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It's Time to End the War on Salt

The zealous drive by politicians to limit our salt intake has little basis in science
SHA RE

LATEST

By Melinda Wenner Moyer on July 8, 2011

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AD VERT IS EMENT

Fordecades,policymakershavetriedandfailedtogetAmericanstoeatless
salt.InApril2010theInstituteofMedicineurgedtheU.S.FoodandDrug
Administrationtoregulatetheamountofsaltthatfoodmanufacturersputinto
productsNewYorkCityMayorMichaelBloomberghasalreadyconvinced16
companiestodosovoluntarily.ButiftheU.S.doesconquersalt,whatwillwe
gain?Blandfrenchfries,forsure.Butahealthynation?Notnecessarily.

Thisweekametaanalysisofsevenstudiesinvolvingatotalof6,250subjectsin
theAmericanJournalofHypertensionfoundnostrongevidencethatcutting
saltintakereducestheriskforheartattacks,strokesordeathinpeoplewith
normalorhighbloodpressure.InMayEuropeanresearcherspublishinginthe
JournaloftheAmericanMedicalAssociationreportedthatthelesssodium
thatstudysubjectsexcretedintheirurineanexcellentmeasureofprior
consumptionthegreatertheirriskwasofdyingfromheartdisease.These
findingscallintoquestionthecommonwisdomthatexcesssaltisbadforyou,
buttheevidencelinkingsalttoheartdiseasehasalwaysbeentenuous.

Fearsoversaltfirstsurfacedmorethanacenturyago.In1904Frenchdoctors
reportedthatsixoftheirsubjectswhohadhighbloodpressureaknownrisk
factorforheartdiseaseweresaltfiends.Worriesescalatedinthe1970swhen
BrookhavenNationalLaboratory'sLewisDahlclaimedthathehad
"unequivocal"evidencethatsaltcauseshypertension:heinducedhighblood
pressureinratsbyfeedingthemthehumanequivalentof500gramsofsodium
aday.(TodaytheaverageAmericanconsumes3.4gramsofsodium,or8.5
gramsofsalt,aday.)

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Dahlalsodiscoveredpopulationtrendsthatcontinuetobecitedasstrong
evidenceofalinkbetweensaltintakeandhighbloodpressure.Peoplelivingin
countrieswithahighsaltconsumptionsuchasJapanalsotendtohavehigh
bloodpressureandmorestrokes.Butasapaperpointedoutseveralyearslater
intheAmericanJournalofHypertension,scientistshadlittleluckfindingsuch
associationswhentheycomparedsodiumintakeswithinpopulations,which
suggestedthatgeneticsorotherculturalfactorsmightbetheculprit.
Nevertheless,in1977theU.S.SenatesSelectCommitteeonNutritionand
HumanNeedsreleasedareportrecommendingthatAmericanscuttheirsalt
intakeby50to85percent,basedlargelyonDahl'swork.

Scientifictoolshavebecomemuchmoreprecisesincethen,butthecorrelation
betweensaltintakeandpoorhealthhasremainedtenuous.Intersalt,alarge
studypublishedin1988,comparedsodiumintakewithbloodpressurein
subjectsfrom52internationalresearchcentersandfoundnorelationship
betweensodiumintakeandtheprevalenceofhypertension.Infact,the
populationthatatethemostsalt,about14gramsaday,hadalowermedian
bloodpressurethanthepopulationthatatetheleast,about7.2gramsaday.In
2004theCochraneCollaboration,aninternational,independent,notforprofit
healthcareresearchorganizationfundedinpartbytheU.S.Departmentof
HealthandHumanServices,publishedareviewof11saltreductiontrials.Over
thelongterm,lowsaltdiets,comparedtonormaldiets,decreasedsystolic
bloodpressure(thetopnumberinthebloodpressureratio)inhealthypeople
by1.1millimetersofmercury(mmHg)anddiastolicbloodpressure(thebottom
number)by0.6mmHg.Thatislikegoingfrom120/80to119/79.Thereview
concludedthat"intensiveinterventions,unsuitedtoprimarycareorpopulation
preventionprograms,provideonlyminimalreductionsinbloodpressureduring
longtermtrials."A2003Cochranereviewof57shortertermtrialssimilarly
concludedthat"thereislittleevidenceforlongtermbenefitfromreducingsalt
intake."

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Studiesthathaveexploredthedirectrelationshipbetweensaltandheart
diseasehavenotfaredmuchbetter.Amongthem,a2006AmericanJournalof
Medicinestudycomparedthereporteddailysodiumintakesof78million
Americanstotheirriskofdyingfromheartdiseaseoverthecourseof14years.
Itfoundthatthemoresodiumpeopleate,thelesslikelytheyweretodiefrom
heartdisease.Anda2007studypublishedintheEuropeanJournalof
Epidemiologyfollowed1,500olderpeopleforfiveyearsandfoundno
associationbetweenurinarysodiumlevelsandtheriskofcoronaryvascular
diseaseordeath.Foreverystudythatsuggeststhatsaltisunhealthy,another
doesnot.

Partoftheproblemisthatindividualsvaryinhowtheyrespondtosalt."It's
toughtonailtheseassociations,"admitsLawrenceAppel,anepidemiologistat
JohnsHopkinsUniversityandthechairofthesaltcommitteeforthe
2010DietaryGuidelinesforAmericans.Oneoftcited1987studypublishedin
theJournalofChronicDiseasesreportedthatthenumberofpeoplewho
experiencedropsinbloodpressureaftereatinghighsaltdietsalmostequalsthe
numberwhoexperiencebloodpressurespikesmanystayexactlythesame.
Thatisbecause"thehumankidneyismade,bydesign,tovarytheaccretionof
saltbasedontheamountyoutakein,"explainsMichaelAlderman,an
epidemiologistattheAlbertEinsteinCollegeofMedicineandformerpresident
oftheInternationalSocietyofHypertension.

Somephysiciansarguethatalthoughtinybloodpressuredropswillnothavea
bigeffectonindividualstheywillnotreallyaffectyourriskofhavingaheart
attacktheymayendupsavinglivesatthepopulationlevel,inpartbecausea
smallpercentageofthepopulation,includingsomeAfricanAmericansand
elderlyindividuals,seemtobehypersensitivetosalt.Forinstance,astudy
publishedinFebruary2010intheNewEnglandJournalofMedicineestimated
thatcuttingsaltintakebyabout35percentwouldsaveatleast44,000
Americanlivesperyear.Butsuchestimatesarenotevidence,eithertheyare

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conjecture.Andlowsaltdietscouldhavesideeffects:whensaltintakeiscut,
thebodyrespondsbyreleasingreninandaldosterone,anenzymeanda
hormone,respectively,thatincreasebloodpressure.

Ratherthancreatedrasticsaltpoliciesbasedonconflictingdata,Aldermanand
hiscolleagueHillelCohenproposethatthegovernmentsponsoralarge,
controlledclinicaltrialtoseewhathappenstopeoplewhofollowlowsaltdiets
overtime.Appelrespondsthatsuchatrial"cannotandwillnotbedone,"inpart
becauseitwouldbesoexpensive.Butunlesswehavecleardata,evangelical
antisaltcampaignsarenotjustbasedonshakysciencetheyareultimately
unfair."Agreatnumberofpromisesarebeingmadetothepublicwithregardto
thisenormousbenefitandlivessaved,"Cohensays.Butitis"basedonwild
extrapolations."
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ABOUT T HE AUT HOR( S)

MelindaWennerMoyer
MelindaWennerMoyerisafreelancesciencewriterandfrequentcontributorto
ScientificAmericanMind.
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