‘Wasn’t there a time when the brightest minds in the world believed that the earth was flat? And up until, what, fifty years ago, you all thought the atom was the smallest thing, until you split it open and this whole mess of crap came out?’ – Pheobe Buffay, disputing the theory of evolution
The Institute of Medicine’s study on salt, which most of us learned about from last Monday’s article in The New York Times, has caused a bit of a stir. Readers have posted over 300 comments to The NYT website in response to the article. While many of the comments are anecdotal (my wife’s blood pressure always seems to skyrocket after a salty meal) and still others drift into the irrational (one guy quotes the Bible), the majority of comments are astute and intelligent, reflecting a heartening level of critical and well-informed independent thought.
A theme among the comments is skepticism, not surprising given that on matters of health and diet, disagreement among experts, not consensus, is what we are accustomed to. That the skepticism is directed in large part not at this new IOM study, but rather at the current established claims about salt intake, to me represents a reassuring shift away from blind faith in guidelines whose merit is simply that they are long-held. The majority of us live with what is officially considered elevated salt intake, and apparently we welcome a reconsideration of the American Heart Association’s recommended daily allowance of 1,500 milligrams. (Around the world, excepting those few areas where access to salt/sodium is limited, the average daily human intake of sodium is about 3,400 milligrams.) Or are we just fed up with sweeping conclusions about what is good and bad for us going unchecked for generations? With research dating as far back as the 1960s and 1970s still guiding health and medical professionals? And with the deceitful food industry practices fostered by stale opinions on nutritional science, such as the unchecked labeling and marketing of food products as healthy via buzz words like ‘low cholesterol’ and ‘low sodium.’ Serious, ongoing reconsideration of yesterday’s claims is needed.
The salt study itself calls into question the AHA’s recommendations and ‘undercuts’ if not outright contradicts some of the for-years accepted facts about sodium intake. In particular, a decrease in sodium as sharp as that which the AHA recommends may have little benefit. Even more controversial is the re-examination of other related claims about salt RDAs, with the subsequent implication that higher levels of sodium intake may not be as detrimental as currently presumed; and, in fact, a daily intake of sodium in the range of 2,000 to 3,000 milligrams daily may be just fine for most. (The upper end of the current recommended daily intake range is 2,300 milligrams.)
Prior to 2006, studies overall, including former research by the same Institute of Medicine, supported the claim that ‘blood pressure can drop slightly when people eat less salt’ (my emphasis). High blood pressure is associated with heart disease, we know, and the AHA’s goal is to lower or keep low the blood pressure of as many Americans as possible. ‘Ninety percent of all Americans are expected to develop high blood pressure in their lifetime,’ they say. To achieve this, groups like the AHA must rely on broad, across-the-board (some would say indiscriminate) recommendations.
Since 2006, on the other hand, some studies have shown that lower sodium intake does not as a rule protect against/prevent/decrease the various serious problems associated with heart disease (The NYT mentions two studies specifically, conducted in 2008 and 2011, neither without its critics and detractors). About half-way through the piece is a factoid sure to be overlooked by anyone not enthralled enough by the issue to read through to the end: a Dr. Alderman, ‘a dietary sodium expert at Albert Einstein College of Medicine who was not a member of the (Institute of Medicine) committee,’ describes other consequences of too little sodium in the diet: ‘As sodium levels plunge, triglyceride levels increase, insulin resistance increases, and the activity of the nervous systems increases. Each of these factors can increase the risk of heart disease.’ That’s right. According to an expert with pretty fancy credentials, lowering sodium too much can be bad for the heart.
The AHA has called the study ‘incomplete.’ In a piece on their website (dated May 14, the day The NYT article was published), the Association’s CEO says the AHA ‘disagrees with key components of the study.’ The AHA will continue to recommend 1,500 milligrams daily to all Americans. Their supporting quotes from experts are just as punchy as The NYT’s, and they cite some heavyweight groups, such as the World Health Organization. Of course, this your study is faulty-our study is sound sparring is par for the course when one study contradicts another. If you’ve been following at all the ongoing debate on cholesterol—the disagreement about whether cholesterol is the true culprit in arteriosclerosis; a closer look at the role cholesterol plays in the human body and the thus potential harm lowering cholesterol to the currently recommended levels could pose; and to what extent the annual $30 billion profit to the pharmaceutical industry in statins sales dissuades us, the scientific community included, from seeking stronger evidence to support the decades-long demonization of cholesterol—this salt intake debate will seem initially like a playground spat. Still, to be sure, a lengthy and complex battle over salt is likely to ensue. That’s a good thing.
Health professionals invariably fret and protest when a new study refutes facts they’ve based their very careers on, facts that have backed the untold diagnoses, drug prescriptions, lifestyle and dietary recommendations made over the course of their professional lives. A reversal of an accepted guideline—even the mere suggestion of contradictory evidence—must first cause upheaval. Personally, I can understand this, even empathize. It’s a normal reaction. What I cannot stomach, however, is what almost always follows: the condescension, the arrogance dressed up as concern for the masses. After crying that their old facts are right and their peers’ new-fangled facts are wrong (or at least faulty), the experts then move on to us, the consumers, the general public. What with our superficial (poor) understanding of the complexities involved in studies of this sort, surely we will take away the wrong message. From The NYT article: ‘Bonnie Liebman, director of nutrition at the Center for Science in the Public Interest, an advocacy group that has taken a strong position against excessive salt consumption, worried that the public would get the wrong message. “It would be a shame if this report convinced people that salt doesn’t matter,” Ms. Liebman said.’ In other words, all we’ll see is the headline. And come tomorrow morning we’ll be spooning salt over our Corn Flakes. (On second thought, skip the Corn Flakes. You’re better off.)
To me, this pattern speaks to the professional-to-layperson paradigm we’ve all grown up with, one that places the onus of information (the power) solely with experts—the scientist, the doctor, the dietician—a relationship the modern age’s speed-of-light access to information has both muddied and democratized. (Nothing, absolutely nothing, will make your M.D.’s ears smoke like the words ‘Well I read on the internet…’). Anyone who has ever faced a grave medical diagnosis knows well the inner struggle between trusting and questioning your doctor; the axioms ‘follow doctor’s orders’ and ‘always get a second opinion’ do not easily reconcile. Yet it is the ‘pain in the ass’ patient, the one who reads and asks questions, who takes notes on what doctor says, who comes to the next appointment asking for clarification on a study that recommends the opposite of what doctor recommended (awkward, but worth it)—this is the profile of a patient who thrives, who has a better chance of survival (this has been statistically demonstrated, I’ve heard; it’s certainly purported often enough). I’ve been both kinds of patient, the passive/good patient and the pushy/bad patient; while the bad patient may suffer more in the short-term (in measures of chagrin, self-doubt, and stress), the good patient will inevitably concede the power of information to the experts—a long-term regret, I believe. So to the AHA I would say, if I could, thank you for your kind condescension, but you’ll forgive me if I remain steadfastly skeptical, if I don’t take your rebuttal as a conclusive end to this matter.
Consider this list of dietary claims and recommendations, plucked from my memory alone. (I was born in 1971; I started paying grown-up attention to what I eat around 1994.):
- Do not eat more than two or three eggs a week.
- Choose low fat food products.
- Eat more tofu; soya and soy products are a healthy source of protein.
- Sugar substitutes are just fine.
- Margarine is a healthy alternative to butter.
- A grains-based diet is the healthiest diet.
- Non-fat milk is better than whole fat milk.
In the past 15 or so years, these claims have been seriously re-thought if not altogether reversed. Turns out eggs are great for us and we can, and probably should, eat one a day. Low-fat crackers and diet soda are pretty much killing us. If you’re still eating soy, do some research (be prepared to be completely freaked out). And remember the 6 to 11 daily servings from the bread/rice/ cereals/pasta group recommended for years via the USDA food pyramid? Makes you laugh (or cry) now, right? Margarine is possibly one of the nastiest foodstuffs man ever created. And skim milk ain’t gonna keep you, or your kids, skinny.
On the fringe of almost every food-related discussion these days is a growing awareness of the true villain: processed foods. The AHA has stated that keeping the RDA of sodium super low is needed because people eat so much processed, canned, frozen, and prepared foods. This is an acknowledgement of the issue. However, the AHA and other influential associations, those entrusted with oversight (and funding) and to whom we are meant to look for guidance, simultaneously sidestep or distract us from the problem of processed foods. For example, the USDA has included some thorough, well-written warnings about trans-fats in its recommendations, but still states that canola, soy, and corn oil should be used over butter in cooking (another fomenting food debate: butter is a real food, while the veggie oils noted here are manufactured / heated / hydrogenated / all around scary ‘healthy’ fats). The American Diabetes Association presents lots of great information on their site, including an interesting section on sugar myths, the differences between real and fake sugars, and so on. But included as well is a page on making ‘healthy’ fast-food choices! This would almost be funny if it weren’t so…well, just wrong. Here’s what the AHA has to say on this specifically:
‘A majority of the sodium Americans eat is in the form of salt that is added to processed foods and restaurant foods which makes it difficult for consumers to choose and control how much sodium they consume. While the food industry has reduced the sodium content of some foods, more significant reductions are needed. As a result, the association supports federal regulations that would limit the amount of sodium in foods…’
Americans are consuming most of their salt—pushing them into AHA’s danger zone range—while eating out, eating junk. Why is the message so watered down, so flimsy? Not to mention offensive, with its implicit point that we’re too lazy or too stupid to choose or control what we consume. We are capable of monitoring our salt (or fat or sugar) intake, but we’ve first got to take responsibility for our eating habits and accept the solution to our numerous, grave diet-related issues. It’s staring right at us: eliminate processed foods. The AHA offers instead recommendations designed to all but trick people into eating less junk food by scaring us about hidden salt (or is it the opposite?)! Fine, to their credit the AHA ‘supports federal regulations that would limit the amount of sodium in foods.’ But who are we kidding? When have legislated limits and controls ever truly changed habits? Whether moonshine or raw milk, stigmatized, forbidden substances always find their way to those who want them badly enough. The tip-toeing around the issues must end. It’s really very simple, and we don’t need doctors or associations or the government to do it for us: Move your body every day and eat real food every day. Period.
These are bizarre food times we live in. Anxiety is the new hallmark of our experience of food. It’s with us when we are told yesterday’s recommendations are today’s prohibitions (and vice-versa); it’s the constant companion to our fears—well-founded fears, it turns out—about how our foods are produced, treated, handled, labeled, and distributed. ‘There’s nothing I can safely eat,’ said someone to Mark Bittman (referenced in an Opinionator piece that calls for a bit of calm and reason amidst the storm of snap judgments and alarming or misapplied language characterizing much of today’s food talk). What should be one of the simplest human acts—eating real food—has become at best a nearly full-time occupation, at worst a politically-charged obsession (we all know at least one crazy-extreme foodie). Often the current climate feels at once divisive and hopeful, as reflected in the uproar caused by this salt study—some are launching insults and accusations, others are intrigued by and want to know more about a different view on salt. We need discussion, debate, and education more than ever, but most of all we need a skeptical viewpoint and a real food diet.