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A Harvard Medical School Special Health Repor
Price: 29
In this report:
Sodas and juice
Salt and sodium
What the labels mean
Self-defense: Sugar-reducing strategies
Recipes
SPECIAL SECTION
Blood pressure matters
Reducing Sugar and Salt:Strategies for minimizing risks to your health
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Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115This Harvard Health Publication was prepared exclusively for blanco prieto - Purchased at http://www.health.harvard.edu/
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REDUCING SUGAR AND SALT
SPECIAL HEALTH REPORT
e ca tor eresa ung, c , .
Adjunct Professor of Nutrition,arvard School of Public Health
tor. . errett
opy tor
o n et ertonrt rectoreves en ns
rea ve rec or u rouse
ustratorscott e g ton, ason aram e
u s e y arvar e ca c oont ony . omaro , . ., tor n ewar o urn, u s ng rector
n association with
Belvoir Media Group, LLC, 800 Connecticut Avenue, Nor-
walk, CT 06854-1631. Robert Englander, Chairman andCEO; Timothy H. Cole, Executive Vice President, Editorial
Director; Philip L. Penny, Chief Operating Officer; Greg
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opyright 2012 by Harvard University. Written permission is
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ISBN 978-1-61401-015-9
The goal of materials provided by Harvard Health Publications
is to interpret medical information for the general reader. This
report is not intended as a substitute for personal medical
dvice, which should be obtained directly from a physician.
Contents
A brief history of sugar and salt . . . . . . . . . . . . . . . . . . . . . .2
The lowdown on sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Rise and fall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Insulin resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Glycemic index: The type of carbohydrate matters . . . . . . . . . . . . .8
Factors that affect a foods glycemic index . . . . . . . . . . . . . . . . . .8
Glycemic load: Measuring the full effect . . . . . . . . . . . . . . . . . . . . 8
Beyond the glycemic load . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
o as an u ce
e uc ng sugar 12
Salt and sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Sodium in excess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Sodium reduction helps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
A salt step-down in the works . . . . . . . . . . . . . . . . . . . . . . . . . .17
SPECIAL SECTION: Blood pressure matters . . . . . . . . . . . 18Understanding the numbers . . . . . . . . . . . . . . . . . . . . . . . . . . .19
A call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Self-defense: Sugar-reducing strategies . . . . . . . . . . . . . . 23
Do some detective work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Say no to liquid calories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
What about artificial sweeteners? . . . . . . . . . . . . . . . . . . . . . . .25
Other strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Self-defense: Conquering your salt habit. . . . . . . . . . . . . . 28
10 tips for reducing salt in your diet . . . . . . . . . . . . . . . . . . . . .29
Recipes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Breakfast. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Lunch and Dinner Entres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Snacks and Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Desserts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
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Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
Dear Rea er,
Salt and sugar are two of the most humdrum items in kitchen cupboards. But they have been
centers o controversy in aca emic e ates an arguments over pu ic ea t po icies as ex-
perts dispute the hazards of taking in too much of these nutrients and the benefits of cutting
ac . In just t e ast ew years, t e evi ence o ow muc arm t ese tasty flavor en ancers
can o as ecome un enia e.
Its not t e spoon u o sugar at rea ast or t e as o sa t at t e inner ta e t at are t e ig
worries. Instea , its t e sugars a e to sweetene everages, juices, esserts, an cerea s, an
t e sa t i en in prepare oo s. We nee zero a e sugar ecause we get a t e sugar wenee rom w ats natura y in oo , an ecause t e o y can ma e oo sugar rom a most
any carbohydrate-containing food. Yet added sugars now provide almost 20% of the average
Americans ai y ca ories. We nee on y a scant amount o so ium ess t an one gram a ay
(about 1/30th of an ounce)to survive. But because it is in so many of the processed foods we
ave come to re y on, we ta e in an average o a out 3.5 grams o so ium a ay.
W y are t e excesses o sugar an sa t an issue? A e sugars provi e so-ca e empty ca o-
ries, energy wit no ot er nutritiona va ue. ere is mounting evi ence t at t ey are e ping
ue t e astronomica rise in o esity an ia etes in t e Unite States an aroun t e wor .
oo much salt can lead to high blood pressure and related health problems like stroke, heartisease, an i ney ai ure.
We cant blame salt and sugar for tasting good. ey are, aer all, key stimulators of our taste
u s, an or soun evo utionary reasons. Sugar s sweetness represents ca oric energy, t e ue
o i e. An every ce in t e o y nee s t e so ium in sa t. But t e consequences o over oing
t em are visi e a aroun us.
is report aims to e p you ma e your own ecisions y exp aining t e serious ea t ris s
associated with taking in too much sugar and salt and offering ways to reduce their use with-
out sacrificing taste.
Sincerely,
eresa Fung, Sc.D.,RD
A junct Pro essor o Nutrition, Harvar Sc oo o Pu ic Hea t
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A brief history of sugar and salt
Sugar an sa t are inexpensive ingre ients t at are
u iquitous in t e oo supp y. at asnt a ways
een t e case.
Sugar starte out as a ar -to-come- y ingre ient.
roughout most of human history, it was available
on y w en ruit ripene or ees a een usy. But
once the technology of extracting sugar from plants
evo ve first rom sugar cane an t en rom eets
sugar not on y ecame a un ant ut a so e pe
irect t e course o istory, ea ing in t e New Wor
o co onies, p antations, an t e scourge o s avery.
Salt was once so diffi cult to get that it was used
as currency. In some ear y economies it was wort its
weight in gold. e word salary comes from the Latin
sa arium, w ic means sa t money. It is t oug t to
re er to part o t e pay given to Roman so iers to uy
sa t. Cities were ui t aroun sa t eposits; wars ave
een oug t over it.
o ay, sugar an sa t are pro uce in vast quan-
ities. Accor ing to estimates y t e U.S. Department
of Agriculture and the U.S. Geological Survey, in 2011
e wor pro uce near y 200 mi ion tons o sugar
and 320 million tons of salt.
As a resu t, two commo ities t at were once ar
to come y are now a most impossi e to avoi . In
recent years, researc ers commente in t e jour-
na ature in 2012, sugar as een a e to virtu-
ally every processed food, limiting consumer choice.
Nature ma e sugar ar to get; man ma e it easy.
Why is this a problem? As described more fully in
t e o owing c apters, too muc o a goo t ing can
e azar ous to ea t . e average American ta es in
more t an 350 ca ories a ay rom a e sugars, oen
in so a, energy rin s, an ot er sweetene ever-
ages. ose empty calories are contributing to the obe-
sity pro em in t e Unite States. A out one-t ir o
American children and more than two-thirds of adults
are overweig t or o ese. Excess weig t is strong y
in e to t e eve opment o ia etes, eart isease,
some cancers, osteoart ritis, an more. Too muc sa t
is a ey contri utor to ig oo pressure yperten-
sion). By age 65, more t an a o Americans ave
ig oo pressure; aer age 75, t ree-quarters ave
it. People with high blood pressure are more prone to
aving a stro e or eart attac or eve oping eart
failure or kidney failure.
It on y ma es sense t at cutting ac on a e
sugars can e p cut ca ories. An a compe ing stu y
pu is e in e New Eng an Journa o Me icine
estimate t at i Americans as a w o e cut ac sa t
intake by teaspoon a day (about 1,200 milligrams
o so ium; see Table 1, le), at sma c ange wou
prevent up to 99,000 heart attacks, 66,000 strokes, and
92,000 premature eat s eac year.
Becoming aware o ow muc sugar an so ium
you consume, an fin ing ways to a just t em ea t -
u y, are goo strategies or your ea t . In t e o owing
pages we s ow you ow to o t at.
Table 1 ompar ng sa an so um
By weight, table salt (sodium chloride) is about 40% sodium.This table can help you convert between teaspoons of salt andmilligrams of sodium.
SALT(TEASPOONS)
SALT(MILLIGRAMS)
SODIUM(MILLIGRAMS)
1,450 600
2,900 1,200
4,250 1,800
1 5,800 2,300
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The lowdown on sugar
Asugars, rom refine w ite sugar to oney an
agave nectar, are a type o car o y rate. Car o-
y rates are c emica compoun s t at contain on y
ree e ementscar on, y rogen, an oxygenin a
dizzying array of combinations. Sugars and other car-
o y rates are t e main nutrient in rea , pasta, cere-
als, beans, vegetables, and dairy foods.
Once upon a time, t e on y sugars we consume
were t ose natura y in t e oo s we ate. To ay, muc
o t e sugar in our oo supp y as een put t ere
y umans. e USDA egan to use t e term a e
sugars in 2000 to help consumers identify foods that
ave a e ca ories wit no a e nutrition. A e
sugarswhite sugar, brown sugar, maple syrup, honey,
mo asses, ig - ructose corn syrup, an morenow
represent 16% o t e tota ca ories we consume. In
ot er wor s, a out one-sixt o our ca ories ave no
nutritiona va ue. A e sugar as een in e to an
overa ec ine in t e qua ity o t e U.S. iet, as we
as to weig t gain an increases in o esity an eart
disease. e latest Dietary Guidelines for Americans
oo aim at sugars a e to oo s uring processing
in food plants, in the kitchens of restaurants, and even
at our rea ast ta es.
C emists initia y ivi e car o y rates into two
groups: simp e an comp ex. Simp e car o y rates
inc u e sugars i e g ucose sometimes ca e ex-
rose), fructose (fruit sugar), lactose (milk sugar),
an sucrose ta e sugar). Comp ex car o y rates
were made up of interlocking chains of sugar mole-
cu es, i e t ose oun in starc an fi er. Simp e ver-
sus comp ex is a per ect ivision or c emists, ut it
oesnt at a exp ain ow car o y rates affect ea t .
Our o ies re y on just one type o sugarg u-
cose. But we never nee to eat g ucose, or any sugar
or t at matter, since t e o y can turn many in s
of food into glucose. ink of glucose as the univer-
sa currency o t e o ys car o y rate economy, an
he organs of the digestive system as a 24/7 currency
exc ange, turning simp e an comp ex car o y rates
into g ucose. I nee e , our o ies can even turn pro-
tein an at into oo sugar.
W en you eat a ow o w ite rice, a s ice o
whole-grain bread, or an orange, the body breaks
own igesti e car o y rates into sugar mo ecu es.
Glucose is rapidly passed into the bloodstream and
e ivere to ce s rom t e rain to t e toes. Leover
g ucose can e in e into ong c ains ca e g ycogen
an store in t e iver or ater use, or converte into
at an store in at ce s. e spee wit w ic a car-
bohydrate-containing food becomes blood sugar can
influence weig t an ong-term ea t .
Rise and fallPicture a ro er coaster trac p enty o ups an
owns, some ig an steep, ot ers ow an gent e.
ats essentially what your blood sugar and insulin
eve s oo i e over t e course o a ay. Mea s an
snacks cause highs that drop to lows later on. Learning
to eat in a way t at ma es your oo sugar eve s oo
more like a kiddie coaster than a wild, breathtaking
ri e can ma e a ifference to your ea t .
Because every ce in t e o y epen s on
instant access to just t e rig t amount o oo sugar,
Go i oc s- i e mec anisms are in p ace to ma e sure
that blood sugar doesnt rise too high or fall too low.
Sometimes, t oug , t ey can e overw e me .
A rise in blood sugar stimulates the pancreas to
re ease insu in into t e oo stream. is ormone te s
ce s to a sor g ucose; wit out insu in, t ey cant ta e
it in. e ig er t e oo sugar eve , t e more insu-
in re ease . As ce s sponge up g ucose, t e amount o
g ucose in t e oo stream egins to ri ownwar ,
o owe y t e amount o insu in (see Figure 1, page
4). As blood sugar approaches the lowest safe level, the
pancreas egins re easing anot er ormone, ca e g u-
cagon. It tells the liver to start breaking down glycogen
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an re ease t e resu ting g ucose into t e oo stream.
is provides a steady supply of blood sugar for the
rain an ot er ce s. at re ease o store g ucose is
why you can go for hours, or even days, without eating
an your ce s sti ave a stea y supp y o ue .
Heres w ere t e type o car o y rate comes into
play. A meal or snack containing foods that the body
imme iate y converts into g ucose i e w ite rea
or white rice) causes a rapid, high spike in blood
sugar. ats o owe y an equa y ig spi e in insu-
in (see Figure 1, below). But a ig jo t o insu in can
quic y rive oo sugar own to or e ow t e sa e
zone. I t ere isnt any more igesti e car o y rate
in t e stomac or intestines, t e gut an rain sen
out signa s t at get you oo ing or somet ing more to
eatwhile at the same time the liver is breaking down
g ycogen an pumping g ucose into t e oo stream.
Easily digested carbohydrates are abundant in
t e American iet (see Carbs matter, le). ey are
t oug t to contri ute to weig t gain ecause t ey trig-
ger unger signa s re ative y soon aer eating. In a i-
tion, t e g ut o insu in t at o ows a ig spi e in oo
sugar prompts the body to convert glucose into fat.
A mea or snac o s ow y igeste car o y rates
(like whole grains or beans) smooths out the blood
sugarinsu in ro er coaster. e igestive system ta es
ow oo sugar an insu in rise an a in t e oo stream epen s on t e type o car o y rate t at is eing igeste .
Source: Eat, Drink, and Be Healthy(Free Press, 2005)
Figure 1 Blood sugar roller coaster
1 2 3 4 5
Time (hour)
Easily Digested Carbohydrate
Change
in
blood
sugar,insulin
Blood Glucose
Insulin
Slowly Digested Carbohydrate
Change
in
blood
sugar,insulin
0 1 2 3 4 5
Time (hour)
Blood Glucose
Insulin
Carbs matter
Car o y rates contri ute a out a o a ca oriesto a typica American iet. A worrisome a o t esecarbohydrate calories come from eight sources, noneo w ic even remote y qua i es as a ea t oo . Aare c oc - u o rapi y igeste car o y rates.
1. So t rin s, so as, an ruit- avore rin s
2. Cake, sweet rolls, doughnuts, and pastries
3. Pizza
4. Potato c ips, corn c ips, an popcorn
5. Rice
6. Brea , ro s, uns, Eng is mu ns, an age s
7. eer
8. Frozen potatoes an Frenc ries
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onger to rea own t ese car o y rates into sugar
molecules (see Figure 1, page 4). at means blood
sugar rises more s ow y an its a ower pea , as oes
insulin. is is good for health (see Insulin resis-
tance, below). It a so means it ta es onger to get un-
gry aga n.
mong peop e wit ia etes, ig eve s o oo
sugar an insu in contri ute to many o t e comp i-
cations o t is isease, suc as nerve amage, oss
o vision, i ney isease, sexua ys unction, an
wounds that wont heal. Routine high blood sugar and
insu in can a so pose pro ems or seeming y ea t y
individuals. ey can tip people toward developing
ia etes. Researc suggests t ey may a so contri ute
o ot er c ronic con itions, inc u ing reast cancer,
co on cancer, an po ycystic ovary syn rome. W i e
smoot ing out your oo sugar an insu in eve s
may help you prevent these conditions, the proven
enefits are preventing eart isease an ia etes an
controlling weight.
Insulin resistanceIn a ea t y o y, iver an at ce s imme iate y
respond to insulins open up for sugar signal and
egin to pu in g ucose rom t e oo stream. In a
growing number of people, the response to this essen-
ia signa ecomes mute . is resistance to insu in
causes two key problems. It keeps blood sugar at high
eve s or onger perio s. Over time, t is can amage
nerves, blood vessels, and other tissues. It also makes
t e pancreas pro uce more an more insu in aer
every meal or snack in an effort to help cells to absorb
oo sugar. As an overwor e pancreas wears out,
insu in pro uction s ows. is causes oo sugar to
s yroc et aer eating an to remain ig or onger
perio s. ese are signs o type 2 ia etes once ca e
a u t-onset ia etes an non-insu in- epen ent ia-
etes). In 1980, a out six mi ion Americans a ia-
betes. Today, it affects more than 25 million, one-third
o w om ont now t ey ave it.
Insulin resistance isnt just a blood sugar problem.
It as a so een in e wit a variety o ot er pro -
ems, inc u ing ig oo pressure, ig oo ev-
e s o trig yceri es a type o at), ow oo eve s o
ig - ensity ipoprotein HDL, goo c o estero ),
heart disease, and possibly some cancers.
Hig oo sugar an insu in eve s a so contri -
ute to the buildup of fat around the waist. is belly
at tec nica y ca e a omina at or viscera at)
appears to pose more o a ea t pro em t an at t at
accumu ates aroun t e ips an t ig s. It as een
in e to ig oo pressure, ig c o estero , ig
oo sugar, an eart isease (see Do you have met-
abolic syndrome? page 6). Be y at offers a snaps ot
that can tell you how healthy you are. Simply measur-
ing t e waist can e use u ecause many peop e gain
abdominal fat as they go through midlife, even those
Is high-fructose corn syrup a special problem?
For centuries, Americans satis e t eir craving or sugarwith sucrose (table sugar) from sugar cane and sugar beets,
oney, map e sugar, an mo asses. Beginning in t e 1970s,more an more o w at sweetens our oo s an everageshas come from corn, most of it in the form of high-fructosecorn syrup. Found in everything from sugared sodas to baby
oo , ig - ructose corn syrup now ma es up more t ana o t e a e sugar we now consume.
C emica y, ig - ructose corn syrup is very simi ar tosucrose. Every molecule of sucrose contains one molecule ofg ucose an one o ructose. Hig - ructose corn syrup is pureg ucose mixe wit pure ructose in a most equa propor-tions (about 55% fructose and 45% glucose). So its likelyt at ta e sugar an corn sweeteners ave simi ar e ects on
oo sugar, insu in, an meta o ism.
Yet some peop e ave vi i e ig - ructose corn syrup asone of the key culprits behind the obesity epidemic. Itsan easy argument to make, since its adoption by the foodin ustry para e s t e trajectory o o esity rates. An w i eits true that the body processes fructose in a different wayhan it processes glucose, both refined sugar and high-
ructose corn syrup contain a out t e same amounts oructose.
So ar, t ere isn t any so i evi ence t at ig - ructose cornsyrup is worse than any other added sugar. Whats impor-ant is eeping your inta e o alla e sugars in c ec . T e
American Heart Association recommen s eeping your in-ake of added sugars under 100 calories a day (24 grams, or
6 teaspoons or women an un er 150 ca ories 36 grams,or 9 teaspoons or men.
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w o are not gaining weig t. A waist ine t at expan s
more than two or three inches over the years should
trigger a warning t at you nee to reeva uate your
diet and physical activity levels. To see how your waist
measurement stac s up, see Figure 2, below.
Four main actors contri ute to insu in resistance.
One o t em cant e contro e , ut t e ot er t ree can. Genes. Insu in resistance is more common
among Native Americans, Pacific Is an ers, an ot er
peop e o Asian eritage t an it is among t ose o
European descent. Although you cant change your
genes, you can eat a genetic pre isposition to insu in
resistance by staying lean, being physically active, and
eating a ea t u iet. Weight. e urt er you stray rom a ea t y
weig t, t e ar er it is or your o y to an e g u-
cose. One way to etermine i your weig t is in t e
healthy range is to determine your body mass index
BMI). is is a measure o weig t or eig t. You can
find your BMI in Table 2, page 7, or calculate it online
at www.health.harvard.edu/BMI. Exercise. During exercise, musc es extract g u-
cose rom t e oo more effi cient y, an wit ess
Do you have metabolic syndrome?Meta o ic syn rome, a c uster o con itions t at occurtoget er, increases t e ris o eart isease, stro e, an
ia etes. One o its ey eatures is a arge waist. I you
have one, youre more likely to have the other character-istics.
You ave meta o ic syn rome i you ave t ree or more
o t ese ve traits:
1. Waist circum erence more t an 35 inc es in
women or 40 inches in men
2. Fasting oo trig yceri e eve o 150 mi igrams/
deciliter (mg/dL) or higher
3. HDL goo c o estero o ess t an 40 mg/ L in
men or less than 50 mg/dL in women
4. Systoic oo pressure t e top num er o a rea -
ing) of 130 mm Hg or higher, or diastolic pressure
t e ower num er o 85 mm Hg or ig er5. Fasting blood sugar level of 100 mg/dL or higher.
(Note: You are considered to have a trait if you receive
treatment or it, even i your num ers are norma wit
this treatment.)
Source: National Heart, Lung, and Blood Institute
Figure 2 Check your belly
Waist circumference
Minimum waist-to-hip ratio associatedwith increased health risks:
For men:0.91.00For women:0.85
ips are usuallyeasured at theidest circumference,round the buttocks
Waist circumference associatedwith increased health risks:
For men:More than 40 inches 102 cmFor women: More than 35 inches (88 cm)
Waist-to-hip ratio
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e p nee e rom insu in, t an musc es o at rest.
e effect lasts for several hours aerward. Being a
couc potato oesnt o muc to c ear g ucose rom
he bloodstream. People who arent very active have
ig er at-to-musc e ratios t an active peop e, even i
eir BMIs are in t e ea t y range.
Dietary fat.A t oug t e mix o ats in t e iet
plays a small role in insulin resistance, it can make a
i erence. A ig inta e o trans at rom margarines
and prepared foods) and a low intake of polyunsatu-
rate at rom vegeta e oi s an atty is ) contri ute
to insu in resistance.
Table 2 n ng your
The body mass index (BMI) is an index of weight by height. The definitions of normal, overweight, and obese were established after researchersexamined the BMIs of millions of people and correlated them with rates of illness and death. These studies identified the normal BMI range asthat associated with the lowest rates of illness and death.
HEIGHT BODY WEIGHT IN POUNDS
10 91115 119138 143162 167186 191+
11 94119 124143 148168 173193 198+
50 97123 128148 153174179199
204+
51 100127 132153 158180 185206 211+
52 104131 136158 164186 191213 218+
53 107135 141163 169191 197220 225+
54 110140 145169 174197 204227 232+
55 114144 150174 180204 210234 240+
56 118148 155179 186210 216241 247+
57 121153 159185 191217 223249 255+
58 125158 164190 197223 230256 262+
59 128162 169196 203230 236263 270+
510 132167 174202 209236 243271 278+
511 136172 179208 215243 250279 286+
60 140177 184213 221250 258287 294+
61 144182 189219 227257 265295 302+
62 148186 194225 233264 272303 311+
63 152192 200232 240272 279311 319+
64 156197 205238 246279 287320 328+
BMI 19
24 25
29 30
34 35
39 40+
NORMAL OVERWEIGHT CLASS I OBESITY CLASS II OBESITY CLASS III OBESITY
You can ca cu ate your own BMI wit t e o owing ormu a:
1. ake your weight in pounds and multiply it by 703.
.Measure your eig t in inc es an mu tip y it y itse .
3.Divide the number from step two into the number from step one. The answer is your BMI. If your BMI is less than 20 you areun erweig t; etween 20 to 24.9, you are at a norma , ea t y weig t; etween 25 to 30, you are overweig t; an a ove 30,you are o ese.
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Glycemic index:The type of carbohydrate mattersC assi ying car o y rates as simp e versus comp ex
does little to tell us which carbohydrate-containing
oo s re ease t eir sugars in a flas an w ic yie
em more i e t ose time -re ease co capsu es you
see on te evision commercia s.
o fin a etter way, Cana ian nutrition researc er
Davi Jen ins an is co eagues i somet ing revo-
utionary in t e ear y 1980st ey measure ow i -
erent types of carbohydrate-containing foods affected
oo sugar compare wit pure g ucose. ey ca e
his comparison the glycemic index.
Measuring g ycemic in ex is a painsta ing process
at requires a vo unteer to consume an amount o a
est oo w o e oats, pear, ac eans, ice cream,
an so ont at contains 50 grams o car o y rate.
His or her blood sugar is then measured at regular
interva s over t e next two ours. On anot er ay,
he same volunteer does the same thing, but this time
consumes 50 grams o g ucose. en t e va ues or t e
oo an g ucose are compare , y ivi ing t e rise in
oo sugar spar e y t e test oo y t e rise ue to
g ucose.
e higher the glycemic index, the faster and
more strong y t e oo affects oo sugar. e ower
he glycemic index, the lower and slower the rise in
oo sugar.
Since the concept was created, researchers have
measure t e g ycemic in ex o severa t ousan
oo s. As you can see in Table 3, page 9, t e g ycemic
in ex c ear y s ows t at not a comp ex car o y rates
are goo , an not a simp e ones are a . Cornfla es,
chemically a complex carbohydrate, have a high gly-
cemic in exin t e 80smeaning t ey quic y an
strongly boost blood sugar. Fructose, the simplest of
sugars, as a very ow g ycemic in ex23meaning
it as itt e effect on oo sugar. Its use u to t in o
oo s in t ree categories: Low glycemic index (55 or less):Most ruits an veg-
eta es, eans, minima y processe grains, pasta,
ow- at airy oo s, an nuts. Moderate glycemic index (56 to 69):Sweet potatoes,
corn, w ite rice, pasta, some rea ast cerea s
such as Cream of Wheat and Mini Wheats.
High glycemic index (70 or higher): W ite rea ,
white rice, potatoes, rice cakes, most crackers,
age s, ca es, oug nuts, croissants, wa es, most
packaged breakfast cereals.
C oosing oo s ow on t e g ycemic in ex can
e p you avoi ig oo sugar ig s an ows.
Factors that affect a foodsglycemic indexGlycemic index isnt a set, unvarying value like molecu-
ar weig t. Processing an coo ing met o s, as we as
what you eat with the food, all affect how rapidly your
o y rea s own its car o y rates an ow quic y
your oo stream a sor s t e i erate g ucose. Grinding grain dramatically increases how fast
digestive enzymes can attack the starch and break it
apart.Wheat flour has more surface area to attack than
w eat erries. Most w eat our as a so een strippe
of its branthe protective, hard-to-digest, fibrous
outer coat t at s ows t e action o igestive enzymes.
Stee -cut oats, w ic are s ice oat grains, ave a ower
g ycemic in ex t an regu ar oatmea , w ic is ma e o
smas e oat grains.The more indigestible fiber a food contains, the
lower its glycemic index.T ats ecause i er carries
along partly digested food and protects it from diges-
tion. T is sprea s out t e a sorption o g ucose into
the bloodstream.Fats slow the digestive process.Eating at wit a
car o y rate-ric oo can temper t e rise in oo sugar.Lemon juice, vinegar, and other acidic ingredients
a so e ay t e rise in oo sugar a ter you eat a car o-
hydrate-rich food.
Glycemic load:
Measuring the full effecte g ycemic in ex o a oo te s on y part o t e
story. How muc o t e oo is consume a so affects
blood sugar and insulin levels. ats why research-
ers at t e Harvar Sc oo o Pu ic Hea t eve ope
the concept they call glycemic load. It is calculated by
mu tip ying a oo s g ycemic in ex y t e num er o
grams of carbohydrate consumed and dividing by 100.
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Table 3 Glycemic index and glycemic load values for commonly eaten foods
The glycemic index and glycemic load offer information about how a food affects blood sugar and insulin. The lower the glycemic index or glycemicload, the less the food affects blood sugar and insulin levels. Scientists have calculated glycemic index and glycemic load for more than 2,500 foods. Asample is provided in the table below. The University of Sydney in Australia maintains a free searchable database of glycemic index and glycemic loadvalues at www.glycemicindex.com. The healthiest choices are those with a glycemic index below 55 and a glycemic load below 10.
FOOD SERVING SIZEGLYCEMICINDEX (%)
CARBOHYDRATE(in grams)
GLYCEMICLOAD*
WHITE RICE 5 ounces 89 48 43
CRANBERRY JUICE 1 cup 68 35 24
SPAGHETTI, COOKED 1 cup 49 48 24
CORNFLAKES 1 cup 93 25 23
SNICKERS BAR 1 bar (2 ounces) 68 34 23
JELLY BEANS 1 ounce 80 28 22
POTATOES (WHITE), BOILED 1 cup 78 26 20
GRAPE-NUTS CEREAL cup 75 22 16
COCA-COLA 12 ounces 63 26 16CHEERIOS 1 cup 74 20 15
SHREDDED WHEAT CEREAL 2 biscuits 67 20 13
OATMEAL (ROLLED OATS) 1 cup 58 22 13
BANANA (RIPE) 1 medium 51 25 13
RAISIN BRAN CEREAL 1 cup 61 19 12
ORANGE JUICE 1 cup 46 26 12
CORN TORTILLA 2 medium 46 22 11
WHITE BREAD 1 slice 75 14 10
STRAWBERRY JAM 1 tablespoon 51 20 10
WHOLE-WHEAT BREAD 1 slice 74 13 10
PIZZA HUT SUPER SUPREME PIZZA 2 slices 36 24 9
ENGLISH MUFFIN 1 muffin 77 11 8
ALL-BRAN CEREAL cup 42 21 8
BLACK BEANS 1 cup 43 23 7
APPLE (GOLDEN DELICIOUS) 1 medium 39 16 6
ENGLISH MUFFIN, WHOLE GRAIN 1 muffin 43 11
PUMPERNICKEL (DARK RYE BREAD) 1 slice 41 12MILK, SKIM 1 cup 37 13
RED LENTILS 1 cup 21 18
TABLE SUGAR (SUCROSE) 1 teaspoon 65 2.6
FRUCTOSE 1 teaspoon 15 0.6
*Glycemic load is calculated by multiplying grams of carbohydrate by glycemic index and dividing by 100.Source: Atkinson FS, Foster-Powell K, Brand-Miller JC. International tables of glycemic index and glycemic load values: 2008, Diabetes Care(2008), Vol. 31, No.
, pp. .
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a e spag etti, or examp e. It as a g ycemic
index of 46. An average serving delivers 31 grams of
car o y rate: 46 times 31 ivi e y 100 equa s 14.
s with the glycemic index, putting foods into
ree categories can e p etermine goo c oices an
ort on s zes: Low glycemic load (10 or lower):Lenti s an eans
i ney, gar anzo, ac , etc.); i er-ric ruits an
vegeta es; nuts an see s; w o e grains i e ar-
ey, w eat erries, an t e i e. Medium glycemic load (11 to 19):Steel-cut oatmeal;
w o e-w eat pasta an some rea s; ruit juices
without extra sugar; brown rice; sweet potatoes. High glycemic load (20 or higher):So a, energy rin s,
an ot er sugar-sweetene everages; can y;
w ite rice; Frenc ries an a e potatoes; sug-
ary rea ast cerea s.
Because glycemic load includes information on
ow muc car o y rate is consume , it is etter
han glycemic index alone at capturing whats going
on in your oo stream aer you eat a car o y rate-
containing oo .
Some oo s ave a ig g ycemic in ex ut very
itt e car o y rate per serving. Ta e waterme on as
an example. It has a high glycemic index (80), which
mig t ma e you stay away rom it. Yet as its name
implies, watermelon is mostly water; a cup of water-
me on cu es contains just six grams o car o y rates.
So t e g ycemic oa is sma , un er 5.
Sugary so a as a mo erate g ycemic in ex
ecause it contains a air amount o ructose, w ic
as re ative y itt e effect on oo sugar. But it a so
e ivers p enty o car o y rates, so it as a ig g y-
cemic load.
Fo owing a iet wit a ow g ycemic oa wi e p
you to make healthier food choices. And because the
oo s are typica y ig er in fi er an nutrients, you
wi ee satisfie onger, w ic can e p contro weig t.
Beyond glycemic loade g ycemic in ex an g ycemic oa are gui es to
choosing carbohydrate-containing foods, not strict
ru es. Its a so important to eva uate t e ot er nutri-
ents in a oo . Some car o y rate-ric oo s e iver
ar more t an just sugar. Fruits an vegeta es offer
Figure 3Sugar intake through sweetened drinks
n the United States, average consumption of sugar from sweetened beverages peaks in the teen years.Source: CDC/NCHS, National Health and Nutrition Examination Survey, 20052008.
Caloriesperday
Age (years)
0
50
100
150
200
250
300 FemaleMale
60 and over40592039121961125All
178
71
141
273
252
159
112
171
138
70 70
103
86
42
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fi er, vitamins, minera s, an p enty o active p yto-
chemicals. e same is true for intact or slightly pro-
cesse grains.
e biggest value of the glycemic load may be
or eci ing among various options. W en pic ing
a snac or p anning a mea , c oosing oo s wit ow
g ycemic oa s is etter or your insu in-ma ing ce s
an your overa ea t t an c oosing t ose wit ig
g ycemic oa s.
Sodas and juiceSprinkling 10 to 12 teaspoons of sugar on a bowl of
cerea wou ma e it muc too sweet to eat. Yet accor -
ing to t e Harvar Sc oo o Pu ic Hea t s Nutrition
Source, t ats ow muc sugar is in a 12-ounce can o
many popu ar so rin s. See www.hsph.harvard.
edu/nutritionsource/healthy-drinks/how-sweet-is-it
or a ist o t e amount o sugar in popu ar everages.)
Given ow muc so a, ruit everages, an ot er so
drinks Americans consume, almost half of the added
sugar in t e U.S. iet comes rom so rin s an ruit
juices. Among youths, sugar intake from sugar-sweet-
ene everages represents near y 15% o t eir ai y
inta e o ca ories (see Figure 3, page 10).
A num er o stu ies ave in e sugar-sweetene
rin s to weig t gain an an increase ris o type 2
diabetes. e most recent, a trio of reports published
n e New Eng an Journa o Me icine, in regu-
lar consumption of sugar-sweetened beverages to the
eve opment o o esity in c i ren, a o escents, an
adults. Other studies have found that men and women
w o regu ar y ran sugar-sweetene everages were
at increase ris o stro e an eart isease, even
aer ot er un ea t u i esty e or ietary actors were
accounte or.
Sugar-sweetened beverages generally deliver pure
ca ories wit out any o t e ea t u nutrients you
What about fruit juice?
Fruit juice is i erent rom so as an ot er sugar-sweetene everages, rig t? It epen s on ow muc youdrink. As an accompaniment to your breakfast, or as theoccasiona t irst quenc er, 100 juicenot juice- avoresugar watercan e part o a ea t y iet. Rea juice
gives you some vitamins, minerals, and maybe a bit ofer.
Keep in mind that 100% fruit juice can deliver a lot ofca ories. Twe ve ounces o orange juice e ivers a out 150ca ories, t e same as a simi ar amount o sugar-sweetenesoda. If juice is part of your morning routine, use a smallg ass t at o s 6 ounces.
e main pro em wit rin ing juice to quenc t irst ist at many peop e on t eat ess to a just or t e extra ca -ories in it. Thats a surefire recipe for gradual weight gain.Its also easy to confuse 100% juice with juice drinks,w ic are itt e more t an juice- avore sugar water.
I you use juice to quenc your t irst, i ute it wit regu aror spar ing water. Start wit two parts juice to one partwater and gradually work your way to one part juice tot ree or our parts water. Or s ip t e juice a toget er ana a squeeze o emon or ime to p ain or spar ing water.Vegetable juices are usually lower in calories than fruit
juices, ut c ec t e a e to e surean on t orget toma e note o t e so ium content.
An eep in min t at not a juices are equa . Grape ruitjuice, or examp e, c anges t e way some peop e a sorand metabolize certain drugs. It can make it hard for the
o y to a sor some rugs, ea ing to ower oo eve s.is appens wit t e a ergy me ication exo ena ine A -
legra); digoxin, which is used to treat heart failure; losartanCozaar , use to contro oo pressure; an t e antican-
cer rug vin astine. Grape ruit juice canboost oo eve sof other drugs, sometimes to dangerous heights. Drugsin t is category inc u e ca cium-c anne oc ers suc ase o ipine P en i , ni e ipine Procar ia , an niso ipine
(Sular), which are used to control high blood pressure; car-amazepine Car atro , Tegreto , use to contro epi epsy;
some wi e y use c o estero - owering me ications sucas lovastatin (Mevacor), atorvastatin (Lipitor), and simvas-atin Zocor ; cyc osporine, an immunosuppressant ta en
main y y peop e w o ave a an organ transp ant; anbuspirone (BuSpar), used to fight alcohol abuse, depres-sion, panic isor er, an a variety o ot er pro ems.
Something in grapefruit juice also appears to create condi-ions t at e p orm i ney stones. In t e Nurses Hea t
Stu y an t e Heat Pro essiona s Fo ow-up Stu y, every8 ounces of grapefruit juice consumed a day increased
e c ances o eve oping i ney stones y 44 . W i emore researc is nee e to con rm t is n ing, it s a gooreason to limit your intake of grapefruit juice.
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mig t get rom rea ruit juices or, etter yet, ruit
vitamins, minerals, other phytochemicals, and in
some cases even some fi er. ats a pro em or sev-
eral reasons: Weight gain.Many peop e treat iqui ca ories
rom sugar-sweetene everages as some ow i erent
rom oo ca ories, an ont ma e up or t e ca o-
ries in so a or juice y eating ess. Drin ing one can
o so a a ay oesnt seem i e a ig ea , an pro -
a y isnt i you cut ac on ca ories e sew ere an eat
lenty of fruits and vegetables. But if you dont adjust
your iet, t e extra 120 to 150 ca ories a ay rom a
sugar-sweetened beverage could easily translate into
ig er num ers on t e sca e an extra at aroun t e
e y. Exhausting insulin.T e rapi y igeste sugars in
so a an ruit juices quic y oost oo sugar an
insu in eve s. W en t is appens severa times a
dayin addition to the blood sugar boosts that occur
aer eatingit can cause pro ems. Among women
participating in the Nurses Health Study, those who
ran one so a a ay near y ou e t eir ris o ia-
etes. Among peop e w o are insu in resistant, ta ing
in ots o easi y igeste car o y rates raises t e oo
eve o trig yceri es, a in o at-carrying partic e t at
increases t e ris o eart isease.
Reducing sugarNow that you know more about added sugars and how
t ey can affect ea t , its time to earn w ere t ey are
an ow you can cut ac . Strategies or oing t is are
escri e in Self-defense: Sugar-reducing strategies,
beginning on page 23.
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Salt and sodium
To a c emist, sa t is w at you get w en positive an
negative ions enter eac ot ers or it. To t e rest o
us, sa t is so ium c ori e, t e w ite crysta s e over
w en seawater evaporates.
e human body needs sodium for many essen-
ia tas s. Nerves nee it to transmit impu ses. Musc e
fibers, including those in the heart and blood vessels,
nee it to contract an re ax. So ium e ps t e o y
maintain a proper flui a ance. But it oesnt ta e
muc so ium to accomp is t ese jo s. e Yano-
mamo peop e o t e Amazon rain orest get y on just
200 milligrams (mg) of sodium a day (the amount in
1/10t teaspoon o sa t). By comparison, t e average
merican gets 17 times more than that3,400 mg a
ay a out 1 teaspoons o sa t; see Figure 4, below).
e current Dietary Gui e ines or Americans
p aces t e ea t y upper imit or so ium at 2,300 mg a
day, or about 1 teaspoon of salt. at drops to no more
t an 1,500 mg a ay or A rican Americans, in ivi ua s
with high blood pressure (hypertension), diabetes, or
i ney isease, an anyone over age 51. e American
Heart Association says that everyone should try to keep
so ium inta e un er 1,500 mg a ay.
Too muc sa t as een in e to ea t pro ems
or centuries. A out 5,000 years ago, Emperor Huang
Di Neijin o C ina wrote: I too muc sa t is use or
food, the pulse hardens. In the modern era, Dr. Lewis
Da rom t e Broo aven Nationa La oratory egan
proposing in the 1950s that diets high in sodium con-
tri ute to ig oo pressure. His ypot esis was
c a enge y ot er researc ers, an t e so ium con-
troversy as rage ever since.
e ong-running e ate over w et er cutting
ac on sa t in t e iet as meaning u effects on
ea t as een most y ai to rest. A arge o y o
research accumulated over the past two decades shows
c ear enefits rom consuming ess sa tnot just or
lowering blood pressure but also for reducing the risk
o stro e an eart pro ems (see Self-defense: Con-
quering your salt habit, page 28).
Sodium in excesse uman o y as sop isticate mec anisms
for making sure enough sodium is always available.
C a t at up to two acts: every ce in t e o y nee s
so ium, an so ium was scarce t roug out most o
uman evo ution. Now t at so ium is a un ant, t ose
mec anisms may e wor ing against us.
Most Americans get ar more so ium t an t ey
nee . Its ar not to. Prepare oo s are oa e wit
table salt. An 8-ounce serving of macaroni and cheese
or an or er o ast oo ries can serve up as muc as
1,000 mg of sodium (see Table 4, page 14).
Figure 4 The rise of sodium consumption
0
Women
ages 2074
Men
ages 2074
Sodium(
mg/day)
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
1971197420032006
he American diet has become saltier since the seventies.
ccor ing to ietary surveys, average ietary so ium inta e rose
consi era y rom t e ear y 1970s to t e ear y 2000s.Source: Institute of Medicine.
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In ea t y in ivi ua s, t e i neys respon to
excess sodium by flushing it out in the urine. When
is process oesnt wor proper y an extra so ium
is retained, the kidneys hang on to water. Some of
at water ma es its way into t e oo stream. As
e amount o flui flowing t roug oo vesse s
increases, t e pressure insi e t em increases, orcing
e eart to wor ar er. In a ition, excess so ium
ma es oo vesse s ess flexi e, unting t eir a i ity
to re ax an contract wit ease. It may a so overstimu-
late the growth of heart tissue.
A out one-quarter o peop e wit norma oo
pressure and nearly 50% of people who have high
oo pressure are sa t sensitive, meaning consuming
too muc so ium e evates t eir oo pressure an
puts t em at ris or comp ications. Dozens o stu ies
ave s own t at oo pressure rises wit ig er ev-
e s o so ium in t e ietan t at cur ing sa t inta e
Table 4 Hidden salt in commercially prepared food
DAILY LIMIT (2,300 MG)
Kung Pao chicken with rice 2 cups 2,610 113
Ham sandwich with mustard 9 ounces 2,340 102
Lasagna 2 cups 2,060 90
Sauerkraut, canned 1 cup 1,560 68
Tuna salad sub sandwich 6 inches 1,293 56
Baked beans, canned 1 cup 1,106 48
Chicken noodle soup, canned 1 cup 1,106 48
Macaroni and cheese, canned 1 cup 1,061 46
Pasta sauce 1 cup 1,030 45
Corned beef brisket 3 ounces 964 42
Burger King Whopper 1 900 39Chicken pot pie 1 small 857 37
Dill pickle 1 (3 ounces) 833 36
Chicken bouillon 4-gram cube 743 32
Ham 2 slices 739 32
Vegetable juice cocktail 1 cup 653 28
KFC Biscuit 1 560 24
Cottage cheese cup 457 20
American cheese 1 slice 442 18
McDonald's French fries Super size 390 17
Waffle, frozen 1 383 17
Raisin Bran cereal 1 cup 361 16
Green beans, canned 1 cup 354 15
Cheese pizza 1 slice 336 15
Sources: U.S. Department of Agriculture, Agricultural Research Service. 2012. USDA National Nutrient Database for Standard Reference, Release 25. Nutrient Dataaboratory Home Page, www.ars.usda.gov/ba/bhnrc/ndland the Center for Science in the Public Interest (see www.cspinet.org/salt.
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owers oo pressure. e an mar DASH-So ium
rial is perhaps the best example of these (see e
DASH diet, below).
Writing in the Journal of Human Hypertension,
researc ers at t e Imperia Co ege o Science, Tec -
no ogy, an Me icine in Lon on escri e ot er
harmful effects attributed to high salt consumption
eyon raising oo pressure. Hig so ium inta e
increases the mass of the le ventricle (the hearts
main pumping c am er), w ic ma es t e eart wor
The DASH dietDASH stan s or Dietary Approac es to Stop Hypertension, a
iet eve ope y nutritionists to ower oo pressure. Putto t e test in two arge c inica tria st e rst escri e in
The New England Journal of Medicinein 1997t e DASHiet passe wit ying co ors. For many peop e w o o ow
it, t e iet is enoug to eep oo pressure in t e normarange wit out me icine.
Key eatures o t e DASH iet inc u e p enty o ruits,
vegetables, and whole grains; several servings daily ofow- at airy pro ucts; some s , pou try, rie eans, nuts,
an see s; an minima re meat, sweets, an sugar- a eneverages. T is mix o oo s provi es amp e ca cium,potassium, magnesium, vitamins, and fiber while limiting
saturate at, c o estero , an so ium. Compare wit t etypica American iet, t e DASH eating p an as a re ative y
ig er ca cium content an ess sa t, tota at, saturate at,an c o estero . It a so as 173 more magnesium, 150
more potassium, 240 more er, an 30 more protein.he blood pressurereducing ability of the DASH diet cant
e attri ute to any sing e nutrient.
In t e origina DASH stu y, 459 vo unteers were ran om yassigned to one of three diets. One was based on what most
Americans eat, wit 37 o ca ories rom at. T e seconwas a simi ar regimen wit ruits an vegeta es a e .
e t ir was a com ination iett e DASH ietcon-
taining 27 o ca ories rom at, p us p enty o ruits anvegeta es, w o e grains, ow- at or non at airy pro ucts,
an sma amounts o meat, s , pou try, an nuts.
A ter o owing t e DASH p an or eig t wee s, participantswit ig oo pressure experience average re uctions
o 11.4 mi imeters o mercury mm Hg in systo ic pressuret e top num er o a oo pressure rea ing an 5.5 mm
Hg in iasto ic pressure t e ottom num er . T ese resu tsare compara e to t e e ects o some oo pressure
rugs. Participants wit or er ine ig oo pressure a soexperience improvements, suggesting t at t e DASH ietmay eep some peop e rom eve oping ig oo pres-
sure in the first place. The second diet, which was higherin ats ut a so ric in ruits an vegeta es, a so owere
blood pressure, although not as much as the DASH plan.A re uctions occurre wit out peop e c anging t eir sa t
intake, alcohol consumption, or weightfactors known toin uence oo pressure.
urt er ana ysis o t e tria s resu ts oun t at t e DASHdiet reduced blood pressure in virtually all groups tested re-gardless of such factors as age, sex, race, and hypertensionstatus. Its e ects were most pronounce , t oug , in A ricanAmericans and people with high blood pressure. In fact, theresults were so promising that federal dietary guidelinesnow recommen t at a Americansnot just t ose wit
ig oo pressure o ow t e DASH iet.
A o ow-up stu y, t e DASH-So ium tria , compare a typi-cal American diet (the control diet) with the DASH diet at
i erent so ium eve s 3,300, 2,400, or 1,500 mg per ay .eop e wit ig oo pressure w o ate t e DASH iet athe lowest sodium level had an average systolic pressure
rea ing 11.5 mm Hg ower t an participants eating t econtro iet at t e ig est so ium.
Sti more support or DASH came rom t e Harvar - aseurses Hea t Stu y. Among near y 90,000 ema e nurses
whose diets, other habits, and health were followed for 24years, t ose w ose eating patterns most c ose y resem e
e DASH iet a ewer eart attac s an stro es anwere less likely to have died of heart disease compared withwomen reporting average American iets.
Com ining a structure weig t- oss program wit t e DASHiet can rop your oo pressure even more t an DASH
a one, accor ing to a stu y o 144 overweig t or o ese peo-p e wit ig oo pressure w o weren t ta ing any oopressure owering rugs. A out a t ir o t em o owe
e DASH iet a ong wit a weig t-management program.Another third did DASH alone, and the other third followed
eir regu ar iet. T e weig t-management program re ieon a strategy nown as appetite awareness training,which teaches people to identify their natural hunger andu ness cues to e p t em earn w en an ow muc to eat.
e program a so inc u e supervise exercise sessions t at
eatured biking, walking, or jogging for 45 minutes (includ-ing a warm-up an coo - own t ree times a wee .
After four months, average blood pressure readings for theDASH-p us-weig t-management group roppe y 16.1/9.9mm Hg, compare wit 11.2/7.5 mm Hg or t e DASH-on ygroup and 3.4/3.8 mm Hg for the control group. The bloodpressure re uctions seen in t e weig t-management groupwere simi ar to w at octors wou expect rom a ig oseof a blood pressure drug.
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ar er. Too muc so ium t ic ens an stiffens t e
arteries that nourish the heart and kidneys. It is linked
o increase ris o stro e, eart isease, an eart
ailure. High sodium intake may also increase the loss
o ca cium an one in o er women an men.
One way to eva uate t e evi ence on a particu ar
opic, i e t e effect o so ium on ea t , is to com ine
e resu ts o many stu ies an ana yze t em toget er.
is is called a meta-analysis. One meta-analysis of
stu ies con ucte etween 1966 an 2008, pu is e
in the British Medical Journal, found that high salt
inta e was associate wit significant y increase
risk of stroke and total cardiovascular disease. e
researc ers oun t at most popu ations aroun t e
wor ave ai y sa t inta es ig er t an 6,000 mg
or 2,500 mg so ium), wit parts o Eastern Europe
an Asia averaging a ove 12,000 mg o sa t 5,000 mg
so ium) a ay. ey estimate t at re ucing ai y sa t
intake could yield modest reductions in blood pres-
sure t at wou ower stro e rates y 24% an eart
disease by 18%.
Sodium reduction helpsIn t e 1980s, t e Tria s o Hypertension Prevention
teste various e aviora an ietary strategies or
e ping peop e avoi an fig t ig oo pressure.
e first group, which included men and women
ages 30 to 54 wit s ig t y e evate oo pressures,
were asked to try non-pharmaceutical interventions,
inc u ing so ium re uction, weig t oss, stress man-
agement, an nutritiona supp ements. ey were
taug t ow to ower so ium inta e y earning to
i enti y so ium in t eir iet an se ecting an prepar-
ing lower-sodium foods and seasonings. (People in the
contro group were as e to o ow t eir usua eating
habits and given general guidelines for a healthy life-
sty e.) e participants were o owe or 18 mont s
etween 1987 an 1990.
Vo unteers in t e secon tria group were in t e
same age range an a so a s ig t y e evate oo
pressures, ut were somew at overweig t. Some were
as e to ose weig t, some to re uce so ium, some
both, and some neither. ey were followed for three
years etween 1990 an 1995.
Fieen years later, researchers from Harvard-
affi iate Brig am an Womens Hospita examine
ow t e participants ea t a are since t e tria s
en e . Among t ose w o a o owe a ower-so ium
regimen, t e ris o aving a a car iovascu ar
eventsuch as a heart attack or strokewas 25%
ower t an among t ose w o a n t c ange t eir
sodium intake. Sodium reduction, previously shown to
ower oo pressure, may a so re uce ong-term ris o
car iovascu ar events, t e researc ers conc u e .
Cutting ac on sa t appears to save ives, too. In
a tria con ucte in Taiwan invo ving near y 2,000
e er y men, owering ietary so ium an increasing
potassium e to a 41% rop in eat s rom car io-
vascular disease.
A more recent stu y pu is e in e New Eng-
land Journal of Medicineprojected that in the United
QIf I exercise daily and sweat, which means
I lose salt, can I have more than the daily
recommended limit of sodium?
AAlthough technically the answer is Yes, it really
depends on how much you exercise and sweat,
and how much sodium is currently in your diet. You
lmost certainly get most of it from salt (sodium chloride).
You need to have enough sodium in your diet each day to
keep up with the sodium you lose in urine and sweat. It is
recommended that most adults ages 50 or younger have
no more than 2,300 milligrams (mg) per day of sodium. For
people 51 or older, for African Americans of any age, and
for people with diabetes, high blood pressure, or kidney
disease, the recommended level is 1,500 mg per day.
But the average U.S. adult takes in about 3,400 mg of
odium per daymuch more than recommended. Their
bodies remove some of the excess sodium each day by
passing it out in the urine.
If you are a manual laborer working a shift of eight to
12 hours, you can lose a lot of sodium5,000 to 6,000
mg per day. If that describes you, you can safely have more
than the recommended amount of sodium in your diet. Onthe other hand, if you work out at the gym for 30 minutes
day and are otherwise sedentary, there is a reasonable
hance that you still may be taking in too much salt. While
the exercise is good for you in many ways, it isnt a reason
to increase the salt in your diet.
Anthony L. Komaroff, M.D.Editor in Chief
Harvard Health Letter
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States, cutting ac on ietary sa t y 3,000 mg a ay
about teaspoon, or 1,200 mg of sodium) would
re uce t e num er o new cases o coronary artery
disease by 60,000 to 120,000, strokes by 32,000 to
66,000, eart attac s y 54,000 to 99,000, an eat s
y 44,000 to 92,000. So ium re uction wou e goo
or a segments o t e popu ation, wit women en-
efiting particu ar y rom stro e re uction, t e e er y
rom re uce inci ence o coronary artery is-
ease, an younger a u ts rom ower eat rates. e
researchers estimated that such a population-wide
effort wou save 10 i ion to 24 i ion annua y
and add years to life.
A salt step-down in the works? e accumu ating evi ence against excess sa t as
spurred several organizations into action. e World
Hea t Organization recommen e imiting con-
sumption o sa t to no more t an 5,000 mg a ay
(about 2,000 mg of sodium). e federal Dietary
Gui e ines or Americans recommen e a imit o
5,800 mg of salt (2,300 mg of sodium). In a long-
awaite stu y an report commissione y Congress,
t e Institute o Me icine recommen e in 2010 t at
t e FDA require re uctions in t e amount o sa t in
commercia y prepare oo in t e Unite States. e
proposa suggests a step- own approac t at wou
gra ua y ower t e amount o sa t in prepare oo s
from 2010 to 2020. Such a move could make a big dif-
erence, since most o t e sa t in t e American iet is
put there by someone elsea food company or cook.
For more etai on t ese an ot er efforts, see A call
to action, page 20
But t eres no nee to wait or government or pu -
ic ea t agencies to act. ere are many t ings you
can do right now to de-salt your diet; see Self-defense:
Conquering your salt habit, beginning on page 28.
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SPECIAL SECTION
Blood pressure matters
Blood pressure has gotten a bad reputation, taking the rap
for its harmful variant, high blood pressure. Pressure
is absolutely essential for circulation. Without it, blood
couldnt move from the heart to the brain, toes, and everywhere
in between, then get back to the heart again. Pressure in thebloodstream comes from two sources: contractions of the heart
and resistance from blood vessels.
norma contraction o t e
eft ventricle, the hearts main
umping c am er, pus es out
about 70 milliliters of blood (2
ounces). is pu se creates a wave
o pressure t at passes t roug
t e aorta an a t e arteries in t e
body. Relaxed and flexible arter-
ies offer a ea t y amount o resis-
tance to each pulse of blood.
B oo pressure c anges con-
stant y. It respon s instant y to
w at you are oing, t in ing, an
feeling. It also follows a daily cycle,
itting a ow point just e ore you
wake and peaking during midday.
Hig oo pressure octors
ca it ypertension) is not a isease.
Instea , it is a sign t at somet ing
is wrong in t e eart, oo vesse s,
i neys, or e sew ere. Sometimes
it stems rom an overpro uction o
hormones by the thyroid or adrenal
g an s. It can e cause y t e use
of prescription or over-the-counter
me ications suc as aspirin, i upro-
en, pseu oep e rine, some anti e-
Figure 5How high blood pressure affects the body
High blood pressure has far-reaching
effects. It not only harms arteries,
ma ing t em sti er an narrower,
but can also damage the heart,
rain, eyes, an i neys. T ese are
known as the target organs ofypertension. Hig oo pressure is
a key contributor to heart attack and
stroke, heart failure, kidney failure,
and many other chronic conditions.
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Blood pressure matters | SPECIAL SECTION
ressants, steroi s, an ot ers. Most
o t e time, t oug , ig oo
ressure resu ts w en arteries ave
become rigid or constricted. Less-
flexi e arteries offer more resis-
ance to the flow of blood, which
s ows up as ig er oo pressure.
Untreate ig oo pres-
sure can ea to eart isease an
stro e. It can amage t e i neys,
estroy vision, an cause pro ems
in t e rain t at ea to memory
oss and dementia (see Figure 5,
page 18). It oes t is wit out caus-
ing any symptoms, which is why
ypertension is sometimes re erre
o as a si ent i er.
Hig sa t consumption is one
reason oo pressure rises. Ot er
ey contributors include smok-
ing, excess weig t, ac o p ysica
activity, a poor iet, rin ing too
muc a co o , an some me icines
and diseases.
Understandingthe numbersW en oo pressure is measure ,
t e resu t is two num ers, oen
given like this: 122/87. e num-
ers origina y represente mi -
limeters of mercury, because the
origina oo pressure evices
used a column filled with mercury
an mar e in mi imeters.
e top num er gives t e sys-
to ic pressure. is is t e amount
o pressure generate y a eart-
beat (the hearts pumping phase
is nown as systo e). e ottom
num er gives t e iasto ic pres-
sure. It represents t e pressure in
the bloodstream when the heart
re axes etween eats t is resting
phase is known as diastole).
A ea t y oo pressure is
120/80 or ower.
B oo pressure ten s to c im
wit age, a sign o s ow ut stea y
amage to oo vesse s. At one
time, t e ru e o t um or a ea t y
systolic blood pressure was 100 plus
your age. For an octogenarian, t at
would be 180 to 190. We now know
t at s muc too ig .
To ay, ypertension is efine
as aving a systo ic rea ing o at east
140 or a iasto ic rea ing o at east
90, or both (see Table 5, below).
Table 5 ass y ng an rea ng yper ens on
CATEGORY*
SYSTOLIC BLOOD
PRESSURE (TOP NUMBER)
DIASTOLIC BLOOD PRESSURE
(BOTTOM NUMBER) WHAT YOU SHOULD DO
Normal Less than 120 ess than 80Stick with a healthy lifestyle, including following adiet rich in fruits and vegetables and low in salt, usingalcohol moderately, and maintaining a healthy weight.
Prehypertension 120139 80 89
Change health habits. If youre heavy, lose weight.Reduce salt in your diet. Eat more fruits and vegetables,and get more exercise. Drink alcohol only in moderation.You do not need medication at this stage if you donthave other health conditions. If you have diabetes orkidney disease, begin drug therapy if your blood pressureis at or above 130/80.**
Stage 1hypertension
140159 9099
Change your health habits and take a blood pressure
drug. Many people start with one medication, but mayneed to go to a second or third to find a treatment thatworks. If you have other health conditions, you may needa different drug or an additional one.
Stage 2hypertension
160 or higher 100 or higherChange your health habits. Its likely that youll need totake at least two blood pressure medications.
*When systolic and diastolic pressures fall into different categories, physicians rate overall blood pressure by the higher category. For example, 150/85 mm Hg is
classified as stage 1 hypertension, not prehypertension. **Because both hypertension and diabetes target the same major organs, drug therapy is generally initiated at
an earlier stage in people with diabetes. The goal is to maintain blood pressures below the 130/80 threshold. For people with diabetes or chronic kidney disease, stage 1
hypertension is defined as systolic pressure of 130159 or diastolic pressure of 8089.
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A call to action
Some groups are a vocating stronger measures to
egin re ucing sa t an sugar in t e American
iet. Heres a oo at some o t eir efforts.
Sugar e Harvard School of Public Health has been helping
ea t e c arge to improve t e U.S. iet. In Apri 2012,
e Department o Nutritions acu ty e a wi e y
u icize press con erence c a enging everage
manu acturers to create a new c ass o rin s wit
70% less sugar. Weve suggested that manufacturers
rovi e an option in etween ig -sugar an sugar-
ree drinks to help people step down if they cant
go co tur ey rom u sugar to no sugar, sai
Dr. Wa ter Wi ett, c airman o t e Department o
Nutrition at Harvar Sc oo o Pu ic Hea t . Fu -
sugar everages, e sai , are in a c ass wit to acco.
eres only harm, no benefit.
e Institute o Me icine IOM)a ig y
regarded, independent nonprofit organization that
rovi es evi ence- ase in ormation an a vice to t e
government and public on matters of healthrecently
recommen e to t e FDA t at it require manu acturers
o start a new ront-o -t e- ox a e ing system t at
etai s t e amount o a e sugar in eac serving o
a pro uct. Meanw i e, t e USDA as provi e an
online interactive food tracker that lists the amount of
a e sugar in more t an 8,000 oo s an a ows you
o compare them side by side to help you make choices.
e we site, avai a e at www.choosemyplate.gova so
rovi es too s or e ping you c oose nutritiona goa s
an to eep trac o t e oo s you eat an ow t ey
stac up towar meeting t ose targets.
e University researc ers ave
oun t at t e east ea t u
ereals are most heavily mar-
ete to c i ren. Some o
the worst nutrition offend-
ers are cerea s i e Corn Pops, Reeses Puffs, an Froot
Loopscerea s t at are ig er in sugar an ower in
fiber than cereals marketed to adults. ey are the
ocus o mi ions o o ars in te evision a vertising
and Internet marketing each year. A new rating system
eve ope y t e Ru Center or Foo Po icy an
Obesity at Yale takes into account a cereals nutritional
va ue an ow eavi y it is mar ete to c i ren. e
searc a e ata ase is avai a e at www.cerealfacts.org
In June 2012, t e Wa t Disney Company
announce p ans to a vertise on y ea t ier oo s to
ids on its media outlets beginning in 2014, making
it t e first major me ia company to set a stan ar
or food and drink ads during shows aimed at kids.
o get an a s ot, a cerea wi ave to ave ess t an
10 grams o sugar per serving. Accor ing to t e Ru
Center, oo an rin a s aime at i s ec ine y
5% in 2011, ut on average, c i ren sti are expose
o a out 13 a s a ay t at promote pro ucts wit
itt e or no nutritiona va ue. An Disney s cut-off
evel for cereal advertisements10 gramsis still 2
easpoons o sugar, or a t e recommen e ai y
imit of 5 teaspoons of added sugar.
recent ea t po icy report in e New Eng an
Journa o Me icine cite t e in etween sugar-
sweetene everages an t e ris s o o esity, ia etes,
an eart isease, an propose using taxes to re uce
consumption. Not only would a tax discourage
consumption, t e aut ors argue , ut t e revenues
could be used for health care programs. Currently,
33 states ave sa es taxes on so rin s, ut t e
average rate o 5.2% is not steep enoug to iscourage
consumption, an t e revenues are not earmar e
or ea t care. e aut ors propose a o 1-cent-
er-ounce tax on any everage t at as a e ca oric
sweetener. Ot er options wou e a tax per gram o
added sugar or setting a threshold of 1 gram of sugar
er ounce. e a vantage o t e t res o approac ,
hey noted, would be that it would encourage
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manu acturers to go ac to t e rawing oar an
reformulate their products.
e revenues generate rom a tax on sugar-
sweetened beverages would be considerable, the study
suggeste . A nationwi e tax o 1 cent per ounce wou
raise 14.9 i ion in t e first year a one. e un s, t e
aut ors propose , cou go towar c i oo nutri-
ion an o esity prevention programs.
Researc y Dr. Ro ert H. Lustig an co eagues
at t e Department o Pe iatrics an t e Center or
Obesity Assessment, Study, and Treatment at the
University o Ca i ornia, San Francisco, suggests t at
he worldwide increase in sugar consumption is the
root cause o a wi e range o c ronic iseases reac -
ing epi emic eve s. Sugar as ecome so ingraine in
e American iet t at e ucation an awareness cam-
aigns wi not so ve t e pro -
em, the authors said, calling for
u ic inter vention. A co o ,
hey wrote in the journal Nature,
as een regu ate or t e pu -
ic goo ase on our criteria:
unavoi a i ity pervasiveness
roug out society), toxicity,
otentia or a use, an a nega-
ive impact on society. Sugar
meets the same criteria, they wrote. It similarly war-
rants some orm o societa intervention. Using t e
control of tobacco and alcohol as a model, they pro-
ose imiting avai a i ity. An t ey ca e or t e
FDA to consi er removing ructose rom t e ist o
ro ucts it genera y regar s as sa e.
In Septem er 2012, New Yor Citys Boar o
Health voted to limit to 16 ounces the size of sugary
rin s so in oo service esta is ments in or er to
combat the growing obesity epidemic that is taking
e ives o 6,000 New Yor ers every year, as t e
oar s announcement sai . e imit app ies to any
everage t at is more t an 25 ca ories per 8 ounces
an oes not app y to everages t at are 100% ruit
or vegetable juice. Obesity is an illness that is slowly,
ain u y estroying ea t an ta ing ives, sai New
Yorks Deputy Mayor for Health and Human Services
Lin a I. Gi s. Over time, our environment as een
increasingly working against uspeople move less
an eat more, portion sizes ave grown, an sugary
beveragesfull of empty calorieshave grown
exponentia y.
SaltOn t e so ium si e, a recent stu y o 21 states s owe
t at U.S. a u ts are a rea y re ucing t e amount o
so ium t ey consume. More t an 70% o a u ts w o
a ig oo pressure a een a vise to re uce
sodium in their diets, and four out of five of those
a a rea y egun to o so on t eir own. Ot er ata
showed that the majority of adults in the United States
un erstan t e connection etween so ium inta e
an ea t , an 68% o peop e over age 50 are t in ing
a out re ucing sa t in t eir iet or ave a rea y
starte . e Harvar Sc oo o
Public Health has estimated that
cutting t e average in ivi ua s
consumption of salt by half
wou prevent at east 150,000
eat s a year in t e Unite States
a one.
out 10% o t e so ium in
our iet is rom t e natura con-
ent in oo s, 10% is rom t e
shaker, and 80% comes from processed and restaurant
oo s. Current y, t ere is no imit on t e amount o
salt food manufacturers can put into their products.
Li e sugar, sa t enjoys a regu atory status nown as
GRAS, or genera y regar e as sa e, w ic a ows
oo manu acturers to a un imite amounts to any
oo . For years now, some pu ic ea t a vocates
have been trying to get that status revoked.
In 2008, t e American Me ica Association
(AMA) called for the FDA to revoke salts GRAS status
to a ow stricter regu ation o t e amount o so ium
in oo s. Step en Havas, t e AMAs vice presi ent
or science, qua ity, an pu ic ea t , sai t at t e
eat s attri uta e to excess so ium inta e represent
a uge to t e equiva ent o a jum o jet wit 400
a u ts a oar cras ing every ay o t e year, year aer
year. e AMA called on the FDA and food manu-
acturers to set as t eir goa a 50% re uction in t e
amount of sodium in fast food, restaurant foods, and
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rocesse oo s over t e next 10 years. Dr. Havas sai
meeting this goal would save 150,000 lives a year.
W i e t e IOM as agree t at t e current eve
of sodium in manufactured foods is too high to be
sa e, it as not recommen e t at sa t e ta en off
e GRAS ist. However, a committee appointe y
e IOM recommen e in 2010 t at t e FDA regu ate
e amount o sa t in commercia y prepare oo s y
wor ing wit oo companies to step own t e amount
o sa t use . e committees report ac now e ge t at
he strategy of labeling and education has not worked
o re uce so ium inta e. Rat er, t e IOM as ca e
or the FDA to work with restaurants and food manu-
acturers to enact a gra ua re uction in sa t content
at wou ma e c anges impercepti e to consum-
ers. e pre erence or sa ty taste can e c ange , t e
IOM report state . W at is nee e is a coor inate
effort to reduce sodium in foods across the board by
manu acturers an restaurantst at is, create a eve
laying field for the food industry. All segments of the
oo in ustry wou e carrying out t e same re uc-
ions an none wou e at a isa vantage.
Some cerea an snac ma ers ave egun to
ower sodium levels in their products, but overall the
eve s remain ig . It remains to e seen i ot er seg-
ments of the food industry will follow suit without
new regu ations orcing t em to o so.
cost ana ysis con ucte at Stan or University
an pu is e in Anna s o Interna Me icine c aime
at a nationwi e tax on so ium cou save over a mi -
ion life-years and billions of dollars. Although no
country as imp emente a tax to ecrease so ium
consumption, the researchers wrote, economic
incentives affect consumer e avior, an taxes ave
been successful in reducing tobacco and alcohol con-
sumption. e stu y cite a co a orative effort in
Great Britain etween government an in ustry t at
roug t a out a 9.5% ecrease in typica so ium
inta e. e researc ers estimate t at an equiva ent
decrease in the United States, whether brought about
y taxes, regu ations, or vo untary comp iance, wou
revent 513,885 strokes and 480,358 heart attacks over
e i etimes o peop e ages 40 to 85 a ive to ay an
wou save 32.1 i ion in irect me ica costs.
Sodium cutbacksEncouragingly, many food companies have already begun cutting back on sodium content in their products, some by25 w ic is not a ot, ut sti a goo start. T e Nationa Sa t Re uction Initiative is a coa ition o 85 organizations anoca an state eat aut orities t at ave p e ge to e p oo provi ers vo untari y re uce t e amount o so ium in 62packaged food categories and 25 restaurant food categories. The effort started in New York City in 2010 with the HealthyHeartCut t e Sa t campaign. Here are t e companies t at ave signe on so ar to re uce so ium content y 20 overt e next ve years t e ist is i e y to c ange as more esta is ments join; o ow t e up ate ist on t e initiatives we siteat www.nyc.gov/health/salt):
u on a n
Bertucci s Ita ian Restaurant
Black Bear European Style
De i Boars Head Provisions
Butter a
Camp e Soup Company
De aize America
Dietz & Watson
FreshDirect
Furmano s
Goya Foo s
Hain Celestial
Heinz
Hostess Bran s
Ken s Foo s
Kra t Foo s
LiDestri Foo s/FrancescoRina i
Mars Food US
cCain Foo s
remio
ed Gold
Sny ers-Lance
Starbucks Coffee Company
Su way
arget Corporation
ni ever
no C icago Gri
ite Rose
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23www.hea l th .ha rva rd .edu Reducing Sugar and Salt
Self-defense: Sugar-reducing strategies
Te uman o y oes not nee any a e sugar. It
gets a it nee s rom w ats natura y in oo . Cut-
ing ac on t e amount o sugar you consume wi
e p you manage your weig t an eep eart isease
and diabetes at bay. e American Heart Associa-
ion recommen s eeping ca ories rom a e sugars
under 100 calories a day (24 grams, or 6 teaspoons)
or women an un er 150 ca ories 36 grams, or 9 tea-
spoons) or men.
I you eci e its time to start re ucing t e amount
o a e sugar in your an your ami ys iet, t ere
is no reason to wait for new government guidelines
or or t e oo an everage in ustry to vo untari y
start lowering the amount of sugar used to attract our
aste u s. e easiest an quic est way is to i enti y
e oo s an rin s t at contri ute t e most a e
sugar to your iet an imit or rep ace t em a toget er.
Rea ing a e s is a goo p ace to start.
Do some detective workSpotting a e sugar on oo a e s can require some
sleuthing. Manufacturers are required to provide the
ota amount o sugar in a serving ut o not ave to
spe out ow muc o t is sugar as een a e an
ow muc is natura y in t e oo (see Figure 6, right).
e sugars must e inc u e on t e ingre ients ist,
which is presented in descending order by weight. e
ric is ecip ering w ic ingre ients are a e sug-
ars. ey come in a variety of guises. Aside from the
o vious onessugar, oney, mo assesa e sugar
can appear as agave nectar, cane crysta s, corn sweet-
ener, crysta ine ructose, extrose, evaporate cane
juice, ructose, ig - ructose corn syrup, invert sugar,
actose, ma tose, ma t syrup, an more.
wise approac is to avoi pro ucts t at ave any
of these added sugars at or near the top of the list of
ingre ientsor ones t at ave severa ifferent types
of sugar scattered throughout the list. If a product is
chock-full of sugar, you would expect to see sugar
iste first, or may e secon . But oo ma ers can
fudge the list by adding sweeteners that arent techni-
ca y ca e sugart at term is app ie on y to ta e
sugar, or sucrose ut t at a to t e sugar content
a t e same. e tric is t at eac sweetener is iste
separate y. e contri ution o eac a e sugar may
be small enough that it shows up fourth, fih, or even
urt er own t e ist. But a t em up an you can
get a surprising dose of added sugar.
Lets ta e as an examp e a popu ar oat- ase cerea
wit a mon s w ose pac age oasts t at it is great
tasting, eart ea t y an w o e grain guarantee .
Heres t e ist o ingre ients:
Whole-grain oats, whole-grain wheat, brown sugar,almond pieces, sugar, crisp oats,* corn syrup, barleymalt extract, potassium citrate, toasted oats,* salt,malt syrup, wheat bits,* honey, and cinnamon.
contain sugar, high-fructose corn syrup, honey, and/or brownsugar molasses
Near y a o t e a e sugar consume y Americans ages two
years and older comes from sugar-sweetened beverages.
Source: Dietary Guidelines for Americans, 2010
Figure 6 Sources of added sugars
Yeast breads2.1%
Sugarsand honey
Ready-to-eatcereals
Tea
All otherfood categories
15.4%
Soda, energy drinks,sports drinks
35.7%
Grain-baseddesserts12.9%Fruit drinks
10.5%
Dairydesserts6.5%
Candy
6.1%
3.8%
3.5%
3.5%
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Com ine rown sugar, sugar, corn syrup, ar ey ma t
extract, high-fructose corn syrup, honey, brown sugar
mo