Look at the panel on the right: • find the quantity per 100g column (circled) • find the sodium (circled) • check across and find 60 mg/100g • this yoghurt is a low salt food, as the

sodium is less than 120 mg/100g

Following the Australian Dietary Guidelines is a quick way to help prevent and control salt related conditions.

1. Follow the salt guideline at all times - Choose foods low in salt (sodium not above 120 mg/100g)

2. Eat more fresh foods—they are low salt foods with rare exceptions (Salt Matters page 270)

3. Choose low salt PROCESSED foods (sodium not above 120 mg/100g).

Salt Matters: the killer condiment by Dr Trevor Beard is essential reading to understand the ‘why and how’ of managing a low salt diet and is available from good book stores. Dr Beard has edited this shopping guide. Note: The national Dietary Guidelines benefit all Australians except a few with special medical needs. However, if you are pregnant, ill, or taking prescription drugs (especially diuretics) you should show your doctor the attached 3-page "Salt Control" document before adopting a strict low salt diet.

LOW SALT FRESH FOODS These include the healthiest produce on the market, fresh fruit and vegetables, fresh meat, fish and poultry, unsalted nuts and milk. With vinegars, herbs and spices they can make delicious meals.

LOW SALT PROCESSED FOODS These are hard to find but will be easier when more customers ask for them! Check the Nutrition Information Panel (NIP). Food labels must show these panels by law.

BREAKFAST CEREALS Kellogg’s make Just Right (30mg/100g) & Sustain (80mg/100g). Sanitarium make Weet-Bix Kids (45mg/100g). Other examples of low salt cereals are shown on page 2.

LUNCH AND MAIN MEALS You can dine well on all the fresh meat, poultry, fish and vegetables that shops provide. Cook vegetables without salt by roasting, baking, barbecuing, stir-frying, microwaving, slow cooking or pressure-cooking. Vegetables are full of flavour without adding any salt when roasted with a joint or steamed. Boiling is not recommended as the flavour is boiled out!

LOW SALT STOCK POWDER Stock cubes are almost pure salt, but low salt stock powders are full of flavour. Low salt stock powders are available from health food shops or by mail order (see pages 3 & 4 for suppliers).

Shopping Guide (this page last updated 13th Mar 2018) Page 1

A QUICK GUIDE to FINDING LOW SALT FOODS SALT MATTERS!

It causes or aggravates over 20 salt related health problems including: the rise of blood pressure with age, prehypertension, hypertension, premenstrual syndrome,

asthma, diabetic retinopathy, osteoporosis and the severe vertigo of Meniere’s disease Over 6 million Australians (half the adult population) have one or more salt related health issues

See also: www.findlowsaltfood.info Low Salt Foods Shopping List 1 (NAS = No Added Salt) Nearly all fresh foods are naturally low in salt. Exceptions are shellfish and crustaceans (prawns, oysters etc) but fish are OK. This sheet lists some processed foods that are low in salt (no more than 120mg sodium per 100g of food). Products change, so check the NIP. Barcodes aid enquiries – the supermarket should be able to check from the barcode if it is in store and where it is located. Suppliers are given for hard to obtain items. (Designed & compiled by David Brigden & Peter Chamberlain. Last updated 13th Mar 2018)

Kellogg's Just Right

30mg/100g

Supermarkets 9310055165854

Muesli (low in sodium)

eg SunSol 18mg/100g

Supermarkets 9311898192182

Rolled Oats (Porridge) Low sodium ~10mg/100g

lowsodiumfoods.com.au

www.tlc.org.au

www.bresnahans.com.au lowsodiumfoods.com.au

lowsodiumfoods.com.au lowsodiumfoods.com.au

lowsodiumfoods.com.au

NAS Tomato Sauce such as Fountain

20mg/100g

See also: www.findlowsaltfood.info Low Salt Foods Shopping List 2 (This page last updated 13th Mar 2018)

lowsodiumfoods.com.au

lowsodiumfoods.com.au

lowsodiumfoods.com.au

beerenberg.com.au

lowsodiumfoods.com.au

lowsodiumfoods.com.au

lowsodiumfoods.com.au

lowsodiumfoods.com.au lowsodiumfoods.com.au

lowsodiumfoods.com.au

lowsodiumfoods.com.au

The over-riding importance of BREAD No other single food adds so much to the huge overload of salt in the Australian diet as bread – it contributes 25% of our salt intake. It is such a staple food and is much more salty than most people realise. The average sodium content of 450mg/100g for white bread is nearly four times too high. However, some supermarkets and speciality shops do sell low salt bread (see pictorial shopping list). Some bakeries sell ‘salt-free’ (meaning no-added-salt) bread, or you can make your own in a bread machine. The taste is different but your palate adapts in time. (Dr. Beard's book Salt Matters has a whole chapter on bread and there are tips and recipes for NAS bread on www.findlowsaltfood.info) BAKING YOUR OWN BREAD A standard bread recipe using plain flour will make a low salt loaf if the salt is reduced to one fifth of the amount in the recipe. You can also make no-added-salt (NAS) bread. Salt is a dough improver, and without it the loaf is heavier. Other dough improvers work equally well without salt and give a lighter loaf. Adding gluten flour to your recipe will also help your NAS bread to rise. Using a breadmaker makes it easy to knead and bake your own bread. Commercial premixes are pre-salted Instead use high quality bread flour and add dough improver. Some small bakeries including some Baker’s Delight franchises take orders for ‘salt free’ (NAS) bread and Brumby’s franchises can get the official Brumby’s ‘salt-free’ recipe from their Head Office.

The flavour of low salt foods and NAS bread: The best salt substitute is an adapted palate! Nature rapidly repairs the damage that salt has done to your taste buds and you will start to taste the real flavour of food. Some people adapt quickly to NAS bread, but even the slowest are happy with NAS fruit bread, and for most palates potassium chloride salt substitute (No Salt) makes NAS bread taste like ordinary bread.

IODINE IS GOOD—UNLESS COMBINED WITH SALT Iodised salt is still 39% sodium—39,000 mg/100g—and has no place on the table of a family where salt causes or aggravates a health problem. Salt Matters has a whole chapter on iodine. Sea fish (fresh or NAS canned) and many brands of multivitamin capsules contain iodine, and you can iodise home-made bread with potassium iodide drops for breadmakers. Go to www.salt-matters.org and click on Salt and Iodine, or ask a friend with a computer to print out the two pages for you.

Where to get help! WEBSITES: http://www.salt-matters.org http://www.findlowsaltfood.info http://www.smanz.info https://www.lowsodiumfoods.com.au

JOIN AN EMAIL DISCUSSION GROUP on good control of salt. Just send a blank email to: saltmatters-subscribe@ozdocit.org Available from Low Sodium Foods ~ https://www.lowsodiumfoods.com.au/ The No Salt Cookbook ~ Emily George The Dizzy Chef ~ Healthy Cooking Recipe Book Salt Matters – the killer condiment, by Dr Trevor C Beard ~ the essential book for salt skippers Low Salt Stock Powders ~ beef, vegetable, or chicken No Added Salt liquid soup stocks ~ beef, chicken, vegetable, and mushroom Salt Skip Baking Powder & Salt Skip Potassium Bicarbonate Tinned NAS Salmon & Tuna (hard to find elsewhere), low salt dressings, condiments, sauces, spices, baked beans and snacks, including NAS crackers & NAS potato chips. Low Sodium Foods is run by Anne McKenzie & Marie Pearson. You can order from their website, or contact them ~ Email: info@lowsodiumfoods.com.au Tel: 08 8336 1673 Mob: 0407 792 938 Shopping Guide (this page last updated 13th Mar 2018) Page 4

1000

1000

SALT CONTROL—‘more effective and less troublesome than diuretics’ [1] Notes for health professionals on the rationale of the clinical routine at

the Menzies Research Institute, Hobart The Menzies Salt Skip Program is a collection of web-based resources and literature (now in book form) to help people follow the Australian Dietary Guidelines—with close attention to the salt guideline [2]. It provides good salt control for healthy people. Medication and some rare diseases raise ethical and medicolegal problems, especially with diuretics, unless the referring practitioner agrees to withhold diuretics* [3].

Good salt control is defined by 24-hour urinary sodium excretion [4]. A diet of natural (unsalted) foods can give sodium excretion rates from 5 to 35 mmol/day [5], and Hobart clinical experience is that full compliance can give surprisingly similar results. Fluid retention begins at sodium excretion rates above 50 mmol/day [6], and preventing fluid retention by full compliance with the salt guideline usually prevents the vertigo of Meniere’s disorder [1, 7, 8].

The ‘normal’ diet of industrial societies provides an extremely wide range of 24-hour urinary sodium excretion from about 20 to about 400 mmol, and these Hobart survey results (n=194) are typical [9]:

400

200

100

50 25

10 10 25

50 100

200 400

sodium mmol/day

Industrially processed foods are the cause of the large variation. They vary in sodium content from 5 to 9000 mg/100g, and supply about 75% of the average family’s salt intake [10], thus widely scattered urine results are inevitable when shoppers ignore the sodium content. The outward appearance of good control (under 50 mmol) for six people was accidental and ephemeral—urine results vary over a wide range from day to day except when all foods are consistently selected for low sodium content.

Diuretics disturb the serum electrolyte balance and good salt control normalises it [11]. Symptomatic hyponatraemia can occur at any salt intake, but the risk is inversely proportional to the salt intake, and below 50 mmol/day diuretics are contra- indicated [12]. The risk is greater with indapamide (Natrilix, Dapa-Tabs, Indahexal, Insig, Napamide) and with combination diuretics such as Moduretic [13]. The risk is also greater in women and the elderly [14].

Diuretics only control fluid retention above 50 mmol/day—where salt expands the extracellular fluid volume [15]—and we have known since 1934 that vertigo in Meniere’s Disorder is rare below 50 mmol [7]. Sydney teaching hospitals have been prescribing the Salt Skip literature for a decade, and their verdict is that ‘a urinary sodium less than 50 mmol/day (there has been no proper clinical trial) is more effective and less troublesome than diuretics’ [1]. Informed consent is unobtainable for double-blind salt loading—it causes severe vertigo attacks [16], but even surgery

Salt Matters — Australia and New Zealand (SMANZ) HR29/07/2007 + minor update 14/03/2018

GOOD SALT CONTROL

l l l l l l l l l l l

women

men

pota

ssiu

m m

mol

/day

Salt Matters — Australia and New Zealand (SMANZ)

Salt Control - Page 2

has had no ‘proper clinical trials’ for vertigo (sham operations in the control group are ethical only in animals). Clinical observation is that salt control works very well. *Prescribing diuretics combined with salt control. Life-threatening illness such as heart failure may justify the risk of combining diuretics with good salt control, especially as these patients are already under close supervision for the illness. Another exception can be made for patients with the severe vertigo of Meniere’s Disorder. Some are sensitive to even transient salt loads—especially if salt control is normally very good—and fullness in the ears or other premonition of vertigo may be an indication for a single tablet of a diuretic as well as the usual prophylactic dose of prochlorperazine (Stemetil, Stemzil).

The Laboratory Reference range has no clinical relevance for sodium excretion. Reference ranges show the middle 95% of the distribution, whereas serum cholesterol [17] and salt have an abnormal distribution in an industrial society, which is unrelated to the physiological normality of your patient’s urine result.

The Upper Intake Limit (UL) for sodium intake in Australia—100 mmol/day— is based only on presumed feasibility. To treat hypertension there is a Suggested Dietary Target of 70 mmol/day (1600 mg) [18]. To treat the vertigo of Meniere’s Disorder and other effects of fluid retention the upper limit is 50 mmol/day [1, 7, 8], which is also more effective for treating hypertension [19].

Diet-drug interactions can be as critical as drug-drug interactions with good salt control unless the dose is adjusted. After diuretics another important drug that is sensitive to salt control is lithium carbonate, where good salt control may convert an effective dose into an overdose. Controlling salt potentiates most antihypertensives, especially ACE inhibitors and angiotensin antagonists, but has little if any effect on calcium channel blockers.

Pregnancy and lactation are normal even at the lowest salt intake ever recorded in any culture [20] but, at the habitually high salt intake of industrial societies, salt control and diuretics may have paradoxical effects during pregnancy. Paradoxical effects are rare enough for some countries to ignore the risk—even at excretion rates as low as 20 mmol/day [21]—but in line with the Australian consensus we normally recommend the full Salt Skip Program in pregnancy only for women who were following it before the onset of pregnancy. During pregnancy we recommend salt control de novo only at the discretion of the obstetrician.

Rare diseases that can increase the need for salt include Addison’s disease and cystic fibrosis, but (by the time it is clinically significant) patients are usually aware of the diagnosis and the need for more salt.

Iodine supplementation by means of a vitamin & mineral supplement that contains sufficient iodine should be considered (provided there are no contraindications) as the use of iodised salt is not a feasible option for those practising good salt control. One that contains an iodine supplement of 100mcg/day should be sufficient for most people, raised to at least 150mcg/day for pregnancy and breastfeeding. Although many multivitamin supplements contain sufficient iodine, some do not. There is an inexpensive supplement (for women planning to become pregnant) that contains just two ingredients: 250mcg iodine (as potassium iodide) and 500mcg folic acid (Blackmores I-Folic).

Dr Trevor C Beard Honorary Research Fellow Menzies Research Institute Hobart, Tasmania

July 2007

Salt Matters — Australia and New Zealand (SMANZ)

Salt Control - Page 3 References: 1. Halmagyi GM, Cremer PD. Assessment of dizziness. J Neurol Neurosurg Psychiatry

2000;68:129–134. 2. Riley MD, Beard TC. Choose foods low in salt. In: National Health and Medical Research

Council, Dietary Guidelines for Australian Adults. Canberra: Australian Government Publishing Service; 2003:133–150.

3. Beard TC. Appendix 1. Skipping salt safely. In: Salt Matters: a consumer guide. Melbourne: Lothian Books; 2004:227–32.

4. Beard TC. Appendix 2. The 24-hour urine collection. In: Salt Matters: a consumer guide. Melbourne: Lothian Books; 2004:233–39.

5. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. British Medical Journal 1988;297:319–28.

6. Freis ED, Wanko A, Wilson IM, Parrish AE. Treatment of essential hypertension with chlorothiazide (Diuril). Journal of the American Medical Association 1958;166:137–40.

7. Furstenberg AC, Lashmet FH, Lathrop F. Ménière's symptom complex: medical treatment. Annals of Otology, Rhinology and Laryngology 1934;43:1035–46.

8. Harrison MS, Naftalin L. Meniere's disease: mechanism and management. Springfield, Illinois: Charles C Thomas; 1968:85–101.

9. Beard TC, Woodward DR, Ball PJ, Hornsby H, von Witt RJ, Dwyer T. The Hobart Salt Study 1995: few meet national sodium intake target. Medical Journal of Australia 1997;166:404–07.

10. James WPT, Ralph A, Sanchez-Castillo CP. The dominance of salt in manufactured food in the sodium intake of affluent societies. Lancet 1987;1:426–29.

11. Beard TC, Cooke HM, Gray WR, Barge R. Randomised controlled trial of a no-added- sodium diet for mild hypertension. Lancet 1982;2:455–58.

12. van Brummelen P, Schalekamp M, de Graeff J. Influence of sodium intake on hydrochlorothiazide-induced changes in blood pressure, serum electrolytes, renin and aldosterone in essential hypertension. Acta Med Scand 1978;204:151–57.

13. Brown MA, Whitworth JA. Think again about combination diuretics. Australian Prescriber 1993;16(1):4–5.

14. Mathew T, Boyd I, Rohan A. Hyponatraemia due to the combination of hydrochlorothiazide and amiloride (Moduretic): Australian spontaneous reports 1977–1988. Med J Aust 1990;152:308–09.

15. Freis ED. Salt, volume and the prevention of hypertension. Circulation 1976;53:561–63. 16.www.saltmatters.org. (click on 'IS IT TRUE?' Accessed 10 February 2007). 17. Rose G. Sick individuals and sick populations. International Journal of Epidemiology

1985;14:32–38. 18. National Health & Medical Research Council. Nutrient reference values for Australia and

New Zealand. Canberra: Australian Government Publishing Service; 2006. 19. MacGregor GA, Markandu ND, Sagnella GA, Singer DRJ, Cappuccio FP. Double-blind

study of three sodium intakes and long-term effects of sodium restriction in essential hypertension. Lancet 1989;2:1244–47.

20. Oliver WJ, Neel JV, Grekin RJ, Cohen EL. Hormonal adaptation to the stresses imposed upon sodium balance by pregnancy and lactation in the Yanomama Indians, a culture without salt. Circulation 1981;63:110–16.

21. Steegers EAP, Van Lakwijk HPJM, Jongsma HW, Fast JH, De Boo T, Eskes TKAB, et al. (Patho)physiological implications of chronic dietary sodium restriction during pregnancy: a longitudinal prospective randomized study. 1991;98:980–87.