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Cited by 228Sodium Intake and HealthBlood Pressure and Hypertension StudiesNutritional Studies and Diet

Sodium Intake and All-Cause Mortality Over 20 Years in the Trials of Hypertension Prevention

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Cook, Nancy R., Appel, Lawrence J., Whelton, Paul K.·2016·Journal of the American College of Cardiology
DOI 10.1016/j.jacc.2016.07.745PMC PMC5098805
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Abstract

Background While several studies suggest beneficial effects of lower sodium on cardiovascular disease, the relationship with total mortality remains controversial. Some have reported a J-shaped curve, but this may be due to poor quality measurement of sodium or confounding bias. Objective To examine the relationship of well-characterized measures of sodium intake, estimated from urinary sodium excretion, with long-term mortality. Methods Two trials [Phase I (1987-90) over 18 month and Phase II (1990-5) over 36 months in the Trials of Hypertension Prevention] implemented sodium reduction interventions. Multiple 24-hour urines were collected from pre-hypertensive adults aged 30-54 during these trial periods. Post-trial deaths were ascertained over a median 24 years through December 31, 2013 using the National Death Index. The association of mortality with both the randomized intervention and average sodium intake was examined. Results Among 744 Phase I and 2382 Phase II participants randomized to sodium reduction or control, 251 deaths occurred, with a nonsignificant 15% lower risk in the active intervention (hazard ratio (HR)=0.85, 95% CI=0.66-1.09, p=0.19). Among 2,974 participants not assigned to an active sodium intervention, 272 deaths occurred. There was a direct linear association of average sodium intake with mortality, with HR=0.75, 0.95, 1.00 (reference), and 1.07 (p-trend = 0.30) for <2300, 2300-<3600, 3600-<4800, and >=4800 mg/24hr, respectively, with HR=1.12 per 1000 mg/24hr (95% CI = 1.00-1.26, p=0.05) and no evidence of a J-shape or nonlinear relation. The HR per unit increase in sodium/potassium ratio was 1.13 (95% CI = 1.01-1.27, p=0.04). Conclusions This study, with carefully characterized measures of sodium intake, found an increased risk at high sodium intake and a direct relation with total mortality even at the lowest levels of sodium intake. Overall, these results are consistent with a benefit of reduced sodium and sodium/potassium on total mortality over a period of over 20 years.

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  • The American Heart Association's ideal sodium intake recommendation is no more than 1500 mg per day.

    “The American Heart Association recommends no more than 1500mg of sodium/day as ideal.”

    From Reducing Dietary Sodium to 1000 mg per Day Reduces Neurovascular Transduction Without Stimulating Sympathetic Outflow (2019) · cites this paper as [6]

    The Introduction discusses an Institute of Medicine assessment of sodium intake below 2,300 mg/day, and the Discussion mentions an Institute of Medicine recommendation for gradual sodium reduction. Neither passage states the American Heart Association’s ideal intake recommendation. Searches for the American Heart Association and a 1,500 mg/day limit found no passage in our copy establishing the claim. (LLM, conf=0.72)

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Authors
Cook, N. R., Appel, L. J., & Whelton, P. K.
Affiliations
  • Brigham and Women's Hospital (US)
  • Johns Hopkins University (US)
  • Tulane University (US)
Corresponding author
Cook, Nancy R.
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2016-10
Volume
68
Issue
15
Pages
1609-1617
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/j.jacc.2016.07.745
PMC
PMC5098805
OpenAlex
W2528889533
Semantic Scholar
50b93e33224a6fde20dbfff8905e05478f8fc67d
Cited by
228
References
32
Citations by year
2026: 11 · 2025: 11 · 2024: 32 · 2023: 19 · 2022: 19 · 2021: 30 · 2020: 30 · 2019: 31 · 2018: 24 · 2017: 13 · 2016: 7 · 2013: 1
FWCI
26.11
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • American Heart Association (14GRNT18440013)
  • National Institutes of Health
  • National Heart, Lung, and Blood Institute (HL-37924, HL 37849, HL 37899, HL37852, HL 37904, HL-37854, HL-37872, HL37906, HL37853, HL 37884, R01HL057915, HL-57915, HL-37907, 14GRNT18440013)
  • National Institute of Diabetes and Digestive and Kidney Diseases (P30DK072488)
Topics
  • Health Sciences › Nursing › Nutrition and Dietetics › Sodium Intake and Health
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
Keywords
sodium intake, all-cause mortality, sodium excretion, Na+/K+ ratio, J-shaped relationship, long-term mortality, dietary sodium, hypertension prevention, post-trial follow-up, 24-hour urine collection
MeSH terms
Adult, Cause of Death, Female, Humans, Hypertension, Male, Middle Aged, Mortality, Sodium, Sodium, Dietary, Time Factors, Risk Assessment

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