Salt has been a key component of human diets for a long period of human history. Our salt intake has been shaped by several factors including our transition from hunter gatherers to agriculturalists, the move towards a diet high in processed foods, the use of salt as a preservative as well as concerns about our health. While modern advice often emphasizes reducing salt intake to manage blood pressure, the relationship between salt consumption, metabolic health, and dietary patterns reveals a complicated picture. Do we really need salt at all? This blog aims to simplify the science for you so you can make your own choices about what is best for your health.
Salt and Early Human Civilisation
Archaeological evidence from ancient civilizations shows that salt was a valued resource. Sites like the Hallstatt salt mines reveal early salt extraction and use going back as far as 7000 years ago. Even further back in the neolithic period there is plenty of evidence of salt springs being used to collect salt laden waters which were heated to evaporate the water and crystalise salt. Once we discovered that we could preserve food with salt this made a significant impact on human societies, facilitating food storage and trade. While early humans likely had varied diets including sodium from natural sources, the development of salt extraction and preservation methods likely marked a substantial rise in salt in the diet.
Pre-agricultural humans have been estimated to have a low salt intake, in Palaeolithic times it is estimated to be less than 1g per day and it came from eating meat, blood, and especially organs like the kidneys and liver which naturally contain sodium and other essential electrolytes. As a comparison most people today in a modern westernised society are consuming 10 to 30 times more salt than our ancestors or modern traditional tribal communities. Isolated tribal communities around the world continue to eat a low salt diet ranging from around 0.05g to 2g of salt per day. They remain fit and healthy with less cardiovascular disease than the Western population. In addition, there are certain groups of people eating traditional diets who have never eaten salt with food, this includes Numidian nomads, certain Bedouins, inland Mauri populations and traditional Eskimo communities.
Herbivores & Carnivores
Animals which travel miles to visit salt licks are herbivores, meaning they eat plants. Carnivores (meat eaters) only visit the same places to eat the herbivorous animals, not to eat the salt!
As humans in the palaeolithic era we evolved to become predominantly carnivores and likely got all our salt needs from simply eating meat and other animal products. As our societies became agricultural based our diets became much more plant dominated and we lived in larger groups in towns and cities. With this growth in population we needed to preserve our food, initially this was done by fermentation and then with salt. So we evolved as hunters and gatherers mainly eating meat and fat and we are still genetically adapted to this environment meaning that we likely have little physiological need for salt, however, this assumes that we are eating a mainly carnivore diet, which of course most of us are not.
Salt Intake in Modern Diets
Around about 1000 years ago, salt intake in the Western world had risen to about 5 g per day. It continued to rise into the 19th century when, in Europe, it was about 18 g per day. In some areas of Europe in the 16th century where there was a high consumption of salted fish, and it has been calculated that the daily salt intake rose to as much as 100 g per day. Then, as refrigeration took over as the way to preserve food there was a reduction of salt intake to an average of 10 g per day during the 20th century. Of course, as well as preservation, salt can be used to flavour food just like spices can and salt came to be used for culinary purposes and in modern society the combination of salt, fat and refined carbohydrates, combinations that are never found in nature, has also led to food addiction problems.
Sodium and Metabolic Health
Our modern dietary guidelines recommend reducing salt intake to manage blood pressure and metabolic health. Excessive sodium consumption is linked to hypertension (high blood pressure) which is a major risk factor for cardiovascular disease. In the modern western diet, high salt intake often correlates with a high consumption of processed foods, which contributes to metabolic syndrome and insulin resistance. If you want to learn more about insulin resistance read this blog, but it is sufficient here to say that insulin resistance is one of the key root causes of chronic diseases. What we can take from this is, if we eat a diet high in processed foods, which is a diet also high in fat, carbohydrates and salt, then we put ourselves at risk of metabolic health problems. If we want to keep eating this way, then we should lower our salt intake as there is some evidence it can slightly lower blood pressure. But salt is not the cause of metabolic diseases and lowering salt will not solve the root problem or reverse metabolic health problems.
Here is a direct quote from the World Action on Salt, Sugar & Health which I think quite nicely explains the link between carbohydrate (or sugary substance) intake and salt.
“Obesity - Whilst salt is not a direct cause of obesity, it is a major influencing factor through its effect on soft drink consumption. Salt makes you thirsty and increases the amount of fluid you drink. 31% of the fluid drunk by 4-18 year olds is sugary soft drinks which have been shown to be related to childhood obesity.”
So perhaps it is not just salt but also sugar or refined carbohydrates which are driving our chronic disease epidemic. Let’s keep that in mind!
Low-Carb and Ketogenic Diets & Salt
Low-carb and ketogenic diets, have become popular for helping control weight and improve metabolic health, reversing insulin resistance, and potentially putting chronic diseases like Type2 Diabetes into remission. On a ketogenic diet, the body undergoes changes that affect electrolyte balance (that’s the balance of salts like sodium and potassium). This is because ketogenic diets are very low in carbohydrates especially glucose.
This means that the body requires to make glucose through a process called glycogenolysis where glycogen stored in the muscles and liver is broken own. For every gram of stored glycogen, the body also stores 3 grams of water which means that when glycogen is broken down water is released too. Studies of people on ketogenic diets have shown that when ketones are detected in the urine so too are higher levels of sodium. Basically, especially in the early stages of a ketogenic diet you break down glycogen which releases water, you pee out the water and where water goes sodium goes too, due to the osmotic effect.
When people start a ketogenic diet, they are often advised to increase their salt intake to avoid the adverse temporary side effects known as "keto flu," which can include dehydration and is typically characterised by dry mouth, headache, dizziness/orthostatic hypotension (low blood pressure) and electrolyte abnormalities. These symptoms can mostly be alleviated by increasing electrolyte or salt intake. Most commonly people are advised to take between 3g and 5g a day of sodium.
Is It The Carbs or The Salt?
But if we don’t have a physiological need for salt, why would we need to increase it on this diet? It seems a bit confusing!
Some proponents of a ketogenic diet argue that it can be a low sodium diet and that this can lead to adrenal insufficiency with symptoms such as fatigue, insomnia, slow recovery post exercise and anxiety. This argument is used because epidemiological studies have shown that at a certain threshold of sodium intake the risk of mortality (that is death) increases. Unfortunately, epidemiological research is generally of low quality based on self-reported dietary analysis which we know itself is a very inaccurate source of data. Often people can be followed up for years but only asked once every few years what they thought they ate in the last 12 months. You can probably see the problems inherent with getting reliable data from this as we can’t often remember what we ate three days ago let along get the averages right over a year!
The other problem is that this kind of research is carried out on populations eating a standard Western diet that is high in refined carbohydrates and processed food so does not tell us what the outcomes would be in a population eating a more evolutionarily appropriate diet. In fact, the researchers are aware of this and have reported that they found that increased sodium intake was positively correlated with increased energy intake (from eating ultra-processed food) so it is difficult to separate out the impact of salt from the diet in this situation. So, it could mean theoretically that it was not just the sodium but a combination of the high sodium content and high fat combined with highly refined carbohydrates that was the problem.
Another interesting way to look at this question is from studies that have evaluated the excretion rates of sodium and potassium under fasting conditions. One review paper found that potassium excretion is rapid during the early part of fasting and then tapers off to a constant level of about 10 to 15 mEq/day; sodium excretion is also enhanced early in fasting, declining progressively to between 1 and 15 mEq/day. 15 mEq a day is roughly 0.2 g in terms of sodium, so equivalent to just a pinch of salt. The researchers found that this loss could be stopped abruptly as soon as carbohydrates were reintroduced even at a low caloric (energy) intake. They said “why fasting results in sodium loss and why only carbohydrate sources can reverse this loss are questions that remain unanswered… it is speculated that the carbohydrate inhibitory effect on sodium excretion could have clinical usefulness in the management of certain disease states.”
An earlier study that looked at what happened to sodium excretion rates on refeeding with different types of macronutrients found that carbohydrate refeeding induces very rapid suppression of the excretion of sodium and potassium in the urine, while protein has a delayed action and fat refeeding further increased the sodium excretion. Maybe we are getting to the root cause of the problem!
Salt on a Carnivore Diet
How about we look at people eating a carnivore or nearly carnivore diet which is perhaps the closest to what we are evolutionarily adapted to eat. Tribes that rely heavily on cattle blood and milk, such the Masai have traditionally had very low rates of hypertension, however when these people move into urban environments and consume a more modern diet their rates of hypertension rise.
If we take a look at anecdotal reports from carnivore groups on social media there are mixed reports, those saying eat salt as you like, others saying reduce salt or avoid it entirely. Many long term carnivores seem to feel they fair better with less salt.
Where Salt Comes From Today
About 75% of the daily salt intake today in Western populations is derived from salt added to processed foods by manufacturers; 15% comes from table salt and salt being added to food whilst cooking and the remaining 10% occurs naturally in basic foodstuffs. This means that around 90% of the salt in the typical diet comes from manufactured salt that is added to the food supply.
The Importance of Potassium Vs Sodium
Studies have shown that it is not just the sodium content of salt is important to take note of but also the dietary ratio of sodium to potassium. The average Western diet has a sodium content much higher than its potassium content. Interestingly studies of modern day hunter gatherer populations have found that there was no sign of hypertension (high blood pressure) among populations consuming low levels of sodium. In modern populations studies of the sodium:potassium ratio can predict the risk of hypertension (high blood pressure), with each 1g increase in sodium excretion (in urine – a marker of intake) or 1g decrease in potassium being associated with an 18% increase in risk. Unfortunately no studies have looked at the levels down as low as those found in hunter gatherer populations.
There are a number of factors that affect the modern ratio of sodium to potassium, first is that most salt in the Western diet comes as sodium chloride from manufactured salt. Second is that Western diets are high in vegetable oils and refined carbohydrates which are very low in potassium. The high percentage of highly processed food consumed along with the high levels of carbohydrates in the diet has pushed down the number of foods consumed with higher potassium concentrations, therefore reducing the potassium content of the diet. Natural food sources of potassium include organ meat such as liver, heart and kidney as well as red meat and which have a naturally high potassium to sodium ratio of between 3:1 and 1:1. Fruit and vegetables tend to have even higher, in some cases much higher ratio of potassium to sodium.
However, in relation to Palaeolithic times the modern ultra-processed diet has led to a 400% decline in potassium intake while at the same time resulting in a 400% increasing in sodium intake. We now have a diet much higher in sodium than potassium which we are not evolutionarily adapted for and is likely impacting our health and contributing to the modern epidemic of chronic disease. This combination has been found to impact many different conditions from hypertension and stroke to asthma, insomnia, and Meniere’s syndrome.
Our ancestors hunter‐gatherer potassium intake is estimated to have been high with approximately 7000 mg/day for those living in coastal areas vs. 2500 mg/day in the current modern diet. Away from the coast the potassium:sodium ratio was closer to 7:1.1 with slightly less sodium.
Salt & Health
The reason that the potassium to sodium ratio is crucial for health is because it plays a significant role in regulating several vital body functions, particularly in maintaining fluid balance, blood pressure, and nerve function. Sodium and potassium are both electrolytes that help control the balance of fluids inside and outside your cells. Sodium is mainly found outside the cells, while potassium is mainly inside.
Blood Pressure Regulation
Higher levels of sodium in the body and in the blood lead to water retention. In the blood this increases blood volume which in turn can raise blood pressure. Potassium helps promote the excretion of sodium via the kidneys with the effect of relaxing blood vessel walls, thereby lowering blood pressure. Therefore, a higher potassium to sodium ratio is associated with lower blood pressure and a reduced risk of hypertension and cardiovascular disease. A high sodium-to-potassium ratio, on the other hand, increases the risk of high blood pressure and heart disease. Remember that the studies looking at this have all been done with individuals on a typical western processed diet.
Muscle and Nerve Function
Both sodium and potassium are essential for the proper function of muscles and nerves. Sodium helps to transmit electrical signals between nerves and cells. Potassium works with sodium to generate electrical signals and muscle contractions. A higher ratio of potassium to sodium helps to prevent muscle cramps and ensures smooth nerve communication.
Kidney Health & Excretion of Waste
The kidneys play a key role in regulating sodium and potassium levels. High potassium intake supports kidney function by helping to filter out excess sodium and maintain proper electrolyte balance. A low potassium to sodium ratio can lead to kidney strain and impaired function over time.
Fatigue
As mentioned, sodium and potassium are needed to transmit signals between cells, their interaction is known as the sodium-potassium pump which is essential for maintaining the electrical gradient and across the cell wall. If this pump is impaired, due to a lack of potassium or excess sodium, it can lead to muscle weakness and fatigue.
So How Does A Keto Diet Affect This?
When someone switches to a ketogenic diet three things happen that can have an impact on their sodium and potassium levels. Firstly, the levels of the hormone insulin drop, second they will lose more electrolytes in their pee and third there will be a loss of fluid from the body too.
Insulin is released in response to eating carbohydrates so if someone stops or significantly reduces their consumption of carbohydrates there will be a reduction in the secretion of insulin. Insulin helps the kidneys retain sodium, so when insulin levels drop, the kidneys will excrete more sodium. Where sodium goes so does water due to the osmotic effect, resulting in more water being peed out.
A real food ketogenic diet means that someone is are no longer consuming processed foods so their consumption of sodium will be reduced. On a high-carbohydrate diet, the body stores glucose in the form of glycogen, and each gram of glycogen is bound to approximately 3-4 grams of water. So by switching to a ketogenic diet, glycogen stores deplete quickly, making it possible to lose a significant amount of water.
In the early stages of a ketogenic diet this can explain the symptoms of keto flu which is a set of temporary symptoms that some people experience including dizziness, headaches, nausea, fatigue, muscle cramps. The symptoms can all potentially be explained by dehydration and electrolyte (salt) imbalances affecting the sodium-potassium pump. Other electrolytes can be involved too including magnesium.
However, having said all this, it is possible for some of these symptoms to be due to too much salt, or not enough fluid consumption. One of the key symptoms of excessive salt intake is muscle cramps, if you think this could be an issue, then it may be appropriate to try drinking more water and reducing salt intake.
Trials To Lower Blood Pressure With Diet
A 2024 meta-analysis of 20 studies looking trials which used a variety of different ways to help people reduce sodium in their diets, including data from 5,703 participants, found that the health education interventions resulted in a significant reduction in systolic pressure of -2.75 mmHg and a reduction in diastolic pressure of -2.1 mmHg. Mmm…. That’s not much!
Let’s compare this to the ketogenic diet or low carbohydrate diets. You might be hoping for some amazing results, but in fact it is a mixed picture. There are some reviews that haven’t found any significant impact but if we look to real world evidence where low carbohydrate diets are used in primary care, Dr David Unwin, a GP in the UK, has found that in a sample of 154 of his patients who adopted a low carbohydrate diet, they had a significant and substantial reduction in blood pressure with mean systolic pressure reducing by 10.9 mmHg and mean diastolic pressure by 6.3 mmHg. This is a lot more than the low sodium diet results.
A paper published by Virta Health which uses ketogenic diets with diabetic patients in a real-world setting showed significant reductions in systolic pressure (− 3 mmHg) and diastolic pressure (− 7 mmHg) at the same time as finding an 11.4% decrease in anti-hypertensive medication and a 9.7% decrease in diuretic medication (used to help the kidneys remove more fluid from the body).
There were also results published from a randomised trial in 2023 that directly compared the DASH diet (Dietary Approaches to Stop Hypertension) to a ketogenic diet. The DASH diet comprises of fruit, vegetables, whole grains and is low fat and low salt which is the standard diet suggested to people to help lower blood pressure. Participants had to have a blood pressure of ≥130 mmHg despite any anti-hypertensive medication. Systolic blood pressure decreased by 4.49 mmHg in the DASH group and by 9.92 mmHg in the ketogenic group, which was a statistically significant difference between the groups of −5.43 mmHg. There was also a difference in the deprescribing of antihypertensive drugs and of 31.3% in the ketogenic group versus 13.0% in the DASH group. So the ketogenic arm of the trial performed much better than the low salt diet arm.
Overall these results suggest that the overall diet consumed perhaps has more effect than the salt on blood pressure.
Types of Salt: Table Salt vs. Natural Salt
What are the differences between the different kinds of salt we can add to food?
1. Table Salt:
Table salt is heavily processed to remove impurities and often includes additives like anti-caking agents and iodine. It is mainly sodium and lacks other minerals and has been associated with health problems. It does not usually contain potassium (although you can buy low sodium salt with added potassium) and there is some evidence that this could be supportive for heart health.
2. Natural Salts:
Natural salts, such as Celtic sea salt and Himalayan pink salt, are less processed and retain a variety of trace minerals, including magnesium, potassium, and calcium. These salts are often recommended for their broader mineral content, but their sodium content is still similar to table salt. Trace elements from mineral based salts like Himalayan salt can include copper, chromium, lead, mercury, selenium, aluminium, calcium, iron, manganese, nickel and zinc. Levels vary by the type of salt and location of extraction but sometimes these salts can contain higher levels of toxic elements such as lead. Salt made from evaporated sea water can be contaminated with chemicals as well as microplastics. Sea salt mined and extracted from prehistoric seabed that was deposited millions of years ago maybe the best bet for the least contaminated salt products.
Electrolytes
Actually there is a third option which is using an electrolyte product which will contain a mixture of electrolytes such as magnesium and chloride in addition to sodium and potassium. Again choose one that comes from ancient sea beds and contains to additives, including sweeteners or flavourings. Some may contain additional elements such as zinc and trace elements including boron, chromium, copper, fluorine, iodine, iron, manganese, molybdenum and selenium. Check the manufacturers website to see if they check for levels of heavy metals and what the results show.
Although I am not discussing it in detail in this blog we will all lose salt and other electrolytes in our sweat too and how much varies from person to person dependent on the climate, the amount of intensive exercise and your sweat concentration (how salt it is) which can vary up to 5 or 6 fold between individuals. If you want to read about this more you can go to this link.
What Should You Do?
This blog is not about giving you advice, instead it is providing you with information to make an informed decision about how you want to go about optimising your health. These are the key points to consider:
A a diet high in refined processed food is going to be high in sodium with a high sodium to potassium ratio. The diet will also be high in carbohydrates leading to high insulin levels which in turn will make the body will hold onto water and electrolytes including sodium. This increases the risk of hypertension (high blood pressure).
On a ketogenic diet there will initially be water loss which will include electrolytes, especially in the early days of the diet, then it will likely come to an equilibrium. During the transition more fluid may be needed to optimise hydration and perhaps some extra salt, possibly best to get from an electrolyte solution that provides sodium, potassium as well as others such as magnesium.
If plant foods are consumed in any significant quantity, it seems possible that it may lead to a higher need for salt. This maybe because plant food generally contain little sodium and plants also are much more abundant in potassium relative to sodium, so it would make sense that animals eating a mainly plant food diet may seek to get it from other sources.
On the other hand a human who is a hypercarnivore, meaning most of the food comes from animal based sources, perhaps has less need for supplementing salt.
If you need to supplement with salt, choose a good quality sea salt mined from ancient seabed deposits. Alternatively choose a high quality electrolyte liquid with no additives.
There is no exact science here to tell you how much salt to consume so you are likely going to have to experiment! Listen to your body, if you have symptoms, you suspect might be relate to your salt or electrolyte intake then think about what food your are consuming, how much salt you are adding and see what happens if you change it.
All my references are further down this page if you would like to look up any of the research I used in my writing.
I have the following resources available below: my free Quick Start Keto Guide, my Fix Your Fatigue Keto Recipe Book, a link to my Carnivore Challenge Guides and a link to my free Brain Energy Reboot E-book.
You can download my quick start keto guide.
My Fix Your Fatigue Keto Recipe https://www.moiranewiss.co.uk/fix-your-fatigue-ebookBook
Disclaimer: Before changing your diet or lifestyle and taking any supplements always seek the advice of your doctor or another suitably qualified professional such as a nutritional therapist. The content of this blog is for informational purposes only and is not a substitute for professional medical advice. Always seek the advice of your doctor with regards to any questions you have about a medical condition.
References
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Aliasgharzadeh S, Tabrizi JS, Nikniaz L, Ebrahimi-Mameghani M, Lotfi Yagin N. Effect of salt reduction interventions in lowering blood pressure: A comprehensive systematic review and meta-analysis of controlled clinical trials. PLoS One. 2022 Dec 7;17(12):e0277929. doi: 10.1371/journal.pone.0277929. PMID: 36477548; PMCID: PMC9728935.
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https://www.precisionhydration.com/performance-advice/hydration/how-to-estimate-sweat-salt-loss/
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