Archive for salt
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The salt debate continues to rage and found its way to the pages of the New York Times today. However, if you are a regular reader of this blog you were informed well ahead of the curve with my timely article published in a recent issue of Pacific Standard Magazine. And not only are our readers forewarned, because of the data provided in the articles they are forearmed as well. However, critics would argue that the substantiation for the benefits of sodium restriction can be made evident in extreme cases like treating acutely decompensated congestive heart failure (ADHF). For decades, for reasons covered in my aforementioned article, sodium restriction along with fluid restriction to alleviate the volume overload state associated with ADHF has been a cornerstone-and an unquestionable common sense approach-of therapy.
Yet like many commonsense sodium reduction strategies, when put to the test the strategies fail to demonstrate any benefit. Some previous information had suggested that in ADHF patients there was no benefit to rigorous sodium and fluid restriction. Despite the near universal practice of this commonly accepted traditional therapeutic approach, a randomized trial was performed at centers in Brazil and Portugal1. Although the study was small in terms of absolute numbers involving only about 75 patients, the results were dramatic. Half the patients were allowed a normal fluid intake (≥2.5 L per day) and sodium intake (3-5 g per day) and half were restricted to 0.8 L per day of fluid and 0.8 g per day of sodium. There was no clinical difference in outcomes. However, the patients subjected to the treatment arm of fluid and sodium restriction were made quite a bit more miserable. It seems by restricting their fluid and sodium they were made miserably thirsty the entire time. At least the trial demonstrated this bit of common sense bore out under intense scientific scrutiny.
1Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure: A randomized clinical trial. JAMA Intern Med 2013; DOI:10.1001/jamainternmed.2013.552
Confused about all the recommendations for salt?
Read Dr. Mike’s definitive article published in the highly esteemed and respected: Pacific Standard Magazine
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It’s a pirate’s life for me. Surf, sun, sea and salt; especially when my salt tablet is topped with whisky cured salmon. We may not live by bread alone, but bread and this salmon mixed with shallot, parsley, lemon juice, tomatoes and capers-along with a proper gulper- well, yea that just about does it.
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You heard it here first months ago. We reported on the questionable link between sodium reduction and cardiovascular health benefits thusly derived. Leading authorities like Dr. Yusef from McMaster University have examined all the data and find the link weak and inconclusive. Several recent studies (reported on here) have even suggested a possible detriment to very low sodium diets. Now another meta-analysis examining 167 smaller studies draws similar conclusions.For example, in Caucasian persons without hypertension, sodium restriction reduces blood pressure less than 1%. However, their total cholesterol and triglyceride levels rose by 2.5 and 7 percent, respectively. Extrapolating the data, this could lead to a detrimental outcome.
The study author, Niels Graudal of Copenhagen University Hospital in Denmark, concludes that “I can’t really see, if you look at the total evidence, that there is any reason to believe there is a net benefit of decreasing sodium intake in the general population.” The critics argue that long term effects were not adequately assessed in the many small trials examined here. However, other studies have examined longer the effects over the longer term and have failed to show a benefit from reduction. This is because the hypothesis is based on the following supposition:
Increased sodium intake→Increased blood pressure→ Increased cardiovascular risk.
We know that in general, increased blood pressure→ increased cardiovascular risk. Hypertension is a risk factor for stroke and other cardiovascular morbidity. Therefore the hypothesis, if indeed correct and sodium is causative in nature of
cardiovascular risk, would result in a decrease of cardiovascular events with a decrease in sodium. This is what has not been what has been seen in study after study. We do not know that by reducing “A” we reduce “C” in the equation.
As reported here earlier, what is suggestive is data from the recent Nurses’ Health Study that suggests it is the sodium/potassium ratio, not the absolute amount of sodium that correlates with cardiovascular risk. While that needs more verification, this information along with the current data it intimates that we do not have a complete and cogent understanding of the role of dietary sodium intake and cardiovascular risk. What is interesting is the investment many organizations and the government have in reducing sodium. In the United States, a sodium reduction is part of the “Million Hearts” Initiative sponsored by both professional organizations and the US government. It is funded in part (with millions of dollars) by the Affordable Care Act under the preventative health care section of the law. It is not the goals of reducing myocardial infarction that are at issue (that is a noble and justifiable pursuit). What is worrisome is the pursuit of public health benefits and public expenditure of critical health care dollars for an attractive, yet unsubstantiated, hypothesis.
 (Grauda, Hubeck-Graudal, & Jurgens, 2011)
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For many a year I have preached the Grassroots Gourmet Gospel about eating fresh and avoiding adulterated products through following The Path of The Three“Be’s”:
- Be Aware and Avoid the call of the Junk Food/Fast Food Siren
- Be Fresh-But No Adultery!
- Be On Time and In Proportion
Yet, many people are still unaware that this goes beyond simply avoiding fast food or junk food. Simply because something is purchased at a supermarket does not mean it is free from prior manipulation. The act of altering our foodstuffs by adding or subtracting compounds and/or altering the form of the food by cooking, irradiating or freezing has some effects. Some, perhaps the vast majority, of these effects are negligible. Perhaps some only have significance with long cumulative exposure or critical combination. Perhaps others are altered, for better or worse, by a tincture of time. Other effects may only manifest in the setting of susceptible genetics or physiology. These are the great unknowns regarding the Law of Unintended Consequences. What is clear is that the variables and thus the result operate in equations much more complex than simple addition and subtraction.
And it is also an oversimplification to label groups of foods as simply good or bad. Red meat, as a group, contains the entire gamut of possibilities. There are fresh lean game cuts and grass fed free range beef steaks. AT the other end there are industrialized geometrically symmetrically processed patties with a list of additives longer than Keith Richards’ toxicology report. As chef and an interventional cardiologist I am often asked my opinion about red meat consumption. So I shall opine: as but one in long lineage of omnivores, to put it quite simply, I love my meatses. And I love my meatses fresh. Although my choices are driven by my taste buds and several million years of evolutionary hardwiring I find adjudication within the confines of medical science. As an example several recent studies, including a meta-analysis comprising over a million participants worldwide performed by Harvard, have failed to demonstrate a correlation between consumption of fresh red meat and increased cardiovascular risk[i],[ii],[iii],[iv],[v]. However, there did appear to be increased cardiovascular risk and an increased risk of developing diabetes when highly processed meat products were regularly consumed.
Why? How? Is there a difference? Isn’t eating any red meat the cardiovascular equivalent of launching an atherosclerotic drone into your coronary artery? The answer is there appear to be major differences and it’s time we moved beyond bovine bigotry by regarding all red meat as a single class of foodstuffs. It’s like lumping a Yugo and a Ferrari together as “cars” and being confused at the quarter mile time trial results.
Consistent with the previous data examining cardiovascular risk and the consumption of fresh red meat, the largest study to date examining red meat consumption and stroke risk was recently published[vi]. Over 40,000 Swedish men aged 45-79 were followed by questionnaire for over a ten year period. The researchers found that consumption “of processed meat, but not of fresh red meat, was positively associated with risk of stroke.” The increased risk was over twenty percent. Dr. Robert Eckel, a Professor of Medicine at The University of Colorado and a past President of The American Heart Association also noted that the group with the highest intake of processed meat in the Swedish study also had a healthier diet overall, including more fruit, vegetables, and whole grains. He commented that this “suggests that the effects of processed meat may confound the benefit of a heart-healthy diet.”
This study follows on the heels of a very large and interesting study demonstrating the increased cardiovascular risk when the dietary ratio of sodium (often referred to as “salt intake”) to potassium is greater than one. This may explain why previous studies have failed to definitively link increased absolute amounts of sodium to cardiovascular morbidity and mortality. The effect may lie in a ratio, not absolutes. The processing of a piece of fresh pork, with sodium to potassium ratio less than one, to produce a slice of ham (even low-fat ham) inverts that ratio. The causative possibilities are intriguing, but the important question remains.
Where’s the beef?
It should be back on the menu-but only if you keep it fresh!
[i] (Micha, Wallace, & Mozaffarian, 2010)
[ii] (Siri-Tarino, Sun, Hu, & Krauss, 2010)
[iii] (Micha & Mozaffarian, Saturated fat and cardiometabolic risk factors, coronary heart disease, stroke, and diabetes: a fresh look at the evidence, 2010)
[iv] (Siri-Tarino P. , Sun, Hu, & Krauss, 2010)
[v] (Siri-Tarino P. , Sun, Hu, & Krauss, Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease, 2010)
[vi] (Larsson, Virtamo, & Wolk, 2011)
Recently there has been a lot of press about the role of salt, or sodium, as a risk factor for the development cardiovascular disease and subsequent events. A recent meta-analysis looked at salt intake and found that higher levels of salt intake were associated with a modest increase in blood pressure. This increase did lead to an increase in the absolute number of cardiovascular events, but this did not reach statistical significance. This follows on the heels of another study that examined normotensive (those without hypertension) individuals and found that the highest mortality risk was in the group with the lowest sodium intake, as measured by sodium excretion. These findings have reignited the debate of the role of sodium in the development of heart disease and levels of appropriate sodium intake; even as the new guidelines call for the consumption of lower amounts.
What do we know? The data seem clear that increasing levels of salt, or sodium, are associated with increases in blood pressure and contributes to or worsens hypertension. Hypertension is a risk factor for the development of cardiovascular disease and a potent risk factor for stroke risk. Treating underlying hypertension has been demonstrated to reduce both cardiovascular and stroke risk. The operative hypothesis to this point has been that the communicative property applies here: that reducing salt intake would reduce the blood pressure and thus translate into a reduction in cardiovascular risk. Unfortunately, as Dr. Yusuf, DPhil from McMaster University and a cardiovascular expert on meta-analysis notes the direct evidence linking high dietary salt consumption and cardiovascular disease is “weak and inconsistent.” We also know that in the body, sodium exists in a ratio related balance with potassium. Potassium is another element necessary for proper bodily functioning and is especially important from a cardiovascular perspective.
A recent study published in the Archives of Internal Medicine sheds some new light into the reason why we have seen these apparently contradictory results (Yang, Liu, & Kuklina, 2011). As one of the study investigators, Dr. Kuklina, notes, “This is the first large, nationwide study where we followed a pretty big cohort of people and looked at sodium and potassium at the same time.” The examined over 12,000 people for all cause and cardiovascular risk as part of the Third National Health and Nutritional Examination Survey (NHANES III). What they found over a 15 year period was that the highest risk group had a very high ratio of sodium to potassium in their diet. Previous analytic concentration focusing on only half the equation would explain the dichotomous findings over the years. As sodium increased, risk increased about 20% for every 1000mg/day. However, for every 1000mg/day increase in potassium, the risk decreased about 20%. Thus, based on these findings what is of paramount import is maintaining a sodium/potassium ratio less than 1.
What does this mean? It means even more evidence to be following our Grassroots Gourmet™ principles. Firstly, Fast/Junk food is often loaded with sodium, which is why we strive to be aware and avoid the call of the junk food fast food siren. Second we want to be fresh-but no adultery! Over 75% of our intake of sodium each day is derived from pre-packaged, processed and prepared food. When using sodium to season and create a perfectly balanced and delicious meal, we add only about 5% of what is our daily intake. Not only that, but processing adulterates and alters the composition of our food in a potentially detrimental way. As noted by the study authors, a 100g (about 3 ½ ounces) serving of natural wholesome fresh pork contains roughly 60 mg of sodium and about 340mg of potassium. But if you industrially process that into the average deli ham you end up with 920mg of sodium and only 240mg of potassium. Avoiding fast food and preprocessed adulterated food will help reduce sodium intake. Consuming foods rich in potassium such as fruit (apricots, bananas, avocados, tomatoes, cantaloupes and oranges for example), vegetables (like beets, brussel sprouts, lima beans, winter squash, potatoes and spinach) and legumes like peanuts as well as yogurt will contribute to increasing potassium intake. As with all things in Nature, it’s about the balance.