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Journal of Cardiovascular Nursing:
doi: 10.1097/JCN.0b013e3181ec4b7b
DEPARTMENTS: Progress in Prevention

Dietary Sodium Reduction: A Public Health Approach to Decreasing Hypertension

Hughes, Suzanne MSN, RN, FAHA, FPCNA

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Suzanne Hughes, MSN, RN, FAHA, FPCNA Director, Health Education and Nursing Research, Robinson Memorial Hospital, Ravenna, Ohio.

Correspondence Suzanne Hughes, MSN, RN, FAHA, FPCNA, Health Education and Nursing Research, Robinson Memorial Hospital, 6847 N. Chestnut, Ravenna, OH 44266 (

In the years between 1960 and 1991, the prevalence of hypertension in the United States decreased from 29.7% to 20.4%. The recognition of hypertension as the "silent killer" and the work of the National High Blood Pressure Education Program contributed to this public health success. In recent years, however, hypertension has reemerged as a major public health problem. The prevalence of hypertension in US adults has steadily increased and now hovers between 29% and 30%. This increase is due in part to aging demographics as well as the epidemic of overweight and obesity. It is now estimated that nearly 75 million or 1 in every 3 adults has hypertension.1

Hypertension constitutes a significant risk factor for myocardial infarction, stroke, heart failure, and renal failure. Cardiovascular clinicians have an enormous armamentarium of pharmacological agents that, particularly when used in combination, have the potential to control most cases of hypertension; indeed, control rates have risen over time, according to an article published in The Journal of the American Medical Association in May 2010.2 In an accompanying editorial, Aram Chobanian,3 Boston University Medical Center, and first author of the Joint National Committee on the Prevention Detection and Treatment of Hypertension (JNC 7) guidelines,4 commented that although the progress in treatment is encouraging, rates of high blood pressure will continue to rise as the population ages unless steps are taken to change some of its underlying causes.

Ford and colleagues,5 in a recent article, calculated the percentage of Americans considered "low risk" for CVD. The trend from the period 1999 to 2004 was unfavorable, demonstrating that only 7.5% (down from 10.5% in the period 1988-1994) would be considered low risk. One factor contributing to this negative trend was the decrease in the percentage of normotensive patients.

Recently, the Institute of Medicine (IOM), in its report entitled "A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension," published in February 2010, declared high blood pressure a "neglected disease."6 In its report, the IOM called for population-based strategies designed to impact large numbers of people and improve population health status. The IOM further championed behavioral and lifestyle interventions that target risk factors that contribute to hypertension, identifying the following: unhealthy diets, excess salt consumption and low dietary potassium intake, overweight/obesity, and sedentary lifestyles.

In April 2010, the IOM released a second report related to the hypertension document, "Strategies to Reduce Sodium Intake in the United States," focusing on a population approach to dietary sodium reduction.7 In 2008, Congress actually petitioned the IOM for recommendations on strategies to reduce dietary sodium intake. The average intake of sodium for American adults is approximately 3400 mg daily, fully 50% more than the current upper limit recommendation of no more than 2300 mg daily. (Actually, for at least 70% of adults in the United States-those with hypertension, African Americans, and those older than 40 years-the daily consumption of sodium should not exceed 1500 mg.8) Typically, when clinicians open a dialogue with hypertensive or heart failure patients regarding reducing dietary sodium intake, patients often reply that "the salt shaker is not even on the table," unaware that only about 6% of dietary sodium comes from salt added at the table. Approximately 75% of dietary sodium comes from processed food.9

Voluntary efforts to reduce sodium intake have been unsuccessful. The IOM recommends a coordinated approach and calls for government standards for levels of sodium in foods. The proposed strategy involves a gradual approach to meet recommended standards using a stepwise reduction of the sodium content in foods, such that the change would be nearly imperceptible to consumers. A similar approach was taken in the in the United Kingdom. The UK Food Standards Agency, an independent government agency charged with food safety, initiated its work with food manufacturers in the United Kingdom in 2003 to decrease sodium content in certain foods. This has resulted in nearly a 10% decrease in the population sodium intake. Efforts in the United Kingdom have resulted in a reduction of the average population intake of sodium from 3800 mg in 2004 to 3440 mg in 2008.10

Intuitively, a similar benefit might be expected in the United States. Recently, a scientific approach was taken to examine the potential impact. Bibbins-Domingo and colleagues11 used a computer-simulated Coronary Heart Disease Policy Model to calculate the cardiovascular benefits of population-wide reductions of 1200 mg daily in dietary sodium intake. They projected that this population strategy could reduce the annual number of deaths from stroke to 66 000 from 98 000, and myocardial infarction to 99 000 from 153 000. Although both older and younger, all races, men and women would benefit, blacks would benefit proportionately more. Women benefit especially from reduction in stroke risk. The projected CVD risk reduction associated with reduced sodium intake is as powerful as that associated with population-wide reduction in tobacco use.11

Counseling hypertensive and heart failure patients on reduced dietary sodium intake requires enormous resources of time, effort, and repetition. Many cardiovascular nurses can attest to the disappointing and inconsistent results.12 We can all recall a patient with heart failure experiencing a life-threatening exacerbation of disease due to an unintentional dietary indiscretion. The expectation that patients will be able to adhere to recommendations by reading and understanding food labels and choosing wisely may be impractical.13

In a New England Journal of Medicine editorial addressing the potential benefit of a population-based approach, Appel and Anderson comment, "As we deliberate health care reform, let us not neglect this inexpensive, yet highly effective public health intervention for the prevention of disease."13 The recognition of hypertension as a "neglected disease" creates an opportunity for cardiovascular nurses to embrace in both the clinical setting and the population health arenas. Public health experts and leaders from the food industry are leveraging the IOM report to inform the public about the call to action to lower the sodium content in foods. The time is now for cardiovascular nursing to add its powerful voice and clinical insight to population-based preventive strategies. Dr Chobanian3 declared, "In the long run, the far superior approach to controlling hypertension and cardiovascular diseases will be prevention rather than treatment."

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10. He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens. 2009;23:363-384.

11. Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010;362:590-599.

12. Wingate S. Moving beyond the salt shaker. Heart Lung. 2010;39(2):93.

13. Appel LJ, Anderson CAM. Compelling evidence for public health action to reduce salt intake. NEJM. 2010;362:650-652.

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