The Benefits and Detriments of Salt: It's Complicated

June 15, 2016

The Benefits and Detriments of Salt: It's Complicated

  1. Harlan M. Krumholz, MD, SM

The effects differ between those with and without hypertension.

  1. Harlan M. Krumholz, MD, SM

Controversy surrounds recommendations about sodium consumption. In a pooled analysis of four partially manufacturer-supported studies involving 133,118 individuals from 49 countries (roughly half hypertensive and half normotensive), investigators sought to define the relationship between sodium intake and cardiovascular events. The study group comprised participants in four prospective studies for whom measures of 24-hour urinary sodium excretion were available. These measures were used to infer intake. The median follow-up was 4.2 years.

The results varied by hypertension status: higher sodium intake was most strongly associated with higher systolic blood pressure in those with hypertension, although the association was positive in both groups. Higher sodium intake (sodium excretion, ≥7 g/day) was associated with higher risk for all-cause death and major cardiovascular events only in those with hypertension. Lower sodium intake (excretion, <3 g/day) was associated with increased risk for death and major cardiovascular events in both those with hypertension and those without.


This large, international study shows interesting complexity in the relationship of sodium intake to risk. Lower intake was a consistent risk-raising factor, whereas higher intake was a risk factor only for those with hypertension. In an era of precision medicine, these findings raise questions regarding our ability to determine why risk is associated with sodium intake in some and, ultimately, our ability to determine individual risk. A one-size-fits-all approach may not serve everyone, and for now, these results suggest that people with hypertension have the most to gain by avoiding high-sodium diets.

Editor Disclosures at Time of Publication

  • Disclosures for Harlan M. Krumholz, MD, SM at time of publication Consultant / Advisory board United Healthcare (Advisory Board); Element Science (Consultant) Equity ImageCor; Hugo PHR Grant / Research support Agency for Healthcare Research and Quality; Food and Drug Administration; National Heart, Lung, and Blood Institute; Robert Wood Johnson Foundation; Medtronic; Johnson & Johnson; Chinese National Center for Cardiovascular Disease; Centers for Medicare & Medicaid Services Editorial boards; American Journal of Managed Care; American Journal of Medicine; Archives of Medical Science; Critical Pathways in Cardiology; Current Cardiovascular Risk Reports; JACC: Cardiovascular Imaging; Circulation: Cardiovascular Quality and Outcomes; Circulation (Associate Editor)


Reader Comments (3)

Jerry Amos Other, Other, Home, retired

My blood tests show sodium levels fine, just above mid-range.
We eat mostly whole foods vegetables, fruits, nuts & seeds including legumes, whole grains. We don't add the salt in recipes. We do little processed foods.
I'm 81, blood pressure fine. At 58 my blood pressure started creeping up, I started keeping servings of processed food less than 100 mg and blood pressure went down. That's pretty tough with bread since one slice is typically well above 100mg. I have located some below a 100mg for occasional use, I eat some flat breads and crackers well below 100mg.
My opinion, sodium prevalence is primarily as a very cheap substitute for spices.
We do a small strip of kelp for iodine.

JUNE M SPOONER Other, Unspecified, retired

this article is very true. I wanted to say that natural "unrefined" sea salt has no harm at all....many good nutrients are in it....thank you-

H ROBERT SILVESTEIN Physician, Cardiology, Preventive Medicine Center

This article & the review are misguided to begin with. The history of the human race is that just about 200 (two hundred) mg/day is our historical baseline sodium intake. There are currently hypertensionless (systolic BP 90-110 and never above) societies that still have that same intake/day. 3 grams/day is likely our top SAFE sodium intake level. Salt has always been a luxury & the phrase "salt money" reflects that first available spendable income after necessities. Higher salt intake is related to the development of LVH even in the absence of HBP, osteoporosis and MS...

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