Delegates take aim at salt intake

Chicago -- Salt. Sugar. Getting and staying fit. These broad topics led to debate and discussion during the American Medical Association's Annual Meeting last month regarding several specific strategies to improve the country's nutrition and health.

Evidence indicates that most Americans have too much sodium in their diets and that more than three-quarters of it comes from processed, restaurant or fast food. This finding amplifies long-standing worries surrounding the link between sodium consumption and hypertension, which, in turn, can lead to cardiovascular and kidney disease. Thus, AMA delegates urged a 50% reduction over the next decade in the salt found in these products. This objective should be achieved without upping the levels of other unhealthy ingredients.

The Association also asked the Food and Drug Administration to revoke salt's "generally recognized as safe" status, develop regulations that will lead to sodium limits in processed food and create labels that will warn if a food is high in this ingredient. These new policies were adopted as part of a Council on Science and Public Health report on this subject.

"The problem is that wherever you turn, people are being exposed to foods that have a high sodium content," said AMA Trustee J. James Rohack, MD, a cardiologist in Temple, Texas. "If we can start to reduce the hidden salt exposure to patients, they're going to be better off."

The AMA has previously called for reductions of sodium in processed foods, but this is the first time it has made such pointed recommendations. The approach is in line with efforts in other countries to reduce sodium intake and is similar to policy from the American Public Health Assn.

A salt industry representative criticized the report, saying evidence that reduced salt intake affected mortality was insufficient and that what was needed was additional research. "The AMA recommendation is scientifically unjustified and a waste of time and money," said Richard Hanneman, president of the Salt Institute.

And what about sugary drinks?

The AMA House of Delegates also debated whether a small tax should be added to the cost of soft drinks sweetened with sugar. Those who favored the levy said it was not intended as a deterrent to consumption but rather would raise awareness regarding how these drinks can lead to obesity. Supporters also said it would be a funding source for anti-obesity programs.

"[This is] one strategy, but an important strategy, to address the obesity epidemic," said AMA President-elect Ron Davis, MD. "We're talking about products that are extremely harmful to people's health."

A small number of states already have imposed such a tax, and some physicians would like to see the concept become much more widespread.

"We don't expect this to be a panacea for the obesity epidemic, but an important step in the right direction," said Erica Frank, MD, MPH, a preventive medicine physician from Atlanta, who spoke for the American College of Preventive Medicine.

By a slim margin, delegates voted to refer this proposal, part of a Board of Trustees report, for more study.

In the debate, some expressed concern that money raised would not go where the AMA directed. "Small taxes tend to become big taxes. There's also no guarantee that the money raised by this tax is going to be used for the intended purpose," said Daniel J. Koretz, MD, an internist from Ontario, N.Y., who represented his state.

Others maintained that such a tax would place too much emphasis on the role that sugared, carbonated drinks might play in the development of obesity and take away attention from other contributing factors such as sedentary behavior. The tax also could motivate soft drink producers to use other equally high-calorie sweeteners to get around it.

"Any manufacturer who puts sugar in a drink and finds himself being taxed will just simply add cane juice or corn syrup," said Debra R. Judelson, MD, a cardiologist from Beverly Hills and a California delegate.

This concept, which is expected to come up again at the Association's Interim Meeting in November, received a negative response from the industry that would be affected. "We need to do the hard work of balancing the equation of calories consumed and calories burned rather than look for solutions that are not going to make a difference," said Kevin Keane, the American Beverage Assn.'s senior vice president for communications.

Incentives for healthy choices

As delegates considered policies to help patients be more nutritionally responsible, they also adopted guidelines for the growing number of incentive programs that encourage healthy lifestyles by rewarding patients with cash or other perks.

According to a joint report from the Council on Medical Service and the Council on Science and Public Health, these initiatives, which have been advanced by insurers and employers, should be designed with doctor input. They also should reward behaviors, not health status, and allow for individualization. Any such efforts should support long-term lifestyle change, and patient confidentiality is needed.

"There's not a lot of data on this, but there's a lot of activity going on," said Albert J. Osbahr III, MD, the member of the Council on Science and Public Health who presented the report. "Because of that, we want physicians and the public involved in this issue to at least understand what is out there and what kind of guidelines would be very important to follow in developing such a program."