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Salt vs. sugar, a nutrition battle royale

designed by Jane Martin, photo by Pat Greenhouse

Ah, summer and its treats: fried dough dusted with sugar at the fairground, cookies and lemonade on the patio, hot dogs and soda at the ballpark, ice cream cones and french fries at the beach.

Even if you usually opt for choose kale salad, grilled salmon, and fresh fruit, something about summertime — like the winter holiday season — tempts us to relax the rules about what we eat and drink.

And when given the choice, many of us feel somewhat better about grabbing usually forbidden snacks that are sweet as opposed to over those that are salty, believing that because of its well-known links to cardiovascular disease, salt presents the bigger health risk.

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Things are not that simple, nutritionists say.

Added sugar, particularly in sugar-sweetened beverages, has been implicated in weight gain, high blood pressure, and type 2 diabetes, all of which raise risk the risk for cardiovascular disease, the number one preventable cause of death in the United States, according to the US Centers for Disease Control and Prevention.

Recent research also suggests that for reasons that are not clearly understood, a high-sugar diet may elevate your chances of dying of heart problems.

Last month the US Food and Drug Administration issued recommendations that Americans drastically curb the amount of added sugar they consume. If approved, new nutrition labels will declare that added sugar should not exceed 10 percent of an adult’s total daily calories. “Added sugars” would appear below the line where “sugars” are now listed in grams on the familiar labels.

The guidelines, which are not yet final, go only half as far as the World Health Organization's suggestion that sugar account for fewer than 5 percent of daily calories.

This could be sour news for America's sweet tooth.

Right now, the FDA says, about 16 percent of the calories Americans consume come from added sugar.

Based on 2,000 calories a day, the new recommendations would cap added sugar at the equivalent of 12 teaspoons a day. That's the amount of sugar in one 16-ounce can of soda.

Beverages, from soda to sweetened coffee to juice to sports drinks, account for almost half of the added sugars that Americans take in every day, although rates have been falling since the late 1990s in tandem with more recently plateauing obesity rates. On average, Americans eat about 20 teaspoons of added sugar a day.

People who never drink sugar-sweetened beverages can easily swallow added sugar from multiple sources beyond the usual suspect of baked goods. A tablespoon of ketchup contains about one teaspoon of sugar. A cup of bottled spaghetti sauce equals six teaspoons of sugar.

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Dr. Caroline Apovian, director of the Nutrition and Weight Management Center at Boston Medical Center and professor of medicine and pediatrics at Boston University School of Medicine, called the new US recommendations "a baby step."

"I think this is a continued step in the right direction. The better step would be to mandate reduction of total added sugars," she said . "But I guess this is a baby step — meaning education of how much sugar is in foods and drinks and letting the consumer make the decision."

Alice Lichtenstein, a professor of nutrition science and policy at Tufts University, agrees that the new recommendations are useful but warns that a wider education effort on nutrition is needed.

"Knowing the amount of added sugar would be very helpful to someone choosing between, for example, two flavored yogurts or breakfast cereals," she said. "However, just because a food is low in added sugar — for example, crackers or breakfast cereal — does not mean it is a good choice if it was high in salt or made with refined flour rather than whole grain flour."

Lichtenstein, who is also director of the Cardiovascular Nutrition Laboratory of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts, is wary of single-ingredient approaches to nutritional guidance.

"Hindsight has taught us we need to guard against unanticipated consequences, as occurred during the low-fat era," she said.

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In the past, low-fat dietary regimens often meant high carbohydrates, an imbalance that some blame for the rise in obesity dating to the 1980s. In general, Lichtenstein said, it's important to take the long-term view and think about dietary patterns and not individual foods or nutrients.

Take salt.

In some people, salt can make the body retain excess fluid, increasing blood pressure. That places an extra burden on the heart, raising the risk of heart attack, stroke, and heart failure. The American Heart Association recommends consuming no more than 1,500 mg per day of sodium, far shy of the nearly 3,500 milligrams of sodium a day Americans typically consume.

A 2013 Institute of Medicine report challenged that one-size-fits-all strategy, suggesting low-salt diets only for people who are sensitive to salt. If they discover at the doctor's office that they have elevated blood pressure, they can test whether they're salt sensitive by altering their diets.

The biggest danger posed by added sugar or salt may be that each ingredient rarely rides alone. A hot dog is salty, but it's also high in fat. The same is true of cookies; sugar plus fat make it tasty. Ice cream? Fat plus sugar again. Cheeseburger? Fat and salt.

Almost 20 years ago, Dr. Thomas Moore, now director of the Office of Clinical Research at Boston University Medical Center, studied what happened when volunteers followed the DASH diet, short for Dietary Approaches to Stop Hypertension. Their blood pressure went down, but so did their cholesterol and blood sugar.

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The diet emphasized "real," not processed foods: fruits, vegetables, low-fat dairy foods with reduced saturated and total fat, much like the Mediterranean diet. In other words, a healthy diet associated with better health outcomes — not just a low-salt diet.

Marion Nestle, a nutrition professor at New York University who studies the influence of the food industry on nutrition and health, said focusing on one ingredient makes sense only in the context of calories.

What should people be concerned about?

"Eating too much," she said, "of anything."


Elizabeth Cooney can be reached at lizcooney40@yahoo.com. Follow her on Twitter at @cooney_liz.