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Reducing Sodium Intake in the Population.

Reducing Sodium Intake in the Population To the Editor Dr Frieden’s Viewpoint1 discussed the proposal from the US Food and Drug Administration (FDA) to limit food sodium. However, he did not acknowledge several facts germane to the discussion of the safety and efficacy of reducing sodium. The 2013 National Academy of Medicine (NAM, formerly the Institute of Medicine) report “Sodium Intake in Populations” concluded that sodium guidelines should be based on health outcomes, not blood pressure.2 Additionally, because it found the available data to be “inconsistent and insufficient,” the NAM committee could not determine whether the proposed target intake of 2300 mg/d had any effect on the risk of cardiovascular disease (CVD) or all-cause mortality in the general population. Also left unanswered was what constituted excessive intake. Sodium consumption in the range of 2800 to 5500 mg/d has been documented from data acquired over 5 decades in more than 400 000 individuals in more than 60 countries, and confirmed by numerous reports,3 including that from the Global Burden of Diseases Nutrition and Chronic Diseases Expert Group cited by Frieden.1 Sodium, like all essential nutrients, bears a Jor U-shaped relation to morbidity and mortality. The general population’s greatest risk is at intakes below 2800 to 3000 mg/d, whereas intakes above 5500 mg/d increase risk only in those with CVD.3 The proposed FDA target of 2300 mg/d is significantly below that lower limit and thus unsafe. The Trials of Hypertension Prevention, phase II (TOHP II) study,4 whose health outcomes data Frieden cited, used lowsodium foods in an attempt to achieve a target intake of 1955 mg/d. Even with easy access to low sodium foods and frequent counseling, the nadir intake at 6 months was 2567 mg/d. By the study’s third year, mean intake regressed to 3220 mg/d, well into the normal range. Thus, TOHP II suggests that the FDA’s target is not feasible. Furthermore, Frieden claimed that the United Kingdom proved that lowering sodium intake is feasible, but the government’s website states that changes for the relevant survey period of 2008-2011 were not significant.5 TOHP II utilized 24-hour urinary sodium excretion to define intake, as have the majority of the randomized clinical trials of sodium’s effects on blood pressure. Frieden accepted 24hour collections in trials supporting lowering sodium intake, but not in the more than 30 reports of health outcomes challenging the safety of sodium restriction.3 The FDA proposal should await the NAM’s determination of sodium’s healthy range. To do otherwise is an experiment that may expose Americans to harm.