Abstract
Universal reduction in sodium intake has long been recommended, largely because of its proven ability to lower blood pressure for some. However, multiple randomized trials have also demonstrated that similar reductions in sodium increase plasma renin activity and aldosterone secretion, insulin resistance, sympathetic nerve activity, serum cholesterol and triglyceride levels. Thus, the health consequences of reducing sodium cannot be predicted by its impact on any single physiologic characteristic but will reflect the net of conflicting effects. Some 23 observational studies (>360,000 subjects and >26,000 end points) linking sodium intake to cardiovascular outcomes have yielded conflicting results. In subjects with average sodium intakes of less than 4.5 grams/day, most have found an inverse association of intake with outcome; in subjects with average intakes greater than 4.5 grams/day, most reported direct associations. Finally, in two, a “J-shaped” relation was detected. In addition, three randomized trials have found that heart failure subjects allocated to 1.8 g of sodium have significantly increased morbidity and mortality compared with those at 2.8 g. At the same time, a randomized study in retired Taiwanese men found that allocation to an average intake of 3.8 g improved survival compared with 5.3 g. Taken together, these data provide strong support for a “J-shaped” relation of sodium to cardiovascular outcomes. Sodium intakes above and below the range of 2.5 to 6.0 grams/day are associated with increased cardiovascular risk. This robust body of evidence does not support universal reduction of sodium intake.
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References
Kempner W. Treatment of hypertensive vascular disease with rice diet. Am J Med. 1948;4(4):545–77.
Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Circulation. 2006;113(10):e409–49.
National Research Council. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate: The National Academies Press; 2005.
Resources USDoAaUSDoHaH: Dietary Guidelines for Americans 2010, 7 edn. Washington, DC: U.S. Government Printing Office; 2010.
Strazzullo P, D'Elia L, Kandala NB, Cappuccio FP. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ. 2009;339:b4567.
Alderman MH. Presidential Address: 21st Scientific Meeting of the International Society of Hypertension: dietary sodium and cardiovascular disease: the 'J'-shaped relation. J Hypertens. 2007;25(5):903–7.
Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens. 2012;25(1):1–15.
Petrie JR, Morris AD, Minamisawa K, Hilditch TE, Elliott HL, Small M, et al. Dietary sodium restriction impairs insulin sensitivity in noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metabol. 1998;83(5):1552–7.
Grassi G, Dell'Oro R, Seravalle G, Foglia G, Trevano FQ, Mancia G. Short- and long-term neuroadrenergic effects of moderate dietary sodium restriction in essential hypertension. Circulation. 2002;106(15):1957–61.
Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease: a meta-analysis of randomized controlled trials (Cochrane review). Am J Hypertens. 2011;24(8):843–53.
Paterna S, Parrinello G, Cannizzaro S, Fasullo S, Torres D, Sarullo FM, et al. Medium term effects of different dosage of diuretic, sodium, and fluid administration on neurohormonal and clinical outcome in patients with recently compensated heart failure. Am J Cardiol. 2009;103(1):93–102.
Paterna S, Fasullo S, Parrinello G, Cannizzaro S, Basile I, Vitrano G, et al. Short-term effects of hypertonic saline solution in acute heart failure and long-term effects of a moderate sodium restriction in patients with compensated heart failure with New York Heart Association class III (Class C) (SMAC-HF Study). Am J Med Sci. 2011;342(1):27–37.
Bernstein AM, Willett WC. Trends in 24-h urinary sodium excretion in the United States, 1957–2003: a systematic review. Am J Clin Nutr. 2010;92(5):1172–80.
Hall JE. The kidney, hypertension, and obesity. Hypertension. 2003;41(3 Pt 2):625–33.
Miller JZ, Daugherty SA, Weinberger MH, Grim CE, Christian JC, Lang CL. Blood pressure response to dietary sodium restriction in normotensive adults. Hypertension. 1983;5(5):790–5.
Alderman MH, Lamport B. Moderate Sodium Restriction - Do the Benefits Justify the Hazards. Am J Hypertens. 1990;3(6):499–504.
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. The Trials of Hypertension Prevention Collaborative Research Group. Archives of internal medicine 1997, 157(6):657–667.
Kagan A, Popper JS, Rhoads GG, Yano K. Dietary and other risk factors for stroke in Hawaiian Japanese men. Stroke; a Journal of Cerebral Circulation. 1985;16(3):390–6.
Hu HH, Sheng WY, Chu FL, Lan CF, Chiang BN. Incidence of stroke in Taiwan. Stroke; a journal of cerebral circulation. 1992;23(9):1237–41.
Alderman MH, Madhavan S, Cohen H, Sealey JE, Laragh JH. Low urinary sodium is associated with greater risk of myocardial infarction among treated hypertensive men. Hypertension. 1995;25(6):1144–52.
Tunstall-Pedoe H, Woodward M, Tavendale R, A'Brook R, McCluskey MK. Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish Heart Health Study: cohort study. BMJ. 1997;315(7110):722–9.
Alderman MH, Cohen H, Madhavan S. Dietary sodium intake and mortality: the National Health and Nutrition Examination Survey (NHANES I). Lancet. 1998;351(9105):781–5.
Ascherio A, Rimm EB, Hernan MA, Giovannucci EL, Kawachi I, Stampfer MJ, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation. 1998;98(12):1198–204.
He J, Ogden LG, Vupputuri S, Bazzano LA, Loria C, Whelton PK. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. JAMA. 1999;282(21):2027–34.
Tuomilehto J, Jousilahti P, Rastenyte D, Moltchanov V, Tanskanen A, Pietinen P, et al. Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study. Lancet. 2001;357(9259):848–51.
He J, Ogden LG, Bazzano LA, Vupputuri S, Loria C, Whelton PK. Dietary sodium intake and incidence of congestive heart failure in overweight US men and women: first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Arch Intern Med. 2002;162(14):1619–24.
Nagata C, Takatsuka N, Shimizu N, Shimizu H. Sodium intake and risk of death from stroke in Japanese men and women. Stroke; a journal of cerebral circulation. 2004;35(7):1543–7.
Cohen HW, Hailpern SM, Fang J, Alderman MH. Sodium intake and mortality in the NHANES II follow-up study. Am J Med. 2006;119(3):275 e277-214.
Geleijnse JM, Witteman JC, Stijnen T, Kloos MW, Hofman A, Grobbee DE. Sodium and potassium intake and risk of cardiovascular events and all-cause mortality: the Rotterdam Study. Eur J Epidemiol. 2007;22(11):763–70.
Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK, 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.
Umesawa M, Iso H, Date C, Yamamoto A, Toyoshima H, Watanabe Y, et al. Relations between dietary sodium and potassium intakes and mortality from cardiovascular disease: the Japan Collaborative Cohort Study for Evaluation of Cancer Risks. Am J Clin Nutr. 2008;88(1):195–202.
Cohen HW, Hailpern SM, Alderman MH. Sodium intake and mortality follow-up in the Third National Health and Nutrition Examination Survey (NHANES III). J Gen Intern Med. 2008;23(9):1297–302.
Larsson SC, Virtanen MJ, Mars M, Mannisto S, Pietinen P, Albanes D, et al. Magnesium, calcium, potassium, and sodium intakes and risk of stroke in male smokers. Arch Intern Med. 2008;168(5):459–65.
Cook NR, Obarzanek E, Cutler JA, Buring JE, Rexrode KM, Kumanyika SK, 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(1):32–40.
Takachi R, Inoue M, Shimazu T, Sasazuki S, Ishihara J, Sawada N, et al. Consumption of sodium and salted foods in relation to cancer and cardiovascular disease: the Japan Public Health Center-based Prospective Study. Am J Clin Nutr. 2010;91(2):456–64.
Ekinci EI, Clarke S, Thomas MC, Moran JL, Cheong K, MacIsaac RJ, et al. Dietary salt intake and mortality in patients with type 2 diabetes. Diabetes Care. 2011;34(3):703–9.
Thomas MC, Moran J, Forsblom C, Harjutsalo V, Thorn L, Ahola A, et al. The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Diabetes Care. 2011;34(4):861–6.
Yang Q, Liu T, Kuklina EV, Flanders WD, Hong Y, Gillespie C, et al. Sodium and potassium intake and mortality among US adults: prospective data from the Third National Health and Nutrition Examination Survey. Arch Intern Med. 2011;171(13):1183–91.
Stolarz-Skrzypek K, Kuznetsova T, Thijs L, Tikhonoff V, Seidlerova J, Richart T, et al. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA. 2011;305(17):1777–85.
O'Donnell MJ, Yusuf S, Mente A, Gao P, Mann JF, Teo K, et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA. 2011;306(20):2229–38.
The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure. Hypertension Prevention Trial Research Group. Archives of internal medicine 1990, 150(1):153–162.
The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels. Results of the Trials of Hypertension Prevention, Phase I. JAMA : the journal of the American Medical Association 1992, 267(9):1213–1220.
Morgan T, Adam W, Gillies A, Wilson M, Morgan G, Carney S. Hypertension treated by salt restriction. Lancet. 1978;1(8058):227–30.
Chang HY, Hu YW, Yue CS, Wen YW, Yeh WT, Hsu LS, et al. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. Am J Clin Nutr. 2006;83(6):1289–96.
Paterna S, Gaspare P, Fasullo S, Sarullo FM, Di Pasquale P. Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? Clin Sci (Lond). 2008;114(3):221–30.
Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010;362(7):590–9.
Appel LJ, Anderson CA. Compelling evidence for public health action to reduce salt intake. N Engl J Med. 2010;362(7):650–2.
National Research Council. Dietary Reference Intakes for Calcium and Vitamin D: The National Academies Press; 2011.
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This article is being published simultaneously in the American Journal of Hypertension.
We wish to thank Christina Re for assistance with the manuscript.
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Alderman, M.H., Cohen, H.W. Dietary Sodium Intake and Cardiovascular Mortality: Controversy Resolved?. Curr Hypertens Rep 14, 193–201 (2012). https://doi.org/10.1007/s11906-012-0275-6
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DOI: https://doi.org/10.1007/s11906-012-0275-6