October 2009 Issue

Seasonings of Change
By Maura Keller
Today’s Dietitian
Vol. 11 No. 10 P. 40

Training the public on how to read food labels and avoid hidden sources of salt in processed foods is an important step in helping them reduce their sodium consumption and associated health risks.

Excessive dietary sodium is a major risk factor for high blood pressure, which can lead to heart disease, atherosclerosis, stroke, and kidney failure. But with improved communication and education, dietitians can lead the charge against high sodium consumption and help consumers realize the importance of limiting their intake.

Current Recommendations
To RDs, the concern over sodium intake is nothing new; you’ve known for quite some time that Americans consume much more sodium than the daily recommendation. In fact, the American Dietetic Association (ADA) has created a brochure called “The Sodium Story” with the goal of educating the public on the benefits of reducing sodium in the diet and providing steps they can take toward change.

“As dietitians, we are asked to help guide individuals through the somewhat overwhelming task of lowering the amount of sodium in their diets while still maintaining some taste and variety. That’s easier said than done,” says Kelly O’Connor, RD, LDN, CDE, of Mercy Medical Center in Baltimore. “As has been well publicized, most Americans consume several times the recommended daily amount, and what is more worrisome is that they may not even be aware of it.”

According to Nancy Bennett, MS, RD, CDE, a nationally recognized certified diabetes educator and Foster Farms nutritionist based in San Francisco, there is no one recommendation level for sodium in the diet. “The Department of Health and Human Services suggests reducing sodium to 2,400 mg to prevent the development of high blood pressure. While the National Research Council of the National Academy of Sciences recommends an approximate daily range of 1,100 to 3,300 mg of sodium for adults, the Institute of Medicine and the American Medical Association recommend limiting sodium to 1,500 mg/day,” she says. “And the American Dietetic Association and the American Heart Association recommend limiting sodium to 2,300 milligrams per day. The USDA is responsible for the guidelines on the label of foods. Their recommendation for sodium intake is 2,400 mg.”

It’s important to note that sodium is a naturally occurring mineral, and we do need some of it daily. “The amount that is required daily is estimated to be just somewhere around 500 mg per day,” says O’Connor. “Sodium helps regulate the fluid balance of our cells. So if the body takes in less sodium, causing there to be less extra fluid in our cells, the amount of blood our heart has to pump is reduced and this is, in effect, how blood pressure can be lowered. Therefore, one doesn’t need to entirely eliminate sodium from their diet but rather be mindful of how much they are taking in on a daily basis.”
Many dietitians and health professionals steer consumers toward limiting their intake to 1,500 mg of sodium each day. According to Susan Kasik-Miller, MS, RD, CNSC, a clinical dietitian at Sacred Heart Hospital in Eau Claire, Wis., “There are recommendations to decrease sodium intake to 1,500 mg, which is based on research showing that people with this intake had the greatest reduction in blood pressure from people with an intake of 3,000 mg.”

Bennett points out that the ADA’s position paper on women’s health suggests that women follow the Dietary Approaches to Stop Hypertension (DASH) guidelines and limit sodium intake to 2,300 mg/day. This recommendation is based on the fact that 52% of all women over the age of 45 have high blood pressure. “Also, each year this country spends more than $15 billion on medications to treat high blood pressure but nothing on encouraging Americans to cut back on their sodium intake,” Bennett says.

What’s more, people with high blood pressure, African Americans, and adults who are middle aged or older tend to be more salt sensitive. “This is the group that should aim for less than 1,500 mg sodium daily,” says Constance Brown-Riggs, MSEd, RD, CDE, CDN, an ADA spokesperson. “But not only should they reduce sodium, they should increase potassium to at least 4,700 mg daily. Potassium can actually blunt the effect of the sodium. So my conversation with clients is not limited to reducing sodium; it includes education on how to boost potassium intake.”

Sources of Sodium
Almost all processed and manufactured foods contain sodium. Preparing foods that are fresh, frozen, or made without salt is the better choice, but many people feel they lack the skills or time to cook their meals.

“As most Americans eat some 40% of our meals away from home, we have less control over the ingredients that are used in preparing our meals,” Bennett says. “Though many fast-food restaurants do have a nutritional analysis of their offerings, this data is not available at the point of sale. Hence, the nutritionally conscientious consumer needs to do their research before heading out for lunch.”

It’s also important to note that most people have no frame of reference—they just don’t know how much sodium they should aim for on a daily basis. “Once my clients understand their sodium goals, then we go on to look at how much sodium is in the food they are actually eating—they are always amazed,” Brown-Riggs says. “Eating out can be a real land mine when it comes to reducing sodium intake. Fast food is particularly high in sodium, but sodium-laden foods can be found in any restaurant.”

One issue regarding sodium in processed foods is that there can be excessive sodium in seemingly “natural” foods. “Take some brands of fresh chicken, for example,” Bennett says. “Fresh, unadulterated chicken contains 67 mg of sodium per 4-oz serving. However, the fresh chicken from some poultry producers is plumped with ‘flavor enhancers’ or injected with broth or sea salt. This chicken contains 440 mg of sodium per serving. This food contributes nearly 30% of the sodium recommended by the Institute of Medicine.”

Labeling Is Paramount
The first step in avoiding hidden salts or sodium is teaching clients how to read the Nutrition Facts label and the ingredient list. Food labels are an excellent tool to help the consumer identify how much sodium is in a serving of a food. “Sodium is clearly identified and the quantity plainly listed on the label,” Kasik-Miller says. “People do need to remember to check the serving size to ensure they are eating the recommended serving size and not two or three servings.”

As Brown-Riggs explains, since 75% of the sodium that people eat on a daily basis comes from cured and processed meats, canned foods, salad dressings, condiments, bottled sauces and marinades, boxed mixes, frozen dinners, salted snacks, cheeses, and even some ready-to-eat cereals, ensuring clients understand these “land mines” is key.
Dietitians also need to teach clients the sodium language. In other words, teach them to look for key words and ingredients that are indicators of high sodium. “It’s not that the information is not on the label; people don’t know how to interpret that information,” Brown-Riggs says. “What’s high sodium? What’s low sodium? They just don’t know. So educating the public is key. Then there are those who don’t even bother to look at the label.”

In most cases, the label can be deceiving. Currently, the amount of sodium in the food and the percentage that food contributes to the overall sodium in the diet is listed on the Nutrition Facts label. “However, the figures represent those suggested by the USDA (2,400 mg/day) and not those recommended by the Institute on Medicine (1,500),” Bennett says.

Boston-based dietitian Kate Scarlata, RD, agrees: “Food manufacturers often list the portion size and sodium content of that portion based on the serving size of a toddler. Who would eat 4 oz of soup for a meal?”

She continues: “Many people purchase condensed soups but don’t add any water to them. [In the case of one company’s] chicken noodle soup, a mere 1⁄2 cup contains 890 mg of sodium. Dare you eat the entire can, which has 2.5 servings, you would be consuming 2,225 mg of sodium.”

Scarlata notes that Americans should focus not only on sodium but also on other dietary measures that sustain health. “It is unfortunate, but food manufacturers focus on the health topic of the year, modify that one ingredient, and Americans then buy the food item. For example, when low-carb diets were the trend, food manufacturers lowered the carbs in their food but added other unhealthy ingredients in for taste. In the fat-free trend, fat was removed, and salt and sugar were added. If the goal is for Americans to lower blood pressure, stroke, and heart disease, monitoring the sodium in their diet is just one step toward the goal. The DASH diet, shown to lower blood pressure, incorporates the notion of a healthy diet, including fruits, vegetables, nuts, legumes, rich calcium foods, not simply focusing on one component or one nutrient. Americans need to see the bigger picture to lower risk of all diseases linked with poor diet, including cancer, heart disease, and osteoporosis.”

Dietitians’ Role
What can dietitians do to help curb the public’s overconsumption of sodium-infused foods? Sheana Brighton, RD, LDN, clinical coordinator of food and nutrition at Advocate South Suburban Hospital in Hazel Crest, Ill., says education is key. “Once people become aware of what they are consuming, they can change and make the ‘healthier’ foods part of their everyday lifestyle,” Brighton says. “Dietitians can encourage Americans to seek out nutritional counseling from a registered dietitian so that they may be educated on the food label and what it means and guide people to prepare their own food to taste great without the salt.”

Ilona Fordham, RD, a health coach in San Diego, explains that there is an overall push from health organizations to reduce sodium consumption levels. However, she believes the emphasis needs to be on choosing whole, unpackaged foods rather than reading food labels and adding up a day’s worth of sodium. “This can be laborious and confusing for people and, in my experience, emphasizing what can be eaten rather than what can’t be eaten works much better for people,” Fordham says.

She continues: “When clients are first encouraged to switch to whole foods and lots of fruits and vegetables, there is a common lament that the food is bland and tasteless. It’s not tasteless; this is the true taste of food. People are so used to the taste of salt that nothing else will suffice. This is a big problem.”

Fordham believes that by emphasizing less packaged foods, not only will people’s sodium intake decrease, but their nutrient levels and fiber intake will increase, and hopefully their taste buds will be trained to enjoy less salty foods. “In this way, people are eating for health and not simply to reduce sodium levels,” she says. “It really involves a whole lifestyle change with an emphasis on disease prevention and health promotion rather than simply focusing on one nutrient: sodium. This takes time, support, and encouragement, but the goal is worth it, and clients always say they feel better and more energized by the process.”

— Maura Keller is a Minneapolis-based writer and editor.

What Dietitians Should Recommend
RDs looking for ways to educate their clients on sodium intake should consider the following tips from Nancy Bennett, MS, RD, CDE:

• Whenever possible, buy fresh. Mother Nature added very little sodium to fruits, vegetables, whole grains, poultry, and lean meats.

• Beware the word “natural.” According to the FDA, natural means the food contains no synthetic ingredients, such as flavors, colors, or preservatives. Salt is a “natural ingredient.” So are sea salt, seaweed, and kelp. All of these ingredients can contribute excessive sodium to a food product.

• Look for the words “low sodium,” which mean less than 140 mg/serving, and “very low sodium” products have less than 35 mg/serving. “Reduced sodium” means the food contains at least 25% less sodium than the company’s standard product; it does not mean 25% less than another company’s product.

• If buying prepared foods, realize that “soda” (sodium bicarbonate), broth, sea salt, Kosher salt, and seaweed contribute to sodium intake.

• Cook and eat at home. You’ll save both your wallet and your heart. Restaurant items are not only pricey, but they can supply up to 90% of your daily sodium allotment.

• Beware of beverages. Some beverages (sports drinks) can contain considerable amounts of sodium.

• Grow fresh herbs and use them. Seasoning foods with fresh rosemary, cilantro, basil, oregano, or chives packs a huge flavor punch to grilled chicken. Throw chopped onions and/or garlic into the dish. Try marinating chicken and meats in citrus juice and citrus zest. Finally, try using a touch of flavored vinegar to dial up the taste factor of your meal.