Nutr Res Pract.  2020 Oct;14(5):501-518. 10.4162/nrp.2020.14.5.501.

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

Affiliations
  • 1Department of Food and Nutrition, Human Ecology Research Institute, Chonnam National University, Gwangju 61186, Korea
  • 2Department of Public Health Sciences, BK21PLUS Program in Embodiment: Health-Society Interaction, Graduate School, Korea University, Seoul 02841, Korea
  • 3Friedman School of Nutrition Science & Policy, Tufts University, Boston, MA 02111, USA

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 CVDassociated deaths attributable to high sodium intake/excretion also decreased. In terms of association with mortality, when participants were grouped into quartiles (Q) by energyadjusted 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.

Keyword

Sodium; cardiovascular disease; mortality; mortality

Figure

  • Fig. 1 Flow chart of study subject selection for the CRA analysis and mortality association analysis. The number of study participants were represented as a range because there were differences in survey questionnaire and number of participants every year. (A) Flow chart for CRA analysis about dietary sodium intake. (B) Flow chart for CRA analysis about urinary sodium excretion. Urinary sodium excretion was only available in 2008–2011 and 2014–2016. (C) Flow chart for mortality association analysis about dietary sodium intake. Mortality data were available in 2007–2015.KNHANES, Korea National Health and Nutrition Examination Survey; CRA, comparative risk assessment.

  • Fig. 2 Trend in sodium exposure determined by (A) dietary sodium intake and (B) estimated 24-h urinary sodium excretion between 1998 and 2016 by sex and age.P, P for trend.

  • Fig. 3 PAFs of (A) stroke and (B) IHD by high sodium intake between 1998 and 2016 according to sex and age.PAF, population attributable fraction; IHD, ischemic heart disease; P, P for trend.

  • Fig. 4 PAFs of (A) stroke and (B) IHD by high levels of estimated 24-h urinary sodium excretion between 2008 and 2016 according to sex and age.PAF, population attributable fraction; IHD, ischemic heart disease; P, P for trend.

  • Fig. 5 Estimated number of deaths due to high sodium intake or excretion by disease and year.HSTK, hemorrhagic stroke; IHD, ischemic heart disease; ISTK, ischemic stroke.

  • Fig. 6 HRs for all-cause mortality according to the quartile of energy-adjusted sodium intake. HRs were obtained by Cox regression analysis controlled for age, sex, region, education, income, tobacco use, alcohol use, physical activity, body mass index, total energy intake, presence of diabetes or hypertension at baseline.CI, confidence interval; HR, hazard ratio; Q, quartiles.*P < 0.05.

  • Fig. 7 HRs for CVD-associated mortality according to the quartile of energy-adjusted sodium intake. HRs were obtained with Cox regression analysis controlled for age, sex, region, education, income, tobacco use, alcohol use, physical activity, body mass index, total energy intake, presence of diabetes or hypertension at baseline.CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio; Q, quartiles.*P < 0.05.


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