- Ultra-processed foods comprise about 70% of the average American’s diet and a significant proportion of its sodium intake.
- All of the supposed benefits of reducing sodium intake stem from hypothetical data extrapolations.
- The processing of food — rather than the amount of sodium — is what correlates to the development of disabilities and diseases.
There was a study recently published in the prestigious Journal of the American College of Cardiology (JACC) that seemed to garner little interest outside of those who like to delve into the arcane art of obscura cardiologica. The article was entitled, “Effect of High Dietary Sodium Intake in Patients with Postural Tachycardia Syndrome,” so you get an idea excitement level that generates outside of a very small circle of people. Postural Tachycardia Syndrome is also known as Postural Orthostatic Tachycardia Syndrome or POTS — part of the qualifications for being a cardiologist is coming up with clever acronyms.
POTS is a unique condition in the world of cardiology in that the remedy often involves the recommendation of a high salt (sodium) diet in an effort to increase intravascular blood volume. It is, in the words of the study’s authors, “a chronic disabling disorder characterized by excessive tachycardia [fast heart rate] and worsening of symptoms when upright, then improvement with recumbence.[i]” It is an exaggeration of a normal response. When we stand up from a sitting or lying position, our heart rate normally increases to prevent a drop in our blood pressure. However, in patients with POTS, estimated to be about 0.2% to 1% of the population, this reflex is excessive; and defined as an increase of over 30 bpm in adults when arising to a standing position from sitting or reclining.
The lack of benefit of a low-salt diet
Why this is important is in light of the persistent efforts of The World Health Organization (WHO) and other entities to push a low dietary sodium mandate upon us, whilst ignoring the documented perils of ultra-processed foods, which comprise about 70% of the average American’s diet. The lack of effect, and lack of benefit, from a low-salt diet has been evident for years, prompting many experts such as Professor Niels Graudal of Copenhagen University Hospital in Denmark to remark that, “It is surprising that many countries have uncritically adopted sodium reduction, which probably is the largest delusion in the history of preventive medicine.”
The average American consumes roughly 3.4 grams of sodium or about 150mmol per day (which is also the worldwide average[ii]). In such a population with this level of sodium consumption, sodium reduction has no effect on blood pressure.[iii] In fact, all the supposed benefits from reducing sodium — like the World Health Organization’s claim that excess sodium consumption costs 3 million lives per year intake stems from hypothetical data extrapolations. No study, examining only dietary sodium restriction, has demonstrated a decrease in hard endpoints like cardiovascular disease or early mortality. In fact, in other parts of the world where there has been a 50% increase in sodium intake; this was associated with a fall in hypertension prevalence from 30% to 15%.[iv]
The idea that less sodium leads to better health is based on flawed assumptions from the 1970s in which the US government concluded that since “consuming less salt or sodium is not harmful, it is understandable why the Federal Government recommends that healthy normal individuals moderate their salt and sodium intake." The only problem here is that many studies, some acknowledged in the government's own position paper, have questioned the safety of too much sodium restriction — or even any restriction at all. Populations on minimal salt intake have extreme activation of the renin-aldosterone system and an increase in lipids and catecholamines.[v]
Activation of the renin-aldosterone system is associated with hypertension and all its ill effects. There is an associated rise in catecholamines, which are commonly known as stress hormones like epinephrine and norepinephrine. Higher circulating levels of catecholamines are also associated with disease states that congestive heart failure; were low sodium diets are often prescribed. However, data from the HART study found “there was no [italics mine] demonstrable evidence that dietary sodium restriction is associated with a lower rate of death or HF hospitalization. In fact, dietary sodium restriction was associated with increased risk [italics mine] of adverse outcomes, particularly HF hospitalization.[vi]” Additional studies of healthy populations demonstrate increased all-cause mortality with low sodium intake.[vii]
What is fascinating about this recent POTS study are the findings in the normal control group. It is important to note a critical caveat here, the study was not designed to examine the observations in the control group, per se, so the extrapolation here must be taken in context. However, given the currently known data, it does provide an intriguing opportunity to delve further into the intricate relationship we have with the salt we must consume for appropriate physiologic function.
In the group of healthy individuals (controls), restricting sodium was associated with a statistically significant increase in plasma levels of renin, aldosterone (a hormone associated with hypertension), and norepinephrine. Elevated levels of these hormones are associated with pathologic disease states and an increased risk of early mortality. Such findings may explain why there is not only a dearth of any observable benefit with routine dietary sodium restriction but evidence of increased early mortality and untoward outcomes.
In their statement, the World Health Organization appropriately notes that “a significant proportion of sodium in the diet comes from manufactured foods such as bread, cereal, processed meats, and dairy products.[viii]” However, there continues to emerge an incontrovertible amount of evidence that it is the adulteration of natural food in the ultra-processing — rather than the specific amount of sodium — that correlates to the development of disabilities and diseases like obesity, diabetes, cardiovascular disease, and many others.[ix],[x]
The time is now to move away from such useless, antiquated, and clearly ineffective recommendations and focus on the quality and character of the food we eat, and pay attention to the manner in which it is produced. To ignore the facts, and conclude that the solution, as the WHO does, is that “potato crisps should contain a maximum of 500 mgs of sodium per 100g serving, pies and pastries up to 120 mgs and processed meats up to 360mgs,” is the height of folly.
That is why this shift in perspective, this focus on positively refocusing, reforging, and reconnecting the individual’s relationship to the food they eat — to their personal and intimate food experience — is at the heart of the Culinary Medicine approach.
[i] (Garland, et al., 2021)
[ii] (McCarron, Geerling, Kazaks, & Stern, 2009)
[iii] (Staessen, et al., 1988)
[iv] (Gregg, et al., 2005)
[v] (Graudel, Hubeck-Graudel, & Jurgens, 2011)
[vi] (Doukky, et al., 2016)
[vii] (Stolarz-Skrzypek, et al., 2011)
[viii] (Nebehay, 2021)
[ix] Srour, Fezeu, Kesse-Guyot, & etal, 2020)
[x] (Monteiro, et al., 2016)
CDC. (2021). Sodium. Retrieved from CDC.gov: https://www.cdc.gov/salt/pdfs/QandA-508.pdf
Doukky, R., Avery, E., Mangla, A., Collado, F. M., brahim, Z. I., Poulin, M.-F., . . . . Powell, L. H. (2016). Impact of Dietary Sodium Restriction on Heart Failure Outcomes. JACC : Heart Failure, 4:(1) 24-35 http://dx.doi.org/10.1016/j.jchf.2015.08.007.
Fenster, M. (2018 . Food Shaman: The Art of Quantum Food. New York: Post Hill Press.
Fenster, M. S. (2012, January 4). Don't Hold the Salt: Attempts to Curb Sodium Intake Are Misguided. Retrieved from The Atlantic: Health: https://www.theatlantic.com/health/archive/2012/01/dont-hold-the-salt-a…
Fenster, M. S. (2013, May 23). DON'T PASS ON THE SALT. Retrieved from Pacific Standard: https://psmag.com/social-justice/stop-worrying-about-salt-reduction-583…
Fenster, M. S. (2014). The Fallacy of The Calorie: Why the Modern Western Diet is Killing Us and How to Stop It. New York, NY: Koehler Books.
Garland, E. M., Gamboa, A., Nwazue, V. C., Celedonio, J. E., Paranjape, S. Y., Black, B. K., . . . Raj, S. R. (2021). Effect of High Dietary Sodium Intake in Patients With Postural Tachycardia Syndrome. Journal of the American College of Cardiology, 77(17): 2174-2184.
Graudal, N., & Jurgans, G. (2011). The sodium phantom. BMJ, 343: d6119.
Graudel, N., Hubeck-Graudel, T., & Jurgens, G. (2011). Effects of Low-Sodium Diet Versus High Sodium Diet on Blood Pressure, Rennin, Aldosteronen, Catecholamines, Cholesterol and Triglyceride. Cochrane Database Syst Rev, (11): CD004022.
Gregg, E., Cheng, Y., Cadwell, B., Imperatore, G., Williams, D., & Flegal, K. (2005). Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA, 293:1868-74.
Gupta, D., Georgiopoulou, V. V., Kalogeropoulos, A. P., Dunbar, S. B., Reilly, C. M., Sands, J. M., . . . Butler, J. (2012). Dietary Sodium Intake in Heart Failure. Circulation, 126: 479-485.
McCarron, D., Geerling, J., Kazaks, A., & Stern, J. (2009). .Can dietary sodium intake be modified by public policy? . Clin J Am Soc Nephrol , 4:1878-82.
Mente, A., O'Donnell, M., Rangarajan, S., Dagenais, G., Lear, S., McQueen, M., . . . Yusuf, S. (2016). Associations of Urinary Sodium Excretion with Cardiovascular Events in Individuals with and without Hypertension: A Polled Ananlysis of Data from Four Studies. The Lancet, http://dx.doi.org/10.1016/50140-6736(16)30467-6.
Monteiro, C. A., Cannon, G., Lawrence, M., de Costa Louzada, M. L., & Pereira Machado, P. (2019). Ultra-processed foods, diet quality, and health using the NOVA classification system. Rome, Italy: Food and Agriculture Organization of the United Nations.
Monteiro, C. A., Cannon, G., Moubarac, J.-C., Levy, R. B., Louzada, M. L., & Jaime, P. C. (2016). The UN decade of nutrition, the NOVA ood classification and the trouble with ultra-processing. Public Health Nutrition, 21 (1): 5-17.
Monteiro, C., Levy, R., Claro, R., Castro, I., & Cannon, G. (Cad Saude Publica). A new classification of foods based on the extent and purpose of their processing. . 2010, 26:2039–49.
Nebehay, S. (2021, May 6). Don't pass the salt - WHO issues benchmarks for sodium content in food. Retrieved from Reuters Health Medical News: https://www.mdlinx.com/news/dont-pass-the-salt-who-issues-benchmarks-fo…
O'Donnell, M. J., Yusef, S., Mente, A., Gao, P., Mann, J. F., & Teo, K. (2011). Urinary Sodium and Potassium Excretion and Risk of Cardiovascular Events. Journal of The American Medical Association, 306(20):2262-2264.
Srour, B., Fezeu, L., Kesse-Guyot, E., & etal. (2020). Ultraprocessed Food Consumption and Risk of Type 2 Diabetes Among Participants of the NutriNet-Santé Prospective Cohort. JAMA Intern Med., 180(2):283–291. doi:10.1001/jamainternmed.2019.5942.
Staessen, J., Bulpitt, C., Fagard, R., Joossens, J., Lijnen, P., & Amery, A. (1988). Salt intake and blood pressure in the general population: a controlled intervention trial in two towns. . J Hypertens, 6:965-73.
Stolarz-Skrzypek, K., Kuznetsova, T., Thijs, L., Tikhonoff, V., Seidlerová, J., & Richart, T. ( 2011). European Project on Genes in Hypertension (EPOGH) Investigators. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA, 305:1777-85.