A high sodium or Na+ intake, whose main source is salt or sodium chloride or NaCl, contributes to blood pressure raise, and hypertension development.
Many epidemiologic studies, animal studies, migration studies, clinical trials, and meta-analyses of trials support this, with the final evidence from rigorously controlled, dose-response trials. Furthermore, in primitive society Na+ intake is very low and people experience very low hypertension, and the blood pressure increase with age does not occur.
Probably, sodium intake effect sizes are to be underestimated!
- Recommended daily intake
- Food sources of sodium
- Diet modifies response of blood pressure to sodium
Recommended daily intake
Sodium’s physiologic requires are very low; in fact, the minimum recommended Na+ intake for maintain life is 250 mg/day (Note: iodized salt is an important source of dietary iodine in the United States and worldwide).
An Americans consumes the mineral in great excess of physiologic requires: despite the guidelines from the Departments of Agriculture and Health and Human Services, during the period from 2005 through 2006 the average salt intake in USA is of 10.4 g/day for the average man and 7.3 for the average woman, amount in excess regarding preceding years.
A study published on February 2010 on “The New England Journal of Medicine” have shown that “A population-wide reduction in dietary salt of 3 g per day (1200 mg of Na+ per day) is projected to reduce the annual number of new cases of coronary heart disease (CHD) by 60,000 to 120,000, stroke by 32,000 to 66,000, and myocardial infarction by 54,000 to 99,000 and to reduce the annual number of deaths from any cause by 44,000 to 92,000″ (Bibbins-Domingo et all., see References). These benefits are similar in magnitude to those from:
- a 50% reduction in tobacco use;
- a 5% reduction in body mass index among obese adults;
- a reduction in cholesterol levels.
These benefits regard all adult group age, black and nonblack, male and female. The benefits for black are greater than nonblack, in both sex and all age group. It’s estimated an annual savings of $10 billion to 24 $ billion in health care costs.
Clinical trials have also documented that a reduced Na+ intake can lower blood pressure in the setting of antihypertensive medication, and can facilitate hypertension control.
But, in USA dietary salt intake is on the rise!
So, it is recommended, to prevent hypertension development, a reduction in its intake and, in view of the available food supply and the currently daily Na+ intake, a reasonable recommendation is an upper limit of 2.3 g/day or 5.8 g/day of salt.
How achieves this level? It can be achieved:
- cooking with as little salt as possible;
- refraining from adding salt at the table;
- avoiding highly salted, processed foods.
Food sources of sodium
- salt used at the table: up to 20% of the daily salt intake;
- salt or sodium compounds added during preparation or processing foods: between 35 to 80% of the daily sodium intake comes from processed foods.Which foods are?
Processed, smoked or cured meat and fish e.g. sliced salami, sausage, salt pork, tuna fish in oil etc.; meat extracts and sauce, salted snack, soy sauce, barbecue sauce, commercial salad dressing; prepackage frozen foods; canned soup, canned legumes; cheese etc.
There are also many sodium-containing additives as disodium phosphate (e.g. in cereals, ice cream, cheese), monosodium glutamate (i.e. meat, soup, condiments), sodium alginate (e.g. in ice creams), sodium benzoate (e.g. in fruit juice), sodium hydroxide (e.g. in pretzels, cocoa product), sodium propionate (e.g. in bread), sodium sulfite (e.g. in dried fruit), sodium pectinate (e.g. syrups, ice creams, jam), sodium caseinate (e.g. ice creams and other frozen products) and sodium bicarbonate (e.g. baking powder, tomato soup, confections).
So pay attention to ingredients!
- Inherent sodium of foods. Generally low in fresh foods.
The blood pressure response to lower dietary Na+ intake is heterogeneous with individuals having greater or lesser degrees of blood pressure reduction. Usually the effect of reduction tend to be greater in blacks, middle-aged and older persons, and individuals with hypertension, diabetes or chronic kidney disease.
Furthermore genetic and dietary factors influence the response to sodium reduction.
Diet modifies response of blood pressure to sodium
Some components of the diet may modify response of blood pressure to sodium.
- A high dietary intake of calcium and potassium rich foods, such as fruit, vegetable, legumes (e.g. mediterranean diet), and low-fat dairy products (e.g. DASH diet), may prevent or attenuate the rise in blood pressure for a given increase in sodium intake.
- Some evidences, seen primarily in animal model, suggest that high dietary intake of sucrose may potentiate salt sensitivity of blood pressure.
Note: high Na+ intake can contribute to osteoporosis: they result in an increase in renal calcium excretion, particularly if daily calcium intakes are low.
- Appel L.J., Brands M.W., Daniels S.R., Karanja N., Elmer P.J. and Sacks F.M. Dietary approaches to prevent and treat HTN: a scientific statement from the American Heart Association. Hypertension 2006;47:296-308. doi:10.1161/01.HYP.0000202568.01167.B6
- Bibbins-Domingo K., Chertow G.M., Coxson P.G., Moran A., Lightwood J.M., Pletcher M.J., and Goldman L. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590-599. doi:10.1056/NEJMoa0907355
- Cappuccio FP. Overview and evaluation of national policies, dietary recommendtions and programmes around the world aiming at reducing salt intake in the population. World Health Organization. Reducing salt intake in populations: report of a WHO forum and technical meeting. WHO Geneva 2007;1-60.
- Chen J, Gu D., Jaquish C.E., Chen C., Rao D.C., Liu D., Hixson J.E., Lee Hamm L., Gu C.C., Whelton P.K. and He J. for the GenSalt Collaborative Research Group. Association Between Blood Pressure Responses to the Cold Pressor Test and Dietary Sodium Intervention in a Chinese Population. Arch Intern Med. 2008;168:1740-1746. doi:10.1001/archinte.168.16.1740
- Denton D., Weisinger R., Mundy N.I., Wickings E.J., Dixson A., Moisson P., Pingard A.M., Shade R., Carey D., Ardaillou R., Paillard F., Chapman J., Thillet J. & Michel J.B. The effect of increased salt intake on blood pressure of chimpanzees. Nature Med 1995;10:1009-1016. doi:10.1038/nm1095-1009
- Ford E.S., Ajani U.A., Croft J.B., Critchley J.A., Labarthe D.R., Kottke T.E., Giles W.H, and Capewell S. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med 2007;356:2388-2398. doi:10.1056/NEJMsa053935
- Geleijnse J.M., Witteman J.C., den Breeijen J.H., Hofman A., de Jong P., Pols H.A. and Grobbee D.E. Dietary electrolyte intake and blood pressure in older subjects: the Rotterdam Study. J Hyperten 1996;14:73741.
- Harlan W.R. and Harlan L.C. Blood pressure and calcium and magnesium intake. In: Laragh J.H., Brenner B.M., eds. Hypertension: pathophysiology, diagnosis and management. 2end ed. New York: Raven Press 1995;1143-1154
- Holmes E., Loo R.L., Stamler J., Bictash M., Yap I.K.S., Chan Q., Ebbels T., De Iorio M., Brown I.J., Veselkov K.A., Daviglus M.L., Kesteloot H., Ueshima H., Zhao L., Nicholson J.K. and Elliott P. Human metabolic phenotype diversity and its association with diet and blood pressure. Nature 2008;453:396-400. doi:10.1038/nature06882
- Pickering T.G. New guidelines on diet and blood pressure. Hypertension 2006;47:135-136. doi:10.1161/01.HYP.0000202417.57909.26
- Simpson F.O. Blood pressure and sodium intake. In: Laragh J.H., Brenner B.M. eds. Hypertension: pathophysiology, diagnosis and management. 2end ed. New York: Raven Press 1995;273-281
- Strazzullo P., D’Elia L., Kandala N. and Cappuccio F.P. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ 2009;339:b4567. doi:10.1136/bmj.b4567
- Tzoulaki I., Brown I.J., Chan Q., Van Horn L., Ueshima H., Zhao L., Stamler J., Elliott P., for the International Collaborative Research Group on Macro-/Micronutrients and Blood Pressure. Relation of iron and red meat intake to blood pressure: cross sectional epidemiological study. BMJ 2008;337:a258. doi:10.1136/bmj.a258
- Weinberger M.H. The effects of sodium on blood pressure in humans. In: Laragh JH, Brenner BM, eds. Hypertension: pathophysiology, diagnosis and management. 2end ed. New York: Raven Press 1995;2703-2714.
- Writing Group of the PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER Clinical Trial. JAMA 2003;289:2083-2093. doi:10.1001/jama.289.16.2083
- World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. Guidelines and recommendations. J Hyperten 2003;21:1983-1992.