Korean Circ J.  2020 Jul;50(7):555-571. 10.4070/kcj.2020.0042.

Sodium Intake, Blood Pressure and Cardiovascular Disease

Affiliations
  • 1Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, Korea
  • 2Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea

Abstract

Sodium intake reduction has been emphasized because sodium adversely impacts health, especially blood pressure (BP), and the cardiovascular (CV) disease risk. However, data obtained from several cohort studies have raised questions regarding the effects of high sodium intake on BP and the CV disease risk. In the present study, we systematically reviewed the literature to evaluate these associations. Studies showing negative associations between urine sodium and BP and CV outcomes relied on estimated 24-hour urine sodium from spot urine that is inappropriate for determining sodium intake at an individual level. Furthermore, controversy about the association between 24-hour urine sodium and BP may have been caused by different characteristics of study populations, such as age distribution, ethnicity, potassium intake and the inclusion of patients with hypertension, the different statistical methods and BP measurement methods. Regarding the association between sodium intake and the CV disease risk, studies showing negative or J- or U-shaped associations used a single baseline measurement of 24-hour urine sodium in their analyses. However, recent studies that employed average of subsequently measured 24-hour urine sodium showed positive, linear associations between sodium intake and CV outcomes, indicating that controversies are caused by the different sodium intake measurement methods and analytic designs. In conclusion, the study shows that positive associations exist between sodium intake and BP, CV outcomes, and mortality, and that the argument that reducing sodium intake is dangerous is invalid. Sodium intake reduction should be recommended to all, and not limited to patients with hypertension or CV disease.

Keyword

Sodium intake; Urine; Blood pressure; Cardiovascular

Figure

  • Figure 1 Comparison between measured and estimated 24HUNa in septile groups divided according to measured 24HUNa. Estimated 24-hour urine sodium was calculated by using previously suggested equations. (A) Kawasaki, and (B) Danish equation. When the 24HUNa is calculated by applying the formulas to groups with smaller 24HUNa than that of formula development population, there is a tendency of overestimation of population mean 24-hour urine sodium. On the other hands, in groups with greater 24-hour urine sodium than that of the formula development population, there is a tendency of underestimation of 24-hour urine sodium.24HUNa = 24-hour urine sodium excretion.


Cited by  2 articles

Ultra-Processed Foods as a Less-Known Risk Factor in Cardiovascular Diseases
Hae-Young Lee
Korean Circ J. 2021;52(1):71-73.    doi: 10.4070/kcj.2021.0362.

Ultra-Processed Foods as a Less-Known Risk Factor in Cardiovascular Diseases
Hae-Young Lee
Korean Circ J. 2021;52(1):71-73.    doi: 10.4070/kcj.2021.0362.


Reference

1. He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens. 2009; 23:363–384. PMID: 19110538.
Article
2. Adrogué HJ, Madias NE. Sodium and potassium in the pathogenesis of hypertension. N Engl J Med. 2007; 356:1966–1978. PMID: 17494929.
Article
3. Nagata C, Takatsuka N, Shimizu N, Shimizu H. Sodium intake and risk of death from stroke in Japanese men and women. Stroke. 2004; 35:1543–1547. PMID: 15143292.
Article
4. Kupari M, Koskinen P, Virolainen J. Correlates of left ventricular mass in a population sample aged 36 to 37 years. Focus on lifestyle and salt intake. Circulation. 1994; 89:1041–1050. PMID: 8124789.
Article
5. Cianciaruso B, Bellizzi V, Minutolo R, et al. Salt intake and renal outcome in patients with progressive renal disease. Miner Electrolyte Metab. 1998; 24:296–301. PMID: 9554571.
Article
6. Cappuccio FP, Kalaitzidis R, Duneclift S, Eastwood JB. Unravelling the links between calcium excretion, salt intake, hypertension, kidney stones and bone metabolism. J Nephrol. 2000; 13:169–177. PMID: 10928292.
7. Tsugane S, Sasazuki S, Kobayashi M, Sasaki S. Salt and salted food intake and subsequent risk of gastric cancer among middle-aged Japanese men and women. Br J Cancer. 2004; 90:128–134. PMID: 14710219.
Article
8. Mente A, O'Donnell M, Rangarajan S, et al. Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. Lancet. 2018; 392:496–506. PMID: 30129465.
Article
9. O'Donnell M, Mente A, Rangarajan S, et al. Urinary sodium and potassium excretion, mortality, and cardiovascular events. N Engl J Med. 2014; 371:612–623. PMID: 25119607.
10. Adler AJ, Taylor F, Martin N, Gottlieb S, Taylor RS, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev. 2014; CD009217. PMID: 25519688.
Article
11. Rhee MY. High sodium intake: review of recent issues on its association with cardiovascular events and measurement methods. Korean Circ J. 2015; 45:175–183. PMID: 26023304.
Article
12. 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. PMID: 11384956.
Article
13. Brown IJ, Tzoulaki I, Candeias V, Elliott P. Salt intakes around the world: implications for public health. Int J Epidemiol. 2009; 38:791–813. PMID: 19351697.
Article
14. Luft FC, Fineberg NS, Sloan RS. Estimating dietary sodium intake in individuals receiving a randomly fluctuating intake. Hypertension. 1982; 4:805–808. PMID: 7141607.
Article
15. He FJ, Campbell NR, Ma Y, MacGregor GA, Cogswell ME, Cook NR. Errors in estimating usual sodium intake by the Kawasaki formula alter its relationship with mortality: implications for public health. Int J Epidemiol. 2018; 47:1784–1795. PMID: 30517688.
Article
16. The WHO STEPwise approach to noncommunicable disease risk factor surveillance [Internet]. Geneva: World Health Organization;2017. cited 2019 October 10. Available from: http://www.who.int/chp/steps/en/.
17. Ji C, Miller MA, Venezia A, Strazzullo P, Cappuccio FP. Comparisons of spot vs 24-h urine samples for estimating population salt intake: validation study in two independent samples of adults in Britain and Italy. Nutr Metab Cardiovasc Dis. 2014; 24:140–147. PMID: 24119990.
Article
18. 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; 32:1005–1014. PMID: 24569420.
19. Toft U, Cerqueira C, Andreasen AH, et al. Estimating salt intake in a Caucasian population: can spot urine substitute 24-hour urine samples? Eur J Prev Cardiol. 2014; 21:1300–1307. PMID: 23559538.
Article
20. Rhee MY, Kim JH, Shin SJ, et al. Estimation of 24-hour urinary sodium excretion using spot urine samples. Nutrients. 2014; 6:2360–2375. PMID: 24955740.
Article
21. McLean R, Williams S, Mann J. Monitoring population sodium intake using spot urine samples: validation in a New Zealand population. J Hum Hypertens. 2014; 28:657–662. PMID: 24573130.
Article
22. Kelly C, Geaney F, Fitzgerald AP, Browne GM, Perry IJ. Validation of diet and urinary excretion derived estimates of sodium excretion against 24-h urine excretion in a worksite sample. Nutr Metab Cardiovasc Dis. 2015; 25:771–779. PMID: 26044517.
23. Han W, Sun N, Chen Y, Wang H, Xi Y, Ma Z. Validation of the spot urine in evaluating 24-hour sodium excretion in Chinese hypertension patients. Am J Hypertens. 2015; 28:1368–1375. PMID: 26009166.
Article
24. Peng Y, Li W, Wang Y, et al. Validation and assessment of three methods to estimate 24-h urinary sodium excretion from spot urine samples in Chinese adults. PLoS One. 2016; 11:e0149655. PMID: 26895296.
Article
25. Whitton C, Gay GM, Lim RB, Tan LW, Lim WY, van Dam RM. Evaluation of equations for predicting 24-hour urinary sodium excretion from casual urine samples in Asian adults. J Nutr. 2016; 146:1609–1615. PMID: 27358415.
Article
26. Polonia J, Lobo MF, Martins L, Pinto F, Nazare J. Estimation of populational 24-h urinary sodium and potassium excretion from spot urine samples: evaluation of four formulas in a large national representative population. J Hypertens. 2017; 35:477–486. PMID: 27898506.
27. Ma W, Yin X, Zhang R, et al. Validation and assessment of three methods to estimate 24-h urinary sodium excretion from spot urine samples in high-risk elder patients of stroke from the rural areas of Shaanxi province. Int J Environ Res Public Health. 2017; 14:1211.
Article
28. Vidal-Petiot E, Joseph A, Resche-Rigon M, et al. External validation and comparison of formulae estimating 24-h sodium intake from a fasting morning urine sample. J Hypertens. 2018; 36:785–792. PMID: 29120960.
Article
29. Allen NB, Zhao L, Loria CM, et al. The validity of predictive equations to Estimate 24-hour sodium excretion: the MESA and CARDIA urinary sodium study. Am J Epidemiol. 2017; 186:149–159. PMID: 28838062.
30. Rhee MY, Kim JH, Shin SJ, et al. Estimating 24-hour urine sodium from multiple spot urine samples. J Clin Hypertens (Greenwich). 2017; 19:431–438. PMID: 27735123.
Article
31. Zhou L, Tian Y, Fu JJ, et al. Validation of spot urine in predicting 24-h sodium excretion at the individual level. Am J Clin Nutr. 2017; 105:1291–1296. PMID: 28356277.
Article
32. J'drusik P, Symonides B, Gaciong Z. Comparison of three formulas to estimate 24-hour urinary sodium and potassium excretion in patients hospitalized in a hypertension unit. J Am Soc Hypertens. 2018; 12:457–469. PMID: 29678424.
33. Zhang Y, Peng Y, Li K, Peng X. Assessing whether a spot urine specimen can predict 24-h urinary sodium excretion accurately: a validation study. J Hypertens. 2019; 37:99–108. PMID: 30063643.
34. Emeville E, Lassale C, Castetbon K, et al. Estimating sodium intake from spot urine samples at population level: a validation and application study in French adults. Br J Nutr. 2019; 122:186–194. PMID: 31006386.
Article
35. Rhee MY, Lee SY, Oh SW, et al. Study for the Effect of Natrium Intake on the Prevalence of Cardiovascular Disease. Cheongju: Ministry of Food and Drug Safety;2014.
36. 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. 2017; CD004022. PMID: 28391629.
Article
37. He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013; 346:f1325. PMID: 23558162.
Article
38. Rhee OJ, Rhee MY, Oh SW, et al. Effect of sodium intake on renin level: Analysis of general population and meta-analysis of randomized controlled trials. Int J Cardiol. 2016; 215:120–126. PMID: 27111173.
Article
39. Whelton PK, Appel L, Charleston J, et al. The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels. Results of the Trials of Hypertension Prevention, Phase I. JAMA. 1992; 267:1213–1220. PMID: 1586398.
40. Jula AM, Karanko HM. Effects on left ventricular hypertrophy of long-term nonpharmacological treatment with sodium restriction in mild-to-moderate essential hypertension. Circulation. 1994; 89:1023–1031. PMID: 8124787.
Article
41. 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; 157:657–667. PMID: 9080920.
42. Takahashi Y, Sasaki S, Okubo S, Hayashi M, Tsugane S. Blood pressure change in a free-living population-based dietary modification study in Japan. J Hypertens. 2006; 24:451–458. PMID: 16467647.
Article
43. van Buul BJ, Steegers EA, van der Maten GD, et al. Dietary sodium restriction does not prevent gestational hypertension: a Dutch two-center randomized trial. Hypertens Pregnancy. 1997; 16:335–346.
Article
44. 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; 297:319–328. PMID: 3416162.
45. Angell SY, Yi S, Eisenhower D, et al. Sodium intake in a cross-sectional, representative sample of New York city adults. Am J Public Health. 2014; 104:2409–2416. PMID: 24432875.
Article
46. Xu J, Wang M, Chen Y, et al. Estimation of salt intake by 24-hour urinary sodium excretion: a cross-sectional study in Yantai, China. BMC Public Health. 2014; 14:136. PMID: 24507470.
Article
47. Rodrigues SL, Souza Júnior PR, Pimentel EB, et al. Relationship between salt consumption measured by 24-h urine collection and blood pressure in the adult population of Vitória (Brazil). Braz J Med Biol Res. 2015; 48:728–735. PMID: 26132095.
Article
48. Ndanuko RN, Tapsell LC, Charlton KE, Neale EP, O'Donnell KM, Batterham MJ. Relationship between sodium and potassium intake and blood pressure in a sample of overweight adults. Nutrition. 2017; 33:285–290. PMID: 27712964.
Article
49. Xu J, Chen X, Ge Z, et al. Associations of usual 24-hour sodium and potassium intakes with blood pressure and risk of hypertension among adults in China's Shandong and Jiangsu provinces. Kidney Blood Press Res. 2017; 42:188–200. PMID: 28494444.
Article
50. Glatz N, Chappuis A, Conen D, et al. Associations of sodium, potassium and protein intake with blood pressure and hypertension in Switzerland. Swiss Med Wkly. 2017; 147:w14411. PMID: 28322418.
Article
51. Jackson SL, Cogswell ME, Zhao L, et al. Association between urinary sodium and potassium excretion and blood pressure among adults in the United States: National Health and Nutrition Examination Survey, 2014. Circulation. 2018; 137:237–246. PMID: 29021321.
52. Maseko M, Mashao M, Bawa-Allah A, Phukubje E, Mlambo B, Nyundu T. Obesity masks the relationship between dietary salt intake and blood pressure in people of African ancestry: the impact of obesity on the relationship between sodium and blood pressure. Cardiovasc J Afr. 2018; 29:172–176. PMID: 29443353.
Article
53. Kyung Kim M, Kwon M, Rhee MY, et al. Dose-response association of 24-hour urine sodium and sodium to potassium ratio with nighttime blood pressure at older ages. Eur J Prev Cardiol. 2019; 26:952–960. PMID: 30729801.
Article
54. McLean R, Edmonds J, Williams S, Mann J, Skeaff S. Balancing sodium and potassium: estimates of intake in a New Zealand adult population sample. Nutrients. 2015; 7:8930–8938. PMID: 26516912.
Article
55. Mente A, Dagenais G, Wielgosz A, et al. Assessment of dietary sodium and potassium in Canadians using 24-hour urinary collection. Can J Cardiol. 2016; 32:319–326. PMID: 26454468.
Article
56. Mizéhoun-Adissoda C, Houinato D, Houehanou C, et al. Dietary sodium and potassium intakes: data from urban and rural areas. Nutrition. 2017; 33:35–41. PMID: 27908548.
Article
57. Mohammadifard N, Khaledifar A, Khosravi A, et al. Dietary sodium and potassium intake and their association with blood pressure in a non-hypertensive Iranian adult population: Isfahan salt study. Nutr Diet. 2017; 74:275–282. PMID: 28731609.
Article
58. Vallejo M, Colín-Ramírez E, Rivera Mancía S, et al. Assessment of sodium and potassium intake by 24 h urinary excretion in a healthy mexican cohort. Arch Med Res. 2017; 48:195–202. PMID: 28625323.
59. Chen SL, Dahl C, Meyer HE, Madar AA. Estimation of salt intake assessed by 24-hour urinary sodium excretion among Somali adults in Oslo, Norway. Nutrients. 2018; 10:900.
Article
60. Shin SJ, Lim CY, Rhee MY, et al. Characteristics of sodium sensitivity in Korean populations. J Korean Med Sci. 2011; 26:1061–1067. PMID: 21860557.
Article
61. Elijovich F, Weinberger MH, Anderson CA, et al. Salt sensitivity of blood pressure: a scientific statement from the American Heart Association. Hypertension. 2016; 68:e7–46. PMID: 27443572.
62. 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; 334:885–888. PMID: 17449506.
Article
63. Cook NR, Appel LJ, Whelton PK. Sodium intake and all-cause mortality over 20 years in the Trials of Hypertension Prevention. J Am Coll Cardiol. 2016; 68:1609–1617. PMID: 27712772.
64. Appel LJ, Espeland MA, Easter L, Wilson AC, Folmar S, Lacy CR. Effects of reduced sodium intake on hypertension control in older individuals: results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Arch Intern Med. 2001; 161:685–693. PMID: 11231700.
65. He FJ, MacGregor GA. Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet. 2011; 378:380–382. PMID: 21803192.
Article
66. Stolarz-Skrzypek K, Kuznetsova T, Thijs L, et al. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA. 2011; 305:1777–1785. PMID: 21540421.
Article
67. 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; 34:861–866. PMID: 21307382.
Article
68. Joosten MM, Gansevoort RT, Mukamal KJ, et al. Sodium excretion and risk of developing coronary heart disease. Circulation. 2014; 129:1121–1128. PMID: 24425751.
Article
69. Singer P, Cohen H, Alderman M. Assessing the associations of sodium intake with long-term all-cause and cardiovascular mortality in a hypertensive cohort. Am J Hypertens. 2015; 28:335–342. PMID: 25159082.
Article
70. Lelli D, Antonelli-Incalzi R, Bandinelli S, Ferrucci L, Pedone C. Association between sodium excretion and cardiovascular disease and mortality in the elderly: a cohort study. J Am Med Dir Assoc. 2018; 19:229–234. PMID: 29042264.
Article
71. Cook NR, Appel LJ, Whelton PK. Lower levels of sodium intake and reduced cardiovascular risk. Circulation. 2014; 129:981–989. PMID: 24415713.
Article
72. Mills KT, Chen J, Yang W, et al. Sodium excretion and the risk of cardiovascular disease in patients with chronic kidney disease. JAMA. 2016; 315:2200–2210. PMID: 27218629.
73. Polonia J, Monteiro J, Almeida J, Silva JA, Bertoquini S. High salt intake is associated with a higher risk of cardiovascular events: a 7.2-year evaluation of a cohort of hypertensive patients. Blood Press Monit. 2016; 21:301–306. PMID: 27495189.
74. Olde Engberink RH, van den Hoek TC, van Noordenne ND, van den Born BH, Peters-Sengers H, Vogt L. Use of a single baseline versus multiyear 24-hour urine collection for estimation of long-term sodium intake and associated cardiovascular and renal risk. Circulation. 2017; 136:917–926. PMID: 28655835.
Article
75. O'Donnell MJ, Yusuf S, Mente A, et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA. 2011; 306:2229–2238. PMID: 22110105.
76. He FJ, Ma Y, Campbell NR, MacGregor GA, Cogswell ME, Cook NR. Formulas to estimate dietary sodium intake from spot urine alter sodium-mortality relationship. Hypertension. 2019; 74:572–580. PMID: 31352828.
Article
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