The sodium content of four New Direction beverages (in the Very Low-Calorie Diet) is between 2600 and 2800 meq/day (depending on the beverage choices). The diuretic effect of ketosis usually allows the vast majority of patients to have no problem with fluid retention or blood pressure effects. In fact, for most patients who take a diuretic prior to starting the Very Low-Calorie Diet, they need to discontinue it within the first month due to low Blood Pressure, low serum sodium levels, and/or low potassium and magnesium. For the unusual patient with pre-diet ejection fraction (EF) < 30%, this degree of sodium intake does not result in symptoms; in fact, the progressive weight loss can actually improve the EF and reduce the need for concomitant diuretics. I have had a couple of patients from our academic heart failure clinic with EF < 20% successfully lose weight on the 4 beverages without symptoms. - Peter Jones, MD, FACP