Guest Essay by Kip Hansen
Prologue: This is the first in a series of several essays that will discuss ongoing scientific controversies, a specific type of which are often referred to in the science press and elsewhere as “Wars” – for instance, this essay covers the Salt Wars1. The purpose of the series to illuminate the similarities and differences involved in each.
Warning: This is not a short essay. Dig in when you have time to read a longer piece.
From the New York Times, Wednesday, June 1 2016, “F.D.A. Proposes Guidelines for Salt Added to Food”:
“The Food and Drug Administration proposed voluntary guidelines for the food industry to reduce salt on Wednesday [1 June 2016], a move long sought by consumer and public health advocates who said the standards could eventually help save thousands of American lives.”
….
“Americans eat almost 50 percent more sodium than what most experts recommend. High-sodium diets have been linked to high blood pressure, which is a major risk factor for heart disease and stroke.”
….
“While there has been some scientific controversy over how much to reduce sodium, scientists at the F.D.A. said the health advantages are beyond dispute.”
If one follows the offered link to “some scientific controversy” one finds this report in the New York Times piece No Benefit Seen in Sharp Limits on Salt in Diet, by Gina Kolata, May 2013, regarding the Institute Of Medicine of the National Academies booklet-sized review of the entirety of modern science on salt intake and health titled “SODIUM INTAKE IN POPULATIONS: ASSESSMENT OF EVIDENCE” written by its Committee on the Consequences of Sodium Reduction in Populations issued in 2013 [free pdf].
Among the several findings and conclusions of this massive review is:
“Finding 2: The committee found that the evidence from studies on direct health outcomes was insufficient and inconsistent regarding an association between sodium intake below 2,300 mg per day and benefit or risk of CVD outcomes (including stroke and CVD mortality) or all-cause mortality in the general U.S. population.”
And further:
“…the committee found that the available evidence on associations between sodium intake and direct health outcomes is consistent with population-based efforts to lower excessive dietary sodium intakes, but it is not consistent with recommendations that encourage lowering of dietary sodium in the general population to 1,500 mg per day.”
Gina Kolata, the long-time NY Times Health journalist, summarized is this way:
“In a report that undercuts years of public health warnings, a prestigious group convened by the government says there is no good reason based on health outcomes for many Americans to drive their sodium consumption down to the very low levels recommended in national dietary guidelines.”
The American Journal of Hypertension, October 2013 issue, covered the topic extensively in this issue largely dedicated to the Salt Wars following on the Institute of Medicine’s 2013 report (mentioned and linked above). The INTRODUCTION: The Salt Discourse in 2013, written by Theodore A. Kotchen, characterizes the findings of the IOM report as:
The IOM report concluded the following:
- “The evidence supports a positive relationship between higher levels of sodium intake and risk for CVD.”
- “The evidence on health outcomes is not consistent with efforts that encourage lowering of dietary sodium in the general population to 1,500 mg/day.”
- “There is no evidence on health outcomes to support treating population subgroups differently than the general US population.”
Yet, as we see reported on the first of June 2016, The Food and Drug Administration just issued guidelines to the processed food industry based on the assumption that “the health advantages [of population-wide dietary salt reduction] are beyond dispute”.
Are the health advantages of population-wide dietary salt reduction beyond dispute?
Hardly. The latest salvo fired in what has long been called The Salt Wars1 was published last month, on 20 May 2016. A huge international review study [paywalled] led by Professor Andrew Mente, PhD, the title of which begins with “Associations of urinary sodium excretion with cardiovascular events….”, in one of the world’s leading medical journals, The Lancet. The study had a cohort of 133,000 individuals across 49 countries and was undertaken and written by 29 internationally recognized researchers, all PhDs and/or MDs. Their published interpretation of its findings is:
“Interpretation: Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension. These data suggest that lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets.” [emphasis mine – kh]
In an accompanying Comment [also paywalled] in the same issue of The Lancet, Professor Dr. Eoin O’Brien of the Professor of Molecular Pharmacology, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, and past President of the Irish Heart Foundation writes:
“When apparent dogma is challenged, we should speak not of controversy but rather accede to the all-encompassing expression of so-called scientific uncertainty, so as to avoid unbecoming rhetoric. The issue of population strategies for salt consumption is a good case in point. There is no argument other than “excessive salt in the diet raises blood pressure”, and that strategies to reduce salt in individuals with hypertension prevent the cardiovascular consequences of the disease. However, the corollary that reducing sodium intake across populations will be beneficial to all, has been challenged with the assertion that doing so might indeed be harmful.”
Todd Neale reports bluntly on the study for tctmd.com (an industry supported news aggregator covering interventional cardiology news and education):
” Consuming less than 3 grams of sodium per day is associated with a greater risk of all-cause death or major cardiovascular events compared with more moderate intake in both hypertensive and normotensive individuals, an observational study of more than 130,000 participants has shown. In contrast, consuming 7 grams or more per day is tied to worse outcomes in hypertensive patients only.
The findings conflict with advice by the American Heart Association (AHA) to consume no more than 1.5 grams of sodium per day.”
The Neale article continues with:
But Daniel Jones, MD [past President of the American Heart Association] (University of Mississippi Medical Center, Jackson, MS), speaking to TCTMD on behalf of the AHA, which issued a public statement refuting the study, strongly disputed its results.
“This is a flawed study, and no health policy should be based on this study,” he said. It’s “difficult to do good studies, but the preponderance of the evidence is that most people eat too much sodium and that people’s general health will be improved by eating less sodium. This message that people should be concerned about eating too little sodium is just something that should not be taken seriously.”
Indeed, the American Heart Association fired back with a press release and web page titled “Experts criticize new study about salt consumption”. Two experts, the current and immediately-past President of the AHA, are quoted:
Mark Creager, M.D., president of the American Heart Association…..“The link is proven between excess sodium and high blood pressure, and I find it worrisome that adoption of the authors’ recommendations may reverse the progress that has occurred in modifying dietary sodium intake and reducing the risk of high blood pressure and its effect on heart disease and stroke,” Creager said. “Today’s widely accepted sodium recommendations are based on well-founded scientific research – and that’s what people should understand.”
Elliott Antman, M.D., associate dean for clinical/translational research at Harvard Medical School and senior physician in the Cardiovascular Division of Brigham and Women’s Hospital in Boston, said the findings of the new study should be disregarded.
“This is a flawed study and you shouldn’t use it to inform yourself about how you’re going to eat,” said Antman, immediate past president of the AHA. “The AHA has reviewed the totality of the evidence and we continue to maintain that no more than 1,500 milligrams of sodium a day is best for ideal heart health.”
So far, that’s three American Heart Association Presidents trotted out to attack the new study and its findings, which agree with and expand on the findings of the National Academies’ Institute of Medicine from 2013.
What in the world is going on here?
* * * * *
Let’s roll the clock back 15 years, to the turn of the century and look at this article from the New York Times Science section: With Dietary Salt, What ‘Everyone Knows’ Is in Dispute by Abigail Zuger (NY Times, January 9, 2001). Zuger leads with this:
“Diet fads may come and go, but low salt is forever. Or so, at least, any reasonable person might conclude from the consistent message in most guidelines over the last two decades: eat less salt.
But behind the official pronouncements rages one of the longest, most vituperative battles in medicine. It has continued despite a decades-long procession of ”landmark” studies, each designed to end the debate, and each only provoking more disagreement.”
Already, in 2001, the Salt Wars have been raging for decades. Zuger outlines the battle lines for us:
“One set of scientists, backed by most of the country’s major health organizations, maintains that cutting back on salt is good for people, whether they have high blood pressure or not.
”Salt matters,” said Dr. Frank Sacks, an associate professor of nutrition and medicine at Harvard, who led the most recent study. ”The results are so clear-cut, there’s just not much controversy left.”
Dr. Jeremiah Stamler, an emeritus professor of preventive medicine at Northwestern University Medical School in Chicago, who has spearheaded the anti-salt forces for decades, said that he himself stopped eating most salt in 1948.
”The question of salt is settled,” Dr. Stamler said. ”It’s a food additive we don’t need.”
And on the proverbial other hand:
“But other equally respected scientists still rally firmly behind the salted pretzel, maintaining that there are better tools for controlling blood pressure than salt reduction, and that low-salt eating may actually be harmful to health. [emphasis mine – kh]
”The problem is not so much whether we have too much salt in our diet as it is the deterioration of the American diet,” said Dr. David McCarron, a professor of medicine at Oregon Health Sciences University in Portland, who argues that salt makes little difference in blood pressure control when people eat balanced diets that emphasize fruits, vegetables and low-fat dairy products. ”That’s really the issue.”
Dr. Michael Alderman, a professor of medicine and epidemiology at Albert Einstein College of Medicine in the Bronx and past president of the American Society of Hypertension, said: ”I don’t believe there is any basis whatsoever for a public health recommendation for eating any particular sodium content diet. A scientific problem ought to be solved by data. And there is no data.”
Fifteen years ago, the then-recent dual studies undertaken by the National Institutes of Health – called “Dietary Approaches to Stop Hypertension” or the DASH studies – had shown that blood pressure could be better controlled by eating a well-rounded diet high in fruits, vegetables, and dairy. This so-called DASH diet produced blood pressure reductions on the same level as blood pressure medications. The second DASH study seemed to show that the DASH diet coupled with salt reduction produced even better results. Both studies have been challenged by both sides of the Salt Wars, both sides interpreting the results in favor of their viewpoints.
“….Dr. Stamler of Northwestern said….[regarding] the findings of the second DASH study, ”there is no question that for everyone else [those who do not already have optimal blood pressure] there is a significant effect from lowering salt.”
however
“Not so, Dr. McCarron said. ”The most important finding in the second DASH study is the unequivocal evidence that the first step in blood pressure control should be adding things missing from the diet: the fruits, vegetables and low-fat dairy products,” he said. ”If people have to put their money down on a dietary intervention, the blood pressure response they will get from that is far better than from worrying about salt.”
[all quotes immediately above are from the Zuger NY Times piece – kh]
On a pragmatic level, the DASH studies found that “cutting back on sodium from 3,300 milligrams a day to 2,400 milligrams [note: this recommendation has since been dropped even further to 1,500 mgs/day – kh] lowered blood pressure in the study by an average of 2.1/1.1 for people who ate a normal diet. Changing to a DASH diet lowered their pressure substantially more, by 5.9/2.8, without any salt restriction at all.” [included quote from the Zuger NY Times piece – kh]
Let’s look at that more closely. A salt reduction diet, cutting back to 2,400 mg/day, for people with a normal diet, resulted in an average lowering of blood pressure (BP) of 2.1/1.1 (mmHg). If your blood pressure (BP) was 150/95 (which was and is considered high), then, on average, salt reduction to 2,400 mm/day would lower your BP to 147.9/93.9. That amount of improvement does not stand up as a Minimal Clinically Important Difference – “The MCID defines the smallest amount an outcome must change to be meaningful to patients.” In other words, no one’s high BP is cured by a reduction of 2.1/1.1, such a small reduction doesn’t improve a patient’s well-being or general state of health. In fact, that is a fraction of the “white coat effect” which raises some people’s BP by 10 to 30 mmHg simply because their BP is being measured by a doctor – “The term white coat hypertension may be used if you have high blood pressure readings (i.e. readings that are consistently 140/90mmHg or above) only when you are in a medical setting. Your blood pressure readings may be normal when they are taken at home.”
This brings us full circle back to the most recent Salt Wars salvo, the Mente et al. study in the latest issue of The Lancet, “Associations of urinary sodium excretion with cardiovascular events….” [paywalled], which, 18 years later, confirms the findings of Alderman: “Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular [CV] events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension.” In other words, while high sodium (salt) intake does increase the risk of CV or death in those who are already hypertensive (have high BP), enforced low sodium diets, population wide, will have overall negative health effects – increasing risk of CV events and increasing risk of all-cause death – for everyone, without respect to BP – the most optimum health outcomes are found with moderate salt intake regardless of BP status.
For the American Heart Association, and its allies who share its long-term anti-salt stance, these findings — no matter how scientifically sound, no matter how robust, no matter that they replicate and confirm earlier findings – are simply unacceptable. The AHA has publicly stated that these findings should be “disregarded”.
Let’s take a break for a minute. The information discussed so far represents a only a tiny bit of the vast literature involved in the Salt Wars. I have purposefully steered clear of science journalist Gary Taubes and his work in the NY Times and in Science magazine, which together comprise the best summary of the Salt Wars up to mid-1998. Taubes had written about the Salt Wars for more than two decades. [He is perhaps more well-known for his efforts in the Obesity Wars.] His work – on the pragmatic salt-is-salt side of the Wars – is legendary. I have also avoided the opinions of and work by “The Salt Guru”, Morton Satin, who came out of retirement to be the Vice President of Science and Research at The Salt Institute, a non-profit trade association based in Alexandria, Virginia, an association that taints his work in the eyes of many. (Before that, Satin spent sixteen years as the Director of the United Nations Food and Agriculture Organization’s Agribusiness Program.) Satin’s general view is that the salt debate is filled with shoddy science and outright misinformation.
In a funny aside – and many reading here will recognize this situation — it has been reported that Satin has claimed Taubes won’t even take his phone calls for fear of becoming tainted by contact. Taubes denies this. But, I mention it because, as in other modern scientific controversies, “guilt-by-association” is rampant – a modus operandi practiced by all factions.
What We Know About Dietary Salt:
- Salt is an absolutely necessary element of the human diet – humans die without adequate salt intake.
- For most people, consuming a moderate amount of salt daily (2,500-5000 mgs) has no adverse effects.
- High blood pressure (BP) is associated with cardiovascular disease and risk of premature death.
- For almost everyone, eating more salt causes an increase in BP, but the increase is not clinically important, averaging around 2.1/1.1 mmHg.
- For a certain percentage of people, believed to be in the 10-15% range, who can be labeled “salt sensitive”, dietary salt causes higher BP and for those already suffering high BP and who have a high salt intake, dietary salt reduction combined with improved diet (the DASH diet – more fruits, vegetables, and low-fat dairy, specifically) can help reduce BP to healthier levels.
- For most people, a diet too low in salt increases risk of cardiovascular events and increase risk of all-cause death.
- The science to quantify what constitutes “too low”, “moderate”, and “too high” regarding salt intake is best characterized as “somewhat uncertain”.
What We Know About Salt Politics:
- The Salt Wars have been raging for 30 years, at least.
- One side of the Salt Wars believes that because dietary salt increases BP (in most people just by a small amount) and causes a big increase BP in some people, coupled to the idea that high BP is associated with increased heart disease and risk of death, that governments should take action to reduce the salt intake of everyone – population wide – through regulation of the food industry, setting dietary guidelines, etc. Arrayed on this side we find the American Heart Association, United Nations’ World Health Organization, and the US FDA. Many food and diet advocacy groups stand with the AHA against salt. Taken together, these groups represent a view that consists of a “bureaucratically entrenched hypothesis advocating an enforced solution”.
- The opposition believes that the science is not adequate to mandate a population-wide reduction of salt intake, maintaining that, in addition to being not necessary, it will cause harm instead of good, increasing cardiovascular events and premature death among all groups. The majority of scientists on this side of the issue also hold that the DASH diet is far more effective in reducing high BP than salt reduction.
- Despite the mounting evidence of harm from population-wide enforced salt reduction, various government agencies have been passing rules, regulations, and guidelines to force the food processing industry and, most recently, in New York City, mandatory labeling of highly salted foods by chain restaurants.
- As in all modern scientific controversies, the faction occupying a societal Bully Pulpit, in this case the AHA, FDA, and WHO, has a huge advantage, even when the hard scientific facts are not on their side. [“A bully pulpit is a sufficiently conspicuous position that provides an opportunity to speak out and be listened to…. a terrific platform from which to advocate an agenda.”]
- The Salt Wars are an exemplar of what can happen when a hypothesis is scientifically correct but its real-world overall effect becomes grossly exaggerated. This can lead to a “mandated solution” which is then sold as a cure-all for some existing problem. As the underlying science is in fact uncertain, scientists in support of this view must turn themselves into advocates to make their case. Political advocates in turn pretend to be scientists, advising governments to enforce a “one-size-fits-all” solution on the whole society – even though it is probable that the claims of benefit range from uncertain, at best, to nonsensical [see footnote 2 for the my rationalization for this statement in the Salt Wars].
Modern scientific controversies, sub-category Science Wars, all follow a similar pattern and have common features. As this series progresses, it will become obvious what these features are and the harm they cause to the reputation of Science and Scientists.
# # # # #
Footnotes:
- Please note that in all instances, the word salt in this essay, and in all included quotes, refers to common table salt, sodium chloride, in all of its customary forms found in kitchens, restaurants, grocery stores and food processing plants. The use of the term “Salt Wars” does not originate with me but has been in common usage in science journalism for some time. I offer this link: Scientific American – Health – The Salt Wars Rage On: A Chat with Nutrition Professor Marion Nestle in support of its use. (Nestle is pronounced like the action “to nestle”, Dr. Nestle is not related to the famous chocolate fortune family). The term’s use in this essay (and SA) is not to be confused with the many actual armed conflicts over the ages and around the world that have shared the title Salt War.
- From the same source as Footnote 1, I quote Marion Nestle “I was once at a sodium meeting at which there were a bunch of statisticians. And I left with the statisticians and they said that “anyone who thinks that salt has anything to do with hypertension is delusional.” And that was on the basis on the clinical trials that show so little. And yet every single committee that has dealt with this question says, ‘We really need to lower the sodium in the food supply.’ Now either every single committee that has ever dealt with this issue is delusional, which I find hard to believe—I mean they can’t all be making this up—[or] there must be a clinical or rational basis for the unanimity of these decisions.” And “Everybody argues about every clinical trial no matter what the conclusion. So I find the whole thing completely fascinating.”
# # # # #
Author’s Comment Policy:
I have been sidelined for the last six-months by a heart attack that acted to reset my priorities somewhat. I have, thankfully, fully recovered and spent a month sailing with family up the Eastern Seaboard of the United States, with my youngest son acting as Captain.
As always, I will be glad to answer your questions about the Salt Wars – which I have followed since the 1980s. I am open to suggestions on which of the current Science Wars to cover in this series, I am aware of a half dozen or more.
I realize that many readers here will want to move on immediately to discuss the Climate Wars – one of the distinctive science wars of our day. I ask that you please try to restrain yourselves – we’ll get to that later on in the series.
The last essay in the series will be an attempt to layout a coherent pattern of modern science wars and maybe suggest ways that the different science fields themselves can break these patterns and return their specific area of science back to the standards and practices that should exist in all scientific endeavors.
# # # # #
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Have you done any research on High Fructose Corn syrup? My suspicion is this is part of a larger plan to control our lives. Millennials seem in general to be freaked out about all kinds of dietary intake primarily because they haven’t any substantial education regarding the scientific method.
and GMO’s, but maybe Kip will get to those …
Reply to Tom Ragsdale and Bubba Cow ==> Yes, I agree, the HFCS issue is developing into a science war — often wrapped up in the more general Obesity Wars and the Sugar Wars. I’ll put it on my list.
Bubba — The GMO Wars are already on my list. Plenty of craziness there to amuse us….
There’s too many epidemiologists out there publishing. I would prefer the epi locate a relationship and then a scientist step in to attempt to determine causal pathways… if they can’t then the epi goes back out and tries again.
As to fructose fears, do these fearful types fear fruit? Honey? no – they really need to learn a bit about chemistry then they might not fear the sources of their sugars quite so much.
The only reason why we use High Fructose Corn Syrup is because the government keeps the price of sugar artificially high by restricting how much sugar the country is allowed to import.
when you hear the phrase “settled science” you know there is an agenda and science has left the building.
Thanks Kip
Would it be possible to post a pdf of your essay?
Marcel
Reply to Marcel Crok ==> Certainly — here.
There is a whole bunch of more on this to be found at the American Councel for Science and Health:
http://acsh.org/?s=salt&cat=0&x=12&y=31
Without wanting to side-track this discusiion, there is another scientific topic that has had and still has high attention by policy makers: The effects of secondhand-smoke exposure. I have been studying this topic for over 10 years. So far I haven’t found even a single statsistic of causes of death from CAD or respiratory diseases that can be associated with bans on smoking in pubs and restaurants. Shoddy science at best.
Shoddy “science” masquerading as “medical” advice is being used heavy-handedly to enforce “virtue.” Where morality-based temperance movements failed, scare-tactics have replaced them. What they’ve done to smoking, they’re ramping up with alcohol–it’s all about taking control.
I was told by one young socialist that he didn’t care if second hand smoke was bad or not.
He hated the smell of cigarettes and he didn’t want to worry about whether his chosen restaurant permitted smoking or not.
It was so much easier on him to just have the government ban it everywhere, and he wouldn’t have to worry about making that choice any more.
As far as he was concerned, his life style preferences trumped everyone else’s.
MarkW I know that same socialist I think ! I had the same conversation, got the same ‘I don’t like the smell’ retort, so I put it that I loathed the smell of onions cooking outside hardware stores on weekends and Brut 33 on the train so they should be banned too – and was promptly told ‘well that’s just stupid’
Funny story (I think): My family went to Utah on vacation and we went out to eat, as you do. The hostess asked how many were in our party, and I said, “Six, non-smoking.” She gave us an odd look, at which point we remembered where we were. (Non-Americans, Utah’s population is majority Mormon, and the devout ones do not smoke.)
I told this to a local relative, thinking it was just a funny thing because of the Mormon thing, and she told me that Utah had recently passed a law prohibiting smoking in restaurants. This was one of the first I had heard of being passed. Several years later, a similar measure passed in Virginia.
Really, banning the smoking sections and other such “sins” just makes it harder to brandish one’s superiority. It is like using an e-reader. How are you supposed to signal your condescension if no one can see the book cover or massive number of pages?
Reply to Ben Palmer ==> Thanks for the link — it shows how current the Salt Wars are — and how pervasive.
You’ve only got to to look at occupational health and safety guidelines for the various components of cig smoke (as legitimate researchers did) to find even in the smokiest old pubs the concentrations were far, far below restriction guidelines. Interestingly I even stumbled across some research on the background behind nicotine’s toxicity and it seems the LD50 ascribed to it was basically made up back in 1909 and never challenged since then.. and if taken on face value should see smokers dropping dead after 2 cigs !
(But we probably shouldn’t be discussing sm0king.. hysterics love to tie Den|er5 of climate to evil t0bacco advocacy)
An interesting article. My only comment is that most people do not have any idea of the amount of salt in the processed food that they eat. While they may not add much extra salt to their diet, they may already be way over even the 5000mg target from products that we might assume had zero.
Very interesting.
OK, i would like to go back and pick up the story circa 1975.
Salt causes hypertension was dogma, even back then. Fairly draconian low-salt/no-salt diets which were very hard to live with were common, all over the place. Everybody knew at least a few people who was on one, and would often get an earful about how hard it was to deal with.
So that is the situation in 1975.
Right at that time, I took a course in physiology, an advanced course from the Biology Dept. which assumed a good set of background skills in Bio., Chem., and (of course) Biochemistry. The textbook was excellent, as was the prof. The curriculum was intense and demanding, and was specifically slanted away from general biology and towards human clinical, to service those going on into medical fields.
When we got to blood pressure regulation, and the role of salt, the stated explanation simply did not make sense. In fact, It seemed, from what was presented in the textbook, that salt should have little, if any effect. In confusion, I brought my concerns to the prof. The prof. agreed that the stated explanation made no sense at all, but that was the accepted mechanism, nonetheless.
I most certainly expected that any biological/chemical mechanism used to explain any biological effect should at least make sense to someone with a good and proper background in the sciences. This one simply did not.
So why does the medical community think what it does? I cannot answer that, but I can make an observation. I would later find out that the physiology course I took mirrored that which was taught in Med School, not pre-med! (That’s why it was so hard.)
{I digress: Often, the students would whine “why do I have to learn *all* this stuff, I am not going to be a MD”. I would always respond “Learn it. In 20 or 30 years you are going to be glad you know this stuff.” But I digress}
A Parting Shot:
If you want to elucidate the mechanism of salt in blood pressure mediation, you need to do some hard-core biochemistry. All the medical population studies with all the statistical analysis in the world are not going to get you anywhere.
And that is how wars get started.
I’m not educated in any biological field but as I had kidney failure I have taken an interest. Transplanted now 9 years and doing pretty good.
I’m not sure where I got this idea but I’ve always thought the “salt is bad” assumption came from the idea that more salt retains more water, which raises systolic b.p. and causes arteriosclerosis. I just use a little moderation.
Damn Warmists are bad for my blood pressure!
Reply to TonyL ==> Thanks for sharing your university experience with us.
BP regulation is an extremely complex topic — most MDs haven’t a clue, they just follow “best practices” rules.
You are most welcome, of course.
This is an excellent article and I look forward to the whole series.
One way I was taught to evaluate the quality of research was by the standard of “biological plausibility.” If the known physiology shows a clear pathway for the theory to work, it’s passed a significant test. If there IS no plausible pathway, just majick or “standard practice,” you’ve uncovered a piece of the Great Unknown.
An interesting article, thank you for posting.
Like the controversy that rages around the human impacts on climate, the complex arguments about how much salt is acceptable has pitted highly qualified individuals in a contest that does little more than confuse the wider audience. This must concern, not only because it is difficult to know what to do for best, but more importantly today’s political operator has grasped the chance to use such issues to impose their own cure all solutions. The trouble is, that in far too many cases these so called answers are in fact detrimental to the future of the majority of mankind.
What dismays me in particular about this is that we have the ability and means to work out ideas that take into account the uncertainties surrounding such disputes. For climate related concerns for example, we can take advantage of nuclear processes to generate electricity without adding CO2 to the atmosphere. Yet rather than addressing the concerns of such a technology, we squander the chances by fear mongering. In essence mankind as a species has ceased to advance into the broad sunlight uplands spoke about by Winston Churchill, instead we have lost our nerve and have become fearful of our own shadow.
Comes down to THIS: If you are one of the 5% of severe hypertensives who are salt-sensitive, follow your doctor’s recommendations and restrict what you must. The rest of us need never give it a second thought.
And NO ONE needs to lose a minute’s sleep over their “carbon footprint” or the rest of the CAGW claims–they’ve had 30 years to prove their hypothesis and it has demonstrably failed miserably.
“in one of the world’s leading medical journals, The Lancet. ” I stopped reading your article right there. The Lancet published ridiculous estimates of deaths in Iraq as if they were facts and has shown itself happy over the past decade or so to publish all kinds of biased, non-scientific articles as long as they support “the correct position.” Try again with reliable sources.
Further evidence of the unreliability of The Lancet (this should sound familiar to readers of WUWT): From The Lancet: “Climate change could be the biggest global health threat of the 21st century. Effects on health of climate change will be felt by most populations in the next decades and put the lives and wellbeing of billions of people at increased risk. During this century, the earth’s average surface temperature rises are likely to exceed the safe threshold of 2°C above pre-industrial average temperature. ” http://www.thelancet.com/commissions/climate-change#Apr24
Quite frankly, I’m shocked the Salt article quoting The Lancet was even considered a valid article for publication here by Anthony.
So your focus is not what was said and why but instead you focus on who said it and therefore it must be wrong.
@DonK31 – Of course I considered the source; once I identified it as a source that has lied repeatedly in the past, I immediately ignored what it said. I imagine if someone lied to you repeatedly, you would trust them as a source of information? After 4 or 5 times of being lied to, a rational person stops listening and finds other sources that are trustworthy.
If you don’t have the resources or the knowledge to evaluate the claims for yourself, the next option is to evaluate the trustworthiness of the source.
The Lancet has proven time and again that it puts politics and political correctness ahead of actual science.
I too have difficulty with using The Lancet publications as unbiased authority, but I applaud the revelation of government medicine as more pseudo-science.
Yes, I did the math on the Lancet article at the time. In order to be valid there would need to have been 100’s of deaths every day for the time period considered. The media gleefully reported every incident and most days the death count was zero. Only a few specific major incidents got over 100
Reply to Patrick B ==> You raise an issue that is very important == Does the publishing of a study in top tier journal guarantee that it is scientifically sound?
The correct answer is — Of Course Not — There Are No Guarantees.
Unfortunately, you take the opposite, equally incorrect view — If a journal has ever published a study that was later found not to be scientifically sound, or that your disagreed with, or that had to be retracted, then no content in that journal should ever be trusted again.
The error in both views is that they rely on a logical fallacy — The Genetic Fallacy.– judging an argument (a study, in this case) solely by its (publishing) source.
The Lancet itself is not the source of the study nor its findings, any more than JAMA is. They are scientific publishers, scientific journals.
Top tier journals, in all fields, do have better peer review (certainly no guarantee), are more careful with details, and have more rigorous procedures that help to weed out poor science.
Each and every study, published in a top tier journal or in an online junk journal, needs to be evaluated on its merits.
@Kip Hansen – Kip, you make the error of assuming The Lancet is an unbiased “top tier” journal attempting to publish only proper studies which, like any journal, may now and then pick an article about a study that turns out to have an error in it. That is not the case with The Lancet. The Lancet has a proven record of a publishing bias and a proven willingness to ignore blatant errors so as to bring attention to, and show support for, certain social/political ideologies. As such, The Lancet cannot be viewed or treated as an unbiased scientific journal but should be viewed with the same skepticism as a political rag. Likewise, it is not unwarranted to assume those working with a political rag are willing to cut corners to prove a point as well.
Life’s too short to read everything so we don’t pay attention to every two bit blog post – or any psuedo-scientific political hack journals like The Lancet.
The Lancet has proven itself to be fallible a lot more than once.
eggs and cholesterol
Dietary cholesterol does not equate to serum cholesterol. Eggs are beneficial in so many ways and the yolks provide much needed nutrition. I know some people who order “egg whites only” and seem to wear that as a badge of intelligence much like vegetarians.
Reply to Latitude and Ton in Florida ==> Tom is correct — most recent studies have shown that dietary cholesterol plays almost no role in cardiovascular problems.
As with much of the biological world, things are both more and less complicated than they seem. The cardiovascular disease wars are 60 or 70 years old now. What wasn’t known as clearly then, maybe, compared to today is that local immune regulation of the damaged cell response is key to many of the diseases of long life. Blanket recommendations such as “Everyone cut your sodium chloride intake (NaCl is *not* the only *salt* we need)” will make some sick, make some recover from certain sicknesses, and make no difference for more than either.
Our bodies develop by intricate chemical signaling. Apoptosis at the wrong time and place results in a damaged body. Nevertheless, that body that developed contains within it the seeds of its own self-destruction. Mortal man, doomed to die. 120 years is all we get. A key change in the DNA/RNA repair and regulation regime cut us from having bodies that could last 10 centuries down to 1.
The definition of a healthy diet is the one that does not make *you* sick. That will not necessarily apply to others.
Nice job on the salt wars, Kip. I think a lot of people instinctively realize that the “alarmist” approach is overstated. The same statement can be made about the climate wars. But it seems to be limited to people who are instinctively skeptical, and this comes from education and temperament. In both cases, many of those who buy the “consensus” do so impassively – almost the path of least resistance. If they’re interested in other things, or simply disengaged generally, folks are more likely to believe the consensus.
A few blogs have been ruined by the climate wars. Dot Earth had some of the most toxic commenters on the planet, and Andy Revkin, a reasonable person who was catching hate from both sides, got to where he couldn’t stand it any longer. I think he will avoid the climate wars and steer toward other aspects of “sustainability” – such as energy science and policy. I hope he sticks around in the blog space, but blog sponsors have to find a way to moderate out the loonier voices. Andy has done a poor job here, and NYT comment policy hasn’t helped him.
I haven’t studied commenting and commenters on this blog, but my instinct is that WUWT has done a better job of winnowing out toxic bloggers, and comments here have a more moderate tone. I’d like to see a bit more openness to the warmist side in its featured articles (warmists do have some valid points) but its sponsors seem content to leave warmism to the many blogs that have drunk the KoolAid. Warmists don’t have a monopoly on dogma and intolerance, and we skeptics need to be very cognizant of straying into this sort of disfunction.
Reply to scraft1 ==> Until recently, I had been a frequent commenter at Andy Revkin’s blog at the NY Times. I agree that the “Dirty Dozen” commenters there have ruined the comment section, making it “mostly worthless”. Revkin himself seems to have discovered that it is more fun being on the “winning side” — certainly gets him more invites to important conferences and speaking engagements. In my opinion, he is simply too busy teaching kids to be propagandists to write for his own blog. Suspect the NY Times will drop him soon.
True, Andy has found that there’s a good living to be made catering to the warmist side of the climate wars. I’m not sure even he believes it – He definitely has a skeptic streak in him.
Science tends toward improvement of the human condition, these groups ignore it, most of these people believe that there are to many humans, a lot of their counter science arguments will eliminate some humans, when that is your goal, increased mortality cannot be viewed as a negative outcome. It is the preferred outcome and is repeated again and again, GMO, DDT, CO2, Y2K, etc. Any time you direct resources at a unnecessary event, you are almost by definition denying resources to a necessary event.
Not sure why you include Y2K in your list. In that case, there were very real concerns that were prevented by the directing of resources at solving the problem.
Good medical outcome for you Kip, thankfully.
Your approach here is interesting and important.
Leaving aside the phenomenon that few people nowadays can envisage a new enterprise that is not regulated, an interesting topic in itself, we find this pattern of group intervention ‘for the public good’ to have flawed research behind it time and again.
If not on your list, there is a wonderful pre-packed capsule example in the book “The Apocalyptics” by Edith Efron. In exquisite detail, she follows the course of an invented epidemic of USA cancers caused by man-made chemicals, 1960-80s period. Huge structure set up, new laws made, lots of money spent – but the epidemic never happened.
As you infer, strange outcomes can flow from groupthink about what seems like a good theory at the time. I suspect that it is much more common a human failing than most people are aware of.
To be controversial, I would propose that there is a strong link with organised religion in the sense that many individuals believe in very low-probability events like life after death, a place in the clouds named heaven and so on. People must know these cannot exist yet half the population are believers and so we have special structures and special laws like tax free concessions.
If people accept this religious conundrum, maybe they accept the salt wars puzzle and the non-epidemic of cancer.
It is all around us with belief in acupuncture, homeopathy, seaweed extracts to make better gardens, tablets with anti- oxidants, acceptance of “I am from the government, I am here to help.”
Philosophically, it is simply weird. People en mass are gullible in the extreme.
Problem is, I have no idea on how to show them that they are being conned. An advertising expert might have some ideas, since they help cause some of the stupidity.
Good luck with your project, Kip. It will be fascinating to find which further topics you have selected.
Geoff.
Reply to Geoff Sherrington ==> Thanks for your input, Geoff.
Never safe to use religion as an example. I, for instance, majored in religious studies at UCSB back in the day and am am more-than-a-believer in life — before, during, and after this mortal existence — go figure, huh?
Human gullibility is the root of the multi-billion dollar health-food/vitamin-supplement racket.
Yes Kip,
So having admitted to some of the ‘faults’ that you seek to criticise when others adopt irregular concepts, logically (not personally) are you now in a poor position to continue with the essays? Or can you erect a 100% perfect personal Chinese Wall?
Geoff, your atheist assertion is not science based. The cosmological argument stands. Science is limited to cause and affect, which demands a first cause of unlimited energy beyond science or rules of causation, or asserts that all things inclusive are without cause, causeless, thus limiting its very foundation to an existing cosmos, but entirely unfit for finalities.
Kip’s, or anyone else’s belief in a soul or a divinity is not necessarily related to their scientific acumen. Science governs the laws for an existing and functioning cosmos, via the cosmological argument it cannot address infinite solutions beyond its own governing cause/affect laws.
Reply to Geoff ==> I do appreciate your general input on topic. However, this is not an appropriate topic for discussion on this thread or at this blog.
I only mentioned my beliefs as an example of how easy it is to incorrectly assume the belief systems of other people and to gently point out that denigrating the religious beliefs/understandings of others is, as you say, “controversial” at best. In the normal course of conversation, especially on a public forum where most others are strangers unknown to you, it is poor manners.
So, let’s leave it at that. This blog concerns “News and commentary on puzzling things in life, nature, science, weather, climate change, technology, and recent news” and this essay, and thus this comment section, concerns Science Wars in general and the Salt Wars in particular.
There are other blogs where fighting the Atheist Wars on Theists is the order of the day — but not here, please.
Not being able to prove something is not the same as proving it to be a low probability event.
What I find fascinating is the way atheists have to constantly attack believers. It’s almost as if they are still trying to convince themselves.
As an atheist I feel that you have the situation reversed. I have never had an atheist knock on my door to try to get me to “notbelieve” but various religious types frequently arrive to try to persuade me to believe in their belief system. These people I consider to be fair game and I try to educate them in the failed science that I consider religion is. Unfortunately it is very difficult or even impossible to persuade these people to look at their religion of choice in a logical manner, even when the illogic of the religion is pointed out to them.
Thank you Richard for helping to prove my point regarding the intolerance of your average atheist.
The fact that you actually believe that religion should be looked at scientifically just goes to prove how ignorant and arrogant you are on the entire subject.
I would try to educate you on the subject but it is quite obvious that your mind is sealed shut on the whole subject.
MarkW,
Sorry, I made no statement attacking either atheists or believers. I merely drew some parallels from widespread experiences.
If you disagree about the existence of life after death and a place called heaven in the clouds, you are welcomed to provide evidence to support such a belief.
If you cannot, it kinda makes a point, eh?
Reply to Geoff, MarkW, Richard of NZ ==> Repeating here for emphasis:
I do appreciate your general input when it is on topic. However, this comment thread is not an appropriate topic for discussion at this blog.
Clearly stated on the Policy page: “Certain topics are not welcome here and comments concerning them will be deleted. This includes topics on religion, ….”
I only mentioned my beliefs (in response to a comment by Geoff S.) as an example of how easy it is to incorrectly assume the belief systems of other people and to gently point out that denigrating the religious beliefs/understandings of others is, as you say, “controversial” at best. In the normal course of conversation, especially on a public forum where most others are strangers unknown to you, it is poor manners.
So, let’s leave it at that. This blog concerns “News and commentary on puzzling things in life, nature, science, weather, climate change, technology, and recent news” and this essay, and thus this comment section, concerns Science Wars in general and the Salt Wars in particular.
There are other blogs where fighting the Atheist Wars on Theists is the order of the day — but not here, please.
Being that I grow and cook much of my vegetables. I also preserve all I can. from pickles, cucumber/okra, to tomatoes sauce and homemade honey mead wine. I have found that processed foods, not only a bit bland, but excessive in its salt. If your mouth dries out after you have eaten, well to much salt. Most foods are designed for maximum flavor, which is deemed to require a high salt content to achieve. I have found this is only an inability to prepared quality food since most vegetables are picked prior to their best flavor. If and when I use processed foods, I always pour out all excess liquids and do not add salt until the very end, if and only if needed to brighten the flavor. Those that prefer more can just add on their own. The biggest issue is that people do not take responsibility for their own intake. And many people do not have senses that allow them to determine quality flavors. An example for me is that my wife does not have a strong sense of smell which effects her taste buds. I can cook the same foods that she enjoyed before, but will no appreciate them the same. I believe if you eat MC’D pink ooze enough, quality of food will be known. Most importantly do not eliminate your salt intake unless a qualified doctor recommends it. Then be cautious to the extent of sweating during workouts.
Right on the money Tom. I will add that salt, like sugar, is an addictive taste. Once you get used to less salt, you will no be able to tolerate overly salted foods.
Ding, ding, ding. We have a winner. There is an optimum daily range, which varies by individual. The problem is that there’s so much sodium in processed food that it’s farcical http://www.nytimes.com/interactive/2016/06/07/health/salt-in-food.html?_r=0 Most of the population has significantly higher than optimum intake, and would benefit from a reduction in sodium/salt.
The point about reducing sodium/salt in processed food is that if you’re an athlete/construction-worker/whatever who needs extra salt, you can always take salt tablets, or add salt to your food. People who do not need all that sodium/salt are the majority, and yes, they would benefit from a reduction of sodium/salt in processed food.
Reply to Walter Dnes ==> Your expressed viewpoint is exactly the logic used by the FDA and others pushing for a reduction of added salt in processed foods,
This part of your comment “People who do not need all that sodium/salt are the majority, and yes, they would benefit from a reduction of sodium/salt in processed food.” is what the Salt Wars are about.
The AHA/FDA/WHO side agrees with you.
The loyal opposition says that the majority of people DO NEED that salt anyway, and that it is a minority for whom salt reduction shows any benefit — and maintain that if processors are required to eliminate/reduce added salt, that the majority will be salt deficient and suffer adverse consequences.
Your evidence that most people would benefit from less salt is, what exactly?
As Kip has pointed out, the actual science does not support such a position.
Reply to Kip Hansen (WordPress doesn’t allow nesting that deep) ==> There is an ever-growing (in both meanings of the word) segment of the population that is overweight. They are the ones at risk of hypertension, diabetes, stroke, and heart attack.
Yes, it would be nice if they could be convinced to eat healthier foods, which incidentally cost less than heavily processed junk. But since you can’t force them to do that, the next best step is to cut down the sodium overdose in the foods you do eat. I’ve had to go the (medically supervised) diet route in the past year. I’ve read labels in the stores, and the amount of sodium in food is ridiculous.
I’ve gotten to the point in my diet where I can handle the occasional treat. I take in fish-n-chips at a small place here in Toronto. No “liquor licence” just fish-n-chips. The chips come unsalted, and there are salt and pepper shakers on each table. You want salt, you can have it. You don’t want salt, don’t pour it on. This is about freedom of choice. You can always add salt if you so desire.
Reply to Walter Dnes ==> If you have medical issues, follow the advice of your physician and educate yourself on the subjects involved. Your might look into the DASH diet coupled to your salt reduction approach. Linked several times in the main essay.
Thank you, Kip, for all this work. I look forward to your future installments!
It’s not science, it’s politics. In any case, the real problem is blood pressure, which is one of the primary things your primary physician monitors. If it is high, it is easily, cheaply controlled. The issue is thus trivial, if you’re getting regular check-ups. Advocating reduced salt for everyone is authoritarian nonsense, a symptom of fatal conceit, found extensively and almost exclusively in leftists.
There is no point in having a publicly funded organisation speaking as an authority if you do not use that authority to bully the public, expanding your powers over them.
I had this argument with my grandmother over 40 years ago. Grandma: salt is bad for you, causes high blood pressure. Me: No, in a healthy person the body regulates blood salt levels, excess salt intake just results in salty pee.
Heart doctors have been pushing their nonsense for such a long time, it is burned into their brains. Everyone else gets it. Enjoy your pretzels. Salt, ADDED sugar, high carb low fat diets, it seems the goverment is off track.
I’ve been following this issue on salt casually for many years, and it is reassuring to find I did understand the problem. Most of the controversy is due to the contempt the public health establishment has for the public. What the establishment is doing in trying to restrict salt is of benefit to only a small minority with salt-sensitive high blood pressure, and a relatively small harm to the majority. They will not defend what is a rather questionable strategy on the presumption the general public is too stupid to understand what they are trying to do.
Seems as if the AHA is trying to create business, not reduce it…
Reply to Peter Sable ==> The AHA is, of course, a non-profit organization. They have taken a stand on salt — and they have shown a remarkable tenacity of sticking to it despite all and any evidence that arises that contradicts their platform.
They have the audacity to simply declare studies that contradict them “flawed” (without any scientific basis for this label) and tell the public and medical professionals to “disregard” them. Like Climate science’s “Team”, they fear that contrary data, scientifically correct or not, will “dilute their message”.
This is what I refer to as a “bureaucratically entrenched hypothesis advocating an enforced solution”.
I dunno. AHA wants to benefit its members. If you follow the money, it doesn’t pay for any of these organizations to cure the illness they are about. The most profitable system is where the illness still occurs but they have the (expensive) cure.
The AMA, like most other large organizations is run by politicians. Even if a small handful of those politicians also have MD after their name.
Bored MD here. This is a tempest in the teapot.
The body’s levels of sodium, potassium, calcium, chloride, phosphate, magnesium etc. are all closely regulated by hormonal mechanisms that affect uptake from the gut and excretion or retention in the kidneys, and they are very effective. Using these mechanisms, a healthy body will be able to retain enough salt from regular food, even when unsalted. On the other hand, a healthy body will be able to dispose of surplus salt without problem, unless the intake is truly excessive (e.g. through washing down your salt pretzel with seawater).
I do like my food salty, and I indulge myself without worrying, since like most people I don’t have hypertension. However, diuretic drugs that lower the sodium concentration are proven to lower blood pressure, and it stands to reason that they will be more effective when combined with limiting salt intake. If such a diet is unacceptable to a patient, there are indeed other treatment options.
Same goes for cholesterol. But that doesn’t stop MD’s from loading people up with statins, lowering their serum levels of steroid hormones and jacking up (technical term there) their livers.
Reply to Michael Palmer ==> Dr. Palmer, you are medically and biologically correct.
The battle is over enforced salt reduction, either through insistence of MDs that all patients reduce salt intake even when BP is what-used-to-be normal (but is now considered “high” due to lowering of the bar, part-and-parcel of the
salt.BPsalt/BP wars) or through regulation of the food industry, for all.The data is there for you to see in the Lancet study (you’ll probably have access to the full study as am MD).
I see your point. However, how exactly is anyone going to “enforce” a certain sodium intake? Short of introducing salt stamps and prosecuting all black market trade in them, I don’t see how that could be done.
Maybe this “war on salt” comes just in time though – after all, we need to keep all the cops happy who will no longer be needed for the war on marijuana.
Reply to Michael Palmer ==> ah — point taken — they can not “enforce” individual sodium intake….their efforts are to regulate the food industry into reducing sodium content of foods so that individuals eating a normal US diet would not exceed the extremely low limits they think are necessary. They attempt to influence individuals through public [mis-]education programs, through setting standards of care for your personal physician to follow (her demanding that you reduce salt intake), public health departments ordering fast food restaurants to label food with high salt content to make them look ‘dangerous’, etc.
How fare the sugar wars?
Nearly four years ago I was diagnosed with congestive heart failure with the standard dietary instructions about salt and, of course, bunches of pills. After nearly three years I was seeing little progress … until I eliminated my soft drink habit. Daily average sugar intake over the course of four decades was over 5 times recommended level (I did love my Coke). Six months later, with the cumulative effects of sugar eliminated, my systolic was averaging (over 45 days) at 110 (it’s since crept up to around 113). Now I can enjoy some processed food without guilt.
Now, if only I could get the message across to the staff at the VA that I’m not a suicidal dipsomaniac …
Diet Coke “is an acquired taste”,but I learned to like it. I’m talking about the “brown label” version with zero calories and zero caffeine. That’s the only type of pop that my weight-loss doctor allowed. There are also Pepsi and generic equivalants. I dropped 70 pounds in 4 months (Oct 2015 through Jan 2016) and am maintaining the weightloss, so I figure he knows his stuff. The other thing is 8-to-10 glasses of fluid (no more than one glass of pop) per day. I was originally referred to him because my blood pressure was too high. I’m now off the blood pressure meds.
Reply to Leon Brozyna and Walter Dnes ==> The Sugars Wars continue unabated, though the battle-lines are not as clearly drawn, nor is the science nearly so one sided.
Many people ingest far too much sugar for their own good. In my opinion, they must be doing it knowingly — no one thinks that bottle after bottle of highly sugared soft drinks are part of a healthy diet. (I drink ‘no calorie’ soft drinks.)
That said, the “sugar is poison” crowd are equally wrong — sugar is food — sugar is energy for bodies.
Too much of a good thing is a bad thing.
I love salt. I buy very good salt. I eat approx five times the UK govt’s recommended daily amount. I’m 65 in a couple of months, and also devour a lot of just cooked red meat. My blood pressure hovers between 140/85 and 145/85.
They can sod off with their salt warnings. It’s the stuff of life, and lack of salt is far more likely to kill you than too much.
Proponents of CAGW and salt restriction diets have the same goal, control. Each is just an arrow in their quivers. They use only the data that supports giving them the power to make decisions for you. They are no different than any other dictator or despot. You are just too stupid to understand what is good for you. After all, “we are from the government, and we are here to help.”
The salt scare is fundamentally anti-Darwinian. The mammalian tongue craves salt in an effort to retain the diluted seawater composition of the blood. Your dog loves to lick the salt off your sweat dried skin–no use all that salt going to waste. Considering the scarcity of natural salt deposits on land it is remarkable that the tongue has retained its salt sensitivity as one of only a few such, sweet, tart, bitter. It suggests that sugar and salt are the most important things for primate survival.
The Romans linked salt and health in their language: salt, salutary, in English; dozens of such words in the Romance languages. Maybe salt prevented food from spoiling but its inorganic nutritional value probably had much to do with the supposed connection.
Wiki has a tidbit: https://en.wikipedia.org/wiki/Mineral_lick
–AGF
At one point, the Roman Legions were paid their monthly wages in sea salt.
“A man worth his salt”
“Anti-Darwinian?” ;-)) We’re talking here about the same folks who are trying to convince us that your sex is subjective, “fluid,” and can be changed at will! Dunno ’bout them, but I know what’s in MY pants!
behind the paywall:
http://dx.doi.org.sci-hub.bz/10.1016/S0140-6736(16)30467-6
and
http://dx.doi.org.sci-hub.bz/10.1016/S0140-6736(16)30510-4
it may ask you to type a ‘captcha’
Reply to gnomish ==> Thank you for these links to the full original Mente study and O’Brien comment.
READERS: The two links in gnomish’s comment lead to a site, in some Cyrillic alphabet, which demands a captcha input. They do, however, safely deliver .pdfs of the two articles from The Lancet.
yarr!
ip freely!
P-}