Advice in the world of nutrition is always changing, but for years now, two strains from government agencies have stayed constant: Lower your intake of salt and limit your intake of fat. Scientists have suspected for decades that excess sodium (most commonly found in table salt) is linked to hypertension, a risk factor for heart attack and stroke; a diet high in fat has been linked to obesity, heart disease and certain types of cancer. As a result of such evidence, many people may have assumed that the less of those two substances you consume, the healthier you will be.

But several high-profile reports on salt and fat in the diet have made headlines and stirred up the confusing stew of nutritional advice even more, because they seem to contradict the well-established diet dogma that lowering your intake of salt and fat will improve your health. In this article, nutritionists, researchers and restaurateurs weigh in on the place of salt and fat in our diet.

The good, the bad and the moderate

"Fat and sodium are both essential nutrients. Without them you're dead, so a goal of 'as low as you can go' is ridiculous," says Felicia Busch, M.P.H., R.D., spokesperson for the American Dietetic Association (ADA) and owner of Felicia Busch & Associates, a nutrition consulting firm in St. Paul, Minnesota, that works with restaurants, foodservice corporations and grocery stores nationwide.

Fat is important for brain and nerve tissue development, especially in children, Busch notes; adults who don't get at least some fat with every meal are unable to absorb fat-soluble vitamins like A, D, E and K. People who eliminate too much fat may thereby increase their intake of refined carbohydrates, which can lead to problems with insulin production and to diabetes, she adds.

Sodium, too, is a critical element in keeping the body healthy. "Restaurateurs may think of foods' flavor, texture or color when they think of salt, but for the human body, salt is an essential nutrient," says Richard Hanneman, president of the Salt Institute in Alexandria, Virginia. "Humans need salt to maintain good electrical conductivity into and out of cells. Therefore, sodium is essential to the operation of the body's nervous system and for muscle control." Sodium also helps maintain fluid balance in the body, notes Busch.

Of course, many Americans consume more sodium and fat each day than necessary. Current Dietary Guidelines encourage a daily fat intake of no more than 30 percent of calories from fat (about 67 grams on a typical 2,000-calorie diet) with no more than 10 percent of calories from saturated fat; according to a 1998 ADA position paper citing 1994 figures, most Americans get about 34 percent of their calories from fat (with 12 percent from saturated fat).

The Guidelines urge people to eat a diet "moderate" in sodium: the food label lists a daily reference amount of 2,400 milligrams per day, but many Americans consume much more than that amount. Estimates of average consumption vary. The Salt Institute's Hanneman places it at about 3,500 milligrams a day for most Americans, while the ADA's Busch says that for many people consumption climbs as high as 7,000 to 14,000 milligrams per day. Obviously there is room for people to cut back on both nutrients, but those cuts may not have to be drastic to be healthful.

The lowdown on low-fat diets

The American Heart Association (AHA) published a statement in the September 1998 issue of its journal Circulation that announced that very-low-fat diets should not be recommended across a general population. Although eating a low-fat diet (the recommended 30 percent of calories or less from fat) has been shown to reduce some risk factors associated with heart attack and stroke, ultra-low-fat diets (deriving 15 percent of calories or less from fat), according to the statement, do not seem to provide any additional health benefits and may even introduce new risks.

Co-authors Alice Lichtenstein, D.Sc., an associate professor of nutrition at Tufts University, and Linda Van Horn, Ph.D., R.D., of Northwestern University Medical School have suggested that very-low-fat diets may increase levels of triglycerides in the blood and decrease HDL (so-called "good cholesterol") levels without further decreasing LDL ("bad cholesterol") levels. Elevated triglycerides and lower levels of HDL have been linked to heart disease. The AHA statement also noted that ultra-low-fat diets can pose serious health risks to certain segments of the population, such as children and pregnant women.

"We applauded the Heart Association because what they said was that very-low-fat diets are not appropriate for the entire population. In fact, they may be posing a risk for certain subgroups, like the very young and the elderly," says Judith Dausch, Ph.D., R.D., nutritionist for the National Restaurant Association. It's time, she says, to change the nutritional messages about fat, and studies like this help. "Consumers have gotten that message about fat to the extreme, so that a lot of them think that it's just bad," she says. The different types of fats — some of which are more healthful than others — muddy the picture even more. "We don't want people to be extreme. We want them to take advantage of all the food choices that are out there," says Dausch. It's a variety of food choices and a well-balanced eating plan that will "lead people down the path to good health."

Going against the grain

The already-hot debate on salt has gotten even hotter. For decades, reduced-sodium diets have been shown to reduce blood pressure in some hypertensive individuals, and such a dietary course has become routine treatment for the condition. Because of that link, the government has promoted reduced sodium intake for the population as a whole.

"It was simple logic: Sodium was involved in maintaining blood pressure, and some people — though not all — were able to reduce blood pressure when they drastically restricted dietary sodium," says Hanneman. "Since researchers had demonstrated that populations with relatively lower blood pressures had lower incidence of strokes and heart attacks, the hypothesis suggested, lower-sodium diets would lower the incidence of heart attacks. Simple. But was it simplistic?" The answer, it now seems, is yes. "What was never tested, of course, was whether low-sodium diets actually did reduce the incidence of heart attacks," Hanneman explains.

But some testing has been done, and the results are shaking up the salt story. For example, a report entitled "Moderate Sodium Restriction: Do the Benefits Justify the Hazards?," authored by Michael H. Alderman and Bernard Lamport of the Albert Einstein College of Medicine in Bronx, New York, and published in the June 1990 American Journal of Hypertension, concluded that moderate sodium restriction led to a fall in blood pressure for only some patients with mild hypertension, and that imposing such restriction on people in general might be dangerous, for a variety of reasons. For some people, it could actually increase blood pressure, disturb sleep patterns and decrease resistance to other illnesses. A few years later, another Alderman study, published in the June 1995 issue of the AHA's Hypertension, followed 1,900 hypertensive men for four years and revealed that during that period more than four times as many heart attacks occurred among men with low sodium excretion as among those with high sodium excretion.

Even more recently, on March 14, 1998, the Lancet, a British medical journal, published an even more startling Alderman study of more than 11,000 individuals, which found that the number of deaths both from all causes and from cardiovascular disease was inversely related to daily sodium intake — those with a lower sodium intake were more likely to die.

The most important aspect of the studies, however, is not the suggested negative effects of low-sodium diets — it's the realization that restricted diets may not benefit the general population. As Alderman and his co-authors conclude in the summary section of the most recent study: "[T]hese results do not support current recommendations for routine reduction of sodium consumption, nor do they justify advice to increase salt intake or to decrease its concentration in the diet."

Alderman is not alone in that conclusion. For example, in its May 6, 1998, issue, JAMA: The Journal of the American Medical Association published a meta-analysis of previous trials (1966 through December 1997) to estimate the effects of sodium restriction on blood pressure, among other conditions. Author Niels A. Graudal and his colleagues found that the effect on normotensive individuals (those with normal blood pressure) was very slight and concluded: "This effect size does not justify a general recommendation for reduced sodium intake." Those results corresponded to findings in previous meta-analyses.

Still other recent studies suggest that dietary measures other than sodium restriction may help people who suffer from hypertension. The April 17, 1997, issue of the New England Journal of Medicine included a study on Dietary Approaches to Stop Hypertension (also known as "DASH"), which found that diets rich in fruits and vegetables or fruits, vegetables and low-fat dairy products with reduced saturated and total fat were successful in substantially lowering blood pressure. Sodium intake remained constant, and therefore, could not have been responsible for the decrease.

"There is no demonstrated proof that low-sodium diets will deliver better health to the general public," says Hanneman. "It may be that low-sodium diets are a real health threat; that thesis deserves further testing. What stands uncontroverted today is that no study shows that lowering blood pressure by means of a low-sodium diet will reduce the incidence of heart attacks, which, of course, is why the intervention was recommended in the first place."

Although Dausch questions some of the methodology involved in many of the studies, she, too, agrees with their ultimate conclusions. "We can't make a blanket recommendation that everybody should lower their salt intake," she says.

Salt and fat to taste?

Blanket dietary recommendations are one of nutrition scientists' greatest challenges today; in fact, some experts believe they should be abolished altogether. "It's hard to say that there's an ideal number for a whole population. It's going to vary by individual," says Dausch. "That's why things are moving more toward individualized diets."

"We know that the need for sodium varies among individuals," says Hanneman. Most people are "salt-resistant" in that their blood pressure remains the same or even increases on low-sodium diets, he notes, although some are "salt-sensitive," meaning that their blood pressure responds to changes in the amount of dietary sodium in their bodies. People's metabolisms differ in their handling of salt and require different recommendations.

"Nutrition scientists continue to debate whether 2,400 milligrams should be the daily value for sodium as a public-health measure or whether we should address individual needs for sodium," says Laura Pensiero, nutritionist and instructor at The Culinary Institute of America in Hyde Park, New York.

Busch believes that many people can safely go above 2,400 milligrams a day. She suggests that for most non-salt-sensitive people, anywhere from 2,000 milligrams to 6,000 milligrams a day would be appropriate. "The Daily Value suggested on the food label is 2,400 milligrams per day. That's unreasonably low for anyone who eats processed foods or who eats out frequently," she notes. Busch adds that the 30 percent recommendation for fat may also be too restrictive. "Newer research indicates that for some individuals and young children, 35 percent of calories from fat is a more appropriate upper limit," she says.

"The best advice is to monitor your blood pressure, consult your doctor and follow a professional's directions, complete with frequent checkups," says Hanneman.

From debate to the plate

And so the debates on salt and fat go on. But what does that mean for restaurateurs and chefs? The studies, say the experts, should not move restaurateurs to make any significant changes, because the answers are still far from clear and more testing needs to be done. "Everyone is confused by conflicting nutrition recommendations — even dietitians," says Busch. "Since nutrition is such a new science, it's becoming clearer every day how little we really understand."

Restaurateurs should continue to do what they have always done — serve their customers — but they must be sure they're serving all their customers. "There's a segment of the population that really cares about what they're eating, and it's part of the whole business aspect of running a restaurant that you have to address all your diners," says Pensiero.

Dausch says that chefs should focus on adding foods rather than taking them away to produce a balanced and healthy meal. Simply taking the fat or salt out of an entree usually doesn't cut it with customers, she notes. Instead, chefs should take advantage of the vast array of ingredients and flavor enhancers available to them to create flavorful and fun new dishes that also happen to be healthful. Fruits and vegetables are one way to accomplish that. "Consumers are trying to find new ways to add fruits and vegetables to their diets," says Dausch. "Restaurants can take that into account when planning dishes that are tasty, such as adding a chutney or a fruit sauce instead of a cream sauce."

Pensiero is also against taking too much out of meals to make them healthful. "If we get too restrictive in a culinary setting, we're sabotaging nutritious cooking," she says. "Salt does play a role in cooking, and it does enhance flavor. It brings out natural flavor. If you don't season food — not overseason, but to the appropriate level — then you're not doing much to dispel the notion that nutritious cooking is flavorless."

Pensiero also agrees that chefs should add more fruits and vegetables to dishes, pointing to the DASH study as evidence of how healthful eating more plant products can be. The diets that lowered blood pressure in that study contained eight to 10 servings of fruits and vegetables a day. Pensiero also notes that fruits and vegetables offer benefits beyond their healthful attributes. "They can be cost-effective for chefs. They add a lot of color and flavor dimensions, especially if the chef is creative in his or her cooking method and presentation," she says.

To help control the fat in dishes, Pensiero recommends that chefs moderate the use of animal products. "You can still use these items, but use less of them," she suggests. Composed dishes like stir-fries, stews and casseroles can lower the amount of fat and cholesterol in a dish but still keep it "meaty." The most effective diet in the DASH study was the combination diet, which added about three servings of low-fat dairy foods to the eight to 10 servings of fruits and vegetables. Healthy cooking techniques, like roasting, stewing and baking in wood-burning ovens, also produce flavorful dishes with minimum amounts of salt and fat.

Taking tips from older, established ethnic cuisines can also help moderate the amount of salt and fat in a dish. "We're a country of fusion cooking. Taking cues from naturally healthy authentic cuisines helps direct chefs toward nutritional balance without getting obsessed with numbers and provides great flavor," says Pensiero. Highly seasoned cuisines, such as those of the Southwest, the Caribbean and the Mediterranean, offer a wide array of heat and flavors to spice up dishes.

Healthful menus make a difference

More and more restaurateurs across the country are taking nutritional awareness to heart — and to the heart of their menus.

Ann Gentry started Real Food Daily about 10 years ago as a delivery service. The 45-seat restaurant in Santa Monica opened five years ago, and a new West Hollywood unit opened this past October. From the start — as the name implies — real, wholesome, balanced food has been the hallmark of the business. The restaurant promotes a healthful, organic, vegetarian diet and encourages patrons to learn more about the relationship between food and wellness.

When preparing dishes, Gentry draws inspiration from many cuisines, especially Asian cooking. Miso, tamari, rice vinegar and sesame oil, for example, "really give vegetarian food a great kick, a great taste," she says, and often add a stronger taste than salt. At the table, diners are offered a shaker of gomasio — a blend of roasted sesame seeds and sea salt at a ratio of about 14 to 1 — which adds a lot of flavor with only a little sodium. Gentry does use some salt throughout the cooking process, though. "You do need salt — your body needs it to be healthy, and you need it to help bring out the flavors," she says. She also uses fats — mainly oils like canola and sesame — in moderation.

Bennigan's Grill and Tavern restaurants, based in Plano, Texas, has also pleased customers with its Health Club menu. Although it doesn't follow any particular organization's nutritional guidelines, that section of Bennigan's extensive 75-item menu features balanced fare with lower levels of sodium, fat and cholesterol.

"There were so many conflicting guidelines [when the menu was created] several years ago, that we chose a little bit different philosophy," says Paul Freeman, vice president of food and beverage for Bennigan's, which is operated by the Metromedia Restaurant Group. "That section of the menu was really designed to not take a stance one way or the other but simply provide information so that our guests could make informed menu choices."

As important as he believes creating healthful options is, Freeman does caution restaurateurs not to get carried away to the point that it interferes with the restaurant. "Whatever people develop, they have to keep the integrity of their menu. They have to make it so that men and women in the restaurants can execute these items on a daily basis," he says. And, he adds, operators shouldn't lose sight of their customers. Restaurateurs must keep their guests in mind. "They have to have special profiles, if you will, that will appeal to guests in certain segments. And you have to be flexible to any special requests.

Taking better care of guests was the central motivation behind the creation of Hyatt Hotels and Resorts' Cuisine Naturelle menu items, which are available in all Hyatt properties in the United States. "We always had a certain degree of people that were diet-sensitive, so fruit plates and vegetable plates and things like that for us were a big deal, because we made them very ornate," says Philip Kendall, vice president of food and beverage for Hyatt, based in Chicago. But in the late 1980s, he says, those options — ornate though they were — began to get a little tired.

"We thought, 'let's make a menu that doesn't necessarily speak to a specific group as far as diet concerns,'" says Kendall. "'Let's tee off on something and make it a really balanced meal but be sensitive — use either low-fat or no-fat oils and dressings; be sure that we cook with herbs and unprocessed things; and where we can, eliminate salt as best we can.'"

Hyatt hired a nutritionist and launched a study of food history to add depth and flavor to the original Cuisine Naturelle menu as well as health. (The menu was updated about four years ago.) Items like "Red Lentil Chili" (275 calories), "Couscous With Tomato and Asparagus" (445 calories) and "Garden Pasta" (320 calories) are rich in grains, vegetables, vitamins and flavors from all over the world and naturally lower in fat, sodium and cholesterol.

Although the nutritional breakdown of the items is important (Cuisine Naturelle items, on average, provide about 38 percent of daily protein, 34 percent of daily fiber and a low 15 percent of calories), the numbers take second place to the "story about the food," says Kendall. One key piece of advice that serves the menu well is "always have color on your plate," he says, "because the different vegetables all sponsor a different nutritional aspect."

Garlic, long purported to possess health benefits, plays a big role in Cuisine Naturelle items, as does the Mediterranean food pyramid. "That pyramid is a wonderful basic throwback to that old-wives'-tales sort of mentality: Eat as many unprocessed fruits and vegetables as you can, eat meat on a sparing basis, eat fish whenever possible," says Kendall. "It doesn't say anything about the number of grams of fat or the number of grams of protein or the number of milligrams of sodium that you and I should take in every day. I really like that approach."

To flavor Cuisine Naturelle foods, Kendall says the staff relies on herbs, onions, tomatoes, garlic and red peppers, among other fresh flavors. Pepper, too, plays a big role. "Pepper is something that you should be liberal with, because at this point at least, pepper has not been charged with anything," he notes.

Beef up your nutritional knowledge

According to Kendall, one of the most critical steps in creating healthful and successful dishes is research. "Take the time to get some food history, to get some nutritional background. So much information is available," he says. Nutritional news changes quickly, and only by doing research can operators successfully sift their way through the information that's out there and discover the best ways to serve their customers.

That advice echoes the suggestions of National Restaurant Association nutritionist Dausch, who believes that expanding nutritional knowledge and passing it along to customers is going to be one of restaurateurs' biggest challenges in the future. "Restaurateurs must be aware of trends and consumer needs, because some customers may request help in following certain dietary principles, so they need to be prepared for that."

To provide the nutritional options customers crave, operators must know the ingredients of all dishes, standardize recipes and take advantage of advances in food technology and of the nutritional-analysis tools available to help them plan their menus. Above all, restaurateurs need to keep abreast of changes and use them to their advantage, Dausch says. And that's something that will never change, no matter what nutritional news comes to light next.

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