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How much salt should you eat? The American Heart Association says 1,500 mg of sodium per day. The WHO says below 2,000 mg. The USDA Dietary Guidelines say below 2,300 mg. But a study of 101,945 people across 17 countries found something different. The PURE study (Prospective Urban Rural Epidemiology), led by Andrew Mente and Salim Yusuf at McMaster University and published in the New England Journal of Medicine (2014), tracked sodium intake and cardiovascular outcomes over four years. The results formed a J-shaped curve. The lowest risk of cardiovascular events and death occurred at 3,000-5,000 mg of sodium per day. Below 3,000 mg, risk increased. Below 2,000 mg, risk increased substantially. The recommendation to eat less than 1,500 mg of sodium falls on the harmful side of the curve. How did we get the salt advice so wrong?
In 1904, French physicians Ambard and Beaujard observed that restricting salt reduced blood pressure in some hypertensive patients. This observation launched a century of salt restriction advocacy.
In 1972, Lewis Dahl published studies showing that rats fed extremely high-sodium diets developed hypertension. The doses he used, extrapolated to human equivalents, were roughly 35,000-50,000 mg of sodium per day. Nobody eats that much. But the headline stuck: salt causes high blood pressure.
In 1977, the US Senate Select Committee on Nutrition and Human Needs (the McGovern Committee) recommended Americans reduce salt intake. No randomized controlled trial supported this recommendation.
In 1980, the first USDA Dietary Guidelines recommended salt restriction. Every subsequent edition maintained or strengthened this recommendation.
The DASH diet trial (Sacks and colleagues, NEJM 2001) showed that reducing sodium from 3,300 mg to 1,500 mg lowered systolic blood pressure by an average of 7.1 mmHg in hypertensive individuals. This became the evidence base for the 1,500 mg target.
But lowering blood pressure is a surrogate endpoint. The question that matters is: does low salt reduce heart attacks, strokes, and death? The PURE study answered that question. And the answer wasn't what the guidelines assumed.
The PURE study is the largest prospective study of sodium intake and cardiovascular outcomes ever conducted.
101,945 participants from 17 countries (income levels from low to high), tracked over a median of 3.7 years. Sodium intake estimated from morning fasting urine samples using the Kawasaki formula.
Results:
Sodium intake above 7,000 mg per day: increased risk of cardiovascular events and death. No surprise here.
Sodium intake 3,000-5,000 mg per day: lowest risk of cardiovascular events and death. This is the sweet spot.
Sodium intake below 3,000 mg per day: risk increased. The lower the sodium, the higher the risk.
Mente and colleagues published this in NEJM (2014), followed by additional analyses in Lancet (2016 and 2018) confirming the J-shaped relationship.
Why does low sodium increase risk?
Activation of the renin-angiotensin-aldosterone system (RAAS): When sodium is low, the kidneys activate RAAS to retain sodium. RAAS activation raises angiotensin II (vasoconstrictor), aldosterone (sodium-retaining), and sympathetic nervous system activity. These are cardiovascular risk factors.
Insulin resistance: Low sodium diets increase insulin resistance. Garg and colleagues demonstrated this in Hypertension (2011). Sodium restriction activates the sympathetic nervous system, which impairs insulin signaling.
Increased triglycerides and LDL cholesterol: Graudal and colleagues published a meta-analysis in the American Journal of Hypertension (2012) showing that sodium restriction increased triglycerides by 2.5% and LDL cholesterol.
Low sodium creates the metabolic conditions for cardiovascular disease while slightly lowering blood pressure. The blood pressure drop doesn't compensate for the metabolic harm.
Only about 25-30% of the population is "salt sensitive," meaning their blood pressure responds significantly to sodium intake. For the other 70%, sodium intake has minimal effect on blood pressure.
Weinberger and colleagues at Indiana University developed the concept of salt sensitivity, published in Hypertension (1986). They showed that some individuals' blood pressure rose substantially with salt loading and dropped with restriction, while others showed little change.
Who is more likely to be salt sensitive? African Americans (higher prevalence of salt sensitivity). People over 65. People with existing hypertension. People with chronic kidney disease. People with insulin resistance.
Even in salt-sensitive individuals, the blood pressure reduction from sodium restriction is modest: typically 5-10 mmHg systolic. Whether this translates to reduced cardiovascular events in these individuals specifically hasn't been established in randomized trials.
For the 70% of people who aren't salt sensitive, restricting sodium to 1,500 mg per day provides no blood pressure benefit while potentially causing the metabolic harms described above.
This is why population-wide sodium restriction recommendations are problematic. They apply a one-size-fits-all solution to a condition (salt sensitivity) that affects a minority of the population.
Sodium doesn't exist in isolation. It works in concert with potassium, magnesium, and calcium to regulate blood pressure, fluid balance, and cellular function.
The sodium-potassium ratio may be more important than sodium intake alone. Cook and colleagues published in Archives of Internal Medicine (2009) that the sodium/potassium ratio was a stronger predictor of cardiovascular disease than either mineral alone.
Our ancestors consumed approximately 2,000-3,000 mg sodium and 8,000-10,000 mg potassium daily. Modern Americans consume 3,400 mg sodium and only 2,500 mg potassium. The ratio has inverted.
Increasing potassium may be more effective than restricting sodium. The DASH diet's benefits come primarily from increased potassium (from fruits and vegetables), not sodium restriction. Aburto and colleagues confirmed this in the BMJ (2013): increased potassium intake reduced blood pressure by 3.5/2.0 mmHg and was associated with 24% lower stroke risk.
Magnesium and calcium also contribute to blood pressure regulation. Addressing all four electrolytes is more effective than fixating on sodium alone.
Practical application: Eat more potassium-rich foods (avocados, sweet potatoes, bananas, leafy greens, coconut water). Supplement magnesium if deficient. Use mineral-rich salt (Celtic sea salt, Redmond Real Salt) instead of refined table salt, which contains added anticaking agents and has been stripped of trace minerals.
Table salt (refined sodium chloride) is not the same as unrefined mineral salt.
Refined table salt is mined salt that has been heated to 1,200 degrees F, stripped of trace minerals (magnesium, potassium, calcium, and over 60 other trace elements), and had aluminum-based anticaking agents (sodium aluminosilicate) and sometimes dextrose added.
Unrefined mineral salts (Celtic sea salt, Himalayan pink salt, Redmond Real Salt) contain sodium chloride plus trace minerals. Celtic sea salt contains approximately 82 trace minerals. Himalayan salt contains approximately 84.
While the quantities of individual trace minerals per serving are small, the cumulative intake over months and years contributes to mineral status. And you're not consuming aluminum-based anticaking agents.
The research on sodium and health used dietary sodium intake as the variable, not salt type. It's possible (though not yet proven) that unrefined salt with its mineral cofactors behaves differently in the body than refined sodium chloride. The traditional populations with high salt intake and low cardiovascular disease (like the Japanese) consume mineral-rich sea salt, not refined table salt.
Practical recommendation: Switch from refined table salt to Celtic sea salt or Redmond Real Salt. Use salt to taste. Most home-cooked food is undersalted, not oversalted. The sodium problem in the American diet comes from processed foods, not from salting your eggs.
Based on the PURE study and the broader evidence:
Don't fear salt. If you eat whole foods and cook at home, you're unlikely to overconsume sodium. Salt your food to taste. Your body's taste receptors are a reasonable guide to sodium needs.
The sweet spot is 3,000-5,000 mg sodium per day (approximately 1.5-2.5 teaspoons of salt). This is where the PURE study found the lowest cardiovascular risk.
Avoid extremes. Very high sodium (above 7,000 mg) is associated with increased risk, particularly in salt-sensitive individuals. Very low sodium (below 2,500 mg) activates RAAS, increases insulin resistance, and raises cardiovascular risk.
Focus on potassium. Increasing potassium to 4,000-5,000 mg per day may be more important for blood pressure than reducing sodium. Eat avocados, sweet potatoes, leafy greens, and bananas.
Use quality salt. Celtic sea salt, Himalayan pink salt, or Redmond Real Salt instead of refined table salt.
Monitor blood pressure. If you are salt sensitive (blood pressure rises measurably with increased salt intake), moderate restriction to 2,500-3,500 mg is reasonable. But verify with testing before restricting.
Athletes, people who sweat heavily, and those in hot climates need more sodium. Hyponatremia (low blood sodium) from excessive sweating with inadequate salt intake is dangerous and underappreciated.
If you have kidney disease or heart failure, work with your doctor on sodium management. These conditions require individualized guidance.
For everyone else: stop fearing salt. Start fearing the processed food industry that put 1,500 mg in a single can of soup while telling you to eat less than 2,300 mg per day.
The salt recommendation of 1,500 mg per day has weak evidentiary support and contradicts the largest observational study on the topic. The PURE study of over 100,000 people across 17 countries found that 3,000-5,000 mg of sodium per day was the sweet spot. Going below 3,000 mg increased cardiovascular risk. Salt sensitivity affects only 25-30% of the population. Population-wide severe restriction harms the majority to theoretically benefit the minority. Focus on food quality. Cook at home. Use mineral-rich salt. Eat potassium-rich foods. Monitor your blood pressure. The enemy isn't salt from your kitchen. It's sodium from the factory.
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