The Salt Skip Program for Meniere's Disorder Comments by Dr Alfhild Larson MD FRCPC I have had Meniere’s for about two years now. At first, I had daily disabling vertigo, including one attack that sent me to hospital. The traditional medications —diuretics, Serc, a short course of steroids—did not help. It was a dreadful time. I am a single mother of teenagers, and a busy paediatrician who works with children with
disabilities. At that stage it looked as if my life as I had known it was over. However, once started on the low salt guidelines, avoiding standard bread and other
foods processed with salt, the vertigo disappeared over two to three weeks. In two years,
I have had vertigo only twice—both times when I had been tempted to break the diet. The diet takes some getting used to, and definitely requires extra work. However I enjoy a wide variety of gourmet foods, and wonder how I ever tolerated ‘normally’ salted foods. Social situations such as invitations to friends’ homes, and eating out, require
careful planning. But on this diet I am free of vertigo. For me, the choice is clear.
Comments by Dr Trevor Beard OBE MA MB BChir MPH FRACGP I have five comments:
In the Salt Skip Program Dr Larson’s result is typical for patients with Meniere's disorder;
It was obtained without drugs or surgery;
It follows the Australian Dietary Guidelines;
Deafness and tinnitus may respond to some degree but vertigo is usually abolished;
About 5% of patients with good urine results have persistent vertigo needing other treatment.
What are the Dietary Guidelines? Many people have already cut out table salt and cooking salt—just for better health—but few realise that 75% of their salt intake comes from processed foods. The salt guideline is: ‘choose foods low in salt’, and the food regulations define low salt foods—sodium is no more than 120 milligrams per 100g (120 mg/100g). The label must show the sodium
content by law, but foods like bread are exempt if sold without a wrapper. Fresh foods such as fruit, vegetables, meat, milk and yoghurt are well under the sodium limit, but most processed foods are well over it. Look for the exceptions. In 2004 for instance Kellogg’s Corn Flakes contained 820 mg/100g, yet their popular Just Right
Original had only 30 mg/100g, and Sanitarium Lite-Bix had 20 mg/100g. The sodium content of bread usually varies between 400 and 725 mg/100g. Controlling vertigo requires bread with no added salt, which is available from a few bakeries in all Australian capital cities, and you can easily make it at home, either by hand or with a
bread machine. How do people tolerate meals without salt? Of course they miss the salt at first, especially in bread, just as they miss sugar if they stop taking it in tea. After 3 months without sugar they find it’s sweet tea that is
intolerable. The palate adapts just as well to less salt as it does to less sugar. You begin
to notice it within a week. There are literally hundreds of ways of adding flavour to food when you count all the herbs and spices, vinegars, lemon juice, and flavourful toppings. Avoid cooking methods that destroy flavour (like boiling in water). After your taste buds have adapted, many
‘normal’ foods taste unpleasantly salty.
Salt Matters ― Australia and New Zealand (SMANZ) 05/08/2007
The Salt Skip Program for Meniere's Disorder 2 of 3Why is such a simple change so effective? Salt causes fluid retention, varying throughout the day with fluctuating intake. The Salt Skip Program controls sodium to a level that will not start a cycle of variable fluid retention. No studies can show exactly how skipping salt controls vertigo (no volunteers want to risk an attack of vertigo) but the big reduction provided by the salt guideline would eliminate fluid shifts in the body, which can in turn cause vertigo if the fluid balance in the inner ear is affected. Why not use diuretic tablets instead? Diuretic tablets accelerate the loss of fluid and sodium, but during the daily fluid shift some people may still have an attack of vertigo. WARNING: If you follow the low salt guideline, with sodium excretion below 50
mmol/day, diuretics must be avoided. They can cause serious side-effects, especially hyponatraemia (low blood sodium). This does not occur with the diet alone; it is a drug side-effect. It can be severe enough to require hospital admission, and the danger is greater for elderly women , and for people who take combination diuretics such as Dyazide or Moduretic .
What if the vertigo persists? If vertigo persists, it is usually because the diet is not low enough in salt. Most supermarket foods contain far more added salt than most people realise (taste is no guide). Only about
10% of the salt in the average diet comes from the salt naturally found in food; 15% is added in cooking or at the table, and a massive 75% is added to processed foods by the manufacturer . Don’t assume that the diet is not working unless you have measured your actual salt intake. You can do this by asking your doctor to order a 24-hour urine collection to measure how much sodium you excrete. This is not a routine medical test, and doctors who need more information will find it in Salt Matters: the killer condiment (Hachette Livre, 2007,
RRP $24.95, ISBN: 978 0 733622 16 8). Medical laboratories report sodium in millimoles (abbreviated mmol) and the goal for controlling vertigo is less than 50 mmol/day (preferably 40 mmol for a woman), with more potassium than sodium. A blood test will not measure sodium intake, because healthy kidneys keep blood sodium levels constant within narrow limits. Excess salt in the diet ends up in the urine. People whose vertigo persists in spite of satisfactory 24-hour urine results may belong to the 5% with Meniere’s disease who fail to respond . While salt is a major trigger for the vertigo there may be others that are less well defined. Stress is often regarded as a trigger; also the underlying disease may be progressive.
Several drugs may help (but diuretics must be avoided) and surgery may be advised. As the first treatment we recommend the Salt Skip Program to anyone who is willing to take the trouble to follow it, since it is usually so effective – with no other treatment . In any case the Dietary Guidelines are worth following indefinitely for other reasons. They
are meant for the whole Australian population (not just people with Meniere’s disorder) and the salt guideline is based on the evidence that it would help to prevent high blood pressure. If your blood pressure is low, a low salt intake is harmless. If it is already high, the Salt Skip Program will usually reduce it, and your doctor may be able to reduce the dose of medication. Some drugs can be discontinued (in fact diuretics may do harm unless they are
stopped). _____________________________________________________________ Salt Matters ― Australia and New Zealand (SMANZ)
The Salt Skip Program for Meniere's Disorder 3 of 3Other illnesses Theoretically some people might need added salt after 50 years of having far too much, especially if they are ill. The Salt Skip Program does warn people not to change their diet without medical advice if they have these special problems: gastrointestinal fistula, ileostomy, Addison’s disease, cystic fibrosis, advanced kidney failure, extensive burns, severe eczema or other exudative skin diseases, or medication with lithium, diuretics, ACE inhibitors or angiotensin antagonists. If future research leads to other authentic
warnings the Salt Skip Program will publish them. Pregnancy Women should not alter their salt intake during pregnancy except under medical supervision. But women stabilised on a low salt diet before pregnancy should continue,
as happened before we invented table salt, and still occurs in the world’s most salt free society [5,6]. Books and website about The Salt Skip Program The Salt Skip Program is fully explained in Salt Matters: the killer condiment
(Hachette Livre, 2007, RRP $24.95, ISBN: 978 0 733622 16 8) which is in the bookshops and also available from Meniere's Support Groups in Australia, and the
Queensland Hypertension Association. For more details about the book visit This website also
publishes the 2-monthly newsletter Salt Skip News, with updated shopping information, research news and comment, and recipes. You can also join an email discussion group for people interested in good control of salt intake. To join, send a blank email to New members of the Queensland Hypertension Association (QHA) receive the Salt Matters book and a 2-monthly newsletter for 12 months after they join. If you already have the book and don't need another copy, you can join the QHA at a lower subscription rate. The address is PO Box 193, Holland Park, QLD 4121, Phone (07) 3899
1659, FAX (07) 3394 7815. Email: References
1. Matthew TH, Boyd IW, Rohan AP. Hyponatraemia due to the combination of
hydrochlorothiazide and amiloride (Moduretic): Australian spontaneous reports. Med J
2. Brown MA, Whitworth JA. Think again about combination diuretics. Aust Prescriber
3. James WPT, Ralph A, Sanchez-Castillo CP. The dominance of salt in manufactured food
in the sodium intake of affluent societies. Lancet 1987; 1:426-9.
4. Based on clinical experience in Hobart, 1990–2004. 5. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte
excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ 1988; 297:319-28.
6. Oliver WJ, Neel JV, Grekin RJ, Cohen EL. Hormonal adaptation to the stresses imposed
upon sodium balance by pregnancy and lactation in the Yanomama Indians, a culture without salt. Circulation 1981; 63:110–16.
We are indebted to Professor WPR Gibson and two other specialists (Mr Philip Moore and Mr David Merry) and several of our patients (names withheld) for editorial advice and comment. This information brochure has been provided by the Meniere’s Support Group of NSW Inc.
_____________________________________________________________ Salt Matters ― Australia and New Zealand (SMANZ)
Case5:10-cv-05246-JF Document37 Filed02/14/11 Page1 of 29DAVID W. ICHEL ( pro hac vice )[email protected] ELIZABETH McGARRY ( pro hac vice )[email protected] M. McLAUGHLIN ( pro hac vice )[email protected] THACHER & BARTLETT LLP425 Lexington AvenueNew York, New York 10017Telephone: (212) 455-2000SIMONA G. STRAUSS, [email protected] P. BLAKE, 260069
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