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• The purpose of this study was to Identify the best of three methods of treating hypertensive outpatients in order to minimize dietary sodium levels and thereby decrease the need for antihypertensive drugs. Forty-eight outpatients with hypertension were randomly assigned to three treatment programs: (1) advice; (2) an intensive educational program; and (3) small-group management plus feedback. This last program had a problem-solving format in which patients shared ideas and provided mutual support for dietary change. Only these group management patients were told the results of their sodium determinations. In a one-year study, group management plus the feedback to patients of Information on the sodium content of their urine was more effective in decreasing dietary sodium intake than advice or an intensive educational effort. ( Arch Intern Med 1984;144:1415-1417)

To the Editor:— The prevailing dominance of psychiatry and psychology over the whole field of medicine is bound to create certain one-sided attitudes. Thus the view is held that obesity is merely a question of overeating, emotionally conditioned and medicinally controlled only with negligible success. According to the recent editorial inThe Journal, July 9, page 1141, only 2% of treated patients "maintain a significant weight loss for as long as two years." Moreover, on page 1131, Dr. Modell's article estimates that in only 10% of all cases of obesity do genetic, glandular, or other causes play a role. The same paper calls the use of salt restriction or diuretics meaningless and senseless. These statements are in stark contrast to my experience with successfully treated patients during the past 30 years. It is a commonly ignored fact that not all obese people are hyperphagic; quite a few are euphagic or

To the Editor:— Boley and coworkers (199:215, 1967) state that potassium citrate and potassium gluconate in slow-release-form tablets appear to be safe for oral administration. Safety of administration is not a measure of effectiveness of a drug. The Committee on Therapeutic Agents at the Veterans Administration Research Hospital has, on numerous instances, discussed the topic of small-bowel ulceration resulting from oral administration of enteric-coated and other tablet forms of potassium chloride, which produce high local concentrations.While potassium salts, other than the chlorides, such as potassium gluconate and effervescent potassium salts, may appear to offer a greater margin of safety, it is the opinion of the committee that potassium without chloride ion has a very limited value in replacement therapy, and may in fact present a potential hazard. Patients with severe cardiac failure who are being treated with salt restriction and thiazides may possibly utilize the chloride-free preparation. Alkalosis

It is well established that patients with essential hypertension have an exaggerated natriuretic response to the rapid intravenous administration of sodium. 1-4 While the mechanisms responsible for the enhanced natriuresis of essential hypertension remain unknown, a defect in the renal tubular capacity to conserve sodium has been proposed as a possible explanation. 5 Most of the available literature relating to salt conservation in patients with hypertension is concerned with the response to chronic salt restriction. The experiments of Black 6 and Renwick 7 seem to offer conclusive proof that the hypertensive patient conserves sodium normally under these conditions. However, these chronic experiments may not be applicable to the problem of exaggerated natriuresis, because the latter occurs only in response to an acute stimulus for sodium excretion. The enhanced natriuretic response is a transient one and is followed by a rate of sodium excretion comparable to that of the normotensive subject.

A new method for ascertaining diuretic efficacy, carried out in bed-patients in congestive failure within the framework of a highly effective therapeutic regimen which included rest, digitalization, and salt restriction, was applied in a comparison of the maximally effective doses of chlorothiazide and meralluride, a 2-Gm. oral dose of the former and a 2-cc. intramuscular dose of the latter. Each patient received both agents, but not simultaneously, the sequence alternating within and between patients. The comparisons were made in terms of 24-hour weight losses. Only the first four doses with paired responses provided the data which were analyzed by signs and the sign test, also by ratios with confidence limits. Contrary to the prevailing opinion, the 2-Gm. oral dose of chlorothiazide was found to exert only 40% of the diuretic effect of the 2-cc. intramuscular dose of meralluride.

To the Editor: —The warning of the Council on Foods and Nutrition (J. A. M. A.149:1317 [Aug. 2] 1952) against possible nutrient deficiencies was evidently intended to apply only to artificially processed commercial articles offered for approval, but careless reading may give an impression of such dangers in low-salt diets in general. Actually, the warning was thus extended by a speaker before the American Chemical Society in Atlantic City on Sept. 19 and was given publicity in the daily press. However technically correct these statements may be, the effect among average physicians is to magnify the difficulties of this diet and to increase the confusion concerning salt restriction, which is either too lax on the one hand or too risky or onerous on the other hand. I have even seen a panel of experts unable to meet a challenge put to them by Dr. Kempner to show a

To the Editor:— The Journal, March 17, page 997, carried my letter mentioning evidence that saltless diet can reduce puerperal eclampsia to the vanishing point. Newspapers now are informing the public of observations presented at the recent meeting of the American Society for Experimental Pathology at Atlantic City, N. J., showing that among 1,346 employees of the Brookhaven National Laboratory the incidence of essential hypertension was significantly related to the salt intake. This adds to the large growth of evidence supporting salt restriction for treatment and prophylaxis, which I have advocated since 1920. Negative arguments regarding saltless diet have been (1) that it fails to reduce the pressure in a group of "refractory" cases, though its similar failure to clear up many cases of advanced anasarca does not discredit its benefit for edema, and (2) that many hypertension cases are "benign" in the sense of being compatible with longevity; but

Excerpt Introduction: The prevalence of the prescribing of the diet of salt restriction for patients suffering with chronic interstitial nephritis, edema or hypertension is emphasized by Allen1who ...

IN A PREVIOUS paper, 1 a survey was given of the serum electrolyte pattern of patients on strict rice diet who had hypertensive vascular disease without advanced renal involvement. It was found that in 95% of these patients, serum electrolyte concentrations were well maintained. One should expect this to be different in patients with advanced kidney disease, and doubts are occasionally expressed whether or not salt restriction is applicable at all in such instances. The purpose of this paper is to report on the tolerance to rigid salt restriction in a series of patients with severe renal disease who were treated with the rice diet. The presence of renal insufficiency greatly complicates the study and interpretation of chemical changes which take place in the body fluids as a result of dietary measures. Whereas in the previous group of patients a systematic approach was possible, determining the serum electrolytes at equal

Excerpt The use of a low salt diet as a diagnostic test in doubtful cases of Addison's disease was suggested by Harrop and his coworkers1in 1933. Two to five days after beginning the restriction of...

Although the typical case of Addison's disease can be recognized clinically, the laboratory becomes an indispensable aid in the diagnosis of those cases which do not entirely fit the ordinary picture. Realizing the serious prognosis implied in such a diagnosis, as well as the importance of evaluating the therapy, my associates and I have in doubtful cases employed the salt restriction test suggested by Harrop and his co-workers1for final diagnosis. In cases of Addison's disease during restriction of sodium chloride, signs of early relapse can be expected any time after the first day but usually somewhere between the third and the fifth. Characteristic concomitant alterations in the blood are lowering of the sodium and chloride, elevation of potassium and nitrogen, hemoconcentration and diminution in blood volume. An example of this is the case of T. M., in whom a typical addisonian crisis occurred on the fifth day following

SALT EQUILIBRIUM The sodium chlorid in the body fluids is normally maintained at a constant level. Below and above this level normal function becomes perverted. Hence the body tenaciously retains a definite percentage of sodium chlorid and reacts by an exaggerated elimination when its intake is increased, by a depression and finally a complete cessation of its output when the intake is decreased. So long as the means of output remain competent salt accumulation is merely temporary. About 2 gm. of sodium chlorid per diem suffice to maintain salt equilibrium and this amount at least must daily be added to the diet. Sodium chlorid in this respect occupies a peculiar position in our dietary, inasmuch as it is the only minera constituent of the food that must be artificially supplied. 1 SALT ELIMINATION The elimination of sodium chlorid is chiefly a function of the kidneys. Some sodium chlorid is eliminated