Excess salt is a primary cause of chronic disease and premature mortality. Cardiovascular and brain diseases, diabetes, and cancers in the face of which Covid 19 itself, as noted, has been listed as a secondary cause of the hundreds of thousands of deaths recorded so far (362,776 on 5/29/20, 3 p.m. Source Worldometer).
Excess sodium/salt and disease, a public health emergency
Awareness of the serious damage to health caused by excessive sodium intake (of which salt, sodium chloride, is a primary source) is still very low. Average intakes, in Europe, remain double the WHO(World Health Organization, or WHO) recommended safe threshold of 5 grams of salt per day. Despite public education efforts conducted globally and in Europe and in Italy by the Ministry of Health.
ISS (Istituto Superiore di Sanità), with the ‘Heart Project,’ informs and educates Italian citizens to prevent cardiovascular and brain diseases by drastically reducing dietary sodium intake. (1) A commendable and necessary effort, but not sufficient. Whereas:
– nutrition statements on food labels are not sufficient to effectively warn consumers with respect to salt/sodium content in various foods,
– shelf-stable food products still have sodium levels that are incompatible with public health needs, with rare exceptions. Critical levels also on vegetarian, vegan and gluten-free products, sometimes cloaked in an aura of wholesomeness. As well as, more generally, on convenience foods and
finger foods
.
Nutriscore-the colorful nutrition labeling system, on the label front-may help mitigate the problem. If applied on the labels of all foods, as European citizens are clamoring for. Offering producers the incentive to reformulate foods, consumers the ease of choosing healthier foods.
Homo sapiens, evolution and involution
Since the dawn of time, the ancestors ofHomo sapiens have been accustomed to consuming plant-based foods, meats and fish, without adding salt. (2) This resulted in a high intake of potassium, related 5:1 to sodium (also naturally contained in unprocessed foods). From the original paleo-diet to the modern diet, the potassium-to-sodium ratio has instead reversed to 1:5. (3)
From an evolutionary perspective, the human organism has thus been ‘programmed’ over millions of years to retain sodium and metabolize large amounts of potassium. Thus, the introduction of ultra-processed high-sodium foods in recent decades has led to a condition of severe stress on the body. (4)
In just a few decades , average salt intakes have risen from 1-1.5 grams per day to highs of 8-12 grams, with peaks of more than 6 grams for children and increasing doses as age progresses. (5) Their drastic reduction is therefore imperative, based on established scientific literature highlighting the dangers associated with this imbalance. (6,7)
Fig. 1. Reduce salt, the recommendations of ISS (Istituto Superiore di Sanità)
Salt and health, inverse relationship
The main risks associated with excessive salt consumption pertain to high blood pressure, cardiovascular and renal disease, and stomach cancer. (8) STRIVE(SalT Reduction InterVEntion)-a randomized, double-blind versus placebo clinical trial conducted in Copenhagen in 2018 in adults and children-demonstrated how an intervention of progressively decreasing salt in the diet can lead to surprising results in as little as four months. Reducing major cardiovascular risk factors as well as food flavor preferences. (9) Eureka!
A scientific review of research published up to 1.7.16 demonstrates in turn the extraordinary cost-effectiveness of national policies that follow an integrated approach. Reduction or substitution of salt in processed foods, taxes, labeling, awareness campaigns including through primary care medicine in the territory. (10) Limiting himself, among other things, to considering the danger of excess salt to the cardiovascular system.
The onset of diabetes-another epidemic disease with markedly increasing prevalence-is in turn associated with excess salt. And so do several cognitive diseases, such as Alzheimer’s. In fact, recent studies show how salt, by increasing the hyperintensity of the brain’s white matter, affects the onset of disease in small cerebral vessels and the extent of lesions. Other adverse effects include the occurrence of osteoporosis. (11)
Fig. 2. Adverse effects associated with excessive salt consumption (Kotchen et al., 2013)
Salt and health, synergies lacking
Industry, distribution and mass catering have a social responsibility to contribute to public health by reducing salt/sodium from food to a but drastic extent. The effectiveness of the intervention is linked to its progression but more importantly to its systemic application by all practitioners on the ground. (12)
Proper label information and public education are equally essential. Consumers are not yet able to associate the news on the label with the safe thresholds to keep at bay, nor are they aware of the negative health effects of excess salt. Beyond hypertension alone. (13)
Fig. 3. Possible synergistic interventions on salt consumption reduction (Ekmekcioglu et al., 2013)
The state and regions, including in Italy, need to strengthen communication and interventions. To effect a change in eating habits, with significant impact on chronic disabling diseases premature mortality. Well-informed consumers would reduce the doses of salt used if they were aware of the adverse health effects. But to this day, salt consumption is associated with the taste of foods and not with health. (14)
Consumers and the associations that aspire to represent them also have a role. Changing habits and reducing sodium intake is also an individual’s responsibility to their loved ones, as well as to themselves. (15) And it is essential to provide young children with a good example, so that they can rid themselves of diseases whose recurrence in the family stems not from genes but from unhealthy diets and lifestyles. (16, 17)
Dario Dongo and Andrea Adelmo Della Penna
Notes
(1) ISS. Heart Project, http://www.cuore.iss.it/
(2) Roberts. (2001). High salt intake, its origins, its economic impact, and its effect on blood pressure. Am. J. Cardiol. 88:1338-1346, doi: 10.1016/s0002-9149(01)02105-1
(3) Adrogue et al. (2007). Sodium and potassium in the pathogenesis of hypertension. N. Engl. J. Med. 356:1966-1978, doi: 10.1056/NEJMra064486
(4) Halperin et al. (2006). Control of potassium excretion: a paleolithic perspective. Curr. Opin. Nephrol. Hypertens. 15:430-436, doi: 10.1097/01.mnh.0000232884.73518.9c
(5) Brown et al. (2009). Salt intakes around the world: implications for public health. Int. J. Epidemiol. 38:791-813, doi: 10.1093/ije/dyp139
(6) ISS (2009). Reduce salt and sodium: everyone can do it-but why, and how? http://www.cuore.iss.it/prevenzione/pdf/sale_broch4pag.pdf
(7) FAO (2003). Diet, nutrition and the prevention of chronic diseases. WHO Technical Report Series 916, http://www.fao.org/3/AC911E/AC911E00.htm#Contents
(8) Neal (2014). Dietary salt is a public health hazard that requires vigorous attack. Canadian Journal of Cardiology 30:502-506, http://dx.doi.org/10.1016/j.cjca.2014.02.005
(9) Bjoernsbo et al. (2019). Salt reduction in families investigating metabolic, behavioral and health effects of targeted intake reductions: study protocol for a four-month three-armed, randomized, controlled “Real-Life” trial. International Journal of Environmental Research and Public Health 16:3532, doi:10.3390/ijerph16193532
(10) Schorling E, Niebuhr D, Kroke A. (2017). Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review. Public Health Nutr. 2017;20(11):1993‐2003. doi:10.1017/S1368980017000593
(11) Kendig et al. (2019). Reviewing the effects of dietary salt on cognition: mechanisms and future directions. Asia Pac. J. Clin. Nutr. 28(1):6-14, doi: 10.6133/apjcn.201903_28(1).0002
(12) Ekmekcioglu et al. (2013). Too much salt and how we can get rid of it. Forsch Komplementmed 20:454-460, doi: 10.1159/000357413
(13) Grimes et al. (2009). Consumer knowledge and attitudes to salt intake and labeled salt information. Appetite 53:189-194, doi:10.1016/j.appet.2009.06.007
(14) Jepson et al. (2010). The effectiveness of interventions to change six health behaviors: a review of reviews. BMC Public Health 10:538, doi: 10.1186/1471-2458-10-538
(15) Birch. (1999). Development of food preferences. Annu. Rev. Nutr. 19:41-62, doi: 10.1146/annurev.nutr.19.1.41
(16) Birch et al. (2001). Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatr. Clin. North. Am. 48:893-907, doi: 10.1016/s0031-3955(05)70347-3
(17) Honkanen et al. (2005). Intention to consume seafood – the importance of habit. Appetite 45:161-168, doi: 10.1016/j.appet.2005.04.005
Dario Dongo, lawyer and journalist, PhD in international food law, founder of WIISE (FARE - GIFT - Food Times) and Égalité.
Graduated in Food Technologies and Biotechnologies, qualified food technologist, he follows the research and development area. With particular regard to European research projects (in Horizon 2020, PRIMA) where the FARE division of WIISE Srl, a benefit company, participates.
