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Salt and High Blood Pressure: Sailesh MOHAN and Norm R. C. CAMPBELL
Salt and High Blood Pressure: Sailesh MOHAN and Norm R. C. CAMPBELL
1042/CS20080207 1
R E V I E W
A B S T R A C T
HBP (high blood pressure) is the leading risk of death in the world. Unfortunately around the world,
Key words: cardiovascular disease, high blood pressure, hypertension, salt, salt reduction, sodium.
Abbreviations: BP, blood pressure; CHD, coronary heart disease; DASH, Dietary Approaches to Stop Hypertension; DBP, diastolic
BP; HBP, high BP; SBP, systolic BP; TOHP, Trials of Hypertension Prevention; WHO, World Health Organization.
Correspondence: Dr Norm R. C. Campbell (email [email protected]).
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2 S. Mohan and N. R. C. Campbell
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Salt and high blood pressure 3
and the sodium composition is regulated largely by high sodium in the diet causes significant direct vascular
renal excretion and conservation. Sodium is needed for and cardiac damage independent of BP [21,28–31].
maintaining extracellular fluid, acid–base balance and
oncotic pressure, as well as muscle and nerve activity.
Furthermore, it helps generate transmembrane gradients EVIDENCE
which permit the uptake of nutrients by cells of the
intestinal mucosa and renal tubules. Most functions of Epidemiological investigations
sodium are interdependent with potassium. Although Many large observational epidemiological investigations
any decrease in extracellular fluid volume, due to falling conducted worldwide link high salt intake and
plasma volume, lowers BP, any rise in extracellular fluid hypertension. In one of the first major global studies on
volume increases BP by increasing plasma volume [4,19]. sodium intake (INTERSALT), 24 h urinary sodium was
significantly associated with BP as well as the increase
in BP with age [16]. Lowering salt intake by 5.8 g was
Hypertensive mechanisms associated with a 3.1 mmHg decrease in SBP (systolic BP)
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Intervention trials
Results from many clinical trials of salt reduction in
humans generally confirm increases in BP with increases
in dietary salt. The exception is trials where interventions
to lower dietary salt had little effect on dietary sodium,
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Salt and high blood pressure 5
− 0.3)
− 0.6)
− 0.6)
+0.3)
0.3)
0.0)
review included trials (20 in hypertensive subjects and
to
to
to
to
to
to
11 in normotensive subjects) lasting more than 4 weeks
(− 1.7
(− 0.5
(− 1.6
(− 0.9
(− 1.4
(− 1.1
with a reduction in salt of at least 2.3 g/day [49]. It
BP change in normotensive subjects (95 % CI) found reductions of 5.0/2.7 mmHg in SBP/DBP among
− 1.0
− 0.1
− 1.1
− 0.3
− 1.0
− 0.5
DBP
hypertensive patients with a median reduction in salt
of 4.6 g/day, and 2.0/1.0 mmHg in SBP/DBP among
normotensive subjects with a median reduction of 4.4 g
− 0.7)
− 0.5)
− 1.2)
− 0.6)
− 1.5)
− 0.3)
of salt/day. Furthermore, a dose–response relationship
was observed, with a BP reduction of 7.1/3.9 mmHg
to
to
to
to
to
to
among hypertensive patients and 3.6/1.7 mmHg among
(− 1.8
(− 2.7
(− 1.6
(− 2.6
(− 2.6
(− 1.9
normotensive participants in SBP/DBP per 6 g decrease in
urinary sodium [49]. Another meta-analysis by Hooper
− 1.7
− 1.0
− 1.9
− 1.2
− 2.0
− 1.1
SBP
(− 3.2 to − 1.8)
(− 2.5 to − 1.3)
(− 3.2 to − 2.3)
− 2.7
− 7.0
DBP
SBP
2.0–2.4
4.5
6.9
Normal
2220
2374
1689
2581
2326
760
1188
HBP
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Salt and high blood pressure 7
SALT INTAKE AND CARDIOVASCULAR ment by 24 h urinary sodium excretion. However, none
DISEASE MORTALITY of these methods is ideal, and there are several challenges
that limit accuracy. The 24 h urinary sodium excretion
Several observational studies have examined salt intake is considered the gold standard method. However,
and cardiovascular disease outcomes; however, large this and other more reliable methods (method iii) are
high-quality randomized trials examining morbidity and difficult to implement, whereas simpler ones (method
mortality have not been conducted. A few ecological ii) compromise reliability [11,16,83]. Furthermore, there
studies have reported a direct association between higher is considerable intra-individual variability in intake such
salt intake or urinary sodium excretion and stroke that a single day’s measure does not adequately represent
mortality [76,77]. Prospective studies [78–80], with the usual intake. Current methods when used to assess intake
exception of three studies undertaken by single group on a single day do not accurately predict usual salt
investigators [36–38], also report higher salt intake intake on an individual basis. In addition, methods that
to predict the incidence of cardiovascular events. In rely on recall do not adequately quantify salt added while
addition, studies from Finland and Japan found an cooking or at the table and, thus, lead to underestimates,
association between dietary sodium and increased risk rendering them to be of little use in populations where
of CHD or stroke [79,80]. The Finnish study estimated much of the salt is added in cooking or at the table.
that a 6 g/day increase in salt intake was associated
with a 56 % increase in CHD deaths, 36 % increase in
cardiovascular disease deaths and 22 % in all deaths [79].
A cluster randomized trial among elderly Taiwanese
GUIDELINES AND PUBLIC HEALTH POLICIES
veterans, which substituted regular salt with potassium- TO REDUCE SALT CONSUMPTION
enriched salt, found that the lower-sodium diet was
Rising salt intakes coupled with escalating burden of
associated with a markedly reduced cardiovascular event
hypertension and cardiovascular disease globally has
rate [81]. In a more recent long-term post-trial follow-up
prompted the WHO (World Health Organization) to
of patients in the TOHP trials, Cook et al. [82] reported
recommend that salt intake be less than 5 g/day [11].
a 30 % reduction in cardiovascular disease events at 10–
Many nations have developed their own nutritional/die-
15 years in the reduced salt intervention group. These
tary guidelines on dietary sodium [84]. The U.K.
studies provide important evidence, consistent with
guidelines recommend salt intake of 6 g/day or less for
animal studies, that salt reduction not only lowers BP, but
adults [19,85]. The US Institute of Medicine report set
also prevents adverse cardiovascular disease outcomes.
3.75 g/day salt as an adequate intake, and 5.8 g/day as
the upper tolerable intake level for most adults [86].
SALT MEASUREMENT AND MONITORING However, worldwide, most individuals continue to
have intakes well in excess of this level. Groups such
Assessment of population salt intake is critical in as the UK Consensus Action on Salt and Health [17]
monitoring the effectiveness of salt reduction initiatives. have calculated dose–responses that support a further
The primary methods are: (i) estimating salt intake by reduction to 3 g/day, which it claims could achieve a one-
weighing ingested food, (ii) dietary recall, (iii) estimating third reduction in strokes and a one-quarter reduction
salt content of food before ingestion, and (iv) measure- in CHD and, thus, having greater population impact in
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8 S. Mohan and N. R. C. Campbell
reducing cardiovascular disease than current guidelines on the health risks of salt and mechanisms to reduce
would have (see http://www.actiononsalt.org.uk/). dietary salt (see http://www.worldactiononsalt.com/).
Despite these guidelines and the importance to health,
most governments have been ineffectual in implementing
these recommendations. COST EFFECTIVENESS OF SALT REDUCTION
The WHO recommends that governments implement
policies on food labelling, legislation and product Studies have found that national programmes to reduce
reformulation in collaboration with the food industry dietary salt consumption, including labelling changes and
[11]. Processed foods are the major source of salt in reformulation of products, are very cost effective [91].
developed countries therefore collaboration with or Selmer et al. [92] estimated that effective implementation
regulation of the food industry to reduce salt content is of salt-reduction interventions in Norway could reduce
critical. This strategy combined with public education mortality by 1–2 %, increase life expectancy and result
is being employed successfully in the U.K. [87]. Major in a 5 % reduction in people requiring antihypertensive
reductions in the salt content of foods have been achieved medication. This was projected to save $ 270 million
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Salt and high blood pressure 9
Program, University of Calgary, Calgary, Canada, and 15 Chockalingam, A. and Balaguer-Vintro, I. (1999)
Blood Pressure Canada. Impending Global Pandemic of Cardiovascular Diseases:
Challenges and Opportunities for the Prevention and
Control of Cardiovascular Diseases in Developing
Countries and Economies in Transition, The World Heart
FUNDING Federation, Prous Science, Barcelona
16 Intersalt Cooperative Research Group (1988)
INTERSALT: an international study of electrolyte
S. M. is supported by the Canadian Institutes of Health excretion and blood pressure: results for 24 h urinary
sodium and potassium excretion. Br. Med. J. 297, 319–328
Research Canada-HOPE Fellowship, and N. C. is 17 He, F. J. and MacGregor, G. A. (2003) How far should
supported by the Canadian Institutes of Health Research salt intake be reduced? Hypertension 42, 1093–1099
Canada Chair in Hypertension Prevention and Control. 18 James, W. P., Ralph, A. and Sanchez-Castillo, C. P. (1987)
The dominance of salt in manufactured food in the
sodium intake of affluent societies. Lancet i, 426–429
19 Scientific Advisory Committee on Nutrition (2003) Salt
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