A recent editorial questioned the new more aggressive blood pressure (BP) targets for the pharmaceutical treatment of hypertension (HTN), noting that their adoption means that most people form age 45 to 75 will be diagnosed with HTN and most of them will be taking drugs. An editorial in the British Medical Journal noted, "The new guidelines also put millions at risk of the 'psychological morbidity' that comes with the label of a chronic disease, and at risk for more adverse events caused by inappropriate use of drug therapy." It appears we are reaching the point of diminishing returns with the use of anti-HTN drugs for treating elevated BP levels. Is there a better path to pursue than this pharmacological approach to perhaps the world's number one cause of death and disability?
From my perspective, we ought to stop viewing added dietary salt as socially acceptable. Is the answer to consuming too much salt most days just more MD visits to get more prescriptions for drugs which, at best, mitigate some of the ill effects of salt toxicity? Too often these BP meds end up causing other adverse side effects, since the drugs themselves have toxic side effects.
Trying to figure out how high one's BP needs to be before a diagnosis (Dx) of HTN and justifying treatment (Tx) with drugs that are themselves harmful and never cure the disease, while denying payment for dietary counseling for those with a Dx of HTN seems far from an ideal solution. Pathologically elevated BP and other ills clearly caused by salt toxicity sooner or later cause nearly all Americans to develop some adverse health event(s). Over 90% of Americans will develop HTN sooner or later, yet most of those cases could almost certainly have been prevented if salt intake simply was not excessive or toxic. Debating at what level of BP and what level of other risk factors need be present before labelling someone with HTN and pushing him or her to take anti-HTN drugs for the rest of his or her life while you have the CMS and most "health insurers" denying payment for expert dietary counseling to address the cause of the disease (and in the vast majority of cases potentially eliminating the disease far more safely and efficaciously than with prescription drugs) because certain groups appears to put the financial interest of the medical establishment above what is best for the health and well-being of Americans is a huge scandal that is largely flying under the radar.
So, is there a public health model that could guide us into policies and provide incentives for doing the right thing in dealing with salt toxicity and HTN, which is the #1 cause of death and disability in the USA today?
I think so. What if we changed the rules and incentives on salt the way we did with tobacco? Let's see if the two are analogous and whether similar public health efforts might work.
First off, I think it is safe to say everyone who smokes is going to suffer pathological changes, but at no point did more than 70% of Americans smoke, although many nonsmokers were harmed by secondhand smoke. Most smokers will likely die prematurely from one or more of these tobacco-related ills. By contrast, nearly all Americans consume too much salt, and for the majority it is "second hand" salt. That would be salt added by the commercial food industry.
Why does the main government watchdog of food safety, whose reason for existing is to protect Americans from unsafe food additives, still classify dietary salt in any amount "GRAS" (generally recognized as safe)? Yet most experts have long recognized that large amounts of added dietary salt is not safe.
Step #1 The time has come for the FDA to reclassify salt as something other than GRAS and perhaps start limiting the amount of salt that can be added to food. Or, if banning high-salt foods outright is viewed as too authoritarian, then perhaps we should start taxing foods that contain dangerous amounts of added salt. We have long taxed tobacco products to make them more expensive and to hopefully encourage young people to not smoke and to encourage smokers to quit. Why shouldn't a similar tactic be taken for foods with clearly unsafe amounts of added salt?
Step #2 Start taxing foods with large amounts of added salt. Both restaurant and processed foods high in salt should be taxed.
Step #3 would be to use those tax dollars to help fund a public health campaign to inform all Americans about the numerous known and likely risks of damage to one's health caused by salt toxicity and to encourage people to take steps to limit their salt/sodium intake.
Step #4 We require tobacco products to contain clear warning labels about the health risks they carry. We have largely banned ads for tobacco. In public schools kids are taught about how dangerous tobacco products are. Why not do the same for commercial foods with excessive amounts of added salt?
Step #5 We have increasingly banned the use of tobacco smoking in public spaces, thus making their use a social disability. We could certainly either ban the placement of salt shakers in restaurants that cater to families and especially to kids or at least put a warning label on salt shakers in all restaurants. "Caution: The Surgeon General has determined that added salt causes high blood pressure". Smoking is not allowed in public schools and yet most school lunches come loaded with a toxic amount of added salt. What message does this give to children?
Step #6 We charge smokers more for health insurance and do not pretend that they have "pre-existing conditions. " We also require health insurers to charge smokers no more than those who chose not to smoke. Yet HTN is viewed as a pre-existing condition and in most cases it can be reversed (cured even) by the adoption of a healthful, largely plant-based, unprocessed foods diet that is low in salt. Both smoking and BP that is controlled with anti-HTN drugs are associated with at least a 2-fold increase in CVD events. Nearly all MDs encourage their smoking patients to quit smoking or chewing tobacco and yet most MDs say little or nothing about the many proven adverse health effects of excess added salt (2).
Step #7 Health professionals and the media rarely, if ever, talk about the clear scientific evidence showing that a healthful diet can mitigate the risk of smoking. It appears that a healthier diet and lifestyle would at least halve the risk of death and disability for people who chose to smoke. By contrast, the public is being constantly confused about the adverse effects of salt with the Tobacco Institute proclaiming that most Americans with HTN do not benefit from salt restriction and are more likely to benefit from a DASH diet, exercise and weight loss. This is utter nonsense. Adopting a healthful DASH-style diet or a whole foods, largely plant-based Mediterranean diet, regular exercise, and weight loss clearly would mitigate the health risk in smokers, but you rarely hear about this as the public health message is aimed at the primary cause of tobacco-related disease and not secondary factors. By contrast, for those consuming too much salt there is a blatant attempt to confuse health professionals and the public about the health benefits of reducing dietary salt intake. A similar attempt to confuse the public about the dangers of smoking would be widely attacked. And yet confusing claims persist that adopting a healthy lifestyle is more important than reducing salt intake for preventing and treating HTN. The DASH sodium trial showed that reducing sodium on a typical unhealthful Western diet from about average to only 1500mg per day lowered systolic BP 7.7mmHg on average. By contrast, the DASH diet without sodium restriction lowered systolic BP by only 5.9mmHg. Clearly salt reduction is more efficacious than all other components of a healthy diet combined. The DASH study authors concluded that: "Long-term health benefits will depend on the ability of people to make long-lasting dietary changes and the increased availability of lower sodium foods" (3).
Bottom Line: Have these efforts to basically socially demonize the use of tobacco products worked? It would appear so as the prevalence of smoking has markedly declined, saving hundreds of thousand lives each year and markedly reducing "healthcare" costs for tobacco promoted illnesses. Could America take similar steps outlined above to demonize the consumption of a toxic amount of salt? I believe so, and the public health benefits would potentially be at least equal to what we have seen already with similar measures targeting tobacco products. It is time to stop viewing elevated BP as a medical condition except in those far less common cases where it is a secondary disease process primarily responsible for driving up the BP.
By James J. Kenney, PhD, FACN
Stephanie Ronco has been editing in a professional capacity for the past 10 years. In addition to her work as an editor, Ronco has also served as a ghostwriter and writing tutor. A voracious reader, Ronco loves watching language evolve and change. When she’s not delving into her latest project, Ronco can be found teaching acting classes, performing in community theater, or sailing with her husband.