Lick the Salt

Helping Patients Lick Their Salt Habit

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March is National Nutrition Month and a great time to educate patients about the relationship between food and health. We’ve called upon our regular contributing editor Jill Shuman—a Registered Dietitian—to share her thoughts about some surprising data published by the CDC regarding the sodium intake of Americans, the sodium content of foods, and how to explain it all to patients.

A new study published by the Centers for Disease Control and Prevention (CDC) has found that nearly all Americans consume more sodium than they should, with most of their salt coming from common restaurant or grocery store items.[1] The data were compiled from more than 7,200 Americans, including nearly 3,000 children from the What We Eat in America, National Health and Nutrition Examination Survey, 2007–2008. Respondents, or their adult caretakers, were polled twice during the two-year study and asked to fill out a detailed 24-hour dietary questionnaire.

The study had two parts. The first section described sodium consumption among Americans, noting that the average American consumes about 3,300 milligrams of sodium per day, not including any salt added at the table—more than twice the recommended limit for about half of all Americans and 60% of all adults. The U.S. Dietary Guidelines recommend limiting sodium intake to less than 2,300 milligrams per day, with a recommendation of 1,500 mg per day for people older than 50 years and anyone with high blood pressure, diabetes, or chronic kidney disease, as well as African Americans.[2]

The second piece of the study compared the relative contribution of various foods to sodium intake, which is the segment that was picked up by many news and media outlets throughout the United States. It turns out that 10 categories of food items contribute 44% of the total dietary sodium consumed each day, exclusive of salt added at the table. (Table).[1]

While correctly reporting that the largest contributor of sodium to the diet was breads and rolls, many outlets failed to report why. These foods aren’t inherently higher in sodium, but contribute greatly to the sodium because they are consumed so often and by so many Americans. As well, many of the news stories were remiss in reporting the purchase site of the sodium-rich foods: 65% of sodium came from food sold in stores and 25% came from meals purchased in restaurants. So before patients start fussing about eliminating chicken from their diet, remind that that the sodium content attributed to chicken is more likely to have come from fast-food restaurants and supermarkets as opposed to that cooked at home in the oven.

According to CDC Director Thomas Frieden, MD, “Too much sodium raises blood pressure, which is a major risk factor for heart disease and stroke. These diseases kill more than 800,000 Americans each year and contribute an estimated $273 billion in healthcare costs.”[3] But nutritionists believe that salt poured at the table is rarely the culprit in sending Americans past the threshold, because eaters can more easily control the salt shaker at home; it’s the hidden salt found in many processed foods, or in meals eaten outside the home, that help push Americans over the limits. CDC estimates that reducing the sodium content of the 10 leading sodium sources by 25% would lower total dietary sodium by more than 10% and could play a role in preventing up to an estimated 28,000 deaths per year.[1]

So what can you tell patients who are concerned about their sodium intake?

Read labels. A slice of white bread, for example, can range from 80 to 230 mg of sodium.
Prepare foods at home whenever possible. Broiled chicken prepared at home contains less than two-thirds the amount of sodium compared with chicken prepared in the supermarket or purchased in restaurants.
Remove the salt shaker from the table. If food tastes ‘flat’ without salt, consider adding garlic or onion powder, dill, or other savory seasonings.
Buy fresh or plain frozen vegetables versus canned or those in sauces. Vegetables packaged with cheese or other sauces are typically high in sodium. Canned vegetables always contained significantly more sodium than fresh or frozen. For example, a 16-oz can of peas contains more than three times more sodium than its fresh or frozen counterparts.
Use fresh poultry, fish, and lean meat rather than canned or processed meats.
Provide a visual. 2000 mg of sodium is the equivalent of only 1 teaspoon of table salt. Some healthcare providers keep a salt shaker on the desk and pour it out to emphasize how little sodium it takes to exceed the Dietary Guidelines.
Debunk the hype. Remind patients that despite broad advertising claims, kosher salt and various sea salts have exactly the same sodium content as plain table salt and are ‘no more healthy.’
Remind patients that salt is an acquired taste and can be manipulated. Most published and anecdotal research suggests that after a short time of cutting back on salty foods, people actually begin to prefer foods that are less salty![4]

And while sodium reduction is an important component of reducing cardiovascular risk, take the opportunity to remind patients that overall cardiovascular health is also influenced by calorie reduction, physical activity, and smoking cessation.

Jill Shuman, MS, RD
Published March 6, 2012

References:

  1. Centers for Disease Control and Prevention. Vital signs: food categories contributing the most to sodium consumption—United States, 2007-2008. MMWR Morb Mortal Wkly Rep. 2012;61:92-98.
  2. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Ed. Washington, DC: U.S. Government Printing Office; December 2010.
  3. Press Release: Nine in 10 U.S. adults get too much sodium every day. Centers for Disease Control and Prevention Website. http://www.cdc.gov/media/releases/2012/p0207_sodium_food.html?s_cid=2011_p0207_sodium_food.html. Updated February 7, 2012. Accessed March 6, 2012.
  4. Controlling what—and how much—we eat. Taste preferences can be changed so that we crave salty and sugary food less and learn to like vegetables and whole grains more. Harv Health Lett. 2011;36(12):1-3.