Sodium and the Dietary Guidelines

Slide 1: Sodium and The Dietary Guidelines Nutrient Essentials Penny Kris-Etherton, Ph.D., R.D. Department of Nutritional Sciences Pennsylvania State University

Slide 2: 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

Slide 3: Dietary Guidelines for Americans, 2005 Key Scientific Recommendations • Consume a variety of foods within and among the basic food groups while staying within energy needs • Control calorie intake to manage body weight • Be physically active every day • Increase daily intake of fruits and vegetables, whole grains, and reduced-fat milk and milk products • Choose fats wisely for good health • Choose carbohydrates wisely for good health • Choose and prepare foods with little salt • If you drink alcoholic beverages, do so in moderation • Keep food safe to eat

Slide 4: 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.

Slide 5: Dietary Guidelines, 2005 Recommendations 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.

Slide 6: 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

Slide 7: 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

Slide 8: Current Dietary Recommendations for Sodium & Potassium 2003-2006 2006 AHA Diet and Lifestyle An achievable goal – 2.3 g/d; upper level could Revision be as low as 1.5 g/d 2006 AHA Science Statement Lower salt intake as much as possible: 1.5 g/d on Prevention and Treatment of Increase potassium to 4.7 g/d Hypertension 2005 Dietary Guidelines for Consume less than 2.3 g/d; persons with Americans hypertension, blacks, middle-age & older adults: 1.5 g/d. Increase potassium to 4.7 g/d 2004 DRI from National AI = 1.5 g/d, UL = 2.3 g/d Academies Potassium, AI = 4.7 g/d 2003 NIH/ NHLBI, JNC 7 Consume less than 2.4 g/d

Slide 9: Less Than 25% of Population has Sodium Intake of 2400 mg or Less National Health and Nutrition Examination Survey, NCHS, CDC

Slide 10: 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

Slide 11: Lifestyle Modifications to Manage Hypertension Modification Recommendations Approximate SBP Reduction Weight Reduction Maintain normal body 5-20 mm Hg for each weight (BMI 18.5-24.9) 10 kg weight loss Adapt DASH eating plan Consume diets rich in 8-14 mm Hg fruits, vegetables, low fat dairy and low saturated fat Dietary sodium reduction Reduce sodium to no more 2-8 mm Hg than 2.4 g/day sodium or 6 g/day NaCl Increase physical activity Engage in regular aerobic 4-9 mm Hg activity such as walking (30 min/day on most days) Moderate alcohol consumption Limit alcohol to no more 2-4 mm Hg than 2 drinks/d for men and 1 drinks/day for women. 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.

Slide 12: USDA Food Guide - Food Group Recommendations 1600 kcals 2000 kcals 2400 kcals Fruits 1.5 c (3 serv) 2 c (4 serv) 2 c (4 serv) Vegetables 2 c (4 serv) 2.5 c (5 serv) 3 c (6 serv) 2 c/wk 3 c/wk 3 c/wk dark green 1.5 c/wk 2 c/wk 2 c/wk orange 2.5 c/wk 3 c/wk 3 c/wk legumes 2.5 c/wk 3 c/wk 6 c/wk starchy other 5.5 c/wk 6.5 c/wk 7 c/wk Grains 5 oz. equivalent 6 oz. equivalent 8 oz. equivalent whole grains 3 oz. 3 oz. 4 oz. other grains 2 oz. 3 oz. 4 oz. Lean meat/beans 5 oz. equivalent 5.5 oz. equivalent 6.5 oz. equivalent Milk 3c 3c 3c Oils 22 g 24 g 31 g 132 362 Discretionary kcal 267

Slide 14: 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.

Slide 15: 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

Slide 16: Macronutrient Profile of a Mypyramid.gov Recommended 2000 kcal diet Energy , kcal/day 1987 Carbohydrate, % energy 55 Protein, % energy 18 Total Fat, % energy 29 SFA, % energy 7.8 MUFA, % energy 10.7 PUFA, % energy 8.9 Trans FA N/A Cholesterol, mg/day 230 Fiber, gm/day 31 Sodium, mg/day 1779 Alcohol N/A

Slide 17: DASH PYRAMID

Slide 18: cartoonstock.com

Slide 19: Sources of Sodium in the Diet Added at table Added during cooking 5% 6% Inherent in foods 12% Food Processing 77%

Slide 20: Food Group Contributions to Sodium Intake as a % of Total Intake Beverages, Sugars, Sweets 2% Fruits <1% Fats & oils 4% Milk Products 8% Grain Products Vegetables 37% 14% Meat, Poultry, Fish, Beans, Eggs, Nuts 35% CNPP Nutrition Insights 1997

Slide 21: But, Doctor, I Never Use A Salt Shaker Yes, Mr. Smith. You don’t salt anything, but you do eat a lot of sodium!

Slide 22: Low-Sodium Cookbooks

Slide 24: 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

Slide 25: 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

Slide 26: 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

Slide 27: Minnesota Heart Survey : Overall HDPEI Scores Between 1980 and 2002; improvements level off from 1995-2002 Lee S. et al., JADA, 107:213-222, 2007

Slide 28: Improvements in Selected Variables Across Quintiles of the Heart Disease Prevention Eating Index (HDPEI) –Minnesota Heart Survey (n=11,439) Variable (means) Q1 Q2 Q3 Q4 Q5 P for 28.7 32.8 36.9 trend 22.3 44.0 mean score 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 Lee S. et al., JADA, 107:213-222, 2007

Slide 29: 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