Salt Gets an Unfair Shake, Public Health Feels

the Pinch

CO-AUTHORED BY: James J. DiNicolantonio, PharmD-10/13/2015

New York City is set to become the first city in the United States to require sodium
warnings on menus. The citys Board of Health voted unanimously to require large
chain restaurants, theaters, and ballparks to post warnings (a salt-shaker symbol in
ominous black triangle) for any item containing more than 2,300mg of sodium.
2,300 mg of sodium is the upper level of intake recommended by existing Dietary
Guidelines for Americans and by the 2015 Dietary Guidelines Advisory Committee. But
are these recommendations actually justified? And will labeling appropriately focus
consumer attention and improve public health?
Problematic Guidance on Dietary Sodium
Unfortunately, a growing body of evidence suggests that current guidance on dietary
sodium may actually be misdirected. Moreover, the effect of sodium labeling could be
to direct attention away from bigger problems with nutrition and make consumers
decidedly less healthy.
Just as background, the rationale for calling attention to sodium at all relates to blood
pressure, the leading risk factor for the #1 cause of death in the US and NYC: heart
disease. But the link between sodium and blood pressure is actually more-inconsistent,
less-pronounced, and more-nuanced than most people realize, and the link between

sodium and heart disease represents a leap in logic.

In biology, just because A (sodium) leads to B (blood pressure) and B (blood pressure)
leads to C (heart disease) does not mean A (sodium) necessarily leads to C (heart
disease). In other words, even though higher sodium intake might in some instances
raise blood pressure, it might not lead to heart issues, and lower sodium intake might
not protect hearts or health.
The Importance of Sodium in the Diet
It is worth noting that sodium is an essential nutrient. Although most people have
been conditioned to believe that the less sodium they consume the better, evidence
suggests that somewhere between 3 to 6 grams of dietary sodium per day may not only
be safe, but optimal for hearts and health.
Across diverse populations, eating habits, and time, sodium intake is remarkably
stable. Average intake in Western populations consistently falls between about 3 to 5
grams daily, regardless of specific food offerings or public-health interventions. Our
bodies recognize the need to maintain sufficient levels of sodium, and sodium intake is
in large part regulated through unconscious internal controls.
The Problem of Low Sodium Intake
When people consume relatively lower amounts of sodium, blood pressure may fall to
a small degree, although in some people reducing sodium intake can
actually increaseblood pressure. In those seeing their blood pressure lowered with
reduced sodium consumption, decreases might be only as much as 1-4 mmHg on
average (on a scale where up to 120 mmHg is considered normal).
Regardless of possible effects on blood pressure though, individuals
consuming lesssodium than around 3 grams per day actually experience greater risk of
heart attacks, stroke, and early death.
Conversely, individual consuming greater than about 5 grams of sodium daily do not
seem to have greater risk for heart attacks, stroke, or early death (specifically in
population-representative samples adjusted for appropriate confounders).
The detrimental, sometimes deadly, effect of low sodium intake may be due sodiums
other effects on the heart and blood vessels. For instance, reducing sodium intake
may stimulate hormones that increase heart rate, cardiac workload, and cardiac stress,
and lead to unhealthy levels of blood cholesterol. People with even low-normal sodium
levels in their blood are at greater risk of death from heart attacks and stoke.
Health Consequences for Vulnerable Groups

Initiatives aimed at lowering sodium consumption could be a decidedly bad thing for
public health. Harmful effects may be particular problems for societys vulnerable
groups.
NYC Health Commissioner, Dr. Mary Basset, rightfully worries about premature
mortality rates among black and Latino New Yorkers. But it is precisely these New
Yorkers who may be harmed most by initiatives aimed at dietary sodium
restriction.Diabetes, kidney disease, and heart disease are all more prevalent among
minority groups, and the respected Institute of Medicine (now the National Academy
of Medicine) has determined that sodium intake as low as recommended for people
having these medical conditions may cause harm.
Broader Dietary Considerations
Importantly, net effects on health from dietary intake relate not just to the amount of
sodium in any given menu item but to that menu items other constituents and to all
other food items in the diet. After all, people eat foods, not isolated food
componentslike sodium.
Other components of food may mitigate unhealthy effects of unusually high-sodium
intake.
Potassium, for example, is associated with lower risk of heart attack, stroke, and dying
early. Eating vegetables (good sources of potassium among other healthy components)
that are generously seasoned with a saltshaker is not likely to undo the benefits those
vegetables provide.
However, the predominant source of sodium in the diet is not salt added to whole
foods by the saltshaker. It is salt incorporated into processed items in industrial plants
and prep kitchens.
Admittedly, there are many items on NYC menus containing incredible amounts of
sodium. But it is not the sodium in these items that is the problem, per se. The
problem is the items themselves.
The items that NYCs new sodium initiative will highlight will generally be industrial
formulations of ultra-processed ingredients. In particular, items will be full of refined
starches and added sugars, which themselves may constitute greater risk for
hypertension and heart disease than sodium.
Unintended Effects on Foods and Diets
When NYCs saltshaker labeling takes effect, food companies will be incentivized to
reduce sodium in their high-sodium items. The companies will inevitably need to
replace the salt with something else to achieve palatable products. Often, what will

replace the salt is sugar.

Sugar may increase blood pressure through a variety of mechanisms. A diet high in
added sugars has been found to increase blood pressure and cause a 3-fold increased
risk of death due to cardiovascular disease. Will incentivizing industry to provide, and
customers to consume, products higher in sugar be good for public health?
Even if food companies did not modify their high-sodium products at all except for
subtracting out the sodium (a feat which would be impossible in actuality due to
palatability constraints), consumers might still wind up taking in more sugar (as well
as more unhealthy fats and various other ultra-processed artificial ingredients: e.g.,
colors, flavors, fillers, stabilizers, emulsifiers, etc.).
Recall that sodium intake is highly stable across populations and unconsciously
regulated. If sodium content of food items goes down, consumers will need to consume
a greater quantity of items or a greater number of items to get the sodium their bodies
demand (and they will get bigger doses of all the other unhealthy constituents in those
items as a consequence).
Would individuals possibly ordering and eating more now lower in sodium nachos,
processed meats, and saucy noodle and rice dishes be a good thing? Certainly for
businesses it would, which is why some companies may embrace NYCs sodiumlabeling initiative or protest only half-heartedly against it. But for consumers, it may
mean eating more in general and more unhealthy stuff specifically.
A Path Forward for Public Health
Sodium labeling is emblematic of other misdirected public health initiatives focused on
single food components. Years ago, when campaigns focused on dietary fat, the food
industry substituted starches and sugars and the result was greater obesity and higher
rates of chronic diseases. Today, with initiatives like those focused on sodium, the
result is likely to be the same: food companies will engineer substitutions that make
unhealthy products perhaps just as unhealthyor even more so.
The time has come to stop focusing on food components and start focusing on whole
foods and whole diets. If the NYC health department wants a symbol to accompany
menu items at various city eateries, then an indicator of overall nutritional quality
would be far superior. Scoring systems already exist that might be applied. In the
interim, continued focus on isolated menu constituents, particularly sodium, is likely
to produce the exact opposite effects of those intended. What we need is initiatives that
are worth their salt.
Follow Sean C. Lucan, M.D., MPH, MS on Twitter:

Posted by Thavam