For years, Americans have been advised to consume less sodium, and they’ve taken that advice with a grain of salt.
Even many health-conscious consumers figured it was the least of their worries, especially compared with limiting their intake of calories, saturated fat, trans fat, cholesterol and sugar.
All that changed last week when a report from the Institute of Medicine urged the government to gradually reduce the maximum amount of sodium that manufacturers and restaurants can add to foods, beverages and meals. The report put a spotlight on what doctors and nutritionists have argued is a major contributor to heart disease and stroke.
More than half of Americans have either high blood pressure or pre-hypertension, says cardiologist Clyde Yancy, president of the American Heart Association and medical director at the Baylor Heart and Vascular Institute in Dallas.
“That puts a lot of us in the bucket of people who need to be on a lower sodium diet. Sodium contributes to most people’s high blood pressure, and for some it may be the primary driver.”
Cutting back on sodium could save thousands of people from early deaths caused by heart attacks and strokes each year, and it could save billions of dollars in health care costs, he says.
Others second that. “Salt is the single most harmful element in our food supply, silently killing about 100,000 people each year,” says Michael Jacobson, executive director of the Washington, D.C.-based Center for Science in the Public Interest. “That’s like a crowded jetliner crashing every single day. But the food industry has fended off government action for more than three decades.”
Now salt has our attention.
But reducing it in the American diet is easier said than done. “We have, in essence, ignored the advice because we are driven by convenience, and sodium makes a fast-food lifestyle very easy,” Yancy says. “To change, we would need to live and eat differently.”
Americans now consume an average of about 3,400 milligrams of sodium a day, or about 1?? teaspoons, government data show. Men consume more than women.
But most adults ??? including those with high blood pressure, African Americans, the middle-aged and the elderly ??? should consume no more than 1,500 milligrams a day, according to the dietary guidelines from the U.S. Department of Agriculture. Others should consume less than 2,300 milligrams, or less than a teaspoon, the guidelines say.
And yet it’s virtually impossible to limit yourself to such amounts if you often eat processed foods, prepared foods or restaurant fare, including fast food. Most Americans’ sodium intake comes from those sources, not the salt shaker on the table.
Some restaurant entrees have 2,000 milligrams or more in one dish. Fast-food burgers can have more than 1,000 milligrams. Many soups are chock-full of sodium. So are many spaghetti sauces, broths, lunch meats, salad dressings, cheeses, crackers and frozen foods.
Can’t see it, can’t taste it
Salt serves many functions in products. Besides adding to a food’s taste, it is a preservative.
“You can’t see it,” Yancy says. “You can’t even taste it because you are so accustomed to it. If you want the freedom to make healthy choices, you are limited by today’s foods. That’s a problem.”
To change that, food companies and restaurants will have to come up with new ways to formulate products and recipes to help consumers gradually lower their salt levels, which would wean them off the taste.
That’s a huge challenge, but nutritionists and public health specialists say it can be done and will be worth it. “There is no health benefit to a high-sodium diet, and there is considerable risk,” says Linda Van Horn, a professor of preventive medicine at Northwestern University Feinberg School of Medicine.
Even those whose blood pressure is in the normal range should watch their intake, Yancy says. “Here’s a wake-up call: Every American who is age 50 or older has a 90% chance of developing hypertension. That increases the risk of heart disease and stroke. This is a preventable process, and it’s preventable with sodium reduction, weight control and physical activity.”
Why it can be harmful
There are several theories for why sodium increases blood pressure, Yancy says, “but the most obvious one is that it makes us retain fluids, and that retention elevates blood pressure,” which injures blood vessels and leads to heart disease and stroke. “It’s a connect-the-dots phenomenon.”
Some people, especially some African Americans, are more salt-sensitive than others, Yancy says.
“When they are exposed to sodium, they retain more fluid, and because of the way their kidneys handle sodium, they may have a greater proportional rise in blood pressure,” he says.
The cost of this damage? An analysis by the Rand Corp. found that if the average sodium intake of Americans was reduced to 2,300 milligrams a day, it might decrease the cases of high blood pressure by 11 million, improve quality of life for millions of people and save about $18 billion in annual health care costs.
The estimated value of improved quality of life and living healthier longer: $32 billion a year. Greater reductions in sodium consumption in the population would save more lives and money, says Roland Sturm, a senior economist with Rand.
Yancy says the country doesn’t just need health care reform, “we need health reform. If we don’t adjust the demand part of the equation, no system will work. Remarkably, people might be overall healthier by simply reducing sodium.”
But Yancy says people need to keep in mind that sodium is just one of the factors that increase the risk of heart disease and stroke. Others include obesity, consuming too much sugar and too few fruits and vegetables, lack of physical activity and smoking.
Salt industry disagrees
Leaders in the salt industry say their product is being unfairly maligned. The Institute of Medicine report and the government “are focusing on one small aspect of health, which is a small increase in blood pressure in a small segment of population,” says Lori Roman, president of the Salt Institute, an industry group.
Some of the research that ties salt to health risks is based on faulty assumptions and extrapolations, Roman says. She says a recent worldwide study indicated there is no country where people eat an average of less than 1,500 milligrams a day. “That’s way below the normal range,” Roman says. The Italians eat more sodium than Americans, but their cardiovascular health is better than Americans’, and the reason is they eat a lot of fruits and vegetables, she says.
“This is the real story that the government is missing,” Roman says. “It is the secret to good health.”
She says people may end up following a less healthy diet if they cut back on sodium. “Have you ever bought a can of low-sodium string beans and then tried to season it to taste good? It’s impossible,” Roman says. “Here’s one of the unintended consequences of this recommendation: People will eat fewer vegetables, and by eating fewer vegetables, they will be less healthy.”
Yancy says the first step for many people is making the decision to cut back on salt intake. He knows from experience that it can be done.
An African American, Yancy, 52, has high blood pressure and a family history of heart disease and stroke. He’s lean and exercises for an hour a day, but still he has to take medication for hypertension. Before he started watching his sodium intake a few years ago, Yancy says, he was consuming more than 4,000 milligrams a day, partly because he grew up in southern Louisiana and was used to a salty, high-fat diet.
But he has weaned himself off the taste. He doesn’t have a salt shaker in his house, and he reads the labels on grocery store items and doesn’t buy any that have more than 100 milligrams of sodium in a serving.
“I taste the salt in items and put them aside. I find it difficult to enjoy prepared soups. I can taste the salt in prepared meals. I’ve learned to make my own soups.”
When he eats out, he orders salads and asks for his fish and meat to be grilled. “Typically, I eat fish with lemon juice and pepper.”
Even so, he believes his sodium intake is probably higher than it should be because he often eats in restaurants and cafeterias, and many foods have hidden sodium.
Changes in food products need to be made over time as the Institute of Medicine report suggests, says Van Horn, a research nutritionist at Northwestern. “If we drop the sodium overnight, people will be desperately seeking salt shakers.”
So how hard is it going to be to reduce the salt in processed and prepared foods?
“We’ve been trying to reduce the sodium in foods for more than 30 years. If this were easy, it would have been accomplished,” says Roger Clemens, a professor of pharmacology at the University of Southern California and a spokesman for the Institute of Food Technologists.
The primary dietary source of sodium is sodium chloride, also known as table salt, he says. There are other sodium salts, such as sodium bicarbonate (baking soda) in baking and sodium benzoate (preservative) in bread and beverages. And there are potassium salts that are used in foods ??? as emulsifiers in cheese and buffers in beverages, he says.
“Salt is a natural preservative. It has been used in the food supply to ensure food safety for centuries,” Clemens says. “It’s critical for preserving bacon, olives, lunch meats, fish and poultry.
“Some foods, such as cheese, can only be produced with salt. No other compound allows the proteins to knit together to become cheese.”
If it doesn’t taste good…
To make cheese that is lower in sodium, foodmakers must put the cheese through a special procedure that basically extracts some of the sodium. “It’s a very long, tedious process,” he says.
Salt also is crucial for making most breads. To get dough to rise, manufacturers use sodium chloride and sodium bicarbonate, Clemens says. “If you were to eat a sodium-free product, the texture and flavor would be markedly different. It would be more compressed. I don’t think you’d like it at first.”
He says some manufacturers have experimented with low-sodium items, and in some cases consumers have turned up their noses. “If it doesn’t taste good, consumers won’t buy it.”
Melissa Musiker, a nutrition spokeswoman for the Grocery Manufacturers Association, agrees. “You can’t get ahead of consumers,” she says. “You work on the recipes, test them, see how consumers respond and go back and tweak.”
There is no one single alternative for replacing it in various foods, she says. “It has to be replaced on an ingredient-by-ingredient basis.”
Clemens says food companies will continue to try to develop new technologies to lower the sodium.
“It has taken us 30 years to get this far, and it will probably take us another decade to get a significant difference in the intake. If we can lower sodium in our diet, we’ll have a huge health impact on generations to come.”
By Nanci Hellmich, USA TODAY