Sodium Restriction in HF: Take It With a Grain of Salt?

Ileana L. Piña, MD, MPH


January 10, 2019

Hello. I am Ileana Piña, formerly of Montefiore Medical Center. I now will be at Wayne State and the Detroit Medical Center in the upcoming months. This is my blog.

I have a very interesting discussion for you today and it has to do with sodium. There was a beautiful paper in JAMA Internal Medicine by Mahtani and colleagues[1] out of Oxford that went deeply into the literature to figure out why we are so insistent on low-sodium diets. It is in every guideline. I have been cantankering patients for years, having them look at everything that they eat, read the labels, add up the sodium, and never exceed that famous [threshold of] 2 g sodium. I think we probably extrapolated it from the hypertension literature, as we know that there are salt-sensitive individuals who have significant hypertension.

Lacking Data

They reviewed every paper and found 2700 articles that dealt with sodium. However, when it came down to having good data and good analysis, they came down to fewer than 30.—therefore, less than 100 patients per study. Most of them did not have accurate or very thorough measurements of the diet and what the recommendations have been. Some studies showed benefits, some did not. Some were neutral.

The bottom of this is that we really have no good evidence, yet we are so evidence-driven. Every single drug that I ever use in heart failure I have learned from the evidence. How do we do the evidence in heart failure? We do clinical trials. We do randomized clinical trials that are controlled. We have placebo groups. Why have we not done this with sodium?

We all espouse the dictum of the low-sodium diet. Maybe it's because it is very difficult to do sodium-based trials. You have to control the diet. You have to control what is in the foods and you have to have the patient sequestered in some format. We all know that diaries are full of bias and recollection is very poor. How do we do this?

It may be very difficult, but the accompanying editorial by my friend Clyde Yancy[2] basically says, "Let's put the pedal to the metal and do the trials." I agree. At some point we need to have the data.

Advice to Patients

I will tell you what I have been doing in the past few years because I am very concerned with patient adherence. They leave the hospital with 13 different drugs. How are you ever going to take 13 drugs in a day? When we whittle it down in our postdischarge clinics, I can probably get them down to about eight. Four of them alone are heart failure drugs. The others could be for diabetes, chronic lung disease, arthritis, or a lot of other comorbidities. There are other drugs that they need to take. Their lives are already complicated with taking medications, hopefully only once or twice a day, and all the clinic visits that they have to attend.

Adding the dietary issue is one more burden that will lead to nonadherence. When they get tired of it and fed up, they will ignore the dietary recommendations. The daily food may be prepared by somebody else in the family, so with families in tow I need to be as clear but as broad as I possibly can. What do I say to them? "I want you to [eat food cooked] primarily at home." I know that the food on the outside is bound to be high in sodium and have hidden sodium, so it may not be tasted with the salt taste, but it is still there. They can cook with a little bit of salt because patients do complain about food having no taste if there is no salt. A little bit of salt is, in essence, a 2-g sodium diet. And do not have a salt shaker at the table. Do not eat processed foods like from the delis in the Bronx, where I was working. All of those processed meats have a lot of sodium. Keep it simple.

The other important point is that if they gain fluid weight because they are overeating sodium, I always give them a flexible diuretic regimen: X mg of Lasix (furosemide) for 3 pounds over a 3-day period. That has been imbedded in our education booklets.

Make life easier for them, because I want them to take their medications. There I have no compunctions about being very direct that I do not want them skipping their medication.

I hope I leave you with this piece of advice and that it will help you in your clinics. Thank you. This is Ileana Piña, signing off.


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