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Less salt: it’s that simple

It has been known for decades that dietary sodium is significantly associated with hypertension and coronary heart disease.  Despite this knowledge, Americans continue to consume more sodium, most of it coming from processed foods.  Various approaches have been used to help individuals modify their behavior, one of the most popular of which is the DASH diet.  Given what we know, you would think that a low-sodium diet would be especially popular with “alternative” practitioners.  After all, what could be more “natural” than lifestyle modification (a mainstay of real medicine since…well…forever).

But as any clinician knows, it’s much easier to get someone to take something than to eliminate something.  Lifestyle modification is difficult, but achievable to a degree as experience has shown with cholesterol, smoking, and other modifiable risk factors.  A recent study in the New England Journal of Medicine evaluated what the possible effect would be of lowering U.S. sodium consumption to 3g/day.  The authors found that, “Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.”

It really could be that simple: a combination of education and regulation could save lives and money.  And you would think the altmed folks could get behind something like this.  But taking simple, cheap recommendations and turning them into something “alternative” (and profitable) is a specialty of modern shamans.

A good example of this is a “holistic family practice” in the Midwest U.S. From the FAQs on their website:

Q:Should I eliminate salt in my diet?
A:The correct form of salt is an extremely important substance for our body. There is a big difference between refined salt and unrefined salt. As I discuss in Salt: Your Way To Health, refined salt is a toxic substance that needs to be avoided. Refined salt has no minerals and is contaminated with substances such as ferrocyanide. Unrefined salt has over 80 minerals in it. I have found unrefined salt a wonderful addition to a healthy holistic regimen.

If that sounds fishy to you, good.  You have probably already noticed the most glaring error: that refined salt contains “no minerals”.  Of course, sodium chloride is a mineral (as are potassium chloride, potassium iodide, etc.).  Following the link to his book is revealing because his special salt can cure all kinds of problems. And, to make your life easier, he sells just the right salt.  One of his special salts is called “Celtic Sea Salt”, which, at $6.00/lb, “balances the body and can help with adrenal exhuastion, low blood pressure, and mineral deficiencies.”  Links to evidence?  None.  Price of typical American table salt? Less than a dollar per pound (not that you should be using added salt in any significant quantity anyway).

This is typical of the altmed movement.  They accuse real medicine of being a profit-driven juggernaut that ignores simple treatments, but then promote their own useless and expensive nostrums. It would be comical if it weren’t real people who suffer.

References

Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, & Goldman L (2010). Projected effect of dietary salt reductions on future cardiovascular disease. The New England journal of medicine, 362 (7), 590-9 PMID: 20089957

Posted in: Science and Medicine

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23 thoughts on “Less salt: it’s that simple

  1. Anarres says:

    Very useful, thanks. Spices are great at preserving and seasoning the food.

  2. Jack123 says:

    Do you have an explanation for the NHANES I, II and III data showing no or J-shaped associations between salt intake and mortality?

  3. Nescio says:

    I looked into this recently, having come across claims that unrefined salt is good for us because of its superior mineral content. For some perspective, I compared the mineral content of ‘Light Grey Celtic Sea Salt’ with a McDonalds Big Mac (not the most nutritious of foods I think you will agree).

    A McDonalds Big Mac contains 8 times as much magnesium as a 1/4 tsp of ‘Light Grey Celtic Sea Salt’. A Big Mac also contains 146 times as much potassium, 169 times as much calcium, 31 times as much iron, 139 times as much zinc, 10 times as much copper and 22 times as much manganese as 1/4 tsp of ‘Light Grey Celtic Sea Salt’. I couldn’t find the content of other minerals
    in a Big Mac, but I think these make the point adequately.

    To get the RDA of magnesium from this salt you would have to ingest around 20 teaspoons of it.

    Sources: http://www.nal.usda.gov/fnic/foodcomp/search/
    http://curezone.com/foods/saltcure.asp

    BTW, bat guano is even more nutritious than either Celtic Sea Salt or a Big Mac. Yum.
    http://rspb.royalsocietypublishing.org/content/273/1585/439/T2.expansion.html

  4. Brookster says:

    I think this is an over-simplistic treatment of a subject that’s much more complicated.

    I’m prepared to accept lowering salt intake across the board would be beneficial to the country as a whole. However, that’s not to say that the salt always causes hypertension – many people are insensitive, in terms of blood pressure, to increased salt in their diet.

  5. I’ve always been a bit sanguine about my salt intake. Perhaps this is because people who take my blood pressure usual comment “That’s good.” or “Is your blood presurre usually this low?”

    That said, I do cook for the whole family, so perhaps I should be more aware of the risks. Although I don’t generally add salt to processed foods, I do find that the veggies have a better chance of being eaten if a bit of butter or margerine and some salt is added. For seasoning, I usually use sea salt, because I like the flavor. For baking I use table salt, because it measures better. I’m not sure how different the content actually is (aside from Iodine), could just be the grind.

    I noticed that this article seems to come to a different conclusion on the amount of evidence that controlling salt intake would benefit public health than the article “The War on Salt” by Dr. N – http://www.sciencebasedmedicine.org/?p=3367

    This example of conflicting views on diet recommendations is one of the reasons I am sanguine about many of my dietary choices. If one doctor says one thing and another doctor say another, I figure, I’ll just make the tasty choice. For me, it’s actually hard enough to cut back on calories* and eat five fruits and veggies a day without worrying about salt.

    *I love pastries

  6. Dave Ruddell says:

    But I like salt!

  7. tmac57 says:

    micheleinmichigan- I re-read the article that you referenced by Dr N., and it seems to me that his general conclusion is that salt reduction in the diet is warranted. He concluded:

    “While there remains legitimate dissent on the role of salt in vascular health, the current consensus is something like this:

    - Most of the world, including Americans and those in industrialized nations, consume more salt than appears to be necessary.

    - In the US most of that salt comes from processed or restaurant food (while in other countries, like Japan, most salt intake is added while cooking).

    - There is a plausible connection between excess salt intake, hypertension, strokes and heart attacks.

    - There is evidence to suggest that reducing overall salt intake will reduce the incidence of these health problems, but the evidence is not yet conclusive and longer term and sub-population data is needed. ”

    My personal experience with salt reduction in my diet was that at first I really missed it, and the food seemed more bland. Then as I adjusted to it, I began to find prepared foods and most restaurant fare tasted too salty. So your palate can adjust to the change, and it doesn’t take all that long either.

  8. Dawn says:

    I generally don’t cook with salt, (unless baking where it is needed), but add it afterwards. I found I use much less if I just add it afterwards. IIRC, they did a study and found people use less salt that way, because they can taste it, whereas if it is cooked in, they add more because they can’t taste it.

    However, I happily admit to being a salty foods addict; very few foods are too salty for me (I even love Smithfield ham without soaking it…). I also love spicy flavored foods (not the “so spicy hot you can’t taste anything foods, but spiced foods). I don’t do much sweet stuff.

  9. tmac57 – I guess that I was focusing on the last line “There is evidence to suggest that reducing overall salt intake will reduce the incidence of these health problems, but the evidence is not yet conclusive and longer term and sub-population data is needed. ”

    To me that sounds different than “The authors found that, “Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.”

    The issue for me, of course, that a “modest reduction” would mean I would have to track how much the family is eating now, then seek alternative products that include less sodium. I would also have to attempt to train my children to eat healthy foods with no or less salt added, which will mean many more meal time battles.

    I already deal with a certain number of food issues with the kids. We must limit my son’s sugar intake due to tooth decay issues and increase my daughter’s fiber and monitor her daily dairy consumption due to constipation issues (these are doctor, dentist recommendations, not my GoogleU ideas.) My husband’s health is fine, besides lactose intolerance :) he has good blood pressure, eats well and exercises quite a bit.

    So, I’m going to have to see some pretty solid evidence that salt intake is going to negatively effect our health, as individual, to make the effort to lower intake.

    That said, I would be very happy if I could buy lower sodium versions of the process foods that I often buy, such as canned soups, canned beans, I think canned salmon, frozen dumpling, etc. I suspect that if I salted to taste (rather than having it added in the factory) they all would end up with a healthier level of salt.

  10. Zetetic says:

    Nescio:

    A Curezone reference! I love that web site – It’s like a carnival freak show that you can’t stop watching!

  11. # Dawnon 01 Apr 2010 at 12:04 pm

    “I generally don’t cook with salt, (unless baking where it is needed), but add it afterwards. I found I use much less if I just add it afterwards.”

    Yes, I think I have heard that too. I think I’ll have to think about what I do in that regard. If I follow a recipe for cooking, I sometimes add as cooking. I often use less salt than called for, though, then salt to taste at the end. Often for veggies, I cook, then add butter (margarine, olive oil…) and salt to the bowl before plating. Just easier for me that way. Often if a dish calls for cheese, I don’t salt, because most cheese is very salty.

  12. Peter Lipson says:

    As some have noted, the sodium issue is rather complex. The evidence is becoming clearer that sodium negatively impacts health, independent of its affect on the blood pressure of an individual patient.

    Many patients have a sodium-responsive hypertension, many do not.

    The interesting thing for me here was how quacks and quack-like folks take an interesting concept and twist it into something invalid and profitable.

  13. Chris says:

    I grew up in a house where there was a parent whose hypertension was affected by salt. So we cooked with very little salt, substituted herbs and spices.

    It is sometimes weird dealing with others who did grew up that way. It took me five years to keep spouse from drowning food with salt. I wish I could grab Martha Stewart through the TV screen and remove the salt from her hand (and why do she and her staff grab salt from a bowl, yesterday one of her staff chopped up pork tenderloin and then without washing took salt out of the bowl!).

    I went to a fancy-shmancy cookery store for a demo on cooking pasta. The chef instructed us to cook it in salty water. When we got to taste it, I thought it was inedible due to its saltiness.

    That same fancy-shmancy store also sells funny colored salt, like pink salt. I wonder how much they would sell at outrageous prices if the customers knew it was pink due to the presence of bacteria who like the brine that comes from making salt from sea water (halophilic archaebacteria).

    Also, why is sea salt supposed to be better than mined salt? Mined salt is from ancient seas which dried up long before the industrial revolution. I would assume that “Celtic Sea Salt” may have extra hydrocarbons from road runoff and perhaps from an occasional oil spill. (the Salt Mine Berchtesgaden tour is very fun, it is in Germany just across the border from Salzburg, Austria… now take a guess why it has that name!)

  14. Chris says:

    AArgh… The first sentence in second paragraph should read “It is sometimes weird dealing with others who did not grow up that way.”

  15. AlexisT says:

    Chris: Many of the TV cooks who grab salt from a bowl are using kosher salt, which is a different shape of crystal and about half as salty, volume for volume. (Yes, if you weigh it, a cup of kosher salt will weigh half of what a cup of table salt weighs.) They may not be throwing in as much salt as they seem to be.

  16. Janel says:

    AlexisT: I think Chris’s concern over grabbing salt from a bowl from the raw pork tenderloin incident is less about the amount grabbed and instead more about food safety.

  17. hrichmon says:

    My wife, who has a strong preference for chiropractors and NDs, has been advised by her current chiro/ND to take a half teaspoon of pink salt a day, preferably Himalayana brand salt. His advice is based on slightly low serum levels of sodium and chloride. This particular brand has a label that says the pink color comes from iron and other, unspecified minerals. The label does not indicate how much of the other minerals, besides NaCl is contained in the salt. I was interested in Chris’s comment about the color of salt being caused by bacteria.

  18. Chris says:

    AlexisT, how does grabbing kosher salt from a bowl prevent the spread of bacteria from raw pork? And I don’t care if it is kosher or not, the pasta at the demonstration at the fancy-shmancy cookery store was much too salty.

    hrichmon, the information the pink salt was from my freshman biology book (with a photo of a salt operation with pink pools). just look up halophilic archaebacteria. With a bit of googling, I found a Google Book section showing a Himalayan salt sample that was colored by the bacteria eons ago. Look here, and read the caption under the photo.

    The bacteria aren’t dangerous. It is just interesting that the folks peddling the pink stuff neglect to mention how it gets its color! I personally think the bacteria who like the extreme conditions are more interesting than the bland “minerals” explanation.

    If your wife needs more iron, have her cook her food in a cast iron pan. If she wants more minerals, try including a variety of fruits, and vegetables in her diet, along with a variety of lean meats (beef and fish… the be careful with the amount of mercury in the latter, if you puree salmon that still has some little bones and create a spread there is added calcium). Some very good sources are also nuts and legumes.

    If you can’t tell, I am a foodie (which is why I hang around fancy-shmancy cookery stores). I have an herb garden that I am constantly using, and the garden is generally edible (my front fence are espaliered apple trees). I even make my own salt-free chicken stock from the remains of a roasted chicken, vegies, garden herbs, pepper and one clove.

    I am also anal about food safety. Not only do I use separate cutting boards for meat and vegies, I use separate counters. The island is for vegies, and meat is only cut on the counter between the cook-top and the sink (because I also need to wash my hands between touching meat and anything else).

  19. Chris says:

    Ack, my comment is in moderation.

    Yes, I was more concerned with food safety rather than flavor.

    The information about the pink salt and bacteria was from a basic biology book on my book case. I found a link to a google book which shows that Himalayan pink salt is from bacteria on page 33. The book is “Archaea: molecular and cellular biology By Ricardo Cavicchioli”, and I found it by using the search terms “halophilic archaebacteria himalayan pink salt” in google.

    Later today I will entertain myself with another book that I just found on my shelf: On Food and Cooking, The Science and Lore of the Kitchen by Harold McGee.

  20. Basiorana says:

    The only times I add salt are to hard-boiled eggs, and to certain kinds of curries that call for it (works out to 1/16 tsp or less per serving– curries don’t have to be salty, the other spices provide the needed flavor). I NEVER salt store-bought pasta, though! They always recommend it, and it does stick less and cook faster, but lordy it gets salty. When I make my own pasta I don’t include salt so I can salt it in the pot, and that’s fine for me.

    My favorite salt substitute for soups is celery. Chopped or just the seeds, it provides that salty flavor you really want in chicken noodle but you don’t tend to add as much.

    My sister’s very big on kosher salt– she started using it all the time, since she went to a Jewish college and worked in a kosher cafe. My attitude is, sure, you’re adding less salt overall because of crystal shape, but you’re still adding salt to canned soups and pretty much every dish!

  21. hatch_xanadu says:

    The more I think on this, the more I realize just how despicable it is for someone representing medical authority to push “special” salt on a person already concerned with salt intake. My mother-in-law — who’s already hypertensive and at very high cardiovascular risk — is a victim of this sort of “holistic” quack. A person approaching a family physician (who may very well be at serious risk) asking “Should I cut out salt?” should never receive as an answer, “Here, eat a bunch of this salt.”

  22. nicci says:

    I’m a first-time poster, long time lurker, and a big fan of the work you guys are doing on this site. I have to say, though, that I think this posting involves a failure in critical thinking that does a real disservice to you, and to the extent that similar failures are made, to the practice of medicine in general.

    First of all, a certain amount of sodium IS necessary for healthy bodily function. In the study quoted (http://content.nejm.org/cgi/reprint/344/1/3.pdf), the lowest level of sodium in the DASH diet is 1500mg a day. For a long time I was eating significantly less than this (generally in the range of 500-1000mg a day), and started having problems with low blood pressure. My primary care physician (an MD) told me to add more salt to my diet. I did, and my symptoms improved. So recommending that a patient add salt to their diet is not automatically bad advice, and can help with low blood pressure. I eat almost no processed food, very few baked goods, and am not in the habit of adding salt to my food. While this is atypical for most Americans, it’s pretty typical for health nuts (i.e. the target audience of holistic medicine sites), so it is actually a good idea to spread the information widely that the body does want some minimal amount of salt (or at least sodium) for optimal health.

    As far as the differences in mineral content between unrefined sea salt and regular table salt, there is a significant difference between the mineral content of 1tsp of unrefined salt and 1tsp of table salt. Assuming their data is correct, the listing for 1 tsp (6g) of “salt, table” on NutritionData (http://www.nutritiondata.com/facts/spices-and-herbs/216/2) shows only sodium (2300mg) and calcium (1.4mg). Again, assuming their data is correct, the listing on curezone for 1/4 tsp of the unrefined salt (http://curezone.com/foods/salt/Celtic_Sea_Salt_Analysis.asp) shows slightly more calcium as well as a host of other minerals, and that’s for only 1/4 tsp. So you do have to say that unrefined sea salt is far higher in minerals on a relative basis than refined table salt.

    As a side note: it is true that sodium chloride is a mineral, but it’s also true that when speaking in dietary terms, “minerals” typically refers to the ones (calcium, iron, zinc, etc.) that you want more of in your diet. I’m willing to adopt different terminology to make things clearer, but it’s not fair to criticize the holistic family practice for saying table salt doesn’t have “minerals” when any dietician or doctor would say the same thing. This is also off-topic, but it WOULD be fair to criticize the holistic practitioner advocating salt for the treatment of “adrenal exhaustion”. I’m pretty sure no one has even established that there really is such a thing as “adrenal exhaustion”, let alone that it can be treated with any form of salt, sea or table.

    Back to the topic at hand, the amount of “minerals” contained in even 1 tsp of sea salt is very small, smaller by far than what would be contained in the average multivitamin. It’s entirely likely that for the $6.00 you pay for a pound of unrefined sea salt, you can get a pound of Morton’s plus a bottle of multivitamins. Considering nothing other than cost and quantity of vitamins, the Morton’s+multivitamins proposition is the winner.

    However, I (and many other people who buy unrefined sea salt and other expensive whole, unrefined foods) believe that it to be the case generally that vitamins/minerals consumed in their natural form are more beneficial and less harmful than those derived synthetically, also that processing frequently adds harmful substances to food and treats the food in ways that make it less nutritious, and thus we pay an exorbitant amount of money to eat whole foods that are naturally high in vitamins/minerals. I did say “BELIEVE”: I adopted this general principle because it made good sense to me, not because I have proof that it is correct in every instance. In the case of the salt, specifically, I don’t know of any proof that the anti-caking agents used in the production of regular table salt are harmful, I just prefer not to consume them. I don’t know that consuming the minerals naturally dissolved in seawater and dried into sea salt makes them in any way more beneficial than the same minerals synthetically derived or isolated from other substances and packed into vitamin pills, but I prefer to consume the minerals in the salt than in the pills. Someone could spend the money to do high-quality studies to prove or disprove these things, but thus far nobody has (at least not that I could find), so absent proof one has to make their decisions on common sense and what they believe. My decision is to eat whole, naturally nutritious foods (including unrefined sea salt in lieu of refined foods whenever possible) despite their cost.

    My main criticism of this posting is that there is a significant difference between outright hokum (like homeopathy, etc.) that has been disproven by science, and relatively sensible stuff that has not been scientifically tested (or tested much), and it’s important to withhold judgment (or at least strong criticism) on the latter until the data is in. To do otherwise is a failure, albeit an understandable, human one, of critical thinking.

  23. Chris says:

    nicci, the amount of any extra minerals in the bit of sodium chloride that is safe to eat per day is not enough to eschew normal salt for expensive “sea salt.” Just remember to eat a balanced diet with plenty of colorful veggies, including legumes and whole grains. Cooking in cast iron is good for getting iron. Meats and fishes are also good in moderation, like soup bases made with simmered bones.

    Especially if you want more calcium. If you grind fish with bones in a food processor for a mousse you get lots of calcium… there are very good recipes in the book What to Eat While You Are Expecting. My daughter makes smoothies from that book that uses frozen fruit, dried milk and regular milk. It is a double calcium hit that is good for her teenage body. The problem is that she used up all of the frozen peaches, and that tree died this winter (yes, they were from my yard). Now I have to find store bought frozen peaches (she mixed them with frozen strawberries).

    Get the minerals in your food, not the salt.

    Besides, you can buy mined salt (from seas before there was industrial pollution) that is not refined. It was for sale at Berchtesgaden. Plus the Himalayan Pink Salt is mined, the bacteria that made it pink died several hundred thousand years ago.

    In short: You doth protest too much.

    Previously I said:

    (and why do she and her staff grab salt from a bowl, yesterday one of her staff chopped up pork tenderloin and then without washing took salt out of the bowl!)

    I think either someone else noticed that and complained… or one of them reads this blog! Because today while I was catching up on “Martha Stewart” I noticed they are now using spoons to sprinkle the salt and pepper. Yay!

    All hail good food safety practices!

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