Shaking the Salt Habit

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Reducing the sodium in your diet can lower your risk of high blood pressure and other serious ailments.

You PASS ON USING THE SHAKER at the table and use a variety of herbs and spices in place of salt when you cook. Can you still be getting too much of the white stuff?

Absolutely. The federal government's National High Blood Pressure Education Program (NHBPEP) recommends that adults consume no more than 2,400 grams of sodium per day, which is about the amount in a teaspoon of salt. The government Dietary Guidelines for Americans updated in 2005 are even stricter, saying people should consume fewer than 2,300 grams daily, and that those with high blood pressure, African-Americans and middle-aged and older adults should get only two-thirds of that amount of sodium. The American Heart Association (AHA) advises people with heart disease to consume no more than 2,000 milligrams of sodium per day.

These are broad-brush recommendations. Individuals respond differently to sodium, and you may be more or less sensitive to its effects than average. In general, though, less sodium is better for your health.

How much better? A recent report by Britain's Medical Research Council (MRC) estimates that a 37% reduction in that nation's sodium consumption--which is even higher than in the US--would result in a 13% reduction in stroke and a 10% decrease in the incidence of heart disease.

Research recently presented at the American Heart Association's Scientific Sessions shows specifically how cutting back on dietary salt intake can reduce the risk of heart disease. Back in 1987 to 1995, as part of a nationwide trial, men and women ages 30 to 54 with high normal blood pressure learned how to identify, select and prepare low-salt foods. Researchers at Brigham and Women's Hospital in Boston followed up with the participants and found that those who reduced their sodium intake had lowered their subsequent risk of cardiovascular disease or death by 26%. The researchers also found that a higher average intake of sodium was associated with increased risk of later cardiovascular events.

"A decrease in sodium in the diet, even among those with only modestly elevated blood pressure, lowers risk of cardiovascular disease later in life," says Brigham and Women's researcher Nancy Cook, DSc.
Hypertension and Other Risks

The primary threat from too much salt in your diet is high blood pressure, which is a major risk factor for cardiovascular disease--the nation's number-one killer. Salt increases blood pressure because its sodium--one of salt's two " ingredients" (for the difference between salt and sodium, see the box below)--makes the body retain extra water. The additional water in the blood vessels creates more pressure. To pump the added fluid, the heart has to work harder, putting an added strain on your heart.

About 65 million people have high blood pressure, according to a recent study published in the journal Circulation. Those with normal blood pressure at age 55 nonetheless bave a 90% chance of eventually developing hypertension, defined as a blood-pressure reading of 140/90 or higher.

According to Stephen Havas, MD, MPH, MS, vice president for science, quality and public health for the American Medical Association, 700,000 Americans die each year of heart disease and more than 160,000 die of stroke. "Those who don't consume a healthy diet are putting their lives at risk," says Dr. Havas, who also represents the American Public Health Association on an expert committee that advises the National Institutes of Health on hypertension.

He adds that an estimated 150,000 lives are lost each year directly attributable to excess sodium consumption.

"Unfortunately, a lifetime of eating too much salt is needlessly increasing the risk of dying from cardiovascular disease." Sodium consumption, Dr. Havas says, is "the driving force" behind hypertension in particular.

Besides a heart attack, hypertension also increases your risk of stroke and kidney disease. Too much salt can worsen symptoms such as swelling and shortness of breath and cause weight gain. Extremely high salt consumption affects bone health and may contribute to stomach cancer.

Pregnant women have also long been cautioned to cut back on salt to avoid preeclampsia, a toxic condition associated with swelling and elevated blood pressure, usually late in a pregnancy. More recent studies, however, have found that sodium consumption close to or below the adequate intake of 1.5 grams per day seems to have no effect on whether preeclampsia occurs. "Thus, the recommended intake for sodium during pregnancy is the same as for nonpregnant women," the National Academies (which includes the National Academy of Science) said in its Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate in 2004.

Although sodium is an essential nutrient your body needs. Dr. Havas says no one fails to get enough from natural sources. In fact, the National Academies' Dietary Reference Intakes report in 2004 estimated that the Yanomamo Indians of Brazil survive with less than 200 milligrams per day of sodium. At the opposite extreme, the report noted that the average daily sodium intake in northern Japan is more than 10,300 milligrams per person--three times the average US level. (The Japanese diet also is typically heavy in potassium; for more on the yin and yang of potassium and sodium, see the box on the next page.)
How Much Is Too Much?

Last September, the US Food and Drug Administration (FDA) amended pending rules so that meals and main-dish products can call themselves "healthy" if they have 600 milligrams or less of sodium (480 milligrams for individual products); more restrictive levels had been scheduled to take effect on Jan. 1 of this year. The FDA cited technological barriers to reducing sodium in processed foods and poor sales of products that did meet the pro-posed lower levels. In light of the government's own guideline of 2,300 milligrams of sodium daily, however, some health advocates say those higher levels don't exactly seem like an all-out war on salt.

That's what the British government has recently launched, following the MRC's findings about the health benefits there of slashing sodium intake. According to the MRC, the average Brit consumes a whopping 9,500 milligrams or salt per day (that's 3,800 milligrams of sodium). The national goal is to cut that amount to 6,000 milligrams of salt per day (or 2,400 milligrams of sodium) by 2010 for adults.

That's an ambitious goal. The MRC says a survey conducted in 2000-01 found that just 15% of British men and 31% of women consumed less than 2,400 milligrams of salt per day. And salt consumption has actually been rising in Britain: That 9,500 milligrams average was up from a 1986-7 study in which adults were taking in 9,000 milligrams of salt each day.

The government recently launched a public-awareness campaign that includes a television ad in which chick- en curry, spaghetti sauce and other pre- pared foods vie for a shopper's attention. She makes her selection based on the salt content listed on the label. "Eat no more than six grams [6,000 milligrams] of salt a day," ends the ad from the Food Standards Agency, an independent department similar to the United States' FDA.

"Bringing our salt intake down to below the recommended level of six grams per day for adults will result in many thousands of lives saved in years to come," says Graham MacGregor, MD, professor of cardiovascular medicine at London's St. George's Hospital and chairman of England's Consensus Action on Salt and Health (CASH), a group of specialists concerned with salt and its effects on health,

Americans may not consume quite as much salt as the British, but most of us also have a way to go to reach our own government's guideline of no more than 2,300 milligrams of sodium daily, According to the recently released report, "What We Eat in America," based on data from the ongoing National Health and Nutrition Examination Survey (NHANES) compiled in 2001-02, the average American consumes 3,292 milligrams of sodium daily. The figures are worse for certain segments of the population: Males ages 31-50 consume the most sodium, a whopping 4,252 milligrams daily. Only infants, on average, are getting less than the recommended maximum of 2,300 milligrams a day. Overall, across all gender and age groups, 86% of Americans are consuming too much sodium, according to the report.

Richard L. Hanneman, president of the industry-sponsored Salt Institute, maintains that no medical studies have concluded that the health of people who consume salt at the rate we do in the US is at risk. He says sodium should be judged on its overall effects on health, not just blood pressure. He says it's plausible--though untested--that since salt intakes are relatively predictable and unchanging over time, "the body may use salt as a feed-limiter, turning on or off humans' appetite mechanism and affecting total food intake. If that would prove true, substituting low-sodium foods into the diet might not reduce total sodium, but might lead to increased caloric intake and contribute to overeating."

But Dr. Havas says the salt-calorie equation is exactly the other way around. Salt makes you thirsty, which causes you to drink more high-calorie fluids such as sodas and alcoholic beverages. "Why else do you think bars put out bowls of salty peanuts?"
How to Cut Back

In any case, most medical experts agree that reducing your sodium intake is an important step to better health. The only real question is how to do it?

The tricky part about shaking the salt habit is that as much as 90% of the salt you consume every day is " hidden"--salt that you don't shake on at the stovetop or the dining table. According to one tally, about 77% of the sodium in the average American diet comes from processed foods and restaurant foods. About 12% occurs naturally in foods such as dairy and seafood. Only 5% is added during cooking, and just 6% gets added at the table from your salt shaker.

For example, one cup of canned ham and bean soup comes in at 972 milligrams of sodium per serving. One company's individual-sized pan pizza has 983 milligrams of sodium per serving. One hamburger chain's signature burger has 1,070 milligrams, representing nearly half the upper limit of your recommended sodium for the day before you've even asked for fries (more salt, plus of course saturated fat and calories) or had something to drink. (That diet soda can add another 50 milligrams of sodium.)

If you're in the habit of eating on the run, whether it's via fast-food restaurants or heat-and-serve products at home, don't try to change your salt intake overnight. Salt adds flavor to food, and going to the opposite extreme cold turkey is a recipe for failure. As the FDA noted in amending its rules on sodium content in "healthy" food labels, some foods that are good for us aren't good for the manufacturers' bottom line. In another acknowledgement of that fact, the National Academies' Dietary Reference Intakes recommended additional research to guide the food industry in developing technologies that reduce prepared and processed foods' sodium content while maintaining food quality, acceptability and cost.

For success in cutting down on sodium, take a leaf from HHS's Dietary Approaches to Stop Hypertension, or DASH, Eating Plan. DASH is an outgrowth of research sponsored by the National Heart, Lung and Blood Institute (NHLBI). The plan, which is low in sodium, saturated fat, cholesterol and total fat, and emphasizes fruits, vegetables and low-fat dairy foods, is considered the best dietary blueprint against hypertension.

But even expert sources such as DASH and the American Heart Association recommend gradual change to retrain your tastebuds. For example, you might simply remove the salt shaker from your table or refrain from using the salt packet that came in the bag with your fast food. Rather than cutting out popcorn (which is a good source of whole grain), consider the brands that don't add salt or butter--or pop it yourself from kernels.

You can lose a lot of dietary sodium painlessly just by switching from canned vegetables to fresh or frozen produce. If you can't find affordable produce options, seek out reduced sodium varieties of canned vegetables, as well as low-sodium chicken broth, soup and other packaged foods.

You can also cut the sodium in canned vegetables by draining and giving them a quick rinse: According to Steve Harrison at Bush Brothers, a packager of beans, for instance, the nutrition facts on a can of variety beans (chicken peas, kidney beans, etc.) assume the entire contents, the beans plus the brine. By simply draining the beans, you reduce the sodium content by approximately 40%, Harrison says, based on an analysis by an independent lab. A 30-second rinse with plain water reduces the sodium by about another 3%. In a simple can of beans, this two step trick can reduce the sodium content per serving from a typical 400 milligrams to 228 milligrams.

As this example shows, it's important to read those nutrition labels! Unlike fat and fiber listings that can sometimes be confusing, sodium is a label line that's easy (albeit sometimes shocking) to read and understand. Just make sure you're aware of the serving size that goes with that sodium figure.

But the battle against sodium doesn't end at the supermarket. Many restaurant meals contain more than an entire day's worth of sodium. "Ask for low-salt alternatives when you order," , suggests Dr. Havas. "And if they can't comply, switch restaurants."

Try these other sodium-cutting tips that we've culled from the DASH Eating Plan and the British Food Standards Agency:

• Use fresh poultry, fish and lean meat, rather than canned, smoked or processed types.

• Choose ready-to-eat breakfast cereals that are lower in sodium.

• Limit cured foods (such as bacon and ham), foods packed in brine (such as pickles, pickled vegetables, olives and sauerkraut) and condiments such as MSG, mustard, horseradish, catsup and barbecue sauce.

• Limit even lower-sodium versions of soy sauce and teriyaki sauce.

• Flavor foods with herbs, spices, lemon, lime, vinegar or salt-free seasoning blends.

• Cook rice, pasta and hot cereals without salt.

• Cut back on instant or flavored rice, pasta and cereal mixes, which usually have added salt.

• Cut back on frozen dinners, mixed dishes such as pizza, packaged mixes, canned soups or broths, and salad dressings--these often have a lot of sodium.

• Rinse canned foods such as tuna, to remove some sodium.

• Marinate meat and fish in advance to give them more flavor without salt.

• Add red wine to stews and casseroles, and white wine to risottos and sauces for chicken. (Don't make the mistake, however, of buying " cooking wine," which contains sali: to make it undrinkable.)

• Make your own stock and gravy instead of using cubes or granules.
A DASH of Healthy Eating

Once you've had success with those modifications, you may wish to delve more deeply into a low-sodium lifestyle, such as that outlined in the DASH Eating Plan.

The research behind DASH was conducted at Brigham and Women's; Duke University Medical Center in Durham, NC; Johns Hopkins; and the Pennington Biomedical Research Center at Louisiana State University in Baton Rouge, beginning in 1994. It initially involved 459 adults with blood pressure below 160/80-95. Twenty percent had high blood pressure; about half were women, and 60% were African-American. Participants followed one of three eating plans--a typical diet; a typical diet higher in fruits and vegetables; and DASH--all of which had about 3,000 milligrams of sodium per day. Both DASH and the plan higher in fruits and vegetables reduced blood pressure, with DASH having the greater effect, particularly among those with high blood pressure.

In the next phase, from 1997 to 1999, 412 participants with blood pressure readings of 120-159/80-95 followed either DASH or a typical diet at one of three sodium levels (3,300,2,400and 1,500). "Results showed that reducing dietary sodium lowered blood pressure for both eating plans," the NHLBI says. "At each sodium level, blood pressure was lower on the DASH eating plan than on the other eating plan. The biggest blood pressure reductions were for the DASH eating plan at the sodium intake of 1,500 milligrams per day. Those with hypertension saw the biggest reductions, but those without it also had large decreases."

In an added benefit, "Those on the 1,500-milligram sodium intake eating plan, as well as those on the DASH eating plan, had fewer headaches," NHLBI says.

Recent research has found that modifying a DASH-like diet by switching 10% of calories from carbohydrates to protein or monounsaturated fat may make this healthy eating plan even better. See the story on page 1 of this issue.

Remember that cutting back on salt is only part of the answer to fighting hypertension and its related health problems. You'll want to Limit overall calories and maintain a healthy weight. It's important to also develop an exercise plan that fits your interests and your needs. And, just for fun, throw a pinch of that salt you're not using over your shoulder for luck!

TO LEARN MORE: Dietary Approaches to Stop Hypertension Eating Plan . British 6-gram effort and . National Academies' Dietary Reference Intakes report and other scientific information of interest . USDA Nutrient Data Laboratory . National High Blood Pressure Education Program . American Heart Association and .
Where the Salt Is-and Isn't

Only a small amount of sodium occurs naturally in foods; most of the sodium in your diet gets added in processing. This table from the DASH Eating Plan gives examples of the amounts of sodium in some foods:

Legend for Chart:

A - Food Groups
B - Sodium (milligrams)

A B

Grains and Grain Products

Cooked cereal, rice, pasta, unsalted, ½ cup 0-5
Ready-to-eat cereal, 1 cup 100-360
Bread, 1 slice 110-175

Vegetables

Fresh or frozen, cooked without salt, ½ cup 1-70
Canned or frozen with sauce, ½ cup 140-460
Tomato juice, canned ¾ cup 820

Fruit

Fresh, frozen, canned, ½ cup 0-5

Lowfat or Fat-Free Dairy Foods

Milk, 1 cup 120
Yogurt, 8 ounces 160
Natural cheeses, 1 1/2 ounces 110-450
Processed cheeses, 1 1/2 ounces 600

Nuts, Seeds, and Dry Beans

Peanuts, salted 1/3 cup 120
Peanuts, unsalted, 1/3 cup 0-5

Beans, cooked from dried, or frozen, without

Salt, ½ cup 0-5
Beans, canned, ½ cup 400

Meats, Fish, and Poultry

Fresh meat, fish, poultry, 3 ounces 30-90
Tuna canned, water pack, no salt added, 3 ounces 35-45
Tuna canned, water pack, 3 ounces 250-350
Ham, lean, roasted, 3 ounces 1,020

Kitchen Chemistry Lesson

You'll often hear the terms "salt" and "sodium" used interchangeably, but they're not exactly the same thing. Chemically speaking, salt consists of 40% sodium and 60% chlorine. Remember the NaCl formula from your high school chemistry class? The "Na" (from the Latin "natrium") stands for sodium, the "Ci" for chlorine. Even though it takes one of each to make a salt molecule, the atomic weight of chlorine is roughly half again as much as that of sodium, so chlorine makes up 60% of the weight of salt.

That means that if you want to convert an amount of salt to sodium, you need to divide the salt figure by 2.5; to convert sodium to salt, multiply by 2.5. So 1,000 milligrams of salt would be 400 milligrams of sodium; 1,000 milligrams of sodium would be 2,500 milligrams of salt. The amount of sodium that the government dietary guidelines recommend as the maximum per day--2,300 milligrams-would be contained in 5,750 milligrams of salt, about one teaspoon.

Potent Potassium

Potassium just might be the anti-salt, it turns out. "Diets rich in potassium not only reduce blood pressure, but also blunt some of the rise in blood pressure that occurs in response to sodium intake," according to Lawrence Appel, MD, MPH, professor of medicine, epidemiology and international health at Johns Hopkins Medical Institutions. "High intakes of potassium also reduce bone loss and can prevent kidney stone recurrence in men and women." Potassium also helps to reduce irregular heart beats suffered by those with congestive heart failure.

The National Academies' Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate, a report developed by American and Canadian scientists and released in 2004, as well as the Dietary Guidelines for Americans 2005 recommend that people consume 4,700 milligrams of potassium each day from fruits, vegetables and juices. No upper limit was set. That's a lot of potassium: a cup of baked acorn squash, one of the richest potassium sources, has about 900 milligrams, while a banana has between 400 and 500 milligrams. Other fruits and vegetables to consider as potassium sources include spinach and other dark, leafy greens; cantaloupes; oranges; tomatoes; winter squash; potatoes; and beans. Almonds and dairy products are also good sources.

Remember in selecting your potassium sources to balance other concerns, such as sugar. And the Dietary References Intakes report noted that people with known kidney problems and on certain medications, such as those for high blood pressure, have to carefully monitor their potassium intake and should follow their health care professionals' advice rather than the general recommendations.

Salty Language

What's the difference between, say, "low sodium" and "reduced sodium"? Here's a quick rundown on the Food and Drug Administration's definitions of various sodium content terms:

Sodium free or salt free: Less than 5 milligrams (mg) per serving

Very low sodium: 35 mg or less of sodiumper serving

Low sodium: 140 mg or less of sodium perserving

Reduced or less sodium: At least 25% less sodium than the regular version

Light in sodium: 50% less sodium than the regular version

Lightly salted: At least 50% less sodium per serving than reference amount

Unsalted, without added salt, no salt added: No salt added during processing, and the food it resembles and for which it substitutes is normally processed with salt

Hunting Hidden Sodium

Britain's Medical Research Council suggests you watch out for these sodium-based food additives:

Additive Use

Sodium citrate Flavoring, preservative
Sodium chloride Flavoring, texture, preservative
Monosodium glutamate Flavor enhancer
Sodium cyclamate Artificial sweetener
Sodium bicarbonate Yeast substitute
Sodium nitrate Preservative, color fixative

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