American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, October 8, 2014

Salt in the wound

We eat too much salt, and so do our children. We can reduce our intake by eating less highly processed food, which is the source of nearly 80% of the sodium in our diets. Doing that, and eating more foods direct from nature would be good for us anyway, because it would also reduce our intake of added sugars and sweeteners, refined starches, miscellaneous chemical mischief, trans fats, and calories, while increasing our intake of beneficial nutrients.

Wholesome foods in sensible combinations would reduce our ambient sodium intake. More importantly, it would fix everything else wrong with our diets, too. That’s the punch line for those in a real hurry. For everyone else, here is rest of the story.

Once upon a time, we were relatively secure in our knowledge that we ate too much salt. That didn’t mean we were inclined or likely to fix it any time soon, but at least we thought we knew what was broken.

That level of conviction about anything having to do with nutrition just won’t do in our culture. For one thing, it’s the job of the news media to afflict the comfortable. So any time we seem too comfortable about any part of our complete breakfast, lunch, or dinner, it’s time to tell us why it’s the root of all evil in the universe.

For another thing, we seem to prefer hopeless befuddlement about everything having to do with the basic care and feeding of Homo sapiens. So a never-ending parade of contradictory headlines works out well for all concerned.

So there we were, secure in the knowledge that most of us ate too much salt. The meant that every study indicating the potential dangers of eating too little salt, however theoretical, needed to make headlines; and so they did. The news we were getting about salt started to look like a Ping-Pong match. When it comes to science in general, and nutrition in particular, that’s never good.

The propagation of confusion by competing studies, and associated headlines, reached its peak on August 14, when three studies on the perils of salt intake were published in the same issue of the New England Journal of Medicine. Two, by the same investigators, suggested that while too much salt is clearly harmful, so, potentially, is too little. I have addressed the studies in some detail before, so no need to do it again. Suffice to say they were converted into headlines implying we should abandon all restraint, and “pour on” the salt. The investigators themselves never said any such thing, of course, but that’s how this game is played.

The third article in the same issue of the New England Journal concluded that nearly 2 million global deaths each year are the direct result of sodium intake above the rather low threshold of 2.0 grams per day. We were getting too much, after all.

So perhaps we might have settled comfortably into a state of permanent discomfort and confusion about salt. But it was not to be. Along came yet another study just 3 days ago, pouring salt indeed on the still-raw wound.

The CDC analyzed a nationally representative sample of children in the U.S., and concluded that sodium intake is dangerously excessive in kids and adolescents. Average sodium intake for 6- to 18 year-olds was 3,300 milligrams per day from processed foods alone, which is not only higher than the current guideline, but even higher than what the guideline would be if we decided it were currently too low. The excessive sodium intake was linked to an already high, and rising rate of high blood pressure in children.

The study reaffirmed what we already knew about the salient contribution of processed food to the pickling of our population, and our progeny. Nearly half of the salt intake in our kids comes from just ten popular food items, before ever a hand reaches for the salt shaker. That list predictably includes the likes of deli meats, potato chips, and chicken nuggets.

Sodium is an essential nutrient. We can, of course, consume too little. But generally, in the real world, we don’t. And certainly none of us is suffering from a baloney deficiency syndrome.

Of course, you’re the boss. It’s your life and your diet, and I’m just a guy with an opinion. Well, that and about 40,000 hours of post-graduate training, but we all know what that’s worth. Either way, you’re the boss, and you have two options.

I put option A in the opening paragraph: eat good foods, and let salt (and every other nutrient) take care of itself. Option B is to restrict the salt intake of your children scrupulously, while simultaneously both carefully restricting and liberalizing your own intake of salt so as to avoid both deficiency and excess, while wearing a neck brace to deal with the permanent case of headline whiplash.

Most of us, and our children, eat too much salt, and the best way to fix it is modifications to the typical American diet that would be good for us all anyway. That’s the prevailing reality. I recommend we act on that. I do.

That action does not require fixating on salt. Rather, focus on wholesome foods in sensible combinations, and sodium, along with every other nutrient, will tend to sort itself out. And yes, it is possible to get there from here. Not effortless, but possible.

Hypothetically, we could find ourselves in trouble by eating too little salt. But hypothetically, we could incur injury from an excess of oxygen. That’s not a good reason to stop breathing. You might prefer to wait until there are no dissenting voices, no conflicting data, and no contradictory headlines about diet and health. That’s your decision, but permit me to suggest that whatever you eat between now and then, you not hold your breath.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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