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The sodium story isn’t one-sided — and the debate goes back decades

The American Heart Association recommends that everybody take in no more than 1,500 mg of sodium a day.

Given how controversial the topic is, I wasn’t all that surprised by the speed and vehemence with which some people lashed out at the sodium study published last week in JAMA Internal Medicine.

As I reported at the time, the study, which followed more than 2,600 healthy adults in their 70s for 10 years, found no significant correlation between the consumption of a high amount of sodium — more than 2,300 milligrams (mg) a day — and an increased risk of death.

That finding flies in the face of current U.S. guidelines, which recommend that all of us limit our sodium to less than 2,300 mg daily and that certain groups — including people over the age of 51, all African-Americans, and people with high blood pressure, diabetes or kidney disease — limit it to less than 1,500 mg daily.

The American Heart Association (AHA) is even stricter. It recommends that everybody take in no more than 1,500 mg of sodium a day.

Plenty of weaknesses

Now, this new study is definitely not the final word on sodium and health. After all, it was an observational study, which can never prove anything definitely. And it had other limitations as well, especially that fact that it relied on the participants reporting their own eating habits. Furthermore, the participants reported those habits only once, near the beginning of the study. They could have dramatically altered their food choices later, but the study wouldn’t have picked that up.

Those and other weaknesses in the study were jumped on by its critics, including Dr. Elliott Antman, president of the AHA. In a blog post reprinted on MedPage Today, he called the JAMA Internal Medicine study “problematic” and said that “nothing” in it would cause the AHA to reconsider its sodium recommendation.

“For a science-based organization dedicated to saving and improving lives, confusion about something as dangerous as excess sodium is unacceptable,” he added. “We owe it to the public to provide the most scientifically sound dietary advice.”

Only one side of the story

But Antman is being disingenuous with that comment, as Larry Huston, a medical journalist who specializes in reporting on cardiovascular matters, explains in an online column for Forbes magazine. For there’s another side to the sodium story — one Antman omits in his blog post.

Writes Huston:

If you only read Antman’s post you would think the study under attack was a lonely island in a sea of overwhelming evidence supporting the AHA guideline. You’d never know that for decades there’s been a lively, heated scientific debate over the salt recommendations. Antman doesn’t tell you that there is much more additional evidence casting doubt on the AHA recommendation than this week’s study. And Antman doesn’t tell you that the scientific basis for the AHA recommendation is at least as weak as the scientific basis for opposing views.

To cite only 2 important recent developments: in 2013 the prestigious Institute of Medicine published a report concluding that there’s no evidence to support current efforts to lower sodium consumption to less than 2,300 mg/day. And then last summer the New England Journal of Medicine published two papers from the PURE study that also did not support the AHA recommendation. PURE — like all studies in this field — is far from perfect, but it was much more rigorous than the study assailed this week by Antman. Just how divided is the field? The NEJM papers were accompanied by an editorial that also expressed disagreement with the AHA low salt recommendations. Unless and until there is better evidence, “the results argue against reduction of dietary sodium as an isolated public health recommendation,” wrote the editorialist, Suzanna Oparil.  Here’s the kicker: Oparil is, herself, a former president of not only the American Society of Hypertension but also Antman’s own American Heart Association. I find it remarkable that the current AHA president doesn’t feel it necessary to note an opposing view from his own predecessor.

Important to get it right

Given its track record — and what’s at stake (people’s health) — the AHA needs make sure it gets its sodium recommendations right, says Huston.

“As I’ve said before,” he writes, “there’s widespread speculation that the AHA’s earlier guidelines on cholesterol and diet, which demonized fats starting back in the 1980s, may have had the catastrophic consequence of pushing people to consume more carbohydrates, including sugar. We will probably never know the full extent of the damage, but many have speculated that this may have contributed to the obesity and diabetes epidemics. Let’s make sure this doesn’t happen again with salt.”

You can read Huston’s column on the Forbes website.

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