Fighting Heart Failure with a Low Sodium Diet

Nearing a heart transplant, a patient is guided away from surgery

A year after a major heart attack and surgery, Bruce Simon found himself back in the hospital for more surgery. This time, his doctors in his home town of Billings, Mont., began to talk about a heart transplant. Simon wasn't arguing. His congestive heart failure was so extreme that he had to sleep sitting up, with oxygen to help him get enough air, and he couldn't walk more than a few feet without getting breathless.

Yet four years later, Simon is the proverbial picture of health. He hasn't had a heart transplant or any other type of heart surgery. He's on the lowest dosages of fewer medications than he's ever taken. He's back to spending long days rowing down the Smith River to his favorite fly fishing spot and he can walk two miles on a treadmill at a 3.5-mile per hour pace. It wasn't high tech medicine that drove his recovery: It was simply avoiding salt.

"A lot of people with heart failure come to a cardiologist's office and expect to get medications," said Simon's doctor, Dipanjan Banerjee, medical director of Stanford's Mechanical Circulatory Support Program. "Probably the most important thing we do in our clinic is focus on lifestyle and dietary changes—the cornerstone of our therapy for our congestive heart failure patients is sodium restriction."

The science behind a low sodium diet

Among other electrolytes, including calcium and magnesium, sodium helps cells use and carry electrical impulses throughout the body, facilitating the absorption of nutrients and minerals. However, most Americans have too much salt in their diet—typically more than 3,000 mg daily. The American Heart Association recommends a limit of 2,300 mg and a low sodium diet for people with certain health issues like coronary artery disease and heart failure.

Simon had performed just a little too well on the heart transplant evaluation tests, so Banerjee sat him down to talk about diet. Even though Simon did not have high blood pressure or high cholesterol—two key precursors of coronary artery disease—his heart was stressed by the effort needed to pump accumulated excess fluid. Sodium in excess puts more stress on the heart, Banerjee said, because it causes water retention, making the heart work harder to pump that extra fluid around the body. "For people who don't have congestive heart failure, reducing sodium is not as important. For a patient with congestive heart failure, low sodium intake is crucial," Banerjee said.

Rather than prescribe higher doses of diuretics to help rid Simon's body of excess fluid, Banerjee wanted him to try living by a simple rule he often prescribes for his patients with heart failure. "Nothing out of a can, nothing out of a bag, nothing out of a box and no processed foods," is how Simon remembers it. "I thought they were nuts," he said, "but I also recognized that I'd been sent to one of the finest medical facilities in the world and I was under the care of some of the best doctors in the world, so I thought I should pay attention."

"Medications are important," Banerjee said, "but they can't be used in isolation. For example, we've found that coronary artery disease isn't just a passive accumulation of cholesterol in the blood vessels. Now we know that there's active inflammation in those blood vessels and if we don't treat that inflammation, patients can have heart attacks and even strokes. We also know that sodium restriction, or a low sodium diet, plays a role in reducing inflammation, especially in patients with heart failure."

How to gauge a low sodium diet

Sodium chloride, otherwise known as table salt, is just one form of sodium found in foods. It is also added to foods as sodium bicarbonate, monosodium glutamate and sodium-based preservatives. A very low sodium diet is 35mg of sodium or less per serving. A low sodium diet has 140mg of sodium or less per serving. A reduced sodium has at least 25 percent less sodium than the original product.

In addition to its impact on cardiovascular diseases like hypertension and congestive heart failure, salt can increase levels of kidney and liver disease.

Sticking with a low sodium diet is not an easy change. "We realize that patients have had a certain diet for their entire lives," Banerjee said, "but patients with diabetes have to modify their diet to reduce sugar and over time, if they're able to do that, some of those patients can come off their therapies for diabetes. We see patients with heart failure who can experience the same therapeutic benefits."

Low sodium diet challenge succeeds

That is what began to happen with Simon. Not only did was he able to add exercise to his daily routine, another suggestion from Banerjee, but his low sodium diet was so effective against his heart failure symptoms that he noticed a difference within two weeks. Soon, he was sleeping without oxygen, just as he had before his heart failure. By the end of a month on the new diet, the pressures in his heart were normal and an echocardiogram showed that the right side of his heart, once much enlarged, was also back to normal size. "He was an unqualified success," Banerjee said, "largely because of the work he did. That won't be true for everyone, but we try to avoid invasive treatments and to first manage our patients' health with lifestyle changes."

Now 72, Simon has become a vigorous advocate for the low sodium diet and delightedly accepts compliments about how good he looks. "People tell me I don't even look like the same guy" he said. "I feel great and I can do just about anything I want. Eating carrots and celery is a whole lot better than having a heart transplant."