Most of the symptoms that the internet community attributes to ‘Keto-flu,’ ‘Atkins-flu,’ and ‘adrenal fatigue’, insomnia, anxiety, and slow recovery after exercise can be cured by a modest daily supplement of one essential nutrient – sodium (aka salt).
There is no science linking carbohydrate restriction and/or nutritional ketosis to impaired adrenal function (i.e., inadequate cortisol or adrenaline production).
To avoid confusion, we need to differentiate between ‘sodium depletion’ – which triggers the renin/aldosterole pathwaythat reduces sodium excretion – and simple dehydration. Dehydration triggers thirst, which stimulates water consumption. But water consumption alone cannot reverse the symptoms of sodium depletion. Without enough sodium in the body, no amount of water intake can maintain normal volume in the circulation. Dehydration by itself tends to be self-correcting. Sodium depletion are symptoms less specific.
Sodium – Essential But Still Controversial
Sodium has been recognized for thousands of years as an essential mineral for human well-being and function, but the optimum level of intake for humans remains highly controversial. Sodium intake has been linked to increased blood pressure in about 25% of the general population, and given the strong association between hypertension and cardiovascular disease, the assumption has been that we all should consume less sodium to reduce our heart-attack risk. In other words, we are all told to limit our salt intakes because this is assumed to be benign for most of us and life-saving for the minority with what is called ‘salt-sensitive hypertension.’
We must question this one-size-fits-all recommendation. Why? Because no one has bothered to do the obvious study in which people with normal blood pressure restrict their salt intakes for years at a time to see if this improves their overall health, or at least does them no harm.
The Salt/Sodium Adrenal-Hormone Connection
Eat no salt for more than a few weeks and you die. Don’t eat quite enough salt long term and you will develop symptoms that are the same as those described for ‘adrenal fatigue’, such as weakness, fatigue or low energy, headache, nausea, vomiting, muscle cramps or spasms, confusion and irritability.
Sodium is an essential mineral found in your blood, specifically in your serum, and in the extra-cellular fluid that surrounds all of the body’s cells. Its level in the blood is guarded by the actions of both your kidneys and adrenal glands. Eat too much salt and your kidneys accelerate its excretion.
Eat too little and your adrenals make a hormone called aldosterone that causes your kidneys to conserve sodium, but in doing so they are physiologically obligated to simultaneously waste potassium. Wasting too much potassium is not good because your muscles, heart, and nerves need to contain the right amount of potassium to work properly.
The reduced amount of sodium available in the circulation that triggers the adrenal gland to increase production of aldosterone also increases adrenal production of the stress hormone cortisol and the fight-or-flight hormone adrenaline. Increased cortisol and adrenaline levels are stress hormones that are potent impediments of healthy sleep.
Bottom line: salt, potassium, adrenaline, and cortisol are intimately connected; there is a clear relationship between inadequate dietary sodium and the purported signs of ‘adrenal fatigue.’
How Nutritional Ketosis Affects Your Sodium Needs
With adaptation to nutritional ketosis over a number of weeks, many basic functions of the body undergo profound changes:
- Fat (and ketones made from fat) replaces glucose as the primary fuel
- Sensitivity to multiple hormones, including insulin and thyroid hormones, improves
- The kidneys switch from retaining sodium to rapidly excreting it, (normal sodium metabolism with nutritional ketosis).
For those who are prone to retain sodium (e.g., causing bloating, high blood pressure, congestive heart failure, edema/ankle swelling), this accelerated sodium excretion with nutritional ketosis is a blessing. But once any excess sodium and water have been cleared from the body in the first few weeks of a ketogenic diet, a new balance of sodium intake to sodium excretion then has to occur so that adequate blood circulation (aka, circulating volume) can be maintained. However if, in this keto-adapted state, dietary sodium is restricted, your brain and kidneys signal your adrenals to increase aldosterone and cortisol. What this means is that a combination of nutritional ketosis plus salt restriction leads to adrenal stress.
Nutritional ketosis + salt restriction = adrenal stress
Research Linking Ketogenic Diets to Adrenal Stress
Despite the hundreds of published studies of humans on ketogenic diets lasting as long as 2 years, there is no credible scientific evidence for adrenal damage or fatigue.
Research Showing Normal Blood Cortisol During Ketogenic Diets
There is just one paper showing that serum cortisol levels remained normal in 12 men given a well-formulated ketogenic diet for 6 weeks (Volek, 2002).
Why It Is Safe to Recommend Adding Salt to a Ketogenic Diet
First,since nutritional ketosis accelerates sodium excretion by the kidneys, whatever risk might be associated with too much sodium at any one level of salt intake would be less during ketosis than when eating a high carb intake. Stated another way, a high carbohydrate intake suppresses the body’s natural ability to excrete sodium and thus reduces a person’s ‘salt tolerance.’ Insulin is known to be involved in renal sodium metabolism.
The second important point is found in a recently published study that threatens to derail the whole anti-salt crusade. An international group of scientists collected urine samples from over 100,000 adults in 17 countries and then observed their health status for 4 years (O’Donnell 2014). They reported that people consuming less than 4 grams of sodium per day had a sharply increasing risk of death, almost doubling when they got down to 2 grams/day of sodium. In contrast, with higher sodium intakes, the risk of death rose very slowly beginning with intakes above 6 grams/day. For example, as shown in the diagram below, mortality risk was increased by only 15% at 8 grams/day.
See the Chart: ** Estimated sodium excretion and risk of death from any cause
Optimum Sodium Intake During Nutritional Ketosis
Virta’s recommended sodium intake for most people during a well-formulated ketogenic diet is based upon the amount needed to avoid the symptoms of ‘Atkins flu’ or ‘adrenal fatigue’ is 5 grams per day (3 grams in your food, 2 grams from broth/bouillon).
There are still variations between individuals that necessarily modify this advice.
- People with high blood pressure or fluid retention that persists after keto-adaptation, and particularly if they are taking a diuretic medication, should not increase their sodium intake above 3 grams per day until these symptoms are resolved and the diuretic medication stopped.
- People routinely taking NSAID medications like ibuprofen (Motrin, Advil) or (Aleve, Naprosyn) are more ‘sodium sensitive’ because these drugs block salt excretion by the kidneys and raise blood pressure.
- Heavy physical exercise in the heat will cause increased sodium loss in sweat, which can increase one’s daily sodium requirement above the 5-gram level.
And finally, as always, it is important to distinguish between grams of sodium and grams of salt.
Salt and sodium are not the same.
1 teaspoon of salt = 5 grams of salt = 2.3 grams of sodium (the rest is chloride)
High quality studies published by Virta and others continues to lead us to the scientifically correct view: nutritional ketosis is good for you. In particular, given the emerging view of ketones as both a fuel and beneficial epigenetic signal (arising from nongenetic influences on gene expression), there is unique therapeutic value to nutritional ketosis. And all that is needed to capture these benefits is to supply the daily salt intake required to maintain an optimum balance of sodium and potassium in the body.
Ask yourself this question: if nutritional ketosis has been shown to markedly increase my defense against oxidative stress, and it also makes mice and worms live 13-26% longer, why would I give up these advantages just so I could eat sugar and refined carbs?
This Post has been condensed from: Sodium, Nutritional Ketosis, and Adrenal Function
By Stephen Phinney, MD, PhD, Jeff Volek, PhD, RD, Citations for scientific studies.
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