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    This mostly-raw blueberry pie is a snap to make and very versatile--the filling microwaves in a few minutes, and you don't even have to bake the zippy gingered graham cracker crust--perfect for a hot Fourth of July and all summer long.

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  • SlowFoodFast sometimes addresses general public health topics related to nutrition, heart disease, blood pressure, and diabetes. Because this is a blog with a personal point of view, my health and food politics entries often include my opinions on the trends I see, and I try to be as blatant as possible about that. None of these articles should be construed as specific medical advice for an individual case. I do try to keep to findings from well-vetted research sources and large, well-controlled studies, and I try not to sensationalize the science (though if they actually come up with a real cure for Type I diabetes in the next couple of years, I'm gonna be dancing in the streets with a hat that would put Carmen Miranda to shame. Consider yourself warned).

Testing salt reduction on a really large scale

Microwaved platter of low-sodium tofu with snow peas

This tofu dish with snow peas and shiitake mushrooms uses low-sodium dipping sauce ingredients as its base rather than soy sauce or oyster sauce. It’s also microwaveable from start to finish and takes about 10 minutes total.

If you have a big enough–and motivated–study population, even modest reductions in daily sodium intake can make a big difference in preventing strokes and heart attacks. Last month, cardiovascular researchers from Beijing and Sydney announced a new 5-year diet trial in Science to do just that (see the general overview article, “China tries to kick its salt habit”).

China’s northern rural poor eat an estimated 12 grams of salt a day on average, considerably more than Americans’ 9 grams a day (which is still over the top) and more than twice the WHO’s recommended 5 grams or less. An estimated 54%, more than half, of Chinese adults over 45 have high blood pressure these days, and the Chinese government is taking practical steps to provide antihypertensive medications and shift the tide back–but that’s an awful lot of prescriptions.

Given the cost of antihypertensive drugs for such a huge population, and the cost of dealing with side effects and consequences of untreated or undertreated high blood pressure, prevention seems the better way to go. The researchers project that reducing the national average by even 1 gram of salt a day would save 125,000 lives a year in China. So they’ve recruited 21,000 villagers so far in China and Tibet, and plan to provide test groups with nutrition counseling plus a lower-sodium salt substitute for cooking, then compare their sodium intakes and rates of heart attack and stroke with those for a control group.

Most Chinese still do their own cooking at home, especially outside the big cities.  If lowering the sodium content of the salt they use works, it has the potential to get an awful lot of people off daily hypertension medication and reverse a major health threat. But will people do it if they’re not in the trial, or once it ends? Will it catch on? And is it the right answer in the long run?

Salt substitutes, with potassium chloride replacing some of the usual sodium chloride, have been tried by heart patients in the US since the 1970s or so. They’re a little more expensive than table salt or kosher flake salt, at least in the US, but they’re not all that expensive. But they’ve never really caught on here with most consumers.

Similarly, a few decades ago, a big public health campaign in Japan to reduce the high rate of stroke led to the introduction of low-sodium soy sauces, with about half the sodium content per tablespoon of traditional ones.

Not much market research is available on how many people have been buying low-sodium vs. regular soy sauce in Japan since its introduction. From the few current market reports I could find–one of them an executive report from Kikkoman–it looks like low-sodium is still a smaller if steady fraction of their business in Japan, and that it’s more popular in Europe and the US than at home.

It’s important to have a low-sodium line for reasons of corporate responsibility and even prestige, but there was no mention of its percentage of total domestic or worldwide sales. Traditional soy sauces, which can range from 14-18% sodium concentration w/v, are still apparently preferred for taste, and the Kikkoman executives attribute much of their expected taste appeal to salt rather than the other flavors in each one’s profile.

That’s kind of discouraging to me. The Japanese are known for more refined and sensitive palates on average than Americans, and their range of soy sauces and tamaris for specific food combinations is much broader and more sophisticated. The higher-quality low-sodium soy sauces are produced by ion filtration to get sodium out rather than simply diluting them with water, so most of the flavor that’s actually flavor remains. I would have hoped the key flavor signature of each match was the actual flavor of the brewed soy sauces, not the saltiness.

It’s likely, though, that the Japanese are just as susceptible as the rest of the world to the sodium tolerance phenomenon–the more sodium you eat habitually each day, the more you expect and consider normal in your food, and you almost stop even noticing it as a separate flavor.

The overall Chinese market for soy sauce is currently estimated at $20 billion and grew about 23.4 percent over the past 5 years, mostly due to population growth. The stakes are pretty high for China, but the government has tighter control of its salt and soy sauce producers than other countries do, and the will to make a broad change seems to be present, at least at a government level, and if the new study is anything to go by, among ordinary villagers as well. So maybe this time it will catch on once the study’s over.

But obviously, if you’re starting out at a 12-gram-a-day salt habit, the best way to reduce sodium in home-cooked food would be to cut back hard on salt and salted items altogether. That takes time, practice, awareness and deciding that it’s worth going through that first couple of weeks until your palate readjusts to a lower-sodium diet (which it will, but it takes a couple of weeks and a little patience).

Can cutting the salt be done with Chinese food? Not American souped-up chain restaurant caricatures of Chinese dishes, which are hideously over-the-top and greasy as well, but actual home cooking? I’ve done low-sodium Continue reading

Instant Pickles, Hold the Salt

Fast-marinated cucumbers, half-sour kosher dill style

One of the things that kept me motivated for blogging SlowFoodFast after the first fine careless rapture was my indignation at how popular over-the-top salting was becoming in popular food magazines, cookbooks, blogs and TV shows as chefs became celebrities, and how dangerous I knew it was for most people to eat that way regularly. A large part of my career a couple of decades ago was exploring the history of dietary sodium in cardiovascular research and writing about the DASH Diet.

What I’ve missed the past few years is just how many people, particularly younger ones, are starting to take up the challenge of cooking low-sodium and blog about their trials and successes. There’s a whole community out there, and they’re cooking pretty well. It is definitely possible, and generally easy once you get past the “how do I read a label and cook from scratch” aspect.

I just ran into Sodium Girl (aka Jessica Goldman Foung)’s blog-based cookbook, “Sodium Girl’s Limitless Low-Sodium Cookbook”. Diagnosed with lupus and kidney failure in her early 20s, she turned around her diet by dropping her sodium intake drastically to give her kidneys a rest in the hope they’d regenerate, and it worked. She’s been innovating with low- and near-to-no-sodium versions of favorite foods ever since, working with the National Kidney Foundation and other organizations. Her book, like her blog, is attractively photographed, full of cheerful writing and surprise takes on favorite foods.

One of the substitutions she makes that I have to approve of is a molasses-and-vinegar-based “faux soy sauce”. So I wasn’t the only one!

Another of her successful experiments is pickles. She goes for sugar-and-vinegar-style pickles, which makes sense, since they have no added salt in them, but I can’t help it–I have always cringed at sweet pickled anything. If it’s supposed to be a pickle, for my money, it’s gotta be a half-sour kosher dill and nothing but (or else an Indian lime or mango achaar pickle, or Moroccan preserved lemons, but that’s another story and still pretty high-salt at this writing. I’m working on it, but not yet holding out a lot of hope…)

Anyway, looking through Foung’s book reminded me of a simple, hearty and low-to-very low sodium version of my favorite pickles in the world. Continue reading

You must read this. Take an hour if you have to.

Today’s New York Times has an excerpt from investigative reporter Michael Moss’s forthcoming book on the processed food industry’s push to engineer addictive foods. It’s a long article, more than 12 pages, but well worth the read.

The Extraordinary Science of Addictive Junk Food – NYTimes.com.

Questionable sodium study, even more questionable comments

A new European study that purportedly shows low-sodium diets to be ineffective in preventing high blood pressure, and even more unlikely, that they increase the risk of death from heart attack or stroke, is being published in the May 4 issue of JAMA, and predictably it’s already excited a variety of comments in Gina Kolata’s current New York Times article from the CDC and from…Dr. Michael Alderman.

Predictably, because the CDC researchers think too few people were studied for too short a time with unreliable methods (24-hour urine collection to measure sodium intake indirectly, after the fact as it were.)

Alderman’s reaction was also predictable: he’s still insisting that only a nation-wide feeding study sort of clinical trial that follows its subjects until they die is sufficient to prove a true link between sodium intake and cardiovascular disease. Something so expensive and unwieldy it couldn’t be completed even if it were started, and we’d still be waiting around 30 years later wondering if salt had anything to do with heart attacks or strokes. Very convenient for the processed food industry, but pretty useless for public health. And also conveniently, Gina Kolata found more than one expert to say so.

What she didn’t find, but could have, is that a number of large-scale feeding studies have already been done and shown that eating a balanced lower-sodium diet helps reduce blood pressure and prevent blood pressure increases. DASH-Sodium is one of them. And no one had to wait until the study subjects died to figure it out.

AHA: Diet sodas and excess salt both linked to strokes

The latest from the American Heart Association and American Stroke Association’s joint International Conference on Stroke 2011, which is going on in Los Angeles this week from Wednesday through Friday.

Diet soda may raise odds of vascular events; salt linked to stroke risk.

Two large studies on a mixed-race/age/gender/other health status population have just shown that:

1. Drinking diet soda every day increases your risk of a heart attack or stroke in the next 9-10 years. In the study, diet soda regulars had a 48% higher rate than nondrinkers even after accounting for metabolic syndrome and existing or past heart disease.

2. For every 500 milligrams of sodium you eat per day over the AHA’s recommended 1500 max, you have a 16% higher risk of getting a stroke–no matter whether you have high blood pressure or normal blood pressure.

There was one other piece of really bad news announced:

The Centers for Disease Control’s analysts looked at hospitalizations for ischemic stroke (blocked arteries to the brain) between 1994 and 2007 and found that while strokes are decreasing in people over 65 (which is good), they’re INCREASING in children, teens and younger adults. Although older adults still have much higher overall risk of stroke than younger people, the trend toward higher stroke hospitalization rates for younger people is significant and needs to be explored further. Stroke hospitalizations increased by:

  • 31% among boys 5-14; 36% among girls 5-14
  • 51% in men 15-34, 17% in women 15-34
  • 47% in men 35-44, 36% in women 35-44

The CDC researchers didn’t have clear evidence of a cause for the rise in strokes among younger people, but said the rise in average body weight, blood pressure and diabetes, which are known risk factors for stroke, bore a closer look.

The fact that stroke hospitalization rates started rising in children over 5 (the researchers looked at younger children as well but didn’t find an increase under age 5) suggests to me that part of the trend may be due to a more processed diet with higher salt consumption as children head for school. All in all, it gives you the impression that we are the junk food generation, and it’s catching up with us as we speak.

Age, salt and the new USDA dietary guidelines

Last Monday the USDA released its latest version of the Dietary Guidelines for Americans (nominally dated “2010”). I was driving home and NPR carried USDA Secretary Tom Vilsack’s speech, in which he listed a few of the new highlights: eat less, eat less food with solid fats, eat less processed food, eat more vegetables and fruits, eat less sodium.

How much less sodium? About 2300 mg or 6 grams (1 teaspoon) of table salt per day, he said, is the recommended maximum for healthy adults, in line with the long-standing National High Blood Pressure Education Program’s guidelines, which are shared by the American Heart Association and many other professional medical groups.

There’s a second lower-sodium recommendation for anyone overweight, African-American, with heart or kidney disease or high blood pressure or diabetes, and anyone middle-aged or older. This year, as the more specifically heart-health-oriented professional organizations already recommend, the USDA guidelines set the lower maximum at 1500 mg per day, or about 3 grams of table salt.

And you’d think that was great, and I do, that the USDA guidelines have finally caught up with what the medical associations have been demanding based on the overwhelming weight of studies on dietary sodium intake as it affects blood pressure, cardiovascular disease including stroke, and kidney disease.

But there are two catches hidden in the midst of all this, and I’m not even sure Vilsack was aware of it. Smaller one first: Middle-aged? How old is middle-aged?

“Fifty-one and older,” Vilsack said. Whew, I thought. Four more years before I have to start thinking of myself as middle-aged. By the time I get there, I’m hoping the standard will have gotten fudged upward by at least another decade or so.

Because, you know, if you’re not 50 yet, 51 sounds reasonable–and comfortably remote for a lot of younger adults. Which I am, thank you very much. Don’t look at me like that.

So here’s Catch-51: When I was working at the National Heart, Lung and Blood Institute back in the mid-’90s, the general working recommendation for lowering sodium to 1500 mg/day was all the other high-risk groups Vilsack mentioned…and healthy adults 40 and up. Not 51 and up.

The choice of a cutpoint at age 40 for otherwise healthy people was based on the risk data from the first three National Health and Nutrition Education Surveys, which began collecting data across the nation starting in the 1970s. The latest version collected data around 2006 and its findings were just released last spring by the Centers for Disease Control. All the NHANES studies correlate  in-depth interviews about diet, exercise and lifestyle patterns, and cardiovascular history along with clinical health measurements (height and weight, blood pressure, cholesterol, urinary sodium excretion, blood iron, etc.) from thousands of ordinary Americans. Even early on, there appeared to be an independent higher risk and a greater need to lower sodium at 40 and older, all other health risk factors being equal.

But of course 40 seems too young to be middle-aged. And the USDA, which issues the Dietary Guidelines for Americans, tends to downplay certain elements of the risk statements so that no one, or at least not the agency’s chief constituents, gets upset. The no one in this case might easily be the Continue reading

Unappetizing: Nutrition “Awareness” on Top Chef

Perhaps it’s a futile attempt to understand how restaurant chefs think about food and nutrition, but lately I’ve been watching the very warped “Top Chef” episodes for the last couple of seasons–easy to do online. I can’t help wondering not only at the contestants, all of whom seem to display basic ignorance of what used to be called the “Four Food Groups,” but at some of the judges who fault them on nutritional challenges.

In this season there have been two, the School Lunch Challenge and–not that the judges even thought about it as a nutritional challenge, which they should have–the Baby Food Challenge. In both, the judges seemed at least as lacking in nutritional knowledge as the contestants, and in some aspects even worse.

The School Lunch Challenge brought out scathing comments on the show and on a number of blogs, particularly when the bottom-ranked chef, who went home for her gaffe, attempted to make a banana pudding palatable by adding sugar. Tom Colicchio made a big deal of her adding two pounds of sugar to the pudding–which was to feed 50 students.

And admittedly it’s not great for nutrition, but it was hardly the disaster he and the other judges made out. If anyone had bothered to whip out a calculator and known how to use it for pounds-to-kilos conversions, they’d have discovered that the two pounds of sugar amounts to 0.91 kilos. Or 909 grams, to be a little more precise (which we shouldn’t, the chef was eyeballing what she added). Divide by 50 and you get 18 grams per serving or about 4 teaspoons–not all that surprising an amount of sweetener in any prepared dessert. Add that to the starch already present as thickener and the sugars from the milk and bananas and you probably have 30-40 grams of carb or thereabouts per half cup of pudding.

It would be a lot for someone diabetic, like my daughter, but not disastrous as long as she knew how much carb was in it, and it certainly wouldn’t be disastrous for most school kids if the rest of the meal was balanced with low-fat protein and vegetables and not too much other starch.

But actually, most of the lunch entries were pretty starchy. The fact that they didn’t all have as much noticeable added sugar is almost immaterial–starches break down into sugars. You have to count them all.

What really stood out was the pathetic nature of the criterion “to include a vegetable.” One that was most-praised–a slab of caramelized (talking of sugar) sweet potato under a chocolate sorbet as a dessert–was mostly a starch, though in its favor it had vitamin A and fiber. Another team served celery (no vitamins and very low fiber, despite the stringiness) with a peanut-butter mousse (why, oh lord, not just peanut butter? chef-think at work?) piped out directly onto the celery, supposedly so kids would eat it. No one liked the mousse because it looked Continue reading

Food Mags Rethinking Salt

For years, lobbyists and nutrition pundits have insisted–hopefully or despairingly–that government public health campaigns to cut sodium in processed and restaurant foods wouldn’t really do much good, that the public wouldn’t pay attention, that they wouldn’t care enough or that they’d resent the guidelines advice so much that they’d never change their habits.

But the past year has brought the brining of America into the headlines and people are starting to pay attention. Especially with state-led nutrition labeling laws for restaurant chains, large diet/health studies, and citizen/government coalitions to pressure the food industry to reformulate down to sane salt levels.

Gourmet-leaning media have been especially slow to come around from the enthusiasm of exotically named and sourced salts and imitation of the aggressive restaurant-style use (and overuse) of salt as a texturizing chemical rather than for flavor. As late as January, I was still seeing frequent “famous chef” defense commentaries, on food shows and in publications from Salon.com to the New York Times, on the absolute necessity of salting food at every turn.

I hope it’s not just a one-issue fluke, but a quick scan of the July issues of Bon Appétit and Saveur shows that both have cut out the insidious, automatic “1 teaspoon of salt” they used to list in most of their recipes. Sunset magazine doesn’t seem to have caught on yet, but Good Housekeeping appears to be ditching the extra salt, so maybe we’re on the cusp of a better trend. And maybe next year I’ll have nothing to kvetch about.

It could happen.

FDA Regulation–Too Slow on Salt?

The Washington Post carried a story today that the FDA is finally getting a move on and planning how to regulate salt in processed foods–after numerous and repeated failures of laissez-faire voluntary self-regulation attempts. It’s been a long time coming; the FDA has been petitioned repeatedly by the American Heart Association, the Center for Science in the Public Interest, and many other organizations, both private and governmental, and has always maintained up to this administration that salt was a “generally recognized as safe” ingredient.

So I’m glad that the FDA is finally making some effort to regulate sodium in food and drop the “generally recognized as safe” status. I’m unfortunately not amazed at all that they’re trying to drag it out to a 10-year process. People’s taste for salt can be downshifted significantly in two or three weeks on average, so there’s really no excuse for such a gradual decrease except for the manufacturer’s cost of reformulation. They seem to be pacifying the processed food manufacturers–all the classic  prechewed food industry claims about reduced customer satisfaction appear to be overtaking discussion and usurping the issue of health risk.

But what really gets me is the last quote in the article:

“Historically, consumers have found low-sodium products haven’t been of the quality that’s expected,” said Todd Abraham, senior vice president of research and nutrition for Kraft Foods. “We’re all trying to maintain the delicious quality of the product but one that consumers recognize as healthier.”

Tell the truth: Those foods aren’t really all that delicious now. It’s like admitting that heavy salt is the predominant flavoring (the other being cardboard).

Getting the Salt Out: NSRI and Voluntary Compliance, Again

In the wake of its city-wide diabetes reduction and restaurant nutrition labeling initiatives, the New York City Department of Health is leading yet another dietary health campaign, this time one that involves a national coalition of cities, states, and medical organizations. My hat’s off to them, even though I think the demands they intend to make of the food industry are much too light and much too toothless.

The National Salt Reduction Initiative, announced on Monday, will  encourage “voluntary compliance” from the processed food and restaurant industries to lower their sodium content by about 20% over the next 5 years. That’s pretty modest considering that both industries have doubled the standard sodium content of many common foods in the past 20-30 years, and that the national obesity epidemic seems to have coincided pretty nearly with that trend.

The UK’s national salt reduction campaign, which started in 2003 and serves as a model for NSRI, has government backing and its goal is 40% reduction of sodium in processed foods within 5 years, not 20%. They seem to be getting there, too.

NSRI’s coalition includes the Los Angeles Department of Health and a variety of medical organizations like the American Heart Association and the American College of Cardiology. What it doesn’t include this year, to my surprise–and, frankly, dismay–is involvement, funding or guidance from the National Heart, Lung and Blood Institute at NIH.

Ten years ago the NHLBI would have participated one way or another in encouraging this sort of initiative, but that was before the Bush years. NHLBI has been reorganized several times in the last decade. Two of its key diet-related outreach and education programs–the National Cholesterol Education Program and the National High Blood Pressure Education Program, which would have been the leading outreach proponent for NSRI–have receded from view, with perfunctory descriptions on the agency web site, no functioning links to current activities if there are any or to updated program pages, and no clear leadership or place in the agency’s organizational chart. But the need for them certainly hasn’t ended.

Voluntary compliance programs don’t have a great track record in the processed food industry. Look at the recent Smart Choices nutrition labeling program fiasco (see under, Froot Loops) from October.

Starting a national  program like this with voluntary compliance as a key component means the designers don’t think there’s much way to enforce the changes other than persuasion. It also means the government doesn’t have the tools, the money, or–and here is the crux of it–the will to enforce even modest limits on sodium content. Both the AHA and the AMA have been working on the FDA for years to get salt off the “generally harmless Continue reading