SASHA-ANN SIMONSI'm Sasha-Ann Simons, sitting in for Kojo Nnamdi. Salt makes food taste good. We're not going to pretend it doesn't. But excessive dietary salt is a problem for many Americans and can have debilitating and deadly consequences like heart attacks, strokes, kidney disease. The list goes on. And black and Latinx communities suffer from these maladies in disproportionately high numbers.

SASHA-ANN SIMONSStill, when it comes to nutritional no-no’s, salt doesn't get a fraction of the attention paid to fat and sugar. And salt is everywhere. It's in salad dressing, bread, and other places that you might not even suspect. So, what's the problem with salt and what should be done about it? Joining us to discuss is Michael Jacobson. He's a co-founder and senior scientist and former executive director at the Center for Science in the Public Interest. He's also the author of "Salt Wars: The Battle Over the Biggest Killer in the American Diet." That was published this week by the MIT Press. Hi, Michael. Welcome to the show.

MICHAEL JACOBSONHi. Good afternoon.

SIMONSNow, Michael, before we talk about salt, I want you to tell us a little bit about the group that you cofounded about 40 years ago. And it's called the D.C. Center for Science in the Public Interest. What's it all about?

JACOBSONCSPI has been very active, particularly on nutrition and food safety. And we try to educate consumers by reaching out in the media and through our nutrition action health letter. And we also advocate policy solutions to some health problems. So, we're the group who led the efforts to get rid of trans fat from the food supply, to get nutrition facts on labels, to improve school foods, and beginning in the late 1970s, believe it or not, trying to reduce sodium in the food supply. But we have not been totally successful, I must say.

SIMONSNow, I feel like I've been hearing this since the beginning of time, but how long have we actually known salt is a problem? And tell me what inspired you to actually write a whole book about this.

JACOBSONWell, you know, I think back especially to the 1969 White House conference on food, nutrition and health, which recommended reductions in sodium levels in the food supply, especially baby food, back then.

SIMONSAlso on the line, we've got Dr. Reggie Elliott who's a medical director and a family physician at the Brentwood Health Center in Northeast Washington. That's part of the Unity Healthcare Group. Hi, Dr. Elliott. Welcome to the program.

REGGIE ELLIOTTThank you for having me.

SIMONSCan you tell us about the Unity Healthcare network and your role within it?

ELLIOTTSure. I'm the medical director of the Brentwood Unity Healthcare clinic site. Unity Healthcare has been in existence for about 35 years now. We started off as healthcare for the homeless. Since then, we've expanded our sites to about nine clinics, about 11 homeless sites. We're also in a few of the D.C. high schools. And we have, certainly, a few teen clinics that we are in charge of.

SIMONSSo, tell me about your patients in general. You know, racially, ethnically, economically, who are they?

ELLIOTTYeah, most of the patients that I see happen to be patients of color, whether that be African-American or black or Latino. Most of them tend to have diabetes or high blood pressure or issues with cholesterol.

SIMONSAnd the prevalence of hypertension among African-Americans is the highest in the world, actually. You know, according to the CDC, more than 40 percent of non-Hispanic African-Americans have it, compared to less than a third of white Americans. So, doctor, how prevalent are salt-related ailments, like hypertension, among your patients? And why are they suffering from it?

ELLIOTTYeah, I'm glad you asked. Yesterday, about 60 percent of the patients that I provided care to had high blood pressure. So, that is certainly more than the average that's out there. And there's so many factors that coincide or lead to high blood pressure. Chronic stress is certainly one of the factors. And living under COVID-19, I mean, who's not under chronic stress? Another thing is smoking, exercise and obesity, as well as family history.

SIMONSAnd I want to make sure everyone's with us and we all understand hypertension. What is it, exactly?

ELLIOTTSure. Hypertension is a medical term which basically means high blood pressure.

SIMONSOkay.

ELLIOTTAnd there are two numbers that we look at when we're trying to evaluate blood pressure.

SIMONSRight. It's always, you know, something over something.

ELLIOTTExactly.

SIMONSWhat do those numbers actually represent?

ELLIOTTSure. The top number represents something that we call systolic blood pressure reading. And the bottom number is what's called diastolic. The top number indicates the amount of pressure in your arteries when your heart beats. And that bottom number represents the amount of pressure in your arteries when your heart is relaxed, basically between beats.

SIMONSSo, what's a normal healthy blood pressure?

ELLIOTTWell, the guidelines that are widely followed are what we call the Joint National Committee 8 guidelines, which recommends that the top number should not be more than 140 and the bottom number should not be more than 90.

SIMONSSo, if patients do have hypertension, what can they do about it?

ELLIOTTYou know, there's several things that can be done. Working on decreasing stressors, exercising, certainly changing eating habits. I don't like to use the word diet. I like to use the word lifestyle modifications, because it's a lifestyle that you're going to implement. Stopping the use of cigarettes and certainly decreasing salt intake as a part of changing dietary or lifestyle modifications.

SIMONSOur other guest, Michael Jacobson, as a reminder, is the author of "Salt Wars: The Battle Over the Biggest Killer in the American Diet." That book was published this week by the MIT Press. Tell us why you called your book "Salt Wars."

JACOBSONWell, “Salt” because it's the substance we're concerned about, and “Wars” because of battles between scientists over the years and also battles between the food industry and the government and Congress to try to -- over battles to reduce sodium levels.

SIMONSAnd, Dr. Elliott, you know, trying to reduce the amount of salt that we eat, do we just look for the word salt on the food package? Is it that simple?

ELLIOTTWell, you won't find the word salt, (laugh) most of the time.

SIMONSSodium?

ELLIOTTExactly. You'll find the word sodium. And if you turn the back of the package to the label, you'll see the word sodium. And believe it or not, Sasha, we should not have more than a teaspoon, that's a small spoon, worth of salt for the entire day. But you'll be surprised of the salt or sodium content in, for example, if we're going to talk about chicken noodle soup.

ELLIOTTI mean, we're headed into wintertime and, you know, people looking for comfort foods. A can of chicken noodle soup basically equals the amount of salt that you should have in an entire day, or has the salt content of an entire day. So, just imagine, the other foods that we're consuming throughout the day, it really tips us over that measure.

SIMONSMichael, this is something you've been looking to, as well, of course, to be able to write the book. How much do people actually consume? How much salt, the average person?

JACOBSONWe consumer about 50 percent more than we ought to, about 3,400 milligrams, compared to the 2300. And Dr. Elliott is certainly right about chicken noodle soup and so many other packaged foods. But when you go to restaurants, then you really hit some numbers, where a restaurant meal can have two or even three times as much sodium as a person should consume in an entire day.

JACOBSONA Red Lobster's meal called an Admiral's Feast has more than twice as much sodium. An IHOP Bacon Temptation Omelet with three buttermilk pancakes contains 50 percent more sodium. So, the numbers are just crazy. And that reflects high sodium levels in the foods and huge portions at restaurants.

SIMONSDoctor, let's talk about this pandemic. You know, how has that affected patients that you're treating for hypertension?

ELLIOTTYou know, I am certainly seeing more patients that are having higher numbers of blood pressure readings than they would normally have prior to this pandemic. A lot of it comes about through the stress and anxiety about what's going to happen in the future. Many individuals have lost loved ones. And most of us are really trying to protect ourselves and, you know, trying to stay safe.

JACOBSONWhen you mention the pandemic, we should also be thinking of salt, the high sodium levels in our diet, as another pandemic. It's been going on year after year. The epidemiologists have estimated that if we could reduce sodium intake by one-third to one-half, not get rid of it completely, but one-third to one-half, that can save something like 50 to 100,000 lives per year. You know, that's the magnitude of this problem.

JACOBSONAnd the economic costs are also enormous. You know, just for medical care, it's 10 to $20 billion a year. And we really should be treating this as a salt epidemic, or an epidemic of hypertension and cardiovascular disease caused by excess sodium intake.

SIMONSDr. Elliott, are you there?

ELLIOTTI'm here, yes.

SIMONSJust in time for a question here from Tommy from Vienna. He called, but he actually couldn't stay on the line. But he asked: What should the average person do to change their lifestyle?

ELLIOTTOne of the key factors is recognizing those stressors that we have that causes us to have high blood pressure or anxiety or depression. So, identifying those factors, I think, would be a key factor in controlling high blood pressure and other issues, as well as a lifestyle modification.

SIMONSNow, Michael, you and others who are concerned about excessive dietary salt, you've actually advocated for various proposals to tackle the problem. What are they, and have any of them been acted on?

JACOBSONWell, we've been pushing for mandatory limits on sodium content of foods. And that's what the National Academy of Science has recommended in 2010. The FDA said no, not mandatory limits, but we're going to recommend voluntary limits. And it did that in 2016. That was just as the Obama administration was packing its bags. And for the past four-and-a-half years, the Trump Administration has done absolutely nothing on this issue.

JACOBSONAnd even if the government does act in the future -- hopefully next year -- the consumers shouldn't wait for government action forcing sodium levels down in the food supply. Instead, there are three things consumer's ought to do, and some listeners might hate me for these three recommendations. I’ll barge ahead, anyhow.

SIMONSOkay. Go ahead.

JACOBSONAnyhow, "Salt Wars" recommends, one, preparing more foods from scratch at home. Secondly, when you buy processed foods, compared labels between different brands of the same product. Because you can often get a product with one-third or half as much sodium as another brand of the same peanut butter or cheese or whatever. And the third thing is to eat out less often, because the sodium levels in restaurant foods are uniformly enormous.

SIMONSAnd you mentioned the Trump administration a moment ago. Will the outcome of the presidential election affect the salt wars?

JACOBSONWell, I assume if Trump is reelected, the administration will continue to do nothing. If Biden is elected, I assume that his Food and Drug Administration will try to implement -- will finalize the proposals made back in 2016. So, a lot is hinging on it, and we're talking about 50 to 100,000 lives per year, year in and year out.

SIMONSYour book also talks about the food industry and its Salt Institute, in particular, for their efforts to thwart policies to reduce the amount of salt in Americans' diets. Can you just tell us about the Salt Institute and what it's done to keep our food salty? And why is the food industry so opposed to change?

JACOBSONWell, two questions. One about the Salt Institute, that was a trade association composed of Morton, Cargill and other salt manufacturers. And, boy, any time anybody said anything critical about salt, they would jump in with these exaggerated attacks and try to prevent any kind of action, whatsoever. When the government hinted at some action, they would try to block it. Fortunately, and amazingly, the Salt Institute went out of business in 2019.

SIMONSWhy?

JACOBSONAnd it's so rare that a trade association goes out of business, but yippee, they did. And that should reduce opposition to lowering sodium.

SIMONSDr. Elliott, do you find that because you're black, your African-American patients are more willing to take your suggestions, especially when you're talking about reducing dietary salt and other steps that they can take to improve their health?

ELLIOTTYou know, I think that me being black does help, certainly. But I can't say that just because I am black and the patients that I serve are black, that they would take my advice wholeheartedly. But it certainly helps. It certainly helps to build trust. And, you know, oftentimes, there's a cultural similarity that we have that we can share amongst each other about, you know, I use this instead of that or, you know, I substitute this type of food for this that's healthier. And so, I think being black or African-American is indeed helpful.

SIMONSI hear an African-American patient of yours shared some vaccine skepticism with you recently. How does that skepticism relate to race, and how did you respond to her reticence to get a flu shot?

ELLIOTTRight. Very interesting. You know, I am recommending, like all the providers here, the flu vaccine. We're headed – or, actually, we're already in the flu season. And so, I recommended the flu vaccine to the patient. And she was very opposed to it. She says, no, I'm not going to take that vaccine. There's something in it.

SIMONSI hear that a lot, too.

ELLIOTTAnd I won't take it unless you take it. That day, I just so happened to have proof of me having received a flu vaccine. So, I went to my office, and I brought back that piece of paper that said Dr. Reggie Elliott, flu vaccine. And she took the flu vaccine, because I was the example that I'm fine. Everything worked out well. I'm alive.

SIMONS(laugh) I wonder if you ever, in other instances, you know, use yourself as an example when it comes to nutrition. Because you say that having grown up in this area, you are a big seafood fan. But you're also aware that it often comes with a generous helping of salt. We heard Michael talk about Red Lobster's Admiral's Feast earlier. But, Dr. Elliott, how do you balance your love for shrimp and crab with the desire to eat a low-salt diet?

ELLIOTTYou know, I use it as a treat. So, throughout the week, I'm basically a very healthy eater. But maybe on a Saturday, you know, I'll go out and buy some seafood. And it's used, again, as a treat for having, you know, worked a long week at work. We'll be surprised, however, the salt content, not only in lobsters, but shrimp and other forms of shellfish.

SIMONSJasmine from Maryland called us, but she couldn't stay on the line. I believe you might have answered this earlier, but she's kind of got a twist to her question. She says, what should the average blood pressure be, but she said, specifically for the black community, if there's a difference there. She said, I've heard 130 over 80, but I'm not sure. Is there a difference?

ELLIOTTYeah, well, the National Joint Committee recommends 140 over 90. However, if there are risk factors that you have that lead to a 10 percent risk of having a heart attack or stroke, we want that blood pressure reading to then be 130 over 80, not 140 over 90. So, it really depends on your risk factors for having a heart attack or stroke in the next 10 years.

SIMONSAnd Tommy called us back, Dr. Elliott. He says, if you are an active person, where you don't meet the average sodium intake, what should your intake be?

ELLIOTTWell, no one should have more than that teaspoon of sodium a day. And so, that 2300 milligrams of sodium is a maximum that anyone should have in their diet, even if they're active.

SIMONSMichael, one big issue is prepackaged and prepared foods, which they typically have a lot of added salt. But not everybody has time to prepare food at home from scratch. I know that was one of your three recommendations earlier. What do you recommend to folks who are having trouble with preparing foods at home?

JACOBSONWell, if you can't cook your meals -- and everybody's going to be eating some packaged foods -- you really have to read labels and read them carefully. One of the developments over the last, I don't know, 20 years or so has been that the red meat industry -- beef and pork and chicken -- have been injecting their products with salt or sodium phosphate, you know, greatly increasing the amount of sodium in those foods. You know, from something like 75 milligrams per serving to 400 milligrams.

JACOBSONAnd I didn't realize that until recently, but frozen fish, frozen shrimp or finfish is often also treated with salt. And so, you end up with very high levels in places where you don't suspect it. So, if you're trying to keep your sodium low, read labels carefully.

SIMONSDr. Elliott, you know, we tend to think of excess salt and high blood pressure as an adult problem. Do we have to worry about hypertension in kids?

ELLIOTTWell, certainly hypertension in anyone, it's something that we have to be concerned about. But it is not a recommendation to pay close attention to kids who are not having any symptoms and who have high blood pressure.

SIMONSWe do see high blood pressure in kids, as well, and it is often related to obesity. Michael, are you able to pick that up at all?

JACOBSONYeah, I think it's important for everybody, including kids, to have lower sodium diets, so that we all get accustomed to eating that kind of a diet, and not have to make a radical change when we develop high blood pressure when we're 40, 50, 60 years old. You know, something like 80 to 90 percent of us will end up with high blood pressure.

SIMONSWe've got just about 30 seconds, Michael. Are you optimistic about the prospects for sound nutrition to prevail in the salt wars?

JACOBSONWell, I'm hopeful in terms of the Food and Drug Administration and industry actually doing something. But to educate 300-and-some million people to reduce their sodium is probably impossible to do. But each individual can do it for him or herself.

SIMONSMichael Jacobson is co-founder, senior scientist and former executive director at the Center for Science in the Public Interest. He's also author of "Salt Wars: The Battle Over the Biggest Killer in the American Diet," published this week. Thanks, Michael.

JACOBSONThank you very much, Sasha.

SIMONSAnd Dr. Reggie Elliott, medical doctor and family physician at the Brentwood Health Center, appreciate your time, doctor. This segment on the perils of salt was produced by Lauren Markoe. And our conversation about reopening schools with D.C.'s School Chancellor Lewis Ferebee and WAMU education reporter Debbie Truong was produced by Kurt Gardinier.

SIMONSComing up tomorrow on the Kojo Nnamdi Show, tired of election and coronavirus coverage? We got you. We're going to talk about fall food traditions. That all starts tomorrow. Thanks for listening. I'm Sasha-Ann Simons.