Healthy Salt Recommendations

This post came with a big plot twist for me.  My intention was to research and report on whether the type of salt we choose has an effect on wellness.  As I sifted through the studies, I learned the real story is that government guidelines for sodium restriction could actually CAUSE the very diseases salt restriction is supposed to prevent. It forced me to go looking for healthy salt recommendations based on evidence.

The ideal amount of salt to consume per day has been a source of controversy for decades. The point of contention generally comes down to the effect (or lack thereof) salt has on blood pressure.

Salt does NOT have the impact on blood pressure and disease outcomes that you may have been led to believe. In this post, we will take a look at the evidence and find out what the real blood pressure culprits are.

What is salt?

Salt is a crystalline mineral made of two elements, sodium (Na) and chlorine (Cl).  When the elements are combined in the correct ratio, they become sodium chloride, or salt.

Chemically, salt is 60.663% elemental chlorine (Cl) and 39.337% sodium (Na). And in case you ever need to know, it has a melting point of 1,473.4° F.

We think of salt as a flavor and also as a preservative, but it is also a crucial electrolyte.

Sodium is needed for: adrenal gland function, cell wall stability, muscle contractions, nerve stimulation, pH and water balance regulation. Most of the sodium we consume comes from salt added to food.

Chloride (an ion of chlorine) works in conjunction with sodium and potassium to regulate pH in the blood and the passage of fluids across cell membranes. Chloride is the basis of hydrochloric acid which is needed to digest protein. Chloride also activates enzymes that digest carbohydrates and is necessary for the proper growth and functioning of the brain. Trace amounts of chloride can also be found in celery and coconut.

Salt is also used in almost every industry. Examples include the manufacture of pulp and paper; the setting of dyes in textiles and fabric; the production of soap, detergent, and various bath products. Salt is also the major source of industrial chlorine and sodium hydroxide.

Types of salt

Most of the world’s salt is harvested from salt mines, or by evaporating sea water or other mineral-rich waters. There are many different kinds of salt and they do differ in taste, texture, mineral content and sodium content.  Here are some of the most common.

Refined Salt (plan old table salt)

• Highly refined and heavily ground with most impurities and trace minerals removed
• Can clump together so anti-caking agents are added so it doesn’t clump.
• Table salt is 97% or higher pure sodium chloride.  Other naturally occurring trace minerals are removed.
• Iodine is often added.  This was originally done by Morton salt company in 1924 as a public health measure to help prevent iodine deficiency. Iodine is needed for many biochemical processes including: fat metabolism, mental development, muscle function, the production of sex hormones and thyroid function.  Foods high in iodine include fish, dairy, eggs and seaweed. It is also found in butter, asparagus, artichokes, dark green vegetables and pineapple. Over-iodization has been shown to abnormally enlarge the thyroid gland and cause thyroid-related autoimmune disorders.
• It is chemically produced, not naturally occurring.
• May contain MSG and/or white processed sugar to help stabilize the iodine.
• May contain aluminum derivatives such as sodium solo-co-aluminate.
• When saltwater fish are placed in salt water made with table salt, they die.

Sea Salt

• Sea salt is made by evaporating seawater.
• Like table salt, it is mostly sodium chloride.
• Contains around 60 trace minerals like potassium, iron, magnesium and zinc.
• According to Patricia Atkins Analysis of Gourmet Salts for the Presence of Heavy Metals, the darker the sea salt, the higher its concentration of “impurities” and trace minerals. However, sea salt can also contain trace amounts of heavy metals like lead.
• Often less ground than regular refined salt, if you sprinkle sea salt on your food after it has been cooked, it may have a slight crunch and seem more flavorful than refined salt.
• The trace minerals and impurities found in sea salt can also affect the taste.  Taste can vary between brands.

Himalayan (Pink) Sea Salt

• Known as “pink gold”
• Doctors of functional medicine generally recommend Himalayan Sea Salt the most.
• Himalayan salt is harvested in Pakistan.
• It is mined from the Khewra Salt Mine, the second largest salt mine in the world.
• The pink color comes from trace amounts of iron oxide (rust).
• It contains small amounts of calcium, iron, potassium and magnesium.
• It contains slightly lower amounts of sodium than regular salt.
• Many people prefer the flavor of himalayan salt.
• The main difference seems to be the color.

Kosher Salt

• Kosher salt was originally used for religious purposes. Jewish law required blood to be extracted from meat before it was eaten. Kosher salt has a flaky, coarse structure that is particularly efficient at extracting the blood.
• The main difference between regular salt and kosher salt is the structure of the flakes. Due to its large flake size, other salt is easier to pick up with your fingers and spread over food.
• After the salt dissolves into the food, there really isn’t any difference compared to regular table salt.
• Kosher salt is less likely to contain additives like anti-caking agents and iodine.

Celtic Salt

• Made from sea water and originally became popular in France. It is harvested in Brittany France near the Celtic Sea using a 2,000-year old Celtic method.
• Has a greyish color and also contains a bit of water, which makes it moist.
• Contains trace amounts of minerals
• A bit lower in sodium than plain table salt.

Minerals in Different Types of Salt

A 2010 study showed the mineral content of different salt types. The table shows a comparison between

The table shows the comparison between Table Salt, Maldon Salt (a sea salt), Himalayan Salt and Celtic Salt:

The Celtic salt tested showed the least amount of sodium and the highest amount of calcium and magnesium, while Himalayan salt led the pack in potassium.

I need to point out that these are extremely tiny amounts.  To put it in perspective, you would need to eat 100 grams of salt to reach the recommended daily amount of magnesium (which is already too low).

The mineral content of salt ends up not being a very compelling argument for one salt over another.

The main benefit in selecting any other kind of salt over regular table salt is to avoid the additives, anti-caking agents and the chemical and heat processing.  Among the more natural types, select the taste and texture that pleases you most.  My preference is Himalayan Sea Salt.

The main reason to avoid table salt is anti-caking agents and chemical processing. Click To Tweet

The amount of sodium usually recommended

Here’s the daily amount of sodium recommended by major health organizations:

• United States Department of Agriculture (USDA): 2300 mg.
• American Heart Association (AHA): 1500 mg.
• Academy of Nutrition and Dietetics (AND): 1500 to 2300 mg.
• American Diabetes Association (ADA): 1500 to 2300 mg.

There’s a definite consensus among the major health organizations that our daily salt intake should be in the range of 1500 – 2300 mg per day.

1500 mg of sodium is about 3.75 grams or 0.75 teaspoons of salt per day, while 2300 mg equals 6 grams or about one teaspoon of salt per day.

According the to US Centers for Disease Control (CDC), the average amount of salt consumed by Americans is 3300 mg per day or more.  This average has not increased in 50 years, despite an increase in cardiovascular problems.

According to the CDC, “Eating too much sodium puts Americans at risk for developing serious medical conditions, like high blood pressure, heart disease,and stroke.”  It’s true that hypertension (high blood pressure) is a major risk factor for diseases, like heart disease, stroke and kidney failure.

The government recommendations came from one flawed study

The genesis of the sodium myth lies with one study that seemed to show a link between salt and hypertension.

The DASH-sodium study was conducted in 1997 to determine whether or not a low-salt diet would control hypertension. The DASH diet consists of fresh vegetables and fruits, lean protein, whole grains, and low-fat dairy, and is very low in salt. But Dr. Mercola points out, “…it’s ALSO low in sugar/fructose. So, while people on DASH diets do show reduced hypertension, the reason for this is not the reduction in salt, but the reduction in fructose. Hypertension is actually promoted more by excess fructose than excess salt. Researchers were so eager and personally invested in proving their salt theory that they completely overlooked other factors, thereby drawing the wrong conclusion altogether. This is where the sodium myth really gained its footing. Salt got the blame for the damage sugar was causing in a monumental rush to judgment.”

Government recommendations for salt reduction came from one flawed study. Click To Tweet

Does salt restriction prevent disease?

25 years of evidence have failed to show any benefit from a low salt diet. Let’s take a look.

1985:  A study published in British Medical Journal involved people that had a family history of high blood pressure. The participants restricted their salt intake for eight weeks. At the end of the study, no differences were found in their blood pressure readings.

1987:  J Chronic Dis – The number of people who experience drops in blood pressure after eating high-salt diets almost equals the number who experience blood pressure spikes; many stay exactly the same.

1988:  Intersalt study, BMJ Conclusion: There is no relationship between sodium and hypertension; in fact, those who ate the most salt had a LOWER median blood pressure than those who ate the least salt.

1995:  AMA study published in the journal Hypertension, found low urinary sodium associated with an increased risk of heart attack.

1997:  DASH-sodium study, NEJM Conclusion: “A diet rich in fruits, vegetables, and low-fat dairy foods and with reduced saturated and total fat can substantially lower blood pressure. This diet offers an additional nutritional approach to preventing and treating hypertension.”

1998:  Researcher Gary Taubes published a report called “The (Political) Science of Salt” in Science Magazine. In the report, Taubes concluded that “After decades of intensive research, the apparent benefits of avoiding salt have only diminished. This suggests that either the true benefit has now been revealed and is indeed small or that it is non-existent and researchers believing they have detected such benefits have been deluded by the confounding of other variables.”

1998:  NHANES I, Lancet Conclusion: “These results do not support current recommendations for routine reduction of sodium consumption, nor do they justify advice to increase salt intake or to decrease its concentration in the diet.”

2003:  Cochrane review Conclusion: “There is little evidence for long-term benefit from reducing salt intake.”

2003:  Cochrane Review – Low sodium diets were found to cause an increase in LDL (“bad” cholesterol) by 4.6% and an increase in triglycerides by 5.9%.

2006:  NHANES II, Am J Med Conclusion: Lower sodium diets led to HIGHER mortality rates among those with cardiovascular disease, which “raised questions regarding the likelihood of a survival advantage accompanying a lower sodium diet.”

2007:  Rotterdam Study, Eur J Epidemiol Conclusion: “From this and other epidemiological studies we conclude the effect of dietary salt on clinical cardiovascular endpoints and overall mortality within the range of intake commonly observed in Western countries has not yet been established.”

2008:  Clin Sci (Lond): Low-sodium diets result in worse clinical outcomes for people with congestive heart failure, due to “detrimental kidney and neurohormonal effects.”

2011:  Cochrane review Conclusion: Cutting down on the amount of salt has no clear benefits in terms of likelihood of dying or experiencing cardiovascular disease.

2011 Rotterdam Study, JBMR Conclusion: “Mild hyponatremia in the elderly is associated with an increased risk of vertebral fractures and incident nonvertebral fractures, but not with bone mineral density. Increased fracture risk in hyponatremia also was independent of recent falls, pointing toward a possible effect on bone quality.”

2011:  JAMA Conclusion: “Systolic blood pressure, but not diastolic pressure, changes over time aligned with change in sodium excretion, but this association did NOT translate into a higher risk of hypertension or cardiovascular disease complications. Lower sodium excretion was associated with higher cardiovascular disease mortality.”

2011:  Meta-Analysis AJH Conclusion: “Despite collating more event data than previous systematic reviews, there is still insufficient power to exclude clinically important effects of reduced dietary salt on mortality or cardiovascular disease morbidity.”

2011:  Metabolism Clinical and Experimental – Just 7 days on a low sodium diet increased insulin resistance, a leading cause of obesity, diabetes and metabolic syndrome.

2011:  ADA – In patients with type II diabetes, less sodium was associated with an increased risk of death.

Less salt doesn't lower blood pressure but does increase LDL, triglycerides and heart attacks. Click To Tweet

Please note that if you have a medical condition like salt-sensitive hypertension then you may be an exception to the studies.

Factors that effect blood pressure more than sodium restriction

Fructose is STRONGLY linked to hypertension

Most excess salt in the standard American diet (SAD) comes from processed food, which is a bad idea to eat anyway.  But processed food is also typically very high in fructose.  I have a related post on fructose.

Dr. Jospeh Mercola says, “The connecting link between fructose consumption and hypertension lies in the uric acid produced. Uric acid is a byproduct of fructose metabolism, and increased uric acid levels effectively drive up your blood pressure.”

We need a little more potassium than sodium

A 20013 BMJ Study found: “High quality evidence shows that increased potassium intake reduces blood pressure in people with hypertension and has no adverse effect on blood lipid concentrations, catecholamine concentrations, or renal function in adults. Higher potassium intake was associated with a 24% lower risk of stroke (moderate quality evidence). These results suggest that increased potassium intake is potentially beneficial to most people without impaired renal handling of potassium for the prevention and control of elevated blood pressure and stroke.”

Imbalance in the sodium to potassium ratio can not only lead to hypertension but also contribute to a number of other diseases, like:

• Cataracts
• Erectile dysfunction
• Heart disease and stroke
• Kidney stones
• Memory decline
• Osteoporosis
• Rheumatoid arthritis
• Ulcers and stomach cancer

CBS News reported on the study: “If you have too much sodium and too little potassium, it’s worse than either one on its own,” said Dr. Thomas Farley, New York City’s health commissioner, who has led efforts to get the public to eat less salt… “Potassium may neutralize the heart-damaging effects of salt,” said Dr. Elena Kuklina, one of the study’s authors at the Centers for Disease Control and Prevention… The research found people who eat a lot of salt and very little potassium were more than twice as likely to die from a heart attack as those who ate about equal amounts of both nutrients. Such a dietary imbalance posed a greater risk than simply eating too much salt, according to the study.”

So, how do you ensure you get these two important nutrients in more appropriate ratios? Dr. Mercola advises: “Ditch processed foods, which are very high in processed salt and low in potassium and other essential nutrients, and eat a diet of whole, unprocessed foods, ideally organically-grown to ensure optimal nutrient content. This type of diet will naturally provide much larger amounts of potassium in relation to sodium.”

Some sources rich in potassium:

• Lima beans (955 mg/cup)
• Winter squash (896 mg/cup)
• Cooked spinach (839 mg/cup)
• Avocado (500 mg per medium)

Other potassium-rich fruits and vegetables include papayas, prunes, cantaloupe, and bananas, broccoli, Brussels sprouts, avocados, asparagus, and pumpkin.

Be careful of bananas as they are high in sugar and have half the potassium than an equivalent of amount of green vegetables. The potassium is twice as high in green vegetables.

To lower blood pressure, increase potassium instead of cutting salt. Click To Tweet

Chocolate(!) helps reduce blood pressure

A 2007 JAMA study concluded: “…inclusion of small amounts of polyphenol-rich dark chocolate as part of a usual diet efficiently reduced BP and improved formation of vasodilative nitric oxide.”

A low carb diet can reduce blood pressure twice as much as salt restriction

An 8 week study found:  “Systolicblood pressure decreased by an average of 9.0 mmHg (1 mmHg = 133.322 Pa) (p < 0.01) and diastolic blood pressure decreased by 7 mmHg (p < 0.05).”

Exercise can reduce blood pressure twice as much as salt restriction

A 1998 study in the Clinical Journal of Sports Medicine concluded: “These studies showed reductions in blood pressure (systolic blood pressure/diastolic blood pressure) of-13/-18 mm Hg in hypertensive patients. Most of the antihypertensive effect of exercise training was observed after 10 weeks, whereas training more than three times per week or for more than 50 minutes did not confer added benefit. Lower intensity exercise resulted in greater blood pressure reduction than did high intensity exercise.”

A 1985 JAMA study reported excellent blood pressure reduction after 16 weeks of exercise: “Reductions in systolic pressures were 6.3 mm Hg, 10.3 mm Hg, and 15.5 mm Hg for control, normoadrenergic, and hyperadrenergic groups, respectively.”

Other factors have double the effect of sodium reduction on blood pressure. Click To Tweet

The optimum amount of salt

The Journal of the American Medical Association published a study in 2011 that concluded: “The association between estimated sodium excretion and CV events was J-shaped. Compared with baseline sodium excretion of 4 to 5.99 g per day, sodium excretion of greater than 7 g per day was associated with an increased risk of all CV events, and a sodium excretion of less than 3 g per day was associated with increased risk of CV mortality and hospitalization for CHF. Higher estimated potassium excretion was associated with a reduced risk of stroke.”

So the answer according to the 2011 study is: 4000 – 6000 mg per day of sodium (along with slightly higher potassium).

Note how the study indicated 3000 mg per day, or less, was associated with an increased risk of a cardiovascular event.  One has to ask why the major health organizations still recommend 1500 – 2300 mg per day.

According to researcher and Chris Kresser M.S., L.Ac: “While salt recommendations vary between individuals based on age, gender, physical activity, and health conditions, I feel that the data supports an intake between 3000 and 7000 milligrams of sodium, or 1.5 to 3.5 teaspoons of salt, per day. People who are quite active or sweat a lot should consume salt on the higher end, and those who are less active may want to consume on the lower end. Of course, there may be some conditions where moderate salt restriction is warranted, but for the majority of healthy individuals, salting to taste will provide an appropriate level of sodium in the diet.”

It is possible to consume too little salt

A sodium deficiency is called hyponatremia.

According to the Mayo Clinic: “A low-sodium, high-water diet can sometimes disturb the proper balance between sodium and fluids in your blood.”

Signs of hyponatremia include:

• Changes in appetite
• Coma
• Confusion
• Cramps
• Fatigue
• Hallucinations
• Headache
• Loss of energy
• Muscle weakness
• Nervousness, restlessness and irritability, and other mood changes
• Seizures
• Spasms
• Nausea
• Urinary incontinence
• Unconsciousness
• Vomiting

2007:  CJASN – In athletes, a low sodium intake can cause a sodium deficiency which can be very dangerous.

2009:  International Urology and Nephrology – A study of large-bone fractures in the elderly found the incidence of hyponatremia in patients with fractures was MORE THAN DOUBLE that of non-fracture patients. They postulated the reason for the sodium deficiency might have been the use of selective serotonin receptor inhibitors (SSRIs), a type of antidepressant drugs.

Conclusions

It’s probably best to avoid the anti-caking agents and chemical processing of regular table salt.  Stick with the unrefined varieties like Himalayan pink salt for optimum taste, texture and the maximum trace minerals.

If you eat a diet of whole, unprocessed foods you don’t need to be worried about consuming too much salt.  In fact, you may have to pay attention to making sure you get enough salt.  I salt my food to taste at every meal and still add additional salt to cups of water to get enough for adrenal support.  My preference is pink Himalayan salt.

The Wellness Repair plan for salt intake is:

1. Eat whole unprocessed food.  See the Wellness Repair Food Facts for a list of suggestions.
2. Salt (and butter with grass-fed butter) to taste.

Salt plan: 1) Eat whole, unprocessed foods. 2) Salt to taste. Click To Tweet

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Thanks for reading!
Jeff

Additional Resources

Authority Nutrition – The Salt Myth – How Much Sodium Should You Eat Per Day?