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Letter to the Editor |
Division of Nephrology, Hypertension, and Clinical Pharmacology Department of Medicine Oregon Health Sciences University Portland, OR E-mail: dmccarron{at}academicnetwork.com
Dear Sir:
A cease-fire in the salt war is long overdue. I am in complete agreement with Strazzullo's assertion that it is time to set aside prejudicial thinking and work together to find resolutions to the sodium controversy. Such has been my own contention for 20 y.
In our analysis of the first National Health and Nutrition Examination Survey dietary data published in Science in 1984 (1), we concluded that health measures to reduce hypertensive cardiovascular disease are not best served by focusing on isolated dietary components, but rather by "the consumption of a diet balanced in all the essential nutrients and appropriate for the individual's level of physical activity." My commentary in the proceedings of the 1991 NIH Workshop on Salt and Blood Pressure (2), entitled "A Consensus Approach to Electrolytes and Blood Pressure: Could We All be Right?" speculated that salt was but one of many dietary components contributing to high blood pressure, and that "our future understanding of the effects of dietary NaCl on blood pressure will only be advanced if we approach the task from the position that salt's action on blood pressure regulation must be viewed in the context of the whole diet."
In 1998, in an editorial in Science entitled "Diet and blood pressure—the paradigm shift" (3) that followed the publication of the first DASH Study, I concluded that "emphasis on sodium as the single dietary culprit is counterproductive to our significantly reducing cardiovascular risk. . . and diverts attention from the issues we need to address." The DASH-Sodium Study, along with several other studies and analyses [described in the article to which Strazzullo is referring (4)], have proven this to be the case.
My stand that we should shake up the dietary guideline is based on the fact that, as it presently exists, the guideline does not represent the most current evidence. Rather, it is narrowly based on data from one side of the sodium controversy and merely iterates the status quo that has dominated this area for the past 20 y. We would not still be debating this issue if the evidence were as solid as the guideline proponents allege it to be.
If we are to find common ground in the salt war, as Strazzullo and most of the rest of us would like, then the data on both sides of the argument must be put forth, considered as objectively as possible, and integrated into a clear and unified message to policymakers, practitioners, and the general public.
Does Strazzullo also call on the proponents of the sodium guideline to set aside their prejudices in this issue? A recent press release of the DASH-Sodium Study (5) offers a prime example of how advocates of the current policy promote only one side of the data. In this release, the National Heart, Lung, and Blood Institute's director Lenfant focused only on the effects of sodium restriction in specific subjects, ignoring the most compelling results from this federally supported trial: that the blood pressure–lowering effect of improved dietary patterns were far greater and more uniform than were those of sodium restriction. What could have been an opportunity both to promote the DASH-Sodium Study's full findings and potential population-wide benefits and to advance efforts to bring unity to this conflict became another presentation of incomplete and unbalanced data, serving only to further inflame this issue.
By continuing this argument, proponents of the current sodium guideline in the nutrition research and policy communities do the public a great disservice. Strazzullo suggests, and I fully concur, that the continued conflict and acrimony among the scientific community with regard to sodium and blood pressure is a major deterrent to widespread and effective implementation of nonpharmacologic management of high blood pressure by both patients and physicians.
In addition to weakening the public's confidence in nutritional advice, a national health policy that promulgates an unresolved recommendation further jeopardizes public health by diverting attention away from areas where it can be beneficial. Public health emphasis must be aligned with the evidence—it must be placed where it can actually effect change.
We know unequivocally that both obesity and alcohol are leading risk factors for hypertension and numerous other medical conditions. We now know that dietary patterns are more important in blood pressure regulation than are modifications of any single nutrient intake. Today, we have the information necessary to design public health policies that can truly benefit public health. It is in these areas that our emphasis and our efforts should be targeted.
Although Strazzullo states that his views are in opposition to mine, we share the desire to find an equitable peace in the salt war. I welcome Strazzullo's voice of reason in this controversy and join him in calling for an enlightened approach to its resolution, a position I have maintained for nearly 2 decades.
REFERENCES
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