How Much Salt Should You Consume for Heart Health?

(This article was updated 12/9/2022)

The skeptical cardiologist found himself reading a cookbook the other day, something he heretofore had avoided. Cookbooks somehow seemed archaic and, I presumed, exclusively the domain of the women in my life.

My mother had loads of them, hiding their food-stained bindings behind a cabinet door in my childhood kitchen. Whereas I can stare longingly at all manner of books on bookstore shelves, I scrupulously avoid the cooking section, finding nothing that intrigues or attracts me in their heavily illustrated contents.

The eternal fiancee’ of the skeptical cardiologist (EFOSC), I believe, had requested I find the recipes for several dishes we (more accurately, she) could prepare the next week and had headed off to Whole Foods or Nordstrom Rack or Pier 1 (all of which, strangely and conveniently sit side by side).

After receiving directions on where these mysterious tomes resided, I grabbed the cookbook that looked the most interesting: Ruhlman’s TWENTY: 20 Techniques, 100 Recipes, A Cook’s Manifesto.

Instead of searching for recipes, I ended up being distracted by Chapter 2: Salt: Your Most Important Tool.

In Chapter 2, Ruhlman makes the bold statement that “if you don’t have a preexisting problem with high blood pressure and if you eat natural foods-foods that aren’t heavily processed-you can salt your food to whatever level tastes good to you without worrying about health concerns.”

As I’ve written previously, I agree with him, and a recent article published in The Lancet casts further doubt on recommendations for the general population to limit sodium consumption drastically.

In the Lancet article, the authors did a pooled analysis of four large prospective studies involving 133118 patients in 49 countries. They studied the relationship between salt consumption, measured by 24-hour urine excretion of sodium (because what goes in must come out), and the incidence of cardiovascular disease and death over about 4 years.

The findings:

1. Patients without hypertension who excreted more than 7 grams/day of sodium were no more likely to have cardiovascular disease or death than those excreting  4-5 grams/day.
2. In fact, in both normotensive and hypertensive groups, sodium excretion of < 3 g/day was associated with a significantly (26% higher in normotensives, 34% in hypertensives) increased risk of cardiovascular disease and death.
3. The only group that would appear to benefit from lower sodium consumption was the hypertensive group which excreted 7 g/day of sodium and when compared to the hypertensive group that excreted 4-5 g/day of sodium had a 23% higher risk of CV death and disease.

If we have to worry about anything with salt consumption, this study (and others) suggests that it is consuming too little salt.

The only group that needs worry about too much salt consumption is those who have hypertension and who consume a really large amount of salt.  Since the average American Average consumes 3.4 grams per day of salt, very few of us are consuming over 7 g/day.  

Despite this, The American Heart Association continues to stick by its totally unjustified recommendation that sodium levels be no higher than 1,500 mg/day, and other organizations recommend sodium levels below 2,300 mg/day.

What Kind of Salt Should We Consume

Ruhlman recommends coarse kosher salt, preferably Diamond Crystal or if that’s not available, Morton’s.

Why? Because “salt is best measured with your fingers and eyes, not with measuring spoons.”

“Coarse salt is easier to hold and easier to control than fine salt.”

He feels that salting is an inexact skill and one should always salt to taste.

“When a recipe includes a precise measure of salt, a teaspoon, say, this is only a general reference, or an order of magnitude–a teaspoon, not a tablespoon. You may need to add more. How do you know? Taste the food.”

These words were music to my ears as I am an advocate of serendipity, chaos and creativeness in the kitchen.  When I make a frittata, as I did this morning, I measure nothing precisely; not the butter and olive oil used to sauté, the bell peppers, onions and garlic; not the milk mixed with the eggs; not the cheese sprinkled on top; not the time spent in the oven or even the heat; and most assuredly, not the salt and pepper.

At the end of the frittata creation process I took a bite. It was delicious but it needed something: a touch more salt. I sprinkled some David’s kosher salt on top and tried again, Perfection!

Although I have hypertension, I know (see discussion here) that my salt consumption is way below 7 grams/day and, if anything, based on the most recent studies, I should be worrying about too little sodium in my diet.

Saltatorily yours,

-ACP

N.B. As I outlined in one of my previous posts on salt, here is what I tell my patients:

• Spend a day or two accurately tracking your consumption of salt to educate yourself. I found this app to be really helpful. I’ll expand on this in a future post.
• Recognize that not everybody needs to follow a low-salt diet. If your blood pressure is not elevated and you have no heart failure you don’t need to change your salt consumption.
• If your blood pressure is on the low side and especially if you get periodic dizzy spells, often associated with standing quickly liberalize your salt intake, you will feel better.
• If you have high blood pressure, you are the best judge of how salt affects your blood pressure. In the example I gave in a previous post, my patient realized that all the salt he was sprinkling on his tomatoes was the major factor causing his blood pressure to spike.
• The kidneys do a great job of balancing sodium intake and sodium excretion if they are working normally. If you have kidney dysfunction you will be more sensitive to the effects of salt consumption on your blood pressure and fluid retention.
• If you are following a Mediterranean diet with plenty of fresh fruits and vegetables you are going to be in the ideal range for both potassium and sodium consumption.