pile of salt next to a salt shaker low sodium diet

Warning: prepare for whiplash! We know that for the last 50 years you have heard a constant drum beat from public health officials, cardiologists, nutritionists and most other health professionals to lower your salt intake! It is hard to wrap your head around a different message, so please brace yourself.

In a the journal, JAMA Internal Medicine (online, October 28, 2013), an important article was published titled:

“The Institute of Medicine [IOM] Report Sodium Intake in Populations: Assessment of Evidence

Summary of Primary Findings and Implications for Clinicians”

What Did the Study Find?

People with diabetes, high blood pressure, kidney disease or cardiovascular disease may not achieve benefit and may actually experience harm at these reduced levels. There are no data showing that lowering sodium below 1,500 mg (a quarter teaspoon daily) is helpful. People with congestive heart failure may be harmed when sodium consumption drops below 2,300 mg daily.

Did the Experts Get Their Advice Exactly Wrong?

Yikes! It is precisely these high-risk patients who have been told for decades that they must lower their salt intake dramatically to be healthy. Now the IOM is saying that this advice to follow a low salt diet might have been wrong.

The Institute of Medicine represents the best and the brightest in American medicine. These experts are considered the final authority on most medical issues. Although they do suggest that a high-sodium diet is common in the U.S. and that we should try to moderate our salt intake, they also urge caution about the guidelines set by public health organizations to get sodium intake below 1500 mg daily.

Okay, that’s just the first article that challenges standard wisdom and policy. Here’s the knock-out punch. The November 2013 issue of The American Journal of Medicine has a review article titled: “Dietary Sodium Restriction: Take It with a Grain of Salt.”

Strap on your seatbelt. These experts have reviewed the research on sodium and they are far more outspoken than the Institute of Medicine. They contradict the American Heart Association’s goal to achieve “Ideal Cardiovascular Health” by lowering dietary sodium to 1500 mg per day.  Here are some selected quotes:

Low Sodium Intake and Blood Pressure:

“Although there are reasonable data to support that sodium restriction lowers blood pressure, the effects may be transient and inconsistent, with some individuals even having paradoxical increases in blood pressure. The degree of blood pressure lowering on average might be clinically trivial, approximately 2 mm Hg in normotensive individuals and approximately 4 mm Hg in hypertensive individuals. Finally, sodium restriction also has the adverse effects of activating the renin-angiotensin-aldosterone system, increasing catecholamines, and adversely affecting insulin and lipids.”

What that means in plain English is that restricting sodium does not make a meaningful difference in blood pressure reduction and may lead to a stressful physiological reaction. Adrenaline (epinephrine) goes up along with insulin (not a good thing). Increases in lipid levels mean that your cholesterol levels could climb (also not a good thing).

But wait, it gets even more confusing. Here again are selected quotes from The American Journal of Medicine article about “Dietary Sodium Restriction: Take It with a Grain of Salt”:

Low Sodium Intake and Type 2 Diabetes:

These reviewers point out that people with type 2 diabetes who cut way back on salt may have a higher death rate from cardiovascular causes compared to diabetics who consume a normal level of salt. Even more heretical was their analysis of the data on heart failure:

Low Sodium Intake and Systolic Heart Failure:

“The low sodium diet caused increased mortality and heart failure hospitalizations versus normal sodium diet in patients with systolic heart failure. These results have been verified across multiple randomized, controlled trials in patients with systolic heart failure.”

Low Sodium Intake and Thyroid Function:

“A major source of dietary iodine is through salt. Therefore, a low sodium diet could lead to worsening of thyroid diseases.”

And for the grand finale, their summary:

Conclusions:

There is no conclusive evidence that a low sodium diet reduces cardiovascular events in normotensive and pre-hypertensive or hypertensive individuals. On the contrary, there is sound evidence that a low sodium diet leads to a worse cardiovascular prognosis in patients with systolic congestive heart failure or type 2 diabetes mellitus. Worldwide sodium restriction, through its adverse effects on insulin resistance, may lead to an increase in the rates of type 2 diabetes mellitus…Advising low sodium diets seems misguided and potentially dangerous and illustrates the problem of guidelines based on flawed studies using surrogate measures.”

Wow and WOW! What are we to make of this turn around? For starters, your health professional has probably not read the IOM report or this article in The American Journal of Medicine. The CDC and the American Heart Association are still aiming for less than 1,500 mg of sodium a day. Here is what the premier public health organization (the Centers for Disease Control and Prevention” says on its website:

…”If you are in the following population groups, you should consume no more than 1,500 mg of sodium per day…

  • You are 51 years of age or older
  • You are African American
  • You have high blood pressure
  • You have diabetes
  • You have chronic kidney disease

The 1,500 mg recommendation applies to about half of the U.S. population overall and the majority of adults. Nearly everyone benefits from reduced sodium consumption.”

How do you cope with these completely contradictory messages? We have to wonder whether our public health officials are even bothering to read the medical literature. What do you think? Please share your experience and your thoughts on this complicated and confusing issue below.

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  1. Bev
    Denton, Texas
    Reply

    I think the person who said that we are coming to the point where “one size fits all” medical advice is no longer the best way made the most sense. We are all different, even within so-called “racial” categories, especially in the US, where the vast majority of blacks are a mix of European, Native American, and African stock.

  2. Cecile
    Colorado
    Reply

    While the IOM study on sodium is fascinating, the article would have been much more valuable if it suggested appropriate amounts of daily sodium intake. If 1500 mg daily is too low, what is appropriate? What is a “normal level” of salt?

  3. BobK
    Bluffton, SC
    Reply

    The original data suggested a lowering of 2mm to 6mm Hg when on a low salt diet. This out of say a typical pre-hypertensive number of 150mm to me is insignificant and is puzzling as to why such an alarm was rung regarding salt? Why did everyone jump on the low salt bandwagon given these low numbers?

  4. Lou G
    San Antonio
    Reply

    Many years ago when I was diagnosed with high blood pressure (HBP), I was told to cut my intake of salt, which I enjoy very much. So slowly I did, and about 2 years ago, my blood tests kept showing my sodium level was low. So I was told to increase sodium and my primary care doctor changed my blood pressure (BP) medication to Losartan instead of Lisinopril as supposedly Lisinopril lowers sodium levels.

    I was on a low dose (81 MG) aspirin for many years, then a month ago an EKG showed I had Atrial Fibrillation (AFIB). So my aspirin was increased to 325 MG. After a 24 hour heart monitor test and then an echo cardiogram, it was confirmed I definitely have AFIB.

    At first, the cardiologist was going to change my BP medication to metropolol, a beta blocker, I believe. But I had a bad experience with metropolol 3 1/2 years ago prior to having spine surgery. Because I was in so much pain, my BP was in the 150’s – 160’s so my primary care doctor put me on metropolol as a test for 2 weeks, and she warned it can cause severe dizziness. It did, and except for days when I had an appointment, I tried it and it kept me so dizzy all day long, after 2 weeks, I told her I would no longer take it.

    I related this to the cardiologist and she decided to leave me as is except change my aspirin to 2 – 81 MG (162 MG) a day. Nothing was mentioned about sodium. So when I received today’s People’s Pharmacy newsletter, it was interesting that the second article is about HBP and it mentions a low sodium diet, and this article indicates perhaps it’s not such a good idea. So folks like me are in a quandary, more salt or less? I’ll listen to my doctors, and hope for the best.

  5. rick
    Reply

    With out salt dehydration becomes a reality and I would much sooner by hydrated as this effects every cell in your body. When I swim is the ocean my pain goes away when I swim in the lake its just not the same!

  6. megb
    charlotte nc
    Reply

    ” We have to wonder whether our public health officials are even bothering to read the medical literature.” This includes your site where a few articles above you suggest a low salt DASH diet to treat hypertension.

  7. Sue
    Bel Air, MD
    Reply

    I’ve been on somewhat lower sodium for many years, primarily for blood pressure (and my parents’ blood pressure, when they were restricting it and I ate with them). That is, I buy lower sodium chips, soups, etc., when I can; I skip high-sodium items when I can if I think to look at the label; I hardly ever add salt when I’m cooking or at table. I think I still get plenty of salt. The main thing about continuing these practices is that I no longer crave the saltiest versions, in fact they often taste way too salty to me. I’d rather add extra herbs & spices, vinegar, ginger, etc. Don’t think this new info will change my practices, although I’ll probably no longer worry about salt that much.

  8. J. David Auner
    Springfield, MO, USA
    Reply

    People eating 6 to 10 grams of sodium should cut back. Few people are harmed by 3 to 4 grams of sodium a day. An office worker in air conditioning will not need as much salt as a manual laborer or a worker in the heat – lot of salt lost in that sweat.

  9. Liz
    Raleigh, NC
    Reply

    BEWARE IF YOU TAKE DIURETICS. On October 29, 2014, I was in my neighbor’s yard around dusk to check on his cat and fell on something and hit my head, ending up in the trauma intensive care unit for four days with four staples in my head to close the cut. I have limited memory before I fell and no memory at all for about three days while in the hospital. The diagnosis: low sodium–mine was 116, the normal range being 136-145. I had no noticeable signs before I fell that anything was wrong.

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