REVIEW ARTICLE

Potential Importance of Low-Sodium Bread

and Breakfast Cereal to a Reduced
Sodium Diet
John T. Daugirdas, MD

Purchasing data suggest that bread and cereal products are responsible for approximately 18% of normal daily un-
restricted sodium intake; this percentage may be substantially higher in subjects attempting to follow a reduced so-
dium diet by avoiding added salt and salty sauces and meats. Substituting with low-sodium bread would be
expected to result in a sodium intake reduction of 0.6 g/day or higher, depending on the amount of bread normally
eaten. Many cold breakfast cereals typically contain 0.2 to 0.3 g of sodium per serving. A number of zero-sodium or
low-sodium cold cereal options are commercially available, and many hot cereals are available in forms that contain
no sodium. Because bread and breakfast cereals are not commonly thought of as being salty foods, substituting
these with low-sodium alternatives might help achieve additional substantial sodium intake reduction without
much disruption of the diet.
Ó 2013 by the National Kidney Foundation, Inc. All rights reserved.

sodium-free or low-sodium alternatives for those

Related Article available online, p. e5
A NUMBER OF renal societies now recom-
mend sodium restriction for patients with
chronic kidney disease (CKD),1 as does the Insti-
tute of Medicine, and the American Heart Associ-
ation now recommends restricting sodium intake
to ,1.5 g/day for all.1 For stage 1 to 4 CKD pa-
tients, Kidney Disease Outcomes Quality Initia-
tive and other guideline bodies currently
recommend limiting daily sodium intake to
,2.4 g/day.2
Given that most sodium consumed is added to
food before purchase,3 a logistics approach to re-
ducing sodium intake should focus on substituting
Department of Medicine, University of Illinois College of Medi-
cine, Chicago, Illinois.
Financial Disclosure: The author declares that there are no relevant
financial interests.
Address correspondence to John T. Daugirdas, MD, Department of
Medicine, University of Illinois College of Medicine, 820 South
Wood Street, Chicago, IL 60612. E-mail: jtdaugir@uic.edu
Ó 2013 by the National Kidney Foundation, Inc. All rights
reserved.
1051-2276/$36.00
http://dx.doi.org/10.1053/j.jrn.2012.03.002
foods responsible for a substantial portion of daily
sodium intake. A recent analysis of food purchas-
ing records in the United Kingdom has identified
the main sources of sodium in purchased foods.
Bread and bakery products accounted for 13% of
the sodium intake, cereal products accounted for
5%, processed meats accounted for 18%, and sau-
ces and spreads accounted for 11%. Herbs, spices,
and salt purchased separately were responsible for
23% of the sodium intake.4 In subjects already lim-
iting the use of added salt, salty spices, and other
commonly accepted sources of high sodium, the
residual impact of sodium from bread and cereal
products would be expected to be substantially
higher. In a study done in Argentina, French
bread, which has a particularly high sodium con-
tent, was found to account for 25% of daily so-
dium consumption.5 Although the role of sauces
and spreads as well as processed meats in terms of
contributing to dietary sodium is well known,
the role of bread and cereal products is less well ap-
preciated. Both bread and cereals have no intrinsic
sodium content, and their salt load is due entirely
to added sodium during preparation or packaging.
Because the sodium is not located on the food sur-
face (e.g., as in the case of snack chips), the sodium

Journal of Renal Nutrition, Vol 23, No 1 (January), 2013: pp 1–3 1

2 DAUGIRDAS
content of bread and cereals can be quite high,
even when a salty taste is not evident.
Breads
Most bread sold in stores or bakeries contains
a sizeable amount of sodium. A report on the so-
dium content of bread products from Australia by
the Gorge Institute for Global Health found that
in 2010, for the 97 bread products surveyed, the
mean sodium content per 100 g was 436 mg.6
The slice weights of bread can vary greatly,
with 20 g to 40 g being a common range.6-9 As-
suming an average slice weight of 30 g and a so-
dium content of 440 mg/100 g, a sandwich
comprising two 30-g slices would contain, on av-
erage, 260 mg of sodium owing to the bread
alone. Bagels and English muffins typically con-
tain about 500 mg of sodium each. The bread
used in fast food restaurants has a similar or higher
amount of sodium. For example, the bread-only
sodium content in a 6-inch sandwich from Sub-
way is 290 mg for the Italian White Bread option
and 490 mg for the bread marked as Italian Herb
and Cheese. The 6-inch Roasted Garlic Bread
choice contains 1260 mg, the ‘‘Wrap’’ has 610
mg, and the ‘‘flatbread’’ contains 450 mg of
sodium.10
How should one define low-sodium bread? US
food labeling laws define low-sodium foods as
those having ,140 mg of sodium per serving
size, and very-low-sodium foods as those having
,35 mg per serving size. The slice weights and
portion sizes of bread vary markedly, ranging
from 60 calories for a piece of thin-sliced bread
to 500 calories for a larger bagel. One way to com-
pare the salt content among different breads is to
look at their sodium-to-calorie ratios. If one com-
putes the sodium-to-calorie ratio for most breads,
the mean value will be in the range of 1.9:1.6-9
Thus, a bread with a low sodium-to-calorie ratio
might be defined as having a sodium-to-calorie ra-
tio of ,1.0, but a stricter definition might be to
use a ratio of ,0.5. Low-sodium bread defined
in this way (sodium-to-calorie ratio: ,0.5) is dif-
ficult to find in common grocery chain stores, and
such bread products may not be offered even in
those grocery chains that specialize in ‘‘healthy’’
or organic foods. In the Chicago area, bread
made from sprouted grains that contains zero so-
dium, baked by the Food for Life Baking Com-
pany (Glendale, CA), is available at several large
grocery store chains. However, this bread does
contain 80 mg of phosphorus per slice and so
may not be appropriate for CKD patients follow-
ing a reduced phosphorous diet (although phos-
phorus absorption from vegetable sources is
relatively low, and the fiber contribution of such
wholegrain or sprouted breads may be important
in maintaining cardiovascular health11). Other
brands of low-sodium bread are available in certain
regional chain stores in the United States and in-
clude FRY’s in southwest United States, The Gi-
ant Store in the Baltimore region (MD), and
Safeway (Mrs. Wright’s low sodium bread).12
Matzohs containing zero sodium are another
widely available form of low-sodium bread. Mat-
zohs typically contain less phosphorus than whole
grain bread, given that they usually are made from
refined flour. Some ‘‘crisp breads,’’ such as
those available under the Kavli brand (Kavli Inter-
national, Bergen, Norway), contain 25 mg of so-
dium per 30-calorie piece, and although their
sodium-to-calorie ratio is .0.5, it is lower than
the usual sodium-to-calorie ratio for most breads.
However, not all crisp breads have such lower so-
dium concentrations. The sodium content of
bread purchased in the bakery section of many
grocery stores often is not specified, and many
types of ‘‘French’’ or ‘‘artisan’’ bread may have so-
dium-to-calorie ratios as high as 4:1. Some of
these artisan breads also have a high slice weight,
and the larger serving size compounds their im-
pact on the total sodium load in the diet.
For patients who like to cook, baking low-so-
dium bread from scratch or using a bread maker
is one way to help control sodium intake and
also may save money, as many of the specialty
lower-sodium breads are relatively expensive. Salt
may slow the rising of the yeast used in many
breads, but recipes for lower-salt bread are avail-
able both on the Internet and in a variety of
low-sodium cookbooks.
Ethnic breads, such as tortillas, taco shells, naan,
and pita bread, usually contain sodium amounts
that are similar to those in conventional bread.
For example, in the Australian databases cited pre-
viously,6,7 where conventional bread sodium con-
tent averaged 440 mg/100 g, Arabic flatbread
(all values per 100 g) had somewhat higher sodium
concentrations at 580 mg, and Indian breads, such
as chapatti, paratha, and puri, all contained ap-
proximately 300 mg of sodium, whereas naan
had somewhat higher content at 460 mg. In
 LOW-SODIUM BREAD AND BREAKFAST CEREAL
contrast, Chinese steamed bread contained only
a negligible amount (13 mg) of sodium.
Bread alternatives such as donuts and muffins
typically have a sodium-to-calorie ratio that may
appear to be relatively low (commonly substan-
tially ,2.0), but this is deceptive because a typical
sweet roll or muffin contains 400 to 600 calories
and thus can easily contain 300 to 600 mg of so-
dium, despite a low sodium-to-calorie ratio. Sim-
ilarly, raisin breads and sweetened bagels can
appear to have lower nominal sodium-to-calorie
ratio, but again, the cause is the increase in calories
from added sugar, fat, and/or dried fruit, rather
than a decrease in sodium content per typical serv-
ing size. A good alternative to pastry and muffins is
to make a ‘‘dessert’’ sandwich using low-sodium
bread topped with unsalted almond or peanut but-
ter and/or marmalade, on top of which one can
add a few walnuts, pecans, or sliced almonds.
Breakfast Cereals
Most dry breakfast cereals contain about 200 mg
of sodium per serving, although this may be as
high as 300 mg (e.g., Kellogg’s Bran Flakes).13
The milk usually provides an additional 65 mg of
sodium. A number of zero-sodium dry breakfast
cereals are available, including shredded wheat
squares, puffed rice, and a one particular cereal
from the Kashi line (‘‘7 Whole Grain Puffs’’).
Dry breakfast cereal packaged by the so-called
health food manufacturers often will contain a sub-
stantial amount of sodium. Hot cereals (grits,
cream of wheat, oatmeal) in their most basic
form contain zero sodium, so substituting cold ce-
real with one of these choices is an easy way to
lower sodium intake. One note of caution: when
some hot cereals are marketed in flavored form
or with added calcium, sometimes a substantial
amount of sodium will have been added as well.
Summary
Although efforts by food manufacturers to re-
duce sodium are ongoing,14 the sodium content
of many foods that are commonly eaten is high,
and bread and breakfast cereals are no exception.
Although zero-sodium cereals are readily available,
low-sodium bread products are difficult to pur-
3
chase in stores. Medical and public health societies
recommending sodium reduction could perform
a useful service to help ensure wider availability
of a variety of low-sodium breads, including eth-
nic varieties such as tortillas, taco shells, pita bread,
and naan.
References
1. Turban S, Miller ER III. Sodium and potassium intake. In:
Daugirdas JT, ed. Handbook of Chronic Kidney Disease Management.
Philadelphia, PA: Lippincott Williams and Wilkins; 2011:70-80.
2. National Kidney Foundation. KDOQI nutrition guidelines.
Am J Kidney Dis. 2000;35(suppl 2):1-141.
3. Mattes RD, Donnelly D. Relative contributions of dietary
sodium sources. J Am Coll Nutr. 1991;10:383-393.
4. Ni Mhurchu C, Capelin C, Dunford EK, Webster JL,
Neal BC, Jebb SA. Sodium content of processed foods in the
United Kingdom: analysis of 44,000 foods purchased by 21,000
households. Am J Clin Nutr. 2011;93:594-600.
5. Ferrante D, Apro N, Ferreira V, et al. Feasibility of salt reduc-
tion in processed foods in Argentina. Rev Panam Salud Publica.
2011;29:69-75.
6. George Institute for Global Health. Sodium content of Aus-
tralian bread products, 2007-2010. Camperdown, New South
Wales, Australia; November 2010. Available at: http://www.awa
sh.org.au/documents/Bread%20report%202010%20FINAL.pdf.
Accessed March 12, 2012.
7. National Food Authority. Nutrient Data Table for Use in
Australia (NUTTAB). Canberra, 2007. Available at: http://
www.foodstandards.gov.au/consumerinformation/ausnut2007/.
Accessed March 11, 2012.
8. Bread Research Institute of Australia. Sydney, New South
Wales, Australia; 1993. Available at: http://ramblingsdc.net/Aus
tralia/Bread.html. Accessed April 25, 2012.
9. Greater Merseyside Food Standards Group. Salt in bread sur-
vey. 2005. Available at: http://www.docstoc.com/docs/
19819863/Salt-in-bread-survey. Accessed March 12, 2012.
10. Subway. U.S. Nutrition Information. April, 2011. Avail-
able at: http://world.subway.com/countries/nutritionfiles/nutri
tionvalues.pdf. Accessed March 12, 2012.
11. Park Y, Subar AF, Hollenbeck A, Schatskin A. Dietary fiber
intake and mortality in the NIH-AARP Diet and Health Study.
Arch Intern Med. 2011;171:1061-1068.
12. Heart Healthy Market Online Store. Big Lake, MN. Avail-
able at: http://healthyheartmarket.com/lowsodiumcheeselowso
diummeatslowsodiumbreads.aspx. Accessed March 12, 2012.
13. Self Nutrition Data. Find foods by nutrient. Available at:
http://nutritiondata.self.com/tools/nutrient-search. Accessed
March 12, 2012.
14. Institute of Medicine Report. Strategies to reduce sodium
intake in the United States. April 20, 2010. Available at: http://
www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-In
take-in-the-United-States.aspx. Accessed March 12, 2012.