Jul 12, 2012

Salt, With a Side Order of Salt

Salt is very out of fashion these days.  The government tells us that salt is bad.  Most doctors tell us to lower our salt intake.  Eat less salt!  Avoid a high salt diet!  Sir, please step away from the salt shaker before your head explodes!

Salt does not deserve the evil reputation is has been assigned in modern times.  Salt is literally the "salt of life."  Without salt, we would die.  The ancient Romans valued salt, paying soldiers partially with salt - a salarium.  Thus, a man "not worth his salt" is not deserving of his wages for the day.  This is where we derive the word "salary" from.  So when your boss pays your salary, just think, you could be getting some of that in salt!

Salt was not just used as a currency.  It was used to flavor and preserve foods.  The word "salad" comes from the Roman practice of salting leafy green vegetables (delicious by the way!).  Even going back as far as 6000 B.C., ancient communities that were lucky enough to have a salt production facility often prospered and saw a large growth in their population and wealth.  So let's embrace salt and restore it to it's honorable position in the front and center of the spice rack.

Salt is also great for very modern POTSies.  Most POTS patients can benefit from increasing their dietary salt intake.  Before adding substantial amounts of salt to your diet, you should check with your physician, because there are some forms of POTS and other health problems that would make it unwise for you to increase your salt intake.

How much salt should a POTSy get?
I don't have the magic answer on this.  In theory, I would say as much as you need to help regulate your blood pressure and blood volume to a healthy enough level, so that it improves your symptoms, but not so much that is causes other problems for you.

The medical literature on POTS gives a few different suggested ranges, anywhere from 3-10 grams of salt per day.  Keep in mind that sodium is not the same thing as salt.  Each teaspoon of typical table salt contains about 2.3 grams of sodium.  Each gram of salt contains .4 grams of sodium and .6 grams of chloride.  Again, I would encourage you to speak with your doctor about how much sodium you should get in your diet.

While 10 grams a day may seem like a huge quantity of salt, it really isn't that much sodium.  10 grams of average table salt would give you 4 grams of sodium.  Accodring to the US Center for Disease Control, the average American consumes 3.3 grams of sodium per day.  So consuming 4 grams isn't really that much more than the average joe is consuming.  However, if you have POTS, hopefully you are ecting healthier than the average joe, which means less processed junk that contains all of that salt.  So you if you are eating fresh, natural, not-so-processed foods, you will have to put a little effort in to it to get your 4 grams of sodium per day.

Supplements or Salt Shaker?
You can purchase several different types of salt supplements. Nuun tablets and Thermotabs are popular, but really don't contain that much sodium.  Nuun tables have about .36 grams of sodium per tablet and Thermotabs have .18 grams of sodium.  You would have to take a large quantity of these supplements in one day in order to rely on them exclusively for your sodium needs, but that probably wouldn't be a good idea, since they also contain potassium, and you don't want too much of that.

You can also buy Sodium Chloride tablets.  They usually come in 1g tablets.  They can really irritate your stomach, but some people tolerate them without any problem.  Be sure to drink them with plenty of water and take them with food to minimize the risk of stomach irritation.

I prefer to obtain my 4 grams of sodium per day through a good old fashioned salt shaker, and a cupboard full of high salt, healthy foods.

What Type of Salt?
Be cautious about consuming excessive amounts of iodized table salt.  Regular table salt is iodized.  This can lead to iodine-induced hyperthyroidism in some people.  When I was first sick, we knew I had low blood pressure, so my doctor's encouraged me to consume as much salt as I could, to help increase my blood pressure.  I was using iodized table salt.  I developed flushing, hives, itching all over my body and a host of other symptoms - my doctor thought I had mastocytosis or MCAD (Mast Cell Activation Disorder).  But a young resident at Cornell figured out that all of that iodized salt intake was probably causing these symptoms.  Sure enough, when I switched to sea salt, that does not have added iodine, those symptoms disappeared shortly thereafter.

Iodine is an essential nutrient.  It was added to most of the world's salt supply in the 1920s to prevent goiter.  Goiter is an enlargement of the thyroid gland causing by a lack of iodine in the diet.  If you eat a healthy balanced diet, you shouldn't need additional iodine.  Plenty of regular foods, like eggs, spinach and milk, contain iodine.  Sea salt has trace amounts of iodine in it as well, as iodine is naturally occurring in sea water.  Saltwater fish and sea vegetables (kelp, seaweed, nori) are also a good source of iodine.

High Salt Food Ideas:
Take a cue from the ancient Romans and salt your salad.  A good quality olive oil and a heavy dousing of sea salt on top of baby spinach or mixed greens is delicious.

Broth - store bought chicken, beef and vegetable broth usually contain large quantities of sodium.  Many also contain MSG or other chemical additives, but if you have time to make a homemade broth, it is very easy.  And you can make large batches of it at once and freeze individual sized portions.  Then you can add as much salt as you'd like. Broth actually tastes great with ridiculous amounts of salt in it, and if you add too much salt, you can just as some more water to mellow it out.  I am known to enjoy a cup of chicken broth in a mug in the morning, rather than a coffee.

Soy Sauce/Tamari - Tamari is just soy sauce that doesn't have wheat in it (great for gluten free people). Both contain tons of sodium.  Don't limit your soy sauce to just Chinese take out.  Soy sauce is great with steamed veggies, rice, fish, chicken, beef, turkey, gravies and my favorite, with sunny side up eggs and asparagus.

Nachos - I know you are thinking, how are nachos healthy?  Well, the nacho chips themselves are probably the least healthy part of the meal, but they aren't that bad, and they are high in salt.  Top them with black beans, shredded chicken, salsa, tomatoes, black olives, lettuce, cheese and sour cream. Add a little salt to each ingredient as you make the platter.

Cheese - if you can tolerate dairy, cheese is an excellent source of sodium, and adding more salt to cheese can make it taste even better if you don't overdo it.  I love dipping a small wedge of cheddar into coarse sea salt.  The crunchiness of the salt goes well with the creaminess of the cheese.

Pickles - pickles are basically just cucumbers doused in salt and herbs.  Some brands of store bought pickles have preservatives and chemical additives.  Homemade pickles are very easy to make.  There are endless recipes online.  And when you are done marinating your pickles, you can even drink the juice.  Some people like to add a little sugar to it and partially freeze it, like you would for a frozen margarita.

Mashed Potatoes, Baked Potatoes, Baked French Fries or Sweet Potato Fries are a great way to sneak in lots of salt.  I have never had mashed potatoes that tasted too salty.

Eggs hide salt very well too, and I know I promised to keep this list healthy, but we can't talk about eggs without mentioning that bacon has tons of sodium in it and nothing goes better with eggs than bacon (and a prior item, cheese!).

We'd love to know, what are your favorite high salt foods?


  1. I love popcorn, tomato sauce, V8, olives, pickles, lunch meat, salsa, flavored hummus, tamari, soup (when it's not so hot out!) and when i'm not craving salt thermotabs. A very smart POTS expert recommends at least 9g of sodium a day because that is how much is in 1L IV saline. so even though 10g seems high, you're right it's not really. Interesting what happened with ionized salt... i tend to use table salt more often just cause it tastes better and it's fun to use the grinder but i'll keep that in mind thanks!

  2. * I meant to say, I use sea salt not table salt

  3. I was just diagnosed with POTS yesterday at Vanderbilt. I just graduated from law school and I am studying to take the bar exam at the end of JUly. I just found your blog and instead of studying I can't stop reading it. I saw where you are an attorney as well. I was devestated yesterday bc I have worked so hard and I feel like all of my dreams have been crushed. I have days where I cannot even get out of bed. You have brought me so much comfort through your blog. Are you still a practicing attny?

  4. This made me hungry. During my last pregnancy I craved mashed potatoes and nachos (pickles I eat a lot all the time). Mashed potatoes, baked potatoes, french fries, deviled eggs, sandwiches, nachos, yum.

  5. This is a great list of foods that are very healthy too, much better than the medical textbook diet of fast and highly processed foods. I eat many of these things for my POTS. Since I take florinef my doctor says I should eat more potassium as your kidneys excrete potassium while on florinef. I use NoSalt since it is a great source of potassium. I add it right in with the sodium so I'm getting my sodium and potassium at the same time! I did not know the "salt" history, that's interesting stuff.

    But hey, I have to point out some misinformation about goiters in your post. Having one myself, and having surgery to remove it, I have to let you know the facts. This is cut and pasted from the American Endocrinology Association.

    "Goiter is an enlargement of the thyroid gland. The gland can be generally enlarged or have multiple growths (nodules) leading to enlargement of the whole thyroid gland. The latter is termed multinodular goiter (MNG). There are two forms of multinodular goiter: 1) nontoxic MNG and 2) toxic MNG. If the goiter makes normal amounts of thyroid hormone, it is known as a nontoxic MNG. If the goiter makes higher than normal amounts of thyroid hormone leading to a suppressed TSH, it is known as a toxic MNG. (See Hyperthyroidism) The exact causes of thyroid nodules or multinodular goiters are unknown. In general, the development of goiter is due to a complex mix of genetic and environmental factors. Iodine deficiency as a cause of goiter is rare in North America and most of Europe. However, even in areas of iodine deficiency most patients do not develop goiters."

    Keep up the great work!

    1. The point about iodized salt is well-taken. The reason goiters are not so common anymore is iodized salt. They used to be very common in areas where there is no iodine in the soil, like the midwest. Then they created iodized salt and there aren't anymore goiters anymore. If people don't eat salt - including no prepackaged foods or fast foods, they would get them again unless they eat alot of seafood that is naturally high in salt.

  6. Does anyone have any suggestions on how to deal with the anxiety this seems to bring? After I eat or if I don't get enough sleep seems to make me more prone to be anxious and its driving me insane. I hate the feeling!

  7. Dear xloriricex,

    Everyone is different, but for many POTS patients, the physical sensations of POTS (fast heart beat, chest pains, shortness of breath, lighteadedness, increased sensitivity to noise/lights, etc) can feel like anxiety, but research on POTS patients has shown that is it not an emotional/mental health based anxiety. Those are just the physical symptoms that happen when you have POTS, and they just happen to be the same symptoms that people with anxiety may experience. Often, in POTS, those symptoms are caused by elevated levels of norepineprhine, which is seen in many POTS patients, and worsened by low blood volume.

    Increasing your blood volume can help (salt, fluids, medications like Flourinef, occasional IV saline if you need it), as can improving the return of blood flow to your heart (compression stockings, leg and core strengthening exercises). Some patients also practice meditation, prayer, Buteyko breathing or other relaxation techniques. And finally, there are drugs like Xanax, Klonopin and others meds that can help.

    Also, even though POTS patients are, on the whole, no more likely to have panic or anxiety disorders than the general public, having a chronic illness and all of the uncertainly that comes with it can cause anyone to have "true" anxiety on top of the physical sensations of POTS. Perhaps speaking with a counselor or therapist may help, and of course the anti-anxiety meds I noted above.

    Of course, I am not a doctor, but when you mention that you feel more anxious after eating, that is a hint to me that this is probably not an emotional anxiety for you. After we eat a meal, large amounts of blood are diverted to our GI tract to help digest our meal. This can cause all of our POTS symptoms to flare up, including tachycardia and, in some patients, low blood pressure or impaired cerebral blood flow. Good tricks to minimize the post-eating POTS symptoms... eat smaller meals, graze throughout the day like a cow would, and try wearing an abdominal binder or some very tight Spanx like undies over your belly area - this prevents blood from pooling in your gut. Also, drink a large glass of water or other hydrating fluids a half hour or so before your meal, and salt up your meals and snacks.

    I hope some of this helps.


  8. Thank you for your response. I don't believe it is mental either, but after being told it was anxiety and all in my head for a decade its hard to find another word. I feel like complete crap after I eat, I get cold and feel very tired and a lot of times get anxious. I also get anxious when something makes me excited and my heartbeat goes up...its so aggravating. I feel like I can't be happy or excited about anything. I actually have been avoiding eating until I know I have nothing to do and no one to see afterwards because I feel so odd being so sick. I just drink a lot of Gatorade and Smart Water and that seems to make me feel better during that time. I'm hoping my Electrophysiologist can find an actual thing this stems from so I can try to fix it. I will try using a pair of spanx or something to see if I feel better when eating, thank you for that suggestion.

  9. Hello - it is common for people with POTS and other orthostatic problems to get more symptoms after eating. It has been known for decades in the medical world - it's called "postprandial hypotension". As she said, the blood needs to go to the stomach to digest - BUT - when you stand up and do things, the body protects the head first and cuts down the blood supply to the stomach! Which can cause stomach pain, nausea, vomiting etc..

    Treatment starts with the amount of fluids and salt you take all day, 2-3 liters fluid, 6-10 g salt - both divided throughout the day, and getting the head of the bed raised at night. For eating - generally if you get the orthostatic problems under better control, the GI symptoms start to be better controled. Eating moderate meals and then NOT DOING ANYTHING (like exertion, walking around, standing up) for at least 1 hour afterward to let the blood go to the stomach and digest food. For small snacks - an apple and 6-9 nuts, it doesn't seem to take as long to digest.

    The anxiety is related to the chemicals/hormones that get released when you stand up with POTS or orthostatic problems. It's like being stuck in overdrive most of the time. The chemicals are part of the "fight or flight" system - so with POTS/Orthostatic problems, they never go back down to "0", which is what is the normal reaction after a frightening situation. There are some general things that will help bring the feeling of anxiety down.

    Hope some of that helps - My daughter has had this for the last 8 years - it can be really frustrating but there are more things we know now that help!