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The association between salt intake and blood pressure is mediated by body mass index but modified by hypertension: The ELSA-Brasil study

Journal of Human Hypertension volume 37, pages 472–479 (2023)Cite this article

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Abstract

High salt intake has been linked to both obesity and high blood pressure (BP). Part of the variability of BP attributed to salt intake might be BMI-mediated. To investigate whether hypertension would be an effect modifier in the complex network including salt intake, obesity, and BP, we tested the hypothesis that salt intake has direct and BMI-mediated effects on systolic (SBP) and diastolic blood pressure (DBP). Data from 9,028 participants (aged 34–75 years, 53.6% women) were analyzed. A validated formula was used to estimate daily salt intake from the sodium excretion (12 h urine collection). A path model adjusted for covariates was designed in which salt intake has both a direct and a BMI-mediated effect on BP. In normotensives, standardized beta coefficients showed significant direct (Men: 0.058 and 0.052, Women: 0.072 and 0,061, P < 0.05) and BMI-mediated (Men: 0.040 and 0.065, Women: 0.038 and 0.067, P < 0.05) effect of salt intake on the SBP and DBP, respectively. However, in hypertensive individuals, neither the direct (Men: 0.006 and 0.056, Women: 0.048 and 0.017) nor the indirect effect (Men: −0.044 and 0.014, Women: 0.011 and 0.050) of salt intake on the SBP and DBP were significant. These data suggest that cardiovascular risk stratification should consider the complex interaction between salt intake and weight gain, and their effects on BP of normotensive and hypertensive individuals.

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Fig. 1: Pearson correlation between salt intake and blood pressure.
Fig. 2: Path diagrams for the association of salt intake and SBP having BMI as a mediator.
Fig. 3: Path diagrams for the association of salt intake and DBP having BMI as a mediator.

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Data availability

Additional data are available from the corresponding author on reasonable request.

References

  1. Balakumar P, Maung-U K, Jagadeesh G. Prevalence and prevention of cardiovascular disease and diabetes mellitus. Pharm Res. 2016;113:600–9.

    Article  Google Scholar 

  2. Lawes CMM, Hoorn SV, Rodgers A. Global burden of blood-pressure-related disease, 2001. Lancet 2008;371:1513–8.

    Article  PubMed  Google Scholar 

  3. Zhou D, Xi B, Zhao M, Liang W, Veeranki SP. Uncontrolled hypertension increases risk of all-cause and cardiovascular disease mortality in US adults: the NHANES III Linked Mortality Study. Sci Rep. 2018;8:9418.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Mente A, O’Donnell MJ, Rangarajan S, McQueen MJ, Poirier P, Wielgosz A, et al. Association of Urinary Sodium and Potassium Excretion with Blood Pressure. N. Engl J Med. 2014;371:601–11.

    Article  PubMed  Google Scholar 

  5. Polonia J, Martins L, Pinto F, Nazare J. Prevalence, awareness, treatment and control of hypertension and salt intake in Portugal: changes over a decade. The PHYSA study. J Hypertens. 2014;32:1211–21.

    Article  CAS  PubMed  Google Scholar 

  6. Khaw KT, Bingham S, Welch A, Luben R, O’Brien E, Wareham N, et al. Blood pressure and urinary sodium in men and women: the Norfolk Cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk). Am J Clin Nutr. 2004;80:1397–403.

    Article  CAS  PubMed  Google Scholar 

  7. Larsen SC, Ängquist L, Sørensen TIA, Heitmann BL. 24h Urinary sodium excretion and subsequent change in weight, waist circumference and body composition. PLoS One. 2013;8:e69689.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Yoon YS, Oh SW. Sodium density and obesity; the Korea National Health and Nutrition Examination Survey 2007–2010. Eur J Clin Nutr. 2013;67:141–6.

    Article  CAS  PubMed  Google Scholar 

  9. Lee SK, Kim MK. Relationship of sodium intake with obesity among Korean children and adolescents: Korea National Health and Nutrition Examination Survey. Br J Nutr. 2016;115:834–41.

    Article  CAS  PubMed  Google Scholar 

  10. Feng Q, Yang Z, May M, Tsoi KK, Ingle S, Lee EK, et al. The role of body mass index in the association between dietary sodium intake and blood pressure: A mediation analysis with NHANES. Nutr Metab Cardiovasc Dis. 2021;31:3335–44.

    Article  CAS  PubMed  Google Scholar 

  11. Aquino EM, Barreto SM, Bensenor IM, Carvalho MS, Chor D, Duncan BB, et al. Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): objectives and design. Am J Epidemiol. 2012;175:315–24.

    Article  PubMed  Google Scholar 

  12. Schmidt MI, Duncan BB, Mill JG, Lotufo PA, Chor D, Barreto SM, et al. Cohort Profile: Longitudinal Study of Adult Health (ELSA-Brasil). Int J Epidemiol. 2015;44:68–75.

    Article  PubMed  Google Scholar 

  13. Veronese FV, Gomes EC, Chanan J, Carraro MA, Camargo EG, Soares AA, et al. Performance of CKD‐EPI equation to estimate glomerular filtration rate as compared to MDRD equation in South Brazilian individuals in each stage of renal function. Clin Chem Lab Med. 2014;52:1747–1754.

    Article  CAS  PubMed  Google Scholar 

  14. Lipschitz DA. Screening for nutritional status in the elderly. Prim Care. 1994;21:55–67.

    Article  CAS  PubMed  Google Scholar 

  15. Lin X, Alvim SM, Simões EJ, Bensenor IM, Barreto SM, Schmidt MI, et al. Leisure Time Physical Activity and Cardio-Metabolic Health: Results From the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). J Am Heart Assoc. 2016;5:e003337. https://doi.org/10.1161/JAHA.116.003337

    Article  PubMed  PubMed Central  Google Scholar 

  16. Mill JG, Baldo MP, Molina M, Schmidt MI, Barreto SM, Chor D, et al. Sex‐specific patterns in the association between salt intake and blood pressure: the ELSA‐Brasil study. J Clin Hypertens. 2019;21:502–509.

    Article  CAS  Google Scholar 

  17. Mill JG, Silva AB, Baldo MP, Molina MC, Rodrigues SL. Correlation between sodium and potassium excretion in 24‐ and 12‐h urine samples. Braz J Med Biol Res. 2012;45:799–805.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. He FJ, Tan M, Ma Y, MacGregor GA. Salt Reduction to Prevent Hypertension and Cardiovascular Disease: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75:632–47.

    Article  CAS  PubMed  Google Scholar 

  19. Baldo MP, Rodrigues SL, Mill JG. High salt intake as a multifaceted cardiovascular disease: new support from cellular and molecular evidence. Heart Fail Rev. 2015;20:461–74.

    Article  CAS  PubMed  Google Scholar 

  20. He FJ, Marrero NM, MacGregor GA. Salt intake is related to soft drink consumption in children and adolescents: a link to obesity? Hypertension 2008 Mar;51:629–34.

    Article  CAS  PubMed  Google Scholar 

  21. Thompson P, Logan I, Tomson C, Sheerin N, Ellam T. Obesity, sex, race, and early onset hypertension: implications for a refined investigation strategy. Hypertension 2020;76:859–65.

    Article  CAS  PubMed  Google Scholar 

  22. Sabir JSM, El Omri A, Banaganapalli B, Aljuaid N, Omar AMS, Altaf A, et al. Unraveling the role of salt-sensitivity genes in obesity with integrated network biology and coexpression analysis. PLoS ONE. 2020;15:e0228400.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Feng Q, Yuan S, Yang Q, Lu Y, Loos RJF, Li GHY, et al. Causal associations between urinary sodium with body mass, shape and composition: a Mendelian randomization study. Sci Rep. 2020;10:17475.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Sallehuddin SM, Rashidah A, Othman F, Aziz NSA, Palaniveloo L, Nor NSM, et al. Sodium intake assessed by 24-h urine excretion and its relationship with anthropometric measurements in Malaysian adults. J Health Popul Nutr. 2021;40:9.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Nam GA, Kim SM, Choi MK, Heo YR, Hyun TS, Lyu ES, et al. Association between 24-h urinary sodium excretion and obesity in Korean adults: A multicenter study. Nutrition 2017;41:113–9.

    Article  CAS  PubMed  Google Scholar 

  26. Ma Y, He FJ, MacGregor GA. High Salt Intake: Independent Risk Factor for Obesity? Hypertension 2015;66:843–9.

    Article  CAS  PubMed  Google Scholar 

  27. Ma Y, He FJ, Sun Q, Yuan C, Kieneker LM, Curhan GC, et al. 24-Hour urinary sodium and potassium excretion and cardiovascular risk. N. Engl J Med. (e-pub ahead of print 13 Nov 2021).

  28. He FJ, MacGregor GA. Role of salt intake in prevention of cardiovascular disease: controversies and challenges. Nat Rev Cardiol. 2018;15:371–77. https://doi.org/10.1038/s41569-018-0004-1

    Article  PubMed  Google Scholar 

  29. Strazzullo P, D’Elia L, Kandala NB, Cappuccio FP. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ. 2009;339:b4567. https://doi.org/10.1136/bmj.b4567

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors thank all volunteers for their important contributions.

Funding

Brazilian Ministry of Health (Department of Science and Technology) and Ministry of Science, Technology and Innovation (FINEP, Financiadora de Estudos e Projetos), Grants No. 01 06 0010.00, 01 06 0212.00, 01 06 0300.00, 01 06 0278.00, 01 06 0115.00 and 01 06 0071.00 and CNPq (the National Council for Scientific and Technological Development) Universal No. 404183/2021-2.

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Authors and Affiliations

  1. Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, ES, Brazil

    Suellen Ferreira Chagas, Divanei Zaniqueli & José Geraldo Mill

  2. Department of Pathophysiology, Montes Claros State University – UNIMONTES, Montes Claros, Brazil

    Marcelo Perim Baldo

  3. Department of Medicine, Centro Universitário, UNIFIPMOC, Montes Claros, Brazil

    Marcelo Perim Baldo

  4. Department of Internal Medicine, Medical School, University of São Paulo, São Paulo, SP, Brazil

    Paulo Andrade Lotufo

  5. School of Medicine and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

    Bruce B. Duncan

  6. Laboratory of Health and Environment Education, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil

    Rosane Harter Griep

  7. Center for Clinical and Epidemiological Research, Medical School, University of São Paulo, São Paulo, SP, Brazil

    Isabela Martins Benseñor

  8. Department of Physiological Sciences, Federal University of Amazonas, Av. General Rodrigo Octavio Jordão Ramos 1200, Coroado I, Manaus, AM, 69067-005, Brazil

    Rafael de Oliveira Alvim

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  1. Suellen Ferreira Chagas
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Contributions

SFC and DZ participated in the analysis and interpretation of data and drafting of the manuscript. MPB, PAL, BBD, RHG, IMB, and ROA participated in the conception and design, analysis, and interpretation of data and final approval of the version to be published. JGM participated in the conception and design, analysis and interpretation of data, drafting of the article, critical revision for important intellectual content and final approval of the version to be published.

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Correspondence to José Geraldo Mill.

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Chagas, S.F., Zaniqueli, D., Baldo, M.P. et al. The association between salt intake and blood pressure is mediated by body mass index but modified by hypertension: The ELSA-Brasil study. J Hum Hypertens 37, 472–479 (2023). https://doi.org/10.1038/s41371-022-00714-9

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