Salt has been all over the news this week because of a study just published in The New England Journal of Medicine claiming that if everyone in the U.S. reduced their sodium consumption by 3 grams/day, there would be 32,000 fewer strokes, 54,000 fewer heart attacks, and 44,000 fewer deaths every year. The story that got my attention was:

That’s surprising, I thought. Everything I’ve read suggests that the relationship between salt consumption and cardiovascular disease is weak, inconsistent, and probably only valid for 20-30% of the population. So I expected the article to refer to some new research where, you know, “big benefits” were “seen.” As in observed. Like, in the world. And, given the claim about the magnitude, probably also measured.

To their credit, the authors of the study claim no such thing. The numbers are projections based on the application of several assumed effects of salt reduction, adjusted for different demographics and then applied to a model of the entire U.S. population. Thus, the title of the study: “Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease.”

The article seems to grasp the essentially speculative nature of the findings. The very first sentence uses the conditional tense:

…scientists writing in The New England Journal of Medicine conclude that lowering the amount of salt people eat by even a small amount could reduce cases of heart disease, stroke and heart attacks as much as reductions in smoking, obesity, and cholesterol levels.

The headline, on the other hand, seems to have confused the “scientists” with clairvoyants. Never mind doing any checking into the validity of their assumptions.

And the claim about how the benefits compare to smoking and obesity reduction led to a few headlines like this:

This crazypants idea initially sounds a lot like what the study’s lead author claims:

"The cardiovascular benefits of reduced salt intake are on par with the benefits of population-wide reductions in tobacco use, obesity, and cholesterol levels."

But the logic behind the claim is that a small improvement in the health of every single American would be as significant as a large health improvement in the health of every single smoker:

Dr. Bibbins-Domingo said that for many people the decrease in blood pressure would be modest, which is why, she said, “many physicians have thrown up their hands and said, ‘I’m not going to advise my patients to reduce salt because it’s too hard for patients and the benefits for any individual are small.’

“But small incremental changes in salt, such as lowering salt in tomato sauce or breads and cereals by a small amount, would achieve small changes in blood pressure that would have a measurable effect across the whole population,” she said. “That’s the reason why this intervention works better than just targeting smokers.”

For any given individual, there is no question about whether cutting salt is even close to “as good” as quitting smoking. The evidence for the link between smoking and lung cancer and death is strong, reliable, consistent, and has a clear causal mechanism (carcinogens). The link between salt and cardiovascular disease and death is weak, inconsistent, and still poorly understood.

That latter point starts to get at the problems with the study itself, and not just the headlines it inspired. A number of the assumptions the projection was based on are either demonstrably false or simply unsubstantiated. More on this some other time; for now, a few quotes and links to the essays they come from in Esquire and the medical journal Hypertension:

In a more recent statement, the founder of the American Society of Hypertension, Dr. John Laragh, goes further: "Is there any proven reason for us to grossly modify our salt intake or systematically avoid table salt? Generally speaking the answer is either a resounding no, or at that, at best, there is not any positive direct evidence to support such recommendations."

…

Studies show that 30 percent of the Americans who have high blood pressure would greatly benefit from a low-sodium diet. But that's about 10 percent of the overall population -- the rest of us are fine with sodium. And drastically cutting out sodium may actually hurt some people. ( "Go Ahead, Salt Your Food")

And:

The available data suggest that the association of sodium intake to health outcomes reflected in morbidity and mortality rates is modest and inconsistent. Therefore, on the basis of the existing evidence, it seems highly unlikely that any single dietary sodium intake will be appropriate or desirable for each member of an entire population.... The decision to adopt a low sodium diet should be made with awareness that there is no evidence that this approach to blood pressure reduction is either safe, in terms of ultimate health impact, or that it is as effective in producing cardioprotection as has been proven for some drug therapies. (Salt, Blood Pressure, and Human Health)