, using a massive HHS database, and found 37% greater mortality among those following the Dietary Guidelines' recommedation.

We've reviewed the controversy on our website, http://www.saltinstitute.org/28.html and comment regularly on our blogs http://www.saltinstitute.org/rss/health-other/ and http://www.saltinstitute.org/rss/saltsensibility/. We are a very transparent organization and you can also find all our public statements on this issue online at http://www.saltinstitute.org/advocate.html.

Dick Hanneman
President
Salt Institute

Posted by: Dick Hanneman | October 5, 2006 12:48 PM

Just wanted to post a link to a story in today's Wall Street Journal about Frito-Lay trying to sell baked chips in an inner city Chicago neighborhood.


http://online.wsj.com/public/article/SB116001454312883351-bkdNKhYosOhf_Ua2DyWpYzjRpew_20061012.html?mod=blogs

Posted by: Annys | October 5, 2006 12:53 PM

Someone compared the doctors being funded by Big Salt to prostitutes. I would say that is an unfair comparision - to the prostitutes. At least street walkers are upfront and honest about what they're selling. These scum doctors, however, purport to be working for the public when really they're just lining their pocketbooks - and harming public health in the process.

Posted by: disgusted | October 5, 2006 12:54 PM

I never used much salt consciously, but recent turns of events have forced me to watch the salt that is included in the prepared foods I buy. I appreciate the Nutrition Facts labels, as they help me moderate my intake. It's not easy, but as Steve pointed out, it's possible if you work at it.

However, industry-sponsored rebuttals to sound, scientific research is of significant concern, be it salt or cyanide. Academic research is underfunded as it is, without corporate-sponsored researchers working to undermine their efforts.

Posted by: Alex | October 5, 2006 12:56 PM

Salt is used as a preservative in foods, not just for taste. If you choose a lifestyle in which you want fast food, you will get lots of salt. But if you choose to prepare your own food with fresh produce then you can drastically reduce your salt intake.

I'm constantly amazed at how people immediately jump on the bandwagon of trying to rid the world of industry sponsored research. First of all, you can't tell a company they can't pay for research. Move to the Soviet Union or China if you want that type of government control. Who's going to pay for research? Your tax dollars? Do you want higher taxes? The american tax payer already funds massive number of research studies but do you want to pay for all of them? That's stupid.

Who do you think pays to do research on new drugs? An independent group? No, the pharma industry. The people who will make money on the drugs. Do you want them to stop? That's fine. All of our life expectancies will go back to 50 years instead of living into our 70s, 80s, 90s...

The point is, that it is the companies misusing the research results. Of course there could be experiments that are poorly designed. But, science is science. For almost all scientists (speaking as a scientist myself), no matter the funding source, the science will show the same results. Now, how you or the company uses those results is up to them.

People on here will complain about "big salt" and how they are trying to do studies that show salt is ok. That's fine. But then you go home and pop in your mouth some herb or vitamin that has never, ever been shown to provide a health benefit. Where's the outrage against "Big Vitamin" or "Big Herb". How about that local store down the street that sells "natural" products. Where's the outrage against "Big Natural Products".

Get real.

Posted by: Anonymous | October 5, 2006 2:15 PM

I have to say that the hysteria in this country over anything that could have any chance of ever causing a problem is silly.

For people with high blood pressure, or perhaps a reasonable expectation of future high blood pressure - you should probably watch the sodium intake.

But for myself, and my healthy blood pressure, and my drinking lots of liquids, and my functioning kidneys --- you'd better not take the salt shaker out of the movie theatre, becauase I like my popcorn buttered with a LOT of salt!!!

Personal responsibility people.

The government wants to ban salt, but aspirin (stomach bleeding ulcers) and tylenol (potential liver toxicity) are fine..?

Last time I checked, overdosing on aspirin was a lot easier than overdosing on salt!

Posted by: Michigan | October 5, 2006 2:42 PM

No one has ever disputed the impact of salt on blood pressure, nor for that matter has anyone ever disputed the impact of the myriad stresses we routinely encounter on blood pressure. There is, however, a great debate on whether these impacts per se lead to negative health events.

Hypertension is not a proxy for death, nor is it a surrogate for cardiac disease. Yet the anti-salt lobby ask us to believe it is without the benefit of any scientific data. They rely exclusively on epidemiological studies using hypertension as an end point, ignoring all other variables. They rely on the famous Intersalt Study (Brit. Med J., v. 297, July, 1988) which compared per capita salt consumption to blood pressure in populations around the world. What they did not do was compare salt consumption to longevity. Using the same Intersalt data on salt consumption and the US Census Bureau data on life expectancy across the world, the inescapable conclusion is that those populations which consume the most salt live the longest! No joke, no fudging figures - those populations which consume the most salt, live the longest.

Of course, there are many other factors involved in longevity, just as there are many other factors associated with blood pressure, but it still remains that the more salt a population consumes, the longer they live.

One of the most outspoken and effective British anti-salt advocates, when confronted with data from Japan, whose citizens are amongst the highest per capita salt consumers in the world and also have the longest lifespan, dismissed this simply by stating that they would probably live even longer if they didn't eat so much salt. Some analysis, some science, no?

Posted by: Morton | October 5, 2006 2:47 PM

Who said the government wants to ban salt? Limit your intake, perhaps, but ban? There's a big difference between the two. Making these sweeping generalizations and illogical extensions from the article are just the hysteria we're trying to deter.

Posted by: Anonymous | October 5, 2006 2:48 PM

I go along with Michigan who said "personal responsibility people."

I need to watch my salt intake to control my high blood pressure and water retention and I know this. My daughter has to make sure that she consumes enough sodium to keep her blood pressure up to 90 over 60 so she can function.

We both know this and watch what we eat.

"Too much salt is bad for you, right?" Maybe for me, but not for my daughter and others like her.

I say, it is up to the individual and his or her doctor. But keep the nutrition labels on foods so we can make intelligent, educated decisions!

Posted by: Historian | October 5, 2006 3:10 PM

"What gets a bigger rise out of you? The effort to regulate salt out of your savories? Or Big Salt?"

Actually, I get rather annoyed by the constant allegation that just because someone funded research that they determined the outcome of the research.

Who funds research except those who are interested in the topic?

Oh, that's right, the government. A completely dispassionate entity that would never sway research to meet its own ends. Just purely interested in scientists.

There's a double standard against industry-sponsored research in favor of publicly funded research and this is unacceptable. The source of research's funding has no bearing on whether its conclusions can be independently reproduced by others.

Science is not magic. It's not religion.

We're slipping back into literally medieval mindsets here.


Posted by: athea | October 5, 2006 3:37 PM

Thanks, Althea, for making the observation that we should be looking directly at the science -- the methods, the analysis -- and not so much at the sponsor. Whether the government or some other "interested party" like the American Heart Association or some food or pharmaceutical company pays for the research, they are making that investment of the taxpayers' or their shareholders' resources in hopes of answering questions important to them.

Back in July and August, I raised similar questions on our blog in stories on "Congress probing NIH conflicts-of-interest" (http://www.saltinstitute.org/rss/saltsensibility/2006/08/congress_probing_nih_conflicts.html), "Concern for bias deepens -- but fails to widen" (http://www.saltinstitute.org/rss/saltsensibility/2006/08/concern_for_bias_deepens_but_f.html) and Science and shams (http://www.saltinstitute.org/rss/saltsensibility/2006/07/science_and_shams.html).

And, Althea's right, these questions are scientific. Let's look at the facts, not dredge up "religious" dogma.

Dick Hanneman
President
Salt Institute

Posted by: Dick Hanneman | October 5, 2006 4:00 PM

For anybody questioning the impact of salt on high blood pressure, if there wasn't any evience for this, why has the DASH diet, based on excellent NIH studies (limit salt, increase potassium, magnesium from fruits and veggies and increase calcium from low fat dairy) become the first recommended step in treating hypertension?
Not all ethnic groups or individuals respond the same way to salt. About a third of the population is considered by MDs to be "salt-sensitive" and a higher proportion for African Americans. But since we don't know who is salt sensitive and who is not, it makes sense to recommend liming salt intake to about 3000 mg/day.
Finally, as somebody who likes to cook using fresh ingredients, spices, garlic, onions etc add so much more flavor to food then just salting away, it seems to me that excess salt in many foods is just there to mask poor taste and lack of creativity.
No, we do not need the government to ban salt, but we sure do not need the salt institute and others in the food industry confusing our patients and getting them off track with their efforts to control hypertension, congestive heart failure, edema, etc.

Posted by: Registered Dietitian | October 5, 2006 4:22 PM

The problem isn't how much salt is okay.

The problem isn't that industry funds research.

The problem isn't that science isn't being believed (although I haven't looked at the methods used in this study as Dick Hanneman of the Salt Institute rebuts, so the science may be faulty too).

The problem is how do Americans make educated choices regarding their health when we don't have all the information in front of us. We need full disclosure of ties, financial, political, whatever. The group of people who did not disclose their ties to the industry did everyone a huge disservice by hiding information.

It's hiding their ties that makes me question the science they used.

It's hiding their ties that makes me question industry funded research.

It's hiding their ties that makes me question their results saying how much salt is okay for me!

Posted by: nicole | October 5, 2006 4:52 PM

I don't want to monopolize this exchange, but I agred with Registered Dietitian that the policy debate about what the general, healthy public should be eating should not be allowed to discourage patients from following the advice of their personal medical advisor.

But, please, Registered Dietitian, let's start talking about health outcomes, not blood pressure. It's the net effect of all the various things that happen in the body when we undertake an intervention.

The Salt Institute has endorsed the DASH Diet with enthusiasm -- since the day it was published in 1997. Please, eat more fruits, vegetables and dairy products! That study held salt constant and hypertensive subjects lowered their systolic blood pressure (SBP) by 11.4 mmHg. When a second DASH study was done, lowering salt by 60%, the DASH-dieting hypertensive subjects lowered SBP by 11.5 mmHg. We judge the ifference "statistical noise." The federal funding agency betrayed its bias, issuing a news release trumpeting the results as conclusive proof that "every American" would benefit by lowering dietary salt. We need to "move on" beyond blood pressure to discuss whether salt reduction improves health, but let's keep the issues clear and evidence-based.

Dick Hanneman
President
Salt Institue

Posted by: Dick Hanneman | October 5, 2006 4:53 PM

"I do think it's unethical to publish a "scientific" study of any kind where the facts are misrepresented for personal gain."

Are there allegations here that any facts in the article were actually misrepresented? Or is the complaint simply about the conflict of interest?

Posted by: Anon | October 5, 2006 5:13 PM

I have to disagree with the commenters claiming that "science is science" and that funding sources don't affect research findings. In fact, research has found that published industry-funded studies are more likely to yield industry-friendly results, while industry-funded studies that show the industry's products to have negative health effects are often buried -- or even re-analyzed to yield different conclusions.

In 2003, Yale scientists published "Scope and Impact of Financial Conflicts of Interest in Biomedical Research: A Systematic Review" in the Journal of the American Medical Association (Bekelman et al, JAMA 289:4, p. 454-465). Results from articles covering 1140 original studies "showed a statistically significant association between industry sponsorship and pro-industry conclusions" -- and "industry sponsorship was also associated with restrictions on publication and data sharing."

In the case of the substance Bisphenol A, which is used in manufacturing polycarbonate plastic, a study by Frederick vom Saal and Claude Hughes reviewed 115 pubished studies on the low-dose effects of BPA ("An Extensive New Literature Concerning Low-Dose Effects of Bisphenol A Shows the Need for a New Risk Assessment," EHP 11:8, Aug. 2005). Ninety percent of the government-funded studies reported effects at low doses, but not a single one of the industry-funded studies did.
http://www.ehponline.org/members/2005/7713/7713.html

The case of hexavalent chromium provides an interesting example of how industry-affiliated researchers can re-analyze data to suit the industries' purposes. A consulting firm employed by an industry trade group completed a study that found elevated lung-cancer risk among workers exposed to low levels of hexavalent chromium; rather than publicize the study in that form, they broke the results into two smaller studies, which then showed no increased risk, and published them separately.
http://defendingscience.org/newsroom/Chromium-Report-Release.cfm

I don't know whether the salt industry has tried to twist science to suit its own purposes, but plenty of other industries have.

Posted by: Liz | October 5, 2006 5:27 PM

I read Dick Hanneman's comments with interest. There is overwhelming evidence that salt raises blood pressure and that blood pressure drives cardiovascular death. There is ample direct evidence that for people who are already sick with heart liver or kidney disease, that salt intake leads to much higher risk of death. Also, many studies show that people who eat more fresh foods (lower in sodium) and less processed food (higher in sodium) tend to live longer. But does salt intake directly result in a higher risk of death for ordinary people? There the studies have been inconsistent. While many of the best studies have shown that salt intake in associated with increased risk, many good studies have not shown this association in younger people without disease.

To understand the reasons for this variability, we have to understand the weaknesses in these studies. In a funny way, Mr. Hanneman is correct that an industry group can focus attention on understudied areas and drive the debate forward. For example, the Salt Institute's interest in showing a direct link in population studies between salt intake and cardiovascular mortality has focused attention on the weaknesses of these studies: how to measure the effect of micronutrients (rather than whole foods) on long term outcomes. For example, it is easy to figure out how many hot dogs a person ate, but how much sodium was in each hot dog and how much ketchup and pickle relish (also high in salt) did they put on top? This problem is exacerbated when you are studying something like salt, which can vary in natural foods (depending on how much salt was in the soil or feed) and which can be added in cooking or on the table. Also micronutrients which are in many foods tend to vary together, so that the effect of the high salt might be influenced by high intake of something else (potassium, magnesium and calcium for example, which can lower blood pressure).

How can these problems affect a study? Let's take the study that Mr. Hanneman cited in his letter (Cohen, H. et al. "Sodium intake and mortality in the NHANES II follow-up study." American Journal of Medicine 2006). In this study they did a 24 hour dietary assessment of salt intake among 7000 or so fairly healthy people and then looked at how the salt intake compared with what bad things (and I mean very bad things like strokes, heart attacks or deaths) that subsequently happened to people. They only measured the salt that was in food itself, not salt that might have been added in cooking or from the salt shaker. This is a major problem because people add a lot of salt (garlic salt, salt pork, soy sauce, ketchup, etc.) in the preparation of food. Some (but certainly not all) then add salt at the table as well. The average salt intake in this study (about 2300 mg of sodium) was much lower than most estimates of what Americans eat (about 3500 mg of sodium), possibly because they were missing a lot of the salt that the people really did eat. If you do not know how much salt people ate, you cannot figure out how much of the mortality came from salt. Finally, they found that people who ate less salt also ate much less potassium, calories, and presumably other micronutrients. These other micronutrients, that are known to affect blood pressure and heart disease, were not accounted for statistically in the study (they did try to correct statistically for sodium and calories). I am not criticizing the authors of the study, but merely pointing out how difficult it is to determine the role of salt alone in these kinds of studies. We cannot easily isolate the effect of sodium in these large outcome studies without developing better techniques for measuring it.

What shall we do until better ways of studying this problem come along? What the studies do show is that there is a pattern eating and living that is associated with lower risk of bad outcomes (death, heart disease, strokes). Healthy people should focus on this overall dietary and lifestyle pattern rather than chasing single micronutrients (American Heart Association Dietary and Lifestyle Guidelines Revision 2006). Unfortunately for the Salt Institute, the people who did better in these studies ate a pattern that provides many foods that are rich in potassium, magnesium and other micronutrients but restricts many foods that may contain sodium. How much of the benefit comes from the low sodium? We cannot answer. The basic science suggests that the effect of sodium is large, but Mr. Hanneman is right that further study is needed. Until that time, we should be careful how much salt we eat.

Although this debate focuses on what healthy people without disease should eat, remember that many people with established heart, kidney and liver disease cannot tolerate the amount of salt in the average American diet. As a physician who treats patients with kidney disease, I know how hard it is for people to find processed foods that are low enough in salt. While this is not a problem for those who have the time or money to eat fresh foods, the poor and overworked among us need to have options. As an industry group, the Salt Institute needs to advocate for its members, but they should not loose sight of the acute need (either by choice or necessity) for products with reduced sodium content.

Harold A. Franch, M.D.
Renal Division
Emory University School of Medicine

Posted by: Harold Franch | October 5, 2006 6:06 PM

Outstanding, Dr. Franch. Now I think we're getting somewhere.

Our current medical studies of the health outcomes are flawed. While they show no health benefit for populations on lower salt diets, perhaps a controlled intervention trial would provide support for salt reduction. We won't know until we do the trial. We have called upon HHS to fund such a trial. They have done a three year study, the Trials of Hypertension Prevention, Phase II, that kept people on a low salt diet (reduced by 920 mg/day sodium), but the end point was blood pressure, not mortality or even cardiovascular event incidence. The ALLHAT study showed that different interventions (in this case, pharmacologic interventions) may all produce a blood pressure-lowering effect, but have differing effectiveness in preventing cardiovascular events. We need that study for non-pharmacologic interventions as well. That's the kind of evidence we feel should serve as the foundation for public health nutrition policy. Can you join us in petitioning HHS to fund such a study?

Let me pursue one "new" issue raised in Dr. Franch's post: "the acute need (either by choice or necessity) for products with reduced sodium content." Two thoughts:

1. I'm not so sure food manufacturers would agree to the "acute need" for more low-sodium products; they introduce new products every year and have a wide range in most supermarkets.

2. More importantly, the question of the role of low-sodium foods in the diet is another of those questions that seems to answer itself, but should demand our attention. Surely, one would think, if we substitute low-sodium products for their "original" counterpart (low-sodium mac and cheese for the original, etc.), we will consume low-sodium diets, right? We believe in evidence-based policies and know of no evidence showing that diets replete with low-sodium foods are, in fact, low-sodium diets. In animal diets, we feed trace minerals and medications using salt as the carrier because animals eat a predictable amount of salt. Humans are animals too. Something to think about.

Dick Hanneman
President
Salt Institute

Posted by: Dick Hanneman | October 5, 2006 6:45 PM

Mr. Hanneman badly misquotes the second DASH study (F. Sacks et al. New England Journal of Medicine 2001). This is one of the highest quality studies on diet and blood pressure ever done. The study compared regular and DASH diet with ~3600 mg sodium (US average), ~2400 mg sodium and ~1200 mg sodium. No one was on a high salt diet. Because this was a feeding study (people went to a cafeteria and ate only what was there) we know that people ate exactly what the study said. The effect of eating the lowest sodium diet was equal to that of the DASH diet. In other words eating the fruits, vegetables, and low fat dairy diet was equal to reducing your sodium intake fro 3600 to 1200 mg. Combining the low salt and the DASH diet gave you even greater reductions in BP at every salt level. The effect of the DASH diet was greatest when there was high sodium, but it gave an additional 25% reduction in systolic BP (the top number) even at the lowest salt intake. Moreover, it is known that a DASH style diet increases your abilty to get rid of salt. Overall, the best reccommendation is to follow a dietary pattern that is both high in fruits, vegetables and dairy and also low in sodium.

Who was it who sued the DASH investigators to try to get them to turn over their primary data in an effort to discredit them? I remember it was an industry group. Did the Salt Institute do that?

Posted by: Harold Franch | October 5, 2006 6:49 PM

I was too busy responding to Dr. Franch that I missed his rejoinder. Thanks again for raising these issues. I think this discussion can move policy development forward.

Dr. Franche is exactly right to defend the quality of the DASH Study, both studies, actually. Our endorsement of the results of this short study is a bit of a leap of faith (it being only 30 days and not including health outcomes), but we've not criticized the study. Nor have we sought "primary data in an effort to discredit" the investigators. We haven't sought "primary data" at all. We asked the investigators to release the starting blood pressures and the standard deviations for each of the Study's subgroups. Dr. George Bray was the lead author for the Sept. 2005 publication of the subgroup analyses. While the paper did not include the statistics we requested (not primary data), it did confess that there was no statistical significance in six of the eight subgroups reported (overweight subjects for some reason went unreported). The Salt Institute requested these statistics directly and then through a Data Quality Act petition and court petition. The court ruled that the Data Quality Act is not subject to judicial review; agencies can determine for themselves if they've followed its requirements (a subject for another discussion).

Posted by: Dick Hanneman | October 5, 2006 6:53 PM

Oops, missed something. The DASH-Sodium study did have three levels (3,100 mg, 2,400 mg, and 1,500 mg sodium); it was the higher level that I referenced in my comment about an 11.5 mmHg SBP fall compared to the earlier 11.4 mmHg of the original DASH study.

Dick Hanneman

Posted by: Dick Hanneman | October 5, 2006 6:55 PM

I worked in pharmaceutical industry for 30 years. I cannot comment from direct knowledge about your article, but you used a term that intrigued me - this was a SUPPLEMENT to the journal. Many peer-reviewed pharmaceutical and medical journals provide SUPPLEMENTS. Supplements to journals generally are not peer-reviewed, even though the journal itself is. Supplements are usually provided to individuals, groups, or companies for a fee, and are thus a sort of advertising. Unfortunately, many readers are not aware of it, and some of the journals do not clearly distinguish between the journal itself, and the supplement. Again, I cannot comment from personal knowledge about the situation in your article, but this is something to keep in mind when reading technical literature.

Posted by: Anonymous | October 6, 2006 10:51 AM

I don't have high blood pressure, and I use salt, suger, pepper, and msg on everything I cook. If I end up with high blood pressure, I'll worry about it then. But for now, what's the point of living if you can't enjoy yourself?

Posted by: Fred | October 11, 2006 4:29 PM

Mr Hanneman, President of the Salt Institute, needs to fire his fact checker for incredibly sloppy work. He quotes that 'The Cochrane Collaboration, inventors of "evidence-based medicine" feel there is no evidence supporting a population intervention to reduce salt intake'. The latest Cochrane Collaborative report on salt, first published in 2004 and updated in 2006 (Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004937. DOI: 10.1002/14651858.CD004937. Update published In: The Cochrane Library 2006, issue 3) clearly demonstrates that a reduction in salt intake not only lowers blood pressure in individuals with high blood pressure but with normal blood pressure, and recommends a worldwide reduction in salt intake in order to reduce the appalling burden of strokes, heart attacks and heart failure, i.e. the exact opposite of what he claims.

Posted by: Anonymous | October 13, 2006 7:36 AM

As a physician, I can tell you that not all "journals" are the same. Some are not credible. You have to critically appraise the article (taught ad nauseum in medical school -- it's called evidence-based medicine).

You have to read the article and some of the questions about an article you have to ask are questions such as was the study "double-blinded" meaning the patients and researchers alike did not know who got an actual treatment and who got the placebo.

Also, how many subjects were in the study? The more subjects, generally, the more valid the study.

Studies should be randomized, meaning the subjects are picked at random with specific exclusion and inclusion criteria based on the research question you are asking and study participants in a legitimate study are NOT excluded because their actual results do not agree with your hypothesis...duh! Valid exclusion criteria, for example, may be a patient who is on a medication that can falsely effect the results of the study. Let's say you want to research how much effect exercise has on lowering cholesterol. You obviously would exclude patients on cholseterol-lowering medications (that's just one example). The key is, in a good study, the inclusion and exclusion criteria are defined BEFORE you start the study/analyzing the data.

The basics of a good research study poses a SPECIFIC QUESTION with a specifically defined PATIENT POPULATION, with specifially identified TREATMENTS and OUTCOMES and your HYPOTHESES of what those outcomes would be. And you don't manipulate the data to prove your hypothesis...good studies seek to answer the question (truthfully). There is an acronym that defines this basic evidence-based medicine...PICO. Patient...your research question addresses a specific patient population. Intervention...surgery, medicine, etc...this is heart of the research question. Control...no surgery, no medicine. Outcome...is the surgery or medicine better than the placebo or control. An example of a PICO question might be "In a 7 year old child with RSV bronchiolitis(DEFINED PATIENT POPULATION), is racemic epinephrine (breathing treatment with epinephrine-INTERVENTION) better than supportive care alone (Oxygen, IV fluids-CONTROL) at decreasing length or severity of symptoms and length of hospital stay? So basically that question is asking, do breathing treatments with epinephrine help kids get over bronchiolitis faster than without it? (The answer, by the way, is--can help in some kids, doesn't hurt...so we usually give it. Albuterol treatments in BRONCHIOLITIS are useless...they help with asthma atacks)

And obviously, the researchers shouldn't be on the payroll of those who are trying to prove their product/treatment, etc. is safe and/or effective. You can also look at the journal itself. Every medical journal has what is called an "impact factor" which is how much the journal effects the practice of medicine, which is a direct testament of how valid most of the studies in the journal actually are. Journals such as the Journal of the American Medical Association, the New England Journal of Medicine, the British Medical Journal, and many more have very high impact factors. Journals with high impact factors often will have their articles cited by many other authors of other studies reasearching similar things. All journals with high impact factors rigorously peer review articles that are submitted for publication and most studies are rejected for a multitude of reasons such as, again, validity, study design, and relevant results (or non-relevant) as the case may be. I seriously doubt that the Journal of the College of Nutrition has a very high impact factor. And without peer review and the allegation that the editor of the article was a "paid consultant" to the salt industry makes this "SUPPLEMENT" very shady at best, and an outright lie at worst.

Sorry to be so wordy; bottom line is, what I'm telling you is, JUST BECAUSE IT'S IN A JOURNAL, DOESN'T MAKE IT TRUE OR VALID. YOU HAVE TO ASK A LOT OF QUESTIONS ABOUT THE ARTICLE, THE RESEARCH AND THE MOTIVATION OF THE AUTHORS AND THEIR LEVEL OF BIAS.

So then regarding salt the VALID research shows that dietary salt in conentrations greater than approximately 2 grams/day CAN contribute to high blood pressure especially in older people, people with kidney disease, people who already have high blood pressure, people with diabetes, and a multitude of diseases, patients. There are a multitude of factors way too extensive to talk about on a blog (I've already talked WAY too much anyway...LOL) Ask YOUR PHYSICIAN if too much salt in your diet will adversely effect YOUR health. DO NOT, DO NOT LISTEN TO THIS (ALLEGEDLY) SALT INDUSTRY-SPONSORED SUPPLEMENT IN A JOURNAL THAT PUBLISHED (ALLEGEDLY) A NON-PEER REVIEWED ARTICLE.

Posted by: rt | October 16, 2006 5:09 PM

Fred, the problem with not worrying about it now is high blood pressure isn't called the "silent killer" for nothing. There are rarely symptoms of high blood pressure until it really bites you in the butt...(i.e. STROKE, kidney disease, etc.) And yes, I AM an M.D. What you said about worrying about it later, is like saying "Until I get hit by a bus, I don't need to look both ways." You really are playing with fire my friend.

Posted by: rt | October 16, 2006 5:15 PM

Sorry, I was distracted by some travel and missed some posts. I'll try to respond one by one (if there's more than one to respond to). An unsigned October 13 post accused me of sloppy fact-checking regarding my statement that the Cochrane Collaboration had found insufficient evidence to recommend universal salt reduction. The British Medical Journal article is online at http://bmj.bmjjournals.com/cgi/reprint/325/7365/628.pdf, entitled "Systematic review of long term effects of advice to reduce dietary salt in adults" and it concludes: "Intensive interventions, unsuited to primary care or population prevention programmes, provide only small reductions in blood pressure and sodium excretion, and the effects of deaths and cardiovascular events are unclear." The only findings of a "health benefit" of lowered salt diets in a population with salt intakes approximating the U.S. are the result of extrapolating blood pressure/cardiovascular event data which direct examination has now shown to be problematic. All this suggests what we recommend: a controlled trial of the health outcomes of lowering dietary salt intake.

Posted by: Dick Hanneman | October 19, 2006 7:36 AM

An unsigned October 16 post asserts that the journal supplement in question was "allegedly sponsored by the salt industry." I missed the allegation, but can assure you that not only did the salt industry not sponsor ANY of the research being discussed, it did not sponsor the supplement -- in fact, publication of the supplement came as an entire suprise to me (they say confession is good for the soul).

Posted by: Dick Hanneman | October 19, 2006 7:40 AM

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