Projected effect of dietary salt reductions on future cardiovascular disease
Open accessAbstract
BACKGROUND: The U.S. diet is high in salt, with the majority coming from processed foods. Reducing dietary salt is a potentially important target for the improvement of public health. METHODS: We used the Coronary Heart Disease (CHD) Policy Model to quantify the benefits of potentially achievable, population-wide reductions in dietary salt of up to 3 g per day (1200 mg of sodium per day). We estimated the rates and costs of cardiovascular disease in subgroups defined by age, sex, and race; compared the effects of salt reduction with those of other interventions intended to reduce the risk of cardiovascular disease; and determined the cost-effectiveness of salt reduction as compared with the treatment of hypertension with medications. RESULTS: Reducing dietary salt by 3 g per day is projected to reduce the annual number of new cases of 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. All segments of the population would benefit, with blacks benefiting proportionately more, women benefiting particularly from stroke reduction, older adults from reductions in CHD events, and younger adults from lower mortality rates. The cardiovascular benefits of reduced salt intake are on par with the benefits of population-wide reductions in tobacco use, obesity, and cholesterol levels. A regulatory intervention designed to achieve a reduction in salt intake of 3 g per day would save 194,000 to 392,000 quality-adjusted life-years and $10 billion to $24 billion in health care costs annually. Such an intervention would be cost-saving even if only a modest reduction of 1 g per day were achieved gradually between 2010 and 2019 and would be more cost-effective than using medications to lower blood pressure in all persons with hypertension. CONCLUSIONS: Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.
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A simulation study estimated that reducing salt intake by 3 g/day in the USA would reduce CHD incidence by 5.9-9.6%, stroke incidence by 5.0-7.8%, and death from any cause by 2.6-4.1%.
“A recent simulation study estimated that for the USA, a reduction in salt intake of 3 g/day would result in a reduction of 5.9 -9.6% in the incidence of CHD (low and high estimate based on different assumptions), a reduction of 5.0 -7.8% in the incidence of stroke, and a reduction of 2.6-4.1% in death from any cause.286”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [286]
In 2005, tobacco smoking caused approximately 467,000 adult deaths (19.1%) in the United States; about one third of these deaths were related to cardiovascular disease.
“In 2005, tobacco smoking was the cause of ≈467 000 adult deaths (19.1%) in the United States. Approximately one third of these deaths were related to CVD.15”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In MESA, a large proportion of white, black, and Hispanic participants were overweight (60%-85%) or obese (30%-50%), whereas fewer Chinese American participants were overweight (33%) or obese (5%).
“a large proportion of white, black, and Hispanic participants were overweight (60%–85%) or obese (30%–50%), whereas fewer Chinese American participants were overweight (33%) or obese (5%).15”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Associations have been observed between the 9p21.3 region and coronary artery calcification.
“Associations have also been observed between the 9p21.3 region and coronary artery calcification (CAC).15,16”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
The SEARCH study found the prevalence of elevated blood pressure to be 5.9% among children 3 to 17 years of age with type 1 diabetes and 23.7% among those with type 2 diabetes.
“Analysis of data from the Search for Diabetes in Youth Study (SEARCH), which included children 3 to 17 years of age with type 1 and type 2 DM, found the prevalence of elevated BP to be 5.9% among those with type 1 DM and 23.7% among those with type 2 DM.15”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Diabetes prevalence is projected to increase by 99% among non-Hispanic whites, 107% among non-Hispanic blacks, and 127% among Hispanics.
“DM prevalence is projected to increase by 99% among non-Hispanic whites, by 107% among non-Hispanic blacks, and by 127% among Hispanics.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Increases are projected to be largest for the oldest age groups, with a 220% increase among those aged 65-74 and a 449% increase among those aged 75 or older.
“Increases are projected to be largest for the oldest age groups (for instance, projected to increase by 220% among those 65–74 years of age and by 449% among those ≥75 years of age).”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Projections from NHANES/NCHS studies between 1984 and 2004 indicate that total diabetes prevalence in the United States is expected to more than double from 2005 to 2050, from 5.6% to 12.0%, across all age, sex, and race/ethnicity groups.
“On the basis of projections from NHANES/NCHS studies between 1984 and 2004, the total prevalence of DM in the United States is expected to more than double from 2005 to 2050 (from 5.6% to 12.0%) in all age, sex, and race/ethnicity groups.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
The age/race/ethnicity group with the largest projected increase is expected to be blacks aged 75 years or older, with a projected increase of 606%.
“The age/race/ethnicity group with the largest increase is expected to be blacks ≥75 years of age (projected increase of 606%).15”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In the Bogalusa Heart Study, four variables (BMI, homeostasis model assessment of insulin resistance, ratio of triglycerides to HDL cholesterol, and mean arterial pressure) considered part of the metabolic syndrome clustered together in blacks and whites and in children and adults.
“In the Bogalusa Heart Study, 4 variables (BMI, homeostasis model assessment of insulin resistance, ratio of triglycerides to HDL cholesterol, and mean arterial pressure) considered to be part of the metabolic syndrome clustered together in blacks and whites and in children and adults.15”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
The clustering of rates of change in the components of the metabolic syndrome in blacks exceeded that in whites.
“The clustering of rates of change in the components of the metabolic syndrome in blacks exceeded that in whites.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
The degree of clustering was stronger among adults than among children.
“The degree of clustering was stronger among adults than among children.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Among people with ESRD, CVD is the top cause of death.
“CVD is the leading cause of death among those with ESRD”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Dialysis patients have CVD mortality 5 to 30 times that of age-, sex-, and race-matched general population.
“CVD mortality is 5 to 30 times higher in dialysis patients than in subjects from the general population of the same age, sex, and race.15,16”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
The specific cardiovascular cause of death in ESRD may be more likely arrhythmic than AMI, end-stage HF, or stroke.
“although the specific cardiovascular cause of death may be more likely to be arrhythmic than an AMI, end-stage HF, or stroke.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In that survey, adults unable to work had the highest prevalence (69.3%) of at least 2 risk factors, followed by retired people (45.1%), unemployed adults (43.4%), homemakers (34.3%), and employed people (34.0%).
“Adults who reported being unable to work had the highest prevalence (69.3%) of ≥2 risk factors, followed by retired people (45.1%), unemployed adults (43.4%), homemakers (34.3%), and employed people (34.0%).”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Data from the 2003 CDC BRFSS survey of adults aged 18 and older showed that prevalence of having at least 2 risk factors for heart disease and stroke was successively higher at higher age groups.
“Data from the 2003 CDC BRFSS survey of adults ≥18 years of age showed the prevalence of respondents who reported having ≥2 risk factors for HD and stroke was successively higher at higher age groups.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In that survey, people with household income of at least $50,000 had the lowest prevalence (28.8%) and those with household income below $10,000 had the highest prevalence (52.5%).
“People reporting household income of ≥$50 000 had the lowest prevalence (28.8%), and those reporting household income of <$10 000 had the highest prevalence (52.5%).”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In that survey, prevalence of at least 2 risk factors was similar in women (36.4%) and men (37.8%).
“prevalence was similar in women (36.4%) and men (37.8%).”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Twelve states and 2 territories had a multiple risk factor prevalence of at least 40%: Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Tennessee, West Virginia, Guam, and Puerto Rico.
“Twelve states and 2 territories had a multiple risk factor prevalence of ≥40%: Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Tennessee, West Virginia, Guam, and Puerto Rico.15”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In that survey, prevalence of at least 2 risk factors varied by state/territory from 27.0% in Hawaii to 46.2% in Kentucky.
“Prevalence of ≥2 risk factors varied by state/ territory and ranged from 27.0% (Hawaii) to 46.2% (Kentucky).”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In that survey, prevalence of at least 2 risk factors was highest among blacks (48.7%) and American Indian/Alaska Natives (46.7%) and lowest among Asians (25.9%).
“The prevalence of having ≥2 risk factors was highest among blacks (48.7%) and American Indian/Alaska Natives (46.7%) and lowest among Asians (25.9%);”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
In that survey, prevalence of multiple risk factors ranged from 25.9% among college graduates to 52.5% among those with less than a high school diploma.
“The prevalence of multiple risk factors ranged from 25.9% among college graduates to 52.5% among those with less than a high school diploma (or its equivalent).”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [15]
Even smaller cuts in salt intake are estimated to yield large benefits for populations.
“Smaller reductions in salt intake are also estimated to produce large population benefits.160,161”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [160]
Population recommendations for low sodium intake (<2.0 g/day) have been achieved in short-term feeding trials but not sustained in longer-term trials (>6 months).
“Population- recommendations for low sodium intake (252–254) (< 2.0 grams/day) have been achieved in short-term feeding clinical trials (254), but not sustained in longer-term clinical trials (> 6 months) (255) (256,257).”
From Food Consumption and its Impact on Cardiovascular Disease: Importance of Solutions Focused on the Globalized Food System (2015) · cites this paper as [256]
A few trials found that blood-pressure-lowering effects of sodium restriction were similar in subjects taking or not taking anti-hypertensives.
“a few trials found that BP-lowering effects of sodium restriction were similar in subjects taking or not taking anti-hypertensives.[10][11][12][13]”
From Global Sodium Consumption and Death from Cardiovascular Causes (2014) · cites this paper as [10]
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The Impact of the Aging Population on Coronary Heart Disease in the United States
Odden, M. C., Coxson, P. G., Moran, A., Lightwood, J. M., Goldman, L., & Bibbins-Domingo, K. (2011) · The American Journal of Medicine · doi:10.1016/j.amjmed.2011.04.010 · Cited by 235 · see citing works
Self-citationHe, F. J., Wu, Y., Feng, X.-X., Ma, J., Ma, Y., Wang, H., Zhang, J., Yuan, J. J., Lin, C.-P., Nowson, C. A., et al. (2015) · BMJ · doi:10.1136/bmj.h770 · Cited by 189 · see citing works
- Authors
- Bibbins-Domingo, K., Chertow, G. M., Coxson, P. G., Moran, A., Lightwood, J. M., Pletcher, M. J., & Goldman, L.
- Affiliations
- San Francisco General Hospital (US)
- Stanford University (US)
- Columbia University (US)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2010-02-18
- Volume
- 362
- Issue
- 7
- Pages
- 590-599
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC3066566
- OpenAlex
- W2138955883
- Cited by
- 1,253
- References
- 41
- Citations by year
- 2026: 25 · 2025: 50 · 2024: 40 · 2023: 41 · 2022: 64 · 2021: 51 · 2020: 66 · 2019: 66 · 2018: 62 · 2017: 74 · 2016: 70 · 2015: 107 · 2014: 91 · 2013: 118 · 2012: 123
- FWCI
- 134.75
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Center for Research Resources (UL1RR024131)
- 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 › Health Promotion and Cardiovascular Prevention
- Keywords
- dietary salt reduction, sodium intake, cardiovascular disease, coronary artery disease, stroke, myocardial infarction, mortality, cost-effectiveness, antihypertensive therapy, processed foods, public health policy, quality-adjusted life years, health care costs, racial and sex disparities
- MeSH terms
- Adult, Aged, Cardiovascular Diseases, Computer Simulation, Cost-Benefit Analysis, Diet, Female, Humans, Male, Markov Chains, Middle Aged, Models, Biological, Risk Factors, Sodium, Dietary, United States, Health Care Costs, Quality-Adjusted Life Years
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