Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study

Andrew Mente, Martin O'Donnell, Sumathy Rangarajan, Matthew McQueen, Gilles Dagenais, Andreas Wielgosz, Scott Lear, Shelly Tse Lap Ah, Li Wei, Rafael Diaz, Alvaro Avezum, Patricio Lopez-Jaramillo, Fernando Lanas, Prem Mony, Andrzej Szuba, Romaina Iqbal, Rita Yusuf, Noushin Mohammadifard, Rasha Khatib, Khalid YusoffNoor Hassim Ismail, Sadi Gulec, Annika Rosengren, Afzalhussein Yusufali, Lanthe Kruger, Lungiswa Primrose Tsolekile, Jephat Chifamba, Antonio Dans, Khalid F. Alhabib, Karen Yeates, Koon Teo, Salim Yusuf

Research output: Contribution to journalArticle

49 Citations (Scopus)

Abstract

Background: WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomised trials or observational studies. We investigated the associations between community-level mean sodium and potassium intake, cardiovascular disease, and mortality. Methods: The Prospective Urban Rural Epidemiology study is ongoing in 21 countries. Here we report an analysis done in 18 countries with data on clinical outcomes. Eligible participants were adults aged 35–70 years without cardiovascular disease, sampled from the general population. We used morning fasting urine to estimate 24 h sodium and potassium excretion as a surrogate for intake. We assessed community-level associations between sodium and potassium intake and BP in 369 communities (all >50 participants) and cardiovascular disease and mortality in 255 communities (all >100 participants), and used individual-level data to adjust for known confounders. Findings: 95 767 participants in 369 communities were assessed for BP and 82 544 in 255 communities for cardiovascular outcomes with follow-up for a median of 8·1 years. 82 (80%) of 103 communities in China had a mean sodium intake greater than 5 g/day, whereas in other countries 224 (84%) of 266 communities had a mean intake of 3–5 g/day. Overall, mean systolic BP increased by 2·86 mm Hg per 1 g increase in mean sodium intake, but positive associations were only seen among the communities in the highest tertile of sodium intake (p<0·0001 for heterogeneity). The association between mean sodium intake and major cardiovascular events showed significant deviations from linearity (p=0·043) due to a significant inverse association in the lowest tertile of sodium intake (lowest tertile <4·43 g/day, mean intake 4·04 g/day, range 3·42–4·43; change –1·00 events per 1000 years, 95% CI –2·00 to –0·01, p=0·0497), no association in the middle tertile (middle tertile 4·43–5·08 g/day, mean intake 4·70 g/day, 4·44–5.05; change 0·24 events per 1000 years, –2·12 to 2·61, p=0·8391), and a positive but non-significant association in the highest tertile (highest tertile >5·08 g/day, mean intake 5·75 g/day, >5·08–7·49; change 0·37 events per 1000 years, –0·03 to 0·78, p=0·0712). A strong association was seen with stroke in China (mean sodium intake 5·58 g/day, 0·42 events per 1000 years, 95% CI 0·16 to 0·67, p=0·0020) compared with in other countries (4·49 g/day, –0·26 events, –0·46 to –0·06, p=0·0124; p<0·0001 for heterogeneity). All major cardiovascular outcomes decreased with increasing potassium intake in all countries. Interpretation: Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate. Funding: Population Health Research Institute, Canadian Institutes of Health Research, Canadian Institutes of Health Canada Strategy for Patient-Oriented Research, Ontario Ministry of Health and Long-Term Care, Heart and Stroke Foundation of Ontario, and European Research Council.

Original languageEnglish
Pages (from-to)496-506
Number of pages11
JournalThe Lancet
Volume392
Issue number10146
DOIs
Publication statusPublished - 11 Aug 2018
Externally publishedYes

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Epidemiologic Studies
Cohort Studies
Cardiovascular Diseases
Sodium
Blood Pressure
Mortality
Potassium
Health
Ontario
China
Stroke
Population
Long-Term Care
Research
Canada
Observational Studies
Fasting
Epidemiology
Myocardial Infarction
Urine

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Mente, A., O'Donnell, M., Rangarajan, S., McQueen, M., Dagenais, G., Wielgosz, A., ... Yusuf, S. (2018). Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. The Lancet, 392(10146), 496-506. https://doi.org/10.1016/S0140-6736(18)31376-X

Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality : a community-level prospective epidemiological cohort study. / Mente, Andrew; O'Donnell, Martin; Rangarajan, Sumathy; McQueen, Matthew; Dagenais, Gilles; Wielgosz, Andreas; Lear, Scott; Ah, Shelly Tse Lap; Wei, Li; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Lanas, Fernando; Mony, Prem; Szuba, Andrzej; Iqbal, Romaina; Yusuf, Rita; Mohammadifard, Noushin; Khatib, Rasha; Yusoff, Khalid; Ismail, Noor Hassim; Gulec, Sadi; Rosengren, Annika; Yusufali, Afzalhussein; Kruger, Lanthe; Tsolekile, Lungiswa Primrose; Chifamba, Jephat; Dans, Antonio; Alhabib, Khalid F.; Yeates, Karen; Teo, Koon; Yusuf, Salim.

In: The Lancet, Vol. 392, No. 10146, 11.08.2018, p. 496-506.

Research output: Contribution to journalArticle

Mente, A, O'Donnell, M, Rangarajan, S, McQueen, M, Dagenais, G, Wielgosz, A, Lear, S, Ah, STL, Wei, L, Diaz, R, Avezum, A, Lopez-Jaramillo, P, Lanas, F, Mony, P, Szuba, A, Iqbal, R, Yusuf, R, Mohammadifard, N, Khatib, R, Yusoff, K, Ismail, NH, Gulec, S, Rosengren, A, Yusufali, A, Kruger, L, Tsolekile, LP, Chifamba, J, Dans, A, Alhabib, KF, Yeates, K, Teo, K & Yusuf, S 2018, 'Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study', The Lancet, vol. 392, no. 10146, pp. 496-506. https://doi.org/10.1016/S0140-6736(18)31376-X
Mente, Andrew ; O'Donnell, Martin ; Rangarajan, Sumathy ; McQueen, Matthew ; Dagenais, Gilles ; Wielgosz, Andreas ; Lear, Scott ; Ah, Shelly Tse Lap ; Wei, Li ; Diaz, Rafael ; Avezum, Alvaro ; Lopez-Jaramillo, Patricio ; Lanas, Fernando ; Mony, Prem ; Szuba, Andrzej ; Iqbal, Romaina ; Yusuf, Rita ; Mohammadifard, Noushin ; Khatib, Rasha ; Yusoff, Khalid ; Ismail, Noor Hassim ; Gulec, Sadi ; Rosengren, Annika ; Yusufali, Afzalhussein ; Kruger, Lanthe ; Tsolekile, Lungiswa Primrose ; Chifamba, Jephat ; Dans, Antonio ; Alhabib, Khalid F. ; Yeates, Karen ; Teo, Koon ; Yusuf, Salim. / Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality : a community-level prospective epidemiological cohort study. In: The Lancet. 2018 ; Vol. 392, No. 10146. pp. 496-506.
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abstract = "Background: WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomised trials or observational studies. We investigated the associations between community-level mean sodium and potassium intake, cardiovascular disease, and mortality. Methods: The Prospective Urban Rural Epidemiology study is ongoing in 21 countries. Here we report an analysis done in 18 countries with data on clinical outcomes. Eligible participants were adults aged 35–70 years without cardiovascular disease, sampled from the general population. We used morning fasting urine to estimate 24 h sodium and potassium excretion as a surrogate for intake. We assessed community-level associations between sodium and potassium intake and BP in 369 communities (all >50 participants) and cardiovascular disease and mortality in 255 communities (all >100 participants), and used individual-level data to adjust for known confounders. Findings: 95 767 participants in 369 communities were assessed for BP and 82 544 in 255 communities for cardiovascular outcomes with follow-up for a median of 8·1 years. 82 (80{\%}) of 103 communities in China had a mean sodium intake greater than 5 g/day, whereas in other countries 224 (84{\%}) of 266 communities had a mean intake of 3–5 g/day. Overall, mean systolic BP increased by 2·86 mm Hg per 1 g increase in mean sodium intake, but positive associations were only seen among the communities in the highest tertile of sodium intake (p<0·0001 for heterogeneity). The association between mean sodium intake and major cardiovascular events showed significant deviations from linearity (p=0·043) due to a significant inverse association in the lowest tertile of sodium intake (lowest tertile <4·43 g/day, mean intake 4·04 g/day, range 3·42–4·43; change –1·00 events per 1000 years, 95{\%} CI –2·00 to –0·01, p=0·0497), no association in the middle tertile (middle tertile 4·43–5·08 g/day, mean intake 4·70 g/day, 4·44–5.05; change 0·24 events per 1000 years, –2·12 to 2·61, p=0·8391), and a positive but non-significant association in the highest tertile (highest tertile >5·08 g/day, mean intake 5·75 g/day, >5·08–7·49; change 0·37 events per 1000 years, –0·03 to 0·78, p=0·0712). A strong association was seen with stroke in China (mean sodium intake 5·58 g/day, 0·42 events per 1000 years, 95{\%} CI 0·16 to 0·67, p=0·0020) compared with in other countries (4·49 g/day, –0·26 events, –0·46 to –0·06, p=0·0124; p<0·0001 for heterogeneity). All major cardiovascular outcomes decreased with increasing potassium intake in all countries. Interpretation: Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate. Funding: Population Health Research Institute, Canadian Institutes of Health Research, Canadian Institutes of Health Canada Strategy for Patient-Oriented Research, Ontario Ministry of Health and Long-Term Care, Heart and Stroke Foundation of Ontario, and European Research Council.",
author = "Andrew Mente and Martin O'Donnell and Sumathy Rangarajan and Matthew McQueen and Gilles Dagenais and Andreas Wielgosz and Scott Lear and Ah, {Shelly Tse Lap} and Li Wei and Rafael Diaz and Alvaro Avezum and Patricio Lopez-Jaramillo and Fernando Lanas and Prem Mony and Andrzej Szuba and Romaina Iqbal and Rita Yusuf and Noushin Mohammadifard and Rasha Khatib and Khalid Yusoff and Ismail, {Noor Hassim} and Sadi Gulec and Annika Rosengren and Afzalhussein Yusufali and Lanthe Kruger and Tsolekile, {Lungiswa Primrose} and Jephat Chifamba and Antonio Dans and Alhabib, {Khalid F.} and Karen Yeates and Koon Teo and Salim Yusuf",
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TY - JOUR

T1 - Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality

T2 - a community-level prospective epidemiological cohort study

AU - Mente, Andrew

AU - O'Donnell, Martin

AU - Rangarajan, Sumathy

AU - McQueen, Matthew

AU - Dagenais, Gilles

AU - Wielgosz, Andreas

AU - Lear, Scott

AU - Ah, Shelly Tse Lap

AU - Wei, Li

AU - Diaz, Rafael

AU - Avezum, Alvaro

AU - Lopez-Jaramillo, Patricio

AU - Lanas, Fernando

AU - Mony, Prem

AU - Szuba, Andrzej

AU - Iqbal, Romaina

AU - Yusuf, Rita

AU - Mohammadifard, Noushin

AU - Khatib, Rasha

AU - Yusoff, Khalid

AU - Ismail, Noor Hassim

AU - Gulec, Sadi

AU - Rosengren, Annika

AU - Yusufali, Afzalhussein

AU - Kruger, Lanthe

AU - Tsolekile, Lungiswa Primrose

AU - Chifamba, Jephat

AU - Dans, Antonio

AU - Alhabib, Khalid F.

AU - Yeates, Karen

AU - Teo, Koon

AU - Yusuf, Salim

PY - 2018/8/11

Y1 - 2018/8/11

N2 - Background: WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomised trials or observational studies. We investigated the associations between community-level mean sodium and potassium intake, cardiovascular disease, and mortality. Methods: The Prospective Urban Rural Epidemiology study is ongoing in 21 countries. Here we report an analysis done in 18 countries with data on clinical outcomes. Eligible participants were adults aged 35–70 years without cardiovascular disease, sampled from the general population. We used morning fasting urine to estimate 24 h sodium and potassium excretion as a surrogate for intake. We assessed community-level associations between sodium and potassium intake and BP in 369 communities (all >50 participants) and cardiovascular disease and mortality in 255 communities (all >100 participants), and used individual-level data to adjust for known confounders. Findings: 95 767 participants in 369 communities were assessed for BP and 82 544 in 255 communities for cardiovascular outcomes with follow-up for a median of 8·1 years. 82 (80%) of 103 communities in China had a mean sodium intake greater than 5 g/day, whereas in other countries 224 (84%) of 266 communities had a mean intake of 3–5 g/day. Overall, mean systolic BP increased by 2·86 mm Hg per 1 g increase in mean sodium intake, but positive associations were only seen among the communities in the highest tertile of sodium intake (p<0·0001 for heterogeneity). The association between mean sodium intake and major cardiovascular events showed significant deviations from linearity (p=0·043) due to a significant inverse association in the lowest tertile of sodium intake (lowest tertile <4·43 g/day, mean intake 4·04 g/day, range 3·42–4·43; change –1·00 events per 1000 years, 95% CI –2·00 to –0·01, p=0·0497), no association in the middle tertile (middle tertile 4·43–5·08 g/day, mean intake 4·70 g/day, 4·44–5.05; change 0·24 events per 1000 years, –2·12 to 2·61, p=0·8391), and a positive but non-significant association in the highest tertile (highest tertile >5·08 g/day, mean intake 5·75 g/day, >5·08–7·49; change 0·37 events per 1000 years, –0·03 to 0·78, p=0·0712). A strong association was seen with stroke in China (mean sodium intake 5·58 g/day, 0·42 events per 1000 years, 95% CI 0·16 to 0·67, p=0·0020) compared with in other countries (4·49 g/day, –0·26 events, –0·46 to –0·06, p=0·0124; p<0·0001 for heterogeneity). All major cardiovascular outcomes decreased with increasing potassium intake in all countries. Interpretation: Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate. Funding: Population Health Research Institute, Canadian Institutes of Health Research, Canadian Institutes of Health Canada Strategy for Patient-Oriented Research, Ontario Ministry of Health and Long-Term Care, Heart and Stroke Foundation of Ontario, and European Research Council.

AB - Background: WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomised trials or observational studies. We investigated the associations between community-level mean sodium and potassium intake, cardiovascular disease, and mortality. Methods: The Prospective Urban Rural Epidemiology study is ongoing in 21 countries. Here we report an analysis done in 18 countries with data on clinical outcomes. Eligible participants were adults aged 35–70 years without cardiovascular disease, sampled from the general population. We used morning fasting urine to estimate 24 h sodium and potassium excretion as a surrogate for intake. We assessed community-level associations between sodium and potassium intake and BP in 369 communities (all >50 participants) and cardiovascular disease and mortality in 255 communities (all >100 participants), and used individual-level data to adjust for known confounders. Findings: 95 767 participants in 369 communities were assessed for BP and 82 544 in 255 communities for cardiovascular outcomes with follow-up for a median of 8·1 years. 82 (80%) of 103 communities in China had a mean sodium intake greater than 5 g/day, whereas in other countries 224 (84%) of 266 communities had a mean intake of 3–5 g/day. Overall, mean systolic BP increased by 2·86 mm Hg per 1 g increase in mean sodium intake, but positive associations were only seen among the communities in the highest tertile of sodium intake (p<0·0001 for heterogeneity). The association between mean sodium intake and major cardiovascular events showed significant deviations from linearity (p=0·043) due to a significant inverse association in the lowest tertile of sodium intake (lowest tertile <4·43 g/day, mean intake 4·04 g/day, range 3·42–4·43; change –1·00 events per 1000 years, 95% CI –2·00 to –0·01, p=0·0497), no association in the middle tertile (middle tertile 4·43–5·08 g/day, mean intake 4·70 g/day, 4·44–5.05; change 0·24 events per 1000 years, –2·12 to 2·61, p=0·8391), and a positive but non-significant association in the highest tertile (highest tertile >5·08 g/day, mean intake 5·75 g/day, >5·08–7·49; change 0·37 events per 1000 years, –0·03 to 0·78, p=0·0712). A strong association was seen with stroke in China (mean sodium intake 5·58 g/day, 0·42 events per 1000 years, 95% CI 0·16 to 0·67, p=0·0020) compared with in other countries (4·49 g/day, –0·26 events, –0·46 to –0·06, p=0·0124; p<0·0001 for heterogeneity). All major cardiovascular outcomes decreased with increasing potassium intake in all countries. Interpretation: Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate. Funding: Population Health Research Institute, Canadian Institutes of Health Research, Canadian Institutes of Health Canada Strategy for Patient-Oriented Research, Ontario Ministry of Health and Long-Term Care, Heart and Stroke Foundation of Ontario, and European Research Council.

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