Salt - Low-S-S vs No-S-S

[JeffN]

A thread on the topic, Are You S-S Free, was started in the Lounge and I am moving my comments from the topic here, where I will also add to them.

From the original thread...

viewtopic.php?f=1&t=57097

I addressed the concept of S-S Free previously in another thread of yours.

viewtopic.php?f=1&t=53973&p=549878&#p549878

My comments and this discussion will only address the S (sugar) and the S (salt) ("S-S"). We can save the O for another day.

It comes from True North docs

While there may be a few people who have jumped on this bandwagon (including many who may not understand the literature or how to interpret it), it actually comes directly from Alan Goldhamer and is based on his personal philosophy and thoughts, not on any actual evidence (which he admits), that he thinks none may be best.

Many, if not most of the other TrueNorth docs do not promote it or follow it. Dr Lisle doesn't (just see his Continuum of Evil). Dr Klaper doesn't (just watch his video on Salt Sugar and Oil) where he uses my guidelines.

To me, it's taking the McDougall plan to the "next level" of health which is hard to achieve.

This is a misconception and unfortunately, one that is not true and more often then not, backfires and does more harm then good. While we will always adapt/adjust the program to the individual, somehow thinking that the WFPB low S-S diet is not enough, or that there is a higher level, is incorrect.

All the evidence we have on the WFBP diet, that includes the prevention, treatment and reversal of disease, even in those who are seriously ill, comes from the published work of Kempner, Morrison, CHIP, 7th Day Adventists, Pritikin, Ornish, Esselstyn, Barnard, which is all based on a diet low in S-S and not S-S free.. All the other mainstream evidence that supports this diet and way of life, is also based on a diet low in S-S and not an S-S free.

The CR published research does not use a S-S free diet.

The majority of the published evidence by TrueNorth is on fasting, not eating, and it is mainly on lowering BP. They just released a single care report on lowering Lipids through diet.

I can show you a tremendous amount of evidence for the guidelines I promote for low S-S but not one shred of evidence for S-S free.

We are here because we are an evidence & science based program.

Otherwise, I guess we better go back to all those who have reversed their CVD, T2 DB, HTN, Diabetes, Met Syn, Obesity and/or put their auto-immune disease and cancer in l/t remission etc etc, and let them know that they didn't do it right and still have another level of hierarchy and purity to achieve

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Skip wrote:
To me, it's taking the McDougall plan to the "next level" of health which is hard to achieve.

This is a misconception and unfortunately, one that is not true and more often then not, backfires and does much more harm then good. While we will always adapt/adjust the program to the individual, somehow thinking that the WFPB low S-S diet is not enough, or that there is a higher level, is incorrect.

Thanks for that correction that didn't "sink in" when we discussed this previously......
It is interesting to note that from the current poll, about 1/5 of us are S-S free.

A few things to consider...

First and most important, as with the "hacks" to the MWL program, "We are here because we are an evidence & science based program." Saying something worked, is really meaningless without the supporting evidence. And, just because it may appear to work for an individual (or two) for either personal or medical reasons, doesn't mean it applies to everyone, or has any solid scientific basis.

If we begin to accept these anecdotal stories without the supporting evidence, and treat them as if they are as solid in value as the good evidence we have, then we lower the standard of evidence on which these program are based and to the general public, we become quacks. This is/was the problem with, What The Health, that I pointed out. If we have such good evidence for what we do, why make things up, or exaggerate things and/or promote and make claims for things that have no evidence.

If something does work for someone, then there is a process (as we did with the WFPB low S-S program) to go about turning that story into evidence and that evidence into good evidence. The first process is that it has to be maintained and complied with over time, which would be info that would be needed including (but not limited to.....) how long have you been S-S free, why did you do it, how adherent are you, do you ever eat out, do you ever eat packaged foods, do you prepare all your foods, etc etc?

Second, by accepting these items for more then they are, we then make the rest of the programs, like Pritikin, McDougall, Esselstyn, CHIP, Barnard, etc etc, seem inferior when in actuality, they are the ones with the good evidence.

Kemper took care of very sick people with a specific health issue with a salt free diet. However, once they were able to recover, a 100% salt free diet was not required.

As an FYI, I counsel many patients who have been through TN, McDougall, Essy, Barnard, Ornish, Pritikin, etc. I am amazed at how many think they are on a low S-S (or even S-S free) diet but don't understand all the sources of hidden S-S. I just spoke with one this morning whose intake is way over the Tolerable Upper Limit and thought they were low S-S. I have another appointment today with a former TN patient who is also in a similar situation.

We are health professionals in a quest for good health, not pharisees seeking purity

+++++++++++++++++++++++++++++++++++++++++++++++++++++++

Salt and sugar free is not part of the program but I have never seen added salt and sugar encouraged,

Added salt & sugar, as a condiment, are actually an accepted part of the program and encouraged, much more assertively by Dr McDougall & the McDougalls then me, but encouraged by all as a condiment. Salt shakers and sugar is available at all the meals and in the snack room and the participants are encouraged to use them as a condiment.

Dr McDougall actually has expressed his concern in many lectures, videos, webinars and newsletters about diets that are very low in sodium and the fear of a using either/both for flavor.

The reason my cooking DVD doesn’t use sugar or salt is for the same reason we try to make many of the dishes at the program without adding salt and/or sugar to the recipe. This is because the majority of the added salt & sugar in the typical diet is added by the manufacturer in packaged and prepared products and the best way to keep intake of both to a reasonable & safe level is to avoid it as much as possible in packaged products and in prepared foods. Then, one can safely add it at the table without overdoing it.

You may also want to check out my label reading guidelines and my thread on salt where all of these points (and more) are explained in detail.

As an FYi, a recent communication went out to all the employees of the program acknowledging this so everyone is on the same page and to clarify that we are not an S-S free program...

Salt/Sugar - We are not a salt or sugar free program. We do recommend cooking without them whenever possible but we do encourage the use of salt &/or sugar by sprinkling it on the top of food at the table for flavor.

++++++++++++++++++++++++++++++++++++++++++++

In his 2008 newsletter, Dr. McDougall states:

"A basic diet of starches, vegetables, and fruits (the McDougall Diet) with no added sodium provides less than 500 mg of sodium daily. Adding a half-teaspoon of salt to the surface of your McDougall dishes daily adds about 1100 mg of sodium—making the total daily intake 1600 mg. The “low-sodium diet” fed to a hospitalized patient, following a massive heart attack, under the expert guidance of doctors and dietitians, contains 2000 mg of sodium. Now you understand why I am comfortable putting the saltshaker on the dining tables at our programs."

I checked the cronometer and it says that the rda for sodium is minimum 500 and max 2300 mg per day. So if you follow the McDougall plan and attempt to be S-S free, you may not be getting the rda of sodium which may lead to problems......this is what I glean from this discussion. I wonder how the people who are S-S free feel about this?

A WFPB diet provides about 250-500 depending on the restrictiveness and/or variety. Based on my analysis of the McDougall diet, I say around 350-500 and it would have to be fairly limited and/or restrictive to get down to 200-250 or less.

There is no RDA/DRI for sodium but there is a recommended safe minimum of 500 mg/day though the bare minimum need is estimated to be about 115 or so buy that is under ideal conditions with "maximal adaption and without active sweating" and not recommend as a goal to aim for

"Thus, a minimum average requirement for adults can be estimated under conditions of maximal adaptation and without active sweating as no more than 5 mEq/day, which corresponds to 115 mg of sodium or approximately 300 mg of sodium chloride per day. "

Recommended Dietary Allowances 10th Edition
Subcommittee on the Tenth Edition of the RDAs Food and Nutrition Board Commission on Life Sciences
National Research Council
ISBN: 0-309-53606-5, 302 pages, 6 x 9, (1989
http://www.nap.edu/catalog/1349.html
P 253

The 1500 is the Adequate intake which is actually 1200-1500 depending on age and health. "The Adequate Intake (AI) is set instead of an RDA if sufficient scientific evidence is not available to calculate an EAR. The AI is based on observed or experimentally determined estimates of nutrient intake by a group (or groups) of healthy people." The AHA, ACC, NHLB, etc all use the 1500 too.

https://www.nap.edu/read/10925/chapter/8#270

"The AI for sodium is set for young adults at 1.5 g (65 mmol)/day (3.8 g of sodium chloride) to ensure that the overall diet provides an adequate intake of other important nutrients and to cover sodium sweat losses in unacclimatized individuals who are exposed to high temperatures or who become physically active as recommended in other dietary reference intakes (DRI) reports. This AI does not apply to individuals who lose large volumes of sodium in sweat, such as competitive athletes and workers exposed to extreme heat stress (e.g., foundry workers and fire fighters). The AI for sodium for older adults and the elderly is somewhat less, based on lower energy intakes, and is set at 1.3 g (55 mmol)/day for men and women 50 through 70 years of age, and at 1.2 g (50 mmol)/day for those 71 years of age and older. "

The 2300 is the Tolerable Upper Limits. This is defined as "The highest level of nutrient intake that is likely to pose no risk of adverse health effects for almost all individuals in the general population. As intake increases above the UL, the risk of adverse effects increases."

https://www.nap.edu/read/10925/chapter/8#271

"The adverse effects of higher levels of sodium intake on blood pressure provide the scientific rationale for setting the Tolerable Upper Intake Level (UL). Because the relationship between sodium intake and blood pressure is progressive and continuous without an apparent threshold, it is difficult to precisely set a UL, especially because other environmental factors (weight, exercise, potassium intake, dietary pattern, and alcohol intake) and genetic factors also affect blood pressure. For adults, a UL of 2.3 g (100 mmol)/day is set. In dose-response trials, this level was commonly the next level above the AI that was tested. It should be noted that the UL is not a recommended intake and, as with other ULs, there is no benefit to consuming levels above the AI."

So, if you follow the program as recommended, including a variety of foods from the recommended food groups, you should be close to 300-500. If you add in a 1/2 tsp of salt, you are adding in about 1100 which puts you at 1450-1650.

These are the numbers my guidelines are based on. They are the same guidelines used by Dr's Mcdougall, Klaper, Lederman, Esselstyn, E2, WFM, Pritikin, etc.

This is not recommending the unbridled use of salt, nor is it saying you must hit the 1500-2300 range but showing that most people can easily add "up to" a .25 to .5 tsp and not worry. If you are adding it at the table to the top of the food, even just 200 mg (the amount in one of the small .5 gram salt packets) can taste like quite a bit. So, using 1-3 of those packets a day is a simple way of measuring it and staying around 700-1000.

Here are comments from a recent discussion on this very issue from my colleague Jay Kenny, PhD, who in my mind, knows more about this topic then anyone, and has written several CEU programs on it.

"The vast majority of people can probably get by just fine on 200 to 500mg sodium/day although this level would be dangerous for those taking diuretics, some other drugs and some medical problems including those with seriously impaired renal function. I think shooting for 500 to 1000mg sodium daily is likely a safe and effective target for most people to avoid elevated BP/HTN who want to control their BP without drugs. If one were to eat a diet composed largely of whole fruits, nuts, whole grains, and beans with no added salt or other foods with appreciable amounts of sodium then sodium deficiency is plausible [NOTE: JSN - Depending on the variety and restrictiveness] as these foods have so little sodium intake could fall below 200mg/day which may be insufficient for some people.

People whose adrenals that cannot make enough aldosterone who are not being treated with aldosterone certainly would not want to be on a low-salt diet as their ability to retain salt is severely compromised. They can become hyponatremic even on a normal American diet sometimes. A lot of vomiting might trigger low chloride levels in someone who cannot keep any food down. People with cystic fibrosis lose a lot more sodium in their sweat and cannot adapt as normal people so might have problems on a very low-salt intake. But as long as one has normal adrenal function and normal renal function and are not taking drugs like diuretics worrying about sodium deficiency is a waste of time. Walter Kempner used to put people with malignant HTN on a diet of rice and fruit and sugar which must have less than 200mg of sodium but not for long. He would add some chicken or fish and vegetables and these had sufficient sodium to prevent deficiency. Clearly people can consume zero sodium on a fast for a week or more."

Most of this is covered in the Salt thread. If you follow my guidelines you will be able to add some salt, end up around 500-1100 and not risk your health from too little or too much.

As we say at the program, "the food is your medicine and as Julie Andrews sang, 'just a (very little) spoonful of sugar (and/or salt) helps the medicine go down' "


+++++++++++++++++++++++++++++++++++++++++++++++++++++++

Here is an example of a typical day based on my SNAP meals, that has about 600 mg sodium for about 2000 calories, without adding any salt.

viewtopic.php?t=10519

Here is another typical day that came in at 140 mg sodium for about 2000 calories, without adding any salt.

Breakfast
1 cup fresh blueberries
1 medium orange
2 cups Oatmeal

Lunch and Dinner
3 large baked potatoes
1.5 cups black beans
1 cup cooked zucchini
.5 cup cooked chopped onions
1 cup cooked chopped peppers
1 cup cooked okra
2 cups cooked mushrooms

Snack
1 medium apple

Nutrient Analysis
Energy: 1986 kcal
Sodium 142.3 mg

So, as you can see, it is possible to not only get below the 500, but even below the 200, without any added salt.

I come up with the 350-500 as an average based on eating a variety of foods following my guidelines, but someone following a more repetitive, more limited/restrictive diet, could possibly come in under the 500 & even under the 200 on a regular basis.

In Health
Jeff

[JeffN]

While there are a few others who champion the S-S free diet, the actual modern day promoter of the EWP S-S free diet is Dr Goldhamer. Dr Goldhamer and I met in the mid to late 80's when we were both members of the American Natural Hygiene Association, which was an organization based on the philosophy of Natural Hygiene. Natural Hygiene promoted a very strict, mostly raw, mostly vegan, mostly unprocessed diet without the addition of salt or sugar. That is where this came from. It was based more on philosophy, then actual science. Since he is the originator of this, I wanted to discuss this issue with him.

Dr Goldhamer and I engage in these discussions (low vs no S-S, % Fat, ideal BP, etc) on a regular basis and have been for decades. We are both friends and colleagues. Here is his response to this thread and the points I made (posted with his permission, bold underlined highlight to emphasize a point are mine)

"We appear to be in general agreement on all topics except:

The one point we appear to be at odds is that you believe that by advocating a more moderate approach, this will result in the ultimate consumption of a healthier diet than if you advocate a S-S-free approach.

Both groups will vary from the ideal but you and Doug (Lisle) believe that your approach will result in a superior clinical outcome.

If that assumption proves to be correct, then I will of course have to modify the approach that I am taking.

I want to see it tested before I change my approach.

I don’t doubt that your approach may be superior for some patients but I believe that an S-S-free goal will outperform a more flexible model with a substantial subset of the patients that I see.

I realize I have to prove it. The existing limited information supports your contention.

If I am wrong, I will modify my approach and dogma.

Do you disagree that IF you could get compliance then the S-S-free might outperform the more flexible approach or do you suspect that it would only make a measurable difference in a minority of the population with specific problems? (This will be able to be tested objectively)

i.e.., if we took two groups of healthy patients would the S-S-free diet show measurable improvement in biomarkers etc. over a highly compliant patient on the more flexible (ie standard) Novick approach.

My response to him...

The one point we appear to be at odds is that you believe that by advocating a more moderate approach, this will result in the ultimate consumption of a healthier diet than if you advocate a S-S-free approach.

Just to clarify, I don't have a rule but a set of guidelines and advocate what is appropriate.

Both groups will vary from the ideal but you and Doug Lisle believe that your approach will result in a superior clinical outcome.

I like to think of mine as flexible but yes, I am in agreement with Doug Lisle that we will have much superior outcomes (and believe the data to date support my position). Doug would argue that for many, the goal to be S-S-free might create ego trap issues and result in a net increase in consumption.

If that assumption proves to be correct, then I will of course have to modify the approach that I am taking.

I want to see it tested before I change my approach.

I don’t doubt that your approach may be superior for some patients but I believe that an S-S-free goal will outperform a more flexible model with a substantial subset of the patients that I see.

I might agree here but it depends on some other issues. I just don’t think the total restriction, which may be applicable for some, should universally be applied to all. That is why mine is flexible from what occurs naturally in a variety of healthy food to upward of 1000 mg or so.

I realize I have to prove it. The existing limited information supports your contention.

Thank you

Do you disagree that IF you could get compliance then the S-S-free might outperform the more flexible approach or do you suspect that it would only make a measurable difference in a minority of the population with specific problems? (This will be able to be tested objectively)

I think it would only make a measurable difference in a very small minority of the population with a very specific need.

In the end, you are taking a very strict approach, stricter then any of our 70 years of evidence is based on, and applying it to not only your total population, but also the population at large (when you recommend it publicly). Yet it probably only applies to a very very small minority at most (~1%). While some of the other 99% may choose to go along with this, at least for a while, you are losing more of the other 99% then the few you maybe capturing.

In response to this, Dr Goldhamer said..

I accept the concept that for some patients, perhaps a significant percentage, the ego trap could be more significant than the Pleasure Trap.

You can avoid the pleasure trap by avoiding trigger foods.

You can't escape the ego trap, it's always with you.

In Health
Jeff

PS another discussion with Dr Goldhamer & I on Salt & Blood Pressure.

viewtopic.php?f=22&t=57369#p578187

[JeffN]

Doug would argue for many that the goal to be S-S-free might create ego trap issues and result in a net increase in consumption.

Now, I will quote highlights of Dr Lisle from the same conversation...

My guess is S-S free as the prescription results in very low benefits on average. Maybe 3-5% if the people have excellent outcomes. Maybe 25% get some benefits. And 70% give up, defeated.

...

S-S is clearly not necessary for the vast majority of reversible pathology to reverse. What is needed is very good, not perfection.

And I do not believe that perfection is easier to maintain that excellence. It requires a similar personality and degree of motivation. Modest amounts of any supernormal stimulation will not capsize any ship. For example, 95% of people have zero problem regulating modest alcohol use. A small minority can’t do it.

...

The question becomes, does setting the bar very high win you more than it loses you?

...

I’m probably in the best position of anybody to guess. I’ve talked through the shame and the ego trap with probably 500 individuals. The ego trap is a huge influence here. Set the bar too high, and - huge percentage of people wander off and never return.

...

More potatoes, rice, beans in place of meat and dairy is a solid message, and may permanently alter habits more effectively than S-S (free).

...

My guess? Flexible results in greater net benefit. Better to have sustained improvement than embarrassing and frustrating incapability.

...

It is a fine empirical question, unanswerable by theory. It comes down to the inverse relationship between the pleasure trap and the ego trap. I believe the optimal solution is likely in compromise.

Let's get back to, and focus on, what we know works... "A diet based predominately on a variety of minimally processed plants (fruits, vegetables, starchy vegetables, roots/tubers, whole grains and legumes) that is low in fat, saturated fat, calorie density, and low in added sugars, oils and salt."

In Health
Jeff

[JeffN]

Dr Lisle posted this 8-minute video of a Q&A on salt & sugar filmed at True North this past week. He again confirms that he is not an advocate of the S-S free diet.

Here is the link

https://youtu.be/xnjuxy1D2lI

In Health
Jeff

[JeffN]

I had a conversation with Dr Goldhamer this morning on a recent article on the Seventh Day Adventists and cancer risk. The topic of SOS free came up and we basically rehashed a lot of the above. I again emphasized that there is no evidence that a SOS free diet is better then a low S-S diet and it can actually make adherence harder and put someone in the Ego Trap.

He responded, “Actually, I have no reason to believe that a no added salt (500 - 1000 mg) is better than a low sodium (under 1500 mg) except perhaps in the rare, hypersensitive patient..“

(NOTE: And, they are very rare.)

“I do not think that keeping sodium at 350-500 mg is dangerous OR necessary in order to achieve a high level of health for most patients.”

(NOTE: 350-500 represents a diet with no added salt)

In Health
Jeff

[JeffN]

Blood Pressure Effects of Sodium Reduction
Dose–Response Meta-Analysis of Experimental Studies
Circulation. 2021;143:1542–1567. DOI: 10.1161/CIRCULATIONAHA.120.050371

https://www.ncbi.nlm.nih.gov/pmc/articl ... 3-1542.pdf

BACKGROUND: The relationship between dietary sodium intake and blood
pressure (BP) has been tested in clinical trials and nonexperimental human studies, indicating a direct association. The exact shape of the dose–response relationship has been difficult to assess in clinical trials because of the lack
of random-effects dose–response statistical models that can include 2-arm comparisons.

METHODS: After performing a comprehensive literature search for experimental studies that investigated the BP effects of changes in dietary sodium intake, we conducted a dose–response meta-analysis using the new 1-stage cubic spline mixed-effects model. We included trials with at least 4 weeks of follow-up; 24-hour urinary sodium excretion measurements; sodium manipulation through dietary change or supplementation, or both; and measurements of systolic and diastolic BP at the beginning and end of treatment.

RESULTS: We identified 85 eligible trials with sodium intake ranging from 0.4 to 7.6 g/d and follow-up from 4 weeks to 36 months. The trials were conducted in participants with hypertension (n=65), without hypertension (n=11), or a combination (n=9). Overall, the pooled data were compatible with an approximately linear relationship between achieved sodium intake and mean systolic as well as diastolic BP, with no indication of a flattening of the curve at either the lowest or highest levels of sodium exposure. Results were similar for participants with or without hypertension, but the former group showed a steeper decrease in BP after sodium reduction. Intervention duration (≥12 weeks versus 4 to 11 weeks), type of study design (parallel or crossover), use of antihypertensive medication, and participants’ sex had little influence on the BP effects of sodium reduction. Additional analyses based on the BP effect of difference in sodium exposure between study arms at the end of the trial confirmed the results on the basis of achieved sodium intake.

CONCLUSIONS: In this dose–response analysis of sodium reduction in clinical trials, we identified an approximately linear relationship between sodium intake and reduction in both systolic and diastolic BP across the entire range of dietary sodium exposure. Although this occurred independently of baseline BP, the effect of sodium reduction on level of BP was more pronounced in participants with a higher BP level.



Clinical Perspective
What Is New?
• A comprehensive dose–response meta-analysis of trials detailing the effects of changes in dietary sodium on blood pressure (BP), using the most up- to-date statistical dose–response modeling, shows that the relationship is positive, and almost but not entirely linear.

• The sodium change–BP relationship was present in analyses of long-term trials, although slightly atten- uated compared with the corresponding finding in short-term studies, and was noted in both analy- ses based on differences in sodium intake between study arms and achieved sodium intake.

• Higher background sodium consumption and BP increase strength and steepness of the effects on BP by changes in sodium intake.

What Are the Clinical Implications?
• The clinical implications of a substantially linear positive relationship between sodium intake and BP even in the long-term trials are that a progres- sively large reduction in BP can be expected with decreases in sodium consumption down to lev- els as low as 1 to 1.5 g/d, with no evidence for a threshold in benefit.

• Advice to reduce dietary sodium intake applies not only to adults with hypertension, who can be expected to derive a substantial reduction in BP, but also to those without hypertension, in whom the expected reduction in BP is smaller but still important.