iThrive Wellness Summit 2020

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iThrive

George Guthrie

To Salt or Not to Salt

Our learning objectives, 3 potential problems of inadequate sodium intake.

I'd like you to have those clear in your head.

Explain how to reverse salt sensitivity, another issue altogether, but an important 1 as we discuss this topic.

And then identify a safe sodium intake range for those with type 2 diabetes and identify foods which are highest in potassium.

Wait a minute, I thought we were talking about sodium.

Well, you'll get Sean as we start moving.

Low sodium has been encouraged because of, of course, the hypertension piece of things.

And if we look at the disease, we see there's some risk factors here.

Age over 60, male, race, African-Americans tend to be higher risk.

This whole business of salt sensitivity is another issue.

Obesity is an important part, as part of the metabolic syndrome and you know hypertension kind of fits with that.

Inactivity, heavy alcohol consumption, and oral contraceptives can raise that just a bit as well.

Well, 90 to 95% of it is essential hypertension.

When patients ask me about this, what is essential hypertension?

I say, well, essentially that means we don't know what causes it.

And of course I say that with a little bit of tongue in cheek, but that's changed obviously.

If you talk to the hypertensive people, they still say it's essential, we don't know.

If you talk to the metabolic syndrome people, they talk about vascular inflammation, increase of free radicals, loss of endothelial relaxing factor, and things like that, that are raising the blood pressure.

So we understand that the central hypertension is in most cases attached to the metabolic syndrome.

So renal artery stenosis, I know I've had some patients who wanted to do aggressive lifestyle change and things just weren't changing like they were supposed to.

Send for an ultrasound of the renal arteries to find a stenosis, get that opened up with an intervention.

And what do you know, a blood pressure comes down, blood pressure medications are not needed and the lifestyle change can continue.

Cushing syndrome, of course, tends to run the blood pressure up with cortisol.

Hyperaldosteronism, kind of the same thing.

I've had my 1 lifetime opportunity to see a patient with a tumor that was really driving that blood pressure high from the adrenal.

Blood vessel diseases can also be associated, as well as thyroid.

Some medications can raise blood pressure.

And of course, alcoholism tends to be a problem.

You've probably heard these discussions ad nauseum, salt, table salt, sodium chloride, and then there's monosodium glutamate, and baking soda is sodium bicarbonate, at least in part.

Baking powder has baking soda in it and kind of a double acting sort of a thing.

So there's this concern that too much sodium can cause trouble.

Along with that is something called sodium sensitivity and hypertension.

Some people respond to lowering the salt better than others.

We think those have something called salt sensitivity.

What are the risk factors for salt sensitivity?

Well those that tend to be most sensitive are older folks, black folks, obese fellows, and that really goes along with the metabolic syndrome.

For metabolic syndrome itself tends to increase salt sensitivity.

I think I have a slide towards the end that kind of helps to explain some of that.

Lower renin levels, family history of sodium sensitivity.

Several years ago, actually twice now, I've heard lectures postulate that the reason African-Americans have such a high salt sensitivity is that because the way they came to this continent, this side of the world, from Africa where salt was as good as sodium is as good as money.

They are put in ships and most got a dysentery of some kind on the way across the ocean.

Often a large percentage of them died on the ship so Only those with the genes that could hang on to sodium better than anybody else actually survived.

So there's a gene pool that tends to encourage this salt sodium sensitivity.

The group of people in the DASH study that responded most to lowering sodium was the elderly black female who was obese.

And the average drop in blood pressure for those folks was about 18 millimeters of mercury.

So For some people, they're very salt sensitive.

Maybe hard for us to understand clinically or identify clinically, but we know that that happens.

Those with dyslipidemia, again, associated with the metabolic syndrome and of course, chronic kidney disease, which body has a hard time excreting and the blood pressure just tends to go up.

So what are the guidelines for Americans?

The Institute of Medicine has identified 2.3 grams per day or less.

And also 95.2% of Americans get excessive, that is over that 2.3 grams per day.

Now, sodium and potassium kind of work together And you're gonna find as we go through this that your potassium intake may be as important as your sodium intake.

So let me kind of put that up here first as well.

Institute of Medicine recommends potassium greater than 4.7 grams per day and 98.6 of American population as per the NHANES, National Health and Nutrition Examination Study, are deficient, are not getting the recommended daily allowance of potassium.

So let's start our journey into the science by looking at this 2014 meta-analysis done by Niels Gredahl et al.

They took a look at 274, 683 individuals in 23 different cohorts, including 2 randomized control trial follow-up studies.

There's no randomized control trials in healthy individuals.

I'll state here that it's very difficult to do real randomized controlled trials with sodium and to look at it long term.

The purpose of this was to decide or try to understand what effect sodium had on disease, on death in particular.

Now, down below at the bottom of the chart, you can see the bottom of the slide, there's 0, that would be 0 grams of sodium a day, 1234567.

In Japan, there are reports of people averaging 17, 19 grams of sodium a day.

So this is certainly looking more at our population, although there are individuals and populations that take a lot more sodium.

You can see that the population range runs between about 2.7 to 4.9, and kind of within the confidence intervals of what's average.

American Heart Association is recommending 1.5 grams.

Institute of Medicine says the upper limit of acceptable is 2.3, and the adequate intake is down in the 1.2-1.5 range.

That gives us a picture of where we are as a population.

And we'll see as we go how this meta-analysis comes up.

So in order to look at this Meta-Analysis, they had to have rules to look at the studies that were available.

They excluded those that were advised to take low sodium.

Well, that's kind of a bias by indication.

You tell people and how are things gonna turn out.

Added potassium or recommended weight loss, both of those are confounders to this whole business.

And then they controlled for confounders that they couldn't exclude.

Sex, age, BMI, smoking, ethanol use, diabetes, heart disease, blood pressure, hypertension, diuretic use, total energy intake, potassium, cholesterol, and an education level.

So kind of a good look at the literature.

This is the results of all of those studies.

They also included, this is a second analysis, the NHANES 1 and NHANES 3, National Health and nutrition examination survey.

This is the federal government looking at the population and saying how are they living, what are things like for them.

The first 50 years it was done every 10 years kind of like a census.

Now it's an ongoing evaluation of the nation's health.

So using the data that they had from the NHANES and putting it in, this is kind of what happens.

Please notice the kind of average population ranges is green in the middle.

And They decided in this evaluation to look at the sodium intake in the way Americans eat it.

There is the lower average sodium and the upper average sodium between 3.8 and 4.9.

And they compare that with greater or lesser amounts of sodium intake.

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To Salt or Not to Salt

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