Goodbye to all that salt
Before my current post, I worked at an institution where quite a few of the students were ‘clean eaters’. I joined the institution fairly early on in the trend. I was both impressed and appalled at the self-control needed to maintain not only a vegan diet, but one which excluded anything that tasted good. The students admittedly looked very healthy, but it didn’t seem great fun. The occasional juicy burger (meaty or veggie) surely wouldn’t go amiss, I thought.
A few years later, there was some backlash against clean eating, termed ‘orthorexia’ if taken to extremes. I was hardly susceptible myself — I wasn’t in the target age group — but was intrigued that they were choosing this identity.
With my own diet, I focused on controlling blood sugar, by trying to eat more protein, salad and vegetables — seasoned and beautifully dressed to make them palatable. My main weaknesses were three cups of builder’s tea a day, and Kettle Chips at weekends.
But crisps aside, I thought this was a good diet — assuming that it was the foods themselves and not the added salt that determined whether diet was bad or good. It was pretty DASH-y —namely ‘[a diet based on] fruits, vegetables, and low-fat dairy products, that includes whole grains, poultry, fish, and nuts, that contains only small amounts of red meat, sweets, and sugar-containing beverages, and that contains decreased amounts of total and saturated fat and cholesterol’ (Sacks et al 2001).
But over the last year or two I began to get recurrent headaches, feel very very tired, and struggle with concentration and memory. This all seemed in line with post-pandemic life for people my age juggling children and a horrible commute.
However, my blood pressure readings began to be ‘a bit high’ systematically rather than occasionally. So last month I was given an ambulatory BP monitor — and 24 hours later learned that I was firmly in the red zone.
The GP who rang to discuss the results said that the protocol is a set of checks, followed by medication to reduce blood pressure. She also said — gently — that eating less salt and exercising more was all very well, but that for most people with hypertension, lifestyle modification would not be enough.
I understood. Equally, since the tests will take a few weeks, I thought it was worth trying in the meantime.
I looked at the advice: cut your salt, caffeine, alcohol, stress levels and physical inactivity. I also learned that nearly half of American adults have hypertension (MSD Manual 2022), as do about a quarter of adults in the UK (NHS 2023). Moreover, 90 percent of Americans two years old and over eat too much sodium. In the UK, the average adult consumes 8.4g of salt a day, well above the national target of 6g a day (which is, in turn, above the WHO target of 5g a day).
The children, horrible commute and stress levels would be hard to solve. Salt intake and caffeine could be changed — though this meant losing some of my favourite things!
One compromise has been to keep one proper cup of tea each morning. It tastes even better because of the guilt.
That left salt. I love salty foods, and often added further salt when baking occasional cakes or flapjacks, long before the rise and rise of salted caramel. But I realised I’d been foolish once I’d sat down to look at Google Scholar.
It turns out an estimated 30–50 percent of those with high blood pressure (the hypertensive) and one-quarter of the normotensive are ‘salt-sensitive’, with an abnormal kidney reaction to salt intake (Balafa and Kalaitzidis 2021). Other people are salt-resistant, if not immune to the effects of excess sodium. But this means that excess sodium intake affects a significant minority much more than it affects others.
The relationship between excess sodium intake and hypertension also appears to be causal. In 2021, He et al published results from a large feeding study of Chinese adults, where participants first complied with a high-salt diet, then a low-salt diet. The authors demonstrated that excess sodium intake was a cause rather than consequence of hypertension. Kurtz et al (2022) suggest that high-salt diets cause about a third of cases of hypertension.
Excess sodium also damages cardiovascular health directly besides its effect on blood pressure (Cook et al 2007). Moreover, it is associated with further drivers of hypertension and/or cardiovascular disease, such as insulin resistance (Ertuglu et al 2023), metabolic syndrome (Takase et al 2020) and stress (Costello et al 2023).
Some papers can be found that question whether the problem is the excess sodium or the foods themselves. However, a randomised controlled trial run in the 1990s found that both a DASH diet and reduced sodium intake lower blood pressure significantly — and the effects are greater if done in combination rather than singly (Sacks et al 2001).
One review of nine studies on the benefits of cutting salt intake among those with heart failure suggests that the benefits are uncertain. However, we shouldn’t infer from that that cutting salt intake has no effect on the population at large: sodium intake might possibly have different effects on those who already have very poor cardiovascular health. (Some researchers also argue that the causal claims for excess sodium intake are overstated, though we should look carefully at why they may choose to interpret the extant literature in this way.)
There are therefore multiple direct and indirect mechanisms linking excess sodium to ill health. This makes explaining why excess sodium is usually bad for people more complicated. But they are clearly there.
I also realised that I had a blind spot about excess sodium intake. A single tortilla accounts for 10 percent of a recommended daily allowance. And all shop-bought bread and pastries will be quite salty. I bought a ham-and-cheese wholemeal sandwich for my little girl — for the protein— before reading the nutritional summary and seeing it had more than 50 percent of an adult’s RDA of salt. Ingredients that I depended on heavily, such as soy sauce and fish sauce, can include 20 grams of salt per 100ml of fluid.
So, I am now preparing almost all my food at home. This takes time and is boring — I’ve been cooking double portions and freezing leftovers to minimise this. It’s my own hugely-inefficient production line, for a tiny market.
I use a lot of vinegar, lemon juice, ginger, garlic and chilli to try and whack flavour into bowls of vegetables and brown rice. Porridge — ‘Mayo Weetabix’ — has replaced breakfast cereals. Porridge will never be as great as it used to be in the days when I added a pinch of salt, but toasted seeds, nuts and dried coconut give it crunch.
Cheese is difficult to give up, so I now use it sparingly as a seasoning: salt wrapped in dairy. I don’t like unsalted butter, and have tried baking bread without the usual salt, but found it is nearly tasteless. It is easier to just cut it out. Bacon, sausage and cured meats are completely out, as are shop-bought or restaurant pizzas.
To be honest, I haven’t found that cooking from scratch has opened up a world of healthier food which is even more delicious. It is simply healthier. Further, enhancing flavour when cooking without salt often depends on cooking slowly to concentrate flavours. This takes a lot of simmering, which means using more gas.
But — I’ve now adjusted and the trade is worthwhile. I’ve also found that it’s not so easy to eat a lot of carbohydrate without salt, which perhaps helps with controlling blood sugar — I feel less jittery after eating. And it seems that people are satisfied more quickly when eating unsalted dietary fats than salted.
What I have learned over the past month:
- Salt labelling is extremely helpful, and measures undertaken by the food industry to cut salt have generally worked well — showing that the industry is a large part of the solution. The World Health Organization published The SHAKE Technical Package for Salt Reduction in 2016, citing the UK as providing a successful example of how to reduce salt intake (WHO 2016, p. 29 — see below). But while reduction from 9.5g of salt intake a day in 2004 to 8.1g by 2016 saved thousands of lives, there is still some way to go before the WHO’s recommended daily limit of 5g a day is met.
2. Awareness about the risks of excessive salt intake is too low. People are generally aware that excess calories, sugar and fat intake is bad for health. But the thing that makes the sugar and fat taste so good in combination is the white stuff.
The thing that frustrates me is that I knew that I was at particular risk for cardiovascular disease, because I was of very low birth weight. I was also motivated to protect my long-term health. But I didn’t know that a large minority of people are salt-sensitive, or that excess sodium tends to damage cardiovascular health directly, in addition to increasing blood pressure. Perhaps I didn’t really want to know, because I liked salty foods — Emma Beddington described this refusal-to-know very well a couple of weeks ago in The Guardian. Whatever the reason, my understanding of the risks was completely off.
3. It is difficult to manage salt reduction at an individual level. As the British Heart Foundation has put it, ‘reducing our salt consumption is not solely a matter of personal responsibility, but instead relies on reducing the high salt content the food industry puts in many foods’. The most feasible meal choices — bought from grocery retailers, fast food outlets or restaurants — have been seasoned, or taste much better if seasoned. It is very difficult to find unsalted meal options at the cafeteria at work, or at cafes near work, or train station shops and takeaways. I’m lucky to have a freezer that can store leftovers. But most people are pressed for time, and lack the space and facilities to batch-cook. So systems need to keep changing to make further salt reduction feasible for the whole of society. Otherwise, the salt-sensitive with the least time and money bear the brunt of the food system we share.
We think of our diets as being very varied compared with those in the past. But at another level, we have little choice to avoid processed foods. We need to de-bias the supply of meal options away from being so heavily salted, in the interests of public health.
4. Public communication of the risks of excess salt intake, based on the evidence, needs expanding. It seems plausible that core messaging is impeded by the messaging of industry-supported communicators — and also by purveyors of wellness. When trying to find personal accounts of cutting salt, I did a Google Search on ‘“cutting salt” + lifestyle blog’ and results 3, 6, 8 and 9 all questioned the value of cutting salt.
By comparison, the information on the NHS advice pages is good. But the pages themselves feel a little utilitarian. Who is going to say ‘oh good — this is an easy one. Let’s swap breadsticks and Kettle Chips for celery sticks’?
Emotional content takes resourcing — video, beautiful imagery, compelling communicators, targeting of message, and production in formats that make it easy to share. I have no eye for design, but I could imagine the above NHS advice being made more attention-grabbing and persuasive by skilled communicators. Perhaps pro bono communicators adapting such content could be rewarded in other ways.
It’s also difficult for frontline health professionals if the answer for most patients is not something they can practically put into action. A GP can’t say ‘get a flexible job where you have about two hours spare throughout the day to prepare food — oh, and by the way, I find that weekly veg delivery boxes are really useful’. The problem of excess salt cannot be solved by ‘better choices’ if better choices are out of reach.
For me: so far, so good. Within two weeks, my blood pressure began to edge into the green area. I also feel much better. While high blood pressure is often symptomless, the difference between high and near-normal feels clear to me, perhaps because it’s happened quite quickly.
It might be that this is mostly a placebo effect, or a coincidence. But in terms of single health changes I’ve ever made, it seems to have made the largest and quickest improvement to how I feel — certainly more than exercise. So it seems reasonable to bet that I’m one of the salt-sensitive, and to keep going with this.
Many of the clean eaters may well have been overly restrictive with their eating. But at least some may have been speaking authentically when they said they felt better on their extreme diet. I’ve realised that ‘normal food’ is bad for health for a significant proportion of us. And that while it’s a real effort to prepare everything from scratch, it may be an important and necessary investment — one which can have a surprisingly quick pay-off. The real win would be for ‘normal food’ to be low in salt as a rule, so that a healthy diet is within everybody’s grasp.
