Sodium Intake In Population Research Articles

The IOM Report Fails To Detect Evidence to Support Dietary Sodium Guidelines

The recent Institute of Medicine (IOM) report “Sodium intake in populations: Assessment of Evidence”1 has provided critical information concerning the dietary sodium guidelines currently recommended by agencies of the US government.2 The American Journal of Hypertension has assembled a set of commentaries providing the range of official and independent views addressing how the IOM report will (or should) influence dietary sodium policy and practice.3–7 Our purpose is to provide a concise and comprehensive assessment of how things stand in the immediate aftermath of the IOM report. Our hope is that these manuscripts will further inform what promises to be a lively public and scientific debate about the implications of the IOM report. The balanced review and analysis has the credibility to make this report a paradigm shifting publication. The hypothesis from which sodium guidelines emerged i.e., that because reduced sodium intake lowered blood pressure, it would inevitably prevent cardiovascular morbidity and mortality – has failed to find support in the IOM report. The Committee found that the modest blood pressure effect is not a certain surrogate for health outcomes associated with sodium intake. Instead, the Committee’s case rested upon evidence of actual health consequences associated with reducing sodium intake from the current average of 3,400 mgs/day, to 5,000 mgs) of sodium to all lower intake levels. Third, based upon the large body of mostly observational data reported over the past 8 years, it found that a possibility of harm existed at the lower (<2,300 mgs) end, and more confidently, at the higher (unspecified other than as “excessive”) end as well. This implies that a “safe” range for sodium exists. Fourth, the committee specifically declined to identify any “target” for sodium intake, or a safe range of intakes consistent with optimal human health. Fifth, the committee found insufficient evidence of either harm or benefit from sodium consumption below 2,300 mgs, and cautioned against intakes <1,500 mgs/day. Sixth, and finally, the report specifically failed to find evidence to support current guidelines promoted by both the US Centers for Disease Control and Prevention (CDC) and the New York City Department of Health. Given the prominent role played by the CDC and the New York City Department of Health in promoting current guidelines, the directors of both have been invited to respond to the IOM report.3,4 While all submissions have been subject to peer review, wide latitude has been afforded authors. Investigators who have contributed important data on both sides of the current controversy have also been invited to submit their views.5,6 In addition, a report describing sodium intake in much of the world over the past half century provides critical background for examining the sodium issue.7 And, finally, a distinguished scholar of nutrition and nutrition policy has described how nutrient guidelines have and can be reached, and describes a method, based upon pathophysiology, and consistent with clinical outcomes, for defining a safe range for sodium intake.8

Elliott et al. Respond to "Quantifying Urine Sodium Excretion"

In their commentary (1) on our article (2), de Boer and Kestenbaum briefly summarized recent research on the relationship between salt intake (estimated from urinary sodium excretion) and cardiovascular disease (CVD). They cite a recent article by O'Donnell et al. (3) in which casual urine samples were used to characterize individual sodium intakes and an apparent J-shaped association was observed between sodium intake and CVD risk. de Boer and Kestenbaum state that “a very low intake of dietary sodium may truly increase the risk of CVD” (1, p. 1193); in contrast, an editorial (4) accompanying the article by O'Donnell et al. and subsequent publications (5–7) have highlighted methodological concerns about interpretation of the study findings. These include the use of a clinical trial population with established CVD or diabetes; high rates of medication usage among trial participants; use of a single casual urine sample to estimate individual sodium intake; inclusion of participants with sodium intakes at the bottom end of the distribution who appeared to be sicker than the rest of the study population (reverse causality); and use of data sets not specifically designed to address the sodium-CVD relationship. de Boer and Kestenbaum also cite studies purporting to show that “[d]ietary sodium restriction can lead to adverse biologic responses, including activation of the renin-angiotensin system, stimulation of the sympathetic nervous system, and unfavorable alterations to serum lipids” (1, p. 1193). These matters have been thoroughly examined as part of a systematic review undertaken by the World Health Organization to reassess guidelines on population sodium intakes (8, 9). The World Health Organization reaffirmed its previous advice that salt intake should be less than 5 g (85 mmol sodium) per day in adults and for the first time recommended a reduction in sodium intake to control blood pressure in children (8). The World Health Organization review found no evidence for adverse effects on physiological response to sodium reduction, including on the sympathetic nervous system or blood lipids (8, 9). We agree with de Boer and Kestenbaum that the International Cooperative Study on Salt, Other Factors, and Blood Pressure (INTERSALT) equations “now represent the best available method to estimate urine sodium excretion from casual urine samples” (1, p. 1194), although there are limitations. They suggest that simple transformations may improve model fit. We re-ran the equations using the natural logarithm of the urinary excretion values. This resulted in only modest improvement in model fit; the adjusted R2 increased from 0.2659 (Table 1 of our original article) to 0.2684 in men, and from 0.2327 to 0.2418 in women. We confirm that addition of urine potassium concentrations did not meaningfully improve the models; with exclusion of potassium, the adjusted R2 was reduced to 0.2636 in men and 0.2310 in women. We therefore agree with de Boer and Kestenbaum that urinary potassium can be excluded from the models and provide revised model estimates that exclude potassium in Table 1. We disagree with de Boer and Kestenbaum that inclusion of dummy variables for the 5 regions included in the models may inflate the community-level performance of the equation (1). We think it is important to include such an adjustment; by fitting a different intercept for each region, we reduce the impact of cross-region differences in levels of sodium excretion on the within-region associations of casual to 24-hour sodium excretion. Table 1. Multiple Linear Regression Analyses of Sex-Specific Individual 24-Hour Urinary Sodium Excretion in Test and Validation Data Sets Combined, International Cooperative Study on Salt, Other Factors, and Blood Pressure, 1984–1987 We restricted our analyses to Western populations in INTERSALT for which we had the most data and which are likely to be the most representative of the situation in North America and Europe. We therefore agree that the equations should be used with caution outside of these 2 settings and outside the age range for which the equations were developed (20–59 years). Finally, we agree that single urinary measures of sodium excretion are limited for assessing individual (compared with population-wide) sodium intakes. We also concur that multiple urine collections are preferable and required to increase reliability and reduce the “regression-dilution” problem for studies of individuals (10, 11).

The USDA Automated Multiple-Pass Method accurately assesses population sodium intakes

Given current sodium-reduction strategies, accurate and practical methods to monitor sodium intake in the US population are critical. Although the gold standard for estimating sodium intake is the 24-h urine collection, few studies have used this biomarker to evaluate the accuracy of a dietary instrument. Our objective was to compare self-reported dietary intake of sodium with 24-h urinary excretion obtained in the USDA Automated Multiple-Pass Method (AMPM) Validation Study. Subjects were healthy, weight-stable volunteers aged 30-69 y recruited from the Washington, DC, area. Data from 465 subjects who completed at least one 24-h recall and collected a complete 24-h urine sample during the same period were used to assess the validity of sodium intake. Reporting accuracy was calculated as the ratio of reported sodium intake to that estimated from the urinary biomarker (24-h urinary sodium/0.86). Estimations of sodium intake included salt added in cooking but did not include salt added at the table. Overall, the mean (95% CI) reporting accuracy was 0.93 (0.89, 0.97) for men (n = 232) and 0.90 (0.87, 0.94) for women (n = 233). Reporting accuracy was highest for subjects classified as normal weight [body mass index (in kg/m(2)) <25]: 1.06 (1.00, 1.12) for men (n = 84) and 0.99 (0.94, 1.04) for women (n = 115). For women only, reporting accuracy was higher in those aged 50-69 y than in those who were younger. Findings from this study suggest that the USDA AMPM is a valid measure for estimating sodium intake in adults at the population or group level.

Global Iodine Nutrition: Where Do We Stand in 2013?

Dietary iodine intake is required for the production of thyroid hormone. Consequences of iodine deficiency include goiter, intellectual impairments, growth retardation, neonatal hypothyroidism, and increased pregnancy loss and infant mortality. In 1990, the United Nations World Summit for Children established the goal of eliminating iodine deficiency worldwide. Considerable progress has since been achieved, largely through programs of universal salt iodization. Approximately 70% of all households worldwide currently have access to adequately iodized salt. In 2013, as defined by a national or subnational median urinary iodine concentration of 100-299 μg/L in school-aged children, 111 countries have sufficient iodine intake. Thirty countries remain iodine-deficient; 9 are moderately deficient, 21 are mildly deficient, and none are currently considered severely iodine-deficient. Ten countries have excessive iodine intake. In North America, both the United States and Canada are generally iodine-sufficient, although recent data suggest pregnant U.S. women are mildly iodine-deficient. Emerging issues include discrepancies between urinary iodine status in pregnant women compared to school-aged children in some populations, the problem of re-emerging iodine deficiency in parts of the developed world, the importance of food industry use of iodized salt, regions of iodine excess, and the potential effects of initiatives to lower population sodium consumption on iodine intake. Although substantial progress has been made over the last several decades, iodine deficiency remains a significant health problem worldwide and affects both industrialized and developing nations. The ongoing monitoring of population iodine status remains crucially important, and particular attention may need to be paid to monitoring the status of vulnerable populations, such as pregnant women and infants. There is also need for ongoing monitoring of iodized salt and other dietary iodine sources in order to prevent excess as well as insufficient iodine nutrition. Finally, it will be essential to coordinate interventions designed to reduce population sodium intake with salt iodization programs in order to maintain adequate levels of iodine nutrition as salt intake declines.

Estimating salt intake in a Caucasian population: can spot urine substitute 24-hour urine samples?

A simple and valid alternative for 24-hour urine collection to estimate populational 24-hour urinary sodium excretion would be desirable for monitoring sodium intake in populations. To assess the validity of the predicted 24-hour urinary sodium excretion using spot urine and two different prediction methods in a Danish population. Overall, 473 Danish individuals provided a para-aminobenzoic acid-validated complete 24-hour urine collection and a spot urine sample. Data were collected in the DanThyr study (248 women aged 25-30 years and 60-65 years) and the Inter99 study (102 men and 113 women aged 30-60 years), respectively. The measured 24-hour urine sodium excretion was compared with the predicted 24-hour sodium excretion from a causal urine specimen, using both the Tanaka prediction method and a prediction model developed in a Danish population. The measured 24-hour sodium excretion (median, 5th to 95th percentile) was men 195 (110 to 360) and women 139 (61 to 258), whereas the predicted 24-hour sodium excretion for the Tanaka model was men 171 (117 to 222) and women 153 (92 to 228) and for the Danish model was men 207 (146 to 258); women 134 (103 to 163). The Spearman correlation between predicted and measured 24-hour sodium excretion was 0.39 and 0.49 for the Tanaka and the Danish model, respectively. For both prediction models, the proportion of individuals classified in the same or adjacent quintile was 74% for men and 64% for women. Both prediction models gave a reasonable classification of individuals according to their sodium excretion. However, the median daily sodium intake was estimated more precisely by the Danish model, especially among men.

Abstract MP78: Validity of Predictive Equations for 24-Hour Urine Sodium Excretion in Young Black and Other Adults

Introduction: Reducing mean population sodium intake by ~1200 mg is projected to reduce thousands of deaths from heart disease and stroke and save billions of health care dollars annually. Twenty-four hour urine collection is recommended for assessing changes in mean population sodium intake, but can be difficult to implement. Predicting 24-hour urine sodium excretion using spot urines is not recommended due to diurnal variations in excretion. Further, sodium excretion patterns differ between black and white persons. We assessed the validity of previously published prediction equations for 24-hour sodium excretion in black and other young adults by timing of spot urine collection. Design: Of 481 adult volunteers aged 18-39 years (50% Blacks) asked to participate in a 2011 study in the Metropolitan DC area, 407 collected each urine void in a separate container for 24 hours. Four timed voids from the 24-h urine collection were selected (morning, afternoon, evening, and overnight) to use with previously published predictive equations. Predictive equations were based on one of two approaches; 1) an indirect approach using spot urine sodium-to-creatinine concentrations and predicted 24-hour creatinine excretion ( Tanaka, Kawasaki, Mage ), and 2) a direct approach using spot urine sodium, potassium, and creatinine concentrations, and age, and body mass index with separate equations by sex ( Brown ). We assessed mean differences between predicted and measured 24-hour sodium excretion (bias) and individual differences across levels of sodium excretion using Bland-Altman plots. Results: Among participants, mean measured 24-hour sodium excretion was ~3300 mg (SD ~1400 mg). Of the equations evaluated, mean bias in predicted 24-hour sodium excretion was least from Brown equations when using morning (-165 mg, 95% confidence interval [CI], -295, -36 mg), afternoon (-90 mg, 95% CI, -208, 28 mg) or evening ( -120 mg, 95% CI -230, -11 mg) spot urines. When using overnight spot urines, mean bias from Brown equations was greatest and statistically significant (-247 mg, 95% CI, -348, -151 mg). When using overnight spot urines, mean bias from Tanaka (-23 mg) or Mage (-145 mg) equations was not significant, however, when stratified by sex, mean biases were significant and in opposite directions. Among Blacks, mean biases from Brown were not significant (-167 to 122 mg) except using overnight specimens among Black females (-267 mg, 95% CI, -525, -47 mg). Across equations and time periods, Bland-Altman plots indicated significant bias at the individual level. Conclusions: Of the evaluated equations, predicted 24-hour urine sodium excretion using the Brown equations with morning, afternoon, or evening specimens may provide the least biased estimates of group mean sodium intake among young US adults. None of the equations adequately predicted individual 24-hour sodium excretion measured on the same day.

The feasibility of achieving low-sodium intake in diets that are also nutritious, low-cost, and have familiar meal components.

ObjectiveGiven the importance of high sodium diets as a risk factor for disease burden (ranked 11th in importance in the Global Burden of Disease Study 2010), we aimed to determine the feasibility of low-sodium diets that were also low-cost, nutritious and (for some scenarios) included familiar meals.MethodsThe mathematical technique of “linear programming” was used to model eight optimized daily diets (some with uncertainty), including some diets that contained “familiar meals” for New Zealanders or were Mediterranean-, Asian- and Pacific-style diets. Data inputs included nutrients in foods, food prices and food wastage.FindingsUsing nutrient recommendations for men and a cost constraint of <NZ$9/d (US$6.84), the sodium intake levels in the eight optimized daily diets were all well below the 2300 mg/d (5.8 g salt/d) recommended maximum. The only diet to not consistently fall below the recommended “target” upper limit of 1600 mg/d included an evening meal with sausages (median = 1640 mg/d, 95% simulation interval: 1551–1735 mg/d). Many additional nutritional aspects of these optimized low-sodium diets suggest that they would reduce cardiovascular disease risk in other ways (e.g., improved polyunsaturated to saturated fat ratio) and also reduce risk of cancer and other chronic diseases (e.g., via higher intakes of vegetables, fruits and dietary fiber). Even healthier diets (e.g., with higher intakes of fruit) occurred when the cost constraint was relaxed to $NZ15/d (US$11.40). Similar results were obtained when the modeling considered diets for women.ConclusionsThese results provide some reassurance for the feasibility of substantially reducing population sodium intake given currently available low-cost foods and while maintaining some level of familiar meals. Policy makers could consider ways to promote such optimized diets and foods, including regulations on maximum salt levels in processed foods, and taxes on alternative foods that are high in salt, sugar and saturated fat.

Trends in the major dish groups and food groups contributing to sodium intake in the Korea National Health and Nutrition Examination Survey 1998-2010

The purpose of this study was to evaluate trends in the sources of dietary sodium intake in a representative Korean population in the Korea National Health and Nutrition Examination Survey (KNHANES) conducted in 1998, 2001, 2005, 2007, 2008, 2009, and 2010. The study consisted of 53,570 men and women aged 7 years or older participating in the KNHANES during the corresponding years. Overall sodium intake and the mean percent contribution of each dish and food group to dietary sodium intake across 1998-2010 were calculated. The means of sodium intake ranged between 4,572.6-5,498.9 mg/d across 1998-2010. The major dish groups contributing to dietary sodium intake were kimchi (1,154.8-1,521.2 mg/d), noodles and dumplings (505.3-760.5 mg/d), soups (465.3-714.8 mg/d), and stews and casseroles (387.0-579.8 mg/d). The combined mean percent contribution from the top four dish groups contributing to dietary sodium intake showed a slight decrease over the period; 64.4% in 1998, 64.5% in 2001, 59.3% in 2005, 58.2% in 2007, 56.3% in 2008, 56.7% in 2009, and 54.4% in 2010. The major food groups contributing to dietary sodium intake were seasonings (1,852.9-2,435.9 mg/d), vegetables (1,425.6-1,792.1 mg/d), grains (482.2-778.1 mg/d), and fish and shellfish (257.2-351.4 mg/d). In addition, the combined mean percent contribution from the top four food groups showed a slight decrease over the period; 92.8% in 1998, 93.2% in 2001, 93.8% in 2005, 92.1% in 2007, 91.7% in 2008, 90.9% in 2009, and 90.7% in 2010. In summary, we did not observe a reduction in dietary sodium intake over time, however, the percent contributions from the top major dish groups or food groups to dietary sodium intake showed a decrease over the last decade. (Korean

Attempting to Reduce Sodium Intake Might Do Harm and Distract From a Greater Enemy

Take it with a grain of salt: despite assertions to the contrary,1 we do not know that reducing mean population sodium intake would decrease the risk of cardiovascular disease or save lives. Yes, we know that “excess sodium consumption raises blood pressure”1 (at least transiently, for most people,2 to a clinically minor degree3,4). But based on the intermediate outcome of blood pressure, we cannot extrapolate that lowering sodium consumption would reduce cardiovascular risk or premature death. In fact, randomized controlled trial evidence suggests just the opposite: that lower sodium intake may lead to worsened cardiovascular disease and earlier death.5 It turns out that biological response to sodium intake is complex. Reducing sodium intake may lower blood pressure; but it may also decrease insulin sensitivity, alter lipids, and stimulate a variety of neurohormonal pathways detrimental to the cardiovascular system.4,6,7 For these reasons, our bodies may work to keep our sodium intakes higher than the levels the Institute of Medicine and other authorities now advise. In fact, mean sodium consumption—well above recommended levels1,8—has been fairly constant across diverse populations for multiple generations.8 Thus, although it may be true that “individuals have little control over their sodium intake,”1 it is probably not for the reasons Angell and Farley contend in their editorial blaming the food industry and consumers’ inability to avoid high-sodium processed and prepared foods.1 Sodium consumption may have much more to do with human physiology than food formulations.8 If food reformulations were to make processed foods less palatable and discourage their consumption, this might be the only way the National Salt Reduction Initiative could be good for public health. Indeed, it is probably not the sodium in processed foods but the foods themselves that are the problem. Among other issues, these “foods” are generally engineered from dizzying arrays of highly refined carbohydrates; the consumption of which is associated with obesity, unhealthy lipids, high blood pressure, and insulin resistance, all as part of a broader metabolic syndrome9,10 (likely much more a risk for cardiovascular disease and early death than any modest effect of “excess” sodium intake). When it comes to preventing cardiovascular disease and early death, refined carbohydrates are a greater enemy. Although there has been some action targeting refined carbohydrates, current action falls short. If sugar-sweetened beverages are a public-health problem, then why aren’t sugar-laden cookies? If an energy drink is unhealthy, why not an energy bar? If reformulating products to have less sodium results in more sugar, will that be good for public health? New York City could build on the momentum of its sugar-sweetened beverage work to refocus national action. Targeting high-sugar prepared and processed foods, as opposed to sodium, would be a decided start in the right direction.

Sodium, Blood Pressure, and Cardiovascular Disease

Recent reports of selected observational studies and a meta-analysis have stirred controversy and have become the impetus for calls to abandon recommendations for reduced sodium intake by the US general population. A detailed review of these studies documents substantial methodological concerns that limit the usefulness of these studies in setting, much less reversing, dietary recommendations. Indeed, the evidence base supporting recommendations for reduced sodium intake in the general population remains robust and persuasive. The American Heart Association is committed to improving the health of all Americans through implementation of national goals for health promotion and disease prevention, including its recommendation to reduce dietary sodium intake to <1500 mg/d.

1051 ESTIMATES OF NEW ZEALAND POPULATION SODIUM INTAKE

Background: Spot urinary sodium measurement represents a practical alternative to the ‘gold standard’ of 24-hour urinary sodium excretion, especially in large population samples. Design and methods: The New Zealand Adult Nutrition Survey (2008/09) analysed sodium excretion from spot urine samples from a representative sample of 3315 adults 15 years and over. Three published formulae were modelled to estimate 24-hour sodium excretion. A WHO conversion protocol was chosen as the most likely approach to reflect actual 24 hour sodium excretion.(1) The 24-hour estimates have been compared estimates from 24-hour diet recall assessment. Results: Mean estimated population 24-hour urinary sodium excretion was 3544mgs/day (4013mgs/day for men, and 3116mgs/day for women), indicating a mean dietary intake of approximately 3900mgs sodium per day. Sixty five percent of New Zealanders had an estimated 24-hour sodium excretion that exceeded the recommended upper level (UL) of intake 2300mgs sodium/day (74% of men and 57% of women). There are significant differences in mean excretion by age and sex. Mean estimated sodium intake by dietary recall assessment was 2504mgs/day (2953mgs/day for men and 2094 mg/day for women) an inevitable underestimate of actual intake as discretionary salt use was not included. Conclusions: Spot urinary sodium assessment is a useful way to estimate dietary sodium intake in large representative population samples, and might help explain the increase in blood pressure in New Zealand since 2002. New Zealanders’ mean sodium intake is in excess of current nutrient reference values. Public Health interventions to reduce population sodium intake in New Zealand are warranted. References WHO/PAHO Regional Expert Group for Cardiovasular Disease Prevention through Population-wide Dietary Salt Reduction. Protocol for Population Level Sodium Determination in 24-hour Urine Samples. Geneva: World Health Organization 2010.

Urinary Sodium to Creatinine Ratio in Healthy Infants

Rationale Sodium is essential for adequate growth; the daily requirement in infants is 2 to 3 mmol/kg/d. Objectives The study aimed to establish a reference range for the ratio of urinary sodium (UNa) to creatinine (UCr) in healthy infants in a suburban setting in the United States. Methods UNa and UCr were measured in healthy infants and UNa:UCr was calculated. Daily sodium intake was estimated by parental report. Results Mean estimated sodium intake in the 71 infants was 1.34 mEq/kg/d (95% confidence interval = 1.23-1.44). The mean UNa:UCr was 11.73 (95% confidence interval = 10.24-13.23) and did not differ significantly in age-groups. There was no direct correlation between sodium intake and UNa:UCr in healthy infants. Conclusions The UNa:UCr was 11.73 in this population of healthy infants. This likely reflects the appropriate physiologic response to sodium intake in the study population, which was at the lower end of the usual estimated needs for infants.

Abstract P362: Validation of a Simple Method to Estimate Populational 24-h Urinary Sodium Excretion Based on a Casual Urine Specimen in an Adult Danish Population

Background: Tanaka et al (J Hum Hypert 2002; 16: 97-103) developed a simple method to estimate populational 24-h urinary sodium excretion using a casual urine specimen. However, this method was developed and validated in a Japanese population and thus this method might not be valid in populations that differ markedly from this population. Hypothesis: We assessed the hypothesis that the 24 hour urinary sodium excretion can be estimated from a casual spot urine using the Tanaka prediction method in a Danish general population. Methods: Overall 473 Danish individuals provided both a 24h urine collection and a spot urine sample. Data were collected in the Danthyr study (248 women aged 25-30 years and 60-65 years) and the Inter99 study (102 men and 113 women aged 30-60 years), respectively. Only participants with complete 24h urine collection (validated by the PABA method) were included. We compared the estimated daily sodium excretion through 24h urine (the gold standard) with the predicted 24 h sodium excretion from a causal urine specimen, using the Tanaka prediction method. Results: The predicted median 24 h sodium excretion (median [5 and 95 percentile]) was 8.6 gram [3.7;17.5] compared with a median measured 24 h sodium excretion of 8.9 [5.4; 13:1]. The mean (sd) residual (measured minus predicted 24 h sodium excretion) was 0.08 (3.7). The correlation (Spearman) between predicted and measured 24 h sodium excretion was 0.39 and the R 2 was 0.17. The proportion of individuals classified in the same or adjacent quintiles was 67%. Gross misclassification was found for 3% of the individuals. However, a Bland-Altman plot indicated a tendency of underestimation the sodium excretion for individuals with a high level of sodium excretion (&gt;14 g per day). Conclusion: The Tanaka prediction model gives a reasonable estimate of sodium intake in a Danish population using casual spot urines. However, the validation study showed a tendency of underestimation of the sodium intake for individuals with a high sodium excretion (&gt;14 g per day).

Key opportunities for sodium reduction in New Zealand processed foods

To identify key opportunities for reformulation of processed foods that could best decrease population sodium intakes in New Zealand (NZ). Relevant national literature and reports were used to identify major food groups contributing to population sodium intakes in NZ. Sodium content data for these food groups were collected from the Nutrition Information Panels of processed foods in one large supermarket. Key opportunities for reformulation were identified by comparing mean sodium content with 2012 targets from the United Kingdom (UK) Food Standards Agency (FSA) and mean sodium values from Australia and the UK. Major contributors to NZ sodium intakes are: bread (26%), processed meats (10%), and sauces (6%). Mean (SD) sodium contents of these processed foods were: 447 (125) mg/100 g, 1,169 (444) mg/100 g, and 1,046 (1,235) mg/100 g, respectively. Food categories with the lowest percentage of products meeting corresponding FSA targets were: sausages/hot dogs and sliced meat (0%); salami/cured meat (2%); liquid meal-based sauces (4%); and multigrain bread (14%). Mean sodium contents of NZ products were higher than for similar products in the UK. Key opportunities identified for sodium reduction were: white bread, sausages and hot dogs, and salami/cured meats. There is substantial scope to reduce the sodium content of NZ processed foods. This paper identifies three key opportunities for reformulation of processed foods that could produce substantial decreases in sodium intakes in NZ, and benefits to population health.

Reducing the population's sodium intake: the UK Food Standards Agency's salt reduction programme

To describe the UK Food Standards Agency's (FSA) salt reduction programme undertaken between 2003 and 2010 and to discuss its effectiveness. Relevant scientific papers, campaign materials and evaluations and consultation responses to the FSA's salt reduction programme were used. Adult salt intakes, monitored using urinary Na data collected from UK-wide surveys, indicate a statistically significant reduction in the population's average salt intake from 9·5 g/d in 2000-2001 to 8·6 g/d in 2008, which is likely to have health benefits. Reducing salt intake will have an impact on blood pressure; an estimated 6 % of deaths from CHD in the UK can be avoided if the number of people with high blood pressure is reduced by 50 %. Salt levels in food, monitored using commercial label data and information collected through an industry self-reporting framework, indicated that substantial reductions of up to 70 % in some foods had been achieved. The FSA's consumer campaign evaluation showed increased awareness of the benefits of reducing salt intake on health, with 43 % of adults in 2009 claiming to have made a special effort to reduce salt in their diet compared with 34 % of adults in 2004, before the campaign commenced. The UK's salt reduction programme successfully reduced the average salt intake of the population and increased consumers' awareness. Significant challenges remain in achieving the population average salt intake of 6 g/d recommended by the UK's Scientific Advisory Committee on Nutrition. However, the UK has demonstrated the success of its programme and this approach is now being implemented elsewhere in the world.

Salt in nutrition of University of Sarajevo students

Introduction: The role of salt in the diet is very important, however what effect will lead to its entry into the organism depends on the amount of salt ingested. Elevated salt intake is a risk factor for hypertension, heart disease, adversely affects the kidneys, helps the development of osteoporosis. The aim was to examine sodium intake in the student population through an objective assessment of nutrition students and the students' subjective experience of salty foods and salty foods influence on the organism.Methods: The research is cross-sectional study, which is carried out in April 2010 among students at the University of Sarajevo.Results: More than half of students from the FHS considers that the greatest amount of salt into the body, adding salt to food during the meal, 34% considered that it was during the preparation of food by 10% of processed products in the food industry and 4% said that it was the intake of salt, which naturally found in foods. Not in a group of students there who suffer from hypertension, while in their families the disease is present.Conclusions: Subjects eat a quantity of salt that are well above the recommended. This problem must be approached in a more organized educational, health educational and research terms.

Trends in 24-h urinary sodium excretion in the United States, 1957–2003: a systematic review

Few studies have examined temporal trends in sodium intake in the US population. Collections of 24-h urine sodium excretions are reliable markers for dietary sodium intake. We examined temporal trends in 24-h urine sodium excretions to estimate temporal trends in sodium intake in the US population. We performed a systematic search of English-language articles in MEDLINE for studies that reported collections of 24-h urine sodium excretions in the United States. We estimated mean urine sodium excretions over time for all studies and demographic subgroups. We analyzed 38 studies, which dated from 1957 to 2003, and estimated a mean (± SE) 24-h urine sodium excretion per person of 3526 ± 75 mg Na. In a multivariate random-effects model with study year, sex, age, and race, the study year was not associated with any significant change in sodium excretions (coefficient = 154 mg Na · 24 h⁻¹ · 10 y⁻¹; 95% CI: -140, 448 mg Na · 24 h⁻¹ · 10 y⁻¹). In subgroup analyses, there was no significant temporal trend seen in male, female, black, or white study participants. Sodium intake in the US adult population appears to be well above current guidelines and does not appear to have decreased with time.

Salt Sensitivity, Insulin Resistance and Public Health in India

To provide a current overview of the worldwide prevalence and pattern of cardiovascular disease and discuss the role of sodium intake and salt sensitivity, with a focus on the Asian Indian population. An extensive search of the literature from PubMed and the Cochrane Library was undertaken. Moreover, the pathophysiologic basis of the relationship between sodium intake and insulin sensitivity in various populations was reviewed. High blood pressure is the most common cause of cardiovascular disease and mortality globally. Although salt sensitivity is a frequent determinant of hypertension, a strong link between salt sensitivity and cardiovascular disease associated with insulin resistance has not received adequate attention. This may be particularly relevant to the public health challenges of increasing prevalences of obesity, diabetes, and cardiometabolic syndrome in India where, according to recent estimates, approximately 60% of the world's cases of cardiovascular disease occur and the salt consumption is among the highest in any large population. There is evidence for a strong link between increased salt sensitivity and insulin resistance leading to metabolic syndrome and cardiovascular disease. This relationship may be particularly relevant to the escalating epidemic of cardiovascular disease in the southern Asian Indian population. A broad-based community action to achieve at least a modest restriction of salt intake can yield important health benefits and is urgently needed.

Comparison of sodium and potassium intake and excretion: Results from the AMPM Validation Study

Due to their relationship to hypertension, reliable assessments for sodium and potassium intake in populations are important. Although a 24hr urinary excretion for each nutrient is believed to provide the best estimate of intake, few studies have used these biomarkers to evaluate the accuracy of a dietary instrument. The purpose of this research is to compare self‐reported dietary intake of sodium and potassium and their corresponding 24hr urinary excretion in the US Department of Agriculture Automated Multiple‐Pass Method (AMPM) Validation Study. The AMPM, used to collect 24hr recalls in What We Eat in America, NHANES, was validated in a large doubly labeled water study and shown to reduce bias in the collection of energy intakes in a study population that included 524 men and women, aged 30–69 years. Using data from subjects (n=465) who completed at least one 24hr dietary recall plus collected a complete 24hr urine during the same period, the validity of sodium and potassium intake is assessed. Reporting accuracy, calculated as the ratio of reported intake to that estimated from the corresponding urinary biomarker, is 0.88 for sodium and 0.95 for potassium. For sodium only, there is a decrease (p&lt;0.5) in reporting accuracy between normal weight and obese individuals; 0.99 vs. 0.75, respectively. Estimations of sodium intake are adjusted for discretionary use of salt in cooking but do not quantify salt added at the table.Funding source for this study: ARS, USDA

Population Strategies to Decrease Sodium Intake and the Burden of Cardiovascular Disease

Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake. To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax. A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke. Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data. U.S. adults aged 40 to 85 years. Lifetime. Societal. Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted. Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period. Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake. Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict. Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses. Department of Veterans Affairs, Stanford University, and National Science Foundation.