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Who Should Restrict Salt?

Three studies on salt consumption in the New England Journal of Medicine (August 14, 2014) did not resolve the decades-long debate over the value of trying to get people to restrict salt. Two of the studies measured the amount of salt in the urine of more than 100,000 people in 17 different countries and followed them for the next four years for blood pressure, heart attacks, strokes, and deaths. They concluded that people who eat very large amounts of salt should restrict salt intake, but those who have an average salt intake won't benefit from salt restriction. The third study is a review of 200 previous studies of salt restriction, which mainly shows how much time and effort researchers have spent on the subject.

For many years I have taken the contrary position that most people should not try to micro-manage their diets to reduce salt intake. Instead, they should concentrate on the major lifestyle changes that help to prevent heart attacks, strokes and high blood pressure, and avoid excess salt intake, by not using  a salt shaker and not eating a lot of meat.   These lifestyle changes will help your body maintain healthful levels of salt without having to pay attention to every mouthful of food.

• A high-salt diet is likely to be a diet high in junk foods and processed foods, high in animal products and low in fresh vegetables and fruits. If you maintain a healthful diet, excess salt is unlikely to be an issue. Fruits and vegetables are low in salt, while meat is naturally high in salt. Most people can control high blood pressure without drugs if they follow a healthful diet; see my Modified DASH Diet.

• People who are overweight are the ones most likely to have high blood pressure caused by excessive salt consumption or for any other reason. Therefore, maintain a healthful weight or lose weight if you are overweight.

• Exercisers lose large amounts of salt through sweat and thus usually need more, not less, salt in their diets. This is just one of the many benefits of a regular vigorous exercise program.  Among healthy people, only heavy exercisers need extra salt, so they can use a salt shaker, particularly when they are exercising in hot weather.  If they do not replace their lost salt, they will not recover from their workouts and be tired and exhausted all the time.

Who Needs to Restrict Salt?
The people who are most likely to get high blood pressure from taking in too much salt are those whose cells do not respond well to insulin (Hypertension, Jan 2013). People whose cells do not respond well to insulin are called "insulin resistant" or "insulin insensitive". People who are insulin insensitive usually are already diabetic or have what is called metabolic syndrome. You have metabolic syndrome if you have any three of the following:
• storing fat primarily in your belly
• having small hips
• being overweight
• having high blood triglycerides (>150)
• having low HDL cholesterol (<40) • having a fatty liver (diagnosed with a simple sonogram of the liver) • having a high fasting blood sugar >100 (HbA1c> 5.7)
• having high insulin levels
• having high blood pressure

My Recommendations
Instead of asking patients to focus on restricting salt in foods, I believe that doctors should push all of the other established healthful guidelines for preventing high blood pressure, heart attacks, strokes and premature death:
• lose excess weight
• exercise
• eat large amounts of vegetables and fruit
• eat a healthful diet that is high in plants and low in red meat and processed foods
• stop using a salt shaker
• keep hydroxy-vitamin D levels above 75 nmol/L
• restrict alcohol
• do not smoke

Checked 1/2/17

August 24th, 2015
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About the Author: Gabe Mirkin, MD

Sports medicine doctor, fitness guru and long-time radio host Gabe Mirkin, M.D., brings you news and tips for your healthful lifestyle. A practicing physician for more than 50 years and a radio talk show host for 25 years, Dr. Mirkin is a graduate of Harvard University and Baylor University College of Medicine. He is board-certified in four specialties: Sports Medicine, Allergy and Immunology, Pediatrics and Pediatric Immunology. The Dr. Mirkin Show, his call-in show on fitness and health, was syndicated in more than 120 cities. Read More
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