The salt "sweet spot"

  Sometimes I crave salt, as I imagine most people do. I don’t know whether the craving means my sodium level is down. Maybe it does. Salt (sodium) is one of the most important nutrients in your body. It maintains normal blood pressure, supports the work of nerves and muscles, and regulates your body's fluid balance. Your body strives to maintain a constant sodium level. If you have normal kidney function and blood pressure, your kidneys can deal with wide variations in sodium intake without increasing your blood pressure. To maintain the sodium level, if you drink too much, your body excretes the excess water it doesn’t need.

Most Americans eat between 3.0 and 4.4 grams of salt per day, with women consuming less and men consuming more. (A teaspoon contains six grams of salt.) According to the USDA’s Dietary Guidelines for Americans, that’s too much. They recommend less than 2.3 grams a day, an amount that would supposedly lower blood pressure and, in turn, result in a lower incidence of cardiovascular disease.  However, scientists reporting in the September 2021 issue of Nutrients found that current evidence indicates that “the risk of adverse health outcomes increases when sodium intake exceeds 5 g/day or is below 3 g/day [my italics].” In other words, the “sweet spot” for sodium intake is three to five grams a day, with “both lower and higher levels of intake associated with higher risk of cardiovascular disease or death.” (The increased risk associated with five grams per day was largely confined to those with hypertension.) In studying populations worldwide, the scientists involved in this study found that, in fact, most people around the world consume this moderate range of salt (three to five grams a day)—a level “associated with the lowest risk of cardiovascular disease and mortality.” 

You can ignore the Dietary Guidelines of 2.3 grams of salt per day. It’s not enough

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For good health, eat a low carb, high fat diet

 In one of the largest and most rigorous trials to date, a new study, published in the American Journal of Clinical Nutrition, found that eating a diet low in carbohydrates and higher in fats is good for you. As you probably know, I, and many others, have been saying this for years. In commenting about the new study, Dr. Dariush Mozaffarian, a cardiologist and dean of the Friedman School of Nutrition Science and Policy at Tufts University, said “It’s a well-controlled trial that shows that eating lower carb and more saturated fat is actually good for you…Most Americans still believe that low-fat foods are healthier for them, and this trial shows that at least for these outcomes, the high-fat, low-carb group did better.”

The study participants were divided into groups in which 20 percent, 40 percent or 60 percent of their calories came from carbohydrates. (The low carb diet largely eliminated highly processed and sugary foods and emphasized carbs from whole fruits and vegetables, beans and legumes. I can’t argue with that.) Protein was kept at 20 percent for all groups. The remaining calories came from fat.

The low carb group got 21 percent of their daily calories from saturated fat, an amount double that recommended by the federal government’s dietary guidelines. Nevertheless, they experienced no detrimental changes in their cholesterol levels. Their LDL cholesterol—the so-called “bad” kind—stayed about the same as those who got just 7 percent of their daily calories from saturated fat. What’s more the low-carb, high-fat group had a roughly 15 percent reduction in their levels of lipoprotein(a), a fatty particle in the blood that is strongly linked to the development of heart disease and strokes.

The low carb/high fat group also showed a 15 percent drop in their lipoprotein insulin resistance scores, which indicates a reduction in the risk of diabetes. Those on the high carbohydrate diet saw their scores rise by 10 percent. What’s more, the low carb group had a drop in their blood triglyceride levels—a good thing because high levels are linked to heart attacks and strokes. They also had increases in their levels of adiponectin, a hormone that helps lower inflammation and makes cells more sensitive to insulin, another good thing.

So what's not to like? 

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Problems with generic drugs

 When a drug goes off patent, competing companies can make generic versions of the drug. Initially, there’s a fortune to be made, but then brutal competition causes prices to drop. Even though generic medications represent 90 percent of prescriptions that are filled in this country, they’re often so cheap that companies stop making them or cut corners to turn a profit. Now, most generics are produced overseas. In fact, a recent study found that of the top 100 generic drugs that Americans consume, 83 had no American source for the drugs' ingredients. The study also revealed that there's no American source for 97 percent of the most prescribed antivirals, and no American source for 92 percent of the most prescribed antibiotics. Chinese companies flooded the US market with penicillin so cheap that American companies couldn’t compete. The last American factory making key ingredients for penicillin closed in 2004.

One problem with this arrangement is that we have no idea where our drugs are manufactured, or the names of the companies contracted to make it. This information is considered trade secrets in the pharmaceutical industry. Another problem is lack of quality control. With drugs being manufactured overseas (mostly China and India), it’s harder for the FDA to inspect factories. They don’t drop in unannounced like they do here. During the pandemic in 2020, the FDA managed to perform just three foreign inspections. More than a thousand inspections had to be postponed. In 2008 at least 81 people died from a poisoned blood thinner traced back to a Chinese supplier. In another case, Valsartan, a generic drug used to treat high blood pressure was found to contain a probable carcinogen. Another blood-pressure medicine, Lisinopril, was found to vary widely from one batch to the next. An inspection of Ben Venue Laboratories in Ohio revealed that poorly maintained equipment shed particles into the drugs. Major companies have been caught faking and manipulating the data that is supposed to prove that drugs are effective and safe. And so on.

Quality control issues are a leading cause of drug shortages both at American plants and overseas. Sometimes the FDA shuts down a plant after discovering violations. Other times companies with quality control issues stop making a drug rather than investing in expensive upgrades to their facilities. 

So we don't know who makes our generic drugs or whether we can trust them for safety and efficacy. Maybe shortages aren't such a bad thing.

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A thirty-year study of old people

 I recently found the transcript of a May 4, 2014, edition of 60 Minutes that discussed a study of  people who are 90-plus. The study was sparked by a discovery, in 2003, of a survey that had been completed in 1981 by 14,000 residents of Leisure World, a retirement community in California. Residents had provided data about their diet, exercise, vitamins, activities, and other health-related matters. In poring over the records from 1981, the researchers discovered that 1,900 of these people were still alive and enrolled 1,600 of them in a follow-up study. Here is what they learned about the still-healthy “oldest old”:

• Exercise: “People who exercised definitely lived longer than people who didn’t exercise. As little as 15 minutes a day on average made a difference.” Forty-five minutes was best and it didn’t have to be every intense.
• Socializing: "For every hour you spent doing activities in 1981, you increased your longevity and the benefit of those things never leveled off."
• Vitamins: “People who took Vitamin E didn’t live any longer than people who didn’t take Vitamin E…The short answer is none of ‘em [vitamins] made any difference."
• Alcohol: “Moderate alcohol was associated with living longer…Up to two drinks a day led to a 10-15 percent reduced risk of death compared to non-drinkers."
• Caffeine: "Caffeine intake equivalent to 1-3 cups of coffee a day was better than more, or none."
• Weight: “It turns out that the best thing to do as you age is to at least maintain or even gain weight." People who were overweight or average weight outlived people who were underweight.
• Blood pressure: “If you have high blood pressure it looks like your risk of dementia is lower. “

 I find most of these findings heartening.

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Costa Rica’s health care beats ours

 Costa Rica spends less on health care as a percentage of income than we do. Its per-capita income is a sixth that of ours, and its per-capita health care costs are a fraction of ours. Nevertheless, their life expectancy is nearly 81 years, while ours peaked at just under 79 years in 2014 and has declined since then. For people between ages 15 and 60, the mortality rate in Costa Rica is 8.7 percent. Here, it’s 11.2 percent—a 30 percent difference. In Costa Rica, the average sixty-year-old survives another 24.2 years compared to 23.6 years in the U.S. Here’s why: Costa Rica has made public health central to the delivery of medical care. Individual health and public health are inseparable. Even in countries that have good universal health care, public health is an add-on, not central to health care. In Costa Rica, it’s been a priority for decades.

Here's how they do it: They set up community health care teams throughout the entire country. The teams consist of a physician, nurse, and community health worker. Every Costa Rican is assigned to one of the teams. The health care worker visits every household at least once a year. Children have regular pediatric visits starting from the first day of life. People with diabetes are enrolled in classes to learn about controlling their blood sugar. Everyone gets contacted about vaccination appointments. And so forth. It’s all free. The Ministry of Health also deals with community-wide concerns and undertook programs to deal with malnutrition, toxic hazards, running water, and other health-related issues.

In the U.S., according to Dr. Atul Gawande, our medical systems “seldom focus on any overarching outcome for the communities they serve. We doctors are reactive. We wait to see who arrives at our office and try to help out with their ‘chief complaint.’” We’ve got plenty to complain about.

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