Salt: A New Villain?

By Claudia Wallis

Yes, say the doctors, and the country scrambles to change its eating habits

KILLER SALT screams the book cover from a huge display of volumes with titles like Shake the Salt Habit!, Cooking Without a Grain of Salt and Halt! No Salt. These days they are selling in the the hundreds of thousands.

"Are you a saltaholic?" the insinuating voice asks, as the TV camera eye interrupts the hapless soul at his repast and observes him dousing dish after dish with a blizzard of deadly sodium chloride. It is a scare-the-consumer ad for NoSalt, a brand-new, fast-selling salt substitute. And a prime-time sign of the times. For salt has just pushed to the fore as the guilty food of the year-- and maybe of the decade.

After years of regarding it as a favorite flavoring, preferred preservative and nutrient, Americans are suddenly saying no to salt. According to a national survey, 40% of the population is trying to cut back. The diamond crystal has become the demon crystal and "the No. 1 food fear," according to California Nutritionist Ronald Deutsch. Says Deutsch, an irreverent observer of food fads: "This society is pervaded by a 'What's the latest hysteria?' attitude when it comes to nutrition, and salt is the latest."

The hysteria may be too strong a response, but there is reason for a healthy concern. Too much salt is known to contribute to hypertension, which is a factor in half the deaths in the U.S. each year. One of four Americans suffers from some form of high blood pressure, though many do not know it. The so-called silent killer, it often remains symptomless and undetected for years until it leads to a disabling or deadly heart attack or stroke. For the unaware and unwary, excess salt is all too often its equally stealthy silent accomplice.

The case against salt (or rather, the sodium that is in salt) has been accumulating steadily. In the mid-1970s, in response to public outcry and Government and medical criticism, manufacturers stopped adding it to baby food. An over-salted infancy, it was thought, could be the start of a lifelong habit. For decades, cutting down on salt has been a primary medical treatment for the control of hypertension. More important, an extraordinary statistical connection has been found between the amount of salt that a population consumes and its incidence of hypertension.

Since World War II, mainly because of the growing popularity of presalted, processed and frozen foods as well as a penchant for eating out, Americans have been taking in megadoses of salt. In the U.S. today the average adult consumes two to 2 1/2 teaspoons a day, more than 20 times what the body needs. An estimated 35 million people suffer from hypertension, 60 million if mild cases are included. Nearly half of the population over 65 years old is affected. Says Boston Hypertension Expert Dr. Lot Page, chief of medicine at the Newton-Wellesley Hospital: "The link between salt and hypertension is as firm as the link between high cholesterol and heart disease."

Doctors and nutritionists are clamoring for action against the overuse of salt. Says Dr. Henry Blackburn of the University of Minnesota Medical School: "Scientists have a social obligation to advocate cutting down on salt as a low-risk way of producing a more healthy population." Americans in general are becoming highly conscious of dangers that may lurk in their food. Saccharin, nitrates, sugar, cyclamates have all come under suspicion. Few are as committed on the salt issue as Food Columnist Craig Claiborne, who turned from salt addict to antisalt agitator after his own hypertension was detected. When it comes to the demon crystal, Claiborne goes straight to the point. Says he: "They should label salt just as they do cigarettes, saying that it is injurious to your health."

How to get food packages labeled, not as injurious to health but simply for their sodium content, is now the concern of the public health care establishment, including such groups as the American Medical Association, the American Heart Association, the National Heart, Lung and Blood Institute and the U.S. Food and Drug Administration. Says A.M.A. Nutritionist Stephanie Crocco: "Our immediate concern is helping people who already have hypertension to cut back, but we are also worried about anyone whose salt consumption is well above average." For those who have hypertension, reducing salt intake (and losing weight) can often lower blood pressure. It can also prevent incipient cases from getting worse.

This week in Washington, D.C., the A.M.A. is holding a national meeting, where doctors, nutritionists and Government watchdogs are threshing out the practical details of labeling with representatives of the food-processing industry. The aim: to work out the best way to organize and expedite both sodium labeling and reduction of sodium in packaged foods. The keynote speaker will be one of the prime movers in antisalt politics, Food and Drug Administration Commissioner Arthur Hull Hayes.

Before being appointed to his job last year, Hayes, 48, was for eight years director of a hypertension clinic in Hershey, Pa. There he observed the baneful effects of salt and learned to his frustration that patients ordered by their doctors to go on low-salt diets were unable to comply, even if they tried. Says he, "I might tell the Pennsylvania Dutch, for instance, that they could have their sauerkraut if they watched their sodium from other foods." But, he notes, they couldn't tell how much was in the other foods.

The reason is that salt and sodium lurk in unlikely places (see chart). Limiting salt is not just a matter of giving up pickles, pretzels and anchovy pizzas, or throwing out the salt shaker. A single serving of instant chocolate pudding can have twice as much sodium as a small bag of potato chips, and a scoop of cottage cheese three times that of a handful of salted peanuts. Thanks in part to the sodium in baking powder and baking soda, baked goods and cereals are the No. 1 source of sodium in the diet of many Americans. Preservatives such as sodium benzoate and sodium nitrite and flavorings like monosodium glutamate (MSG) also contribute. Even vitamin C is often added to foods in the culpable form of sodium ascorbate.

Different companies use different processing methods, many of them established before salt was thought to be potentially dangerous. Amazing differences from brand to brand of the same kind of product often result. A 6-oz. can of Del Monte tomato paste has a mere 112 mg of sodium; Hunt's has 610. A Kellogg blueberry waffle has 260 mg, while the same size serving of Aunt Jemima hits 352 mg. Canned fruit is salty when it is peeled with lye. Because peas are sorted in brine for canning, a tablespoonful of canned peas has as much sodium (30.8 mg) as 5 1/2 lbs. of fresh.

Hayes has already outlined Government goals in a major antisodium crusade. Complying with President Reagan's policy against excess Government regulation, he has chosen a "voluntary" approach. Though he has made progress by mixing persuasion and pressure, he threatens "to do something mandatory" if food makers do not cooperate. Hayes' object is to convince businesses that they must 1) label for sodium content, 2) change cooking directions so that adding salt is optional, 3) reduce the amount of sodium in processed foods and 4) offer many more low-sodium or salt-free products. He plans to follow up with a consumer-education program to ensure that labels are understood. Hayes already points to some victories. When the FDA first announced the crusade last April, only 13% of FDA-regulated food was labeled for sodium. Hayes expects that one-third to one-half will be by year's end. General Foods has already sodium-labeled its Shake 'n Bake, Post cereals and Birds Eye frozen vegetables; General Mills has tagged 200 products from Bisquick to Hamburger Helper. Mighty Campbell's, king of soups, has just introduced a new line of low-sodium flavors nationally. Among the green-and-yellow-bannered cans are variations on traditional chicken noodle, split pea and chunky vegetable beef.

Jewel Food Stores, a Midwest chain, has brought out its own private-label brand of low-salt canned goods. So has Stop & Shop in New England. McDonald's, which annually sells the public 700 million lbs. of hamburger and 542 million bushels of fries, has completed a study on the sodium content of Chicken McNuggets, Big Macs and French fries. Customers who request it may now have the information in the form of a booklet with sample menus. Example: Big Mac, French fries and milk (1,240 mg).

Hayes' chief ally in the fight for labeling, Tennessee Congressman Albert Gore, is unimpressed by these achievements. Gore thinks the voluntary approach is "almost certainly doomed to failure." What is needed, he believes, is a bill to require labeling under law. Along with Iowa Representative Neal Smith, he has written legislation requiring that the sodium and potassium content be marked on all processed and canned foods governed by the Food, Drug and Cosmetic Act, if the total exceeds 35 mg. The bill is now before a House health subcommittee chaired by California's Henry Waxman. It has 79 co-sponsors in the House, but Gore is worried about its future. Says he: "Salt is the cheapest flavor enhancer. There is an enormous competitive advantage to loading food with salt and not telling people about it." Waxman is worried for the same reason: "We are having difficulty getting the votes to pass this legislation because of industry pressure."

One of the food industry's arguments against sodium labeling involves the somewhat equivocal nature of the medical case against salt. As with smoking and cancer, cholesterol and heart disease, it is difficult to prove direct cause and effect.

Statistically the link is clear. In countries where sodium intake is high, so is the frequency of hypertension. Japan is the most striking example. With a diet based largely on fish, pickled vegetables and soy sauce (1,029 mg sodium per tablespoon), the average Japanese citizen consumes nearly three teaspoons of salt a day. In the northern agricultural provinces, where salt is still widely used as a preservative, six teaspoons or more a day is not uncommon. And what is probably the highest sodium diet in the world coincides with what seems to be the world's highest rate of hypertension; in some villages fully 40% of the residents have high blood pressure. No national statistic for hypertension is available for Japan as a whole, but until last year, stroke was the country's leading cause of death.

Japan and the U.S., however, are both complex societies where citizens are subject to all sorts of variables, including stress, that could contribute to hypertension. More convincing evidence against sodium conies from simpler cultures, where it is still possible to find people living relatively simple lives on low-salt diets. The tribesmen in New Guinea, the Amazon Basin, the highlands of Malaysia and rural Uganda all eat very little salt. Hypertension is virtually unheard of in those regions, and the blood pressure of individuals does not rise steadily with age, as it does in the U.S. and other salt-loving nations. But when salt is introduced into a salt-free culture, blood pressure climbs.

In a classic study, Dr. Lot Page headed up a Harvard team that from 1966 to 1972 studied six tribes in the Solomon Islands. Three were totally unaffected by Western culture and three, otherwise very "primitive" (no roads, no telephones, no pollution), got to eat salt-heavy canned ham and beef jerky supplied to them by Chinese traders. Only in the second group did blood pressure increase with age. It was highest in the tribe that traditionally cooked its fish and vegetables in sea water. The tribes did not differ in weight or any other medically significant way. Says Page: "When we analyzed all the components of change, diet always showed up as the key factor."

Lowering salt intake seems to reduce hypertension too. Beginning in 1972, Dr. John Farquhar of Stanford University conducted a three-year study of 1,500 men and women selected at random in three California towns. In two of the towns, subjects cut salt intake 30%. In the third, no dietary change was made. The result: blood pressure was 6.4% lower among the low-salt people than in the control town.

At the heart of the salt debate is a medical mystery. Salt may contribute directly to hypertension, but nobody knows exactly how. Sodium chloride is essential to all living things. The tissues of the human body are constantly moistened by a briny solution thought to be of about the same salinity as the primordial sea from which life emerged. As Hayes puts it, we are "miniature oceans encased in skin." The balance of salt to water in that internal ocean must be carefully maintained: virtually all vital functions, including nerve impulses and heart action, depend on it. Keeping that proper balance is mainly the work of the kidneys. The healthy body needs, and can use, only about 200 mg of sodium per day. Anything more is excreted by the kidneys in order to keep balance. "The human body has a tremendous capacity to get rid of salt," explains Physiologist Arthur Guyton of the University of Mississippi School of Medicine at Jackson. Though it is unwise to do so for long, Guyton notes, "most people can load up on salted junk food and excrete twelve times their normal sodium intake in just a few days with no ill effects." Only in hypertensives, for reasons as yet unknown, does too much salt mean trouble.

A problem in kidney functioning is almost certainly at fault, and the trouble is probably inherited. It seems to run in families and in races. Blacks, for example, are twice as likely to have hypertension as whites. No matter how much salt is used, only certain individuals will develop hypertension; an estimated 20% to 40% of the population is susceptible. Still, "it is very difficult to determine in advance who is and who isn't sensitive to salt," says Dr. Allan Forbes of the FDA. "That's why many medical experts believe it is reasonable to modify the sodium intake for everyone."

While it seems prudent for the U.S. to keep the salt load light, antilabeling forces can, and do, complain that any Government action would expensively penalize industry and force upon an uninterested majority rules and reforms desirable only to a minority. Most people like salt, says William Dickinson, president of the Salt Institute, which represents salt processors in the U.S. and abroad. "It's easy to say cut back, but food just doesn't taste good without it. If we eliminate salt, we'll just see a lot more processed food being scraped into the garbage can." Dickinson also thinks that any labeling that singles out sodium is "scare labeling." He opposes it unless "all other nutrients of concern to the consuming public" are labeled as well. Adds Dickinson: "Who says sodium is more important than excess fats or calories?"

Food processors also point to the difficulty of determining the sodium content of many products. Pretzels are a problem, they say, because nobody knows how much salt actually sticks to the pretzel and how much comes off in the bag. Cost is a problem too. The Center for Science in the Public Interest claims that the cost of labeling will be less than 1% of the price of the product, and in most cases less than .5%. But according to General Foods, the cost of its voluntary labeling so far has proved "not insignificant." If done across the board, it might drive food prices up considerably.

Implicit in the antilabeling position is the presumption that anyone who really needs to cut down on salt can easily do so now. As to the general public, the thought is that it can cut down simply by exercising a little common sense at the salt shaker. In fact it is very difficult to find one's way in the present patchwork of labeled and unlabeled products.

Even if labeling is worked out to everyone's satisfaction, many antisalt advocates fear that the general public will still not cut down on sodium. Says Michael Jacobson, executive director of the Center for Science in the Public Interest: "It is unlikely that the school-age child whose father or mother has hypertension will scrutinize labels, or the black teen-ager whose blood pressure is slightly above normal, or the 35-year-old trucker whose diet consists largely of convenience and restaurant foods."

But Jacobson has some hopes too: "Just like it's a plus to say there are 'no preservatives,' soon it will be a plus to say 'no salt added.' " All present signs suggest that American food tastes and label-reading skills are dramatically changing. And business, with a potential market of more than 40 million consumers watching their blood pressure or simply worried about salt, is already responding to the change. "Low-sodium sales are growing. Our own no-salt-added products are selling at 50% to 90% of the levels of regular brands," says Jane Armstrong, vice president of Jewel supermarkets. She also notes: "Whole families are cutting back in salt as the feeling grows that less sodium can't be harmful and may be healthy."

The change is visible in the nation's restaurants. At George's, an Italian restaurant on Chicago's West Kinzie Street, Owner George Badonsky still serves highly flavored sauces and rich Gorgonzola. But some of his younger customers object. Says he: "The biggest complaint I get is that the food is too salty." That is not a problem at Chez-Eddy in Houston, which specializes in lowfat, low-salt French cuisine and has no salt shakers on the tables. But, says one patron who is mad for their salmon mousse, "the place is always packed at lunchtime."

To learn how to go low sodium without having to eat like swamis or food faddists, Americans are buying books, taking courses and exchanging gourmet gossip. The skill and zeal they display would have been impossible before the country became fascinated, for other reasons, with do-it-yourself health and haute cuisine. Says John Terry, consultant to the Allen Canning Company in Siloam Springs, Ark.: "The whole convenience idea--Just Heat, Then Serve--isn't as big now. More consumers are ready to do their own seasoning."

Low-salt recipes now appear routinely in newspapers and women's magazines. Special desalinated cookery tomes exist to meet all pocketbooks, if not all palates. They tend to be heavily sprinkled with garlic and pepper. All make clear that there is more to low-salt life than just throwing away the salt shaker. Craig Claiborne's Gourmet Diet Book and Eleanor Brenner's Gourmet Cooking Without Salt are probably the most sophisticated guides going. They provide recipes for such things as low-salt pates, souffles and exotica like Baba Ghanouj (eggplant with sesame paste). The most ferocious anti-salt volume is Killer Salt by Marietta Whittlesey. Published in 1977 and still selling, it is not merely a cookbook but a polemic. It warns about salt addiction and threatens readers with "hypogeusia" (having dull taste buds) from oversalting. One of the most down-to-earth entries is an American Heart Association book, Cooking Without Your Salt Shaker. A sample recipe: mock sour cream, made with lemon juice, skim milk, onion powder and unsalted dry cottage cheese. The most convivial way of becoming an ex-saltaholic is in a course, in a group large enough so :hat members can pass along useful hints and discoveries. One such class is given at the Frances Stern Nutrition Center at Tufts University in Boston. In six hours, for $105 (covered by Blue Cross if prescribed by a doctor), the course takes up cooking techniques, label deciphering, entertaining and low-salt stratagems for eating out. Course Director Carol Stollar hands out lists of restaurants that will cook low-sodium meals if asked. Her counsel to the students: don't avoid restaurants, just find those that are accommodating and "learn to be pleasantly assertive."

Don Jackson, 48, a Boston hospital administrator with mild hypertension, found the course changed his life. In no time at all, he became a man for all substitute seasonings, especially angostura bitters, cumin, vinegar, vermouth and table wine (cooking wine contains salt). He learned to read labels like a lawyer going over a contract. "Now when I go to a grocery store," says Jackson, "I know what all those words mean." He discovered, for instance, that consumers must look out for the words soda and brine, as well as for salt and sodium. "Tuna in water" means "tuna in water and salt." Tomato paste and canned tomatoes, ingredients for his favorite homemade spaghetti sauce, turned out to be dangerous. So he took to raising his own tomatoes in the backyard, parboiling, then freezing them for use later. He learned to skip ham, cured meats and gravies and to use tabasco sauce (24 mg per teaspoon) in place of Worcestershire (69 mg per teaspoon). Baked potatoes become a standby. Concludes another student in Don Jackson's course: "It means really cooking at home a lot, and goodbye to TV dinners and chili from a can."

Much of the information in low-salt courses is basic. But some of it varies according to regional tastes. Sophia Taylor, 64, has learned low-sodium cooking in a follow-up program for hypertensives in Jackson, Miss. Because she is used to salt-heavy Southern dishes, some of the things she was warned against are special. Avoid instant grits. Do not use self-rising flour, because it is full of soda and baking powder. Do not cook with salt pork. Use yeast-leavened bread. The course also gives instruction on how to make low-sodium corn bread and biscuits. Recalls Taylor: "Before my taste buds adjusted, the squash, the okra just tasted yukky. But I finally got used to it. Now the thought of eating salted nuts makes me think I'm eating brine." Most of the advice Taylor received would be useful anywhere. Avoid cheese, and if you cannot do that, at least do not buy processed slices, which have far more sodium than the block. In the supermarket, do not buy any product if salt is listed among the first three ingredients.

It may take from three to six weeks or people to adjust to life with less salt. After making the break, many prefer lower-salt foods. Says Ardelle Tuma, vice president of Chicago's Carson Pirie Scott department stores: "I found that unsalted butter has a fantastic taste all its own, and vegetables have a finer, purer flavor without salt." The reason may be that a high-salt diet blunts the natural ability to perceive salt, while cutting back makes the palate more sensitive. Research by Berkeley Food Sciolist Angela Little has led her to believe that "high intake of salt produces a salty background in the saliva, raising the threshold at which salt is noticed in food."

If salt is bad, and it certainly is for many people, why do they like it so much? The answer, suggests University of Minnesota Hypertension Expert Louis Tobian, is that in prehistoric times, man's taste for salt may have been an advantage. He says: "In a world of salt-poor plants, there was no chance of his getting too much." But the desire for salt may have propelled him to find a valuable nutrient.

There is no evidence, though, that a taste for salt is inborn. Babies show a clear natural preference for sweetness, but as a group are indifferent to the taste of salt. Some babies do appear to like salt more than others, and recent research now suggests that those who do, have higher blood pressure, an indication of a hypertensive future.

As if to confirm that the low-salt way may become the wave of the future, Morton Norwich, which converts millions of pounds of salt into dollars every year, reports that sales have dropped 10% over the past five years. But the company need not be glum. Sales of Morton's salt substitutes have risen 12%. So have the sales of other brands of table-salt substitutes. Store managers report NoSalt, perhaps because of its TV advertising, is selling so fast they cannot keep it in stock.

Most of the substitutes are made of potassium chloride. They may taste salty enough but can be so bitter that gourmet cooks tend to avoid them entirely. There is a possibility of danger too, according to some doctors. In very large doses, potassium can cause gastrointestinal ulcers, and for some kidney patients, more moderate doses can be lethal.

A happier aid for salt watchers: Mattel Electronics' new Diet Trac, a pocket computer specially designed to keep track of your cholesterol, caloric or sodium intake. Just tell it your nutrient goals, keep it up to date on what you are eating, and it will do the counting for you, down to the last milligram. Properly programmed, it will even send you a warning BEEP, BEEP, BEEP if an overdose of sodium is imminent.

--By Claudia Wallis. Reported by Patricia Delaney/Chicago and Jeanne Saddler, Washington

With reporting by Patricia Delaney/Chicago, Jeanne Saddler/Washington

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