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The!recommendations!for!sodium!restriction!put!forth!in!
the!US!Dietary!Guidelines!are!justified!as!a!means!to!
reduce!the!risk!of!hypertension!and!heart!disease.!
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Con$Argument$

Katie!Dinkel,!Leigh!Osborne,!Liz!Sullivan!
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Table!of!Contents!
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Background!Research..!1!
Research!Disputing!Current!Guidelines!..!14!
Research!Supporting!Current!Guidelines!27!
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Leigh&Osborne-Background&Research&&

Background&Research&&
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The&USDA&currently&recommends&that&the&general&population&consume&less&than&2,300&

mg&of&sodium&and&that&the&following&populations&reduce&intake&to&1,500&mg:&persons&over&51&
years,&African&Americans,&and&persons&who&have&hypertension,&diabetes&or&chronic&kidney&
disease&(1).&These&guidelines&are&in&place&to&prevent&hypertension&and&cardiovascular&disease&in&
the&general&public.&However,&a&growing&body&of&research&suggests&that&lowering&sodium&intake&
may&not&have&a&beneficial&effect&on&blood&pressure&for&the&general&population&and&could&possibly&
contribute&to,&rather&than&prevent&cardiovascular&related&events.&&&
&

A&review&article&done&by&Alderman&and&Cohen&in&2012&provides&insight&into&the&

physiological&role&that&sodium&plays&in&the&body,&and&provides&a&review&of&epidemiological&as&
well&as&randomized&clinical&trials&investigating&the&relationship&between&sodium&intake&and&
cardiovascular&disease&(2).&The&authors&of&this&review&concluded&that&lowering&sodium&intake&
does&not&have&an&effect&on&blood&pressure&in&those&with&normal&kidney&functioning,&however&it&
may&be&beneficial&for&those&with&hypertension&(2).&This&finding&was&also&supported&by&the&data&
from&a&meta-analysis&done&with&randomized&controlled&trials&that&included&a&total&of&1,131&
hypertensive&patients&and&2,374&normotensive&patients&(3).&&A&meta-analysis&of&the&NHANES&III&
and&IV&studies&did&not&find&a&direct&positive&relationship&between&sodium&intake&and&
hypertension,&and&in&fact&an&inverse&relationship&was&observed&in&systolic&hypertensive&
participants&(4).&&This&study&also&found&that&low&intake&of&potassium,&calcium,&and&magnesium&
was&associated&with&systolic&hypertension&(4).&&
&

The&Alderman&and&Cohen&review&also&discussed&the&negative&hormonal&implications&

associated&with&low&sodium&consumption&(2).&&Also&in&support&of&these&implications,&a&random,&
double&blind&clinical&trial&done&with&mildly&hypertensive&patients&found&that&low&sodium&intake&
was&associated&with&increased&insulin&resistance,&increased&serum&cholesterol,&increased&

Leigh&Osborne-Background&Research&&

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concentration&of&apoB&proteins,&and&decreased&apoA-1&concentration&(5).&Further&data&from&the&
Alderman&and&Cohen&review&suggests&that&sodium&intake&and&negative&cardiovascular&outcomes&
have&a&J&-shaped&relationship&with&the&most&risk&occurring&with&intake&below&2&g&and&above&
intake&of&6&g&of&sodium&per&day&(2).&A&meta-analysis&that&included&data&from&45&countries&from&
the&years&1957&to&2010,&concluded&that&the&average&world-wide&intake&of&sodium&ranges&from&
2,622-4,830&mg/d,&and&suggested&that&sodium&intake&is&driven&by&biological&need,&in&a&range&that&
the&Alderman&and&Cohen&review&found&to&be&unassociated&with&increased&cardiovascular&events&
(6).&To&conclude,&a&review&article&of&an&IOM&report&is&included,&discussing&the&appropriateness&of&
the&current&sodium&intake&recommendations&(7).&&
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Leigh&Osborne-Background&Research&&

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References!
1. U.S.!Department!of!Agriculture!and!U.S.!Department!of!Health!and!Human!
Services.!Dietary!Guidelines!for!Americans,!2010.!7th!Edition,!Washington,!
DC:!U.S.!Government!Printing!Office,!December!2010.!!
2. Alderman!MH,!Cohen!HW.!Dietary!sodium!intake!and!cardiovascular!
mortality:!controversy!resolved?!Curr$Hypertens$Rep.!2012;14(3):193R201.!
3. Midgley!JP,!Matthew!AG,!Greenwood!CM,!Logan!AG.!Effect!of!reduced!dietary!
sodium!on!blood!pressure:!a!metaRanalysis!of!randomized!controlled!trials.!
JAMA.!1996;275(20):1590R1597.!
4. Townsend&MS,&Fulgoni&VL&3rd,&Stern&JS,&Adu-Afarwuah&S,&McCarron&DA.&Low&mineral&
intake&is&associated&with&high&systolic&blood&pressure&in&the&Third&and&Fourth&National&
Health&and&Nutrition&Examination&Surveys:&could&we&all&be&right?&Am#J#Hypertens.&
2005;18(2&Pt&1):261-269.&doi:10.1016/j.amjhyper.2004.09.017.!

5. Del&Rio&A,&Rodriguez-Villamil&JL.&Metabolic&effects&of&strict&salt&restriction&in&essential&
hypertensive&patients.&J#Intern#Med.&1993;233(5):409-414.!

6. McCarron&DA,&Kazaks&AG,&Geerling&JC,&Stern&JS,&Graudal&NA.&Normal&range&of&human&
dietary&sodium&intake:&a&perspective&based&on&24-hour&urinary&sodium&excretion&
worldwide.&Am#J#Hypertens.&2013;26(10):1218-1223.&doi:10.1093/ajh/hpt139.!

7. McGuire&S.&U.S.&Department&of&Agriculture&and&U.S.&Department&of&Health&and&Human&
Services,&&Dietary&Guidelines&for&Americans,&2010.&7th&Edition,&Washington,&DC:&U.S.&
Government&Printing&Office,&January&2011.&Adv#Nutr.&2011;2(3):293-294.&
doi:10.3945/an.111.000430.!
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Leigh&Osborne-Background&Research&&

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Alderman&MH,&Cohen&HW.&Dietary&sodium&intake&and&cardiovascular&mortality:&controversy&
resolved?&Curr#Hypertens#Rep.&2012;14(3):193-201.&&
&
In&order&to&perform&a&through&investigation&into&the&health&consequences&of&reducing&
sodium&intake&this&article&reviewed&randomized&controlled&trials&investigating&the&physiological&
impacts&of&ingestion&of&varying&levels&of&sodium,&23&observational&studies&linking&dietary&sodium&
to&cardiovascular&disease,&and&9&randomized&clinical&trials&comparing&morbidity&and&mortality&
rates&to&sodium&intake.&&
&
Physiological+consequences+of+sodium+reduction+
Several&studies&found&that&reducing&sodium&intake&by&an&average&of&2.9&grams&per&day&
(64%&from&4.5&to&1.6&g)&could&reduce&mean&systolic&blood&pressure&ranging&from&1&to&10&mmHg&
and&that&this&effect&was&greater&in&older,&black,&and&hypertensive&individuals.&&However,&in&most&
individuals,&healthy&kidneys&can&accommodate&changes&in&sodium&intake,&and&a&change&in&blood&
pressure&is&not&observed.&&
Decreased&sodium&intake&was&also&associated&with&increased&sympathetic&activation,&
plasma&renin&activity,&aldosterone&secretion,&serum&cholesterol&and&triglyceride&levels,&resistance&
to&insulin,&and&adrenaline&secretion.&These&effects&have&consistently&been&shown&in&multiple&
randomized&clinical&trials.&&
These&results&suggest&that&sodiums&effect&on&blood&pressure&is&not&the&only&
physiological&effect&to&consider&when&setting&dietary&sodium&recommendations.&&
&
Epidemiological+evidence+of+association+with+cardiovascular+disease+morbidity+and+mortality+
+

Among&the&23&studies&analyzed,&results&were&conflicting&concerning&sodium&intake&and&

negative&cardiovascular&outcomes.&&9&of&these&studies,&conducted&with&various&populations,&used&
urinary&excretion&to&assess&sodium&intake&and&1&showed&a&direct&relationship,&three&showed&an&
inverse&relationship,&2&showed&a&J&shaped&curve,&and&3&showed&no&relationship.&Based&on&the&
results&of&these&studies&the&authors&concluded&that&in&the&majority&of&studies&where&sodium&
intake&was&less&than&4.5g/day,&there&was&an&inverse&association&with&intake&and&outcome&
showing&that&lower&sodium&intake&was&associated&with&increased&cardiovascular&morbidity&and&
mortality.&They&also&concluded&that&when&subjects&daily&intake&of&sodium&was&higher&than&
4.5g/day,&a&positive&correlation&between&sodium&intake&and&cardiovascular&events&was&observed.&
In&a&study&done&with&European&adults&with&type&1&diabetes,&a&J-shaped&curve&was&seen,&with&

Leigh&Osborne-Background&Research&&

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cardiovascular&risk&increasing&when&sodium&intake&was&less&than&2.0g&and&greater&than&4.6g.&Also&
an&analysis&of&hypertensive&treatment&trials&resulted&in&the&conclusion&that&CVD&events&were&
lowest&in&subjects&whose&sodium&intakes&were&between&4.0g&and&5.9g/day,&with&increased&risk&
above&and&below&these&levels.&&
&

These&correlational&studies&do&not&prove&causation,&but&they&do&raise&concern&about&the&

current&USDA&recommendations&for&sodium&being&set&at&2,300&mg/day&and&provide&ample&
background&for&further&clinical&trials&to&be&done.&&
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Randomized+clinical+trials+comparing+morbidity+and+mortality+to+sodium+intake+
&

This&study&first&focused&on&7&clinical&trials&that&the&2011&Cochrane&collaboration&

reviewed&and&concluded&that&the&evidence&was&insufficient&to&associate&a&reduction&in&sodium&
with&positive&health&effects.&&5&of&the&studies&had&flawed&designs&to&effectively&determine&a&
morbidity&or&mortality&effect&based&on&sodium&intake.&&1&study&found&a&marginally&significant&
reduction&in&cardiovascular&events&associated&with&a&low&sodium&diet,&however&this&was&paired&
with&potassium&supplementation,&so&the&cause&of&the&outcome&is&unclear.&&The&last&study&
observed&increased&hospitalization&and&mortality&in&heart&failure&patients&assigned&a&1.8g&of&
sodium&per&day,&compared&with&those&assigned&2.8g&per&day,&with&all&other&treatments&constant&
between&groups.&These&results&were&supported&by&2&additional&studies&not&included&in&the&
Cochrane&review.&
&

Based&on&these&results,&its&suggested&that&the&current&USDA&recommendations&

concerning&sodium&have&the&potential&to&cause&more&cardiovascular&harm&rather&than&
prevention.&&
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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(20):1590-1597.&
&
In&order&to&determine&the&effect&of&dietary&sodium&restriction&on&blood&pressure&in&
hypertensive&and&normotensive&individuals,&a&meta-analysis&was&conducted&including&56&trials&
(28&hypertensive&and&28&normotensive)&that&met&the&following&criteria:&randomized&allocation&to&
control&and&intervention&groups,&monitored&by&timed&sodium&excretion,&and&outcome&measures&
of&both&systolic&and&diastolic&blood&pressure.&The&average&age&in&the&normotensive&group&was&26&
years&versus&47&years&in&the&hypertensive&group.&There&was&no&information&given&in&regards&to&
gender&distribution.&There&was&a&total&of&1131&hypertensive&patients&studied&and&2374&
normotensive&patients&studied.&&
Of&the&56&trials,&41&used&a&crossover&study&design,&with&the&median&duration&of&
intervention&being&14&days.&The&mean&dietary&sodium&reduction&in&the&trials&done&with&
hypertensive&patients&was&95&mmol/d&(71-119mmol/d)&and&the&mean&sodium&reduction&in&the&
trials&done&with&normotensive&patients&was&125&mmol/d&(95-156&mmol/d).&&

&
Comparisons&were&made&between&baseline&and&end&of&study&blood&pressure&readings&
(systolic&and&diastolic)&for&normotensive&and&hypertensive&patients.&The&data&was&adjusted&for&
measurement&error&of&urinary&sodium&excretion.&After&a&100-mmol/d&reduction&in&daily&sodium&

Leigh&Osborne-Background&Research&&

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excretion&the&mean&decrease&in&blood&pressure&in&the&hypertensive&patients&was&3.7mm&Hg&
(P<.001)&for&systolic&and&0.9&mm&Hg&(P=0.09)&for&diastolic.&In&normotensive&patients,&the&mean&
decrease&in&blood&pressure&was&1.0&mm&Hg&(P<.001)&for&systolic&and&0.1&mm&Hg&(&(P=.64)&for&
diastolic.&&
&

A&subgroup&analysis&was&done&and&it&was&found&that&there&was&a&greater&decrease&in&

blood&pressure&observed&in&hypertensive&individuals&45&years&or&older&compared&with&all&
hypertensive&individuals&&(mean&6.3&mm&Hg&decrease&for&systolic&and&2.2&mm&hg&decreased&for&
diastolic).&In&hypertensive&patients&under&45&years,&the&mean&systolic&decrease&in&blood&pressure&
was&smaller&and&the&mean&decreased&in&diastolic&blood&pressure&was&negligible&and&not&
significant.&&
&
Conclusion:&This&data&suggests&that&a&reduction&of&dietary&sodium&does&not&have&a&significant&
impact&on&blood&pressure&in&healthy&(normotensive)&individuals.&While&there&may&be&some&
short-term&reduction&in&blood&pressure&in&response&to&reducing&sodium&intake&in&hypertensive&
individuals&over&45,&this&does&not&warrant&a&recommendation&to&the&general&public&to&reduce&
sodium&intake&for&blood&pressure&lowering&effects.&&
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Townsend&MS,&Fulgoni&VL&3rd,&Stern&JS,&Adu-Afarwuah&S,&McCarron&DA.&Low&mineral&intake&is&
associated&with&high&systolic&blood&pressure&in&the&Third&and&Fourth&National&Health&and&
Nutrition&Examination&Surveys:&could&we&all&be&right?&Am#J#Hypertens.&2005;18(2&Pt&1):261-269.&
doi:10.1016/j.amjhyper.2004.09.017.&
&
In&order&to&assess&the&relationship&between&hypertension&and&mineral&intake&data&from&
NHANES&III&survey&(10,033&participants)&and&NHANES&IV&survey&(2,311&participants)&was&
examined.&The&following&criteria&was&used&for&inclusion&in&this&study:&age&20-75&years,&not&
pregnant,&not&lactating,&not&taking&medicine&for&blood&pressure&or&diabetes,&and&not&diagnosed&
with&hypertension&or&diabetes.&In&NHANES&III&8988&participants&were&found&to&be&normotensive&
(48%&male,&52%&female)&and&1045&were&found&to&be&hypertensive&(63%&male,&37%&female).&In&
NHANES&IV&2012&participants&were&found&to&be&normotensive&(50%&male,&50%&female)&and&299&
were&found&to&be&hypertensive&(55%&male,&45%&female).&&
Both&NHANES&surveys&utilized&a&complex,&stratified,&multistage&probability&cluster&
sampling&design.&Both&surveys&consisted&of&in&home&interviews&and&3-hour&examinations&in&the&
Mobile&Examination&Center.&Nutrient&information&was&extrapolated&from&24-hour&recalls&and&
calcium,&magnesium,&and&potassium&were&combined&for&a&mineral&variable,&while&the&
sodium/potassium&ratio&was&calculated&as&another&variable.&&
Comparisons&were&made&between&hypertensive&(systolic,&diastolic,&and&both)&and&
normotensive&subjects.&Calcium&intake&was&significantly&lower&in&hypertensive&individuals&in&the&
NHANES&III&study&(80232.2&mg&vs&86012.5&mg)&and&was&marginally&lower&in&the&NHANES&IV&
study&(78844.5&mg&vs&88019.2&mg)&compared&with&normotensive&individuals.&Intakes&between&
normotensive&and&hypertensive&groups&in&both&studies&did&not&differ&in&sodium,&potassium,&or&
magnesium.&&
Significantly&lower&mineral&intake&(potassium,&calcium,&and&magnesium)&was&seen&in&the&
systolic&hypertensive&group&(NHANES&III:&100&3.5&mmol,&NHANES&IV:&93.1&4.0&mmol)&compared&
to&diastolic&(NHANES&III:&114&5.6&mmol,&NHANES&IV:110&8.8&mmol)&and&combined&hypertensive&
groups&(NHANES&III:&113&6.7&mmol,&NHANES&IV:&109&7.6&mmol)&in&both&studies,&related&to&
lower&intakes&of&dairy&products,&fruits,&and&vegetables.&&
Dietary&sodium&intake&was&significantly&lower&in&individuals&with&isolated&systolic&
hypertension&compared&with&normotensive&individuals&(3257156.2&mg/day&vs&368644.4&&
mg/day&in&NHANES&III&and&3171156.6&&mg/day&vs&358451.6&&mg/day&in&NHANES&IV).&&

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&
Conclusions:&This&data&suggests&that&a&diet&low&in&sodium&does&not&necessarily&help&prevent&
hypertension&and&that&it&may&be&more&beneficial&to&focus&on&a&patients&overall&nutrition&profile&
for&dietary&management&of&hypertension,&rather&than&placing&so&much&emphasis&on&one&
nutrient.&&
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Del&Rio&A,&Rodriguez-Villamil&JL.&Metabolic&effects&of&strict&salt&restriction&in&essential&
hypertensive&patients.&J#Intern#Med.&1993;233(5):409-414.&
In&order&to&study&the&metabolic&effects&of&severe&salt&restriction&in&mildly&hypertensive&
patients,&30&non-diabetic,&mildly&hypertensive&(DBP&90-104&mmHg)&untreated&patients&(17&
males,&13&females,&ages&30-65&years)&with&normal&kidney&function&successfully&completed&this&
study.&
After&a&2-week,&normal&diet,&no&medication&washout&period,&in&a&random,&double-blind&
clinical&trial,&patients&were&assigned&to&eat&a&low&salt&diet&of&2&g/day&and&take&5&placebo&pills/day&
or&to&eat&the&same&diet&with&2&grams&of&salt&plus&the&ingestion&of&5&NaCl&pills&per&day&(2&g&of&NaCl&
in&each)&for&two&weeks.&After&another&2-week&washout&period,&the&patients&were&assigned&to&the&
opposite&diet&than&previously&followed,&for&two&weeks.&Patients&were&educated&on&how&to&
accomplish&these&diets,&and&emphasis&was&placed&on&keeping&fat&and&fiber&content&consistent.&At&
the&end&of&each&low&or&high&salt&diet&the&following&was&measured:&blood&pressure,&body&weight,&
urinary&24&hour&excretion&of&sodium&and&potassium,&and&serum&levels&of&plasma&lipid&and&
alipoprotein&concentrations,&and&immunoreactive&insulin,&plasma&renin&activity.&&
Comparisons&were&made&between&patient&lab&values&taken&after&a&low&salt&diet&versus&after&a&
high&salt&diet.&

There&was&not&a&significant&difference&found&between&the&dietary&periods&in&regards&to&
blood&pressure,&likely&due&to&the&compensatory&increase&(139%)&in&plasma&renin&activity&
seen&in&the&low&salt&diet.&&

Levels&of&plasma&glucose&were&the&same&for&both&dietary&periods,&with&plasma&insulin&
being&significantly&higher&(26%&increase)&during&the&low-salt&diet.&This&could&indicate&an&
increase&in&insulin&resistance&during&the&low-salt&period.&&

After&the&low-salt&diet,&total&concentration&of&serum&cholesterol&increased&by&5%,&serum&
concentration&of&apoB&proteins&increased&by&10%&and&the&concentration&of&apoA-1&
decreased&by&10%.&&There&was&not&a&significant&difference&in&triglycerides&between&the&
dietary&periods.&

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Conclusion:&Sodium&intake&did&not&have&an&affect&on&blood&pressure.&However,&low&sodium&
intake&was&associated&with&increased&risk&factors&that&could&lead&to&cardiovascular&disease,&
rather&than&prevent&it.&&
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McCarron&DA,&Kazaks&AG,&Geerling&JC,&Stern&JS,&Graudal&NA.&Normal&range&of&human&dietary&
sodium&intake:&a&perspective&based&on&24-hour&urinary&sodium&excretion&worldwide.&Am#J#
Hypertens.&2013;26(10):1218-1223.&doi:10.1093/ajh/hpt139.&
&
In&order&to&expand&upon&previous&research&(1),&which&concluded&that&there&is&a&normal&
range&of&human&sodium&intake&that&is&defined&by&biological&needs,&rather&than&food&supply,&
additional&studies&were&meta-analyzed,&expanding&the&numbers,&durations,&and&cultures&
observed.&&
Researchers&analyzed&data&from&studies&not&previously&used&that&included&24-hour&UNaV&
data&sets&from&free-living&people.&This&study&did&not&include&age,&gender&or&disease&data.&The&
following&data&was&extracted&from&each&study:&sample&size,&mean&SD&of&the&reported&24-hour&
UNaV,&sex&composition&of&the&sample,&time&period&of&data&collected,&and&country&of&origin.&&
129&new&data&sets&were&analyzed,&which&included&50,060&participants&and&an&additional&
12&countries&to&those&previously&studied.&When&added&to&the&old&data&set,&there&is&a&total&of&
69,011&participants,&190&collection&sites&in&45&countries&and&a&span&of&more&than&50&years&(19572010).&This&data&set&represents&populations&exposed&to&a&wide&variety&of&food&sources&as&
availability&changes&over&time&and&location.&&
Using&combined&data&sets,&the&mean&estimated&intake&of&sodium&was&159.422.3&
mmol/d&(3,666&mg/day)&with&a&range&of&114-210&mmol/day&(2,622-4,830&mg/d).&There&was&no&
significant&variation&based&on&ethnicity&or&age.&This&data&suggests&that&there&is&a&fairly&narrow,&
biologically&determined&range&of&human&sodium&intake&that&is&not&affected&by&decade,&location,&
or&food&diversity.&&
&
Reference&Cited:&
1.&&

McCarron&DA,&Geerling&JC,&Kazaks&AG,&Stern&JS.&Can&dietary&sodium&intake&be&

&

modified&by&public&policy?&Clin#J#Am#Soc#Nephrol.&2009;4(11):1878-1882.&

&

doi:10.2215/CJN.04660709.&

&
&
&
&
&
&
&

12

Leigh&Osborne-Background&Research&&

!
McGuire&S.&U.S.&Department&of&Agriculture&and&U.S.&Department&of&Health&and&Human&
Services,&&Dietary&Guidelines&for&Americans,&2010.&7th&Edition,&Washington,&DC:&U.S.&Government&
Printing&Office,&January&2011.&Adv#Nutr.&2011;2(3):293-294.&doi:10.3945/an.111.000430.&
&
Due&to&conflicting&research&the&CDC&of&the&U.S.&Department&of&Health&and&Human&
Services&asked&the&Institute&of&Medicine&to&determine&the&appropriateness&of&the&current&
recommendations&for&sodium&intake.&The&literature&was&reviewed&and&conclusions&were&
published&in&a&2013&report,&Sodium#Intake#in#Populations;#Assessment#of#Evidence.&&
&
The+following+conclusions+were+made:+
1. Evidence&suggests&an&association&between&higher&salt&intake&and&greater&risk&for&
cardiovascular&disease&in&the&United&States,&which&supports&the&current&
recommendations&of&lowering&salt&intake&based&on&blood&pressure&data.&&
2. Evidence&does&not&support&a&positive&or&negative&effect&of&lowering&sodium&intake&to&
<2300&mg/d&in&the&general&population,&in&reference&to&cardiovascular&risk&or&mortality.&&
3. There&is&insufficient&evidence&to&suggest&a&negative&effect&of&low&sodium&intakes&(<1840&
mg/d)&in&mid-&to&late-stage&coronary&heart&failure&patients,&with&low&ejection&rates&and&
undergoing&aggressive&therapeutic&intervention.&These&interventions&are&not&typically&
used&in&the&United&States,&so&the&generalizability&of&this&conclusion&depends&on&further&
research.&
4. For&at&risk&populations,&such&as&those&with&diabetes&or&prehypertension,&the&data&does&
not&support&additional&benefits&of&lowering&sodium&intake&to&<2300&mg/d.&It&was&
concluded&that&different&sodium&diets&than&recommended&for&the&general&population&
should&not&be&prescribed&for&these&sub&groups.&&
&
Further+research+needs+to+be+done+in+the+following+areas:+
1. Establishment&and&use&of&standardized&methods&of&assessing&sodium&intake.&&
2. The&evaluation&of&outcomes&related&to&current&sodium&recommendations.&
3. Analyses&that&measure&health&outcomes&as&well&as&other&factors&like&potassium&balance,&
energy&intake,&and&use&of&anti-hypertensive&medication.&&
4. Further&randomized,&clinical&intervention&trials&to&further&explore&the&physiological&
mechanisms&involved&in&sodiums&role&in&health&and&disease.&&

13

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&

Research&Disputing&Current&Guidelines!
!
The&general&recommendations&by&the&US&dietary&guidelines&for&a&sodium&restriction&are&
not&justified&as&a&means&to&reduce&the&risk&for&hypertension&and&heart&disease.&In&order&for&a&
general&recommendation&to&be&made,&further&research&is&necessary&to&understand&the&
regulatory&mechanisms&of&sodium&and&water&in&the&body&(1).&The&following&long+term&and&short+
term&primary&studies,&including&one&meta+analysis,&illustrate&the&need&to&address&the&
consequences&that&result&from&a&low+sodium&diet&in&persons&with&normal&blood&pressure,&high&
blood&pressure,&compensated&heart&failure,&and&uncompensated&heart&failure.&
Sodium&is&required&for&multiple&cellular&processes.&Without&sodium,&we&simply&wouldnt&
exist&as&human&beings.&Due&to&the&indisputable&need&of&sodium&in&the&body,&there&are&many&
ways&in&which&we&are&able&to&regulate&how&much&is&retained&and&how&much&is&excreted&so&that&
the&amount&of&sodium&excreted&in&the&urine&directly&reflects&sodium&intake&(2).&While&effects&of&
sodium&on&cardiovascular&disease&have&been&studied&extensively,&the&regulatory&mechanisms&
have&made&it&difficult&for&there&to&be&consistent&data&showing&that&a&low+sodium&diet&causes&a&
decrease&in&mortality&from&cardiovascular&disease&(2).&&
The&following&five&studies&discuss&harmful&outcomes&from&consuming&a&low&sodium&diet,&
such&as&an&increase&in&the&neurohormonal&response&(1,&3,&4),&increased&lipid&levels&(3),&increased&
hospital&readmissions&(1,&4),&and&increased&mortality&(1,&4).&These&outcomes&make&a&strong&case&
for&the&negative&and&null&(5)&effects&of&a&low+sodium&diet&on&hypertension&and&heart&disease,&and&
provide&significant&evidence&for&other&factors&that&influence&blood&pressure&such&as&calorie&(6)&
and&fluid&restriction&(1,&4).&Before&a&general&recommendation&can&be&made&to&reduce&dietary&
sodium,&the&conclusions&made&from&the&following&research&studies&need&to&be&put&into&serious&
consideration.&&
!
!
!
!
!
!
!
!
!
!
!

14

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
!
!
References:!
!
1. Parrinello&G,&Di&Pasquale&P,&Licata&G,&et&al.&Long+term&effects&of&dietary&sodium&intake&on&
cytokines&and&neurohormonal&activation&in&patients&with&recently&compensated&
congestive&heart&failure.&J.#Card.#Fail.&2009;15(10):864+73.&&
2. McCarron&D&a,&Kazaks&AG,&Geerling&JC,&Stern&JS,&Graudal&N&a.&Normal&range&of&human&
dietary&sodium&intake:&a&perspective&based&on&24+hour&urinary&sodium&excretion&
worldwide.&Am.#J.#Hypertens.&2013;26(10):1218+23.&&
3. Graudal&NA,&Galle&AM,&Garred&P.&Effects&of&sodium&restriction&on&blood&pressure,&renin,&
aldosterone,&catecholamines,&cholesterols&and&triglyceride.&2015;279(17):1383+1391.&
4. Paterna&S,&Parrinello&G,&Cannizzaro&S,&et&al.&Medium&term&effects&of&different&dosage&of&
diuretic,&sodium,&and&fluid&administration&on&neurohormonal&and&clinical&outcome&in&
patients&with&recently&compensated&heart&failure.&Am.#J.#Cardiol.&2009;103(1):93+102.&&
5. Aliti&GB,&Rabelo&ER,&Clausell&N,&Rohde&LE,&Biolo&A,&Beck+da+Silva&L.&Aggressive&fluid&and&
sodium&restriction&in&acute&decompensated&heart&failure:&a&randomized&clinical&trial.&
JAMA#Intern.#Med.&2013;173(12):1058+64.&doi:10.1001/jamainternmed.2013.552.&
6. Hypertension&prevention&trial:&three+year&effects&of&dietary&changes&on&blood&pressure.&
Arch#Intern.#Med.#1990;150:153+162.&
&
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
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!
!
!

15

!
Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
&
Graudal&NA,&Galle&AM,&Garred&P.&Effects&of&sodium&restriction&on&blood&pressure,&renin,&
aldosterone,&catecholamines,&cholesterols&and&triglyceride.&2015;279(17):1383+1391.&
&
In&order&to&quantify&the&effects&of&a&low&sodium&diet&on&blood&pressure,&body&weight,&
and&plasma&or&serum&levels&of&renin,&aldosterone,&catecholamines,&cholesterol,&and&triglycerides,&
a&cumulative&meta+analysis&was&performed&on&studies&from&Medline&between&1966&and&1997.&
Inclusion&criteria&included:&(1)&participants&randomized&to&either&a&low+sodium&or&high+sodium&
diet,&(2)&sodium&intake&measured&by&24+hour&urinary&sodium&excretion,&(3)&concurrent&
interventions&(such&as&antihypertensive&medication&or&potassium&supplementation,&etc.)&were&
identical&in&both&low+sodium&and&high+sodium&diets,&(4)&studies&reported&systolic&blood&pressure&
(SBP),&diastolic&blood&pressure&(DBP),&and&mean&blood&pressure&(MBP),&and&(5)&the&mean&age&
higher&than&15&years.&
A&total&of&83&references&were&used,&which&included&114&randomized&trials.&From&each&
trial,&the&following&data&was&extracted:&sample&size,&mean&age,&ratio&of&females&to&males,&
duration&of&the&intervention,&method&of&measurement&of&sodium,&SBP&and&DBP&before&and&after&
the&intervention,&the&differences&between&SBP&and&DBP&during&low+sodium&and&high+sodium&
diets,&P&values&and&t&values&to&show&significant&differences,&and&blood&levels&of&hormones&and&
lipids.&&
114&randomized&trials&were&used,&which&included:&
"

58&hypertensive&study&samples&containing&low+sodium&and&high+sodium&treatment&
groups&

"

Median&age&=&49&years&(range&=&23+73)&

Median&study&duration&=&28&days&(range&=&4+365)&

Total&participants&=&2161&

56&normotensive&study&samples&containing&low+sodium&and&high+sodium&treatment&
groups&

Median&age&=&27&years&(range&=&15+67)&

Median&study&duration&=&8&days&(range&4+1100)&

Total&participants&=&2581&

16

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
Overall,&the&low+sodium&groups&all&showed&a&significant&increase&in&renin&(P&=&0.47)&and&
aldosterone&(P&=&0.13).&In&22&samples&where&less&than&20&mmol/24&hours&of&sodium&was&
excreted,&there&was&an&increase&in&plasma&renin&by&a&factor&of&5.7&and&plasma&aldosterone&by&a&
factor&of&5.0.&There&were&no&differences&between&normotensive&and&hypertensive&groups&in&their&
renin&and&aldosterone&responses.&However,&noradrenaline&secretion&was&much&more&responsive&
in&hypertensive&participants&than&normotensive&participants.&Recent&studies&have&shown&that&
there&is&a&greater&risk&for&myocardial&infarction&in&persons&with&a&high&renin&profile&as&well&as&in&
males&with&a&low&sodium&excretion.&
Highly&reduced,&short+term&sodium&intake&had&small&adverse&effects&on&lipid&profile.&
There&was&a&significant&increase&in&cholesterol&and&LDL&in&the&low+sodium&group.&There&was&an&
increase&in&adrenaline&and&triglyceride&levels,&but&neither&was&significant.&There&was&no&change&
in&HDL&levels.&Further&investigations&are&necessary&for&concluding&the&clinical&significance&and&
long+term&changes&on&hormones&and&lipid&profile&in&low+sodium&diets.&&
The&authors&found&that&blood&pressure&decreased&by&1.2/0.3&mm&Hg&in&normotensive&
persons&when&there&was&a&mean&daily&sodium&reduction&of&160&mmol/24&hours&for&seven&days.&
According&to&the&authors,&a&blood&pressure&change&of&less&than&1&mm&Hg&in&normotensive&
individuals&is&not&significant&enough&to&support&a&general&recommendation&to&reduce&sodium&
consumption.&&
Blood&pressure&decreased&by&3.9/1.9&mm&Hg&in&hypertensive&persons&when&there&was&a&
mean&daily&sodium&reduction&of&118&mmol/24&hours&for&28&days.&A&blood&pressure&change&of&
3.9/1.9&mm&Hg&in&hypertensive&individuals&is&a&smaller&effect&than&antihypertensive&drugs.&
According&to&the&authors,&this&indicates&that&a&low+sodium&diet&could&be&used&as&a&supplemental&
treatment&for&hypertension,&but&does&not&justify&a&general&recommendation&for&reduced&sodium&
intake.&
!
!
!
!
!
!
!
!
!

17

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
Hypertension&prevention&trial:&three+year&effects&of&dietary&changes&on&blood&pressure.&Arch#
Intern.#Med.#1990;150:153+162.&
&
The&affects&of&sodium,&potassium,&and&calorie&intake/restriction&on&841&healthy&men&and&
women&between&the&ages&of&25+49&years&was&studied&in&order&to&assess&preventative&measures&
for&hypertension.&Participants&were&followed&for&3&years&to&assess&how&dietary&changes&affected&
blood&pressure.&Other&inclusion&criteria&included:&(1)&diastolic&blood&pressures&between&76&
mm/Hg&and&99&mm/Hg&at&the&first&baseline&visit,&and&between&78&mm/Hg&and&89&mm/Hg&7+30&
days&later&at&the&second&baseline&visit.&Exclusion&criteria&included:&(1)&use&of&antihypertensive&
medications,&patients&with&cardiovascular&disease,&(2)&a&BMI&>35,&(3)&dietary&requirements&that&
were&incompatible&with&the&dietary&counseling,&(4)&consumption&of&21&or&more&alcoholic&drinks&
per&week,&or&(5)&unable&to&comply&with&the&study&schedule.&
Participants&were&randomly&assigned&into&the&control&group,&receiving&no&dietary&
counseling,&or&one&of&four&treatment&groups,&where&dietary&counseling&was&given&on&either&
calories&(Cal),&sodium&(Na),&sodium&+&calories&(NaCal),&and&sodium&+&potassium&(NaK).&The&
treatment&groups&met&for&dietary&counseling&once&per&week&for&the&first&10&weeks&of&the&study,&
then&once&every&two&weeks&for&the&next&4&weeks,&and&then&once&every&two&months&for&the&
remainder&of&the&study&and&follow+up.&Trained&personnel&with&experience&in&changing&behaviors&
such&as&shopping,&cooking,&and&eating&practices&were&in&charge&of&the&dietary&counseling.&
Data&was&collected&3&and&6&months&after&randomization,&and&every&6&months&during&the&
3+year&follow+up.&Data&collection&included&weight,&height,&urine&samples,&sodium&and&potassium&
levels,&24+hour&excretion&rates,&and&blood&pressure.&&
The&control&and&treatment&groups&were&as&follows:&

"

Control:&no&dietary&counseling&(n&=&196)&

"

Reduced&Cal&(n&=&125)&

"

Reduced&Na&(n&=&196)&&

"

Reduced&Na&+&Cal&(n&=&129)&

"

Reduced&Na&+&increased&K&(n&=&195)&

18

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
Blood&pressure&decreased&in&all&treatment&groups&when&compared&with&baseline&and&was&
below&the&levels&of&the&control&group.&However,&these&decreases&were&not&significant,&suggesting&
that&the&decreases&in&blood&pressure&were&likely&due&to&chance.&For&example,&the&reduced&Na&
treatment&group&resulted&with&decreased&blood&pressure,&but&was&not&statistically&significant&&
(+1.7&mm/Hg&at&6&months&of&follow+up,&p&=&0.13;&and&+0.1&mm/Hg&at&3&years&of&follow&up,&p&=&
0.89).&&
In&the&NaCal&treatment&group,&blood&pressure&changes&were&smaller&than&for&the&Cal&
treatment&group,&suggesting&that&when&sodium&and&calories&were&both&reduced,&there&was&less&
of&an&affect&on&blood&pressure.&There&was&no&significant&affect&on&blood&pressure&in&the&NaK&
treatment&group.&
There&were&no&differences&between&any&of&the&treatment&groups&in&relation&to&
hypertensive&events&or&morbidity&in&general&(indicated&by&hospitalization&and&deaths).&
&

&
!
!

&

19

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
Aliti&GB,&Rabelo&ER,&Clausell&N,&Rohde&LE,&Biolo&A,&Beck+da+Silva&L.&Aggressive&fluid&and&sodium&
restriction&in&acute&decompensated&heart&failure:&a&randomized&clinical&trial.&JAMA#Intern.#Med.&
2013;173(12):1058+64.&doi:10.1001/jamainternmed.2013.552.&
!
In&order&to&assess&whether&a&fluid+restricted&and&sodium+restricted&diet&would&affect&
weight&loss&and&clinical&stability&in&comparison&to&a&diet&without&those&restrictions,&75&inpatient&
adults&with&acute&decompensated&heart&failure&(ADHF)&were&studied.&Inclusion&criteria&included:&
(1)&adult&inpatients&with&ADHF&between&the&ages&of&49&and&71&who&had&systolic&dysfunction&
45%,&(2)&had&a&Boston&criteria&score&of&at&least&8,&and&(3)&were&recently&admitted&to&the&hospital&
(length&of&stay&was&no&more&than&36&hours).&&
Fluids&and&sodium&were&each&restricted&to&no&more&than&800&mL&and&mg/day&
respectively&for&7&days,&or&less&than&7&days&if&patients&were&discharged&before&then.&Every&day&a&
physical&examination&was&administered&for&patients&in&the&intervention&group&as&well&as&
perceived&thirst,&body&weight,&and&the&use&of&intravenous&diuretics,&vasodilators,&and&inotropes.&
The&control&group&was&able&to&drink&fluids&(at&least&2.5&L/d)&and&consume&sodium&(about&3+5&g/d)&
ad&libitum.&
Clinical&stability&and&weight&loss&were&measured&after&three&days.&Improvement&in&
clinical&congestion&and&termination&of&all&intravenous&pharmacotherapy&such&as&diuretics,&
inotropes&or&vasodilators&were&measured&as&clinical&stability.&To&measure&weight&loss,&digital&
scales&were&used&and&patients&were&weighed&wearing&as&little&clothing&as&possible,&barefoot,&and&
after&urination.&Perceived&thirst&was&measured&at&the&end&of&the&7+day&trial&by&a&patient+graded&
scale&from&0+10.&
Comparisons&were&made&between&two&groups:&
"

Intervention&Group&(IG):&sodium&and&fluid&restriction&(n=38)&

"

Control&Group&(CG):&no&restrictions&(n=37)&

&&&&&

&

20

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
Clinical&stability&(left):&There&was&a&similar&improvement&in&clinical&congestion&in&both&
groups.&At&baseline,&the&CG&was&scored&with&12.8&points&and&the&IG&was&scored&with&12.6&points&
(p&=&0.67).&After&three&days,&the&CG&was&given&a&score&of&+3.44&points&and&the&IG&was&given&a&
score&of&+4.03&points&(p&=&0.47).&&
Weight&loss&(right):&At&baseline,&the&mean&body&weight&was&similar&between&both&groups&
(p&=&0.29).&After&three&days,&there&were&no&significant&changes&between&the&groups.&The&CG&
mean&changed&by&+4.67&kg&and&the&IG&mean&changed&by&+4.67&(p&=&0.47).&&
Perceived&thirst&(below):&Perceived&thirst&was&similar&between&the&two&groups&at&
baseline.&At&the&end&of&the&study&period,&perceived&thirst&was&significantly&worse&in&the&IG&
(average&score&=&5.1)&than&the&CG&(average&score&=&2.0)&(p&=&0.01).&

&
During&the&duration&of&the&study,&there&were&no&significant&differences&between&groups&
of&the&differences&of&various&lab&tests&such&as&serum&creatinine,&urea,&sodium,&potassium,&and&
hemoglobin.&

&
Overall,&the&common&clinical&recommendation&for&patients&hospitalized&with&ADHF&to&
restrict&fluid&and&sodium&is&unlikely&beneficial,&and&likely&neutral.&
&

21

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
&
Parrinello&G,&Di&Pasquale&P,&Licata&G,&et&al.&Long+term&effects&of&dietary&sodium&intake&on&
cytokines&and&neurohormonal&activation&in&patients&with&recently&compensated&congestive&heart&
failure.&J.#Card.#Fail.&2009;15(10):864+73.&&
Long+term&effects&of&sodium&intake&on&cytokines&and&neurohormones&on&the&pathology&
of&heart&failure&were&studied&for&12&months.&Body&hydration&and&clinical&outcome&of&patients&
with&congestive&heart&failure&were&evaluated&in&173&patients&hospitalized&within&30&days&for&
worsening&advanced&heart&failure&between&the&ages&of&65&and&80&years.&Inclusion&criteria&
included:&(1)&a&functional&classification&for&congestive&heart&failure;&(2)&signs/symptoms&of&
congestive&heart&failure;&(3)&unresponsiveness&to&oral&treatment&of&high&doses&of&furosemide&
and/or&combinations&of&diuretics,&angiotension+converting&enzyme&inhibitors,&digitalis,&+
blockers,&and&nitrates;&(4)&left&ventricular&ejection&fraction&<35%;&(5)&serum&creatinine&<2&mg/dL;&
(6)&blood&urea&nitrogen&(BUN)&60&mg/dL;&(7)&reduced&urinary&volume&(<500&mL/24&hrs);&and&(8)&
low&natriuresis&(<60&mEq/24&hrs).&Exclusion&criteria&included:&(1)&cerebral&vascular&disease;&(2)&
dementia;&(3)&cancer;&(4)&uncontrolled&diabetes;&(5)&severe&hepatic&disease;&(6)&pacemaker&
implants;&and&(7)&alcoholic&habits.&
Participants&were&randomly&assigned&to&either&a&low+sodium&diet&or&a&moderate&sodium&
restrictive&diet.&&Both&groups&received&125+250&mg/bid&of&furosemide.&Consumption&of&saturated&
fat,&fruits,&and&vegetables&were&ensured&to&be&equal&between&groups.&Participants&received&a&
weekly&phone&call&and&interview&by&the&physician&or&dietitian&to&make&sure&the&diet&was&being&
followed.&
Baseline&measurements&of&blood&pressure,&body&weight,&blood&urea&nitrogen,&serum&
sodium,&serum&potassium,&urinary&sodium,&serum&creatinine,&ejection&fracture,&systolic&blood&
pressure,&diastolic&blood&pressure,&and&heart&rate&were&recorded.&During&the&first&month,&
participants&were&evaluated&each&week.&For&the&next&two&months,&participants&were&evaluated&
every&other&week,&and&for&the&remainder&of&the&study,&participants&were&evaluated&once&a&
month.&At&these&evaluations,&patients&were&given&a&physical&examination&as&well&as&an&
assessment&of&the&signs/symptoms&of&congestive&heard&failure.&Participants&were&also&measured&
for&neurohormonal&biomarkers&such&as&brain&natriuretic&peptide&(BNP),&plasma&renin&activity&
(PRA),&and&aldosterone,&as&well&as&inflammatory&markers&such&as&IL+6,&IL+10,&and&TNF+.&&

22

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
Comparisons&were&made&between&2&groups:&
"

Group&1&(n=86):&moderate&restriction&in&sodium&(120&mmol&to&2.8&g/day)&plus&oral&
furosemide&(125+250&mg/bid)&&
o

Note:&this&amount&was&chosen&because&this&is&the&estimated&mean&of&salt&
consumption&in&Europe.&&

"

Group&2&(n=87):&low&sodium&diet&(80&mmol&to&1.8&g/day)&plus&oral&furosemide&(125+250&
mg&bid)&

&
Readmissions&increased&about&4+fold&and&mortality&increased&5+fold&in&patients&following&
a&low+sodium&diet.&Sudden&death&increased&4+fold&and&irreversible&heart&failure&incidence&
increased&over&5+fold&in&patients&following&a&low&sodium&diet.&
After&12&months,&the&moderate&restriction&group&showed&a&significant&reduction&(p&<&
0.0001)&in&neurohormonal&biomarkers&and&inflammatory&cytokines,&whereas&the&low+sodium&
group&showed&a&significant&increase&(p&<&0.0001).&The&low&sodium&group&also&had&a&significant&
increase&in&IL+10&(an&anti+inflammatory&cytokine):&
"

Moderate&Restriction:&&
o

"

BNP&=&225,&PRA&=&3.4,&Aldosterone&=153;&TNF+&=&12,&IL+6&=&12.8,&IL+10&=&92&

Low+Sodium:&&
o

BNP&=&681,&PRA&=&5.3,&Aldosterone&=&393;&TNF+&=&22,&IL+6&=&26.3,&IL+10&=&65&

Overall,&a&moderate&sodium&restrictive&diet&combined&with&a&diuretic&was&shown&to&be&
the&best&option&for&reducing&neurohormonal&and&cytokine&activation&in&patients&with&recent&

23

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
worsening&of&congestive&heart&failure.&A&low&sodium&diet&with&free&fluid&intake&is&not&
recommended.&Further&research&is&necessary&to&understand&the&regulatory&mechanisms&of&
sodium&and&water.&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&

24

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
&
Paterna&S,&Parrinello&G,&Cannizzaro&S,&et&al.&Medium&term&effects&of&different&dosage&of&diuretic,&
sodium,&and&fluid&administration&on&neurohormonal&and&clinical&outcome&in&patients&with&
recently&compensated&heart&failure.&Am.#J.#Cardiol.&2009;103(1):93+102.&&
In&order&to&determine&the&rate&of&readmissions&and&mortality&in&patients&who&were&
previously&readmitted&to&the&hospital&for&worsening&heart&failure,&the&effectiveness&of&a&
combined&treatment&with&varying&sodium&diets,&diuretics,&and&fluid&restrictions&was&studied.&
Inclusion&criteria&included:&(1)&a&diagnosis&of&uncompensated&heart&failure&that&met&the&
Framingham&crieteria&and&NYHA&functional&classification,&or&who&were&unresponsive&to&various&
treatments&with&furosemide&or&diuretics;&(2)&a&left&ventricular&ejection&fraction&<35%;&(3)&serum&
creatinine&<2&mg/dL;&(4)&blood&urea&nitrogen&<60&mg/dL;&(5)&decreased&urinary&volume&<500&
mL/day;&and&(6)&low&natriuresis&(<60&mEq/day).&Participants&were&65+85&years&of&age.&&
The&410&participants&were&first&brought&to&a&compensated&state&by&receiving&the&same&
treatment&of&high+dose&furosemide&(250&mg&twice&daily),&hypertonic&saline&solution,&a&sodium&
diet&of&120&mmol/day&(considered&a&normal&intake),&and&a&decreased&fluid&intake&of&1,000&
ml/day.&Once&patients&were&classified&and&stable&in&NYHA&class&II&compensated&heart&failure,&
they&were&discharged,&but&continued&these&treatments&for&30&days&before&the&trial&began.&
Patients&were&randomly&assigned&to&one&of&eight&treatment&groups&with&varying&levels&of&fluid,&
sodium,&and&furosemide.&Patients&received&laboratory&tests&and&clinical&evaluations&once&per&
week&for&the&first&month,&once&every&two&weeks&for&months&2&and&3,&and&then&once&per&month&
for&the&remainder&of&the&study&(total&of&180&days).&Patients&were&given&standard&diets&including&
the&varying&amounts&of&fluid,&sodium,&and&furosemide&for&each&treatment&group.&&
Comparisons&were&made&between&8&groups:&

"

Group&A&(n=52):&1000&ml&fluid,&120&mmol&Na,&250&mg&furosemide&

"

Group&B&(n=51):&1000&ml&fluid,&120&mmol&Na,&125&mg&furosemide&

"

Group&C&(n=51):&1000&ml&fluid,&80&mmol&Na,&250&mg&furosemide&

"

Group&D&(n=51):&1000&ml&fluid,&80&mmol&Na,&125&mg&furosemide&

"

Group&E&(n=52):&2000&ml&fluid,&120&mmol&Na,&250&mg&furosemide&

"

Group&F&(n=50):&2000&ml&fluid,&120&mmol&Na,&125&mg&furosemide&

"

Group&G&(n=52):&2000&ml&fluid,&80&mmol&Na,&250&mg&furosemide&

"

Group&H&(n=51):&2000&ml&fluid,&80&mmol&Na,&125&mg&furosemide&

25

Katie&Dinkel+&Research&Disputing&Current&Guidelines!

&
Participants&in&treatment&group&A&had&the&most&significantly&reduced&incidence&of&
readmissions&and&mortality&out&of&all&the&groups&(readmissions&=&4;&mortality&=&1;&sudden&death&
=1;&p&<&0.05).&The&second&most&effective&treatment&was&seen&with&group&B&(readmissions&=&15;&
mortality&=&2;&sudden&death&=&0).&The&least&effective&treatment&was&seen&with&group&H&
(readmissions&=&40;&mortality&=&8;&sudden&death&=&2).&There&was&also&an&association&between&the&
number&of&readmissions&and&neurohormonal&changes.&For&example,&natriuretic&peptide,&
aldosterone,&and&plasma&renin&activity&were&significantly&lower&in&group&A,&whereas&all&the&other&
groups&had&significant&increases.&These&results&suggest&that&a&fluid&restriction&with&a&normal&
sodium&diet&and&higher&doses&of&diuretics&have&the&highest&reduction&in&neurohormonal&
activation,&renal&dysfunction,&hospital&readmissions&and&mortality,&and&that&a&higher&fluid&intake&
with&a&low&sodium&diet&and&low&doses&of&diuretics&is&the&least&effective&treatment.&

26

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$

Research$Supporting$Current$Guidelines
These$articles$examine$the$benefits$of$sodium$reduction$as$a$means$to$reducing$hypertension$
and$cardiovascular$disease$risk.$For$a$long$time,$salt$was$used$primarily$as$a$preservative;$with$the$
advent$of$refrigeration,$use$began$to$decline.$However,$because$of$the$increased$prevalence$of$
processed$food,$the$average$individual$intake$in$most$countries$is$between$9$and$12$grams$per$day,$
more$than$we$need$for$physiological$functioning$(1).$The$increased$salt$puts$strain$on$our$kidneys$
leading$to$increased$blood$pressure$resulting$increased$risk$of$cardiovascular$disease$and$renal$disease,$
in$addition$to$other$cardiovascular$problems$independent$of$BP,$such$as$stroke$and$left$ventricle$
hypertrophy$(1).$Reduced$sodium$diets$have$been$shown$to$be$effective$at$reducing$blood$pressure$for$
people$with$and$without$hypertension$(2).$The$Dietary$Approaches$to$Stop$Hypertension$(DASH)$diet$
has$been$particularly$effective$in$reducing$blood$pressure,$especially$if$combined$with$a$salt$intake$of$50$
mmol/day$(3).$Most$studies$have$examined$the$relationship$between$blood$pressure$and$salt$intake$in$
white$populations,$but$significant$reductions$have$been$seen$in$Black$and$Asian$populations$as$well$(4).$
In$elderly$populations,$a$reduction$in$salt$intake$has$been$shown$to$be$as$effective$as$a$single$
antihypertensive$drug$(5).$In$individuals$with$high$normal$blood$pressure,$small$but$significant$
reductions$in$blood$pressure$have$been$seen$with$long$term$sodium$reduction,$showing$both$the$
effectiveness$and$feasibility$of$a$reduced$sodium$diet$as$a$lifestyle$(6).$In$addition$to$the$blood$pressure$
effects$noted$in$many$of$these$studies,$other$vascular$benefits$independent$of$blood$pressure$have$also$
been$reported$in$those$consuming$a$low$sodium$diet;$specifically,$flow$mediated$dilatation$is$increased$
(7).$The$findings$of$the$following$collection$of$studiesindicate$that$the$US$Dietary$Guidelines$for$a$low$
sodium$intake$are$a$reasonable$and$effective$means$of$reducing$incidence$of$hypertension$and$other$
markers$for$cardiovascular$disease.$

27

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$
Sacks$FM,$Svetkey$LP,$Vollmer$WM,$et$al:$Effects$on$blood$pressure$of$reduced$dietary$sodium$and$the$
Dietary$Approaches$to$Stop$Hypertension$(DASH)$diet.$DASH+Sodium$Collaborative$Research$Group.$N$
Engl$J$Med$2001;344:3+10
Population*or*problem
This$was$a$2$year,$randomized$trial$designed$to$test$the$effects$of$three$levels$of$sodium$intake$in$a$
typical$US$diet$and$the$Dietary$Approaches$to$Stop$Hypertension$(DASH)$diet$on$blood$pressure$in$412$
participants$with$pre+hypertension$or$stage$I$hypertension.$The$high$sodium$level$reflected$current$
average$sodium$intake$for$an$American,$while$the$intermediate$level$represented$the$upper$limit$of$
current$recommended$intake$levels$to$reduce$blood$pressure.$The$low$level$was$tested$to$determine$if$it$
would$cause$a$further$reduction$in$blood$pressure.$
Subjects$had$to$be$22$years$old$(average$age$4810$years)$with$an$average$systolic$blood$pressure$of$120$
to$159$mmHg$and$an$average$diastolic$of$80$to$95$mmHg.$Both$diet$groups$were$roughly$55%$women$
and$50%$black.$BMI$for$the$DASH$diet$group$was$295$kg/m2$and$the$control$group$was$305$kg/m2.$
Exclusion$criteria$included$heart$disease,$renal$insufficiency,$poorly$controlled$hyperlipidemia$or$
diabetes$mellitus,$diabetes$requiring$insulin,$special$dietary$requirements,$intake$of$more$than$14$
alcoholic$drinks$per$week,$or$use$of$antihypertensive$drugs.$
Intervention
For$two$weeks,$all$participants$ate$a$high$sodium$control$diet.$They$were$then$randomly$assigned$to$
follow$one$of$two$diets:$a$control$diet$typical$of$an$individual$in$the$US,$and$a$DASH$diet.$All$meals$and$
snacks$were$provided$for$participants.$Each$diet$had$three$three$sodium$levels,$high$(150$mmol/day),$
intermediate$(100$mmol/day)$and$low$(50$mmol/day).$The$participants$consumed$each$diet$for$30$days$
in$random$order.$Participants$were$provided$the$number$of$calories$to$maintain$current$weight,$with$an$
appropriate$increase$in$sodium$to$maintain$the$kcal$to$sodium$ratio.$The$DASH$diet$also$had$lower$total$
fat,$saturated$fat,$and$cholesterol;$it$had$higher$protein,$carbohydrates,$fiber,$potassium,$and$calcium.$
Blood$pressure$was$measured$twice$during$the$run$in$period;$weekly$during$the$first$three$weeks$of$
each$30$day$intervention$period;$and$at$five$clinic$visits$during$the$last$nine$days$of$each$intervention$
period.$Additionally,$a$24$hour$urine$collection$was$taken$during$the$last$week$of$each$intervention$
period.$Baseline$consisted$of$the$average$of$two$run$in$and$three$screening$measurements;$post+
intervention$blood$pressure$is$an$average$of$five$measurements$from$the$final$nine$days$of$each$
intervention.$
Comparison*or*Control
Comparisons$were$made$between$6$groups:$
Control$diet,$low$sodium$intake$
Control$diet,$intermediate$sodium$intake$
Control$diet,$high$sodium$intake$$
DASH$diet,$low$sodium$intake$
DASH$diet,$intermediate$sodium$intake$

28

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$

DASH$diet,$high$sodium$intake$$

Outcome*5*Results*and*Conditions
Systolic*Blood*Pressure:$There$was$a$significant$decrease$in$SBP$between$the$high$and$low$sodium$
intake$levels$of$the$control$diet$(6.7$mmHg,$p<0.001$and$the$DASH$diet$(3.0$mmHg,$p<0.001).$$Between$
the$high$sodium$phase$of$the$control$diet$and$the$low$sodium$phase$of$the$DASH$diet,$there$was$a$
significant$decrease$of$8.9$mmHg$(p<0.001).$
Diastolic*Blood*Pressure:*DBP$significantly$decreased$between$the$high$and$low$sodium$intake$levels$of$
the$control$group$(+3.5$mmHg,$p<0.001)$and$the$DASH$diet$(+1.6$mmHg,$p<0.001).$There$was$a$DBP$drop$
of$4.5$mmHg$(p<0.001)$between$the$high$sodium$phase$of$the$control$diet$and$the$low$sodium$phase$of$
the$DASH$diet.$
Blood$pressure$reductions$were$found$in$people$with$and$without$hypertension,$although$the$effects$
were$greater$in$those$with$hypertension.$Researchers$found$a$more$significant$effect$on$blood$pressure$
when$the$sodium$intake$went$from$intermediate$to$low,$rather$than$starting$at$the$high$level$(the$
average$sodium$intake$in$the$US).$The$combination$of$a$low$sodium$DASH$diet$was$more$effective$than$
either$intervention$alone.$Ultimately,$the$findings$show$than$aggressive$sodium$reduction,$combined$
with$the$DASH$diet,$is$an$effective$way$to$reduce$blood$pressure$and$could$be$applicable$to$the$majority$
of$the$US$population.$

29

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$
Dickinson$KM,$Keogh$JB,$Clifton$PM:$Effects$of$a$low+salt$diet$on$flow+mediated$dilatation$in$humans.$Am$
J$Clin$Nutr$2009;89:485+490.
Population*or*problem
29$men$and$women$(mean$age$52.76)$participated$in$a$randomized$crossover$design$study$to$
determine$the$effect$of$a$low$sodium$diet$on$vascular$function$as$measured$by$flow$mediated$dilatation.$
Flow$mediated$dilatation$can$indicate$endothelial$dysfunction$which$precedes$cardiovascular$disease.$
Exclusion$factors$included$metabolic$disease,$cardiovascular$disease,$a$systolic$blood$pressure$above$160$
mmHg,$significant$weight$loss$in$the$last$6$months,$a$BMI$of$less$than$27$kg/m2$or$greater$than$40$kg/m2,$
and/or$use$of$antihypertensive$medication.$At$baseline,$mean$weight$was$87.49.5$kg;$mean$systolic$
blood$pressure$was$11610$mm$Hg;$and$mean$diastolic$blood$pressure$was$737$mm$Hg.$$
Intervention
Participants$were$randomly$assigned$to$either$a$US$diet$(150$mmol/day)$or$a$low$sodium$diet$(50$
mmol/day)$for$two$weeks$each,$with$no$washout$period$in$between.$Both$diets$were$designed$for$
weight$stability.$Potassium$levels$were$constant$across$both$diet$periods$(100$mmol/day)$because$of$its$
potential$BP$lowering$effect.$Saturated$fat$was$also$kept$consistent$across$the$diets.$Participants$were$
provided$with$bread$and$butter$(unsalted$or$salted$depending$on$the$diet)$but$made$independent$food$
choices$otherwise.$Participants$were$provided$with$written$dietary$advice$and$label$reading$education.$
Three$day$food$logs$were$collected$and$analyzed.$
Flow+mediated$dilatation$of$the$right$brachial$artery$was$measured$after$each$dietary$intervention;$the$
test$was$done$in$the$morning$after$an$overnight$fast.$Pulse$wave$readings$were$also$taken$at$weeks$two$
and$four.$Blood$pressure$and$a$24$hour$urine$collection$were$taken$at$baseline,$two$weeks,$and$four$
weeks.$$
Comparison*or*Control
All$participants$follow$both$diets$for$two$weeks.$The$results$were$compared$to$each$other$to$determine$
the$different$effects$of$the$diets.$
Outcome*5*Results*and*Conditions
Absolute$flow$mediated$dilatation$was$1.52%$greater$(p$=$0.001)$with$the$low$sodium$diet$than$the$US$
diet,$and$remained$significant$after$controlling$for$weight$loss,$saturated$fat,$and$change$in$blood$
pressure.$FMD$was$not$correlated$with$24+hour$sodium$excretion$or$changes$in$blood$pressure$in$either$
diet.$A$small$significant$reduction$was$observed$in$the$low$sodium$diet;$SBP$was$11211$mmHg$for$the$
low$sodium$diet$and$11713$mmHg$for$the$US$diet.$Changes$in$diastolic$pressure$were$not$significant.$
There$was$no$change$in$pulse$wave$velocity.$This$study$suggests$that$there$is$increase$in$FMD$
independent$of$blood$pressure,$indicating$that$there$are$additional$vascular$benefits$of$a$low$sodium$
diet$unrelated$to$blood$pressure.$Additionally,$subjects$were$normotensive,$indicating$a$beneficial$effect$
of$sodium$reduction$for$those$without$hypertension.$

30

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$

He$FJ,$Marciniak$M,$Visagie$E,$Markandu$ND,$Anand$V,$Dalton$RN,$et$al.$Effect$of$modest$salt$reduction$
on$blood$pressure,$urinary$albumin,$and$pulse$wave$velocity$in$white,$black,$and$Asian$mild$
hypertensives.$Hypertension$2009;54:482+8.
Population
The$purpose$of$the$randomized,$double$blind,$crossover$trial$was$to$determine$the$effect$of$a$modest$
reduction$of$salt$intake$on$blood$pressure$in$whites,$blacks$and$Asians$with$untreated$slightly$raised$
blood$pressure.$Additionally,$the$study$intended$to$determine$the$effects$of$this$salt$reduction$on$24$
hour$urinary$albumin$excretion$and$pulse$wave$velocity.$
Individuals$with$a$secondary$cause$for$hypertension,$impaired$renal$function$with$plasma$creatine$>150$
mol/L,$previous$stroke,$ischemic$heart$disease,$heart$failure,$diabetes$mellitus,$malignancy,$or$liver$
disease$were$excluded.$Women$who$were$pregnant,$breastfeeding,$or$using$contraceptive$pills$were$
also$excluded.
There$were$187$participants,$ranging$from$30$to$75$years$old$(mean$5011).$There$were$71$whites,$69$
blacks,$and$29$Asians.$There$were$113$men$and$56$women.$At$baseline,$the$mean$24$hour$urinary$
sodium$was$13150$mmol,$equivalent$to$7.7$grams$of$salt.$The$average$blood$pressure$was$
14713/918$mmHg.$
Intervention
Baseline$measurements$were$taken$and$then$participants$received$detailed$advice$from$specially$
trained$nurses$on$how$to$reduce$salt$intake.$The$goal$was$to$achieve$and$intake$of$~5$g/day$(85$
mmol/day).$If$the$participant$did$not$cook$at$home,$the$person$who$did$cook$also$received$counseling.$
Advice$was$reiterated$at$each$follow$up.$Salt$free$bread$was$provided$for$participants.$
After$two$weeks$of$the$reduced$salt$diet,$participants$were$randomized$into$the$trial$of$either$the$slow$
sodium$tablet$or$placebo$group.$All$participants$remained$on$the$reduced$sodium$diet.$Participants$in$
the$intervention$group$were$given$9$slow$sodium$tablets$(10$mmol$sodium$per$tablet)$or$9$placebo$pills$
per$day$for$6$weeks$before$switching$treatments.$$
At$the$end$of$each$6+week$period,$three$blood$pressure$readings$were$taken$at$1$to$2$minute$intervals$
and$the$last$two$readings$were$averaged.$Blood$samples$were$also$taken$to$measure$routine$
biochemistry,$plasma$renin$activity,$and$aldosterone.$Participants$provided$two$consecutive$24$hour$
urine$collections$for$measurements$of$urinary$sodium,$potassium,$creatinine,$calcium,$and$albumin.$The$
mean$of$the$two$measurements$was$used.$
Comparison*or*Control
The$measurements$taken$during$the$sodium$treatment$were$compared$to$the$measurements$from$the$
placebo$treatment.$

31

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$

Outcome*5*Results*and*Conditions
The$mean$24$urinary$sodium$was$16558$mmol$(9.7$grams$salt)$for$the$sodium$pills,$and$11049$(6.5$
grams$salt)$for$the$placebo.$There$was$a$significant$reduction$of$4.8$mmHg$for$systolic$blood$pressure$
(p<0.00)$and$2.2$mm$Hg$for$diastolic$blood$pressure$(p<0.001)$for$the$placebo$group$as$compared$to$the$
sodium$group.$Blood$pressure$fell$significantly$for$all$three$groups.$Blacks$and$Asians$are$not$well$
represented$in$the$research$on$the$effects$of$sodium$reduction$and$blood$pressure,$and$this$research$
fills$that$gap.$The$study$shows$that$a$modest$reduction$in$salt$intake$as$is$currently$recommended$can$
result$in$significant$blood$pressure$decreases$in$both$black$and$Asian$individuals$with$hypertension.$
There$was$an$11%$reduction$in$24$urinary$albumin$in$the$placebo$group$as$compared$to$the$sodium$
group.$Urinary$albumin$excretion$is$an$important$independent$risk$factor$for$the$development$of$renal$
disease$and$cardiovascular$disease$for$people$with$diabetes,$chronic$kidney$disease,$and$hypertension.$
These$results$indicate$that$a$modest$reduction$in$sodium$intake$has$long+term$benefits$for$blood$
pressure,$cardiovascular$disease,$and$renal$disease$in$a$wide$range$of$individuals$with$mild$hypertension$
and$there$are$likely$benefits$for$the$general$population$as$well.$

32

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$
Whelton$PK,$Appel$LJ,$Espeland$MA,$et$al,$for$the$TONE$Collaborative$Research$Group.$Sodium$reduction$
and$weight$loss$in$the$treatment$of$hypertension$in$older$persons:$a$randomized$controlled$trial$of$
nonpharmacologic$interventions$in$the$elderly$(TONE)$[published$correction$appears$in$JAMA.$1998;279:$
1954].
$

Population*and*Problem
975$men$and$women$from$four$centers$between$the$ages$of$60$and$80$years$old$(mean$66.54.6$years)$
participated$in$this$three$year$study$to$find$whether$weight$loss$or$a$reduced$sodium$diet$is$effective$in$
treating$older$patients$with$hypertension.$Participants$had$a$blood$pressure$of$less$than$145$mmHg/85$
mmHg$while$receiving$single$antihypertensive$medication.$Exclusion$criteria$included$history$of$a$heart$
attack$or$stroke$within$the$previous$6$months,$current$angina$pectoris,$congestive$heart$failure,$insulin$
dependent$diabetes,$serious$mental$or$physical$illness,$involuntary$weight$loss$of$4.5$kg$in$the$previous$
year,$a$BMI$of$less$than$21$kg/m2$or$greater$than$33$kg/m2$for$men$and$37kg/m2$for$women,$inability$to$
comply$with$the$protocol,$hypercreatinemia,$hyperkalemia,$hyperglycemia,$and$anemia.$
Intervention
Obese$participants$were$randomized$into$one$of$the$following$groups:$sodium$reduction,$weight$loss,$
sodium$reduction$and$weight$loss$combined,$or$usual$care.$Non+obese$participants$were$randomized$
into$sodium$reduction$or$usual$care.$
For$the$combined$group,$the$goal$for$sodium$reduction$was$a$24+hour$dietary$sodium$intake$of$80$mmol$
(1800$mg)$and$achievement$and$maintenance$of$a$10$pound$or$greater$weight$loss.$These$parameters$
were$the$same$for$the$independent$sodium$reduction$and$weight$loss$group$loss$groups,$respectively.$
Nutritionists$and$exercise$counselors$used$a$combination$of$small$group$and$individual$meetings$to$
advise$participants$on$eating$patterns$and$physical$activity$(for$the$weight$loss$group$only).$There$were$
three$phases$of$intervention$for$all$groups:$intensive,$extended,$and$maintenance,$with$different$level$of$
contact$between$participants$and$the$counselors.$The$usual$care$group$received$no$counseling$in$
lifestyle$related$change.$
Blood$pressure$and$body$weight$were$collected$quarterly$from$August$1992$to$December$1995;$follow$
up$ranged$from$15$to$36$months$(average$29$months).$24+hour$urine$collections$were$obtained$twice$
during$the$enrollment$periods$and$at$the$9+month,$18+month,$and$final$visits.$A$24+hour$dietary$recall$
was$taken$by$a$trained$clinician$twice$during$enrollment,$at$the$9+month$and$12$month$follow$up$visits,$
and$every$6$months$after$that.$
The$end$points$were$(1)$the$occurrence$of$high$BP$at$one$or$more$visits$after$withdrawal$of$
antihypertensive$medication$(190/110$mm$Hg$at$a$single$visit$a$mean$of$170/100$mm,$(2)$continued$or$
restarting$use$of$antihypertensive$medication$or$(3)$a$cardiovascular$disease$event.$$
Comparison*or*Control
The$three$intervention$groups$(sodium$reduction,$weight$loss,$and$combined$group)$were$compared$to$
each$other$and$the$usual$care$group.$

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$

Outcome*5*Results*and*Conditions
The$median$time$from$intervention$to$withdrawal$of$antihypertensive$medication$was$3.2$months$
(similar$for$all$intervention$groups).$In$the$30+month$follow$up$period,$38%$of$those$in$the$sodium$
reduction$group$remained$off$antihypertensive$medication$with$a$blood$pressure$less$than$150/90$mm$
Hg$and$no$cardiovascular$disease$event.$This$is$compared$to$24%$of$the$non+sodium$reduction$group$
(p<0.001).$$The$hazard$ratio$for$trial$end$points$were$0.60$for$the$sodium$reduction$group$(p<0.001),$
0.74$for$the$weight$loss$group$(p=0.002),$and$0.47$for$the$combined$group$(p<0.001)$as$compared$to$the$
usual$care$group.$
Systolic$and$diastolic$blood$pressure$were$significantly$lower$in$all$intervention$groups$as$compared$to$
the$usual$care$group$at$the$last$visit$before$attempted$withdrawal$from$anti+hypertensive$medications.$
Study$results$show$that$non+pharmacologic$interventions$can$be$a$safe$way$to$control$high$blood$
pressure$in$older$adults$with$hypertension.$Older$patients$were$able$to$achieve$and$maintain$lifestyle$
changes$without$negative$results,$indicating$that$public$health$officials$and$clinicians$could$have$
significant$impact$through$campaigns$to$reduce$salt$intake$and$increase$weight$loss$in$older$patients$
with$hypertension.$

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Liz$Sullivan+$Research$Supporting$Current$Guidelines
$
The$Trials$of$Hypertension$Prevention$Collaborative$Research$Group.$The$effects$of$nonpharmacologic$
interventions$on$blood$pressure$of$persons$with$high$normal$levels:$results$of$the$Trials$of$Hypertension$
Prevention,$Phase$I.$JAMA$1992;267:1213+20.
Population*and*Problem
This$was$a$randomized$multicenter$trial$to$test$whether$seven$nonpharmacologic$interventions$would$
be$feasible$and$effective$in$the$short$term$for$people$with$high$normal$diastolic$blood$pressure.$This$
annotation$will$address$the$sodium$reduction$and$weight$loss$intervention$versus$usual$care.$There$
were$2,182$participants,$aged$30$+$54$years$(average$age$43$years)$over$a$13+month$period$recruited$
from$10$clinics.$$70%$were$male.$The$mean$blood$pressure$was$125/84$mm$Hg$and$the$mean$BMI$was$
27.6$k/m2.$Participants$had$high$normal$diastolic$blood$pressure$with$no$antihypertensive$drugs$in$the$
prior$2$months.$Exclusion$criteria$included$clinical$or$lab$evidence$of$cardiovascular$or$other$life$
threatening$or$disabling$diseases,$conditions$that$would$prevent$compliance$with$interventions,$or$
unwillingness$to$comply$with$interventions.$$$
Intervention*
There$were$three$counseling$groups:$weight$reduction,$sodium$reduction,$and$stress$management.$The$
weight$reduction$group$received$counseling$on$reduced$calorie$intake$with$no$counseling$on$sodium$
levels.$The$sodium$reduction$group$was$counseled$on$reduced$sodium$intake,$and$the$stress$
management$group$received$information$on$relaxation$techniques.$Group$education$sessions$ranged$
from$11$+$12$participants.$Sessions$were$conducted$weekly$for$90$minutes$in$the$initial$phase$and$then$
continued$semimonthly$and$then$monthly$for$the$remaining$12$months.$
Blood$pressure,$weight,$and$urine$were$collected$at$3,$6,$12,$and$18$months.$Food$frequency$
questionnaires$and$24$hour$recalls$were$collected$at$the$final$visit.$
$$
Comparison*or*Control
The$results$of$the$3$lifestyle$intervention$groups$were$compared$against$each$other$and$the$usual$care$
group.$
Outcome*5*Results*and*Conclusions*
The$sodium$reduction$and$weight$loss$groups$both$demonstrated$significant$reductions$in$diastolic$
blood$pressure$and$systolic$blood$pressure$as$compared$to$control.$$The$sodium$reduction$group$had$a$
0.9$mm$Hg$reduction$in$diastolic$pressure$($p<0.05)$and$1.7$mm$Hg$reduction$in$systolic$blood$pressure$
(p<0.01).$The$weight$loss$group$had$larger$reductions$(2.3$mm$Hg$diastolic$and$2.9$mm$Hg$systolic,$
p<0.01).$Attendance$at$the$group$education$sessions$was$high$for$both$the$sodium$reduction$and$weight$
loss$groups$(74%$and$88%,$respectively),$indicating$the$feasibility$of$such$interventions.$Blood$pressure$
reductions$were$also$largely$maintained$in$the$18$month$follow$up$period.$These$results$indicate$that$
sodium$reduction$(and$weight$loss)$is$a$feasible$long$term$intervention$for$reducing$blood$pressure$and$
preventing$hypertension.$$
What$about$stress$management?

35

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$
He$FJ,$MacGregor$GA;$Effect$of$longer+term$modest$salt$reduction$on$blood$pressure:$Cochrane$
systematic$review$and$meta+analysis$of$randomised$trials.$BMJ.%2013$Apr;$346:$1+15.$
This$meta+analysis$included$randomized$trials$that$lasted$at$least$4$weeks$and$included$a$modest$
reduction$in$salt$intake.$Thirty$four$trials$were$included$for$a$total$of$3,230$participants.$The$studies$
showed$that$a$reduction$of$4.4$grams$per$day$of$salt$$(75$mmol/day)$was$associated$with$a$mean$
decrease$of$4.18$mm$Hg$in$systolic$blood$pressure$and$2.06$mm$Hg$in$diastolic$blood$pressure.$A$
decrease$of$6.6$grams$per$day$of$salt$was$associated$with$a$mean$decrease$of$5.8$mm$Hg$for$systolic$
blood$pressure.$
One$of$the$biggest$concerns$with$research$on$the$effects$of$sodium$intake$on$blood$pressure$is$the$
differences$between$participants$with$and$without$hypertension.$In$this$meta+analysis,$participants$with$
hypertension$had$a$decrease$of$5.39$mm$Hg$and$2.82$mm$Hg$for$systolic$and$diastolic$blood$pressure,$
respectively.$Normotensive$people$had$a$decrease$of$2.42$mm$Hg$for$SBP$and$1$mm$Hg$for$DBP.$The$
systolic$decrease$was$significant$for$men$and$women,$and$black$and$white$people.$
Although$the$levels$were$smaller$for$those$without$hypertension,$researchers$still$deemed$them$
significant$and$concluded$that$a$reduction$in$salt$intake$would$lead$to$significant$falls$in$blood$pressure$
and$have$wide$ranging$public$health$impacts.$$

36

Liz$Sullivan+$Research$Supporting$Current$Guidelines
$
He$FJ,$MacGregor$GA.$Reducing$population$salt$intake$worldwide:$from$evidence$to$implementation.$
Prog$Cardiovasc$Dis$2010;$52:363+82.
He$and$MacGregor$reviewed$over$100$studies$to$cover$the$negative$effects$of$salt$consumption,$the$
beneficial$effects$of$sodium$reduction,$and$how$various$countries$around$the$world$have$implemented$
salt$reduction$programs.$Salt$was$first$widely$used$as$a$preservative,$and$intake$began$to$decline$with$
the$advent$of$the$refrigerator.$However,$the$boom$of$the$processed$food$industry$lead$to$an$increase$in$
consumption$of$salt,$with$the$average$intake$in$most$countries$between$9$and$12$grams$per$day.$
Physiologically$and$evolutionarily,$we$only$need$0.25$grams$per$day,$and$the$dramatic$increase$puts$
strain$on$our$kidneys$leading$to$increased$blood$pressure$resulting$increased$risk$of$cardiovascular$
disease$and$renal$disease,$in$addition$to$other$cardiovascular$problems$independent$of$BP,$such$as$
stroke$and$left$ventricle$hypertrophy.$
The$contribution$of$salt$to$high$blood$pressure$has$stronger$and$more$diverse$evidence$compared$to$
other$factors.$Animal$studies$have$shown$increased$salt$intake$to$lead$to$large$and$progressive$increased$
in$BP.$Human$epidemiological$studies$have$shown$that$countries$without$access$to$salt$have$a$lower$BP$
as$compared$to$those$with$access.$Migration$studies$have$shown$that$moving$from$an$isolated$low$salt$
society$to$an$environment$with$increased$salt$intake$is$correlated$with$an$increase$in$blood$pressure.$
Treatment$trials$in$hypertensive$individuals$have$shown$that$decrease$salt$intake$from$9+$12$grams$per$
day$to$5+6$grams$per$day$leads$to$reductions$in$blood$pressure$equivalent$to$single$antihypertensive$
drug$therapy.$Many$studies$have$not$achieved$significant$salt$reduction$and$thus$have$not$shown$a$
decrease$in$blood$pressure.$A$reduction$to$3$grams$per$day$would$be$ideal,$but$would$be$challenging$on$
a$public$health$scale$unless$the$food$industry$was$involved.$
Salt$intake$may$also$have$an$effect$on$cardiovascular$disease$independent$of$blood$pressure$effects.$In$
the$1960s,$the$government$in$Japan$started$a$campaign$to$reduce$salt$intake$from$an$average$$of$13.5$
grams$per$day$to$12.1$grams$per$day$leading$to$an$80%$reduction$in$stroke$mortality.$Finland$has$also$
implemented$a$salt$reduction$program$leading$to$75+80%$decrease$in$stroke$and$coronary$heart$disease$
mortality.$Additional$harmful$effects$of$salt$are$discussed,$in$addition$to$the$effects$of$increased$salt$
intake$on$various$populations.$
The$authors$of$this$review$conclude$that$there$is$overwhelming$evidence$for$a$reduction$in$salt$intake$
worldwide,$leading$to$major$decreases$in$blood$pressure$and$cardiovascular$disease.$

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