Sodium in Diet Issues

Health activists have waged a decade-long war on sodium, citing its role in high blood pressure and cardiovascular risks. They've urged consumers to avoid foods that have high sodium content.

International researchers have produced a study that takes a contrary view. Yes, too much sodium is harmful to people with high blood pressure, but they maintain that a low-sodium diet for everyone else is not only not beneficial, but may be harmful, increasing cardiovascular risk and even death.

The study, which may prove to be controversial, included more than 130,000 people from 49 countries. It was led by researchers at McMaster University and Hamilton Health Sciences, in Canada. The researchers focused on the relationship between sodium consumption and death, heart disease, and stroke.

What made the study different was the separation of the subjects into those with high blood pressure and those with a normal blood pressure reading.

Surprising result

The results found that subjects who had a reduced sodium consumption level were more likely to have suffered a heart attack, stroke, or death.

“These are extremely important findings for those who are suffering from high blood pressure,” said lead author Andrew Mente. “While our data highlights the importance of reducing high salt intake in people with hypertension, it does not support reducing salt intake to low levels.”

The take-away from the study, Mente says, is a low-sodium diet is best used for people with high blood pressure, but not the public in general. This conflicts with current medical conventional wisdom.

Current assumptions

The Mayo Clinic staff notes that Dietary Guidelines for Americans recommends limiting sodium to less than 2,300 mg a day. But the staff says “less is usually better,” especially for consumers who are have a sodium sensitivity.

“If you aren't sure how much sodium your diet should include, talk to your doctor or dietitian,” the staff says on the Mayo Clinic website.

Without mentioning the Canadian study, the American Heart Association (AMA) has underscored its belief that all people should reduce sodium consumption. It says its lifestyle guidelines on sodium reduction were based on more than 30 scientific studies.

The organization stands behind a 2014 consensus statement among scientists that concluded “population-wide reduction of sodium intake is an integral approach to reducing cardiovascular disease events and mortality in the United States.”

But the Canadian researchers say their findings are conclusive, showing that risks associated with low-sodium intake, which they define as less than three grams per day, are consistent whether or not someone has high blood pressure.

They state that there is a limit below which sodium intake may be unsafe and the risk associated with high sodium consumption appears to only affect those with hypertension.

Results of a study published in the New England Journal of Medicine last week made a lot of waves. It suggested that a low-salt diet might be harmful to your health. At least, that was the way it was interpreted in most media reports.

Researchers at the University of Alabama Birmingham (UAB) studied people who consumed varied amounts of sodium in their daily diet. Not surprisingly, it found that people who consumed 6 or more grams of sodium each day had a higher risk of high blood pressure and cardiovascular disease.

But it also found that people who consumed 1.5 grams or less each day had a higher risk of heart-related death. So the headline on the study concluded that consuming too little sodium could be harmful, just as consuming too much.

Misleading?

But is that really what the study says? Read how Suzanne Oparil, director of the vascular biology and hypertension program in UAB’s School of Medicine, put it.

“Importantly, the very large PURE study provides evidence that both high and low levels of sodium intake may be associated with an increased risk of death and cardiovascular disease outcomes,” she said.

Notice what she didn't say. She didn't say the research had found a causation link – only a correlation. The media was quick to conclude that consuming less than 1.5 grams of sodium daily was harmful but that's not what the study says. It says only that people on a low-sodium diet are more likely to die from heart disease than people who consume 3 to 6 grams.

Ask yourself – who exactly is on a low-sodium diet, one in which they consume 1.5 grams or less of sodium daily? Wouldn't it mostly be people with a history of heart disease, or people at higher risk of cardiovascular disease? Maybe they were people who once consumed 6 grams or more of sodium, until they developed heart disease and their doctor put them on a low-sodium diet.

And might not people with existing heart disease, or high risk of heart disease, be the people most likely to die of heart disease?

Controversial

The interpretation of the study is somewhat controversial, since the U.S. government, in 2010, lowered its recommended sodium intake for children and adults to no more than 2.3 grams daily. The American Heart Association (AHA) recommends even less sodium – below 1.5 grams daily.

The AHA was quick to criticize the PURE study, saying it contained several substantial “methodological issues” that limit its usefulness for developing guidelines for healthy sodium consumption.

“The AHA has been concerned about the quality of these studies and strongly believes that other types of evidence, particularly the well-documented clinical trial relationship of sodium intake and blood pressure, provide the best scientific basis to guide policy,” said AHA President Elliott Antman.

AHA is joined in its critique by the Center for Science in the Public Interest (CSPI), a consumer group that has long advocated reduced sodium consumption in the American diet. CSPI Nutrition Director Bonnie F. Liebman notes that many low-sodium consumers in the study may have already been sick, a “serious shortcoming” in the study.

Liebman also notes that the same issue of the New England Journal of Medicine contained articles about 2 other sodium studies, one of which she says quantifies the massive toll caused by high-sodium diets. Consumers are eating too much sodium, she says, not too little.

“Americans are consuming about 4,000 mg of sodium per day—twice as high as those researchers recommend,” she says. “As a result, tens of thousands of Americans die prematurely every year due to cardiovascular disease.”

For years, health officials and consumer advocates have been urging restaurant chains to go easy on the salt, but a study finds those appeals have largely fallen on deaf ears.

A review of 136 meals from 17 top restaurant chains finds that the companies have reduced sodium on average by 6% between 2009 and 2013, or just 1.5% per year. The nonprofit Center for Science in the Public Interest says that the progress has been slow and inconsistent.

The biggest reductions in sodium were posted by Subway, Burger King, and McDonald's, but KFC and Jack in the Box actually increased sodium by 12.4% and 7.2%, respectively, in the sample of meals reviewed.

At table-service chains such as Red Lobster, Chili's, and Olive Garden, it's easy to find meals in the ballpark of 5,000 mg of sodium — more than most people should consume over the course of three days. CSPI says that these alarming levels are one reason why the Food and Drug Administration should set reasonable limits on the amounts of sodium that can be used in various categories of food.

"For far too long, the FDA has relied on a voluntary, wait-and-see approach when it comes to reducing sodium in packaged and restaurant food," said CSPI executive director Michael F. Jacobson. "If chains like KFC, Jack in the Box, and Red Lobster are actually raising sodium levels in some meals, FDA's current approach clearly isn't working."

Health effects 

Despite the progress, 79% of the 81 adult meals in the study still contained more than 1,500 milligrams (mg) of sodium. A majority of Americans, including people 51 and older, people with high blood pressure, and African-Americans, should try to limit themselves to 1,500 mg of sodium per day, according to the Centers for Disease Control and Prevention.

At higher levels, sodium promotes high blood pressure, stroke, heart attacks, kidney disease, and other health problems, making it the single most harmful ingredient in the food supply, according to CSPI.

The average sodium in 55 kids' meals dropped by just 2.6%.

Dramatic progress at Subway

Subway showed dramatic progress between 2009 and 2013, reducing sodium in every one of the 10 meals reviewed in the study.

In 2009, a meal of a Footlong Ham Sandwich, a bag of Lay's Classic Potato Chips, and a Diet Coke had 2,730 mg of sodium. In 2013, that meal had just 1,895 mg of sodium. In 2009, a Subway meal of a six-inch Veggie Delite Sandwich, Apple Slices, and a Coke had a very reasonable 500 mg of sodium. In 2013, it had just 295 mg of sodium.

The chain showed similar progress in the four children's meals reviewed in the study, which were reduced in sodium by an average of 29%.

We're constantly being nagged to reduce our salt intake but a new study suggests that the levels recommended by federal agencies are "excessively and unrealistically low."

Besides making food taste like cardboard, the low levels recommended by the Centers for Disease Control and Prevention (CDC) may actually do more harm than good, researchers say.

Dr. Niels Graudal, the study's lead author, says the results are an important extension of the findings of a major 2013 Institute of Medicine (IOM) report, which cast doubt on the current CDC recommendations but failed to establish any specific optimum range of intake.

"Our results are in line with the IOM's concern that lower levels could produce harm, and they provide a concrete basis for revising the recommended range in the best interest of public health," Graudal said.

"The good news," he added, "is that around 95% of the global population already consumes within the range we've found to generate the least instances of mortality and cardiovascular disease."

The study concluded that 2,645 – 4,945 mg of sodium per day, a range of intake within which the vast majority of Americans fall, actually results in more favorable health outcomes than the CDC's current recommendation of less than 2300mg/day for healthy individuals under 50 years old, and less than 1500 mg/day for most over 50 years.

This study was a combined analysis of 25 individual studies, which measured results from over 274,683 individuals.

Analysis of the results found that, as with all other essential nutrients, there was a U-shaped correlation between sodium intake and health outcomes. When consumption deviated from the 2,645 – 4,945 mg range mortality increased, so that both excessively high and low consumption of sodium were associated with reduced survival.

There's been a major push the last few years to get Americans to consumer less salt in their but a new report from the Institute of Medicine (IOM) says it's important to not go too far in salt reduction efforts.

“[N]ew studies support previous findings that reducing sodium from very high intake levels to moderate levels improves health,” said Brian Strom, George S. Pepper Professor of Public Health and Preventive Medicine at the University of Pennsylvania Perelman School of Medicine, who chaired the IOM committee studying the matter. “But they also suggest that lowering sodium intake too much may actually increase a person’s risk of some health problems.”

While it's true that many Americans consumer too much salt, evidence from the new studies reviewed by the IOM committee do not support reduction in sodium intake to below 2,300 mg per day, the IOM committee concluded.

That finding is not going down too well with some health advocates. 

"What the committee failed to emphasize is that most Americans are deep in the red zone, consuming 3,500 to 4,000 milligrams of sodium a day," said Bonnie Liebman of the Center for Science in the Public Interest. "It's clear that those excessive levels increase the risk of high blood pressure, heart attacks, and strokes. Whether we aim for 2,300 or 1,500 milligrams a day is irrelevant until we move down out of the red zone."

Whether the report emphasized it or not, the IOM committee did find that the average American consumes 3,400 mg or more of sodium a day – equivalent to about 1 ½ teaspoons of salt. The current Dietary Guidelines for Americansurge most people ages 14 to 50 to limit their sodium intake to 2,300 mg daily.

Subgroup issues

People ages 51 or older, African Americans, and people with hypertension, diabetes, or chronic kidney disease – groups that together make up more than 50 percent of the U.S. population – are advised to follow an even stricter limit of 1,500 mg per day, the IOM committee said.

These recommendations are based largely on a body of research that links higher sodium intakes to certain “surrogate markers” such as high blood pressure, an established risk factor for heart disease. 

After reviewing the new studies, the IOM committee, while cautioning that numbers in the studies were small, concluded that: 

• evidence supports a positive relationship between higher levels of sodium intake and risk of heart disease;

• studies on health outcomes are inconsistent in quality and insufficient in quantity to conclude that lowering sodium intake levels below 2,300 mg/day either increases or decreases the risk of heart disease, stroke, or all-cause mortality in the general U.S. population; and

• evidence indicates that low sodium intake may lead to risk of adverse health effects among those with mid- to late-stage heart failure who are receiving aggressive treatment for their disease.

The committee found limited evidence addressing the association between low sodium intake and health outcomes in population subgroups, such as  those with diabetes, kidney disease, heart disease, hypertension or borderline hypertension; those 51 years of age and older; and African Americans).

On balance, the report said that the evidence does not support recommendations to lower sodium intake within these subgroups to or even below 1,500 mg daily.

The report was sponsored by the Centers for Disease Control and Prevention (CDC). 

By now, just about everyone knows that packaged foods and restaurant meals tend to be loaded with salt, putting consumers at risk of high blood pressure, heart disease and other bad outcomes.

But baby food?

Yes, it's true. A study led by Joyce Maalouf of the Centers for Disease Control and Prevention (CDC) finds that nearly 70% of commercial pre-packaged meals and snacks for toddlers in the U.S. have high levels of sodium, which may present long-term health risks.

Long-term risks

“Our concern is the possible long-term health risks of introducing high levels of sodium in a child’s diet, because high blood pressure, as well as a preference for salty foods may develop early in life. The less sodium in an infant’s or toddler’s diet, the less he or she may want it when older,” Maalouf said. 

Maalouf and her colleagues analyzed 572 food products for infants and toddlers and analyzed the sodium level in each, with 210 milligrams of sodium per serving being considered as high.

The study found that pre-packaged food for toddlers had higher sodium than the baby food.

The amount of sodium in some of the toddler meals was as high as 630 mg per serving -- about 40% of the 1,500 mg daily limit recommended by the American Heart Association. More than 70% of the toddler meals and snacks had more than 210 mg of sodium per serving,

Nearly all commercial foods for 4- to 12-month-olds were relatively low in sodium. Vegetable and meat baby foods were less salty than pasta options.

“Parents and other caregivers can read the nutrition facts labels on baby and toddler foods, to choose the healthiest options for their child,” Maalouf said.

The American Heart Association recommends limiting sodium consumption to less than 1500 mg a day. 

Without seeing any facts and figures, most of us will admit we use too much salt.

The food we buy is loaded with the stuff -- and most of us dump more of it on as we sit at the table.

But exactly how much is too much? According to research presented at the American Heart Association's Nutrition, Physical Activity and Metabolism and Cardiovascular Disease Epidemiology and Prevention 2013 Scientific Sessions, 75% of the world's population consumes nearly twice the daily recommended amount of salt.

Global sodium intake from commercially prepared food, table salt, salt and soy sauce added during cooking averaged nearly 4,000 mg a day in 2010.

The World Health Organization recommends limiting intake to less than 2,000 mg a day and the American Heart Association recommends staying under 1,500 mg a day.

"This study is the first time that information about sodium intake by country, age and gender is available," said Saman Fahimi, M.D., M.Phil., lead author and a visiting scientist in the Harvard School of Public Health's epidemiology department in Boston, Mass. "We hope our findings will influence national governments to develop public health interventions to lower sodium."

Major problems

Cardiovascular disease is the number one cause of death in the world; excess sodium intake raises blood pressure. High blood pressure is one of the major contributors to the development of cardiovascular disease.

Among women and men, average sodium intake exceeded healthy levels in almost all countries, researchers said. Kazakhstan had the highest average intake at 6,000 mg per day, followed by Mauritius and Uzbekistan at just less than 6,000 mg per day.

Kenya and Malawi had the lowest average intake at about 2,000 mg per day. In the US, the average intake was about 3,600 mg a day.

Way too much

One hundred eighty-one of 187 countries, representing 99 percent of the world's population, exceeded the World Health Organization's recommended sodium intake of less than 2,000 mg a day; and 119 countries, representing 88 percent of the world's population, exceeded this recommended intake by more than 1,000 mg a day. All countries except Kenya exceeded the American Heart Association recommended sodium intake of less than 1,500 mg a day.

The researchers analyzed 247 surveys of adult sodium intake to estimate sodium intake, stratified by age, gender, region and nation between 1990 and 2010 as part of the 2010 Global Burden of Diseases Study, which is an international collaborative study by 488 scientists from 303 institutions in 50 countries around the world.

What’s a consumer to do?

When shopping for food, consumers can read food labels and choose foods that are lower in sodium.

The Nutrition Facts Label on food and beverage packages lists the “Percent Daily Value (%DV)” of sodium in one serving of a food, based on 2,400 mg per day. The %DV tells you whether a food contributes a little or a lot to your total daily diet. Foods providing 5%DV or less of sodium per serving are considered low in sodium and foods providing 20%DV or more of sodium per serving are considered high. But remember, all of the nutrition information on the label is based upon one serving of the food and many packaged foods have more than one serving.

It is recommended that consumers not exceed 100% of the daily value for sodium and those advised to limit intake to 1,500 mg per day should aim for about 65% of the daily value.

Consumers can also be aware of the sources of sodium in their diet. In a report issued in February 2012, the National Centers for Disease Control and Prevention identified these 10 foods as the greatest sources of sodium:

• breads and rolls
• luncheon meat, such as deli ham or turkey
• pizza
• poultry, fresh and processed -- (Much of the raw chicken bought from a store has been injected with a sodium solution.)
• soups
• cheeseburgers and other sandwiches
• cheese, natural and processed
• pasta dishes
• meat dishes, such as meat loaf with gravy
• savory snack foods, such as potato chips, pretzels and popcorn

And how do you know how much sodium is in the food served at your favorite restaurant? Fasano notes that many chain restaurants are putting the nutritional content of their foods -- including calories, fats, sodium and sugars -- on their Websites, or it’s available by asking for it.

The Food and Drug Administration has created a number of online resources to help consumers reduce their sodium intake. They include:

• A Sodium Reduction Website provides links to resources on how to reduce the amount of sodium in your diet.
• A Sodium Education Website offers consumer advice on how to use the Nutrition Facts Label to reduce sodium intake.
• The Spot the Block campaign challenges tweens from 9 to 13 to use the Nutrition Facts Label (the "block") to make healthy food choices.

There's little dispute that most of us use too much salt. If you're a doubter, just check the nutrition labels of the foods you eat. Get out your calculator and add up the amount of salt in each product. That that should convince you.

And that doesn't even take into consideration what you pour of of a salt shaker at every meal.

Need a good reason to cut back on sodium? How about your life? New research in the American Heart Association journal Hypertension finds less sodium in the U.S. diet could save 280,000 to 500,000 lives over 10 years.

Using computer simulations and models, researchers projected the effects of small (about five percent of a teaspoon of salt per person per day), steady annual reductions of sodium consumption in the U.S. diet, reducing sodium consumption by 40 percent -- to about 2,200 mg/day over 10 years.

Key findings

Researchers also found:

• A gradual reduction in sodium consumption by 40 percent to about 2,200 mg/day over 10 years is projected to save hundreds of thousands of lives – between 280,000 and 500,000 depending on the modeled assumptions.
• About 60 percent more deaths could be averted over this time period if these same reductions could be achieved more quickly (500,000 to 850,000 lives).

Three-pronged approach

Three research groups contributed to the study, each using a different approach for their simulation.

One approach used observational cardiovascular outcome follow-up data, while the other two based their projections on established evidence that salt reduction lowers blood pressure. These two groups inferred the cardiovascular effects of reducing sodium from data about the relationship of blood pressure to cardiovascular disease.

"The research groups used the same target populations and baseline death rates for each projection, and our study found that the different sources of evidence for the cardiovascular effects of sodium led to similar projected outcomes," said Pamela Coxson, Ph.D., lead author of the study and a mathematics specialist in the department of medicine at the University of California San Francisco (UCSF).

"It is helpful when three research groups use different approaches and come up with similar results," said Kirsten Bibbins-Domingo, Ph.D, M.D., senior author of the study and associate professor of medicine at UCSF and director of the UCSF Center for Vulnerable Populations.

Cutting back

The three approaches included a gradual reduction of sodium by 40 percent, instant reduction of sodium by 40 percent or instant reduction of sodium to no more than 1500 mg/day. According to the researchers, only the first scenario -- gradual population-wide reduction of sodium by 40 percent over ten years -- is a potentially achievable public health goal.

Currently the U.S. food supply makes it difficult for consumers to choose lower sodium foods and achieve recommended daily levels. Americans consume an average 3,600 mg of sodium a day, with about 80 percent coming from commercially prepared and processed foods, according to the researchers.

Excessive sodium intake contributes to high blood pressure, which increases the risk of heart attacks, strokes and other cardiovascular diseases. In the U.S, cardiovascular disease is the leading cause of death, and nearly half of these deaths are related to high blood pressure.

Everybody wins

"These findings strengthen our understanding that sodium reduction is beneficial to people at all ages," Coxson said. "Even small, gradual reductions in sodium intake would result in substantial mortality benefits across the population."

"Such gradual reductions could be achieved through a combination of consumer education and food labeling, but should likely also include regulation to assure that lower sodium options are available for US consumers," said Bibbins-Domingo.

The American Heart Association recommends consuming less than 1,500 mg of sodium daily, and has called on the Food and Drug Administration to lower the daily value for sodium and set limits on the amount of sodium foods can contain.

The association also favors robust sodium standards for foods served in schools and purchased by governments and encourages the food industry to make meaningful efforts at reducing sodium which would provide consumers with greater choice in foods and a healthier overall food environment. There are a number of healthy recipes and tips for helping you reduce salt in your diet.

What is it about trying to lower our salt intake that’s so difficult?

Most of us have heard the warnings about getting too much sodium, yet many of us still choose to pick up that salt shaker or order something from a restaurant that we know is just loaded with salt.

However, there’s a good portion of consumers that take heed of the medical warnings, and try their very best to incorporate meals that are healthier and try to use other flavors, like low-sodium options or natural ingredients to season their food.

And mostly, the sodium-conscious consumer does their best to avoid those store-bought items that are known to be plagued with salt -- like potato chips, frozen TV dinners or canned soups. By doing this, most would probably assume they’re being successful in their mission at cutting down the amount of salty foods they're bringing into their homes.

But what about those foods that aren’t typically thought of as high in  in sodium? Meaning, those foods that don’t taste salty often fall below the radar. 

Salty cereal

Like breakfast cereals for example — although many of them are lumped into the healthier category by many consumers, some of them can have tremendous amounts of salt that you usually can’t even taste.

Take Kellogg’s Raisin Bran, which contains 210 milligrams per serving. That can add up if you’re eating it daily, and some of us like to eat cereal as a snack, downing a couple a bowls per sitting, and many of us do this because we think it’s healthier than tearing through a bag of chips.

And you can’t forget about children’s cereals, which always get a bad rap for being too high in sugar, and rightfully so, but parents should be equally concerned with the high sodium levels in some brands like Cinnamon Toast Crunch, made by General Mills, which has about 220 milligrams of sodium -- and we all know how much  kids love to scarf that stuff down by the boatload.

According to the Centers for Disease Control and Prevention (CDC), at least half of the U.S. population shouldn’t be consuming more than 1,500 milligrams of sodium per day, and that 50 percent of the population is made up of people who have a history of high blood pressure, those with kidney problems, African-Americans and diabetic patients.

The other half of the population shouldn’t exceed 2,300 milligrams a day, says the CDC.

The government agency also explained the kinds of foods that aren’t normally talked about in high sodium discussions can be even more dangerous since people eat them more, thinking they’re staying away from overly salty foods.

In the CDC’s list of Dietary Guidelines for Americans, it shows just how commonly eaten foods, that aren’t usually considered salty can really truly add up.

3,000 milligrams

On the informational sheet, it shows that during the course of a day a bowl of cereal in the morning, a soup and sandwich for lunch and a quick slice of pizza with a salad can equate to over 3,000 milligrams of sodium for that one day, which is  twice the recommended amount for some.

And although one may say, “Well, I’m not surprised a soup, sandwich and a slice of pizza has so much sodium,” they may not remember or realize that much of the salt is in the salad dressing, the bread for the sandwich and that big bowl of cereal you had in the morning.

Also below the high sodium radar are many of the popular coffee drinks that consumers buy these days, say experts, so consumers should be mindful of how much sodium they’re consuming if they’re making a daily trek to Starbucks or Dunking Donuts for a caffeine fix, especially some of the blended coffee drinks that have a high amount of sodium.

Also, if you take a look at the sodium levels in many of today’s ready-made pancake mixes, you’ll find they contain massive amounts of salt.

For example, a box of Aunt Jemima Original Pancake Mix has a whopping 740 milligrams per serving size, which reaches well over half of the recommended sodium intake for the day, so if you’re eating pancakes first thing in the morning, then you have what’s considered a normal lunch and dinner, there is a very good chance that you’ll exceed the 1,500 or 2,300 milligram count that the CDC suggests.

And it’s certainly not just breakfast foods that are high in sodium and sometimes sneak past us.

Watch the dessert

If you think you’ve successfully stayed away from too much salt on a given day, and decide to reward yourself after dinner with some dessert like cookies or prepackaged sweets, you could be getting way more sodium that you thought you were getting.

Like Entenmanns Carrot Iced Cake, that has 210 milligrams of sodium per serving, which can really add up if you continuously indulge. The company considers a serving slice to be only 67 grams, which is pretty tiny. Also, who has such a small piece of cake and just one slice at that when trying to satisfy  a sweet fix?

A lot of muffins, donuts and candies are also high in sodium, and experts say consumers should consider these foods right along with those foods like potato chips or pretzels when trying to lower their sodium intake.

On average, Americans consume about 3,300 milligrams of sodium per day and it’s safe to say that much of this sodium is coming from sources we're not even thinking of, say experts.

Experts also say to keep reading nutrition labels on packages, cans, on restaurant menus and on restaurant menu boards, and don’t assume that just because foods don’t taste salty they aren’t just as high in sodium or even more so than those foods that we more commonly associate with being high in salt.

Watch your salt!

New studies support limiting daily sodium (salt) consumption to less than 1,500 milligrams, according to a new American Heart Association presidential advisory.

The advisory, published in the American Heart Association's journal Circulation, is based on a thorough review of recent laboratory, animal, observational and clinical studies that reaffirm the association's 2011 advisory that limiting sodium (salt) to less than 1,500 mg per day is linked to a decreased risk of high blood pressure and cardiovascular disease, including stroke.

"Our recommendation is simple in the sense that it applies to the entire U.S. population, not just at-risk groups," said Nancy Brown, chief executive officer of the American Heart Association. "Americans of all ages, regardless of individual risk factors, can improve their heart health and reduce their risk of cardiovascular disease by restricting their daily consumption of sodium to less than 1,500 milligrams."

Confusion, mixed messages

Some recent reports have led to confusion and mixed messages about the healthiest levels of daily sodium for all subgroups of the population.

"People should not be swayed by calls for a change in sodium intake recommendations based on findings from recent studies reporting that a reduction in sodium consumption does not improve cardiovascular health," said Paul K. Whelton, M.D., M.Sc., lead author and Show Chwan Professor of Global Public Health in the Tulane University School of Public Health and Tropical Medicine in New Orleans. "Our detailed review of these studies identified serious methodological weaknesses, which limit the value of these reports in setting or revising sodium intake policy.

"Our focus should be on finding effective ways to implement, not change, the existing American Heart Association policy on sodium intake."

Low-salt benefits

Reducing sodium intake can help fight high blood pressure, which affects more than 76 million U.S. adults and is a major cause of cardiovascular disease.

Yet, most American adults and children consume sodium far in excess of their physiologic needs and guideline recommendations -- with an average daily intake more than 3400 mg per day. Only individuals, primarily those with specific, rare disorders, who have been advised by their physicians to do otherwise, should not reduce their sodium intake to 1500 mg/day, but this is difficult in the current environment.

Most of the sodium the public consumes is "hidden" in processed and prepared foods. The American Heart Association advocates improved nutritional labeling of sodium content and stringent limits on sodium in all foods -- fresh, processed and prepared -- provided to everyone and in particular in schools, marketed to children and purchased by employers and government programs.

Study authors conclude that a comprehensive approach to cardiovascular health promotion and disease prevention is multifactorial that includes regular physical activity, healthy body weight, managing blood pressure, controlling blood sugar, avoiding tobacco and a healthy diet. Sodium reduction is a very important component of a healthy diet.

"An integral component of our campaign to improve the nation's cardiovascular health by 20 percent by 2020 is a nationwide decrease in sodium consumption," said Donna Arnett, Ph.D., M.S.P.H., president of the American Heart Association. "It will require a joint effort between health organizations, policy makers and the food industry to achieve this goal by creating an environment conducive to helping all Americans make healthy, low-sodium food choices."

U.S. consumers, by and large, like their food salty. As a result, the amount of sodium in the average U.S diet has drifted higher, to dangerous levels, over the last three decades, according to the Centers for Disease Control (CDC).

Knowing this, policymakers and public health officials are considering both public education campaigns and the possibility of legislation to address the problem. But to do this effectively, they need good information, not only about the amount of sodium consumed, which the CDC monitors, but also about consumer knowledge and attitudes.

Ignoring sodium

A new study by marketing researchers at the University of Arkansas shows that American consumers ignore the amount sodium they eat, even though excessive sodium intake contributes to cardiovascular disease. And just try avoiding sodium in your diet.

It is the primary ingredient of table salt and is found in many processed foods. The finding that Americans are unaware of their sodium intake is problematic for policymakers because, on average, Americans consume 50 percent more than the daily maximum recommended level for sodium.

“Simply put, Americans consume too much salt,” said Scot Burton, professor in the University of Arkansas Sam M. Walton College of Business. “Unfortunately, only approximately 20 percent of the U.S. population currently consumes the recommended daily level. Reducing the daily intake of sodium from the average of more than 3,400 milligrams down to the recommended level of 2,300 milligrams could potentially prevent almost 100,000 deaths and 66,000 strokes per year while saving billions of dollars in health care costs.”

Education programs can work

Burtson has done research that shows education campaigns about the effects of excessive sodium intake work: Consumers – both hypertensive and non-hypertensive – will modify their purchase intentions if they are given this information, he says.

But isn't the information out there? Sodium content is listed on Nutrition Facts panels on food labels, on some restaurant menus and within a growing body of education material. But are consumers paying attention?

To find out, Burton teamed with fellow researchers from Wayne State University and Loyola Marymount to study two groups of consumers - one with high blood pressure and one normal blood pressure. When given the sodium information, the group with hypertension paid more attention to the information than those without hypertension.

Both encouraging and worrisome

“While it is encouraging that hypertensive consumers pay some attention to sodium levels, it is worrisome that non-hypertensive consumers do not," said University of Arkansas marketing professor Elizabeth Howlett. "Because the effects of excessive sodium intake are cumulative, many who are not yet diagnosed as hypertensive are probably not paying attention to how much salt they consume."

What's needed, the researchers say, is an effective education campaign that makes sodium content and its effect on the body more relevant for more consumers. They say their research shows that relevancy is the key - when consumers understand the harmful effects of too much sodium in the diet, they make different buying decisions when it comes to food.

Health experts at the Centers for Disease Control and Prevention (CDC) are sounding the alarm over sodium. Almost all Americans, they say, consume more of it in their diets than they should.

Too much sodium increases a person's risk for high blood pressure. High blood pressure often leads to heart disease, stroke, and other vascular diseases.

Most consumers don't coat their food with salt and therefore, are not aware of how much sodium they are consuming. Most of our daily sodium intake comes from processed foods and meals served in restaurants.

What are the biggest sources of excess sodium? The CDC counts 10.

• Bread and rolls
• Luncheon meat
• Pizza
• Poultry
• Soup
• Cheeseburgers and other sandwiches
• Cheese
• Pasta dishes
• Meat dishes such as meat loaf
• Snack foods such as chips and popcorn

Bread can be a killer

Some foods that are consumed several times a day, such as bread, add up to a lot of sodium even though each serving is not high in sodium.

“Too much sodium raises blood pressure, which is a major risk factor for heart disease and stroke,” said CDC Director Thomas R. Frieden, M.D., M.P.H. “These diseases kill more than 800,000 Americans each year and contribute an estimated $273 billion in health care costs.”

The report notes that the average person consumes about 3,300 milligrams of sodium per day, not including any salt added at the table. That's twice the recommended daily limit for about 50 percent of the population.

The recommendation is 1,500 milligrams per day for people aged 51 and older, and anyone with high blood pressure, diabetes, and chronic kidney disease, and African Americans. The CDC has a special section of its website that can help you reduce sodium in your diet.

Voluntary efforts by industry to reduce sodium levels in the food supply have failed, according to comments filed with the Food and Drug Administration (FDA) by the nonprofit Center for Science in the Public Interest.

CSPI urged the agency to create strong but realistic mandatory regulations to reduce sodium levels in restaurant and packaged foods.

According to a recent survey commissioned by CSPI, the public sees the need to lower sodium; 71 percent of Americans indicated that the food industry had a responsibility to reduce the sodium content of their foods, and 58 percent support a government requirement to reduce the sodium in processed and restaurant foods.

“Overconsumption of sodium is one of the single greatest causes of hypertension and cardiovascular disease, and restaurant and packaged foods—not salt shakers—are far and away the largest contributors of sodium in the American diet,” said CSPI deputy director of health promotion policy Julie Greenstein. “Unfortunately, the food industry has failed to significantly bring down sodium levels despite 40 years of governmental admonitions. It’s time for the FDA to step in and require reasonable reductions.”

The U.S. government’s 2010 Dietary Guidelines for Americans recommends that people with hypertension, those who are middle-aged or older, and African Americans should consume no more than 1,500 milligrams of sodium per day. According to the Center for Disease Control, about 70 percent of adults fall into those categories, yet current average daily consumption is actually closer to 4,000 mg.

Significant health risk

Recently, the American Public Health Association passed a resolution that calls on FDA to begin regulating sodium in the food supply within one year and to establish a timetable for gradually reducing sodium in the food supply by 75 percent over 10 years. CSPI’s filing notes that reducing sodium consumption would save billions of dollars in medical costs, and upwards of 150,000 lives annually.

Overwhelming evidence indicates that excess sodium levels pose significant health risks, but consumer education efforts are poorly funded and ineffective, according to CSPI, making efforts to reform dietary habits of Americans difficult. A recent survey indicates that 59 percent of Americans are “not concerned” about their sodium intake. As a result, an Institute of Medicine committee recommended mandatory regulations limiting sodium levels to improve public health and decrease healthcare costs.

Many frozen dinners and canned foods contain high amounts of sodium. Boston Market frozen Meatloaf with Mashed Potatoes and Gravy has 1,460 mg of sodium per serving (about one day’s worth). Marie Callender’s frozen Creamy Chicken and Shrimp Parmesan has 1,200 mg of sodium (almost a day’s worth).

One of the worst restaurant offenders is Applebee’s Provolone-Stuffed Meatballs with Fettuccine, which has 3,700 mg of sodium (more than two days’ worth). Denny’s Spicy Buffalo Chicken Melt has 3,760 mg of sodium (two and a half days’ worth).

CSPI first petitioned the FDA in 1978 to reduce salt in processed foods. Besides urging the FDA to set mandatory limits on sodium content in the food supply, CSPI asked the agency to lower the Daily Value for sodium from 2,400 mg to 1,500 mg. 

Does losing one's memory and ability to think clearly have to be part of aging? Obviously not, as there are plenty of people in their 90s who are as sharp as a tack.

So what accounts for some older people retaining their cognitive ability and others losing it?

Canadian researchers pondering that question have shed some new light on the subject. They have concluded that older adults who lead sedentary lifestyles and consume a lot of sodium in their diet may be putting themselves at risk for more than just heart disease. They say they have found evidence that high-salt diets coupled with low physical activity can be detrimental to cognitive health as you age.

The study by researchers Baycrest in Toronto and Institut Universitaire de Gériatrie de Montréal, may have significant public health implications, emphasizing the importance of addressing multiple lifestyle factors that can impact brain health.

Sodium's impact on the brain

"We have generated important evidence that sodium intake not only impacts heart health, but brain health as well," said Dr. Alexandra Fiocco, a scientist with Baycrest's Kunin-Lunenfeld Applied and Evaluative Research Unit (KLAERU) and the study's lead investigator.

While low sodium intake is associated with reduced blood pressure and risk of heart disease, this is believed to be the first study to extend the benefits of a low sodium diet to brain health in healthy older adults.

The study followed the sodium consumption and physical activity levels of 1,262 healthy older men and women (ages 67 – 84) residing in Quebec, Canada, over three years. The adults were recruited from a large pool of participants in the Quebec Longitudinal Study on Nutrition and Successful Aging (NuAge).

Limit sodium to 2.300 mg per day

Most public health experts suggest people 14 years of age and older consume no more than 2,300 mg of sodium per day in their diet. For the purpose of the study, low sodium was defined as being below that amount, while high sodium consumption was set at nearly 3.100 mg, of higher, per day.

Physical activity levels were measured using the Physical Activity Scale for the Elderly.

"The results of our study showed that a diet high in sodium, combined with little exercise, was especially detrimental to the cognitive performance of older adults," said Fiocco. "But the good news is that sedentary older adults showed no cognitive decline over the three years that we followed them if they had low sodium intake."