A great success to decrease salt from 12 grams to 5 grams daily by minimizing processed foods. Changing lifestyles is a journey. Congratulate the patient. With each encounter ask for a food recall. From there suggest culinary changess. I recommend increasing flavorful herbs such as sage, rosemary, and spices . Of course changing taste bud affinity for salt is difficult but possible. I have discovered that rapid changes in salt lowering is not sustainable. The patient has to have a buy on that can only come from education. I even encourage cooking classes and use of social media.

Urinary sodium and potassium relative to creatinine is the only reliable measure.

is there any study point out to the dailly average salt intake (in gram) ?

the other important question I usually faced by junoir staff : Salt restriction may be important in the past before the discovery of potent diuretics!

My answer : this might be partially true :

1-if you can know the average salt intake of individual

2-if the individual has no CKD .

3-if you know how many salt (in mg or gram) can be excreted by one tab of Diuretic(e.g Frusemide 40mg)

Salt intake is a WHO general council since 2006.

I don't thin diuretics control hypertension with hight salt intake.

Salt intake is key factor affecting hypertension. Salt intake must be limited in patients with hypertension. It intake must be calculated for appropriate effect on blood pressure control.

Yes, salt intake can be calculated via many ways. through food preparations and reading food labels to know exact quantities taken in. And in case the hypertensive client is so much sensitive to salt, this is a very good practice to prevent the adverse symptoms of the disorder. Try to limit it to less than 1500mg (1.5g for higher values like; 150/120). A diet plan particularly following a "low sodium diet " should help you work this out.

Yes, salt intake can be calculated via many ways. through food preparations and reading food labels to know exact quantities taken in. And in case the hypertensive client is so much sensitive to salt, this is a very good practice to prevent the adverse symptoms of the disorder. Try to limit it to less than 1500mg (1.5g for higher values like; 160/120). A diet plan particularly following a "low sodium diet " should help you work this out.

It is very important to calculate the quantity of added salt especially with salt-sensitive hypertension. With this condition excessive salt will increase the threshold BP needed to flush out the extra sodium ions, settting the BP to anew higher level

Yes, I agree with Jerry.

It's possible calculate salt intake by several ways, but optimal is 24 h urinary collection. Dietary calculation is an indirect approximation, too long to take in primary care and for not all patientes. 24 h urinary collection is not possible for patients whith loop diuretic like furosemide, specially.

I am not an MD so please excuse me if this sounds naive to a practicing clinician. According to the literature 50% of hypertensives are salt sensitive and therefore only 50% of these patients would benefit from reduced sodium intake. It takes 3 days to get rid of excess salt on a low salt diet, so without going through a rigorous protocol, couldn't you take a 24 hour urine, measure blood pressure, ask the patient to lower their salt intake (if it was high) for a week, take another 24 hour urine and blood pressure measurement and roughly determine if they are salt sensitive? Our lab is vigorously trying to find biomarkers of salt sensitivity precisely because of this issue. By the way 25% of normotensive individuals are also salt sensitive. There is also a class of individuals whose blood pressure rises on low salt diet. I think this means that each person has a personal correct level of salt intake.

Calculation of salt intake is most important. It can be calculated from the type of food we take. It is better to take less salt than more for hypertensive or even normo-tensive. 1.5gm or less salt is adequate for a day. Hypertensive individual should not take additional salt at the dining table, less or no pickle ( salt is mostly more in pickle) and should take less of sodium containing diet.

No, but I am going to do the research on the BP control among patient who are on diuretic among patient who are on high salt diet as in Malaysia, the salt intake was quite high overall.

Which is parameter for 24 urinary collections ? How know if this urinary colletions is high or lot ?

Ana, it's easy, by using creatinine in 24 h urinari collection and direct relation with weight.

Can you direct me to a reference, please?

I have a spanish bibliography only for this topic. Do you want it?

Yes, please! I´m studying salt intake and all help will be appreciated!

My email: [email protected]

Thank you

a subset of patients with essential hypertension are "salt sensitive", also those with renal insufficiency. The DASH diet study is the best evidence- based application and was effective in a subset of patients.

Just last month written a research proposal in this regard. Sending to Ethical Committee for approval

I regulate my daily salt intake and my patients by mean daily source of salt in my community. In averrage we recived 12 gram salts daily. 2 grams at table, 2 gram in raw foods and others (8 garm) in prossessed foods include bread. so in additon to table salt and very salty foods, I decrease salts in cocking foods to half or lesser to get 5 gram salts daily.

But I wonder if DASH is enough and real in diary practice?

One option quite useful is use potassium chloride. It hasn't same taste, but is an option. Do you inditate it?

In the Question -- 'real' is the catch word. My study focus is that specific word. For the In-Patients of the hospital it is easy to monitor as all necessary bio-chemical parameters & dietary control is possible. Even the salt tablets are crashed to fine powder & mixed with food in divided dosages - by the nurses. This control has been made very meticulously & strictly.

But my study concern is common population who are clinically diagnosed Hypertensive. Whichever way the instructions are given -- in reality the salt intake is not monitored at home. Of course, there are many many modifiable/ non-modifiable variables responsible for increasing number of Hypertensive people even in our rural India, alarmingly adolescents -- but calculating salt intake & monitoring -- in real environment -- is my area of investigation.

I am thankful to all the researchers' answers/comments/suggestions -- these are giving directions to enriched & broaden the study dimensions & guidance to develop the tools. Thank you all from heart.

No but this will be interesting to know whether our population who have a high salt intake will be benefited from Diuretics as the first line agent.

Dear Ching. Target must be salt intake reduction and sanitary education, not diuretics or ther treatment, I think.

Especial usefull with culinary advice and meals examples, don't you?

Try to. But in practice it does not work in routine, it works only in severe cases when the patient has oedema or ccf

Dear Javed. is quite common in hypertensive patients see their salt intake is more than 6 grams per day recommended by WHO. They should estimate their intake in all hypertensive patients and not just with edema.

Dear Manuel,

indeed several guidelines recommend a reduction of salt intake. The 2005 Dietary Guidelines for Americans recommend limiting sodium to less than 2,300 mg per day (equal to about 1 teaspoon of table salt). The guidelines further recommend that specific populations (blacks, people with high blood pressure, and middle-aged and older adults) limit their intake to 1,500 mg per day (equal to about 2/3 teaspoon of table salt).

I do recommend (in adolescent/young adults) to lower the salt intake to less than 3 gm per day if feasible. I check (every so often) the urine sodium, aiming at less than 100 mmol/day (2.3 gm Na or 5.8 gm NaCl per day) but often get between 100 and 200 ! Most important in oligo-anuric patients. important in patients with proteinuria (Natriuresis increases proteinuria). common cause of diuretic-resistant HTN (or edema....).

I agree with everybody this is an extremely difficult topic from a public health perspective. Most of the processed food is loaded with salt, so difficult to reduce....

So in summary the science is there to indicate there is good reasons to decrease salt intake, guidelines are there as well, but implementation in real life, as Ratna pointed out, is difficult!! Dieticians should play a role here I think. Hope this help you.

A great success to decrease salt from 12 grams to 5 grams daily by minimizing processed foods. Changing lifestyles is a journey. Congratulate the patient. With each encounter ask for a food recall. From there suggest culinary changess. I recommend increasing flavorful herbs such as sage, rosemary, and spices . Of course changing taste bud affinity for salt is difficult but possible. I have discovered that rapid changes in salt lowering is not sustainable. The patient has to have a buy on that can only come from education. I even encourage cooking classes and use of social media.

Ibrahim Bani, Jazan Medical College

DASH diet , life style changes, and monitoring patients urinary sodium are important tools for control and prevention of hypertension .We are establishing metabolic syndrome clinic which include screening patients attending Diabetic Center. The patients will be followed up through life style changes using a team of health care professionals .

I would like colleagues to share their experience in life style changes .

2300mg sodium per day. I always encourage to: rinse everything out of a can, purchase 'low sodium' products, instead of using table salt use spices

Studies have shown that increase in salt intake up to about 15g/day increased systolic blood pressure by 33 mm Hg, therefore reduction in salt intake is relevant in the management of hypertension

2300 mg sodium per day is about 1/3 teaspoonfull table salt per day

Dr. Asiedu. Please, send us the bibliographic reference of these studies about >15 g/day salt intake. It's very usefull for me specialy.

Dear Ortega, the references of help are " Denton et al., (1995). The effect of inreased salt intake on BP in chimpanzees. Nat. Med:1; 1009 - 1016" and Sacks et al., (2001). Effect on BP of reduced dietary sodium and DASH Diet. New Engl. J. mED : 344; 3 - 10.

Of course, salt reduction should recommended for Hypertensive patients, but in the real life, even if you encourage patients to take less than six grams of NaCl by days, those we are working and take lunch outside, will tell you that is “impossible”.

As nephrologist and internal medicine specialist, in my clinical practice, I consider that the discussion will be dependent whether or not HTA being complicated by cardiac failure and/or edema secondary to cirrhosis or nephritic syndrome. In these cases, salt restriction should be done and associated with diuretics. But be careful, low salt intake associated with the urinary NaCl loss secondary to diuretics and ad libitum water intake will rapidly induce severe hyponatremia with potential cerebral edema ( confusion..), one of the most cause of iatrogenic admissions in our Emergency Department.

For uncomplicated HTA, I prefer low salt intake and use an antihypertensive drug, active young patients being not compliant to an “ad-vitam and to most too most restrictive treatment”.

Thus, I am not sure that monitoring urinary salt will be clinically relevant, even in severely ill patients. For instance, in my medical ICU, we decided with my collaborators that urinary salt loss determination is very rarely useful, and thus should be justified.

I think that we have to dissociate the pathophysiologic point of view (CHLORURE restriction and not Na restriction!) and the real life. We should focus on an old experimental study published in the N England. Authors observed in rats “spontaneously hypertensive” that, when administering the same daily sodium intake, HTA occurred when using NaCl, but not during Na bicarbonate. Thus, sodium intake being stable, they demonstrated that Hypertension was dependent of CHLORURE intake.

Furthermore, it is now well established that, in patients with hypertensive nephropathy with a relatively preserved glomerular filtration (GFR near 75 ml/min), daily oral sodium bicarbonate intake is an effective kidney protector associated with a perfect control of blood pressure with an ACEI (1).

Thus, in my clinical practice, I do not calculate salt intake, I do not control urinary sodium loss even in case of edema, but my patients check regularly at home their blood pressure and their body weight.

(1) Kidney Int. 2010 Aug;78(3):303-9. doi: 10.1038/ki.2010.129. Epub 2010 May 5.

Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy. Mahajan A, Simoni J, Sheather SJ, Broglio KR, Rajab MH, Wesson DE.

Thanks, Dr. Asiedu-Larbi. I had Sacks' reference but the another not.

Thanks, Dr. Brivet. It's an interst reference about this theme and I don't have it. I think is important take control about salt intake in hypertensives patients. Now I'm making my thesis about this theme and I see in my patiets are take more than 15 grams of salt dairy using 24 hours urine analisys. I think this is a great count not benefice hypertension control, don't I?

I am not sure that daily 15 grams of sodium chloride is not armful in case of hypertension. I think that a low salt intake, about six grams ( normal cooking, whitout adding salt during the meal), is perfectly accepted by the patients if they use flavorful herbs, pepper; Furthermore, if they are addict to cheese to eat them with salad instead of bread, which be useful for bodywheigt control . Nearly a cooking class ... during the consultations