Why Salt Restrictions?

Personalized medicine may provide a better way of determining the ideal range for sodium consumption.

An outstanding 93% of patients with diabetes, with the highest risk for developing cardiovascular complications, do not meet low sodium dietary goals. Sara Baqar, an Australian endocrinologist and Ph.D. candidate, found that sodium and potassium consumption does not change among patients with diabetes, regardless of all the investment in public health advocacy. The absence of dietary change is dangerous.  

The dietary sodium and potassium consumption of 904 patients were assessed using 24-hour urinary excretion values (24hUNa), a significant indicator of cardiovascular mortality. The participants from Melbourne University, a teaching hospital with many diabetes outpatient clinics, involved 551 men and 343 women. The mean age was 60 years old. The study consisted of patients with type 1 (n = 144) and type 2 (n = 732) diabetes. Ten participants had latent adult autoimmune diabetes (LADA).  

The mean of four excretion values was recorded throughout the seven years of research to determine if participants met the threshold set by the American Diabetes Association (ADA). The ADA recommends the consumption threshold of less than 2,300 mg of sodium per day for patients with diabetes.  

Only 7% of the participants in the cohort study were successful in meeting the threshold. The univariate analysis showed that men were less likely to meet the restriction criteria (OR = 0.40; 95% CI, 0.31–0.52). The study found that as a patient’s experience with diabetes increased, they became more willing or able to control their sodium consumption (OR = 1.04; 95% CI, 1.02–1.05). Furthermore, higher estimated glomerular filtration rates (OR = 0.99; 95% CI, 0.99–1.00) and triglyceride levels (OR = 0.81; 95% CI, 0.71–0.92) are markers that predict participants will not meet the lower sodium consumption goals. 

Baqar’s research challenges the conventional approach to sodium management in high-risk patients with diabetes. She asks, “Would it be more meaningful for these public health bodies to work with relevant food industry bodies and commit to reducing sodium contents in processed foods?” Dr. Baqar’s research population was patients with diabetes; should healthy people with no health issues also be concerned about their sodium intake? 

Dr. Vallejo, an epidemiologist, revealed that healthy people with no health issues did not meet the World Health Organization recommendation for sodium intake (<2000 mg/d).  He is the head of the department of Instituto Nacional de Cardiología in Mexico. Similar to Dr. Baqar’s research, he analyzed the 24-hour urinary excretion value to assess the sodium and potassium intake of 711 clinically healthy participants in the Tlalpan 2020 cohort study.  The one-year study found that an outstanding 83% of healthy individuals failed to maintain the recommended sodium intake; indeed, an alarming concern. 

However, lowering all sodium consumption for everyone through government regulation on the food industry may cause more harm to mortality than good.  

Dr. Graudal, a Rheumatologist at Copenhagen University Hospital, performed a study to investigate further the effects of sodium on the general healthy population, irrespective of race, age, and sex.  A meta-analysis from 23 cohort studies and two follow-up studies of randomized controlled trials of 274,683 participants revealed a U-shaped association between sodium intake and undesired health outcomes. The data showed that increased risk in mortality, associated with participants, was found at the low and high extremes of sodium dietary intake data. Everyone, not just patients with diabetes, must maintain a specific sodium intake range to protect themselves from increased mortality risk.

Modern medicine is moving forward to personalized therapy; beyond the conventional, “one physician fits all” approach. Baqar and many health communities emphasize that more attention must be focused on personalized dietary sodium management plans, not only for patients with diabetes but also for everyone, complementary to glucose management. Collaborative efforts made among healthcare professionals, agriculture leaders, and communities are necessary to decrease diabetes-related cardiovascular mortality and increase treatment holistically.  

Practice Pearls: 

• Patients rarely meet recommended sodium dietary guidelines. 
• Increased attention to sodium management is needed to promote improved clinical outcomes.  
• Collaboration among all parts of government, healthcare workers, and society is a vital tool to combat diabetes-related mortality. 

Ekinci, Elif I et al. “Dietary salt intake and mortality in patients with type 2 diabetes.” Diabetes care vol. 34,3 (2011): 703-9. doi:10.2337/dc10-1723 

Monostra, Michael. “Sodium, Potassium Guidelines Rarely Met by Adults with Diabetes.” Healio, 2020 

Graudal, Niels et al., Compared With Usual Sodium Intake, Low- and Excessive-Sodium Diets Are Associated With Increased Mortality: A Meta-Analysis, American Journal of Hypertension, Volume 27, Issue 9, September 2014, Pages 1129–1137, https://doi.org/10.1093/ajh/hpu028 

Vallejo, Maite, et al. “Assessment of Sodium and Potassium Intake by 24 h Urinary Excretion in a Healthy Mexican Cohort.” Archives of Medical Research, vol. 48, no. 2, Feb. 2017, pp. 195–202. EBSCOhost, doi:10.1016/j.arcmed.2017.03.012. 

Peter Jay Won, Pharm.D. Candidate, University of South Florida, Taneja College of Pharmacy 

See more about the role of diet and nutrition in diabetes management.