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Dietary Salt Intake and Cardiovascular Disease: Summarizing the Evidence
Public Health Reviews volume 33, pages530–552(2011)
We present a narrative review of the literature linking dietary salt intake with cardiovascular health outcomes in humans and list the tools and strategies to reduce salt intake at the population level. There is a strong agreement among experts that dietary salt intake should be reduced, targeting average population levels less than 5 g per day. The main aim of this reduction is a decline in cardiovascular morbidity and mortality. Experimental data clearly show that reducing salt intake lowers blood pressure. Considering that high blood pressure is a major cardiovascular risk factor, this provides indirect evidence that salt reduction should improve cardiovascular health.1 There is also recent direct evidence that reducing salt intake reduces the incidence of cardiovascular disease. Direct evidence linking reduction in salt intake with decreased overall and cardiovascular mortality is more limited and disputed and the data for stroke are inconsistent. Thus, there is a debate on the quality and nature of the available evidence, particularly on the magnitude of the benefit provided by the achievable reduction in salt intake. Yet, there are no known deleterious consequences of the proposed reduction in salt intake. Several countries have adopted policies aiming at reducing salt intake in the general population. The relevant tools and strategies are directed to both the food industry and the consumers. At the industry level, the most efficient measure is legislation on the salt content of selected foods, an approach much more (cost) effective than voluntary reductions. None of the interventions aiming at reducing salt intake has been rigorously evaluated. In view of recurrent controversies, any intervention in this field should be accompanied by an appropriate monitoring and evaluation program.
Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood pressure? III—Analysis of data from trials of salt reduction. BMJ. 1991;302:819–24.
World Health Organization. The global burden of disease: 2004 update. Geneva, Switzerland: WHO; 2004.
World Health Organization. Creating an enabling environment for population-based salt reduction strategies: report of a joint technical meeting held by WHO and the Food Standards Agency, United Kingdom. Geneva, Switzerland: WHO Press; 2010.
Webster JL, Dunford EK, Hawkes C, Neal BC. Salt reduction initiatives around the world. J Hypertens. 2011;29:1043–50.
Taubes G. The (political) science of salt. Science. 1998;281:898–901, 903–7.
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;305:1777–85.
Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev. 2011(7):CD009217.
He FJ, MacGregor GA. Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet. 2011;378:380–2.
Forte JG, Miguel JM, Miguel MJ, de Padua F, Rose G. Salt and blood pressure: a community trial. J Hum Hypertens. 1989;3:179–84.
Staessen J, Bulpitt CJ, Fagard R, Joossens JV, Lijnen P, Amery A. Salt intake and blood pressure in the general population: a controlled intervention trial in two towns. J Hypertens. 1988;6:965–73.
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;362:590–9.
Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007;370:2044–53.
Brown IJ, Tzoulaki I, Candeias V, Elliott P. Salt intakes around the world: implications for public health. Int J Epidemiol. 2009;38:791–813.
Ambard L, Beaujard E. Causes de l’hypertension artérielle. Arch Gen Med. 1:520–33.
Allen FM. Arterial hypertension. J Am Med Assoc. 1920;74:652.
Kempner W. Treatment of hypertensive vascular disease with rice diet. Am J Med. 1948;4:545–77.
Dahl LK. Possible role of salt intake in the development of arterial hypertension. In: Cottier P, Bock DK, editors. Essential Hypertension, an International Symposium. Berlin: Springer-Verlag; 1960.
Froment A, Milton H, Gravier C. Relationship of sodium intake and essential hypertension. Rev Epidemiol Sante Publique. 1979;27:437–54.
Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ. 1988;297:319–28.
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.
Zhao L, Stamler J, Yan LL, Zhou B, Wu Y, Liu K, et al. Blood pressure differences between northern and southern Chinese: role of dietary factors: the International Study on Macronutrients and Blood Pressure. Hypertension. 2004;43:1332–7.
Machnik A, Neuhofer W, Jantsch J, Dahlmann A, Tammela T, Machura K, et al. Macrophages regulate salt-dependent volume and blood pressure by a vascular endothelial growth factor-C-dependent buffering mechanism. Nat Med. 2009;15:545–52.
Guyton AC. Renal function curve—a key to understanding the pathogenesis of hypertension. Hypertension. 1987;10:1–6.
Guyton AC. Dominant role of the kidneys and accessory role of whole-body autoregulation in the pathogenesis of hypertension. Am J Hypertens. 1989;2:575–85.
Guyton AC, Coleman TG, Cowley AV, Jr., Scheel KW, Manning RD, Jr., Norman RA, Jr. Arterial pressure regulation. Overriding dominance of the kidneys in long-term regulation and in hypertension. Am J Med. 1972;52:584–94.
Kimura G, Brenner BM. A method for distinguishing salt-sensitive from non-salt-sensitive forms of human and experimental hypertension. Curr Opin Nephrol Hypertens. 1993;2:341–9.
Johnson RJ, Rodriguez-Iturbe B, Nakagawa T, Kang DH, Feig DI, Herrera-Acosta J. Subtle renal injury is likely a common mechanism for salt-sensitive essential hypertension. Hypertension. 2005;45:326–30.
Johnson RJ, Schreiner GF. Hypothesis: the role of acquired tubulointerstitial disease in the pathogenesis of salt-dependent hypertension. Kidney Int. 1997;52:1169–79.
Johnson RJ, Rodriguez-Iturbe B, Kang DH, Feig DI, Herrera-Acosta J. A unifying pathway for essential hypertension. Am J Hypertens. 2005;18:431–40.
Lifton RP. Molecular genetics of human blood pressure variation. Science. 1996;272:676–80.
Meneton P, Jeunemaitre X, de Wardener HE, MacGregor GA. Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Physiol Rev. 2005;85:679–715.
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;334:885–8.
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;83:1289–96.
Alderman MH, Cohen H, Madhavan S. Dietary sodium intake and mortality: the National Health and Nutrition Examination Survey (NHANES I). Lancet. 1998;35:781–5.
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;22:763–70.
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;282:2027–34.
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;315:722–9.
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;357:848–51.
Poulter NR. Dietary sodium intake and mortality: NHANES. The Faculty 31st International Society and Federation of Cardiology 10-day Teaching Seminar in Cardiovascular Disease, Epidemiology and Prevention. National Health and Nutrition Examination Survey. Lancet. 1998;352:987–8.
Bogers RP, Bemelmans WJ, Hoogenveen RT, Boshuizen HC, Woodward M, Knekt P, et al. Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons. Arch Intern Med. 2007;167:1720–8.
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, 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;25:1144–52.
Kagan A, Popper JS, Rhoads GG, Yano K. Dietary and other risk factors for stroke in Hawaiian Japanese men. Stroke. 1985;16:390–6.
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;168:459–65.
Nagata C, Takatsuka N, Shimizu N, Shimizu H. Sodium intake and risk of death from stroke in Japanese men and women. Stroke. 2004;35:1543–7.
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;98:1198–204.
Sasaki S, Zhang XH, Kesteloot H. Dietary sodium, potassium, saturated fat, alcohol, and stroke mortality. Stroke. 1995;26:783–9.
Yamori Y, Liu L, Mizushima S, Ikeda K, Nara Y. Male cardiovascular mortality and dietary markers in 25 population samples of 16 countries. J Hypertens. 2006;24:1499–505.
Yamori Y, Nara Y, Mizushima S, Sawamura M, Horie R. Nutritional factors for stroke and major cardiovascular diseases: international epidemiological comparison of dietary prevention. Health Rep. 1994;6:22–7.
Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med. 1990;322:1561–6.
Verdecchia P, Porcellati C, Reboldi G, Gattobigio R, Borgioni C, Pearson TA, et al. Left ventricular hypertrophy as an independent predictor of acute cerebrovascular events in essential hypertension. Circulation. 2001;104:2039–44.
Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Gattobigio R, Zampi I, et al. Prognostic significance of serial changes in left ventricular mass in essential hypertension. Circulation. 1998;97:48–54.
Schmieder RE, Messerli FH, Garavaglia GE, Nunez BD. Dietary salt intake. A determinant of cardiac involvement in essential hypertension. Circulation. 1988;78:951–6.
Daniels SD, Meyer RA, Loggie JM. Determinants of cardiac involvement in children and adolescents with essential hypertension. Circulation. 1990;82:1243–8.
Ferrara LA, de Simone G, Pasanisi F, Mancini M. Left ventricular mass reduction during salt depletion in arterial hypertension. Hypertension. 1984;6:755–9.
Liebson PR, Grandits GA, Dianzumba S, Prineas RJ, Grimm RH, Jr., Neaton JD, et al. Comparison of five antihypertensive monotherapies and placebo for change in left ventricular mass in patients receiving nutritional-hygienic therapy in the Treatment of Mild Hypertension Study (TOMHS). Circulation. 1995;91:698–706.
Tsugane S. Salt, salted food intake, and risk of gastric cancer: epidemiologic evidence. Cancer Sci. 2005;96:1–6.
Dias-Neto M, Pintalhao M, Ferreira M, Lunet N. Salt intake and risk of gastric intestinal metaplasia: systematic review and meta-analysis. Nutr Cancer. 2010;62:133–47.
He FJ, Marrero NM, MacGregor GA. Salt intake is related to soft drink consumption in children and adolescents: a link to obesity? Hypertension. 2008;51:629–34.
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;13:169–77.
Barton P, Andronis L, Briggs A, McPherson K, Capewell S. Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ. 2011;343:d4044.
Cobiac LJ, Vos T, Veerman JL. Cost-effectiveness of interventions to reduce dietary salt intake. Heart. 2010;96:1920–5.
Kelly B, King L, Bauman A, Smith BJ, Flood V. The effects of different regulation systems on television food advertising to children. Aust N Z J Public Health. 2007;31:340–3.
Adams J, Tyrrell R, Adamson AJ, White M. Socio-economic differences in exposure to television food advertisements in the UK: a cross-sectional study of advertisements broadcast in one television region. Public Health Nutr. 2011;15:1–8.
Adams J, Tyrrell R, White M. Do television food advertisements portray advertised foods in a ‘healthy’ food context? Br J Nutr. 2011;105:810–5.
Klaus D, Bohm M, Halle M, Kolloch R, Middeke M, Pavenstadt H, et al. [Restriction of salt intake in the whole population promises great long-term benefits]. Dtsch Med Wochenschr. 2009;134:S108–18.
Hebden L, King L, Kelly B, Chapman K, Innes-Hughes C. Industry self-regulation of food marketing to children: reading the fine print. Health Promot J Austr. 2010;21:229–35.
Mytton O, Gray A, Rayner M, Rutter H. Could targeted food taxes improve health? J Epidemiol Community Health. 2007;61:689–94.
Nnoaham KE, Sacks G, Rayner M, Mytton O, Gray A. Modelling income group differences in the health and economic impacts of targeted food taxes and subsidies. Int J Epidemiol. 2009;38:1324–33.
Grimes CA, Riddell LJ, Nowson CA. Consumer knowledge and attitudes to salt intake and labelled salt information. Appetite. 2009;53:189–94.
Grummer J, Schoenfuss TC. Determining salt concentrations for equivalent water activity in reduced-sodium cheese by use of a model system. J Dairy Sci. 2011;94:4360–5.
Reger B, Wootan MG, Booth-Butterfield S. Using mass media to promote healthy eating: A community-based demonstration project. Prev Med. 1999;29:414–21.
Reger B, Wootan MG, Booth-Butterfield S. A comparison of different approaches to promote community-wide dietary change. Am J Prev Med. 2000;18:271–5.
Elitzak H. Food marketing costs at a glance. Food Reviews: Economic Research Service, United States Department of Agriculture; 2001:47–48.
Swiss Pledge, 2010.
Adams J, Hennessy-Priest K, Ingimarsdottir S, Sheeshka J, Ostbye T, White M. Food advertising during children’s television in Canada and the UK. Arch Dis Child. 2009;94:658–62.
Adams J, Simpson E, White M. Variations in food and drink advertising in UK monthly women’s magazines according to season, magazine type and socio-economic profile of readers: a descriptive study of publications over 12 months. BMC Public Health. 2011;11:368.
Van Cauwenberghe E, Maes L, Spittaels H, van Lenthe FJ, Brug J, Oppert JM, et al. Effectiveness of school-based interventions in Europe to promote healthy nutrition in children and adolescents: systematic review of published and ‘grey’ literature. Br J Nutr. 2010;103:781–97.
Kroeze W, Werkman A, Brug J. A systematic review of randomized trials on the effectiveness of computer-tailored education on physical activity and dietary behaviors. Ann Behav Med. 2006;31:205–23.
Dallongeville J, Dauchet L, de Mouzon O, Requillart V, Soler LG. Increasing fruit and vegetable consumption: a cost-effectiveness analysis of public policies. Eur J Public Health. 2011;21:69–73.
Cutler JA, Follmann D, Elliott P, Suh I. An overview of randomized trials of sodium reduction and blood pressure. Hypertension. 1991;17:I27–33.
Midgley JP, Matthew AG, Greenwood CM, Logan AG. Effect of reduced dietary sodium on blood pressure: a meta-analysis of randomized controlled trials. JAMA. 1996;275:1590–7.
Cutler JA, Follmann D, Allender PS. Randomized trials of sodium reduction: an overview. Am J Clin Nutr. 1997;65:S643S–51.
Graudal NA, Galloe AM, Garred P. Effects of sodium restriction on blood pressure, renin, aldosterone, catecholamines, cholesterols, and triglyceride: a meta-analysis. JAMA. 1998;279:1383–91.
He FJ, MacGregor GA. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens. 2002;16:761–70.
He FJ, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev. 2004(3):CD004937.
He FJ, MacGregor GA. Importance of salt in determining blood pressure in children: meta-analysis of controlled trials. Hypertension. 2006;48:861–9.
Alderman MH, Cohen H, Madhavan S. Dietary sodium intake and mortality: the National Health and Nutrition Examination Survey (NHANES I). Lancet. 1998;351:781–5.
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;282:2027–34.
Cohen HW, Hailpern SM, Fang J, Alderman MH. Sodium intake and mortality in the NHANES II follow-up study. Am J Med. 2006;119:275 e7–14.
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;23:1297–302.
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Bochud, M., Marques-Vidal, P., Burnier, M. et al. Dietary Salt Intake and Cardiovascular Disease: Summarizing the Evidence. Public Health Rev 33, 530–552 (2011) doi:10.1007/BF03391649
- cardiovascular disease