Optimal sodium and electrolyte levels, with Robb Wolf.
Conventional health literature often focuses on a supposed connection between sodium intake and blood pressure. But sodium plays an important role in our health and even regulation of other electrolytes. Join me and my guest Robb Wolf as we discuss recent research, why sodium may be unfairly villainized, and guidelines on salt intake to shoot for.
Dr. Michael Ruscio, DC: Hi, everyone, welcome back to Dr. Ruscio Radio. We are honored to have the good-looking and also devilishly intelligent Robb Wolf here to talk about salt. And I’m super excited to have this conversation, Robb. Someone asked me the other day, “Well, isn’t salt bad for you?” And I said, “No.”
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Dr. R’s Fast Facts Summary
- 4-5 grams of sodium per day
- Active and/or in hot environment could require 8-10 grams/day
- Same if on low carb or keto diet
- Synergistic electrolytes – track your food to monitor this, Cronometer is a good tool
- How to tell how much salt you are getting
How to get it
- Bone broth
- Bouillon cubes
- Salting food
- ⅛ teaspoon to food, soup, stew, curry, workout drink
- ⅛ of table salt w/ small bit of water before bed
How to tell if you need salt
- If you’re on a lower carb or keto diet
- Lightheadedness sit to stand, muscle cramping, insomnia
History of vilifying salt
Healthy diet, that are lower in salt product benefit, it’s not the salt
- Processed foods are high salt, but salt appears an innocent bystander
- Dash Diet (low salt diets) do not show lower blood pressure
- Lower carb diets may decrease blood pressure
How to tell if you are salt sensitive
- If there is a sudden jump in blood pressure
Where to learn more
In this episode…
Episode Intro … 00:00:40
Is High Sodium Intake Actually Unhealthy? … 00:01:46
The Importance of Sodium … 00:07:01
Guidelines for Sodium Intake … 00:09:55
Nutrient & Electrolyte Level Testing … 00:17:11
Signs of Insufficient Sodium Intake? … 00:19:42
Electrolyte Balance and Hyperhydration … 00:26:02
Research on Sodium & Blood Pressure … 00:31:48
Salt-Sensitive People? … 00:38:55
Can High Sodium Damage the Kidneys? … 00:042:48
A Balanced Electrolyte Blend … 00:44:44
Episode Wrap-up … 00:50:09
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But then I realized I don’t feel like I’m super up-to-date on this argument. That I have a bag of the few typical talking points, but I haven’t actually gone into the literature and dug around to really substantiate the case.
So I thought of who could I bring on to do this. I know you’ve been really doing a lot with the ketogenic diet, you’ve also formulated and released your own product. And I know as part of doing that, you really dug into the evidence. So let’s update everyone on why salt is important. Because there are still some people who think that salt is bad for you. It’s going to cause high blood pressure or water retention or whatever. Maybe there’s a small case of people for whom it does, but in any case, let’s dig into the conversation on salt.
Is High Sodium Intake Actually Unhealthy?
Robb Wolf: Oh man, yeah. Thank you for having me. It’s an interesting topic. The notion that sodium or salt is a problem comes from this ubiquity of metabolic-driven blood pressure problems, in particular. So we know pretty well that the body will do a variety of things to retain sodium under different circumstances. And that sodium retention increases fluid volume, which can be good up to a point, but then we can end up in a hypertensive state.
Peter Attia has an interesting look at cardiovascular disease, where he talks about lipoproteins and different factors, and it may be necessary but not sufficient for the atherogenic process. And one could maybe make the case that hypertension is definitely necessary, maybe not entirely sufficient for the atherogenic process. Because when we see atherosclerosis on the pressurized side of the vascular system, you don’t see this process in the venous sites. So there’s definitely something to that.
But the bugger with all this is, in the different dietary interventions that have tried to reduce sodium intake, we don’t really see an impressive reduction in blood pressure. The body is kind of dealing with a secondary or tertiary characteristic of the problem. The problem is overeating, excess calories, hyperinsulinemia, as a consequence of that, and then that process causing sodium retention.
So even if you have someone who is a little metabolically broken or possibly significantly metabolically broken, if they curtail sodium intake, then the body just gets really damn good at holding on to it. So there is definitely this sense in the more mainstream medical circles that sodium is problematic.
And then, from a processed food and hyper-palatability perspective, sodium (or salt) added to food improves the flavor profile. And improves the flavor profile, whether we’re talking about sweet things or salty things. Salt mitigates the bitter characteristics of a lot of foods. This is why you see a lot of chocolate-based items still have a decent amount of salt in them, because it mitigate some of the bitterness there. So salt can be a problem from a dietary perspective, in that it can lead to overconsumption of food. That’s clearly a problem.
But we threw the salty baby out with the salty bathwater in this whole story. Some recent research that was conducted in pretty sick, metabolically broken heart patients, looked at their sodium intake, and looked at all-cause mortality, morbidity mortality. And what was interesting was that a new U curve emerged. At a very low sodium intake, we had remarkably steep and high rates of morbidity and mortality. And it got very, very rapid at and below 2 grams of sodium intake per day. And this is right in the pitch zone for what we are recommended to consume.
What was interesting was within this sick population, the low ebb of morbidity and mortality happened at around 5 grams of intake per day. And this is of sodium, not just sodium chloride, which is table salt. And the sodium portion of that story is only about 60% of sodium chloride. So it’s actually quite a bit of salt when you’re considering the total volume there.
But then, what was really interesting was, it was observed that as the sodium intake was increased, you had to get to about 8 to 10 grams of sodium intake per day to have morbidity and mortality on par with 2 grams of sodium intake per day. So that was a very interesting piece.
And then when you poke around at some of the American College of Sports Medicine (ACSM) guidelines, for folks who are active in hot or humid environment, their baseline recommendations are 7 to 10 grams of sodium per day.
So this was some eye-opening stuff that I had grudgingly come to the notion of. I was never really in the camp that sodium and salt intake was a really big problem.
Loren Cordain, early on, with his paleo diet recommendations, really put table salt, sodium chloride, as bad as gluten or processed sugar and stuff like that. Just observationally, I had never seen that to be the case. Also, from a compliance standpoint, I had always seen the inclusion of at least some salt on your food as being really critical to keeping people on a generally healthier eating process.
The Importance of Sodium
But I didn’t really appreciate the importance of sodium intake until I spent a good amount of time with the founders of Ketogains, Tyler Cartwright and Luis Villaseñor. These guys have a remarkably successful ketogenic diet boot camp, where they move 600 people every 6 weeks through this process. And they pay as much diligence to electrolytes, and, in particular, sodium intake, as they do to the protein, carbs, and fat that people consume.
What was interesting was when people would complain about things like lightheadedness, muscle cramping, things that we would normally ascribe to maybe some HPA axis dysregulation—it’s fallen out of vogue to call it adrenal fatigue, but this disordered circadian biology and some problems around cortisol regulation—inevitably, these folks were under-consuming sodium. And as soon as they got on point with their sodium intake, their athletic performance improved, the signs and symptoms of this kind of adrenalized state seemed to improve.
I’ve got to admit that I’m halfway decent at following the metabolic pathways, but I really overlooked the importance of sodium, Electrolytes in general, but sodium in particular. And this is the value of really good clinicians, the people that are working with people day in and day out, people like yourself who, in addition to being remarkably well-steeped in literature, spend time actually working with people and seeing what works and what doesn’t.
When I started working with Tyler and Luis, I told them that I was having problems keto-fueling my jiu-jitsu. They looked at what I was doing and they said, “Hey, man, you need to really increase your sodium intake.” And my response was, “Yeah, I salt my food, I’m good.” It was about a year of not listening to my coaches before I finally followed exactly what they told me to do. And it was literally like a light switch was flipped.
So I know that that was probably a long meandering answer to a very succinct question. But yeah, the sodium story is remarkably complex. It’s a lot like maybe the saturated fat story. There’s a lot of nuance, a lot of detail. It’s been thrown under the bus, maybe in an inappropriate way. But to your point—and I think you alluded to this early on—there are people that are remarkably responsive to sodium with regards to hypertension. So those folks do need to really keep an eye on intake. But I will default back that, oftentimes, the main driver for that is still that hyperinsulinemic state.
DrMR: Right. So yeah, there’s a lot here to dig into. And I do want to get into all these facets of the conversation. Before we go there, though, I want to try to make sure we don’t bury the lede, so to speak.
Guidelines for Sodium Intake
We understand all the nuance, we understand throwing the baby out with the bathwater, and the research which may have happened historically here. What do we sum it all up to? When we understand all of that, is there a “Get this intake and follow rule one, two, and three?” and that’s the take-home? Let’s try to lead with that and then we can fill it in.
RW: Sure. I think that we have some very safe guidelines, that—for the general population—somewhere between 4 to 5 grams of sodium intake per day likely leads to best case scenario for performance, health, and longevity. That seems to be a really safe place to be for a general population eating a mixed diet.
If folks are active, if they’re in hot environments, humid environments, that requirement can easily double pretty quickly, pop up to 8 to 10 grams of sodium intake per day. If an individual is on a low carb or ketogenic diet, that 5 grams of sodium intake per day is an absolute bare minimum. That’s the starting place. And we’ll have to tinker and fiddle from there to see where we go. And, again, I’m focusing a ton on sodium. We have other electrolytes. We have magnesium, potassium, and calcium being the main players. But I’m operating under the assumption that regardless of how people are eating, they’re focusing on a largely whole, unprocessed diet.
If that’s the case, then the calcium and magnesium are mainly addressed. The potassium is pretty darn good. But the sodium is really the place that we need to put the disproportionate focus. Because what’s interesting is that the body tends to cater to sodium intake in the way that it regulates the other electrolytes. So I’m not purposely neglecting those things. But if we’re really on point with both our food quality in sodium intake, then everything comes out well in the end.
DrMR: Okay. So 4 to 5 grams per day for most people. 8 to 10 if you’re highly active, if you’re in a hot environment. Or perhaps also 8 to 10 may be also the sweet spot if you’re on lower carb or keto. So that seems totally reasonable. But what does that look like? Can you get there with salt alone? Does this require some additional supplementation?
RW: Historically, like with doctors Phinney and Volek and their The Art and Science of Low Carbohydrate Performance, they’ve recommended things like chicken bouillon cubes and broth. Using bone broth and then salting it pretty vigorously is a great option. Most of the electrolyte replacement beverages and supplements in the scene are pretty paltry in the amount of sodium they provide. And they oftentimes are a little too heavy in potassium. You can get into some real problems by overconsuming potassium, particularly at the expense of sodium.
So it takes a little bit of time to habituate to it. You’re oftentimes really salting your food to it to a point that you’re like, “Okay, this might be a little bit on the suspicious side,” but that’s definitely an option. But then, oftentimes, having like a quarter, or one-eighth teaspoon measuring spoon, and a little ramekin of just table salt, and you can use whatever variety that you want in that regard. Adding a little bit of that to beverages, soups, stews, curries, and pre-workout drinks is definitely a good way to go.
DrMR: I’m imagining that some people are probably confused with how much salt they’re getting in their diet at baseline. How do you help people figure out, “Okay, here’s where I’m at now, and here’s how much I have to add?” Because I’m assuming people are just randomly adding some salt as a condiment to their food. They don’t know how much is in there. How much is in that dusting? Is it a quarter teaspoon? So how do you help people calibrate their current salt intake and then figure out where they need to go to get to the minimum requirement?
RW: Yeah, that’s a great question. So some handy tools—and you don’t have to do this forever, but it’s very handy to do it in the beginning—are something like a Cronometer or MyFitnessPal. Inputting your food for three to five days and then looking at what the sodium, potassium, magnesium, and calcium levels are is really an eye opener, so you can just get a sense of what you’re getting as a baseline from your food.
If you frequently consume things like olives, olives are awesome because they have some great monounsaturated fats, but they provide a lot of sodium. It doesn’t take an enormous number of those to get at a gram of sodium. And if you do a little bit of, say, traditionally-cured salamis and things like that, you can get a pretty good whack of sodium. But in the beginning, you do need to track your food, see what you’re getting, and then you need to weigh and measure the salt that you’re adding too, initially. Oftentimes, it’s easier to actually have a food scale and measure its weight than to get the volume.
Sometimes it’s easier to do the volume. But if you just want to do a couple of cracks into, say, salad or something like that, you can use a really light plastic dish on a food scale, zero it out, and then do your cracks in it, see how much is there, throw that on, and then just document that, so that you can get a sense of what your baseline is. But it’s really interesting.
Inevitably, folks, again, if they’re generally following some sort of a largely unprocessed, whole food, paleo, lowish carb type diet, they are almost universally not close to hitting that 5 grams of sodium per day. It’s usually closer to that 2 grams of sodium per day.
DrMR: Yeah. And I think Cronometer has a lot of interesting utility in terms of getting a sense of what your likelihood of a given nutrient deficiency is. Oftentimes, patients in the clinic want to know if we can test for that. And I am open to it. But I’m more concerned with figuring out, is the reason that your, let’s say, vitamin A, as an example, is low in a given test—I think a lot of these tests are kind of questionable anyway—because you need a vitamin A supplement? Or could we just look at your diet for the past 30 days, and look at the four nutrients you are getting the least of and say, “Okay, let’s look up good dietary sources of these four nutrients and have you start incorporating more of those?”
It seems like a better long-term strategy to identify where the dietary insufficiencies are, rather than doing a one-spot analysis through blood or urine, and then try to make decisions based upon that.
Nutrient & Electrolyte Level Testing
And a little tangent here, but what’s your experience with nutrient deficiency testing? Maybe I’m being a little bit too empirical with this and there’s some good testing out there that you found helpful.
RW: No, I completely agree. So a couple of layers to it. Like, how good are the tests? Get that test. Vitamin A and vitamin D are great examples. In particular, vitamin D. And you really helped educate me a lot on this. If vitamin D is low, does that mean that we have low intake? Does that mean we have low production from not being out in the sun? Or does that mean that we’re just burning through it like crazy because it’s being used in mitigating an inflammatory process?
And how we address that can be shockingly different. Then when you shift into the electrolyte story… similar to pH, you have to really work to get pH either a little bit higher or a bit lower. The body will do some remarkable things to compensate and bring things back into a center point. Over the long haul, metabolic acidosis or alkalosis can be damaging, potentially fatal and problematic. But on the moment-to-moment basis, the body is really good at buffering pH and keeping it within pretty tight parameters.
The same is true of electrolytes. The body will do some really remarkable shifting and shuffling of fluid volumes, of excreting potassium, so it maintains sodium/potassium ratios and whatnot. Just taking a snapshot of bloodwork is not as informative as what one would like because you’re getting a picture of what is a three-dimensional movie. So it really isn’t that informative. Yeah, I don’t know if I have a ton more value to add to that.
But we’ve had a lot of questions around, “Hey, should I be checking my electrolyte levels?” My answer currently is no. Let’s drive this from an empirical standpoint. Like, do you feel good? Is your performance good? Do you have any signs and symptoms, like that sit-to-stand hypovolemia, where you get lightheaded and stuff like that? If we have stuff like that going on, then it’s a better diagnostic tool to help us make some decisions about what to do and just a snapshot of bloodwork. And it’s certainly a lot cheaper.
Signs of Insufficient Sodium Intake?
DrMR: Speaking of empiricism, this begs the question, are there a few signs and symptoms that would indicate someone needs to improve or increase their salt intake? You just hinted at if you have this tendency when you’re sitting down or when you’re kind of crunched over, and let’s say you’re tying your shoes, and then you stand up and you get lightheaded. That certainly can be one sign that you’re insufficient in your salt intake.
Is there a common constellation of symptoms? Because oftentimes, fatigue is a symptom of almost everything. So fatigue alone doesn’t really tell you anything because there’s 1000 things that can cause fatigue. Lightheadedness is a good one. So are there are a couple keystone empirical findings that people should be looking out for to indicate that this might be a problem?
RW: Yeah. Definitely a good one is that sit-to-stand lightheadedness. Muscle cramping is another pretty good one.
An interesting one—and, again, this definitely applies a bit more with folks on the low carb side of things, although this kind of applies across the board—if folks are having some problems falling asleep, one of the interesting side effects of having too low of sodium levels is that we will alter the release of antidiuretic hormone in a fashion to retain more sodium. But in the process of modifying that antidiuretic hormone release, we’re also releasing epinephrine and cortisol. It is a stress response that occurs when we’re in a low sodium environment. So actually, disturbed sleep or altered sleep can be a really significant factor.
And Dr. Chris Masterjohn has a little bit of a trick where he will recommend folks take about an eighth of a teaspoon of table salt before bed, just a little bit dissolved in water. Like, salt directly on mucous membranes is actually an irritant, you don’t necessarily want to do that. But just a very sparing tiny bit of water so that you’re not dealing with the problem with needing to pee after you do this, because you’re trying to go to bed. But that can actually just shut down that stress response around bedtime.
If we’re throwing fatigue and lethargy out, because to your point, there can be so many factors there that sit-to-stand piece, the muscle cramping piece. Interestingly, people usually go after magnesium as a solution to that. And that can be helpful up to a point. But what’s interesting there is if we take in adequate sodium, we tend to retain magnesium more effectively. We have inadequate sodium intake, we tend to excrete magnesium at a higher rate. So, again, addressing the sodium really helps to address all of that stuff. And that’s maybe in the more acute stage.
Then people who possibly have, again, what we might call adrenal fatigue, or HPA axis dysregulation, some of the mechanisms that might underlie thyroid dysregulation. We can make a pretty good case that there are mechanisms that could be contributed to those problems from inadequate sodium intake.
DrMR: Yeah. And when I had an intestinal parasite in college, I think I had quite a bit of—I’ll use the term, I don’t love the term, but I think we all understand what’s going on here with the semantics—adrenal fatigue, because I was getting lightheadedness when standing. I don’t think that was because I was salt-insufficient, although maybe I could have had more salt in my diet. I don’t think I was really aware of the importance of salt in the diet. And I was eating pretty low carb. Not keto, but low carb.
But what really pushed me over the edge was just chronic inflammatory stress from having an infection in the gut. So it’s not just intake. As you’re saying, if someone is really sapped of their vitality, then that also can be a case for helping to increase their salt intake, because they may not have the adrenal hormone release that could be needed for that. And I don’t know if that’s really been well-documented. Maybe it has. But certainly, there seems to be some anecdotal evidence that supports that. It seems reasonable just to give some salting a trial.
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A quick question for you, Robb. And sorry, this is above your pay grade with knowledge of Cronometer. But are you able to adjust your desired sodium range in Cronometer? Because I just checked mine, and it seems like it gives you 5000 milligrams as the high end of the range. So is there a way that you can change what your target range is, just so people don’t get confused by Cronometer telling them that they’ve had enough salt and not reading that the range that they’re pre-selecting for you is kind of low?
RW: I’m not sure on that. I know that because of the popularity of low carb diets, that they’ve done some tinkering on their user interface. So I think that you could probably adjust that, but it will still give you a quantitative end point. And that, ultimately, you can rely on.
Electrolyte Balance and Hyperhydration
DrMR: Speaking of cramping, if people are using an electrolyte formula that has a lot of potassium, like you mentioned before, do you ever see cramping get worse because of that?
RW: Yes. Yes. Yes. And the really morbid end point to this is, the thing that they use for lethal injection is a really water-soluble, fast-acting, high-potency form of potassium, because you get a heart cramp and you die. The irony is that we’ve been really beat over the head with “Oh, if you have cramping, eat a banana or some sort of a high-potassium food.” But it’s really the sodium that is the key factor there.
And again, what’s interesting is if you are inadequate in sodium, the body will shed potassium in an effort to maintain the relative ratios. It will excrete both fluid and potassium to try to maintain the ratios.
So, here’s a thought. This is purely speculation on my point, but I’ll throw it out there. I think that part of the problem that we face is we, as a society, consume too much fluid. And I think to some degree, the sodium recommendations that we have to make are kind of an outgrowth of the fact that people over consume liquids in general, and then need to increase the sodium intake to balance that out.
We see some really serious problems with hyperhydration in things like college-hazing scenarios for, like, sororities and fraternities, where people drink a ton of water. Every year, a number of people die at boot camps, football practice, marathons, triathlons, because they over consume water, and dilute their electrolyte status that they can’t effectively function and can get very sick or die. So I think that, to some degree, if we have folks consuming a more modest amount of total fluids, then there isn’t the huge impetus or need for as great of sodium intake.
DrMR: So I put a ton of salt on my food, I also drink a lot of water. And I don’t do this on purpose. I’m pretty active and I like water, and maybe I’ve become habituated to drinking too much and I need to recalibrate what my normal feels like. But it’s interesting that you say that. Are you ever seeing people who are hyper-drinkers, hyper-hydraters, if you will? Do you see them have this craving for salt? Or am I a freak? Haha.
RW: I’m not sure on that piece. But when I put on a little bit of the ancestral lens—and this can always be dangerous because you can create all kinds of Just So Stories around hunter-gatherers and cavemen and all that type of stuff—but we’ve had this interesting progression.
Although as a kid, I had an old milk jug (which was probably just filled with with BPA leaching into the water). But I had an old milk jug that we took out to a football practice. They gave us salt tablets with that, and they always told us to have the salt tablet first, and then have water afterwards.
And then, we’ve definitely grown into a scenario, where… what is one bit of health advice that every dietician says? Drink at least 8 to 10 glasses of water a day. And there’s really not any good science behind that. There’s just this thought that people get dehydrated and that that’s a problem. There’s a whole interesting side note on that. When people do extended fasting, you could make a case that if you really want to ramp up fat mobilization, that you don’t consume water. One of the end products of fat metabolism is water formation. It’s a condensation reaction.
And so, someone who is fasting and mainly being fat fueled, they can make 200, 300 milliliters of water a day, from what they call metabolic water, from fat metabolism. So, when you think about that stuff, and then the paucity of YETI mugs and water bottles throughout most of our history, I think that that may be a piece of why we have to so aggressively add sodium back into the mix. I think we’re just overdoing the fluid intake, the water intake.
I love iced tea. And I’ve been taking this Element product that we developed, and I do what’s called a Salty Palmer. Like I have an iced tea, I put a little stevia in it, and then I put this citrus-flavored electrolyte beverage in it. And it’s amazing. And I can drink 30 to 60 ounces of it in pretty short order. I think that that’s probably more liquid than what I physiologically need, ancestrally need. But I’ve flavored it. I’ve got a stimulant in it. It tastes good. I feel good with it and everything. But then, do I then need to add more sodium than what I would otherwise need to just buffer the effects of consuming so much fluid?
Research on Sodium & Blood Pressure
DrMR: Mm-hmm. And I want to come back to what we were discussing earlier regarding, it may be throwing the baby out with the bathwater… This is what I’m curious to get more of your specific elaboration on. I’m assuming, with red meat being lumped in with processed foods, and the erroneous conclusion being derived from that, that red meat is causal, with all these diseases we see accompanying increased processed food consumption. But the same happens with salt, because many processed foods also have a fair amount of salt added to them.
I’m assuming what has happened in some of the research literature is, people have gone on healthier diets. One of the recommendations wrapped up in that healthier diet was reduce your salt intake. Then people proclaim, well, because the people who cut out all of the processed fats, processed foods, and all the other garbage, and they decreased their salt intake, their lower salt intake must have been one of the reasons why they got healthier.
Just like when people go on diets that have less red meat and less processed food, sometimes people will say, “Aha, look, they ate less red meat and there was less heart disease.” Well, yeah, but you’re attributing all of that to the red meat, and you’re not attributing that to the other things that were cut out of their diet. So is there research that helps us parse some of those confounding variables?
And what I’m guessing is that your answer will be yes, based on what you said a moment ago, which was, there have been some studies that have only attempted to change the salt intake of the diet, and that did not lead to any health improvement. Is that kind of a fair read? And how would you aid in some of this confusion?
RW: Very much so. We have some really nice gold-standard, metabolic ward style trials, where they looked at things like the DASH diet, which is a very low sodium intake, generally appropriate protein. Overall, DASH is not, like, the worst way in the world to eat. It would be problematic for me personally, but it’s not the worst thing in the world.
But what they found is that for the vast majority of people, whether they ate a lot of sodium or virtually no sodium, it had maybe a two- to four-point difference in their systolic and diastolic blood pressure. So on a moment by moment basis, really hitting someone with a bolus of sodium, or really curtailing sodium intake, you can get some crazy changes in fluid volume, but the body equilibrates rather quickly.
So over the course of time, they just didn’t find any real magic sauce with doing that. But it is interesting that one of the key features that has been reported, ever since Atkins came out with his original low carb eating, was that with low carb, you tend to get a dramatic loss of fluid volume and weight initially. This is likely driven from hyperinsulinemia and upregulation of aldosterone, which causes us to retain sodium.
Again, I think that if an individual is generally overeating, and/or if there are some metabolic machinery issues that sodium retention is upregulated due to high insulin levels, then curtailing sodium intake, even if you aren’t really adding much to your food, there is still some in the food, and your body will get very thrifty at retaining it. And I think that this is a lot of the reason why we just haven’t seen much health improvement, particularly on that kind of hypertensive side of the story, other than in these very specific sodium-reactive hypertensives.
DrMR: So is it fair to say that we have decent evidence that lower carb diets can lower blood pressure? I know I’ve read this in one or two studies. But what I’m asking is, is there more of an agreement in the data when looking at low carb diets? We could also include paleo diets in that, because most paleo diets in the research literature seem to be lower carb relative to the standard American diet. Is there a fairly consistent trend in these diets showing blood pressure neutrality or the ability to lower blood pressure?
RW: Yeah, some work that was done at UCSF. I’m blanking on the woman’s name. She’s an MD PhD there, but she’s a nephrologist by training, and she did some really great research on this. This nests under the whole concept of natriuresis of fasting, like the loss of sodium while fasting. It is driven largely by a curtailment in insulin release. And this is where people can get a little bit crazy, where they hang every Boogeyman on insulin release, to the point that they start curtailing protein intake because of a fear of insulin.
That’s a whole other topic for a completely different time. But yeah, it is very well-established in the literature that a key feature of reduced carbohydrate intake, reduced insulin release, is a decrease in fluid volume via sodium excretion. Like, the body just tends to hang on to the sodium less vigorously.
DrMR: Yeah. And I think that’s really important to remind people of. If there are these two pathways, let’s say both these pathways may influence your blood pressure, and there’s your salt intake in your diet, and your carbohydrate intake in the diet, it seems that the more important of these is not the salt intake, as we’re substantiating here, but the more important of them is the insulin intake.
So it’s this travesty, if someone is of a more antiquated dietary paradigm, they may be avoiding salt and eating lots of carbs. And that, for some people, may actually potentiate the problem of making hypertension even worse. It’s not say all carbs are bad, but if we’re going to choose one of these to optimize for that is most likely to have a beneficial impact on blood pressure, it seems optimizing for carbohydrate intake—and not worrying so much about salt—is really the focus we should be looking to.
RW: Absolutely, yeah. And that DASH diet study really helps to bear that out. If the primary problem was just sodium intake, we would see really remarkable fluid shifts and changes in blood pressure with this low sodium intervention. And we just don’t see that. But we do consistently see remarkable blood pressure changes in folks that reduce carbohydrate intake.
DrMR: Now, to address one nuance, there are some people who do appear to be salt-sensitive. And I’m curious, is there a consensus, or an approximation, in terms of what percentage of the population that is?
RW: Oh, man. I’m going to plug a different search engine, that would be a good DuckDuckGo thing to look at. I do know for sure that within African-American populations, you have a disproportionately high ratio or percentage of folks who are particularly good at retaining sodium and getting a hypervolemic effect from sodium. So increased blood volume, increased blood pressure.
So, definitely, within African-American populations, you see that disproportionately represented. But I don’t know what that percentage is off the top of my head, nor what that would be just within, say, like Northern-European populations versus Hispanic, etc.
DrMR: How often do you see it with the people that you’re consulting with and in the various conversations that you have? Do you have a sense? Is this extremely rare? Does it happen periodically? Does it happen somewhat commonly?
RW: I see it quite rarely. I don’t want to couch low carb diets as the cure-all for everything, but what is interesting is, still, the main driver for seemingly the vast majority of people who are these hyper-responders to sodium intake, is that, if they find a carbohydrate intake level that works with their physiology, that they’re not really hyper-responders. That it’s the hyperinsulinemia, in a relative term, that really is the primary driver.
Now, they will disproportionately respond to sodium at most carbohydrate intakes. But once you hit a certain threshold, then it’s as if that problem doesn’t really exist anymore.
DrMR: And I guess someone could just be somewhat pragmatic about this. If they’re trying to determine if they’re salt-sensitive, if they haven’t done anything yet, the first thing I would say, is to get yourself on a fairly healthy diet, whether that’s Mediterranean or paleo. I think there’s some wiggle room there. But I’d start there because any of those will control for insulin.
And don’t be too concerned about your salt intake. I’d say, just get the food quality right first. If you’re seeing no changes in your blood pressure, nothing to worry about. More likely, you’ll see a decrease in your blood pressure. But then you may want to consider upping your salt intake. Look at your blood pressure. If it jumps up all of a sudden, that tells you that you may be salt-sensitive. So it may not be too hard of a thing to suss out if you’re just kind of isolating variables one at a time and working through this in a stepwise fashion.
RW: Absolutely. And I would just throw in the caveat there that the way that I would assess that is maybe you bump total sodium intake up, say, like a gram a day, 1000 milligrams a day. I would do that over the course of 4 to 5 days, and assess that each day. Because on day one, you may get a disproportionate uptick. And then, over the course of time, that may then trend back down to normal.
What you really want to ask is, do you look, feel, and perform better at that higher sodium intake? Is your sleep better? Is your performance better? Or is it a wash and all that you’re doing is consuming more sodium that your kidneys filter, in which case, maybe you don’t need quite as much sodium. But I do think, again, that, in general, that five grams per day is a really good ground floor for the vast majority of people.
Can High Sodium Damage the Kidneys?
DrMR: While we’re on the topic of kidney, is there any evidence that you’re aware of showing that higher salt intakes may be damaging or unfavorable in any way to kidney function?
RW: Very similar to protein intake. In a healthy kidney, it doesn’t really seem to affect things. In an unhealthy kidney… if someone’s on dialysis, then we’re in a very dire scenario of monitoring both sodium, and, in particular, potassium. The potassium monitoring is arguably more fastidiously monitored than the sodium intake.
DrMR: Mm. Anything else that people should be aware of as they’re trying to be more cognizant of their salt intake and trying to navigate finding the sweet spot of their intake?
RW: I think just be open to the notion that your best operating parameters might be at a sodium intake level that’s a good bit higher than what you might have been used to. But, as with all of this stuff, be pragmatic and keep your eyes open. I was convinced that a super grain-heavy vegan diet was going to be the end-all be-all for me. And it was really not a good solution for me. It may be a great solution for other people, but it was disastrous for me.
I was so religiously bought into the idea that this was a good way of eating that for a number of years, I ignored some pretty serious signs and symptoms of this thing not working. So I would encourage people to be open to the potential that modifying their sodium intake upwards could be really beneficial. But at the same time, keep your eyes open and remember that you’re an n=1 experiment, and really let that be the final part of that decision making.
A Balanced Electrolyte Blend
DrMR: Mm-hmm. And then for someone who is having a hard time maybe getting to that recommended range that we discussed a little while ago, the 4 to 5 grams for regular people, and maybe closer to 8 or 10 for active, or those who are in a very hot environment, or those who are keto, you have your Elemental product.
What struck me about this was, and you alluded to this earlier, is the sodium is 1000 milligrams per serving and the potassium is 200. And in many an electrolyte formula, you’re going to see almost an inversion of that. So, yeah, tell us a little bit about your product and how you fell into the formula and anything else with the formula that you want to mention.
RW: Yeah. I had mentioned Tyler Cartwright and Luis from Ketogains. They were my coaches and told me to up my sodium intake. And eventually I did, and magic happened for me. Then, in the process of working with the folks that go through our clinic in Reno, and also observing people that Tyler and Luis and their coaches work with, just so many problems ended up resolving when people appropriately address the underlying sodium need. The electrolyte needs, but, in particular, sodium.
That was really remarkable and jaw-dropping. And for a good two-and-a-half, almost three years, what we did is recommend a how to make your own, what we call, keto-ade, that’s basically a sodium, potassium, magnesium drink that you mix up at home. This was super popular with folks. But it was funny. We started getting tagged on people going on traveling excursions, and they said, “Wow, TSA wasn’t stoked about my three bags of white powder.”
RW: So we started asking ourselves, well, would some ready-to-drink or sachet, rip it open, add water, would this be valuable for folks? And we sat and watched the scene. And virtually everybody in the low-carb keto space—and even some folks peripheral to it—came out with electrolyte products, but they were completely off the mark.
And we had this: “Here’s the ratios, here’s how you do it,” and it was working miracles on people. We had this for free. We do still, on the drinklmnt.com website. But we motored along and saw people really benefiting from getting their electrolytes on point.
This drink was really helpful, but brewing it at home was a pain in the backside. So we decided to give it a shot. We launched Elemental Labs, January of 2019. And it’s really motoring along. I think we identified a legitimate pain point of both the need for adequate sodium and electrolytes overall, but also just a convenience factor. It’s remarkable how easy it is to go grab a stick and put it in water or iced tea and it makes an insanely good margarita base as well.
RW: We have a citrus variety, and then also a raw unflavored variety. Because whenever you flavor and sweeten things, it doesn’t matter what you do for someone, the things that you pick, you’re going to be an idiot and/or Satan, like you’re just going to have done something wrong. So we have a completely raw unflavored version. And Mikhaila Peterson, who has really popularized the carnivore diet by putting her rheumatoid arthritis in remission, has been really talking up the raw unflavored-ness, felt significantly better by adding in additional sodium and electrolytes using that product.
So folks can check that out at the website, drinklmnt.com. And again, if you don’t want to throw some shekels down for a pre-mixed version, I think we have 8 or 12 different make-it-at-home versions, ranging from citrus flavor to raspberry. So we have a bunch of options that you can do at home, or you can check out the product itself.
View Dr. Ruscio’s Additional Resources
And then are there any projects that you’re working on? You came on with the release of your most recent book lately, and we talked about that. But anything new you want to make people aware of, or anywhere you want to point them to on the internet?
RW: Oh, man, everything that’s happening generally ends up at robbwolf.com. My wife and I are still motoring along with our Q&A podcast format. And I’m still working on this risk assessment program. It’s almost like a family member that keeps dying and then coming back from the dead! We had a really interesting breakthrough on the insurance and payer side of that story. So if some good stuff comes out of that, maybe I could bring down property values again and come back on and just let folks know what’s going on with that.
But the really quick back story there is, seven years ago, the clinic that I’m a part of (and the clinic’s based in Reno, Nevada, and I’m now in New Braunfels, Texas) wrapped up a two-year pilot study with the Reno Police, Reno Fire Department. They use some advanced testing to identify police and firefighters at high risk for type 2 diabetes and cardiovascular disease. Once these folks were identified, we were able to use a low carb, paleo type diet, some smart training, watered down CrossFit, and some sleep modification.
And based off the changes in the blood work and the physical parameters of these people, the pilot study is estimated to have saved the city of Reno $22 million, with about a 33-to-1 return on investment. So I’ve put a lot of time trying to take this methodology, scale it, and take it out to the masses. We’ve had multiple spots, where, like I said, I thought the whole thing was either dead or I thought that it was going to go like gangbusters.
Currently, we’ve had a little breath of life breathed into it. One of the major hurdles that we face is this payer story, everybody is crushed under basic health insurance costs. And a really fascinating solution popped up. These folks are epistemologically totally aligned with what we’re up to in this ancestral health space. It’s actually sponsored via a First Nations tribe. And I have to be a little bit oblique about some of this stuff right now. But it’s really exciting, and it could be a complete game changer on the health and wellness front. So fingers crossed on that. But that’s what I hope it can do.
DrMR: That’s awesome. I’ve always loved the approach that you’re taking there, which is, let’s show the cost savings. Because if we really want to try to get this implemented for more of a top-down direction, then speaking to the cost-effectiveness of it is going to be a huge foot in the door.
RW: Yeah. I don’t want to go too far out in the weeds on this. Clearly, we want to help people. But the United States healthcare system, the Congressional Budget Office, predicts that by 2030, the U.S. will be bankrupt due to diabesity-related costs. The diabesity-related costs alone will be equal to gross domestic product. This is before we even layer in the tsunamis of neurodegenerative disease, like Parkinson’s, Alzheimer’s, and dementia. And managing type 2 diabetes is a walk in the park compared to neurodegenerative disease, which are also driven by these metabolic processes.
If we get out ahead of diabesity, then we’re getting out ahead of these neurodegenerative diseases. Even though management of type 2 diabetes is expensive and isn’t really that effective, it’s kicking the can down the road. But neurodegenerative disease requires 24/7 nursing care. And that is so expensive and so difficult.
So I’m optimistic that the challenges that we’re facing are going to force people to be innovative and open to looking at new ideas and new ways of tackling these things. Hopefully, we just keep an environment in which open discussion and exchange of ideas is not so ratcheted down that it’s impossible to get the solution out to the masses.
DrMR: Right. Well, please do keep me posted on that. And absolutely, if there’s a breakthrough or an update, come back and we’ll talk about it. I think that’s something that will do a ton of good in the world when you finally get over the hump. So yep, open invitation whenever there’s an update there to come back on.
RW: Awesome, Doc. Thank you.
DrMR: Yeah. It’s been a pleasure, man. Thank you so much for taking the time to chat with us.
RW: Thank you. And looking forward to get you back on my podcast at some point soon.
DrMR: Yeah, let’s make it happen.
RW: Okay, we’ll do it.
DrMR: All right, brother. Thanks again.
RW: Take care.
What do you think? I would like to hear your thoughts or experience with this.