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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
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SODIUM INTAKE
                        IN POPULATIONS

ASSESSMENT OF EVIDENCE

Committee on the Consequences of Sodium Reduction in Populations

Food and Nutrition Board

Board on Population Health and Public Health Practice

Brian L. Strom, Ann L. Yaktine, and Maria Oria, Editors

INSTITUTE OF MEDICINE

       OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
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THE NATIONAL ACADEMIES PRESS      500 Fifth Street, NW      Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract/Grant No. 200-2011-38807 between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

International Standard Book Number-13: 978-0-309-28295-6
International Standard Book Number-10: 0-309-28295-0

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Suggested citation: IOM (Institute of Medicine). 2013. Sodium intake in populations: Assessment of evidence. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
×

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

—Goethe

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INSTITUTE OF MEDICINE

       OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
×

COMMITTEE ON THE CONSEQUENCES OF SODIUM REDUCTION IN POPULATIONS

BRIAN L. STROM (Chair), George S. Pepper Professor of Public Health, University of Pennsylvania School of Medicine, Philadelphia

CHERYL A. M. ANDERSON, Associate Professor of Family and Preventive Medicine, University of California, San Diego

JAMY ARD, Associate Professor of Epidemiology and Prevention, Wake Forest Baptist Health, Winston-Salem, North Carolina

KIRSTEN BIBBINS-DOMINGO, Associate Professor of Medicine and of Epidemiology and Biostatistics, University of California, San Francisco, and Co-Director, San Francisco General Hospital, California

NANCY R. COOK, Professor in the Department of Medicine at Harvard Medical School and Brigham & Women’s Hospital, Boston, Massachusetts

MARY KAY FOX, Senior Researcher, Mathematica Policy Research, Inc., Cambridge, Massachusetts

NIELS GRAUDAL, Senior Consultant, Copenhagen University Hospital, Rigshospitalet, Denmark

JIANG HE, Joseph S. Copes Professor of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana

JOACHIM IX, Associate Professor of Medicine, Veterans Affairs San Diego Healthcare System, California

STEPHEN E. KIMMEL, Professor of Medicine and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia

ALICE H. LICHTENSTEIN, Gershoff Professor of Nutrition Science and Policy, Tufts University, Boston, Massachusetts

MYRON WEINBERGER, Professor Emeritus of Medicine, Indiana University School of Medicine, Indianapolis and Editor-in-Chief, Journal of the American Society of Hypertension

IOM Staff

MARIA ORIA, Study Director

ANN L. YAKTINE, Study Director

JULIA HOGLUND, Research Associate

COLIN F. FINK, Senior Program Assistant

ANTON BANDY, Financial Officer

GERALDINE KENNEDO, Administrative Assistant

LINDA D. MEYERS, Director, Food and Nutrition Board

ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practices

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

MICHAEL H. ALDERMAN, Albert Einstein College of Medicine

DAVID B. ALLISON, University of Alabama, Birmingham

LAWRENCE J. APPEL, Johns Hopkins University

GLENN M. CHERTOW, Stanford University School of Medicine

JOHANNA T. DWYER, Tufts Medical Center

SHIRIKI K. KUMANYIKA, University of Pennsylvania Perelman School of Medicine

JOSEPH LAU, Brown University

DAVID A. MCCARRON, University of California, Davis

SUZANNE P. MURPHY, University of Hawaii, Manoa

SUZANNE OPARIL, University of Alabama, Birmingham

DONALD B. RUBIN, Harvard University

ANNA MARIA SIEGA-RIZ, University of North Carolina at Chapel Hill

JUDITH S. STERN, University of California, Davis

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
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Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by LYNN R. GOLDMAN, George Washington University, and SUSAN J. CURRY, University of Iowa. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
×

Preface

Heart disease and stroke are major cardiovascular diseases (CVDs) and leading causes of death for both men and women in the United States. Major risk factors of CVD, such as high blood pressure, high levels of low-density lipoprotein cholesterol, and smoking, are frequently found among the U.S. population. Other factors, however, such as a poor diet, also can contribute to high blood pressure and disease risk. For more than four decades, controversies have surrounded the contribution of sodium consumption as a risk factor for noncommunicable diseases, including CVD. Numerous domestic and international organizations and governments have advised populations against consuming high levels of sodium. Investigators have applied models based on blood pressure decreases to predict the number of deaths that would be saved in the general population from reducing sodium consumption. Although most biomarkers have limitations as indicators of risk of adverse health outcomes, the evidence for blood pressure as a surrogate endpoint for risk of CVD and stroke is widely recognized and accepted. Sodium, however, might execute its functions through various processes in addition to blood pressure. Thus, any strategy to reduce the consumption of sodium should include studies that demonstrate an association between sodium consumption and direct health effects. Although there is agreement that sodium policies should be guided by research based on direct health outcomes, unfortunately, randomized controlled trials and observational studies that have looked at the association between sodium and direct health outcomes are few and have been interpreted in many

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
×

different ways. These differences underscore the difficulties in accurately measuring the long-term health effects of diets or individual nutrients that are consumed in the context of a diet.

In 2005, as part of its work on Dietary Reference Intakes, the Institute of Medicine (IOM) conducted a review of the scientific literature on the association between sodium and health effects, including both intermediate and direct health outcomes. Since that time, more data have been collected but the controversies continue and have slowed down the ability to implement sodium policies that are consistent with the current Dietary Guidelines for Americans. Adding to these longstanding controversies is emerging evidence on potential adverse effects of a too-low dietary sodium intake for some population subgroups. The need for an in-depth examination of the scientific literature became obvious. The Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services asked the IOM to convene an expert committee to examine the designs, methodologies, and conclusions of this emerging evidence and to comment on the implications of their findings for population-based sodium-reduction strategies. Of particular interest to the agency was assessing benefits and adverse outcomes of reducing sodium intake in the population and in relevant subgroups that have been described as being particularly at risk. These subgroups are individuals with hypertension and prehypertension, those 51 years of age and older, African Americans, and those with diabetes, chronic kidney disease, and congestive heart failure. The committee conducted an extensive review of the peer-reviewed literature. A public workshop also was conducted, which provided an opportunity for experts outside the committee to present some of the most controversial data and for stakeholders to describe their positions on relevant issues. The contributions of the workshop speakers and additional information gathered by the committee were invaluable for its deliberations.

I am deeply indebted to the committee members who generously gave their time and effort to complete this task in a very short time. Their diversity in expertise and backgrounds and in-depth discussions shed light on highly complex scientific issues. In addition, on behalf of the committee, I would like to thank the IOM staff, study co-directors Ann L. Yaktine and Maria Oria, research associate Julia Hoglund, and senior program assistant Colin Fink, who worked tirelessly to complete this task. My gratitude also goes to the Director of the Food and Nutrition Board, Linda D. Meyers, and the Director of the Board on Population Health and Public Health Practices, Rose Marie Martinez, for their guidance and support during the entire study.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
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It is my hope that the conclusions of this committee will add to current discussions about sodium intake and health and will help future policy makers as they continue to decide and implement sodium strategies that will benefit public health.

Brian L. Strom, Chair
Committee on the Consequences of
Sodium Reduction in Populations

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: The National Academies Press. doi: 10.17226/18311.
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Despite efforts over the past several decades to reduce sodium intake in the United States, adults still consume an average of 3,400 mg of sodium every day. A number of scientific bodies and professional health organizations, including the American Heart Association, the American Medical Association, and the American Public Health Association, support reducing dietary sodium intake. These organizations support a common goal to reduce daily sodium intake to less than 2,300 milligrams and further reduce intake to 1,500 mg among persons who are 51 years of age and older and those of any age who are African-American or have hypertension, diabetes, or chronic kidney disease.

A substantial body of evidence supports these efforts to reduce sodium intake. This evidence links excessive dietary sodium to high blood pressure, a surrogate marker for cardiovascular disease (CVD), stroke, and cardiac-related mortality. However, concerns have been raised that a low sodium intake may adversely affect certain risk factors, including blood lipids and insulin resistance, and thus potentially increase risk of heart disease and stroke. In fact, several recent reports have challenged sodium reduction in the population as a strategy to reduce this risk.

Sodium Intake in Populations recognizes the limitations of the available evidence, and explains that there is no consistent evidence to support an association between sodium intake and either a beneficial or adverse effect on most direct health outcomes other than some CVD outcomes (including stroke and CVD mortality) and all-cause mortality. Some evidence suggested that decreasing sodium intake could possibly reduce the risk of gastric cancer. However, the evidence was too limited to conclude the converse—that higher sodium intake could possibly increase the risk of gastric cancer. Interpreting these findings was particularly challenging because most studies were conducted outside the United States in populations consuming much higher levels of sodium than those consumed in this country. Sodium Intake in Populations is a summary of the findings and conclusions on evidence for associations between sodium intake and risk of CVD-related events and mortality.

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