Reducing sodium in our diets is a health strategy proven to prevent heart attacks and strokes. By paying attention to the sodium in our diet, we can take one more step towards controlling our own health.
—Harvard Health Blog1
Going on a healthier, lower-salt diet is, in theory, one of the easiest lifestyle improvements you could make. But the food environment conspires against you. Most packaged foods are loaded with salt, and restaurant meals contain even more. Even your taste buds conspire against you—they clamor for that salty taste. Still, if you want to make the effort to lower your risk of disease, you can slash the sodium content of your diet. The information in this chapter will help you get started.
But first, what is your sodium intake? And for that matter, what’s your blood pressure? Should you worry? If your blood pressure is under 120/80 mm Hg, you don’t have to worry much about blood pressure now. And if it is well under 120/80, such as 100/60, you may never have to worry—though if you are still in your 40s, 50s, or 60s your blood pressure might rise as you age. After all, more than 80 percent of Americans 75 and older, and as many as 90 percent of Americans ultimately, develop high blood pressure.2 Moreover, salty diets may contribute to problems other than ones related to high blood pressure, such as kidney stones and osteoporosis. Thus, almost regardless of what your blood pressure is now and how old you are, it would be worth consuming less sodium. But the higher your blood pressure is, especially if you are on the younger side, the more important it is to cut back (and lose weight if you’re heavy and exercise more and eat more fruits and vegetables and possibly take blood pressure–lowering drugs).
A good way to start reducing your sodium intake is to estimate how much sodium you consume. You could use the form in this section—see table 11.1 (“My Sodium Intake”)—to help you keep track of all the foods you eat for a whole day or, better, a whole week. Make half a dozen photocopies so you can see a pattern in your salty food choices, and determine your average intake, over time.
Tracking my own sodium intake was enlightening because it highlighted the hefty contribution of bread: I like to toast half a bagel in the morning, often eat a sandwich or two for lunch, and maybe have another slice at dinner—so bread provided a lot more than 6 percent—the national average—of my sodium. The supermarket brand of whole-wheat sandwich bread that I was eating had 135 mg of sodium in a 1-ounce slice. Altogether, bread was contributing over 700 mg of sodium to my daily diet—until I switched brands.
On packaged foods, the Nutrition Facts labels will tell you how many milligrams of sodium each serving contains. Just be sure to adjust the number if your own serving size differs (I often use a kitchen scale to measure how much I’m eating). And be aware of what sodium-related terms on packages mean. For instance, “reduced sodium” foods are not “low” in sodium but have at least 25 percent less than their conventional counterparts. Though companies don’t brag about it on labels, foods that contain 460 mg or more of sodium per serving are considered “high” in sodium.3 Box 11.1 includes FDA definitions of sodium-related terms on food labels.4
It is easy to check labels at the grocery store and look for lower-sodium brands. The differences between brands are often startling. That provides clear evidence that many companies could reduce sodium levels dramatically—and that consumers could reduce their sodium intake dramatically—without rendering their foods unpalatable. And consuming the less-salty foods could gradually lower consumers’ preference for salty foods. For example:
My sodium intake form Date:
| Food | Sodium (mg) per Labeled Serving | My Serving Size | Amount of Sodium I Ate |
|---|---|---|---|
|
Breakfast |
|||
|
Lunch |
|||
|
Dinner |
|||
|
Snacks |
|||
|
TOTALS |
Such comparisons indicate that cutting sodium consumption in half may not be so challenging. But sodium levels in some categories, such as cottage cheese, ketchup, and American cheese, are fairly similar across many brands. (Interestingly, in a large survey of adults in New York City, the frequent label readers with hypertension did not consume less sodium than other people, but that behavior need not apply to you.)6
If you do not have food labels handy, a new (and free) nutrition resource sponsored by the food industry can be found at www.SmartLabel.org. Many of the largest companies, as well as some smaller ones, contribute to that easy-to-use database, which provides information about nutrition, ingredients, allergens, and more. Some online shopping sites, such as www.Peapod.com and www.Walmart.com, also provide nutrition information for thousands of foods.
The most comprehensive database is the US Department of Agriculture’s FoodData Central website (https://fdc.nal.usda.gov/), which provides the nutritional values of thousands of packaged and restaurant foods, as well as produce and other unprocessed foods. When you enter the name of a food category on the home page—“mushrooms,” let’s say—you’ll find that the database lists about 3,000 entries, ranging from plain mushrooms to organic sunflower mushroom stew. Here are some tips to narrow your search within a manageable range: When the first results page comes up, unclick three of the boxes that appear along the left-hand side of your screen (smartphones may have limited options, so best to use a computer), leaving only SR Legacy. Those foods are mostly non-branded. If you’re searching for a particular brand or processed food, enter the generic name on the home page (for instance, “hamburger”). Then, on the first results page, type in the brand name or product (“Big Mac”) at the top of the left column, check the “Require All Words” right below that, and then check the box for “Branded” as well as “SR Legacy.” If you cannot find the exact product you’re researching, look for something similar; its nutritional value will likely be fairly similar.
Restaurants are treacherous territory for health-conscious people. First take advantage of the nutrition information posted on the websites of most chain restaurants, or on FoodData Central. Alternatively, chain restaurants are required to provide brochures (or a computer kiosk or other vehicle) listing the same nutrition information that appears on Nutrition Facts labels. You might find some shocking comparisons. One example: Arby’s Curly French Fries have more than four times as much sodium as McDonald’s French Fries (735 mg vs. 170 mg per 3.5 ounces).
A great online resource for restaurant nutrition is MenuStat (www.menustat.org), which is operated by the New York City health department. It provides periodically updated nutrition information for more than four thousand foods offered by about 100 chain restaurants, from Applebee’s to Zaxby’s.
Some newer chain restaurants feature meals labeled with “fresh,” “sustainable,” “vegetarian,” or other buzzwords that ad agents put on their websites, so diner beware. Those meals might be better than some standard fare, but sodium is still often a real problem. Consider Seasons 52’s Kona-Crusted Lamb Loin with 2,080 mg of sodium or its Open-Face B.L.T.A. with 1,850. Or True Food Kitchen’s Cauliflower Polenta has 1,820 mg and its Unbeatable Burger has 1,880. At non-chain restaurants, upscale or down-home, your best lower-salt bet is to order a salad—but guard against salty croutons and olives, and ask for oil and vinegar dressing. Most cooks at such restaurants are probably not aware of how much sodium is in the food they serve, and have little control of it in any case: the salt is built into most sauces, soups, gravies, baked goods, cheeses, processed meats, and other items that restaurants buy from suppliers. So even if you ask that no extra salt be added to your dish, the sodium reduction is likely to be small.
Chefs who pride themselves on cooking from scratch can be more proactive about keeping a lid on sodium. They turn to the vast array of herbs and spices, lemon juice, garlic, and other low-sodium or sodium-free ingredients that can replace—often more deliciously—the flavor obtained from salt. Cooking this way requires an investment, however, in prep time and ingredients, and it may be too expensive for many establishments to avoid the use of all processed foods when they need to maintain a bottom line in the black.
What’s the bottom line for us, in restaurants and at the grocery store? It is virtually impossible to rely mostly on processed and restaurant foods and achieve a low- or even moderate-sodium diet. One solution is to reserve processed foods and eating out for special occasions, or for days when you just can’t face cooking from scratch. But the best way to lower your sodium intake is to replace processed with unprocessed “whole” foods and prepare low-sodium, delicious meals at home. (I know—easier said than done, especially if you hate cooking!) Make sure you have a good low-salt cookbook, such as the American Heart Association’s Low-Salt Cookbook. And see the tips in box 11.2 for cooking with less salt.7
Fortunately, consuming less salt gradually decreases one’s preference for salty foods and increases one’s enjoyment of lower-sodium foods. Gary Beauchamp of the Monell Chemical Senses Center, an expert on taste preferences, said that after getting used to less-salty meals, “things that used to taste just right now taste too salty, and things that used to taste not salty enough, taste just right.”8 (Beauchamp was a co-author of the 2010 report from the Institute of Medicine, now the National Academy of Medicine, on how to achieve a lower-sodium food supply.) Beauchamp and others at Monell found that people adjust to less-salty foods within two or three months, and they often end up preferring less-salty foods.9
Some critics of reducing sodium contend that if manufacturers and restaurants used less salt, consumers would simply use their handy saltshakers to add back the missing salt—or add back even more. The 2005 “Dietary Guidelines for Americans” laid that concern to rest: “When consumers are offered a lower-sodium product, they typically do not add table salt to compensate for the lower sodium content, even when available.”10 Monell researchers found that after cutting the sodium content of specially prepared meals in half, people added back only 20 percent of what was removed.11
One of the pitfalls of cooking from scratch is that countless recipes in newspapers, cooking magazines, cookbooks, and websites are loaded with unnecessary salt. Normally, the Food section of my hometown newspaper offers reasonably healthy recipes, but sometimes it slips up. A cheeseburger sandwich prepared according to a Washington Post recipe is packed with 720 calories and 1,220 mg of sodium.12 A recipe for pizza with 500 calories per slice has 1,010 mg of sodium.13 But kudos to the Post for providing nutrition breakdowns; the New York Times and most other sources of recipes do not.
Articles quoting chefs may add to the problem. One extreme example comes from cookbook superstar Samin Nosrat, who confessed to being salt-obsessed in a recent New York Times article: “At some point during every cooking class I teach, I do my signature move: dramatically add handful upon handful of salt to a large pot of boiling water, then taste it and add even more.”14 Can you imagine the public outcry if articles encouraged people to smoke cigarettes or spray pesticides in their children’s bedrooms?
Fortunately, not all the influences out there preach using salt with abandon. One surprising convert to low-salt cooking was Craig Claiborne, the renowned New York Times food editor and self-admitted salt “addict.” Perhaps because of his love of salt, according to an article in the Journal of the American Medical Association, he suffered from hypertension, edema, and an unquenchable thirst.15 Motivated by the urgency of his health problems, he co-authored Craig Claiborne’s Gourmet Diet, a best-selling cookbook featuring low-sodium, low-sugar recipes. In Time magazine, Claiborne offered consumers some pithy “secrets”:
If you wish to wean your taste buds away from salt, the object is to find other flavors that will distract your palate. . . . I prefer fresh herbs like parsley, tarragon, finely chopped garlic, and fresh grated horseradish; spices like curry and chili powders, powdered mustard (made into a paste with water), hot pepper flakes, a generous grinding of black pepper and sugar. . . . Use the freshest foods that can be found. There are four vegetables that make an especially fine feast without salt. These are mushrooms, eggplants, really fresh red ripe tomatoes, and good quality onions, white or red.16
One easy way to cut sodium when you’re cooking from scratch is to use the reduced-sodium salts made with potassium chloride (aka potassium salt). As I discuss in chapter 9, some people say that potassium salt tastes exactly like salt and love sprinkling a little on their food, but others find that using too much results in a terrible bitter or metallic aftertaste. So the best substitutes probably are those with about half of the regular salt replaced with potassium salt. Popular brands include Morton’s Lite Salt and GoodSalt from Finland. But don’t use twice as much just because they are low in sodium! I have found that the reduced-sodium products work great in just about any food. However, if you have chronic kidney disease or a heart condition, talk to your doctor before using potassium-based seasonings.
Because I’m no professional chef, I asked some experts for their cooking advice. Cary Neff, the vice-president of corporate culinary support for Morrison Healthcare, wrote the New York Times best-selling cookbook Conscious Cuisine. Echoing Craig Claiborne, he said we should focus not on subtracting sodium but rather on adding flavor, because that should automatically lead to needing less salt. His top tips include:
Kate Sherwood, who writes the “Healthy Cook” page for the Center for Science in the Public Interest’s (CSPI) Nutrition Action Healthletter, trained at the Culinary Institute of America. She is passionate about creating dishes that are both delicious and healthful. None of that “salt to taste” stuff for Kate! She told me, “While no ingredient or combination can entirely replace salt, good technique and quality ingredients make cooking with less salt possible.” Here are several of her favorite suggestions:
In a 2013 opinion survey of 1,000 US adults, 59 percent believed that sea salt contained less sodium than regular table salt.17 In fact, that is rarely the case. Most sea salts—and table salt—are at least 98 percent sodium chloride, with other minerals present in such small amounts that they have no effect on health.18
All salt is technically “sea” salt. Even the salt dug out of salt mines, the source of most table salt, is sea salt, having been left by long-dried-out seas. Whether it is derived from the industrial or artisanal dehydration of ocean water a year ago or by nature over millions of years, salt is almost entirely sodium chloride, especially after it is washed and purified. In that sense, creative marketers could call ordinary Morton salt, obtained from mines deep underground, “ancient sea salt untouched by humans for millions of years.”
The Culinary Institute of America recommends that chefs use sea salt, not because it is lower in sodium, but because it might improve flavor and is “label friendly.”19 Indeed, stating “a touch of sea salt” on a menu or label might suggest to consumers that the product is healthier and allow manufacturers to use a little less salt.
Stephanie L. Drake and MaryAnne Drake, at the Department of Food, Bioprocessing, and Nutrition Sciences at North Carolina State University, compared the mineral content and taste of 38 different sea salts, along with table salts and “lite” salts.20 Two salts from Hawaii—Haleaka Red salt and Kilauea Black salt—had almost 25 percent less sodium than table salt.
In the taste tests organized by the Drakes, New Zealand organic sea salt, Sonoma salt from California, and numerous others tasted a little different from table salt. But those tests were done with salt crystals and not salt added to foods, which could mask any taste differences. I tried adding fleur de sel, Himalayan pink salt, and a couple of other sea salts to low-sodium vegetable broth and to unseasoned brown rice and could not taste any difference.
But I admit that my palate is not the most refined. Cook’s Illustrated, considered by many to be the arbiter of all cooking controversies, taste-tested half a dozen salts. It concluded:
The results were definitive: Tasters couldn’t tell one salt from another in cooked applications. Only when the salts were sprinkled over slices of beef tenderloin could tasters detect subtle flavor nuances. . . . Our advice? Save your money and use fancy sea salts only for garnishing.21
A Swedish company, Saltwell AB, harvests sea salt in Chile that is naturally high in potassium—about 30 percent—and so contains that much less sodium. Saltwell tells food manufacturers that they can label foods made with that specialty salt simply as “salt” to avoid highlighting the presence of chemical-sounding potassium, but I’m not sure that is consistent with FDA rules.22 Many kidney patients and people taking certain antihypertensive medications need to avoid too much potassium.
If you flew from Chile to Israel, you could go to the Dead Sea and obtain salt that is even lower in sodium. Salona Low Sodium Sea Salt consists mostly of potassium and magnesium salts and has only one-twentieth as much sodium as table salt.23 Its manufacturer, a Danish company, says that it can replace up to half the normal amount of salt in foods.24
Some marketers make sea salt out to be a panacea for practically every ill. To pick one egregious example, consider Dr. Josh Axe’s advice (www.DrAxe.com). Axe, who says he is a certified doctor of natural medicine, doctor of chiropractic, and clinical nutritionist, touts sea salt as an almost magical mineral that regulates blood pressure, increases energy, helps reduce signs of aging, improves brain function, eliminates mucus buildup, supports libido, and much more. Axe and others often assert that sea salt contains dozens of minerals that regular salt does not have. That is often true, but the amounts of those minerals are typically trivial and have a trivial effect on health.
If you are surprised that most sea salts are just as unhealthy as table salt, you may be shocked by their prices. For example, SaltWorks (www.seasalt.com) sells a 6-ounce package of Fleur de Sel (obtained for hundreds of years from the Rhône river delta west of Marseille, France) for $10.99, or $29.30 per pound. Or you could spend $7.99 for 1.5 ounces of Icelandic Flake Sea Salt or Kala Namak Sulphur Salt ($85.23 per pound). Or, at Salt Cellar (www.salt-cellar.com), you could spend $15 for 1.5 ounces of Black Truffle Sea Salt ($160 per pound). Maybe those high prices encourage people to use less salt, or maybe they contribute to a mystique around sea salt. In any case, you could buy a 26-ounce canister of table salt for about 60 cents per pound, roughly one-hundredth to one-fiftieth the price of some fancy artisanal salts.
My bottom line on sea salt: use a little, especially as a garnish, if you like its taste more than regular salt, but do not believe any of the hogwash about its health benefits.
I have focused almost totally on salt, because I think it is causing more harm to our health than just about anything else in our diet. But there is more to eating healthfully than just keeping sodium in check. It is worth paying special attention to another mineral, potassium, because it is an essential nutrient and a powerful antidote to the effects of too much sodium. Most of the best sources of potassium are also all-around healthy foods, as I indicate in table 11.2. Build several of the foods high in the table into your diet every day, and you will easily consume at least 3,000 mg of potassium.
For optimal health, people need to focus on numerous nutrients in their diets, not on just one or two. The “Dietary Guidelines for Americans” and other reliable sources of nutrition information generally recommend—and I know I have said this before!—consuming mostly fruits, vegetables, nuts, whole grains, non-fried seafood, low-fat animal products, and polyunsaturated vegetable oil (such as soy and canola) . . . while limiting intakes of refined sugars and starches (soft drinks, candy, cake, cookies, white bread), saturated fat (meat and full-fat dairy foods), and sodium (packaged and restaurant foods).
Bonnie Liebman, CSPI’s nutrition director, has translated the DASH–sodium type of diet, widely accepted as being super-healthy, into an eating plan (see table 11.3). Use the number and size of servings as a guide and aim roughly to average over a week the numbers of daily servings shown. If that is too complicated, just incorporate the “Dietary Guidelines” principles into your life. The trick is to find healthy foods and recipes that you love and keep those foods around the house. With the right ingredients handy, you should be able to whip up healthy, delicious salads, hearty soups and stews, sandwiches, and stir-fry meals in short order. (And, yes, it’s OK to cheat from time to time with less healthy packaged and restaurant foods—we all do!) For some personal stories from people who opted for lower-salt diets and were—usually—rewarded with better health, see box 11.4.
Table 11.2
Potassium content of selected foods (mg)
|
Baked potato with skin, medium |
925 |
|
Acorn squash, baked, 1 cup |
895 |
|
Salmon, farmed, raw, 6 oz. |
650 |
|
Sweet potato with skin, baked, medium |
540 |
|
Cantaloupe, large, ¼ |
540 |
|
Orange juice, 1 cup |
495 |
|
Spinach, cooked, ½ cup |
420 |
|
Banana, medium |
420 |
|
Yogurt, plain, low-fat, 6 oz. |
400 |
|
McDonald’s Quarter Pounder sandwich |
385 |
|
Black beans, canned, ½ cup |
370 |
|
Milk, low-fat (1%), 1 cup |
365 |
|
Chicken breast, boneless, 5 oz. cooked |
345 |
|
Pizza, cheese, Pizza Hut 14″ Thin ’N Crispy, 2 slices |
310 |
|
Lettuce, romaine, 2 cups loosely packed |
230 |
|
Tomato, small, whole, 4 oz. |
215 |
|
Apple, medium, 3-inch diameter |
195 |
|
Cheerios, 1 oz. |
180 |
|
Ice cream, vanilla, ⅔ cup |
175 |
|
Whole wheat bread, 2 slices, 64 g |
160 |
|
Pasta, dry, 2 oz. |
125 |
|
Shrimp, jumbo, cooked, 6 |
60 |
|
Tortilla chips, 1 oz. |
60 |
Source: US Department of Agriculture. USDA Food Composition Databases. https://fdc.nal.usda.gov/ (accessed December 8, 2018).
Table 11.3
A healthy eating plan for a 2,100-calorie diet*
| Food Group | Daily Servings | 1 Serving is |
|---|---|---|
|
Vegetables and Fruit |
11 |
½ cup vegetables, 1 cup greens, 1 piece fruit |
|
Grains |
4 |
½ cup cooked pasta or rice or 1 slice of mostly whole-grain bread |
|
Low-Fat Dairy |
2 |
1 cup milk or yogurt or 1½ oz. hard cheese |
|
Legumes or Nuts |
2 |
½ cup beans, ¼ cup nuts, or 4 oz. tofu |
|
Poultry, Fish, Lean Meat |
1 |
¼ lb. cooked (not fried) |
|
Oils and Fat |
2 |
1 tablespoon vegetable oil or margarine |
|
Desserts, Sweets |
2 |
1 teaspoon sugar, 1 small cookie |
|
Wild Card |
1 |
Poultry, fish, meat, oils/fat, grains, desserts, or sweets |
* Adjust the numbers of servings for diets higher or lower in calories.
Source: Nutrition Action Healthletter, November 2017.
Susan F., Paso Robles, California: I believe my blood pressure responded when I lowered salt intake significantly and increased consumption of fruit and vegetables. I didn’t lose weight or eat less as I am already on the thin side (5′6″ and 122 lbs., age 73). I exercise regularly and have done so for years.
About 6 months ago, my nurse practitioner noticed my BP was elevated (145 over 90-something.) As my BP was usually low (110 over 70-something was common) my doc suggested testing at home and reporting back daily for a while. I did that and started salt restriction and the deliberate addition of potassium-rich foods to my diet. After a month or so, I was seeing 120 over 80 +/-. Last visit to the doc, 110 over 80. I’m still pretty careful but the fear of god has abated somewhat so I cheat a bit when eating away from home. One of my brilliant observations is that eating commercially prepared food is probably not good for my health.
Douglas F., Newton, New Jersey: I was able to avoid having to take blood pressure drugs altogether. My blood pressure readings were getting high in the 150 to 160 range. Now they are down to 130. I was able to achieve this by changing to a low-sodium diet. I carefully read the nutrition labels in the supermarket and avoid foods that are notorious for being high in sodium. Other changes included eating more fruits and vegetables—up to 10 servings per day—exercising regularly, and focusing on reduction of stress.
Cameron McL., Pensacola, Florida: I am a 60-year-old female with a strong family history of cardiovascular disease. I went from a low-salt diet to an almost no-salt one and have been eating an exclusively plant-based diet for 20 years. My daily sodium intake was probably between 2,000 and 4,000 milligrams. After the change it is probably about 2,000. Even that modest change plus exercise lowered my BP over three months from 130/80 to about 110/70 on an average day. I have never taken meds for high blood pressure but had another medical problem that made it important to lower my BP. As a control, I did not change my diet or exercise habits and so credit the change with lowering sodium intake.
Eileen F., Los Angeles, California: I have been a vegetarian for decades. About a year ago I became vegan and within 5 months my blood pressure went from borderline high (I was on meds for it) to borderline low. I actually had to go in to get my BP checked three times because they wanted to make sure it wasn’t a fluke. I think a more plant-based diet (more vegetables and beans and tofu) made a big difference. My doctor took me off the meds.
When I went vegan, I started to cook more, thus reducing processed food from my diet. I definitely stopped eating as much cookie and chip and cracker type food, which I know has a lot of sodium. Also, I have noticed that I don’t need my food to be as salty. I used to use much more to flavor food.
Fred G., Richfield, Ohio: For 40 years I have dealt with high blood pressure and reduced my salt intake over those years. I have been on a limited salt (but not very low-salt) diet for the past 20 years. . . . I have taken two medications for many years—one always being a beta blocker. My blood pressure has been controlled satisfactorily with this combination of diet and medications, but diet alone has not come close to working.
Daniel B., Honolulu, Hawaii: Not only do I feel better, I have noticed a decreased swelling in my lower legs at the end of the day as a result of NO added salt to my diet. . . . I have not needed to wear compression socks and have reduced my Losartan [blood pressure medicine] to 25 from 50mg. I try to go back to the web pages of all the processed foods that I eat and drink [and check the nutrition numbers]. I work with general rules and have no absolute “don’t buys”:
Elinor G., Sarasota, Florida: My doctor took me off blood pressure medication after only three weeks of being on a plant-based, whole-food diet!!!! Just avoiding processed food did it!
John H., Silver Spring, Maryland: For well over a decade, we have deliberately avoided large intakes of salt. Our main tool is reading the nutrition labels when shopping and not eating unlabeled foods [such as at parties] that are notoriously high in salt (and usually also in fat), such as chips. One of our biggest surprises was how many soups contain large amounts of salt. Owing to our long-term reduction in salt content, common salty foods taste too salty to us. We are also near-vegetarians (pescatarians, to be specific), and neither of us has high blood pressure (we are 77 and 83 years old).
Jeanne W., Grand Rapids, Minnesota: Funny you should ask! My doctor just reduced my blood pressure meds in half. I exercise at the “Y” for 2 or 3 hours Monday through Friday. My goal is a whole-food, plant-based diet but mess up at times. I have reduced salt intake, and staying away from processed foods is huge. I am also not pre-diabetic anymore.
So with the scientific facts in the first few chapters of this book and the tips and personal stories in this chapter, I hope you will be well on your way not only to delicious, less salty meals but also to better health. In the epilogue I put the salt–health issue in the context of other science policy controversies fanning the fires of salt wars, and examine the lessons we have learned on the battlefield.