Dietary Sodium Intake and Morality

Cutting salt consumption reduces blood pressure at the population level, and reduces the risk of strokes. The Salt Substitute and Stroke Study just confirmed this (1). 

21,000 rural Chinese with a history of hypertension and/or stroke were divided into two groups. The intervention group was given a low-sodium / high-potassium salt substitute to cook with, the controls were left with table salt. After 5 years the intervention group had a 14% reduction in stroke, a 13% reduction in major cardiovascular events and a 12% reduction in deaths. The controls stroked, infarcted and died just as they did before the white coats arrived.

This study is grossly unethical. It is inconceivable that the scientists, who are associated with major academic and clinical institutions in 4 countries, did not know that the control group was being left at higher risk. The study, which was hailed as a landmark, merely re-traced steps carved out half a century ago by pioneering Finnish scientists.

A team lead by Hekki Karppanen, Eero Mervaala and Pekka Puska worked with the Finnish government which had, uniquely, a medically qualified Minister of Health who cared for the health of his constituents. They ran a regional and then a national campaign to cut sodium intake. 

Food companies were instructed to remove table salt from their formulations and replace it with the salt substitute PanSuola, which combined magnesium and potassium chloride with the amino acid l-lysine. Not only domestic companies; even McDonalds was forced to use PanSuola in the burgers and fries they sold in Helsinki, Turku and Tampere (2). 

Between 1972 and 1992 the average diastolic blood pressure in Finland fell by 10 mm Hg, and deaths from stroke and heart disease in men and women aged 30-59 fell by 60% (2-5). Over that same time period, and despite increasing tobacco and alcohol use and growing obesity, Finnish life expectancy increased by 5 years (5).

I was lucky enough to meet Heikki several times in Helsinki when he was an emeritus professor at the university there, and was impressed by his integrity and decency. He is a good scientist with an enviable list of publications and a genuine concern for the health of his fellow men and women. 

I told him how much I admired the North Karelia Project, as it was called, and how much I hoped it would inform medical and then political praxis. Older and wiser than me, he shook his head. ‘We have the science’, I remember him saying, ‘But that is not enough. Finland is a small country, and our work is drowned out by louder voices who do not like what we have found.’

I subsequently discovered (not from him), that the louder voices were those of the Salt Institute, a US-based trade association which fronted for salt producers and the food companies that relied on salt as a cheap flavor ingredient and preservative. Established in 1914 and a strong supporter of high salt consumption, it was only when the organization ceased operations in 2019 that industrial opposition to salt reduction finally dissolved.

The nefarious activities of the salt lobby mirror those of the sugar lobby, which paid for research designed to downplay any link between sugar and coronary heart disease and to put dietary saturated fat in the frame instead (6). Between them the salt and the sugar industries have killed tens of millions of consumers, probably more than those who died due to tobacco, alcohol or recreational drugs.

Tobacco and alcohol are slapped with warning labels and restrictions on sale and use. Recreational drugs are illegal, though becoming less so now that our wastrel governments are so desperate for cash. Salt and sugar are the odd ones out. If anything we are consuming more of these, thanks to the progressive destruction of the middle classes and our spiraling intakes of ultra-processed foods (7-9).

The multinational food companies spend billions not just marketing their products, but on marketing themselves as benign, cuddly, gemütlich … and it worked. We fucked up. We trusted them (10). We became addicted to their ultra-processed products, to their minutely engineered bliss point and mouthfeel technology that leaves us simultaneously sick, bloated, unsatisfied, brain-damaged and craving for more (11-15).

Modern foods are deliberately designed to be addictive, and the evidence that they are genuinely addictive is persuasive (16-19).

Cravings for these foods involve endogenous opioid peptide tone, and can be modulated by naltrexone (20-22), the same drug used to treat opiate overdose. High sugar concentrations affect dopaminergic brain chemistry in ways similar to drugs of addiction (23, 24); which explains why food addiction generally involves ultra-processed foods (25). Tangential support for this comes from the success of food addiction programs such as Overeaters Anonymous, which uses techniques adapted from Alcoholics Anonymous (26). 

NeuroFAST offers an alternative perspective (27). This organization denies that food can be addictive, and prefers to talk in terms of ‘eating addiction’, a scenario in which the consumer is the problem. You might think this is classic ‘blame the victim’ strategy, and your opinion might be influenced by the fact that NeuroFAST is heavily funded by the EU and is therefore influenced by industry, but I couldn’t possibly comment.

Nor could I possibly describe NeuroFAST as the Salt Council redux. The fact that they faux-naively ask how can foods necessary to survival be addictive, when the food additives that are addictive (such as sugar) are obviously NOT necessary for survival, is just a teeny tiny mis-speak on their part. It must be mere coincidence that the food industry has added some form of sugar to three quarters of all the foods available in the USA (28), because how could they possibly know that adding sugar reliably increases sales (29)? 

The fact that NeuroFAST’s darker twin is a weaponized brain imaging and decoding initiative brought to you by the good people of DARPA (30, 31) is probably just another coincidence. Do not, under any circumstances, look at the man behind the curtain. Do not concern yourself with the fact that the vast amount of added addictive sugar in today’s processed and ultra-processed foods is causing wide-spread liver damage (32-34), diabetes and obesity (35, 36), and profoundly damaging our children.

Enough already. We need to talk about the man, and the menu, behind the curtain.

We cannot go on as we are, becoming fatter, sicker and more stupid as we descend into Idiocracy. We should at least consider changing course. It won’t be easy, however. Addiction, which is engineered by teams of applied psychologists, neurologists and IT specialists into foods, computer games, television programs and increasing numbers of consumer products, is at the core of today’s business model. 

In late-stage crony capitalism, wealth generation has shifted from production towards consumption and finally over-consumption. Just as alcohol companies depend on creating an endless supply of alcoholics, Big Phood now depends on creating over-eaters (37, 38). They have become very good at this.

Big Phood understands in minute and mechanistic detail why you eat a Dorito and continue to eat until the pack is empty. It is nothing to do with hunger. It is about targeting endogenous opioid peptide and dopaminergic tone, and getting the consumer hooked. The more effectively Big Phood can do this, the more successful their product and company will be.

Food techs have honed their skills to the point where the overwhelmingly negative effects of over-consuming their products are quite obviously killing us in very large numbers (ie 39-41). To Big Phood, however, mass disease and early death are unimportant side-effects. Fortunately for us there remains an ethical rump, of sorts.

Business ethics largely consist of avoiding jail, the courts and bad publicity. Increasing reports of ultra-processed deaths have started to trigger corporate messages hinting that their sick and dying consumers should perhaps ease up a little (42-44). 

The caring folk at Coca Cola say, ‘While sugar is fine in moderation, too much of it isn’t good for anyone. Like all food and beverages, soft drinks with sugar can be consumed as part of a balanced lifestyle as long as people don’t consume them to excess (45).

This virtue-signaling has no effect on sales or profits, and if it did would be stopped immediately. It’s a zero-sum game. Making ultra-processed foods less habit-forming would mean losing market share to less scrupulous players, which is unacceptable. There is just one thing Big Phood can do now. They can retain addictiveness and healthy sales only if they make their products genuinely healthier.

The science to achieve this is widely available, so it is just a question of talking to the right people – but who? However many pieces of silver they earn the scientists, psychologists, lawyers, marketeers and other office spacers who enable these machines are flunkies, greasing the wheels of juggernauts beyond their control. The MD’s, CEO’s, CFO’s and CTO’s aren’t really in change either.

Having worked with a few multinationals I no longer believe there is a man behind the curtain. These huge corporate entities are distributed decision engines geared solely to profit maximization, and staff and higher executives are hired by the same algorithm. They consist of databases and spreadsheets with a veneer of brainpower, an egregore that will only change if forced to by new legislation or changing market demands.

In today’s crony capitalism the legislative is bought and regulatory bodies are coopted. It comes down to us, the consumers. If enough of us vote with our wallets, if enough of us learn to cook, there will be change. Salt reduction is a small part of this. If not, pressure will build until at some point, there will be blood.

Next week: The president laid an egg: what happens when food, money and politics collide.

References

1. Neal B, Wu Y, Feng X, Zhang R, Zhang Y, Shi J, Zhang J, Tian M, Huang L, Li Z, Yu Y, Zhao Y, Zhou B, Sun J, Liu Y, Yin X, Hao Z, Yu J, Li KC, Zhang X, Duan P, Wang F, Ma B, Shi W, Di Tanna GL, Stepien S, Shan S, Pearson SA, Li N, Yan LL, Labarthe D, Elliott P. Effect of Salt Substitution on Cardiovascular Events and Death. N Engl J Med. 2021 Aug 29. doi: 10.1056/NEJMoa2105675. Epub ahead of print. PMID: 34459569.
2. http://www.worldactiononsalt.com/worldaction/europe/finland/
3. Karppanen H, Mervaala E. Adherence to and population impact of non-pharmacological and pharmacological antihypertensive therapy. J Hum Hypertens. 2006 Sep-Oct;49(2):59-75.
4. Karppanen H, Mervaala E. Sodium intake and mortality. The Lancet 1998 May 16. 351(9114)
5. Karppanen H, Mervaala E. Sodium intake and hypertension. Prog Cardiovasc Dis. 1996 Feb;10 Suppl 1:S57-61.
6. Kearns CE, Schmidt LA, Glantz SA. Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents. JAMA Intern Med. 2016 Nov 1;176(11):1680-1685.
7. Juul F, Hemmingsson E. Trends in consumption of ultra-processed foods and obesity in Sweden between 1960 and 2010. Public Health Nutr. 2015 Dec;18(17):3096-107.
8. Wang L, Martínez Steele E, Du M, Pomeranz JL, O’Connor LE, Herrick KA, Luo H, Zhang X, Mozaffarian D, Zhang FF. Trends in Consumption of Ultraprocessed Foods Among US Youths Aged 2-19 Years, 1999-2018. JAMA. 2021;326(6):519–530.
9. De Vogli R., Kouvonen A., Gimeno D. The influence of market deregulation on fast food consumption and body mass index: A cross-national time series analysis. Bull. World Health Organ. 2014;92:99–107.
10. https://www.youtube.com/watch?v=-glKGjp50Ug
11. GBD Diet Collaborators. Health effects of dietary risks in 195 countries, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2019;393:1958–1972.
12. Calvo-Ochoa E, Hernández-Ortega K, Ferrera P, Morimoto S, Arias C. Short-term high-fat-and-fructose feeding produces insulin signaling alterations accompanied by neurite and synaptic reduction and astroglial activation in the rat hippocampus. J Cereb Blood Flow Metab. 2014 Jun;34(6):1001-8. 
13. Beilharz JE, Maniam J, Morris MJ. Short exposure to a diet rich in both fat and sugar or sugar alone impairs place, but not object recognition memory in rats. Brain Behav Immun. 2014 Mar;37:134-41.
14. Beilharz JE, Maniam J, Morris MJ. Short-term exposure to a diet high in fat and sugar, or liquid sugar, selectively impairs hippocampal-dependent memory, with differential impacts on inflammation. Behav Brain Res. 2016 Jun 1;306:1-7. 
15. Fusco S, Spinelli M, Cocco S, Ripoli C, Mastrodonato A, Natale F, Rinaudo M, Livrizzi G, Grassi C. Maternal insulin resistance multigenerationally impairs synaptic plasticity and memory via gametic mechanisms. Nat Commun. 2019 Oct 22;10(1):4799. 
16. Spangler R, Wittkowski KM, Goddard NL, Avena NM, Hoebel BG, Leibowitz SF. Opiate-like effects of sugar on gene expression in reward areas of the rat brain. Mol. Brain Res. 2004;124:134–142. 
17. Pelchat ML, Johnson A, Chan R, Valdez J, Ragland JD. Images of desire: Food-craving activation during fMRI. Neuroimage. 2004;23:1486–1493. 
18. Avena NM, Rada P, Hoebel BG. Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake. Neurosci. Biobehav. Rev. 2008;32:20–39. 
19. Lenoir M, Serre F, Cantin L, Ahmed SH. Intense sweetness surpasses cocaine reward. PLoS ONE. 2007;2:e698.
20. Mason AE, Lustig RH, Brown R.R, Acree M, Bacchetti P, Moran PJ, Dallman M, Laraia B, Adler N, Hecht FM, Daubenmier J, Epel ES. Acute responses to opioidergic blockade as a biomarker of hedonic eating among obese women enrolled in a mindfulness-based weight loss intervention trial. Appetite. 2015;91:311–320.
21. Mason AE, Laraia B, Daubenmier J, Hecht FM, Lustig R.H, Puterman E, Adler N, Dallman M, Kiernan M, Gearhardt AN, Espel ES. Putting the brakes on the “drive to eat”: Pilot effects of naltrexone and reward-based eating on food cravings among obese women. Eat Behav. 2015;19:53–56.
22. Mason AE, Epel ES, Aschbacher K, Lustig RH, Acree M, Kristeller J, Cohn M, Dallman M, Moran PJ, Bacchetti P, Laraia B, Hecht FM, Daubenmeier J. Reduced reward-driven eating accounts for the impact of a mindfulness-based diet and exercise intervention on weight loss: Data from the SHINE randomized controlled trial. Appetite. 2016;100:86–93.
23. Johnson PM, Kenny PJ. Dopamine D2 receptors in addiction-like reward dysfunction and compulsive eating in obese rats. Nat. Neurosci. 2010;13:635–641.
24. Davis C, Levitan RD, Kaplan AS, Kennedy JL, Carter JC. Food cravings, appetite, and snack-food consumption in response to a psychomotor stimulant drug: The moderating effect of ‘food-addiction’ Front. Psychol. 2014;5:403.
25. Gordon EL, Ariel-Donges AH, Bauman V, Merlo LJ. What Is the Evidence for “Food Addiction?” A Systematic Review. Nutrients. 2018 Apr 12;10(4):477. 
26. https://www.verywellmind.com/what-is-overeaters-anonymous-5089112
27. Mercer JG, Bird SP. NeuroFAST – the integrated neurobiology of food intake, addiction and stress. Obes Facts. 2012;5(2):293-7.
28. Ng SW, Slining MM, Popkin BM. Use of caloric and noncaloric sweeteners in US consumer packaged foods, 2005–2009. J. Acad. Nutr. Diet. 2012;112:1828–1834.
29. Andreyeva T, Long MW, Brownell D. The impact of food prices on consumption: A systematic review of research on the price elasticity of demand for food. Am. J. Public Health. 2010;100:216–222.
30. https://www.darpa.mil/program/neuro-function-activity-structure-and-technology
31. https://www.darpa.mil/program/our-research/darpa-and-the-brain-initiative
32. Lustig RH, Mulligan K, Noworolski SM, Gugliucci A, Erkin-Cakmak A, Wen MJ. Tai VW, Schwarz JM. Isocaloric fructose restriction and metabolic improvement in children with obesity and metabolic syndrome. Obesity. 2016;24:453–460. 
33. Gugliucci A, Lustig RH, Caccavello R, Erkin-Cakmak A, Noworolski SM, Tai VW, Wen MJ, Mulligan K, Schwarz JM. Short-term isocaloric fructose restriction lowers apoC-III levels and yields less atherogenic lipoprotein profiles in children with obesity and metabolic syndrome. Atherosclerosis. 2016;253:171–177. 
34. Schwarz JM, Noworolski SM, Erkin-Cakmak A, Korn N.J, Wen MJ, Tai VW, Jones GM, Palii SP, Velasco-Alin M, Pan K, Patterson BW, Gugliucci A, Lustig RH, Mulligan K. Impact of dietary fructose restriction on liver fat, de novo lipogenesis, and insulin kinetics in children with obesity. Gastroenterology. 2017;153:743–752. 
35. Basu S, Yoffe P, Hills N, Lustig RH. The relationship of sugar to population-level diabetes prevalence: An econometric analysis of repeated cross-sectional data. PLoS ONE. 2013;8:e57873.
36. Ludwig DS, Aronne LJ, Astrup A, de Cabo R, Cantley LC, Friedman MI, Heymsfield SB, Johnson JD, King JC, Krauss RM, Lieberman DE, Taubes G, Volek JS, Westman EC, Willett WC, Yancy WS, Ebbeling CB. The carbohydrate-insulin model: a physiological perspective on the obesity pandemic. Am J Clin Nutr. 2021 Sep 13:nqab270.
37. https://www.newsweek.com/fast-food-lovers-unite-127987#:~:text=In%20fast%2Dfood%20parlance%2C%20Borucki,burgers%20and%20fries%20he%20loves.
38. https://www.wsj.com/articles/SB947636708123070129
39. Schnabel L, Kesse-Guyot E, Allès B, Touvier M, Srour B, Hercberg S, Buscail C, Julia C. Association Between Ultraprocessed Food Consumption and Risk of Mortality Among Middle-aged Adults in France. JAMA Intern Med. 2019 Apr 1;179(4):490-498.
40. Lane MM, Davis JA, Beattie S, Gómez-Donoso C, Loughman A, O’Neil A, Jacka F, Berk M, Page R, Marx W, Rocks T. Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies. Obes Rev. 2021 Mar;22(3):e13146.
41. Fuhrman J. The Hidden Dangers of Fast and Processed Food. Am J Lifestyle Med. 2018 Apr 3;12(5):375-381.
42. https://www.marketingweek.com/coca-cola-tries-to-prove-it-can-be-part-of-a-balanced-diet/
43. https://www.cnn.com/2012/08/05/tech/gaming-gadgets/blizzard-gaming-addiction-statement/index.html
44. Duran AC, Ricardo CZ, Mais LA, Martins APB, Taillie LS. Conflicting Messages on Food and Beverage Packages: Front-of-Package Nutritional Labeling, Health and Nutrition Claims in Brazil. Nutrients. 2019 Dec 5;11(12):2967. 
45. https://www.coca-colacompany.com/au/faqs/is-coca-cola-bad-for-your-health#:~:text=which%20has%20kilojoules.-,While%20sugar%20is%20fine%20in%20moderation%2C%20too%20much%20of%20it,t%20consume%20them%20to%20excess.