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Gettysburg Medical News
The Clinical View
By P.E. Hoffsten, MD
4 October 2006

CONSIDERATIONS REGARDING SALT

            One of the universal recommendations given to patients with high blood pressure or heart problems is to cut down on the amount of salt in their diet.  It is rather a vague recommendation.  Most patients don’t have a clue how much salt is in their diet or what to cut out of their diet in order to get the salt content down.

            A patient was referred to me recently because “his blood pressure just couldn’t be controlled”.  I did the routine history and physical examination and some basic blood tests with nothing really appearing abnormal.  His kidneys worked fine; he didn’t have any adrenal problems.  There were no heart problems.  He was breathing comfortably.  He was a 45-year healthy individual whose blood pressure had incidentally been found to be elevated.  When I examined him, his blood pressure was 150/100 and he was on four different medications.  Needless to say, he was disappointed with the effectiveness of the medications, the side effects that they were eliciting, and the excessive cost.  I reviewed with him what other medications he might be taking, such as over-the-counter sinus pills with those famous “-olamines” or with non-steroidal anti-inflammatory drugs such as Motrin, Aleve, Orudis, or prescription arthritis medicines.  He volunteered that he was taking occasional Aleve in order to treat muscle aches and pains that occurred after he played tennis.

            I then reviewed his diet.  He volunteered that he loved chips, especially after a hot tennis game in the sun and that he drank a six pack of beer in a weekend and sometimes maybe more than that.  He liked having salty foods.  His weight was not excessive.

            So I asked him to bring in a 24-hour urine collection for two days in a row.  This was over a Saturday/Sunday when he was playing tennis, but he managed to carry the jugs around with him and bring in slightly more than two quarts of urine in each jug. The salt content in one of the jugs was 17 grams on the first day and on the second day was 19 grams.  These are numbers to keep in mind, as will be discussed below. 

            Salt is the major component of our blood and fluid in which our cells are bathed in our body.  This fluid is called extracellular fluid. In the average person, there are about 14 quarts of extracellular fluid in our body.  Each quart has about 9 grams of salt and thus our total body salt content is around 120-130 grams.  This is roughly a quarter of a pound of salt.  But note that our patient above was eating 1/6^th of the total amount of salt in his body on a daily basis. 

            What is a normal salt intake?  On the average, the normal American diet has between 6 and 10 grams of salt per day.  A low salt diet has around 6 grams of salt per day.  If a person eats a substantial number of corn chips or potato chips, which are tastily salty, the amount of salt in the diet gets up into the 15-20 gram level.  In order to get down to a six-gram salt diet, the person has to get the salt-shaker off the table, and canned foods, and commercially prepared foods out of the diet.  The use of fresh vegetables, fresh meat, store -bought milk and bread will achieve around a 6-gram salt diet.  A 4-gram salt diet required for some people with heart failure is tasteless and most people will not stay on it for long.  A 4-gram salt diet requires very special foods.

            The patient above really didn’t need special considerations.  The first thing that he needed to do was get rid of the Aleve which is a salt-retaining drug.  All of the over-the-counter arthritis drugs such as Motrin, Nuprin, Advil, or Orudis, cause fluid retention and raise blood pressure.  These drugs make a person retain salt and water and “blow up the balloon”.  That balloon is the blood vessels in the body which get stretched when too much salt and water are left in the body.  The second thing for him to do was to get the salt that he was eating down to a much lower range.  I explained to him about the avoidance of salty chips, avoidance of sauerkraut, avoidance of prepared meat products such as braunswager, bologna and hot dogs. 

            After long discussion, he had a very cooperative willingness to change his lifestyle and to get the salt out of his diet and avoid the Aleve.  It was also suggested that he cut down the amount of alcohol he drank, as this also raises blood pressure.

            One month later, we checked two more 24-hour urines and they were down to 7.5 grams of salt one day and around 7.8 grams the second day.  At that point, one of his blood pressure pills had been stopped and his blood pressure was 125/80.  Fortunately, we were able to stop the blood pressure pill that was most symptomatic for him and he  was at peace with the program at that point.

            If one thinks about it, the ability to save salt and water did have survival value for those individuals who were genetically adapted to arid dry climates where salt and water were not readily available.   But in our society today, there are water fountains every place we turn and salt is added to every prepared food that we have in order to improve the taste to get us to eat and buy more.  Now those descendants of the salt/water retainers ,who were genetically adapted for survival in the past, are genetically maladapted today because they save the salt and water that they take in and become hypertensive.  On the average, one in five people (20%) in our society have what is called salt-sensitive hypertension.  In order to treat their hypertension effectively, all they have to do is get the salt out of their diet and blood pressures come down.  The other 80% of our hypertensive population are not so fortunate and will require medications.  But even for them, lowering the salt in the diet will help bring their blood pressure down.

            The last group of individuals for whom salt restriction is important is those with heart failure.  A natural body physiologic response to a failing heart is to retain salt and water.  There are complicated explanations and mechanisms for this.  But to make a long story short, when a person has swelling of their ankles and the shortness of breath/fatigue that comes with that, the most important step in care is restriction of salt and restriction of water.  For the heart failure group of people, the restriction of water is even more important than the restriction of salt but restriction of both is important.

            As a last note, I had a patient tell me that she had removed her water softener because it put too much salt in the water.  At most, the softened water has about 0.2 g of salt per quart of water.  If the person drank 5 quarts of water per day it would amount to 1 gram of salt.  Softened water is really not a big player in the diet restriction of salt.  Besides in Pierre the yard, the house, and the driveway, all turn rusty red without soft water. 

            The healthcare providers at your local clinics are well aware of these considerations and can help in treating high blood pressure with the fewest medicines necessary in helping patients with heart failure or hypertension deal with their problems more effectively.