Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP)

Cook, Nancy R; Cutler, Jeffrey A; Obarzanek, Eva; Buring, Julie E; Rexrode, Kathryn M; Kumanyika, Shiriki K; Appel, Lawrence J; Whelton, Paul K

doi:10.1136/bmj.39147.604896.55

Cited by 1,179Sodium Intake and HealthBlood Pressure and Hypertension StudiesNutritional Studies and Diet

Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP)

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Cook, Nancy R, Cutler, Jeffrey A, Obarzanek, Eva, Buring, Julie E, Rexrode, Kathryn M, Kumanyika, Shiriki K, Appel, Lawrence J, Whelton, Paul K·2007·BMJ

DOI 10.1136/bmj.39147.604896.55PMC PMC1857760

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Abstract

OBJECTIVE: To examine the effects of reduction in dietary sodium intake on cardiovascular events using data from two completed randomised trials, TOHP I and TOHP II. DESIGN: Long term follow-up assessed 10-15 years after the original trial. SETTING: 10 clinic sites in 1987-90 (TOHP I) and nine sites in 1990-5 (TOHP II). Central follow-up conducted by post and phone. PARTICIPANTS: Adults aged 30-54 years with prehypertension. INTERVENTION: Dietary sodium reduction, including comprehensive education and counselling on reducing intake, for 18 months (TOHP I) or 36-48 months (TOHP II). MAIN OUTCOME MEASURE: Cardiovascular disease (myocardial infarction, stroke, coronary revascularisation, or cardiovascular death). RESULTS: 744 participants in TOHP I and 2382 in TOHP II were randomised to a sodium reduction intervention or control. Net sodium reductions in the intervention groups were 44 mmol/24 h and 33 mmol/24 h, respectively. Vital status was obtained for all participants and follow-up information on morbidity was obtained from 2415 (77%), with 200 reporting a cardiovascular event. Risk of a cardiovascular event was 25% lower among those in the intervention group (relative risk 0.75, 95% confidence interval 0.57 to 0.99, P=0.04), adjusted for trial, clinic, age, race, and sex, and 30% lower after further adjustment for baseline sodium excretion and weight (0.70, 0.53 to 0.94), with similar results in each trial. In secondary analyses, 67 participants died (0.80, 0.51 to 1.26, P=0.34). CONCLUSION: Sodium reduction, previously shown to lower blood pressure, may also reduce long term risk of cardiovascular events.

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Few of the reviewed studies examined the influence of behavior change on cardiovascular disease events, mortality, hospitalizations, or quality of life, although they examined surrogate endpoints such as lipid or blood pressure changes.
“Although the studies reviewed examined the influence of behavior change on surrogate end points such as lipid or BP changes, few examined the influence of behavior change on CVD events, mortality, hospitalizations, or quality of life.221,222”
From Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults: A Scientific Statement From the American Heart Association (2010) · cites this paper as [221]
Cardiovascular disease event rates are lower following salt reduction.
“Limited evidence from trials, including long-term follow-up of salt-reduction trials, is also consistent with lower CVD event rates after salt reduction.156,157”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [156]
Salt restriction decreases the risk of hypertension with or without weight loss as well as reducing the incidence of CV events.
“Salt restriction decreases the risk of hypertension with or without weight loss as well as reducing the incidence of CV events.133”
From Obesity‐Related Hypertension: Pathogenesis, Cardiovascular Risk, and Treatment: A Position Paper of The Obesity Society and the American Society of Hypertension (2013) · cites this paper as [133]
In 10- to 15-year follow-up of prehypertensive adults who took part in the TONE studies, the risk of a CV event was lower by 25% to 30% in those who had been assigned to the salt-restricted group.
“In 10-to 15-year follow-up of prehypertensive adults who took part in the TONE studies, the risk of a CV event was lower by 25% to 30% in those who had been assigned to the salt-restricted group.133”
From Obesity‐Related Hypertension: Pathogenesis, Cardiovascular Risk, and Treatment: A Position Paper of The Obesity Society and the American Society of Hypertension (2013) · cites this paper as [133]

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Authors: Cook, N. R., Cutler, J. A., Obarzanek, E., Buring, J. E., Rexrode, K. M., Kumanyika, S. K., Appel, L. J., & Whelton, P. K.
Affiliations: Brigham and Women's Hospital (US)
National Heart, Lung, and Blood Institute (US)
University of Pennsylvania (US)
Johns Hopkins University (US)
Loyola Medicine (US)
ORCID: Cook, Nancy R
Buring, Julie E
Rexrode, Kathryn M
Kumanyika, Shiriki K
Appel, Lawrence J
Whelton, Paul K
Venue: BMJ
Publisher: BMJ
Published: 2007-04-20
Volume: 334
Issue: 7599
Pages: 885
ISSN: 0007-1447 (ISSN-L)
0959-8138
1468-5833
DOI: 10.1136/bmj.39147.604896.55
PMC: PMC1857760
OpenAlex: W2120418712
Cited by: 1,179
References: 51
Citations by year: 2026: 16 · 2025: 22 · 2024: 27 · 2023: 39 · 2022: 40 · 2021: 37 · 2020: 57 · 2019: 45 · 2018: 49 · 2017: 71 · 2016: 56 · 2015: 75 · 2014: 108 · 2013: 102 · 2012: 90
FWCI: 9.50
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.bmj.org/licenses/tdm/1.0/terms-and-conditions.html (tdm)
Locations: BMJ (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
HighWire Press Open Archive (submittedVersion)
Funders: National Institutes of Health (2u01hl037884-05, 5u01hl037924-09, 2u01hl037904-05, 5u01hl037906-09, 5u01hl037849-07, 5u01hl037854-09, 5u01hl037852-11, 5u01hl037907-08, 1u01hl037872-01, 5u01hl037899-08, 5u01hl037853-09)
National Heart, Lung, and Blood Institute (HL-37924, HL 37849, HL 37899, HL37852, HL 37904, HL-37854, HL-37872, HL37906, HL37853, HL 37884, R01HL057915, HL057915, HL-37907)
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: dietary sodium reduction, hypertension prevention, cardiovascular outcomes, prehypertension, myocardial infarction, stroke, cardiovascular mortality, coronary revascularization, sodium excretion, long-term follow-up
MeSH terms: Adult, Female, Follow-Up Studies, Humans, Hypertension, Male, Middle Aged, Myocardial Infarction, Myocardial Revascularization, Risk Factors, Randomized Controlled Trials as Topic, Death, Sudden, Cardiac, Sodium Chloride, Dietary, Age Distribution, Sex Distribution, Stroke

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Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP)

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