This document discusses the relationship between salt/sodium intake and cardiovascular disease. It provides a brief history of salt use throughout civilizations and discusses how salt intake affects health outcomes like hypertension, stroke, kidney disease, and others. Several studies are summarized that show reducing salt intake through dietary or pharmaceutical interventions can lower blood pressure and reduce risks of cardiovascular events. Overall, the document argues that reducing salt intake is an important strategy for preventing cardiovascular disease.

1. Salt and Cardiovascular disease
Jafar Al-Said, M.B. CHb. MD. FASN
Nephrology and Internal Medicine Consultant
Bahrain Specialist Hospital 1

2. Presentation scheme:
 Introduction.
 Historical points.
 Salt effect on health:
 HTN.
 Stroke.
 Kidney disease.
 Kidney stones.
 Osteoporosis.
 Stomach Cancer.
 Obesity.
 Meniere’s disease.
 Alzheimer’s disease
 Conclusion.
2

3. NaCl
Source: 1- Mining.
2- Sea Water (brine)
3

4. Boiling Brine into pure salt
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5. Relation of Salt and Na:
Table Salt had 40%-60% Na.
1 gm salt has 400mg-600mg Na.
One tea spoon of Salt has :
-2300 mg Na.
-3500-5500 mg Salt.
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6. Introduction
1. Salt played an important part in Civilizations for
centuries.
2. Its use mentioned since 6050 BC.
3. Egyptian were using it for trade between
Phoenicians an Mediterranean's.
4. It is a major preservative. It was used in preparing
conserving the Mummies in Egypt.
5. It is mentioned in Assyrian, Babylonian, Chinese
and Greek history.
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7. Historic points
Salary = Salarium Argentum= Salt rations for
roman solders.
Salad = Salt.
 One of the commodities in the past.
 Used as Currency and trade.
 Soldiers were paid by Salt.
 Taxies were put on salt trade.
Salt raotes in the Roman times.
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8. Roman Salt Roats
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9. Romans Salt Routes.
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10. Salt in different countries
 Austria: Salzburg = City of Salt.
 Tuzla: Bosina-Herzegovina. ( Tuz= Salt).
 Jordan: As-Salt town. In Byzantine times.
 Syracuse, New York = Salt City.
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11. Salt in Wars and Revolutions:
 16th Century; Spanish bankruptcy after blockade of Iberian Salt
works by Dutch.
 1789-1791; French Revolution.
 18th century Salt played a role in the American Revolutions when
British strategies were to deny American rebels access to salt.
 1812; Napoleon retreat from Moscow many soldiers died because
of unhealed wound from lack of salt.
 1864. American Civil war. Saltville battle in Virginia.
 1930, Gandhi Revolution against British salt taxation in India.
Walk to the sea to gather tax free salt for nations poor.
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12. Salt Monopoly and taxation
 2200 BC Chinese emperor taxed salt.
 1259-1946; “Gabelle” French kings used salt tax.
 1785 Salt Taxes support British colonies. 10000 peoples
arrested in England for smuggling salt.
 1825; Erie Canal in New York. The ditch that salt built. Salt
tax revenues paid half cost.
 Until 1975 Italy taxes the Salt by 70%.
 World free trade had lead to abolishing of this Monopoly.
As in Taiwan.
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13. 13

14. Salt and religion.
 Egyptian Mummies.
 Greek Worshippers.
 Jewish Temple offering include salt.
 Catholic Church use salt in Purifying rituals.
 Buddhist salt repels evil spirit.
 1933 Dalai Lama buried sitting up in a bed of
Salt.
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15. Last Supper; Leonardo da Vinci
1495-1498
15

16. Last Supper; Leonardo da Vinci
1495-1498
16

17. Lets go back to our real medical
world
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21. 21

22. Recommended daily intake of Salt
Age Max. Salt intake/ day
0-6 months <1gm
6-12 months 1gm
1-3 years 2gm
4-6 years 3gm
7-10 years 5gm
>11 years 6gm
22

23. Average Daily Salt Intake in Male and Female Americans, as Ascertained from 24-
Hour Dietary Recall, 2005–2006.
Appel LJ, Anderson CA. N Engl J Med 2010;362:650-652.
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24. Salt and Hypertension
Animal studies : BP in Chimpanzees with modification of salt
10-15gm/day
Denton D, Weisinger R, Mundy N I, et al. The effect of increased salt
intake on blood pressure of chimpanzees. Nat Med. 1995;1:1009-16.
25

25. Epidemiology
 Communities with high salt consumption
showed higher BP.
Page L B, Damon A, Moellering R C, Jr. Antecedents of cardiovascular disease in six
Solomon Islands societies. Circulation. 1974;49:1132-46.
Page L B, Vandevert D E, Nader K, Lubin N K, Page J R. Blood pressure of Qash'qai
pastoral nomads in Iran in relation to culture, diet, and body form. Am J Clin Nutr.
1981;34:527-38.
26

26. Epidemiologic studies
Intersalt study:
N = 10079.
Adults 20-59 years.
Global medical centers = 52 from 32 countries.
Aim: Investigate the relation of electrolyte
excretion to BP.
INTERSALT. Intersalt: an international study of electrolyte excretion and blood
pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt
Cooperative Research Group. Bmj. 1988;297:319-28.
27

27. Intersalt results
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28. Dose response salt reduction
Dose-response relationship between the reduction in salt intake as judged by reduction in 24h
urinary sodium and systolic blood pressure.
INTERSALT. Intersalt: an international study of electrolyte excretion and blood pressure. Results for
24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. British
29
Medical Journal. 1988; 297, 319-28

29. Reducing Salt reduce BP
Trial of Hypertension Prevention( TOHP I & II)
Cumulative incidence of cardiovascular disease (CVD) by sodium intervention group in TOHP I
and II, adjusted for age, sex, and clinic
 Interventional study.
 N = 3000.
 Randomized to salt reduction and control.
 In two cohort populations.
 Net salt reduction was 33-44mmol/day.
 Followed for 10-15years.
Results:
 Cardiovascular events were 25% less in the
interventional group.
30

30. Trial of Hypertension Prevention (TOHP I & II)
Cumulative incidence of cardiovascular disease (CVD) by sodium intervention group in
TOHP I and II, adjusted for age, sex, and clinic
N=3000.
TOHP I = 18 months
TOHP II = 36-48 months.
Decreased salt by 25-30%
Results:
TOHP I decreased BP -1.7/0.9mmHg.
TOHP II decreased BP – 1.2/0.7mmHg
Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK Appel LJ & Whelton PK. Long
term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of
the trials of hypertension prevention (TOTP). BMJ, Apr 2007; 334: 885; doi: 10.1136/bmj.39147.604896.55
31

31. Reducing salt reduce BP in South
Asian population in UK
• Modest salt reduction
4gm/day for 6 wks.
• Decreased BP by -5.4/2.2
mmHg
He et al. Effect of Modest Salt reduction on Blood Pressure, Urinary Albumin and pulse Wave velocity in
white, black and Asian mild hypertensives. Hypertension. 2009; 54, 482-488. 32

32. Salt reduction in new born.
Aim: effect of low salt diet on new born BP.
 N=500 new born.
 For 6months.
 Randomized study to moderate salt reduction.
Results :
 At 6 months the systolic BP was lower by 2.1mmHg.
 The reduction in BP was maintained after 15 years.
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33. Results:
Hofman A, Hazebroek A, Valkenburg H A. A randomized trial of sodium intake and blood
pressure in newborn infants. Jama. 1983;250:370-3.
Geleijnse J M, Hofman A, Witteman J C, et al. Long-term effects of neonatal sodium
restriction on blood pressure. Hypertension. 1997;29:913-7.
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34. Two Village controlled Low salt study
 2 villages in Portugal.
 One village had been offered low salt processed
food.
 It was given information on how to reduce the salt.
Results:
 After one year BP was less and in two years both
systolic and diastolic BP were lower.
Forte J G, Miguel J M, Miguel M J, et al.. Salt and blood pressure: a community trial. J Hum
Hypertens. 1989;3:179-84.
36

35. Results:
Forte J G, Miguel J M, Miguel M J, et al.. Salt and blood pressure: a community trial.
J Hum Hypertens. 1989;3:179-84.
38

36. Population studies
Japan:
Reducing salt from 18gm to 14 gm over one decade.
Stroke mortality reduced by 80%.
Iso H, Shimamoto T, Yokota K, et al. [Changes in 24-hour urinary excretion of sodium and
potassium in a community-based heath education program on salt reduction]. Nippon
Koshu Eisei Zasshi. 1999;46:894-903.
Finland:
14000 population with instruction to reduce salt increase
fruits and vegetables and stop smoking.
 Reduced stroke mortality by 66%
 Reduced CAD mortality by 55%.
RR= 0.5 for salt reduction.
Vartiainen E, Sarti C, Tuomilehto J, Kuulasmaa K. Do changes in cardiovascular risk
factors explain changes in mortality from stroke in Finland ? Bmj. 1995;310:901-4.
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37. Mortality and salt intake
Finland: increased salt intake showed increase
Cardiovascular and total Mortality.
Randomized controlled trial
Increased 6 gm of Salt/day
Tuomilehto J, Jousilahti P, Rastenyte D, Moltchanov V, Tanskanen A, Pietinen P, Nissinen A.
Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study. Lancet.
40
2001;357:848-51

38. Treatment trials
Reduced salt intake from 10-12gm/day to 5-6gm/day
will:
1.Reduce BP as single AntiHTN.
2.Additive to AntiHTN.
3.More in low renin; blacks and elderly.
MacGregor G A, Markandu N D, Best F E, et al. Double-blind randomised crossover
trial of moderate sodium restriction in essential hypertension. Lancet. 1982;1:351-5.
He F J, Markandu N D, Sagnella G A, MacGregor G A. Importance of the renin
system in determining blood pressure fall with salt restriction in black and white
hypertensives. Hypertension. 1998;32:820-4.
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39. Treatment trials
Salt reduction in three levels 12, 6, 3gm/day.
In mild untreated essential HTN individuals:
 Lower BP in lower salt intake.
 Continued BP control for one year.
MacGregor G A, Markandu N D, Sagnella G A, et al. Double-blind study of three
sodium intakes and long-term effects of sodium restriction in essential hypertension.
Lancet. 1989;2:1244-7.
42

40. Meta-analysis of salt reduction and
BP changes
28 RCT trials
Salt reduce from 10 to 5gm.
4wks.
Results:
Reduce salt 6gm/day:
24% decreased stroke death.
20% decrease IHD death
He F J, MacGregor G A. Effect of modest salt reduction on blood pressure: a meta-
analysis of randomized trials. Implications for public health. J Hum Hypertens.
2002;16:761-70. 46

41. Salt intake and stroke death
Perry IJ, Beevers DG. Salt intake and stroke: a possible direct effect. Journal of Human
Hypertension. 1992; 6, 23-25
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42. NIH report 2010
Salt reduction is No.1 Cardiovascular preventive
measure.
Aim to decrease daily salt to:
 6gm in 2015.
 3gm in 2025.
NICE. Prevention of Cardiovascular Disease. Public health guidance 25. Published June
2010
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44. As part of the implementation of the WHO Global Strategy on Diet,
Physical Activity and Health and the 2008-2013 Action Plan for the
Global Strategy for the Prevention and Control of Noncommunicable
Diseases
50

45. Most Americans Should
Consume Less Sodium
(1,500 mg/day or less
Current dietary guidelines for Americans recommend that adults in general should
consume no more than 2,300 mg of sodium per day. At the same time, consume
potassium-rich foods, such as fruits and vegetables. However, if you are in the
following population groups, you should consume no more than 1,500 mg of sodium
per day, and meet the potassium recommendation (4,700 mg/day) with food.
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48. Relation of Salt to LVH in individuals
with systolic BP >121mmHg.
Schmeider RE et al. Dietary salt intake. A determinant of cardiac involvement in essential
hypertension. Circulation. 1988; 78, 951-956
54

49. Cochrane review
Aim: Salt reduction and Cardiovascular Mortality.
Total studies were 7 RCTs.
Population was 6489.(758 (11.6 %)were HTN).
Follow up was variable 3-13 years.
Results:
No strong evidence that reduce salt is beneficial.
2.6 folds higher mortality in heart failure with
decreased salt intake.
Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim SPublished Online: October 5, 2011
Advice to reduce the amount of salt eaten reduces blood pressure but there is
insufficient evidence to confirm the predicted reductions in people dying prematurely or
suffering cardiovascular disease 58

50. Salt intake & Proteinuria
 Decreased Salt intake from 10gm to 5gm
decreased urine protein by 19.4%.
Swift P A, Markandu N D, Sagnella G A, He F J, Macgregor G A. Modest Salt
Reduction Reduces Blood Pressure and Urine Protein Excretion in Black
Hypertensives. A Randomized Control Trial. Hypertension. 2005; 46:308-12
 Decreased Salt from 9.7gm to 6.5gm decrease
24 hour albuminuria.
He FJ, Marciniak M, Visagie E, et al: Effect of modest salt reduction on blood
pressure, urinary albumin, and pulse wave velocity in white, black, and Asian mild
hypertensives. Hypertension 54: 482-488, 2009
59

51. Water retention
Access Salt cause more water retention in:
 Heart failure.
 Renal failure.
 Cirrhosis patients.
 In women cyclical and idiopathic edema.
 Sitting for long time like long flights.
MacGregor G A, de Wardener H E, Idiopathic edema., in Diseases of the kidney.,
G.C. Schrier RW, Editor. 1997, Little Brown and Company.: Boston. p. 2343-2352.
Perry I J, Beevers D G. Salt intake and stroke: a possible direct effect. J Hum
Hypertens. 1992;6:23-5.
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52. Salt and vascular dementia
Salt
HTN
Stroke
Vascular
dementia
• Passmore P. Preventing dementia following a stroke. The Journal of Quality Research in Dementia.
2008;Issue 66.
• Fratiglioni L et al. Prevention of Alzheimer’s disease and dementia. Major findings from the
Kungsholmen project. Physiology & Behaviour.2007; 92;, 98-104.
• Stewart R et al. Change in blood pressure and incident dementia. A 32 year prospective study.
Hypertension. 2009; 54, 233-240.
• Nagai M et al. Hypertension and Dementia. American Journal of Hypertension. 2010; 23(2), 116-12465

53. How to start decreasing the salt in a
community?
Laws to start to enforce:
 Establishing and evaluating public-awareness campaigns.“
 "Setting progressive salt targets for reformulating existing
processed food and engaging with the food industry in setting
standards for new foods."
 "Surveying population salt intake, progress of reformulation,
and effectiveness of communication."
 "Engagement with industry, including regulation, to create a
level playing field so as not to disadvantage more enlightened
and progressive companies."
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54. Conclusion:
 Salt is strongly related to our lives.
 It is one of the oldest compounds used.
 It is strongly related with many diseases:
 HTN.
 Stroke.
 Kidney disease.
 Kidney stones.
 Osteoporosis.
 Stomach Cancer.
 Obesity.
 Meniere’s disease.
 Alzheimer’s disease. 70

55. Take Home Message
Reducing salt in our diet is recommended.
Normotensive: 4-6 gm per day.
Hypertensive: 2-4 gm per day.
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