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Are Salt Substitutes Really Good for Your Health?

Results of a study of people over 60 with high blood pressure

By Sally Benford

The human body needs a certain amount of salt — or rather, the sodium in salt — to maintain bodily functions such as adequate fluid levels, muscle function and proper pH in our blood. Yet for some, consuming salt can cause high blood pressure, especially as we age, putting us at risk for hypertension and heart disease.

A wooden spoon filled with salt. Next Avenue, sodium, salt substitute blood pressure
Credit: Jason Tuinstra

We know that reducing sodium intake is good for overall health and now a new study in the New England Journal of Medicine proves that.

The study found that by reducing salt (sodium) in the diet and replacing it with salt substitutes containing reduced sodium and increased potassium can lower blood pressure. The rates of stroke and major cardiovascular events in participants were also lower with the salt substitute than with regular salt. The study took place over a five-year period in China — a place known for high salt use —  and focused on people 60 and older with high blood pressure.

Americans Love Sodium

"High blood pressure is a well-known cause of developing heart disease and strokes, says Dr. Nachiket Patel, clinical professor of medicine at University of Arizona Medical School in Phoenix and an interventional cardiologist. "Consuming a lot of salt causes water retention and that causes high blood pressure and it can also decrease the beneficial effects of drugs that lower blood pressure."

The average American consumes 3,400 milligrams of sodium per day, well above the 2,300 milligrams — equal to about a teaspoon — recommended by the American Heart Association.

"As we get older, we are more affected by salt in our diets," Patel says. "Salt, by increasing the blood pressure, can lead to uncontrolled high blood pressure, which causes all kinds of negative effects on the heart."

You Are What You Eat

The major culprit of too much sodium in the American diet? Health and nutrition experts place the blame on processed foods.

Dr. Stuart Ruch, a cardiologist with Berkshire Medical Center in Massachusetts, recommends his patients shop on the perimeter of the grocery store and stay away from the interior aisles.

"I've cut out salt, but I've done other things as well, and my doctor says it's working. It's less about elimination and more about moderation."

"You can cut back on sodium, and you need to get potassium from fresh fruit and vegetables. What I tell patients is, 'If it's in a can or a box, you've got to stop that.' ... We've got to find a way to cut down on all the junk we're putting into our bodies," says Ruch. 

He says the reason salt causes problems for some people is that water inevitably follows sodium, and as the volume of this fluid increases, so does the volume of blood. This means the heart must work harder putting more pressure on blood vessels. Over time, this pressure stiffens the blood vessels, which can lead to high blood pressure, heart attack or stroke.

"There's a lot of variability because some people are really sensitive to salt and some people not so much and we don't really know why. Hypertension tends to be diagnosed more in older people. As we age our vessels get stiffer," Ruch says.

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More About Salt Moderation

Allen Raines knew he had to make changes when he had an episode of high blood pressure last year. The 54-year-old from Cincinnati has always been naturally thin, so when he had that health scare, his doctor made several recommendations and one was to reduce his salt intake.

"I've cut out salt, but I've done other things as well, and my doctor says it's working. It's less about elimination and more about moderation," Raines says.

He's the cook in the family and stopped using salt that recipes called for. Instead, he lets his family add salt at the table if they choose. Raines tried salt substitutes initially, but his family didn't care for the taste, so he doesn't cook with them.

"I researched salt substitutes and I don't trust the high potassium levels. It felt a little risky and didn't seem like the route I wanted to go," says Raines. "I'm eating more fruit and vegetables now, getting potassium and sodium naturally. I used to like a sandwich for lunch, heavy with mayonnaise. Now I just use a thin layer."

Patel says: "I think salt substitutes are beneficial with the caveat that you have to work with your doctor. Having high levels of potassium in the body can have very bad effects on the heart. Most people can handle the extra potassium they're ingesting in the salt substitute, provided their kidney function is normal; the patients who have abnormal kidney function have to be very careful of those salt substitutes that are using potassium chloride."

Fresh vs. Frozen vs. Canned

So how do you know what to look for and where to find high- and low-sodium foods?

Lauri Wright, director of University of North Florida's Center for Nutrition and Food Security, says going fresh is always best, frozen is better than canned and reading nutrition labels and comparing sodium amounts against similar products is most important when buying processed foods.

She also advises avoiding snack foods that are loaded with salt and notes that condiments often contain hidden sodium.

"Ketchup can be high in sodium — a tablespoon can have a hundred and fifty milligrams. Watch out for soy sauce and some salsas, salad dressings and dips," says Wright. "Anything pickled is very high is sodium."

"Dishes like chicken parmesan with the marinara, cheese and breading on the chicken can contain almost three thousand milligrams of sodium."

For adding extra flavor naturally, Wright suggests using fresh or dried herbs and spices.

"Play with vinegars and plain mustards to add flavor without heavy sauces. Citrus juices are a nice way to add flavor. Look for herbs and herb blends that state no sodium added," Wright says.

Mildred Pascucci has restricted salt on the advice of her doctor after having pacemaker surgery a few years ago. The 86-year-old cooks with what she calls the "big seven"— garlic, onion, red pepper, basil, oregano, thyme and olive oil.

Pascucci and her husband, who live in Hampstead, N.C., follow the Mediterranean diet, eating a lot of fresh vegetables, pasta and healthy proteins. If she buys canned products, she looks for low-sodium versions.

"I used a lot of salt before because that's how I grew up," says Pascucci. "Salt substitutes didn't work for me, so the best way for me was to just cut it [salt] flat out."

What about dining out? Wright says: skip the cream and cheese sauces and gravies, which are usually loaded with salt, and go for roasted or grilled meat without marinades.

"One important thing you can do is check the restaurant's nutrition information. Dishes like chicken parmesan with the marinara, cheese and breading on the chicken can contain almost three thousand milligrams of sodium," Wright says. "The majority of us need to cut back. Even if it's cutting a half a teaspoon of salt from your daily diet, you're going to see a benefit."

Sally Benford
Sally Benford is a Phoenix-based freelance journalist who currently writes about a wide range of topics, including health, careers, lifestyle, travel and history. Read More
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