Nutrition for Patients with Cardiovascular Disorders

Check Your Knowledge

True	False
□	□	1	Of all seven metrics that define cardiovascular health, the one most in need of improvement among American adults is diet.
□	□	2	The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure primarily because it is low in sodium.
□	□	3	For cardiovascular disease (CVD) risk reduction, it is more effective to focus on single nutrients (e.g., fat or sodium) than the whole eating pattern.
□	□	4	High triglyceride levels are a component of metabolic syndrome (MetS) but are not considered to be directly atherogenic but rather a biomarker of CVD.
□	□	5	A traditional Mediterranean diet is a low-fat diet.
□	□	6	Foods with components that provide cardiometabolic benefits include fish and nuts.
□	□	7	Trans fats increase low-density lipoprotein cholesterol (LDL-C) and therefore risk of CVD.
□	□	8	Alcohol has both positive and negative effects on heart health.
□	□	9	Only people with blood pressure greater than 120/80 mmHg can benefit from lowering their sodium intake.
□	□	10	The need to restrict sodium intake in patients with heart failure is clearly established.

Learning Objectives

Upon completion of this chapter, you will be able to

1 List the metrics that define cardiovascular health.

2 Discuss the metrics that define an optimal healthy diet score for a 2000-calorie intake.

3 Summarize the characteristics of a Dietary Approaches to Stop Hypertension (DASH) diet.

4 Compare the DASH diet with the traditional Mediterranean diet.

5 Plan a 2000-calorie DASH eating plan menu.

6 Name foods associated with cardiometabolic benefits.

7 Name foods associated with cardiometabolic risks.

8 Counsel a client on ways to lower sodium intake.

Cardiovascular disease (CVD) refers to heart and blood vessel conditions such as coronary heart disease (CHD), stroke, hypertension, and heart failure. Although mortality from CVD has been declining over the last few decades in the United States and many Western industrialized countries, it remains the leading cause of death in United States and worldwide (Mozaffarian et al., 2015). CVD is responsible for nearly 1 out of 3 deaths in the United States and more deaths than from all forms of cancer combined (Mozaffarian et al., 2015). Poor diet quality affects several major cardiovascular risk factors, including blood pressure, serum lipid levels, insulin resistance, and weight.

The relationship between diet and CVD has been a major focus of health research for almost half a century (Mente, de Koning, Shannon, & Anand, 2009). For decades, Americans were urged to follow a low-fat diet to reduce the risk of CVD. It is now known that the quality of fat consumed is more important than the total amount. Evidence increasingly supports the shift away from focusing on single nutrients (e.g., fat) to promoting healthy dietary patterns (e.g., a Dietary Approaches to Stop Hypertension-style or Mediterranean-style pattern).

This chapter discusses cardiovascular health and various CVD risks, dietary strategies for the risk reduction, and nutrition therapy for established CVD and heart failure.

Quick Bite

Estimated prevalence of CVD among American adults

High blood pressure: 80 million

CHD: 15.5 million

Myocardial infarction (MI): 7.6 million

Chest pain: 8.2 million

Heart failure: 5.7 million

Stroke (all types): 6.6 million

Source: Mozaffarian, D., Benjamin, E., Go, A., Arnett, D. K., Blaha, M. J., Cushman, M., … Turner, M. B. (2015). Heart disease and stroke statistics—2016 update: A report from the American Heart Association. Circulation, 133, e38-e360. doi:10.1161/cir.0000000000000350

CARDIOVASCULAR HEALTH

The 2020 goal of the American Heart Association is “to improve the cardiovascular health of all Americans by 20% while reducing deaths from CVD and stroke by 20%” (Lloyd-Jones et al., 2010). The new concept of cardiovascular health is defined according to seven metrics: smoking, body mass index (BMI), physical activity, diet quality, total cholesterol level, blood pressure, and fasting plasma glucose level (Table 20.1). It is estimated that 80% of CVD can be prevented by not smoking; eating healthily; being physically active; maintaining a healthy weight; and controlling hypertension, diabetes, and high lipid levels (Mozaffarian et al., 2015).

A scoring system is used to rate cardiovascular health as ideal, intermediate, or poor for each metric and overall. Table 20.1 shows the percentage of American adults who meet the criteria for each metric. Americans score as “ideal” most often in the category of “not currently a smoker” (77.8%) and least often in consuming a healthy eating pattern, such as a DASH-type pattern (1.5%) (Mozaffarian et al., 2015). Poor diet quality, overweight/obesity, hypertension, hypercholesterolemia, and metabolic syndrome are presented in the following sections.

Diet Quality

Of all seven metrics that define cardiovascular health, healthy diet pattern has the worst compliance scores with only 1.5% of adults achieving an ideal score (>80 out of 100 points) (Mozaffarian et al., 2015). An “ideal diet” is described as a calorie-appropriate DASH-type eating plan characterized by five primary and three secondary features as listed in Table 20.1. Comparing 2011 to 2012 scores for the five primary healthy diet metrics to the previous period in 2009 to 2010, American adults (Mozaffarian et al., 2015)

Did not show overall improvement in ideal adherence. However, more adults achieved intermediate adherence (a score of 40%-79%) and fewer had poor adherence (a score of <40%)
Improved most in increasing whole grain intake and reducing consumption of sugar sweetened beverages
Had a small, nonsignificant increase in fruit and vegetable intake
Showed virtually no improvement in fish and sodium intake

Table 20.1 Definition of Ideal Cardiovascular Health Metrics and the Percentage of Adults 20 Years and Older Who Meet the Criteria for Ideal in Each Metric

Ideal Health Factors	Percentage of Adults Who Achieve Ideal Metric
Total cholesterol <200 mg/dL	46.6
Blood pressure <120 mmHg or <80 mmHg	42.2
Not currently a smoker	77.8
Fasting plasma glucose <100 mg/dL	53.0
Ideal Health Behaviors
Physically active ≥150 minutes/week at moderate to vigorous intensity or ≥75 minutes/week at vigorous intensity	44.0
BMI <25 kg/m²	31.3
A DASH-type pattern that meets four to five of these goals	1.5
≥4.5 cups/day fruits and vegetables	17.2
≥2 servings fish/week	21.2
<1500 mg/day sodium	3.1
<36 oz/week sugar sweetened beverages	66.0
Three or more 1-oz servings whole grains/day	12.0
Secondary diet metrics
≥4 servings/week nuts/legumes/seeds	42.0
<2 servings/week processed meats	62.1
<7% total calories from saturated fat	25.9
BMI, body mass index; DASH, Dietary Approaches to Stop Hypertension. *Sources:* Lloyd-Jones, D., Hong, Y., Labarthe, D., Mozaffarian, D., Appel, L. J., Van Horn, L., … Rosamond, W. D. (2010). Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association’s Strategic Impact Goal through 2020 and beyond. Circulation, 121, 586-613 and Mozaffarian, D., Benjamin, E., Go, A., Arnett, D. K., Blaha, M. J., Cushman, M., … Turner, M. B. (2015). Heart disease and stroke statistics—2016 update: A report from the American Heart Association. Circulation, 133, e38-e360. doi:10.1161/cir.0000000000000350

Unfolding Case

Recall Jacob. A diet history reveals that his typical first meal of the day is two egg-and-sausage breakfast sandwiches along with coffee, cream, and sugar. Lunch is two peanut butter and jelly sandwiches on white bread with chips and soda. Dinner is a submarine sandwich, pizza, or tacos. During the evening he eats chips and salsa while drinking three to four beers. How does his usual intake compare to the ideal diet metrics? What specific suggestions would you make to improve his usual intake?

Eating Pattern Recommendations

Current dietary recommendations for the primary or secondary prevention of CVD focus on eating patterns, not individual nutrients, that inherently reflect nutrient targets, such as reducing intakes of sodium, added sugars, saturated fat or fatty acids, and trans fat and increasing intakes of potassium and fiber. Foods with a positive impact on cardiometabolic factors (Table 20.2) are emphasized, and those with a negative impact (Table 20.3) are avoided.

Saturated Fat or Fatty Acids fatty acids in which all the carbon atoms are bonded to as many hydrogen atoms as they can hold, so no double bonds exist between carbon atoms; animal fats (meat and dairy), coconut oil, palm oil, and palm kernel oil are the biggest sources.

Trans Fats fatty acids with hydrogen atoms on opposite sides of the double bond. Most trans fats in the diet come from partially hydrogenated fats.

For “healthy” people, the DASH- and Mediterranean-style eating patterns may help prevent hypertension, CHD, stroke, type 2 diabetes, and obesity if calories are appropriate. For people who are not “healthy” (e.g., those who are being

treated for CHD, hypertension, or diabetes or have had an MI or stroke), these eating patterns and lifestyle changes are an integral part of management. With attention to cultural considerations, as appropriate (Box 20.1), these eating pattern and lifestyle recommendations come close to being “one size fits all.” Tips for choosing “ideal” eating pattern are summarized in Box 20.2.

Table 20.2 Foods Associated with Cardiometabolic Benefits

Food	Components Implicated in Benefits	Possible Cardiometabolic Benefits
Fruits and vegetables	Antioxidant vitamins, potassium, magnesium, fiber, phytochemicals	Improvements in blood pressure, lipid levels, insulin resistance, weight control Lower incidence of CHD Lower incidence of stroke (fruit) Benefits are not replicated with equivalent amounts of mineral or fiber supplements.
Whole grains	B vitamins, vitamin E, fiber, folate, minerals, phytochemicals, polyunsaturated fatty acids	Improvements in glucose-insulin homeostasis; may reduce inflammation and promote weight loss Whole-grain oats decrease LDL cholesterol without lowering HDL-C Higher fiber content contributes to the lower incidence of CHD, diabetes, and possibly stroke from whole grains; the effect of whole grains is not replicated from equivalent amounts of supplemental fiber bran, or isolated micronutrients.
Fish	Specific proteins, unsaturated fats, vitamin D, selenium, omega-3 fatty acids	In human trials, fish oil lowers triglyceride levels, systolic and diastolic blood pressure, and resting heart rate. May reduce inflammation and limit platelet aggregation Lower incidence of CHD, ischemic stroke, cardiac death
Nuts	Unsaturated fatty acids, vegetable proteins, fiber, folate, minerals, antioxidants, phytochemicals	Lower total cholesterol, LDL cholesterol, and postprandial hyperglycemia from high-carbohydrate meals When added to weight loss diets, weight loss is either unchanged or greater. Lower incidence of CHD
Dairy products	It is not known which constituents of dairy products offer cardiometabolic benefits; possibly specific fatty acids, proteins, vitamins, minerals, and other nutrients	May improve satiety and weight loss May contribute to improvements in blood pressure, lipid levels, and insulin resistance regardless of changes in weight Lower risk of stroke and diabetes
Vegetable oils	Polyunsaturated fatty acids (PUFAs), monounsaturated fatty acids, plant-derived omega-3 fatty acids	Improvements in blood lipids and lipoproteins and lower CVD events when PUFAs replace saturated fatty acids Monounsaturated fats from vegetable oils (e.g., olive oil) may lower CVD risk.
Legumes	Micronutrients, phytochemicals, fiber	Nutrient package may reduce cardiometabolic risk.
CHD, chronic heart disease; LDL, low-density lipoprotein; HDL-C, high-density lipoprotein; CVD, cardiovascular disease. *Source:* Mozaffarian, D., Appel, L., & Van Horn, L. (2011). Components of a cardioprotective diet: New insights. Circulation, 123, 2870-2891.

Table 20.3 Foods Associated with Cardiometabolic Risks

Food	Components Implicated in Adverse Effects	Possible Cardiometabolic Risks
Foods and fats containing partially hydrogenated vegetable oils, such as commercially baked products and stick margarine	Trans fatty acids	Strongest link to CHD risk of all types of fat
Red and processed meats such as bacon, sausage, hot dogs	Heme iron, saturated fatty acids, dietary cholesterol; sodium and preservatives (in processed meats)	Consumption of processed meats associated with higher incidence of CHD and diabetes mellitus Red meat and processed meat may increase risk of CHD when they are eaten in place of poultry, fish, and plant proteins.
Sugar-sweetened beverages, sweets, and grain-based desserts and bakery foods	Sugars, refined grains	Sugar-sweetened beverages are linked to obesity; lack of satiety from liquid sugar may contribute to positive calorie balance. Sugar-sweetened beverages may displace the intake of more healthful beverages. High sugar-sweetened beverage consumption associated with higher incidence of diabetes, MetS, and possibly CHD Refined carbohydrates are devoid of beneficial nutrients and may displace more healthful foods.
CHD, chronic heart disease; MetS, metabolic syndrome. *Source:* Mozaffarian, D., Appel, L., & Van Horn, L. (2011). Components of a cardioprotective diet: New insights. Circulation, 123, 2870-2891.

BOX 20.1 Cultural Considerations

For all cultural groups, emphasize the positive aspects of their eating styles and suggest ways to lower saturated fat and sodium content of traditional foods.

African American Tradition

Traditional soul foods tend to be high in saturated fat and sodium. On the positive side, there is a heavy emphasis on vegetables and complex carbohydrates.

Suggested changes in cooking techniques include

Using nonstick skillets sprayed with cooking spray when pan-frying eggs, fish, and vegetables
Using small amounts of liquid smoke flavoring in place of bacon, salt pork, or ham
Using more seasonings, such as onion, garlic, and pepper, in place of some of the salt
Using turkey ham or turkey sausage in place of bacon
Using “lite” or sugar-free syrups

Mexican American Tradition

The traditional diet is primarily vegetarian with a heavy emphasis on fruits, vegetables, rice, and dried peas and beans. Processed foods are used infrequently.

Cooking techniques rely on frying and stewing with liberal amounts of oil or lard. An alternative is to sauté or stew with small amounts of canola or olive oil. High-fat meats and lard are commonly used. Using less meat, choosing lower fat varieties, trimming visible fat, and substituting oil for lard are heart healthy alternatives.

Chinese American Tradition

Traditional Chinese cooking relies heavily on vegetables and rice with plants providing the majority of calories. Meat is used more as a condiment than an entrée. Cooking techniques tend to preserve nutrients. Sauces add little fat.

Sodium intake is high related to heavy use of soy sauce, monosodium glutamate (MSG), and salted pickles. Reduced-sodium soy sauce is available, but it is still high in sodium. Because of the difficulty in eliminating the use of soy sauce, a more practical approach is to gradually use less.

Native American/Alaska Native Traditions

Widely diverse eating styles make useful generalizations difficult. In general,

Encourage traditional cooking methods such as baking, roasting, boiling, and broiling.
Encourage the use of traditional meats, such as fish, deer, and caribou.
Remove fat from canned meats.
Use vegetable oil for frying instead of lard or shortening.

Jewish Tradition

Many traditional foods are high in sodium such as kosher meats (salt is used in the koshering process), herring, lox, pickles, canned chicken broth or soups, and delicatessen meats (e.g., corned beef, pickled tongue, pastrami).

Pareve (neutral) nondairy creamers are often used as a dairy substitute in meals containing meat, but they are high in saturated fat. Encourage light and fat-free versions.

Encourage methods to lower fat in traditional recipes such as

Baking instead of frying potato pancakes
Limiting the amount of schmaltz (chicken fat) used in cooking
Using reduced-fat or fat-free cream cheese on bagels
Using low-fat or nonfat cottage cheese, sour cream, and yogurt in kugels and blintzes

BOX 20.2 Tips for Choosing an “Ideal” Eating Pattern

Replace foods high in saturated fat with foods that provide unsaturated fats.

Avoid fatty meats.
Avoid processed meat.
Choose lean meats and poultry and remove skin from poultry before eating.
Use liquid oils such as canola, olive, and soybean in place of solid fats such as butter, stick margarine, shortening, and lard.

Choose low-fat dairy products.

Enjoy low fat or non-fat milk, yogurt, and cheese.

Choose whole grains.

Replace white enriched breads and cereals with whole grains, such as whole wheat, oats, barley, corn, popcorn, brown rice, wild rice, buckwheat, triticale, bulgur, millet, quinoa, and sorghum.

Eat more fruits and vegetables.

Eat a variety of fresh, frozen, and canned fruits and vegetables without added sugars, salt, or high-calorie sauces.
Eat occasional meatless meals that feature legumes, tofu, or vegetables.
Snack on fresh or dried fruits, fresh vegetables with “healthy” dip, or frozen fruit bars.

Eat more fish.

Eat oily fish, such as mackerel, salmon, herring, lake trout, tuna, and white fish, at least twice a week.

Avoid added fats, added sugars, and sodium.

Read “Nutrition Facts” labels.
Limit high-calorie bakery products—they usually contain white flour, added sugars, and saturated and trans fats.
Avoid sugar-sweetened beverages.
Prepare foods from “scratch” instead of purchasing convenience foods and mixes, which tend to be high in sodium.
Use herbs and spices, lemon juice, and flavored vinegars to flavor vegetables and other foods.

The Dietary Approaches to Stop Hypertension Diet

Dietary Approaches to Stop Hypertension (DASH) was a multicenter feeding study funded by the National Heart, Lung, and Blood Institute (Appel et al., 1997) that set out to test whether eating whole “real” foods rather than individual nutrients would lower blood pressure as a result of some combination of nutrients, interactions among individual nutrients, or other food factors (Appel et al., 1997). The results clearly showed that eating a diet high in fruit, vegetables, and low-fat dairy products; moderate in whole grains, poultry, fish, and nuts; and low in fat, red meat, sweets, and sugar-sweetened beverages substantially lowers both systolic and diastolic blood pressures as well as low-density lipoprotein cholesterol (LDL-C). Reductions in blood pressure were similar in men and women and similar in magnitude to the effects seen with drug monotherapy for mild hypertension. In people who have type 2 diabetes, the DASH diet has been shown to improve numerous cardiac risk factors, including waist circumference, systolic and diastolic blood pressure, fasting blood glucose, hemoglobin A1c, triglyceride levels, LDL-C, high-density lipoprotein cholesterol (HDL-C), and total cholesterol (Azadbakht et al., 2011).

The DASH diet is a healthy eating pattern appropriate for all people, unless contraindicated. Table 20.4 lists food group serving recommendations for various calorie levels. The DASH diet is frequently featured in lay publications. U.S. News & World Report ranks the DASH diet as the best overall “diet” (as in eating plan, not weight loss diet) out of 38 diets evaluated and the best diet for healthy eating (Haupt, 2016).

The original DASH eating plan was rich in potassium, magnesium, and calcium, as well as fiber and protein; low in total fat, saturated fat, and cholesterol; and protein content was slightly increased. It is likely that several aspects of the diet, not just one nutrient or food, lowered blood
pressure (Appel et al., 2006). Especially noteworthy is that the decrease in blood pressure occurred without lowering sodium intake and without lowering calories to produce weight loss.

Table 20.4 The Dietary Approaches to Stop Hypertension Eating Plan at Various Calorie Levels

Food Group and Representative Serving Sizes	Servings Per Day			Examples of Foods	Significance to the DASH Eating Pattern
Food Group and Representative Serving Sizes	1600 Calories	2000 Calories	2600 Calories	Examples of Foods	Significance to the DASH Eating Pattern
Grain 1 slice bread; 1/2 cup cooked rice, pasta, or cereal; 1 oz ready to eat cereal	6	6-8	10-11	Whole grains are recommended for most grain servings, such as whole wheat bread, wholegrain cereals, whole wheat pasta, and brown rice	Provide calories and fiber
Vegetables 1 cup raw leafy vegetable 1/2 cup cut-up raw or cooked vegetable 1/2 cup vegetable juice	3-4	4-5	5-6	All fresh, plain frozen, and low-sodium canned vegetables Use preparation methods to retain the fiber content, such as leaving skins on potatoes	Provide potassium, magnesium, and fiber
Fruits 1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 1/2 cup fruit juice	4	4-5	5-6	All; eat skins and seeds for fiber whenever possible Whole fruits are better choices than fruit juice.	Provide potassium, magnesium, and fiber
Fat-free or low-fat milk and milk products 1 cup milk or yogurt 11/2 oz natural cheese	2-3	2-3	3	Fat-free or low-fat milk; fat-free, low-fat, or reduced-fat cheese; fat-free or low-fat regular or frozen yogurt	Provide calcium, magnesium, potassium, and protein
Lean meats, poultry, and fish 1 oz lean meat, poultry, or fish 1 egg	3-4 or less	6 or less	6 or less	Choose only lean meats; broil, roast, or poach meats; trim away visible fat Limit egg yolks to 4 per week	Provide protein and magnesium
Nuts, seeds, and legumes 1/3 cup or 11/2 oz nuts 2 tbsp peanut butter 2 tbsp or 1/2 oz seeds 1/2 cup cooked legumes	3-4 per week	4-5 per week	1	Any unsalted nuts and seeds Any dried peas and beans (drain and rinse canned varieties)	Provide calories, magnesium, protein, and fiber
Fats and oils 1 tsp soft margarine 1 tsp oil 1 tbsp mayonnaise 2 tbsp salad dressing	2	2-3	3	Soft trans fat-free margarines in tubs or spray form Vegetable oils such as canola, olive, corn, and safflower oils Low-fat mayonnaise Light salad dressing	DASH diet provided 27% of calories from fat including fat in food and fat added to foods.
Sweets and added sugars 1 tbsp sugar 1 tbsp jelly or jam 1/2 cup sorbet and ices	3 or less per week	5 or less per week	Less than 2	Sweets that are low in fat such as sorbets, ices, fruit bars, angel food cake, fig bars, gelatin, hard candy, maple syrup	DASH diet is low in sugar.
Maximum sodium limit	2300 mg/day	2300 mg/day	2300 mg/day
*Source: National Heart, Lung, and Blood Institute. (2015). In brief: Your guide to lowering your blood pressure with DASH*. Available at https://www.nhlbi.nih.gov/files/docs/public/heart/dash_brief.pdf. Accessed on 8/7/16.

A second study, DASH-sodium, was designed to test whether limiting sodium on a DASH diet would yield even better results (Sacks et al., 2001). The results showed the following:

Lowering sodium with either the control diet or DASH diet lowers blood pressure; the lower the sodium intake, the lower the blood pressure.
At each sodium level, blood pressure was lower on the DASH diet than on the control diet.
The greatest reduction in blood pressure occurred at 1500 mg of sodium.
The greatest blood pressure reductions occurred in blacks; middle-aged and older people; and people with hypertension, diabetes, or chronic kidney disease.

Table 20.5 2000-Calorie Dietary Approaches to Stop Hypertension Menus at Two Sodium Levels

2300-mg Sodium Menu	Sodium (mg)	Substitutions to ↓ Sodium to 1500 mg	Sodium (mg)
Breakfast		The same as the 2400-mg sodium menu except
3/4 cup wheat flakes cereal	199	2 cups puffed wheat cereal	1
1 slice whole wheat bread	149		149
1 medium banana	1		1
1 cup nonfat milk	126		126
1 cup orange juice	5		5
1 tsp soft margarine	51	1 tsp soft margarine, unsalted	1
Lunch
Beef sandwich
2 oz ham, low sodium	101	2 oz beef, eye of round	35
1 tbsp Dijon mustard	360	1 tbsp low-fat mayonnaise	101
2 slices cheddar cheese, reduced fat	260	2 slices Swiss cheese, natural	109
1 sesame roll	319		319
1 large leaf romaine lettuce	1		1
2 slices tomato	22		22
1 cup low-fat, low-sodium potato salad	12		12
1 medium orange	0		0
Dinner
3 oz cod with lemon juice	90		90
1/2 cup brown rice	5		5
1/2 cup cooked spinach	88		88
1 small corn bread muffin	363	1 small dinner roll	146
1 tsp soft margarine	51	1 tsp soft margarine, unsalted	1
Snacks
1 cup fruit yogurt, fat free, no added sugar	107		107
1/2 cup dried fruit	6		6
2 large graham cracker rectangles	156		156
1 tbsp peanut butter, reduced fat	101	1 tbsp peanut butter, unsalted	3
Total sodium (mg)	2228		1539

Table 20.5 shows two 2000-calorie DASH menus, one with 2300 mg of sodium and the other at 1500 mg. Given that more than 75% of the sodium in a typical American diet comes from processed foods, it is difficult for people who regularly consume processed, prepackaged, and restaurant foods to lower their sodium intake (Box 20.3). Breads and rolls, cold cuts and cured meats, pizza, soup, sandwiches, and poultry are identified as the top six sources of sodium in a typical American eating pattern (American Heart Association, n.d.). Compliance to a lower sodium intake may improve by gradually lowering intake. Tips to lower sodium intake appear in Box 20.4.

BOX 20.3 The Effect of Food Processing on Sodium Content

Food Groups	Sodium (mg)
Whole and other grains and grain products^*
Cooked cereal, rice, pasta, unsalted, 1/2 cup	0-5
Ready-to-eat cereal, 1 cup	0-360
Bread, 1 slice	110-175
Vegetables
Fresh or frozen, cooked without salt, 1/2 cup	1-70
Canned or frozen with sauce, 1/2 cup	140-460
Tomato juice, canned, 1/2 cup	330
Fruit
Fresh, frozen, canned, 1/2 cup	0-5
Low-fat or fat-free milk and milk products
Milk, 1 cup	107
Yogurt, 1 cup	175
Natural cheeses, 11/2 oz	110-450
Processed cheeses, 2 oz	600
Nuts, seeds, and legumes
Peanuts, salted, 1/2 cup	120
Peanuts, unsalted, 1/2 cup	0-5
Beans, cooked from dried or frozen, without salt, 1/2 cup	0-5
Beans, canned, 1/2 cup	400
Lean meats, fish, and poultry
Fresh meat, fish, poultry, 3 oz	30-90
Tuna canned, water pack, no salt added, 3 oz	35-45
Tuna canned, water pack, 3 oz	230-350
Ham, lean, roasted, 3 oz	1020
Convenience and Fast Foods	Sodium (mg)
1 packet dry onion soup mix	3132
1 tsp salt	2325
1 fast-food single cheeseburger with condiments and bacon	1314
One 6-in, fast-food tuna salad sub	1293
1 large fast-food taco	1233
2 fast-food pancakes with syrup	1104
1 cup canned macaroni and cheese	1061
1 fast-food beef chimichanga	910
^*Whole grains are recommended for most grain servings.

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