Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health

A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time.

METHODS

We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden.

FINDINGS

In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania.

INTERPRETATION

Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children.

FUNDING

Bill & Melinda Gates Foundation.

Subjective evaluation of the frequency of salty food intake and its relationship to urinary sodium excretion and blood pressure in a middle-aged population

OBJECTIVES

The aim of this study was to examine the relationship between subjective evaluations of the frequency of salty food intake and both urinary sodium excretion and blood pressure (BP) in a middle-aged population.

METHODS

Urinary sodium and creatinine concentrations in a spot sample and brachial BP were measured in 419 subjects (mean age 37±9 years, 385 men) during a health examination at a company in Kanagawa, Japan, 2011. Twenty-four-hour urinary sodium excretion was estimated from sodium and creatinine concentrations in the spot sample. The subjects were asked about the frequency of salty food intake on a self-reported questionnaire, choosing their answer from 'seldom', 'sometimes', or 'always' based on their own subjective evaluation. The amount of daily salt intake was converted from 24-h urinary sodium excretion.

RESULTS

The prevalence of high salt intake, defined as greater than the daily average salt intake of Japanese according to the National Health and Nutrition Survey in 2010, gradually increased from the 'seldom' to the 'sometimes', and then 'always' categories (10.3, 13.4, and 24.0%, respectively; P=0.013 for trend). The 24-h urinary sodium excretion among these groups also tended to be different; however, the differences did not reach a significantly significant level (145±41, 152±34, and 160±40 mEq/day, respectively; P=0.076). Both systolic and diastolic BP were similar among the groups.

CONCLUSIONS

Although some of our findings raise the possibility of a relationship between a subjective evaluation of the frequency of salty food intake and urinary sodium excretion, further studies are needed to confirm the relationship. In contrast, no relationship with BP was found.

Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations

Recent reports of selected observational studies and a meta-analysis have stirred controversy and have become the impetus for calls to abandon recommendations for reduced sodium intake by the US general population. A detailed review of these studies documents substantial methodological concerns that limit the usefulness of these studies in setting, much less reversing, dietary recommendations. Indeed, the evidence base supporting recommendations for reduced sodium intake in the general population remains robust and persuasive. The American Heart Association is committed to improving the health of all Americans through implementation of national goals for health promotion and disease prevention, including its recommendation to reduce dietary sodium intake to <1500 mg/d.

Salt reduction in a population for the prevention of hypertension

Hypertension is one of the major risk factors for cardiovascular disease, the prevention of which is acknowledged to be critically important. Human beings are the only animal species which consume large quantities of salt, and their consumption has increased with the advancement of civilization. Many observational and interventional epidemiologic studies have demonstrated that a high intake of salt results in elevation of blood pressure, and that a salt-reduced diet induces blood pressure reduction in patients with hypertension as well as in individuals with normal blood pressure. Reduced salt intake, blood pressure reduction, and a remarkable decrease in mortality due to stroke in Japan are important examples of this effect. A decrease in the mean blood pressure in an entire population can contribute significantly to decreased incidence of cardiovascular diseases. A population-based strategy for preventing hypertension, including a salt-reduced diet, is therefore desirable. Proposed measures include public health education by the mass media, reduced salt content in processed foods, salt reduction in foods served by schools or organizations and at restaurants, and labeling of salt content. Further studies are needed of population-wide salt reduction methods, and the effectiveness of such methods.

ASH position paper: Dietary approaches to lower blood pressure

A substantial body of evidence has implicated several aspects of diet in the pathogenesis of elevated blood pressure (BP). Well-established risk factors for elevated BP include excess salt intake, low potassium intake, excess weight, high alcohol consumption, and suboptimal dietary pattern. African Americans are especially sensitive to the BP-raising effects of excess salt intake, insufficient potassium intake, and suboptimal diet. In this setting, dietary changes have the potential to substantially reduce racial disparities in BP and its consequences. In view of the age-related rise in BP in both children and adults, the direct, progressive relationship of BP with cardiovascular-renal diseases throughout the usual range of BP, and the worldwide epidemic of BP-related disease, efforts to reduce BP in nonhypertensive as well as hypertensive individuals are warranted. In nonhypertensives, dietary changes can lower BP and delay, if not prevent, hypertension. In uncomplicated stage I hypertension, dietary changes serve as initial treatment before drug therapy. In hypertensive individuals already on drug therapy, lifestyle modifications can further lower BP. The current challenge is designing and implementing effective clinical and public health interventions that lead to sustained dietary changes among individuals and more broadly in the general population.

Urinary and dietary sodium and potassium associated with blood pressure control in treated hypertensive kidney transplant recipients: an observational study

Background

In kidney transplant (Kt) recipients , hypertension is a major risk for cardiovascular complications but also for graft failure. Blood pressure (BP) control is therefore mandatory. Office BP (OBP) remains frequently used for clinical decisions, however home BP (HBP) have brought a significant improvement in the BP control. Sodium is a modifiable risk factor, many studies accounted for a decrease of BP with a sodium restricted diet. Increased potassium intake has been also recommended in hypertension management. Using an agreement between office and home BP, the present study investigated the relations between the BP control in Kt recipients and their urinary excretion and dietary consumption of sodium and potassium.

Methods

The BP control defined by OBP <140/90 mmHg and HBP <135/85 mmHg was tested in 70 Kt recipients (mean age 56 ± 11.5 years; mean graft survival 7 ± 6.6 years) treated with antihypertensive medications. OBP and HBP were measured with a validated oscillometric device (Omron M6®). The 24-hour urinary sodium (Na+) and potassium (K+) excretions as well as dietary intakes were compared between controlled and uncontrolled (in office and at home) recipients. Non parametric Wilcoxon Mann–Whitney Test was used for between groups comparisons and Fisher's exact test for frequencies comparisons. Pearson correlation coefficients and paired t-test were used when sample size was >30.

Results

Using an agreement between OBP and HBP, we identified controlled (21%) and uncontrolled recipients (49%). Major confounding effects susceptible to interfere with the BP regulation did not differ between groups, the amounts of sodium excretion were similar (154 ± 93 vs 162 ± 88 mmol/24 h) but uncontrolled patients excreted less potassium (68 ± 14 vs 54 ± 20 mmol/24 h; P = 0.029) and had significantly lower potassium intakes (3279 ± 753 vs 2208 ± 720 mg/24 h; P = 0.009), associated with a higher urinary Na+/K + ratio. Systolic HBP was inversely and significantly correlated to urinary potassium (r = −0.48; P = 0.002), a positive but non significant relation was observed with urinary sodium (r = 0,30;P = 0.074).

Conclusions

Half of the treated hypertensive Kt recipients remained uncontrolled in office and at home. Restoring a well-balanced sodium/potassium ratio intakes could be a non pharmacological opportunity to improve blood pressure control.

Effect of amiloride and spironolactone on renal tubular function and central blood pressure in patients with arterial hypertension during baseline conditions and after furosemide: a double-blinded, randomized, placebo-controlled crossover trial

This study demonstrates that the increased potassium content in the body seems to change both the blood pressure and renal tubular function. We wanted to test the hypotheses that amiloride and spironolactone induced potassium retention reduces ambulatory blood pressure (ABP) and central blood pressure (CBP) during baseline conditions and after furosemide and that the tubular transport via the epithelial sodium channels (ENaCs) and aquaporin-2 (AQP2) water channels was increased by furosemide in arterial hypertension. Each of three 28-day treatment periods (placebo, amiloride, and spironolactone) was completed by a 4-day period with standardized diet regarding calories and sodium and water intake. At the end of each period, we measured pulse wave velocity (PWV), central systolic blood pressure (CSBP), central diastolic blood pressure (CDBP), glomerular filtration rate (GFR), free water clearance (CH2O), fractional excretion of sodium (FENa) and potassium (FEK), urinary excretion of AQP2 (u-AQP2), urinary excretion of γ-fraction of the ENaC (u-ENaCγ), and plasma concentrations of renin (PRC), angiotensin II (p-Ang II), and aldosterone (p-Aldo) at baseline conditions and after furosemide bolus. Ambulatory blood pressure and CBP were significantly lowered by amiloride and spironolactone. During 24-hour urine collection and at baseline, GFR, CH2O, FENa, FEK, u-AQP2 and u-ENaCγ were the same. After furosemide, CH2O, FENa, FEK, u-AQP2, u-ENaCγ, PRC, p-Ang II, p-Aldo, PWV and CDBP increased after all treatments. However, during amiloride treatment, FEK increased to a larger extent than after spironolactone and during placebo after furosemide, and CSBP was not significantly reduced. The increases in water and sodium absorption via AQP2 and ENaC after furosemide most likely are compensatory phenomena to antagonize water and sodium depletion. Amiloride is less effective than spironolactone to reduce renal potassium excretion.

Effect of partial sodium replacement on physicochemical parameters of smoked sea bass during storage

The objective of this work was to study the effect of partial sodium replacement by potassium and packaging conditions on the physicochemical properties of smoked sea bass during cold storage. Sea bass fillets were salted with 100% NaCl (Na samples) or with 50% NaCl-50% KCl (Na:K samples), smoked, packaged under three different conditions (air, vacuum and modified atmosphere) and stored at 4 °C for 42 days. Physicochemical parameters, color and texture were periodically determined in the raw material and in smoked samples during cold storage. The smoking process led to a reduction in moisture, pH and a(w) values, and an increase in water holding capacity, ash and mineral contents. Smoked fish exhibited significant differences in color and texture as compared to fresh fish. The type of packaging had an effect on the pH, water holding capacity and texture. Samples in air exhibited the highest pH values and water holding capacity in these samples gradually decreased during storage. Textural parameters decreased during storage in samples packaged in vacuum and modified atmosphere. The pH of Na samples was initially higher than in Na:K samples, and this difference remained over the rest of the study. The type of salt did not affect the texture or other physicochemical parameters.

Development and pilot test of a culturally sensitive CD-ROM for hypertensive, older Chinese immigrants

Hypertension control remains an issue for older Chinese immigrants because of the unique cultural health practices they use to manage their hypertension. Limited health education information on how to manage hypertension is available in Chinese. Because San Francisco has a large population of older Chinese immigrants, development of culturally sensitive educational material is important to help this population to achieve better blood pressure control. The purpose of this study was to develop and pilot test an innovative, culturally based CD-ROM with a focus on hypertension education and management, directed to the older Chinese immigrant population. The results of this pilot study found that the content of CD-ROM was culturally acceptable for the target population. Given a lack of educational material in Chinese in the United States, this CD-ROM has a potential to be used for a large population of Chinese elders in the United States.

The impact of salt reduction in bread: a review

The dietary intake of sodium chloride has increased considerably over the last few decades due to changes in the human diet. This higher intake has been linked to a number of diseases including hypertension and other cardiovascular diseases. Numerous international health agencies, as well as the food industry, have now recommended a salt intake level of about 5-6 g daily, approximately half the average current daily intake level. Cereal products, and in particular bread, are a major source of salt in the diet. Therefore, any reduction in the level of salt in bread would have a major impact on global health. However, salt is a critical ingredient in bread production, and its reduction can have a deleterious effect on the production process. This includes an impact on dough handling, as well as final bread quality characteristics, including shelf-life, bread volume, and sensory characteristics, all deviating from the expectations of bakers and consumers. This review describes the effect of salt reduction during bread production and the resulting problems, both technological and qualitative, as well as evaluating some techniques commonly used to replace sodium chloride.

Correlation between sodium and potassium excretion in 24- and 12-h urine samples

Low-sodium and high-potassium diets have been recommended as an adjunct to prevention and treatment of hypertension. Analysis of these nutrients in 24-h urine has been considered the reference method to estimate daily intake of these minerals. However, 24-h urine collection is difficult in epidemiological studies, since urine must be collected and stored in job environments. Therefore, strategies for shorter durations of urine collection at home have been proposed. We have previously reported that collecting urine during a 12-h period (overnight) is more feasible and that creatinine clearance correlated strongly with that detected in 24-h samples. In the present study, we collected urine for 24 h divided into two 12-h periods (from 7:00 am to 7:00 pm and from 7:00 pm to 7:00 am next day). A sample of 109 apparently healthy volunteers aged 30 to 74 years of both genders working in a University institution was investigated. Subjects with previous myocardial infarction, stroke, renal insufficiency, and pregnant women were not included. Significant (P < 0.001) Spearman correlation coefficients (r_s) were found between the total amount of sodium and potassium excreted in the urine collected at night and in the 24-h period (r_s = 0.76 and 0.74, respectively). Additionally, the 12-h sodium and potassium excretions (means ± SD, 95% confidence interval) corresponded to 47.3 ± 11.2%, 95%CI = 45.3-49.3, and 39.3 ± 4.6%, 95%CI = 37.3-41.3, respectively, of the 24-h excretion of these ions. Therefore, these findings support the assumption that 12-h urine collected at night can be used as a reliable tool to estimate 24-h intake/excretion of sodium and potassium.

Salt, aldosterone and hypertension

Clinical studies have shown that aldosterone and salt are independently related to hypertension, cardiovascular morbidity and mortality. More recently, studies in humans have demonstrated that, similarly to animals, endogenous aldosterone and dietary salt intake have not only separate, but also combined effects to accelerate target-organ deterioration. The aldosterone-salt interaction has important clinical implications, because combined effects of both can be minimized, if not avoided, by reducing salt intake. This interaction could also be interrupted by blocking the effects of aldosterone, with use of mineralocorticoid receptor antagonists, or by reducing aldosterone effects by adrenalectomy, in patients with aldosterone producing adenoma. Furthermore, aldosterone reduction or blockade may reduce salt appetite.

Lactation and cardiovascular risk factors in mothers in a population-based study: the HUNT-study

Background

Lactation has beneficial short term effects on maternal metabolic health, but the long term effects are less well known.

Methods

We studied the association between lifetime duration of lactation and cardiovascular risk factors in mothers later in life among 21,368 parous women aged 20 to 85 years attending the second Nord-Trøndelag Health Study (HUNT2) in 1995–1997, Norway, a cross-sectional population-based study. General linear modelling was used to calculate mean values of known cardiovascular risk factor levels in five categories of lifetime duration of lactation. Logistic regression was conducted to estimate odds ratios of hypertension, obesity and diabetes.

Results

Among women aged 50 years or younger, lifetime duration of lactation was significantly and inversely associated with body mass index (P-trend, < 0.001), waist circumference (P-trend, < 0.001), systolic and diastolic blood pressure (both P-trends, < 0.001), and serum levels of triglycerides, total cholesterol and low density lipoprotein cholesterol (all P-trends, < 0.001) after adjustment for covariates. Parous women aged 50 years or younger who had never lactated had higher prevalence of hypertension, obesity and diabetes. In this age group, compared to women who had lactated for 24 months or more, parous women who had never lactated had an OR for hypertension of 1.88 (95% CI 1.41, 2.51), an OR for obesity of 3.37 (95% CI 2.51, 4.51) and an OR for diabetes of 5.87 (95% CI 2.25, 15.3). Among women older than 50 years there were no clear associations.

Conclusion

Lifetime duration of lactation was associated with long term reduced cardiovascular risk levels in mothers aged 50 years or younger.

Key opportunities for sodium reduction in New Zealand processed foods

OBJECTIVE

To identify key opportunities for reformulation of processed foods that could best decrease population sodium intakes in New Zealand (NZ).

METHOD

Relevant national literature and reports were used to identify major food groups contributing to population sodium intakes in NZ. Sodium content data for these food groups were collected from the Nutrition Information Panels of processed foods in one large supermarket. Key opportunities for reformulation were identified by comparing mean sodium content with 2012 targets from the United Kingdom (UK) Food Standards Agency (FSA) and mean sodium values from Australia and the UK.

RESULTS

Major contributors to NZ sodium intakes are: bread (26%), processed meats (10%), and sauces (6%). Mean (SD) sodium contents of these processed foods were: 447 (125) mg/100 g, 1,169 (444) mg/100 g, and 1,046 (1,235) mg/100 g, respectively. Food categories with the lowest percentage of products meeting corresponding FSA targets were: sausages/hot dogs and sliced meat (0%); salami/cured meat (2%); liquid meal-based sauces (4%); and multigrain bread (14%). Mean sodium contents of NZ products were higher than for similar products in the UK. Key opportunities identified for sodium reduction were: white bread, sausages and hot dogs, and salami/cured meats.

CONCLUSION

There is substantial scope to reduce the sodium content of NZ processed foods.

IMPLICATIONS

This paper identifies three key opportunities for reformulation of processed foods that could produce substantial decreases in sodium intakes in NZ, and benefits to population health.

Salt intake, plasma sodium, and worldwide salt reduction

There is overwhelming evidence that a reduction in salt intake from the current level of approximately 9-12 g/d in most countries of the world to the recommended level of 5-6 g/d lowers blood pressure (BP) in both hypertensive and normotensive individuals. A further reduction to 3-4 g/d has a greater effect. Prospective studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of cardiovascular disease. Cost-effectiveness analyses have documented that salt reduction is more or at the very least just as cost-effective as tobacco control in reducing cardiovascular disease, the leading cause of death and disability worldwide. The mechanisms whereby salt raises blood pressure and increases cardiovascular risk are not fully understood. The existing concepts focus on the tendency for an increase in extracellular fluid volume. Increasing evidence suggests that small increases in plasma sodium may have a direct effect on BP and the cardiovascular system, independent of extracellular volume. All countries should adopt a coherent and workable strategy to reduce salt intake in the whole population. Even a modest reduction in population salt intake will have major beneficial effects on health, along with major cost savings.

Sodium reduction and the correction of iodine intake in Belgium: Policy options

Many studies suggest that high salt intakes are related to high blood pressure and consequently cardiovascular diseases. In addition salt intake was found to be related with obesity, renal stones, osteoporosis and stomach cancer. Belgium, such as other European countries, is suffering from both salt intakes that are twice as high as the recommended intakes and mild iodine deficiency. No comprehensive strategy encompassing both public health problems has been developed. While specific salt reduction targets for processed foods are still under discussion using a consensus approach with industry, an agreement was signed between the bakery sector and the Ministry of Health in April 2009, to encourage and increase the use of iodised salt in the production of bread. Based on results of recent surveys on population iodine status it is advised not to currently revise iodine concentrations in salt in bread but to advocate for a higher percentage of bakers using iodised salt and to install a good monitoring system to control the percentage of bakers effectively using adequately iodised salt. With regard to salt reduction, it is of utmost importance that all companies contribute and harmonise the salt content of their products according to the lowest possible thresholds in a first step. In order to achieve this goal, it will be necessary, in addition to the consensus approach, to come up with at least some legislative tools such as a salt tax or mandatory labelling of foods exceeding a specific sodium concentration. Once salt reduction targets have been clearly defined in Belgium over the longer term, a legal framework should be set in place where iodine concentration in salt for the production of bread and household salt is strictly regulated by law, to avoid a large variability in the iodine content of salt brands consumed. In conclusion, it is possible to tackle salt reduction and iodine deficiency at the same time on the condition that the approach is coordinated and well monitored. All the interventions and measures taken should clearly include education and communication directed towards consumers, food producers, public health professionals, pharmacists, healthcare workers, and media representatives.

How can diet influence the risk of stroke?

Cerebrovascular diseases are the second cause of mortality in the world, and hypertension is considered a main risk factor for occurrence of stroke. The mechanisms responsible for the increased stroke risk remain unclear. However, dietary interventions have been applied in the management and treatment of their risk factors, which include increased blood pressure levels, obesity, diabetes, and dyslipidemia. Further studies should be conducted to assess the effects of carotenoids, flavonoids, n-3 polyunsaturated fats, and lower salt and high glycemic index intake in risk of stroke.

Activation of the Renin-Angiotensin system mediates the effects of dietary salt intake on atherogenesis in the apolipoprotein E knockout mouse

Dietary salt intake is a major determinant of the activation state of renin-angiotensin-aldosterone system. Given the important role of the renin-angiotensin-aldosterone system in plaque accumulation, we investigated its role in the development of atherogenesis associated with sodium intake in apolipoprotein E knockout mice. Six-weeks of a low-salt diet (containing 0.03% sodium) resulted in a 4-fold increase in plaque accumulation in apolipoprotein E knockout mice when compared with mice receiving normal chow (containing 0.30% sodium). This was associated with activation of the renin-angiotensin-aldosterone system, increased vascular expression of adhesion molecules and inflammatory cytokines, and increased adhesion of labeled leukocytes across the whole aorta on a dynamic flow assay. These changes were blocked with the angiotensin-converting enzyme inhibitor perindopril (2 mg/kg per day). A high-salt diet (containing 3% sodium) attenuated vascular inflammation and atherogenesis, associated with suppression of the renin-angiotensin-aldosterone system, although systolic blood pressure levels were modestly increased (5 ± 1 mmHg). Constitutive activation of the renin-angiotensin-aldosterone system in angiotensin-converting enzyme 2 apolipoprotein E knockout mice was also associated with increased atherosclerosis and vascular adhesion, and this was attenuated by a high-salt diet associated with suppression of the renin-angiotensin-aldosterone system. By contrast, a low-salt diet failed to further activate the renin-angiotensin-aldosterone system or to increase atherosclerosis in angiotensin-converting enzyme 2 apolipoprotein E knockout mice. Together, these data validate a relationship between salt-mediated renin-angiotensin-aldosterone system activation and atherogenesis, which may partly explain the inconclusive or paradoxical findings of recent observational studies, despite clear effects on blood pressure.

Role of dietary therapies in the prevention and treatment of hypertension

Blood pressure naturally rises with increasing age. The rate of change in blood pressure with age is regulated in part by genetic factors, but can also be altered through sustained dietary modification. Dietary approaches to modify blood pressure remain an important part of cardiovascular health promotion, which is especially important given the aging of the general population coupled with the increasing prevalence of obesity and metabolic disturbances. Specific modification of dietary components such as macronutrients and micronutrients could be helpful to lower blood pressure and alter the slope of blood pressure change whereas nutritional supplements are less likely to have a substantial beneficial effect. Population-wide generalizations regarding diet are impractical as individualized strategies are more likely to be successful in facilitating long-term benefits in improving blood-pressure control. Consequently, more effort needs to be focused on evaluating data from large-scale observational and interventional studies and interpreting their information in a clinically relevant manner, which is likely to be helpful for individual patients. Providing education on the relationship between diet and blood pressure from an early age is most likely to produce tangible benefits.