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An unexpected result for sodium--causal or casual?

The study by Alderman et al1 in the current issue of Hypertension provides data that raise a question of whether a decrease in sodium intake lowers risk of cardiovascular disease. The National High Blood Pressure Education Program Working Group2 cited a reduction in sodium intake as one of the most effective approaches to preventing hypertension. They recommend a multifaceted approach to public education that includes limiting excess sodium intake as a key element. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure3 recommends lifestyle modifications, including sodium reduction, as a first-line treatment for mildly and moderately hypertensive individuals.

Much of the evidence concerning the benefit of a decrease in sodium intake is derived from studies of blood pressure. Observational data, from both between-population and within-population studies4 5 and particularly data from the INTERSALT study,6 7 show a consistent direct relationship of sodium excretion (UNaV) to blood pressure. Current estimates from INTERSALT7 suggest a 100-mmol decrease in sodium is associated with a decrease in systolic pressure of 3.1 mm Hg.

Randomized trial data have generally supported these observational results.8 9 The recent Trials of Hypertension Prevention, Phase I10 found that decreases in systolic/diastolic pressures of 1.7/0.9 mm Hg were associated with average sodium decreases of about 44 mmol/24 h, a finding comparable to other trials among normotensive subjects.9 The results in trials among hypertensive subjects tend to be even stronger. An overview9 suggests decreases in systolic/diastolic pressures of 4.9/2.6 mm Hg in trials among …