Association between dietary sodium intake and disease burden and mortality in Koreans between 1998 and 2016: The Korea National Health and Nutrition Examination Survey

Q: What are the key findings of this study?

High energy-adjusted sodium intake (Q4, >=5,709 mg/day) increased CVD mortality in women (HR 1.67, 95% CI 1.02-2.74), while moderate intake (Q2) lowered all-cause mortality vs Q1.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Cardiovascular disease burden and mortality in the general population (n=36909). Intervention: Dietary sodium intake and estimated 24-h urinary sodium excretion vs. Lowest quartile of energy-adjusted dietary sodium intake (Q1: <= 3,015 mg/day, mean 2,239 mg/day) or counterfactual optimal intake of 2,000 mg/day. Primary outcome: CVD-associated mortality in women (Q4 vs Q1 of energy-adjusted dietary sodium intake) and all-cause mortality (HR 1.67, 95% CI 1.02-2.74, p=<0.05).

Q: What does this research mean for the field?

Moderate dietary sodium intake is associated with reduced all-cause mortality compared to lower intake, while high sodium intake increases cardiovascular disease mortality specifically in women. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Clara Yongjoo Park; Garam Jo; Juhee Lee; Gitanjali M Singh; Jong-Tae Lee; Min‐Jeong Shin

doi:10.4162/nrp.2020.14.5.501

January 1, 2020Nutrition Research and PracticeOpen Access

Association between dietary sodium intake and disease burden and mortality in Koreans between 1998 and 2016: The Korea National Health and Nutrition Examination Survey

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Key result

High dietary sodium intake is linked to ~67% higher CVD mortality in women.

HR 1.67
95% CI 1.02-2.74
P<0.05
n=36,909

Why the study?

Sodium intake is positively associated with blood pressure and may increase cardiovascular disease risk, motivating an assessment of the cardiovascular disease burden attributable to sodium intakes above 2,000 mg/day and the association between sodium levels and mortality in Korea.

What is the disease burden of cardiovascular disease attributable to sodium intake >2,000 mg/day between 1998 and 2016, and how is dietary or urinary sodium level associated with all-cause and CVD-associated mortality in Korean adults?

Key Points

To evaluate the cardiovascular disease burden attributable to dietary sodium intake exceeding 2,000 mg/day and evaluate prospective associations with all-cause and cardiovascular mortality in South Korea.
Analyzed Korea National Health and Nutrition Examination Survey data from 1998 to 2016, evaluating 68,578 participants for comparative risk assessment and 33,113 participants for mortality over a mean follow-up of 5.4 years.
Quantified population attributable fractions for stroke and ischemic heart disease, and estimated mortality associations across energy-adjusted sodium intake quartiles using Cox proportional hazard regression.
Mean dietary sodium intake dropped from a peak of 5,550 mg/day in 2001 to 3,647 mg/day in 2016 (P=0.006), alongside declines in the population attributable fractions for stroke and ischemic heart disease.
Participants in sodium intake quartile 2 had a lower risk of all-cause mortality compared with quartile 1, including a 21% lower risk in men (P<0.05).
Cardiovascular mortality did not significantly differ across sodium quartiles in the overall population, but was significantly higher among women in the highest quartile compared with the lowest quartile (HR, 1.67; 95% CI, 1.02–2.74; P<0.05).

Study Design

Type

Cohort (n=36,909)

Multicenter

Yes

Structured PICO

What is the disease burden of cardiovascular disease attributable to sodium intake >2,000 mg/day between 1998 and 2016, and how is dietary or urinary sodium level associated with all-cause and CVD-associated mortality in Korean adults?

P

Population

36,909 Korean adults aged >= 25 years (mean age 52.1 years, 60.0% female) free of baseline cancer from the KNHANES cohort, followed for a mean of 5.4 years (alongside 68,578 participants in comparative risk assessment).

E

Exposure

Higher quartiles of energy-adjusted dietary sodium intake (measured by 24-h dietary recall: Q2 mean 3,590 mg/day [range 3,015–4,182], Q3 mean 4,887 mg/day [range 4,182–5,709], Q4 mean 7,713 mg/day [≥5,709 mg/day]) and estimated 24-h urinary sodium excretion (calculated from fasting spot urine using the Tanaka formula); for CRA, population sodium intake above 2,000 mg/day.

C

Comparator

Lowest quartile of energy-adjusted dietary sodium intake (Q1: ≤3,015 mg/day, mean 2,239 mg/day) for mortality Cox regression; optimal daily sodium intake of 2,000 mg/day as counterfactual minimum risk exposure for CRA.

O

Outcome

All-cause mortality (ICD-10 codes A00–R99, excluding unnatural deaths V01–Y89) and cardiovascular disease (CVD)-associated mortality (ICD-10 codes I00–I99) at a mean follow-up of 5.4 years (2007–2015 baseline followed through December 31, 2016 via linked death certificates and medical records in KOSIS).hard clinical

Main Result

Hazard Ratio: 1.67 (95% CI 1.02–2.74)

p-value: p=<0.05

Although national decreases in dietary sodium intake in South Korea from 1998 to 2016 reduced population-level attributable CVD burden, prospective individual-level mortality data revealed a J/U-shaped relationship where moderate sodium intake (3,015–4,182 mg/day) had the lowest all-cause mortality risk, suggesting current strict sodium guidelines (<2,000 mg/day) may need revision.

Limitations

Precise recall of sodium intake via 24-hour dietary recall is difficult as sodium content among similar dishes varies by preparation method.
Urine samples available from KNHANES were fasting spot urine collections, which have a higher degree of measurement error than 24-hour urine collections.
The Tanaka equation used to estimate 24-hour urinary sodium was developed in Japanese adults aged 20-59 years and was not verified for adults aged >= 60 years.
Unable to exclude participants with other underlying diseases or family history that would motivate them to decrease sodium intake due to increased risk of mortality.
Precise recall of sodium intake is difficult because sodium content among similar dishes differs according to the method of preparation.
Urine samples from KNHANES were fasting spot urine collections, which have a higher degree of measurement error than 24-h urine collections.
The Tanaka formula used to estimate 24-h urinary sodium excretion was not verified for adults aged ≥60 years.
Unable to exclude participants with other underlying diseases or familial history that would motivate them to decrease sodium intake due to increased mortality risk.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

High sodium intake was associated with higher CVD mortality in women; leaves open whether moderate intake optimizes survival in Korean adults.

Abstract

BACKGROUND/OBJECTIVES: Sodium intake is positively associated with blood pressure, which may increase the risk for cardiovascular disease (CVD). Therefore, we assessed the disease burden of CVD attributable to sodium intakes above 2,000 mg/day and prospectively investigated the association between dietary/urinary sodium levels and the risk of all-cause and CVD-mortality using the Korea National Health and Nutrition Examination Survey (KNHNES). SUBJECTS/METHODS: A total of 68,578 and 33,113 participants were included for comparative risk assessment (CRA) analysis and mortality analysis, respectively, and mean follow-up time for mortality was 5.4 years. CRA analysis was used to quantify attributable incidences of stroke, ischemic heart disease (IHD), and deaths attributable to sodium intake between 1998 and 2016. Cox proportional hazard regression model was used to determine the association between sodium intake and all-cause and CVD-mortality. RESULTS: Mean dietary sodium intake decreased over time, reaching 3,647 mg/day in 2016. Similarly, the population attributable fractions of stroke and IHD, and the number of CVD-associated deaths attributable to high sodium intake/excretion also decreased. In terms of association with mortality, when participants were grouped into quartiles (Q) by energy-adjusted sodium intake, those in Q2 had a lower risk of all-cause mortality than those in Q1 with lower intakes. The risk of CVD-associated mortality was higher only in females with high sodium intake in Q4 than those in Q1. CONCLUSIONS: This nationwide data indicates that, in line with previous studies of multiple cohorts, both low and high sodium intakes may be associated with an increased risk of mortality; therefore, the optimal sodium intake for Koreans needs to be revised.

Discussion

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Cite This Study

Park et al. (2020) conducted a cohort in Cardiovascular disease burden and mortality in the general population (n=36,909). Dietary sodium intake and estimated 24-h urinary sodium excretion vs. Lowest quartile of energy-adjusted dietary sodium intake (Q1: <= 3,015 mg/day, mean 2,239 mg/day) or counterfactual optimal intake of 2,000 mg/day was evaluated on CVD-associated mortality in women (Q4 vs Q1 of energy-adjusted dietary sodium intake) and all-cause mortality (HR 1.67, 95% CI 1.02-2.74, p=<0.05). High energy-adjusted sodium intake (Q4, >=5,709 mg/day) increased CVD mortality in women (HR 1.67, 95% CI 1.02-2.74), while moderate intake (Q2) lowered all-cause mortality vs Q1.

synapsesocial.com/papers/6aeb89efafb6ffe4e1e71d4b https://doi.org/10.4162/nrp.2020.14.5.501

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Association between dietary sodium intake and disease burden and mortality in Koreans between 1998 and 2016: The Korea National Health and Nutrition Examination Survey

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Association between dietary sodium intake and disease burden and mortality in Koreans between 1998 and 2016: The Korea National Health and Nutrition Examination Survey

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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