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SaltandBattery:DebateonSodiumTargetsGetsFeisty
MichaelO'Riordan May07,2014
MELBOURNE,AUSTRALIAAnanalysisofmorethan100000participantsintheProspectiveUrbanRural
Epidemiology(PURE)studyisonceagainstokingthedebateoverwhatlevelofsodiumintakeisgoodforhuman
health.ThelatestdatafromPUREsuggestthatbothlowandhighlevelsofsodiumintakeareassociatedwithan
increasedriskofmortalityandcardiovasculareventsinindividualswithandwithouthypertension.

PresentingtheresultsoftheanalysisattheWorldCongressofCardiology2014ScientificSessions,lead
investigatorDrSalimYusuf(McMasterUniversity,Hamilton,ON)saidthatindividualswhoconsumedbetween3000
mgand6000mgofsodiumperdayhadthelowestriskofdeathandcardiovascularmortalitybutthatthereisaUorJ
shapedassociationbetweensodiumintakeandadverseclinicaloutcomesathigherandlowerlevelsofsodiumintake,
wheremortalityandcardiovasculareventsareincreased.

ForYusuf,thefindingsmakesense,giventhatsodiumisanessentialnutrientrequiredbythebody.Heremindedthe
audienceoftheactionpotentialtheylearnedinmedicalschoolphysiologyclasses,notingthatsodiumisrequiredfor
celltocelltransmission.Saltintake,hesaid,isnotacardiovascularriskfactorakintosmoking,wherethegoalisto
reducetheprevalencetozero.Likeotheressentialnutrients,thereislikelyanoptimizedzone,andthesedatasuggest
thatzoneliessomewherebetween3000mgand6000mgofsodiumperday.

If'normal'iswhatthefoodindustrydecidestofeedus,thenitwouldbenormalfor1.2billionpeopletosmoke,because
that'sthenumberofcigarettesthetobaccoindustrydecidestosellus.

DrBruceNeal(UniversityofSydney,Australia),aleadingproponentofreducingsodiumlevelstolowtargetsanda
criticofthefoodindustry,disagreeswiththeconclusions.Nealdiscountedthedata,statingthatheis"disappointedto
seeotherwisehighlycompetentepidemiologistsgetitsowronginthisspace."HealsosaidthatYusufandcolleagues
wereusingtheirpositiontobeoverlyvocalagainstthelowsodiumtargetsandthatitwasunhelpful.

"Thecurrentguidelinestoreducesodiumtolessthan2300mgperdayaremorethanjustifiableandfeasibleandare
appropriatelybeingacteduponaroundtheworld,"saidNeal.

PURESODIUM:Whattheanalysisshowed

ThePURESODIUManalysisincluded101945individualswhoconsumed,onaverage,4900mgofsodium/day.Of
thoseincluded,just8%hadahistoryofcardiovasculardisease.Approximately10%oftheparticipantsconsumed
<3000mgofsodium/dayandanother10%consumed7000mg/dayormore.Justunderhalfoftheparticipants
consumedbetween4000and5990mgofsodiumdaily.Intheiranalysis,theresearchersfoundthatnearlynopatients
consumedlessthan2300mgofsodiumdaily.

Inamultivariateadjustedmodel,thosewhoconsumedlessthan3000mgofsodiumperdayhada25%increasedrisk
ofallcausemortalityandcardiovasculareventscomparedwiththosewhoconsumedbetween4000mgand5990
mg/day(referencegroup).Atthehighend,thosewhoconsumed7000mg/dayormorehada15%increasedriskof
deathandcardiovascularevents.Afterfurtheradjustmentfordietaryfactorsandbloodpressure,thosewhoconsumed
lessthan3000mg/daystillhada21%increasedriskofdeathandcardiovascularevents.

Andfinally,inasubgroupanalysis,thePUREresearchersreportthatthosewithouthypertensionhadanincreasedrisk
ofclinicaleventsatthelowendofsodiumconsumption(<3000mg/day)butnotatthehighend(>6000mg/day).For
thosewithhypertension,therewasaheightenedriskofdeathandcardiovasculareventsatthelowandhighendof
sodiumintake.
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Thefindingsarecontroversial,giventhattheychallengethecurrentrecommendationsfromnumerousorganizations,
includingtheAmericanHeartAssociation(AHA),toreducesodiumintaketoverylowlevels.TheAHArecommends
thatindividualsconsumenomorethan1500mgofsodiumperday.The2010DietaryGuidelinesforAmericans
recommendsadailysodiumintakeof2300mgforthegeneralpopulationand1500mgforindividuals51yearsofage
andolder,AfricanAmericans,orindividualswithhypertension,diabetes,orchronickidneydisease.

DebateonSodiumReductionGetsHeated

Duringthepresentation,YusufsaidthePURESODIUMresultsaresupportedbydatafromtheONTARGETand
TRANSCENDstudiesin28880patientsathighcardiovascularrisk.Inthatanalysis,therewasanincreasedriskof
cardiovascularevents,includingcardiovascularmortality,amongindividualswhoconsumedlessthan3000mgof
sodiumperday.Heacknowledgedtherearecriticsoftheirconclusions,buthestandsbytheirresults.

ForNeal,whoparticipatedinadebateagainstDrMartinO'Donnell(McMasterUniversity,Hamilton,ON)onthe
meritsofsodiumreduction,theresearchers'conclusionsrelysolelyonweakobservationaldatathatarefurther
confoundedbyan"unhealthyfocus"onone'sownresearch.

"Theproblemhereisthatthedataarenotfitforthepurposetheyarebeingused,"saidNeal."Observational
epidemiologyfornutritionhasbeenshowntimeandagaintobebarelyworththepaperit'sprintedon.Unfortunately,
largepiecesofweakepidemiology,suchasONTARGETandPURE,arenobetterthansmallpiecesofweak
epidemiology.Itdoesn'tadvancethefield."

Duringthesodiumdebate,Nealsaidthetotalityofevidencesupportsloweringsodiumintakeatthepopulationlevelto
reducebloodpressuresandthatlowerbloodpressuretranslatesintoreducedcardiovascularandstrokerisk.Whenhe
focusedonthePUREandTRANSCEND/ONTARGETdata,NealdrewtheireofYusufwhenhesuggestedthat
O'Donnell,acoauthorofbothanalyses,mighthaveaworkinginterestwiththefoodindustry.

Therehasbeenasmearcampaignbyagroupofpeopleagainstanybodywhoquestionssalt.

"Therehasbeenasmearcampaignbyagroupofpeopleagainstanybodywhoquestionssalt,"saidYusuf."Theyget
attacked.It'sthesamedozenpeoplewhowritethesamepapersandadvisethesamecommittees.Themomentyou
standupandsay,'Well,itmightnotbeasbadaswethink,'yougetattackedpersonally."

Forhispart,O'Donnelltookthepersonalremarkinstride,statingthathehasnoworkingrelationshipwithindustryand
receivesnofundingfromfoodmanufacturers."Ioccasionallyenjoysaltandvinegarcrisps[chips],whichIpurchase
withmyownmoney,"hesaid."Abaghasneverbeengiventomeforfree."

SaltIstheNewTobacco

Duringthedebate,Nealarguedpassionatelythat"saltisthenewtobacco"andthattheburdenneedstobeonthe
foodindustrytoshowthatthelevelsofaddedsodiumaresafe.Currently,nearlyeverycountryonearthexceedsthe
recommended2300mgofsodium/day,withtheworldaveragesomewherearound10100mg/day.Infact,saidNeal,
"normal"saltconsumptionhasbeendefinedbythefoodindustry,butthephysiologicalrequirementsforsodiumare
between1000mgand2000mg/day.

"If'normal'iswhatthefoodindustrydecidestofeedus,thenitwouldbenormalfor1.2billionpeopletosmoke,
becausethat'sthenumberofcigarettesthetobaccoindustrydecidestosellus,"hesaid.

Nealsaidcurrentcampaignstolowersaltcanbeachievedcheaply,notingtheUKrecentlyhadsuccessinreducing
sodiumintakefrom9500mg/dayin2000to8100mg/dayin2011.Moreover,thepublichealthcampaignstolowersalt

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canbedoneatafractionofthecostofexistinghypertensioncontrolprograms.

O'Donnell,ontheotherhand,saidthequestionisnotwhethersodiumintakeshouldbereducedbutwhetheritshould
bereducedtoalowtargetoflessthan2300mg/day.Heisanadvocateofreducinghighsodiumintakeamonghis
patients,butthereisnoevidencesupportingareductioninsodiumbeyondmoderatelevels.Forexample,thereisno
studythatcomparesalowsodiumdietwithamoderatesodiumdietandshowsthatalowsodiumdietresultsina
reductionincardiovascularevents.

Thereisevidence,hesaid,showingthatverylowlevelsofsodiumcantriggeradversecardiovasculareffects,suchas
theactivationofthereninangiotensinsystemandaspikeincatecholamineactivity.

"Saltisn'tthenewtobacco,"saidO'Donnell."Sittingisthenewtobacco.Notsalt."

TheInstituteofMedicine(IOM)hasrecentlystatedthereisevidencesupportingapositiverelationshipbetween
higherlevelsofsodiumintakeandtheriskofcardiovasculardisease,butthereisnoadvantagetoloweringintake
amongindividualswhoconsumeamoderateamountofsodium.AccordingtotheIOM,theevidenceisnotstrong
enoughtorecommendloweringdailysodiumintaketothe1500to2300mg/dayrange.

HeartwirefromMedscape2014Medscape,LLC

Citethisarticle:SaltandBattery:DebateonSodiumTargetsGetsFeisty.Medscape.May07,2014.

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