Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies

Abstract

Full funding sources listed at end of paper (see Acknowledgments).

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

“…For riskoutcome pairs for which no recent systematic review was available, we either updated reviews developed for GBD 2013 or did a new systematic search of literature (methods appendix pp . Table 2 summarises the evidence using multiple dimensions, which supports our assessment that each included risk-outcome pair meets the criteria of convincing or probable evidence (methods appendix [pp [12][13] contains a justifi cation of the criteria presented to support causality). In this summary of evidence, we have focused on randomised controlled trials and prospective observational studies, along with supporting evidence, like dose-response relationships and biologically plausible mechanisms.…”

“…76 Although multiple lines of epidemiological evidence support the harmful eff ects of very high levels of sodium intake, no scientifi c consensus has been reached on the optimal level of sodium intake. In GBD 2013, on the basis of fi ndings of the Prospective Urban Rural Epidemiology (PURE) collaboration on sodium and cardiovascular mortality 13,77 and to incorporate the absence of scientifi c consensus on the optimal intake of sodium, we expanded the uncertainty for the TMREL for sodium to 1-5 g per day.…”

“…78-80 PURE collaborators subsequently published a further analysis, 13 which raised the possibility that, for those without hypertension, an inverse relationship might exist between sodium intake, all-cause mortality, and cardiovascular events. These fi ndings challenge longstanding beliefs in the public health community with regard to the importance of modulation of sodium intake at the population level.…”

“…[5][6][7] A robust debate on specifi c risks and results emerged after publication of the Global Burden of Diseases, Injuries, andRisk Factors Study 2013 (GBD 2013). 8 Inclusion and exclusion of particular risks and outcomes; 3,4,9 the optimum targets for indicators such as high systolic blood pressure, 10,11 cholesterol, 11,12 diets high in sodium, 13 and air pollution; 4,14 and the certainty of some dietary components of risk 8,15 were challenged, in addition to some details of methods. Underlying many of these discussions were heterogeneities in the strength of causal evidence for diff erent risk-outcome pairs.…”

Commentary: The Salt and Hypertension Issue Today

“…In 2016, American Heart Association News reported a study that suggested that reducing excessive salt benefits some people with high blood pressure, but low-sodium diets do not help people with lower risks for heart disease, stroke or death. A study published in the Lancet [6] involved more than 130,000 people from 49 countries, concluded that low-salt diets in people with and without high blood pressure may actually increase the risk of cardiovascular disease and death compared to average salt consumption. Criticism of that study in the Lancet correspondence (Lancet 388, page 2111) only goes to show the persistence of the proponents of the low salt diet and the apparent power they have with governments.…”