Heart Health issues with a low-salt diet

Image Credit: Leonid Mamchenkov/ Flickr

Could a low-salt diet be bad for your heart?

Hello Dr. Greger, I was curious about your take on a new report of a recent study (http://www.msnbc.msn.com/id/45224421/ns/health-heart_health/#.TrrabPSImU8) that appears to demonstrate possible heart health issues with a low-salt diet (increases cholesterol, increases fat, increases hormone levels). It also appears to be adding to previous studies showing similar results. Thanks for any information you can provide.

maybush1 / Originally posted on Dietary guidelines: with a grain of Big Salt

Answer:

None of the studies over 4 weeks in length noted in the review cited by that report showed any negative effects on cholesterol and in fact the American Heart Association (AHA) has just gone further and recommended that everyone shoot for 1500 mg a day (not just those at high risk). See my video Salt OK if Blood Pressure is OK?

According to the AHA, cutting American sodium intake 1,200 mg per day could lead to as many as 66,000 fewer strokes, almost 100,000 fewer heart attacks, and up to 92,000 fewer deaths despite what the salt industry would have us believe (see Dietary Guidelines: With a Grain of Big Salt and Dietary Guidelines: Pushback From the Sugar, Salt, and Meat Industries). It’s hard to get down to the recommended 1,500mg a day, though, unless one sticks to an unprocessed plant-based diet.

Image Credit: Leonid Mamchenkov / Flickr

Discuss

Michael Greger M.D., FACLM

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.


32 responses to “Could a low-salt diet be bad for your heart?

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  1. Hello. Would you be willing to show an example of a meal-by-meal rundown of sodium intake on an unprocessed plant-based diet? I am at that stage of trying to polish my primarily whole-foods vegan diet and would love to see a daily calculation like this. Thank you for considering this!

    1. As long as you not consuming added salt in your diet from a salt shaker then you will never get too much sodium on a whole foods plant based diet.

  2. Dr. Greger, I am surprised that you would fall back to blind reliance on AHA guidelines and projections without citation to actual medical studies showing the benefits of reduced sodium on overall mortality rates. In addition, among other flaws, the studies you have cited concerning possible benefits in vascular health of reducing sodium intake are in themselves short term studies of 4 weeks or less. Should we simply dismiss them as well as being too short in duration?

    Maybe you should admit that as of now it is unclear whether reducing sodium will have a significant impact on reducing incidents of cardiovascular disease and more studies need to be conducted.

    1. You can read in detail the national academy of sciences recommendation on sodium as well as results that they present from consuming too much.
      http://www.nap.edu/openbook.php?record_id=10925&page=269

      Based on the available evidence, we cannot dismiss consuming too much sodium as neutral in both the long term and short term. The short term studies, even for 4 weeks, would seem like quite a good time for the body to adapt to the higher sodium diet.

      1. Thanks for the link but you have failed to cite a single study that establishes an improvement in either mortality rates or incidents of cardiovascular diseases from reducing sodium intake. It is pureuly conjecture at this point. There is certainly insufficient evidence to indicate that 100,000 fewer heart attacks will occur and 90,000 lives will be saved by reducing sodium consumption. Furthemore, Dr. Greger himself dismisses studies under 4 weeks that indicate an increase in cholesterol from reducing sodium intake yet cites studies of under 4 week duration for purposes of establishing improved vascular function. Looks like cherry picking to me.

        In addition, a recent study:

        Normal range of human dietary sodium intake: a perspective based on 24-hour urinary sodium excretion worldwide.

        now indicates that the human body maintains a consistent and narrow range of sodium in the body over the long term and that attempts to reduce sodium intake may have no impact on these biologically determined sodium levels. Sounds very similar to B12 levels which the body can self-regulate by eliminating any excess it doesn’t need.

        1. I needed some time to relocate some forgotten information but I have relocated it thanks to Jeff Novick.

          “A recent Cochrane Review by Rod Taylor and colleagues, published simultaneously in The Cochrane Library1 and the American Journal of Hypertension2, stated in the plain language summary that “Cutting down on the amount of salt has no clear benefits in terms of likelihood of dying or experiencing cardiovascular disease”.1 The Cochrane Library’s own press release headline included this statement: “Cutting down on salt does not reduce your chance of dying”.3 Both of these statements are incorrect.

          The study reported in the paper by Taylor and colleagues is a meta-analysis of randomised trials with follow-up for at least 6 months on the effect of reducing dietary salt on total mortality and cardiovascular mortality and events.[1] and [2] There were seven trials with 6250 participants (665 deaths). One of these trials in heart failure,4 in our view, should not have been included because the participants were severely salt and water depleted due to aggressive diuretic therapy (frusemide 250-500 mg twice daily, and spironolactone 25 mg per day) as well as captopril 75-150 mg per day and fluid restriction to 1000 mL per day.4 While on these treatments, participants were randomly assigned to a reduced salt intake or their usual salt intake.4 In view of the fact that the dose of diuretics was not adjusted downwards, a lower salt intake is likely to worsen the salt and water depletion and therefore, unsurprisingly, resulted in worse outcomes.

          In the remaining six trials, there is a reduction in all clinical outcomes (all-cause mortality, cardiovascular mortality and events) (table), although none of these are statistically significant. This trend of consistent reductions in all clinical outcomes seems to have been overlooked by Taylor and colleagues.1 The non-significant findings are most likely the result of a lack of statistical power, particularly as Taylor and colleagues analysed the trials for hypertensives and normotensives separately. We have reanalysed the data by combining data for hypertensives and normotensives together. Our results show that there is now a significant reduction in cardiovascular events by 20% (p<0·05) (figure) and a non-significant reduction in all-cause mortality (5-7%), despite the small reduction in salt intake of 2·0-2·3 g per day. The results of our reanalysis, contrary to the claims by Taylor and colleagues, support current public health recommendations to reduce salt intake in the whole population.

          Table. Change in salt intake, blood pressure, and clinical outcomes with results from the meta-analysis by Taylor and colleagues1 (excluding the trial in heart failure)
          —————————————————–
          Trials in normotensives (n=3)* Trials in hypertensives (n=3)*
          —————————————————–
          Reduction in salt intake at end of trial (g per day [95% CI]); duration 6-36 months 2·0 (1·1 to 2·9) 2·3 (1·8 to 2·8)
          Fall in blood pressure at end of trial (mm Hg [95%CI]); duration 18-36 months
          Systolic 1·11 (?0·11 to 2·34) 4·14 (2·43 to 5·84)
          Diastolic 0·80 (0·23 to 1·37) 3·74 (?0·93 to 8·41)
          Difference in all-cause mortality at longest follow-up (95%CI); duration 7 months to 12·7 years 10% reduction (RR 0·90, 0·58 to 1·40) 4% reduction (RR 0·96, 0·83 to 1·11)
          Difference in cardiovascular events at longest follow-up (95%CI); duration 7 months to 11·5 years 29% reduction (RR 0·71, 0·42 to 1·20) 16% reduction (RR 0·84, 0·57 to 1·23)
          Difference in CVD mortality at longest follow-up (95%CI); duration 7 months to 6 years – 31% reduction (RR 0·69, 0·45 to 1·05)
          —————————————————–
          RR=relative risk; CVD=cardiovascular disease.
          * Not all measurements were made in all trials.

          Taylor and colleagues call for further large long-term randomised trials of salt reduction on clinical outcomes.[1] and 2 RS Taylor, KE Ashton, T Moxham, L Hooper and S Ebrahim, Reduced dietary salt for the prevention of cardiovascular disease: a meta-analysis of randomized controlled trials (Cochrane Review), Am J Hypertens 24 (2011), pp. 843-853.[2] According to their own calculations, at least 2500 cardiovascular events need to be obtained to detect a 10% reduction (at 80% power and 5% significance level).2 This would require randomisation of about 28 000 participants to a low or high salt intake and then maintenance of the two separate diets for at least 5 years. Such a trial is impractical because of logistical and financial constraints, and the ethical issues of putting a group of people on a high salt diet for so many years.

          In our view, Taylor and colleagues' Cochrane review and the accompanying press release reflect poorly on the reputation of The Cochrane Library and the authors. The press release and the paper have seriously misled the press and thereby the public-for example, in the UK the Daily Express front page headline read "Now salt is safe to eat-Health fascists proved wrong after lecturing us all for years"5 and there were similar headlines throughout the world.

          The totality of evidence, including epidemiological studies, animal studies, randomised trials, and now outcome studies all show the substantial benefits in reducing the average intake of salt.[6], [7], [8] and [9] Most countries have adopted policies to reduce salt intake by persuading the food industry to reformulate food with less salt, as is occurring successfully in the UK,10 and also by encouraging people to use less salt in their own cooking and at the table. WHO has recommended salt reduction as one of the top three priority actions to tackle the global non-communicable disease crisis.11 A reduction in population salt intake will have major beneficial effects on health along with major cost savings in all countries around the world.[6], [12] and [13]

          http://www.actiononsalt.org.uk/news/Salt%20in%20the%20news/2011/58301.pdf

          http://ruhlman.com/wp-content/uploads/2011/07/ajh2011115a.pdf

          "This paper is a Position Statement from an ‘ad hoc’ Scientific Review Subcommittee of the PAHO/WHO Regional Expert Group on Cardiovascular Disease Prevention through Dietary Salt Reduction. It is produced in response to requests from representatives of countries of the Pan-American Region of WHO needing clarification on two recent publications casting doubts on the appropriateness of population wide policies to reduce salt intake for the prevention of cardiovascular disease. The paper provides a brief background, a critical appraisal of the recent reports and explanations as why the implications have been misinterpreted. The paper concludes that the benefits of salt reduction are clear and consistent, and reinforces the recommendations outlined by PAHO/WHO and other organizations worldwide for a population reduction in salt intake to prevent strokes, heart attacks and other cardiovascular events.

          Strong and consistent evidence shows that a diet high in salt is harmful to health and that reducing its intake is among the most cost effective possible means to reduce disease risk [1e5]. Excess dietary salt causes an increase in blood pressure, the leading risk for premature death in the developed and developing world. In addition, a high dietary salt intake is strongly associated with stroke and cardiovascular outcomes [6], gastric cancer, loss of calcium in urine and the ensuing risks of calcium-containing kidney stones and osteoporosis [7]. There are also strong associations and a pathophysiological basis for high dietary sodium intake to contribute to obesity [8].

          Recently two highly publicized reports have been used by public and scientific media to suggest that high dietary sodium intake does not adversely affect health [9,10]. The critical appraisal that follows seeks to put these studies in the broader scientific and methodological context, and shows that these studies do not form a rational basis upon which to make changes to existing public health efforts to reduce population dietary salt intake.

          The background to these studies is fifty years of intensive animal and human research that has seen a vast array of studies conducted on dietary sodium intake and health [1e5]. The human research program has been particularly extensive including migration studies, cross sectional studies, cohort studies, randomized trials and meta-analyses and has involved hundreds of thousands of individuals. Like most research programs it is comprised of pieces of work of varying quality and significance and the interpretation of any one project requires careful consideration of both its indi- vidual strengths and weaknesses and the broader scientific context. When taken overall, the message is very clear e salt causes high blood pressure and vascular disease. This consensus is widely accepted by national and international governmental, scientific and health organizations.

          Discovering truth in science is dependent upon two key aspects of research design e precision and validity. Preci- sion describes the capacity of a piece of work to determine exactly what is going on by controlling for random errors (the play of chance) and mostly it relates to the size of the studies done. Small projects provide poor precision and are at high risk of turning up findings just by chance, or missing real effects because the study was unlucky. Even then science compromises because to be absolutely precise is usually impractical. So we settle on the notion that ‘truth’ is defined by studies that have a 90% chance of picking up a real effect if it does exist (90% power) and only a one in 20 change of showing a chance positive finding that isn’t really there (p Z 0.05). It is very important to look at every study in this context and to interpret the reported findings in light of what the study was actually able to show.

          Validity describes a different concept, that of control- ling for systematic (or non-random) errors and truly understanding the cause and effect relationship. Con- founding of associations is a particular problem in nutri- tional epidemiology and has been a major cause of the debate in the salt field. Caution is required in interpreting the findings reported by cohort studies with very close examination of the mechanisms that the researchers have put in place to control for potential confounding factors and the extent to which these methods are likely to have been successful. In particular, if the observed effects in the observational data do not fit with what the results of the unconfounded randomized trials they need to be treated with extreme caution.

          Recently JAMA published an article by Stolarz-Skrzypek and colleagues [10]. This cohort study examined urinary sodium excretion in relation to hypertension and fatal and non-fatal outcomes and concluded that low sodium diets increased cardiovascular disease and should not be rec- ommended on a population basis. The key problem with this trial is residual confounding. The data from the Stolarz- Skrzypek’s study show that the group consuming low salt diets were very different from the group consuming high salt in many more ways than just their level of salt consumption. They had higher levels of many known risks for CVD that would be expected to result in a poor outcome regardless of their salt intake e the lowest educational attainment, higher baseline systolic blood pressure, older age and higher total cholesterol. While the investigators sought to adjust for these confounders statistical models mostly fail to achieve full correction for such imbalances. The very large changes produced by statistical adjustment in this study are a cause for concern because this suggests that confounding was substantial and that under-correction may therefore also have been substantial. Similar imbal- ances were a feature of 2 previous cohort studies by Alderman and Cohen et al. and statistical adjustment in that case resulted in the conclusion of no significant rela- tionship between high dietary salt and adverse outcomes [11,12]. In the examples of Alderman and Cohen, the data was from a cohort derived from the NHANES in the United States, and notably two studies by different groups of investigators examining salt consumption using NHANES data refuted their findings, confirming high salt intake was associated with cardiovascular disease [13,14].
          The lower sodium excretion group in the Stolarz- Skrzypek study also had lower urinary creatinine, urinary potassium, and urine volumes suggesting concurrent illness or non adherence to the collection of the full 24 h urine sample. In diverse research studies poor adherence, even to placebo, is a strong marker of bad outcomes [15,16]. The Stolarz-Skrzypek data are also unusual in that lower sodium intake is almost always also associated with a higher potassium intake and excretion because the main mecha- nism for reducing dietary sodium is to eat unprocessed foods that are high in potassium (such as vegetables and fruits) [17].
          In addition to major concerns about validity, the study had very limited precision. The study population was young with a low cardiovascular disease event rate and the conclusions were based on just a small number of events. Statistical power was negligible and there is a very high risk of this being a spurious finding. When the study of Stolarz- Skrzypek is included in an updated meta analysis of all the prospective cohort studies addressing this question the overall finding is that high dietary sodium is associated with an increased incidence of stroke with a corresponding trend toward higher total cardiovascular events [18].

          The second, more recent report derives from the Cochrane Collaboration and examined the impact of high dietary salt consumption on death and disability in a meta analysis of randomized controlled trials [9]. The overview found no strong evidence that salt reduction through indi- vidual dietary advice reduced all-cause mortality or CVD morbidity in normotensive persons or hypertensive patients. The media have widely misreported the findings and a false sense of controversy has been broadcast, confusing the public on important health messages. The key issue here was the study power. The overview simply did not have large enough numbers of people studied, long enough trials or large enough reductions in dietary salt to adequately assess the question being addressed. The study also separated trials of people with normal blood pressure and those with high blood pressure further limiting the studies statistical power. Another major limitation of this study is their decision to truncate follow-up in the TOHP studies to just the trial period [19]. Extended follow-up documented a significant reduction in cardiovascular events over the long-term (not evident in the trial phase alone) [19]. In contrast to the media reports, the Cochrane meta analysis results were absolutely consistent with large reductions in death and disability from lower salt diets with clear effects of salt reduction on blood pressure that were exactly in line with what would have been anticipated.

          A further limitation of the Cochrane overview was the decision to include a trial done in people with severe heart failure on very high doses of diuretic. This is an inappro- priate group in which to study the effects of salt reduction, since the high doses of diuretic will have left many already substantially salt depleted. The adverse findings in this study are therefore not entirely unsurprising and the small size of the study also makes the findings prone to the play of chance. Interestingly, repeating the Cochrane meta analysis and combining the studies of people with normal and high blood pressure together results in an overall estimate of effect showing a substantive reduction in cardiovascular events [20].

          Perhaps as important as the science which over- whelmingly supports the health and economic benefits of reducing dietary salt is the media attention and controversy it has generated. Many headlines have been generated that confuse the public and health care professionals. The new studies should not deter efforts to reduce dietary salt and do not change our understanding, regarding the adverse impact of salt on health. In conclusion, the benefits of salt reduction are clear and consistent, the recent studies do not indicate that salt does not affect hypertension or CVD, their publication does not change the priorities outlined by PAHO/WHO and worldwide for a population reduction in salt intake to prevent heart attacks and strokes."
          www2.warwick.ac.uk/fac/med/staff/cappuccio/publications/nmcd_2011_salt_position.pdf

          1. Thanks for providing these comment papers criticizing the methodology utilized in the Cochrane meta-analysis. However, I am not convinced that combining the populations of normal blood pressure patients with high blood pressure patients is a more valid methodology. In which case, the authors of the comment agree that there was no statistically significant reduction in mortality rates or cardiovascular events. What is the basis for the assumption that aggregating data from populations with very different blood pressure levels is more valid than the methodology of separating the studies of these two disparate groups adopted by the Cochrane meta-analysis?

            I also find it particularly interesting that with respect to increases in cardiovascular disease and mortality rates that decreases in the sodium consumption of the normal blood pressure individuals apparently resulted in a greater reduction in cardiovascular events and mortality rates than reductions in the sodium consumption of high blood pressure individuals. One would assume that the opposite result would be true if sodium intake was a significant causal factor. Unfortunately, there is no discussion in the comments regarding this rather peculiar discrepancy.

            Finally, no one apparently disputes the fact that there is not a sufficient population sample size (which would require a population size of approximately 25,000 individuals) to make any definitive conclusions regarding reduction of sodium intake and improvement in mortality rates or reduction of cardiovascular events.

            1. I would also be interested in hearing Greger’s response to the findings of the recent study entitled Normal range of human dietary sodium intake: a perspective based on 24-hour urinary sodium excretion worldwide authored by the researchers at UC Davis.

              1. Finally, there are the conclusions from the study entitled Dietary Sodium Intake and Cardiovascular Mortality: Controversy Resolved? which indicates that a sodium intake significantly above or below a range of sodium intake results in increased cardiovascular events:

                Sodium intakes above and below the range of 2.5–6.0 g/day are associated with increased cardiovascular risk.

                If anything, the evidence to date would seem to indicate that recommending a low sodium diet could result in greater cardiovascular events and is, therefore, unwarranted.

        2. Continue binging on salt cause it tastes good, and get back to us in 15 years. You’ll be a test subject. If you have any buddies that are willing to binge on salt for the next 15 years, let them join in as well.

  3. My question about salt is about quality! now im on a whole foods, vegan diet, my diet has very little added ‘table salt’. There lies my question! when cooking i use Himalayan pink salt, and i mean logically, your cells need sodium to function, so ?I would conclude, bad salt bad, good salt good!?

  4. Nobody mentions the difference between table salt (refined and causing mineral imbalance) and sea salt or himalayan pink salt rich in various minerals. I think they are completely different and I agree table salt is bad, but I think real salt may be beneficial.

    1. DesLivresALire: I haven’t researched topic this lately, but the last time I did research it, I learned that the “real” salt as you call it, has only trace minerals that we can easily get and in more quantity from other sources. And when all is said an done, it’s still concentrated salt. I didn’t find any sources I would consider credible who thought that “real” salt was any different health-wise than typical white table salt.

      I’m not an authorative person for this topic. I just thought I would share my take on it. Maybe someone more knowledgable can jump in.

      1. Thanks Thea!
        I am more and more interested in holistic nutrition and so, as a general rule, whole is always best than refined. And the percentage of nutrients removed is less important than the fact of removing them. White rice or brown rice are both mostly rice, but they act totally differently in the body. Why should salt be different?
        If only white rice was ever studied, the conclusion would have been that rice was unhealthy. And for salt, I wonder if this is what happened. Maybe the studied table salt is bad and the understudied sea salt is beneficial.

        1. DesLivresALire: This is a fun discussion. Thanks for your nice reply.

          To continue the discussion: I agree with you in the larger principles, but I disagree with you in the details for this case.

          The rice example is a perfect one. In the case of white rice, we know it is bad for you because we know that *significant*, important nutrients are removed. We know the fiber and minerals in whole rice add significantly to health. And we know that when you remove these important pieces of the plant, what is left might be affecting our blood sugar levels in a way that is not so healthy. In the case of refined salt, we know that we are taking out miniscule amounts of minerals which are not known to have any special health benefit. So, there is every reason to believe that salt is different than rice when it comes to refining.

          I like your general principle of, “I am more and more interested in holistic nutrition and so, as a general rule, whole is always best than refined.” Agreed. However, to me, that statement means that getting our salt from whole plants, as Toxins suggests, is the way to go. Salt, whether sea salt or otherwise, is not really a natural food in my book. How many animals die off from lack of concentrated salt? Sea salt is just concentrated salt with a few trace minerals that we can easily get other ways.

          If, for the sake of argument, your theory is correct that we *need* some kind of concentrated salt in our diet (ie, assume that we can’t get enough salt from whole plant foods) to supplement what we get from plant foods, then what we would need is the sodium chloride part of the salt. I am not aware of any theory or evidence to suggest that people who get necessary salt from sea salt are better off/healthier than people who get necessary salt from refined salt.

          That’s just my take on it.

          1. I agree with you Thea. It would be better to get enough sodium from plants, but I checked some of them and they range at about 1% of the RDA (25 mg) and even as a vegan, I am not eating 50 or 100 veggies a day. Plants can’t make sodium and it has to come from the soil. So, I assume that produces cultivated on lands previously covered by the ocean are high in sodium but not all are equal.

            For the rice, we know that we removed important nutrients … and so, we created a unhealthy rice. And getting the missing fibers, the vitamins and minerals from other sources won’t make white rice as healthy than brown rice.
            So, applying the same principle with salt, I don’t think we can conclude that we don’t need the trace minerals from it because we can get them from another food.

            I don’t either know any study concluding than sea salt is better than table salt and that was my initial question: to know if there were scientific proofs about the potential need and/or benefits of unrefined salt.

    2. Many people assume because they are eating sea salt, they are eating healthier. In actuality, sodium chloride has the same effect on our body whether it be from the sea or from the land. We should strive to keep our sodium intake between 1200-1500 milligrams a day or less and we can get by without any added salt as salt occurs naturally in food. The estimated minimum required amount to maintain good health is said to be about 115 mgs per day by the National Academy of Sciences. Sea salt proponents claim that sea salt contains minerals in it. Lets look at the actual mineral content as Jeff Novick has shared.

      1 tsp of Sea Salt contains

      12 mgs of calcium

      7 mgs of potassium

      27 mgs of magnesium

      The recommended daily values of these nutrients are

      600 mgs of calcium

      4700 mgs of potassium

      400 mgs of magnesium

      So to get just 25% of this daily value, we would need to eat

      Calcium, we would need to take in 24,600 mgs of sodium

      Potassium, we would need to take in 335,000 mgs of sodium

      Magnesium, we would need to take in 7,407 mgs of sodium

      Consuming sodium in these amounts is extremely unhealthy and most likely toxic.

      Now looking at iodized table salt, i personally prefer iodized over sea salt because Iodine is a somewhat rare mineral which is why salt is iodized to begin with. It is rarely found in the plant world and animal world. 500 mg of iodized salt would achieve our daily value for iodine from salt alone.

      1. Thanks Toxins

        Of course I was not talking about getting the RDA of every mineral from salt. They are plenty of wonderful plants for that.

        But the fact is that we loose sodium everyday, and by working on a hot day, we can lose more than 15 g of salt a day ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267797/ ). So, a minimum amount of 115 mg a day seems very little to me. And as the best way to get sodium seems to be salt, I think it is essential to get salt. And of course I know table salt is unhealthy. But is it also the case of sea salt?

        I mean, the other minerals may account for 2% of the salt content but it doesn’t mean they are useless. If you give someone a car without the keys, we are in the same scenario, he gets 99.9% of the car but can’t do anything good with it.

        And as far as now, every study I saw says the same thing as you said: the sodium content is the same so the effects are the same. But I’m not satisfied by that answer because they never consider the food as a whole but only isolated elements. And the question is not about eating isolated sodium, but whole salt.

        PS: I get my iodine from see vegetables.

        1. I know you are trying to apply the wholistic approach to this, but salt is salt. It is not a “whole food”, it is by definition a mineral. It is difficult to apply the wholistic approach when we are looking at something so simple. Your previous example of brown rice to white rice is not comparable because there are hundreds of phytonutrients at play with these 2 foods. Where as salt does not provide anything…but salt. And of course the miniscule trace minerals found in sea salt that overall have no effect on the quality of the diet.

          Of course you would need more salt if working outside in the summers heat, but your body adapts to release less sodium on a lower sodium diet.

          1. I found my answer in the book Raw Food Controversies: Salts are all about the same and it is not required to add salt in a raw diet (and probably in other diets as well).

  5. Medications and sodium: I was recently diagnosed with low sodium. My GP says i am on certain medications effect sodium levels. while i’m happy to eat lots of salted peanuts, I really need to find a solution that makes sense.

    http://www.australianprescriber.com/magazine/26/5/114/7/ :
    “SUMMARY
    Drug-induced hyponatraemia is commonly associated with diuretics, selective serotonin reuptake inhibitors and antiepileptics. With increasing polypharmacy and an ageing population, the prevalence of drug-induced hyponatraemia is likely to increase.”

    Well i’m not asymptomatic. I am pretty miserable. The medications are prescribed to manage serious mental illness and I’ve been taking most of them for quite a while. I am wondering what if any would you suggest to manage this rather unnatural condition? Could foods help push the body back toward balance?
    I will be following my GPs advice but all thoughts would be appreciated. We baby boomers are being medicated more and more. I’d love to off medications but there are also times when it is the lesser of 2 evils.

  6. Dr Greger what is your opinion on iodine supplimentation and the protocol suppliments as outlined by dr brownstein, etc? one of the suppliments recommended was 1/2 tsp unprocessed salt per day to help flush bromine from the body due to taking the iodine.

    1. Hi Tammy – Dr. Greger recommends eating iodine-rich foods vs. taking iodine supplements. Dr. G’s recommended daily intake of iodine is 150 mcg. Sea vegetables are a great source of iodine – you can meet this daily recommendation with two sheets of nori. The only exception would be pregnant or breast-feeding women – they should receive a daily prenatal vitamin that contains iodine. Dr. G discusses iodine in more detail on pages 409-10 in his latest book How Not to Die. Hope this helps!

      1. I dont care for seafood of anykind. I guess i need to ask his opinion of the addition of unprocessed salt such as redmonds in the protocol. U add 1/2 tsp per day and do a flush with additional1/4 tsp in warm water until urination begins to flush bromine. As a nurse i always understood to avoid it. But since this isnt regular table salt….i dont know

  7. I am looking for the brand name of Dr. Greger’s favorite salt which has no salt in it. I just finished my first bag but can’t find the name. I read about it in How Not to Die but couldn’t find it in the index under sodium. I loved it and want to buy another bag. I’m surprised he doesn’t talk about it more. Thank You.

  8. Hi Daphne T Stevens, thanks for your question. Dr Greger mentions that some of the flavorings you can use instead of salt include pepper, onion, garlic, tomato, sweet peppers, basil, parsley, thyme, celery, lime, chill, nettle, rosemary, smoke flavor, curry, coriander, and lemon.

    Even if you do add salt, though, it’s probably better than eating out, where even at non-fast food restaurants, they tend to pile it on. And finally, avoid processed foods that have salt added. I hope that is useful to you.

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