Salt

In the 1980s, a low-sodium diet was seen as the gold standard for healthy behavior. In 2026, salt has been repackaged as “electrolytes” and is now cast as a core component of wellness. How did we get here? Also, an important correction: One pound of butter to one pound of potatoes is Joel Robuchon’s recipe. Support us: Hear bonus episodes on PatreonWatch Aubrey's documentaryBuy Aubrey's bookListen to Mike's other podcastGet Maintenance Phase T-shirts, stickers and moreLinks! The 25 Saltiest R...

• 0:11Speaker 00

  Welcome to Maintenance Phase, the podcast... Wait, why can't I do this? Oh yeah, welcome to Maintenance Phase, the podcast that will finally make an episode that other people will call salty.

• 0:22Speaker 01

  There we go!

• 0:24Speaker 00

  See?

• 0:25Speaker 01

  You did it!

• 0:26Speaker 00

  It's okay, it's like 6 out of 10.

• 0:28Speaker 01

  We're doing the episodium.

• 0:31Speaker 00

  I'm Michael Hops.

• 0:32Speaker 01

  I'm Aubrey Gordon. If you would like to support the show, you can do that at patreon.com/maintenancephase. You can also subscribe through Apple Podcasts, it's the same audio content.

• 0:43Speaker 00

  Same stuff, Aubrey.

• 0:45Speaker 01

  We're talking about salt today, Mike.

• 0:47Speaker 00

  This was like the anxiety around diet growing up. It was like low fat and like low salt were the two things you need to strive for.

• 0:55Speaker 01

  This came up in our bonus episode about 80s diets, that a ton of them were like extremely low salt. 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.

• 1:19Speaker 00

  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 can salt it at the end and I keep trying to explain that that's not how it works. Sorry, Mom. She can't, she can't overcome her heritage.

• 1:36Speaker 01

  That's right.

• 1:37Speaker 00

  Everyone's white mom grew up like this.

• 1:38Speaker 01

  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.

• 2:04Speaker 00

  Yeah.

• 2:04Speaker 01

  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.

• 2:12Speaker 00

  Right.

• 2:13Speaker 01

  So how do we get from point A to point Z?

• 2:17Speaker 00

  Cause it's kind of fallen off the radar, like the wellness radar. You don't hear about salt in the way that you used to.

• 2:24Speaker 01

  People have this idea that like, you're not going to be able to salt your food at the table. If we talk about salt, that's not true. According to the research, depending on which study, between three and 7% of American salt is added in home cooking or at the table.

• 2:40Speaker 00

  Oh, interesting. Okay.

• 2:41Speaker 01

  So we're talking about like a vanishingly small amount of the salt is what you decide to add to your food.

• 2:48Speaker 00

  Right.

• 2:49Speaker 01

  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.

• 3:01Speaker 00

  Yeah.

• 3:01Speaker 01

  Or you don't really think about is consuming.

• 3:03Speaker 00

  Although I am policing your behavior, you should salt food when you're cooking it. If you don't do that, I'm bringing a protein bar when I come to your house.

• 3:08Speaker 01

  In order to like, get the conversation going, I think we gotta do like a little bit of myth busting up top.

• 3:14Speaker 00

  Okay.

• 3:15Speaker 01

  And the way that we're going to do that is a salt quiz.

• 3:17Speaker 00

  Okay. I think you were going to say we need to do a taste test where we each just eat us a teaspoon of salt.

• 3:22Speaker 01

  Go get your salt shaker. How does it taste? Fucking delicious.

• 3:25Speaker 00

  But let's both get grounded here and just eat a bunch of salt, just the sound of me puking in the background.

• 3:30Speaker 01

  So question number one, Michael.

• 3:33Speaker 00

  Aubrey.

• 3:33Speaker 01

  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?

• 3:54Speaker 00

  I think we're in the top 100, but not particularly high.

• 3:57Speaker 01

  We're number 50.

• 3:58Speaker 00

  Okay. Who's the highest?

• 4:00Speaker 01

  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.

• 4:15Speaker 00

  Okay.

• 4:15Speaker 01

  With 17 grams of salt a day.

• 4:19Speaker 00

  But are you sure this wasn't a survey of which country is the saltiest? Like, the most irritable?

• 4:24Speaker 01

  You think China is the most irritable country? And we're number 50?

• 4:28Speaker 00

  I can't argue with statistics, Aubrey.

• 4:30Speaker 01

  So Samoa at 5 grams of salt is much, much closer to the actual WHO recommendations, FDA recommendations, all of that kind of stuff.

• 4:40Speaker 00

  Wait, so what is, what is the WHO recommendation in teaspoons?

• 4:43Speaker 01

  Uh, it's like about a teaspoon is the, what we should be aiming for. That's like the goal.

• 4:48Speaker 00

  Okay.

• 4:48Speaker 01

  Next question. We're gonna do a little salt mortal combat.

• 4:53Speaker 00

  Ooh, okay.

• 4:54Speaker 01

  Finish him. Which of these has the most salt? We're gonna do one teaspoon of each of these things. Which one do you think has the most salt? And which one do you think has the least salt?

• 5:04Speaker 00

  Okay.

• 5:04Speaker 01

  The options are a teaspoon of table salt, a teaspoon of MSG, a teaspoon of marmite, a teaspoon of soy sauce, and a teaspoon of grated Parmesan.

• 5:20Speaker 00

  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? I'm sure I'm wrong.

• 5:35Speaker 01

  You're very wrong.

• 5:35Speaker 00

  Okay.

• 5:36Speaker 01

  Marmite contains less sodium than a teaspoon of salt.

• 5:41Speaker 00

  Really? It's so salty, though, on my, on my mouth.

• 5:43Speaker 01

  Uh, so here's the story. One teaspoon of salt contains 2,300 milligrams of sodium. A teaspoon of soy sauce has 3,000 milligrams of sodium.

• 5:56Speaker 00

  Wow, okay.

• 5:57Speaker 01

  So considerably more, right? Like, almost 50% more sodium.

• 6:01Speaker 00

  Yeah.

• 6:02Speaker 01

  A teaspoon of marmite has 340 milligrams of sodium.

• 6:06Speaker 00

  Wait, what? One tenth?

• 6:07Speaker 01

  Almost one tenth the amount as soy sauce.

• 6:10Speaker 00

  Was I the wrongest it's possible to be?

• 6:12Speaker 01

  No.

• 6:12Speaker 00

  Was I like the lowest one?

• 6:13Speaker 01

  You weren't the wrongest it's possible to be.

• 6:15Speaker 00

  Okay.

• 6:15Speaker 01

  Here's the other one that I found fascinating. Grated Parmesan has about 25 milligrams of sodium in one teaspoon.

• 6:23Speaker 00

  Wait, 2,500 or 25?

• 6:24Speaker 01

  25, 25.

• 6:25Speaker 00

  But it tastes so salty. Aubrey, what's happening? What's going on?

• 6:28Speaker 01

  Right. So all of this is to say, if you're counting on things tasting salty to determine what has sodium in it, we're almost all getting it wrong.

• 6:37Speaker 00

  Wait, I did exactly the thing. I did exactly the concept that you wanted to illustrate.

• 6:43Speaker 01

  Yeah.

• 6:44Speaker 00

  I'm putty in your hands. I've been puppeteered.

• 6:46Speaker 01

  So the last question that I have for you for our salt pop quiz.

• 6:50Speaker 00

  This is so fun.

• 6:50Speaker 01

  Are you enjoying it?

• 6:51Speaker 00

  This is so fun.

• 6:52Speaker 01

  Which of the following is the highest sodium dish at an American chain restaurant?

• 6:59Speaker 00

  Ooh, okay.

• 7:00Speaker 01

  A, the Wendy's Triple Baconator. That's three beef patties and six strips of bacon.

• 7:06Speaker 00

  I gotta go to Wendy's more.

• 7:10Speaker 01

  B, Long John Silver's Footlong Chili Cheese Dog. C, Bob Evans Steakhouse Salad. D, Outback Steakhouse's Blooming Onion. Or E, The Cheesecake Factory's Chicken and Broccoli Pasta.

• 7:29Speaker 00

  Well, with these questions, the surprising answer is always the correct answer.

• 7:34Speaker 01

  How dare you?

• 7:34Speaker 00

  So you shouldn't be thinking about what is correct. You should be thinking about what the surprising answer will be.

• 7:38Speaker 01

  You're trying to hack my brain and I don't appreciate it.

• 7:42Speaker 00

  The most surprising answer would be one of the salads, or probably the Bob Mackie Salad, whatever thing.

• 7:49Speaker 01

  Bob Mackie, the Bob Fosse.

• 7:52Speaker 00

  I've never heard of this restaurant, but okay.

• 7:54Speaker 01

  Yeah, Bob Evans Steakhouse Salad is number one.

• 7:56Speaker 00

  Okay.

• 7:56Speaker 01

  It is 7,700 milligrams of sodium in a salad.

• 8:02Speaker 00

  Three times your daily recommended in a salad?

• 8:04Speaker 01

  Correct.

• 8:05Speaker 00

  Is lettuce secretly really salty?

• 8:07Speaker 01

  No, salad dressing's all right.

• 8:09Speaker 00

  It's the dressing, right?

• 8:10Speaker 01

  Absolutely. The lowest sodium of those is the Triple Baconator.

• 8:15Speaker 00

  Wait, really?

• 8:15Speaker 01

  Yep.

• 8:16Speaker 00

  Okay.

• 8:17Speaker 01

  That one's just shy of 1,800 milligrams of sodium.

• 8:20Speaker 00

  Right, because I heard recently that just because things taste salty doesn't mean that they're high in sodium.

• 8:24Speaker 01

  Oh, interesting. Where'd you hear that one?

• 8:26Speaker 00

  So just letting you know.

• 8:27Speaker 01

  You could just eat one Triple Baconator in a day and be like, I nailed. It by the FDA guidelines.

• 8:35Speaker 00

  That's technically an electrolyte. A triple bacon cheeseburger is an electrolyte.

• 8:39Speaker 01

  You're just getting hydrated.

• 8:41Speaker 00

  That's your recovery drink. My recovery cheeseburger.

• 8:44Speaker 01

  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?

• 8:58Speaker 00

  The Cheesecake Factory. It's all coming from the Cheesecake Factory.

• 9:00Speaker 01

  Salt is used in food in ways that go way beyond palatability, right? The big one is that salt is overwhelmingly used as a preservative.

• 9:10Speaker 00

  Right.

• 9:11Speaker 01

  Cured foods, especially things like lox, bacon, ham, prosciutto, salami, really high in sodium. Pickled foods.

• 9:20Speaker 00

  Oh, yeah.

• 9:20Speaker 01

  Are pickled with a mixture of salt and sugar, so they have quite a bit of both. Canned foods use salt both to preserve and to inhibit bacteria growth. Salt is also heavily used in meat production, not just as seasoning, but as a way to increase profits.

• 9:41Speaker 00

  Okay.

• 9:42Speaker 01

  Because salt helps retain moisture, saline is often added generously to meat before it is sold.

• 9:52Speaker 00

  Okay.

• 9:52Speaker 01

  Meat with more moisture weighs more.

• 9:56Speaker 00

  Right.

• 9:56Speaker 01

  And meat is sold by the pound. So it's a way to make more money from the same amount of livestock. 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.

• 10:18Speaker 00

  According to the USDA, 21% of beef, 78% of chicken, and 57% of pork is bulked out in this way. Such products are far higher in sodium than plain, natural meat. Judging by a 2006 study of poultry, consumers nationwide were paying $2.6 billion, adjusted for inflation, annually for the added solution. Add in the beef and pork products that are watered down, and it appears that consumers are now being cheated out of at least four billion. Million dollars annually and possibly much more. This is why I kind of hate it at the grocery store, how they like spritz the produce with water. You know, and they have like the cute little thunder sound now and then like the little spray comes on. I'm like, I'm paying by the pound for these apples. I don't want little drops of water on them.

• 10:59Speaker 01

  I want them shriveled as God intended.

• 11:03Speaker 00

  Do you know how much water a fucking head of broccoli will soak up? I'm like shaking it out at the store as if, as if I'm like opening a sugar packet. I'm like.

• 11:11Speaker 01

  Your cheapskate tendencies really are boundless.

• 11:16Speaker 00

  I'm not paying for water.

• 11:17Speaker 01

  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.

• 11:39Speaker 00

  Right, yeah.

• 11:39Speaker 01

  So to speak.

• 11:40Speaker 00

  There's also, I think this is probably an urban legend, but when I was living in London, there's a thing where you go to nightclubs, drink whatever. It's like two in the morning, you're walking home and they have like, not quite food trucks, but like booths on the street that will sell like hot dogs and like french fries and stuff. And they call it mistake away because it's always bad. You feel like shit the next day. But people there, the sort of the explanation of these was that if you're at a bar, you're drinking a ton of liquid. So your body's like salt balance is out of whack at the end of a night of drinking. And so your body craves like super salty foods because you're low in sodium. So that's like why you want like french fries and like a shawarma or whatever at the end of the night. It's sort of like at a subconscious level, you're just like, oh, I want like terrible food.

• 12:23Speaker 01

  Absolutely.

• 12:24Speaker 00

  I don't know whether that's true, but I did eat those hot dogs all the time for my health.

• 12:26Speaker 01

  The main thing we're going to talk about today, as we start to sort of chart the path of like how we got here, is something called the salt hypertension hypothesis.

• 12:34Speaker 00

  Ah, yes.

• 12:35Speaker 01

  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. Heart gets, right? It can contribute to an enlarged heart. Presumably then, the inverse would be true, that cutting out salt would decrease blood volume and blood pressure.

• 13:02Speaker 00

  And when you say that someone has a big heart, you're implying that they're at risk of a stroke?

• 13:05Speaker 01

  The idea that sodium intake is linked to heart health stretches back centuries. There is a classic text in Chinese medicine called Huangdi Nezhi, 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."

• 13:27Speaker 00

  Ooh, okay.

• 13:28Speaker 01

  That is the first mention that we see of like relating, uh, salt to your blood pressure or to your heart health.

• 13:36Speaker 00

  I love that phrase.

• 13:37Speaker 01

  The pulse hardens.

• 13:39Speaker 00

  Yeah.

• 13:39Speaker 01

  Empirical testing of this question of the link between sodium and blood pressure and heart health started very early in the 20th century. In 1904, two French researchers reported that treating hypertensive patients with a low-salt diet reduced blood pressure. So that starts to kick off a series of other little studies. They're mostly small sample sizes. They're mostly working with patients that already have hypertension. Most of those studies seem to largely bear out the hypothesis. That's like, oh yeah, when you cut down on

• 14:19Speaker 01

  salt, for people who already have high blood pressure, it appears to improve their blood pressure, either a little bit or a fair amount, right?

• 14:28Speaker 00

  I thought you were gonna tell me that people with hypertension also eat a lot of salt and it would be these like correlational studies, but these sound fine. They're actually doing interventions and finding that changing your diet reduces your blood pressure.

• 14:39Speaker 01

  That is an overwhelming majority of the studies that we're gonna talk about.

• 14:43Speaker 00

  Cool.

• 14:43Speaker 01

  In 1939, there is sort of, uh, 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.

• 14:58Speaker 00

  Okay.

• 14:58Speaker 01

  Kempner believed that salt was a quote unquote waste byproduct. Of the kidney.

• 15:04Speaker 00

  Okay.

• 15:04Speaker 01

  Uh, and that reducing sodium intake would protect kidney function, right? You're giving your kidneys less salt to have to contend with and filter out. And he thought that if you could devise a super low sodium diet, that that would help folks with kidney function and heart function, right?

• 15:23Speaker 00

  It was the marmite and Parmesan cheese diet. Just spoonfuls.

• 15:28Speaker 01

  So the diet that Dr. Kempner devised is a fucking wild one, Mike. It's not heavy on the calorie restriction. The maximum was 2,000 calories, which is not as unhinged as we get and is pretty normal.

• 15:41Speaker 00

  Yeah.

• 15:42Speaker 01

  It had a maximum of five grams of fat.

• 15:46Speaker 00

  Oh, yeah. Okay.

• 15:46Speaker 01

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

• 15:51Speaker 00

  Okay.

• 15:51Speaker 01

  It had a maximum of 20 grams of protein. It had a maximum of 150 milligrams of sodium, which is.

• 16:03Speaker 00

  Oh, wow.

• 16:04Speaker 01

  Nothing.

• 16:04Speaker 00

  So what you're saying is it's just three Wendy's Baconators per day?

• 16:08Speaker 01

  No, it's unlimited rice.

• 16:12Speaker 00

  Is that what it is?

• 16:13Speaker 01

  It's called the Kempner Rice Diet.

• 16:15Speaker 00

  Oh, it's not named after a researcher named Rice? I thought it was like two researchers and one of their last names was Rice.

• 16:20Speaker 01

  It's a guy and a food, Kempner Rice.

• 16:24Speaker 00

  So you're just eating unsalted fucking rice like three meals a day?

• 16:27Speaker 01

  Unlimited rice and, uh, unlimited fruit juice and you could have white sugar.

• 16:34Speaker 00

  That's like the most 80s ass diet. I know this isn't the 80s, but it's like the most 80s ass diet I've ever heard in my life.

• 16:38Speaker 01

  It's 1939, but we're getting a head start on the 80s. Absolutely. To be clear, that 150 milligram sodium ceiling is almost impossible to manage.

• 16:52Speaker 00

  Right.

• 16:53Speaker 01

  Five stalks of celery has over 150 milligrams of sodium.

• 16:58Speaker 00

  No way.

• 16:59Speaker 01

  Two unseasoned eggs has over 150 milligrams of sodium, right? Sodium is a mineral that exists in soil, which means it exists in almost every fruit and vegetable.

• 17:11Speaker 00

  Right.

• 17:12Speaker 01

  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%.

• 17:26Speaker 00

  Yeah, miserable.

• 17:27Speaker 01

  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?

• 17:36Speaker 00

  Right.

• 17:37Speaker 01

  It's not functional to say, you pretty much can't eat vegetables. There's too much salt in them.

• 17:43Speaker 00

  The only thing you have to do is never derive any pleasure from food the rest of your life.

• 17:48Speaker 01

  Never have a slice of cake at a birthday party. Never eat another sandwich.

• 17:53Speaker 00

  You will get scurvy, but think of how small your blood will be.

• 17:56Speaker 01

  The people who did experience improvement, whether Kempner was studying it or others were studying it. They saw improved blood pressure. They saw improved electrocardiograms, right? Like they're seeing sort of like significant improvements in heart health across measures.

• 18:13Speaker 00

  All right. Clip it and ship it. They'll start giving everybody the fucking rice diet.

• 18:17Speaker 01

  Please enjoy only rice, nothing else.

• 18:19Speaker 00

  We solved it.

• 18:20Speaker 01

  There aren't really blood pressure meds on the market at this point. So the Kemner 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 anticonvulsant 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.

• 18:44Speaker 00

  Yeah.

• 18:44Speaker 01

  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.

• 19:03Speaker 00

  But then if we eat those rats and chickens, do we also have high blood pressure? Is that the real problem?

• 19:07Speaker 01

  No, then we have superpowers.

• 19:10Speaker 01

  This research was like generally received as a confirmation of the salt hypertension hypothesis, but there are a couple of significant challenges with the research. One, rats and chickens don't display significant variance in blood pressure response to salt intake. Humans do. And two, the doses were nutso. The human equivalent of the dose that these rats got would have been 40 grams of salt per day.

• 19:39Speaker 00

  You're basically preserving yourself.

• 19:40Speaker 01

  That's right.

• 19:41Speaker 00

  An Iberian ham.

• 19:42Speaker 01

  You're pickled now.

• 19:43Speaker 00

  Yeah.

• 19:44Speaker 01

  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 US government when it starts making large-scale nutritional recommendations about salt. We've got the Kempner rice diet, we've got this early French research, and we've got a number of animal studies. So 1969 is the point at which the US federal government starts talking about reducing salt intake. At that point, again, the data is like definitely imperfect, but all of it seems to point to

• 20:29Speaker 01

  sodium reduction as a strategy worth pursuing. And there's certainly nothing outperforming sodium reduction as a treatment strategy for hypertension.

• 20:39Speaker 00

  Right.

• 20:40Speaker 01

  In 1977, a Senate Select Committee published dietary goals for Americans. It's sort of the predecessor to the Dietary Guidelines for Americans, which were 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 1,500 and 2,300 milligrams of sodium. The nutritional recommendation is now sort of baked into the dietary guidelines. And it becomes almost boilerplate language that just gets carried over and carried over and carried over.

• 21:24Speaker 01

  Right. But that's when large scale human studies start to roll out. And that's when the so-called salt wars begin.

• 21:34Speaker 00

  Dude, is it fucked up that this is making me hungry for salty food? And now I'm eating the smoked salmon that I have in the fridge.

• 21:40Speaker 01

  I feel like you now understand why I fucking burned through that jar of Gorgonzola olives.

• 21:47Speaker 00

  Oh, no.

• 21:48Speaker 01

  So there is a huge landmark study in the early eighties called intersalt.

• 21:57Speaker 00

  Okay.

• 21:58Speaker 01

  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 US.

• 22:42Speaker 00

  Right.

• 22:43Speaker 01

  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 things, right? You need salt to de-ice roads.

• 22:58Speaker 00

  Right. Yeah.

• 22:59Speaker 01

  So the gold standard for this kind of stuff are biomarkers, either blood work or urinalysis.

• 23:05Speaker 00

  And it's like, how much sodium I ate in the last 24 hours or something?

• 23:08Speaker 01

  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.

• 23:19Speaker 00

  Okay.

• 23:19Speaker 01

  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 than people with the same demographics that consumed less.

• 23:35Speaker 00

  Okay.

• 23:36Speaker 01

  Intersalt'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 Intersalt 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?

• 24:14Speaker 00

  Right. It's a descriptive study. They're just like trying to find a phenomenon.

• 24:18Speaker 01

  That's right, but it's released in the late 80s, which is like exactly when certainly the US is like taking off in terms of like health conscious behaviors.

• 24:29Speaker 00

  Right.

• 24:29Speaker 01

  So a bunch of people hear this thing about salt consumption is associated with higher blood pressure and they go, aha, gotta take the salt chaser off the table.

• 24:40Speaker 00

  Right.

• 24:41Speaker 01

  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 Y percent of your sodium. And sodium is included in that labeling requirement.

• 25:00Speaker 00

  Yeah.

• 25:00Speaker 01

  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 low salt moms and uncles and whatever, right?

• 25:14Speaker 00

  The white people took this and rammed.

• 25:16Speaker 01

  Following Intersalt and the findings of Intersalt, a bunch of nations around the world, including the US, launched national trials related to sodium and hypertension. In the US, 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. And 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.

• 25:56Speaker 01

  So what they decided to do was be like, cool, you're eating two of your three meals a day at the research center.

• 26:04Speaker 00

  Oh.

• 26:04Speaker 01

  And then you're getting a third one in a cooler to take home with you.

• 26:09Speaker 00

  Okay, so it's super prescribed.

• 26:11Speaker 01

  Study participants were cycled through three different diets, each for three weeks at a time. And they also answered a standard like 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?

• 26:29Speaker 00

  Every single one of them just said, I'm hungry.

• 26:31Speaker 01

  I'm so hungry.

• 26:32Speaker 00

  I'm eating these terrible meals that the lab gives me.

• 26:35Speaker 01

  Feed me.

• 26:37Speaker 00

  I've been living like this for six weeks.

• 26:38Speaker 01

  So the three diets are this. One, there's a control 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 control 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.

• 27:06Speaker 00

  Okay.

• 27:06Speaker 01

  That diet was high in calcium, high in magnesium, high in potassium, protein and fiber. It was low in fat and saturated fat.

• 27:15Speaker 00

  But it's not super low in salt?

• 27:16Speaker 01

  No.

• 27:17Speaker 00

  Oh.

• 27:17Speaker 01

  So the first dash trial is just, can we look at just the foods that people eat, period?

• 27:25Speaker 00

  So it's like low fat, careful eating and baconator. It's just comparing those three things.

• 27:31Speaker 01

  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 ish.

• 27:51Speaker 01

  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.

• 28:00Speaker 00

  So the dash diet worked to reduce blood pressure, which is the goal of the diet?

• 28:04Speaker 01

  Absolutely. 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.

• 28:26Speaker 00

  Okay, cool.

• 28:27Speaker 01

  The results this time were even more striking. The lower sodium diets yielded much more significant drops in blood pressure.

• 28:35Speaker 00

  Okay.

• 28:36Speaker 01

  We're now into the world of like double digit changes in your blood pressure, and that's genuinely huge, right?

• 28:43Speaker 00

  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.

• 28:53Speaker 01

  So here's the challenge with the dash diet. The dash diet hinged on someone else preparing your food for you.

• 29:02Speaker 00

  Right, right.

• 29:03Speaker 01

  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 a bunch of different ways.

• 29:11Speaker 00

  And you're motivated. You know it's a short term thing.

• 29:14Speaker 01

  Absolutely.

• 29:14Speaker 00

  That's very different than doing it for the rest of your life.

• 29:16Speaker 01

  Yes, you're having those like quasi celebrity experience of like kind of having a personal chef.

• 29:21Speaker 00

  Yeah, or people asking you like, what'd you eat today? It's like dating someone.

• 29:24Speaker 01

  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%.

• 29:50Speaker 00

  Oh, wow.

• 29:50Speaker 01

  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%.

• 30:02Speaker 00

  Oh, wow. I'm assuming these are self-reported as well.

• 30:05Speaker 01

  That's right. And as ever, the maintenance phase is the diet, right? Like pretty explicitly.

• 30:11Speaker 00

  She said the name of the song.

• 30:12Speaker 01

  Oh, my God, it's happening!

• 30:16Speaker 01

  Like, pretty clearly, the DASH diet is designed to be followed for life.

• 30:21Speaker 00

  Yeah, yeah.

• 30:22Speaker 01

  If people are having this hard a time, even in short test periods.

• 30:27Speaker 00

  Right, yeah.

• 30:28Speaker 01

  It doesn't bode well for how that translates in terms of like, a set of public practices, right?

• 30:34Speaker 00

  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.

• 31:16Speaker 01

  Right, and you should have made the heart-healthy choice of ordering a Baconator.

• 31:20Speaker 00

  Right, exactly, yeah. I think it was like an Anthony Bourdain episode where he mentioned, kind of offhand, that restaurant mashed potatoes are typically 50% butter.

• 31:30Speaker 01

  That's the Jean Georges ratio.

• 31:33Speaker 00

  Oh, really?

• 31:33Speaker 01

  Famously, that he was like, 1 pound of potato to 1 pound of butter.

• 31:37Speaker 00

  Yeah, like, restaurant food's hella good, because part of it is like, they don't care how much, like, sugar, fat, salt, whatever they put in the food.

• 31:44Speaker 01

  So, one of the problems with the DASH diet, and with like, kind of any low-sodium diet recommendations, is adherence rates, right? The other is that, as we learn, as the research sort of continues to unfold, is that different people respond really differently to sodium. As you can imagine, following the release of the DASH trials and the DASH sodium trials, there is kind of an explosion in sodium intake and heart health research, because there is sort of this sense of like, "Okay, we're on to something."

• 32:20Speaker 00

  Yeah.

• 32:21Speaker 01

  "Let's dig in, let's figure out how those DASH diets impact normative people, people who don't have hypertension."

• 32:28Speaker 00

  Normative?

• 32:29Speaker 01

  That is the term of art, Michael.

• 32:32Speaker 00

  Turfs would call that a slur. They think cisgender's a slur.

• 32:37Speaker 01

  In the process of calling it a slur, they become hypertensive.

• 32:43Speaker 01

  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.

• 32:59Speaker 00

  Yeah, as a member of the norm intensive community, I need to know what I can take from this. You know, I'm norm intensive. You've changed.

• 33:05Speaker 01

  Among other things, we learned that not everyone has the experience of increased sodium intake, increasing their blood pressure.

• 33:12Speaker 00

  Oh.

• 33:13Speaker 01

  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.

• 33:25Speaker 00

  Your, your heart expands expecting salt.

• 33:28Speaker 01

  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.

• 33:42Speaker 00

  Right, right.

• 33:42Speaker 01

  All of that means that the public health question then starts to shift, right? If a significant portion of the population has hypertension and sodium reduction can help prevent heart attacks, strokes and death, is it worth reorganizing our food systems to keep those folks alive?

• 34:02Speaker 00

  Right.

• 34:03Speaker 01

  Right? Or do we need to do a bunch more research on people who are at less risk?

• 34:08Speaker 00

  Right.

• 34:09Speaker 01

  In order to make those kinds of like food systems level decisions, right?

• 34:14Speaker 00

  And also there's also, I mean, the problem of adherence is not a minor problem.

• 34:18Speaker 01

  No.

• 34:18Speaker 00

  Giving people food in this very structured way is actually very different from telling people to eat differently.

• 34:24Speaker 01

  Totally. And again, this is all research on people who have high blood pressure and who have heart disease.

• 34:32Speaker 00

  Right. And are super motivated. Yeah.

• 34:34Speaker 01

  And are super motivated and have high stakes sitting right in front of them.

• 34:38Speaker 00

  Right.

• 34:38Speaker 01

  And the question is, what do we do for everybody?

• 34:41Speaker 00

  Also, I just looked up hypertension prevalence and it's fucking 47%.

• 34:46Speaker 01

  It's really fucking high, Mike.

• 34:48Speaker 00

  It's a massive deal. If this is useful for people with hypertension. Yeah.

• 34:52Speaker 01

  In that way, we're kind of doing a trolley problem.

• 34:55Speaker 00

  Right, right.

• 34:56Speaker 01

  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.

• 35:08Speaker 00

  Okay.

• 35:08Speaker 01

  So we're just getting like more and more and more nuance, more and more light and shading to the sort of salt data.

• 35:15Speaker 00

  Right.

• 35:16Speaker 01

  There are some broader limitations to the research 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 NHANES, which is a long-running nutrition research study.

• 35:39Speaker 00

  Yeah.

• 35:40Speaker 01

  Where researchers ask folks to recall just what they've eaten in the last 24 hours.

• 35:44Speaker 00

  Right.

• 35:44Speaker 01

  And then those researchers run analysis.

• 35:47Speaker 00

  Highly problematic methodology, but there's not a lot of other methodologies available. Because like people cannot remember what they ate. And then also, if somebody says like, "I had a pizza yesterday", it's not totally clear how much sodium that had, right?

• 35:59Speaker 01

  100%.

• 35:59Speaker 00

  It depends on the pizza, depends on how much pizza.

• 36:01Speaker 01

  You're gonna have to make some assumptions in NHANES world. One of those assumptions that they make in terms of sodium data is that when people say that they ate rice, they assume that folks have salted the water in which their rice is cooked.

• 36:15Speaker 00

  Oh, interesting. But these are boomers, they're not doing it.

• 36:17Speaker 01

  It's actually less relevant about sort of findings across age and much more relevant around findings around race.

• 36:25Speaker 00

  Yeah, they do have race data, so they should assume that the white people are not salting their rice.

• 36:29Speaker 01

  Incorrect, Michael.

• 36:32Speaker 00

  Wait, really?

• 36:33Speaker 01

  The white people are salting their rice water. But some studies that drilled down on sodium consumption of Asian Americans, as we've noted before, soy sauce is really high in sodium, right?

• 36:47Speaker 00

  Right.

• 36:48Speaker 01

  Those studies found that fewer Asian Americans were salting their rice water, which could be leading to a miscount of around 325mg per day for folks who eat rice regularly but don't salt their rice water.

• 37:02Speaker 00

  Even salting your pasta or your rice can be like a teaspoon or like three tablespoons, depending on the person, right? I mean, even that is like not completely accurate. I know I'm just like nitpicking now, but it's just so fucking hard to do these studies.

• 37:14Speaker 01

  That's exactly right. That's the whole point, Mike, is 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?

• 37:31Speaker 00

  Right.

• 37:31Speaker 01

  There are so many other factors with hypertension, right?

• 37:34Speaker 00

  Right.

• 37:34Speaker 01

  Your baseline life stress is as much a factor. Your like socioeconomic status, your educational attainment. It's not possible for us to isolate, okay, when we're only looking at salt in someone's life. We can get closer to the mark, but we can't go, okay, it's just specifically the salt. It's only the salt, right?

• 37:56Speaker 00

  Right.

• 37:56Speaker 01

  Because of this large boom of research in salt, there are some studies that are like, ooh, wait a minute, we're looking at normative people. It's your people, Mike.

• 38:07Speaker 00

  It's my community.

• 38:08Speaker 01

  Those studies find that there may be an association with very, very low sodium diets and increased mortality.

• 38:17Speaker 00

  Okay.

• 38:17Speaker 01

  But those studies are not very large. And in a place like the US, 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?

• 38:35Speaker 00

  Right.

• 38:36Speaker 01

  But that sort of drop in the bucket of like, ooh, 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.

• 38:54Speaker 00

  Right.

• 38:55Speaker 01

  So this lands as like, uh, like an edgelord kind of like man bites dog kind of story, right? Hey, wait a minute, what if everything we knew on this topic was wrong, right?

• 39:05Speaker 00

  Yeah.

• 39:05Speaker 01

  It's an enticing little hook.

• 39:07Speaker 00

  Someone should make a podcast with like that as like a concept or like a title.

• 39:10Speaker 01

  Interesting. What if we're wrong about everything we thought?

• 39:12Speaker 00

  Preconceptions that we had previously.

• 39:14Speaker 01

  So there's this article that comes out in Science that collapses it into this, see, we're being misled.

• 39:21Speaker 00

  Right.

• 39:22Speaker 01

  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?

• 39:31Speaker 00

  Right.

• 39:32Speaker 01

  Those stories are not really contextualized in a broader conversation like the one that we're having today that is like, okay, but let's look at who needs it the most, right? Let's look at the scale of the problem here.

• 39:45Speaker 00

  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.

• 39:53Speaker 01

  Right. And if you do have hypertension, even if you're super motivated, your adherence is going to be low because it's not really possible for you to hang in our current food environment with a lower salt diet.

• 40:03Speaker 00

  Yeah.

• 40:03Speaker 01

  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.

• 40:17Speaker 00

  The salt industry? Is that just like the packaged foods industry?

• 40:20Speaker 01

  No.

• 40:21Speaker 00

  There's Big Salt? Big Salt exists?

• 40:24Speaker 01

  There is. Their lobbying arm was called the Salt Institute. So they named it so that they could, they billed themselves as, quote, "the world's foremost experts on sodium." So they tried to make themselves seem kind of like they were academics, but they are straightforwardly a, an industry lobby group.

• 40:43Speaker 00

  They should have called it the Sodium Podium. Because we're standing there and we're talking to you.

• 40:47Speaker 01

  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, ALEC. 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.

• 41:28Speaker 00

  The only thing she loves more than salt is black people not voting.

• 41:31Speaker 01

  And in some cases, not living because they also fomented stand your ground laws, voter ID laws.

• 41:38Speaker 00

  Okay, fuck it. Never eat salt again. I've heard enough.

• 41:41Speaker 01

  So this is the thing that absolutely Jokerfied me is I was like, okay, so fuck these guys.

• 41:46Speaker 00

  Yeah, fuck salt.

• 41:46Speaker 01

  Also, one of the Salt Institute staffers, someone named Morton Satin, which I think is very funny.

• 41:53Speaker 00

  Morton, yeah.

• 41:54Speaker 01

  The salt guy was named Morton.

• 41:56Speaker 00

  Even weirder that he has a yellow raincoat on and an umbrella wherever he goes.

• 41:59Speaker 01

  Morton Satin also wrote extensively for the Weston A. Price Foundation.

• 42:05Speaker 00

  Every one of our episodes leads to the same fucking URL. The same people saying the same shit.

• 42:11Speaker 01

  Their advocacy efforts have generally been completely and totally fucking unhinged.

• 42:17Speaker 00

  Right.

• 42:17Speaker 01

  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.

• 42:33Speaker 00

  Right.

• 42:34Speaker 01

  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.

• 42:46Speaker 00

  Okay.

• 42:47Speaker 01

  They're like, they shouldn't be able to advertise that.

• 42:49Speaker 00

  Just cartoon evil, yeah.

• 42:51Speaker 01

  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.

• 43:05Speaker 00

  Right.

• 43:05Speaker 01

  In 2016, for example, Lori 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."

• 43:24Speaker 00

  What?

• 43:24Speaker 01

  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.

• 43:32Speaker 00

  Okay, so I'm holding the salt constant, but just adjusting the amounts of food.

• 43:37Speaker 01

  Now I'm gonna eat three times as much if there's one-third as much salt, which you're like, lady, absolutely not.

• 43:43Speaker 00

  I don't think so.

• 43:44Speaker 01

  And they also start to get some kind of salt curious pieces out of centrist outlets. One of them comes from our friends at The Atlantic and is titled...

• 43:57Speaker 01

  The Great Salt Debate: So Bad? Question mark?

• 44:01Speaker 00

  Question mark. Love those.

• 44:02Speaker 01

  It seems like it's going to sort of like litigate the science of like, wait a minute, what do we know now about salt consumption and like how dangerous it is? It's not that. It is straightforwardly a profile of a guy who works for the Salt Institute.

• 44:16Speaker 00

  Oh, really?

• 44:17Speaker 01

  Yeah.

• 44:18Speaker 00

  Oh, that's so fucking funny.

• 44:19Speaker 01

  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."

• 44:32Speaker 00

  Yeah.

• 44:33Speaker 01

  Absolutely, ideally, and we could study this for another 50 years and still feel like the results were inconclusive.

• 44:40Speaker 00

  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.

• 44:45Speaker 01

  Yep.

• 44:46Speaker 00

  But I kind of remember being like, "Oh, okay, salt is chill. I just like, don't need to think about my salt consumption." And that's basically what I've done ever since.

• 44:52Speaker 01

  Yeah, yes.

• 44:53Speaker 00

  So I'm part of the problem.

• 44:54Speaker 01

  So while this debate is going on, while all of this research continues, so does policymaking. 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, Campbell's did a big rollout, being like, "We're cutting our sodium by 40%."

• 45:17Speaker 00

  I remember that, yeah.

• 45:18Speaker 01

  People had such a negative reaction to it that Campbell sort of rolled it back.

• 45:22Speaker 00

  Really? They actually reversed it?

• 45:24Speaker 01

  They reversed, uh, big parts of it. Um, they didn't go back to their original super high sodium levels, but they did increase sodium again.

• 45:32Speaker 00

  That's so fucking funny.

• 45:33Speaker 01

  And they dropped the labeling. And actually, that's part of what happens from here on out, is that companies start reformulating their products to be lower in sodium, which is good, but none of them are talking about it.

• 45:45Speaker 00

  It's also so funny to me that like, the population is pissed off. There's less sodium in their food.

• 45:49Speaker 01

  People get so irrationally mad. It's like gluten levels of anger.

• 45:55Speaker 00

  Because it's not like you can't just add salt. Like, if Campbell's Chicken Soup tastes bad, you just add a fucking half a teaspoon of salt when you make it. It's not like that big of a deal.

• 46:04Speaker 01

  It's really not, and people lose their fucking

• 46:07Speaker 00

  I add salt to my peanut butter and it's bomb as hell. Cause you have to stir it anyway cause it separates. Like almond butter is awful without salt. If you just add like a fuck ton of salt, it's so much better. So like, yeah, I don't complain there's not enough salt in the peanut butter. I just add fucking salt.

• 46:20Speaker 01

  That's right. And also like, again, we're not even talking about palatability for so much of this, right?

• 46:25Speaker 00

  I thought my peanut butter and my heart is small as hell. Cause they're always telling me I have a small heart.

• 46:30Speaker 01

  The FDA rolls out these voluntary sodium reduction programs that again, surprised me that they did as much as they did. The American Heart Association started advocating with companies directly to reformulate. Nestle, General Mills, PepsiCo, Kraft, Heinz, Subway, and Panera all took on voluntary initiatives to reduce sodium in their products in the 2000s and 2010s. And more Americans were self-reporting that they checked labels for sodium. That's them telling someone, I checked the label for sodium.

• 47:04Speaker 00

  Right.

• 47:04Speaker 01

  Which I think just means they know that's the right health conscious answer. And they want to seem like a health conscious person. But even if they're just saying it, there is some sense of like, okay, well, the writing's on the wall. We should probably pay attention to this.

• 47:18Speaker 00

  Right.

• 47:19Speaker 01

  And it's borne out by sales data. So a 2017 JAMA study looked at grocery and convenience store sales data and found that between 2000 and 2014, Americans' food purchases reflected a 12% drop in dietary sodium.

• 47:40Speaker 00

  Okay.

• 47:41Speaker 01

  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.

• 48:00Speaker 00

  We're still way over it, but it's, it's getting there. Yeah.

• 48:03Speaker 01

  In 2019, to sort of everyone's surprise, the Salt Institute closed.

• 48:08Speaker 00

  Vaccinated?

• 48:12Speaker 01

  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 in 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.

• 48:36Speaker 00

  I'll bet those emails are wild.

• 48:37Speaker 01

  I bet they're nutty.

• 48:39Speaker 00

  It's like the psycho salt lobbyist and the psycho restaurant lobbyist, like, fighting.

• 48:44Speaker 01

  In terms of where we are today, there is some disagreement about the specific threshold, but most major health institutions in the US 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 US's per capita sodium intake is plateauing. Some measures show it reducing a tiny bit. But the good news is that even without those sort of salt interventions, which could accelerate this, deaths related to heart disease have been declining since the 1970s.

• 49:26Speaker 00

  Right.

• 49:27Speaker 01

  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 US government to today, we have like dozens of treatments that have come on to the market that are way more effective.

• 49:49Speaker 00

  Well, that's the other thing.

• 49:50Speaker 01

  Earlier detection, the rollout of those little blood pressure machines and people taking their blood pressure at home.

• 49:56Speaker 00

  Yeah.

• 49:57Speaker 01

  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.

• 50:08Speaker 00

  Yeah.

• 50:08Speaker 01

  The same goes for SGLT2 inhibitors, like Jardiance and Farsiga.

• 50:13Speaker 00

  Oh, right.

• 50:13Speaker 01

  Those received FDA approval for the first time in the 2010s. Those medications work regardless of a patient's salt sensitivity, and they don't have the same absolutely brutal adherence rates, right?

• 50:27Speaker 01

  Like a lot of people can take a pill once a day. The biggest barrier there is how fucking expensive they are.

• 50:33Speaker 00

  Right. I think there's this, 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.

• 50:45Speaker 01

  We've just gotten better at talking about a bunch of facets of it.

• 50:49Speaker 00

  Right.

• 50:49Speaker 01

  And salt is one of many facets.

• 50:52Speaker 00

  I do think this is the most it depends episode we've ever done.

• 50:56Speaker 01

  It's such an it depends episode. You're exactly right.

• 50:58Speaker 00

  Cause like some people should reduce their salt.

• 51:00Speaker 01

  Some people should increase it.

• 51:01Speaker 00

  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.

• 51:09Speaker 01

  Yeah.

• 51:09Speaker 00

  And there's more effective treatments.

• 51:11Speaker 01

  Yeah.

• 51:12Speaker 00

  It's not like, stop using light salad dressing. It's like, take a statin.

• 51:16Speaker 01

  Yeah, I think that's right. And also the take a statin stuff is like more effective.

• 51:20Speaker 00

  Right.

• 51:20Speaker 01

  Than an intervention that is very difficult to do with a very low adherence rate because of how difficult it is to do.

• 51:26Speaker 00

  Right.

• 51:27Speaker 01

  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?

• 51:40Speaker 00

  Right.

• 51:41Speaker 01

  But it can also be true that our food system has a fuck ton of sodium in it.

• 51:46Speaker 00

  Right.

• 51:46Speaker 01

  And we should be able to control for that in ways that allow people to have the control that they need.

• 51:52Speaker 00

  Right.

• 51:52Speaker 01

  So that if you are a person who needs to up your sodium, you know that you're upping your sodium.

• 51:57Speaker 00

  Right.

• 51:57Speaker 01

  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.

• 52:06Speaker 00

  Yeah.

• 52:07Speaker 01

  The food system cuts in favor of the presumably small number of people who need more sodium in their diet.

• 52:15Speaker 00

  Right.

• 52:15Speaker 01

  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.

• 52:28Speaker 00

  Yeah.

• 52:28Speaker 01

  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.

• 52:39Speaker 00

  Although after the show comes out, everyone is swapping soy sauce for baconators. Everyone's doing it.

• 52:45Speaker 01

  For your health!