Blood Pressure Effects of Sodium Reduction: Dose-Response Meta-Analysis of Experimental Studies

Nonpharmacologic Management of Hypertension in Older Adults

Hypertension is ubiquitous among older adults and leads to major adverse cardiovascular events. Nonpharmacologic lifestyle interventions represent important preventive and adjunct strategies in the treatment of hypertension and have benefits beyond cardiovascular disease in this population characterized by a high prevalence of frailty and comorbid conditions. In this review, the authors examine nonpharmacologic interventions with the strongest evidence to prevent cardiovascular disease with an emphasis on the older adults.

Autonomic Nervous System: A Therapeutic Target for Cardiac End-Organ Damage in Hypertension

More than 1.5 billion people worldwide have arterial hypertension. Hypertension increases the risks of death and cardiovascular disease, such as atrial fibrillation and heart failure. The autonomic nervous system plays an essential role in hypertension development and disease progression. While lifestyle factors, such as obesity and obstructive sleep apnea, predispose to hypertension by increasing sympathetic activity, hypertension itself maintains the autonomic nervous imbalance, providing the substrate for atrial fibrillation and heart failure. Therefore, autonomic nervous system modulation either by direct targeting or indirect treatment of comorbidities has the potential to treat both hypertension and related atrial and ventricular end-organ damage. We discuss interventions for the modulation of the autonomic nervous system for hypertension and related cardiac end-organ damage, including pharmacological adrenergic beta-receptor blockade, renal denervation, carotid baroreceptor stimulation, low-level vagal stimulation, and ablation of ganglionated plexuses. In summary, the literature suggests that targeting the autonomic nervous system potentially represents a therapeutic approach to prevent atrial and ventricular end-organ damage in patients with hypertension. However, clinical trials specifically designed to test the effect of autonomic modulation on hypertension-mediated cardiac end-organ damage are scarce.

Diet to Stop Hypertension: Should Fats be Included?

PURPOSE OF REVIEW

International guidelines emphasize advice to incorporate dietary measures for the prevention and in the management of hypertension. Current data show that modest reductions in weight can have an impact on blood pressure. Reducing salt and marine oils have also shown consistent benefit in reducing blood pressure. Whether other dietary constituents, in particular the amount and type of fat that play important roles in cardiovascular prevention, influence blood pressure sufficiently to be included in the management of hypertension is less certain. In this review, we provide a summary of the most recent findings, with a focus on dietary patterns, fats and other nutrients and their impact on blood pressure and hypertension.

RECENT FINDINGS

Since reducing salt consumption is an established recommendation only corollary dietary advice is subject to the current review. Population studies that have included reliable evaluation of fat intake have indicated almost consistently blood pressure lowering with consumption of marine oils and fats. Results with vegetable oils are inconclusive. However dietary patterns that included total fat reduction and changes in the nature of vegetable fats/oils have suggested beneficial effects on blood pressure. Plant-based foods, dairy foods and yoghurt particularly, may also lower blood pressure irrespective of fat content. Total fat consumption is not directly associated with blood pressure except when it is part of a weight loss diet. Consumption of marine oils has mostly shown moderate blood pressure lowering and possibly greatest effect with docosahexaenoic acid-rich oil.

Left ventricular structure and function in relation to sodium dietary intake and renal handling in untreated Chinese patients

Whether left ventricular structure and function is associated with sodium dietary intake and renal handling while considering blood pressure (BP) remains unclear. Consecutive untreated patients referred for ambulatory BP monitoring were recruited. Standard echocardiography was performed to measure left ventricular structure and function. Fractional excretion of lithium (FELi) and fractional distal reabsorption rate of sodium (FDRNa) were calculated as markers of proximal and distal tubular sodium handling, respectively. The 952 participants (51.0% women; mean age, 50.8 years) included 614 (64.5%) ambulatory hypertension and 103 (10.8%) left ventricular hypertrophy. There were significant interactions of urinary sodium excretion with FELi (P ≤ 0.045), but not FDRNa (P ≥ 0.36), in relation to left ventricular posterior wall thickness (LVPW), mass (LVM) and mass index (LVMI), but not functional measurements. Only in tertile 1 of FELi, the multivariate-adjusted regression coefficients for urinary sodium excretion reached statistical significance (P ≤ 0.049), being 0.16 ± 0.05 mm, 4.32 ± 1.48 g, and 1.64 ± 0.83 g/m2 for LVPW, LVM and LVMI, respectively. In mutually adjusted analyses, the regression coefficient for LVMI was statistically significant for FELi, FDRNa and 24-h systolic BP, being -2.17 ± 0.49, -1.95 ± 0.54, and 2.99 ± 0.51 g/m2, respectively (P < 0.001). Multivariable analysis of variance showed that sodium renal handling indexes (P ≥ 0.14), but not sodium urinary excretion (P = 0.007), were similarly as 24-h BP associated with LVMI. Heat maps on left ventricular hypertrophy provided a graphical confirmation of the findings. Sodium dietary intake and renal handling interact to be associated with left ventricular structure. Renal handling indexes were similarly in size as, jointly in action with and independently of 24-h BP.

Cardiovascular Risks in People With Narcolepsy: Expert Panel Consensus Recommendations

BACKGROUND

Observational and retrospective studies suggest that people with narcolepsy may have an increased prevalence of cardiovascular and cardiometabolic comorbidities and may be at greater risk for future cardiovascular events. An expert consensus panel was formed to establish agreement on the risk of hypertension and cardiovascular/cardiometabolic disease in people with narcolepsy and to develop strategies to mitigate these risks.

METHODS AND RESULTS

Experts in sleep medicine and cardiology were selected to participate in the panel. After reviewing the relevant literature, the experts identified key elements, drafted recommendation statements, and developed discussion points to provide supporting evidence for the recommendations. The draft and final recommendations were rated on a scale from 0 (not at all agree) to 4 (very much agree). All experts had an agreement rating of 4.0 for all 14 revised recommendation statements for patients with narcolepsy. These statements comprised 3 themes: (1) recognize the risk of hypertension and cardiovascular/cardiometabolic disease, (2) reduce the risk of hypertension and cardiovascular/cardiometabolic disease, and (3) reduce sodium intake to lower the risk of hypertension and cardiovascular disease.

CONCLUSIONS

These consensus recommendations are intended to increase awareness of potential cardiovascular/cardiometabolic risks in patients with narcolepsy for all clinicians. Early monitoring for, and prevention of, cardiovascular risks in this population are of great importance, especially as narcolepsy usually develops in adolescents and young adults, who will be exposed to adverse effects of the disease for decades. Prospective systematic studies are needed to determine association and causation of narcolepsy with cardiovascular/cardiometabolic disorders.

Global, regional, and national burden of stroke attributable to diet high in sodium from 1990 to 2019: a systematic analysis from the global burden of disease study 2019

Purpose

Given the increasing occurrence of stroke and high-sodium diets (DHIS) over the past 30 years, it is crucial to assess the global, national, and regional impact of DHIS on the burden of stroke.

Methods and materials

The Global Burden of Diseases Study 2019 provided the study's data. We used the Bayesian meta-regression tool DisMod-MR 2.1 to evaluate the burden of stroke attributable to DHIS. Age-standardized disability-adjusted life years (ASDR) and age-standardized mortality rate (ASMR) were used to quantify the burden. We perform correlation analysis utilizing the Spearman rank-order correlation method, and we calculate the estimated annual percentage change (EAPC) to evaluate temporal trends.

Results

Globally, DHIS accounts for 17,673.33 thousand disability-adjusted life years (DALYs) and 700.98 thousand deaths of stroke in 2019. The burden of stroke attributable to DHIS has declined between 1990 and 2019 globally and in the majority of regions, with the largest declines seen in regions with high sociodemographic indexes (SDI). Both ASMR and ASDR were higher regionally in regions with moderate SDI than those in developed regions. Furthermore, the absolute values of EAPC, reflecting the rate of decrease, were notably lower in these regions compared to developed nations. High-income North America, categorized within the SDI regions, notably witnessed the smallest decline in ASDR over the last three decades. Additionally, from 1990 to 2019, males consistently bore a larger burden of stroke attributable to DHIS.

Conclusion

The burden of stroke attributable to DHIS remained a major concern despite advancements in public knowledge of stroke and their utilization of emergency medical services. Over the past 30 years, more burden has been placed on males and regions with moderate SDI values; in males, higher EAPC values for both ASMR and ASDR have been found. This underscores the urgent need for effective interventions to alleviate the burden of stroke associated with DHIS.

Selected highlights in the updated treatment of hypertension

Hypertension remains the leading international risk factor for cardiovascular disease and premature death but, despite effective treatments, hypertension remains significantly underdiagnosed and undertreated. In the present review paper, we provide a selected update on recent developments of interest in the management of hypertension. We focus on summarizing four topics that we believe are worth highlighting to a clinical audience: (1) the evidence and strong motivation for new lower systolic BP treatment targets; (2) new studies reporting on the efficacy of renal denervation in the management of hypertension; (3) interesting new data to inform the great salt debate; and (4), perhaps most importantly, pioneering new work highlighting the huge potential of multi-disciplinary care in the management of hypertension.

Alcohol Intake and Risk of Hypertension: A Systematic Review and Dose-Response Meta-Analysis of Nonexperimental Cohort Studies

BACKGROUND

Alcohol consumption has been associated with higher blood pressure and an increased risk of hypertension. However, the possible exposure thresholds and effect-modifiers are uncertain.

METHODS

We assessed the dose-response relationship between usual alcohol intake and hypertension incidence in nonexperimental cohort studies. After performing a systematic literature search through February 20, 2024, we retrieved 23 eligible studies. We computed risk ratios and 95% CI of hypertension incidence using a nonlinear meta-analytic model based on restricted cubic splines, to assess the dose-response association with alcohol consumption.

RESULTS

We observed a positive and almost linear association between alcohol intake and hypertension risk with risk ratios of 0.89 (0.84-0.94), 1.11 (1.07-1.15), 1.22 (1.14-1.30), and 1.33 (1.18-1.49) for 0, 24, 36 and 48 g/d, respectively, using 12 g alcohol/d as the reference value. In sex-specific analyses, the association was almost linear in men over the entire range of exposure but only observed above 12 g/d in women, although with a steeper association at high levels of consumption compared with men. The increased risk of hypertension above 12 to 24 g alcohol/d was similar in Western and Asian populations and considerably greater in White than in Black populations, mainly due to the positive association in women at moderate-to-high intake.

CONCLUSIONS

Overall, our results lend support to a causal association between alcohol consumption and risk of hypertension, especially above an alcohol intake of 12 g/d, and are consistent with recommendations to avoid or limit alcohol intake. Sex and ethnicity appear to be major effect-modifiers of such association.

Associations of E-proteinoid 3 receptor genetic polymorphisms with salt sensitivity, longitudinal blood pressure changes, and hypertension incidence in Chinese adults

The E-proteinoid 3 receptor (PTGER3), a member of the prostaglandin E2 (PGE2) subtype receptor, belongs to the G-protein-coupled superfamily of receptors. Animal studies have demonstrated its involvement in salt sensitivity by regulating sodium reabsorption. This study aimed to investigate the association between genetic variants of PTGER3 and salt sensitivity, longitudinal blood pressure (BP) changes, and the incidence of hypertension in Chinese adults. A chronic salt intake intervention was conducted involving 514 adults from 124 families in the 2004 Baoji Salt-Sensitivity Study Cohort in northern China. These participants followed a 3-day regular baseline diet, followed by a 7-day low-salt diet (3.0 g/d) and a 7-day high-salt diet (18 g/d), and were subsequently followed for 14 years. The findings revealed a significant relationship between the single nucleotide polymorphism (SNP) rs17482751 of PTGER3 and diastolic blood pressure (DBP) response to high salt intervention. Additionally, SNPs rs11209733, rs3765894, and rs2268062 were significantly associated with longitudinal changes in systolic blood pressure (SBP), DBP, and mean arterial pressure (MAP) during the 14-year follow-up period. SNP rs6424414 was significantly associated with longitudinal changes in DBP over 14 years. Finally, SNP rs17482751 showed a significant correlation with the incidence of hypertension over 14 years. These results emphasize the significant role of PTGER3 gene polymorphism in salt sensitivity, longitudinal BP changes, and the development of hypertension in the Chinese population.

Barriers and Facilitators to Dietary Salt Reduction Among Patients With Hypertension in Southern Nigeria: A Hospital-based Qualitative Study

Introduction

Reduction in salt intake improves blood pressure control and reduces the risk of hypertension and other noncommunicable diseases (NCDs). However, salt intake remains high among Nigerians. This study aimed to identify barriers and facilitators to salt reduction among hypertensive patients attending a family medicine clinic in southern Nigeria.

Methodology

A focussed group discussion (FGD) exploring patients' perceptions of the barriers and facilitators to salt reduction was conducted with 8 groups of purposefully selected 74 hypertensives who consumed excess dietary salt, stratified by age and sex, using an FGD guide. Thematic analysis was then performed using Nvivo® version 12 pro. Ethical approval was obtained from Irrua Specialist Teaching Hospital (ISTH), and written informed consent was obtained from the patients before the FGD.

Results

Respondents had a mean age of 51.96 ± 8.98 years. The majority were females (47, 63.5%) and had uncontrolled blood pressure (66, 89.2%). Five major themes were identified, from which several minor themes emerged. Respondents rated their overall health as good but expressed concerns about their poor blood pressure control. Identified barriers to salt reduction included family pressure, ignorance, ready availability and affordability of salt and lack of affordable alternatives. Facilitators of salt reduction were measuring the amount of cooking salt, removing salt from the dining table and providing substitutes. Respondents, however, expressed willingness to reduce their salt consumption.

Conclusion

The study identified barriers and facilitators to salt reduction. There is a need to create awareness of the safe amount of salt to be consumed and provide safe and readily available alternatives.

Japanese Diet Indices and Nutrient Density in US Adults: A Cross-Sectional Analysis with NHANES Data

BACKGROUND

Previous studies have shown that Japanese dietary patterns are associated with high nutrient density. However, these studies were limited to the Japanese population. We examined this association in the US population.

METHODS

A cross-sectional analysis was conducted using data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018. We included 3138 people aged 20-79 years. Food and nutrient intake data were based on the 24 h recall method. Three Japanese diet indices were used: (1) Japanese Diet Index (JDI, based on 9 food items), (2) modified JDI (mJDI, based on 12 food items), and (3) weighted JDI (wJDI, selected and weighted from mJDI food items). The nutrient density (ND) score was calculated based on the Nutrient-Rich Food Index 9.3. Spearman's rank correlation coefficients were calculated.

RESULTS

The correlation coefficients with the ND score were 0.24 (p < 0.001) for the JDI and 0.38 (p < 0.001) for the mJDI. The correlation coefficient between the wJDI and ND score was 0.48 (p < 0.001). The three Japanese diet indices were correlated with the ND score in all racial groups (p < 0.001).

CONCLUSIONS

Even among the US population, higher degrees of Japanese diet defined by the JDI or mJDI were associated with higher nutrient density.

Effect of salt substitute and antihypertensive medications among high cardiovascular risk patients: A sub-study of Salt Substitute and Stroke Study (SSaSS)

The relationship between the differential protective effect of salt substitute between hypertensive and normotensive individuals and the use of cardiovascular medications remains unclear. This study involved 4211 individuals with a history of stroke or hypertension who participated in the Salt Substitute and Stroke Study (SSaSS) from 120 villages in Shanxi Province. The aim of this study was to investigate the differences in major adverse cardiovascular events and blood pressure changes between the salt substitute and the regular salt group in the subgroups of participants taking different antihypertensive medications. Mixed models were employed and adjusted for the cluster effect (village) and potential confounding variables. During the average follow-up period of 4.66 years, a significantly protective effect of salt substitute on reducing the risk of cardiovascular events was observed in the participants who taking antihypertensive medications (rate ratio: 0.81, 95% CI: 0.68 to 0.95. p = 0.011), whereas no significant effect in participants not taking antihypertensive medications (rate ratio: 0.91, 95% CI: 0.62 to 1.32, p = 0.612). Significant effects to lower systolic blood pressure of the salt substitutes were observed in the participants who took different antihypertensive medications. This study emphasized that the use of salt substitutes might enhance the efficacy of anti-hypertensive medications in lowering blood pressure and reducing the risk of adverse cardiovascular events.

Global Associations of the Traditional Japanese Diet Score with Hypertension Prevalence and Systolic Blood Pressure from 2009 to 2019: A Cross-Sectional and Longitudinal Ecological Study

OBJECTIVE

Prevention and improvement of hypertension is one of the most important health issues worldwide. The traditional Japanese diet contributes to the prevention of some non-communicable diseases associated with hypertension. However, whether traditional Japanese dietary patterns are associated with hypertension prevalence and systolic blood pressure (SBP) worldwide remains unknown. In this study, we aimed to investigate whether the traditional Japanese diet score (TJDS) is associated with hypertension prevalence and SBP.

METHODS

This cross-sectional and longitudinal ecological study from 2009 to 2019 included 141 countries with a population of at least 1 million. All data used for analysis were obtained from internationally available databases. The TJDS was calculated using country-specific supplies of five foods commonly eaten in the traditional Japanese diet (rice, fish, soybean, vegetables, and egg) and three less commonly eaten foods (wheat, milk, and red meat). Hypertension was defined by SBP ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or use of antihypertensive medications. The mean SBP was >25 age-standardized data. A general linear model was used for the cross-sectional model in 2009, and a linear mixed model was used for the longitudinal analysis from 2009 to 2019. The covariates included gross domestic product, percentage of population aged >65 years, years of education, smoking rate, average body mass index, physical activity, and energy supply.

RESULTS

The TJDS was negatively associated with hypertension prevalence (β ± standard error: -0.861 ± 0.202, p < 0.001) and SBP (β ± standard error: -0.364 ± 0.154, p < 0.05) in the cross-sectional analysis. The TJDS was significantly negatively associated with hypertension prevalence (β ± standard error: -0.845 ± 0.200, p < 0.001) and SBP (β ± standard error: -0.312 ± 0.149, p < 0.05) in the 10-year longitudinal analysis controlled for full covariables.

CONCLUSIONS

Traditional Japanese dietary patterns are associated with lower hypertension prevalence and SBP worldwide.

Adding salt to foods and risk of psoriasis: A prospective cohort study

BACKGROUND

High salt intake may play a critical role in the etiology of psoriasis. Yet, evidence on the association of high salt intake with risk of psoriasis is limited.

OBJECTIVE

To estimate the association between frequency of adding salt to foods and risk of psoriasis.

METHODS

We conducted a prospective cohort study of 433,788 participants from the UK Biobank. Hazard ratios (HRs) and their 95 % confidence intervals (CIs) for risk of psoriasis in relation to frequency of adding salt to foods were estimated using multivariable Cox proportional hazards models. We further evaluated the joint association of adding salt to foods and genetic susceptibility with risk of psoriasis. We conducted a mediation analysis to assess how much of the effect of adding salt to foods on risk of psoriasis was mediated through several selected mediators.

RESULTS

During a median of 14.0 years of follow-up, 4279 incident cases of psoriasis were identified. In the multivariable-adjusted model, a higher frequency of adding salt to foods was significantly associated with an increased risk of psoriasis ("always" versus "never/rarely" adding salt to foods, HR = 1.25, 95 % CI: 1.10, 1.41). The observed positive association was generally similar across subgroups. In the joint association analysis, we observed that participants with a high genetic risk (above the second tertile) and the highest frequency of adding salt to foods experienced 149 % higher risk of psoriasis, when compared with participants with a low genetic risk (below the first tertile) and the lowest frequency of adding salt to foods (HR = 2.49, 95 % CI: 2.05, 3.02). Mediation analysis revealed that 1.8 %-3.2 % of the positive association between frequency of adding salt and risk of psoriasis was statistically significantly mediated by obesity and inflammatory biomarkers such as C-reactive protein and systemic immune-inflammation index (all P values < 0.004).

CONCLUSIONS

Our study demonstrated a positive association between frequency of adding salt to foods and risk of psoriasis. The positive association was independent of multiple other risk factors, and may be partially mediated through obesity and inflammation.

Cost-effectiveness analysis of low-sodium potassium-rich salt substitutes in Indonesia: an equity modelling study

Background

Evidence suggests low-sodium potassium-rich salt substitutes (LSSS) are effective in reducing blood pressure (BP). However, the health and economic impacts of LSSS in Indonesia are currently unknown.

Methods

We developed a proportional multistate lifetable Markov model to assess a government-led strategy implementing the use of LSSS compared to current regular salt consumption. BP data were derived from the Indonesian Basic Health Research Survey (RISKESDAS 2018), while epidemiological data were from the Global Burden of Disease 2019 study. We estimated implementation costs and the impact of changes in BP on disease events and healthcare costs, and incremental cost-effectiveness ratios. Outcomes were simulated over different time horizons for the 2019 Indonesian population overall, and by income quintiles. Probabilistic sensitivity analysis was done to capture uncertainty.

Findings

Over the first 10 years, LSSS could prevent 1.5 million non-fatal cardiovascular disease (CVD) events (8.3%-19.4% reduction) and 643,000 incident chronic kidney disease (CKD) cases (8.2% reduction), while averting over 200,000 CVD and CKD deaths (0.2%-5.2% reduction). This translated to over 24.6 million health-adjusted life years (HALYs) gained over the lifetime of the population, and reduced CVD-related health inequalities (concentration index, -0.075, 95% CI: -0.088 to -0.062). Implementation cost (US$ 1.2 billion [IDR 17.2 trillion] total; US$ 4.5 [IDR 63,665] per capita, as of July 2019) was outweighed by the net health expenditure savings (∼US$ 2 billion [IDR 27.7 trillion] total; US$ 7.3 [IDR 103,300] per capita) in the first 10 years. LSSS were cost-saving over the lifetime, and very cost-effective even with a high LSSS price.

Interpretation

Scaling the use of LSSS nationally could be a cost-saving strategy to prevent substantial cardiovascular and kidney disease burden in Indonesia.

Funding

Griffith University Postdoctoral Fellowship.

Sodium Intake and Incident Atrial Fibrillation in Individuals With Vascular Disease

Importance

Numerous prospective cohort studies have reported a J-shaped association of urinary sodium excretion with cardiovascular events and mortality.

Objective

To study the association between sodium intake and incident atrial fibrillation (AF).

Design, Setting, and Participants

This cohort study included participants in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomised Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease (TRANSCEND) multicenter, randomized clinical trials comparing the effect of ramipril 10 mg daily with telmisartan 80 mg daily, or their combination (ONTARGET) or 80 mg telmisartan daily with placebo (TRANSCEND) for the outcome of death from cardiovascular causes, myocardial infarction, stroke, or hospitalization for heart failure. ONTARGET and TRANSCEND included 31 546 participants with vascular disease or high-risk diabetes, and this study excluded participants without a urine sample for sodium measurement, missing data for key covariates, a history of AF, or AF detected in the first year after enrollment. Analyses were performed in July 2023 to May 2024.

Exposure

Estimated sodium intake from a morning fasting urine sample (Kawasaki formula).

Main Outcomes and Measures

The main outcome was incident AF. The association between estimated sodium intake and incident AF was modeled using multivariable adjusted Cox regression and cubic splines.

Results

A total of 27 391 participants (mean [SD] age, 66.3 [7.2] years; 19 310 [70.5%] male) were included. Mean (SD) estimated sodium intake was 4.8 (1.6) g/d. During a mean (SD) follow-up of 4.6 (1.0) years, 1562 participants (5.7%) had incident AF. After multivariable adjustment, a J-shaped association between sodium intake and AF risk was observed (P for nonlinearity = .03). Sodium intake of 8 g/d or greater (3% of participants) was associated with incident AF (hazard ratio, 1.32; 95% CI, 1.01-1.74) compared with sodium intake of 4 to 5.99 g/d. Cubic splines showed that sodium intake greater than 6 g/d (19% of participants) was associated with a 10% increased AF risk per additional 1-g/d sodium intake (hazard ratio, 1.10; 95% CI, 1.03-1.18), but with no further lowering of AF risk at lower levels of sodium intake.

Conclusions and Relevance

In this cohort study of sodium intake and AF risk, there was a J-shaped association between sodium intakes and AF risk in patients with cardiovascular disease or diabetes. Lowering sodium intake for AF prevention is best targeted at individuals who consume high sodium diets.

Animal vs Plant-Based Meat: A Hearty Debate

Plant-based meat alternatives (PBMAs) are highly processed food products that typically replace meat in the diet. In Canada, the growing demand for PBMAs coincides with public health recommendations to reduce ultra-processed food consumption, which prompts the need to investigate the long-term health implications of PBMAs. This review assesses the available literature on PBMAs and cardiovascular disease (CVD), including an evaluation of their nutritional profile and impact on CVD risk factors. Overall, the nutritional profiles of PBMAs vary considerably but generally align with recommendations for improving cardiovascular health; compared with meat, PBMAs are usually lower in saturated fat and higher in polyunsaturated fat and dietary fibre. Some dietary trials that have replaced meat with PBMAs have reported improvements in CVD risk factors, including total cholesterol, low-density lipoprotein cholesterol, apolipoprotein B-100, and body weight. No currently available evidence suggests that the concerning aspects of PMBAs (eg, food processing and high sodium content) negate the potential cardiovascular benefits. We conclude that replacing meat with PBMAs may be cardioprotective; however, long-term randomised controlled trials and prospective cohort studies that evaluate CVD events (eg, myocardial infarction, stroke) are essential to draw more definitive conclusions.

Prevalence, Clustering, and Current Management of Cardiovascular Risk Factors Upon First Referral to Hypertension Specialists: the APPROACH Study

INTRODUCTION

Several observational studies have been conducted to assess the prevalence of cardiovascular risk factors in hypertensive patients; however, none has yet investigated prevalence, clustering, and current management of cardiovascular risk factors upon first referral to hypertension specialists, which is the aim of the present study.

METHODS

Consecutive adult outpatients with essential/secondary hypertension were included at the time of their first referral to hypertension specialists at 13 Italian centers in the period April 2022-2023 if they had at least one additional major cardiovascular risk factor among LDL-hypercholesterolemia, type 2 diabetes, and cigarette smoking. Prevalence, degree of control, and current management strategies of cardiovascular risk factors were assessed.

RESULTS

A total of 255 individuals were included, 40.2% women and 98.4% Caucasian. Mean age was 60.3±13.3 years and mean blood pressure [BP] was 140.3±17.9/84.8±12.3 mmHg). Most participants were smokers (55.3%), had a sedentary lifestyle (75.7%), suffered from overweight/obesity (51%) or high LDL-cholesterol (41.6%), had never adopted strategies to lose weight (55.7%), and were not on a low-salt diet (57.4%). Only a minority of patients reported receiving specialist counseling, and 27.9% had never received recommendations to correct unhealthy lifestyle habits. Nearly 90% of individuals with an estimated high/very high cardiovascular risk profile did not achieve recommended LDL-cholesterol targets.

CONCLUSIONS

In patients with hypertension, both pharmacological and lifestyle therapeutic advice are yet to improve before referral to hypertension specialists. This should be considered in the primary care setting in order to optimize cardiovascular risk management strategies.

Scientific Committee guidance on appraising and integrating evidence from epidemiological studies for use in EFSA's scientific assessments

EFSA requested its Scientific Committee to prepare a guidance document on appraising and integrating evidence from epidemiological studies for use in EFSA's scientific assessments. The guidance document provides an introduction to epidemiological studies and illustrates the typical biases, which may be present in different epidemiological study designs. It then describes key epidemiological concepts relevant for evidence appraisal. This includes brief explanations for measures of association, exposure assessment, statistical inference, systematic error and effect modification. The guidance then describes the concept of external validity and the principles of appraising epidemiological studies. The customisation of the study appraisal process is explained including tailoring of tools for assessing the risk of bias (RoB). Several examples of appraising experimental and observational studies using a RoB tool are annexed to the document to illustrate the application of the approach. The latter part of this guidance focuses on different steps of evidence integration, first within and then across different streams of evidence. With respect to risk characterisation, the guidance considers how evidence from human epidemiological studies can be used in dose-response modelling with several different options being presented. Finally, the guidance addresses the application of uncertainty factors in risk characterisation when using evidence from human epidemiological studies.

Nutrients and Foods Recommended for Blood Pressure Control on Twitter in Japan: Content Analysis

BACKGROUND

Management and prevention of hypertension are important public health issues. Healthy dietary habits are one of the modifiable factors. As Twitter (subsequently rebranded X) is a digital platform that can influence public eating behavior, there is a knowledge gap regarding the information about foods and nutrients recommended for blood pressure control and who disseminates them on Twitter.

OBJECTIVE

This study aimed to investigate the nature of the information people are exposed to on Twitter regarding nutrients and foods for blood pressure control.

METHODS

A total of 147,898 Japanese tweets were extracted from January 1, 2022, to December 31, 2022. The final sample of 2347 tweets with at least 1 retweet was manually coded into categories of food groups, nutrients, user characteristics, and themes. The number and percentage of tweets, retweets, and themes in each category were calculated.

RESULTS

Of the 2347 tweets, 80% (n=1877) of tweets mentioned foods, which were categorized into 17 different food groups. Seasonings and spices, including salt, were most frequently mentioned (1356/1877, 72.2%). This was followed by vegetable and fruit groups. The 15 kinds of nutrients were mentioned in 1566 tweets, with sodium being the largest proportion at 83.1% (n=1301), followed by potassium at 8.4% (n=132). There was misinformation regarding salt intake for hypertension, accounting for 40.8% (n=531) of tweets referring to salt, including recommendations for salt intake to lower blood pressure. In total, 75% (n=21) of tweets from "doctors" mentioned salt reduction is effective for hypertension control, while 31.1% (n=74) of tweets from "health, losing weight, and beauty-related users," 25.9% (n=429) of tweets from "general public," and 23.5% (n=4) tweets from "dietitian or registered dietitian" denied salt reduction for hypertension. The antisalt reduction tweets accounted for 31.5% (n=106) of the most disseminated tweets related to nutrients and foods for blood pressure control.

CONCLUSIONS

The large number of tweets in this study indicates a high interest in nutrients and foods for blood pressure control. Misinformation asserting antisalt reduction was posted primarily by the general public and self-proclaimed health experts. The number of tweets from nutritionists, registered dietitians, and doctors who were expected to correct misinformation and promote salt reduction was relatively low, and their messages were not always positive toward salt reduction. There is a need for communication strategies to combat misinformation, promote correct information on salt reduction, and train health care professionals to effectively communicate evidence-based information on this topic.

Dissociation of Hypertension and Renal Damage After Cessation of High-Salt Diet in Dahl Rats

BACKGROUND

Every year, thousands of patients with hypertension reduce salt consumption in an effort to control their blood pressure. However, hypertension has a self-sustaining character in a significant part of the population. We hypothesized that chronic hypertension leads to irreversible renal damage that remains after removing the trigger, causing an elevation of the initial blood pressure.

METHODS

Dahl salt-sensitive rat model was used for chronic, continuous observation of blood pressure. Rats were fed a high salt diet to induce hypertension, and then the diet was switched back to normal sodium content.

RESULTS

We found that developed hypertension was irreversible by salt cessation: after a short period of reduction, blood pressure grew even higher than in the high-salt phase. Notably, the self-sustaining phase of hypertension was sensitive to benzamil treatment due to sustaining epithelial sodium channel hyperactivity, as shown with patch-clamp analysis. Glomerular damage and proteinuria were also irreversible. In contrast, some mechanisms, contributing to the development of salt-sensitive hypertension, normalized after salt restriction. Thus, flow cytometry demonstrated that dietary salt reduction in hypertensive animals decreased the number of total CD45+, CD3+CD4+, and CD3+CD8+ cells in renal tissues. Also, we found tubular recovery and improvement of glomerular filtration rate in the postsalt period versus a high-salt diet.

CONCLUSIONS

Based on earlier publications and current data, poor response to salt restriction is due to the differential contribution of the factors recognized in the developmental phase of hypertension. We suggest that proteinuria or electrolyte transport can be prioritized over therapeutic targets of inflammatory response.

Misinformation surrounding sodium reduction for blood pressure: content analysis of Japanese posts on X

This content analysis aimed to assess misinformation themes regarding sodium reduction and blood pressure on X with the goal of providing strategies to address and debunk such misinformation. A total of 531 posts were manually coded into sodium-related misinformation themes, with inclusion criteria for posts asserting no association between sodium reduction and hypertension or claiming consuming sodium is beneficial for health. Numbers and post frequencies per misinformation theme were calculated. Post characteristics, including information sources, advertisements and narratives, were coded, and a correlation analysis was conducted to assess their association with each misinformation theme. Fourteen sodium-related misinformation themes were identified and consistently disseminated on X. The predominant theme, 'Natural Salt', accounted for 37.7% (n = 200), reaching 1.6 million followers, followed by 'Reducing salt could be bad for my health' theme, comprising 28.6% (n = 152) and reaching 1.5 million followers. There was a statistical correlation between the natural salt misinformation theme and advertisements. Many of the most frequent misinformation themes identified in this study have not been systematically debunked by organizations such as the World Health Organization and the American Heart Association. This study underscores the importance of continuous monitoring and analysis of sodium-related misinformation on social media platforms and their underlying commercial interests. Such monitoring has the potential to identify prevalent misinformation themes that may pose harm to the public and to inform public health organizations, enabling them to proactively address potential issues through debunking.

Development and validation of a scale to measure hypertensive Chinese individual's behavior toward salt reduction consumption

OBJECTIVE

This study aimed to develop and validate the Salt Reduction Behavior Scale (SRBS) to measure the behavior of hypertensive Chinese individuals in adhering to salt reduction practices.

METHODS

The SRBS was constructed based on the Health Belief Model, consisting of five constructs: knowledge, perceived severity, perceived benefits, perceived barriers, and cues to action. Data were collected from 2,082 hypertensive patients in Beijing, China, who completed a questionnaire administered through an online platform. Kaiser-Meyer-Olkin (KMO) test was used to assess the adequacy of the sample and the Bartlett's test of sphericity to examine the factorability of the dataset. Confirmatory Factor Analysis (CFA) was used to assess the structural validity and reliability of the SRBS.

RESULTS

The KMO analysis yielded a notably elevated value of 0.95, indicating that the data was highly suitable for Exploratory Factor Analysis (EFA). Bartlett's test of sphericity yielded a statistically significant test statistic (P < 0.001). The 32-item SRB questionnaire demonstrated strong internal consistency with a Cronbach's alpha coefficient of 0.923. A second-order Confirmatory Factor Analysis (CFA) revealed that, after removing the unrelated construct of barriers, SRB could be represented by four sub-constructs: knowledge, severity, benefits, and action. The final version of the SRBS consists of 21 items. These items displayed high factor loadings, indicating a strong relationship between the items and their respective sub-constructs. The discriminant validity analysis revealed that the SRBS sub-constructs were distinct from each other. The SRBS scores were positively correlated with self-reported salt reduction practices. This demonstrates that individuals with higher SRBS scores were more likely to engage in actual salt reduction behaviors, indicating concurrent validity.

CONCLUSION

The results illustrate that the Salt Reduction Behavior Scale is a robust and comprehensive instrument for assessing salt reduction behavior among hypertensive Chinese individuals. The scale's specific sub-constructs provide a detailed understanding of their knowledge, attitudes, and practices related to salt consumption. Healthcare professionals and policymakers can utilize this tool to tailor interventions and educational programs to encourage healthier dietary habits, thereby reducing the risk of cardiovascular diseases in China.

Temporal dynamics of drinking water sodium levels in coastal areas, Cyprus 2009-2020

Around the world, groundwater salinity levels are increasing in coastal areas, as a result of its systematic overexploitation for domestic, agricultural and industrial demand and potentially due to climate change manifestations (such as, sea level rise). We hypothesized that the groundwater quality of many Mediterranean coastal areas is already being perturbed, especially for water salinity, depending on the groundwater distance from the seafront. The objectives of this study were: i) to evaluate the magnitude and temporal variance of drinking water sodium (Na) as a metric of salt intake used for public health purposes using drinking water data in Cyprus; and ii) to examine the degree of Na enrichment in drinking water as defined by the seawater coastline distance of each sampling point. Open access governmental data of drinking water Na (n = 3304), daily max ambient air temperature and total rainfall were obtained for the period of 2009-2020 from governmental repositories. Linear mixed-effect regression models of drinking water Na with unsupervised covariance matrix were used. After adjusting for temperature and rainfall data, there was a significant annual increase in drinking water Na levels over time (beta = 0.01; 95 % CI: 0.00, 0.02; p = 0.02) for the coastal areas (<10 km from coastline, cutoff used by the EU Environment Agency), but this was not the case for non-coastal areas (>10 km distance from coastline). The distance of each sampling point from the coastline in Cyprus was negatively associated with drinking water Na in coastal areas (beta = -0.04, 95%CI: -0.06, -0.01; p = 0.002); this was not the case for non-coastal areas. More research is warranted to better understand the impacts of global environmental change on water quality in association with the burden of disease in coastal areas.

Croatian Action on Salt and Health (CRASH): On the Road to Success-Less Salt, More Health

The World Health Organization recommends adjusting salt intake as a part of the nine global targets to reduce premature mortality from non-communicable chronic diseases as a priority and the most cost-effective intervention. In 2006, the main aim of the Croatian Action on Salt and Health was to decrease salt intake by 16% because of its critical intake and consequences on human health. We have organized educative activities to increase awareness on salt harmfulness, define food categories of prime interest, collaborate with industries and determine salt intake (24 h urine sodium excretion). It was determined that the proportion of salt in ready-to-eat baked bread should not exceed 1.4%. In the period 2014-2022, salt in semi-white bread was reduced by 14%, 22% in bakery and 25% in the largest meat industry. Awareness of the harmfulness of salt on health increased from 65.3% in 2008 to 96.9% in 2023 and salt intake was reduced by 15.9-1.8 g/day (22.8% men, 11.7% women). In the last 18 years, a significant decrease in salt intake was achieved in Croatia, awareness of its harmfulness increased, collaboration with the food industry was established and regulatory documents were launched. However, salt intake is still very high, underlying the need for continuation of efforts and even stronger activities.

Spatiotemporal trends in the burden of aortic aneurysms caused by high sodium intake from 1990 to 2019: A global, regional, and national analysis

BACKGROUND AND AIMS

This study, drawing on Global Burden of Disease (GBD) data, examines spatiotemporal trends in mortality and disability-adjusted life years (DALYs) linked to aortic aneurysm (AA) from high sodium intake. The aim is a comprehensive analysis globally, regionally, and nationally spanning 1990 to 2019.

METHODS AND RESULTS

Quantifying AA deaths and DALYs due to high sodium intake, incorporating age-standardized mortality rate (ASMR) and age-standardized DALYs rate (ASDR), revealed a global surge. Deaths rose by 86.09 %, DALYs by 74.02 % from 1990 to 2019. EAPC for ASMR and ASDR displayed negative trends (-0.72 and -0.77). High/middle-high Socio-demographic Index (SDI) regions bore higher burdens than lower SDI regions. Males consistently had higher burdens across SDI regions, with both genders showing a slight downward trend. Age-wise, AA deaths and DALYs rose with age, followed by decline. A positive correlation existed between SDI and global burden, inversely related to EAPC for ASMR and ASDR.

CONCLUSION

AA burden from high sodium intake is pronounced in high SDI regions, necessitating targeted interventions. The global data highlights a significant increase in AA deaths and DALYs due to high sodium intake, urging prompt and effective control measures.

Using Genetics to Inform Interventions Related to Sodium and Potassium in Hypertension

BACKGROUND

Hypertension is a key risk factor for major adverse cardiovascular events but remains difficult to treat in many individuals. Dietary interventions are an effective approach to lower blood pressure (BP) but are not equally effective across all individuals. BP is heritable, and genetics may be a useful tool to overcome treatment response heterogeneity. We investigated whether the genetics of BP could be used to identify individuals with hypertension who may receive a particular benefit from lowering sodium intake and boosting potassium levels.

METHODS

In this observational genetic study, we leveraged cross-sectional data from up to 296 475 genotyped individuals drawn from the UK Biobank cohort for whom BP and urinary electrolytes (sodium and potassium), biomarkers of sodium and potassium intake, were measured. Biologically directed genetic scores for BP were constructed specifically among pathways related to sodium and potassium biology (pharmagenic enrichment scores), as well as unannotated genome-wide scores (conventional polygenic scores). We then tested whether there was a gene-by-environment interaction between urinary electrolytes and these genetic scores on BP.

RESULTS

Genetic risk and urinary electrolytes both independently correlated with BP. However, urinary sodium was associated with a larger BP increase among individuals with higher genetic risk in sodium- and potassium-related pathways than in those with comparatively lower genetic risk. For example, each SD in urinary sodium was associated with a 1.47-mm Hg increase in systolic BP for those in the top 10% of the distribution of genetic risk in sodium and potassium transport pathways versus a 0.97-mm Hg systolic BP increase in the lowest 10% (P=1.95×10-3). This interaction with urinary sodium remained when considering estimated glomerular filtration rate and indexing sodium to urinary creatinine. There was no strong evidence of an interaction between urinary sodium and a standard genome-wide polygenic score of BP.

CONCLUSIONS

The data suggest that genetic risk in sodium and potassium pathways could be used in a precision medicine model to direct interventions more specifically in the management of hypertension. Intervention studies are warranted.

Technology-supported behavior change interventions for reducing sodium intake in adults: a systematic review and meta-analysis

The effects of technology-supported behavior change interventions for reducing sodium intake on health outcomes in adults are inconclusive. Effective intervention characteristics associated with sodium reduction have yet to be identified. A systematic review and meta-analysis were conducted, searching randomized controlled trials (RCTs) published between January 2000 and April 2023 across 5 databases (PROSPERO: CRD42022357905). Meta-analyses using random-effects models were performed on 24-h urinary sodium (24HUNa), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Subgroup analysis and meta-regression of 24HUNa were performed to identify effective intervention characteristics. Eighteen RCTs involving 3505 participants (51.5% female, mean age 51.6 years) were included. Technology-supported behavior change interventions for reducing sodium intake significantly reduced 24HUNa (mean difference [MD] -0.39 gm/24 h, 95% confidence interval [CI] -0.50 to -0.27; I2 = 24%), SBP (MD -2.67 mmHg, 95% CI -4.06 to -1.29; I2 = 40%), and DBP (MD -1.39 mmHg, 95% CI -2.31 to -0.48; I2 = 31%), compared to control conditions. Interventions delivered more frequently (≤weekly) were associated with a significantly larger effect size in 24HUNa reduction compared to less frequent interventions (>weekly). Other intervention characteristics, such as intervention delivery via instant messaging and participant-family dyad involvement, were associated with larger, albeit non-significant, effect sizes in 24HUNa reduction when compared to other subgroups. Technology-supported behavior change interventions aimed at reducing sodium intake were effective in reducing 24HUNa, SBP, and DBP at post-intervention. Effective intervention characteristics identified in this review should be considered to develop sodium intake reduction interventions and tested in future trials, particularly for its long-term effects.

Dietary Sodium Reduction Is Best for Reducing Blood Pressure: Controversies in Hypertension

The global burden of cardiovascular disease (CVD) continues to grow, as does the incidence of hypertension, one of the most important modifiable risk factors of CVD. Non-pharmacologic, population level interventions are critically needed to halt the hypertension pandemic, but there is an ongoing debate as to whether public policy efforts should focus more on dietary sodium reduction or increasing potassium. In this commentary, we summarize arguments in favor of policy geared towards reduced sodium intake. Recognizing increasing dietary sodium as one of the drivers of the hypertension pandemic is critical to developing public policy to reduce population level sodium exposure and blood pressure. We draw from a robust field of evidence to show that reducing sodium intake improves blood pressure in a linear fashion, across the lifespan, at an individual level and a population level, and may even reduce CVD events. While potassium plays an important role in blood pressure regulation, potassium interventions are less effective at reducing blood pressure, carry risk of hyperkalemia in select populations, and are more logistically challenging. There is an urgent need for nation-wide policies to reduce sodium intake to help stem the hypertension pandemic and prevent CVD.

Consumption of Discretionary Salt and Salt from Bouillon among Households, Women, and Young Children in Northern Region, Ghana: A Mixed-Methods Study with the Condiment Micronutrient Innovation Trial (CoMIT) Project

Background

Information on salt consumption patterns is needed to inform the need for and design of salt reduction strategies.

Objectives

In northern Ghana, this study aimed to estimate household consumption of salt, including salt from bouillon, and compare (estimated) women and children's salt intake to global recommendations; to estimate the proportion of salt consumed from bouillon; and to identify factors, including knowledge, attitudes, and practices, associated with household salt consumption.

Methods

Employing mixed-methods methodology, we conducted a pilot survey (n = 369 households enrolled) and focus group discussions (FGDs; n = 20) in Tolon and Kumbungu districts (14 urban, 14 rural clusters) (clinicaltrials.gov registry: NCT04632771). Households reported purchases of discretionary salt (DS, "table salt") and bouillon cubes. DS and total salt (TS; DS+salt from bouillon) consumption for women (15-49 y) and children (2-5 y) were estimated using the Adult Male Equivalent method and compared with global recommendations (<5 g/d women; <3.75 g/d children). Women's salt intake was also predicted from urinary sodium excretion (INTERSALT equation). Associations between DS and TS consumption, as well as household and women's characteristics, were tested with minimally adjusted and multivariable linear mixed-effects models. Qualitative FGD themes were generated using the Framework Method.

Results

From household purchase data, estimated TS consumption exceeded global recommendations for 44% of children [median: 2.9 (IQR: 1.9, 5.2) g/d] and 60% of women [6.0 (4.0, 10.2) g/d]; 35% of children and 50% of women exceeded recommendations from DS alone. Bouillon contributed <25% of households' TS consumption. Few characteristics were associated with DS or TS consumption. Salient qualitative themes that shaped salt consumption behaviors included salt's ubiquity as a seasoning, key household members' influence on food procurement and preparation, and perceptions about health.

Conclusions

Purchase data suggest salt consumption among women and children exceeds recommendations, even when excluding salt from bouillon; food prepared outside the home likely further contributes. Salt reduction interventions may be warranted in this context.

Association between socio-demographic factors, lifestyle, eating habits and hypertension risk among middle-aged and older rural Chinese adults

BACKGROUND AND AIMS

Hypertension is a global health issue with increasing prevalence. This study aimed to understand the epidemiological characteristics and influencing factors of hypertension in rural Chinese populations and help develop effective prevention and control strategies.

METHODS AND RESULTS

This cross-sectional study used database from the Early Diagnosis and Early Treatment Project of Esophageal Cancer conducted in a rural population from September 2012 to December 2017. A total of 10,111 subjects aged 35-75 years residing in Huai'an District, Huai'an City, Jiangsu Province for at least three years were included. Unconditional univariate and multivariate logistic regression models were performed to evaluate the association between socio-demographic information, lifestyle habits, dietary characteristics and the risk of hypertension. The prevalence of hypertension was 34.32 % in this rural population. Men and older individuals are more likely to have hypertension when compared with women and young individuals, respectively. Factors associated with an increased risk of hypertension included: fast eating speed, a high-salt diet (both currently and ten years ago), a high-spicy diet ten years ago, high BMI, poor educational attainment, preference for fatty meats, hot diet, green tea drinking, intake of pickled potherb mustard and corn flour, family smoking and alcohol consumption. Light smoking in males, consumption of fruits, adzuki bean, and pork liver were associated with reduced risk of hypertension.

CONCLUSIONS

The study identified some factors, including eat habits and lifestyle, associated with hypertension risk, and highlighted the need for targeted policies and interventions in rural China to address potential risk factors for hypertension.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Does fluoride exposure affect thyroid function? A systematic review and dose-response meta-analysis

INTRODUCTION

Fluoride exposure may have various adverse health effects, including affecting thyroid function and disease risk, but the pattern of such relation is still uncertain.

METHODS

We systematically searched human studies assessing the relation between fluoride exposure and thyroid function and disease. We compared the highest versus the lowest fluoride category across these studies, and we performed a one-stage dose-response meta-analysis for aggregated data to explore the shape of the association.

RESULTS

Most retrieved studies (27 of which with a cross-sectional design) were conducted in Asia and in children, assessing fluoride exposure through its concentrations in drinking water, urine, serum, or dietary intake. Twenty-four studies reported data on thyroid function by measuring thyroid-related hormones in blood (mainly thyroid-stimulating-hormone - TSH), 9 reported data on thyroid disease, and 4 on thyroid volume. By comparing the highest versus the lowest fluoride categories, overall mean TSH difference was 1.05 μIU/mL. Dose-response curve showed no change in TSH concentrations in the lowest water fluoride exposure range, while the hormone levels started to linearly increase around 2.5 mg/L, also dependending on the risk of bias of the included studies. The association between biomarkers of fluoride exposure and TSH was also positive, with little evidence of a threshold. Evidence for an association between fluoride exposure and blood concentrations of thyroid hormones was less evident, though there was an indication of inverse association with triiodothyronine. For thyroid disease, the few available studies suggested a positive association with goiter and with hypothyroidism in both children and adults.

CONCLUSIONS

Overall, exposure to high-fluoride drinking water appears to non-linearly affect thyroid function and increase TSH release in children, starting above a threshold of exposure, and to increase the risk of some thyroid diseases.

Sodium - a systematic review for Nordic Nutrition Recommendations 2023

Blood pressure (BP) rises along with increasing sodium intake from early childhood to late adulthood, and leads to hypertension among most men and women living in Nordic and Baltic countries. Elevated BP is the leading global risk factor for premature deaths and disability-adjusted life-years. A reduction in sodium intake is essential in the prevention of hypertension in individuals, in the lowering of BP levels, in the treatment of hypertensive individuals, and in decreasing risks associated with elevated BP. There is a progressive linear dose-response relationship between sodium intake and BP beginning from a sodium intake of less than 0.8 g/day. Sodium reduction decreases BP linearly by a dose-response manner down to a sodium intake level of less than 2 g/day. Randomised intervention studies with a duration of at least 4 weeks confirm the efficiency and safety of reducing blood sodium intake to a level of less than 2 g/day. Results from prospective cohort studies show that higher sodium intake is positively associated with an increased risk of stroke and cardiovascular events and mortality among the general adult population, and the associations are linear in studies using proper sodium assessment methods. Analyses assessing sodium intake using at least two 24-h urine samples have shown a linear positive relationship between sodium intake and the risk of a cardiovascular event or death. Based on an overall evaluation of the available data, a limitation of the sodium intake to 2.0 g/day is suggested for adults. The optimal sodium intake level would be probably about 1.5 g/day. Sodium intake recommended for children can be extrapolated from the recommended sodium intake for adults. According to national dietary surveys, the average sodium intakes in Nordic countries range in adult men from 3.6 to 4.4 g/day and in adult women from 2.6. to 3.2 g/day, and in Baltic countries in men from 2.6 to 5.1 g/day and in women from 1.8 to 3.6 g/day.

Age differences in the impact of dietary salt on metabolism, blood pressure and cognitive function in male rats

The influence of salt consumption on physiological processes, especially blood pressure (BP), metabolism, and cognition, remains a topical concern. While guidelines endorse reduced salt diets, there are gaps in understanding the age-specific implications and challenges in adherence. The present study delved into the differential effects of salt intake on young adult and aged male rats over a 12-week period, using control, low-, and high-salt diets. Key metrics, such as BP, cognition, and general parameters, were monitored. Our findings revealed significant age-dependent effects of salt intake on survival rates, body weight, blood sodium, blood glucose, blood lipids, BP, heart rates, and cognition. Notably, young adult rats did not show significant sodium level changes on a high-salt diet, whereas aged rats experienced increased sodium levels even on a normal salt diet. Blood glucose levels decreased significantly in aged rats on a high-salt diet but remained stable in young adults. Aged rats had the highest survival rates on low-salt diets. Low-salt diets led to reduced BP in both age groups, more significantly in young adults. Young adult rats displayed increased BP variability on both high- and low-salt diets, while a decrease in BP variability was exclusive to aged rats on a low-salt diet. There were significant differences across age groups in short-term memory, but not in long-term memory. The study provides a nuanced understanding of the age-dependent physiological effects of salt intake, suggesting the necessity of age-specific guidelines for public health.

Dietary Salt Restriction and Adherence to the Mediterranean Diet: A Single Way to Reduce Cardiovascular Risk?

The dietary restriction of salt intake and the adhesion to Mediterranean dietary patterns are among the most recommended lifestyle modifications for the prevention of cardiovascular diseases. A large amount of evidence supports these recommendations; indeed, several studies show that a higher adherence to Mediterranean dietary patterns is associated with a reduced risk of cardiovascular disease. Likewise, findings from observational and clinical studies suggest a causal role of excess salt intake in blood pressure increase, cardiovascular organ damage, and the incidence of cardiovascular diseases. In this context, it is also conceivable that the beneficial effects of these two dietary patterns overlap because Mediterranean dietary patterns are typically characterized by a large consumption of plant-based foods with low sodium content. However, there is little data on this issue, and heterogeneous results are available on the relationship between adherence to salt restriction and to Mediterranean dietary patterns. Thus, this short review focuses on the epidemiological and clinical evidence of the relationship between the adherence to Mediterranean dietary patterns and dietary salt restriction in the context of cardiovascular risk.

Associations between estimation of salt intake and salt-restriction spoons and hypertension status in patients with poorly controlled hypertension: a community-based study from Huzhou City, Eastern China

BACKGROUND

As the prevalence of hypertension increases in China, it is advised to use salt-restriction spoons (SRS) as a lifestyle modification. This study aimed to examine the associations between estimated salt consumption, SRS usage, and the hypertension status in individuals with poorly controlled hypertension.

METHODS

Data was collected in Huzhou City, Zhejiang Province, in 2021 using convenience sampling. The analysis involved ordinal logistic regression and restricted cubic splines to assess the relevant factors.

RESULTS

The study found that 73.34% of the 1215 patients had uncontrolled blood pressure (BP). Urinary excretion was assessed through the utilization of the Kawasaki, INTERSALT, and Tanaka formulas. The outcomes of these three methodologies revealed average daily sodium excretion values of 208.70 (65.65), 154.78 (33.91), and 162.61 (40.87) mmol, respectively. The prevalence of utilizing SRS was found to be 37.78% in this study. Despite the acknowledgment among SRS users of the potential hazards associated with excessive salt consumption, there exists a contradictory pattern of attitudes and behaviors concerning salt reduction. Among individuals with different levels of salt intake (quartiles 1-4, Q1 vs Q4), there was a positive association between limiting salt and hypertension status when controlling for other variables (Kawasaki adjusted OR = 0.58, 95% CI = 0.43-0.79; INTERSALT adjusted OR = 0.62, 95% CI = 0.41-0.92; Tanaka adjusted OR = 0.61, 95% CI = 0.45-0.92, p < 0.05). Our research also revealed that using or used SRS was a protective factor for blood BP control (adjusted OR = 0.79, 95% CI = 0.64-0.99, P < 0.05). The restricted cubic spline plots illustrated a monotonic upward relationship between estimated 24-h urinary Na and BP (P-overall association < 0.05; P-non-linear association > 0.05).

CONCLUSIONS

The use of dietary SRS could result in decrease in daily salt intake for BP control in patients with poorly controlled hypertension. To reduce the impact of high BP in China, additional studies are required to create interventions that can enhance the results for patients.

Sodium, potassium intake, and all-cause mortality: confusion and new findings

BACKGROUND

The World Health Organization (WHO) has established recommended daily intakes for sodium and potassium. However, there is currently some controversy regarding the association between sodium intake, potassium intake, the sodium-to-potassium ratio, and overall mortality. To assess the correlations between sodium intake, potassium intake, the sodium-to-potassium ratio, and overall mortality, as well as the potential differences in sodium and potassium intake thresholds among different population groups, we analyzed data from NHANES 2003-2018.

METHODS

NHANES is an observational cohort study that estimates sodium and potassium intake through one or two 24-h dietary recalls. Hazard ratios (HR) for overall mortality were calculated using multivariable adjusted Cox models accounting for sampling design. A total of 13855 out of 26288 participants were included in the final analysis. Restricted cubic spline analyses were used to examine the relationship between sodium intake, potassium intake, and overall mortality. If non-linearity was detected, we employed a recursive algorithm to calculate inflection points.

RESULTS

Based on one or two 24-h dietary recalls, the sample consisted of 13,855 participants, representing a non-institutionalized population aged 40-80 years, totaling 11,348,771 person-months of mean follow-up 99.395 months. Daily sodium intake and daily potassium intake were inversely associated with all-cause mortality. Restrictive cubic spline analysis showed non-linear relationships between daily sodium intake, potassium intake, sodium-potassium ratio, and total mortality. The inflection point for daily sodium intake was 3133 mg/d, and the inflection point for daily potassium intake was 3501 mg/d, and the inflection point for daily sodium-potassium ratio intake was 1.203 mg/mg/d. In subgroup analyses, a significant interaction was found between age and high sodium intake, which was further confirmed by the smooth curves that showed a U-shaped relationship between sodium intake and all-cause mortality in the elderly population, with a inflection point of 3634 mg/d.

CONCLUSION

Nonlinear associations of daily sodium intake, daily potassium intake and daily sodium-potassium ratio intake with all-cause mortality were observed in American individuals. The inflection point for daily sodium intake was 3133 mg/d. And the inflection point for daily sodium intake was 3634 mg/d in elderly population. The inflection point for daily potassium intake was 3501 mg/d. The inflection point for daily sodium-potassium ratio intake was 1.203 mg/mg/d, respectively, A healthy diet should be based on reasonable sodium intake and include an appropriate sodium-to-potassium ratio.

Salt restriction for treatment of hypertension - current state and future directions

PURPOSE OF REVIEW

Given the adverse effects of excess dietary sodium chloride (also known as table salt) on blood pressure (BP) and cardiovascular disease (CVD), restriction of dietary sodium is recommended by numerous guidelines. The strictest of these recommend no more than 1.5 g/day of dietary sodium among hypertensive persons. However, average dietary sodium intake in the population is closer to 5 g/day and there is debate about whether too much sodium restriction may be associated with increased CVD risk. Herein, we aim to provide a balanced update on this topic.

RECENT FINDINGS

In 2021, the Salt Substitute and Stroke Study (SSaSS) demonstrated a significant reduction in BP, CVD, and death among Chinese adults randomized to a low sodium salt-substitute supplemented with potassium. This trial largely puts to rest any remaining debate about the benefits of dietary sodium restriction among persons with excess baseline intake (dietary sodium intake fell from approximately 5 down to 4 g/day in the active arm of SSaSS). However, whether achieving and maintaining a dietary sodium of less than1.5 g/day is feasible in real-world settings and whether this low an intake is harmful remain open questions.

SUMMARY

Aiming for sodium intakes of 2--3 g/day in the general population and as low as 2 g/day in persons with hypertension or CVD seems most reasonable, but there is some uncertainty around lower targets.

Salt and Aldosterone - Reciprocal and Combined Effects in Preclinical Models and Humans

Primary aldosteronism is an endocrine disorder caused by excessive production of aldosterone by the adrenal glands, and is recognized as the most important cause of endocrine hypertension. With specific therapy, this type of hypertension is potentially curable. In the general population, high salt intake increases the risk for cardiovascular diseases like stroke. In populations with aldosterone excess, observational and experimental data suggest that aldosterone-induced organ damage requires a combination of high dietary salt intake and high plasma aldosterone, i.e., plasma aldosterone levels inappropriately high for salt status. Therefore, understanding the relationship between plasma aldosterone levels and dietary salt intake and the nature of their combined effects is crucial for developing effective prevention and treatment strategies. In this review, we present an update on findings about primary aldosteronism and salt intake and the underlying mechanisms governing their interaction.

Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension

Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

Effect of Acute and Chronic Ingestion of Exogenous Ketone Supplements on Blood Pressure: A Systematic Review and Meta-Analysis

Exogenous ketone supplements have been suggested to have potential cardiovascular benefits, but their overall effect on blood pressure is unclear. Our objective was to perform a systematic review and meta-analysis on the effects of exogenous ketone supplements on blood pressure (BP) and concomitant changes in resting heart rate (HR). Five databases were searched on January 27th, 2023, for randomized and non-randomized studies. A random-effects model meta-analysis was performed including all studies jointly and separately for acute and chronic ingestion of ketone supplements. Out of 4012 studies identified in the search, 4 acute and 6 chronic studies with n = 187 participants were included. Pooled results (n = 10) showed no change in systolic (SMD [95% CI]= -0.14 [-0.40; 0.11]; I2= 30%; p = 0.17) or diastolic BP (-0.12 [-0.30; 0.05]; I2= 0%; p = 0.69), with a potential tendency observed toward increased resting heart rate (0.17 [-0.14; 0.47]; I2= 40%; p = 0.10). Similar results for systolic and diastolic BP were observed when assessing separately the effect of acute and chronic ingestion of ketone supplements (p ≥ 0.33). Supplement dosage was found to modulate the increase in resting heart rate (0.019 ± 0.006; p = 0.013; R2=100%), suggesting that higher supplement doses lead to a higher resting heart rate. Based on currently available data, acute or prolonged ingestion of ketone supplements does not seem to modulate BP. However, a tendency for HR to increase after acute ingestion was observed, particularly with higher doses. Higher quality studies with appropriate standardized measurements are needed to confirm these results.

Cardiometabolic and renal phenotypes and transitions in the United States population

Cardiovascular and renal conditions have both shared and distinct determinants. In this study, we applied unsupervised clustering to multiple rounds of the National Health and Nutrition Examination Survey from 1988 to 2018, and identified 10 cardiometabolic and renal phenotypes. These included a 'low risk' phenotype; two groups with average risk factor levels but different heights; one group with low body-mass index and high levels of high-density lipoprotein cholesterol; five phenotypes with high levels of one or two related risk factors ('high heart rate', 'high cholesterol', 'high blood pressure', 'severe obesity' and 'severe hyperglycemia'); and one phenotype with low diastolic blood pressure (DBP) and low estimated glomerular filtration rate (eGFR). Prevalence of the 'high blood pressure' and 'high cholesterol' phenotypes decreased over time, contrasted by a rise in the 'severe obesity' and 'low DBP, low eGFR' phenotypes. The cardiometabolic and renal traits of the US population have shifted from phenotypes with high blood pressure and cholesterol toward poor kidney function, hyperglycemia and severe obesity.

Comparative Analysis of Hypertension Guidelines: Unveiling Consensus and Discrepancies in Lifestyle Modifications for Blood Pressure Control

Background

Hypertension is a major global health concern, and lifestyle modifications have been recommended as first-line treatment for hypertension in many guidelines. However, different guidelines may recommend different types of lifestyle adjustment, and it is unclear which ones are most effective. In this review, we compared hypertension guidelines to identify any differences and/or consensus in content, efficacy, and timing of initiation of lifestyle modifications.

Methods

We conducted a search of databases to identify hypertension guidelines available in English. We extracted and compared information about lifestyle modifications recommended by the guidelines.

Results

Five hypertension guidelines from America, Europe, the UK, Canada, and the International Society of Hypertension are included. They all recommend diet adaptation, sodium reduction, alcohol restriction, physical exercise, and weight reduction. Other lifestyle interventions emphasized by some guidelines, such as potassium supplementation, smoking cessation, and stress management, are not recommended by all the five guidelines. Among lifestyle changes, the dietary approaches to stop hypertension (DASH) diet may be considered the most effective treatment for reducing blood pressure. These guidelines recommend that for patients with high-normal blood pressure or grade 1 hypertension without high risk factors, lifestyle medicine should be used first for 3-6 months, if blood pressure is still not controlled, then start medication. For those patients who need drug treatment, lifestyle changes can also enhance the effects of antihypertensive therapy.

Conclusion

Lifestyle modifications are crucial in the treatment of hypertension and should be recommended to most hypertensive patients. Among these lifestyle interventions, diet adaptation containing low sodium and alcohol restriction may be the most effective in reducing blood pressure. Physical exercise and weight reduction are also recommended. In some cases, lifestyle modifications should be tried first. They may also enhance the effects of antihypertensive drugs in other patients.

Validation of spot urine in estimating 24-h urinary sodium, potassium and sodium-to-potassium ratio during three different sodium diets in healthy adults

PURPOSE

To evaluate the validity of spot urine assay methods in estimating the 24-h urinary sodium, potassium and sodium-to-potassium ratio during three different sodium diets.

MATERIALS AND METHODS

Twelve healthy volunteers were asked to adhere to 3 dietary sodium targets (3.3-5.0g/day,<3.3 g/day and >5.0 g/day) for three consecutive weeks and to measure salt excretion daily in spot urine samples using a self-monitoring device. On day 7 of each week, 24-h urine was collected to compare measured with estimated 24-h salt excretion (by the Kawasaki, Tanaka and INTERSALT equations).

RESULTS

Correlation coefficients relating measured and estimated 24-h sodium excretion were low and not significant for Kawasaki and INTERSALT and moderate for the Tanaka equation (τ 0.56-0.64,p<.05). Bland-Altman plots showed considerable differences between estimated and measured sodium excretion across all salt diets. Over 40% of the participants showed an absolute difference between measured and estimated 24-h sodium of more than 1000 mg/day. The correlation coefficients between 24-h and spot Na/K ratio were 0.67, 0.94 and 0.85(p<.05), and mean differences were 0.59, 0.06 and 0.48 for the intermediate, low and high sodium diets, respectively.

CONCLUSION

These findings do not support estimation of individual 24-h salt excretion from spot urine by the Kawasaki, Tanaka, or INTERSALT formula. Plain language summaryAccurate monitoring of salt intake is essential to improve BP control. At present, measurement of sodium and potassium excretion in multiple non-consecutive 24-h urinary collections is considered the gold standard for measuring dietary sodium intake. However, this method is burdensome, time-consuming and error prone.Therefore, we assessed and compared the validity of three formula-based approaches to estimate 24-h urinary sodium and potassium excretion and the Na/K ratio from spot urine samples measured by a self-monitoring device under three different sodium diets using 24-h urine collections as the reference.We conclude that use of three commonly used equations that estimate 24-h urinary sodium and potassium excretion result in substantial bias, poor precision and poor accuracy and are therefore not recommended. The Na/K ratio based on multiple casual urine samples may be a useful, low-burden, low-cost alternative method to 24-h urine collection for monitoring daily salt intake.

Urine sodium excretion is related to extracellular water volume but not to blood pressure in 510 normotensive and never-treated hypertensive subjects

PURPOSE

High sodium intake is an accepted risk factor for hypertension, while low Na⁺ intake has also been associated with increased risk of cardiovascular events. In this cross-sectional study, we examined the association of 24-h urinary Na⁺ excretion with haemodynamics and volume status.

MATERIALS AND METHODS

Haemodynamics were recorded in 510 normotensive and never-treated hypertensive subjects using whole-body impedance cardiography and tonometric radial artery pulse wave analysis. The results were examined in sex-specific tertiles of 24-h Na⁺ excretion, and comparisons between normotensive and hypertensive participants were also performed. Regression analysis was used to investigate factors associated with volume status. The findings were additionally compared to 28 patients with primary aldosteronism.

RESULTS

The mean values of 24-h urinary Na⁺ excretion in tertiles of the 510 participants were 94, 148 and 218 mmol, respectively. Average tertile age (43.4-44.7 years), office blood pressure and pulse wave velocity were corresponding in the tertiles. Plasma electrolytes, lipids, vitamin D metabolites, parathyroid hormone, renin activity, aldosterone, creatinine and insulin sensitivity did not differ in the tertiles. In supine laboratory recordings, there were no differences in aortic systolic and diastolic blood pressure, heart rate, cardiac output and systemic vascular resistance. Extracellular water volume was higher in the highest versus lowest tertile of Na⁺ excretion. In regression analysis, body surface area and 24-h Na⁺ excretion were independent explanatory variables for extracellular water volume. No differences in urine Na⁺ excretion and extracellular water volume were found between normotensive and hypertensive participants. When compared with the 510 participants, patients with primary aldosteronism had 6.0% excess in extracellular water (p = .003), and 24-h Na⁺ excretion was not related with extracellular water volume.

CONCLUSION

In the absence of mineralocorticoid excess, Na⁺ intake, as evaluated from 24-h Na⁺ excretion, predominantly influences extracellular water volume without a clear effect on blood pressure.

Self-Reported Frequency of Adding Salt to Food and Risk of Incident Chronic Kidney Disease

Importance

The self-reported frequency of adding salt to foods could reflect a person's long-term salt taste preference, and salt intake has been associated with increased risk of cardiovascular diseases (CVD). Whether self-reported adding of salt to foods is associated with increased risk of chronic kidney disease (CKD) remains unknown.

Objective

To prospectively examine the association of self-reported frequency of adding salt to foods with incident CKD risk in a general population of adults.

Design, Setting, and Participants

This population-based cohort study evaluated UK Biobank participants aged 37 to 73 years who were free of CKD at baseline. Participants were enrolled from 2006 to 2010 and prospectively followed up for disease diagnosis. Data were analyzed from October 2022 to April 2023.

Exposure

Self-reported frequency of adding salt to foods, categorized into never or rarely, sometimes, usually, and always.

Main Outcome and Measure

Incident CKD cases were defined by diagnostic codes. Hazard ratios (HRs) and 95% CIs were calculated by using Cox proportional hazards models. Models were adjusted for several potential confounders including age, sex, race and ethnicity, Townsend Deprivation Index, estimated glomerular filtration rate (eGFR), body mass index, (BMI), smoking status, alcohol drinking status, regular physical activity, high cholesterol, diabetes, CVD, hypertension, infectious disease, immune disease, and nephrotoxic drugs use at baseline.

Results

Within a cohort of 465 288 individuals (mean [SD] age 56.32 [8.08] years; 255 102 female participants [54.83%]; 210 186 male participants [45.17%]), participants with higher self-reported frequency of adding salt to foods were more likely to have a higher BMI, higher Townsend Deprivation Index score, and diminished baseline eGFR compared with those who reported a lower frequency of adding salt to foods. Participants who added salt to their foods were also more likely than those who did not add salt to their foods to be current smokers and have diabetes or CVD at baseline. During a median (IQR) follow-up of 11.8 (1.4) years, 22 031 incident events of CKD were documented. Higher self-reported frequency of adding salt to foods was significantly associated with a higher CKD risk after adjustment for covariates. Compared with those who reported never or rarely adding salt to foods, those who reported sometimes adding salt to food (adjusted HR [aHR], 1.04; 95% CI, 1.00-1.07), those who reported usually adding salt to food (aHR, 1.07; 95% CI, 1.02-1.11), and those who reported always adding salt to food (aHR, 1.11; 95% CI, 1.05-1.18) had an increased risk of CKD (P for trend < .001). In addition, eGFR, BMI, and physical activity significantly modified the associations, which were more pronounced among participants with a higher eGFR, lower BMI, or lower level of physical activity.

Conclusions and Relevance

In this cohort study of 465 288 individuals, a higher self-reported frequency of adding salt to foods was associated with a higher risk of CKD in the general population. These findings suggest that reducing the frequency of adding salt to foods at the table might be a valuable strategy to lower CKD risk in the general population.