Skip to main content

Advertisement

SpringerLink
Log in

Salt Restriction in Diabetes

  • Lifestyle Management to Reduce Diabetes/Cardiovascular Risk (E Mayer-Davis and C Shay, Section Editors)
  • Published:
Current Diabetes Reports Aims and scope Submit manuscript

Abstract

There are no long-term interventions examining the effects of salt reduction in people with diabetes, and these are urgently required. Sodium reduction is controversial as it appears that an intake below 2.5 g and above 6 g/day of salt is associated with increased cardiovascular disease risk. However, pre-existing illness leading to a lower salt intake may confound the findings. Only a few studies have prospectively collected data on the sodium intake and excretion of people with diabetes and examined hard end points. In addition, future studies need to collect more data on food intake as well as coexistent illnesses to address potential confounding. The World Health Organization recommends a reduction to less than 5 g/day salt in adults. Given that the available evidence suggests that the salt intake of people with type 2 diabetes is generally well above 6 g/day it seems reasonable to ensure individuals with diabetes have an intake below 6 g/day. However, such recommendations need to be individualized.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

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

  1. http://www.who.int/nutrition/publications/guidelines/sodium_intake/en/ accessed April 2015

  2. American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015;38 Suppl 1:S1–94.

    Google Scholar 

  3. European heart journal 2013 doi:10.1093/eurheartj/eht108

  4. Whelton PK, Appel LJ, Sacco RL, Anderson CA, Antman EM, Campbell N, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2010;126(24):2880–9. doi:10.1161/CIR.0b013e318279acbf.

    Article  Google Scholar 

  5. Graudal N, Jürgens G, Baslund B, et al. Compared with usual sodium intake, low- and excessive-sodium diets are associated with increased mortality: a meta-analysis. Am J Hypertens. 2014;27(9):1129–37. doi:10.1093/ajh/hpu028. This meta-analysis of cohort studies demonstrated a U shaped relationship between salt intake and mortality.

    Article  PubMed  Google Scholar 

  6. O’Donnell MJ, Yusuf S, Mente A, et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA. 2011;306(20):2229–38. doi:10.1001/jama.2011.1729.

    PubMed  Google Scholar 

  7. O’Donnell M, Mente A, Rangarajan S, et al. PURE investigators. Urinary sodium and potassium excretion, mortality, and cardiovascular events. N Engl J Med. 2014;371(7):612–23. doi:10.1056/NEJMoa1311889.

    Article  PubMed  Google Scholar 

  8. Elliott P, Dyer A, Stamler R. The INTERSALT study: results for 24 hour sodium and potassium, by age and sex. INTERSALT Co-operative Research Group. J Hum Hypertens. 1989;3(5):323–30.

    CAS  PubMed  Google Scholar 

  9. Blood Pressure Lowering Treatment Trialists’ Collaboration, Sundström J, Arima H, Woodward M, Jackson R, Karmali K, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384(9943):591–8. doi:10.1016/S0140-6736(14)61212-5.

    Article  Google Scholar 

  10. He FJ, Li J, Macgregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev. 2013;4, CD004937. doi:10.1002/14651858.CD004937.pub2.

    PubMed  Google Scholar 

  11. Gilleran G, O’Leary M, Bartlett WA, et al. Effects of dietary sodium substitution with potassium and magnesium in hypertensive type II diabetics: a randomised blind controlled parallel study. J Hum Hypertens. 1996;10(8):517–21.

    CAS  PubMed  Google Scholar 

  12. Suckling RJ, He FJ, Macgregor GA. Altered dietary salt intake for preventing and treating diabetic kidney disease. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD006763. doi: 10.1002/14651858.CD006763.pub2DiabetesCare. 2009 32(8):1398–403. doi: 10.2337/dc08-2297.

  13. Underwood PC, Chamarthi B, Williams JS, et al. Nonmodulation as the mechanism for salt sensitivity of blood pressure in individuals with hypertension and type 2 diabetes mellitus. J Clin Endocrinol Metab. 2012;97(10):3775–82. doi:10.1210/jc.2012-2127.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  14. Yoshioka K, Imanishi M, Konishi Y, et al. Glomerular charge and size selectivity assessed by changes in salt intake in type 2 diabetic patients. Diabetes Care. 1998;21(4):482–6.

    Article  CAS  PubMed  Google Scholar 

  15. Vedovato M, Lepore G, Coracina A, et al. Effect of sodium intake on blood pressure and albuminuria in type 2 diabetic patients: the role of insulin resistance. Diabetologia. 2004;47(2):300–3.

    Article  CAS  PubMed  Google Scholar 

  16. Ekinci EI, Thomas G, Thomas D, et al. Effects of salt supplementation on the albuminuric response to telmisartan with or without hydrochlorothiazide therapy in hypertensive patients with type 2 diabetes are modulated by habitual dietary salt intake. Diabetes Care. 2009;32(8):1398–403. doi:10.2337/dc08-2297.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  17. Ekinci EI, Thomas G, MacIsaac RJ, et al. Salt supplementation blunts the blood pressure response to telmisartan with or without hydrochlorothiazide in hypertensive patients with type 2 diabetes. Diabetologia. 2010;53(7):1295–303. doi:10.1007/s00125-010-1711-2.

    Article  CAS  PubMed  Google Scholar 

  18. McMahon EJ, Bauer JD, Hawley CM, et al. A randomized trial of dietary sodium restriction in CKD. J Am Soc Nephrol. 2013;24(12):2096–103. doi:10.1681/ASN.2013030285. This small study which included some people with type 2 diabetes demonstrated that a change in dietary sodium of 120 mmol/day led to a change in systolic blood pressure of 10 mm Hg showing that in this group salt restriction would be valuable for blood pressure reduction.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. He FJ, MacGregor GA. Salt intake and mortality. Am J Hypertens. 2014;27(11):1424. doi:10.1093/ajh/hpu095.

    Article  PubMed  Google Scholar 

  20. 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(4):394–402. This paper showed that the association between low sodium excretion and heart failure was likely due to confounding.

    Article  CAS  PubMed  Google Scholar 

  21. Tikellis C, Pickering RJ, Tsorotes D, et al. Activation of the renin-angiotensin system mediates the effects of dietary salt intake on atherogenesis in the apolipoprotein E knockout mouse. Hypertension. 2012;60(1):98–105. doi:10.1161/HYPERTENSIONAHA.112.191767.

    Article  CAS  PubMed  Google Scholar 

  22. Tikellis C, Pickering RJ, Tsorotes D, et al. Association of dietary sodium intake with atherogenesis in experimental diabetes and with cardiovascular disease in patients with type 1 diabetes. Clin Sci (Lond). 2013;124(10):617–26. doi:10.1042/CS20120352. Low sodium diets aggravate and high sodium diets protect against atherosclerosis in this animal model via the renin angiotensin system.

    Article  CAS  Google Scholar 

  23. 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). JAMA Intern Med. 2015. doi:10.1001/jamainternmed.2014.6278. Published online January 19.

    PubMed  Google Scholar 

  24. Ekinci EI, Clarke S, Thomas MC, et al. Dietary salt intake and mortality in patients with type 2 diabetes. Diabetes Care. 2011;34(3):703–9. doi:10.2337/dc10-1723.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Ekinci EI, Moran JL, Thomas MC, et al. Relationship between urinary sodium excretion over time and mortality in type 2 diabetes. Diabetes Care. 2014;37(4):e62–3. doi:10.2337/dc13-1947. High sodium excretion was protective in this well studied group of people with type 2 diabetes. No reason was obvious but blood pressure control was not an advantage either so the group was somewhat unusual.

    Article  CAS  PubMed  Google Scholar 

  26. 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.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  27. Meland E, Aase Aamland A. Salt restriction among hypertensive patients: modest blood pressure effect and no adverse effects. Scand J Prim Health Care. 2009;27(2):97–103.

    Article  PubMed Central  PubMed  Google Scholar 

  28. 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;11, CD004022. doi:10.1002/14651858.CD004022.pub3.

    PubMed  Google Scholar 

  29. Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONECollaborative Research Group. JAMA. 1998;279(11):839–46.

    Article  CAS  PubMed  Google Scholar 

  30. Espeland MA, Whelton PK, Kostis JB, et al. Predictors and mediators of successful long-term withdrawal from antihypertensive medications. TONE Cooperative Research Group. Trial of Nonpharmacologic Interventions in the Elderly. Arch Fam Med. 1999;8(3):228–36.

    Article  CAS  PubMed  Google Scholar 

  31. 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(7599):885–8.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Adler AJ, Taylor F, Martin N, et al. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev. 2014;12, CD009217. doi:10.1002/14651858.CD009217.pub3.

    PubMed  Google Scholar 

  33. Chang HY, Hu YW, Yue CS, 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 

  34. Keogh JB, Cleanthous X, Wycherley TP, et al. Increased thiamine intake may be required to maintain thiamine status during weight loss in patients with type 2 diabetes. Diabetes Res Clin Pract. 2012;98(3):e40–2. doi:10.1016/j.diabres.2012.09.032.

    Article  CAS  PubMed  Google Scholar 

  35. Villani AM, Clifton PM, Keogh JB. Sodium intake and excretion in individuals with type 2 diabetes mellitus: a cross-sectional analysis of overweight and obese males and females in Australia. J Hum Nutr Diet. 2012;25(2):129–39. doi:10.1111/j.1365-277X.2011.01223.x.

    Article  CAS  PubMed  Google Scholar 

  36. Petersen KS, Blanch N, Wepener RH, et al. Dietary quality in people with type 1 and type 2 diabetes compared to age, sex and BMI matched controls. Diabetes Res Clin Pract. 2015;107(2):e7–10. doi:10.1016/j.diabres.2014.12.001.

    Article  PubMed  Google Scholar 

  37. Murray AE, McMorrow AM, O’Connor E, et al. Dietary quality in a sample of adults with type 2 diabetes mellitus in Ireland; a cross-sectional case control study. Nutr J. 2013;12:110. doi:10.1186/1475-2891-12-110.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  38. Iqbal R, Anand S, Ounpuu S, et al. INTERHEART study investigators. Dietary patterns and the risk of acute myocardial infarction in 52 countries: results of the INTERHEART study. Circulation. 2008;118(19):1929–37. doi:10.1161/CIRCULATIONAHA.107.738716.

    Article  CAS  PubMed  Google Scholar 

  39. Petersen KS, Torpy DJ, Chapman IM, et al. Food label education does not reduce sodium intake in people with type 2 diabetes mellitus. A randomised controlled trial. Appetite. 2013;68:147–51. doi:10.1016/j.appet.2013.04.028.

    Article  PubMed  Google Scholar 

  40. Gray KL, Petersen KS, Clifton PM, et al. Attitudes and beliefs of health risks associated with sodium intake in diabetes. Appetite. 2014;83:97–103. doi:10.1016/j.appet.2014.08.004.

    Article  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Peter Clifton and Jennifer Keogh declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

The article contains reference of the previous studies with human subjects performed by the authors. Procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Author information

Authors and Affiliations

  1. School of Pharmacy and Medical Sciences, University of South Australia, P5-16 Playford Building, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia

    Peter M. Clifton

  2. School of Pharmacy and Medical Sciences, University of South Australia, P1-23 Playford Building City East Campus, IPC CEA 19, GPO Box 2471, Adelaide, SA, 5000, Australia

    Jennifer B. Keogh

Authors
  1. Peter M. Clifton
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jennifer B. Keogh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter M. Clifton.

Additional information

This article is part of the Topical Collection on Lifestyle Management to Reduce Diabetes/Cardiovascular Risk

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Clifton, P.M., Keogh, J.B. Salt Restriction in Diabetes. Curr Diab Rep 15, 58 (2015). https://doi.org/10.1007/s11892-015-0629-y

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11892-015-0629-y

Keywords

Search

Navigation