The People's Perspective on Medicine

Is a Low Salt Diet Dangerous for Your Health?

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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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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All I can add to the “salt revelation” is that when my Hubby uses table salt, his feet and legs start to swell within the hour. . He has COPD, and has spells where he can’t get off the couch. He dozes off, and I have constant worry. He was scheduled for a series of tests, couldn’t get off the couch to get to the hosp to have the tests done. So they were cancelled. His Physician doesn’t seem very concerned, and I suppose thats because he’s ( hubby) and a smoker. He ‘tries’ and who’s he foolin, He can’t put the smokes down. And that brings on the stigma, that he doesn’t care about himself. And I understand that. But back to the salt. I watch his intake carefully. I read labels. I worked in Food and Nutr. dept for 25, years, so this comes easy to me. Right now, he’s using “potassium chloride” instead of salt. I’d like to know your feelings on this. His feet/leg swelling has changed drastically for the better. He just turned 70 and his weight is 165 and he’s 5’11”.

I think the worst thing about the whole situation is that I’ve never heard a nutritionist or health professional refer to nutrition as a confusing topic, where there can be legitimate disagreements between intelligent people. I’m thoroughly convinced that their ability to convince people they know what they’re talking about is the first thing on their minds. It’s how they make money.

My doctor says, according to my blood tests, I can eat a bit more salt. When I do, my ankles swell something awful. If I lower the salt, they don’t swell. I have a wonderful primary care doctor. He makes the patient a part of the team rather than my other doctors, who are specialists, who assume you are going to do whatever they say.

The nurses are absolutely shocked when I say I don’t want this test today. They say “I’m afraid he is going to have you do it anyway.” I still do as I please. I am over 85 and there is little, if any, research for people our age. The percentage of people still alive is too small to justify the costs of research. I honestly don’t think anyone knows whether I should eat more, or less, salt. I sure don’t know. But I trust my swollen ankles to tell me more than any scale of one size fits all.

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.

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?

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?

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.

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!

” 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.

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.

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.

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.

I almost died two years ago when I had hyponatremia (low sodium in the blood), caused by diuretics prescribed by a new-to-me cardiologist. I had avoided a lot of salt for years, but that wasn’t what caused the hyponatremia. It was the diuretics.

I, like you, suffered memory loss.

Question aout Iodine ontent – Is the salt intake now recommended for salt that contains iodine or does that not matter? Sea salts sold in most natural food stores do not have the iodine content that iodized salts do.
I bought some good old iodized salt and was astonished by the number of additives in it. Probably to keep it flowing smoothly.

This may sound antediluvian, but I think that the more you avoid doctors and their pills, the better. Eat lots of fruits and vegetables, exercise, and minimize continual stress. Get tested * only when facing persistent symptoms. Always avoid taking “the latest thinking” so seriously that you stray from your basic way of living. And know that when you’re about to see a medical specialist that your troubles may only just be beginning.

*Colonoscopy in middle age probably the exception.

I am 85 years old and have a daily average BP reading in the 150’s and 160’s over 80. Diastolic number is steady. However when under intense pressure, BP will run as high as 200/90. My salt count was barely under “Normal”, whatever and for whomever that might be if one size fits all. My doctor says to eat a little more salt. In the past, I have been concentrating on potassium and other minerals. When I up my salt intake, my ankles swell. Which to choose? I don’t believe any doctor knows, especially for the very aged. My BP has been this way for 30-40 years. I take two 10 mg lisinopril daily. I know it is doing daily damage but I also know high blood pressure will also hasten my death. I have gotten to this age by using my own brain. Doctors have hurt more than they have helped, in many ways, though I can’t say they haven’t helped any. I sense that the real clue is my emotional state. I don’t dread dying but I do dread what doctors and other medical personnel will put me through so that I can’t have a peaceful death. I know that medical staff have their own life problems and their need to be successful, but many forget there is a person in that body and they can be downright mean! If I could find more peace, I know my blood pressure would cease to be a major problem.

I was diagnosed with high blood pressure two yrs. ago . I am 59 and just got out of hospital a week ago. My pressure was 232/120. They don’t know why it shot up. As far as I know tests were all good. Stress echo, chest X-ray, blood, they found small kidney stone. They told me to follow a 2 gram sodium diet.

I was so nervous about the pressure when I came home I wasn’t sure what to eat wasn’t hungry and I know my salt intake had to be low was not feeling good. Now I bought the dash cookbook and following that. I’m worried about the sodium bc I had leg cramps. My sodium by me counting is around 1200 – 1500 for the last five days. Confused by book bc she adds salt and I don’t. Many thanks for ur help.

I am on a salt free diet, could that cause bad leg cramps?
I am taking Tamoxifen and Quinine for leg cramps.
still getting bad cramps

Yes leg cramps are a sign of dehydration and salt is needed to retain water in cells

Tamoxifen gave my sister breast cancer. My sister and I were in a Breast Cancer trial, because my Mom and my sister had had breast cancer in their mid 40’s. The trial was for us to take Tamoxifen to keep from getting breast cancer. I chickened out, didn’t take any. My sister took it, and two years later had breast cancer in the other breast. Instead of taking HRT after menopause, I used Progesterone cream twice a day, rubbing about 1/8 to 1/4 teas. of cream on my chest or tummy, or thighs. I started on it at age 52, I’m now 70, and still healthy.

I use Himalayan Pink Salt. It contains a variety of minerals along with iodine and tastes much better.

I use the same salt as well. What most consumers don’t realize is that plain table salt has no nutritional benefits. This salt has been chemically processed, thus what mineral properties were in it prior, are stripped out. Table salt today is even more of a naked ingredient than many years ago. Throw in the mix of prescription drugs and that is another can of worms.

Respuesta a Americo:
bicarbonate de sodio. on google.
mi Espanol is malo. lo siento.
mucho information on google.
good luck,
michael

Of course, those of us who suffer from Ortho Static Hypotension know that salt is needed to keep from keeling over.
That’s the advise I received from my DR. cardiologist from up north. Instead of medication, he said take a little more salt.
Worked well!!!

My ankles swell when I add salt to my food. They do not when I leave it off, so I eat very little salt. Sometimes my lab work shows low sodium, sometimes high. I have no idea the best plan is for me.
People’s Pharmacy response: Since your ankles swell, it seems that avoiding salt is best for you.

Have you ever considered that you may be suffering from congestive heart failure!

Too little salt can kill you. That was why GatorAde was invented. On the other side, I have seen no studies defining a maximum salt intake. I would rather err on the side of staying alive, so I use quite a bit if salt. Your body will tell you if you are taking in too much, but I suspect that the spread between too little and too much is much, much wider than the “experts” say.

Once again, we’re seeing unsound medical advice based on non existent comprehensive studies being deflated. This keeps happening… old incomplete and poorly formatted studies are used far too often as a basis of medical and dietary advice. How many more of these do we need to read about before we apply some common sense?
Extreme dietary changes don’t save lives.
I abide by the wonderful precept… “Moderation in all things”.

Do you actually feel that double blind studies done by pharmaceutical companies are actually concerned about your health!

MIMIB summed it up for me: Moderation in all things! Also, we know that a lot of salt is added to processed foods, so one way to be at a moderate level is to stick to fresh, whole foods when possible and add a reasonable amount of salt yourself.

This from the CDC: “You hyave high blood pressure”
I find it difficult to trust sites that have typos in their pronouncements.

I am a healthy person and do a lot of hiking. I was hiking in hot weather and got dizzy when bending over. I had a feeling that I needed salt. Adding salt corrected the dizziness.

My blood pressure rises when I eat salt. I need no study that tells me otherwise. I’ve proved it over and over. I take my blood pressure daily. When I’ve had salt or caffeine it rises.

Yes caffeine raises your blood pressure because it triggers your adrenal cortex

I am not a doctor. Read the package label. My box says that 1/8th teaspoon contains 150 mg of sodium (salt) which is very small. But, do read the rest of the labels and warnings on the box. There are important warnings about when and how to use sodium bicarbonate.
Why are you taking this? For indigestion? You might consider a) losing weight, and b) identifying the foods which cause indigestion–too much fat, chocolate, alcohol, spicy foods. And try sleeping with your head raised slightly.

At 72 I have been on reduced salt intake for many years. I recently read on People’s Pharmacy that salt reduction could result in iodine deficiency. I decided on my own to purchase 400 mcg kelp capsules. I also read the precautions about overdosing on kelp. The first day I took a kelp capsule, I had the sensation of occasional tiny pin pricks in the region of my thyroid. I have not had any similar sensations since that time. I now take a kelp tablet once a week. I think that I really was deficient in iodine and thanks to information on People’s Pharmacy, I now have more energy and feel much better.

Many years ago, my sodium and potassium levels went so low, I nearly died. I have to get my levels checked and my sodium and chloride numbers are usually quite low. I’ve been told by doctors to add more salt to my diet, even though it would be adequate for most people. I have relatives who also need more salt in their diets. So, don’t guess. Get the blood tests so you know if you are getting enough sodium.

What about the source of salt? Is sea salt more nutritious than standard white salt??

Unrefined sea salts (Celtic sea salt, himalayan pink salt, etc. ) do not have the other minerals removed.

I believe that the day will come when our ‘one size fits all’ approach will disappear, and individuals will receive dietary advice based on genetic makeup. Until then, moderation in all things, and if salt restriction hasn’t significantly lowered your blood pressure, then stop restricting it!

Pat wrote, “There is so much salt in processed food that it is hard to avoid.”
It’s not the salt you should be worried about. It’s the processed food!!!

I have mild high blood pressure and take a very small dose of medicine for it. At home I do not add salt to foods and do not eat salty foods like potato chips, fries etc. My blood pressure rises significantly when I eat out and have some of these foods.

High salt intake is harmful and raises bp, I know because I´ve tried. But I don´t consider a salt intake under 3000mg being high. So an intake below that is not needed for having good results on bp.
But most people eat maybe 4000-6000 mg/day and then it´s harmful. So yes, limit your salt intake if you eat as mauch as that.

My last few lab tests have shown me to be low in electrolytes and I have severe leg cramps at night. One of the things that helps is consuming 12 green olives (high in salt) right before I go to bed.
Sodium is one of the electrolytes necessary for good health. And, yes, I’ve tried the soap under the sheets and it didn’t help.

I know from personal experiences with my mother-in-law that not eating enough salt has adverse affects.
A couple of years ago, when she was 80, she had a bad bout with feeling weak, having dizzy spells and who knows what else. We took her to the doctor and they found that her sodium levels were very low.
That was the only new symptom that showed up. She takes synthroid daily along with a blood pressure med and cholesterol meds. She also takes 1/2 of a 5mg Xanax, not sure how many times a day.
The doctor told her to start adding salt to everything she eats. Well, she probably goes a little overboard, but she has not had any of the above issues for a little more than 2 years.
Now she is a healthy, active 82 year old.

That’s a lot of Xanax for an 80 year old!! I am 58 and take 1mg at bedtime!!

I don’t know how lower sodium is affecting my blood glucose level but I do know that by keeping it lower I have less swelling in my body, especially my legs and feet. Also, I breath better so somehow high sodium affects my lung function.

The Weston A. Price Foundation has a good article regarding salt. http://www.westonaprice.org/
Mary Enig, one of their founders, was the woman who exposed the dangers of trans fats and told us that saturated fats are good for us. I trust them but I do not trust the AHA or the AMA or the ADA.
My husband has always eaten a LOT more salt than I have, and unlike me he never had thyroid issues or high BP. Now that I eat more salt, I am doing better as well.

I was damaged by ibuprofen when it was first introduced; it was a prescription for a large biopsy: 400 mg 4 X day.
As a result I was on medication for many years for kidney damage.
My sodium intake is less than 500 mg/day and I’m healthy as a “horse” at 72.
P.S. My thyroid was removed many years ago for Hashimoto’s Disease–an auto-immune disorder where one’s thyroid “eats” itself. For that I take Levothyroxine 150 mcg/day.

This reminds me that Gary Taubes (who has been on your program in the past year on another topic) wrote an article in the 1990’s that reviewed the research on the hazards of salt intake and concluded that the science did not support restricting salt in one’s diet as was being recommended by the authorities at the time – and apparently still is.

My English is not good, I write from Peru. My question is : I have high blood pressure Can I intake bicarbonate of Sodium?
thanks to Joe and Terry Graedon
People’s Pharmacy response: Bicarbonate of sodium is not recommended for people with high blood pressure. Carbonate of calcium would be preferred for occasional heartburn.

I feel much better the less salt I consume. I don’t have that “puffy” feeling in my face, hands, or feet. I do not add salt to any food I prepare. There is so much salt in processed food that it is hard to avoid. My BP is good. I’m not going to start salting my food as a result of the findings in this article, but I’m not going to stress about the use of salt either.

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