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A compelling case for halving the current global average sodium intake

Comment by Kausik Ray, EACPR Prevention, Epidemiology and Population Science Section

Global Sodium Consumption and Death from Cardiovascular Causes
D. Mozaffarian et al.
N Engl J Med 2014; 371:624-634, August 14, 2014, DOI: 10.1056/NEJMoa1304127


  • The recent report by D. Mozaffarian et al. attempted to quantify more reliably than previously possible the global burden of disease related to sodium consumption, both overall and by region, age and gender.  The authors retrieved information for previously conducted national or subnational surveys on individual level sodium consumption based on 24 hour urinary excretion, estimated dietary intake, or both  conducted between 2008-2011. The surveys were conducted in 66 countries which contain approximately ¾ of the global population.  Furthermore the authors conducted a meta-analysis of 107 randomised interventions to assess the relationship between reduced sodium intake and blood pressure.

    Using these data the authors used a previously published hierarchical Bayesian model. The authors estimated the mean level of sodium consumption by age, sex, and calendar year in 187 nations and its relationship with blood pressure. This allowed the authors to model the effects of blood pressure on cause-specific cardiovascular mortality and to characterise current blood-pressure levels and numbers of cause-specific deaths according to country, age, and sex.

    The authors concluded that by 2010, the mean level of consumption of sodium worldwide was 3.95 g/day, with regional means ranging from 2.18 to 5.51 g/day. Approximately, 99.2% of the adult population in the world had estimated mean levels of sodium intake exceeding the WHO recommendation of 2.0 g per day, and 88.3% of the adult population exceeded level by more than 1.0 g/day. Importantly the authors observed clear evidence of a linear dose response relationship between reduced sodium intake and blood pressure with no apparent threshold up to ~7g/day sodium intake.

    The authors used a reference level corresponding to a population mean (±SD) intake of 2.0±0.2 g of sodium per day and estimated that 1.65 million deaths from cardiovascular causes  worldwide in 2010 were attributable to sodium consumption above this level. Of these deaths:

    •    687,000 (41.7%) were due to coronary heart disease (CHD)
    •    685,000 (41.6%) were due to stroke
    •    276,000 (16.7%) were due to other cardiovascular disease
    •    40.4% occurring in persons younger than 70 years of age
    •    84.3% occurring in low-income and middle-income countries.

    Using a lower reference range of 1.0 g of sodium per day, the authors estimate that the number of deaths from cardiovascular causes in the world that were attributable to sodium consumption increased by approximately 40%, to 2.30 million (CI 1.55 million to 3.07 million).  

    The authors estimated that 512,901 deaths from cardiovascular causes globally could be prevented per year if sodium intake in the highest countries (>4.0±0.4 g per day) lowered their intake to <4g/day. In more conservative estimates where the effect of sodium restriction on blood pressure did not continue below 125 mm Hg systolic, it was estimated that 1.55 million deaths from cardiovascular causes in the world could be averted by reducing sodium intake to 2.0 g per day.

    Whilst the data are based on modelling and don’t provide evidence for a direct effect of sodium restriction on the prevention of cardiovascular deaths, the data are consistent with what is known and provide the largest most reliable evidence of the number of potentially preventable deaths from sodium restriction.

    Whilst there is uncertainty about the exact level of daily sodium intake, the authors make a compelling case for halving the current global average intake of ~4g/day to 2g sodium / day. Within Europe the greatest benefits are likely to be seen in Central and Eastern Europe with such policies.  Public health policies that target sodium restriction are likely to be cost effective especially in middle to low income countries.