Salt and Cardiovascular Disease: Insufficient Evidence to Recommend Low Sodium intake

Martin O'Donnell; Andrew Mente; Michael H. Alderman; Adrian J.B. Brady; Rafael Diaz; Rajeev Gupta; Patricio López-Jaramillo; Friedrich C. Luft; Thomas F. Lüscher; Giuseppe Mancia; Johannes F.E. Mann; David McCarron; Martin McKee; Franz H. Messerli; Lynn L. Moore; Jagat Narula; Suzanne Oparil; Milton Packer; Dorairaj Prabhakaran; Alta Schutte; Karen Sliwa; Jan A. Staessen; Clyde Yancy; Salim Yusuf


Eur Heart J. 2020;41(35):3363-3373. 

In This Article

Is There a Fundamental Flaw in Public Health Policy for Very Low Sodium Intake?

An arguable flaw in the current approach to dietary guidelines is the level of evidence required before determining a recommended intake range or target. In the case of sodium intake, the original decision to target low sodium intake (<1.5 g/day) was based on a meta-analysis of small and short-term trials demonstrating a reduction in blood pressure and the DASH-Sodium trial,[18] which evaluated low sodium intake for 30 days. In general, the evidence required to make a strong dietary recommendation has been of lower strength and quality compared with the evidence required to recommend a medication for a given indication. Guidelines on sodium intake were implemented without considering that a valid and convenient measure of sodium intake in individuals was not available, without evidence that achieving very low levels of sodium intake was feasible (and had never been demonstrated in general populations), without adequate regard to the effects on consumption of other foods and nutrients (e.g. potassium intake), and without sufficient evidence that low sodium intake would reduce cardiovascular events (compared with usual moderate levels of intake).

Two guideline panels have adopted the GRADE system for representing the strength of evidence.[4,5] However, the GRADE approach was primarily developed to summarize evidence related to medical interventions (i.e. medicines and medical devices). The application of GRADE methodology for developing guideline recommendations on public health interventions presents challenges, particularly for essential nutrients where observational studies play an important role.[121] There is a clear need for new methodologies, or refinement of existing ones, to address recommendations for assessing the health effects of essential nutrients.