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Advanced Topics: The Dangers of Salt Restriction

The Dangers of Salt Restriction

migraine For decades, we have been advised to cut back on salt and sodium intake because of its effects on increasing blood pressure and potential consequences such as kidney and heart disease. More recent investigations, however, suggest that sodium was not the main culprit in these conditions; insulin resistance is the culprit that, in turn, leads to sodium retention. Efforts should therefore focus on correcting insulin resistance that reverses sodium sensitivity.


Most people with hypertension have insulin resistance and sodium restriction in that situation can reduce blood pressure (BP) by a few points: 5.5 mmHg systolic, 2.9 mmHg diastolic. People without hypertension, however, experience no reduction in blood pressure with sodium restriction but develop undesirable physiological consequences with sodium restriction--the pivotal issue is insulin resistance, not sodium.

Sodium restriction, whether hypertensive at the start or not, exerts adverse effects on renin, angiotensin, aldosterone, adrenaline, heart rate and other factors with more re-cent evidence of increased cardiovascular death as a result. Consistent with the kidney’s substantial capacity to clear sodium, the range for safe sodium intake is wide and far higher than current guidelines suggest.

The best evidence therefore suggests that current guidelines for sodium restriction lead to increased cardiovascular death in people without hypertension, in people with hypertension, and in people with diabetes type 1 and type 2. The ideal intake of sodium is a daily sodium intake of between 3000 and 7000 mg per day or 7600 to 17800 mg salt (3.3 to 7.7 teaspoons) per day. At a practical level, never purchase low- or reduced-sodium foods and use your salt shaker and salt your food to taste.

What the guidelines say

According to the American Heart Association (AHA):

sodium intake

The science of sodium intake has evolved over time. Early studies employed flawed measures such as dietary questionnaires that are known to be inaccurate, as well as spot sodium measures that reflect recent intake and not necessarily habitual intake patterns. Early studies were also almost entirely observational, not randomized, prospective nor blinded, meaning incapable of establishing cause-effect associations and often generating false conclusions.

Earlier studies also looked only at blood pressure as an endpoint. More recent evidence suggests, however, that, despite a modest reduction in blood pressure experienced with sodium restriction by people with hypertension, adverse effects develop that either negate the benefits of blood pressure reduction or are associated with increased risk for cardiovascular events and death. The AHA and other agencies presently advocate severe restriction of sodium even though this level of intake has been associated with increased cardiovascular death. (and, by the way, this severe sodium restriction completely neglects the fact that this virtually assures iodine deficiency if salt is the primary source of iodine.) The U.S. Dietary Guidelines for Americans suggests a limit of 2300 mg sodium per day, 1500 mg per day if hypertension is present. (One level teaspoon salt = 2300 mg sodium. The AHA advice therefore restricts salt to 2/3 of one teaspoon per day, a level few people are able to achieve.) Current advice is therefore dangerously outdated. Let’s examine the evidence to decipher how we should manage our sodium and salt intake for health.

New evidence

Recent evidence demonstrates that, not only is sodium restriction minimally effective in reducing blood pressure, but there are adverse effects beyond blood pressure that were not anticipated.

For example, reducing dietary sodium:
  • Increases renin, angiotensin, and aldosterone—This is the body’s response to sodium deprivation in an attempt to conserve sodium that has been associated with increased cardiovascular death. Unfortunately, this has led many authorities to advocate blocking the renin-angiotensin-aldosterone system using pharmaceutical agents, rather than addressing the root cause.

  • Increases sympathetic system activation—With an increase in blood pressure (in some people) and resting heart rate, an effect that correlates with increased cardiovascular risk.

  • Increases resistance to insulin—People with hypertension nearly all have in-creased insulin resistance to begin with, worsened by sodium restriction. People without hypertension who restrict sodium experience an increase in insulin re-sistance.

  • Increases total and LDL cholesterol (with no change in HDL or triglycerides). However, this may represent a short-term effect only, dissipating over longer time periods.

The greater the sodium restriction, the higher renin and aldosterone rise, with a 3.6-fold rise in renin, 3.2-fold rise in aldosterone with the greatest degree of sodium restriction—substantial changes that account for the increase in cardiovascular risk and deterioration in insulin sensitivity.

Conversely, if sodium deprivation causes such unphysiologic responses, sodium sup-plementation should reverse many of these phenomena. This has indeed been borne out in clinical studies. In one study, for example, 2 000 mg of salt (7/8 teaspoon) four times per day vs. placebo were supplemented in people with hypertension; salt supple-mentation modestly improved insulin sensitivity, an effect that also applied to people with type 2 diabetes and sodium-sensitivity (although BP did rise in sodium-sensitive individuals with average HbA1c of 6.4% (i.e. in the high pre-diabetic range, signifying substantial insulin resistance).

In randomized, prospective clinical trials, restricting sodium also does not reduce risk for cardiovascular events such as myocardial infarctions (heart attacks), stroke, or cardiovascular death, and more than doubled mortality in people who begin with congestive heart failure. As often happens, this is in contrast to the findings of observational epidemiological studies that suggested that sodium restriction reduced risk for cardiovascular events, once again reflecting the potentially misleading nature of observational data. Efforts to compensate for the deficiencies of observational data, such as performing serial 24-hour urine sodium collections over 9.5 years, showed a strong correlation: the higher the sodium loss in urine (reflecting higher sodium intakes), the lower the cardiovascular mortality. Other prospective analyses have suggested that sodium intakes of less than 3 grams per day or greater than 7 grams per day (based on urine sodium) are both associated with increased risk for cardiovascular death. This same range also held in people with hypertension with increased risk for cardiovascular events with sodium intakes of less than 3 grams per day or greater than 7 grams per day.

The essential issue to address in hypertension is therefore insulin resistance with the severity of insulin resistance reduced by adding more sodium to daily intake, as well as other efforts such as restricting carbohydrates, weight loss, restoration of vitamin D, magnesium supplementation, etc. Reversal of insulin resistance eliminates sodium sensitivity in the majority of people, making sodium restriction of no benefit, only harm.

There are indeed people who cannot consume greater amounts of salt. These include anyone diagnosed with hyperaldosteronism and kidney failure. While water and salt restriction have been a standard component of management of congestive heart failure, there is newer evidence that sodium restriction increases hospitalization rates and death from cardiovascular disease, as well as all-cause mortality, suggesting that sodium restriction should be abandoned in this setting.

Are there adverse effects of unrestricted sodium/salt intake? There is speculation and relatively low-quality evidence (i.e. experimental and observational) that sodium may encourage immune responses associated with autoimmune diseases. However, on the background of overall improved health with unrestricted sodium intake, this line of evidence is unlikely to yield productive insights.

How to get your salt

Conventional salt such as Morton’s is the only way to obtain iodine with salt, as the other forms such as sea salt, Kosher, Himalayan, artisinal, etc. contain negligible to no iodine. Unfortunately, brands such as Morton’s add a variety of different agents to inhibit clumping, as salt absorbs moisture from the air. Morton’s and other brands therefore have added calcium carbonate, magnesium carbonate, and aluminum hydroxide that helps maintain free flow. While the first two are benign, aluminum hydroxide potentially exposes you to aluminum that should be avoided. A small amount of sugar is also added to keep the potassium iodide added from yellowing the salt crystals.

There are also plenty of overblown claims made for the various forms of salt, including those over the mineral content of sea salt, Himalayan, and other forms. In truth, we simply need salt and the additional ingredients are present in relatively minor amounts, likely too small to materially add to health benefits. Nonetheless, many people report that the taste of such salts are better than conventional iodized table salt.

In general, salt harvested from salt mines on land is, from a microplastic standpoint (below), safer than that sourced from the ocean, since inland sources are the remnants of ancient seas before microplastics and other contaminants were introduced.

Sea salt—Harvested from sea water, sea salt seems like a reasonable choice. Sea salt contains trace quantities of minerals but no iodine. However, concerns about the booming proliferation of microplastics has raised concerns about sea salt. A recent study demonstrated that the majority of sea salt products contain microplastic, highest in products sourced from Asia. While microplastic is toxic at the cellular level, it is not clear what implications this poses for human health.

Redmond Real Salt—This brand of sea salt is sourced from the remnants of an ancient ocean located in Utah, so it does not share the concerns with microplastics of sea salt sourced from modern oceans.

Himalayan sea salt—This is salt harvested from the remnants of an ancient sea in Pakistan, thereby presumably not containing modern contaminants. While often touted as a good source for minerals such as magnesium, zinc, and iron, the quantities contained are too trivial to contribute to health.

Kosher salt—Kosher salt is a larger crystal form of salt, though not necessarily truly verified as Kosher for religious purposes. The name originates with the practice of “koshering” (i.e. salting meats to extract blood from the muscle, not with certification as Kosher). As with conventional table salt, beware of a variety of additives, as well as sourcing from sea water with concerns about microplastics discussed above.

Go to Forum discussion.


I call this discussion The Dangers of Salt Restriction, because for many years we were told that we should, fairly severely, restrict our salt (or sodium) intake, and that the observational data (that is: very poorly constructed studies) suggested that there was a benefit to that — particularly a benefit in reducing blood pressure.

It's become clear that salt retention, or salt sensitivity, develops in people with insulin resistance, and that's the process that makes people retain salt. The real solution is not to reduce salt; it's to reverse insulin resistance, which you know is rampant in the U.S., right.

So how do we reverse insulin resistance? Well, the Undoctored Wild-Naked-Unwashed program does that, in great majority of people, very effectively. We remove grains and sugars that raise blood sugar, and thereby lead to high insulin and insulin resistance — we remove those. We correct Vitamin D deficiency. That helps reduce insulin resistance. Fish oil, magnesium, iodine and thyroid optimization — that all reverses insulin resistance. And cultivation of healthy bowel flora also contributes to reversal of insulin resistance.

Put all those six strategies together, and you have a spectacularly effective way to reduce or reverse insulin resistance, and thereby, sodium sensitivity. So there is no need, once you correct insulin resistance, there is no need to restrict salt. And this happens quite quickly. That's why, in the start of your program, I tell everybody:
• hydrate more than usual, and
• salt your food,
because if you don't, you can actually pass out in that first 7 to 10 days, because of loss of salt. That's what happens when you reverse insulin resistance, which happens very rapidly on the Undoctored program.

And long term, I encourage salt intake. The evidence has become quite clear. Better data — randomized prospective data, using better measures of sodium intake, have shown that if you restrict sodium, particularly to the severe degree advocated by the American Heart Association — of 1500 milligrams per day — there is an increase in cardiovascular events and death. It is not a good idea to restrict sodium to that degree. It's not a good idea to restrict sodium at all, unless of course you have kidney failure or some other unusual conditions.

For most of us, ideal intake of sodium is between 3000 and 7000 milligrams of sodium per day, which translates into about 3½ to 7½ teaspoons of salt per day. The average American takes in 3400 milligrams of sodium per day, which is perfectly fine, even though the heart association and other people say it's too high.

At a practical level, salt your food to taste. Enjoy it. If you want to dash some salt in your drinking water, that's a very good idea — or your salad, or your salmon, or your steak — go ahead. Enjoy the salt. Don't restrict salt. There is no benefit to restricting sodium or salt in the diet. Sodium and salt makes food taste better, and it's healthier for you.

If possible, try to buy the sea salt, or Himalayan type sea salt, or even the best: Redmond [brand] Real Salt®, because that's sourced from remnants of an ancient ocean, in Utah. It's therefore not sourced from modern ocean water, which has issues like microplastics and other contaminants. I think the safest source is salt sourced from this ancient ocean in Utah, called Redmond.

So go ahead — enjoy your salt, and enjoy all the health benefits that come from not restricting salt.

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