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WNY researcher shakes up nutrition world with new book on salt

Forget what you think you know about salt.

A leading cardiovascular research scientist from Western New York is among those who say the mineral got a bad rap four decades ago when it was lumped in with nutritional warnings about eating too much fat and sugar.

"We never demonized an essential mineral – ever – until we demonized salt,” said James DiNicolantonio, author of “The Salt Fix,” released this week at bookstores and online.

A growing body of research suggests medical advice many Americans have heeded to cut back on salt has been one of the drivers of obesity, diabetes and heart attack rates, according to DiNicolantonio. The proper amount of salt, he said, can ward off sugar cravings, ease chronic illness and improve sports performance.

"James knows this topic better than anyone I've ever met, so this is not some idle opinion. This is fact-based, practical stuff that a lot of physicians don't understand yet, but they'll come around," said Dr. James O'Keefe, a Mayo Clinic-trained cardiologist and director of the St. Luke's Mid America Heart Institute Preventative Cardiology Program in Kansas City, Mo.

DiNicolantonio, an Amherst native, is a clinical pharmacist in Rochester, N.Y., as well as a cardiovascular research scientist with the Mid America Heart Institute and associate editor of the British Medical Journal's (BMJ) Open Heart. He has published more than 200 research papers, some with O'Keefe.

That and other research lays the foundation for "The Salt Fix," which DiNicolantonio hopes will dispel the long-held belief that a low-salt diet boosts heart health and return salt to its rightful place in a balanced diet.

"Paradoxically, the people who follow the low-salt diets tend to do the worst," O'Keefe said. "Like with most things, it turns out a moderate amount is fine, probably better than following the national guidelines."


How did salt become villainized? How much do we really need? How does it work best in a healthy diet?

DiNicolantonio and O'Keefe talked about this in separate interviews.


Salt began to intrigue DiNicolantonio, 30, while he was a member of the wrestling and cross-country teams at Williamsville North High School, and he discovered regulating his salt intake helped his performance. His interest grew as he graduated from high school in 2004 and followed the path of his great-grandfather, mother and brother into the University at Buffalo pharmacy school. He was already conducting research when he graduated with a doctorate degree in 2010.

His pharmacy work helping to medically manage chronically ill patients helped clarify his belief that leading health and nutrition experts got salt wrong.

"Most of us view salt as a non-essential, potentially addictive substance, something that we’re eating too much of and that doesn’t have many health benefits," DiNicolantonio said. "When people sprinkle salt, they are almost consciously counting the granules, worried it's going to increase their blood pressure and lead to a stroke or heart attack. It's so ingrained in everybody's mind. I wanted to understand where that concept even came from."

The 1980 Dietary Goals in America recommended a high-carb diet and restricted intake of fat, saturated fat, cholesterol, sugar and salt. The recommendation to limit daily salt intake to 2,300 milligrams – about 1 teaspoon – was based on the expert opinions of Louisiana State University scientists George Meneely and Harold Battarbee, who noted in a paper that too much salt was harmful to people who ate too little potassium and were genetically susceptible to salt's blood pressure-raising effect.

"Those nuances got lost in translation," DiNicolantonio said. Worse, he said, those with high blood pressure or a family history of heart disease were encouraged to limit sodium intake to 2,000 milligrams.

"If your body's telling you that you need more salt, you should listen to that signal because your body's smarter than any dietary guideline," James DiNicolantonio says.

The recommendations have remained unchanged for almost four decades. During the last four years, however, they have come under increased fire as mounting research has thrown them into question – and as controversy swirls over past recommendations that cutting fat was more crucial than limiting sugar. American obesity and diabetes races climbed steadily in the decades that followed.

After a major review in 2013, the Institute of Medicine concluded there was insufficient evidence connecting salt consumption limits with better health outcomes. A year later, Dr. Salim Yusuf – a  Hamilton, Ont. cardiologist and president of the World Heart Federation – published results of a study that followed more than 100,000 people from 18 countries over nearly four years and showed worse heart health outcomes among those who consumed too little salt than those who consumed too much. Those who moderated their salt use fared best. These, and the St. Luke's-related studies, were funded by government and other sources, not the salt industry.

Dennis Bier, a professor at Baylor College of Medicine and then-editor of the American Journal of Clinical Nutrition, told the Washington Post two years ago the salt debate was the biggest hot button issue in medicine. “When you are making recommendations for 300 million people," he told the Post, "you have to be concerned about any data that suggests harm.”

As leaders in the medical field prepare the 2020 guidelines, will the latest research be enough to revise the guidelines?

"I bet it will," said O'Keefe, also a professor of medicine at the University of Missouri. "We've learned from some of these past dietary mistakes in guidelines and there's already some movement toward that."


In recommending a daily salt limit of 2,300 milligrams of sodium per day, the Centers for Disease Control and Prevention reports that the vast majority of Americans eat about 3,400 milligrams – about 1½ teaspoons.

That amount has been consistent in most of the world for at least a half century, "which tells you that our bodies control salt intake," DiNicolantonio said. "The three countries with the lowest rate of coronary heart disease mortality - France, South Korea and Japan - all eat a high-salt diet. We know the Mediterranean Diet is healthy and that's a high-salt diet."

Certain activities can sap your body of salt and boost cravings, he said. Those who exercise vigorously for an hour or drink four cups of coffee in a day can lose up to 1,200 milligrams of salt, for instance. Those with intestinal diseases, Rheumatoid arthritis or lupus find it harder to absorb salt.

"If your body's telling you that you need more salt, you should listen to that signal because your body's smarter than any dietary guideline," DiNicolantonio said. A healthy person on average can safely consume 3,000 to 6,000 milligrams of salt, he said. O'Keefe put the "sweet spot" at 3,000 to 3,500 milligrams.

"If you have really, really high blood pressure, we don't want you on a high-salt diet," O'Keefe said. "If you have heart failure, I don't want you on a high-salt diet. But I wouldn't want you on less than 2,300 milligrams, either."


"Patients are so confused about diets in general that my standard advice is that the evil white crystal that you need to avoid in the American diet is sugar," says Dr. James O'Keefe, director of the St. Luke's Mid America Heart Institute Preventative Cardiology Program in Kansas City, Mo.

It takes a heavy dose of barbecue, deli meats, potato chips and added salt to surpass a 6,000-milligram daily salt threshold. That's where salt mixes with unhealthy fats, sugars and chemicals in processed foods that raise the risk of cardiovascular disease and shorten longevity, O'Keefe said.

Worse, however, is too little salt – a building block for cells – which at very low levels spur the creation of stress hormones that can speed the heart, tax the kidneys and disrupt the insulin response. Low-sodium cases in hospitals "make doctors shudder," O'Keefe said. "It's (a) bad marker of somebody who's not doing well."

"Most studies show the need to hit 7,000 milligrams for a detrimental effect, which is a 20, 30 percent increase in cardiac events," DiNicolantonio said. "If you go below 2,300 milligrams, you can see almost a doubling of cardiovascular events." Healthy kidneys can excrete more than 10 times a normal intake of salt, he said. "It's been confirmed in clinical trials."


Physicians across the country have, for decades, encouraged patients to follow the dietary guidelines, so what should you do if you have a history of heart disease in your family and your doctor has told you to limit or avoid salt?

"I would recommend 'The Salt Fix' to them," O'Keefe said. "Physicians might bristle at that but honestly, I'm a typical physician. I had 16 years of training and I got zero training in nutrition. None. Not a lecture. The point is that the average doctor, if he or she knows anything about nutrition, is self-taught – and most physicians are not experts about diets, to say the least."

The salt and fat guideline recommendations didn't work for O'Keefe personally, "which is one of the reasons I started looking at diet," he said. "I'm also married to a smart dietitian, Joan O'Keefe. She's been salting veggies and fish for years." Still, the cardiologist said, your doctor should know the individual circumstances surrounding your health and be able to explain why diet restrictions are necessary.


"Himalayan salt probably isn't worth the 10 times more you're going to pay for it compared to table salt," DiNicolantonio said. O'Keefe recommended an iodized salt, which can support thyroid care. DiNicolantonio favors organic sea salts culled from ancient oceans.


"Patients are so confused about diets in general that my standard advice is that the evil white crystal that you need to avoid in the American diet is sugar," O'Keefe said. "The mantra that most people should be thinking about when it comes to diet is 'Eat real food and salt it to taste.' Eat mostly vegetables and fruits, and nuts and berries and fish, and a little bit of lean meat. As much as possible, avoid processed foods. … If you eat that way, you do have to salt foods. Salt makes real food taste better. When you eat real food you tend to eat the right amount, you fill up faster and you stay healthy."

Neither DiNicolantonio nor O'Keefe favors low-salt versions of food, which generally contain more sugar, artificial sweeteners and artificial preservatives. They also worry that the body's need for adequate levels of salt may drive low-salt food eaters to consume more than they need, promoting weight gain and its associated health challenges.

"We're so scared of nature's most natural preservative – salt – that we'd rather have an artificial preservative and call it 'low-salt' so people think it's healthier," DiNicolantonio said. "That's just crazy."



What: Cardiovascular researcher James DiNicolantonio will sign copies of his new book, "The Salt Fix: Why the Experts Got It All Wrong – and How Eating More Might Save Your Life."

When: 1 p.m. June 17

Where: Barnes & Noble, Boulevard Consumer Square, 1565 Niagara Falls Blvd., Amherst

More info: Learn more at



Twitter: @BNrefresh, @ScottBScanlon

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