Salt is a major health problem that industry can solve

A recent article on Medscape takes a look at the other deadly incredient in our diets-salt. Fat has been getting as lot of attention because of the obesity problerm. Researchers found that taking out 3 grams per day could save $20+ billion in healthcare costs and reduce strokes by about 30,000. The article Halt the salt! Please was written by Sandra Fryhofer, MD of Emory University School of Medicine. It is available at; however you must register on the site to read the article.

This issue of Staying Well focuses on an initiative than can help save lives and save money: cutting down on salt in our diet. With healthcare reform on the national agenda, reducing medical costs while at the same time judiciously utilizing precious healthcare resources is a top priority. Decreasing sodium intake is a part of the solution. Here's why.

Sodium intake increases blood pressure.[1-3] Salt (sodium chloride) is 40% sodium by weight and is the main source of sodium in food. Salt intake has increased by 69% in women and 48% in men since the 1970s.[4] Lowering salt intake lowers blood pressure.[1]

Heart disease and stroke are leading causes of death.[5] High blood pressure, deemed a "neglected disease" by the Institute of Medicine, is a major risk factor for cardiovascular disease.[1,5] The greater the increase in blood pressure over 115/75 mm Hg, the greater the cardiovascular disease risk,[6] with each 20-mm Hg increase over 115 mm Hg doubling heart attack and stroke risk.[5] Nearly one third of adults in the United States, around 73 million people, already have hypertension (blood pressure 140/90 mm Hg and higher).[1,2] Another third of the US adult population, an additional 59 million people, have pre-hypertension (blood pressure 120-139/80-89 mm Hg).[1,2] Direct and indirect costs attributable to hypertension have a price tag of more than $73 billion dollars a year.[1]

Skimping on salt can save lives and money. Two 2010 studies used computer models to quantify these savings. In The New England Journal of Medicine, Bibbins-Domingo and colleagues postulated that cutting daily salt by 3 g/day would save up to $24 billion dollars in healthcare costs and reduce the yearly number of strokes by 32,000, heart attacks by 44,000, and new cases of heart disease by 60,000.[7] In the Annals of Internal Medicine, Smith-Spangler and colleagues suggest that a 10% decrease in sodium intake could translate into a decrease of $32 billion dollars in medical costs and a million lives saved from heart attack and stroke.[8]

How to Get Rid of Salt in the Diet

You can take the salt shaker away but that won't solve the problem. Only 6% of salt is added at the table. An additional 5% is added in cooking. So this excessively salty problem is out of our hands, literally. More than 75% of sodium comes from processed and restaurant foods.[2,3,6] That's why Smith-Spangler's computer model is based on decreasing sodium through collaboration with the industry. This means that processed, including packaged, foods need sodium limits, and restaurants also need to lower salt added in their recipes.

America Is Behind the Curve

Compared with other countries, the United States is behind the curve in salt-lowering activities. Other countries, including Australia, Canada, Finland, Ireland, New Zealand, and the United Kingdom, are way ahead of us and have already made great strides in reducing sodium intake.[2,3] The United Kingdom's Food Standards Agency has implemented a "traffic-light" system for labeling sodium content, with labels on low sodium food given a green color and high sodium marked in red.[2,3,5] The United Kingdom has successful voluntary collaboration with food manufacturers, which has resulted in salt reductions of 20%-30% in most processed foods. The goal is a 40% overall reduction in sodium intake by year 2012.[5] Based on these successes, a 10% salt reduction in Smith-Spangler's computer model is realistic and attainable with industry cooperation.[8] Like taxes on tobacco products and alcohol, a salt tax might reduce consumption, yet no country has tried this strategy.[5,8] It makes sense that incremental changes in salt content might be more palatable to consumers. That's why, back in 2006, the American Medical Association's Council on Science and Public Health recommended at least a 50% cut in sodium in both processed foods and restaurant foods over 10 years.[1,2]

How Much Is Too Much?

Dietary guidelines. The 2005 US Department of Agriculture Dietary Guidelines say our intake should be no more than 2300 mg of sodium per day -- about the amount of sodium in a teaspoon of salt (5.8 g salt).[9] For certain population groups, the guidelines are even more restrictive. Blacks, middle-aged and older adults, and those already diagnosed with hypertension should take in even less: no more than 1500 mg sodium a day, which is three-fourths teaspoon of salt.[9] The National Health and Nutrition Examination Survey data suggest that the more restrictive salt recommendation applies to nearly 70% of all US residents.[10]

Here is the reality. We are failing miserably at complying with these recommendations, and the tradeoff is expensive and deadly. On average, we take in about 3900 mg sodium a day, more than twice what is recommended for the majority of Americans.[8] The Institute of Medicine says that for 87% of US adults, the amount of salt they ingest is too much.[1]

Food labels can be confusing. Reading sodium daily value (%DV) on food labels can be confusing. Although for the general population the goal is less than 100% DV, for the "specific" population, the total daily intake should not exceed 65% DV, which corresponds to 1500 mg daily sodium intake.[9]

Salt Reduction: An Important Public Health Initiative

The health benefits of reducing salt are comparable to other effective public health interventions -- smoking cessation, weight reduction, exercise, and use of cholesterol-lowering medications.[8,11] Start a conversation with patients about salt intake. Urge your patients to get rid of the salt shaker at the table and, instead, use herbs and spices to flavor foods. Make sure your salt talk includes specific numbers. Remind patients that three fourths of sodium load is "hidden" in processed and packaged foods. Talk about food labels. Encourage patients to read package labels carefully. Remind them that 65% DV -- not the 100% DV -- salt limit applies to most individuals.

The Institute of Medicine has convened an ad hoc consensus committee to study Strategies to Reduce Sodium Intake. I hope their insight and recommendations (release expected mid April) will provide useful strategies to help put a halt to salt.

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Comment by Leona Ow Woodbridge on May 26, 2010 at 6:24pm
You are so right about the lack of focus on hypertension. In some ways is it the step-sister chronic disease. Dr. Fryhofer is featured in a Medscape video discussing concrete policy/practice steps can be taken to reduce sodium intake." target="_blank

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