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The Salt
Skip Program
Comments by Dr
Alfhild Larson MD FRCPC
I have had
Ménière’s for about two years now. At
first, I had daily disabling vertigo, including one attack that sent me to
hospital. The traditional
medications—diuretics, Serc, a short course of steroids—did not help. It was a dreadful time. I am a single mother of teenagers, and a busy
paediatrician who works with children with disabilities. At that stage it looked as if my life as I
had known it was over.
However, once started on the low salt guidelines,
avoiding standard bread and other foods processed with salt, the vertigo
disappeared over two to three weeks. In
two years, I have had vertigo only twice—both times when I had been tempted to
break the diet.
The diet takes some getting used to, and definitely
requires extra work. However I enjoy a
wide variety of gourmet foods, and wonder how I ever tolerated ‘normally’
salted foods. Social situations such as
invitations to friends’ homes, and eating out, require careful planning. But on this diet I am free of vertigo. For me, the choice is clear.
Comments by Dr
Trevor Beard OBE MA MB BChir MPH FRACGP:
I have five
comments:
·
In
the Salt Skip Program Dr Larson’s result is typical for patients with Ménière’s
disease;
·
It
was obtained without drugs or surgery;
·
It
follows the Australian Dietary Guidelines;
·
Deafness
and tinnitus may respond to some degree but vertigo is usually abolished;
·
About
5% of patients with good urine results, have persistent vertigo needing other
treatment.
What are the
Dietary Guidelines?
Many people have
already cut out table salt and cooking salt—just for better health—but few
realise that 75% of their salt intake comes from processed foods. The salt guideline is: ‘choose foods low in salt’, and the
food regulations define low salt foods—sodium is no more than 120 milligrams
per 100g (120 mg/100g). The label must
show the sodium content by law, but foods like bread are exempt if sold without
a wrapper.
Fresh foods such as fruit, vegetables, meat, milk and
yoghurt are well under the sodium limit, but most processed foods are well over
it. Look for the exceptions. In 2004 for instance Kellogg’s Corn Flakes
contained 820 mg/100g, yet their popular Just Right Original had only 30
mg/100g, and Sanitarium Lite-Bix had 20 mg/100g.
The sodium
content of bread usually varies between 400 and 725 mg/100g. Controlling vertigo requires bread with no
added salt, which is available from a few bakeries in all Australian capital
cities, and you can easily make it at home, either by hand or with a bread
machine.
How do people tolerate meals without
salt?
Of course they miss the salt at first, especially in bread, just
as they miss sugar if they stop taking it in tea. After 3 months without sugar they find it’s
sweet tea that is intolerable. The palate adapts just as well to less salt as
it does to less sugar. You begin to
notice it within a week.
There are literally hundreds of ways of adding flavour
to food when you count all the herbs and spices, vinegars, lemon juice, and
flavourful toppings. Avoid cooking methods that destroy flavour (like boiling
in water). After your taste buds have
adapted, many ‘normal’ foods taste unpleasantly salty.
Why
is such a simple change so effective?
Salt causes
fluid retention, varying throughout the day with fluctuating intake. The Salt Skip Program controls sodium to a
level that will not start a cycle of variable fluid retention.
No studies can show exactly how skipping salt controls
vertigo (no volunteers want to risk an attack of vertigo) but the big reduction
provided by the salt guideline would eliminate fluid shifts in the body, which
can in turn cause vertigo if the fluid balance in the inner ear is affected.
Why not use
diuretic tablets instead?
Diuretic tablets
accelerate the loss of fluid and sodium, but during the daily fluid shift some
people may still have an attack of vertigo.
warning: If
you follow the low salt guideline, with sodium excretion below 50 mmol/day,
diuretics must be avoided. They can
cause serious side-effects, especially hyponatraemia (low blood sodium).
This does not occur with the diet alone; it is a drug
side-effect. It can be severe enough to
require hospital admission, and the danger is greater for elderly women [1],
and for people who take combination diuretics such as Dyazide or Moduretic [2].
What if the vertigo persists?
If vertigo
persists, it is usually because the diet is not low enough in salt. Most
supermarket foods contain far more added salt than most people realise (taste is no guide). Only about 10% of the salt in the average
diet comes from the salt naturally found in food; 15% is added in cooking or at
the table, and a massive 75% is added to processed foods by the manufacturer
[3].
Don’t assume that the diet is not working unless you
have measured your actual salt intake.
You can do this by asking your doctor to order a 24-hour urine
collection to measure how much sodium you excrete. This is not a routine medical test, and
doctors who need more information will find it in Salt
A blood test will not measure sodium intake, because
healthy kidneys keep blood sodium levels constant within narrow limits. Excess salt in the diet ends up in the urine.
People whose vertigo persists in spite of satisfactory
24-hour urine results may belong to the 5% with Ménière’s disease who fail to
respond [4].
While salt is a major trigger for the vertigo there
may be others that are less well defined.
Stress is often regarded as a trigger; also the underlying disease may
be progressive. Several drugs may help
(but diuretics must be avoided) and surgery may be advised.
As the first treatment we recommend the Salt Skip Program to
anyone who is willing to take the trouble to follow it, since it is usually so
effective – with no other treatment [4].
In any case the Dietary Guidelines are worth following
indefinitely for other reasons. They are
meant for the whole Australian population (not just people with Ménière’s
disease) and the salt guideline is based on the evidence that it would help to
prevent high blood pressure.
If your blood pressure is low, a low salt intake is harmless. If it is already high, the Salt Skip Program
will usually reduce it, and your doctor may be able to reduce the dose of
medication. Some drugs can be
discontinued (in fact diuretics may do harm unless they are stopped).
Other illnesses
Theoretically
some people might need added salt after 50 years of having far
Pregnancy
Women should not
alter their salt intake during pregnancy except under medical supervision. But women stabilised on a low salt diet before
pregnancy should continue, as happened before we invented table salt, and still
occurs in the world’s most salt free society [5,6].
Books & Website about The Salt Skip Program
The Salt Skip Program is fully explained in Salt Matters: the killer condiment (Hachette Livre, Sydney, 2007, ISBN-13: 978-0-733622-16-8, RRP $24.95), which is in the bookshops and also available from the Meniere's Support Group of Victoria – see their website: http://www.menieres.org.au/. There are various other ways of buying it – these are listed on http://www.saltmatters.org (Click on "Books" in the left hand menu). The salt matters website has lots of other relevant content, including more details about the Salt Skip Program. It also has for download, the 2-monthly newsletter Salt Skip News, with updated shopping information, research news and comment, and recipes.
You can also join an email
discussion group for people interested in good control of salt intake. To join
the discussion group, send a blank email to:
saltmatters-subscribe@ozdocit.org
The address is
Email: qhainc@ozemail.com.au
References
1.
2. Brown MA, Whitworth
JA. Think again about combination
diuretics. Aust Prescriber
1993;16(1):4–5.
3. James WPT, Ralph A,
Sanchez-Castillo CP. The dominan1.3ce of
salt in manufactured food in the sodium intake of affluent societies. Lancet 1987;1:426-9.
4. Based on clinical
experience in
5. Intersalt Cooperative
Research Group. Intersalt: an international study of electrolyte
excretion and blood pressure. Results
for 24 hour urinary sodium and potassium excretion. BMJ 1988;297:319-28.
6. Oliver WJ, Neel JV, Grekin RJ, Cohen EL. Hormonal adaptation to the stresses imposed
upon sodium balance by pregnancy and lactation in the Yanomama Indians, a
culture without salt. Circulation
1981;63:110–16.
We are
indebted to Professor WPR Gibson and two other specialists (Mr Philip Moore and
Mr