Salt

Welcome to Manus Phase. The podcast, wait, why can't I do this? (laughing) Oh yeah, welcome to Manus Phase.

The podcast that will finally make an episode

that other people will call salty. ♪ There we go ♪ ♪ See ♪ ♪ You did it ♪ Okay, it's like six out of ten.

We're doing the episodium. I'm Michael Hoops. I'm Aubrey Gordon. If you would like to support the show, you can do that at patreon.com/meansface.

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.

Yep, 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. He's sorry mom. So 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

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 altogether 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? Does it kind of fall and 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 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. So we're talking about like a vanishingly small amount

of the salt is what you decide to add to your food.

We're talking much less about individual decisions

and sort of policing 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. You don't really think about is consuming salt.

So I am pleasing 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 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 gonna do that is assault quiz. - Okay. I think we're gonna say we need to do a taste test. - We'll be each just eat a teaspoon of salt. - Do your salt checker, how does it taste?

- Fucking delicious. - Let's both get grounded here. I just eat a bunch of salt. Just the sound of me puking in the background. - So question number one, Michael.

- I'm right. - 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, then what is the WHO recommendation in teaspoons? - 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 combat. - Okay, finish him. - Which of these has the most salt? We're gonna do one teaspoon of each of these things.

And which one do you think has the least salt? - Okay. - Questions 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 fucking 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? - You're very wrong. - Okay. - Marmite contains less sodium than a teaspoon of salt. - Really, it's so salty though, on my mouth.

- So here's the story. One teaspoon of salt contains 2,300 milligrams of sodium. A teaspoon of soy sauce has 3000 milligrams of sodium. - Wow. - So considerably more, right?

Like almost 50% more sodium. - Yeah. - A teaspoon of marmite has 340 milligrams of sodium. - Wait, what? - One tenth? - Almost 1/10th the amount of soy sauce.

- With either wrongest, it's possible to be, without like the lowest one. - No, we're 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 1 teaspoon. - Wait, 2,525. - 25? - 2,5.

“- But it takes us all the debris, what's happening?”

What's going on? - Great, 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 wrong.

- Wait, I did exactly the thing. I did exactly the concept that you wanted to illustrate. - Yeah. - I'm putting your hands, I've been puppeteered. - So the last question that I have for you

for our salt pop quiz. - Is this so fun? - Are you enjoying it? - This is so fun. - Which of the following is the highest sodium dish

at an American chain restaurant? - Ooh, okay. - Hey, the Wendy's triple baconator. That's three beef patties and six strips of bacon. - I gotta go to Wendy's more, okay.

(laughing) - B, long John Silver's foot, long chili cheese dog. C, Bob Evans, steakhouse salad. D, outback steakhouse's blooming onion. Or E, the cheesecake factories chicken and broccoli pasta.

- Well, with these questions,

the surprising answer is always the correct answer.

- The contrary. - So you shouldn't be thinking about what is correct.

“You should be thinking about what the surprising answer”

is. - You should be. - And I hacked my brain and I don't have brain. - The most surprising answer would be one of the salads. Or probably the Bob Mackey salad, whatever the.

(laughing) - The Bob Fossie. - I've never heard of this restaurant, but okay. - Bob Evans, steakhouse salad is number one. - Okay.

- 7,700 milligrams of sodium in a salad. - Three times your daily recommended in a salad. - Correct. - Is lettuce like secret, really, really salty? - No salad dressing right?

- It's the dressing right? - Absolutely. - The lowest sodium of those is the triple baconator. - Wait, really? - Yep.

- Okay. - Okay. - That one's just shy of 1,800 milligrams of sodium. - Right, 'cause I heard recently that just because things taste salty doesn't mean that they're high

and so the only interesting one I heard of. - 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 super high levels of sodium from the baconator, but we are from like a salad. - Where the fuck 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 palletability, right? The big one is that salt is overwhelmingly used as a preservative.

- Right. - Cured foods, especially things like locks, bacon, ham, prosciutto, salami, really high and sodium, pickled foods. - Oh yeah.

- Are pickled with a mixture of salt and sugar, so they have quite a bit of both. Can't 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 it is sold. - Okay. - Meat with more moisture, weighs more.

- Right. - And meat is sold by the pound. So it's a way to make more money

So I'm gonna 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 in the Public Interest. According to the USDA, 21% of beef, 78% of chicken and 57% of pork is booked 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 hated 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 of water on them. I want them shriveled as God intended. - Do you know how much water a bucket head of broccoli will soak up? I'm like shaking it out at the store,

as if, as I'm like opening a sugar packet, I'm like, you're a cheat-skate tendency. It's really, our battle bless. - I'm a man of 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, booze on the street,

they will sell like hot dogs and like french fries and stuff. And they call it mistake away,

'cause 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 shwarma or whatever at the end of the night, it's sort of like at a subconscious level. You're just like, ooh, I want like terrible food.

- Absolutely. - I don't know whether that's here, but I did eat those hot dogs all the time for my help. - The main thing we're gonna 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.

- I guess.

“- 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 a large tart. Presumably then the inverse would be true, that cutting out salt would decrease blood volume and blood pressure. And 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 Wang D. Nayshing, 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." - So that is the first mention that we see of like relating salt to your blood pressure

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, yeah, when you cut down on salt for people who already have high blood pressure, it appears to improve their blood pressure. - I have a little bit of 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.

We're going to do 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. 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. - Okay. - Kempner believed that salt was a quote-unquote waste byproduct of the kidney and that reducing sodium intake

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.

(laughing) - Spoonfuls. - So the diet that Dr. Kempner devised is a fuckin' 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 is pretty normal. - Yeah. - It had a maximum of five grams of fat. - Oh yeah, okay.

“- One chicken thigh has more than five grams of fat, right?”

- Okay. - It had a maximum of 20 grams of protein. - 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. (laughing) Is that one of this?

- It's called the Kempner rice diet. - Oh, it's not named after a researcher named rice. Other than it was like two researchers and one of their last names in rice. - No, it's a guy, I'm a food.

Kempner rice. (laughing) - Jews eating unsalted fuckin' rice like three yells a day. Unlimited rice and unlimited fruit juice.

And you could have white sugar. - That's like most 80s asked diet. I know it's in the 80s but it's like the most 80s asked diet I've ever heard my life.

“- It's 1939 but we're getting a head start on the 80s.”

- Absolutely. - To be clear, that 150 milligrams sodium ceiling is almost impossible to manage. - Right, five stalks of celery has over 150 milligrams of sodium. - No way.

- Two unseasoned eggs has over 150 milligrams of sodium. - No way. - Sodium is a mineral that exists in soil which means it exists in almost every fruit and vegetable.

- Right. - 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%. - Yeah, miserable. - 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 of it 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 improvement, whether a company 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.

Let's start giving everybody the fucking rice to enjoy only rice, nothing else. - We solved it. - There aren't really blood pressure meds on the market at this point.

So the kind of rice diet is one of 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. - 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. (laughing)

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 variants

in blood pressure response to salt intake, humans do. And two, the doses were nuts, so the human equivalent of the dose that these rats got would have been 40 grams of salt per day.

- You're basically preserving yourself, right?

- That's right. - An Iberian ham. - You're a 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 should be cut down from there. That is the data that is available to the U.S. government

when it starts making large-scale nutritional recommendations

We've got the kind of 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 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.

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 1500 and 2,300 milligrams of sodium. The nutritional recommendation is now sort of baked in to the dietary guidelines,

and it becomes almost boilerplate language that just gets carried over and carried over and carried over, right? 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 I'm eating this milk salmon that I haven't fridge.

- I feel like you now understand why I fucking burned

through that jar of Gorgonzola olives. - I don't know. - So there's a huge landmark study in the early '80s called InterSalt. 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

in their diet, right? The other one you can do is you can look at consumer data about how much salt people are buying per capita.

But dietary salt, like culinary salt,

is such a small fraction of salt sales in the U.S. Salt is used in a bunch of like medical equipment and treatments, like you've got to have medical grade saline solution, right? For a bajillion fucking thing, right?

You need salt to D.I.s roads. - Right. - So the gold standard for this kind of stuff are biomarkers, either blood work or urine alicis. And it's like how much sodium I ate in the last 24 hours?

- Or something? - Yeah, it's how much is coming out in your pee. So they're taking urine samples, they're measuring these sodium biomarkers and they're taking folks blood pressure regularly.

Okay, they ran a bunch of controls on the study. They found that across genders, across races, and across nationalities, people who consumed more sodium had higher blood pressure on average. Then people with the same demographics

that consumed less. - Okay. - Inter-salt's results were released in the late 1980s and they made a huge splash. That led to a huge wave of press,

but neither the findings nor the press around them,

“accounted for some really important variables, right?”

One is where the sodium was coming from, which varies pretty widely from one country's food system to the next, right? The other thing that the Inter-salt study didn't account for is what individuals should do

as a result of these findings, right? That's not actually what the study was. It wasn't looking for, hey, what should most people do for their health? It's a descriptive study.

They're just trying to find a phenomenon. - That's right, but it's released in the late 80s, which is exactly when, certainly, the U.S. is like taking off in terms of health conscious behaviors. - Right, so a bunch of people hear this thing

about salt consumption is associated with higher blood pressure and they go, "Uh-huh, gotta take the salt anchor off the table." - Right. - In 1990, Congress passed the nutrition labeling and education act, which is what standardized our food labels

to include, like, X percent of your vitamin C for the day and why percent of your sodium and sodium is included in that labeling requirement. - Yeah. - This is kind of where we start to get the unhinged. I wrote this in my notes before your mom was the example,

but I did write, "This is where we get your unhinged,

Right, the white people took us in a ram following

“inter-salt and the findings of inter-salt,”

a bunch of nations around the world, including the U.S. launched national trials related to sodium and hypertension. In the U.S., ours was the dash study. Dietary approaches to stop hypertension.

Dash was a randomized controlled trial of 459 adult participants that all had elevated blood pressure. So we're once again looking at interventions for hypertension, right? All of the sort of adherence stuff that we've talked about

is a challenge when you're in the wild, so what they've decided to do was be like, "Cool, you're eating two of your three meals a day "at the research center."

- Oh. - And then you're getting a third one

in a cooler to take home with you. - Okay, so it's super prescribed. - Study participants were cycled through three different diets, each four, three weeks at a time. And they also answered a standard battery of questions

about symptoms that they might be having, like the classic, like, back of the head, hypertension, headache, or that kind of thing, right? - Everything, a lot of them just said, "I'm hungry." - I'm so hungry.

- I'm eating these terrible meals. - The last game. - The last game. (laughing) - I've lived it like this for six weeks.

- So the three diets are this. One, there's a controlled diet. It was sort of intended to reflect the standard American diet at the time, right? The fruits and vegetables diet was similar

to the controlled diet, but had just more fruits and vegetables in it, more fiber. And then the dash diet, which centered around fruits, vegetables, and low fat dairy. - Okay.

- That diet was high in calcium, high in magnesium, high in potassium, protein, and fiber, it was low in fat, and saturated fat. But it's not super low in salt? - No.

- So the first dash trial is just,

“can we look at just the foods that people eat, period?”

- So it's like low fat, careful eating, and baconator. It's just preparing those three things. (laughing) The findings were significant, and they were heralded as such.

People who didn't have hypertension, but did have sort of elevated blood pressure, had a modest, but meaningful decrease in their blood pressure of like three to five points, and people who did have hypertension on average had a much larger decrease in blood pressure

of five to 11 points. That's with the dash diet. So the dash diet worked to reduce blood pressure, which is the goal of the diet. - Absolutely.

- Okay. - So as a follow-up to the dash trial, those same researchers ran a second dash study

called the dash sodium trial.

Same kind of research design, but instead of cycling through these three different diets, they cycled through the dash diet at different sodium levels. - Okay.

- The results this time were even more striking. The lower sodium diets yielded much more significant drops in blood pressure. - Okay. - We're now into the world of like double digit changes

in your blood pressure, and that's genuinely huge. - Yeah, this actually sounds like a pretty good study, or at least something promising as a biological mechanism

“that like you should do more research to figure out,”

but like they found a real effect. - So here's the challenge with the dash diet. The dash diet hinged on someone else preparing your food for you, right? - Right.

- You also have the effect of being observed as part of a health study, right? So people kind of straighten up and fly right in the books in different ways, and you're motivated, you know, with the short term thing.

- Absolutely. - That's very different than doing it for the rest of your life. - Yes, you're having the quasi-selebrity experience of like kind of having a personal chef. - Yeah, people ask, and you're like,

"What'd you eat today?" - It's like dating someone. - When you put that in the real world, and you ask folks to adhere to a low sodium diet, the adherence rates out in the world

are notoriously terrible. A 2024 study of patients in heart failure found that even in that group, right? Folks who have really high stakes adherence to a low sodium diet was around 50%.

- Oh, wow. - Right. It goes down from there with some studies of people with known hypertension, putting the real world adherence to a low sodium 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?

Pretty explicitly. - You said the name of the show.

- Like pretty clearly, the dash diet is designed to be followed

for life. - Yeah, yeah. - If people are having this hard 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 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 bacon eater. - Right, exactly. (laughing) I think it was like an Anthony Bourdain episode where he mentioned kind of offhand that restaurant mashed potatoes are typically 50% butter.

- That's the George ratio, famously, that he was like one pound of potato to one pound of butter. - Yeah, like restaurant foods, hell a good, because the parties like they don't care how much sugar fats, all whatever they put in the food.

- So, one of the problems with the dash diet, and with 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”

normative people, people who don't have hypertension. - Normative, that is the term of art, Michael. - Turfs would call that a slur. - Good thing. (laughing)

- It makes us genders a slur. - In the process of calling it a slur, they become hypersensical. (laughing) 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 normative community,

and you can know what I can take from this. As you know, I'm normative, you've changed. - Among other things, we learn 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 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 attack strokes and death, is it worth reorganizing our food systems to keep those folks alive, right? Or do we need to do a bunch more research on people

who are at less risk in order to make those kinds of like food systems level decisions? - Right. - I don't know if there's also, I mean, the problem of adherence is not a minor problem.

- No. - Giving people food in this very structured way is 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

and are super motivated and are super motivated and have high stakes sitting right in front of them. 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 with hypertension. - Yeah. - We are in that way, we're kind of doing a trolley problem.

- Right. - We 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 more and more and more nuance, more and more light and shading to the sort of salt data.

As a whole, we talked about the ways to measure 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 US, our primary sodium intake data per capita comes from Enhance, which is a long running nutrition research

study 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 methodologies available.

'Cause 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 happens on the pizza, it depends on how much pizza.

- You're gonna have to make some assumptions in Enhance world. One of those assumptions that they make in terms of sodium data is that when people say that they eat rice, they assume that folks have salted

the water in which their race is interesting.

But these are boomers, they're not doing it. - It's actually less relevant about sort of findings across 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 something they're rice. - They're incorrect, incorrect. Michael. - Wait, really?

- The white people are salt thing, they're race water. But some studies that drill 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 race water, which could be leading to a discount of around 325 milligrams per day for folks who eat rice regularly, but don't salt their race water.

- 'Cause also even salting your pasta or your rice

can be 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, Michael. It's so fucking hard to do these studies, and it's so fucking hard to 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?”

Your baseline life stress is as much a factor. You're 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 life.

We can get closer to the mark, but we can't go, okay, it's just specifically the salt. It's really the salt, right? - Right. - Because of this large boom of research in salt,

there are some studies that are like, "Ooh, wait a minute, we're looking at normatensive people." It's your people, Mike. - It's my community. Those studies find that there may be an association

with very, very low sodium diets and increased mortality. But 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 into guidance saying,

“"You should probably reduce your sodium."”

- Right. - So this lands as like an edge lord kind of man by its 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. - So I'm sure make a podcast with like, that is like a concept that we're talking about. - What if we're talking about everything we thought? - Pre-conceptions 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. - 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 have hypertension, you don't really need to worry about it. - Right. - And if you do have hypertension, even if you're super motivated,

you're adherence is gonna be low because it's not really possible for you to hang. - 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.

Is that just like the package foods industry?

- No. - There's big salt, big salt exists. - There is. They're lobbying arm was called the salt institute. So they named it, so they built themselves as quote,

the world's foremost experts on sodium. So they tried to make themselves seem kind of like they were academics. - Okay. - But they are straightforwardly an industry lobby group.

- They should have called it the sodium podium. (laughs) - This was standing there and we're talking to you. - The salt institute was founded in 1914 in the US. Their highest profile president was someone named Lori Roman.

Lori 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. - Oh.

- 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 SB 1070, better known as Arizona's show me 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 fomented, stand your ground laws. - Oh, right. - The right laws.

- Okay, fuck it. Never thought again. - I've heard of that. - So this is the thing that absolutely joker fired me as I'm like, okay, so fuck these guys?

- Yeah, fucks up. Also, one of the salt institute's staffers, was someone named Morton Satton, which I think is very funny. Morton.

- Yeah, salt guy was named Morton. - Even waiter that he has a yellow raincoat on and umbrella, where there he goes. - Morton Satton also wrote extensively for the West and A price foundation.

- Every one of our ups. - So it's lead to the same fucking URL. (laughs) The same people, the same shit. - They're 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 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 should be able to advertise things. - Yeah, 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? - 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. - Oh, 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 my own third as much salt,

which you're like lady absolute. - 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 Atlanta

and his title, "The Great Salt to Bet" 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, it's to do it.

- Oh, I really? - Yeah! - Oh, that's so fucking funny. - And 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, 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.

“- I think 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. - Yeah, but I kind of remember being like, "Oh, okay, salt is chill. "I just don't need to think about myself consumption."

That's basically what I've done ever since.

- Yeah, yeah. - 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 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, Campbells did a big rollout being like, "We're cutting our sodium, I remember that."

- Yeah. - People had such a negative reaction

to it that Campbell sort of rolled it back. - Really to actually reverse that? - They reversed big parts of it. They didn't go back to their original super high sodium levels, but they did increase,

so they got so fucking drunk to 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, that the population is pissed off, there's less sodium in their food. - Look at this. - Look at this. - So irrational. - It's like gluten levels of anger.

- 'Cause it's not like you can't just add salt. Like if Campbell's chicken soup tastes bad, he 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 mind.

- I add salt to my peanut butter,

“and it's bomb as hell. - Oh, you have to stir it.”

- Anyway, 'cause it separates. All the butter is off-over-out salt, if you add 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 again, we're not even talking about palliability, for so much of this. - Right, right.

- I thought my peanut butter and my heart is small as hell.

- But 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, nestled general mills, PepsiCo, Kraft Heinz,

Subway, and Panera, all took on voluntary initiatives to reduce sodium in their products in the 2020s. And more Americans were self-reporting that they checked labels for sodium. - Right. - That's them telling someone,

“I check the label for sodium, which I think just means,”

they know that's the right health conscious answer. - Yeah, yeah. - Yeah, yeah. - Yeah, yeah. - Yeah, yeah. - Like a health conscious person. But even if they're just saying it,

there is some sense of like, okay, well, the ratings on the wall, we should probably pay attention to this. - Right. - And it's born out by sales data. So a 2017 JAMA study looked at grocery and convenience store sales data

and found that between 2014 Americans' food purchases reflected a 12% drop in dietary sodium. - Okay. - Buying food and eating food are different things, of course. But if those sales data translate into dietary changes,

that would be a 400 milligram drop in sodium intake, which is really significant. That's like 40% 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 getting there.

- 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, okay? - Okay.

- 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. - Oh, bet those emails are wild. - I bet they're nuts.

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. is 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 dozens of treatments that have come on to the market that are way more offensive than anything. Earlier detection, the rollout of those little blood pressure machines and people taking their blood pressure at home,

new treatments have entered the market. The first ACE inhibitor was approved by the FDA in 1981, those lower blood pressure about twice as much as salt reduction. The same goes for SGLT-2 inhibitors, like Jardians and Farsega.

Those received FDA approval for the first time in the 2010s,

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.

- Episodes are done. - It is such in the it depends episode. You're exactly right. - 'Cause 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 like salad dressing.

It's like, take a satin. - Yeah, I think that's right, and also the take a statin stuff is like more effective. - Right. - 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 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 up in 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.

“And the truth is this is like a really complex issue”

that on a public health level is gonna 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.

(laughing) Everyone's doing it. - Everyone's doing it. (upbeat music) (upbeat music)