JUST PUBLISHED!

The research that I completed as part of my studies in the Graduate School of Public Health at San Diego State University is now published in the November 2008 issue of The American Journal of Health Promotion. The article is called, "Measuring Salt Consumption to Guide Behavior Change in Applied Settings: A Critical Review". The journal article focuses on salt eating related behaviors described in research done over the past 25+ years. The article also discusses the possibly inaccurate assumptions made about the types of measures used to quantify how much salt a person eats in a given time period. With the increasing burden of cardiovascular disease in the aging population better methods to assess and control salt consumption are critically needed. The accuracy of measuring how much salt people eat may improve by breaking "salt consumption" into behavioral steps leading from how salt gets from store to plate to table to actual ingestion. Each behavioral step offers an opportunity for measurement, and when clarified, may be easier to identify and to address assumptions about measurement in order to improve the validity of measurement results. For more information or if you would like a copy of the article for personal use, you may contact me at srpark@SalTrax.com or the American Journal of Health Promotion at http://www.healthpromotionjournal.com/publications/journal.htm

IMPORTANT NEWS: Healthy People 2020 is interested in obtaining public opinions about the framework that will be used to organize the Healthy People 2020 objectives. Every ten years the U.S. Department of Health and Human Services (HHS) sets national goals and objectives for problems that are of great importance to our nation's health. Nearly all national, state and local public health related organizations use this document to create their strategic plans and measure their progress and success in meeting these goals/objectives.

Public comment on specific objectives will be sought in 2009. For more information on this very important project, please go to: http://www.healthypeople.gov/HP2020/comments/default.asp

There are many competing issues being considered as health priorities; the advisory committee making recommendations to HHS is weighing the opinions of the public very heavily in its decision making. I urge you to strongly consider adding your voice in this process to make sure that the issue of lower dietary sodium intake is a national priority for the next 10 years and longer.

My comment to the Healthy People 2020 committee last April in San Francisco was included in the materials sent to attendees for the meeting of the Advisory Committee on Thursday and Friday September 4th & 5th. The document summarized the public comments submitted through five nationwide regional meetings in the spring of 2008. The summary included examples of the types of comments submitted in a particular subject area. The subject area "Nutrition/Food Safety" had comments from such organizations as The American Dietetic Association, The University of Iowa, Sharp Health Plan etc. My excerpted comment follows

The Healthy People 2010 objective #19-10 is a broad goal for increasing the proportion of persons aged 2 years and older who consume 2,400 mg or less of sodium daily to a target of 65%. However, this objective doesn't go far enough to describe how we as a nation are going to reach this goal when we are currently at 21%. How we move to reach the goal must be addressed in a step-wise fashion including specific sub-objectives based on a combination of education, environment, and enforcement. For development of Healthy People 2020, we need to consider including behavioral factors that get at the "how-to" of managing sodium intake and plan objectives that may include more valid measurements of sodium intake.

More detailed background information about Healthy People 2020 follows (and is excerpted from: http://www.healthypeople.gov/HP2020/

The U.S. Department of Health and Human Services (HHS) convened five regional meetings to discuss the development of the framework for Healthy People 2020, the national health goals for the next decade. A sixth meeting was held in Washington DC (Bethesda, MD) to gain input from national organizations and other interested groups and individuals.

Making a Difference
Healthy People provides science-based, 10-year national objectives for promoting health and preventing disease. Since 1979, Healthy People has set and monitored national health objectives to meet a broad range of health needs, encourage collaborations across sectors, guide individuals toward making informed health decisions, and measure the impact of our prevention activity. Currently, Healthy People 2010 is leading the way to achieve increased quality and years of healthy life and the elimination of health disparities.

Now Is the Time
Every 10 years, the U.S. Department of Health and Human Services (HHS) leverages scientific insights and lessons learned from the past decade, along with new knowledge of current data, trends, and innovations. Healthy People 2020 will reflect assessments of major risks to health and wellness, changing public health priorities, and emerging issues related to our nation's health preparedness and prevention.

The Process
The Healthy People process is inclusive; its strength is directly tied to collaboration. The development process strives to maximize transparency, public input and stakeholder dialogue to ensure that Healthy People 2020 is relevant to diverse public health needs and seizes opportunities to achieve its goals. Since its inception, Healthy People has become a broad-based, public engagement initiative with thousands of citizens helping to shape it at every step along the way. Drawing on the expertise of a Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 and public input, Healthy People will provide a framework to address risk factors and determinants of health and the diseases and disorders that affect our communities.

Stay Involved and Informed
Public participation will shape Healthy People 2020, its purpose, goals, organization, and action plans. HHS will seek input from communities and stakeholders through public meetings across the country and public comment periods. As a national initiative, Healthy People's success depends on a coordinated commitment to improve the health of the nation. Subscribe to the Healthy People listserv for the latest information on Healthy People 2020 and to receive e-mail notices of related news, events, publications, and more!

Timing
Healthy People 2020 will be released in two phases. The framework (the vision, mission, goals, focus areas, and criteria for selecting and prioritizing objectives) will be released in late 2008 - early 2009. A year later, in January 2010, the Healthy People 2020 objectives will be released along with guidance for achieving the new 10-year targets.

Did you know that May is National High Blood Pressure Education Month?
If you don't have high blood pressure (HBP), also known as Hypertension, you can take steps to prevent it. A number of lifestyle habits can raise your risk for HBP. Lifestyle measures can help you maintain normal blood pressure. Many people who take one or more of these steps are able to prevent or delay HBP. The more steps you take, the more likely you are to lower your blood pressure and avoid related health problems.
Here are seven things you can do to lower your risk of having high blood pressure:
1. Lower the amount of sodium (salt) in your diet. An example of a healthy eating plan is the National Heart, Lung, and Blood Institute's (NHLBI) Dietary Approaches to Stop Hypertension (DASH) eating plan found at: www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdfAlso visit www.saltrax.com for a helpful new book called, "How to keep track of your salt intake: Easy as 1-2-3".
2. Drink alcohol in moderation. Moderation is defined as one drink a day for women; two drinks a day for men of 12 oz. of beer, 5oz. of wine or 1 1/2 oz. of liqour. Go to: www.nhlbi.nih.gov/hbp/prevent/l_alcohol/quiz.htm for a brief quiz on alcohol and blood pressure
3. Eat enough potassium in your diet. Go to: www.fruitsandveggiesmatter.gov to find out how many fruits and vegetables you should eat in a day for your best health.
4. Get enough moderate physical activity. According to the Centers for Disease Control and Prevention (CDC) everyone of all ages can benefit from regular physical activity and it doesn't need to be hard or challenging to be effective. Visit: www.cdc.gov/nccdphp/dnpa/physical/everyone/recommendations/index.htm for more information about physical activity.
5. Stop smoking. For support and resources to quit smoking visit: www.smokefree.gov/quit-smoking/index.html or Call the National Network of Tobacco Cessation Quitlines at 1-800-QUITNOW (1-800-784-8669) TTY 1-800-332-8615. This number works anywhere in the country. You can get one-on-one help quitting, support and coping strategies, and referrals to resources and local cessation programs.
6. Lose weight if you're overweight or obese. A good resource for losing weight is from the U.S. Food and Drug Administration: www.fda.gov/loseweight
7. Manage your stress and learn to cope with stress. A family history of HBP raises your risk for the condition. Long-lasting stress also can put you at risk for HBP. You're also more likely to develop HBP if you have pre-hypertension. Pre-hypertension means that your blood pressure is in the 120-139 / 80-89 mmHg range. A good resource for learning to manage your stress is: www.nlm.nih.gov/medlineplus/stress.html

What you can do if you already have High Blood Pressure: If you have HBP, you can still take steps to prevent the long-term problems it can cause. Lifestyle measures (listed above) and medicines can help you live a longer, more active life. Follow the treatment plan your doctor prescribes to control your blood pressure. It can help you prevent or delay coronary heart disease, stroke, kidney disease, and other health problems.
For more educational information about High Blood Pressure contact:
NHLBI (National Heart, Lung, Blood Institute)Health Information Center
Email: nhlbiinfo@nhlbi.nih.gov
P.O. Box 30105 Bethesda, MD 20824-0105
Phone 301 592-8573
TTY: 240 629-3255

Did you know that Red Bull Energy drink (both regular and sugar-free) has almost twice as much sodium as Gatorade, a drink that is often thought of as having too much sugar and sodium for kids? Red Bull has about 200 milligrams of sodium for every 8 ounces, whereas Gatorade has about 110 mg of sodium for every 8 ounces.

It is ironic to think that our children are drinking this for "energy" when in reality they are drinking lots of sugar and salt which makes them thirsty, tired and hungry while increasing their risk for obesity, high blood pressure, and diabetes!

An article released just this week in the journal Hypertension, Journal of the American Heart Association is titled, "Salt intake is related to soft drink consumption in children and adolescents: A link to Obesity?" In this study the authors found a significant association between salt intake and soft drink consumption among children in Great Britian. The authors state that a decreased salt intake might play a role in helping reduce childhood obesity because it might also decrease the amount of sugary soft drinks that kids want to drink.

To read this important article, please see: http://hyper.ahajournals.org/cgi/content/full/51/3/629

FDA Hearing on Sodium Follow up:

I am pleased to share that I had the opportunity to travel to Washington D.C. to attend and testify at the U.S. Food and Drug Administration (FDA) hearing on sodium held November 29, 2007 (please see the November 13 entry for details about the hearing).

Overall, the majority of scheduled presenters and those providing public comment were in favor of a sodium reduction in processed, packaged and restaurant foods; they only differed on the amount of the reduction and how it should be implemented (i.e. all at once or in a stepwise fashion). Many of the presenters also stated that a change in package labeling is needed to help consumers make better choices. A discussion of whether to change the daily recommended values for sodium will take place at another time.

An historic event occurred in the month prior to this hearing when Dr. Michael Jacobson of the Centers for Science in the Public Interest (CSPI) met with representatives from the Grocery Manufacturers Association / Food Products Association (GMA/FPA)and other stakeholders to work collaboratively on finding solutions to the problem of excess sodium in the American diet.

The representative from the American Diabetes Association, Dr. Richard Kahn, gave an excellent analogy of one pill that is taken which creates optimal health, however when twenty pills are taken creates a toxic situation that is harmful to health; he then asked the FDA panel if this were the case, wouldn’t the FDA step in to regulate the drug? He stated that this is what is happening with sodium and the FDA should step in to regulate it.

When someone questioned why sodium was being singled out, another presenter, Dr. Larry Appel who is a professor of Medicine, Epidemiology and International Health at Johns Hopkins Medical Institutions, made the point that sodium is the only nutrient/food additive that you can ask for, add yourself and have available at every table.

Dr. Stephen Havas represented the American Medical Association and spoke of his organization's strong, unanimous support and recommendations for reducing the sodium in our foods:

1. reducing sodium content by 50% using a stepwise approach

2. revoking the "generally regarded as safe" (GRAS) status of salt

3. working together to educate the public

4. revising food labeling

Dr. Havas stated that currently consumers have no idea how much sodium they currently eat in a day. In countries like Finland, who began focusing efforts on reducing sodium 30 years ago, cardiovascular disease mortality has been reduced by 80%. The United Kingdom uses innovative color coded labeling for sodium in their public health efforts.

There were a few dissenting opinions regarding lowering sodium in processed, packaged and restaurant foods. Several of those presenters, when questioned by the FDA panelists were unable to provide supportive evidence for their positions other than to say, "Americans won't eat food without salt added to it".

My presentation wove a "real life" story about a patient named Bob who ends up in the hospital over and over again for fluid build up in his lungs since he cannot cook, has no family nearby and doesn't know HOW to keep track of his salt intake. I also included the scientific evidence from my many years of reviewing sodium related studies. My Masters' thesis which was a review of the measures of the behaviors of salt/sodium eating was completed in 2005; the current manuscript, co-authored by Dr. Stergios Roussos of San Diego State University, has been accepted for publication by the American Journal of Health Promotion (AJHP) and should be published in late 2008. The journal graciously gave permission to submit a draft copy of the article to the FDA committee that is reviewing all submissions regarding sodium.

The journal article entitled, "Measuring Salt Consumption to Guide Behavior Change in Applied Settings: A Critical Review" is the first comprehensive review to summarize and outline the potential errors in past research primarily because research has relied on indirect measures as opposed to direct measures of salt eating behavior.

I made the point that eating sodium is a long-standing, hard to change habit that is largely considered "personal preference" and is essentially invisible. Furthermore, I stated that measuring the sodium that someone excretes in urine or through asking them to recall foods they ate is like measuring the safety of a car by asking someone if it feels safe to ride in it rather than conducting crash tests.

Addressing possible solutions, I stated that one way to improve accuracy is to use a direct measure of the behavior as the behavior occurs, stressing the importance of policies that guide food labeling as a critical strategy to produce behavioral changes. I emphasized the need to develop strategies and tools to directly measure and impact behavior change; further stating that when we teach people to observe their own behavior using a direct measure such as a tracking tool, we actually change the behaviors that matter most to the problem of excess dietary sodium intake.

If anyone would like to read my entire presentation to the FDA committee, please e-mail me at srpark@saltrax.com or feel free to post a comment or question here.

If you have an opinion regarding this important issue, please consider submitting comments to the FDA (you have until March 28, 2008 to submit comments).

*Submit written comments to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852 

*Submit electronic comments to http://www.fda.gov/dockets/ecomments

The FDA panelists mentioned to the attendees during the meeting and to me afterwards that they are very interested in hearing the consumer opinions regarding sodium. The more opinions they hear, the better their decision about this issue will be. Remember - Your voice counts!!