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Hisamatsu T, Kogure M, Tabara Y, Hozawa A, Sakima A, Tsuchihashi T, Yoshita K, Hayabuchi H, Node K, Takemi Y, Ohkubo T, Miura K. Practical use and target value of urine sodium-to-potassium ratio in assessment of hypertension risk for Japanese: Consensus Statement by the Japanese Society of Hypertension Working Group on Urine Sodium-to-Potassium Ratio. Hypertens Res 2024:10.1038/s41440-024-01861-x. [PMID: 39375509 DOI: 10.1038/s41440-024-01861-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 07/10/2024] [Accepted: 07/14/2024] [Indexed: 10/09/2024]
Abstract
Epidemiological studies have demonstrated that the urine sodium-to-potassium (Na/K) ratio is more positively associated with high blood pressure and cardiovascular disease risk than either urine sodium or potassium excretion alone. In this consensus statement, we recommend using the average Na/K ratio of casual urines randomly taken in various times on at least four days a week for a reliable individual estimate because of high day-to-day and intraday variability of casual urine Na/K ratio within individuals. Although a continuous positive association exists between the Na/K ratio and high blood pressure or cardiovascular disease risk, for clinical and public health decision making for Japanese, we recommend using an average urine Na/K ratio of 2 as an optimal target value because this aligns with recommendations for both sodium and potassium intake in the Dietary Reference Intakes for Japanese, 2020, considering a typical Japanese dietary pattern. We also suggest that an average urine Na/K ratio of 4 is a feasible target value to achieve a temporary goal of being below the mean values of the urine Na/K ratio across Japanese general populations. These recommendations apply mainly for apparently healthy individuals, but not for patients with specific conditions due to the lack of supporting data. Current evidence for the usefulness of measuring the urine Na/K ratio for the prevention or control of hypertension remains inconclusive and warrants further investigation.
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Affiliation(s)
- Takashi Hisamatsu
- Department of Public Health, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mana Kogure
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Yasuharu Tabara
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan
- Center for Genomic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Atsushi Hozawa
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Division of Epidemiology, School of Public Health, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Sakima
- Health Administration Center, University of the Ryukyus, Okinawa, Japan
| | - Takuya Tsuchihashi
- Cardiovascular Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Katsushi Yoshita
- Graduate School of Human Life and Ecology, Osaka Metropolitan University, Osaka, Japan
| | - Hitomi Hayabuchi
- Graduate School of Health and Environmental Sciences, Fukuoka Women's University, Fukuoka, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
- Japanese Society of Hypertension, Tokyo, Japan
| | - Yukari Takemi
- Faculty of Nutrition, Kagawa Nutrition University, Sakado, Japan
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Katsuyuki Miura
- Japanese Society of Hypertension, Tokyo, Japan.
- NCD Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan.
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Kario K, Katsuya T, Wada J, Motoki H, Kuwahara K, Tsujita K, Taguchi T, Tanabe A, Shimosawa T. Factors influencing the efficacy and safety of esaxerenone in hypertensive patients: a pooled analysis of five clinical studies on different comorbidities. Hypertens Res 2024; 47:2826-2839. [PMID: 39090179 PMCID: PMC11456503 DOI: 10.1038/s41440-024-01818-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 07/01/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
This study aimed to identify factors associated with a strong home blood pressure (BP)-lowering effect of esaxerenone and the incidence of elevated serum potassium levels in hypertensive patients treated with esaxerenone. A pooled analysis of five multicenter, prospective, open-label single-arm studies was conducted, including 479 patients in the full analysis set (FAS) and 492 patients in the safety analysis set. Multivariate linear regression analysis of morning home systolic BP (SBP) and diastolic BP (DBP) changes from baseline to Week 12 in the FAS (primary endpoint) showed that male sex (estimated change 4.37 mmHg), office pulse rate ≥100 beats/min (25.10 mmHg), and calcium channel blocker (CCB) use as a basal antihypertensive agent (4.53 mmHg) were significantly associated with a positive estimated change (weaker BP-lowering effect) in morning home SBP. CCB use (3.70 mmHg) was associated with a positive estimated change in morning home DBP. Urine albumin-to-creatinine ratio 30 to <300 mg/gCr (-4.13 mmHg) was significantly associated with a negative estimated change (stronger BP-lowering effect) in morning home SBP. Based on multivariate logistic regression analysis, elevated baseline serum potassium level (≥4.5 vs < 4.5 mEq/L, odds ratio 13.502) was significantly associated with a high incidence of serum potassium level ≥5.5 mEq/L after esaxerenone treatment. In conclusion, factors associated with a strong BP-lowering effect of esaxerenone were female sex and use of renin-angiotensin system inhibitors as a basal antihypertensive drug. Patients with baseline serum potassium levels ≥4.5 mEq/L had an increased risk of developing elevated serum potassium levels (≥5.5 mEq/L) after esaxerenone treatment.
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Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
| | | | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co. Ltd., Tokyo, Japan
| | - Ayumi Tanabe
- Data Intelligence Department, Daiichi Sankyo Co. Ltd., Tokyo, Japan
| | - Tatsuo Shimosawa
- Department of Clinical Laboratory, School of Medicine, International University of Health and Welfare, Chiba, Japan
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Campbell NRC, McLean RM, He FJ, MacGregor GA. Is there a safe level for adding sodium to food versus is it safe to reduce dietary sodium intake? J Hypertens 2024; 42:607-608. [PMID: 38441182 DOI: 10.1097/hjh.0000000000003678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Norm R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Rachael M McLean
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
| | - Feng J He
- Wolfson Institute of Population Health, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, UK
| | - Graham A MacGregor
- Wolfson Institute of Population Health, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, UK
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Katsuya T, Inobe Y, Uchiyama K, Nishikawa T, Hirano K, Kato M, Fukui T, Hatta T, Iwasaki A, Ishii H, Sugiura T, Taguchi T, Tanabe A, Sugimoto K, Shimosawa T. Exploratory study on the relationship between urinary sodium/potassium ratio, salt intake, and the antihypertensive effect of esaxerenone: the ENaK Study. Hypertens Res 2024; 47:835-848. [PMID: 38212366 PMCID: PMC10994843 DOI: 10.1038/s41440-023-01519-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/30/2023] [Accepted: 11/05/2023] [Indexed: 01/13/2024]
Abstract
Excessive salt intake is one of the causes of hypertension, and reducing salt intake is important for managing the risk of hypertension and subsequent cardiovascular events. Esaxerenone, a mineralocorticoid receptor blocker, has the potential to exert an antihypertensive effect in hypertensive patients with excessive salt intake, but evidence is still lacking, especially in clinical settings. We aimed to determine if baseline sodium/potassium ratio and baseline estimated 24-h urinary sodium excretion can predict the antihypertensive effect of esaxerenone in patients with essential hypertension inadequately controlled with an angiotensin receptor blocker (ARB) or a calcium channel blocker (CCB). This was an exploratory, open-label, interventional study with a 4-week observation period and a 12-week treatment period. Esaxerenone was orally administered once daily in accordance with the Japanese package insert. In total, 126 patients met the eligibility criteria and were enrolled (ARB subcohort, 67; CCB subcohort, 59); all were included in the full analysis set (FAS) and safety analysis. In the FAS, morning home systolic blood pressure (SBP)/diastolic blood pressure (DBP) significantly decreased from baseline to end of treatment (primary efficacy endpoint) (-11.9 ± 10.9/ - 6.4 ± 6.8 mmHg, both p < 0.001); a similar trend was observed in both subcohorts. Significant reductions were also shown in bedtime home and office SBP/DBP (all p < 0.001). Each BP change was consistent regardless of the urinary sodium/potassium ratio or estimated 24-h urinary sodium excretion at baseline. The urinary albumin-creatinine ratio (UACR) and N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly decreased from baseline to Week 12 in the total population and both subcohorts. No new safety concerns were raised. Esaxerenone significantly decreased morning home, bedtime home, and office BP; UACR; and NT-proBNP in this patient population, regardless of concomitant ARB or CCB use. The antihypertensive effect of esaxerenone was independent of the urinary sodium/potassium ratio and estimated 24-h urinary sodium excretion at baseline.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Toshiyuki Sugiura
- Medical Corporation Association Koukeikai Sugiura Clinic, Kawaguchi, Japan
| | | | | | | | - Tatsuo Shimosawa
- Department of Clinical Laboratory, School of Medicine, International University of Health and Welfare, Narita, Japan
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Brobak KM, Melsom T, Eriksen BO, Høieggen A, Norvik JV, Solbu MD. The Association between Urinary Sodium-Potassium Ratio, Kidney Function, and Blood Pressure in a Cohort from the General Population. Kidney Blood Press Res 2024; 49:184-195. [PMID: 38382490 DOI: 10.1159/000535977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/07/2023] [Indexed: 02/23/2024] Open
Abstract
INTRODUCTION Subclinical kidney dysfunction may contribute to salt-sensitive hypertension. We assessed the association between the urinary sodium-potassium ratio (Na/K ratio) and blood pressure (BP) in a general population cohort without diabetes, chronic kidney disease, cardiovascular disease, or treated hypertension. We investigated whether any such association was mediated by the kidney function markers measured glomerular filtration rate (mGFR), urinary albumin-creatinine ratio (ACR), and urinary epidermal growth factor-creatinine ratio (EGF-Cr). METHODS The Tromsø Study is a population-based study of inhabitants of the municipality of Tromsø, Northern Norway. Participants aged 50-62 years, without diabetes, chronic kidney disease, or cardiovascular disease, were invited to the substudy Renal Iohexol Clearance Survey in Tromsø 6 (RENIS-T6; 2007-09). For the present study, we excluded participants reporting the use of 1 or more antihypertensive agents, leaving 1,311 RENIS-T6 participants for a cross-sectional analysis. We measured office BP, 24-h ambulatory blood pressure (ABP), and mGFR using iohexol clearance. Na/K ratio, ACR, and EGF-Cr were measured in morning urine samples. RESULTS Urinary Na/K ratio was significantly associated with systolic office BP and ABP independently of cardiovascular risk factors and kidney function markers. A one-standard deviation unit increase in the Na/K ratio was associated with increased systolic ABP by 1.0 (0.3-1.6) mm Hg. Urinary Na/K ratio showed a stronger association with office BP than ABP. EGF-Cr, ACR, and mGFR did not mediate the relationship between urinary Na/K ratio and systolic BP. CONCLUSIONS In a representative sample of the middle-aged North-European population without diabetes, chronic kidney disease, cardiovascular disease, or treated hypertension, there was a consistent association between urinary Na/K ratio and BP. The association with BP was not mediated through kidney function measures, suggesting a relationship between a diet with high sodium and low potassium and higher BP regardless of kidney function.
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Affiliation(s)
- Karl Marius Brobak
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Toralf Melsom
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Bjørn Odvar Eriksen
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Aud Høieggen
- Department of Nephrology, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jon Viljar Norvik
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Marit Dahl Solbu
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
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Campbell NRC. The associations between dietary sodium and atherosclerosis: are the methods used accurate and reproducible? EUROPEAN HEART JOURNAL OPEN 2023; 3:oead110. [PMID: 37953822 PMCID: PMC10634625 DOI: 10.1093/ehjopen/oead110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/07/2023] [Accepted: 10/13/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Norman R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, 9th Floor, 1403-29th Street NW, Calgary, Alberta T2N 2T9, Canada
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Zhang Q, Guo Y, Li M, Yang R, Yao Y, Zhao Y, Yin H, Zhang H, Liu W, Liu Z. Excessive dietary sodium intake augments long-term risk of atrial fibrillation in older adults with hyperglycemia: A community-based prospective cohort study. DIABETES & METABOLISM 2023; 49:101475. [PMID: 37678758 DOI: 10.1016/j.diabet.2023.101475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/07/2023] [Accepted: 08/19/2023] [Indexed: 09/09/2023]
Abstract
AIM Studies investigating the association between sodium intake and new-onset atrial fibrillation (AF) have come to controversial results. This study aimed to assess the effect of excessive sodium intake on new-onset AF in individuals with hyperglycemia. METHODS Between April 2007 and November 2011, 2841 community-dwelling individuals aged 60 years and older were recruited from the Shandong area, China. Dietary sodium intake was estimated using 24-hour urine collection within seven consecutive days. Fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) were assessed. New-onset AF was diagnosed using ICD-10 with codes I48 (I48.0 - I48.9) during follow-up. RESULTS The findings were that excessive sodium intake significantly and independently increased the risk of new-onset AF in older adults with hyperglycemia: hazard ratio (HR) 1.525 [95% confidence interval 1.147;2.029] adjusted P = 0.004. The risk of new-onset AF increased by 29.3% (HR 1.293 [1.108;1.509] adjusted P = 0.001) with a one-standard deviation increase in sodium intake. Excessive sodium intake synergistically interacted with hyperglycemia on the increased risk of new-onset AF (HR 1.599 [1.342;1.905] adjusted P < 0.001 for FPG and HR 1.516 [1.271;1.808] adjusted P < 0.001 for HbA1c). CONCLUSION Our findings indicate that excessive sodium intake independently enhances the risk of new-onset AF among patients with hyperglycemia. A sodium-restricted diet may perhaps result in a multiplier effect on reducing the risk of new-onset AF.
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Affiliation(s)
- Qin Zhang
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China; Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China
| | - Yuqi Guo
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Mei Li
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China; Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China
| | - Ruizhen Yang
- Centers for Disease Control of Hanting District, Weifang, Shandong, 261199, China
| | - Yanli Yao
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Yingxin Zhao
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Haipeng Yin
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Hua Zhang
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China; Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China
| | - Weike Liu
- Department of Cardiology, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, 150001, China.
| | - Zhendong Liu
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China; Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China.
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Campbell NRC, He FJ, McLean RM, Cappuccio FP, MacGregor GM. Comment on: Less sodium and more potassium to reduce cardiovascular risk and the PURE study. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead096. [PMID: 37860077 PMCID: PMC10584077 DOI: 10.1093/ehjopen/oead096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 09/06/2023] [Accepted: 09/14/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Norm R C Campbell
- Department of Medicine, University of Calgary, Calgary, Alberta T3L1S7, Canada
| | - Feng J He
- Wolfson Institute of Population Health, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Rachael M McLean
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand
| | - Francesco P Cappuccio
- University of Warwick, Warwick Medical School, WHO Collaborating Centre for Nutrition, Coventry CV47AL, UK
| | - Graham M MacGregor
- Wolfson Institute of Population Health, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
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Watso JC, Fancher IS, Gomez DH, Hutchison ZJ, Gutiérrez OM, Robinson AT. The damaging duo: Obesity and excess dietary salt contribute to hypertension and cardiovascular disease. Obes Rev 2023; 24:e13589. [PMID: 37336641 PMCID: PMC10406397 DOI: 10.1111/obr.13589] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023]
Abstract
Hypertension is a primary risk factor for cardiovascular disease. Cardiovascular disease is the leading cause of death among adults worldwide. In this review, we focus on two of the most critical public health challenges that contribute to hypertension-obesity and excess dietary sodium from salt (i.e., sodium chloride). While the independent effects of these factors have been studied extensively, the interplay of obesity and excess salt overconsumption is not well understood. Here, we discuss both the independent and combined effects of excess obesity and dietary salt given their contributions to vascular dysfunction, autonomic cardiovascular dysregulation, kidney dysfunction, and insulin resistance. We discuss the role of ultra-processed foods-accounting for nearly 60% of energy intake in America-as a major contributor to both obesity and salt overconsumption. We highlight the influence of obesity on elevated blood pressure in the presence of a high-salt diet (i.e., salt sensitivity). Throughout the review, we highlight critical gaps in knowledge that should be filled to inform us of the prevention, management, treatment, and mitigation strategies for addressing these public health challenges.
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Affiliation(s)
- Joseph C. Watso
- Department of Nutrition and Integrative Physiology, Florida State University, Tallahassee, Florida, USA
| | - Ibra S. Fancher
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Dulce H. Gomez
- School of Kinesiology, Auburn University, Auburn, Alabama, USA
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Orlando M. Gutiérrez
- Division of Nephrology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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