The Pharmaceutical Journal
Vol 277 No 7422 p460
14 October 2006

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Cutting down the consumption of salt more
Wisdom dredged from the depths of a bog more
Facing up to the bully in medical school more
Questionnaires and the ticking of boxes reduced to absurdity more

Cutting down the consumption of salt

An editorial in the 16 September issue of the BMJ draws attention to the current battle between health experts and trade organisations concerned with adding salt to our diet.

In June the American Medical Association voted to implement strategies designed to reduce salt intake in general, and urged the US Food and Drug Administration to revoke the “safe” status of salt and develop measures limiting its amount in processed and restaurant foods. The objective is a 50 per cent reduction over the next decade. In addition, consumers should be educated in the benefits of long-term re-education and labelling should draw attention to high-salt foodstuffs. The warning follows a series of reports in the US of the adverse effect of excessive salt consumption on blood pressure.

Industry predictably made its riposte. The Salt Institute, on behalf of salt producers, claimed that the evidence had been misread, and stroke and mortality confused with blood pressure changes. Nevertheless, raised blood pressure is an important risk factor for cardiovascular and renal diseases.

Reducing salt intake requires both a substantial public health approach and changes in individual behaviour. Unlike cigarette smoking, where use of the product is evident, salt in the diet is not readily apparent. More than 75 per cent of it comes from processed foods, and so any efforts to reduce intake must involve persuasion or regulation of food manufacturers.

Lifestyle interventions are notoriously difficult to achieve, but clinical trials have indicated the need to set a daily mean salt consumption of 100mmol of sodium, equivalent to 5.8g of salt, in the general population. The upper limit should be reduced to 65mmol in particularly sensitive individuals such as African-Americans, middle-aged and older people and those with hypertension, diabetes or chronic kidney disease.

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Wisdom dredged from the depths of a bog

An interesting piece of information appears in the 4 August issue of Science.

A bulldozer operating in a Irish bog recently unearthed an ancient book written on vellum, still in its original binding and folders. Archaeologists from the National Museum of Ireland found that it contained ancient Christian psalms and was perhaps 1,200 years old. This is judged to be the first manuscript discovered in a bog and preserved by peat.

The volume consists of 80 pages, comprising 40 sheets of vellum fabric and the psalms are inscribed in a Latin script used by scribes in early Christian Ireland, resembling the rounded characters known from the illuminated manuscript of the famous Book of Kells, also about 1,200 years old. The text of Psalm 83 can be read, and experts who have examined it think the manuscript may contain all the psalms and in addition some clues to religious practices current in the period in which the book was written. Once the relic has been safely dried and preserved scholars will be paying close attention to what it may reveal.

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Facing up to the bully in medical school

An editorial in the 30 September issue of the BMJ draws attention to the problem of bullying and harassment in medical schools. Of course, schools of any kind are the recognised breeding grounds of bullies, but the malpractice extends into all manner of institutions.

Bullying causes pain, distress, physical illness and damage to a career, and can also lead to errors in the treatment of others. Verbal threats, physical intimidation and offensive comments play their part but, eventually, the sole purpose of bullying is to hide the bully’s inadequacy and incompetence.

One way of facing it is to make a direct approach, preferably in the presence of a colleague, and request that the behaviour cease. Failure to follow up may mean that others get the same treatment.

It is important to remember that students subjected to bullying may suffer higher rates of alcohol abuse, depression and even suicidal tendencies, as well as finding a career less satisfactory than it would otherwise be.

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Questionnaires and the ticking of boxes reduced to absurdity

There is an intriguing comment in the BMJ of 9 September by James Owen Drife, of Leeds, on the modern habit of expressing opinions by placing a tick in a space.

Professor Drife remarks that no one knows when or where the first human ticked the first box, but there is no Biblical reference to the word “tick”. There is no archaeological evidence for “boxes” or their ticking or crossing in Egyptian papyri or inscriptions in French caves or Asian temples. This has led to the conclusion that in fact the great civilisations of the past flourished without resorting to questionnaires and that the modern craze for expressing opinion by a tick is something for which our bureaucrats must accept responsibility. Personally, I find the proliferation of requests for our tick or cross repugnant and bearing the mark of Big Brother and the Nanny State.

Professor Drife has mentioned that aerial photographs of Peru show regular rows of box-like outlines over an area of several square miles, headed by pre-Inca hieroglyphs for sun, moon and cloud. However, there are no traces of ticks or other distinguishing features associated with them.

The questionnaires so prevalent today were invented by psychologists who studied small children unable to read or write. By the end of the 20th century they were being used to monitor the medical profession. This raised controversy. British medical teachers complained that this was an oversimplification of their assessment of pupils, reducing it to a computerised game.

Professor Drife’s vision of the future suggests that a Third International Congress on Medical Box-Ticking report in 2012 would agree a simple generic form for all medical questionnaires seeking feedback from colleagues, patients, patients’ relatives and managers. This would prompt lay people to tick all middle boxes regardless of the questions. The reaction to this would reduce questionnaires into blank sheets that would become obsolete because no one would trouble to read them.

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