High-salt diet linked to 1.6 million heart deaths

Behind the Headlines

Thursday August 14 2014

Too much salt in the diet is believed to cause cardiovascular disease

Nearly 1 in 10 heart disease deaths may be linked to salt

"Salty diet 'causes 1.6 million deaths worldwide each year'," reports The Daily Telegraph. It goes on to quote a researcher saying this is "nearly 1 in 10 of all deaths from cardiovascular causes worldwide".

This scary-sounding headline has a grain of truth in it, but the science it's based on doesn't prove that salt is causing these deaths. In fact, the news is based on a modelling study.

To estimate the effect of current sodium intake on cardiovascular mortality worldwide, researchers used available data on:

  • sodium consumption
  • the dose-response effects of sodium consumption on blood pressure
  • the association between blood pressure and cardiovascular mortality
  • data on cause-specific deaths

Globally, 1.65 million deaths from cardiovascular causes in 2010 were attributed to people consuming more than 2g of sodium per day. That's roughly 5g of salt a day. Currently, UK advice is for adults to eat no more than 6g of salt a day.

But this study could not prove that sodium restriction reduces cardiovascular mortality. This means the findings are generally in keeping with current salt recommendations that adults consume no more than 6g of salt a day.

 

Where did the story come from?

The study was carried out by researchers from Tufts University, the Harvard School of Public Health, Brigham and Women's Hospital, Harvard Medical School, and the University of Washington in the US, and the Cambridge Institute of Public Health and Imperial College London in the UK.

It was funded by the Bill and Melinda Gates Foundation.

The study was published in the peer-reviewed New England Journal of Medicine. This article was open access, which means it's free to view online.

The media coverage is generally representative of this research, but it's worth bearing in mind that the study's results are estimates only. Also, the link between sodium and death has only been indirectly assessed by examining sodium's effect upon blood pressure, and then blood pressure's effect upon cardiovascular death.

 

What kind of research was this?

This was a modelling study that aimed to estimate the effects of sodium intake on cardiovascular deaths around the world.

This modelling study can estimate how many deaths from cardiovascular disease can be attributed to a sodium intake over 2g.

However, it does not prove that sodium consumption of more than 2g a day caused any of these deaths, or that sodium restriction reduces cardiovascular mortality.

 

What did the research involve?

Salt special

Elsewhere in this week's New England Journal of Medicine, a separate study analysed sodium in the urine of more than 100,000 people. It found the association between the intake of sodium and blood pressure was greatest in those with high blood pressure, the elderly, and those with high sodium diets (more than 5g of salt a day).

 

And a further salt study, again looking at more than 100,000 people, found a sodium intake of more than 6g a day (about 15g of salt) is associated with an increased risk of death and cardiovascular events. The risk of death and cardiovascular events was lowest in people who ate between 3g and 6g of sodium a day (about 7.5g to 15g of salt). Eating less than 3g of sodium a day was associated with an increased risk.

 

This was reported as "no need to cut back on salt" by the Mail Online as current UK guidelines state people should consume no more than 6g of salt a day. The Mail provided a good summary of the research, and mentioned some of its limitations, including some concerns over how sodium intake was measured.

The researchers modelled the effects of sodium intake on cardiovascular mortality around the world. They estimated the fraction and numbers of deaths estimated to be attributable to sodium intake above a reference level of 2g of sodium a day.

To do this, the researchers needed estimates of global sodium consumption, the effect of sodium intake on blood pressure, and the effect of blood pressure on cardiovascular deaths.

Estimating global sodium consumption

Previously conducted national or subnational surveys on individual level sodium consumption were systematically traced by the researchers. These surveys were based on measurements of sodium in urine, or estimates of sodium intake in the diet, or both. The researchers quantified consumption according to age, sex and country.

Assessing the effect of sodium intake on blood pressure

The researchers carried out a meta-analysis of all randomised controlled trials identified in two prior systematic reviews that had evaluated the effect of reduced sodium on blood pressure. They looked at the effects according to age, race and the presence or absence of hypertension.

Assessing the effects of blood pressure levels on deaths caused by cardiovascular disease

The effect of blood pressure levels on deaths as a result of cardiovascular disease was assessed by combining results from two large international projects (including 99 cohorts, comprising a total of 1.38 million participants, among whom there were 65,000 cardiovascular events) that pooled individual level data. The researchers looked at the effects according to age.

The number of people who die from cardiovascular disease was estimated from the Global Burden of Disease Study 2010.

 

What were the basic results?

The researchers estimated the average level of consumption of sodium worldwide was 3.95g a day and regional averages ranged from 2.18g to 5.51g a day. From their meta-analysis of randomised controlled trials, they found reducing sodium intake reduced blood pressure.

Each reduction of 2.30g of sodium a day was associated with a reduction of 3.82mmHg in blood pressure, although the effects depended on population characteristics such as age and race.

They also found lower blood pressure was associated with a reduced risk of cardiovascular death.

The researchers calculated nearly 1 of every 10 deaths from cardiovascular causes (1.65 million deaths a year, 9.5% of all cardiovascular deaths) is attributed to a sodium intake of more than 2g a day.

Four of every five deaths (84.3%) occurred in low- and middle-income countries, and two of every five deaths (40.4%) were premature (before 70 years of age).

The rate of death from cardiovascular causes associated with sodium intake above the reference level was highest in Georgia and lowest in Kenya.

 

How did the researchers interpret the results?

The researchers concluded that: "In this modelling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0g per day."

 

Conclusion

This month in salt news

August is usually known as the "silly season" for news (because papers are too short-staffed to find "proper" stories).

 

But this year, August looks set to be the "salty season". As well as today's flurry of salty news, we've had salt injections touted as a cure for cancer and news that cheese can be "saltier than seawater".

This modelling study used the data currently available on sodium consumption, dose-response effects of sodium consumption on blood pressure, and the association between blood pressure and cardiovascular deaths, together with data on cause-specific deaths, to estimate the effect of current sodium intake on cardiovascular mortality worldwide.

Globally, 1.65 million deaths from cardiovascular causes in 2010 were attributed to sodium consumption of more than 2g a day. That's equivalent to 1 in 10 cardiovascular deaths caused by eating more than 5g of salt a day.

The researchers seemed to use the best available methods to estimate their parameters. But they did not include any studies that looked at the association between sodium consumption and cardiovascular death.

Instead, they looked at the effect of salt consumption on blood pressure and the association between blood pressure and cardiovascular mortality. Therefore, the association between sodium intake and cardiovascular death was not direct.

The researchers state a meta-analysis of prospective cohort studies has shown higher sodium consumption is associated with a higher rate of death from coronary heart disease and stroke, but they did not use this in their model.

However, surprisingly, a cohort study published in the same issue of the New England Journal of Medicine found the risk of death and cardiovascular events was lowest in people who ate between 3g and 6g of sodium a day (equivalent to 7.5g to 15g of salt).

This study could not show that sodium consumption of more than 2g a day caused any of these deaths, or that sodium restriction reduces cardiovascular mortality.

This study will be of value in further understanding the burden of cardiovascular disease worldwide and its estimated association with salt intake. Overall, the findings are generally in line with current salt intake recommendations. Currently, in the UK adults are advised to eat no more than 6g of salt a day – around one full teaspoon (equivalent to 2.4g of sodium). Children should eat less than this.

One of the easiest ways to reduce salt intake is to limit its use in cooking and avoid adding table salt to food. But much of our salt intake is hidden in the packaged food we eat, so looking at the salt content on food labels is always a good idea.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Analysis by Bazian

Edited by NHS Choices

Links to the headlines

Salty diet 'causes 1.6 million deaths worldwide each year'. The Daily Telegraph, August 13 2014

Links to the science

Mozaffarian D, et al. Global Sodium Consumption and Death from Cardiovascular Causes. New England Journal of Medicine. Published August 14 2014

Further reading

Tufts University (via EurekAlert). Estimated 1.65 million global cardiovascular deaths each year linked to high sodium consumption. Published August 14 2014

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