Physicians' Academy for Cardiovascular Education

No evidence for a J-curve for association between sodium intake and CVD

Cook NR et al. Circulation 2014 - Circulation. January 10, 2014


Lower Levels of Sodium Intake and Reduced Cardiovascular Risk

Cook NR, Appel LJ, Whelton PK
Circulation. January 10, 2014 doi: 10.1161/​CIRCULATIONAHA.113.006032


Although the American Heart Association recommends lowering sodium intake to <1500 mg/24h [1,2], and the World Health Organization recommends <2000 mg/24hr [3], there is not enough data to support a lowering to below 1500 mg/24 hr, according to the Institute of Medicine (IOM) in a review of the effects of sodium intake on health effects other than blood pressure.
Recently data from the FLEMENGHO and EPOGH cohorts have shown adverse cardiovascular disease (CVD) outcomes with very low sodium intake [4], although the IOM concluded that the quality of the data was insufficient. All studies that have reported a paradoxical inverse or J-shaped association between sodium intake and CVD have been based on secondary analyses of studies that were not specifically designed to evaluate this relationship. Suboptimal measurements of sodium  are also a major concern.
Mulitiple 24-hour urine specimens were collected over either 18 months [5] or 3-4 years [6] in the phase I and II of the Trials of Hypertension Prevention (TOHP). In participants not on active sodium intervention, these measures were averaged to represent long-term usual intake of sodium. This report sheds more light on the relationship of sodium to CVD, specifically around the low absolute sodium intake levels, based on follow-up data of after the TOHP 1 and 2 trials, including 4526 healthy participants (prehypertensive).

Main results



This TOHP Follow-up Study used an average of multiple 24-hour urine collections as a more accurate measure of sodium exposure than previously applied in studies evaluating the association between sodium and CVD. A continued decrease in CVD events was seen among those with sodium levels as low as 1500 mg/day, thus no evidence of a J-shape in a spline curve. The 32% risk reduction in those excreting less than 2300 mg/day was substantial, although not statistically significant due to the small size of the subgroup.
Thus, these results are consistent with overall health benefits and current guidelines of reducing sodium intake to the 1500 to 2300 mg/day range in the majority of the population. The practical implementation of such targets is challenging, but even a small reduction in the average intake of dietary sodium could yield improved CVD health.

Editorial comment [7]

Based on the findings of Cook et al., the ideal level of sodium intake to reduce CVD risk was below 2300 mg/day (less than one teaspoon of salt. Despite public health efforts to encourage lower sodium consumption in the United States, Americans consume over an average 3400 mg/day. It has been estimated that 12% of sodium intake occurs naturally in food, 11% is added while preparing food or at the table, and 77% of sodium comes from processed/packaged food or restaurant food.
The low availability of lower sodium choices makes lower sodium consumption challenging. Individuals should use the information on the Nutrition Facts panel on package labels, to be informed on the sodium content, among other measures that can reduce sodium intake.
Cooperation from the food an restaurant industries to lower sodium in manufactured and restaurant foods would assist Americans in meeting the lower sodium recommendations, as well as public health nutrition strategies to help people select lower sodium foods for better CV health.
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