Cited by 1,218Sodium Intake and HealthBlood Pressure and Hypertension StudiesNutritional Studies and Diet

The DOI matches its Crossref record; 37 of the 37 references it cites were found in a registry or an index; none of the 64 sources its claims cite is checked for support yet.

Global Sodium Consumption and Death from Cardiovascular Causes

Open access

Abstract

BACKGROUND: High sodium intake increases blood pressure, a risk factor for cardiovascular disease, but the effects of sodium intake on global cardiovascular mortality are uncertain. METHODS: We collected data from surveys on sodium intake as determined by urinary excretion and diet in persons from 66 countries (accounting for 74.1% of adults throughout the world), and we used these data to quantify the global consumption of sodium according to age, sex, and country. The effects of sodium on blood pressure, according to age, race, and the presence or absence of hypertension, were calculated from data in a new meta-analysis of 107 randomized interventions, and the effects of blood pressure on cardiovascular mortality, according to age, were calculated from a meta-analysis of cohorts. Cause-specific mortality was derived from the Global Burden of Disease Study 2010. Using comparative risk assessment, we estimated the cardiovascular effects of current sodium intake, as compared with a reference intake of 2.0 g of sodium per day, according to age, sex, and country. RESULTS: In 2010, the estimated mean level of global sodium consumption was 3.95 g per day, and regional mean levels ranged from 2.18 to 5.51 g per day. Globally, 1.65 million annual deaths from cardiovascular causes (95% uncertainty interval [confidence interval], 1.10 million to 2.22 million) were attributed to sodium intake above the reference level; 61.9% of these deaths occurred in men and 38.1% occurred in women. These deaths accounted for nearly 1 of every 10 deaths from cardiovascular causes (9.5%). Four of every 5 deaths (84.3%) occurred in low- and middle-income countries, and 2 of every 5 deaths (40.4%) were premature (before 70 years of age). The rate of death from cardiovascular causes associated with sodium intake above the reference level was highest in the country of Georgia and lowest in Kenya. CONCLUSIONS: In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day. (Funded by the Bill and Melinda Gates Foundation.).

Overview

AI snapshot

Written from a shortened version of the paper’s full text (it is longer than we read).

TL;DR

This is the supplementary appendix to Mozaffarian et al. (NEJM 2014), documenting the methods and results of a global comparative risk assessment of sodium consumption and cardiovascular mortality. It reports that in 2010, 1.65 million CVD deaths (9.5% of all CVD deaths) worldwide were attributed to sodium intake above a 2.0 g/d reference level.

Key findings

  • Global mean sodium intake in 2010 was 4.0 g/d (95% UI 3.9–4.0); sodium above 2 g/d was attributed to 1,648 thousand CVD deaths (95% UI 1,095–2,223), or 9.5% of total CVD deaths (95% UI 6.4–12.8) (Table S4).
  • Among premature CVD deaths (before age 70), 17.8% globally were attributed to sodium above the reference level (95% UI 12.3–23.1); the proportion was highest in upper-middle-income countries (21.6%), similar in lower-middle-income (15.3%) and high-income (15.8%) countries, and lowest in low-income countries (12.5%) (Text S8).
  • Among the 30 most populous nations, the highest absolute sodium-associated CVD mortality was in Ukraine (1,540 deaths/million adults/year; 95% UI 1,017–2,099), Russia (1,316; 873–1,781), and Egypt (570; 370–761); the US had 284/million (184–394), or 6.3% of CVD deaths (4.1–8.7%), while the highest proportional burdens were in China (15.3%; 10.5–20.2), the Philippines (15.2%), and Myanmar (15.1%) (Text S9).
  • In a de novo meta-analysis of 103 randomized trials (107 comparisons; 6,970 subjects), each 100 mmol/d sodium reduction lowered systolic BP by 3.74 mm Hg (95% CI 2.29–5.18) in white normotensives at age 50, with larger reductions per year of age (0.105 mm Hg; 95% CI 0.047–0.164), among Blacks (+2.49 mm Hg; 0.13–4.85), and among hypertensives (+1.87 mm Hg; 0.12–3.63) (Text S1, Figure S2).

Methods

  • Design: comparative risk assessment combining country-, age-, and sex-specific sodium intake, blood pressure, relative risks, and cause-specific mortality to estimate population-attributable fractions above a reference intake of 2.0 ± 0.2 g/d, with no further benefit quantified below 115 mm Hg systolic BP (Text S7).
  • Data: sodium intake from 24-hour urinary and dietary surveys (1,348 age- and sex-specific data points from 63 countries, 40% nationally representative, covering 74% of the world's adult population) pooled with DisMod3; BP from 786 country-years and 5.4 million participants; mortality from the 2010 GBD study across 187 countries (Text S1, S5, S6; Table S1).
  • Analysis: de novo inverse-variance-weighted meta-regression of sodium reduction on systolic BP; age-specific relative risks of BP on CVD interpolated from two pooling projects (99 cohorts, 1.38 million participants, 65,000 CVD events); uncertainty propagated via 1,000 simulation draws (Text S1, S2, S7).

Limitations

  • Stated in the paper: 24-hour urine collections and diet questionnaires estimate population mean intakes reasonably but poorly measure individual intakes, which could bias or substantially underestimate associations with disease risk; limited information from clinical CVD event studies precludes strong conclusions about more substantial sodium reduction (e.g., to 1.5 or 1.0 g/d); and other physiologic benefits of sodium reduction beyond BP were not incorporated, which could lead to underestimation of attributable deaths (Text S3).
  • Evident from the text: this document is the supplementary appendix rather than the main article, so the primary results, figures, and discussion of the published paper are not included here; several key inputs (e.g., the sodium intake estimates and the BP–CVD pooling analyses) are drawn from previously published work rather than generated de novo in this analysis.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1056/nejmoa1304127

Cites

37 of 37 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

0 of 64 cited sources checked · 0 supported · 0 flagged

Show all 108 claims

  • It may state two separate claims as one. 28
  • Probably not a substantial claim. 42
  • The quote only partly states this claim. 1
65 of 65
  • The authors state this as an assumption.

    The dose-response relationship between blood pressure and cardiovascular disease is log-linear until a blood pressure level of 115 mm Hg.

    “Based on the evidence, we assumed a log-linear dose-response between BP and CVD until a BP level of 115 mm Hg”
  • The authors state this as an assumption.

    Above a blood pressure level of 115 mm Hg, blood pressure has no further contribution to cardiovascular disease risk.

    “after which we assumed no further contribution to risk.”
  • The authors state this as an assumption.

    CVD benefits extend down to a systolic blood pressure of 115 mm Hg, but no further.

    “In our analysis, we assumed CVD benefits down to a systolic BP of 115 mm Hg, but no further.16”
  • The authors state this as an assumption.

    The effects of sodium consumption on BP and the effects of BP on each disease outcome are log-normally distributed.

    “based on log normal distributions characterized by each risk estimate and its 95% confidence interval.”
  • The authors state this as an assumption.

    The distribution of sodium consumption for each country-age-sex group is characterized by its mean and standard error.

    “We drew 1,000 times from the distribution of sodium consumption for each country-age-sex group as characterized by its mean and standard error.”
  • The paper relies on this without support.

    The associations between sodium intake and cardiovascular outcomes observed in prior studies are causal.

    “Mean intakes associated with better outcomes”
  • The paper relies on this without support.

    The included national surveys and data sources are representative of global sodium consumption.

    “Data were from 56 national surveys Sibling history Data represented 1,557 survey years from 61 countries”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • East/Southeast Asia CVD components exceed their total

    Major

    Table S4 lists 190, 378, and 1080 thousand deaths for the three CVD subtypes, but reports 676 thousand for all CVD. The components sum to 1648 thousand; the discrepancy is far beyond rounding.

    Reported 676 · recomputed 1648

  • Two tables give different worldwide adult populations

    Minor

    Table S7 gives 4,430 million adults for both sexes overall, whereas Table S6 gives 3,830 million for the worldwide adult population. Both describe adults aged 20 and over in the same analysis.

2 of 2

Citations

Cites

Flagged first, then by citations

Show all 37 references

Research works printed but not linked: 3

  1. He FJ, 2013, Cochrane Database Syst Rev, 4, CD004937
  2. Graudal NA, 2011, Cochrane Database Syst Rev, 11, CD004022
  3. Institute of Medicine. Sodium intake in populations: assessment of evidence. Washington, DC: National Academies Press,2013.

Cited by

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Metadata

Authors
Mozaffarian, D., Fahimi, S., Singh, G. M., Micha, R., Khatibzadeh, S., Engell, R. E., Lim, S., Danaei, G., Ezzati, M., & Powles, J.
Affiliations
  • Tufts University (US)
  • Harvard University (US)
  • University of Washington (US)
  • MRC Centre for Environment and Health (GB)
  • University of Cambridge (GB)
Venue
New England Journal of Medicine
Published
2014-08-14
Volume
371
Issue
7
Pages
624-634
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
OpenAlex
W2125436925
Cited by
1,218
References
37
Citations by year
2026: 50 · 2025: 64 · 2024: 83 · 2023: 97 · 2022: 134 · 2021: 135 · 2020: 138 · 2019: 93 · 2018: 104 · 2017: 95 · 2016: 91 · 2015: 103 · 2014: 30
FWCI
99.03
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Archive ouverte UNIGE (University of Geneva) (publishedVersion, other-oa)
  • Ghent University Academic Bibliography (Ghent University) (submittedVersion, other-oa)
  • Dépôt institutionnel de l'Université libre de Bruxelles (Université Libre de Bruxelles) (submittedVersion)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
  • Hirsla (Landspítali University Hospital) (submittedVersion)
Funders
  • United States Agency for International Development
  • University of Chicago
  • London School of Hygiene and Tropical Medicine
  • University of Cambridge
  • Korea Health Industry Development Institute
  • Stavros Niarchos Foundation
  • Universidade de São Paulo
  • National Research University Higher School of Economics
  • Ministry of Health and Social Solidarity, Greece
  • Hellenic Health Foundation
  • George Institute for Global Health
  • National Institutes of Health (DK007703)
  • Centers for Disease Control and Prevention
  • University of North Carolina at Chapel Hill
  • Russian Academy of Sciences
  • Barts and The London School of Medicine and Dentistry
  • National Cancer Institute (P20CA210305)
  • National Institute of Diabetes and Digestive and Kidney Diseases (DK007703., T32DK007703)
  • National Institute of Environmental Health Sciences (P42 ES10349, P42ES010349)
  • Carolina Population Center, University of North Carolina at Chapel Hill
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, cardiovascular mortality, blood pressure, hypertension, attributable mortality, comparative risk assessment, low- and middle-income countries, premature mortality, global burden of disease, dietary salt
MeSH terms
Adult, Aged, Cardiovascular Diseases, Diet, Female, Humans, Male, Middle Aged, Sodium, Sodium, Dietary, Global Health, Sex Distribution

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