The Low-Salt Fiasco

For several decades, mainstream health authorities have recommended that we avoid saturated fat in our food and keep our cholesterol low. For about the same length of time, they’ve also warned us about the dangers of salt: that it causes hypertension – high blood pressure, a major risk factor for cardiovascular disease – and that we should all keep our salt intakes low, as low as possible. The first dogma, on cholesterol and fat, has come under increasing scrutiny and skepticism in recent years, exemplified by books like Good Calories, Bad Calories and The Big Fat Surprise. Now, James DiNicolantonio’s new book, The Salt Fix, aims to do for salt what others have done for fat and cholesterol.

Why low salt?

Humans have prized salt and gone out of their way to get it since before recorded history, and animals also seek it out. And of course they do, since salt is a required nutrient.

Chemically, ordinary table salt is sodium chloride, and it makes up about 90% of all minerals in the blood and other body fluids, and is present at a concentration of about 0.8%. Given its importance in maintaining electrolyte balance, the body closely regulates the concentration of sodium and chloride, mainly through the action of the kidneys and various hormones secreted by them and acting on them. Both abnormally low and abnormally high blood sodium lead to, or are associated with, serious illness and even death.

Prehistoric humans and modern hunter-gatherers seek out salt, and DiNicolantonio cites evidence that salt consumption in Europe a few hundred years ago – 16th to 18th centuries – was many times higher than today. Due to the use of salt as a food preservative, early modern Europeans consumed 40 to 70 grams of salt daily, and in some places as much as 100 grams, compared to the average American’s current consumption of about 8 grams, or about 3.4 grams of sodium. (Keep in mind that sodium makes up about 40% of the weight of salt, and authorities often speak in terms of sodium, not total salt, consumption, so the numbers can be confusing.)

Salt consumption in the U.S. has been quite stable since the first half of the 20th century, yet the rate of hypertension is about 3 times higher. So why have health authorities argued that decreasing salt intake is critical for controlling hypertension?

DiNicolantonio traces the history of how the low-salt ball got rolling, and that story bears many similarities to the story of Ancel Keys and saturated fat. Several researchers became convinced, through dubious experiments and case reports, that salt caused hypertension, and went on a crusade to convince doctors and the public that salt was a villain.

Among those researchers was Dr. Walter Kempner, who devised the well-known (or infamous, perhaps) Kempner Rice Diet, which he put into use at a clinic for the treatment of severe hypertension, at a time when no drugs were available to treat it. The Kempner Rice Diet was low in sodium, protein, and calories, and consisted mainly of rice, sugar, fruit, and fruit juice. Kempner made extraordinary claims for his diet, but even by his own less-than-scientific standards, it didn’t help everyone, and in those it did help, results were modest. It also led to serious illness in some patients. Other researchers were unable to replicate his results. Furthermore, the diet was low in calories and caused weight loss, which may have been responsible for whatever success it had in lowering blood pressure.

A later study done at the Cleveland Clinic found that a low salt diet helped only about 25% of severe hypertensives, and even then results were modest.

Nevertheless, due to relentless campaigning, the McGovern committee recommended in 1977 that Americans limit their salt intake to 3 grams daily (about 1200 mg sodium). This was the same committee that recommended we stay away from saturated fat.

Low salt has less than impressive results and may be harmful

Severe sodium restriction has little effect on the blood pressure of normotensives, that is, people with normal blood pressure; it lowers their systolic blood pressure by around 1 mm Hg, or less than about 1%. Around 80% of normotensives see no rise in blood pressure from increased salt intake; among hypertensives, around 55% are unaffected by salt, and a reduction of sodium intake in them leads to an average reduction in systolic blood pressure of only about 3.6 mm Hg, an unimpressive result.

It’s even possible that blood pressure can rise with low salt intake, since low salt activates the renin-angiotensin system, the purpose of which is to raise blood pressure. As we saw in a recent article, inhibition of the renin-angiotensin system can increase lifespan even beyond its effects on blood pressure, so higher salt could be life-extending by decreasing renin-angiotensin activation. (Although that’s my idea, and not from the book.)

Low salt consumption leads to a higher heart rate, which is independently associated with higher mortality. Therefore any benefit from lower blood pressure could be negated by a higher heart rate.

Low salt consumption could even lead to obesity, since if we’re starving for salt we may eat more food to get it.

Increasing our salt intake may even be a healthy thing to do.

DiNicolantonio cites fascinating evidence regarding the effects of salt on sex and reproduction. In livestock, cutting sodium reduces birth weights and litter size, and may act as a “natural contraceptive”. In humans, low salt causes a reduced sex drive, reduced odds of pregnancy, increased erectile dysfunction, fatigue, and poor sleep.

How much salt do we really need? DiNicolantonio believes that we have a “salt set point” that “seems to hover around 3 to 4 grams of sodium per day”. (Around 7 to 10 grams of salt.) While sodium balance can be maintained on a low salt intake, that doesn’t mean that that intake is optimal.  We may be driven to maintain a sodium surplus, since someone with enough or excess sodium is more likely to survive a sodium-depleting event such as blood loss, diarrhea, or infection. More salt may also be required for heavy exercise, low-carbohydrate diets, and in pregnancy and lactation.

If salt didn’t cause the rising epidemic of hypertension, what did? The author makes a good case for our huge consumption of sugar, and the obesity that goes with it.

The low-salt fiasco

Ultimately, there seems no good reason for a population-wide restriction of sodium consumption, and in fact the urging of health authorities for everyone to restrict sodium may be doing considerable harm. In hypertensives, sodium restriction may benefit some, but even there, results may be modest and harm may result.

For most of us, limiting salt probably does more harm than good. Far from being a health panacea, eating less salt may be another fiasco brought about by bad science and overzealous health authorities.

Full disclosure: I’ve had a good deal of online contact with James DiNicolantonio, consider him a friend, and he sent me the book for review.

PS: My new book is Best Supplements for Men.

PPS: Check out my Supplements Buying Guide for Men.


Leave a Comment:

Steve says June 18, 2017

Not related to salt but related to iron issues and new data shows aspirin is probably not. So good.

    Montgomery says June 18, 2017

    Probably all things have a positive and negative effect at the same time.
    Yes, Aspirin rises the chances for gastric bleeding and brain hemorrhage – but it also reduces the chances
    for ischemic stroke and quite a few kinds of cancer.
    The net effect seems to be very positive:
    The additional troubles Aspirin can cause are all not especially life-threatening, while the kind of problems Aspirin seems to protect from are very much so.

      P. D. Mangan says June 18, 2017

      Right. I’ve certainly never been less than forthcoming on the risks of aspirin. It’s been known that the over 75 age group, which that report is about, has the highest risks for bleeding. But they also have the highest risks of cancer and heart attack. Even in a previous report by Rothwell (foremost aspirin researcher) et al., they state that that age group has highest risks but it’s not known whether they should stop taking aspirin because of their risk of heart disease and cancer. In the age range of 50 to 75, and for most people, benefits generally outweigh the risks. The recent report of the U.S. Preventive Services Task Force on aspirin use estimates an overall ~7% decreased mortality rate with long-term aspirin use. Therefore it’s a life-extension drug.

Montgomery says June 18, 2017

Short-term dietary sodium restriction increases serum lipids and insulin

Maybe you want to take a look at the work of this guy, Professor Stumpe from an University clinic in Germany.
His research was about salt’s effects from diet specifically:

Short version of his results:
In most people a low-salt diet rises LDL cholesterol; insulin and uric acid rise as well significantly.

Just like the advice about diet from the “experts” about avoiding saturated fats, eating vegetable oils, and eating a lot of carbs – restricting salt makes people objectively sicker.

I somehow doubt the odds that all the official experts are always advising the exact opposite of what is
demonstrably truly healthy. Who really pays those guys?
Their expertise seems to be really about making a population fat, weak, unhappy and sick.
Their expertise also leads to an artificially created market for medicines.
The market alone for diabetes drugs and dialysis is north of 100 billion $ annually and growing – exponentially growing. This market would vanish almost completely if people would limit their carbs intake.

Eat all the salt you crave – but drink enough water – mostly this has not even to be consciously controlled,
because if you eat too much salt you will guaranteed become very thirsty soon after – just rely on your
body to keep the perfect equilibrium for his needs – any salt overload is quickly and easily removed.

I wonder if the food industry could make people eat more (carbs) by exploiting this health fad and lowering
salt in their products – would people eat more, say, cornflakes, if those would contain almost no salt?

Manfred says June 18, 2017

12g Salt could help with your diet:

in the article you find two links to the scientific studies.

MG says June 18, 2017

how about iodine? for how long did we have iodine fortification in the USA? I think it’s been more than 4 decades since we stopped adding this micronutrient. In order to measure the impact of table salt in the past we should consider the iodine as well.

    P. D. Mangan says June 18, 2017

    Salt in the US is fortified with iodine. Sea salt contains some iodine but not ordinary salt unless it’s added. Goiter from lack of iodine is characteristic of inland areas far from the sea, so perhaps in the past many people were getting iodine from salt, I don’t know.

      BC says June 18, 2017

      Also look into aluminum as an additive. IIRC, aluminum is added to most table salt to prevent clumping. If your salt is white as snow and flows like desert sand, it likely contains some aluminum. Yet another reason to use natural mineral and rock salts.

Alan says June 18, 2017

PD, I see no mention of low potassium. So allot of sodium and low potassium would be a problem. Might this combination cause high BP?

      Mattias Carlsson says June 19, 2017


      In Sweden we have a table salt made of 50% Sodium Chloride, 40% Potassium Chloride, 10 % Magnesium sulphate and 5mg Iodine per 100g. It tastes okay after I got used to it. I even eat it on boiled eggs where the taste is more obvious. Similar salts are probably US-Available too… No for preservation/conservation purpose though.

        P. D. Mangan says June 19, 2017

        Thanks, Mattias. We have a similar one here. Tastes a bit metallic to me though.

        BETO says June 19, 2017

        What is the daily iodine recommendation? 0, 15mg/day? If it is, it would be equivalent to the 3g of salt a day

Bill says June 18, 2017

PD Thanks for the review of DiNicolantoni’s book. A couple of reflections by way of reply..

In the past my own diet at times included a lot of processed foods: potato crisps, refrigerated ready prepared take home meals, bread etc. etc.

And in all those foods there is usually a lot of salt even if we do not know it or choose to not check out the nutrition panels…And then there are the food from KFC, Macca’s and Hungry Jack’s.. All are loaded with salt

So I suggest that most of the population eating all the common processed foods are getting their fill of salt.

It is the health conscious folk who have reduced their salt intake in recent years and vegetarians, vegans especially and maybe low carb, paleo folk as well.

Also I find it confusing that nutrition panels do NOT say how much salt is in a food. They talk about sodium. Now that is utter BS. Nobody adds pure sodium. It spontaneously burns in the presence of oxygen. So printing sodium is just obfuscation and generates confusion.

A final request : Is it possible to change the settings so that the last 10 comments are listed on your home page ? When comments are running hot on a couple of posts, it’s easy to miss some.

    P. D. Mangan says June 18, 2017

    Hey Bill, I agree, it’s the health-conscious people who are more in danger of not getting enough salt. And I changed the comment thingie to 10 comments listed.

bigmyc says June 19, 2017

Just wanna say, P.D., that this piece couldn’t be more timely as just yesterday, I engaged in the exact same topic with my lady friend doctor, who seemed to be of mixed sentiment, understandably. However and also this week, this topic was actually more on point with a debate that I had with a long time friend of mine in which I was asserting essentially the same thing…actually, there’s really no “essentially” about it, my line of reasoning was basically verbatim with this most recent offering of yours.

Just wanted to say, “cheers and thanks” for once again, being in step with some of the things that I try to impart to those closest to me. At worst, your information fortifies a benevolent, “I told you so” moment and at best, it’s simple verification for a better way of living for those that I care about.

    P. D. Mangan says June 19, 2017

    Thanks, bigmyc.

Brandon says June 19, 2017

FYI I was just looking up the amount of iron in cereals and it is more than would be thought. For example, honey nut cheerios says it has 25% RDA per serving, but I looked up what the actual amount is and its 4.5mg, which means they are basing the RDA at 18MG, which is for women apparently. The RDA for men is 8MG so a single lously little 110 calories of Honey Nut Cheerios has more than half the RDA of iron for men.

    P. D. Mangan says June 19, 2017

    That’s pretty bad, especially when you consider that that amount of cereal would be about a quarter of a serving for many men. They could be getting double the RDA of iron just for breakfast.

Barbara says June 19, 2017

Actually I have rheumatoid arthritis and put myself on a 1000mg salt diet and in 2 days my swelling went down

    Nick says June 22, 2017

    Interesting. But correct me if I’m wrong, doesn’t that amount to one gram of salt? You mean, one extra gram a day?

louis sir says June 19, 2017

From what I recall, wasn’t there some study that based all this on some island based Japanese village that had a high amount of salt because ocean and some higher than average heart attack data…the goofballs said aha, salt caused this.

Nick says June 24, 2017

I’ve *always* used very little salt in cooking, and hardly ever add it to food. I’ve always felt like I’m sensitive to it, and of courser, having grown up in the shadow of Eisenhower’s heart attack, I was programmed to believe it was better avoided.

Now, I’m wondering if my life-long swerving of it hasn’t been to my disadvantage, at least somewhat. A hard-gainer, testosterone only 467 at 52, etc. I “ate” about a tablespoon the other night, or 3 gm. And I was fine. I’m going to start doing that regularly.

Thanks again, Dennis, for such valuable info.

    P. D. Mangan says June 24, 2017

    Cheers, Nick. While I’ve never avoided salt, I eat little processed food, so any salt I have is mostly added by me. (occasional olives, ham, things like that.) I also drink coffee, tea, and wine, and the body necessarily loses some salt via greater urine volume. So, I recently started adding a cup of buillon daily, which is about 1200 mg sodium, as an experiment. I suspect, as you do, that this could be related to being a hard gainer, which I am as well. So, we’ll see. The book is definitely an eye-opener, and salt is not something to be avoided.

      Nick says August 12, 2017

      UPDATE…nice tip on the boullion. I started making a zesty, spicy broth with beef boullion to pour over the raw broccoli & cabbage that I eat pretty regularly during the week as breakfast, normally with 2 or 3 eggs poached in it. It should give me about 6 gm salt, plus I’ve been taking 2 gm of salt tablets in the morning pretty often. And I noticed an immediate improvement in my sleep, but I’m not 100% sure it’s due to just that.

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