From the Publisher

Donald Gazzaniga, diagnosed with congestive heart failure, was headed for a heart transplant - the only effective medical treatment. Urged by his doctor to keep his sodium intake "under 1,500-2000 mg. a day," Don headed for the kitchen and went to work. Aware that cutting out table salt is the barest beginning of a true low-sodium diet, Don devised recipes for delicious low-sodium dishes that added up to less than 500 mg. daily, 70% lower than those in other low-sodium cookbooks. The result? Don's name has been removed from the transplant list and his doctors believe that his diet played a significant role.

The No-Salt, Lowest-Sodium Cookbook contains:

* Hundreds of good tasting, easy-to-make recipes
* An introduction by Dr. Sandra Barbour of the Kaiser Permanente Foundation
* Advice on finding low-sodium prepared foods, eating in restaurants, etc.
* Accurate sodium content of every ingredient and of the total servings
* A twenty-eight-day low-sodium menu planner by Dr. Jeannie Gazzaniga, Ph.D., R.D.

This book is for informational purposes only. Readers are advised to consult a physician before making any major change in diet.

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The No-Salt, Lowest-Sodium Cookbook

Griffin

Chapter One

Straight Talk from a Cardiologist

Dr. Michael B. Fowler, Fellow, Royal College of Physicians
Stanford Heart Transplant Clinic, Stanford Medical School

Few patients with heart failure fully appreciate the pivotal role that sodium plays in the severity of their symptoms, and their ability to be free of alarming sensations and avoid hospitalization. Conversely, those individuals who do understand the role of sodium and who adjust their diets to control their sodium intake at consistently low levels frequently experience a dramatic improvement in their general well-being. I have known many patients whose heart failure symptoms were recurrent and so severe that they were advised to undergo heart transplantation, yet these same patients improved so much with sodium restriction that they no longer required a heart transplant. The author of this book is one of those. The diet he himself designed and followed brought his daily sodium intake to under 500 mg and had a profound impact on his ability to live without overt heart failure symptomsand thereby remove his need for a heart transplant.

Heart failure from any cause is characterized by symptoms that result from retention of sodium (salt is the biggest culprit). Sodium is used by the body to regulate fluid status. In all circumstances that lead to heart failure sodium (and with it water) tends to be retained. In some individuals this may only be apparent at times of additional stress to the heart such as lack of blood-carrying oxygen (leading to angina), change in heart rhythm, intercurrent illnesses such as flu, or when the dietary intake of sodium is especially high (as with pizza). The majority of individuals with heart failure (and many with hypertension) have to combat a constant tendency to retain sodium. Those individuals are generally treated with diuretic drugs.

All diuretics ("water pills") work by increasing the amount of sodium removed from the bloodstream by the kidneys and from the body by elimination. Most diuretics also cause potassium to be lost, an undesirable side effect often requiring potassium supplementation and/or the use of special potassium-retaining diuretics.

The amount of sodium loss achieved by a diuretic is largely dependent on the dose of the drug and how often it is taken. The required dose of diuretics is strongly influenced by the dietary sodium intake, although an individual's diuretic requirement in heart failure also varies widely depending on other factors, including the tendency to retain sodium and the individual's sensitivity to the actual diuretics being given.

It follows that restricting sodium to a constant low level of ingestion is a crucial component to finding and maintaining the correct dose and type of diuretic. Too high a dose will cause a patient to be susceptible to dehydration and lightheadedness, particularly when the dietary sodium intake falls. A more common problem is that even high-dose diuretics may be incapable of removing all the sodium ingested by an individual who does not keep to a carefully regulated and restricted sodium intake. This will result in recurrent episodes of salt and water retention accompanied by breathlessness or abdominal bloating and possible swelling of the ankles. By using this book and sticking to a diet you design, you will achieve a constant level, one that should not alter your lowered level of sodium to the point where your diuretics react in a way you would not desire.

Individuals who remove all added sodium from their diet, whether that added by the manufacturer or in the patient's own kitchen, will provide the best environment to achieve the maximum improvement in symptoms and a reduced risk of hospitalization. These individuals will also create the clinical stability to achieve the correct doses of other drugs, especially ACE inhibitors and beta blockers necessary for the control of the patient's heart failure.

Here are some of the symptoms and adverse effects of sodium in heart failure:

· Difficulty in breathing, especially when lying flat. Waking at night short of breath. The need to sleep with additional pillows.

· Weight gain due to extra fluid. Bloating, especially of the abdomen. Swelling of the ankles.

· Thirst; an excessive desire to drink water.

· Increased diuretic requirements. "Refractory" sodium retention. Low concentration of sodium in the blood. Loss of potassium.

· Hospitalization; emergency room visits.

The benefits of low sodium achieved by a careful fresh food diet are:

· Allows stability of the diuretic dose.

· Allows stability of potassium replacement measures.

· Increases the possibility of optimizing the doses of other drugs that lessen the risk of major adverse events.

Such a regime usually also results in reduced fat intake (important especially in coronary artery disease or when the patient is overweight).

Patients with heart failure, especially those who are treated with diuretics or who take diuretics every day, will benefit from restricting their sodium to the few milligrams per day they find in food consisting of, or prepared from, fresh ingredients. The recipes in this book make it clear that there is little hardship when following this important aspect of living well and as long as possible with heart failure.

Patients who had previously had their dose of diuretics increased to deal with recurrent episodes of decompensated heart failure may become dehydrated and run the risk of reduced kidney function or spells of lightheadedness (or even blackouts) if they abruptly reduce their sodium intake from previously high levels. Patients should discuss these issues with their physicians before making substantial changes in their sodium intake and ensure that they report these changes to their doctor.

In general, be creative with your cooking ideas and have fun. If you have a "salt tooth," you can learn to prefer low-sodium food just by eating it. Within two months your tastes should adjust to the point where you won't miss the salt. Removing salt can bring out flavors that have been hidden by the salt.

Dr. Michael B. Fowler is a leading researcher in the medical field of congestive heart failure (CHF). Since 1982, he has been with the Stanford Heart Transplant Clinic, where he has been involved in research leading to the use of new beta-blockers such as carvedilol (Coreg) and low-sodium diets to help improve the quality of patients' lives as well as the survival rate for those who develop congestive heart failure.

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Excerpted from The No-Salt, Lowest-Sodium Cookbook by Donald A. Gazzaniga Copyright ©2002 by Donald A. Gazzaniga. Excerpted by permission.
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