Category Archives: salt

Salt Talks Two

The skeptical cardiologist found himself reading a cookbook the other day, something he heretofore had avoided. Cookbooks somehow seem 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).

IMG_6880 copyAfter 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 need 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  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.”

IMG_6874
The skeptical cardiologist’s frittata.

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.

IMG_6876At 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

PS>

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 effects 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.

Salt Loss, Tennis, and The Optimal Sodium Intake

The first day I tried to measure my salt consumption was one of the hottest we have had this summer in St. Louis with the thermometer reaching the high 90s and the heat index well over 100. In the midst of this heat I rode my bike to my local gym, worked out on the elliptical for about 35 minutes then rode home. Although the distance i rode was not far (maybe 3 miles) I was sweating profusely.

This profuse sweating was not the norm for me but it clearly was changing my salt “balance” for the day. The optimal amount of salt to consume may be controversial  but clearly the more you sweat the more salt you should consume to replace the lost sodium.

Even the AHA , which continues to stand by its ultra low 1.5 gram per day salt limit for everyone recognizes this factor and states

“The recommendation for less than 1500 mg/day does not apply to people who lose large amounts of sodium in sweat, such as competitive athletes and workers exposed to extreme heat stress (for example, foundry workers and fire fighters)”

FEDERER ACTION
Roger Federer hits his magnificent one-handed top spin backhand and loses sodium

I was back on my elliptical today (after a bike ride that resulted in no sweating)  and watched the men playing the round of 16 in The US Open Tennis Tournament on the large TV screens conveniently placed to entertain me. Temperatures have been unusually high In NYC this week and the players have been suffering as a result. The men play best of 5 sets and matches routinely last longer than 3 hours played in the heat of the day with full sun exposure.

Scientists have studied professional tennis players and measured their sweat loss to be as high as 2.5 L/ hour while playing singles in hot circumstances. A liter of sweat contains around 920 mg of sodium.

That means these guys are losing 2.3 grams of sodium per hour of tennis played! This happens to be one teaspoon of salt and  equal to the more moderate limit on sodium consumption (compared to the AHA) of the USDA. Clearly, consumption of salt on the order of 8 grams/ day would be needed in these circumstances to maintain salt balance and acceptable sodium levels in the blood.

How much are more normal individuals losing daily and how much does that vary depending on activity, ambient temperature and humidity?

The simple answer has to be that no authority  knows the amount of salt  each individual loses daily. Sweating and salt loss vary widely between individuals and over time in the same individuals.

It is common for my patients to note that during the summer months their blood pressure drops when they spend time gardening or if they have a job that requires heavy exertion in hot conditions. Often a downward adjustment in blood pressure medications is needed to account for this (especially if a diuretic is one of their BP drugs).

These variations in salt loss in the context of large variations in cardiovascular physiology and blood pressure regulation between individuals is further support for abandoning the ultra-low salt limits suggested by the AHA and the USDA.

Moderation may not be best for all things in diet (processed foods and added sugar come to mind) but for salt consumption moderation appears best.

 

 

 

Salt Consumption: Less Is Not Always Better

After a week of trying to track my salt consumption I have learned two things

1. Tracking salt consumption (unless you make  all your meals at home from scratch or buy from fast food restaurants) is very tedious.

2. My salt consumption is low: less than the 1.5 grams per day recommended by the American Heart Association (AHA) every day (unless I attend a Cardinals game)

After reviewing the latest scientific publications on salt, however, I have to think that for most people, it is not worth the effort to  track daily salt consumption.

Yes , this is nutritional heresy and goes against what my patients have been reading from authoritative nutritional sources for decades.

The AHA 1.5 gram/day limit for all Americans comes from a small, short term (4 weeks) study (Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med2001;344:3-10.)

The findings are not applicable to all Americans because more than 50% of participants in the DASH study had hypertension or prehypertension, more than 50% of participants were of African ancestry, potassium intake was markedly lower than in the general U.S. population, the trial involved only 412 persons, and a limited range of sodium intake was studied (1.5 to 3.3 g per day).

I asked most  of my patients this week about their salt consumption. None of them could tell me what their average daily salt consumption was. However, almost to a man (or woman) they told me they had been consciously limiting their consumption of salt because they knew that this was healthy.

Thus, the 35 year old white woman with a blood pressure of 110/50 , palpitations and periodic dizzy spells is following the same recommendations to limit salt consumption as the 70 year old African-American with poorly controlled hypertension.

In the last few years this focus on lower salt consumption has been questioned after close analysis by the Institute of Medicine and the Cochrane Analysis.

Two articles in the prestigious New England journal of Medicine published a few weeks ago have convinced me that most individuals who are following a Mediterranean diet do not need to be concerned about their salt consumption.

Salt and Blood Pressure

In the first PURE study paper,(a prospective cohort study that included 101,945 people from five continents)

very few participants had an estimated sodium intake of less than 2.3 g per day, and almost none had an intake of less than 1.5 g per day. This suggests that, at present, human consumption of extremely low amounts of sodium for prolonged periods is rare.

The PURE Study looked at sodium excretion versus blood pressure and

 found a steep slope for this association among study participants with sodium excretion of more than 5 g per day, a modest association among those with sodium excretion of 3 to 5 g per day, and no significant association among those with sodium excretion of less than 3 g per day.

Salt and Death

The second PURE study paper examined the relationship between sodium excretion (a measure of sodium consumption) and death and cardiovascular events

 

saltvsdeath
As Eric Topol has opined at the heart.org ” In other words, consumption of too little sodium is as harmful as consumption of too much sodium. In fact, the AHA guideline would lead — at least according to this latest research — to about a twofold risk for major adverse events.”

This graph of data from the PURE study  shows that lower levels of sodium excretion , below about 3 grams per day were associated with a higher risk of death.

Starting above about 5 grams per day  the risk of death increased with increasing amounts of sodium excretion.

 

This is quite a shocker for those of us who have assumed for the last 20  years that the less salt we consumed the longer we would live.

 

Potassium Consumption

Drawing less controversy were the findings from these two studies on potassium consumption. Higher levels of potassium consumption were associated with lower blood pressures and lower risk of death. The authors point out that high potassium intake may simply be a marker of healthy dietary patterns that are rich in potassium (e.g., high consumption of fruit and vegetables).

You can read more about these papers, including critical and positive comments at the heart.org here.

My Recommendations on Salt Consumption

Here is what I will be telling my patients about salt after a week of tracking my consumption and reading the relevant scientific literature.

  • 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 effects 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.

Public health experts are always seeking a “one size fits all” message to give the public. In the case of salt consumption, however, the message of less is better does not apply to all.

 

 

Are You Consuming Too Much or Too Little Salt?

He is embarrassed to admit this, but the skeptical cardiologist has no idea how much salt he consumes.

I have never stressed to my patients that they engage in obsessive assessment of their salt consumption. The data that everyone needs to limit salt consumption to , say 1.5 grams/ day, as the AHA recommends are not compelling. If asked, my typical response is to recommend not adding additional table salt from the salt shaker and to avoid processed and fast foods (which apparently accounts for 75% of salt consumed in the US).

I definitely have some patients with hypertension and some with heart failure in whom watching for excessive salt consumption is important. One of my patients with fairly well controlled hypertension called me last week because he was recording blood pressures of 210/120. Before I could add another blood pressure agent he had decided to stop adding the salt to the tomatoes he was eating and over a period of a week the blood pressure came back to normal values. Manyl of my severe  heart failure patients will report weight gain due to ankle swelling after a particularly salty meal.

On the other hand, I have many patients who are symptomatic from low blood pressure. These patients have frequent episodes of dizziness and have been following the recommended low salt diet thinking that this was enhancing their health. When I get them to liberalize salt intake, blood pressures and their symptoms go away.

Recent papers on salt consumption suggest that either too much or too little salt is bad for you and consequently the public must be totally confused on what they should be doing.

Since I have high blood pressure which seems to randomly fluctuate I’ve decided to try to measure exactly how much salt I consume daily. Maybe I am consuming more than 5 grams daily (I think that is too much).

This is not going to be an easy task. If i eat out during this time I’m not sure how I will have any clue what amount of salt is in the meal. If I decided to fry a couple of eggs this morning , I will shake some salt on them from the salt cellar. Is it possible to measure this amount? If I put some cheese on the eggs, will I need to precisely measure the amount of cheese? Looks like there are some free iPhone apps I can utilize to assist me in the process.

To my readers and patients, please join me in this exciting and informative adventure. Over the next week, try to track your daily salt consumption and report the numbers to me. Or do it for one day.  The Great Salt Measurement Challenge is On!