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Dietary Sodium and Cardiovascular Disease

  • Prevention of Hypertension: Public Health Challenges (P Muntner, Section Editor)
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Abstract

Although an essential nutrient, higher sodium intake is associated with increasing blood pressure (BP), forming the basis for current population-wide sodium restriction guidelines. While short-term clinical trials have achieved low intake (<2.0 g/day), this has not been reproduced in long-term trials (>6 months). Guidelines assume that low sodium intake will reduce BP and reduce cardiovascular disease (CVD), compared to moderate intake. However, current observational evidence suggests a J-shaped association between sodium intake and CVD; the lowest risks observed with 3–5 g/day but higher risk with <3 g/day. Importantly, these observational data also confirm the association between higher intake (>5 g/day) and increased risk of CVD. Although lower intake may reduce BP, this may be offset by marked increases in neurohormones and other adverse effects which may paradoxically be adverse. Large randomised clinical trials with sufficient follow-up are required to provide robust data on the long-term effects of sodium reduction on CVD incidence. Until such trials are completed, current evidence suggests that moderate sodium intake for the general population (3–5 g/day) is likely the optimum range for CVD prevention.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Kotchen TA, Cowley Jr AW, Frohlich ED. Salt in health and disease—a delicate balance. N Engl J Med. 2013;368:1229–37.

    Article  CAS  PubMed  Google Scholar 

  2. Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open. 2013;3:e003733.

  3. Mente A, O’Donnell MJ, Rangarajan S, et al. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med. 2014;371:601–11. This prospective cohort study (n = 102,216 from 18 countries), primarily of people without established cardiovascular disease, showed a nonlinear association between sodium intake (measured using fasting morning urine samples) and blood pressure, with stronger relationships seen in older persons, those consuming high-sodium diets and those with hypertension.

    Article  PubMed  Google Scholar 

  4. Frost CD, Law MR, Wald NJ. By how much does dietary salt reduction lower blood pressure? II—analysis of observational data within populations. BMJ. 1991;302:815–8.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Alderman MH. Sodium and cardiovascular disease. N Engl J Med. 2014;371:2137.

    PubMed  Google Scholar 

  6. Graudal N, Hubeck-Graudal T, Jurgens G, McCarron DA. The significance of duration and amount of sodium reduction intervention in normotensive and hypertensive individuals: a meta-analysis. Adv Nutr. 2015;6:169–77.

    Article  CAS  PubMed  Google Scholar 

  7. Aburto NJ, Hanson S, Gutierrez H, et al. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. BMJ. 2013;346:f1378.

    Article  PubMed  Google Scholar 

  8. 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.

    Article  Google Scholar 

  9. Stamler J, Dolecek TA. Relation of food and nutrient intakes to body mass in the special intervention and usual care groups in the multiple risk factor intervention trial. Am J Clin Nutr. 1997;65:366S–73.

    CAS  PubMed  Google Scholar 

  10. Stamler J, Elliott P, Dennis B, et al. INTERMAP: background, aims, design, methods, and descriptive statistics (nondietary). J Hum Hypertens. 2003;17:591–608.

    Article  CAS  PubMed  Google Scholar 

  11. Zhou BF, Stamler J, Dennis B, et al. Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study. J Hum Hypertens. 2003;17:623–30.

    Article  CAS  PubMed  Google Scholar 

  12. Dennis B, Stamler J, Buzzard M, et al. INTERMAP: the dietary data–process and quality control. J Hum Hypertens. 2003;17:609–22.

    Article  CAS  PubMed  Google Scholar 

  13. Shimazu T, Kuriyama S, Hozawa A, et al. Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study. Int J Epidemiol. 2007;36:600–9.

    Article  PubMed  Google Scholar 

  14. Anderson CA, Appel LJ, Okuda N, et al. Dietary sources of sodium in China, Japan, the United Kingdom, and the United States, women and men aged 40 to 59 years: the INTERMAP study. J Am Diet Assoc. 2010;110:736–45.

  15. Titze J. Sodium balance is not just a renal affair. Curr Opin Nephrol Hypertens. 2014;23:101–5.

    Article  CAS  PubMed  Google Scholar 

  16. Rakova N, Juttner K, Dahlmann A, et al. Long-term space flight simulation reveals infradian rhythmicity in human Na(+) balance. Cell Metab. 2013;17:125–31. This study of men completing space flight simulations that consumed fixed salt intake showed rhythmic sodium excretion and retention patterns occur independent of blood pressure, body water and salt intake.

    Article  CAS  PubMed  Google Scholar 

  17. Kawasaki T, Itoh K, Uezono K, Sasaki H. A simple method for estimating 24 h urinary sodium and potassium excretion from second morning voiding urine specimen in adults. Clin Exp Pharmacol Physiol. 1993;20:7–14.

  18. Tanaka T, Okamura T, Miura K, et al. A simple method to estimate populational 24-h urinary sodium and potassium excretion using a casual urine specimen. J Hum Hypertens. 2002;16:97–103.

    Article  CAS  PubMed  Google Scholar 

  19. Brown IJ, Dyer AR, Chan Q, et al. Estimating 24-hour urinary sodium excretion from casual urinary sodium concentrations in Western populations: the INTERSALT study. Am J Epidemiol. 2013;177:1180–92.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Cogswell ME, Wang CY, Chen TC, et al. Validity of predictive equations for 24-h urinary sodium excretion in adults aged 18–39 years. Am J Clin Nutr. 2013;98:1502–13.

  21. Mente A, O’Donnell MJ, Dagenais G, et al. Validation and comparison of three formulae to estimate sodium and potassium excretion from a single morning fasting urine compared to 24-h measures in 11 countries. J Hypertens. 2014;32:1005–14. Discussion 1015.

    Article  CAS  PubMed  Google Scholar 

  22. Espeland MA, Kumanyika S, Wilson AC, et al. Statistical issues in analyzing 24-hour dietary recall and 24-hour urine collection data for sodium and potassium intakes. Am J Epidemiol. 2001;153:996–1006.

    Article  CAS  PubMed  Google Scholar 

  23. Coffman TM. The inextricable role of the kidney in hypertension. J Clin Invest. 2014;124:2341–7.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride. Cochrane Database Syst Rev 2011:CD004022.

  25. Oudot C, Lajoix AD, Jover B, Rugale C. Dietary sodium restriction prevents kidney damage in high fructose-fed rats. Kidney Int. 2013;83:674–83.

    Article  CAS  PubMed  Google Scholar 

  26. Trudu M, Janas S, Lanzani C, et al. Common noncoding UMOD gene variants induce salt-sensitive hypertension and kidney damage by increasing uromodulin expression. Nat Med. 2013;19:1655–60.

    Article  CAS  PubMed  Google Scholar 

  27. Damgaard M, Goetze JP, Norsk P, Gadsboll N. Altered sodium intake affects plasma concentrations of BNP but not proBNP in healthy individuals and patients with compensated heart failure. Eur Heart J. 2007;28:2726–31.

    Article  CAS  PubMed  Google Scholar 

  28. Yilmaz R, Akoglu H, Altun B, et al. Dietary salt intake is related to inflammation and albuminuria in primary hypertensive patients. Eur J Clin Nutr. 2012;66:1214–8.

    Article  CAS  PubMed  Google Scholar 

  29. Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012;126:2880–9. This review article is a key paper as it represents the opinion of the American Heart Association and includes their justification for the AHA guideline recommendations to reduce dietary sodium intake to <1500 mg/day.

  30. Aburto NJ, Ziolkovska A, Hooper L, et al. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ. 2013;346:f1326.

    Article  PubMed  Google Scholar 

  31. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344:3–10.

    Article  CAS  PubMed  Google Scholar 

  32. The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The trials of hypertension prevention, phase II. Arch Intern Med. 1997;157:657–67.

    Article  Google Scholar 

  33. Cook NR, Appel LJ, Whelton PK. Lower levels of sodium intake and reduced cardiovascular risk. Circulation. 2014;129:981–9.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  34. Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ. 2007;334:885–8.

    Article  PubMed Central  PubMed  Google Scholar 

  35. O’Donnell MJ, Yusuf S, Mente A, et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA. 2011;306:2229–38. This prospective cohort study (a post-hoc analysis of the ONTARGET and TRANSCEND trials, n = 28,880) showed a nonlinear relationship between estimated sodium intake and cardiovascular events, with the lowest risk observed with intake of 4–5.99 g/day.

  36. O’Donnell M, Mente A, Rangarajan S, et al. Urinary sodium and potassium excretion, mortality, and cardiovascular events. N Engl J Med. 2014;371:612–23. This prospective cohort study (n = 101,945 from 17 countries), primarily of people without established cardiovascular disease, showed a nonlinear relationship between estimated sodium intake (measured using fasting morning urine samples) and death and cardiovascular disease, with the lowest risk observed with intake of 3–6 g/day.

  37. Joosten MM, Gansevoort RT, Mukamal KJ, et al. Sodium excretion and risk of developing coronary heart disease. Circulation. 2014;129:1121–8. This prospective cohort study (n = 7,543) of people without cardiovascular or kidney disease showed no overall association between sodium intake (measured using two 24-h urine collections) and risk of coronary heart disease, although higher intake was associated with an increased risk of coronary heart disease in those with hypertension or those with increased plasma N-terminal pro-B-type natriuretic peptide.

    Article  CAS  PubMed  Google Scholar 

  38. Thomas MC, Moran J, Forsblom C, et al. The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Diabetes Care. 2011;34:861–6. This prospective cohort study (n = 2,807) of people with type 1 diabetes mellitus but without end-stage renal disease showed that sodium intake (measured using 24-h urine collection) was nonlinearly associated with all-cause mortality, as those with the highest and lowest sodium intakes were associated with reduced survival.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  39. Ekinci EI, Clarke S, Thomas MC, et al. Dietary salt intake and mortality in patients with type 2 diabetes. Diabetes Care. 2011;34:703–9.

    Article  PubMed Central  PubMed  Google Scholar 

  40. Saulnier PJ, Gand E, Hadjadj S, Group SS. Sodium and cardiovascular disease. N Engl J Med. 2014;371:2135–6. This prospective cohort study (n = 1,439, France) of patients with type 2 diabetes showed a nonlinear relationship between sodium excretion and cardiovascular mortality, with the lowest risk observed with intake 5–6 g/day.

  41. Pfister R, Michels G, Sharp SJ, et al. Estimated urinary sodium excretion and risk of heart failure in men and women in the EPIC-Norfolk study. Eur J Heart Fail. 2014;16:394–402. This prospective cohort study (n = 19,857, UK) of patients aged 40–79 attending general practices showed a U-shaped association between 24-h urinary sodium excretion and heart failure, with the lowest risk observed with intake of 3.5 g/day (150 mmol/day).

  42. Kalogeropoulos AP, Georgiopoulou VV, Murphy RA, et al. Dietary sodium content, mortality, and risk for cardiovascular events in older adults: the health, aging, and body composition (health ABC) study. JAMA Intern Med. 2015;175:410–9. This prospective cohort study (n = 2,642, USA) of adults aged 71–80 years showed that sodium intake was not associated with mortality, incident cardiovascular disease or heart failure and a nonsignificant tendency towards a J-shaped association.

  43. Alderman MH, Cohen HW. Dietary sodium intake and cardiovascular mortality: controversy resolved? Curr Hypertens Rep. 2012;14:193–201.

    Article  CAS  PubMed  Google Scholar 

  44. Graudal N, Jurgens G, Baslund B, Alderman MH. Compared with usual sodium intake, low- and excessive-sodium diets are associated with increased mortality: a meta-analysis. Am J Hypertens. 2014;27:1129–37.

    Article  PubMed  Google Scholar 

  45. Iqbal R, Anand S, Ounpuu S, et al. Dietary patterns and the risk of acute myocardial infarction in 52 countries: results of the INTERHEART study. Circulation. 2008;118:1929–37.

    Article  CAS  PubMed  Google Scholar 

  46. Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med. 2009;169:659–69.

    Article  CAS  PubMed  Google Scholar 

  47. Morris Jr RC, Schmidlin O, Frassetto LA, Sebastian A. Relationship and interaction between sodium and potassium. J Am Coll Nutr. 2006;25:262S–70.

    Article  CAS  PubMed  Google Scholar 

  48. Cook NR, Obarzanek E, Cutler JA, et al. Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the trials of hypertension prevention follow-up study. Arch Intern Med. 2009;169:32–40.

    Article  PubMed Central  PubMed  Google Scholar 

  49. Chang H-Y, Hu Y-W, Yue C-SJ, et al. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. Am J Clin Nutr. 2006;83:1289–96.

    CAS  PubMed  Google Scholar 

  50. Felder RA, White MJ, Williams SM, Jose PA. Diagnostic tools for hypertension and salt sensitivity testing. Curr Opin Nephrol Hypertens. 2013;22:65–76.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  51. Heaney RP. Sodium: how and how not to set a nutrient intake recommendation. Am J Hypertens. 2013;26:1194–7.

    Article  PubMed  Google Scholar 

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Acknowledgments

No funding was received for the current article. Authors received funding from the Heart and Stroke Foundation of Ontario for PURE Salt Study of association of sodium intake and cardiovascular events and mortality.

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Conflict of Interest

Andrew Smyth, Martin O’Donnell, Andrew Mente and Salim Yusuf declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada

    Andrew Smyth, Martin O’Donnell, Andrew Mente & Salim Yusuf

  2. HRB Clinical Research Facility Galway, NUI, Galway, Ireland

    Andrew Smyth & Martin O’Donnell

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  1. Andrew Smyth
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  2. Martin O’Donnell
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Correspondence to Andrew Smyth.

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This article is part of the Topical Collection on Prevention of Hypertension: Public Health Challenges

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Smyth, A., O’Donnell, M., Mente, A. et al. Dietary Sodium and Cardiovascular Disease. Curr Hypertens Rep 17, 47 (2015). https://doi.org/10.1007/s11906-015-0559-8

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