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dietary sodium; dietary Na+; dietary salt

Epidemiology: - foods contributing to dietary sodium in the US - bread & rolls > cold cuts > pizza > poultry > soups > sandwiches > cheese > pasta mixed dishes > meat mixed dishes > savory snacks - 2/3 of dietary sodium comes from foods purchased at stores; the remainder comes from restaurants, cafeterias ... [6] - 90% of school-aged children eat more than recommended daily allowance of sodium (< 2300 mg/day) [13] - on the average, school-age children consume 3300 mg/day - 90% of Americans consume excess dietary salt [16] - decline in sodium content of packaged food & beverages 2000- 2014 ~ 400 mg daily per person [20] - estimated mean dietary sodium intake is 3608 mg/day [23] Dosage: - < 2300 mg/day in young individuals - < 2000 mg/day for adults (WHO) [6] - < 2300 mg/day for persons age >- 14 years (USDA, HHS) [15] - 1500 mg/day for people with hypertension, > age 40, or African Americans - see DASH diet - 3000 mg/day may be optimal for healthy people [12] Adverse effects: 1) high Na+ intake associated with increased mortality in overweight, but not normal weight patients [1] a) increased risk of stroke b) increased risk of myocardial infarction c) increased all-cause mortality [1] 2) higher Na+ intake is associated coronary atherosclerosis & carotid atherosclerosis [33] 3) excessive dietary salt may contribute to progression of cerebral small vessel disease in older adults [34] - effects of salt may be mediated in part by hypertension 4) sodium intake is not significantly associated with mortality or development of cardiovascular disease or heart failure in elderly 71-80 years of age [14] 5) high Na+ intake in patients with chronic renal failure is associated with increased risk for cardiovascular events [17] 6) low urine sodium excretion may be associated with increased risk of cardiovascular mortality [4,12] 7) hypertension a) reduction is systolic BP of 1.1 mm Hg & diastolic BP of 0.6 mm Hg by sodium restriction unlikely to be helpful for hypertension in general [2] b) age & race may play a role in the effects of dietary sodium on hypertension [4] c) increase in systolic BP & diastolic BP with increased sodium intake > 3 g/day [12] d) increase in systolic BP due to sodium < 13 mm Hg e) dietary salt decreases intestinal Lactobacilli in mice & humans & increases blood pressure [21] 8) salt added to food increases risk of chronic kidney disease (11%) [36] 8) in culture, human CD4 cells exposed to increasing amounts of NaCl result in a dose-dependent increase in IL-17, an inflammatory mediator linked to multiple sclerosis, psoriasis & other autoimmune disorders [8] Laboratory: - 24 hour urine sodium [23] - 90% of dietary sodium is excreted in the urine Management: - lower salt intake a) lowers blood pressure regardless of baseline blood pressure, sex, or race - 4.3 mm Hg drop in systolic blood pressure [27] - 5.6 mm Hg drop in systolic blood pressure for every 100 mmol/day reduction in urinary sodium excretion (87 mmol/day corresponds to 2 g/day), corresponding drop in diastolic BP is 2.3 mm Hg [29] - relationship of sodium intake & systolic blood pressure is linear [29] - average 8 mm Hg lower systolic blood pressure vs high sodium diet [35] - 12 mm Hg drop in systolic BP for 1 gram of sodium vs 6 grams/day - corresponding drop for diastolic BP 5 mm Hg [29] b) no significant adverse physiological effect c) may reduce risk of stroke via lower blood pressure [9] d) associated with 15% lower (but not statistically significant) 20 year mortality in prehypertensive adults [19] e) very low sodium intake is not associated with mortality [19] - FDA announced draft guidance for voluntarily reducing sodium in processed & restaurant food [18] - 2-year target aims to reduce sodium intake to 3000 mg/day - 10-year target aims for sodium intake < 2300 mg/day, following the Dietary Guidelines for Americans' recommendation - people age >= 14 years should reduce sodium intake to < 2300 mg/day [26] - sodium restriction may be most beneficial in communities with the highest sodium consumption [24] - moderate sodium (3-5 g/day) & high potassium intake (> 2.1 g/day) associated with lowest cardiovascular mortality [26] - reducing sodium intake does not improve outcomes in patients with chronic heart failure [32] - salt substitute (70% sodium chloride, 30% potassium chloride) to replace regular salt lowers systolic blood pressure 3.3 mm Hg assessed at year 5 [30] - salt substitute significantly lowers risk of stroke & all-cause mortality - lower urine sodium & higher urine potassium associated with fewer adverse cardiovascular events [31] Comparative biology: - in mice, excess dietary salt inhibits resting cerebral perfusion & endothelial function, leading to cognitive impairment [22] - effect depends on expansion of TH17 cells in small intestine, resulting in an increase in plasma IL-17 - IL-17 facilitates Rho-kinase dependent inhibitory phosphorylation of endothelial nitric oxide synthase reducing nitric oxide production in cerebral endothelial cells

Related

Dietary Approaches to Stop Hypertension (DASH) diet low sodium diet; Na+ restriction Na+

General

nutritional (essential) mineral

References

  1. Journal Watch, Mass Med Soc 20(1):2 (Jan 1) 2000
  2. Journal Watch 22(22):164, 2002 Hooper et al, BMJ 325:628, 2002
  3. Prescriber's Letter 16(6): 2009 Blood Pressure-Lowering Benefits of Reduced Salt Intake COMMENTARY: Blood Pressure-Lowering Benefits of Reduced Salt Intake PATIENT HANDOUT: How to Eat Less Salt PDF: Patient Guide to the DASH Diet Detail-Document#: 250605 (subscription needed) http://www.prescribersletter.com
  4. Stolarz-Skrzypek K et al. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA 2011 May 4; 305:1777 PMID: 21540421
  5. Taylor RS et al Reduced Dietary Salt for the Prevention of Cardiovascular Disease: A Meta-Analysis of Randomized Controlled Trials (Cochrane Review) Am J Hypertens, July 6, 2011 PMID: 21731062 http://www.nature.com/ajh/journal/vaop/ncurrent/abs/ajh2011115a.html http://www.nature.com/ajh/journal/vaop/ncurrent/full/ajh2011115a.html Alderman MH The Cochrane Review of Sodium and Health Am J Hypertens, July 6, 2011 PMID: 21731063 http://www.nature.com/ajh/journal/vaop/ncurrent/full/ajh2011117a.html
  6. World Health Organization Guideline: Sodium intake for adults and children. 2012 http://www.who.int/nutrition/publications/guidelines/sodium_intake_printversion.pdf
  7. Centers for Disease Control and Prevention Vital Signs: Food Categories Contributing the Most to Sodium Consumption - United States, 2007-2008 MMWR February 7, 2012 / 61(Early Release);1-7 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm61e0207a1.htm
  8. O'Shea JJ and Jones RG Autoimmunity: Rubbing salt in the wound Nature. March 6 2013 PMID: 23467087 http://www.nature.com/nature/journal/vaop/ncurrent/full/nature11959.html
  9. He FJ et al. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ 2013 Apr 4; 346:f1325 PMID: 23558162 - Aburto NJ et al. Effect of lower sodium intake on health: Systematic review and meta-analyses. BMJ 2013 Apr 4; 346:f1326 PMID: 23558163
  10. Strom BL, Yaktine AL, Oria M, Editors; Committee on the Consequences of Sodium Reduction in Populations Food and Nutrition Board; Board on Population Health and Public Health Practice Institute of Medicine http://www.nap.edu/catalog.php?record_id=18311
  11. Kotchen TA The Salt Discourse in 2013 Am J Hypertens (2013) 26 (10): 1177. PMID: 24042542 http://ajh.oxfordjournals.org/content/26/10/1177.full
  12. Mozaffarian D et al Global Sodium Consumption and Death from Cardiovascular Causes. N Engl J Med 2014; 371:624-634. August 14, 2014 PMID: 25119608 http://www.nejm.org/doi/full/10.1056/NEJMoa1304127 - Mente A et al Association of Urinary Sodium and Potassium Excretion with Blood Pressure. N Engl J Med 2014; 371:601-611. August 14, 2014 PMID: 25119606 http://www.nejm.org/doi/full/10.1056/NEJMoa1311989 - O'Donnell M et al Urinary Sodium and Potassium Excretion, Mortality, and Cardiovascular Events. N Engl J Med 2014; 371:612-623. August 14, 2014 PMID: 25119607 http://www.nejm.org/doi/full/10.1056/NEJMoa1311889 - Oparil S Low Sodium Intake - Cardiovascular Health Benefit or Risk? N Engl J Med 2014; 371:677-679. August 14, 2014 PMID: 25119614 http://www.nejm.org/doi/full/10.1056/NEJMe1407695
  13. Cogswell ME et al Vital Signs: Sodium Intake Among U.S. School-Aged Children - 2009-2010 MMWR. September 9, 2014 / 63(Early Release);1-9 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0909a1.htm
  14. Kalogeropoulos AP 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. Published online January 19, 2015. PMID: 25599120 http://archinte.jamanetwork.com/article.aspx?articleid=2091399
  15. 2015-2020 Dietary Guidelines for Americans. U.S. Department of Health and Human Services (HHS) U.S. Department of Agriculture (USDA) http://health.gov/dietaryguidelines/2015/guidelines/executive-summary/
  16. Jackson SL et al Prevalence of Excess Sodium Intake in the United States - NHANES, 2009-2012. MMWR. Weekly. January 8, 2016 / 64(52);1393-7 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6452a1.htm
  17. Mills KT Sodium Excretion and the Risk of Cardiovascular Disease in Patients With Chronic Kidney Disease. JAMA. 2016;315(20):2200-2210. PMID: 27218629 http://jama.jamanetwork.com/article.aspx?articleid=2524189 - Powe NR, Bibbins-Domingo K Dietary Salt, Kidney Disease, and Cardiovascular Health. JAMA. 2016;315(20):2173-2174 PMID: 27218627 http://jama.jamanetwork.com/article.aspx?articleid=2524166
  18. FDA News Release. June 1, 2016. FDA issues draft guidance to food industry for voluntarily reducing sodium in processed and commercially prepared food. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm503874.htm - DEPARTMENT OF HEALTH AND HUMAN SERVICES. June 2, 2016 Food and Drug Administration [Docket No. FDA-2014-D-0055] Voluntary Sodium Reduction Goals: Target Mean and Upper Bound Concentrations for Sodium in Commercially Processed, Packaged, and Prepared Foods; Draft Guidance for Industry. https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-12950.pdf - Cogswell ME et al Dietary Sodium and Cardiovascular Disease Risk - Measurement Matters. N Engl J Med. 2016 Jun 1. [Epub ahead of print] PMID: 27248297 http://www.nejm.org/doi/full/10.1056/NEJMsb1607161
  19. 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(15):1609-1617 PMID: 27712772 https://content.onlinejacc.org/article.aspx?articleID=2557459 - Mente A, O'Donnell MJ, Yusuf S. How Robust Is the Evidence for Recommending Very Low Salt Intake in Entire Populations? J Am Coll Cardiol. 2016;68(15):1618-1621 PMID: 27712773 https://content.onlinejacc.org/article.aspx?articleID=2557470
  20. Poti JM, Dunford EK, Popkin BM. Sodium reduction in US households' packaged food and beverage purchases, 2000 to 2014. JAMA Intern Med 2017 Jun 5; PMID: 28586820 http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2629447
  21. Wilck N, Matus MG, Kearney SM et al. Salt-responsive gut commensal modulates TH17 axis and disease. Nature 2017 Nov 30; 551:585. PMID: 29143823 https://www.nature.com/articles/nature24628 - Relman DA. Microbiota: A high-pressure situation for bacteria. Nature 2017 Nov 30; 551:571 PMID: 29143820 https://www.nature.com/articles/nature24760
  22. Faraco G, Brea D, Garcia-Bonilla L. Dietary salt promotes neurovascular and cognitive dysfunction through a gut-initiated TH17 response. Nature Neuroscience. Jan 15, 2018 PMID: 29335605 https://www.nature.com/articles/s41593-017-0059-z
  23. Cogswell ME, Loria CM, Terry AL et al Estimated 24-Hour Urinary Sodium and Potassium Excretion in US Adults. JAMA. Published online March 7, 2018 PMID: 29516104 https://jamanetwork.com/journals/jama/fullarticle/2674711 - Ix JH, Anderson CAM Measurements of 24-Hour Urinary Sodium and Potassium Excretion. Importance and Implications. JAMA. Published online March 7, 2018 PMID: 29516102 https://jamanetwork.com/journals/jama/fullarticle/2674710
  24. Elia J, Sofair A, Chavey WE Salt Restrictions for Some May Be Better Than for All. Physician's First Watch, Aug 10, 2018 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  25. Mahtani KR, Heneghan C, Onakpoya I et al Reduced Salt Intake for Heart Failure. A Systematic Review. JAMA Intern Med. Published online November 5, 2018. PMID: 30398532 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2712563
  26. O'Donnell M et al. Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: Prospective cohort study. BMJ 2019 Mar 13; 364:l772 PMID: 30867146 Free full text https://www.bmj.com/content/364/bmj.l772
  27. Huang L, Trieu K, Yoshimura S et al Effect of dose and duration of reduction in dietary sodium on blood pressure levels: systematic review and meta-analysis of randomised trials. BMJ 2020;368:m315 PMID: 32094151 Free full text https://www.bmj.com/content/368/bmj.m315
  28. National Academies of Sciences, Engineering, and Medicine Dietary Reference Intakes for Sodium and Potassium Consensus Study Report. 2019 https://www.nap.edu/catalog/25353/dietary-reference-intakes-for-sodium-and-potassium
  29. Filippini T et al. Blood pressure effects of sodium reduction: Dose-response meta-analysis of experimental studies. Circulation 2021 Apr 20; 143:1542 PMID: 33586450 PMCID: PMC8055199 (available on 2022-04-20) https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.050371
  30. Neal B, Wu Y, Feng X et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med 2021 Aug 29; [e-pub]. PMID: 34459569 https://www.nejm.org/doi/10.1056/NEJMoa2105675 - Ingelfinger JR. Can salt substitution save at-risk persons from stroke? N Engl J Med 2021 Aug 29; [e-pub] PMID: 34459568 https://www.nejm.org/doi/10.1056/NEJMe2112857
  31. Ma Y, He FJ, Sun Q et al. 24-hour urinary sodium and potassium excretion and cardiovascular risk. N Engl J Med 2021 Nov 13; [e-pub]. PMID: 34767706 https://www.nejm.org/doi/10.1056/NEJMoa2109794
  32. Ezekowitz JA et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): An international, open-label, randomised, controlled trial. Lancet 2022 Apr 2; [e-pub]. PMID: 35381194 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00369-5/fulltext
  33. Wuopio J, Ling YT, Orho-Melander M et al The association between sodium intake and coronary and carotid atherosclerosis in the general Swedish population. Eur Heart J Open. 2023 Mar 30;3(2):oead024. PMID: 37006408 PMCID: PMC10063371 Free PMC article https://academic.oup.com/ehjopen/article/3/2/oead024/7093096
  34. Liu D, Zhang Q, Xing S et al Excessive salt intake accelerates the progression of cerebral small vessel disease in older adults. BMC Geriatrics. 2023. May 2. PMID: 37131130 PMCID: PMC10155382 Free PMC article https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-023-03877-3
  35. Gupta DK, Lewis CE, Varady KA et al Effect of Dietary Sodium on Blood Pressure. A Crossover Trial. JAMA. Published online November 11, 2023. PMID: 37950918 https://jamanetwork.com/journals/jama/fullarticle/2811931
  36. Tang R, Kou M, Wang X et al Self-Reported Frequency of Adding Salt to Food and Risk of Incident Chronic Kidney Disease. JAMA Netw Open. 2023;6(12):e2349930 PMID: 38153731 PMCID: PMC10755616 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813410