Before the diuretics (especially the loop diuretics) became available in the late 1960’s, if a person had fluid retention from kidney or heart problems, we treated them with a very low salt diet. If they developed too much fluid retention (what in the good old days was called “dropsy”) we would hospitalize them, put them on complete bedrest, or gave them a shot of a (somewhat toxic) mercury diuretic.

The mainstay back then for sluggish kidneys (azotemia), congestive heart failure, or high blood pressure back then was a low sodium (low salt) diet.

And what was a  “low salt”diet”? For most folks, we tried to cut them to 2 gm of salt a day, and for severe problems, 1 gm a day. But the dirty little secret is that hardly anyone was able to stay on a 1 gram salt a day diet.

So you would see Aunt Mary coming into the Emergency Room at 4 a.m. in acute pulmonary edema (drowning from too much fluid in her lungs) because she just “had to” have a bite of Kielbasa and sauerkraut with her bland supper.

Such episodes are rare nowadays, and the reason? TGFL: Thank God for Lasix

One of the hardest parts in preventive medicine is changing a person’s diet.

Which is why I am sceptical that the powers that be have decided to tell you to cut your salt down drastically. From the Washington Post:

…If a federal advisory committee has its way, (1,500 mg of sodium) will be the recommended daily amount adults should consume, down from 2,300, when the Dietary Guidelines for Americans 2010 are updated in December.

Well, good for them. And if you think Americans are going to do this, I have a bridge in Brooklyn that I can sell you.

Let’s put this into perspective.

The average American takes 3-4 gms of salt in their food each day. If you eat “fast foods”, it is probably two or three this amount.

So if we encourage people to keep stop eating salty food, the result will be a lot less heart and kidney disease from high blood pressure.

But I am wondering what dodo decided that it was practical to issue guidelines that keep the sodium level down to 1.5 grams. Even the Post is skeptical:

Put in real-food terms, it could mean: Cheerios with skim milk and orange juice for breakfast (about 300 mg), two pieces of whole-grain white Wonder Bread with peanut butter and plain yogurt (about 600 mg) and a healthful entree for dinner (about 600 mg).  Sound appetizing? Not so much. But if cutting sodium makes sense to you (and your doctor), there are easy ways to do so without sacrificing flavor.

Uh, not really. The herbs, lemon and vinegar can lower your salt intake, but you need some salt to make the food palatable. And there in lies the problem.

In the “good old days”, we docs tried to keep our patients on a low sodium diet, with little success. Then came thiazides and lasix, and we gave up the fight, and just told them to throw away the salt shaker and please, please stay away from pickles and salted meats.

Nor is this just an “American” problem.

Those of us who eat a “healthy” Asian diet tend to take in 2 or three times that much salt, partly due to the salt in seafood, but mainly due to the fact that we lavish our foods with soy sauce or fish sauce or similar high salt condiments.

It is well known that a high salt diet contributes to high blood pressure. From the British Medical Journal:

    • Higher salt intake is associated with significantly greater incidence of strokes and total cardiovascular events, with a dose dependent association
    • A difference of 5 g a day in habitual salt intake is associated with a 23% difference in the rate of stroke and 17% difference in the rate of total cardiovascular disease
    • Each year a 5 g reduction in daily salt intake at the population level could avert some one and a quarter million deaths from stroke and almost three million deaths from cardiovascular disease worldwide

Ergo, cut the salt.

Why yes, but…

The problem with these “guidelines” is that they overdid it. Most folks, except for the “OCD” types who weigh every particle of food and obsess about every gram of fat in their diet are not going to be able to live on a 1.5 sodium diet.

And where are the studies on very low salt diets in a diverse population? There are very few populations who actually have such a low sodium diet, and now with globalization, when you can buy soft drinks and chips in the most isolated villages, I suspect there are even fewer,. However, thirty years ago I worked with a tribe in Africa who lived far from the ocean, and still ate a “traditional” diet. And you know what? We saw little if any hypertension, except among the educated (who ate a western diet).

But we also had folks die of minor infections, because their diet also lacked protein and proper vitamins.

In contrast, here in the Philippines, with our Patis and bagoong, hypertension is a major killer. The middle aged die of strokes, and it is especially severe in our poor, who cannot afford 5 pesos (ten cents US) a day for the medicine to treat the high blood pressure.

So I agree. Want to live longer? cut down your salt. Even more importantly, cut down the salt in your kids’ diets, since once you actually have high blood pressure, cutting the salt will only help a little bit, whereas if you eat a lifelong lower salt diet, you probably will have a lower chance of getting high blood pressure.

As for those “guidelines”:

Tell you what.

If those who are making up these guidelines can stay on a 1.5 gm salt diet for a year, and if (more importantly) they can persuade their entire family to do the same, then I will take them seriously.

In the meanwhile, throw out the salt shaker, cut down the chips and your fast food intake, and use a bit of common sense when eating, and you will live longer and be a lot more healthy.


Nancy Reyes is a retired physician living in the rural Philippines. She blogs at Finest Kind Clinic and Fishmarket, and writes medical essays at Hey Doc Xanga Blog

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