“Salt is so common, so easy to obtain, and so inexpensive that we have forgotten that from the beginning of civilization until about 100 years ago, salt was one of the most sought-after commodities in human history.” - Mark Kurlansky, Salt: A World History
Salt is a staple in all cooking. It is used not only to season food, but enhance the dishes flavors, helping to bring out the subtleties that would otherwise be missed. That is why people will often describe low-sodium foods as “bland.” We have a long history with salt, as it not only enhances foods flavor but it also helps with preservation. Before refrigeration, salt was used to cure and preserve meats and other foods to last through the winters when supplies were apt to dwindle. It is also used to control the fermentation process, enhance colors, and tenderize foods. When we discuss dietary health, we typically hear the word sodium and salt used interchangeably. But are they really the same thing?
Salt vs Sodium
Salt is actually a generic term that refers to any crystallized substance made up of a cation and an anion. Taking you back to high school chemistry, ions are charged atoms or small molecules, and ions can be divided into cations that are positively charged and anions, which are negatively charged. Cations and anions are also called electrolytes, as they are good conductors of electricity when they are dissolved in water. Sodium is an example of a cation and is an important electrolyte for human health. It is the 11th element on the periodic table and signified by the letters Na, which come from the Latin natrium for natron, a mineral composed of a mixture of sodium carbonate and sodium bicarbonate that was used by many early civilizations as a cleaning product. Natron was also used by the Egyptians in the process of mummification. Today we refer to sodium carbonate as “washing soda” or “soda ash” and is used frequently in homes that utilize water softeners. Sodium bicarbonate is used by many bakers and known commonly as “baking soda.”
The salt that many of us associate with cooking, table salt, is sodium chloride. This salt comes in many forms and varieties. Iodized salt is probably the most commonly used, and while it is primarily sodium chloride, it has small amounts of other iodine containing salts, such as potassium iodide, sodium iodide, and sodium iodate, added as a way to ensure we get an adequate amount of iodine in our diet. Iodine is vital in the production of thyroid hormone and without adequate intake children can develop a developmental disease called cretinism, characterized by intellectual disability, stunted growth, and hypothyroidism. Adults deficient in iodine can develop enlarged thyroid glands called goiters.
Salt also comes in different shapes and sizes. Classic table salt is made up of fine crystals that are best for getting accurate measurements when baking, whereas kosher salt is made of larger crystals perfect for adding texture when seasoning meat. You can also find salt flakes, which are typically used as a garnish, such as on a piece of chocolate or salted caramel. Sea salt has a slightly distinct flavor from table salt, as it contains traces of other salts containing magnesium, calcium, and sulfates. Himalayan salt, which can now be found in many grocery stores, is mostly sodium chloride, but gets its pink hue from mineral impurities. Himalayan salt is not fortified with iodine like table salt.
But the salt we sprinkle over our foods or that is added to processed foods is not the only source of sodium in our diets. Fresh fruits and vegetables and unprocessed meats already contain sodium, especially meat products, as this is an important electrolyte vital for life. Our bodies require a certain amount of sodium, which is crucial for cellular function, water balance, transmitting nerve signals, and a host of other functions. In medicine, we focus primarily on the concentration of sodium in our bodies, which is assessed by measuring the concentration of sodium in the blood. As with most things in medicine, it is all about balance or homeostasis. Rapid changes in the sodium levels can have devastating effects as it causes water to quickly shift in or out of cells. The brain is especially sensitive to these rapid shifts of fluid, leading to coma and death.
Dietary Sodium & Health
While table salt helps to enhance our gustatory experience while eating, consuming a diet high in sodium can lead to increased blood pressure (hypertension), which in turn increases your risk of heart disease, atherosclerosis, and stroke. In fact, building upon previous data that showed an increased risk of heart disease with higher sodium diets, a study conducted by Yang, et al (2011) demonstrated that higher sodium intake was associated with an increased risk of death from all causes. In the ’90s, studies began to look into the dietary effects on blood pressure, leading to the creation of new diet recommendations for those with hypertension. Three landmark studies helped further our understanding about the effects of dietary sodium on our health, specifically blood pressure. Karanja, et al (2004) provides a terrific review of these major studies and their findings. Click through the tabs below to learn a bit about each of them.
Funded by the National Heart, Lung, and Blood Institute, Appel. et al (1997) developed a clinical trial to investigate the effects of the Dietary Approaches to Stop Hypertension (DASH) diet on blood pressure. Based on findings that, on average, vegetarians have lower blood pressure than non-vegetarians, the DASH diet consisted of a diet high in fruits and vegetables, low-fat dairy, whole grains, poultry, fish and nuts, and low in fats (remember this was ’90s when we didn’t distinguish between healthy and non-healthy fats), red meat, sweets and sugary beverages. These specifications made the DASH diet high in calcium, magnesium, potassium, and fiber.
The study enrolled individuals who had a systolic blood pressure (SBP, the top number) less than 160 mm Hg and diastolic blood pressure (DBP, the bottom number) between 80 and 95 mm Hg. After controlling participants diet for three weeks, they were divided into three groups: 1) a control group receiving a diet similar to that of the average American, 2) a diet high in fruits and vegetables, and 3) the DASH diet as stated above. In this study, all participants received the same amount of sodium (3 grams/day with 500 mg of discretionary sodium). Participants followed this diet for eight weeks. What the researchers found was that those consuming the DASH diet had a greater decrease in blood pressure overall, but this change was more pronounced in those participants with hypertension. There was no significant difference in the change seen between those increasing their fruit and vegetable intake alone compared to the control diet.
The original DASH study kept all participants at a sodium intake of 3 grams per day, which was less than the average American diet, but still 600 mg higher than the recommended 2,400 mg per day. So, four years later, Sacks, et al (2001) set out examine the effects of the DASH diet combined with a reduction in sodium intake. Participants were divided into two separate groups: 1) control diet and 2) DASH diet. However, participants would be consuming these diets with varying levels of sodium intake. Sodium levels were defined as high (3,000 mg per day), intermediate (2,400 mg per day), and low (1,500 mg per day). All participants consumed diets for 30 days at each of these three levels and the order that they were given these was also randomized.
Again, as we’d expect, results showed that those consuming the DASH diet had a greater reduction in their blood pressure than those consuming the control diet. This effect was seen at all levels of sodium intake, adding further credence to the DASH diet to lower blood pressure. Similarly, decreasing sodium levels also showed a step-wise decrease in blood pressure with the greatest decrease in blood pressure seen in the low sodium groups, regardless of whether it was a control diet or the DASH diet. What was most interesting though, was that compared to the control diet with high sodium, those consuming the DASH diet with low sodium had significantly lower blood pressures, leading to changes that were greater than either the DASH diet or low sodium intake alone. This difference was most pronounced in those participants who had hypertension, leading to a decrease in SBP and DBP of 12 and 6 mm Hg, respectively; compared to 7 and 4 mm Hg, respectively, in non-hypertensives. This combination of DASH diet and low sodium was also more pronounced in women and black participants.
The problem with both DASH and DASH-Sodium were that both of them were not really designed for the real world. Participants were provided all of their meals, in an effort to control for any variation in diet and increase adherence to the diet. The PREMIER study (2003) tackled this issue by examining if these two recommendations, the DASH diet and reduced sodium intake, could be imparted on individuals to carry out in their normal daily living. Thus, participants were divided into three groups: 1) advice only, who received one 30-minute session with a registered dietitian regarding factors affecting blood pressure (weight, physical activity, sodium intake, and the DASH diet) and a handout to take home, 2) a behavioral intervention, and 3) a behavioral intervention plus the DASH diet. The behavioral intervention consisted of 18 sessions over 6 months, which focused on weight loss, increased physical activity, reduced sodium (no more than 2,300 mg per day), and decreased alcohol intake. The third group also received training in their sessions for incorporating the DASH diet into their daily lives and daily goals to achieve this.
Results from this study were not as dramatic as those seen in DASH and DASH-Sodium, but it still demonstrated a decrease in blood pressure, which was most dramatic in the behavioral intervention plus DASH diet group. In fact, 77% of those in the behavioral intervention and DASH diet group, who started the study with hypertension, were no longer hypertensive at the conclusion of the study. Some of the factors that the author points out that may have lead to the less dramatic results include the improvements seen in the advice only group, which was better than previous control groups. Additionally, while those who were encouraged to follow the DASH diet did increase their fruit and vegetable consumption to about 7.8 servings per day, this was still less than the 9.6 servings per day observed in the prior studies. I would add that the reduction in sodium was closer to the intermediate level from DASH-Sodium and perhaps a bigger difference would have been observed if participants had been instructed to achieve a goal of no more than 1,500 mg per day like the low-sodium intake group of DASH-Sodium.
Reducing Your Sodium Intake
So, the evidence is pretty clear that it’s better for us to reduce our sodium intake, by reducing the amount of salt we add to our foods, while also following the DASH diet. Because people with hypertension benefited the most from this, it is primarily recommended for those who have high blood pressure or are at risk of developing high blood pressure. For those with high blood pressure, it is recommended to reduce your sodium intake to a goal of less than 1,500 mg per day, which is about the equivalent to 2/3 of a teaspoon. For those who do not have hypertension, the daily goal should be no more than 2,400 mg or 1 teaspoon of salt. Individuals who partake in strenuous physical activity that leads to excessive sweating for extended periods of time should be more liberal with their salt intake and not worry about restricting. Because the body excretes sodium in the process of sweating, those who restrict in the setting of excessive sweating can find themselves depleting their body’s sodium.
But it’s not just the sodium that we add to our food. Because there is sodium in everything that we eat, it is even more important to read nutrition labels and track the amount of sodium that you are consuming before you even add any salt in the cooking process. Beware of and try to limit foods that are high in hidden sodium, including deli, processed and cured meats (e.g., bacon, salami, pepperoni), fast food, packaged snack foods, cheese, bread, soups (i.e., broth and bouillon), salad dressings, soy sauce, Worcestershire sauce, and pickled foods. The CDC has more on the Top 10 Sources of Sodium.
But if salt is what we’ve used for centuries to enhance not only flavor, but many other aspects of the dining experience, how do we reduce our salt without reducing the quality of our food? Here are six ways to reduce your daily intake of sodium.
- Choose homemade over pre-packaged foods – Cooking at home allows you more control over the ingredients that are used and salt added to a dish, which in turn allows you more control over the total amount of sodium in your food.
- Reduce recipe salt to 25% – When cooking something from a recipe, reduce the amount of added salt to 25% of what is listed in the ingredients. That means if a recipe calls for 1 teaspoon, reduce the salt added to 1/4 teaspoon. If a recipe calls for 2 teaspoons, you would reduce it to 1/2 teaspoon. You may notice a difference at first, but if you stick with it, your sense of taste will adapt and soon you won’t notice the decrease.
- Add umami – We normally think of taste as being divided into sweet, salty, bitter, and sour, but there’s actually a fifth taste, which is umami. Umami is the taste that makes something meaty or savory, and corresponds with the glutamate content of food. Since many of these foods already have some saltiness to them, they are a good way to round out the flavor profile without adding a lot of extra salt. This can be achieved by adding such things as tomato paste, mushrooms, fish sauce, Worcestershire sauce, or aged cheeses, such as Parmesan.
- Increase herbs and spices – Adding salt isn’t the only way to increase flavor in a dish. Try adding some more herbs and spices. In case you were wondering what the difference is, herbs are aromatic leaves, which can be dried or fresh. Examples of herbs are parsley, cilantro, rosemary, and sage. Spices, on the other hand, are dried mixtures made from the bark, roots, buds, seeds, fruit, or berries of a plant. Examples of spices are cinnamon, cumin, paprika, red pepper flakes, nutmeg, and coriander.
- Add vinegar or citrus – Adding an acid to the dish, such as a vinegar or juice from a citrus fruit can help to brighten a dish. It can also add a salty quality, thus reducing the need for adding more salt. Add these at the end of cooking or use them as a finishing garnish, as this will make the acid more pronounced, increasing it’s function to brighten and flavor the dish.
- Be choosy about veggies and beans – When selecting vegetables or beans, instead of canned options, opt for fresh or frozen vegetables, or dried beans. Canned vegetables and beans can contain a lot of added salt. If you do reach for a can of veggies or beans, ensure that it labeled as “no salt added.” You can always add a little bit of salt later, but you can’t remove it once it’s already been added.
Balancing Flavor
One of the best ways to decrease sodium without losing flavor is to stop relying solely on salt to enhance a dishes flavor. There are four other tastes that add to a dishes flavor and can be adjusted to make up for a decrease in salt. Tastes are different than flavor, in that taste is the reaction triggered by taste buds on your tongue that correspond with one of five tastes: salt, sour, bitter, sweet, and umami. A sixth taste, spice or heat, doesn’t trigger a taste bud response, but rather triggers a pain response, which gets added to the dishes flavor profile. Flavor on the other hand is the mixture of these tastes in addition to your sense of smell, which plays a large role in how we perceive and interpret flavor. Remember when you were a kid, forced to eat those vegetables, so you would plug your nose? Without the sense of smell, you may be able to tell something is salty or sweet, but the flavor is lacking, because of the integral role smell plays in flavor perception.
Each of these tastes plays a distinct role in balancing of flavors. The art of cooking is learning how to balance these tastes to create a well-balanced flavor in your dishes.
- Acidity/sour – Acidity provides that sour taste we get from citrus like lemons and limes, and various varieties of vinegar. Acidity brightens a dishes flavor and can even add or enhance a salty profile. Additionally, it helps to balance sweetness and bitterness.
- Sweet – You might not think of sweetness as having a role outside of the realm of baking, but it can actually add a lot to cooking, creating balance and roundness. It can be as simple as adding fruit to a salad or salad dressing, or the light sweetness you get from BBQ sauce or the glaze of a ham. It helps to balance acidity, bitterness, and spice, while enhancing saltiness or umami in a dish.
- Bitter – This is not one of those tastes that helps a dish when it is the highlight; bitterness works best as a background flavor. It helps to balance sweetness, as well as umami and salt. It helps with balance by cutting through a dishes richness.
- Umami/salty – Umami and salt provide many of the same qualities to food. They enhance flavors and add a savoriness to a dish. It enhances sweetness, while balancing bitterness.
- Spice/heat – Spice isn’t just limited to habaneros and jalapenos; spices like cinnamon, nutmeg, and ginger can provide a fair amount of spice or heat to a dish. This works well to balance sweetness in a dish, which is probably why we see many of these used in baking as well.
Image source: CookSmarts; CookSmarts provides a great description of the various tastes and how they work together, plus examples of foods within each taste to help balance your dishes.
Now that we’ve discussed the basic tastes and how they can interact with one another, let’s take a look at how we can use this knowledge to troubleshoot recipes. How many times have you been cooking and find that one flavor is overwhelming your dish. Let’s say it’s too salty, how can you fix that? Or what if it’s too sour? What if you were a little heavy handed with the hot sauce? Hover over the tiles below to see how you can balance the flavors of your dish.
Too Bland
Too Salty
Too Sweet
Too Sour
Too Bitter
Too Spicy
The DASH Diet
Lowering sodium is only half of the solution to lowering blood pressure. The other half is consuming the DASH diet. I will outline the DASH diet below, but you will see that in many ways it is very similar to the Mediterranean diet, yet there are still some stark differences between the two.
- Fruits & vegetables – 8-10 servings daily divided roughly in half should be the goal, as these are rich in potassium, magnesium, and fiber, which are integral nutrients of the DASH diet.
- Whole grains – 7-8 servings daily are recommended as the major source of energy and fiber.
- Low-fat or fat-free dairy – 2-3 servings daily provide the daily source of calcium and protein.
- Meats, poultry, & fish – 2 or less 3-oz servings daily are recommended from sources like lean meats trimmed of visible fat or skin. Options of cooking methods include broiling, roasting, or boiling. Frying should be avoided. This provides a source of protein and magnesium.
- Nuts, seeds, & dry beans – 4-5 servings per week are recommended as sources of energy, magnesium, potassium, protein, and fiber.
- Fats & oils – 2-3 servings daily are recommended to make up close to 30% of the daily caloric intake either from the foods themselves or added fats.
- Sweets – 5 servings per week is the limit to these sugary treats. They should also be low in fat.
As you can see, they both focus on increasing fruits and vegetables, and encourage increased consumption of nuts, seeds, and legumes. There is also a focus on whole grains in both diets, and both recommend decreasing consumption of meat. Where they differ is their take on fats, as the DASH diet focuses more on low-fat options, whereas the Mediterranean diet focuses on selecting healthy fats. The Mediterranean diet also focuses on limiting the daily intake of dairy products, whereas the DASH diet puts more emphasis on selecting dairy products that are fat-free and low-fat. The DASH diet also lumps meat, poultry, and fish into one category, compared to the Mediterranean diet that actually puts more of an emphasis on decreasing meat and poultry while increasing consumption of fish.
As of 2019, there have not been any randomized clinical trials to compare the effects of a low-sodium Mediterranean diet on blood pressure similar to those that were done with the DASH diet in the late ’90s and early ’00s. This would be an interesting area of study, especially given the cardiovascular benefit associated with consumption of the Mediterranean diet. I think you can think of these as two different recipes for a similar outcome. As with any recipe, see what works for you. Adopt those aspects you like into your daily lifestyle. Whether your diet is more like the Mediterranean or the DASH diet, or even if it falls somewhere in between, as long as it is not consistent with the current American diet, you will likely see some benefit from making a change.