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Testing salt reduction on a really large scale

Microwaved platter of low-sodium tofu with snow peas

This tofu dish with snow peas and shiitake mushrooms uses low-sodium dipping sauce ingredients as its base rather than soy sauce or oyster sauce. It’s also microwaveable from start to finish and takes about 10 minutes total.

If you have a big enough–and motivated–study population, even modest reductions in daily sodium intake can make a big difference in preventing strokes and heart attacks. Last month, cardiovascular researchers from Beijing and Sydney announced a new 5-year diet trial in Science to do just that (see the general overview article, “China tries to kick its salt habit”).

China’s northern rural poor eat an estimated 12 grams of salt a day on average, considerably more than Americans’ 9 grams a day (which is still over the top) and more than twice the WHO’s recommended 5 grams or less. An estimated 54%, more than half, of Chinese adults over 45 have high blood pressure these days, and the Chinese government is taking practical steps to provide antihypertensive medications and shift the tide back–but that’s an awful lot of prescriptions.

Given the cost of antihypertensive drugs for such a huge population, and the cost of dealing with side effects and consequences of untreated or undertreated high blood pressure, prevention seems the better way to go. The researchers project that reducing the national average by even 1 gram of salt a day would save 125,000 lives a year in China. So they’ve recruited 21,000 villagers so far in China and Tibet, and plan to provide test groups with nutrition counseling plus a lower-sodium salt substitute for cooking, then compare their sodium intakes and rates of heart attack and stroke with those for a control group.

Most Chinese still do their own cooking at home, especially outside the big cities.  If lowering the sodium content of the salt they use works, it has the potential to get an awful lot of people off daily hypertension medication and reverse a major health threat. But will people do it if they’re not in the trial, or once it ends? Will it catch on? And is it the right answer in the long run?

Salt substitutes, with potassium chloride replacing some of the usual sodium chloride, have been tried by heart patients in the US since the 1970s or so. They’re a little more expensive than table salt or kosher flake salt, at least in the US, but they’re not all that expensive. But they’ve never really caught on here with most consumers.

Similarly, a few decades ago, a big public health campaign in Japan to reduce the high rate of stroke led to the introduction of low-sodium soy sauces, with about half the sodium content per tablespoon of traditional ones.

Not much market research is available on how many people have been buying low-sodium vs. regular soy sauce in Japan since its introduction. From the few current market reports I could find–one of them an executive report from Kikkoman–it looks like low-sodium is still a smaller if steady fraction of their business in Japan, and that it’s more popular in Europe and the US than at home.

It’s important to have a low-sodium line for reasons of corporate responsibility and even prestige, but there was no mention of its percentage of total domestic or worldwide sales. Traditional soy sauces, which can range from 14-18% sodium concentration w/v, are still apparently preferred for taste, and the Kikkoman executives attribute much of their expected taste appeal to salt rather than the other flavors in each one’s profile.

That’s kind of discouraging to me. The Japanese are known for more refined and sensitive palates on average than Americans, and their range of soy sauces and tamaris for specific food combinations is much broader and more sophisticated. The higher-quality low-sodium soy sauces are produced by ion filtration to get sodium out rather than simply diluting them with water, so most of the flavor that’s actually flavor remains. I would have hoped the key flavor signature of each match was the actual flavor of the brewed soy sauces, not the saltiness.

It’s likely, though, that the Japanese are just as susceptible as the rest of the world to the sodium tolerance phenomenon–the more sodium you eat habitually each day, the more you expect and consider normal in your food, and you almost stop even noticing it as a separate flavor.

The overall Chinese market for soy sauce is currently estimated at $20 billion and grew about 23.4 percent over the past 5 years, mostly due to population growth. The stakes are pretty high for China, but the government has tighter control of its salt and soy sauce producers than other countries do, and the will to make a broad change seems to be present, at least at a government level, and if the new study is anything to go by, among ordinary villagers as well. So maybe this time it will catch on once the study’s over.

But obviously, if you’re starting out at a 12-gram-a-day salt habit, the best way to reduce sodium in home-cooked food would be to cut back hard on salt and salted items altogether. That takes time, practice, awareness and deciding that it’s worth going through that first couple of weeks until your palate readjusts to a lower-sodium diet (which it will, but it takes a couple of weeks and a little patience).

Can cutting the salt be done with Chinese food? Not American souped-up chain restaurant caricatures of Chinese dishes, which are hideously over-the-top and greasy as well, but actual home cooking? I’ve done low-sodium Continue reading

Questionable sodium study, even more questionable comments

A new European study that purportedly shows low-sodium diets to be ineffective in preventing high blood pressure, and even more unlikely, that they increase the risk of death from heart attack or stroke, is being published in the May 4 issue of JAMA, and predictably it’s already excited a variety of comments in Gina Kolata’s current New York Times article from the CDC and from…Dr. Michael Alderman.

Predictably, because the CDC researchers think too few people were studied for too short a time with unreliable methods (24-hour urine collection to measure sodium intake indirectly, after the fact as it were.)

Alderman’s reaction was also predictable: he’s still insisting that only a nation-wide feeding study sort of clinical trial that follows its subjects until they die is sufficient to prove a true link between sodium intake and cardiovascular disease. Something so expensive and unwieldy it couldn’t be completed even if it were started, and we’d still be waiting around 30 years later wondering if salt had anything to do with heart attacks or strokes. Very convenient for the processed food industry, but pretty useless for public health. And also conveniently, Gina Kolata found more than one expert to say so.

What she didn’t find, but could have, is that a number of large-scale feeding studies have already been done and shown that eating a balanced lower-sodium diet helps reduce blood pressure and prevent blood pressure increases. DASH-Sodium is one of them. And no one had to wait until the study subjects died to figure it out.

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