To meet the new clinical practice guidelines on hypertension published in November 2017 by the American College of Cardiology (ACC) and American Heart Association (AHA) in collaboration with nine other organizations, health professionals need to be prepared to engage more patients in actively reshaping lifestyle.(1) Whether talking to people with elevated blood pressure or stage 1 hypertension (the new terms replacing “prehypertension”), or those with stage 2 hypertension and already taking multiple medications, part of that engagement involves helping people reduce sodium intake.
The first step to lowering sodium intake is to break through patient misconceptions about where sodium is found in the diet and then explore ways to create a delicious “new normal” way to eat.
The new guideline recommends a daily sodium intake of no more than 1,500 milligrams (mg) per day as ideal.(1) However, this target will require significant changes in many people’s food choices and may not be realistic. The average sodium intake for adults is 3,529 mg/day.(2) Even a target of 2,300 mg/day is exceeded by 97% of men and 81% of women.(3)
If the ideal goal is unrealistic, the new guideline offers an alternative: decreasing sodium intake by 1,000 mg/day. A change of this magnitude generally reduces systolic blood pressure by 5-6 mm Hg among people with hypertension, and by 2-3 mm Hg among normotensive individuals.(1)
For most people, achieving this goal means looking beyond the salt shaker to the “hidden” sodium in the average diet. The top sources of dietary sodium vary among individuals, but the vast majority of Americans’ sodium consumption comes from processed foods.(4)
To help patients recognize this and identify opportunities for reducing their sodium intake, seek creatives ways to demonstrate that foods not considered salty may have surprisingly high sodium content. For example, the Wellness Network Health for Life Minute video Control Hypertension, uses an interactive guessing game to show that foods people perceive as “healthy” may actually contain large amounts of sodium. This engaging approach can encourage people to think outside the box when it comes to novel ways to reduce sodium.
Each patient is individual, but there are few broad categories of popular foods that together provide more than half of the sodium in the average American diet.(4) This includes the AHA’s Salty Six: sandwiches, pizza, bread, poultry, soup and deli meat.
Some patients be surprised to see bread on this list—but it might help if they considered that a single slice of whole-grain bread typically contains 140¬–150 mg of sodium, along with the valuable fiber and nutrients. This means a single sandwich can have as much as 300 mg of sodium, before any high-sodium lunchmeat is added. Instead, people should also be encouraged to seek out other whole grains, such as brown rice and quinoa that provide less than 15 mg sodium/cup.
Other foods that contribute significant amounts of sodium include convenience food mixed dishes (frozen or boxed mixes), savory snack foods, condiments, cheese, and highly processed vegetables.
Finding Alternative Sources of Sodium
Once the major sources of sodium in a patient’s diet are identified, it’s important to identify alternatives. By learning how to use food labels, patients can discover brands that are lower in sodium. They can also be coached to identify less highly processed alternatives that are still tasty. For example, rice and potatoes, hot and cold cereals, and cheese and salad dressing all come in more and less sodium-dense options.
Supporting patients as they experiment with lower-sodium alternatives requires individual attention to food preferences and lifestyle, and awareness of the sodium levels in various foods. For many patients, a consultation with a registered dietitian nutritionist (RDN) can yield new options and ideas and provide valuable support.
Although decreasing dietary sodium produces clinically significant reductions in blood pressure, it reduces blood pressure even further when it’s part of an eating pattern exemplified by the DASH diet.(1,5,6) This eating pattern increases vegetables, fruits, low-fat dairy products, whole grains, poultry, fish and nuts; and it decreases saturated fat, red meat, sweets and sugar-sweetened beverages. Blood pressure can be further improved with enhanced physical activity, limited alcohol use and reduced calorie intake for those with overweight or obesity.
According to the new guidelines on the diagnosis and treatment of high blood pressure, 45.6% of U.S. adults now have hypertension and 12.1% have elevated blood pressure.(1) For those who say that diet hasn’t “worked” to reduce blood pressure before, it’s worth trying again with more specific guidance and an eye on the overall picture of healthy eating. Reminding people that even reducing sodium intake by 1,000 mg/day can have a clinically significant effect on blood pressure is a powerful message.
- Paul K. Whelton, Robert M. Carey, Wilbert S. Aronow, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017;HYP.0000000000000065, originally published November 13, 2017
- U.S. Department of Agriculture, Agricultural Research Service. 2016. Nutrient Intakes from Food and Beverages: Mean Amounts Consumed per Individual, by Gender and Age, What We Eat in America, NHANES 2013-2014. Available: www.ars.usda.gov/nea/bhnrc/fsrg
- Scientific Report of the 2015 Dietary Guidelines Advisory Committee Report. Supplementary Documentation, Appendix E-2.1: Usual Intake Distributions, 2007-2010, by Age/Gender Group. (Taken from What We Eat in America, NHANES 2007-2010.)
- U.S. Department of Agriculture and U.S. Department of Health and Human Services. 2015-2020 Dietary Guidelines for Americans, 8th Edition. December 2015. Available at: https://health.gov/dietaryguidelines/2015/guidelines/ Accessed 12/13/2017.
- Sacks FM, Svetkey LP, Vollmer WM et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344(1):3-10.
- Juraschek SP, Miller ER, Weaver CM, Appel LJ. Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure. J Amer College Cardiology. Nov 2017, 24343; DOI:10.1016/j.jacc.2017.10.011