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Salt intake, stroke, and cardiovascular disease : meta-analysis of prospective studies

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Strazzullo, Pasquale, Elia, Lanfranco d', Kandala, Ngianga-Bakwin and Cappuccio, Francesco P.. (2009) Salt intake, stroke, and cardiovascular disease : meta-analysis of prospective studies. BMJ, Vol.339 . b4567. ISSN 0959-535X

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Official URL: http://dx.doi.org/10.1136/bmj.b4567

Abstract

Objective: To assess the relation between the level of habitual salt intake and stroke or total cardiovascular disease outcome. Design: Systematic review and meta-analysis of prospective studies published 1966-2008. Data sources: Medline (1966-2008), Embase (from 1988), AMED (from 1985), CINAHL (from 1982), Psychinfo (from 1985), and the Cochrane Library. Review methods: For each study, relative risks and 95% confidence intervals were extracted and pooled with a random effect model, weighting for the inverse of the variance. Heterogeneity, publication bias, subgroup, and meta-regression analyses were performed. Criteria for inclusion were prospective adult population study, assessment of salt intake as baseline exposure, assessment of either stroke or total cardiovascular disease as outcome, follow-up of at least three years, indication of number of participants exposed and number of events across different salt intake categories. Results: There were 19 independent cohort samples from 13 studies, with 177 025 participants (follow-up 3.5-19 years) and over 11 000 vascular events. Higher salt intake was associated with greater risk of stroke (pooled relative risk 1.23, 95% confidence interval 1.06 to 1.43; P=0.007) and cardiovascular disease (1.14, 0.99 to 1.32; P=0.07), with no significant evidence of publication bias. For cardiovascular disease, sensitivity analysis showed that the exclusion of a single study led to a pooled estimate of 1.17 (1.02 to 1.34; P=0.02). The associations observed were greater the larger the difference in sodium intake and the longer the follow-up. Conclusions: High salt intake is associated with significantly increased risk of stroke and total cardiovascular disease. Because of imprecision in measurement of salt intake, these effect sizes are likely to be underestimated. These results support the role of a substantial population reduction in salt intake for the prevention of cardiovascular disease.

Item Type:	Journal Article
Subjects:	R Medicine > RC Internal medicine
Divisions:	Faculty of Medicine > Warwick Medical School > Health Sciences Faculty of Medicine > Warwick Medical School > Metabolic and Vascular Health Faculty of Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Salt -- Physiological effect -- Research, Cardiovascular system -- Diseases, Cerebrovascular disease -- Nutritional aspects
Journal or Publication Title:	BMJ
Publisher:	BMJ Group
ISSN:	0959-535X
Date:	24 November 2009
Volume:	Vol.339
Number of Pages:	9
Page Range:	b4567
Identification Number:	10.1136/bmj.b4567
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
Funder:	Seventh Framework Programme (European Commission) (FP7/2007-2013)
Grant number:	FP7-HEALTH- 2007-201550 (FP7)
References:	1 He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 2009;23:363-84. 2 World Health Organization. Reducing salt intake in populations: report of a WHO forum and technical meeting. WHO, 2007:1-60. 3 He FJ, MacGregor GA. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 2002;16:761-70. 4 He FJ, MacGregor GA. How far should salt intake be reduced? Hypertension 2003;42:1093-9. 5 Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of reporting of meta-analyses. Lancet 1999;354:1896-900. 6 Alderman MH, Madhavan S, Cohen H, Sealey JE, Laragh JH. Low urinary sodium is associated with greater risk of myocardial infarction among treated hypertensive men. Hypertension 1995;25:1144-52. 7 Alderman MH, Sealey JE, Cohen H, Madhavan S and Laragh JH. Urinary sodium excretion and myocardial infarction in hypertensive patients: a prospective cohort study. Am J Clin Nutr 1997;65(suppl):682-6S. 8 AldermanMH, Cohen H, Madhavan S. Dietary sodiumintake and mortality: the national health and nutrition examination survey (NHANES I). Lancet 1998;351:781-5. 9 He J,Ogden LG, Vupputuri S,Bazzano LA, Loria C, Whelton PK. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. JAMA 1999;282:2027-34. 10 Kagan A, Popper JS, Rhoads GG, Yano K. Dietary and other risk factors for stroke in Hawaiian Japanese men. Stroke 1985;16:390-6. 11 Hu HH, Sheng WY, Chu FL, Lan CF, Chiang BN. Incidence of stroke in Taiwan. Stroke 1992;23:1237-41. 12 Tunstall-Pedoe H, Woodward M, Tavendale R, A’Brook R, McCluskey MK. Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish heart health study: cohort study. BMJ 1997;315:722-9. 13 Tuomilehto J, Jousilahti P, Rastenyte D, Moltchanov V, Tanskanen A, Pietinen, P, et al. Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study. Lancet 2001;357:848-51. 14 Nagata C, Takatsuka N, Shimizu N, Shimizu H. Sodium intake and risk of death from stroke in Japanese men and women. Stroke 2004;35:1543-7. 15 Cohen HW, Hailpern SM, Fang J, Alderman MH. Sodium intake and mortality in the NHANES II follow-up study. Am J Med 2006;119:275 e7-14. 16 Geleijnse JM, Witteman JC, Stijnen T, Kloos MW, Hofman A, Grobbee DE. Sodium and potassium intake and risk of cardiovascular events and all-cause mortality: the Rotterdam study. Eur J Epidemiol 2007;22:763-70. 17 Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ 2007;33:885-8. 18 LarssonSC, VirtanenMJ, MarsM,MannistoS, Pietinen P, AlbanesD, et al. Magnesium, calcium, potassium, and sodium intakes and risk of stroke in male smokers. Arch Intern Med 2008;168:459-65. 19 UmesawaM, Iso H, Date C, Yamamoto A, Toyoshima H,Watanabe Y, et al. Relations between dietary sodium and potassium intakes and mortality from cardiovascular disease: the Japan collaborative cohort study for evaluation of cancer risks. Am J Clin Nutr 2008;88:195-202. 20 Cohen HW, Hailpern SM, AldermanMH. Sodium intake andmortality follow-up in the third national health and nutrition examination survey (NHANES III). J Gen InternMed 2008;23:1297-302. 21 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377-84. 22 Dersimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177-88. 23 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-60. 24 Egger M, Davey SG, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629-34. 25 Sutton AJ, Duval SJ, Tweedie RL, Abrams KR, Jones DR. Empirical assessment of effect of publication bias on meta-analyses. BMJ 2000;320:1574-7. 26 Bax L, Yu LM, Ikeda N, Tsuruta H, Moons KG. Development and validation of MIX: comprehensive free software for meta-analysis of causal research data. BMC Med Res Methodol 2006;6:50. 27 World Health Organization. The world health report 2002—reducing risks promoting healthy life. WHO, 2002. 28 Scientific Advisory Committee on Nutrition. Salt and health. Stationery Office, 2003:1-134. 29 World Health Organization. Reducing salt intake in populations. Report of a WHO forum and technical meeting. WHO, 2007:1-60. 30 Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a metaanalysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903-13. 31 Karppanen H, Mervaala E. Sodium intake and mortality. Lancet 1998;351:1509. 32 KupariM, Koskinen P, Virolainen J. Correlates of left ventricularmass in a population sample aged 36 to 37 years. Focus on lifestyle and salt intake. Circulation 1994;89:1041-50. 33 Schmieder RE, Messerli FH, Garavaglia GE, Nunez BD. Dietary salt intake. A determinant of cardiac involvement in essential hypertension. Circulation 1988;78:951-6. 34 Du Calair G, Ribstein J, Daures JP, Mimran A. Sodium and left ventricular mass in untreated hypertensive and normotensive subjects. Am J Physiol 1992;263:H177-81. 35 Avolio AP, Clyde KM, Beard TC, CookeHM, Ho KK,O’RourkeMF. Improved arterial distensibility in normotensive subjects on a low salt diet. Arteriosclerosis 1986;6:166-9. 36 Du Calair G, Ribstein J, Mimran A. Dietary sodium and target organ damage in essential hypertension. Am J Hypertens 2002;15:222-9. 37 Verhave JC, Hillege HL, Burgerhof JG, Janssen WM, Gansevoort RT, Navis GJ, et al. Sodium intake affects urinary albumin excretion especially in overweight subjects. J InternMed 2004;256:324-30. 38 National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. Obes Res 1998;(suppl 2):51-209S. 39 Strazzullo P, Barba G, Cappuccio FP, Siani A, Trevisan M, Farinaro E, et al. Altered renal sodiumhandling inmen with abdominal adiposity and insulin resistance: a link to hypertension. J Hypertens 2001;19:2157-64. 40 World Health Organization. The world health report 2004—changing history. WHO, 2004. 41 Selmer RM, Kristiansen IS, Haglerod A, Graff-Iversen S, Larson HK, Meyer HE, et al. Cost and health consequences of reducing the population intake of salt. J Epidemiol Community Health 2000;54:697-702. 42 MurrayCJ, Lauer JA, HutubessyRC,NiessenL, TomijimaN,RodgersA, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 2003;361:717-25. 43 Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:2044-53. 44 Godlee F. The food industry fights for salt. BMJ 1996;312:1239-40. 45 Cappuccio FP. Salt and cardiovascular disease. BMJ 2007;334:859-60.
URI:	http://wrap.warwick.ac.uk/id/eprint/2440