Effect of lower sodium intake on health: systematic review and meta-analyses

Nancy J Aburto, Anna Ziolkovska, Lee Hooper, Paul Elliott, Francesco P Cappuccio, Joerg J Meerpohl, Nancy J Aburto, Anna Ziolkovska, Lee Hooper, Paul Elliott, Francesco P Cappuccio, Joerg J Meerpohl

Abstract

Objective: To assess the effect of decreased sodium intake on blood pressure, related cardiovascular diseases, and potential adverse effects such as changes in blood lipids, catecholamine levels, and renal function.

Design: Systematic review and meta-analysis.

Data sources: Cochrane Central Register of Controlled Trials, Medline, Embase, WHO International Clinical Trials Registry Platform, the Latin American and Caribbean health science literature database, and the reference lists of previous reviews.

Study selection: Randomised controlled trials and prospective cohort studies in non-acutely ill adults and children assessing the relations between sodium intake and blood pressure, renal function, blood lipids, and catecholamine levels, and in non-acutely ill adults all cause mortality, cardiovascular disease, stroke, and coronary heart disease.

Study appraisal and synthesis: Potential studies were screened independently and in duplicate and study characteristics and outcomes extracted. When possible we conducted a meta-analysis to estimate the effect of lower sodium intake using the inverse variance method and a random effects model. We present results as mean differences or risk ratios, with 95% confidence intervals.

Results: We included 14 cohort studies and five randomised controlled trials reporting all cause mortality, cardiovascular disease, stroke, or coronary heart disease; and 37 randomised controlled trials measuring blood pressure, renal function, blood lipids, and catecholamine levels in adults. Nine controlled trials and one cohort study in children reporting on blood pressure were also included. In adults a reduction in sodium intake significantly reduced resting systolic blood pressure by 3.39 mm Hg (95% confidence interval 2.46 to 4.31) and resting diastolic blood pressure by 1.54 mm Hg (0.98 to 2.11). When sodium intake was <2 g/day versus ≥ 2 g/day, systolic blood pressure was reduced by 3.47 mm Hg (0.76 to 6.18) and diastolic blood pressure by 1.81 mm Hg (0.54 to 3.08). Decreased sodium intake had no significant adverse effect on blood lipids, catecholamine levels, or renal function in adults (P>0.05). There were insufficient randomised controlled trials to assess the effects of reduced sodium intake on mortality and morbidity. The associations in cohort studies between sodium intake and all cause mortality, incident fatal and non-fatal cardiovascular disease, and coronary heart disease were non-significant (P>0.05). Increased sodium intake was associated with an increased risk of stroke (risk ratio 1.24, 95% confidence interval 1.08 to 1.43), stroke mortality (1.63, 1.27 to 2.10), and coronary heart disease mortality (1.32, 1.13 to 1.53). In children, a reduction in sodium intake significantly reduced systolic blood pressure by 0.84 mm Hg (0.25 to 1.43) and diastolic blood pressure by 0.87 mm Hg (0.14 to 1.60).

Conclusions: High quality evidence in non-acutely ill adults shows that reduced sodium intake reduces blood pressure and has no adverse effect on blood lipids, catecholamine levels, or renal function, and moderate quality evidence in children shows that a reduction in sodium intake reduces blood pressure. Lower sodium intake is also associated with a reduced risk of stroke and fatal coronary heart disease in adults. The totality of evidence suggests that most people will likely benefit from reducing sodium intake.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: LH, FPC, PE, and JJM received funding from WHO to attend NUGAG Subgroup of Diet and Health meetings, PE receives support from the National Institute for Health Research Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London, FPC is an unpaid member of Consensus Action on Salt and Health (CASH), World Action on Salt and Health (WASH), unpaid advisor to the WHO and the PAHO, a member of the National Heart Forum and former member of the executive committee and trustee of the British Hypertension Society, PE is an unpaid member of CASH, WASH, and an unpaid advisor to WHO; no further financial support from any organisation for the submitted work that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. NJA was a staff member of WHO at the time this work was conducted. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions, or policies of WHO.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816261/bin/abun007380.f1.jpg
Fig 1 Flow of records in adults and children
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816261/bin/abun007380.f2.jpg
Fig 2 Effect of reduced sodium intake on resting systolic blood pressure in adults
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816261/bin/abun007380.f3.jpg
Fig 3 Direct comparisons of effect of sodium consumption of <2 g/day v >2g/day, <1.2 g/day v >1.2 g/day, and a reduction by one third or more versus less than one third relative to control on systolic blood pressure in adults
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4816261/bin/abun007380.f4.jpg
Fig 4 Effect of reduced sodium intake on resting systolic blood pressure in children

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