Salt - How do you know if you are taking enough salt?

The first way to tell if you are getting enough salt and water is called "clinical assessment:"How do you feel? Do you feel better? If you take more, do you feel better or not?

The next question - do you feel better when you take more but you can't keep it up. It might make your mouth hurt or your stomach hurts or is upset - or you just can't stand to take any more. Then, it's time to talk with your doctor about adding medication that will help hold on to the fluid/salt you are getting in.

The third way is to do the urine test. (Described below)

How do you know if you are getting too much?

There are two ways to tell if you are getting enough salt and water. The first way to tell is "clinical assessment" and the physical exam. Many of the physicians treating POTS and NMH start with this approach.

Clinical Assessment

If you taking in more than your body needs inside the blood vessels, the extra fluid will go outside the blood vessels, and collect in the other tissue in your body. You will get "edema" or puffiness in your feet/ankles.

When you are getting more than your body needs for your Orthostatic problem, the extra fluid will collect in the "dependent" parts of your body, the parts of your body that are closest to the floor. When we stand most of the day or sit with our feet on the floor, the dependant parts of our body are our feet, then our ankles and then the lower legs.The fluid could collect in the feet first. If it continues longer, there would be fluid around the ankles and then up the leg. It would first be noticed in the feet, socks or shoes might feel tight. Socks might leave ridges in the skin at the end of the day. The skin might look puffy and shiny.

(If you are sitting in a recliner with your legs up, the most "dependent" or lowest part of your body would be your buttocks. If you are lying in bed most of the day, your buttocks and back would be the dependant part; that is where you would check for fluid collecting.)

How to test to see if you have edema: You can test for edema. Take your 1st finger and gently press on the skin over a bone in the foot or along side the ankle bone. You don't need to press hard, just gentle. Hold your finger there while you count to 30 seconds and then take it off. You might see a dent in the skin where your finger was. If you can't see a dent, run your finger lightly over the skin. Can you feel a little dent? This is called "pitting edema" because it left a "pit" when you pressed on the skin.

One physician's observation: Fludrocortisone is a medication used to retain fluid and salt, Dr. Figuero describes the clinical assessment of fluid status using fludrocortisone: "If the patient gains 3 to 5 pounds (1.2-2.3 kg) and develops mild dependent edema, you can infer that the plasma volume has expanded adequately." Here, we are talking about expanding the amount of plasma (plasma volume) enough just with salt and water!¹

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  How do you tell the difference between this and the edema that comes with blue legs?

You may already gets blue/red legs & edema when you stand too long. Usually, the blueness, pinkness or mottling & edema develops after standing awhile, like in the shower. You may also get blueness in your lips or hands also. It usually goes away with lying down. If there is swelling in your legs that stays, then you would need to check to see if the swelling/edema is more than your 'usual'. You might have to use a tape measure to measure the size of you leg & see if it changes. If it does not go away now, talk it over with your doctor.

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What to do if you think you have edema:Edema suggests you have reached your body's limit for fluid and salt. You should skip your next dose of salt and contact your doctor for more guidance on how much salt you should take. Have your diary/log ready to share what you have been taking and when you first noticed the swelling/edema.

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If you have edema and are having a hard time breathing when you lie down (hint - you don't lie down anymore, you sit up to rest or sleep), you have started a new cough, or you are having pressure or heaviness in your chest, you should contact your physician immediately so that you can be seen. You need to be seen and evaluated.

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The Urine Test

This is a 24-hour collection of urine. The laboratory provides plastic bottles with special chemicals in them for you to use to save your urine. The urine is measured to see how much urine you put out in 24 hours (output, volume) and how much sodium there is in the urine.

• If there is more than 170 mmol of sodium and urine volume more than 1500 ml in 24 hours, you are getting enough salt and fluids. ^2,7
• If there is less than 170 mmol, try up to 6 grams a day, divided up into 3 doses.^1,4
• If there is less than 100 mmol (100 mEq), it would suggest that low fluids/volume.⁵

The test is not often done to check on how much salt is enough. Most clinicans rely on the clinical assessment and physical exam. It is usually only done when the clinical information is confusing or there are other medical conditions present and the inforamtion is needed to sort out the clinical situation..

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Why You Need to Raise the Head of Your Bed - and How Much

 

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References

1. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med. 2010 May;77(5):298-306. Abstract  Article PDF

2. Freeman, Roy. Neurogenic orthostatic hypotension.NEJM 2008;358(6):615-624. Abstract
3. Claydon VE, Hainsworth R. Salt supplementation improves orthostatic cerebral and peripheral vascular control in patients with syncope. Hypertension. 2004 Apr;43(4):809-13. Epub 2004 Feb 23.
4. El-Sayed H, Hainsworth R. Salt supplementation increases plasma volume and orthostatic tolerance in patients with unexplained syncope. Heart 1996; 75:134–140.
5. Thieben MJ, Sandroni P, Sletten DM, et al. Postural orthostatic tachycardia syndrome: The Mayo Clinic experience. Mayo Clin Proc. 2007;82:308–313
6. Personal experience of author.
7. Wieling W, van Lieshout JJ, Hainsworth R. Extracellular fluid volume expansion in patients with posturally related syncope. Clin Auton Res 2002;12:242-9.
8. Recommendations on salt. UK. Consensus Action on Salt & Health. Last accessed September 10, 2012.  
9. Rowe, Peter.General Information Brochure on Orthostatic Intolerance and Its Treatment. June 2010. Accessed from http://www.cfids.org/webinar/cfsinfo2010.pdf. Accessed May 28.2012.
10. U.S. Department of Agriculture, Agricultural Research Service. 2011. USDA National Nutrient Database for Standard Reference, Release 24. Nutrient Data Laboratory Home Page ,http://www.ars.usda.gov/ba/bhnrc/ndl  
11. Low PA and Singer W. Update on Management of Neurogenic Orthostatic Hypotension. Lancet Neurol. 2008 May; 7(5): 451–458. Abstract. Article PDF.
12. Low PA, Sandroni P, Joyner and Shen W. Postural Tachycardia Syndrome (POTS). J Cardopvasc Electrophysiology 2009; 20:352-358.  Abstract.  Article PDF
13. Jacob G, Costa F, Shannon JR, Robertson RM et al. The Neuropathic Postural Tachycardia Syndrome. N Engl J Med 2000;343: 1008-14.   Abstract.   Article PDF.
14. Fu Q, Vangundy TB, Galbreath MM, Shibata S, Jain M, Hastings JL, Bhella PS, Levine BD. Cardiac origins of the postural orthostatic tachycardia syndrome. J Am Coll Cardiol. 2010 Jun 22;55(25):2858-68. Abstract. Article PDF
15. "Iodine in diet". MedlinePlus. External Link. Last accessed 09.13.2012
16. Dietary Supplement Fact Sheet: Iodine. Office of Dietary Supplements. National Institutes of Health. External Link. Last accessed 09.13.2012.
17. Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academy Press: Washington DC, 2001. 2001. External Link

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