1 Salt: A Primer

Salt tastes good—and makes everything else taste good.

—Kimberly Y. Masibay, FineCooking.com1

Sodium chloride. Plain old salt: the condiment most used by consumers and the food industry alike. More than half of all packaged foods contain added salt. Practically every home has several loaded saltshakers, plus a canister of salt in the cupboard. We mostly use it to bring out the flavor of foods, either adding it when we’re cooking a dish or sprinkling it on our food at the table. Its wide use is no surprise, because saltiness is one of the five basic tastes.

James Beard, the cookbook author who long advocated American cuisine, famously asked: Where would we be without salt? “Adrift in a sea of blandness,” answered celebrity chef Samin Nosrat in her recent cookbook Salt, Fat, Acid, Heat.2 Chef Rick Bayless, owner of Frontera Grill, a Chicago institution, declared that home chefs make one of their biggest mistakes when “they don’t salt enough.”3

Chefs in restaurants or homes—and food manufacturers as well—love salt because it is so flavorful and so cheap. That’s a major reason we find salt in 52 percent of all packaged foods—a higher percentage than any other ingredient (sugar and high-fructose corn syrup are found in “only” 40 percent of foods).4 Even a pinch of salt injects a desirable taste, at almost no cost, into an otherwise bland dish or masks the unpleasant taste of one with bitter ingredients. Companies invest heavily in taste testing to identify the “bliss point” at which flavor, whether from salt, fat, sugar, or other ingredients, is optimized.

In addition to adding flavor, salt performs a multitude of other functions, not least as a preservative. In cured meats and seafood, it retards bacterial growth. In bread, it strengthens gluten and inhibits the growth of acid-producing bacteria. In cheesemaking, it helps separate the curds from the whey, facilitates melting, provides flavor, and inhibits the growth of some microorganisms. Salt also adds a sense of thickness (“mouthfeel,” as food technologists say) to soups and beverages.5 Pickle makers know that using the right amount of salt encourages the growth of “good” lactic acid–producing bacteria and discourages the growth of spoilage bacteria.6 Salt brings out the flavor of other seasonings, and it reduces bitterness or sourness in some foods, allowing sweetness or other flavors to pop out.

Add to the versatility of salt the fact that the body absolutely needs small amounts of it to function. Without salt, or with inadequate amounts of it, our bodies would simply break down: it is present throughout the body and involved in countless physiologic processes, from ensuring healthy blood volume to maintaining the optimal potassium levels in cells, from transmitting nerve impulses to contracting and relaxing muscle fibers. Fortunately, our bodies do not need much salt, so virtually no one needs to worry about consuming too little. Even endurance athletes, such as ultra-marathoners who sweat profusely, do not seem to need salt supplements.7 In the rare cases of people who have too little sodium in their blood (hyponatremia), symptoms might include fatigue, nausea, and confusion, among others.8

Aside from possible harms to health when people consume too much, salt serves at least two dubious, often-unrecognized commercial functions. First, food manufacturers add it to mask the off-flavors created when the ingredients they use are low quality or cooked for excessive times or at high temperatures or extruded at high pressures. Richard Horton, the longtime editor of the Lancet medical journal, minced no words when he said (perhaps with a dash of hyperbole) that food manufacturers “desperately need salt to persuade us to swallow the otherwise inedible rubbish they serve up to us daily.”9

Second, as Thomas G. Pickering, a professor of medicine at New York City’s College of Physicians and Surgeons, Columbia University Medical Center, once explained:

In the 19th century, cattle drivers who were taking their cattle to market in Poughkeepsie, NY, used to stop at a place called Salt Lick on the day before they reached the market, where the cattle would take on salt and water, thereby increasing their weight and market value.10

Today, implicitly admitting to a modern-day version of that chicanery, many meat and poultry processors inject or otherwise add water (and flavor) to their product along with a disclaimer on labels: “__% solution of chicken broth and salt added.” I’ve seen “meat” containing as much as 30 percent added water. The ham shown in figure 1.1 had 23 percent added water, sugar, salt, and other ingredients, for which a consumer paid almost five dollars. Companies called such meat “enhanced” until the US Department of Agriculture (USDA) outlawed that euphemism in 2015.11 I call it adulterated, which it surely is. At a press conference I once held up a seven- and-a-half pound package of chicken and deplored that consumers were paying chicken prices for the water added to it, which amounted to 15 percent of its weight, or slightly more than a pound!12

Sodium chloride and sodium phosphates make it possible for meat to hold on to that much extra water. According to the USDA, 21 percent of beef, 78 percent of chicken, and 57 percent of pork is bulked out this way.13 Such products are far higher in sodium than plain, natural meat. Judging from a 2006 study of poultry conducted by California state officials, consumers nationwide were paying $2.6 billion (adjusted for inflation to 2020 dollars) annually for the added solution.14 Add in the beef and pork products that are watered down, and it appears that consumers are now being cheated out of at least $4 billion annually and possibly much more.

Pickering also noted that because salt stimulates thirst, the bars that offer free salted peanuts, pretzels, and potato chips may do so not out of generosity but because people will order more drinks. (Incidentally, Pickering coined the term “white-coat hypertension,” whereby patients experience higher blood pressure in a doctor’s office than elsewhere.15)

Salt itself provides about 90 percent of the sodium added to food, with a host of additives providing the rest.16 Sodium is integral to baking soda (bicarbonate of soda), baking powder (often containing sodium aluminum phosphate), sodium ascorbate (vitamin C added as a nutrient or preservative), monosodium glutamate (MSG, a flavor enhancer), sodium propionate (a mold inhibitor), sodium stearoyl lactylate (an emulsifier that increases bread volume), sodium nitrite (another preservative), and dozens of other ingredients.

How Much Sodium Do We Need?

In the days before people preserved fish, sausages, and other foods with salt, salty foods were rare or nonexistent. People living back then did well with far less sodium—and still do so today in a few communities—than even the strictest, most current advice recommends.

More than 12,000 years ago our Paleolithic ancestors foraged savannas and forests for their food. Their diets are thought to have consisted of roughly two-thirds fruits, legumes, roots, and nuts and one-third wild game. They probably consumed around 3,000 calories a day, somewhat more than the average American consumes today.17 But those calories were accompanied by less than 800 milligrams (mg) of sodium (see figure 1.2). Those modest quantities of sodium were accompanied by potassium, another essential nutrient, in amounts that are huge compared to what processed-food-eating people now consume.

Jeremiah Stamler of the Northwestern University Feinberg School of Medicine observed:

During the 4–15 million years of hominoid and hominid evolution leading to Homo sapiens sapiens, our hunter-gatherer nomadic predecessors had no exposures to the several components of contemporary lifestyles now known to be related present-day to population BP patterns—no exposures to: habitual high salt intake due daily to addition of salt to foods, or to a fare with a high ratio of [sodium to potassium]. . . . On the contrary, having evolved in the warm climate of Africa, a salt-poor continent, on a fare low in salt by present-day practices, the human species became—and remains—exquisitely adapted for the physiological conservation of the limited salt in the food supply, i.e., for salt retention, not for excretion of a chronically excessive intake, 10–20+ times physiological need.18

Stamler, a legendary epidemiologist who has been doing research since 1948, has been called the Father of Preventive Cardiology; he celebrated his one hundredth birthday in 2019.19

Finnish researchers have calculated that because unprocessed, natural foods are so low in sodium, it is almost impossible to consume a totally natural-foods diet that contains more than 1,200 mg of sodium per day.20 Those scientists concluded that “our genetic mechanisms are programmed” to work best with that level of sodium. We are now witnessing what happens when our intake of sodium gets out of kilter with what our bodies evolved to expect.

The hunter-gatherers of today are a throwback to cave dwellers of yore. Let’s travel to South America and meet the Yanomami Indians, an isolated tribe living in the rainforest straddling Venezuela and Brazil. (That isolation is eroding, thanks in part to the illegal entry of miners into tribal lands since the 1970s; the problem worsened since 2018 with an invasion by upwards of 20,000 more miners.)21 Researchers first visited the Yanomamis in the early 1970s and found that they were physically active, short, and rarely obese.22 They ate mostly plantains, cassava, along with some game, fish, and wild vegetables. Using the gold standard for determining sodium intake—the amount excreted in urine over 24 hours—the researchers found that the Yanomamis excreted only about 20 mg of sodium per day, though they consumed somewhat more. They were healthy and presumably had lived with little sodium for millennia.

A 2005 committee of the Institute of Medicine, now the National Academy of Medicine (NAM), said that the minimum sodium requirement for adults is 180 mg per day, but it set the Adequate Intake at 1,500 mg to ensure that people could consume necessary levels of other nutrients and to account for different patterns of physical activity and climate.23 The generous 1,500-mg level, which the NAM still considers adequate, is far above what the isolated tribes consume, but less than what almost every American consumes.

At the other extreme, some people in the northern part of Japan may consume as much as 10,000 mg per day. In the 1600s, aristocrats in northern Europe flaunted their affluence by consuming an estimated 20,000 mg per day—at least five times as much as today’s average American.24

Why do people now find such pleasure in diets that contain 50 or 100 times more sodium than those of our prehistoric ancestors? Probably our taste buds and brains evolved in that salt-scarce era to make us love the taste of salt, and so our ancestors ate salt or salty foods whenever they could. Unfortunately, once people began consuming thousands of milligrams of sodium per day, evolution did not put a brake on our innate love of salty foods or cause us to reject very salty foods or diets. Although we do find extremely salty foods unpalatable, the “distaste level” is too high to be helpful when it comes to limiting ourselves to reasonable, healthful amounts of sodium.

How Much Sodium Should We Consume?

If hunter-gatherers consume well under 1,000 mg of sodium per day and the average American consumes around 3,000 (women) or 4,000 (men) mg per day, you might wonder how much sodium you should consume to protect your health. The federal government’s official recommendation for healthy adults—2,300 milligrams per day—is provided in its “Dietary Guidelines for Americans 2015–2020.” The NAM reiterated that figure in 2019, though the committee did not provide different recommended intakes for those at high risk of, or with, hypertension (high blood pressure).25 But the “Dietary Guidelines,” as well as the American Heart Association, recognize that adults with elevated blood pressure—both prehypertension and hypertension—would especially benefit from consuming closer to 1,500 mg per day.26

The World Health Organization (WHO), which advises governments throughout the world, sets a somewhat stricter standard than the “Dietary Guidelines” by recommending that adults consume less than 2,000 mg per day.27 Perhaps the most restrictive (and protective) advice comes from the United Kingdom government’s National Institute for Health and Care Excellence. In 2010 it set extremely ambitious goals (which are not being met) of having adults consume no more than 2,400 mg per day by 2015 and just 1,200 mg of sodium per day by 2025.28 To be candid, if the average American reduced consumption to 2,300 mg by 2030 that would be a miracle. Currently, only 2 percent of adult men and 20 percent of adult women consume less than 2,300 mg per day.29 (It’s probably not that women are watching their sodium intake more closely than men, it’s that women consume less food.) The percentage of people consuming less than 1,500 mg is microscopic. Getting the average daily intake down to or below 2,300 or 2,000 mg is challenging, especially considering that about 600 mg of the sodium we consume occurs naturally in dairy products, fruit, seafood, and other foods. That doesn’t leave much room for the added sodium in processed and restaurant foods.

Food manufacturers use the number 2,300 to calculate the “% Daily Value” on food labels. Because salt is 40 percent sodium, 2,300 mg of sodium is equivalent to 5,750 mg of salt—just shy of 6 grams (roughly one teaspoonful) of table salt. Note that the 2,300 mg benchmark is an average for men and women, so men (who consume more food) could consume a couple of hundred milligrams more and women should consume a couple of hundred milligrams less.

Young children, being smaller, should consume less sodium than adults. The recommended daily limit for children 1 to 3 years old is 1,200 mg; for children 4 to 8 that limit is 1,500 mg; for children 9 to 13 it is 1,800 mg.30 Health officials hope that when children raised on less-salty foods grow older, they will be satisfied with similar salt levels.

Table 1.1

Calorie and sodium (mg) intakes for people with a sedentary lifestyle*

Age	2–3	4–8	9–13	14–18	19–30	31–50	51–70	71+
Males	1,000	1,400	1,800	2,300	2,400	2,300	2,100	2,000
Females	1,000	1,200	1,500	1,800	2,000	1,800	1,600	1,600

*Sedentary lifestyle includes only the physical activity associated with independent living. Calorie intakes will be higher at greater physical activity levels.

Adapted from data in US Department of Agriculture, US Department of Health and Human Services. “Dietary Guidelines for Americans 2015–2020,” tables A2-1, A7-1; Center for Nutrition Policy and Promotion, US Department of Agriculture. Nutrients in healthy US-style food pattern at each calorie level. https://www.cnpp.usda.gov/sites/default/files/usda_food_patterns/NutrientsInHealthyUS-StyleFoodPattern.pdf (accessed November 17, 2018).

A more refined way of estimating your maximum recommended sodium intake is to tie it to your calorie intake. Young adult women and men around 30 or 40 years old with a sedentary lifestyle consume an average of about 2,100 calories per day. That 2,100 number representing calorie intake is just a little under the 2,300 mg recommendation for daily sodium intake. Hence, you could aim to consume no more than about 1 milligram of sodium per calorie, a 1:1 ratio. Someone consuming 1,600 calories per day should aim for no more than about 1,600 mg of sodium, but someone consuming 2,400 calories would have a looser target of about 2,400 mg. Table 1.1 shows how that translates into recommendations for males and females of different ages whose activity level is described as sedentary (that means most of us).

You could also use that 1:1 ratio of sodium to calories as a guide when you’re reading food labels or recipes. If a food contains much more than 1 mg of sodium per calorie, or 100 mg per 100 calories, that is probably too much. But finding those “1:1 or less” foods may not be easy. A study conducted by the USDA and the Centers for Disease Control and Prevention (CDC) found that only 13 out of 125 different kinds of food (ranging from breakfast cereals to beef hot dogs to barbecue sauce) averaged under 110 mg per 100 calories. Moreover, most of the 13 were not low in sodium but high in calories, such as sugary baked goods and high-fat French fries and peanut butter.31

There are a couple of exceptions to the 1:1 rule. A cup of packaged soup typically provides only about a hundred calories, but its large volume needs anywhere from several hundred to a thousand milligrams of sodium to taste good. Another exception is canned or frozen vegetables, which are also low in calories, so modest amounts of salt could easily exceed the guideline.

How Much Sodium Do We Consume?

Determining exactly how much salt, or sodium, people consume turns out to be a far more challenging task than just conducting a survey to find out what foods they ate. Most people could estimate pretty accurately how many eggs they had for breakfast. But salt is different. Salt is added to countless packaged foods. Natural or processed, organically grown or not, homemade or restaurant-made, almost everything contains sodium. Moreover, levels may vary widely from brand to brand of the same food. You cannot even count on food labels to provide accurate information. Nutrition Facts labels often overstate by 10 percent or so the amount of sodium in a serving, because companies don’t want to be caught illegally understating the amount. The sodium content of meals at chain restaurants is disclosed on websites (calories must be disclosed on menus), but the sodium content of foods served at non-chain restaurants is essentially unknowable.

A 2017 survey of people leaving fast-food restaurants underscored consumers’ ignorance of sodium levels.32 Their average meal contained 1,292 mg of sodium. But they estimated—or, more accurately, guessed—that the meals contained only 279 mg.

For the past several decades, sodium consumption and many other measures of health have been assessed in the National Health and Nutrition Examination Survey (NHANES) conducted by the CDC. The surveyors interview several thousand people from around the country each year, asking them detailed questions about, among other topics, their medical history, what they ate the previous day or about other food-related concerns, and then weighing them and measuring their blood pressure. The dietary responses are then translated into milligrams of sodium by using USDA food composition databases (see USDA’s FoodData Central).33

NHANES found that Americans consume much more than the recommended intake: the average person consumes about 3,400 mg of sodium per day (about 500 mg less for women and 500 mg more for men); that 3,400 mg figure has not budged much in 30 years despite the many recommendations to cut back.34 People in many other countries consume about the same amount, making humans the only animal species that consumes large quantities of salt.

In fact, the CDC found that 88 percent of people consume more than the recommended 2,300 mg, and 98.6 percent of people who met the “Dietary Guidelines” criteria to limit their sodium intake to 1,500 mg per day consume more than that amount.35 Eric Decker, the head of the Department of Food Science at the University of Massachusetts, Amherst, commented on the obvious: “We keep making recommendations and making recommendations and the needle doesn’t move at all.”36

Children, who love salty foods, such as canned soup, hot dogs with mustard on white buns, French fries, and Oscar Mayer Lunchables, also consume much more sodium than is ideal. Three out of four children 1 to 4 years old consume more than the recommended amounts of sodium.37 Children 8 to 17 consume an average of 1,000 mg more than is recommended. But in one promising change, for reasons unknown, in the years 2015 and 2016 combined, children were consuming about 5 percent less sodium than they were a dozen years earlier. Perhaps related, they were experiencing slightly lower rates of elevated and high blood pressure.38

One limitation of dietary surveys is that they tend to understate food intakes. NHANES relies on people’s memories to accurately report the foods and portion sizes they have eaten. Not surprisingly, many people tend to underestimate how much they consume, especially when it comes to unhealthy foods. People may “forget” to tell researchers about that second serving of soup, or they won’t mention they ate the whole 3-ounce bag of pretzels instead of calling it quits after 1 ounce. Researchers believe that the underreporting of foods and serving sizes probably results in a 10 percent underestimate of calorie and sodium intakes. Also, USDA databases may not have accurate data or even any data for certain items. For instance, it is impossible for the databases to know just how much sodium was in that meal you ate at the Thai restaurant last night.

Another problem is that NHANES does not ask people how much salt they use in cooking or add at the table. As I show later in the chapter with figure 1.3, those uses of salt would add another 10 percent to sodium intake. Thus, correcting for the two limitations would boost the actual sodium-intake average by 800 mg to 4,000 mg per day.

To overcome the problems with dietary-recall estimates, in 2014 the CDC began using a more accurate method to measure sodium consumption. They asked some NHANES participants to collect their urine for 24 hours. The amount of sodium in the urine pretty accurately reflects the amount of sodium consumed in a day. But even that approach fails to reflect the 10 percent or so that is lost in sweat and stool. Also, not every participant scrupulously collects every drop of urine. Notwithstanding those limitations, 24-hour urinary excretion is the best way to measure sodium consumption. Based on 24-hour urine samples, Mary Cogswell and others at the CDC found that men between the ages of 20 and 69 excreted 4,205 mg of sodium per day, and women excreted 3,039 mg per day.39 When those numbers were adjusted for the missing 10 percent from sweat and urine, the average actual intake of sodium was found to be 4,008 mg.

Thus, the actual average sodium intake of American adults, as determined by two different methods, is about 4,000 mg per day, not 3,400. (If that figure were incorporated in recommendations, to be consistent the 2,300 mg goal would be raised proportionately to 2,700 mg.) But because most scientists, health officials, and journalists use the uncorrected number—3,400 mg—as the average intake, Salt Wars will generally use that number.

Sodium consumption has remained about the same during the past several decades, even though some manufacturers have reduced sodium moderately in some of their products (see chapter 9). It appears that those decreases were balanced by our consumption of more food, by some companies increasing sodium, or by our eating out more often, where the sky is the limit when it comes to sodium.

It would be interesting to compare how much sodium Americans are consuming now to what our forebearers consumed a hundred years ago. Back then most people ate home-cooked meals in which the sodium came from the salt used in cooking or while eating, the small naturally occurring amounts in foods, or the relatively few packaged foods. But, lacking refrigeration, they were also eating hefty amounts of cured meats and fish (ham, bacon, salted cod, and the like), which were loaded with salt and the preservatives sodium nitrate and sodium nitrite. Furthermore, many more people engaged in physical labor, leading them to consume more food—and, hence, more sodium. Unfortunately, though USDA has tracked food consumption since 1909, it didn’t track nutrient intakes until recent decades. Thus we can only speculate on whether our ancestors consumed more or less sodium than we do today.

Nutrition Facts labels are a starting point for figuring out how much sodium we consume now. Most packaged foods do not have shockingly large amounts of sodium, partly because the portions listed on many labels are unrealistically small, but the milligrams do add up. While 1 ounce of those potato chips contains about 160 mg of sodium, eat an entire 3-ounce bag and you’ve consumed about one-fifth of your recommended daily sodium limit. A typical Campbell condensed soup contains around 800 mg per cup, but many people eat the entire can and consume 2,000 mg. Foods that contain half a day’s sodium or more (see examples in table 1.2, “Salt Bombs at Grocery Stores”) simply can’t fit into a healthy diet.

In contrast to individual servings of packaged foods, countless meals eaten outside the home are loaded with salt. That’s an increasingly important problem because we are increasingly reliant on restaurant meals. In the late 1970s, away-from-home meals and snacks—from restaurants, cafeterias, food trucks, and vending machines—accounted for 18 percent of Americans’ calories.40 In the early 2010s, that figure almost doubled to 34 percent. USDA found that foods served at table-service restaurants had 35 percent more sodium per 1,000 calories than foods prepared at home.41 Fast foods had “only” 22 percent more sodium than home-prepared meals.

But those are averages. Many restaurant meals are huge and contain a whole day’s worth of sodium, with some meals providing two or occasionally even three times as much sodium as a person should consume in an entire day. (The calorie, saturated fat, and sugar contents are equally startling.) In the 1990s, my organization, the Center for Science in the Public Interest (CSPI), conducted widely publicized analyses of the nutrient content of popular foods served at table-service restaurants, ranging from Chinese and Italian to seafood and steak houses.42 We dubbed Fettuccine Alfredo a “heart attack on a plate” and shocked people when we publicized the calorie, fat, and sodium content of movie-theater popcorn (sales of which immediately plummeted). While the fat or saturated fat content varied widely from one type of restaurant to another, the meals were uniformly high in sodium and calories. We found, for instance, that an order of Beef with Broccoli at a Chinese restaurant had 3,150 mg of sodium and a Fried Seafood Combo with tartar sauce, fries, coleslaw, and buttered biscuits at a seafood restaurant had 4,390 mg. Those amounts are way over the recommended daily target of 2,300 mg and, if anything, may have become even saltier since then.43

Table 1.2

Salt bombs at grocery stores

Company	Food	Sodium content per serving (mg)	Days’ worth of sodium*
Campbell	Chicken Noodle Soup, condensed (whole can)	2,120	1
Kohinoor Foods	Mughlai Kofta Curry with Peas Pulao	2,120	1
ConAgra Brands	Banquet Mega Bowls Buffalo-Style Chicken Mac ’N Cheese	2,100	1
The Original Soupman	Crab & Corn Chowder (whole box, 17 oz.)	2,080	1
Pinnacle Foods	Hungry-Man Selects Mesquite Classic Fried Chicken (16 oz.)	2,060	1
La Choy	Chicken Chow Mein (½ can)	2,055	1
Maruchan	Ramen Noodle Soup Soy Sauce Flavor (whole package)	1,760	¾
Walmart	Great Value Meatlovers Calzone	1,600	⅔
Hormel	Dinty Moore Beef Stew (XL) (12.5 oz.)	1,570	⅔
Campbell	Chili with Beans Chunky Soup (15¼ oz. microwaveable bowl)	1,540	⅔
Bob Evans	Sausage & Potatoes Bowl	1,470	⅔
Campbell	Slow Kettle Style Creamy Broccoli Cheddar Bisque (15.5 oz.)	1,420	⅗
Tabasco	Bloody Mary Mix (8 oz.)	1,380	⅗
Tyson	Fully Cooked Chicken Pomodoro Dinner Kit (½ package)	1,350	⅗
Libby’s	Spaghetti & Meatballs (14.5 oz.)	1,280	½
Hormel	Macaroni and Cheese Pasta (10 oz.)	1,250	½

*Based on the recommended limit of 2,300 mg per day; serving sizes not all labeled servings.

Today, by restaurants’ own admission, many meals have far more than 2,300 mg of sodium (see table 1.3, “Salt Bombs at Restaurants”). Because of their larger portion sizes and additional components (salads, bread, etc.), meals at table-service restaurants generally have more salt than those at fast-food restaurants. According to company websites, IHOP’s Bacon Temptation Omelette with a side of three Buttermilk Pancakes has 3,790 mg of sodium, two-thirds more than someone should consume in an entire day. Applebee’s three-course dinner of Chipotle Lime Chicken Quesadilla appetizer, House Salad with Mexi-Ranch Dressing, and the Fiesta Lime Chicken entrée delivers a whopping 7,150 mg of sodium. Chili’s gigantic Ultimate Smokehouse Combo, with its three meats and side dishes, may contain as much as an astonishing 8,050 mg!44 Those last two meals provide three days’ worth of sodium. With meals like that on restaurant menus, it is no surprise that the New York City health department found that the average meal ordered by diners at IHOP and TGI Fridays had more than 2,800 mg and more than 3,400 mg, respectively.45

Restaurants try to explain away those huge amounts of sodium by claiming that people treat eating out as an occasional indulgence and put their health concerns aside. Or they say that the lower-sodium (and lower-calorie) meals also on the menu provide a choice for people who want to avoid the heart attack that many of their other meals might cause. Justifications aside, restaurants need to do a better job of lowering the calorie and sodium content of what they sell to a nation of people who have overweight, obesity, or hypertension.

While almost everyone is consuming too much sodium, a recent national survey found that only about half of all consumers try to limit sodium.46 Another survey found that only 29 percent of people were trying to limit sodium, though 38 percent were trying to limit sugar and 44 percent were trying to avoid artificial sweeteners (which pose a small health risk).47 Still, the percentages of people concerned about salt and trying to reduce their intake are twice as large as in the 1990s.48

If we wanted to consume less salt, it would be helpful to know which foods contribute the most sodium. According to the CDC, 71 percent of all the sodium we consume is added to food by manufacturers and restaurants, not by consumers using a saltshaker (see figure 1.3).49 About 14 percent of our sodium intake is unavoidable because it occurs naturally in everything from spinach to meat; 6 percent comes from salt (and soy sauce, baking powder, MSG, and other ingredients) used when we cook; and just 5 percent comes from what we add at the table. Tap water, drugs, and other sources provide the rest. In other words, except for people who use them with abandon, saltshakers are not a big part of the problem—yet nearly half of all adults believe that table salt is the biggest source of sodium.50

Table 1.3

Salt bombs at restaurants

Company	Food	Sodium content (mg)	Days’ worth of sodium*
Chili’s	Ultimate Smokehouse Combo (with Cheesy Bacon BBQ Chicken, Honey Chipotle Crispers w/Ranch, and Dry Rub Ribs)	8,050 mg	3½
Jimmy John’s	Gargantuan on French bread (16-inch)	7,830	3½
AMC (movie theaters)	Bavarian Legend Soft Pretzel	7,600	3⅓
Applebee’s	Chipotle Lime Chicken Quesadilla, House Salad with Mexi-Ranch Dressing, Fiesta Lime Chicken	7,150	3
Outback Steakhouse	Baked Potato Soup (bowl), Blue Cheese Side Salad with dressing, Grilled Pork Chop	6,990	3
Red Lobster	Admiral’s Feast	5,000	2⅓
Jersey Mike’s Subs	Chipotle Chicken Cheese Steak (giant), Fries (5 oz.)	4,950	2
Chili’s	Honey-Chipotle Crispers & Waffles	4,730	2
Uno Pizzeria & Grill	Deep Dish Buffalo Chicken Mac & Cheese	4,310	1¾
Jason’s Deli	Roasted Turkey Breast Muffaletta (½)	4,240	1¾
Shake Shack	Double SmokeShack (cheeseburger), Fries, Black & White Shake	4,230	1¾
P. F. Chang’s	Long Life Noodles and Prawns	4,120	1¾
Denny’s	The Grand Slamwich with bacon, Bacon Cheddar Tots	3,920	1¾
Chick-fil-A	Spicy Chicken Sandwich, Waffle Potato Fries (medium), Chicken Soup (large)	3,820	1⅔
IHOP	Bacon Temptation Omelette with three Buttermilk Pancakes	3,790	1⅔
The Cheesecake Factory	Breakfast Burrito	3,640	1⅔
Sbarro	Chicken Vesuvio with Spaghetti, Breadstick	3,130	1⅓
KFC	Popcorn (chicken) Nuggets (large)	1,890	⅘

*Based on the recommended limit of 2,300 mg per day. Data obtained from restaurants’ websites.

The sodium content of most natural foods is quite low. One estimate has put the average sodium content of natural foods from plants at only 14 mg per 3.5 ounces (100g), and foods from animals at 59 mg per 3.5 ounces. But processing typically sends those numbers soaring. For instance, a 3.5-ounce boiled potato has 4 mg of sodium (adding a tablespoon of margarine might bring that up to 75 mg),51 while a 1-ounce serving of Lay’s Classic Potato Chips has 170 mg. Four ounces of natural chicken has about 87 mg of sodium. In contrast, a Washington, DC, supermarket was selling a roaster chicken plumped up with so much water, salt, and sodium phosphate that it had 610 mg of sodium in a 4-ounce (raw) portion.52 Even worse, a 3.5-ounce KFC Original Recipe Thigh has 910 mg.53

Tap water is usually not a concern with regard to sodium. In Chicago, New York, and most other cities, water has less than 20 mg per liter (a bit more than four 8-ounce glasses). The EPA considers levels between 30 and 60 mg per liter best for taste. But in some cities, especially in the southwestern United States, tap water can supply a fair amount of sodium. The water in El Paso, Texas, for instance, has about 35 mg of sodium per 8-ounce glass.54 So the five cups of water someone drinks in a day has as much as an ounce of potato chips. (People can ask their city water provider for sodium information.)

Well water, too, may contain excessive sodium. The University of Maryland Extension recommends that people on a sodium-restricted diet get their well water tested.55 The extension service has an online calculator for estimating how much sodium well water might contribute to a diet.

Water softeners can add to the problem. They exchange the minerals that make water hard (calcium, magnesium, and iron) for sodium. The result is a decrease in hardness but an increase in sodium; the harder the water, the more sodium is added. Healthier water softeners exchange the hardness minerals for potassium.

Most drugs and dietary supplements have little or no sodium. An exception is over-the-counter drugs for heartburn or acid indigestion. Alka-Seltzer has about 535 mg of sodium per tablet, averaging the Original and Extra Strength versions. Taking the recommended limit of seven tablets a day for people 12 to 59 years old would provide a whopping 3,750 mg—far more than the daily sodium recommendation.56 (The label advises older adults not to take more than three tablets a day, or 1,630 mg.)

Another way to slice the data on where we get our sodium is to see which individual foods provide the largest amount of sodium. In reality, consumers have no idea where their sodium is coming from. An industry survey asked consumers to name the three biggest sources of sodium in their diet. About half of consumers named snacks like chips and crackers (52 percent), while about one-third named luncheon meats and hot dogs (36 percent) and canned soup (32 percent). Only 24 percent of people rated pizza as one of their three biggest sources of sodium, and only 7 percent thought that bread was one of their biggest sources.57

In fact, the No. 1 source of sodium in the average diet is bread and rolls (see table 1.4). It’s not that bread itself is so high in sodium, but rather that we tend to eat a lot of it. Only 6.2 percent of sodium comes from bread and rolls, though the percentage would be much higher if the bread in sandwiches and the crust of pizza were included in that figure. That is half again more than the sodium from soups and snack foods. The second-biggest source of sodium is pizza, which provides 5.9 percent of the average person’s intake. Salt and other sodium-containing additives are integral ingredients in the crust, sauce, cheese, pepperoni, olives, bacon, and other toppings.

Table 1.4

Top 10 sources of sodium

Food	Percent of sodium intake
1. Bread, Rolls, Bagels	6.2
2. Pizza	5.9
3. Sandwiches (burgers, hot dogs, egg/breakfast, chicken, etc.)	5.7
4. Cold Cuts, Cured Meats	5.4
5. Soups	3.8
6. Burritos, Tacos	3.8
7. Savory Snacks (chips, popcorn, pretzels, etc.)	3.7
8. Chicken (whole pieces)	3.7
9. Cheese	3.5
10. Eggs and Omelets	2.6

Source: Z. S. Quader, L. Zhao, C. Gillespie, et al., “Sodium Intake among Persons Aged ≥2 Years—United States, 2013–2014,” Morbidity and Mortality Weekly Report 66 (2017): 324–328. https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6612a3.pdf.

Still, those Top 10 categories account for only 44 percent of the sodium we eat. The rest is split among scores of other foods.

Bonnie Liebman, the nutrition director and my long-time colleague at CSPI, warns that at fast-food restaurants “the fries, which people typically identify as salty, aren’t the problem; it’s the large amounts of salt hidden in the burgers, the nuggets, the McMuffins, the chicken and fish sandwiches, the biscuits, and more.”58 The same can be said for packaged foods. Yes, some soups and snacks may be pretty salty, but they don’t make up a large part of the average diet. The problem, Liebman says, is that there’s a lot of salt in a lot of foods, and many of them don’t even taste salty.

Eating less of any one or two foods probably would not have a great impact on a person’s total sodium intake. In contrast, average Americans get fully half of their added sugars from soft drinks and other sugar-sweetened beverages, so just cutting out sugar drinks would likely make a big difference in their sugar consumption.59

If we are going to reduce sodium intake, the way to start is by eating more natural foods and less processed and restaurant foods. But, inevitably and realistically, almost all of us are going to continue buying some processed foods (including bread), and we’re not going to stop eating out. That means that we need the food industry to help us by manufacturing and marketing foods with far less added salt. In chapter 9, I explain what some companies have been doing. But first, we need to dig deep into the evidence for and against consuming less sodium. In the next two chapters I describe a great deal of scientific research, so let’s get ready to meet some experts and discover what they have learned from it.