American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, May 29, 2014

Getting granular about salt

In my prior column I made the case that worries about consuming too little sodium are substantially moot in the world where most of us do our eating. Sodium is an essential nutrient, and it is, of course, possible to consume too little. In much of nature (of the terrestrial variety), salt deficiency is a legitimate hazard, and the reason why many animals will make a pilgrimage to a salt lick. All of us who have completed medical training have seen hyponatremia (low sodium levels in the blood) in people as well, and it’s a very unpleasant condition to say the least. While more often due to a metabolic abnormality than low salt intake, cases of hyponatramia, which can be life threatening, vividly demonstrate that too little sodium is not a desirable alternative to too much.

So yes, we can consume too little sodium. And yes, we are rather uncertain at this point about what exactly the ideal threshold is, and just how universally it pertains. But despite any such distillation of misgivings and doubts, the present problem is clear enough. Whatever the optimal intake of sodium is, most of us in the modern world are well above it, with blatantly adverse health effects to show for it. A large aggregation of data from diverse sources indicates that human health improves when sodium intake is dialed down from the levels that now prevail.

So, since too much salt is one of the many ways the modern diet is broken, consuming less is the relevant fix. My argument is not that every question has been answered, but that we are better served to head productively toward the sweet spot than to let worries about overshooting forestall such progress altogether. Perfect is the enemy of good, and less salt would be good for most of us.

All the more so because most of our salt intake reaches us courtesy of processed foods that tend to carry other liabilities as well. The longer the ingredient list of a packaged food, the more sodium it is likely to contain, but also the more sugar (under whatever array of aliases); the more colorings; the more flavorings; the more food chemicals; and the more calories. A focus on eating less salt is no more necessary than a focus on eating less added sugar, or saturated fat, or trans fat, or calories. Rather, eat more “good stuff,” and the nutrient details tend to take care of themselves.

While true, that’s rather vague, and it may also seem a bit Pollyanna. That won’t do for a public health pragmatist like me, so I suspect a bit more granularity is in order. That, then, is today’s mission: getting granular about salt reduction.

Virtually all debate about optimal sodium intake refers to levels well below 2,500 milligrams per day, so we may comfortably accept that as a non-contentious target, apt to do us good. If we superimpose that sodium level on the prototypical diet of 2,000 calories, it gives us 1.25 milligrams of sodium per calorie. If the foods we eat average more than 1.25 milligrams sodium per calorie, our diet will provide more than 2,500 milligrams per day. If salty foods pull our average up, we must rely on non-salty foods to pull it down, so we land somewhere in proximity to the 2, 500 milligrams total.

But what are the salty foods that pull our average up? The usual suspects no doubt come to mind: soup, condiments, and everything in the “salty snack” aisle of the supermarket. If that were the whole story, we’d be in much less of a pickle. Alas, it is not.

Consider that America, purportedly, runs on Dunkin’. So a typical American day might begin with Dunkin’s bacon, egg, and cheese breakfast sandwich. If it does, it starts out with 460 calories, and 1,200 milligrams of sodium. That’s 2.6 milligrams of sodium per calorie, or well over twice as salty as you want your diet to be on average. If breakfast is pulling average salt intake up, what is the chance that lunch and dinner, where the truly salty foods tend to cluster, will pull it down?

Lest you think I am cherry picking my examples, note that most of Dunkin’s other sandwiches, both breakfast and bakery, are more concentrated in sodium than the example I chose. And there’s no reason to pick on Dunkin’; McDonald’s Egg McMuffin delivers 840 milligrams of sodium in 300 calories.

But then let’s presume that you are far too fastidious to have a fast-food sandwich for breakfast. If instead you have a bowl of, say, the seemingly quite virtuous Grape-Nuts cereal, you are getting 290 milligrams of sodium per 210-calorie service. That is, you guessed it, more than 1.25 milligrams per calorie. Grape-Nuts is saltier than our diets should be on average. And no need to pick on Grape-Nuts, either; the same is true of Cheerios, Life cereal, and even Frosted Flakes. Almost the entire inventory of America’s most popular breakfast cereals is saltier than our diets should be on average.

From here, the news could readily go from bad to worse. The Center for Science in the Public Interest has published summaries of both processed foods and restaurant dishes that are not just highly concentrated in sodium, but in some cases deliver nearly a two-day supply (i.e., nearly 5 grams!) in just one dish.

But more bad news won’t help us, so let’s shake things up. Where is the good news?

You may be surprised. Consider, for instance, that Garden of Eatin’, one of my favorite chip brands (yes, I do think the nutritionally virtuous can occasionally eat chips!), offers yellow corn chips, ostensibly a salty snack, with just 70 milligrams of sodium per 140 calories. That’s just 0.5 milligrams sodium per calorie. So this so-called salty snack helps pull down, not up, the average salt level in our diets. Many other offerings in the salty snack aisle do the same. How can that be?

The matter reverts back to the overall degree of processing. The Garden of Eatin’ chips in question have just three ingredients: organic corn, oil, and sea salt. Breakfast cereals with much higher doses of salt taste less salty because other ingredients, notably sugar, mask the salt flavor. (They also taste less salty because our palates have acclimated to, and been desensitized by, the ridiculously high levels of salt and sugar in our diets. This process can be reversed!) When ingredients are few, and nothing obscures the taste of salt, it takes much less of it to impress our taste buds.

This is a generalizable theme. There are breakfast cereals made from short lists of wholesome ingredients that provide dramatically less sodium than the more processed popular brands. The popular Lucky Charms sports a long ingredient list that is not only home to at least 4 dyes and artificial flavors that help multi-colored marshmallows impersonate breakfast, but also provides cover for about 1.7 milligrams of sodium per calorie. So while sugar and chemistry are the obvious liabilities of this product, it is also far saltier than our diets should be on average. In contrast, one of my favorite breakfast cereals, Nature’s Path multigrain, has 1 milligrams of sodium per calorie.

Shorter, simpler ingredient lists are associated with less sodium in not just chips and cereals, but also breads, crackers, dairy products, snack bars, spreads, dressings, sauces, and even meats. These products tend to have less added sugar, too; to avoid harmful oils; to have more beneficial nutrients; and to help fill us up on fewer calories. Of course, to whatever extent you can prioritize foods with an ingredient list just one word long, apples, bananas, tomatoes, carrots, walnuts, broccoli, lentils, and so on, you reach the very pinnacle of this opportunity. Such foods don’t just help pull down our overall sodium intake, they help pull up the overall quality of our diets.

My colleagues and I developed, studied, published, and offer for free a food label literacy program called Nutrition Detectives designed to help kid and their parents trade up food choices in any given category. You can help yourself to the program if so inclined. Minimally, note that one of the 5 clues that constitute the program’s punch line is this: the shorter the ingredient list, the better. Better means much more than less sodium, but it tends to mean that into the bargain. For those with access toNuVal, the nutrient profiling system we similarly developed, studied, and published, higher scoring foods in any given category similarly offer better overall nutrition, and less salt as part of that formula. We have evidence as well that such trade-ups can be made using either approach without spending more money.

The copious excesses of sodium to which we are all exposed reside not just where we would expect them, but almost everywhere in the modern foodscape. The good news is that in all those same food categories there are alternative choices that are simpler, tasty, more nutritious, often no more expensive, and less salty besides. The very granular strategy of choosing foods with shorter ingredient lists allows for cutting out many superfluous grains of salt by way of improving overall nutritional quality. There should be no controversy in that.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

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John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

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Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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