JAPI VOL. 55 JUNE 2007 www.japi.

org 401
Editorial
Salt Intake and Hypertension: Walking the Tight Rope
A Misra*, L Khurana+
H
ypertension, a disease often correlated to affluence,
is becoming increasingly common in urban
popul at i on i n devel opi ng count ri es. Recent
epidemiological studies in India show that prevalence
was 1.2 to 4.2 % in 1940s and has remarkably increased
to nearly 15 to 25% in 1990s in urban areas. A recent
study by Mohan et al
1
reports a prevalence of 20% in
Chennai in the CURES study. Rural areas also showed a
similar increase in prevalence of hypertension (~5-10%)
although the rise was not as steep as in urban areas.
2
The etiology of hypertension is considered to
be multifactorial which includes genetic, dietary,
racial, metabolic and psychological factors, often
in combination. Hypertension is considered to be
etiologically related to obesity and insulin resistance and
is a component of the metabolic syndrome. A genetic role
is implicated as hypertension is seen to be about twice as
common in subjects who have one or both hypertensive
parents. Perinatal influences may also play a role.
3
Low
birth weight and catch-up obesity seems to adversely
affect blood pressure in adult life.
4
Further, low grade
inflammation manifesting as raised C-reactive protein
levels may also be a novel correlate of hypertension.
5

Salt or body sodium level is considered to be one of
the important contributing factors in the pathogenesis of
hypertension. Going as far back as 2,000 B.C., the famous
Chinese Yellow Emperor Huang Ti demonstrated the
association of salt with a hardened pulse. Since then,
evidence from many population-based studies have
demonstrated a positive association.
6-10
The Dietary
Approaches to Stop Hypertension (DASH) study
demonstrated a direct relationship between salt intake
and blood pressure. The subjects put on DASH diet,
containing high amount of fiber, vegetables and fruits,
with low fat dairy products and low salt processed
foods experienced a reduction of blood pressure by
11/6 mm Hg. In this study, diets at three sodium
levels were compared: high (3,300 mg), intermediate
(2,400 mg) and low (1,500 mg). The difference in blood
pressure in those taking lowest sodium-containing
diet to highest sodium-containing diets was 8.3/4.4
mm Hg in patients with hypertension and by 5.6/2.8
*
Department of Diabetes and Metabolic Diseases, Fortis Hospital,
Vasant Kunj, New Delhi 110070. +Center for Diabetes, Obesity,
and Cholesterol Disorders (C-DOC), Diabetes Foundation (India),
C-6/57, SDA, New Delhi 110016.
mm Hg in normotensive people regardless of race and
sex.
7
In the INTERSALT study (a multinational study of
more than 10,000 persons in 52 centers in 32 countries
including India), a direct relationship between average
sodium intake in a population and increase in degree
of blood pressure with aging was seen.
8
The Multiple
Risk Factor Intervention Trial (MRFIT) showed that the
mortality rates from cardiovascular disease (CVD) were
greater in the patients with higher quintiles of sodium
intake.
9
In Trial of non-pharmacologic Interventions
in the Elderly (TONE), obese persons randomized to
sodium reduction showed an effective reduction of
blood pressure which was comparable to that seen
with weight loss.
10
Overall, the evidence was strong that
restriction of salt consumption is an effective measure
of primary prevention of hypertension.
The general perception is that a high salt concentration
in the body is a predisposing factor to hypertension and
increases cardiovascular risk, and a low salt intake would
be beneficial. However, it is still considered debatable
whether lowering the salt intake is an important strategy
in the treatment of hypertension.
First, salt restriction produces only small, even though
detectable changes in blood pressure. Meta-analysis of
randomized trials of sodium restriction in subjects with
hypertension has shown a blood pressure lowering
of 3-6 mm Hg systolic and 1-3 mm Hg diastolic for a
decrease of 2.3 gm in sodium intake.
11
However, it may
still turn out to be significant as even small reduction
in blood pressure may lead to substantial reduction in
mortality. A reduction of 2 mm Hg in systolic blood
pressure is expected to reduce mortality from stroke
by 6%, coronary heart disease by 4%, and all cause
mortality by 3%.
12

Second, the effects of salt depletion in hypertension
are restricted to subjects with a salt-sensitive phenotype.
Ducher et al
13
reported that only a limited proportion of
individuals (5 to 16%), classified as salt-dependent
would benefit from dietary salt restriction. It has been
also argued that factors other than sodium intake
may be important

environmental and behavioral
determinants of blood pressure.
14
In a counterpoint to
the observations of INTERSALT study, it was stressed
that salt intakes neither very high nor too low (despite
being freely accessible) was significantly correlated
with hypertension in 48/52 sites of the study.
15
On re-
analysis of NHANES I data, Alderman et al
16
reported
402 www.japi.org JAPI VOL. 55 JUNE 2007
heterogeneity

of blood pressure response to sodium
restriction, and opined that obesity was a stronger
correlate than salt intake in relation to hypertension.

It has been argued that body has adaptive mechanisms
that make physiological adjustments to changes in
sodium levels in the blood e.g. through renin-angiotensin
system. Interestingly, low salt intake could be linked to
higher incidence of adverse coronary events as reduction
of sodium intake increases plasma renin activity and
aldosterone activity.
17
Further, it has also been shown that
sodium restriction stimulates the sympathetic nervous
system.
18
All these processes singly or in combination
may cause tissue hypoperfusion, vasoconstriction or
insulin resistance leading to adverse cardiovascular
outcomes. Alderman et al
19
showed that patients with
lowest quartile of measured sodium excretion had a
highest incidence of myocardial infarction and total
cardiovascular events as compared to highest quartile
of salt intake. Importantly low salt intake was related
to high all-cause morbidity.
20
The findings of the study
were, however, contentious as the patients with lower
salt intake were older and had preexisting CVD. Finally,
low plasma sodium concentrations have been also seen
to be associated with chronic heart failure.
21
The data,
therefore, point out to adverse cardiovascular outcomes
of both high and too low dietary salt intake. Lowering
sodium intake decreases blood pressure and there is a
deemed necessity of salt restriction and intake, even
though one has to walk a tight rope as too low salt intake
may also lead to adverse cardiovascular outcomes.
Dietary habits of Asian Indians indicate that the
salt intake in them may be higher than some other
populations. Excess salt intake occurs due to intake
of pickles, papads, salty snacks, and chutneys which
are popular household dietary choices, in addition
to increasing consumption of salted potato chips by
children. The mean daily salt intake of salted tea drinking
people residing in Jammu and Kashmir was shown to be
3.5 gm, and daily salt intake was significantly higher in
hypertensives than that of normotensive subjects (mean
3.9 gm vs. 3.3 gm, respectively; p <0001), with intake
of salt tea showing a correlation to hypertension.
22
A
higher salt intake was also reported in the children of
hypertensive families as compared to normotensive
families in Kashmir.
23,24
Salt consumption was found as
a significant predictor of hypertension even in a rural
community in north India.
25
Increased mean arterial
pressure was seen to correlate with increased sodium
consumption, in both urban as well as rural tribals, and
hypertensives from both the groups showed higher
urinary sodium excretion.
26
Despite these anecdotal
data, average salt intake of people living in different
regions of India remain poorly investigated.
In this issue of the Journal, Radhika et al
27
in a follow
up report of the recent paper by Mohan et al
1
report that
the mean dietary salt intake was 8.5 g/day in urban
people residing in Chennai, which was higher than
recommended by World Health Organization (5 gm/
day). The authors have further reported that higher salt
intake was associated with older age and higher socio-
economic status, possibly due to an increased intake
of westernized foods high in salt content. Subjects
in the highest quintile of salt intake had significantly
higher prevalence of hypertension than did those in
the lowest quintile. An odds ratio of 1.16 was reported
in subjects showing positive associations of salt intake
with hypertension, even after adjusting for multiple
factors.
What are the implications of this well-conducted
study? First, we now know that Asian Indians in South
India have high average salt intake. Importantly,
this fact alone would be vital for primary prevention
of hypertension in this population, due to the high
prevalence of stroke and CVD in South India. Second,
the diet intake in this population needs further scrutiny,
given that the prevalence rates of the metabolic
syndrome and type 2 diabetes are also high.
28,29
Clearly,
these observations also stress that key to primary
prevention of several non-communicable diseases in
Asian Indians lies in dietary modulation. Given the
projected high incidence and prevalence of CVD in
India, the findings of this study assume importance
for formulation of primary prevention strategies and
National CVD Control Program. Finally, although we
could roughly project these data to any urban area
in India, documentation of salt intake is necessary in
populations residing in different agro-climatic zones of
India which may help to prepare location-specific future
guidelines for salt intake.
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Announcement
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th
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Venue: Mumbai
Date: 5
th
& 6
th
January 2008
Theme : Master Class in Diabetes and its Therapeutic Intervention
Course Directors: Prof. K. Sreekumaran Nair, David Murdock Dole Professor and Professor of Medicine,
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