The People's Perspective on Medicine

People with Heart Failure Suffer on Low Sodium Diet

A new study shows that heart failure patients following a low sodium diet are more likely to die or be hospitalized than those on regular fare.
Low sodium diet

Should you eat less salt? Public health authorities generally include cutting back on sodium as one of the important dietary steps we can all take for good health.

The American Heart Association has just issued a short checklist of health habits it calls Life’s Simple 7. People who follow all 7 of the suggestions are supposed to be less likely to develop heart failure. The recommendations are based on data collected on people in the Framingham Offspring Study over a 12-year period, and sound a lot like common sense: don’t smoke, lose weight, manage blood pressure, control cholesterol, exercise, eat right and control blood sugar. It is only when you delve into the “eat right” recommendations that a low sodium diet surfaces as a recommendation.

Study Data Contradict Recommendations for a Low Sodium Diet:

Despite the organization’s emphasis on keeping sodium under 1,500 mg/day to avoid heart failure, a new study suggests that people who already have heart failure are at greater risk of hospitalization or death if they restrict sodium intake to less than 2,500 mg/day. The study included 833 people with heart failure; out of these individuals, 145 were on a restricted sodium diet.

What the Data Show:

The statistics show that 42 percent of those keeping their sodium intake low died or were hospitalized with heart failure complications. Among those not restricting sodium, 26 percent suffered that fate.

The scientists urge their colleagues to conduct a randomized controlled trial of sodium restriction in heart failure to determine if this apparently paradoxical finding holds up.

JACC:Heart Failure, Jan., 2016

Not the First Time a Low Sodium Diet Has Been Questioned:

We recognize that the standard of care for patients with congestive heart failure is a low-sodium diet. It is an absolute article of faith that most physicians adhere to and cardiologists preach.

Guidelines from the American Heart Association, the American College of Cardiology, the CDC and the World Health Organization all recommend a low-salt diet, especially for patients with congestive heart failure

The new study in JACC Heart Failure is not the first time that we have heard that a very low sodium diet might pose problems for people in general and heart failure patients in particular.

Here are just a few observations from the medical literature:

Current Opinion in Cardiology (online, Nov. 20, 2015):

“There has been an increasing body of evidence on the effects of sodium restriction in heart failure; however, both observational and experimental studies have shown mixed results. Recent randomized controlled trial data has even suggested that sodium restriction may have detrimental effects in patients with heart failure.”

Journal of Cardiac Failure (Dec., 2015):

“Although clinical practice guidelines support a low-sodium diet and fluid restriction, research findings have revealed that a low-sodium diet may be harmful.”

The Institute of Medicine (IOM) has the most prestigious group of health experts anywhere in the world. In May 2013 the IOM issued an “Assessment of Evidence” with regard to sodium intake. Here are a couple of key observations:

“For population subgroups, some studies indicate that low sodium intake may lead to greater risk of adverse health effects in patients who have a diagnosis of moderate or severe congestive heart failure and are receiving certain aggressive therapeutic treatments. The committee found no evidence for benefit and some evidence suggesting risk of adverse health outcomes associated with sodium intake levels in ranges approximately 1,500 to 2,300 mg/day among those with diabetes, kidney disease, or CVD [cardiovascular disease]…”

By the way, the recommendation by the American Heart Association is for all Americans to keep sodium intake below 1500 mg daily.

The American Journal of Medicine (Nov., 2013):

“…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…Advising low sodium diets seems misguided and potentially dangerous and illustrates the problem of guidelines based on flawed studies using surrogate measures.”

What Should We Do?

No one with congestive heart failure should change his dietary sodium intake without first discussing the latest research with a cardiologist. Heart failure is such a serious condition that it requires constant and careful medical supervision. Changing dietary habits suddenly could lead to disaster!

Physicians should keep up with the latest evidence with regard to sodium and health. Just because a guideline suggests that everyone must keep sodium intake below 1500 mg a day does not make it the best advice for everyone.

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    About the Author
    Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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    This article (& its study data) is confusing.
    I was diagnosed with HF a year ago; cardiomyopathy to be exact and was hospitalized a week to get stable. The cause? Delayed effects of a known chemo that can be toxic to the heart used for treatment of breast cancer 20 years earlier. I am following with diligence the low sodium (1400 mg or less) recommendation daily. I must weigh myself every day (MD order). If I accidentally ingest much more than that, I gain weight, although fluid buildup not readily evident & I remain asymptomatic. If the weight gain is over 3 pounds I have to take a diuretic. It can take days to get back to the pre-fluid weight. Because my body appears to be so sensitive to sodium, I would question if sodium in my diet can be increased? Living on a low sodium diet remains very inconvenient, at best. I am determined not to be admitted into the hospital again so I work hard to take of my body, now 73. I remain active & “look healthy”. I also remain confused by this whole disease.

    My previous note is not about sodium, I realize but is regarding hydration. I really need some advice/feedback.

    Thank you for the sodium information. I do not have heart issues as yet. I am 77 years old, and my doctor says my heart is doing well.

    But my question on sodium and potassium and phosphorous is very important as I have been diagnosed with Chronic Kidney Disease (CKD), stage 3. I am still looking for recipes and menus that I can incorporate. I have been losing weight. I was at 106, and I am down to 99. I have a small frame and am 5 feet tall. I need help to plan my meals. I try using only fresh fruits and veggies and, if I use can, I rinse and rinse and rinse before I eat them. So, any help will be greatly appreciated. I went to the library and was unable to locate any information on Kidney disease. Why is that? Our kidneys are essential to our body. Thank you.

    I have for several years question the advisability of low sodium diets for all, especially the elderly. Both of my parents, and my father-in-law, have been rushed to the emergency room and hospitalized, only to find that their sodium level was dangerously low. More research is certainly needed in this area and if, as I suspect, sodium restriction is found to be unnecessary or actually dangerous for a large portion of the population, new guidelines should be widely disseminated to cardiologists, primary care physicians, and the public.

    The problem with this article is that it does not take into consideration who their reader or audience might be and the fact that if too much salt was a major contributing factor to the persons heart disease then that would change the stats of the article.

    If an older person who is restricting the level of salt they are taking, and I don’t mean eliminating salt all together, but simply watching that they don’t over do it, this person might interpret this article as saying that it is healthier or ok to have whatever level of salt they might normally have if they were not watching it. We are the fool if we assume that on a normal basis people, especially older people are actually watching what they eat and the levels of things like salt.

    Articles such as these are irresponsible and should not be published or distributed without taking all things into consideration, including the misinterpretation by the older generation. Since this website filters comments it is doubtful that this comment will ever been seen by the readers but let’s see how honest the writers and owners of this website are.


    We try to give our readers accurate information. We report what the medical literature reveals. In this article we focused on the latest data regarding a low-sodium diet as proposed by the American Heart Association (less than 1500 mg of sodium daily).

    We never advocate a high-sodium diet and you will see no reference in this article to the idea that people should pig out on pretzels, pickles or potato chips. What comes as a shock to many health professionals is the idea that low-sodium diets could be counterproductive for many people. We felt that information deserved airing, since it is rarely, if ever, mentioned by public health authorities.

    If you read the last paragraph you would have noted this:

    “No one with congestive heart failure should change his dietary sodium intake without first discussing the latest research with a cardiologist. Heart failure is such a serious condition that it requires constant and careful medical supervision. Changing dietary habits suddenly could lead to disaster!”

    We are sorry that you have such little faith in visitors to this website. We think that our visitors are capable of reading and understanding medical research and discussing new findings with their health professionals.

    While not in the position to see long term effects, it is not at all unusual to see wonderfully compliant (with low sodium diets) people come into the ED with neurological changes, with their families worried about a stroke, and are found to have low sodium. These people are almost always admitted to follow their sodium/neurological recovery.

    This is such a waste of healthcare resources; and wasteful of patients time and money. More critically, if following MD orders leads a person to getting hospitalized, he or she will be likely to question or even become noncompliant with other orders eg. “Do I really need this Coreg?”.

    My father, had congestive heart failure for some years before his death and he was in a nursing home for skilled care during the last two years of his life. I was very surprised when he told me that he was restricted to one quart of water per day because of his heart condition. When I spoke with the nursing staff about it, because he liked to drink water without restriction, and I had always heard the advice of drinking a minimum quantity of water around 6 to 8 glasses, I was told that it was processing this amount was hard on his heart.

    Does anyone have more information on whether drinking more water than he was allowed has a good or adverse effect?

    Your article simply enhances the ambivalence surrounding dietary recommendations in general and in particular as respects sodium intake. No trial can take into consideration the complete health profile of the individual participant and the variables so introduced. The best advice, baring specific individual conta-indications, still seems to be moderation in all things.

    My husband had several serious health problems in the years before he passed away Every nurse & Doctor kept telling us that he needs more hydration. Being dehydrated is serious for many diseases which is why the first thing they do when we went hospital was start hydration. I have been clearly shown that drinking enough water makes a huge difference. ,,he just hated water & refused to drink much. So he just got worse. From those experiences I will keep Hydration tops on my list of health necessities

    For years I have followed with interest the research and suggestions for recommended amounts of sodium. The final statement in this article seems wise. Sodium like most other recommendations needs to be individualized. That, of course, is not easy for a doctor.

    Personally, I so far have no diagnosis of congestive heart failure which my father died from. However, swelling of my ankles and now my lower legs is a progressive issue. Sodium has a huge impact for me as does sitting. Beyond restricted sodium the most helpful thing I have discovered is spending more time (8 hours or more per 24) staying in bed or prone. I have a concern about my low sodium diet. So far doctors have had little advice.

    I thought that it is now well recognized that it is NOT the high cholesterol that is the root cause of heart vessels narrowing but their inflammation. If there is inflammation in the heart’s arteries then it is said that it is body’s natural reaction to send cholesterol coursing through the arteries to cover the inflammation for soothing it. If the cause of inflammation is not removed then the cycle repeats itself until the arteries narrow dangerously. So attack the root cause and not something which is indispensable for the life of each cell of our body –cholesterol–and which it makes in abundance for that very reason.

    Why in heaven’s name is AHA still emphasizing the control of cholesterol and not inflammation? What AHA emphasizes the world’s allopaths blindly follow.
    Is it because of the pressure from Big Pharma for indirectly supporting statins or is the ghost of Ancel Keys after them?
    Is my understanding of the actual problem correct or not? I should be grateful if Terry or any other knowledgeable person can provide the answer.

    Perhaps it is the ghost of Ancel Keys. His concepts have had an extraordinarily strong effect on medicine.
    Your grasp of the problem corresponds pretty well with our understanding.

    I have been on salt restriction for 50 years due to problem of edema in feet, ankles and legs. Now at 70 years old I have edema if I eat out at restaurants too often. Makes traveling difficult. Now what?

    * Be nice, and don't over share. View comment policy^