The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction

I thank Morton Satin, Vice President, Science and Research, the Salt Institute for his comments on an article relating to the international variation in the salt/sodium content of fast foods (1). To interpret Morton Satins comments, the reader should be aware the Salt Institute is a trade association for the salt producing industry which earns income from ultimately from the sale of salt (www.saltinstitute.org/ accessed April 23 2012). The Salt Institute's actions and function appear, to me, to be similar to that of the Tobacco Institute that for decades countered evidence on the harmful effects of tobacco products (http://en.wikipedia.org/wiki/Tobacco_Institute accessed April 23 2012). On its website, the Salt Institute claims to be an authoritative voice on salt and it lobbies national governments. Using a small group of consultants and academics, the Institute issues public and scientific press releases to argue against the science that indicate that dietary salt additives cause much death and disability worldwide. The Salt Institute website even advertizes a video on the 'surprising health benefits of salt' and calls Morton Satin, 'the salt Guru armed only with scientific knowledge about sodium chloride'. The one page outline on dietary salt and health from the Salt Institute claims in enlarged type 'A growing body of research shows salt is GOOD for you ....' (with sub text that implies dietary salt increases longevity and intelligence) 'but LOW -salt diets may HARM you'. Needless to say, the salt industry has a strong and direct financial interest in maintaining or increasing sales of salt. However, that salt companies in Canada (The Canadian Salt Company Ltd., Sifto Canada Corp. (Compass Minerals), NSC Minerals Inc.) and elsewhere have a trade association (based on companies in the United States) that functions to counter the scientific and health care community efforts to improve health represents a societal ethical and moral issue to me.

Estimates indicate more than one million deaths per year from excess dietary salt in low and middle income countries (2). It is estimated that 120,000 Canadians are being diagnosed with hypertension annually and 2 million Canadians have hypertension related to dietary sodium* (3-6). Reducing dietary salt is cost saving in developed countries, is indicated to be a best buy** for countries to improve the health of their population by the World Health Organization (WHO) and was a key recommendation to prevent chronic disease by the United Nations in 2011 (www.who.int/nmh/publications/ncd_report_chapter4.pdf, accessed April 23 2012). The evidence base used for the dietary salt recommendations is extensive, inclusive and frequently updated. For example, the WHO has just closed public consultation on an updated scientific review with recommendations for dietary salt with the release expected later this year. Most major Canadian national scientific and health care professional organizations have policies in place to support reduction in dietary salt and most have taken substantive actions to support reductions in dietary sodium.

The World Action on Salt and Health (WASH) is a nongovernment organization with a volunteer membership of scientists and health care professionals who are aiding individuals, organizations and countries to improve population health through reductions in dietary salt (http://www.worldactiononsalt.com/). WASH does not have commercial interests and largely functions to disseminate scientific and health information on dietary salt world-wide. I am a WASH member, which to date has largely entailed receiving informative emails on dietary salt activities from around the world. I have never received any financial support from WASH. I would encourage readers interested in dietary salt and the effort to improve health through reductions in dietary salt to also opt for free membership.

I should also have noted, I have volunteered as a member (or chair) of committees for other governmental and nongovernmental organizations related to reducing dietary salt including the World Health Organization, Pan American Health Organization, the Public Health Agency of Canada, Health Canada, Hypertension Canada, Canadian Society of Internal Medicine, and the Heart and Stroke Foundation. At the time the manuscript was being written, I was a volunteer member or chair of over 40 committees relating to efforts to improve health through improved management of hypertension or prevention of hypertension or prevention of cardiovascular disease and hence these committees all would have involved efforts to reduce dietary salt directly or indirectly. I have also been a short term consultant or speaker for many regional and national governmental and nongovernmental organizations and meetings relating to dietary salt. Many of these organizations and meetings have provided travel support for me. My salary support is from the Heart and Stroke Foundation of Canada and the Canadian Institute of Health Research and is to provide leadership in efforts to prevent and control hypertension and is currently focused on addressing dietary causes of hypertension. My rationale for focusing on being involved in efforts to reduce dietary salt relates specifically to the extensive evidence of the harmful effects of high dietary salt. In the two countries (Chile and USA ) that have assessed the rank order of health risks that included salt, high salt intake was estimated to be the 2nd and 7th leading risk for death respectively (8)(9). In the past, I have viewed my activities outlined above more as my academic credentials which are documented in much greater detail in my annual university reports than conflicts of interest that required public disclosure. I sincerely apologize to CMAJ readers for overlooking to document potential conflicts of interest. Norm Campbell MD.

1) Dunford E, Webster J, Woodward M, Czernichow S, Lun Yuan W, Jenner K, Ni Mhurchu C, Jacobson M, Campbell N, Neal B. The variability of reported salt levels in fast foods across six countries -opportunities for salt reduction. CMAJ 2012. DOI:10.1503 2) Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007; 370(9604):2044- 2053. 3) Campbell NRC, Willis KJ, L'Abbe M, Strang R, Young E. Canadian Initiatives to Prevent Hypertension by Reducing Dietary Sodium. Nutrients 2011;3:756-64 4) Legetic B , Campbell N. Pan American Health Organization Actions to Facilitate Cardiovascular Disease Prevention Through Population Based Salt Reduction in the Americas. Journal of Health Communication. 2011;16:37-48 5) Penz ED, Joffres MR, Campbell NRC. Reducing dietary sodium and decreases in cardiovascular disease in Canada. Can J Cardiol. 2008;24:497 -501. 6) Joffres MR, Campbell NRC, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health costs in Canada. Canadian Journal of Cardiology. 2007;23:437-443 7) Robitaille C, Dai S, Waters C, Loukine L, Bancej C, Quach S, Ellison J, Campbell N, Tu K, Reimer K, Walker R, Smith M, Blais C, Quan H. Incidence, prevalence and mortality of diagnosed hypertension in Canada. CMAJ. January 10, 2012 184:E49-E56. 8) Departamento de Epidemiologia Ministerio de Salud. Chilean Health Report. Chilean Health Report , 1-453. 2003. Gobierno De Chile, Ministerio De Salud. 9-20-2010. 9) Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009;6:e1000058.

* There were 418,000 Canadians with new diagnoses of hypertension 2007/8 and in 2012 there is an estimated 7.5 million Canadians with hypertension (7); 30% of hypertension in Canada is estimated to be related to excess dietary sodium (6). **A best buy is an intervention that is not only highly cost-effective but also cheap, feasible and culturally acceptable to implement

Conflict of Interest:

the letter details my potential interests