Eating a diet low enough in sodium (salt) can prevent the rise in hypertension risk as we age.
High Blood Pressure May Be a Choice
For the first 90% of our evolution, we ate diets containing less than a quarter teaspoon of salt a day, because for the first 90% of our evolution, we ate mostly plants. We went millions of years without salt shakers, and so our bodies evolved into salt-conserving machines, which served us well—until we discovered salt could be used to preserve foods. Without refrigeration, this was a big boon to human civilization. Of course, this may have led to a general rise in blood pressure, but who cares if the alternative is starving to death because all your food rotted away? But where does that leave us now, when we no longer have to live off of pickles and jerky? We are genetically programmed to eat ten times less salt than we do now. Even many low-salt diets can be considered high-salt diets. That’s why it’s critical to understand what the concept of “normal” is when it comes to salt.
Having a “normal” salt intake can lead to a “normal” blood pressure, which can help us die from all the “normal” causes, like heart attacks and strokes.
Doctors used to be taught that a “normal” systolic blood pressure is approximately 100 plus age. Systolic blood pressure means the top number, and indeed that’s about what we’re born with. Babies start out with a blood pressure around like 95 over 60, but then as we age, that 95 can go to 120 by our 20s, then 140 by our 40s (the official cut off for high blood pressure), and keep climbing as we age. That was considered normal, since everyone’s blood pressure creeps up as we get older. And if that’s normal, then heart attacks and strokes are normal too, since risk starts rising once we start getting above the 100 we had as a baby.
But if blood pressures over 100 are associated with disease, maybe they should be considered abnormal, perhaps caused by our abnormally high salt intake—ten times more than what our bodies were designed to handle. Maybe if we just ate a natural amount of salt, our blood pressures naturally would not go up with age, and we’d be protected. Of course, to test that theory, you’d have to find a population in modern times that doesn’t use salt, or eat processed food, or go out to eat. For that, you’d have to go deep into the Amazon rainforest. Meet the Yanomamo people, a no-salt culture.
Lowest salt intake ever reported, which is to say a normal-for-our-species salt intake. And so, what happens to their blood pressure? They start out with a blood pressure of about 100 over 60 and end up with a blood pressure of about 100 over 60. Though theirs is described as a salt-deficient diet, that’s like saying they have a diet deficient in Twinkies. They’re the ones, it seems, eating normal salt intakes, apparently leading to truly normal blood pressures. Those in their 50s have the blood pressure of a 20-year-old. What was the percentage of the population tested that had high blood pressure? Zero, whereas elsewhere in Brazil, up to 38% of the population may be affected. The Yanomamos probably represent the ultimate human example of the importance of salt on blood pressure.
But look, it could be other factors: they don’t drink alcohol, they eat a high-fiber, plant-based diet, get lots of exercise, and have no obesity. There are a number of plant-based populations eating little salt that experience no rise in blood pressure with age, but how do we know what exactly is to blame? Ideally, we’d do an interventional trial. Imagine if we took people literally dying from out-of-control high blood pressure, so called malignant hypertension—where you go blind from bleeding into your eyes, your kidneys shut down, your heart fails, and then you withhold from these patients blood pressure medications so their fate is certain death, and then put them on a Yanomamo level of salt intake, a normal-for-the-human-species salt intake, and if instead of dying, they walked away cured of their hypertension—that would pretty much seal the deal.
Enter Dr. Walter Kempner and his rice and fruit diet. Patients came in with blood pressures of 210 over 140 and left with blood pressures down to 80 over 60. What was the reason he could ethically withhold all modern blood pressure medications and treat with diet alone? The drugs hadn’t been invented yet—this was back in the 1940s. Now the diet wasn’t just extremely low salt, but strictly plant-based, extremely low in fat, protein, and calories. But there is no doubt that Kempner’s rice diet achieved remarkable results, and Kempner is now remembered as the person who demonstrated, beyond any shadow of doubt, that high blood pressure can often be lowered with a diet low enough in salt.
Forty years ago, it was acknowledged that the evidence is very good, if not conclusive, that a low enough reduction of salt in the diet would result in the prevention of essential hypertension—that rising of blood pressure as we age— and its disappearance as a major public health problem. It looks like we knew how to stop this four decades ago. In that time, how many people have died? Today, high blood pressure may wipe out 400,000 Americans every year; 1,000 unnecessary deaths a day.
To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.
Please consider volunteering to help out on the site.
- SS Lim, T Vos, AD Flaxman, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2224-60.
- MR Law, CD Frost, NJ Wald. By how much does dietary salt reduction lower blood pressure? III--Analysis of data from trials of salt reduction. BMJ. 1991 Apr 6;302(6780):819-24.
- LJ Appel, CA Anderson. Compelling evidence for public health action to reduce salt intake. N Engl J Med. 2010 Feb 18;362(7):650-2.
- K Bibbins-Domingo, GM Chertow, PG Coxson, A Moran, JM Lightwood, MJ Pletcher, L Goldman. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010 Feb 18;362(7):590-9.
- J Mancilha-Carvalho Jde, NA Souza e Silva. The Yanomami Indians in the INTERSALT Study. Arq Bras Cardiol. 2003 Mar;80(3):289-300.
- JJ Mancilha-Carvalho, DE Crews. Lipid profiles of Yanomamo Indians of Brazil. Prev Med. 1990 Jan;19(1):66-75.
- WJ Oliver, EL Cohen, JV Neel. Blood pressure, sodium intake, and sodium related hormones in the Yanomamo Indians, a "no-salt" culture. Circulation. 1975 Jul;52(1):146-51.
- SK Ha. Dietary salt intake and hypertension. Electrolyte Blood Press. 2014 Jun;12(1):7-18.
- R Friedman, J Iwai. Hypertension--salt poisoning? Lancet. 1978 Sep 9;2(8089):584.
- RJ Suckling, FJ He, ND Markandu, GA MacGregor. Dietary salt influences postprandial plasma sodium concentration and systolic blood pressure. Kidney Int. 2012 Feb;81(4):407-11.
- K Mezue. The increasing burden of hypertension in Nigeria - can a dietary salt reduction strategy change the trend? Perspect Public Health. 2014 Nov;134(6):346-52.
- WC Roberts. High salt intake, its origins, its economic impact, and its effect on blood pressure. Am J Cardiol. 2001 Dec 1;88(11):1338-46.
- GA MacGregor, ND Markandu, FE Best, DM Elder, JM Cam, GA Sagnella, M Squires. Double-blind randomised crossover trial of moderate sodium restriction in essential hypertension. Lancet. 1982 Feb 13;1(8268):351-5.
- F Delahaye. Should we eat less salt? Arch Cardiovasc Dis. 2013 May;106(5):324-32.
- ED Freis. Salt, volume and the prevention of hypertension. Circulation. 1976 Apr;53(4):589-95.
- DS Celermajer, B Neal. Excessive sodium intake and cardiovascular disease: a-salting our vessels. J Am Coll Cardiol. 2013 Jan 22;61(3):344-5.
- M Hanson, P Gluckman, D Nutbeam, J Hearn. Priority actions for the non-communicable disease crisis. Lancet. 2011 Aug 13;378(9791):566-7.
- W Kempner. Treatment of heart and kidney disease and of hypertensive and arteriosclerotic vascular disease with the rice diet. Ann Intern Med. 1949 Nov;31(5):821-56, illust.
- G Danaei, EL Ding, D Mozaffarian, B Taylor, J Rehm, CJ Murray, M Ezzati. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009 Apr 28;6(4):e1000058.
- CJ Murray, C Atkinson, K Bhalla. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013 Aug 14;310(6):591-608.
Images thanks to lbokel via Pixabay.
For the first 90% of our evolution, we ate diets containing less than a quarter teaspoon of salt a day, because for the first 90% of our evolution, we ate mostly plants. We went millions of years without salt shakers, and so our bodies evolved into salt-conserving machines, which served us well—until we discovered salt could be used to preserve foods. Without refrigeration, this was a big boon to human civilization. Of course, this may have led to a general rise in blood pressure, but who cares if the alternative is starving to death because all your food rotted away? But where does that leave us now, when we no longer have to live off of pickles and jerky? We are genetically programmed to eat ten times less salt than we do now. Even many low-salt diets can be considered high-salt diets. That’s why it’s critical to understand what the concept of “normal” is when it comes to salt.
Having a “normal” salt intake can lead to a “normal” blood pressure, which can help us die from all the “normal” causes, like heart attacks and strokes.
Doctors used to be taught that a “normal” systolic blood pressure is approximately 100 plus age. Systolic blood pressure means the top number, and indeed that’s about what we’re born with. Babies start out with a blood pressure around like 95 over 60, but then as we age, that 95 can go to 120 by our 20s, then 140 by our 40s (the official cut off for high blood pressure), and keep climbing as we age. That was considered normal, since everyone’s blood pressure creeps up as we get older. And if that’s normal, then heart attacks and strokes are normal too, since risk starts rising once we start getting above the 100 we had as a baby.
But if blood pressures over 100 are associated with disease, maybe they should be considered abnormal, perhaps caused by our abnormally high salt intake—ten times more than what our bodies were designed to handle. Maybe if we just ate a natural amount of salt, our blood pressures naturally would not go up with age, and we’d be protected. Of course, to test that theory, you’d have to find a population in modern times that doesn’t use salt, or eat processed food, or go out to eat. For that, you’d have to go deep into the Amazon rainforest. Meet the Yanomamo people, a no-salt culture.
Lowest salt intake ever reported, which is to say a normal-for-our-species salt intake. And so, what happens to their blood pressure? They start out with a blood pressure of about 100 over 60 and end up with a blood pressure of about 100 over 60. Though theirs is described as a salt-deficient diet, that’s like saying they have a diet deficient in Twinkies. They’re the ones, it seems, eating normal salt intakes, apparently leading to truly normal blood pressures. Those in their 50s have the blood pressure of a 20-year-old. What was the percentage of the population tested that had high blood pressure? Zero, whereas elsewhere in Brazil, up to 38% of the population may be affected. The Yanomamos probably represent the ultimate human example of the importance of salt on blood pressure.
But look, it could be other factors: they don’t drink alcohol, they eat a high-fiber, plant-based diet, get lots of exercise, and have no obesity. There are a number of plant-based populations eating little salt that experience no rise in blood pressure with age, but how do we know what exactly is to blame? Ideally, we’d do an interventional trial. Imagine if we took people literally dying from out-of-control high blood pressure, so called malignant hypertension—where you go blind from bleeding into your eyes, your kidneys shut down, your heart fails, and then you withhold from these patients blood pressure medications so their fate is certain death, and then put them on a Yanomamo level of salt intake, a normal-for-the-human-species salt intake, and if instead of dying, they walked away cured of their hypertension—that would pretty much seal the deal.
Enter Dr. Walter Kempner and his rice and fruit diet. Patients came in with blood pressures of 210 over 140 and left with blood pressures down to 80 over 60. What was the reason he could ethically withhold all modern blood pressure medications and treat with diet alone? The drugs hadn’t been invented yet—this was back in the 1940s. Now the diet wasn’t just extremely low salt, but strictly plant-based, extremely low in fat, protein, and calories. But there is no doubt that Kempner’s rice diet achieved remarkable results, and Kempner is now remembered as the person who demonstrated, beyond any shadow of doubt, that high blood pressure can often be lowered with a diet low enough in salt.
Forty years ago, it was acknowledged that the evidence is very good, if not conclusive, that a low enough reduction of salt in the diet would result in the prevention of essential hypertension—that rising of blood pressure as we age— and its disappearance as a major public health problem. It looks like we knew how to stop this four decades ago. In that time, how many people have died? Today, high blood pressure may wipe out 400,000 Americans every year; 1,000 unnecessary deaths a day.
To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.
Please consider volunteering to help out on the site.
- SS Lim, T Vos, AD Flaxman, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2224-60.
- MR Law, CD Frost, NJ Wald. By how much does dietary salt reduction lower blood pressure? III--Analysis of data from trials of salt reduction. BMJ. 1991 Apr 6;302(6780):819-24.
- LJ Appel, CA Anderson. Compelling evidence for public health action to reduce salt intake. N Engl J Med. 2010 Feb 18;362(7):650-2.
- K Bibbins-Domingo, GM Chertow, PG Coxson, A Moran, JM Lightwood, MJ Pletcher, L Goldman. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010 Feb 18;362(7):590-9.
- J Mancilha-Carvalho Jde, NA Souza e Silva. The Yanomami Indians in the INTERSALT Study. Arq Bras Cardiol. 2003 Mar;80(3):289-300.
- JJ Mancilha-Carvalho, DE Crews. Lipid profiles of Yanomamo Indians of Brazil. Prev Med. 1990 Jan;19(1):66-75.
- WJ Oliver, EL Cohen, JV Neel. Blood pressure, sodium intake, and sodium related hormones in the Yanomamo Indians, a "no-salt" culture. Circulation. 1975 Jul;52(1):146-51.
- SK Ha. Dietary salt intake and hypertension. Electrolyte Blood Press. 2014 Jun;12(1):7-18.
- R Friedman, J Iwai. Hypertension--salt poisoning? Lancet. 1978 Sep 9;2(8089):584.
- RJ Suckling, FJ He, ND Markandu, GA MacGregor. Dietary salt influences postprandial plasma sodium concentration and systolic blood pressure. Kidney Int. 2012 Feb;81(4):407-11.
- K Mezue. The increasing burden of hypertension in Nigeria - can a dietary salt reduction strategy change the trend? Perspect Public Health. 2014 Nov;134(6):346-52.
- WC Roberts. High salt intake, its origins, its economic impact, and its effect on blood pressure. Am J Cardiol. 2001 Dec 1;88(11):1338-46.
- GA MacGregor, ND Markandu, FE Best, DM Elder, JM Cam, GA Sagnella, M Squires. Double-blind randomised crossover trial of moderate sodium restriction in essential hypertension. Lancet. 1982 Feb 13;1(8268):351-5.
- F Delahaye. Should we eat less salt? Arch Cardiovasc Dis. 2013 May;106(5):324-32.
- ED Freis. Salt, volume and the prevention of hypertension. Circulation. 1976 Apr;53(4):589-95.
- DS Celermajer, B Neal. Excessive sodium intake and cardiovascular disease: a-salting our vessels. J Am Coll Cardiol. 2013 Jan 22;61(3):344-5.
- M Hanson, P Gluckman, D Nutbeam, J Hearn. Priority actions for the non-communicable disease crisis. Lancet. 2011 Aug 13;378(9791):566-7.
- W Kempner. Treatment of heart and kidney disease and of hypertensive and arteriosclerotic vascular disease with the rice diet. Ann Intern Med. 1949 Nov;31(5):821-56, illust.
- G Danaei, EL Ding, D Mozaffarian, B Taylor, J Rehm, CJ Murray, M Ezzati. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009 Apr 28;6(4):e1000058.
- CJ Murray, C Atkinson, K Bhalla. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013 Aug 14;310(6):591-608.
Images thanks to lbokel via Pixabay.
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High Blood Pressure May Be a Choice
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Content URLDoctor's Note
I’ve badly neglected sodium on NutritionFacts.org, but that’s all going to change. I have about a dozen salt videos queued up that dive deep into the existing controversies. It’s such an enormous topic that it was a bit intimidating at first. There are more than 8,000 articles on the topic in the medical literature, but that’s what you have me for! If you appreciate my efforts, please consider becoming a regular supporter by clicking on the donate button above.
For more on Kempner and his rice diet, see:
- Kempner Rice Diet: Whipping Us Into Shape
- Drugs and the Demise of the Rice Diet
- Can Diabetic Retinopathy Be Reversed?
Canned foods are infamous for their sodium content, but there are no-salt varieties (Canned Beans or Cooked Beans?). Cutting down on sodium is one of the ways we could be Improving on the Mediterranean Diet. Beyond heart health it could also help our kidneys (How to Treat Kidney Stones with Diet). But if you cut down on salt, won’t everything taste like cardboard? See Changing Our Taste Buds.
More on hypertension in How to Prevent High Blood Pressure with Diet and How to Treat High Blood Pressure with Diet. What if you already eat healthy and still can’t get your pressure down? Try adding hibiscus tea (Hibiscus Tea vs. Plant-Based Diets for Hypertension) and ground flax seeds (Flax Seeds for Hypertension) to your diet. And make sure you’re exercising regularly (Longer Life Within Walking Distance).
2020 Update – I just did a new series on blood pressure. See:
- What the New Blood Pressure Range Guidelines Mean
- How to Lower Blood Pressure Naturally with Lifestyle Changes
- Fasting to Naturally Reverse High Blood Pressure
And if you haven’t yet, be sure to watch How Not to Die from High Blood Pressure.
2022 Update – I just added a few new videos about a salt substitute:
- Fewer Than 1 in 5,000 Meet Sodium and Potassium Recommended Intakes
- Are Potassium Chloride Salt Substitutes Effective?
- Potassium Chloride Salt Substitute Side Effects
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