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Sodium intake and high blood pressure among adults on caloric restriction: a multi-year cross-sectional analysis of the U.S. Population, 2007-2018

02 Jan 2021-medRxiv (Cold Spring Harbor Laboratory Press)-

Abstract: and KeywordsO_ST_ABSAimC_ST_ABSSmall studies have shown reduced sodium sensitivity of blood pressure in obese adolescents on caloric restriction. However, no study at the population level has studied such an effect. We aimed to explore the association between mean daily sodium intake and prevalent hypertension among a nationally representative sample of U.S. adults on caloric restriction who participated in the National Health Examination and Nutrition Survey over the last twelve years. Methods and ResultsWe used a design-based regression model to explore the association between sodium intake and prevalent hypertension. We also conducted sensitivity analyses using multiple imputation chained equations and propensity score matching. We also measured the effect of a binary exposure derived from two widely recommended thresholds of sodium intake: 2.3 and 5.0 grams per day. Among 5,756 individuals, we did not detect any significant association between increased sodium and the odds of hypertension (OR: 0.97; CI 95%: 0.90; 1.05). All our sensitivity analyses are consistent with our main findings. ConclusionOur findings suggest that people on caloric restriction--a component of healthy weight loss--would see no benefit in reducing sodium intake to lower blood pressure. These results highlight the need to explore new population-specific strategies for sodium intake reduction, including new dietary prescription approaches to improve dietary adherence and reduce the risk associated with sodium-deficient diets.

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1
Sodium intake and high blood pressure among adults on 1
caloric restriction: a multi-year cross-sectional analysis of the U.S. 2
Population, 2007-2018 3
4
Jorge Andrés Delgado-Ron,
1
Patricio López-Jaramillo,
2
and Mohammad Ehsanul Karim
1,3
5
1. School of Population and Public Health, University of British Columbia, Vancouver, BC, 6
Canada. 7
2. Instituto Masira, Medical School, Universidad de Santander (UDES), Bucaramanga, 8
Colombia. 9
3. Centre for Health Evaluation and Outcome Sciences (CHEOS), St. Paul’s Hospital, 10
Vancouver, BC, Canada. 11
12
Corresponding author: 13
Jorge Andrés Delgado-Ron, School of Population and Public Health, University of British 14
Columbia. 2206 East Mall Vancouver, BC Canada, V6T 1Z3. 15
Phone: +1 604 726 9954 16
Email: andres@delgado.ec
; jorge.delgadoron@ubc.ca 17
. CC-BY 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted January 2, 2021. ; https://doi.org/10.1101/2020.12.27.20248919doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

2
Abstract and Keywords 1
Aim: Small studies have shown reduced sodium sensitivity of blood pressure in obese 2
adolescents on caloric restriction. However, no study at the population level has studied such an 3
effect. We aimed to explore the association between mean daily sodium intake and prevalent 4
hypertension among a nationally representative sample of U.S. adults on caloric restriction who 5
participated in the National Health Examination and Nutrition Survey over the last twelve years. 6
Methods and Results: We used a design-based regression model to explore the association 7
between sodium intake and prevalent hypertension. We also conducted sensitivity analyses using 8
multiple imputation chained equations and propensity score matching. We also measured the effect of 9
a binary exposure derived from two widely recommended thresholds of sodium intake: 2.3 and 5.0 10
grams per day. Among 5,756 individuals, we did not detect any significant association between 11
increased sodium and the odds of hypertension (OR: 0.97; CI 95%: 0.90; 1.05). All our sensitivity 12
analyses are consistent with our main findings. 13
Conclusion: Our findings suggest that people on caloric restriction—a component of healthy 14
weight loss—would see no benefit in reducing sodium intake to lower blood pressure. These results 15
highlight the need to explore new population-specific strategies for sodium intake reduction, 16
including new dietary prescription approaches to improve dietary adherence and reduce the risk 17
associated with sodium-deficient diets. 18
Keywords: Hypertension; Dietary Sodium; Blood Pressure; Weight Loss; Caloric Restriction
19
. CC-BY 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted January 2, 2021. ; https://doi.org/10.1101/2020.12.27.20248919doi: medRxiv preprint

3
Introduction 1
Hypertension causes more death and disability than any other risk factor globally, ahead of 2
smoking, high glucose, and obesity. Nearly 10.4 million deaths worldwide were attributable to 3
elevated blood pressure in 2017.
1
Ambard and Beaujard theorized a potential association between salt 4
consumption and hypertension as early as 1904. However, contradictory evidence from observational 5
studies using low-salt diets led to an intense debate that lasted more than a century.
2
Only recently, 6
well-designed clinical trials provided reliable answers. The Dietary Approaches to Stop 7
Hypertension-Sodium (DASH-Na) trial concluded that “blood pressure can be lowered … by 8
reducing the sodium intake.”
3
Long-term cohort studies support the DASH-Na trial findings.
4
9
The precise mechanisms that cause dietary sodium to modulate blood pressure levels are not 10
well defined, which often translates to uncertainty about who would benefit from such interventions. 11
Past studies have shown the role of specific modifiers like ethnicity, even at the molecular level.
5
12
However, we know much less about the role of energy balance—the equilibrium between calories 13
consumed and calories burned through physical activity
6
—as a modifier of “salt sensitivity” of blood 14
pressure. 15
Energy balance is arguably a more critical modifier than diet or exercise on their own. After 16
all, we reach metabolic tipping points that enable our bodies to regulate blood pressure through the 17
additive interaction of energy intake and energy expenditure.
7,8
Current studies lack this holistic 18
understanding and, as a result, present somehow conflictive evidence. For instance, a reanalysis of the 19
DASH-Na data found less energy intake associated with increased salt sensitivity.
9
Similarly, a 20
community-based study in China found that participants in the highest quartile of physical activity 21
had reduced salt sensitivity compared to the lowest quartile. However, there was not a linear 22
association across quartiles.
10
23
. CC-BY 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted January 2, 2021. ; https://doi.org/10.1101/2020.12.27.20248919doi: medRxiv preprint

4
Caloric restriction and fitness are recommended to prevent or control hypertension.
11,12
The 1
current European and American hypertension guidelines recommend a reduced sodium intake on top 2
of that.
13,14
However, it is not clear if patients would benefit from reducing sodium in their diet once 3
they are on an energy deficit. Caloric restriction—a negative energy balance—reduces blood pressure 4
levels through improved insulin sensitivity, reduced adiposity, and reduced sympathetic activity, 5
independent of reaching an ideal body weight.
15,16
These mechanisms might also play a role in 6
modulating the salt sensitivity of blood pressure.
12,17
Studies that induced weight loss have modified 7
the relationship between sodium and blood pressure. However, they used small samples and are 8
outdated.
16,18
9
In the present work, we used a design-based regression model to explore the association 10
between mean daily sodium intake and prevalent hypertension among U.S. adults on caloric 11
restriction in the National Health Examination and Nutrition Survey (NHANES) from 2007 to 2018. 12
Methods 13
Data source, Design, and Study Population 14
We used publicly available data from NHANES, a cross-sectional four-stage stratified cluster 15
complex survey, representative of the non-institutionalized United States population. NHANES 16
gathers lifestyle and medical information, along with biological samples and a physical examination. 17
Readers can find relevant description design and sampling procedures associated with this survey 18
elsewhere.
19
The study complies with the Declaration of Helsinki and it is covered by item 7.10.3 in 19
the University of British Columbia’s Policy 89 on studies involving human participants and Article 20
2.2 in the Tri-Council Policy Statement Ethical Conduct for Research Involving Humans. 21
. CC-BY 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted January 2, 2021. ; https://doi.org/10.1101/2020.12.27.20248919doi: medRxiv preprint

5
Analytic sample and study variables 1
We included adults aged 20-79 years from six two-year cycles (2007-2018) with an energy 2
deficit of at least -350 calories per day. We chose this cut-off to correct potential underreporting from 3
self-reported dietary data.
20
We derived energy balance from its two essential components: energy 4
input (mean daily intake) and energy output (basal metabolic rate plus physical activity).
6
The basal 5
metabolic rate was calculated using the revised Harris-Benedict equations.
21
Self-reported weekly 6
vigorous and moderate physical activity was transformed into daily metabolic equivalents following 7
NHANES’ suggested scores.
22
NHANES derives the total daily intake from two 24-hour recall 8
interviews, 3 to 10 days apart, using a validated instrument to reduce recall bias.
23
We did not exclude 9
participants with invalid or missing answers for physical activity; instead, we used their basal 10
metabolic rate as total output. 11
We excluded pregnant women and participants with body mass index (BMI) below 18.5 12
(malnutrition) or an active thyroid pathology due to inherent metabolic differences in these patients. 13
Adults over the age of 80 were excluded because their age is not publicly available due to privacy 14
concerns. We also excluded people who reported a “much less than usual” intake during either 15
interview. 16
The primary outcome was hypertension, a binary variable indicating one of the following: 17
self-reported use of antihypertensive medication or systolic hypertension (mean systolic blood 18
pressure
130 mmHg) or diastolic hypertension (diastolic blood pressure
80 mmHg).
11
Individuals 19
without a second valid measurement for either systolic (SBP) or diastolic blood pressure (DBP) were 20
excluded to avoid measurement error. 21
The exposure was self-reported mean consumption of sodium (grams per day) as a continuous 22
measure. Two additional binary variables were derived for our sensitivity analyses (described later). 23
. CC-BY 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted January 2, 2021. ; https://doi.org/10.1101/2020.12.27.20248919doi: medRxiv preprint

References
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Journal ArticleDOI
Abstract: ABCD : Appropriate Blood pressure Control in Diabetes ABI : ankle–brachial index ABPM : ambulatory blood pressure monitoring ACCESS : Acute Candesartan Cilexetil Therapy in Stroke Survival ACCOMPLISH : Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension ACCORD : Action to Control Cardiovascular Risk in Diabetes ACE : angiotensin-converting enzyme ACTIVE I : Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events ADVANCE : Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation AHEAD : Action for HEAlth in Diabetes ALLHAT : Antihypertensive and Lipid-Lowering Treatment to Prevent Heart ATtack ALTITUDE : ALiskiren Trial In Type 2 Diabetes Using Cardio-renal Endpoints ANTIPAF : ANgioTensin II Antagonist In Paroxysmal Atrial Fibrillation APOLLO : A Randomized Controlled Trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly People ARB : angiotensin receptor blocker ARIC : Atherosclerosis Risk In Communities ARR : aldosterone renin ratio ASCOT : Anglo-Scandinavian Cardiac Outcomes Trial ASCOT-LLA : Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm ASTRAL : Angioplasty and STenting for Renal Artery Lesions A-V : atrioventricular BB : beta-blocker BMI : body mass index BP : blood pressure BSA : body surface area CA : calcium antagonist CABG : coronary artery bypass graft CAPPP : CAPtopril Prevention Project CAPRAF : CAndesartan in the Prevention of Relapsing Atrial Fibrillation CHD : coronary heart disease CHHIPS : Controlling Hypertension and Hypertension Immediately Post-Stroke CKD : chronic kidney disease CKD-EPI : Chronic Kidney Disease—EPIdemiology collaboration CONVINCE : Controlled ONset Verapamil INvestigation of CV Endpoints CT : computed tomography CV : cardiovascular CVD : cardiovascular disease D : diuretic DASH : Dietary Approaches to Stop Hypertension DBP : diastolic blood pressure DCCT : Diabetes Control and Complications Study DIRECT : DIabetic REtinopathy Candesartan Trials DM : diabetes mellitus DPP-4 : dipeptidyl peptidase 4 EAS : European Atherosclerosis Society EASD : European Association for the Study of Diabetes ECG : electrocardiogram EF : ejection fraction eGFR : estimated glomerular filtration rate ELSA : European Lacidipine Study on Atherosclerosis ESC : European Society of Cardiology ESH : European Society of Hypertension ESRD : end-stage renal disease EXPLOR : Amlodipine–Valsartan Combination Decreases Central Systolic Blood Pressure more Effectively than the Amlodipine–Atenolol Combination FDA : U.S. Food and Drug Administration FEVER : Felodipine EVent Reduction study GISSI-AF : Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation HbA1c : glycated haemoglobin HBPM : home blood pressure monitoring HOPE : Heart Outcomes Prevention Evaluation HOT : Hypertension Optimal Treatment HRT : hormone replacement therapy HT : hypertension HYVET : HYpertension in the Very Elderly Trial IMT : intima-media thickness I-PRESERVE : Irbesartan in Heart Failure with Preserved Systolic Function INTERHEART : Effect of Potentially Modifiable Risk Factors associated with Myocardial Infarction in 52 Countries INVEST : INternational VErapamil SR/T Trandolapril ISH : Isolated systolic hypertension JNC : Joint National Committee JUPITER : Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin LAVi : left atrial volume index LIFE : Losartan Intervention For Endpoint Reduction in Hypertensives LV : left ventricle/left ventricular LVH : left ventricular hypertrophy LVM : left ventricular mass MDRD : Modification of Diet in Renal Disease MRFIT : Multiple Risk Factor Intervention Trial MRI : magnetic resonance imaging NORDIL : The Nordic Diltiazem Intervention study OC : oral contraceptive OD : organ damage ONTARGET : ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial PAD : peripheral artery disease PATHS : Prevention And Treatment of Hypertension Study PCI : percutaneous coronary intervention PPAR : peroxisome proliferator-activated receptor PREVEND : Prevention of REnal and Vascular ENdstage Disease PROFESS : Prevention Regimen for Effectively Avoiding Secondary Strokes PROGRESS : Perindopril Protection Against Recurrent Stroke Study PWV : pulse wave velocity QALY : Quality adjusted life years RAA : renin-angiotensin-aldosterone RAS : renin-angiotensin system RCT : randomized controlled trials RF : risk factor ROADMAP : Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention SBP : systolic blood pressure SCAST : Angiotensin-Receptor Blocker Candesartan for Treatment of Acute STroke SCOPE : Study on COgnition and Prognosis in the Elderly SCORE : Systematic COronary Risk Evaluation SHEP : Systolic Hypertension in the Elderly Program STOP : Swedish Trials in Old Patients with Hypertension STOP-2 : The second Swedish Trial in Old Patients with Hypertension SYSTCHINA : SYSTolic Hypertension in the Elderly: Chinese trial SYSTEUR : SYSTolic Hypertension in Europe TIA : transient ischaemic attack TOHP : Trials Of Hypertension Prevention TRANSCEND : Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease UKPDS : United Kingdom Prospective Diabetes Study VADT : Veterans' Affairs Diabetes Trial VALUE : Valsartan Antihypertensive Long-term Use Evaluation WHO : World Health Organization ### 1.1 Principles The 2013 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology …

13,846 citations


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Abstract: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Bill & Melinda Gates Foundation.

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