Sodium and The Dietary Guidelines

Nutrient EssentialsPenny Kris-Etherton, Ph.D., R.D.Department of Nutritional SciencesPennsylvania State University

Outline– Dietary Guidelines for Americans, 2005

• General Recommendations• Recommendations for Sodium and Potassium

– AHA Diet and Lifestyle Revision, 2006• General Recommendations• Recommendations for Sodium and Potassium

– Strategies to Achieve Sodium Recommendations• Sources of Sodium in the Diet• AHA Recommendations for Restaurants and the Food Industry

– Long Range Goal –Achieve Dietary Pattern Consistent with Current Dietary Recommendations

• Minnesota Heart Survey

– Summary

Dietary Guidelines for Americans, 2005 Key Scientific Recommendations

1. Consume a variety of foods within and among the basic food groups while staying within energy needs

2. Control calorie intake to manage body weight

3. Be physically active every day

4. Increase daily intake of fruits and vegetables, whole grains, and reduced-fat milk and milk products

5. Choose fats wisely for good health

6. Choose carbohydrates wisely for good health

7. Choose and prepare foods with little salt

8. If you drink alcoholic beverages, do so in moderation

9. Keep food safe to eat

Sodium and Potassium

• Consume < 2,300 mg (~1 tsp. salt) of sodium per day

• Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as fruits and vegetables.

Dietary Guidelines, 2005Recommendations for Special Populations

• Specific recommendations for individuals with hypertension, blacks, and middle-aged and older adults– Aim to consume no more than 1,500 mg of

sodium per day, and meet the potassium recommendation (4,700 mg) with food.

AHA Diet and Lifestyle Goals for Cardiovascular Disease Risk Reduction

• Consume an overall healthy diet

• Aim for healthy body weight

• Aim for recommended levels of LDL-C, HDL-C and triglycerides

• Aim for normal blood pressure

• Aim for normal blood glucose level

• Be physically active

• Avoid use of and exposure to tobacco products

Lichtenstein et al., Circulation, 114, 82-96, 2006

AHA Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction

• Balance calorie intake and activity to achieve a healthy weight• Consume diet rich in fruits & vegetables• Choose whole-grain, high-fiber foods• Consume fish, especially oily fish, 2X per week• Limit intake of saturated fat to <7% of calories, trans fat to <1% of

calories and cholesterol to < 300 mg per day by:– Choosing lean meats and vegetable alternatives– Selecting fat-free, 1% or low-fat dairy products– Minimizing intake of partially hydrogenated fats

• Minimize intake of added sugars• Choose and prepare foods with little or no added salt• If you consume alcohol, do so in moderation• When you eat food outside the home, follow the AHA Recommendations

Lichtenstein et al., Circulation, 114, 82-96, 2006

Current Dietary Recommendations for Sodium & Potassium 2003-2006

2006 AHA Diet and Lifestyle Revision

An achievable goal – 2.3 g/d; upper level could be as low as 1.5 g/d

2006 AHA Science Statement on Prevention and Treatment of Hypertension

Lower salt intake as much as possible: 1.5 g/d Increase potassium to 4.7 g/d

2005 Dietary Guidelines for Americans

Consume less than 2.3 g/d; persons with hypertension, blacks, middle-age & older adults: 1.5 g/d. Increase potassium to 4.7 g/d

2004 DRI from National Academies

AI = 1.5 g/d, UL = 2.3 g/d

Potassium, AI = 4.7 g/d

2003 NIH/ NHLBI, JNC 7 Consume less than 2.4 g/d

Less Than 25% of Population has Sodium Intake of 2400 mg or Less

National Health and Nutrition Examination Survey, NCHS, CDC

Less Than 5 % of U.S. Population Meets Adequate Intake (from DRI’s) for Potassium

*AI from DRIs** statistically unreliable

National Health and Nutrition Examination Survey, NCHS, CDC

Lifestyle Modifications to Manage Hypertension

Modification Recommendations Approximate SBP Reduction

Weight Reduction Maintain normal body weight (BMI 18.5-24.9)

5-20 mm Hg for each 10 kg weight loss

Adapt DASH eating plan Consume diets rich in fruits, vegetables, low fat dairy and low saturated fat

8-14 mm Hg

Dietary sodium reduction Reduce sodium to no more than 2.4 g/day sodium or 6 g/day NaCl

2-8 mm Hg

Increase physical activity Engage in regular aerobic activity such as walking (30 min/day on most days)

4-9 mm Hg

Moderate alcohol consumption Limit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women.

2-4 mm Hg

Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7. Report. JAMA. 2003;289:2560-2572.

USDA Food Guide - Food Group Recommendations

1600 kcals 2000 kcals 2400 kcalsFruits 1.5 c (3 serv) 2 c (4 serv) 2 c (4 serv)Vegetables dark green orange legumes starchy other

2 c (4 serv)2 c/wk

1.5 c/wk2.5 c/wk2.5 c/wk5.5 c/wk

2.5 c (5 serv)3 c/wk2 c/wk3 c/wk3 c/wk

6.5 c/wk

3 c (6 serv)3 c/wk2 c/wk3 c/wk6 c/wk7 c/wk

Grains whole grains other grains

5 oz. equivalent

3 oz.2 oz.

6 oz. equivalent

3 oz.3 oz.

8 oz. equivalent

4 oz.4 oz.

Lean meat/beans 5 oz. equivalent 5.5 oz. equivalent 6.5 oz. equivalent

Milk 3 c 3 c 3 c

Oils 22 g 24 g 31 g

Discretionary kcal 132 267 362

What is a "Healthy Diet"?The Dietary Guidelines describe a healthy diet as one that

•Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products;

•Includes lean meats, poultry, fish, beans, eggs, and nuts; and

•Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars.

Why is it important to eat fruits and vegetables?

•Eating fruit and vegetables provides health benefits – people who eat more fruits and vegetables as part of an overall healthy diet are likely to have a reduced risk of some chronic diseases.

•Most fruits are naturally low in fat, sodium and calories.

•Fruits and vegetables are important sources of potassium, dietary fiber, vitamin C & A and folate

•Prepare foods from fresh ingredients to lower sodium intake. If buying canned vegetables, select those labeled “no salt added”

www.MyPyramid.gov

Macronutrient Profile of a Mypyramid.gov Recommended 2000 kcal diet

Energy , kcal/day 1987Carbohydrate, % energy 55Protein, % energy 18Total Fat, % energy 29SFA, % energy 7.8MUFA, % energy 10.7PUFA, % energy 8.9Trans FA N/ACholesterol, mg/day 230Fiber, gm/day 31Sodium, mg/day 1779Alcohol N/A

DASH PYRAMID

cartoonstock.com

Sources of Sodium in the Diet

Food Processing 77%

Inherent in foods 12%

Added at table 6%

Added during cooking 5%

Food Group Contributions to Sodium Intake as a % of Total Intake

Grain Products 37%

Meat, Poultry, Fish, Beans, Eggs, Nuts 35%

Vegetables 14%

Milk Products 8%

Fats & oils 4%

Beverages, Sugars, Sweets 2%Fruits <1%

CNPP Nutrition Insights 1997

Yes, Mr. Smith. You don’t salt anything, but you do eat a lot of sodium!

But, Doctor, I Never Use A Salt ShakerBut, Doctor, I Never Use A Salt Shaker

Low-Sodium Cookbooks

High-priority Recommendations to Facilitate Adoption of AHA Diet and Lifestyle Recommendations

• Groups included: Health Practitioners, Restaurants, Food Industry, Schools, Local Government

• Specific Recommendations– Restaurants

• Display calorie content or make information easily accessible• Reduce portion sizes• Reformulate products to reduce calories, sodium, saturated and

trans fat• Provide more vegetable options, and prepare them with minimal

added calories and salt• Provide more fruit options, with minimal added sugar• Develop creative marketing approaches for fruits & vegetables• Allow healthy substitutions• Provide whole-grain options

Adapted from Lichtenstein et al., Circulation, 114, 82-96, 2006

High-priority Recommendations to Facilitate Adoption of AHA Diet and Lifestyle Recommendations

• Groups included: Health Practitioners, Restaurants, Food Industry, Schools, Local Government

• Specific Recommendations

– Food Industry

• Reduce salt and sugar content of processed foods

• Replace saturated and trans fat in prepared foods with low-saturated fat oils

• Increase proportion of whole grain foods available

• Package foods in smaller portion sizes

• Develop packaging that allows more stability, preservation and palatability of fresh fruits & vegetables without added sodium

Adapted from Lichtenstein et al., Circulation, 114, 82-96, 2006

Practical Tips to Implement AHA Diet and Lifestyle Recommendations (Sodium Related)

• Food choices and preparation– Use nutrition facts panel and ingredients list to choose food purchases

• Eat fresh, frozen and canned vegetables and fruits without high-calorie sauces, added salt and sugars

• Reduce salt intake by:– Comparing sodium content of products and choosing ones with less

salt

– Choosing reduced sodium versions or foods, including cereals and baked goods

– Limiting condiments (eg. soy sauce, ketchup)

• Limit processed meat intake, especially those high in saturated fat and sodium

Lichtenstein et al., Circulation, 114, 82-96, 2006

Lee S. et al., JADA, 107:213-222, 2007

Minnesota Heart Survey : Overall HDPEI Scores Between 1980 and 2002; improvements level off from 1995-2002

Improvements in Selected Variables Across Quintiles of the Heart Disease Prevention Eating Index (HDPEI) –Minnesota

Heart Survey (n=11,439)

Variable (means) Q1

22.3

Q2 28.7

Q3 32.8

Q4 36.9

Q5

44.0

P for trend

BMI 30.1 27.8 26.7 25.8 24.8 <0.01

% en from Total Fat 40.9 37.2 35.0 32.6 27.0 <0.01

% en from SFA 15.3 13.6 12.4 11.1 8.3 <0.01

% en from TFA 3.0 2.7 2.6 2.3 1.8 <0.01

Cholesterol, mg/d 378 295 266 226 167 <0.01

Sodium, mg/d 3437 3304 3427 3423 3088 <0.01

mean score

Lee S. et al., JADA, 107:213-222, 2007

Summary

• Current dietary guidance targets sodium reduction, and provides strategies for implementation

• Given the widespread distribution of sodium in the food supply, there are many targets

• The restaurant and food industry can play a key role in decreasing sodium and helping consumers adhere to dietary recommendations