You're Probably Not Eating Enough SALT

"Salt is good." ~Jesus, Mark 9:50 & Luke 14:34


Salt. Cholesterol. Saturated Fat. You may think these 3 comprise a sort of unholy nutritional trinity- 3 devilish dietary delights that should be cast out at every opportunity. But is that the truth? And is that what the solid science actually says?


I wrote about cholesterol and saturated fat in my first two books, and I'll try to do an article on each of those two soon, but today I want to take a closer look at salt and see if the low-salt-diet-is-best-for-health adage the U.S. government health agencies have been pushing since 1977 actually holds up under scrutiny.


Disclaimer- the information below is ESPECIALLY important for people with...

* Low energy and/or adrenal issues

* Digestive problems

* Diabetes, blood sugar or insulin issues

* Swelling/edema/water retention

* Hypertension or cardiovascular disease

* Nervous system issues or

* Kidney problems (including kidney stones or CKD)


MORE SUFFER FROM HYPONATREMIA (LOW BLOOD SODIUM LEVELS) THAN HYPERNATREMIA (HIGH BLOOD SODIUM LEVELS)

Despite the common narrative from government health organizations (I'm looking at you W.H.O., U.S.D.A. and others), there's plenty of data showing salt DEFICIENCY to be a much more common (and devastating) occurrence than overconsumption. Studies have found that hyponatremia (low sodium levels in the blood) is much more common than hypernatremia (high blood serum sodium levels), and even in the majority of hypernatremia cases, the condition is rarely caused by excessive sodium intake. Hmm... [1]


SO WHAT EXACTLY IS SALT, AND WHAT DOES IT DO IN MY BODY?

Salt is made up of two essential major minerals- sodium (which makes up 40% of salt) and chloride (which makes up 60% of salt). Both sodium and chloride are also electrolytes, and because they can carry an electric charge when present in the blood, both nutrients play a central role in the regulation of nerve and muscle functioning.


Salt often gets a bad rap when it comes to health, in part because consumption of significant amounts of sodium can -- under certain circumstances -- contribute to elevated blood pressure and/or swelling in the extremities (e.g. edema).


IS IT A TOO-MUCH-SODIUM PROBLEM OR IS IT

A KIDNEY-AND-NUTRIENT-DEFICIENCY PROBLEM?

However, salt intake driving up blood pressure (and/or causing fluid retention) is often more a consequence of under-functioning or damaged kidneys, which play a central role in regulating the volume and electrolyte composition of body fluids, combined with deficiencies in other major minerals such as potassium (and to a lesser degree, magnesium).


If that IS the case (which is the case I'm going to make), then we probably first need to learn a little about kidney disease...



An estimated 15% of adults in the U.S. have Chronic Kidney Disease, and 9 out of 10 of those with CKD don’t know they have it. Clearly, the U.S. is dealing with a bit of a kidney disease epidemic, and judging by the data we are most certainly trending in the wrong direction. But what's causing all of this kidney dysfunction and damage? [2]



As you can (hopefully) see from the above image, the prevalence of kidney issues in the U.S. is in large part the result of a "perfect storm" of factors that includes kidney-damaging medications such as PPIs, certain heart disease meds, radioactive contrast agents and certain cancer drugs, as well as toxic heavy metals and dietary factors, which includes chronic dehydration, excess intake of low quality carbs and proteins, and widespread nutrient deficiencies such as potassium and magnesium (among other factors). Common conditions like obesity, diabetes and cardiovascular disease ALSO drive up the risk of kidney disease, so perhaps it's not a big surprise that so many in the U.S. are struggling with under-functioning and diseased kidneys!


POTASSIUM TO THE RESCUE?

Potassium plays an important role in kidney health, and several studies have demonstrated the value of potassium citrate as a preventative and therapeutic agent for kidney issues (including kidney stones). [3-12]



Sadly, an astounding 97% of Americans fail to meet the recommended dietary intake for potassium. Another 48-75% fail to meet the recommended intake for magnesium, which plays an important role in soft tissue relaxation as well as heart and bone health. [13-16]

Could it be that salt has unjustly been labelled a chief villain when it comes to hypertension and heart disease, when in reality it’s the widespread prevalence of kidney disease (brought on by poor lifestyle and dangerous meds), coupled with deficiencies in important nutrients like potassium that’s really more to blame?


THE NUMEROUS HEALTH BENEFITS OF SALT

While much of the clinical literature is biased against salt, there are several studies that discuss the numerous health benefits provided by proper amounts of dietary sodium and chloride, such as this 2018 study from the Journal of Experimental Neuroscience that highlights salt’s essential role in various physiological processes, including electrolyte homeostasis, nervous system functioning, muscle contraction and nutrient absorption. [17]

SALT (NAMELY, CHLORIDE) IS ESSENTIAL FOR PROPER DIGESTION

Speaking of nutrient absorption, chloride, salt’s lesser talked about partner to sodium, also plays a central role in the formation of hydro-CHLORIC acid (HCL) in the stomach. HCL functions as both a crucial digestive fluid and as vehicle for killing harmful microbes that are sometimes present in beverages, foods and saliva. [18]



Could it be that vilifying and overly restricting dietary salt has led to lower stomach acid levels, which has been linked to an increased risk of h. pylori infections and conditions like stomach ulcers, acid reflux and GERD?

SALT'S IMPORTANT ROLE IN ADRENAL HEALTH & ENERGY LEVELS

Salt also has implications for the adrenal glands and plays a significant role in conditions like adrenal insufficiency (commonly called adrenal fatigue by those in alternative medicine).

Over time, insufficient levels of dietary salt will negatively impact several basic metabolic processes, including nerve signaling and nutrient transport. In response, the body will stimulate other pathways to produce the needed energy to function. One of these pathways is hormonal and involves the adrenal glands (which sit on top of the kidneys) and adrenal hormones like cortisol and adrenaline (aka epinephrine).


If the adrenal gland is continually over-stimulated, then, over time, adrenal insufficiency will result, and levels of several adrenal hormones, including cortisol, will drop. Combine a low salt diet with a high stress lifestyle and you have a formula for the accelerated development of adrenal insufficiency and low energy levels.



Conversely, the stress hormone cortisol plays a role in regulating sodium, and when cortisol levels are abnormally low (which is often the case with the latter stages of adrenal fatigue), then often the body’s retention of sodium also drops, resulting in lower blood sodium levels. This often leads to low energy levels and increased cravings for salt. [26]


In other words, the feedback loop here doesn’t work without an adequate intake of salt!

HIGH STRESS + LOW SALT + KETO DIET = NIGHTMARE

To make matters even more complicated, nutritional ketosis (of which I’m a big fan of in certain situations) tends to accelerate sodium excretion by the kidneys. Put simply, the risk for dangerously low blood sodium levels, as well as adrenal insufficiency/fatigue, may be highest for those with chronically low salt intake, high stress levels and who are trying to eat a very low carb or keto diet. This is one of the reasons I advise many of my clients who are "on keto" to be intentional about their salt intake.


SALT'S ROLE IN BLOOD SUGAR PROBLEMS, INSULIN RESISTANCE, DIABETES & OBESITY

As I briefly mentioned, the U.S. government has been advocating for a low salt diet since at least 1977. That's when the U.S. Senate Select Committee on Nutrition and Human Needs (led by Chairman George McGovern) presented their Dietary Goals- a set of guidelines on what foods Americans should avoid consuming in excess. It was these guidelines that popularized the idea that a high salt diet is unhealthy. This recommendation was based on a paper that said salt could be just one factor in hypertension. Note that these same guidelines also promoted the idea that "eating dietary fat makes you fat"- a theory that's been repeatedly debunked. [19]


In 1976, one year before the Dietary Goals, G. Meneely and H. Bartabee published a paper titled "High Sodium-Low Potassium Environment and Hypertension." Apparently the U.S. Senate Select Committee missed the key findings from this research, which said that salt could possible contribute to hypertension IF it was coupled with low potassium levels in people who were also genetically or otherwise susceptible. [20]


In his book "Salt: A World History", author Mark Kurlansky (James Beard Award winner for Excellence in Food Writing) explains that salt intake in Europe during the 1500 and 1600s was often quite high, to the tune of 40g or more per day, thanks in part to the widespread practice of using salt to preserve fish. [19]


How can the human body handle that much salt? Thanks to the kidneys (healthy kidneys, that is), excess salt is generally disposed of via urine. A 1979 paper from the journal Hypertension found that individuals can excrete up to 86 grams of salt per day! [21]


Some of the issue with salt and sodium being vilified in hypertension and cardiovascular disease seem to be, at least in part, a case of being in the wrong place at the wrong time (i.e. correlation not causation). What do I mean? Highly processed foods are usually higher in salt. These types of foods are also usually high in refined flours, refined sugars and other unhealthy additives. So what's driving up the blood pressure- is it the salt, or is it the low quality carbs and other unhealthy additives found in these kinds of foods? Much of these emerging research seems to suggest it's the later.


This 2014 study suggests that "sugar may be more meaningfully related to blood pressure than sodium, as suggested by the greater magnitude of effect with dietary manipulation." [22]


This 2016 study by Zhao et al. explains that a high sodium diet actually promotes sodium excretion in the urine (natriuresis) AND that it also promotes a reduction in blood sugar (glycosuria). Conversely, hyperglycemia (high blood sugar levels caused by excessive carbohydrate intake) reduces urinary sodium excretion, in part by its affects on the glucose regulating hormone adiponectin. In short- urinary sodium excretion is directly related to blood glucose and adiponectin levels. [23]


The authors from this 2017 study state that "There is no definitive proof that a normal salt intake causes hypertension. The evidence in the literature suggests that sugar, not salt, is the principal driver of hypertension and cardiovascular disease." [24]


And finally, this 2018 study demonstrated that a high salt diet effectively solved hyperglycemia (high blood sugar) and insulin resistance. [25]



THE 2014 P.U.R.E. SALT STUDY FINDINGS

One very large 2014 study from the New England Journal of Medicine really seems to refute the dietary dogma of “less salt is better.” In this study, a group of international scientists collected urine samples from more than 100,000 adults in 17 countries, which included low, middle and high income countries. The scientists then observed the health status of the study participants for 4 years.


What they found was that those consuming less than 3g a day of sodium (or less than 8g of salt per day) significantly increased their overall risk of death, to the point where those consuming only 1.8g of sodium per day (or 4.5g of salt) DOUBLED their risk of death.


While the study found that 4-6g of sodium a day (10-15g of salt) was ideal, even those with very high intakes, up to 12g sodium (or 30g of salt per day) still only increased their mortality risk by roughly 40%, compared to a 200% increase for those consuming only 1.8g of sodium (or 4.5g of salt) per day. [26-27]


GOVERNMENT HEALTH AGENCIES & THEIR ANTI-SALT BIAS

So how do these study findings stack up against what several governmental health organizations recommend?

The W.H.O. suggests consuming no more than 2g of sodium per day (5g salt) and even claims that doing this would SAVE around 2.5 million lives each year.


The U.S.D.A. and the U.S. Department of Health & Human Services have produced the Dietary Guidelines for Americans every 5 years, starting in 1980. The 2020-2025 guidelines (like those before it) recommend adults limit their intake to no more than 2.3g of sodium/day (5.75g salt or slightly less than 1 tsp [1 tsp salt = 5.9g]).

The Institute of Medicine (I.O.M.) recommends that adults only consume 1.5-2.3g of sodium per day (equivalent to 3.75-5.75g of salt).

And the American Heart Association advises no more than 1.5g of sodium or 3.75g of salt a day. [28]


So the government health agencies say we should limit our salt intake to 3.75-5.75g (around 2/3 tsp to 1 tsp) of salt a day, but the PURE study above says the sweet spot for health and longevity is 10-15g (around 1.75 to 2.5 tsp) of salt a day. Those are VERY different recommendations!


The 100,000 participant, multi-national 2014 PURE study essentially says we're better off consuming 2-3 TIMES the amount of salt that's currently recommended by government health agencies. Wow.

Studies have shown that American adults currently consume around 3.4g of sodium (or 8.5g of salt) per day.

If we consider the results from the 2014 PURE, the average American’s salt intake increases their risk of all-cause mortality by about 10%. And that’s because it’s on the LOW end.

If Americans were to follow the advice of the WHO, USDA, IOM and AHA, they’d increase their risk of all-cause mortality by (drumroll)… ANYWHERE FROM 40-250% due to salt deficiency!


MY FAVORITE SALTS (AND WHY I DON'T LIKE IODIZED SALTS)

With salt, I generally recommend a high-quality unrefined fine or extra fine salt such as Redmond’s Real Salt, Celtic Sea Salt or Himalayan Pink Salt (probably in that order). If you want to get a little fancy and gourmet, check out Maldon's Sea Salt Flakes.



Despite my preference for unrefined salts like these, I don't get too caught up in the "this salt also supplies all these additional trace minerals" hoopla. The trace minerals found in most of these unrefined salts aren't usually at levels to make a significant health difference.


We do need to mention iodine here, though. Unrefined salts like those mentioned above do not contain added iodine (there may be very, very small amounts naturally present, however). Brands like Morton and Hain do produce iodized salts, which are salts with iodine added (more specifically, potassium iodide). I generally DON'T recommend salts like these for two reasons...


First, because they usually contain anti-caking agents (ex. calcium silicate, tricalcium phosphate, etc.) and other additives (ex. dextrose) I'd just as soon not consume in this way.


And second, because I find it easier to use other iodine supplements (ex. Lugol's 2% solution) for addressing thyroid issues rather than iodized salts like these.


If for some reason you REALLY want to use an iodized salt with anti-caking agents for your thyroid issues, note that the concentration is generally around 280mcg iodine per 1 tsp.


DON'T GO TO A "HIGHER SALT" DIET WITHOUT ALSO ADDRESSING KIDNEY, BLOOD SUGAR (CARBS) AND NUTRIENT DEFICIENCY ISSUES

If your kidneys are under-functioning, you’re dealing with hypertension or edema, you suspect you have potassium and/or magnesium deficiencies and/or you struggle with blood sugar or insulin issues, I’d encourage you to first spend some time trying to improve your kidney health, potassium and magnesium levels and blood sugar/insulin issues before drastically increasing your salt intake.


One of the simplest ways of managing blood sugar and insulin issues is to reduce excess carbohydrate consumption. I find many of my clients benefit from an intake between 50-125g of net carbs a day. Chromium, berberine and cinnamon are three supplements that also have a track record for supporting healthy blood sugar levels.


When it comes to potassium, I usually recommend potassium citrate. One of the challenges here is that therapeutic dosages may look like 200-1000mg 1-3x a day, but potassium pills are limited to 99mg per pill by law. A potassium citrate powder supplement can solve that problem, as can a high potassium electrolyte supplement like this one by Dr. Berg that contains 1000mg of potassium per serving.


When it comes to kidney health, in addition to the suggestions already made, supplements such as sodium bicarbonate (baking soda) and chanca piedra (aka "stone breaker") also have clinical data showing their ability to support renal health. Apple cider vinegar (containing acetic acid) and lemon juice (containing citric acid) also have data supporting their use in various kidney issues. [29-38]


SUMMARY & FINAL TIPS

* With hypertension and heart disease, excess salt intake is not one of the primary culprits


* Under-functioning kidneys, high blood sugar and insulin levels (caused by excess and low quality carbohydrate consumption), nutrient deficiencies (ex. potassium, magnesium) and other risk factors (ex. obesity, diabetes) are the primary culprits in hypertension


* Government health agencies have been pushing dubious and debunked nutritional advice since at least 1977, including a low salt/sodium diet


* Several studies have shown salt's key role in promoting neurological health, digestive health, adrenal health (and energy levels), proper muscle functioning, and healthy blood sugar and insulin levels (which play a major role in conditions like diabetes and obesity)


* Government health agencies in the U.S. and across the world recommend salt and sodium intakes that are 2-3 TIMES lower than the optimal intake ranges, according to large multinational studies


* Most adults would benefit from consuming 2 to 2.5 tsp of salt a day, versus the 2/3 to 1 tsp recommended by organizations like the W.H.O. and U.S.D.A.


* Before drastically increasing salt intake, those with kidney, blood sugar/insulin and/or nutrient deficiency issues should first spend some time addressing and correcting those issues


* A high quality unrefined salt with no added anti-caking agents, sugars or iodine is usually best


* As salt intake can boost energy levels, I recommend people consume the majority of their daily salt before dinner (high salt intake just before bed may have negative effects on sleep quality)


One way of controlling salt intake is to make the vast majority of your meals from home. You might start by pre-measuring around 2 tsp of salt, to be used in that day's meals (the majority of which may be added to the breakfast and/or lunch meal). Take note of your energy levels and any other relevant symptoms and health markers through the day (ex. blood pressure, blood sugars, hunger levels, water retention/swelling, etc.) and adjust accordingly.


For a deeper dive into the many health benefits of salt, check out Dr. David Brownstein’s 2006 book Salt Your Way to Health, or James DiNicolantonio’s 2017 book The Salt Fix.


ARE YOU READY FOR A HEALTH CHANGE?

If you're ready for a significant, positive health change and want to take a holistic, personalized, evidence-based approach to get there, let me know! I provide health and nutritional consulting as well as personal training services to both local (Charleston, SC area) and remote clients.


SOURCES

1 https://lpi.oregonstate.edu/mic/minerals/sodium (review of clinical data on sodium)

2 www.cdc.gov/kidneydisease/publications-resources/2019-national-facts.html (37 million Americans with Chronic Kidney Disease)

3 www.ncbi.nlm.nih.gov/pmc/articles/PMC5686309/ (2017; use of potassium citrate recommended for children under 2 yrs old with kidney stones/renal calculi)

4 www.ncbi.nlm.nih.gov/pubmed/28762682 (2017; potassium citrate as effective for both preventing & treating kidney stones as well as improving bone mineral density)

5 www.ncbi.nlm.nih.gov/pmc/articles/PMC4265710/ (2014; “potassium citrate therapy causes a significant increase in urinary citrate, pH, and potassium, leading to significantly less stone formation”)

6 www.ncbi.nlm.nih.gov/pubmed/23924538 (2013; citrate is a powerful inhibitor of the crystallization of calcium salts; potassium citrate has been shown effective as both preventative & curative agent for kidney stones)

7 www.ncbi.nlm.nih.gov/pubmed/20576821 (2010; potassium citrate led to dramatic reduction in kidney stone event rate [0.58 to 0.10 stones/yr/patient])

8 www.ncbi.nlm.nih.gov/pubmed/20399488 (2010; potassium citrate corrects high urine calcium & is associated w/ a very high remission rate for kidney stone disease)

9 www.ncbi.nlm.nih.gov/pubmed/19911682 (2009; potassium citrate decreases saturation of calcium oxalate, reduces the rate of stone reoccurrence, increases clearance and dissolution of stone fragments.)

10 www.ncbi.nlm.nih.gov/pubmed/19765769 (2009; potassium citrate therapy decreases risk of kidney stone formation during spaceflight!)

11 www.ncbi.nlm.nih.gov/pubmed/11475849 (2001; therapeutic applications for potassium citrate include oxalate kidney stones, excess calcium & oxalate in urine & treatment of hypertension; 1 year remission of kidney stones observed in 70-75% of cases)

12 www.ncbi.nlm.nih.gov/pubmed/8230497 (1993; randomized trial showed efficacy of pot citrate in preventing new stone formation in those with history of calcium oxalate kidney stones)

13 www.ncbi.nlm.nih.gov/pmc/articles/PMC3650509/ (2013 review on potassium & health; only 3% of Americans meet recommended intake)

14 https://jaoa.org/article.aspx?articleid=2673882 (2018; citing 2005-06 data found that up to 48% of US population deficient in magnesium)

15 www.thorne.com/take-5-daily/article/who-is-at-risk-for-magnesium-deficiency (2018; 55% below RDA and 20% well below RDA for magnesium)

16 www.aafp.org/afp/2009/0715/p157.html#afp20090715p157-b2 (2009 article citing early 1990s data showing 75% of Americans don’t meet daily intake for magnesium)

17 www.ncbi.nlm.nih.gov/pmc/articles/PMC6249657/ (2018; “Salt (NaCl) is an essential nutrient required for various physiological processes, including electrolyte homeostasis, neuronal activity, nutrient absorption, and muscle contraction.”)

18 https://humannaturellc.com/blogs/news/when-salt-restriction-backfires (salt’s role in HCL production)

19 www.bisu.bio/low-salt-bad/ (in depth explanation of relationship between sodium, potassium, carbs, blood sugar, insulin and blood pressure, including history of US dietary guidelines)

20 https://pubmed.ncbi.nlm.nih.gov/793367/ (1976 study on high sodium & low potassium diet and its effects on hypertension)

21 www.ahajournals.org/doi/pdf/10.1161/01.HYP.1.3.261 (1979 study that found that individuals could excrete up to 86g of salt a day via urine)

22 https://openheart.bmj.com/content/1/1/e000167 (2014 study citing sugar, not salt, as principle driver of elevated blood pressure)

23 www.cell.com/cell-metabolism/pdfExtended/S1550-4131(16)30068-7 (2016 study by Zhao et al. that found higher salt intake promotes sodium excretion and reduces blood sugar levels)

24 www.amjmed.com/article/S0002-9343(17)30326-1/fulltext (2017 study implicating sugar, not salt, as principle driver of CVD and hypertension)

25 www.ncbi.nlm.nih.gov/pmc/articles/PMC5884204/ (2018 rat study showing high salt diet effective against hyperglycemia and insulin resistance)

26 www.virtahealth.com/blog/sodium-nutritional-ketosis-keto-flu-adrenal-function (2017; health benefits of salt, including analysis of the 2014 PURE study findings)

27 www.nejm.org/doi/full/10.1056/nejmoa1311889 (2014 salt & mortality study of >100,000 participants from 17 countries)

28 www.healthline.com/nutrition/sodium-per-day (2018; information on salt/sodium guidelines from several health organizations)

29 www.ncbi.nlm.nih.gov/pmc/articles/PMC6642359/ (2019; daily intake of vinegar reduced stone recurrence, increased citrate & reduced calcium in urinary excretion in CaOx stone formers without adverse side effects)

30 www.ncbi.nlm.nih.gov/pubmed/30220653 (2018; in both clinical & experimental studies sodium bicarb has been shown to improve GFR and halt the progression toward end stage renal disease)

31 www.ncbi.nlm.nih.gov/pmc/articles/PMC3641618/ (2013; sodium bicarb supplementation results in increase in serum bicarb and improves lower body strength after short-term intervention in CKD patients w/ mild acidosis)

32 https://academic.oup.com/ndt/article/27/8/3056/1817928 (2012; use of baking soda in patients w/ early to advanced CKD has proved to be reno-protective)

33 www.ncbi.nlm.nih.gov/pmc/articles/PMC3580168/ (2012; systematic review of short and long-term effects of sodium bicarb therapy on chronic kidney disease [CKD] found sodium bicarb therapy associated w/ an improvement in kidney function, which may slow the progression of CKD)

34 www.ncbi.nlm.nih.gov/pmc/articles/PMC6092661/ (2018; 12 week study of 56 people found chanca piedra safe, and causes significant decrease in urinary oxalate & uric acid, and also contributed to elimination of urinary calculi, including kidney stones)

35 www.ncbi.nlm.nih.gov/pmc/articles/PMC4854999/ (2016 review of the genus Phyllanthus, including Phyllanthus Niruri [Chanca Piedra], including it’s use for urinary infections and renal calculi/kidney stones)

36 www.brazjurol.com.br/november_december_2010/Boim_657_664.htm (2010; review of scientific literature found chanca piedra beneficial for preventing and treating nephrolithiasis [kidney stones]).

37 www.ncbi.nlm.nih.gov/pmc/articles/PMC4265710/ (2014; “Patients with low urinary citrate should be encouraged to increase their consumption of foods high in citric acid, such as lemon & lime juice. Consuming just 4 oz of lemon juice/day has been shown to significantly increase urine citrate levels without increasing oxalate levels”)

38 www.ncbi.nlm.nih.gov/pubmed/18946667 (2008; “lemon juice can be an alternative in the treatment of urinary calcium stones in patients with hypocitraturia”)