by Tom Farley
The changes would touch the lives of millions. Kraft had cut sodium in sliced American cheese by 18 percent. Mondelz had taken out 33 percent of the sodium in Teddy Grahams. Subway reduced the sodium in Bloomberg’s favorite Italian BMT sandwich by 27 percent. Mars had taken 15 percent of the sodium out of its Uncle Ben’s flavored rice mixes. And Heinz had met its promise to cut sodium in ketchup by 15 percent. Only three of twenty-four companies that made commitments for 2012 failed to meet them: Hostess, which had gone bankrupt, and Boar’s Head and Bertucci’s, which were still trying.
We got the press attention that we wanted, as upbeat stories ran in news outlets across the country. But even the companies that wanted the public recognition were edgy about what Mayor Bloomberg would say. They didn’t want to broadcast that they were putting less salt in their foods, because they were afraid that it would hurt sales. Susan Kansagra had stopped off at a grocery store that morning to buy Teddy Grahams, Heinz ketchup, and Kraft American cheese in case the reporters wanted to take shots of those foods, but the companies vetoed photos. They didn’t want pictures circulating on the web attracting comments that their name-brand products would now taste bad.
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The more progress we made, the louder the noises from the scientific doubters. And unfortunately, the news media helped them sow confusion.
In 2011 the Journal of the American Medical Association published two papers that seemed to show higher death rates in people taking in low amounts of sodium. Both used data from other studies that were designed to answer different research questions; the authors were engaging in after-the-fact “data dredging.” Both were quickly and roundly criticized as flawed. In particular, the way the authors had measured sodium intake was unreliable. More important, their findings looked like “reverse causation”—that is, people in the study may have been on low-sodium diets because they were already sick with heart or kidney disease. It wouldn’t be surprising, then, if the people taking in less salt were more likely to die within the next few years. But the two studies muddied the issue outside the medical world. Articles appeared like the one in the Times, which ran the headline “LOW-SALT DIET INEFFECTIVE, STUDY FINDS. DISAGREEMENT ABOUNDS.”
At about the same time, a different research group published a prominent “meta-analysis” of trials of low-sodium diets. A meta-analysis combines data from many other studies; this one merged data from seven. The authors claimed to see “no strong evidence that salt reduction reduced all-cause mortality” in people who didn’t already have congestive heart failure. And they saw an increased death rate in people on low-salt diets who already had congestive heart failure—a finding that came from just one of the seven studies they had combined. The authors admitted that even with the combined data, their study did not contain nearly enough people to draw any conclusions about low-salt diets in typical people. And they wrote that “our findings are consistent with the belief that salt reduction is beneficial” in people who didn’t already have advanced heart disease. Nonetheless Michael Alderman (the doctor who had warned against low-salt diets in 2010) trumpeted the meta-analysis, writing that “this scholarly review . . . challenges the assumptions of a relation between sodium intake and CVD [cardiovascular disease] and its policy implications.”
From there, the story gathered momentum. Scientific American ran an article titled “It’s Time to End the War on Salt” and subtitled, “The zealous drive by politicians to limit our salt intake has little basis in science.” That triggered a story in the Wall Street Journal attacking us directly. “Mayor Michael Bloomberg’s war against salt has put him in the cross hairs of medical researchers,” the story read. “A new analysis by an internationally respected research body has cast doubt on the city’s claims about the perils of a salty diet.” Other newspapers went all the way. The U.K.’s Daily Express headline read “NOW SALT IS SAFE TO EAT.”
That was quite a transformation. The story went from the meta-analysis’s authors writing that salt reduction for most people was probably beneficial, to reporters writing exactly the opposite. The pivot seemed to have been Alderman’s editorial. Alderman, the former adviser to the industry’s Salt Institute, wrote frequently that reducing salt intake might be dangerous, which he could do whenever he wanted to because he edited his own journal.
Two years later the story got even fishier when the authors of the meta-analysis retracted their paper. They had learned a disturbing story about the researchers behind the only one of their seven studies showing an increase in mortality from a low-salt diet. The lead author of the suspicious paper was listed as working for Wegmans pharmacy in Ithaca, New York. He and his coauthors were suspected of using data from the same patients in two different studies, then combining them in their own meta-analysis. Either of those would be considered scientific malpractice. When a journal committee investigating asked to see their raw data, the researchers claimed the data no longer existed because of a computer crash. That was enough for the investigating committee. After their suspicious trial was removed from the larger meta-analysis, the results changed sharply, with lower sodium diets now leading to fewer heart attacks and strokes. In the wake of the retraction, Alderman did not retract his editorial, and neither Scientific American nor the Journal corrected its article.
Around the time the meta-analysis was published, the CDC asked the Institute of Medicine to review recent studies and recommend how much Americans should cut their salt intake. The IOM committee reconfirmed that people should take in less sodium, but then got squeamish about exactly how much. The committee was comfortable with the less-than-2,300 mg recommendations in the current guidelines for healthy people. But it wasn’t willing to endorse the recommendations that people with certain health risks (people over fifty, blacks, and those with high blood pressure or diabetes) should go further, cutting back to less than 1,500 mg per day. It ducked, claiming “not sufficient evidence” to address that secondary question.
Michael Alderman jumped on the IOM report too, saying it “has changed the paradigm through which the issue of sodium intake can be addressed. The default position is no longer ‘lower is always better.’” Reporters also interpreted the review as a radical change in scientific thinking. The Washington Post’s headline was “STUDY QUESTIONS EFFORTS TO SLASH INTAKE OF SALT,” and The New York Times wrote that the IOM review “undercuts years of public health warnings.” In their details, the stories didn’t misrepresent the IOM findings, but most people reading only the headlines would think that experts were now saying that salt was not bad for you after all.
This may sound like trivial squabbling among scientists, but many lives were at stake. The scientific facts on salt mattered to the two-thirds of Americans over age sixty who, like Sylvia Birnbaum, had high blood pressure, and to the hundreds of thousands who were dying every year from heart attacks and strokes caused by hypertension. People affiliated with the salt manufacturers were claiming—against decades of evidence—that salt is not bad for you, and the press was serving as their megaphone. Unfortunately, the default course in our democracy is inaction. To prevent progress, the critics don’t have to prove anything. Like climate change deniers, all they have to do is introduce doubt.
The most important fact, which was lost in the Post and Times articles, was that 90 percent of Americans took in more sodium—usually much more—than even the higher recommendation of 2,300 mg. It didn’t matter whether the healthy target was 1,500 mg or 2,300 mg. Even if New York City’s initiative met its ambitious long-term goal of dropping sodium intake by 20 percent, the average American would still be consuming about 2,700 mg. Nearly every expert—other than those affiliated with the Salt Institute—agreed that making that change would save many lives.
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In late 2011 the FDA showed flickers of life. The agency released a “docket,” or an invitation for anyone to comment, on “effective strategies for sustainable and meaningful reduction of sodium in foods.” The docket didn’t obliga
te the FDA to do anything specific, but it meant that the agency wanted to do something on salt.
If we had any hope for long-term success on salt, we needed action from the FDA, the only agency in the nation with authority over packaged food. I wanted the FDA to simply add its regulatory clout to the sodium targets that we had already developed. Lynn Silver, as always, had ideas of her own. She wanted the FDA to put warning labels on food packages if sodium was especially high. When the FDA held a hearing on the docket, Christine Curtis traveled to Washington to tell our story. The hearing brought out the other major players on salt, too. Health experts praised the FDA for finally turning its attention to the problem. Food companies said they were trying to lower sodium but were hamstrung by their customers. And operatives from the Salt Institute and their paid experts said that cutting salt might kill people.
Then we waited. Christine Curtis heard a rumor that the FDA wanted to create its own voluntary sodium-reduction targets. Then we heard that the White House had bottled even that up. “It was clear that there was a general regulatory paralysis going on” in Obama’s White House, said Lynn Silver. It reminded Susan Kansagra of what happened a year earlier, when federal agencies tried to write guidelines to limit the marketing of junk food to children. Even though the guidelines were weak and voluntary, the food industry’s friends in Congress strangled the idea.
In the meantime, other countries’ governments were acting. Health officials in Canada developed their own sodium reduction plan, asking for advice as they did from Curtis. The Canadians built databases like hers and used a similar process to set national targets for food companies. Curtis also talked with government health officials from Australia and New Zealand as they shaped their salt strategies. Most frustrating to us, many of the food companies negotiating with these British Commonwealth countries were the same global companies that Lynn Silver, Sonia Angell, and Christine Curtis had been meeting with since 2007. They were working on salt with more than one national government, but not with our own.
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At the time of that celebratory press conference with Kraft and Goya, it had been eight years since Silver had first seen the report Salt: The Forgotten Killer. In those years, we had succeeded in making salt a little less forgotten. A question that nagged us, though, was how much of the killer the food companies had really taken out.
Curtis had to work around some missing data, especially sales data from Walmart, but she estimated that between 2009 and 2012, the sodium in the U.S. packaged food supply fell by 5 to 6 percent. Among the most important food categories, those showing the biggest changes were breakfast cereal, barbecue sauce, and bread, each down 8 percent, and—a little victory from the meeting in 2009—crackers, down 12 percent. She didn’t see any changes in restaurant food, which was no surprise because the restaurants barely spoke to us.
How important were these changes? Even the people who spent much of their lives thinking about salt disagreed. Kansagra called it only “slight progress.” On the other hand, a CDC expert told me that if we had actually cut sodium by 6 percent over just three years, “that would be huge,” especially after the utter failure over the previous forty years. Curtis also saw the changes much more brightly. The salt reductions in the crackers and bread categories were big, she thought, more than most people ever expected. Also, there was a lag in getting changes into her database, and based on what she was hearing from companies, she expected the fall to continue.
Tom Frieden always demands a “back-of-the-envelope on lives saved,” so here it is: a researcher from the University of California at San Francisco estimated that lowering salt intake by 11 percent would prevent between 17,000 and 28,000 deaths per year nationwide. If Curtis’s estimates are right, our National Salt Reduction Initiative would reduce Americans’ total sodium intake by about a fourth of that. That is, every year in the United States it might prevent 6,000 deaths from heart attack and stroke. Six thousand is more than twice the number of people who died in the 9/11 attacks. It’s only people in public health who consider a number like that to be embarrassingly small.
18
“This is an attack on small business.”
In July 2012, six weeks after the meetings with Coke at Gracie Mansion, the Board of Health was back in the health department’s glass-walled room for a public hearing on the proposed soda portion limit. This time I counted twenty-two video cameras, and our press office counted seventy-five press outlets. At this meeting, any interested citizen had the opportunity to sit at a folding table in front of the board for three minutes—as an LED timer counted down the seconds—and speak his or her mind; the board members were there only to listen.
Coke did not send representatives. Nor did PepsiCo. Nor did McDonald’s, Burger King, KFC, or any other chain restaurant that sold the huge sugary drinks. But the soda industry was amply represented. The industry lobbyists took turns denying that obesity was their clients’ fault. Joy Dubost of the National Restaurant Association said that the restaurant industry “plays a positive role reversing the trend of obesity, including adding more healthful options to menus and disclosing nutrition information.” A representative of the National Association of Theater Owners argued that “in moderation most things are okay. Well, sales of sugary drinks at movie theaters are just that. They are moderation defined. Why? The average moviegoer in New York City only goes to the theater four times a year.” Jim McGreevy of the American Beverage Association was forced to address sugary drinks more head-on. “A substantial body of literature confirms that sugar-sweetened beverages are not a unique driver of obesity rates,” he said.
They and the other opponents hit repeatedly on common themes: The rule wouldn’t work. The exclusions—alcohol, dairy products, convenience stores—were nonsensical. We should instead fight obesity with education and exercise programs. The rule was an interference with personal freedom. The rule was not just a job killer, it was unfair specifically to small businesses, especially minority-owned ones.
Several City Council members joined the soda companies in attacking the proposal. Daniel Halloran, an aggressive Republican with libertarian leanings who later got convicted in a bribery scandal, was the first to speak. “They came for the cigarettes; I didn’t say anything. I didn’t smoke. When they came for the MSG, I really didn’t care because I didn’t order it very often. I am not a big salt eater so I didn’t mind when you guys regulated salt. What will the government be telling me next: What time to go to bed? How big my steak should be? How many potato chips I could have?” He was followed by Council members Robert Jackson, an African American, and Melissa Mark-Viverito, a Puerto Rican, who denounced the rule’s “adverse economic impact on our communities.” Then Joseph Vitta, a hulk of a man and the secretary-treasurer of Teamsters Local 812, warned the board that if sales of soda went down, his union workers would lose jobs.
But the health advocates also had their moments. Walter Willett, the chair of the department of nutrition at the Harvard School of Public Health, warned that “large doses of sugar are metabolically toxic” and said those doses were hitting poor minorities especially hard. Michael Jacobson of the Center for Science in the Public Interest attacked the soda industry more directly, saying that “the freedom to sell supersized junk means little compared to the necessity to protect New Yorkers from the obesity epidemic.” Kelly Brownell, a professor and anti-obesity advocate from Yale, said, “The industry behavior on this is . . . stunningly similar to what I saw in the tobacco wars.”
And David Jones, a prominent African American civil rights advocate, called the soda companies’ behavior “a direct attack on New York’s black and brown communities.” “I should mention, one hundred years ago, we were fighting a somewhat similar effort, where chalk was being used to add to water and sold to poor mothers as a substitute for milk.” And now, he said, the soda companies had “the audacity to equate this whole process to what they describe as the Million Big Gulp March, and it is a takeoff obviously on
the Million Man March, an effort that was made to protect particularly black young people and black men. . . . To suddenly make a sham of that, to equate civil rights and the struggle that is occurring in poor neighborhoods, particularly for the young, to this right to sell nonnutritional substances to young people is an outrage.”
Toward the end of the hearing, Liz Berman, representing the front group New Yorkers for Beverage Choices, theatrically dropped on the witness table a petition with 91,000 signatures and bags of more than 6,000 postcards opposing the proposal. “The citywide outpouring of opposition to this proposal is testament to the fact that New Yorkers feel that this proposal is arbitrary, it is unfair, and it is ineffective.”
But she was followed by Daniel Simon, a bearded, soft-spoken young man who introduced himself as just “a citizen.” “And in the interest of full disclosure, nobody is paying me to be here. In fact, I spent $2.25 of my own money to get here on the subway.” He had been approached by a man on 42nd Street to sign his name to “fight back against the Bloomberg ban.” The man approaching him said he was being paid thirty dollars an hour to collect signatures, and “he told me to e-mail his boss if I wanted a job” doing the same. The man had handed Simon an iPad to sign, but “the full screen was just a field to put my name and digital signature. There was no preamble to the petition even.”
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The board members met again in September 2012 to consider the public comments and to vote on the rule. In advance, they had received a DVD with copies of each of the written comments. There were 32,000 in support and 6,000 in opposition. Although many were from ordinary citizens, the stack made it clear that this war was between health organizations and the soda industry. Unlike comments on most proposed Board of Health rules, virtually none of the criticisms suggested alterations to the rule. The soda companies and their allies wanted only to kill it.