The Sound, The Fury and the Facts of Spodium

If you’ve got high blood pressure and you’re traveling to Lithuania, a family of cooking writers wants to arm you with a special phrase: “be druskos,” no salt. In “Cooking Without a Grain of Salt” (Bantam, $5.99), Elma W. Bagg, Susan Bagg Todd and Robert Ely Bagg also provide ways to refuse salt in a dozen other countries, including China, Greece, Israel, Russia and Sweden.

All very thorough. However, those disinclined to renunciatory zeal may be interested to learn that the former president of the American Society of Hypertension has had his fill of the low- and no-salt movement. “Are people still talking about that?” asks Dr. Michael Alderman of the Albert Einstein College of Medicine in New York.

His question, of course, is rhetorical. Alderman is perfectly aware that they are not only talking but shouting. The tenor of the debate over salt and hypertension is such that in a detailed overview published in Science magazine in September, research commentator Gary Taubes described it as “one of the longest-running, most vitriolic and surreal disputes in all of medicine.” Taubes dates the demonization of salt to the 1970s, a time when a New York physician managed to give rats hypertension with salt--using a dose, critics noted, that would be equivalent to more than a pound a day for a human being.

So began an era in which results of scientific studies, increasingly pumped by specialist scientific and medical journals straight to the mainstream media, hyped health dangers of all kinds of ingredients out of all recognition.

How much of this or that it took to kill a rat became the wisdom of the week. Saccharine became bad, then safe. Margarine good, butter bad, then butter good and margarine bad.

That it should happen with salt is a measure of how uncommon common sense is. We can actually sense quite well whether we’ve had the right amount of salt, because no chemical has a more direct and obvious physiological effect. Sodium chloride famously affects our water retention. Eat too much of it and we become thirsty, drink water and become bloated. Eat too little and we become dehydrated.

As scientific opinion seesaws over salt, Alderman is weighting one end of the board. He recently published results in the British medical journal the Lancet suggesting that extreme salt reduction might not only lack significant health benefits but also pose fresh risks. This was seized on by the Salt Institute, a trade organization for the big seven salt manufacturers: Morton’s Salt, Cargill, IMC Salt Inc., United Salt Corp., Lyons Salt Co., Western Salt and the US Salt Corp.

Salt Institute President Richard L. Hanneman expects that the government will be reluctant to rubber-stamp recommendations to reduce salt intake as put forth by a formidable medical network that includes the American Heart Assn., the American Medical Assn. and the National Heart, Lung and Blood Institute. These organizations would like to see American salt consumption fall from its present average of 4,000 milligrams to 2,400 milligrams per day.

“The Dietary Guidelines Committee has been continually urged to recommend 2,400 milligrams of sodium,” Hanneman says, “but has never put it in. It now seems even less likely to consider this as a pathway to follow.”

However, this is hardly the victory it might seem. The anti-salt lobbyists did not wait for official recommendation but moved unilaterally. The advice already written into pamphlets distributed in doctors’ offices, displayed across a series of Internet sites and falling from the lips of officials at the American Heart Assn., the National Institutes of Health and the Center for Disease Control is 2,400 milligrams of sodium as a fixed goal.

Alderman calls this “an unscientifically based strategy.” He asks, why treat all 250 million Americans in order to reach the 50 million who have hypertension? Moreover, to his mind, there is no good evidence that reducing salt by almost a third will have the desired effect.

Edward J. Roccella, coordinator of the National High Blood Pressure Education Program, disagrees--strenuously. “Populations that consume lots of salt have more hypertension. . . . The question is, how much does the pressure rise within individuals? The answer is, it varies. We don’t know who’s going to be the responder.”

To Roccella, recommending universal salt reduction is akin to requiring motorists to wear seat belts. “We require drivers to wear seat belts when not everyone will be in a car crash,” he points out.

But to a degree, doctors do have an idea about who among us is at risk. American Heart Assn. spokesman Dr. Theodore Kotchen is particularly concerned about hypertension among inner-city blacks. “We did a random survey in inner-city Milwaukee and found that the incidence of hypertension was 42% to 43% in the African-American population,” he says. The question is why. It is not clear, he says, whether it is related to lifestyle, diet or genetic predisposition “or perhaps all of the above.”

A study in Scotland, where white Europeans suffer high levels of heart disease, points not to race or genotype but to diet. A survey of 7,300 Scottish men published in the British Medical Journal in 1988 showed that increased intake of fresh fruit and vegetables was key in reducing hypertension. The study saw increased levels of potassium and calcium as crucial factors.

Nearly a decade later, in 1997, the New England Journal of Medicine published a sweeping American dietary survey that seemed to echo the Scottish findings. Called Dietary Approaches to Stop Hypertension, or DASH, it showed that diets rich in fresh fruits, vegetables and low-fat dairy products--but with no salt restrictions--were even more efficacious than drugs in lowering blood pressure.

While praising the DASH emphasis on fresh food, Roccella again has objections. “The DASH diet was not designed to look at the salt issue,” he says. “DASH was designed to look at increased intake of potassium and low-fat calcium.”

Simply by virtue of eating more fresh foods, he says, the subjects’ salt levels would have been lowered. A new study, DASH II, is underway specifically to scrutinize salt.

It was the March 1998 Lancet report by Alderman that most exercised the anti-salt campaigners. In it, Alderman followed the progress of more than 11,000 Americans whose diets were studied in the 1970s by a U.S. government survey. Of the respondents who had subsequently died of heart disease, the highest mortality rate Alderman found was among those with the lowest salt consumption.

Alderman describes this as one of four studies that “measure sodium intake of a certain population and then count the dead ones. None of them show low sodium is associated with a longer life,” he says.

Roccella in turn objects that Alderman’s data reflect morbidity among underfed subjects and the already chronically ill, not the adverse effect of salt reduction.

And so the argument goes, with skeptics such as Alderman tending to style the campaigners as unscientific and campaigners such as Roccella floating dark hints that the skeptics are somehow in league with the salt industry.

Cutting through the din, there is one clear, sweet note of accord. The Baggs, Roccella, Alderman and even the Salt Institute all agree that anyone worried about hypertension should consult a physician. They may also wish to toss pinches of salt over their left shoulders for good measure.