Let’s face it. Something isn’t working. Obesity rates, diabetes and dementia continue to rise. Cardiovascular disease and cancer consistently sit atop the list of killers. This is a train moving in the wrong direction and it’s up to each of us whether we stay along for the ride or seek out an alternate mode of transportation.

(How’s that for a Happy Holiday greeting?)

The point being made here is that we need to remain or become open to new ideas, especially those counter to what has been dogmatically accepted for years as law. Thankfully we are seeing this growing recognition when it comes to cholesterol (dietary & endogenously produced), fats (especially saturated fats), and beyond. This is crucial as it illustrates a deeper understanding of physiology and serves as reactionary recognition that the guidelines being adhered to, prescribed from the top down for decades, are not only not working, but are more than likely playing a heavy hand in contributing to the very problems they were intended to ameliorate.

This trend of awakening and rethinking formerly held nutritional and health beliefs is gratefully also being seen when it comes to salt; which is especially important for us hot weather runners. Salt is the only essential (meaning we do not produce this on our own and that it must obtained from sources external to the body) mineral that has been demonized and restricted due to a lack of comprehension of how salt interacts with the body. This wasn’t necessarily done maliciously (although a portion of the low salt push was derived from a shameful display of hypothesis driven, cherry picking of data similar to Ancel Keys and The Seven Country Study that landed us in this “fat” mess (pun intended) to begin with), but in an attempt to attenuate one of contributors to and factors in deadly heart disease: blood pressure. A noble intention, no doubt.

However, a notion that can be applied almost universally is based off of the fact that change is constant, and as the volume of knowledge and understanding changes for the better, when applicable, it needs to be considered and evaluated against the in place, older data. This is how we grow, evolve and survive. So let’s look at the latest data on salt, why you should care, and what you can do about it.

Why the bad rap for salt?
First off, as stated, the main reason salt was vilified to begin with was based off its effect on one marker; blood pressure. Decreasing salt intake will indeed drop blood pressure as it leads to a drop in blood volume. However, this drop in blood volume is concurrent with a drop in overall body fluid which can lend to dehydration. A lower salt intake also causes heart rate to go up (as high as 25%, but on average a 10-15% increase in beats per minute) stacked against the average drop in blood pressure being ~1%. This relatively larger increase in heart rate causes more stress on the arteries and heart.

Instead of focusing on and being satisfied with the relatively small drop in blood pressure we generally see and attribute to restricting salt, more attention should be paid to the correlation between hypertension and insulin resistance. When insulin is chronically elevated (the cornerstone of type II diabetes) it leads to activation of the sympathetic (fight or flight) nervous system, elevating heart rate and causing vasoconstriction which both lead to higher blood pressure.

We make this worse if in response to the unrecognized insulin driven hypertension, we are told to go on a low salt diet. This means the kidneys now have to work harder to reabsorb the salt already in our body in order to avoid hyponatremia (low sodium). The body executes this low salt diet prompted survival task by sending insulin to act on the kidneys. To ensure the kidneys get more than enough insulin, other cells become resistant to the insulin. This includes the blood vessels who rely on insulin for its vasodilating (blood vessel widening and thus blood pressure lowering) properties.

(So we see that in this day of the low carb craze, and the problematic elevated levels of insulin that comes with it, insulin is not all bad. It’s when we have it in overabundance, mainly in response to a diet high in processed/refrained grains, carbs and sugar that it becomes an issue. We now understand that a low level of sodium leads to increased insulin levels and, with exception to the kidneys, insulin resistance in the tissues. Sounds like another player in type II diabetes to me.)

Beyond blood pressure, how else can salt, in particular ascribing to a low salt diet, be problematic (especially for a sweaty, salt depleting Florida runner)?

Stubborn Weight Loss or Low Energy Levels?
How about if you are one of the estimated 22 million Americans with a thyroid disorder? It is a function of the thyroid to prompt the kidneys to retain salt. If the thyroid is sluggish (hypothyroid) you may already be susceptible to lower sodium levels due to this lack of retention. A common cause of sluggish thyroid function is iodine deficiency. We can be sure to obtain our necessary allowance of iodine by consuming, you guessed it; salt. (Real salt is not just a sodium and chloride ion, but rather a beneficial combination of a variety of heavy hitting minerals like iodine and magnesium. We will get into type of salt and mineral content shortly.)

So now we can potentially have low salt intake, leading to an iodine deficiency, leading to hypothyroidism, OR hypothyroidism being exacerbated by restricting salt intake, leading to iodine deficiency. Let’s take it one step further and make this scenario runner specific and account for the ~1200mg (half tsp) of sodium and ~75mcg of iodine we lose in our sweat per hour of exercise. We can see how these mineral deficiencies can get out of hand quickly and perpetuate if not be the outright causative factor for the above described thyroid linked issues. As the master gland for metabolism we now have the stage set for fatigue and stubborn to non-existent weight loss despite faithful workout sessions.

Digestive Issues or Heartburn?
Although we mostly speak of sodium when talking about salt, we must not overlook the white crystals other half. The Cl of the NaCl is chloride and it is also crucial to have adequate levels. A low salt diet can lead to low levels of Cl. This is the same Cl of HCl, that is the hydrochloric acid secreted in our stomach and absolutely necessary for proper digestion. (Interestingly, although conventional western wisdom rushes to suppress stomach acid at the first sign of indigestion, hypochlorhydria (low stomach acid) can actually be an underlying cause of what we commonly refer to as heartburn.)
Without adequate HCl (whether due to antacids, proton pump inhibitors or low salt intake), we skip an early, essential step in the orderly process of digestion. We now set the stage for infection and/or overgrowth as stomach acid plays a role in neutralizing pathogens. We decrease the ability to fully digest our food in the intestines leading to nutrient deficiencies, and increase what now become indigestible proteins poking holes in the gut lining (intestinal permeability aka “leaky gut”), leading to inflammation and immune reactions. Could low levels of Chloride due to a low salt diet be at play here?

Worried about Bone Density and Osteoporosis?
As stated, the body will do all it can to keep us out of a state of hyponatremia. This includes pulling sodium from our bones in order to keep circulating levels on par. The problem is that along with the sodium, the calcium, potassium, and magnesium are also stripped from the bone, causing a temporarily misleading elevation in serum levels, as the Ca, K and Mg make their way through the blood to the kidneys and out via the urine. Instead of recklessly throwing Ca in the body hoping it finds its way to the bones, recognition and action based upon comprehension of the delicate internal dance of mineral balance, including adequate salt intake is necessary for bone health and beyond.

There are many other issues that can manifest due to low salt intake, ranging from “keto-flu” symptoms experienced by low carb, high fat dieters, adrenal hyperfunction, and even erectile dysfunction due to low salt induced poor circulation. In addition to all we covered, your curiosity should be further peaked if you experience:
Salt cravings
Decreased exercise tolerance (dizziness, fatigue, exercise induced headaches, overheating etc.)
Reduction in sweat volume
Muscle spasms/cramps
Increased heart rate with or without palpitations
Orthostatic Hypotension (light headed/dizziness upon standing)
POTS (Postural Orthostatic Tachycardia Syndrome: an increase in heart rate (~30bpm) when going from sitting to standing)
Decreased capillary blood fill (can be observed by pinching the finger nail and blood flow not returning within 1-2 seconds)

Lab Markers:
Low Na
Low Cl
Increased Uric Acid
Elevated Insulin
Elevated BUN: This is often elevated, especially in athletes and in the absence of other flags, the common prescription is to drink more fluid to counter dehydration. However, one of the reasons BUN elevates is due to a reduction of blood flow to the kidneys. If on a low salt diet, the resultant lower blood volume leads to less flow to the kidneys. If you find an otherwise deemed insidious elevation of BUN and you stay adequately hydrated, low salt may be the explanation.)

Certain habits or practices can also predispose us to salt loss or “spilling” and a subsequent deficiency and all of these fun things associated with it. This includes, but is not restricted to:

Caffeine: For every 4 cups of coffee, we lose ~1tsp (2400mg) of sodium in the urine; which can cause issues of you ascribe to or are below the RDA of 2000mg.

Sleep Apnea: If you suffer from sleep apnea or are one of the estimated 20 million undiagnosed folks, you could be losing up to 3000mg of Na per night as due to the lack of breathing and subsequent build in central pressure, the body senses overload and looks to excrete fluid and sodium along with it.

Digestive Issues (IBS, Crohn’s, celiac, etc.): All of these conditions can decrease the ability to actually absorb essential minerals like salt in the first place, setting the stage for widespread deficiencies, NaCl included. It would be wise if your physician inquired and/or investigated about this prior to suggesting to apply a one size fits all approach in a low salt diet.

Consuming a Low-Fat Diet: When we strip the fat from the food or look to avoid it, we also strip a portion of the palatability. To make up for this, we add either sugar or salt. If you follow the long standing advice to avoid salt, you end up turning to the wrong white crystal. One could argue that a major contributing factor to this mess of insulin resistance, obesity, diabetes type II, food addiction and the cascade of anatomical and physiological destruction that follows is in part due to the avoidance of the healthier taste enhancers (healthy fats & salt) and the default to sugar.

Conversely, embarking on a journey into a HFLC (high fat low carb) diet can also be a detriment to sodium and other electrolytes if a status of ketosis is achieved. Negatively charged ketones can pull the positively charged sodium out of the system and thus create a deficiency. This can be easily attenuated by intelligently supplementing with a mineral rich salt (see below) during the process.

As an athlete on any level, but especially one who trains and competes in the heat, why is this especially important?

In the presence of salt we actually sweat more as the body is willing to release it, while the lower the salt, the less we sweat as the body attempts to attenuate any further depletion of an already depleted essential mineral. Sweat helps to thermoregulate, cooling the body and allowing us to go longer and harder, especially in the heat.

Salt actually serves as a potent vasodilator, improving circulation and delivering more oxygen to the muscles and other tissues. This helps us two-fold when it comes to lactic acid as the more oxygen available for aerobic respiration, the less lactic acid is produced via anaerobic respiration; and the lactic acid that does form is removed more rapidly via the sodium (from salt) – hydrogen (from lactic acid) transport mechanism.

As we noted above, lower salt intake actually increases heart rate. We strive to keep HR lower as it enables us to go longer, harder and faster, as well as recover more quickly as the change in heart rate will be directly reflected in recovery metrics like HRV.
If you find any of this information sounds like you, or you are curious and intrigued enough to dig deeper in search of optimal health, performance and longevity, I would suggest consulting with your open minded, forward thinking, healthcare professional prior to making any major changes; dietary or otherwise. We work with plenty of patients in this arena and always applaud and encourage any proactive inquiry, investigation and action so feel free to reach out at any time if looking for this up to date, forward thinking opportunity for personal enhancement. (Dr.RClarke@gmail.com 321-848-0987).

The one size fits all approach rarely works, but especially if based upon outdated, disproven and antiquated premises. This approach takes no account for bio-individuality and the myriad of causes for the plethora of issues mentioned here and beyond. You owe it to yourself to work with someone who will dig deeper in order to uncover and rectify the root cause and underlying dysfunction, which will then, more often than not attenuate or outright eliminate symptoms and signs that you are seeking care and being medicated for. Whether you seek out this assistance with myself or someone else, I sincerely wish you success in your quest for optimal quantity and quality of life.

As a closing and a Christmas gift of some take home information to be used at your discretion; should you opt to reunite with salt, we need to choose wisely as all salt is not created equal. We want to stay away from the typical table salt as it has been bleached (most real salt is not actually snow white) and chemically processed which leaves it devoid of other crucial minerals like Iodine, Magnesium, Iron, and Calcium. Typical table salt also is usually mixed with an anti-caking agent (more chemicals) and dextrose (wrong white crystal). Here are some options:
CELTIC SEA SALT: high in Magnesium (~40mg per 10g of salt), but no Iodine
ANCIENT LAKES MAGNESIUM INFUSED SALT: high in Magnesium (44mg per 10g of salt), high in Iodine (120mcg per 10g of salt)
HIMALAYAN SEA SALT: Low in Magnesium (1.4mg per 10g); higher in iron, high but inconsistent in Iodine (can range 100-1000mcg per 10mg)
HAWIAN SALTS: Decent magnesium (30-35mg per 10g), no iodine, great taste.
REDMOND REAL SALT: Low Magnesium (8mg per 10g), Consistently strong Iodine (50-100mcg per 10g)
Additional write ups can be done on the above mentioned iodine and magnesium as both are vitally important, depleted dramatically in sweat, and oft deficient, hence the focus and inclusion above.
As always, thanks for reading and good luck out there. Perhaps a salty Christmas is right for you.

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