Salt
00:00Welcome to maintenance phase.Wait, why can't I do this?Oh yeah.Welcome to maintenance phase, the podcast that will finally make an episode that other people will call salty.There we go.It's okay. It's like six out of ten.We're doing the episodium.I'm Michael Hops.
00:32I'm Aubrey Gordon.If you would like to support the show,you can do that at patreon.com slash maintenance phase.You can also subscribe through Apple Podcasts.It's the same audio content.Same stuff.Aubrey.We're talking about salt today, Mike.
00:47This was like the anxiety around diet growing up.Yep.It was like low fat and like low saltwere the two things you need to strive for.This came up in our bonus episode about 80s dietsthat a ton of themwere like extremely low salt.Yeah.
01:04It is a thing that came up for me with my mom called me and said that a friend of hersinvited her over to taste her cooking and make sure that it had the right amount of saltbecause her friend does not use salt ever.This is a decades-long fight that I've been having with my mom.She does not put salt in foods.And she says if you want salt, you can just salt it at the end.Like if you're eating chili, you could salt it at the end.And I keep trying to explain that that's not.
01:31How it works.Sorry, mom.She can't, she can't overcome her heritage.That's right.Everyone's white mom grew up like this.Right.We're all products of our time.So I think the central question that I wanted to like explore here is how did we get from
01:47this idea in the 70s and 80s that reducing your salt as much as possible was one of themost important things that you could do for your health to the point now where many.many folks have just dropped that guidance altogether. Yeah. And folks are generally not paying attentionto their salt intake. And even some folks are even opting for electrolyte beverages to up their salt intake,right? So how do we get from point A to point Z? Because it's kind of fallen off the radar,like the wellness radar. You don't hear about salt in the way that you used to. People have thisidea that like you're not going to be able to salt your food at the table if we talk about salt.that's not true. According to the research, depending on which study, between three and seven percent of American salt is added in home cooking or at the table.
02:40Oh, interesting. Okay.So we're talking about like a vanishingly small amount of the salt is what you decide to add to your food.Right.We're talking much less about individual decisions and sort of policing individual decisions than we are talking about food supplies and ways in which you might be concerned.that you don't really know is consuming salt or you don't really think about is consuming salt. Although I am pleasing your behavior. You should salt food when you're cooking it. If you don't do that, I'm bringing a protein bar when I come to your house. In order to like get the conversation going, I think we got to do like a little bit of myth busting up top. Okay. And the way that we're going to do that is a salt quiz. Okay. I think you were going to say we need to do a taste test where we each just eat us a teaspoon of salt. Go get your salt chaker. How does it taste fucking delicious? Let's both get grounded here and just eat a bunch of sauce.just the sound of me puking in the background.So question number one, Michael.Aubrey.
03:33The WHO maintains a ranking of estimated sodium consumption across over 150 nations.Mm-hmm.Where in that ranking do you think the United States falls?Do you think we are in the top 25, the top 100, or the bottom 25?I think we're in the top 100, but not particularly high.We're number 50.Okay.Who's the highest?
04:00The highest consumption.Once you learn, so lowest consumption is Samoa.They consume about a teaspoon of salt a day, five grams of salt.So that's two grams of sodium.The highest is China.Okay.With 17 grams of salt a day.But are you sure this wasn't a survey of which country is the saltiest, like the most irritable?
04:24You think China is the most irritable country?and we're number 50?I can't argue with statistics, Aubrey.So Samoa at five grams of salt is much, much closer to the actual WHO recommendations,FDA recommendations, all of that kind of stuff.Wait, so what is the WHO recommendation in teaspoons?It's like about a teaspoon is what we should be aiming for.That's like the goal.
04:48Okay.Next question.We're going to do a little salt mortal combat.Oh, okay.Finish him.Which of these has the most.salt. We're going to do one teaspoon of each of these things. Which one do you think has the mostsalt and which one do you think has the least salt? Okay. The options are a teaspoon of table salt,
05:08a teaspoon of MSG, a teaspoon of marmite, a teaspoon of soy sauce, and a teaspoon of gratedparmesan. From context clues, I think the answer is soy sauce, but also marmite is like pure fuckingsalt. Like on your tongue, it's so unbelievably salty. So I'm going to say Marmite and soy sauce is aclose second. Am I wrong? I'm sure I'm wrong. You're very wrong. Okay. Marmite contains lesssodium than a teaspoon of salt. Really? It's so salty though on my, on my mouth.So here's the story. One teaspoon of salt contains 2,300 milligrams of sodium. A teaspoon of soysauce has 3,000 milligrams of sodium.Wow.
05:57Okay.Considerably more, right?Like almost 50% more sodium.Yeah.A teaspoon of Marmite has 340 milligrams of sodium.Wait, what?One tenth?Almost one tenth the amount as soy sauce.
06:10Was I the wrongest it's possible to be?No, you weren't the wrongest it's possible to be.Okay.Here's the other one that I found fascinating.Graded Parmesan has about 25 milligrams of sodium.in one teaspoon? Wait, 2,500 or 25?25? But it tastes so salty. Aubrey, what's happening? What's going on? Right. So all of thisis to say, if you're counting on things tasting salty to determine what has sodium in it,
06:36we're almost all getting it wrong. Wait, I did exactly the thing. I did exactly the concept thatyou wanted to illustrate. Yeah. I'm putty in your hands. I've been puppeteered. So the last questionthat I have for you for our salt pop quiz. This is so fun. Are you enjoying?This is so fun.Which of the following is the highest sodium dish at an American chain restaurant?Ooh, okay.A, the Wendy's Triple Baconator.That's three beef patties and six strips of bacon.
07:06I gotta go to Wendy's more.Okay.B.Long John Silver's foot long chili cheese dog.C.Bob Evans' Steakhouse salad.D.Outback Steakhouse's.
07:22Lumin Onion, or E, the Cheesecake Factory's Chicken and Broccoli Pasta.Well, with these questions, the surprising answer is always the correct answer.How dare you?So you shouldn't be thinking about what is correct.You should be thinking about what the surprising answer will be.You're trying to hack my brain and I don't appreciate it.The most surprising answer would be one of the salads or probably the Bob Mackey salad, whatever thing.The Bob Fawsey.
07:52I've never heard of this restaurant, but okay.Bob Evans' Steakhouse Salad is number one.Okay.It is 7,700 milligrams of sodium in a salad.Three times your daily recommended in a salad?Correct.Is lettuce, like, secretly, really salty?No, salad dressing.
08:09It's the dressing, right?Absolutely.The lowest sodium of those is the triple baconator.Wait, really?Yep.Okay.That one's just shy of 1,800 milligrams of sodium.Right, because I heard recently,
08:21that just because things taste salty doesn't mean that they're high in sodium.Oh, interesting.Where you hear that one?So just letting you know.You could just eat one triple baconator in a day and be like, I nailed it by the FDA guidelines.That's technically an electrolyte.A triple bacon cheeseburger is an electrolyte.You're just getting hydrated.
08:41That's your recovery drink.My recovery cheeseburger.The question here is, if we're not getting it from foods that taste salty, if we're notgetting super high levels of sodium from the baconator, but we are from like a salad.Where the fuck is the salt coming from?The cheesecake factory.It's all coming from the cheesecake factory.Salt is used in food in ways that go way beyond palatibility, right?
09:05The big one is that salt is overwhelmingly used as a preservative.Right.Cured foods, especially things like locks, bacon, ham, prosciutto, salami, really high in sodium.Pickled foods are pickled with a mixture of salt and sugar, so they have quite a bit of both.Canned foods use salt both to preserve and to inhibit bacteria growth.Salt is also heavily used in meat production, not just as seasoning, but as a way to increase profits.Okay.Because salt helps retain moisture, saline is often added.
09:48generously to meat before it is sold.Okay.Meat with more moisture weighs more.Right.And meat is sold by the pound.So it's a way to make more money from the same amount of livestock.So I'm going to send you a quote.This is from a book called Salt Wars, written by Michael Jacobson, who is the former director
10:15of the Center for Science in the Public Interest.According to the USDA, 21% of beef, 78% of chicken, and 57% of pork is bulked out in this way.Such products are far higher in sodium than plain, natural meat.Judging by a 2006 study of poultry, consumers nationwide were paying $2.6 billion, adjusted for inflation,annually for the added solution.Add in the beef and pork products that are watered down, and it appears that consumers are now being cheated out of at least $4 billion annually, and possibly much more.This is why I kind of hate it at the grocery store, how they like spritz the produce with water.You know, and they have like the cute little thunder sound now.
10:53And then like the little spray comes on.I'm like, I'm paying by the pound for these apples.I don't want little drops of water on them.I want them shriveled as God intended.Do you know how much water a fucking head of broccoli will soak up?I'm like shaking it out at the store as if I'm like opening a sugar packet.I'm like...Your cheap skate tendencies really are.
11:15boundless. I'm not bad for water? The other thing that is sort of related to a profit motiveis that high sodium foods trigger a thirst response. So whether by design or by happenstance,serving high sodium foods can encourage people to order more drinks, which as anybody who'sworked in the restaurant biz knows is like where your bread and butter comes from. Right. Yeah. Soto speak. There's also, I think this is probably an urban legend. But when I was living in London,There's a thing where you go to nightclubs, drink whatever.It's like two in the morning.You're walking home and they have like not quite food trucks,
11:52but like booths on the street that will sell like hot dogs and like French fries and stuff.And they call it mistake away because it's always bad.You feel like shit the next day.But people there, the sort of the explanation of these,was that if you're at a bar, you're drinking a ton of liquid.So your body's like salt balance is out of whack at the end of a night of drinking.And so your body craves like super salty foods because you're low,sodium. That's like why you want like French fries and like a shwarma or whatever at the end of the
12:19night. It's sort of like at a subconscious level. You're just like, oh, I want like terrible food.Absolutely. I don't know whether that's true, but I did eat those hot dogs all the time for myhelp. The main thing we're going to talk about today as we start to sort of chart the path of likehow we got here is something called the salt hypertension hypothesis.Ah, yes. The idea is that because salt helps retain moisture, it increases your blood volume.And the more blood volume you have, the harder your heart has to work.The harder your heart has to work, the greater the likelihood of high blood pressure.The bigger your heart gets, right?
12:53It can contribute to an enlarged heart.Presumably, then, the inverse would be true, that cutting out salt would decrease blood volume and blood pressure.And when you say that someone has a big heart, you're implying that they're at risk of a stroke.The idea that sodium intake is linked to heart health stretches back centuries.There is a classic text in Chinese medicine called Wang Di Nijing estimated to be written sometimebetween 400 BCE and 200 CE and it noted that quote, if too much salt is used for food,the pulse hardens.That is the first mention that we see of relating salt to your blood pressure or to your heart
13:36health.I love that phrase.The pulse hardens.Yeah.Empirical testing of this question of the link between sodium and blood pressure and heart health started very early in the 20th century.In 1904, two French researchers reported that treating hypertensive patients with a low salt diet reduced blood pressure.So that starts to kick off a series of other little studies.They're mostly small sample sizes.
14:08they're mostly working with patients that already have hypertension.Most of those studies seem to largely bear out the hypothesis.That's like, oh, yeah, when you cut down on salt for people who already have high blood pressure,it appears to improve their blood pressure, either a little bit or a fair amount, right?I thought you were going to tell me that people with hypertension also eat a lot of salt,and it would be these like correlational studies.But these sound fine.They're actually doing interventions and finding that changing your diet reduces your
14:38blood pressure. That is an overwhelming majority of the studies that we're going to talk about.Cool. In 1939, there is sort of what is seen at the time as a big breakthrough in salt research.Physician at Duke University, Walter Kempner is his name, creates the Kempner rice diet.Okay. Kempner believed that salt was a quote unquote, waste byproduct of the kidney.Okay.And that reducing sodium intake would protect kidney function, right?You're giving your kidneys less salt to have to contend with and filter out.And he thought that if you could devise a super low sodium diet, that that would help folks
15:21with kidney function and heart function, right?It was the Marmite and Parmesan cheese diet.Just spoonfuls.So the diet that Dr. Kempner devised is a fucking wild one, Mike.It's not heavy on the calorie restriction.The maximum was 2,000 calories,which is not as unhinged as we get,and it's pretty normal.
15:41Yeah.It had a maximum of five grams of fat.Oh, yeah.Okay.One chicken thigh has more than five grams of fat, right?Okay.It had a maximum of 20 grams of protein.It had a maximum of 150 milligrams of sodium,
16:02which is...Oh, wow.Nothing.So what you're saying isit's just threeWendy's baconators per day.No, it's unlimited rice.Is that what it is?
16:13It's called the Kempner rice diet.Oh, it's not named after a researchernamed rice.I thought it was like two researchersand one of their last names was rice.No, it's a guy and a food.Kempner rice.She's eating unsalted fucking rice
16:26like three meals a day?Unlimited rice and unlimited fruit juiceand you could have white sugar.That's like the most 80s-ass diet.I know this isn't the 80s,but it's like the most 80s-ass diet I've ever heard in my life.It's 1939, but we're getting a head start on the 80s.Absolutely.
16:43To be clear, that 150 milligram sodium ceiling is almost impossible to manage.Five stalks of celery has over 150 milligrams of sodium.No way.Two unseasoned eggs.has over 150 milligrams of sodium, right?Sodium is a mineral.It exists in soil, which means it exists in almost every fruit and vegetable.Right.
17:12A stiff breeze will get you to like 600 milligrams of sodium.Like, what the fuck?As a result, because this diet is so extreme, the adherence rate to the diet hovers between25 and 30%.Yeah.Miserable.Part of what you're trying to get at is like, what's our treatment recommendation?for people who have hypertension,
17:34how should they be eating in perpetuity?It's not functional to sayyou pretty much can't eat vegetables.There's too much salt in them.The only thing you have to dois never derive any pleasure from foodthe rest of your life.Never have a slice of cake at a birthday party.
17:51Never eat another sandwich.You will get scurvy,but think of how small your blood will be.The people who did experience improvement,whether Kempner was studying itor others were studying it,They saw improved blood pressure.They saw improved electrocardiograms, right?
18:08Like, they're seeing sort of like significant improvements in heart health across measures.All right.Clip it and ship it.We'll start giving everybody the fucking rice diet.Please enjoy only rice.Nothing else.We solved it.There aren't really blood pressure meds on the market at this point.
18:24So the Kemda Rice diet is one of the only treatments on offer.This is a little bit like the keto diet story, right?where like we didn't have anticonvulsant medications on the market yet.So when people were using the keto diet as a treatment for epilepsy, it was sort of the only game in town.Yeah.Yeah.So in the 1940s and 50s, the research around sodium and heart health continued largely in animal studies, rats and chickens.and American researchers observed an increase in high blood pressure in those rats and chickens during
19:02those animal studies.But then if we eat those rats and chickens, do we also have high blood pressure?Is that the real problem?No, then we have superpowers.This research was like generally received as a confirmation of the salt hypertension hypothesis.But there are a couple of significant challenges with the research.One, rats and chickens don't display significant variants.in blood pressure response to salt intake, humans do.
19:29And two, the doses were nutso.The human equivalent of the dose that these rats got would have been 40 grams of salt per day.You're basically preserving yourself.That's right.An Iberian ham.You're pickled now.Yeah.So like, yes, hypothetically, if humans quadrupled their salt intake, that would have a bigger
19:50effect.But that's not especially helpful in terms of guiding whether or,or not our current much lower levels of salt intake should be cut down from there.That is the data that is available to the U.S. government when it starts making large-scalenutritional recommendations about salt. We've got the Kempner rice diet, we've got thisearly French research, and we've got a number of animal studies. So, 1969 is the point at whichthe U.S. federal government starts talking about reducing salt intake. At that,point, again, the data is like definitely imperfect, but all of it seems to point to sodium reduction
20:30as a strategy worth pursuing. And there's certainly nothing outperforming sodium reduction as atreatment strategy for hypertension. Right. In 1977, a Senate Select Committee published dietarygoals for Americans. It's sort of the predecessor to the dietary guidelines for Americans,which are published for the first time in 1980. Both of those,include broad recommendations to reduce sodium intake, but they don't have like specific goalsjust yet, right?Since then, the recommended daily allowance has sort of for quite some time now heldsteady at between 1,500 and 2,300 milligrams of sodium.
21:15The nutritional recommendation is now sort of baked into the dietary guidelines and it becomesalmost boilerplate language that just gets carried over and carried over and carried over,right? But that's whenlarge scale humanstudies start to roll outand that's when the so-calledsalt wars begin.Dude, is it fucked up that this is making
21:36me hungry for salty food and now I'm eatingthe smoked salmon that I have in the fridge?I feel like you now understand whyI fucking burnedthrough that jar ofGorgonzola olives.Oh, no.So there is a huge
21:51landmark study in theearly 80s called intersalt.Okay.It was a very ambitious global study of sodium consumption.There are different ways to measure sodium intake.One of the ways that you can do it is from self-report data, as we've discussed manytimes on the show.That's like generally unreliable, but it's especially unreliable given how much people
22:21misunderstand where salt is in their diet.right? The other one you can do is you can look at consumer data about how much salt people arebuying per capita. But dietary salt, like culinary salt, is such a small fraction of salt salesin the U.S. Right. Salt is used in a bunch of like medical equipment and treatments. Like you've got tohave medical grade saline solution, right? For a bajillion,fucking things, right?You need salt to de-ice roads.Right, yeah, yeah.
22:59So the gold standard for this kind of stuff are biomarkers, either blood work orurinalysis.And it's like how much sodium might eat in the last 24 hours or something?Yeah, it's how much is coming out in your pee.So they're taking urine samples, they're measuring these sodium biomarkers, and they'retaking folks' blood pressure regularly.Okay.They ran a bunch of controls on the study.
23:22they found that across genders, across races, and across nationalities, people who consumed moresodium had higher blood pressure on average than people with the same demographics that consumed less.Okay.Intersalts results were released in the late 1980s, and they made a huge splash.That led to a huge wave of press, but neither the findings nor the press around themaccounted for some really important variables, right?One is where the sodium was coming from,which varies pretty widely from one country's food system to the next, right?
24:00The other thing that the intersalt study didn't account foris what individuals should do as a result of these findings, right?That's not actually what the study was.It wasn't looking for, hey, what should most people do for their health?Right. It's a descriptive study.They're just like trying to find a phenomenon.That's right.But it's released in the late 80s, which is like exactly when certainly the U.S. is like taking off in terms of like health conscious behaviors.
24:29Right.So a bunch of people hear this thing about salt consumption is associated with higher blood pressure.And they go, aha, got to take the salt chaker off the table.Right.In 1990, Congress passed the Nutrition Labeling and Education Act, which is what's standard.standardized our food labels to include like X percent of your vitamin C for the day and Y percent of your sodium.And sodium is included in that labeling requirement.Yeah.
25:00This is kind of where we start to get the unhinged.I wrote this in my notes before your mom was the example, but I did write, this is wherewe get your unhinged low salt moms and uncles and whatever, right?The white people took this in RAM.Yes.Following intersalt.and the findings of intersalt.A bunch of nations around the world, including the U.S., launched national trials related to sodium and hypertension.
25:30In the U.S., ours was the DASH study, dietary approaches to stop hypertension.Dash was a randomized controlled trial of 459 adult participants that all had elevated blood pressure.So we're once again looking at interventions.for hypertension, right?All of the sort of adherence stuff that we've talked aboutis a challenge when you're in the wild.So what they decided to do was be like, cool,you're eating two of your three meals a day at the research center.
26:04Oh.And then you're getting a third one in a cooler to take home with you.Okay, so it's super prescribed.Study participants were cycled through three different diets,each for three weeks at a time.and they also answered a standard like battery of questions about symptoms that they might be havinglike the classic like back of the head hypertension headache or that kind of thing right every singleone of them just said I'm hungry I'm eating these terrible meals that the lab gives me
26:35I've been living like this for six weeks so the three diets are this one there's a control dietIt was sort of intended to reflect the standard American diet at the time, right?The fruits and vegetables diet was similar to the control diet, but had just more fruits andvegetables in it, more fiber.And then the dash diet, which centered around fruits, vegetables, and low fat dairy.Okay.That diet was high in calcium, high in magnesium, high in potassium, protein and fiber.it was low in fat and saturated fat.
27:15But it's not super low in salt?No.Oh.So the first dash trial is just, can we look at just the foods that people eat, period.So it's like low fat, careful eating, and baconator.It's just comparing those three things.The findings were significant and they were heralded as such.People who didn't have hypertension but did have sort of elevated blood pressure
27:41had a modest but meaningful decrease in their blood pressure of like three to five points-ish.And people who did have hypertension on average had a much larger decrease in blood pressureof five to 11 points. That's with the dash diet.So the dash diet worked to reduce blood pressure, which is the goal of the diet.Absolutely.So as a follow-up to the dash trial, those same researchers,ran a second dash study called the dash sodium trial.Same kind of research design,
28:18but instead of cycling through these three different diets,they cycled through the dash diet at different sodium levels.Okay, cool.The results this time were even more striking.The lower sodium diets yielded much more significant drops in blood pressure.Okay.We're now into the world of like double digit changes in your blood pressure,and that's genuinely.
28:41genuinely huge, right? Yeah, this actually sounds like a pretty good study, or at least somethingpromising as a biological mechanism that, like, you should do more research to figure out,but like, they found a real effect. So here's the challenge with the dash diet. The dash diethinged on someone else preparing your food for you. Right, right. You also have the effect of beingobserved as part of a health study, right? So people kind of straighten up and fly right in a bunchdifferent ways.And you're motivated.You know it's a short-term thing.
29:14Absolutely.That's very different than doing itfor the rest of your life.Yes.You're having those like quasi-celebrity experience of like kind of having a personal chef.Yeah.Are people asking you like,what do you eat today?
29:23It's like dating someone.When you put that in the real world and you ask folks to adhere to a low sodium diet,the adherence rates out in the world are notoriously terrible.A 2024 study of patients in heart failure.found that even in that group, right, folks who have really high stakes,adherence to a low sodium diet was around 50%.Oh, wow.Right.
29:51It goes down from there with some studies of people with known hypertension,putting the real world adherence to a low sodium dash diet at 20%.Oh, wow.I'm assuming these are self-reported as well.That's right.And as ever, the maintenance phase is the diet, right?Like pretty explicitly, oh my God, it's happening.Like pretty clearly the dash diet is designed to be followed for life.
30:21Yeah, yeah.If people are having this hard a time, even in short test periods.Right, yeah.It doesn't bode well for how that translates in terms of like a set of public practices, right?I do think it's worth drawing the distinction between like the adherence rates to a low sodium diet.versus adherence rates to other diets.With something like keto, it's like you know what you're supposed to do,but it's joyless, it's really repetitive.
30:47Whereas the adherence to the dash diet,it feels like it's more like you don't even know what you're supposed to be doing,just because sodium is in so many things.Like, saltiness of taste, as I learned an hour ago,is not the same as having high sodium levels.I think the adherence stuff can oftentimes get boiled down to like a willpower issue,but this might really not be a willpower issue.It might just be like,
31:09we live in a world where you go to a restaurant and there's like two days worth of sodiumin your fucking salad dressing and you just didn't know.Right. And you should have made the heart healthy choice of ordering a baconator.Right. Exactly. Yes. I think it was like an Anthony Bourdain episode where he mentionedkind of offhand that restaurant mashed potatoes are typically 50% butter.That's the Jean-George ratio.Oh, really?Famously that he was like one pound of potato to one pound of butter.
31:37Yeah. Like restaurant food's hella good.because part of it's like they don't care how much like sugar, fat, salt, whatever they put in the food.So one of the problems with the dash diet and with like kind of any low sodium diet recommendations is adherence rates, right?The other is that as we learn as the research sort of continues to unfold is that different people respond really differently to sodium.As you can imagine, following the release of the dash trials and the dash sodium trials,there is kind of an explosion in sodium intake and heart health researchbecause there is sort of this sense of like, okay, we're on to something.Yeah.
32:21Let's dig in.Let's figure out how those dash diets impact normatensive people, people who don't have hypertension.Normatensive.That is the term of art, Michael.Terfs would call that a slur.Because they think cisgender is a slur.In the process of calling it a slur, they become hypertensive.So there is this giant wave of new salt research that hits in the 2000s and 2010s.
32:51So we learn a bunch of things that sort of flesh out the picture and add a lot of light and shading to what we know.Yeah.As a member of the normatensive community, I need to know what I can take from this.how you know I'm norm-attensive, you've changed.Among other things we learn that not everyone has the experience of increased sodium intakeincreasing their blood pressure.Oh.Some people have kind of no real response to added sodium.
33:18Some people have the opposite reaction where they cut out salt and their blood pressure goes up.Your heart expands expecting salt.We don't really know how many people have each kind of response.And at this point, most of our research, and I think rightly so, has been on people who havehypertension and heart disease because we're trying to stop those people from dying.Right.All of that means that the public health question then starts to shift, right?If a significant portion of the population has hypertension and sodium reduction can help
33:53prevent heart attacks, strokes, and death, is it worth reorganizing our food systems to keep those folks alive?Right.Right.Or do we need to do a bunch more research on people who are at less risk?Right.In order to make those kinds of like food systems level decisions.Right.And also there's also, I mean, the problem of adherence is not a minor problem.
34:18No.Giving people food in this very structured way is actually very different from telling people to eat differently.Totally.And again, this is all research on people who have high blood pressure and who have heart disease.Right.And are super motivated, yeah.And are super motivated and have high stakes sitting right in front of them.Right.
34:38And the question is, what do we do for everybody?Also, I just looked up hypertension prevalence.And it's fucking 47%.It's really fucking high, Mike.It's a massive deal if this is useful for people with hypertension.Yeah.We are in that way, we're kind of doing a trolley problem.Right, right.
34:56We also find out that there are some downsides to sodium reduction that a low salt dietmay increase production of some hormones and can increase cholesterol levels.Okay.So we're just getting like more and more and more nuance, more and more light and shading to the sortof salt data.Right.There are some broader limitations to the research as a whole.We talked about the ways to measure salt intake, like how much salt do people buy versus
35:25how much do they like excrete in their urine versus how much shows up in their blood,all that kind of stuff.for the U.S., our primary sodium intake data per capita comes from N. Haynes, which is a long-running nutrition research study.Yeah.Where researchers ask folks to recall just what they've eaten in the last 24 hours.Right.And then those researchers run analysis.Highly problematic methodology.
35:49But there's not a lot of other methodologies available because, like, people cannot remember what they ate.And then also, if somebody says, like, I had a pizza yesterday, it's not totally clear how much sodium that had.It depends on the pizza, it depends on how much pizza.You're going to have to make some assumptions in Enhain's world.One of those assumptions that they make in terms of sodium data is that when people say that they ate rice,they assume that folks have salted the water in which their rice is cooking.Oh, interesting.But these are boomers.
36:16They're not doing it.It's actually less relevant about sort of findings across age and much more relevant around findings around race.Yeah, they do have race data, so they should assume that the white people are not something they're wrong.rice.Incorrect.Michael.Wait, really?The white people are salting their rice water.
36:37But some studies that drilled down on sodium consumption of Asian Americans, as we've notedbefore, soy sauce is really high in sodium, right?Right.Those studies found that fewer Asian Americans were salting their rice water, which could beleading to a miscount of around 325 milligrams per day for folks who eat riceregularly, but don't salt their rice water.Because also even salting your pasta or your rice can be like a teaspoon or like threetablespoons depending on the person, right?
37:09I mean, even that is like not completely accurate.I know I'm just like nitpicking now, but it's just so fucking hard to do these studies.That's exactly right.That's the whole point, Mike.It's so fucking hard to do these studies and it's so fucking hard to extrapolate anythingthat approaches like a level of certainty that like a civilian person like you or Iwould expect to see, right?Right.
37:31There are so many other factors with hypertension, right?Right.Your baseline life stress is as much a factor.You're like socioeconomic status, your educational attainment, it's not possible for us toisolate, okay, when we're only looking at salt in someone's life.We can get closer to the mark, but we can't go, okay, it's just specifically the salt.It's only the salt, right?Right.
37:56Because of this large boom of research in salt, there are some studies that are like,ooh, wait a minute, we're looking at normatensive people.It's your people might.It's my community.Those studies find that there may be an association with very, very low sodium diets andincreased mortality.Okay.But those studies are not very large.
38:19And in a place like the U.S., most of us are so far over the mark that being likevery low sodium is genuinely difficult to do even for the moms and uncles and neighbors who arelike, I don't even have a salt shaker in my house, right?Right.But that sort of drop in the bucket of like, oh, there's some wrinkles here is enough togenerate a bunch of media coverage that's like, actually maybe salt is good for you.We're now like 30 or 40 years into guidance saying you should probably reduce your sodium.Right.
38:55So this lands as like, uh, like an edge lord kind of like man bites dog kind of story.Yeah.Hey, wait a minute.What if everything we knew on this topic was wrong, right?Yeah.It's an enticing little hook.Someone should make a podcast with like that as like a concept of like a title.What if we're wrong about everything we thought?
39:12Preconceptions that we had previously.So there's this article that comes out in science that collapses it into this.See we're being misled.Right.The science doesn't bear out these conclusions.that we've been being told, and maybe it's time to sort of question the sacred cow ofsodium reduction advice, right?Those stories are not really contextualized in a broader conversation, like the one that
39:38we're having today that is like, okay, but let's look at who needs it the most, right?Let's look at the scale of the problem here.Because it sounds like at this time, the consensus is that if you have hypertension, you shouldthink about reducing your salt, but if you don't have hypertension, you don't really need toworry about it.Right.And if you do have hypertension, you don't really need to worry about it.Right.
39:54attention, even if you're super motivated, your adherence is going to be low because it's not reallypossible for you to hang in our current food environment with a lower salt diet.Yeah.So one group of people who are promoting the like salt is actually good for you, hypothesis,are journalists who are interested in a new kind of story.The other is the actual salt industry.The salt industry?Is that just like the packaged foods industry?
40:20No.There's big salt?Big salt exists?There is. Their lobbying arm was called the Salt Institute.So they named it so that they could, they build themselves as, quote, the world's foremost experts on sodium.So they tried to make themselves seem kind of like they were academics.But they are straightforwardly an industry lobby group.They should have called it the sodium podium.
40:45Because we're standing there. We're talking to you.The Salt Institute was founded in 1914 in the U.S.their highest profile president was someone named Lori Roman.Lori Roman was someone who had already been in the media because she had already been in a political leadership position.She was the executive director of the American Legislative Exchange Council, Alec.They opposed divestment from apartheid in South Africa.They opposed, quote unquote, the homosexual movement in the 80s and 90s.they provided the model policy for SB 1070,
41:24better known as Arizona's Show Me Your Papers Law.The only thing she loves more than salt is black people not voting.And in some cases, not living because they also fomented stand your ground laws, voter ID laws.Okay, fuck it.Never eat salt again.I've heard enough.So this is the thing that absolutely jokerified me is I was like, okay, so fuck these guys.Yeah, fuck salt.
41:46Also, one of the Salt Institute's staffers, someone named Morton Satin, which I think is very funny.Morton, yeah.That was salt guy was named Morton.Even weirder that he has a yellow raincoat on and an umbrella wherever he goes?Morton Satin also wrote extensively for the Weston A Price Foundation.Every one of our episodes leads to the same fucking URL.The same people saying the same shit.Their advocacy efforts have generally been completely and totally fucking unhinged.
42:16Right.Nearly every time a finding came out that suggested unlimited salt might not be a great choice for everyone.The Salt Institute would fucking pop out of its trash can to advocate against it, both in government and in media.Right.In 1996, as a, for instance, the Salt Institute asked the FDA to repeal regulations that allowed some manufacturers to label things as low sodium if they were low sodium.They're like, they shouldn't be able to advertise that.Yeah, just cartoon evil.Yeah.
42:51They made a stink every time the dietary guidelines came out because each one includessome mention of sodium reduction.The arguments why they opposed it changed as public opinion changed.Right.In 2016, for example, Lori Roman told the Hill, quote,It's almost as preposterous as limiting water.People are naturally wired to get.the salt they need. By lowering sodium levels in food, you run the risk of increasing obesity.
43:24What? Her thinking is, people want a certain amount of salt, so they'll just eat the volume of foodthat gets them that amount of salt. Okay. So I'm holding the salt constant, but just adjusting the amountsof food. Now I'm going to eat three times as much if there's one third as much salt, which you're like,lady, absolutely not. I don't think so. And they also start to get some kind of,of salt curious pieces out of centrist outlets.One of them comes from our friends at the Atlantic and is titled, The Great Salt Debate,colon, so bad, question mark.Question mark.
44:01Love those.It seems like it's going to sort of like litigate the science of like, wait a minute,what do we know now about salt consumption and like how dangerous it is?It's not that.It is straightforwardly a profile of a guy who works for the salt institute.Oh, we really?Yeah.Oh, that's so fucking funny.
44:19He does seem like a true believer.But like, again, a bunch of his stuff is just going, the science isn't perfect.And actually, maybe it's good for you.And actually, we need to have more research before we make any recommendations.Yeah.Absolutely.Ideally.And we could study this for another 50 years and still feel like the results were inconclusive.
44:40The funny thing is I kind of remember this.I didn't do like a deep dive.You know, this is before we did the show.Yep.But I kind of remember being like, oh, okay, salt is chill.I just, like, don't need to think about my salt consumption.And that's basically what I've done ever since.Yeah, yes.
44:53So I'm part of the problem.So while this debate is going on, while all of this research continues, so does policymaking.The FDA rolls out some voluntary sodium reduction programs, which, like, don't do nothing.They did more than I expected them to do.There are companies that reformulated their products.hilariously Campbell's did a big rollout being like, we're cutting our sodium by 40%.People had such a negative reaction to it that Campbell sort of rolled it back.Really? They actually reversed it?
45:24They reversed big parts of it. They didn't go back to their original super high sodium levels,but they did increase sodium again. And they dropped the labeling. And actually, that's part ofwhat happens from here on out is that companies start reformulating their products to be lower in sodium,which is good, but none of them are talking about it.It's also so funny to me that the population is pissed off.There's less sodium in their food.People get so irrationally mad.It's like gluten levels of anger.
45:55Because it's not like you can't just add salt.Like if Campbell's chicken soup tastes bad,you just add a fucking half a teaspoon of salt when you make it.It's not like that big of a deal.It's really not and people lose their fucking minds.I add salt to my peanut butter and it's a bomb as hell.Because you have to stir it anyway because it separates.Like almond butter is awful without salt.
46:14If you just add like a fuck ton of salt, it's so much better.So like, yeah, I don't complain there's not enough salt in the peanut butter.I just add fucking salt.That's right.And also like, again, we're not even talking about palatibility for so much of this.Right.I saw my peanut butter and my heart is small as hell.Because they're always telling me I have a small heart.
46:30The FDA rolls out these voluntary sodium reduction programs that, again, surprised me that they did as much as they did.the American Heart Association started advocating with companies directly to reformulate.Nestle, General Mills, PepsiCo, Kraft, Heinz, Subway, and Panera all took on voluntaryinitiatives to reduce sodium in their products in the 2000s and 2010s.And more Americans were self-reporting that they checked labels for sodium.That's them telling someone I check the label for sodium, which I think just means they knowthat's the right health conscious answer.Yeah, yeah, yeah, yeah.
47:08Seem like a health conscious person.But even if they're just saying it, there is some sense of like, okay, well,the writing's on the wall.We should probably pay attention to this.Right.And it's borne out by sales data.So a 2017 JAMA study looked at grocery and convenience store sales data and found thatbetween 2000 and 2014 Americans' food purchases.
47:35reflected a 12% drop in dietary sodium.Okay.Buying food and eating food are different things, of course.But if those sales data translate into dietary changes, that would be a 400 milligram drop in sodium intake, which is really significant.That's like 40% of the way to the FDA goal, right?Like that's like really, really significant drop.We're still way over it, but it's getting there.Yeah.
48:03In 2019, to sort of everyone's surprise, the Salt Institute closed.Vaccinated?Vaccinated?They didn't really say why, but there are a few things that could have played a role.One is the National Restaurant Association, which was a one-time ally of the Salt Institute,starts proactively working with its members to start to bring down the sodium levels in some of their dishes,so that we have fewer of those, their 7,000 milligrams.of salt in this one fucking salad kind of thing.
48:36I'll bet those emails are wild.I bet they're nutty.It's like the psycho salt lobbyists and the psycho restaurant lobbyists like fighting.In terms of where we are today, there is some disagreement about the specific threshold,but most major health institutions in the U.S. agree that Americans on average consume moresalt than we probably should.at the population level, it looks as if, again, all these measures are imperfect.It looks as if the U.S.'s per capita sodium intake is plateauing.
49:11Some measures show it reducing a tiny bit.But the good news is that even without those sort of salt interventions, which could acceleratethis, deaths related to heart disease have been declining since the 1970s.Right.A lot has changed since the initial.burst of publicity around salt consumption and heart health, right? During this time from1969, the first sort of low sodium recommendation from the U.S. government to today,we have like dozens of treatments that have come on to the market that are way more effective.
49:49Well, that's the other thing. Earlier detection, the rollout of those little blood pressure machinesand people taking their blood pressure at home. New treatments have entered the market, the firstACE inhibitor was approved by the FDA in 1981.Those lower blood pressure about twice as much as salt reduction.The same goes for SGLT2 inhibitors like Jardians and Farsiga.Those received FDA approval for the first time in the 2010s.Those medications work regardless of a patient's salt sensitivity and they don't havethe same absolutely brutal adherence rates.
50:26Right.Like a lot of people can take a pill once a day.the biggest barrier there is how fucking expensive they are.Right.I think there's this tendency to sort of link, like it has to be lifestyle to this thing.Like salt equals strokes.But it sounds like many, many, many things contribute to it, one of which appears to be salt.But there's just lots of other stuff going on.
50:45We've just gotten better at talking about a bunch of facets of it.Right.And salt is one of many facets.I do think this is the most It Depends episode we've ever done.It is such an It Depends episode.You're exactly right.Because like some people should reduce their salt.Some people should increase it.
51:01God.And also, I'm just like fucking processing this in real time.I like, even if it's the case that you really need to reduce your salt consumption, it'sreally fucking hard to do that.Yeah.And there's more effective treatments.Yeah.It's not like stop using light salad dressing.
51:14It's like, take a satin.Yeah.I think that's right.And also the take a statin stuff is like more effective.Right.Than an intervention that is very difficult to do with a very low adherence rate because of howdifficult it is to do.Right.
51:27Two things can be true at once.right? It can be true that it doesn't make sense to instruct most patients to reduce their sodium intake, right? Because of adherence, because it's, some people have the opposite effect, right? But it can also be true that our food system has a fuck ton of sodium in it. Right. And we should be able to control for that in ways that allow people to have the control that they need. Right. So that if you are a person who needs to up your sodium, you know that you're upping your sodium. Right. And if you're one of the many,many, many, many people who needs to control their sodium intake or who might benefit from that,then you also have the ability to do that. Right now, the food system cuts in favor ofthe presumably small number of people who need more sodium in their diet. I think this is a reallyinteresting case of like there is a shit ton of really nuanced research. There are folks who areinclined to pull that into definitive conclusions in any number of directions. Yeah. Andthe truth is this is like a really complex issue that on a public health level is going to take
52:34a lot of interventions from a lot of directions and one of those is sodium in our food system.Although after the show comes out, everyone is swapping soy sauce for baconators.Everyone's doing it.For your help.
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