pile of salt next to a salt shaker low sodium diet, high sodium

Millions of Americans have heart failure, a condition in which the heart can no longer pump blood efficiently. This is not a heart attack, though once someone has a heart attack, she may be more susceptible to heart failure. Here are just a few people who have died from heart failure: Elizabeth Taylor, Salvador Dali, Danny Thomas, George Carlin and Marlon Brando. One of the most fundamental recommendations for treating this potentially deadly disorder: salt restriction for heart failure. Is it justified?

Doctors Question the Validity of Salt Restriction for Heart Failure

Physicians are admonished to practice “evidence-based medicine.” Most are convinced that they are doing just that. It means that they rely on high-quality research to make decisions about treatment. But something as fundamental as salt restriction for heart failure is surprisingly short on science.

We are always impressed when physicians admit that there is a lack of evidence for a highly recommended practice. A recent review of research on the benefits of this practice revealed surprisingly little evidence to support the recommendation of salt restriction for heart failure (JAMA Internal Medicine, online Nov. 5, 2018).

Out of 2500 studies on heart failure, only 9 were randomized controlled trials looking at how sodium intake affects outcomes. Restricting sodium did not make an obvious difference in heart attacks, strokes or death.

The authors introduce their review this way:

“Despite advances in diagnosis and management, the prevalence of heart failure is increasing. Recent estimates suggest that more than 26 million people are affected worldwide, including inpatients and outpatients…

“Advice to reduce salt intake is recommended in several international cardiovascular guidelines.”

“However, restriction of salt intake has uncertain efficacy. Observational studies have shown potential benefits and harms, whereas some randomized clinical trials (RCTs) have suggested harms. A previous systematic review and meta-analysis concluded that a low-salt diet, compared with normal salt intake, significantly increased morbidity and mortality in individuals with heart failure.”

The authors conclude:

“To our knowledge, this systematic review represents the most up-to-date and comprehensive analysis of current evidence of the effects of reduced salt intake in patients with heart failure. Despite identifying 9 RCTs involving a total of 479 participants, we found no robust high-quality evidence.

“We found no clinically relevant data on whether reduced dietary salt intake affected outcomes such as cardiovascular-associated or all-cause mortality, cardiovascular-associated events, hospitalization, or length of hospital stay.”

What to Make of Salt Restriction for Heart Failure?

For something that is so ingrained in medical practice it is hard to believe that there is inadequate evidence to support the recommendation. It is entirely possible that salt restriction for heart failure makes sense. It is equally possible that it is harmful.

An accompanying editorial in JAMA Internal Medicine notes:

“It is incredulous that in our evidence-based era, we have accepted such a low bar for this particular bedrock recommendation of cardiovascular care.

“…A practical solution might be a shift away from sodium restriction per se and more toward a DASH (Dietary Approaches to Stop Hypertension)-like diet in heart failure.

The physician who wrote the editorial cautions his colleagues:

“Before we persist with unyielding recommendations for aggressive sodium restriction at significant costs for uncertain benefits and unknown harm, do the trials.”

In other words, let’s have some evidence! We could not agree more.

JAMA Internal Medicine, online Nov. 5, 2018

Editorial in JAMA Internal Medicine, online Nov. 5, 2018

Are you surprised that the evidence for salt restriction for heart failure is woefully inadequate? Share your thoughts in the comment section below.

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  1. Phil
    MO
    Reply

    I am wondering if anyone else has experienced anything similar to my experience involving sodium. For nearly a year I had a persistent pain/ache in my left abdomen. I also had terrible fatigue. I was put through every scan available, and none indicated anything wrong. In a routine annual appointment my MD called for standard blood tests which revealed critically low sodium. I had been on a very low sodium diet for decades (I don’t like salty food) so she recommended that I increase my sodium intake. I started salting my morning eggs and taking an electrolyte with 200 mg of sodium (plus other minerals) twice a day. My abdominal pain/ache ceased. Now, when it returns, I take the electrolyte plus two salt tablets and get pain relief in about 45 minutes that lasts for about 8 hours.

    Please, tell me what the relationship is between sodium intake and abdominal pain/ache. I’ve researched the issue online and in an excellent med school library and find nothing.

  2. Kay
    Indianapolis
    Reply

    My husband has congestive heart failure. In 2016 I read a research article published in the Journal of American College of Cardiology titled, “Impact of Dietary Sodium Restriction on Heart Failure Outcomes.” This research concluded that sodium restriction in heart failure patients in the study was associated with significantly higher risk of death or HF hospitalization and a nonsignificant increase in the rate of cardiac death and all-cause mortality. When I asked my husband’s cardiologist about the controversy around sodium restriction and mentioned the article, he defensively stated that “there is no controversy” and recommended a low sodium regime of less than 2000 mg daily for my husband. My husband has chosen to moderate his sodium but not to the level recommended and has done well for the past 3 years.

  3. John
    Croydon, PA
    Reply

    If people adhere to a DASH diet, they would automatically be limiting salt (and increasing potassium). My diet is DASH-like (lots of fruits and vegetables). My blood test shows normal sodium level, and I have normal blood pressure. No need to increase sodium.

  4. Ms. Terry
    Houston
    Reply

    In 1963 When I was about 19 yrs old, they were beginning to say salt was bad for us so I quit using salt. I lived in Oklahoma which is in the “goiter belt” region where there is no iodine in the soil. WHen I was about 23, I developed a low thyroid condition and had to start taking thyroid meds. I did not put that together until a few years ago.

    I started eating iodized salt freely many years ago and I quit taking thyroid meds on my own about 1990 and have not test up as needing them since then.

    I quit feeling guilty about using salt when the studies came out in about 2005 that there was no basis for salt restriction. (If you eat a thing saying “oh, I shouldn’t eat this!” You might as well eat poison. If u are going to eat it, relish it! Enjoy it! Then your body can benefit from it.

    I volunteered as an Ombudsman in 2005 and one of the residents in a nursing home complained to me that they would not let him eat salt!!! He wanted salt!!! I had them go back to his doctor and look at his order again and he removed the restriction!!! Several huge studies had just come out saying there was little medical basis for salt restriction.

    My own suggestion is that you use iodized salt, since you don’t always know where your food is grown. It will say “Iodized” in bold letters on the front of the box.

  5. Bob
    SC
    Reply

    Years ago I contacted NIH regarding the numbers associated with normal versus lower levels of salt and its affect on blood pressure numbers. To my surprise they told me that systolic pressure was only lowered 2 – 6 points which out of a number of 140 or 150 is meaningless. Other studies concluded similar amounts. Then there were statements made on this program that indicated that too much lowering of salt intake could be life threatening because the body needs salt (sodium). And of course there were other trials that concluded that lowering salt intake affects longevity. So why the concern?

  6. Bruce
    Madison Wisconsin
    Reply

    I am incredulous that the editors of the JAMA do not know how to use the word “incredulous.”

  7. Gail
    Mt. Pleasant, SC 29464
    Reply

    I have been reading some functional medicine doctors and nutritionists who differentiate between sodium chloride, I. e. table salt and Celtic and/ or Himalayan sea salt are completely different in that table salt is highly processed and is only composed of sodium and chloride, whereas Celtic sea salt is composed of 82 trace minerals, and Himalayan sea salt is composed of a few less than the Celtic salt. I have been transitioning from Hain iodized sea salt over to Himalayan and Celtic salt, although I don’t know how to get iodine if I use only sea salt. I am on a ketogenic diet which increases one’s need for sodium , so I put electrolytes in the water I drink. I doubt if the studies cited in above articles take into account different types of salt. I would like to hear your opinion on this. I have hypertension, btw but have increased my sodium intake as stated above with no obvious ill effects that I know of.

  8. Cari
    NC
    Reply

    I had been having a frightening arrythmia. My doctor did a metabolic panel, which I requested, and it showed low sodium. I don’t eat fast foods. I am very careful about what I eat. I decided to start salting my food with Himalayan pink salt and my sodium levels went back to normal. The palpitations are much less than they were. I also have a second degree heart block. In my opinion, we need a good balance. My mother, however, had heart failure and she ate a lot of packaged goodies. She had to be put on Lasix, IV in hospital to drain off up to 40 Lbs of water weight. She was eating standard salt and bad foods which necessitated a low sodium diet. I don’t know how things would have turned out for her if she had eaten in a more healthy manner. She died of CHF.

  9. Christine
    Sacramento, CA
    Reply

    When reading this, I thought of Dr. Walter Kempner, founder of the Rice Diet, at Duke University, who cured patients of heart conditions, hypertension, and other conditions with this low salt, low protein, low fat diet. Apparently, he achieved remarkable results, and said that each patient served as his/her own control.

  10. Ron
    Troutville, VA
    Reply

    Doctors do tell you to avoid using salt because of the sodium. But were we live, the grocery stores that we shop at, sell potassium chloride. I’ve asked at two restaurants in the area as to what salt they use. Both said sodium chloride but when they checked, it turned out to be potassium chloride.

    When I told our cardiologist about this he was surprised. Were does the sodium come from that the medical profession tells us to avoid?

  11. DENNIS O'HARA
    North Carolina
    Reply

    Salt, sodium, is the largest element amount in the body. When people talk about high salt and processed foods they are normally talking about high sugar, triglycerides and omega 6 fatty acids which can all be harmful. Magnesium is also very necessary and must be replaced all the time for proper blood pressure and many bodily functions. I have read about people with hyponatremia ending up in ER with seizures etc.

  12. John
    Grapevine, TX
    Reply

    I have never been a salt eater. Had esophageal cancer after treatment and surgery, I crave salt. Haven’t seen any side effects, Blood work is normal. 2 friends that had other types of cancer. I noted that they use lots of salt, even before tasting the food. I don’t understand.

  13. Christine
    Rotherham UK
    Reply

    A few years ago I went on a coach trip down the Rhine.
    Suffice it to say I found the meals so salty compared my usual fare that I was unable to eat them.
    Conclusion – no reports of a large number of Germans dying as a result of this excess. Perhaps limiting ones intake of salt is not as dangerous as some medics would like us to believe.
    Thanks

  14. Berryman
    NC
    Reply

    I believe that, like all minerals, every individual has a salt equilibrium that isn’t obvious through any reliable external indicator, but more accurately determined by the condition of our cells. It is unfortunate that our bodies have no discernable reporting system to warn of too much or too little salt. However, I further believe that, paying close attention to our intake can keep our salt equilibrium in the safe zone.

  15. WILLIAM FLYNN WALLACE
    MS
    Reply

    I read many years ago that only about one out of four people are sensitive to salt – meaning that their blood pressure is affected by salt intake. I have seen nothing since. I have wondered why they couldn’t identify those people who are salt sensitive and recommend restriction only for those people. Or maybe that study wasn’t replicated, or maybe it was ignored, or…………..

  16. Larry
    Orlando, Fl.
    Reply

    Back in 1978 my Aunt was given the firm medical advise to follow a salt free diet due to her suffering with Angina. She held to this diet as strictly as humanly possible. Regrettably, we lost her within a year. She was only sixty-one years old. I questioned this medical advise then and now.

    It appears that Cardiologists are practicing medicine of the past and are desperate to appear to have answers, rather than admit that they either don’t know or refuse to wake up and smell the coffee.

  17. George
    FL
    Reply

    I’ve been diagnosed with Heart Failure With Preserved Ejection Fraction (HFPEF) resulting from surgical scarring to repair an aortic root aneurysm. I limit salt and take a diuretic to reduce fluid volume. As a mechanical engineer, I believe it makes total sense to reduce fluid volume in order to reduce pumping resistance “ load” on a compromised “pump.” However, I very much would like to have statistically relevant data on which to base therapy.

  18. MICHAEL
    Smithfield, NC
    Reply

    I HAVE CONGESTIVE HEART FAILURE, AND I TAKE LASIK AND SPIROLACTINE TO KEEP ME FROM HAVEING TOO MUCH FLUID. IF I TAKE IN MORE THAT 1700 GRAMS OF SALT I CAN FEEL THE BUILD UP IN MY BODY FROM MY LUNGS TO MY TOES. LIMITING MY SALT INTAKE DOES HELP PREVENT ANY PROBLEMS. I HAD A TRIPLE BY PASS 4 YEARS AGO. THANK YOU FOR THE INFORMATION ON SALT. PLEASE KEEP US INFORMED.

  19. Jane T.
    FL
    Reply

    I, and several older friends, have been told after having blood tests, to increase their sodium intake.

  20. Shirley
    FL
    Reply

    I have low sodium. I have to take sodium to keep the numbers up. Been in ER many times. Do you have an answer for low sodium ?

  21. David B.
    KS
    Reply

    When I was diagnosed with heart failure in 2016 I was immediately put on a low salt diet. I was very strict with compliance, and it seemed to make a difference in that I no longer had swelling in my ankles or hands. Now that my heart function, as evidenced by my ejection fraction, is back to normal I still watch sodium intake and have permanently switched my diet away from high sodium canned goods and other processed products, but I’m not nearly as strict as I was at first. When I eat something very high in sodium like pizza, however, my swelling comes back right away. Swelling is the only symptom I had. Prior to my diagnosis I just ignored it or didn’t make a connection with heart function. My theory is that a low salt diet helps mask the symptoms of heart failure so it makes it seem like you’re doing something good for your heart. Whether it actually does anything to affect outcomes is a good question.

  22. Garland
    Columbus NC
    Reply

    When we tried to find low calorie foods, we found high sodium content in all of them. I am using black pepper instead of salt to season my food, since I am “living with heart failure.”

  23. Linda
    Washington
    Reply

    If you Google about the amount of salt in one’s blood, our bodies are quite similar to the ocean.

    Common sense tells me if you restrict a life-sustaining requirement, could that not harm the human body even more????

    Medicine sure has a lot of quirks in which we kill the body with chemo to kill cancer. Coumiden/warfarin, essentially is rat poison and used to thin blood when there are wonderful natural supplements which do the same. My father bled out in the lungs due to Coumadin. Mom was killed off with 34 radiation treatments and chemo in 6 months because of having great medical insurance and physicians telling them in order to live you must….take our poisons. IT IS A CROCK.

    THE EVILS OF BIG PHARMA.

  24. Dagny
    Philadelphia PA
    Reply

    It’s been my impression that one possible reason for having a low blood sodium level is heart failure. This is a concern of mine as I’ve had a low level for the past two years. My doctor has recommended that I salt my food more heavily, and that helps, but this article calls into question how much doctors really know about the effects of salt on the body. Perhaps the reason heart failure patients have a low sodium level is because their doctors have told them to restrict salt! And knowing so little about the effects of salt, how can we know what’s a “normal” level?

    I’m sure that one reason I seem to have a problem with my sodium level is that I buy only organic foods or at least non-GMO foods, and so many of the sellers brag about their products having low to no sodium so it’s difficult to get enough. For now I’m using a special salt that also contains potassium and magnesium in addition to the usual sodium and iodine. As my personal, uneducated theory is that maintaining a balance of vitamins and minerals is what’s most important, and the majority of doctors don’t know much about nutrition.

  25. Dave
    Wake Forest N.C.
    Reply

    I would think that the effect of salt on fluid retention would be enough to limit its use in patients with chf like myself. I know that increased fluid load is a real concern in patients such as myself.

  26. Missy
    Florida
    Reply

    From experience, too much salt causes you to retain extra fluid which causes swelling especially around ankles, which raises blood pressure, and extra fluid can settle around the heart

  27. Deborah
    Norton ma
    Reply

    My personal experience is that salt and sugar are very harmful. These 2 ingredients are packed in most foods sold. Both bring my blood pressure up even on meds.

  28. Laura
    Seattle WA
    Reply

    Here’s my inexpert read on salt restriction: Added salt is present in processed foods and fried foods, both seriously nasty things for cardiovascular health (I’m pretty sure). Plus, added salt encourages consuming larger quantities. That’s why snack foods are heavily salted — so you will eat more.

    Since docs suggesting avoiding all that, they will run into the buzzsaw of the processed food industry, telling patients to reduce salt may be a safer path to the same end. Those practicing overkill and eliminating salt entirely from their diet will kill themselves because salt is a necessary nutrient (I’m pretty sure).

    In the end, I always recommend living with an Italian. We don’t eat most of the stuff that will kill you, and we tend to have a health advantage in cardiovascular health.

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