Louis Dahl’s famous graph in 1960 showing a positive linear relationship between prevalence of hypertension and mean salt intake across five population groups caught the imagination of the blood pressure research community, and it remains influential to this day. It led to an intensification of research on the role of salt in hypertension spanning anthropology, epidemiology, animal studies, studies of mechanisms and clinical trials. In his 1960 paper, Dahl encompasses much of the basic thinking underpinning current-day public health efforts to reduce sodium consumption in the population. First, he notes that daily intakes of salt among Americans and other populations were well in excess of physiological need ~1 g salt/day (17 mmol sodium) compared with the 10 g (170 mmol sodium) or more being consumed on average by a white American man, and.26 g (440 mmol sodium) by northern Japanese farmers (rates of hypertension and stroke were exceptionally high in northern Japan at that time). He remarks that an individual’s dietary salt intake is highly variable and difficult to measure (noting that 24 h urinary excretion was the preferred method); also that salt appetite in humans is induced rather than innate, such that people on a low sodium diet (in some cases as low as a few mmol sodium/day) could rapidly adapt, and furthermore suffered no ill effects. In addition, his animal experiments (and those of Meneely et al. 1 ) had shown that hypertension in rats could be induced by sodium ingestion, in a dose-dependent way over a prolonged period. Though not an epidemiologist by training, he understood and expounded the concept that an environmental risk factor (salt intake) could increase the risk of disease (high blood pressure) in a group, while acknowledging that the risk for any given individual also depended on other factors, including genetic susceptibility. Therefore, the experiment of choice was to examine disease occurrence (rates of hypertension) in different populations with wide variations in exposure (salt intake, measured by 24 h urinary sodium excretion), rather than to compare blood pressures and sodium intakes of individuals within a population. Later, through a series of breeding experiments Dahl expanded on the concept of gene–environment interaction with respect to an animal model of salt and hypertension; he in-bred a strain of rats (Dahl-S rats), which were ‘sensitive’ to salt intake—fed a diet high in salt, the rats would go on to develop hypertension and stroke. In contrast Dahl-R rats (‘resistant’) could tolerate high salt intake without developing hypertension. 2 In his 1960 paper, Dahl postulated that humans would show a range of responses to a high salt intake, but that at the group level, hypertension would be uncommon below an intake of 4–5 g salt/day (68–85 mmol sodium/day). Other authors subsequently extended Dahl’s observations on five populations to other population groups. These studies generally confirmed the Dahl relationship, but, to a greater or lesser extent, suffered from a number of uncertainties and potential biases. Often, the data were not derived from one source, but from a variety of studies in the published literature in which unstandardized and often unspecified methods were used, and few data on confounding variables were available. Perhaps the best known of these reports was by Gleibermann, an anthropologist, who examined the relationship between sodium intake and blood pressure across 27 populations. 3 In contrast to Dahl’s reliance on 24 h urinary data to estimate sodium intake, in six of Gleibermann’s populations, the author’s own estimates of sodium intake (6 g salt/day) were used, while in a further ten ‘a quantitative value for mean salt consumption was reported with or without indications as to how it was calculated’. 3
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