Salt

Introduction to Maintenance Phase

0:00welcome to maintenance phase the podcast 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 see you did it it's okay it's like six out of ten we're doing the episodium i'm michael hopps

0:32i'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 podcast it's the same audio content same

Anxiety Around Diet

0:44stuff aubrey we're talking about salt today mike this was like the anxiety around diet growing up yep it was like low fat and like low salt were the two things you need to strive for this came up in our bonus episode about 80s diets that a ton of them were like extremely low salt yeah it is a thing that came up for me with my mom called me and said that a friend of hers invited her over to taste her cooking and make sure that it had the right amount of salt because her friend does not use salt ever

1:19this 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 how it works sorry mom did you 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

Exploring Salt Guidance

1:40of our time so i think the central question that i wanted to like explore here is how did we get from this idea in the 70s and 80s that reducing your salt as much as possible was one of the most important things that you could do for your health to the point now where many folks have just dropped that guidance altogether yeah and folks are generally not paying attention to 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

2:14point 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 this idea 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 oh interesting okay so we're talking about like a vanishingly small amount of the salt is what you

2:46decide 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 consuming salt that you don't really know is consuming salt or you don't really think about is consuming although i am policing your behavior you should salt food when you're cooking it if you don't do that i'm

Salt Quiz Introduction

3:07bringing 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 um and the way that we're going to do that is a salt quiz okay i think you're going to say we need to do a taste test where we each just eat us a teaspoon of salt go get your salt shaker how does it taste fucking delicious let's both get grounded here and just eat a bunch of salt just the sound of me puking in the background so question number one michael obrey the who maintains a ranking of estimated sodium consumption across over 150

3:40nations where in that ranking do you think the united states falls do you think we are in the top 25

Global Sodium Consumption Rankings

3:49the 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 the 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

4:22country is the saltiest like the most irritable you 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

WHO Recommendations

4:34to the actual who recommendations fda recommendations all of that kind of stuff wait so what is what is the who recommendation in teaspoons uh it's like about a teaspoon is the what we should be aiming for that's like the goal okay next question we're gonna do a little salt mortal combat oh okay finish him which of these has the most salt we're gonna do one teaspoon of each of these things which one do you think has the most salt and which one do you think has the least salt okay the options are a

5:06teaspoon of table salt a teaspoon of msg a teaspoon of marmite a teaspoon of soy sauce and a teaspoon of grated parmesan from context clues i think the answer is soy sauce but also marmite is like pure fucking salt like on your tongue it's so unbelievably salty so i'm gonna say marmite and soy sauce is a close second am i wrong i'm sure i'm wrong you're very wrong okay marmite contains less sodium than a

5:39teaspoon of salt really it's so salty though on my on my mouth uh so here's the story one teaspoon of salt contains 2300 milligrams of sodium a teaspoon of soy sauce has 3000 milligrams of sodium so okay 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 was i the wrongest it's possible

6:11to be no you weren't the wrongest it's possible to be okay here's the other one that i found fascinating grated parmesan has about 25 milligrams of sodium in one teaspoon wait 2500 or 25 25 to 5 but it tastes so salty aubrey what's happening what's going on right so all of this is to say if you're counting on things tasting salty to determine what has sodium in it we're almost all getting it right wait i did exactly the thing i i did exactly the concept that you wanted to illustrate yeah

6:43i'm putty in your hands i've been puppeteered so the last question that i have for you for our salt pop quiz this is so fun are you enjoying it this is so fun which of the following is the highest sodium dish at an american chain restaurant oh okay a the wendy's triple baconator that's three beef patties and six strips of bacon i gotta go to wendy's more okay b long john silver's footlong chili cheese dog c bob evans steakhouse salad d outback steakhouse's

7:22blooming 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 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 uh bob mackie salad whatever thing the bob fossey i've never heard of this restaurant yeah okay bob evans

7:54steakhouse 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 right

Salt and Food Production

8:09absolutely the lowest sodium of those is the triple baconator wait really yep okay uh that one's uh just shy of 1800 milligrams of sodium right because i heard recently that just because things taste salty doesn't mean that they're high in sodium oh interesting i heard 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

8:40hydrated that'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 not getting 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 palatability right the big one is that salt is overwhelmingly used as a preservative right cured foods especially

9:12things like lox bacon ham prosciutto salami really high in sodium pickled foods oh yeah 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 generously to meat

9:49before 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 gonna send you a quote this is from a book called salt wars written by michael jacobson who is the former director of the center for science in the public interest according to the usda 21 percent of beef 78 percent of chicken and 57 percent of pork is bulked out in

10:24this 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 dollars 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 four billion dollars 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 and then like the little spray comes on i'm like i'm paying by the

10:56pound 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 as i'm like opening a sugar packet i'm like your cheapskate tendencies really are boundless i'm not paying for water the other thing that is sort of related to a profit motive is that high sodium foods trigger a thirst response so whether by design or by happenstance

11:28serving high sodium foods can encourage people to order more drinks which as anybody who's worked in the restaurant biz knows is like where your bread and butter comes from right yeah so to 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 but 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

12:00people 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 in sodium so that's like why you want like french fries and like a shawarma or whatever at the end of the night 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 my health the main thing we're going to talk

Salt Hypertension Hypothesis

12:28about today as we start to sort of chart the path of like how 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 it can contribute to an enlarged heart presumably then the inverse would be true that

12:58cutting out salt would decrease blood volume and blood pressure 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 wangdi nejing estimated to be written sometime between 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 um that we see of like relating uh salt to your blood

13:35pressure or to your heart health 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

14:07sample sizes they'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 blood pressure that is an overwhelming

14:40majority of the studies that we're going to talk about in 1939 there is sort of uh 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 uh 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

15:15devise a super low sodium diet that that would help folks with 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 is pretty normal yeah it had a maximum of five grams of fat oh yeah

15:46okay 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 which is oh wow nothing so what you're saying is it's just three wendy's baconators per day no it's unlimited rice is that what it is it's called the kempner rice diet oh it's not named after a researcher named rice i thought it was like two researchers and one of

16:19their last names no it's a guy and a food kempner okay so you're just eating unsalted fucking rice like three meals a day unlimited rice and uh unlimited fruit juice and 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 to be clear that 150 milligram sodium ceiling is almost impossible to manage right five stalks of celery

16:55has 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 a 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 between 25 and 30 percent

17:25yeah miserable part of what you're trying to get at is like what's our treatment recommendation for people who have hypertension how should they be eating in perpetuity right it's not functional to say you pretty much can't eat vegetables there's too much salt in them the only thing you have to do is never derive any pleasure from food the rest of your life never have a slice of cake at a birthday party never eat another sandwich you will get scurvy but think of how small your blood will be the people

17:56who did experience improvement whether kempner was studying it or others were studying it they saw improved blood pressure they saw improved electrocardiograms right like 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 so the kempner rice diet is one of the

18:27only treatments on offer this is a little bit like the keto diet story right where like we didn't have anti-convulsant 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 uh american researchers observed an increase in high blood pressure in those rats and chickens during those animal studies

19:03but 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 variance in blood pressure response to salt intake oh humans do and two the doses were nutso the human equivalent of the dose that these rats got would have been

19:3540 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 effect but that's not especially helpful in terms of guiding whether 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-scale nutritional recommendations about salt we've got the kempner rice diet we've got this

20:12early french research and we've got a number of animal studies so 1969 is the point at which the u.s federal

US Government Sodium Recommendations

20:20government 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 as a strategy worth pursuing and there's certainly nothing outperforming sodium reduction as a treatment strategy for hypertension right in 1977 a senate select committee published dietary goals 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

20:56to reduce sodium intake but they don't have like specific goals just yet right since then the recommended daily allowance has sort of for quite some time now held steady at between 1500 and 2300 milligrams of sodium the nutritional recommendation is now sort of baked into the dietary guidelines and it becomes almost boilerplate language that just gets carried over and carried over and carried over right but that's when large-scale human studies start to roll out and that's when the so-called salt wars

21:33begin dude is it fucked up that this is making me hungry for salty food and now i'm eating the smoked salmon that i have at the fridge i feel like you now understand why i fucking burned through that jar of gorgonzola olives oh no so there's a huge landmark study in the early 80s called inter salt okay um it was a very ambitious global study of sodium consumption there are different ways to measure sodium intake one of the

22:09ways that you can do it is from self-report data as we've discussed many times on the show that's like generally unreliable but it's especially unreliable given how much people misunderstand 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 are buying per capita but dietary salt like culinary salt is such a small fraction of salt sales in the u.s right

22:42salt is used in a bunch of like medical equipment and uh treatments like you've got to have medical grade saline solution right for a bajillion fucking things right you need salt to de-ice roads right yeah so the gold standard for this kind of stuff are biomarkers either blood work or urinalysis and it's like how much sodium i ate 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're taking

23:16folks blood pressure regularly okay they ran a bunch of controls on the study they found that across genders across races and across nationalities people who consumed more sodium had higher blood pressure on average than people with the same demographics that consumed less okay inter salts 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 them accounted for some really important variables right

23:53one is where the sodium was coming from which varies pretty widely from one country's food system to the next right the other thing that the inter salt study didn't account for is 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 right so a bunch of

24:30people hear this thing about salt consumption is associated with higher blood pressure and they go aha i gotta take the salt checker off the table right in 1990 congress passed the nutrition labeling and education act which is what 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 this

25:01is 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 where we get your unhinged low salt moms and uncles and whatever right the white people took this and ran yeah 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 in the u.s ours was the dash study dietary approaches to stop hypertension dash was a randomized

25:38controlled 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 about is 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 oh and then you're getting a third one in a cooler to take home

26:08with 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 having like the classic like back of the head hypertension headache or that kind of thing right every single one of them just said i'm hungry i'm so hungry i'm eating these terrible meals that the lab gives me i've been living like this for six weeks so the three diets are this one there's a control diet it was sort of

26:44intended 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 and vegetables 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 but it's not super low in salt no oh so

27:17the 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 had a modest but meaningful decrease in their blood pressure of like three to five points ish

27:50and people who did have hypertension on average had a much larger decrease in blood pressure of five to eleven points that's with the dash diet so the dash diet worked to reduce blood pressure which is the goal of the diet absolutely okay 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 but instead of cycling through these three different diets they cycled through the dash diet at different sodium levels okay cool the

28:27results 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 huge right yeah this actually sounds like a pretty good study or at least something promising 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 diet hinged on

28:58someone else preparing your food for you right right you also have the effect of being observed as part of a health study right so people kind of straighten up and fly right in a bunch of different ways and you're motivated you know it's a short-term thing absolutely that's very different than doing it for the rest of your life yes you're having those like quasi celebrity experience of like kind of having a personal chef yeah people asking you like what you eat today it'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

29:33in 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 it 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

30:04well that's right and as ever the maintenance phase is the diet right like pretty explicitly like pretty clearly the dash diet is designed to be followed for life yeah 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

30:35distinction 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 whereas 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

31:08might just be like we live in a world where you go to a restaurant and there's like two days worth of sodium in 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 mentioned kind 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 yeah like restaurant food's hella good because part of it's like they don't

31:41care 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 research

32:16because there is sort of this sense of like okay we're on to something yeah let's dig in let's figure out how those dash diets impact normotensive people people who don't have hypertension normotensive that is the term of art michael turfs would call that a slur because they think 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 so we learn a bunch of things that sort of flesh out

32:54the picture and add a lot of light and shading to what we know yeah as a member of the normotensive community i need to know what i can take from this as you know i'm normotensive you've changed among other things we learn that not everyone has the experience of increased sodium intake increasing their blood pressure oh some people have kind of no real response to added sodium some people have the opposite reaction where they cut out salt and their blood pressure goes up your your heart expands

33:26expecting 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 have hypertension 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 prevent heart attacks strokes and death is it worth reorganizing our food systems to keep those folks

34:01alive 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 no 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

34:34are super motivated and have high stakes sitting right in front of them right and 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 we uh also find out that there are some downsides to sodium reduction that a low salt diet may increase production of some hormones and can increase

35:06cholesterol levels okay so we're just getting like more and more and more nuance more and more light and shading to the sort of 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 how 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 nhanes which is a long-running

35:37nutrition research study yeah where researchers ask folks to recall just what they've eaten in the last 24 hours and then those researchers run analysis highly problematic methodology but 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 right it depends on the pizza depends on how much pizza you're gonna have to make some assumptions in nhanes world one of those assumptions that they make in terms of sodium data is that when people say

36:09that they ate rice they assume that folks have salted the water in which their rice is oh interesting but these are boomers they'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 salting their rice incorrect incorrect michael wait really the white people are salting their rice water but some studies that drilled down on sodium consumption of

36:40as we've noted before soy sauce is really high in sodium right right those studies found that fewer asian americans were salting their rice water which could be leading to a miscount of around 325 milligrams per day for folks who eat rice regularly but don't salt their rice water because also even salting your pasta or your rice can be like a teaspoon or like three tablespoons depending on the person right i mean even that is like not completely accurate i know i'm just like nitpicking now but it's just so

37:13fucking hard to do these studies that's exactly right that's the whole point mike is it's so fucking hard to do these studies and it's so fucking hard to extrapolate anything that approaches like a level of certainty that like a civilian person like you or i would expect to see right right there are so many other factors with hypertension right right your baseline life stress is as much a factor your like socioeconomic status your educational attainment it's not possible for us to isolate okay when we're only

37:47looking 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 because of this large boom of research in salt there are some studies that are like oh wait a minute we're looking at normotensive people it's your people mike it's my community those studies find that there may be an association with very very low sodium diets and increased mortality okay but those studies are not very large and in a place like the u.s most

38:21of us are so far over the mark that being like very low sodium is genuinely difficult to do even for the moms and uncles and neighbors who are like 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 to generate a bunch of media coverage that's like actually maybe salt is good for you we're now like 30 or 40 years

Challenging Sodium Reduction Guidance

38:51into guidance saying you should probably reduce your sodium right so this lands as like uh like an edgelord kind of like man bites dog kind of story right 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 interesting what if we're wrong about everything we thought preconceptions 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

39:25and maybe it's time to sort of question the sacred cow of sodium reduction advice right right those stories are not really contextualized in a broader conversation like the one that we'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 should think about reducing your salt but if you don't have hypertension you don't really need to worry about it right and if you do have hypertension even if you're super motivated your adherence is going

39:57to be low because it's not really possible for you to hang yeah 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 no 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

40:30they build themselves as quote the world's foremost experts on sodium so they tried to make themselves seem kind of like they were academics okay they are straightforwardly a an industry lobby group they should have called it the sodium podium because we're standing there we're talking to you the salt the salt institute was founded in 1914 in the u.s their highest profile president was someone named laurie roman laurie roman was someone who had already been in the media because she had already been in a

41:02political leadership position she was the executive director of the american legislative exchange council 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 uh better 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

41:32living because they also uh 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 jokerfied me is i was like okay so fuck these guys yeah fuck salt also one of the salt institute's staffers uh it was someone named morton satin which i think is very funny morton the assault 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

42:04foundation 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 right 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

42:40regulations that allowed some manufacturers to label things as low sodium if they were low sodium okay they're like they shouldn't be able to advertise that just cartoon evil yeah they made a stink every time the dietary guidelines came out because each one includes some mention of sodium reduction the arguments why they opposed it changed as public opinion changed right in 2016 for example laurie roman told the hill quote it's almost as preposterous as limiting water people are naturally wired to get the salt

43:17they need by lowering sodium levels in food you run the risk of increasing obesity what her thinking is people want a certain amount of salt so they'll just eat the volume of food that gets them that amount of salt okay so i'm holding the salt constant but just adjusting the amounts of food now i'm gonna eat three times as much if there's one third as much salt which you're like lady absolutely i don't think so and they also start to get some kind of salt curious pieces out of centrist outlets

43:50one of them comes from our friends at the atlantic and is titled the great salt debate colon so bad question mark question mark love 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 wait really yeah oh that's so fucking funny he does seem like a true believer but like again a bunch of his stuff is

44:24just going the science isn't perfect and actually yeah 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 i see the 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 yeah so i'm part of the problem so while this

44:55debate is going on while all of this research continues so does policy making the fda uh 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 campbells did a big rollout being like we're cutting our sodium i remember that 40 percent yeah people had such a negative reaction to it that campbells sort of rolled it back really they actually reversed it they reversed uh big parts of it um they didn't go back to their original super high sodium levels but they did

45:31increase sodium again and they dropped the labeling and actually that's part of what 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 like the population is pissed off there's less sodium in their food people get so irrationally mad it's like gluten levels of anger because it's not like you can't just add salt like if 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

46:04not and people lose their fucking minds i add salt to my peanut butter and it's bomb as hell because you have to stir it anyway because it separates like almond butter is awful without salt if 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 palatability for so much of this right i thought my peanut butter and my heart is small as hell people are always telling me i have a small heart the fda rolls out these voluntary sodium reduction programs that again surprised me that they did as much as they did the american heart

46:38association started advocating with companies directly to reformulate nestle general mills pepsico craft heinz subway and panera all took on voluntary initiatives 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 checked the label for sodium right which i think just means they know that's the right health conscious answer yeah they want to seem like a health conscious person

47:09but 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 jamma study looked at grocery and convenience store sales data and found that between 2000 and 2014 americans food purchases reflected a 12 drop in dietary sodium okay buying food and eating food are

47:42different 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 it's getting there yeah in 2019 to sort of everyone's surprise the salt institute closed vaccinated they didn't really say why but there are a few things that could have played a role one is the

48:15national restaurant association which was a one-time ally of the salt institute starts proactively working with its members to like start to bring down the sodium levels okay some of their dishes so that we have fewer of those there's 7 000 milligrams of salt in this one fucking salad kind of thing i'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

48:48about the specific threshold but most major health institutions in the u.s agree that americans on average consume more salt 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 is per capita sodium intake is plateauing some measures show it reducing a tiny bit but the good news is that even without those sort of salt interventions which

49:19could accelerate this 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 from 1969 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 that's the other thing earlier detection the rollout of those little blood pressure machines and people taking

49:55their blood pressure at home yeah new treatments have entered the market the first ace inhibitor was approved by the fda in 1981 those lower blood pressure about twice as much as salt reduction yeah the same goes for sgl t2 inhibitors like jardience and farcega all right those uh received fda approval for the first time in the 2010s those medications work regardless of a patient's salt sensitivity and they don't have the same absolutely brutal adherence rates right right like a lot of people can take a pill once a day the biggest

50:29barrier there is how fucking expensive they are right i think there's this 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 we'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 such an it depends episode you're exactly right because like some people should reduce their salt some people should increase it god

51:01and 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's really fucking hard to do that yeah and there's more effective treatments yeah it's not like stop using light salad dressing it'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 how difficult it is to do right two things can be true at once right it can be true that it doesn't make sense to instruct

51:31most patients to reduce their sodium intake right because of adherence because it's some people have the opposite effect right 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 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 yeah the food

52:07system cuts in favor of the presumably small number of people who need more sodium in their diet right i think this is a really interesting case of like there is a shit ton of really nuanced research there are folks who are inclined to pull that into definitive conclusions in any number of directions yeah and the truth is this is like a really complex issue that on a public health level is gonna take a lot of interventions from a lot of directions and one of those is sodium in our food system although after the

52:40show comes out everyone is swapping soy sauce for baconators everyone's doing it for your health you

53:10you you you