Salt

welcome 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 humps i'm aubrey gordon if you would like to support the show you can do that at patreon.com slash maintenance you can also subscribe through apple podcast it's the same audio content same stuff aubrey we're talking about salt today mike this was like the anxiety around diet growing up 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 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 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 of 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 to reduce your salt as much as possible to reduce 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 all together 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 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 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 decide to add to your food right we're talking much less about individual decisions and sort of police 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 so i am policing 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 we're going to say we need to do a taste test where we each just eat us a teaspoon of salt don't you think that's a really good idea get your salt shaker how does it taste delicious let's both get grounded here and just eat a bunch of stuff just the sound of me puking in the background so question number one michael the who maintains a ranking of estimated sodium consumption across over 150 nations 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 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 country 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 to 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 kombat 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 teaspoon 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 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 teaspoon 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 wow okay considerably more right like almost 50 percent more sodium yeah a teaspoon of marmite has 340 milligrams of sodium wait what one-tenth almost one-tenth the amount of soy sauce was i the wrongest it's possible to be without like the lowest one 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 2 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 i'm putty in your hands i've been puppeteered so the last question that i have for you for our salt pop quiz 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 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 foot-long chili cheese dog c bob evans steakhouse salad d outback steakhouse's bloomin 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 is 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 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 is the dressing right absolutely 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 interesting 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 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 it from food that taste salty if we're not getting it from foods that taste salty but we are from like a salad where the 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 things 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 before saline is often added generously to meat before it is sold okay meat with more moisture it is sold okay meat with more moisture weighs more right and meat is sold by the pound so it's 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 of the Center for Science and 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, and 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. 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 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. Serving 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 all. 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 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 about 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. Cutting 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 Huangdi Neijing, 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. The first mention that we see of like relating salt to your blood pressure 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 sample 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 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. OK. Kempner believed that salt was a, quote unquote, waste byproduct of the kidney. OK. 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 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 2000 calories, which is not as unhinged as we get. And it's pretty normal. Yeah. It had a maximum of five grams of fat. Oh, yeah. OK. One chicken thigh has more than five grams of fat. Right. OK. It had a maximum of 20 grams of protein. It had a maximum. 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 their last names was rice. No, it's a guy and a food. Kempner rice. So you're just eating unsalted fucking rice like three meals a day? Unlimited rice and 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 has over 150 milligrams. 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. 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. Yeah, miserable. Part of what you're. 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 who did experience. The people who 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. The only 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 American researchers. Observed an increase in high blood pressure in those rats and chickens during those 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 variance in blood pressure response to salt intake. Humans do. And 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. Like 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. intake should be cut down from that. 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 early French research and we've got a number of animal studies. So 1969 is the point at which the 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 as a strategy worth pursuing. And there's certainly nothing outperforming sodium reduction as a treatment strategy for hypertension. 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. But. Both of those include broad recommendations to 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 fifteen hundred and twenty three hundred 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. But that's when large scale human studies start to roll out and that's when the so-called salt wars begin. 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 is a huge landmark study in the early 1990s. I know. There is a huge landmark study in the early 1970s. There is a huge landmark study in the early 1980s called inter-salt. 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 many times on the show. That's like generally unreliable, but it's especially unreliable given how much people misunderstand where salt is. There are different ways to measure salt intake. hypertension, putting the real world adherence to a low 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 she said the name of the like pretty clearly the dash diet is designed to be followed for life 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 whereas the adherence to the dash diet it feels like it's more like you don't even know what you're supposed to do 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 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 yeah i think it was like an anthony baconator bourdain episode where he mentioned kind of offhand that restaurant mashed potatoes are typically 50 butter that's the jean george ratio 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 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 research because 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 normatensive people people who don't have hypertension normatensive 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 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 do you know i'm normatensive you've changed among other things we learned 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 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 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 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 no giving people food in this very structured way is a very structured way it's a very structured way it's 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 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 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 cholesterol 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 and we talked about 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 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 and then those researchers run analysis highly problematic methodology but there's not a lot of other data 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 n haynes 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 oh interesting but these are boomers they're not doing it it's actually less relevant about sort of findings 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 asian americans as we've noted before soy sauce is really high in sodium 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 fucking hard to do these studies that's exactly right that's the whole point mike is it's so fucking hard to do 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 uh as much a factor your like socioeconomic status your educational attainment it's not possible for us to isolate okay when we're only looking at salt in someone's gut 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 it's my community those studies find that there may be an association with very very low sodium diets and increased mortality okay those studies are not very large and in a place like the u.s. most of 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 and we're not even talking about salt anymore we're not even talking about salt anymore 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 and 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 you should think about reducing your salt but if you don't have hypertension you don't really need to worry about it right right and if you do have hypertension even if you're super motivated your adherence is going to be low because it's not really possible for you right 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 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 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 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 political 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 sp 1070 uh better known as arizona's show me the money 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 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 staffers uh someone named morton satin which i think is very funny morton that 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 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 right nearly every time a finding came out that suggested unlimited salt might not be a great choice for everyone the salt institute staffers are the ones who are the ones who are the ones who are the ones who are 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 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 they 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 one 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 just 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 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 yes so i'm part of the problem so while this debate 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 campbell's did a big rollout being like we're cutting our sodium by 40 percent yeah people had such a negative reaction to it that campbell 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 increase 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 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 not 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 because they're 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 association 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 they want to seem like a health conscious person but even if they're just saying it there is some sense of like well their 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 that between 2000 and 2014 americans food purchases reflected a 12 percent drop in dietary sodium okay buying food and eating food are different things of course but if those sales data are different then it's a different thing so i think it's a different thing i think it's a to translate into dietary changes that would be a 400 milligram drop in sodium intake which is really significant that's like 40 percent 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 national 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 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 about 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's 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 could 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 their blood pressure at home yeah new treatments have entered the market the first ace in 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 Jardiance and Farcega. 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 have the same absolutely brutal adherence rates, right? Like a lot of people can take a pill once a day. The biggest barrier there is how fucking expensive they are. 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. We've just gotten better at talking about a bunch of facets of it. 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. God. 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's really fucking hard to do that. And there's more effective treatments. Yeah. It's not like stop using light salad dressing. It's like take a statin. Yeah, I think that's right. And also the take a statin stuff is like more effective 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 Right. Two 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? 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, the food system 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 going to take a 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. Bye.