World Health Organization (WHO) · Publications

Guideline: sodium intake for adults and children

December 31, 2012 World Health Organization

The full text is hosted by the publishing organisation. lawenc.com indexes the metadata and links to the official source.

Full text

Guideline:

Sodium intake for adults and children

WHO| Guideline

Sodium intake for adults and children

WHO Library Cataloguing-in-Publication Data Guideline1: Sodium intake for adults and children. 1.Sodium, Dietary. 2.Chronic disease – prevention and control. 3.Guideline. I.World Health Organization. ISBN 978 92 4 150483 6 © World Health Organization, 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. (NLM classification: WB 424)

Design and layout: Alberto March Printed by the WHO Document Production Services, Geneva, Switzerland

Suggested citation

WHO. Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), 2012.

This publication is a World Health Organization (WHO) guideline. A WHO guideline is any document, whatever its title, containing WHO recommendations about health interventions, whether they be clinical, public health or policy interventions. A recommendation provides information about what policy-makers, health-care providers or patients should do. It implies a choice between different interventions that have an impact on health and that have ramifications for the use of resources. All publications containing WHO recommendations are approved by the WHO Guidelines Review Committee.

WHO| Guideline

Sodium intake for adults and children

Contents

Acknowledgements Abbreviations and acronyms Executive summary Introduction Scope and purpose Background Justification Advisory groups

V VI 1 4 4 4 7 8 8 8 8 9 10 11 11 11 11 12 14 15 15 15 16 18 18 18 20 20 20 20 21

Guideline development process Advisory guideline group Panel Scoping of the guideline, evidence appraisal and decision-making Management of conflicts of interest Evidence base Adults All-cause mortality, cardiovascular disease, stroke,

Summary of evidence

Blood pressure in adults and coronary heart disease in adults Potential adverse effects in adults Children Blood pressure in children Potential adverse effects in children Final considerations of the evidence Recommendations Remarks Recommendations and remarks

Translation and implementation Research gaps and future initiatives WHO| Guideline

Implications for future research Dissemination Updating the guideline Sodium intake for adults and children

III

Annex 1 Annex 2 Annex 3 Annex 4 Annex 5 Annex 6 Annex 7 Annex 8

GRADE summary of findings tables Examples of sodium content in various foods and food groups WHO Secretariat Members of the WHO Steering Committee for Nutrition Guideline Development 2010 - 2011 Members of the NUGAG Subgroup on Diet and Health and external resource persons 2010 - 2011 External Expert and Stakeholder Panel Priority questions in the format of population, intervention, control and outcomes (PICO) Summary of considerations for determining the strength of

22 26 28

30 32

the recommendations Annex 9 Management of conflict of interest

37 39 43

References

WHO| Guideline

Sodium intake for adults and children

Acknowledgements Technical support This guideline was coordinated by Dr Nancy Aburto under the supervision of Dr Chizuru Nishida. The World Health Organization (WHO) gratefully acknowledges the technical input and expert advice provided by the members of the WHO Nutrition Guidance Expert Advisory Group Subgroup on Diet and Health, and by the external experts and resource persons for the development of this guideline. Thanks are due to the members of the WHO Steering Committee for Nutrition Guidelines Development and the staff of the WHO Guidelines Review Committee Secretariat for their support and guidance throughout the process. We also express our deep appreciation of Mr Issa Matta from the WHO Office of the Legal Counsel for his support and valuable guidance in the management of the conflicts of interest procedures. Special acknowledgement is made to Ms Emma Kennedy from the Nutrition Policy and Scientific Advice Unit, Department of Nutrition for Health and Development, for providing administrative and logistic support. Special thanks are given also to Sharnali Das and Anna Ziolkovska for their work on data collection and extraction for the systematic reviews that informed this guideline. Acknowledgement is also made to Dr Hilary Cadman from Cadman Editing Services in Australia for technical editing of this guideline and Mr Alberto March from Grafmac Inc in USA for the cover design and layout.

Financial support

WHO expresses special appreciation to the Ministry of Health, Labour and Welfare of the Government of Japan, the Korea Food and Drug Administration, the Korea Health Industry Development Institute, and the International Kidney Evaluation Association Japan for providing financial support for this work.

WHO| Guideline

Sodium intake for adults and children

Abbreviations and acronyms AUB CDC CI FAO FSANZ GRADE HDL IAEA KFDA KHIDI LDL MD NCD NUGAG NZFSA PICO RCT RR UN UNU USA WASH WHO American University of Beirut Centers for Disease Control and Prevention confidence interval Food and Agriculture Organization of the United Nations Food Standards Australia New Zealand Grading of Recommendations Assessment, Development and Evaluation high-density lipoprotein International Atomic Energy Agency Korea Food and Drug Administration Korea Health Industry Development Institute low-density lipoprotein mean difference noncommunicable disease Nutrition Guidance Expert Advisory Group New Zealand Food Safety Academy population, intervention, control and outcomes randomized-controlled trial risk ratio United Nations United Nations University United States of America World Action on Salt and Health World Health Organization

Symbols > < ≥ ≤ greater than less than equal to or greater than equal to or less than

WHO| Guideline

Sodium intake for adults and children

Executive summary Background Noncommunicable diseases (NCDs) are the main contributor to mortality and morbidity globally (1, 2), and interventions to reduce the burden of NCDs are highly cost-effective (3). Elevated sodium intake has been associated with a number of NCDs (including hypertension, cardiovascular disease and stroke), and decreasing sodium intake may reduce blood pressure and the risk of associated NCDs (4, 5). Recent data on sodium intake show that populations around the world are consuming much more sodium than is physiologically necessary (6). In many cases, they are consuming much more than the current World Health Organization (WHO) recommendation on sodium consumption for adults, which is 2 g sodium/day (equivalent to 5 g salt/day) (7). Since the publication of the previous WHO guideline on sodium intake (7), an appreciable amount of scientific evidence concerning sodium intake, hypertension and risk of cardiovascular disease has been published. Member States and international partners therefore requested WHO to review the current guideline on sodium intake for adults, and to also generate a guideline on sodium intake for children.

Objective

The objective of this guideline is to provide recommendations on the consumption of sodium to reduce NCDs in most adults and children. The recommendations in this guideline can be used by those developing programmes and policies to assess current sodium intake levels relative to a benchmark. If necessary, the recommendations can also be used to develop measures to decrease sodium intake through public health interventions such as food and product labelling, consumer education, and the establishment of food-based dietary guidelines.

Methods

WHO developed the present evidence-informed guideline using the procedures outlined in the WHO Handbook for guideline development (8). The steps in this process included: • • • • • • identification of priority questions and outcomes; retrieval of the evidence; assessment and synthesis of the evidence; formulation of recommendations; identification of research gaps; planning for dissemination, implementation, impact evaluation and updating of the guideline.

WHO| Guideline

Sodium intake for adults and children

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (9) was followed, to prepare evidence profiles related to preselected topics, based on recent systematic reviews of the scientific literature. An international, multidisciplinary group of experts participated in three WHO technical consultations. The first was held in Geneva, Switzerland on 14–18 March 2011; the second in Seoul, the Republic of Korea on 29 November – 2 December 2011; and the third in Geneva, Switzerland on 27–30 March 2012. At these meetings, the group of experts reviewed and discussed the evidence, drafted recommendations, and reached consensus on the strength of the recommendations. The group took into consideration desirable and undesirable effects of the recommendation, the quality of the available evidence, values and preferences related to the recommendation in different settings, and the cost of options available to public health officials and programme managers in different settings. All guideline group members completed a declaration of interests form before each meeting. An External Expert and Stakeholder Panel was involved throughout the process.

The evidence

Reducing sodium intake significantly reduced systolic and diastolic blood pressure in adults and children. The reduction in blood pressure was detected across a wide range of intake levels, and was independent of baseline sodium intake. Reducing sodium intake to <2 g/day was more beneficial for blood pressure than reducing sodium intake but still consuming >2 g/day. Reducing sodium intake had no significant adverse effect on blood lipids, catecholamine levels or renal function. Higher sodium intake was associated with higher risk of incident stroke, fatal stroke and fatal coronary heart disease. There was no association between sodium intake and all-cause mortality, incident cardiovascular disease and non-fatal coronary heart disease. However, the strong positive relationship between blood pressure and these outcomes provides indirect evidence that reducing sodium intake can improve these outcomes through a beneficial effect on blood pressure. Based on the entire body of evidence, WHO generated the following recommendations for sodium intake in adults and children.

Recommendations

•

WHO recommends a reduction in sodium intake to reduce blood pressure and risk of cardiovascular disease, stroke and coronary heart disease in adults (strong recommendation1). WHO recommends a reduction to <2 g/day sodium (5 g/day salt) in adults (strong recommendation). WHO recommends a reduction in sodium intake to control2 blood pressure in children (strong recommendation). The recommended maximum level of intake of 2 g/day sodium in adults should be adjusted downward based on the energy requirements of children relative to those of adults.

•

A strong recommendation is one for which the guideline development group is confident that the desirable effects of adherence outweigh the undesirable effects. 2 “Control” for this recommendation refers to the prevention of a deleterious rise in blood pressure with age. 1

WHO| Guideline

Sodium intake for adults and children

These recommendations apply to all individuals, with or without hypertension (including pregnant and lactating women), except for individuals with illnesses or taking drug therapy that may lead to hyponatraemia or acute build-up of body water, or require physician-supervised diets (e.g. patients with heart failure and those with type I diabetes). In these subpopulations, there may be a particular relationship between sodium intake and the health outcomes of interest (10, 11). Hence, these subpopulations were not considered in the review of the evidence and generation of the guideline. These recommendations complement the WHO guideline on potassium intake, and should be used in conjunction with that and other nutrient guidelines and recommendations to guide the development of public health nutrition programmes and policies. Addressing the optimal ratio of sodium to potassium was outside the scope of this guideline; however, if an individual consumes the amount of sodium recommended in this guideline and the amount of potassium recommended in the WHO guideline on potassium intake, the ratio of sodium to potassium would be approximately one to one, which is considered beneficial for health (12). These recommendations recognize that salt reduction and salt iodization are compatible. Monitoring of salt intake and salt iodization at country level is needed to adjust salt iodization over time as necessary, depending on observed salt intake in the population, to ensure that individuals consuming the recommended amount of sodium continue to consume sufficient iodine. These recommendations were based on the totality of evidence regarding the relationship between sodium intake and blood pressure, all-cause mortality, cardiovascular disease, stroke and coronary heart disease, as well as potential adverse effects on blood lipids, catecholamine levels and renal function. The evidence regarding the relationship between sodium intake and blood pressure was of high quality, whereas the evidence regarding sodium intake and all-cause mortality, cardiovascular disease, stroke and coronary heart disease was of lower quality. Therefore, these recommendations should be reviewed when more evidence on the relationship between sodium intake and all-cause mortality and cardiovascular disease outcomes becomes available. The successful implementation of these recommendations would have an important public health impact through reductions in morbidity and mortality, improvement in the quality of life of millions of people, and substantial reductions in health-care costs (1, 3, 13).

WHO| Guideline

Sodium intake for adults and children

Introduction Scope and purpose The objective of this guideline is to provide recommendations on the consumption of sodium for most adults and children. It is important to establish nutrient guidelines so that nutrition interventions can be developed in a logical, systematic, and scientific manner taking into account the best available evidence. The recommendations in this guideline can be used by programme and policy planners to assess current sodium intake levels relative to a benchmark and develop measures to decrease sodium intake, where necessary, through public health interventions including, but not limited to, food and product labelling, consumer education, and the establishment of Food-Based Dietary Guidelines (FBDG). This guideline does not provide guidance on specific food intake because such dietary guidelines should be based on the overall dietary goals, which take into consideration all required nutrients. It should be used in conjunction with the guideline on potassium intake and other nutrient guidelines to guide public health nutrition programme and policy development. This guideline provides a global, evidence-informed recommendation on sodium intake for: • • adults (≥16 years of age) for the reduction of blood pressure and risk of cardiovascular disease, stroke and coronary heart disease; children (2–15 years of age) for the control of blood pressure.

The guideline does not provide recommendations for individuals with illnesses or taking drug therapy that may lead to hyponatraemia or acute build-up of body water, or require physician-supervised diets (e.g. patients with heart failure and those with type I diabetes). These special subpopulations were not considered in the review of the evidence and generation of the guideline because, in these subpopulations, there may be a particular relationship between sodium intake and the health outcomes of interest (10, 11). The guideline will help Member States and their partners to make informed decisions on the appropriate nutrition actions to reduce noncommunicable diseases (NCDs). It is intended for a wide audience, including policy-makers and their expert advisers, and technical and programme staff in organizations involved in the design, implementation and scaling-up of nutrition actions for public health. This document presents the key recommendations and a summary of the supporting evidence. Further details of the evidence base are provided in Annex 1 and other documents listed in the references.

Background

NCDs are the leading cause of death globally, killing more people each year than all other causes combined (14). The major NCDs currently account for approximately 60% of all deaths and 43% of disease burden globally, and these levels are expected to continue to rise (2, 15). In 2008, 29 million NCD-related deaths (almost 80%) occurred in low and middle-income countries. In those countries, 29% of NCD-related deaths were in people under 60 years of age; in contrast, in high-income countries, only 13% of such deaths were premature. In 2005, cardiovascular disease itself accounted for 30% of all deaths: the equivalent of infectious disease, nutritional deficiency, and maternal and perinatal conditions combined (2).

WHO| Guideline

Sodium intake for adults and children

Hypertension is considered a major risk for cardiovascular disease, especially heart attack and stroke. Suboptimal systolic blood pressure (>115 mmHg) is estimated to contribute to 49% of all coronary heart disease and 62% of all stroke (13). Thus, the burden of morbidity and mortality from hypertension and related NCDs is currently one of the most urgent public health problems globally. Although NCDs disproportionately affect adults, they and their risk factors are now being detected more frequently in paediatric populations. Diet-related NCDs are chronic, and take years and decades to manifest; thus, delaying the onset of these diseases could improve lives and result in substantial cost savings (3). Blood pressure during childhood has a significant association with blood pressure during adulthood, meaning that children with increased blood pressure are at high risk for hypertension and its related morbidities as adults (16). Additionally, elevated blood pressure in childhood contributes to cardiovascular disease pathology during childhood itself (17). Thus, addressing, during childhood, the problem of elevated blood pressure and other risk factors for NCDs that could manifest later in life is crucial to combat NCDs. Sodium is the principal cation in extracellular fluid in the body, and is an essential nutrient necessary for maintenance of plasma volume, acid–base balance, transmission of nerve impulses and normal cell function. In healthy individuals, nearly 100% of ingested sodium is absorbed during digestion, and urinary excretion is the primary mechanism for maintaining sodium balance (18). Even in hot, humid climates, there are only minimal loses through faeces and sweat. Acclimation to heat occurs rapidly; thus, within a few days of exposure to hot and humid conditions, individuals lose only small amounts of sodium through sweat (19, 20). Under conditions of extreme heat and intense physical activity that result in high sweat production, sodium losses in sweat are increased and appreciable; nonetheless, most individuals can replace the necessary sodium through food consumption, without dietary alterations, supplements or specially formulated products (19-21). Sodium and chloride are the chemical components of common table salt; however, sodium can be found in other forms, and the primary contributors to dietary sodium consumption depend on the cultural context and dietary habits of a population (22). Sodium is found naturally in a variety of foods, such as milk, meat and shellfish (Annex 2). It is often found in high amounts in processed foods such as breads, crackers, processed meats and snack foods (23-26). High amounts of sodium are also found in many condiments (e.g. soy and fish sauces) (23). Thus, a diet high in processed foods and low in fresh fruits and vegetables is often high in sodium (24, 26). Although the minimum intake level necessary for proper bodily function is not well defined, it is estimated to be as little as 200–500 mg/day (18, 27). Data from around the world suggest that the population average sodium consumption is well above the minimal physiological needs, and in many countries is above the value recommended by the 2002 Joint World Health Organization/Food and Agriculture Organization of the United Nations (WHO/ FAO) Expert Consultation (12) of 2 g sodium/day (equivalent to 5 g salt/day) (22). Increased sodium consumption is associated with increased blood pressure, whereas lower sodium consumption appears to decrease blood pressure in adults (12, 28-30). A number of recent high-quality systematic reviews of randomizedcontrolled trials (RCTs) have concluded that decreased sodium intake relative to usual or higher intake results in lowered blood pressure in adults with or without hypertension (30-33). A review concerning advice to reduce sodium consumption concluded that intensive behaviour-change interventions targeting decreasing sodium WHO| Guideline

Sodium intake for adults and children

intake successfully reduced blood pressure in adults with or without hypertension (34). However, the reductions in sodium intake and in blood pressure were modest, and the authors concluded that environmental changes (e.g. reduction of sodium in processed foods) would facilitate a greater reduction in sodium consumption and, therefore, have a greater impact on blood pressure. Increased sodium has also been associated with cardiovascular diseases (7, 35), although the evidence is less clear than that for blood pressure. A recent systematic review of RCTs that reported cardiovascular disease and stroke found no relationship between sodium intake and cardiovascular disease. However, few RCTs reported cardiovascular disease outcomes; hence, there was insufficient evidence to substantiate a relationship between sodium intake and these outcomes (36). Numerous observational cohort studies have explored the relationship between sodium intake and cardiovascular disease. Most of these studies have reported a direct relationship between sodium intake and cardiovascular disease, stroke or coronary heart disease. However, others have reported no relationship, an inverse relationship or even a J-shaped relationship (i.e. increased risk at both the lowest and the highest sodium intake levels). A recent meta-analysis of 13 cohort studies of a duration of 4 years or more, which did not include the most recently published observational cohort studies (37, 38), concluded that there was a direct relationship between increased sodium consumption and subsequent risk of cardiovascular disease and stroke (35). There is little disagreement that decreased sodium intake decreases blood pressure, but there is some concern that it might also lead to adverse effects in health. Decreased sodium intake results in reduced blood volume and thus activates the renin– angiotensin–aldosterone and sympathetic nervous systems (indicated by increased adrenaline and noradrenaline), which help to control blood volume (39). Likewise, a reduction in blood volume without a concurrent reduction in blood lipids can lead to an increased concentration of lipids in the blood. A recent systematic review reported an increase in renin, aldosterone, adrenaline and noradrenaline, total cholesterol and triglyceride with reduced sodium (33). However, the changes in blood lipids and catecholamine levels were transient and no longer present after 4 weeks of reduced sodium intake (33). Although the changes in renin and aldosterone levels persisted with longer term reduced sodium intake, the importance of these changes is uncertain (40, 41). An increased risk of cardiovascular morbidity and mortality with increased renin or aldosterone level has been reported (42, 43), but the evidence is not conclusive (44, 45). Unlike blood pressure, a change in these hormones is not currently recognized as a reliable biomarker for future risk (41, 46).

WHO| Guideline

Sodium intake for adults and children

Justification

Much of the human and social impact caused each year by NCD-related morbidity and mortality could be averted through interventions that are well understood, cost effective and feasible (14). Decreased sodium intake in the population is a cost-effective public health intervention that could potentially reduce the burden of NCD morbidity and mortality (3). Because of the ever-increasing importance of NCDs on health-care costs and burden of disease (2, 3, 15), Members States requested WHO to update its guideline on sodium intake for adults and to develop a guideline on sodium intake for children, to inform public policy. Before a guideline can be generated, benefits and potential harms should be assessed. Some researchers have reported that reducing sodium intake to levels even below those currently recommended by WHO would lead to even greater health benefits (30). Conversely, others have questioned the importance of the modest reduction in blood pressure caused by decreased sodium intake in individuals without hypertension (33). Additionally, two recently published cohort studies have proposed that reducing sodium intake to <2 g/day may be associated with increased risk of cardiovascular disease and stroke (37, 38). The continued debate over the effect of sodium consumption and health outcomes, and the recent research that is continuously adding to the evidence base in the scientific literature, warrant a complete systematic review of all available epidemiological evidence considering sodium and blood pressure, all-cause mortality, cardiovascular disease, stroke, coronary heart disease and potential adverse effects (e.g. changes in blood lipids, catecholamine levels and renal function).

WHO| Guideline

Sodium intake for adults and children

Guideline development process This guideline was developed in accordance with the WHO evidence-informed guideline development procedures outlined in the WHO Handbook for guideline development (8).

Advisory groups

Development of this guideline was undertaken by the WHO Department of Nutrition for Health and Development1, in partnership with the Department of Research Policy and Cooperation and members of the WHO Secretariat (Annex 3). The work was guided by the WHO Steering Committee for Nutrition Guideline Development (Annex 4), which also provided overall supervision of the guideline development process. The WHO Secretariat and the Steering Committee included representatives from all departments of WHO with an interest in the provision of scientific advice on nutrition. Two additional groups were formed: an advisory guideline group and an external expert and stakeholder panel, as outlined below. Advisory guideline group The WHO Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Diet and Health was convened to support the development of this guideline (Annex 5). This group included experts who had previously participated in various WHO expert advisory panels, as well as others identified through open calls for specialists. In forming this group, WHO took into consideration the need for a balanced gender mix, expertise from multiple disciplinary areas and representation from all WHO regions. Efforts were made to include subject-matter experts; statistical, systematic review, program evaluation and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodologists; and representatives of potential stakeholders (e.g. programme managers and other health professionals involved in the health-care process). There were no representatives of commercial organizations, because such individuals are prohibited from being members of any WHO guideline group. External resource persons, including subject matter experts and systematic review and GRADE methodologists, were invited to the NUGAG meetings as observers to provide technical input. These individuals did not participate in the decision-making processes. NUGAG’s role was to advise WHO on the choice of outcomes important for decision-making and the interpretation of the evidence. Panel The External Expert and Stakeholder Panel was formed during the planning stages of guideline development. The panel was consulted on the scope of the guideline, and on the specific research questions to be addressed and outcomes to be investigated in the systematic reviews of the literature. The panel was later asked to review and provide feedback on the completed draft guideline (Annex 6). During the consultations on both the scoping of the guidelines and the draft guideline documents, there was an

The Department of Research Policy and Cooperation has since been reorganized and the nutrition guideline development work is being carried out in close collaboration with the Department of Knowledge Management and Sharing.

WHO| Guideline

Sodium intake for adults and children

open call for all interested parties to join the External Expert and Stakeholder Panel. The panel comprises individuals who responded to direct solicitation for contributions based on their known expertise and interest in the subject matter, or to the WHO open call for public comment executed through the electronic mailing lists of the WHO Department of Nutrition for Health and Development, and that of the Codex Alimentarius Commission, and through the posting of the call for public comment on the WHO and United Nations (UN) Standing Committee of Nutrition websites.

Scoping of the guideline, evidence appraisal and decision-making

WHO developed an initial set of questions to be addressed in the guideline. The questions were based on the needs of Member States and international partners for policy and programme guidance. They were also influenced by the request of the Codex Committee of Nutrition and Foods for Special Dietary Uses. The population, intervention, control and outcomes (PICO) format was used in generating the questions (Annex 7). The PICO questions were first discussed and reviewed by the WHO Secretariat and the WHO Steering Committee for Nutrition Guideline Development and were then made available for public comment from 1 to 28 February 2011. Feedback was received from 16 individuals or organizational stakeholders, and the questions were adapted accordingly. The draft set of PICO questions was presented to the NUGAG Subgroup on Diet and Health during its meeting on 14–18 March 2011. During that meeting, the guideline topic was introduced and the scope of the guideline to be generated finalized. The PICO questions were discussed and outcomes and populations were ranked in importance by NUGAG members. The prioritization of the PICO questions defined the scope of the evidence to be used in informing the guideline development. Subsequent to the meeting, WHO reviewed the scientific literature and conducted new systematic reviews and meta-analyses to address the PICO questions. WHO was supported in the execution of these reviews by external experts with subject-matter expertise, and expertise in systematic reviews and the GRADE methodology. A follow-up meeting of the NUGAG Subgroup on Diet and Health was held from 29 November to 2 December 2011. WHO presented the systematic reviews of evidence, and a draft recommendation that had been prepared before the meeting. This draft recommendation included: • a summary of the evidence from the systematic reviews;

• draft GRADE evidence profiles assessing the quality of the body of evidence; • • potential research gaps, concerns and opportunities for feasible implementation of the recommendations in diverse cultural contexts; appropriate references.

The NUGAG Subgroup on Diet and Health discussed the evidence and the GRADE assessment of the quality of evidence, and advised WHO on the interpretation of

WHO| Guideline

Sodium intake for adults and children

the results. The subgroup also discussed the draft recommendation and, through consensus, reached an agreement on that recommendation. The systematic reviews and the GRADE evidence profiles for each of the critical outcomes were used for drafting the guideline. Classification of the strength of each recommendation included consideration of the desirable and undesirable effects of the recommendation, the overall quality of the evidence, values and preferences related to the recommendation in different settings, and the cost of options available to public health authorities in implementing the recommendation in different settings (Annex 8). The classification was discussed among the NUGAG members, invited external resource persons and the members of the WHO Secretariat present at the meeting. The final wording of the recommendations and their strength were based on the consensus of members of the WHO Secretariat present and the NUGAG members only. There were no strong disagreements among the NUGAG members. From 1 to 29 February 2012, a draft of this guideline was made available for public comment. Participants in the External Expert and Stakeholder Panel were consulted, and other interested parties were invited to comment, as outlined above. More than 165 comments were received from 30 individuals and representatives of stakeholder groups. WHO reviewed the comments and made appropriate updates to the guideline. The guideline was then presented for finalization to the NUGAG Subgroup on Diet and Health at their meeting on 27–30 March 2012. The finalized guideline was submitted for clearance by WHO before publication.

Management of conflicts of interest

According to the rules in the WHO Basic documents (47), all experts participating in WHO meetings must declare any interest relevant to the meeting before participating. The declaration of interest forms for all guideline group members were reviewed by WHO when finalizing the composition of the NUGAG Subgroup on Diet and Health. All NUGAG members, external experts and other special invitees participating in each of the NUGAG meetings submitted a declaration of interests form, together with their curriculum vitae. In addition, each participant verbally declared interests at the beginning of each meeting. The procedures for management of interests strictly followed the WHO Guidelines for declaration of interests for WHO experts (48). The potential interests declared by members of the NUGAG Subgroup on Diet and Health and external expert and resource persons are summarized in Annex 9.

WHO| Guideline

Sodium intake for adults and children

Summary of evidence Evidence base This guideline is based on a review of the epidemiologic literature, including three new systematic reviews conducted by WHO (49-51). One review included a reanalysis of data of a fourth systematic review (36), to explore data needed for the evidence base for this guideline (49). Specific health outcomes considered were: • in adults – blood pressure, all-cause mortality, cardiovascular disease, stroke, coronary heart disease, renal function, blood lipids, catecholamine levels and other potential adverse effects; in children – blood pressure, blood lipids, catecholamine levels and other potential adverse effects.

•

The specific research questions guiding these systematic reviews were: • • What is the effect of decreased sodium intake compared with higher sodium intake on health outcomes in adults and children? Compared with higher sodium intake, what is the effect on health outcomes in adults and children of decreased sodium intake to: - - - less than 2 g/day; 1.2–2 g /day; less than 1.2 g/day?

Evidence was considered conclusive of either a benefit or a harm from decreased sodium intake if the point estimate suggested a benefit or harm and the 95%CI did not overlap a threshold of relevance. That is to say, if the real value were the high or the low 95%CI and that value was still of clinical relevance, the evidence was considered conclusive. If the point estimate were near the null value and the 95%CI did not overlap a threshold of relevance (e.g. if the real value were the high or the low 95%CI value and that value was not of clinical relevance) the evidence was considered conclusive of no effect. In such cases, the point estimates were considered precise. Conversely, evidence was considered inconclusive if the point estimate suggested a benefit or a harm but the 95%CI crossed a threshold of relevance (e.g. if the real value were the high or the low 95%CI value and that value was not of clinical relevance). In such cases, the point estimates were considered imprecise.

Adults

Blood pressure in adults The systematic review to explore the relationship of sodium and blood pressure and potential adverse effects identified 37 RCTs that reported systolic or diastolic blood pressure, renal function, blood lipid concentration or plasma or urinary catecholamine level (49). The studies were undertaken in Australia, Europe, North America and New Zealand, and covered a variety of countries, climates and cultural contexts. Twenty-four studies were undertaken in individuals with hypertension (defined as a blood pressure ≥140/90 mmHg (52)), five in individuals without hypertension, and eight in a mixed group of individuals with or without hypertension. No studies reported results for women separate from men, two studies were conducted in men, and 35 studies were conducted in a mixed group of men and women.

WHO| Guideline

Sodium intake for adults and children

All studies measured 24-hour urinary sodium excretion to estimate sodium intake, which was assumed to be equivalent to excretion (18). The higher sodium intake ranged from 2.07 to 4.77 g/day (mean 3.79 ±0.61 g/day). The reduced sodium intake ranged from 1.13 to 3.34 g/day (mean of 2.04 ±0.54 g/day). The mean decrease in sodium from higher intake was 1.74 ±0.58 g/day or 44.7%. All studies were of a duration of 4 weeks or more. The meta-analysis of 36 studies with 49 comparisons found that decreased sodium intake resulted in a decrease in resting systolic blood pressure of 3.39 mmHg (95% confidence interval [CI]: 2.46, 4.31) (quality of evidence high1) and a decrease in resting diastolic blood pressure of 1.54 mmHg (95%CI: 0.98, 2.11) (quality of evidence high). The meta-analysis of six studies with six comparisons with results on ambulatory blood pressure reported that decreased sodium intake resulted in a decrease in ambulatory systolic blood pressure of 5.51 mmHg (95%CI: 3.16, 7.87) (quality of evidence high), and a decrease in ambulatory diastolic blood pressure of 2.94 mmHg (95%CI: 1.51, 4.36) (quality of evidence moderate). These results are consistent with five previous systematic reviews that reported a decrease in blood pressure with reduced sodium intake in adults (30-34). WHO conducted a meta-analysis of data that directly addressed the question of whether a consumption of sodium of <2 g/day is more beneficial than a consumption of >2 g/day. Two studies with three comparisons randomly assigned participants to multiple intervention arms of varying levels of sodium intake, with one arm consuming reduced sodium at a level <2 g/day, one arm consuming reduced sodium but >2 g/day and one arm consuming higher sodium. The average intake was 1.4 g/day for the lowest consumption group, 2.29 g/day for the middle consumption group and 3.64 g/day for the higher group. A meta-analysis comparing the lowest (<2 g/day) to the middle (>2 g/ day) consumption groups found that reducing sodium intake to <2 g/day compared to reducing intake but still consuming >2 g/day resulted in a decrease in resting systolic blood pressure of 3.47 mmHg (95%CI: 0.76, 6.18) (quality of evidence high), and a decrease in resting diastolic blood pressure of 1.81 mmHg (95%CI: 0.54, 3.08) (quality of evidence high). Only one study directly compared an intake <1.2 g/day to a reduced intake to a level >1.2 g/day. The findings suggested a benefit with a decrease of 8.00 mmHg (95%CI: –1.73, 17.73) (quality of evidence moderate) but were inconclusive. All-cause mortality, cardiovascular disease, stroke, and coronary heart disease in adults WHO conducted a systematic review of the literature for epidemiological evidence on the relationship between sodium intake and all-cause mortality, cardiovascular disease, stroke and coronary heart disease. There were two recent systematic reviews with all-cause mortality, cardiovascular disease, stroke or coronary heart disease as outcomes (35, 36): one included RCTs and the other cohort studies. The data from the review of RCTs were re-analysed to remove the study in an acutely ill population (49). The meta-analysis of data of two RCTs with two comparisons was inconclusive (risk ratio [RR] 0.84 1 ; 95% CI: 0.57, 1.23) (quality of evidence moderate). The authors concluded that there was insufficient power to detect a statistically significant effect because of the limited number of events, even on synthesis of data. 1 Based on the grades of evidence set by the GRADE Working Group: high quality, we are very confident that the true effect lies close to that of the estimate of the effect; moderate quality, we have moderate confidence in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different; low quality, our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect; very low quality, we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of the effect.

WHO| Guideline

Sodium intake for adults and children

WHO then conducted another systematic review of cohort studies to update the previously identified systematic review (35, 50). This review included 15 prospective cohort studies with 167,656 participants that reported the relationship of sodium intake to subsequent all-cause mortality, cardiovascular disease, stroke or coronary heart disease in adults. Studies were conducted in Europe, Japan and the United States of America (USA). Sodium intake was measured through urinary sodium excretion or dietary records. Studies calculated RRs or hazard ratios for the risk of all-cause mortality, cardiovascular disease, stroke or coronary heart disease among groups, based on estimated sodium consumption level. For the meta-analyses, the reference group was always the group consuming the lowest amount of sodium per day, and the comparison group was generally the group consuming the highest amount of sodium per day. One study reported the RR for a one standard deviation increase in consumption level (1.9 g/day), and this value was used in the meta-analyses. Populations had wide ranges of sodium intake, with some consuming as little as 1.4 g/day in the lowest group and 2.6 g/day in the highest group, and others consuming as much as 4 g/day in the lowest group and 6.6 g/day in the highest group. The follow-up period ranged from to 3.8 to 22 years. The meta-analysis of seven studies with 10 comparisons meeting the inclusion criteria that reported all-cause mortality was inconclusive (RR 1.06 2; 95% CI: 0.94, 1.20) (quality of evidence very low). The meta-analysis of 10 cohort studies with 14 comparisons reporting stroke was supportive of a benefit of reduced sodium intake on subsequent risk of stroke (RR 1.24; 95% CI: 1.08, 1.43) (quality of evidence very low). Increased sodium intake was also associated with increased risk of fatal stroke events (RR 1.63; 95%CI: 1.27,2.10) (quality of evidence low). The meta-analyses of sodium intake and cardiovascular disease or coronary heart disease were inconclusive (cardiovascular disease RR 1.12; 95%CI: 0.93,1.34 and coronary heart disease RR 1.04; 95%CI: 0.86,1.24) (quality of evidence very low). The meta-analysis of sodium intake and coronary heart disease mortality detected an increased risk of fatal coronary heart disease events with higher sodium intake (RR 1.32; 95%CI: 1.13,1.53) (quality of evidence very low). The meta-analysis of nine cohort studies with 13 comparisons was inconclusive regarding the relationship of higher sodium consumption and cardiovascular disease (RR 1.12; 95% CI: 0.93, 1.34) (quality of evidence very low). The meta-analysis of six cohort studies with nine comparisons reporting on sodium intake and subsequent risk of coronary heart disease was inconclusive (RR 1.04; 95% CI: 0.86, 1.24) (quality of evidence very low). There is a well-established relationship between increasing blood pressure and increasing risk of cardiovascular diseases, especially coronary heart disease and stroke (13, 53). Blood pressure is therefore considered a reliable biomarker for estimating risk of cardiovascular disease (46, 54). Recognizing the limitations of any biomarker, it was nonetheless determined that blood pressure could be a suitable proxy indicator for risk of cardiovascular disease, coronary heart disease and stroke. Thus, in addition to the direct evidence from cohort studies, the data from the RCTs compiled in the systematic review of the effect of reduced sodium on blood pressure in adults (49) were used as part of the evidence base to consider the effect of reduced sodium on cardiovascular disease, stroke and coronary heart disease. In the analyses of data from RCTs, an RR <1 signifies decreased risk with decreased sodium intake, whereas RR >1 signifies increased risk with decreased sodium intake. 2 In the analyses of data from cohort studies, RR >1 signifies increased risk with increased sodium intake 1

WHO| Guideline

Sodium intake for adults and children

Potential adverse effects in adults Some researchers have reported that reduced sodium could potentially have adverse effects on blood lipid concentrations (i.e. increase total cholesterol, low-density lipoprotein [LDL] cholesterol and triglyceride, and decrease high-density lipoprotein [HDL] cholesterol), catecholamine levels or renal function. To address the potential for decreased sodium to have such adverse effects, WHO included studies reporting these outcomes in the systematic review of RCTs (49). Fifteen studies reported on total cholesterol, LDL, HDL or triglyceride concentration; all had a duration of 1–2 months. The meta-analysis of 11 trials with 15 comparisons reporting total cholesterol concentration reported a nonsignificant increase in total cholesterol of 0.02 mmol/L (95%CI: –0.03, 0.07) (quality of evidence high). Consistent with no effect of reduced sodium intake on total cholesterol levels, four additional studies did not provide numerical data, but reported that there was no statistically significant difference in total cholesterol levels between reduced sodium and usual or higher sodium groups. The meta-analysis of nine studies with 11 comparisons reporting HDL concentration was consistent with a slight, but not physiologically important, decrease in HDL with reduced sodium intake versus usual intake of 0.01 mmol/L (95% CI: 0.00, 0.03) (quality of evidence moderate). The meta-analysis of six studies with eight comparisons reporting LDL concentration reported a nonsignificant increase in LDL of 0.03 mmol/L ( 95% CI: –0.02, 0.08) (quality of evidence high). The meta-analysis of eight studies with 10 comparisons reporting total triglyceride concentration reported a nonsignificant decrease in triglyceride concentration of 0.04 mmol/L (95% CI: –0.01, 0.09) (quality of evidence high). The results showed little or no adverse effect of reduced sodium on blood lipid concentrations. The meta-analysis of seven studies with seven comparisons reporting catecholamine levels showed that reduced sodium intake resulted in a nonsignificant increase in plasma noradrenaline of 8.23 pg/mL (95% CI: –27.84, 44.29) (quality of evidence high). The meta-analysis of four studies with four comparisons reporting plasma adrenaline also reported a nonsignificant increase 6.90 pg/mL (95% CI: –2.17, 15.96) with decreased sodium (quality of evidence high). These results were consistent with the previous systematic review in the literature reporting the effects of reduced sodium on blood lipids and catecholamine levels when only studies of 4 weeks duration or longer were considered (33). Five studies reporting on the effect of sodium intake on indicators of renal function (urinary protein excretion, urinary albumin excretion and urinary albumin:creatinine ratio) met the inclusion criteria for the systematic review. The meta-analysis of one study with three comparisons reporting urinary protein excretion reported a decrease of 76.6 µmol/L (95%CI: 0.97, 154.2) in urinary protein excretion (quality of evidence high). Consistent with a beneficial effect of reduced sodium on renal function, one other study, which could not be combined in the meta-analysis due to the form of the results, reported a reduction in urinary protein excretion with reduced sodium. Additionally, three studies reported urinary albumin excretion, but could not be combined in a meta-analysis due to the highly skewed distribution of this variable. The results were consistent with a beneficial effect of reduced sodium on renal function. One study with 169 participants having a reduced sodium intake and 169 a usual sodium intake reported a significant reduction in urinary albumin levels with reduced sodium intake. One study with 46 participants having a reduced sodium intake and 46 a usual sodium intake reported a non-significant decrease in urinary albumin with reduced sodium. WHO| Guideline

Sodium intake for adults and children

One study with 17 participants having a reduced sodium intake and 17 a usual sodium intake reported no change. Also consistent with a beneficial effect of reduced sodium on renal function, two studies reported a reduced urinary albumin:creatinine ratio with reduced sodium intake. The results suggest that reduced sodium does not have an adverse effect on renal function and may potentially have a beneficial effect.

Children

Blood pressure in children WHO conducted a systematic review of the literature on sodium intake and blood pressure in children. Two previous reviews of the literature were identified (55, 56); these reviews were more than 5 years old and included a wide range of ages and types of studies. Therefore, WHO conducted an original systematic review and meta-analysis of controlled trials including only trials with children 2–15 years of age. WHO identified and included nine controlled trials that tested the effect of reduced sodium on blood pressure in children, and one cohort study that explored the relationship between sodium intake and change in blood pressure over time (51). The studies were conducted in Australia, Europe and the USA. The controlled trials included children 5–15 years of age. The children in the cohort study were 5–17 years at baseline and were followed for 7 years. The meta-analysis of nine controlled trials with 14 comparisons testing systolic blood pressure found that decreased sodium resulted in a decrease in resting systolic blood pressure of 0.84 mmHg (95%CI: 0.25, 1.43) (quality of evidence moderate). The meta-analysis of eight controlled trials with 12 comparisons measuring resting diastolic blood pressure found that decreased sodium resulted in a decrease in resting diastolic blood pressure of 0.87 mmHg (95%CI: 0.14, 1.60) (quality of evidence moderate). The cohort study reported a slightly higher (not significant) difference in the rate of increase in blood pressure over time in the group consuming the highest amount of sodium compared to the lowest group. Although there were a number of high-quality controlled trials testing the effect of reduced sodium intake on blood pressure in children, the data from the systematic review conducted in adults (49) were also used as part of the evidence base for the recommendation for children. Renal function is fully developed in early childhood; thus, it was considered acceptable to use information from adults to infer the effect of sodium intake on blood pressure in children. The evidence from studies conducted in adults was downgraded from high to moderate in quality because of indirectness (i.e. the use of a proxy population for the target population). Potential adverse effects in children WHO conducted a systematic review of the literature of potential adverse effects such as changes in blood lipids and catecholamine levels in children. The review identified no studies that measured the effect of reduced sodium on blood lipids or catecholamine levels in children. The data from the systematic review in adults (49) were used as the evidence base for the effect of reduced sodium on blood lipids, catecholamine levels and other potential adverse effects in children. The evidence was downgraded from high to moderate quality because of indirectness.

WHO| Guideline

Sodium intake for adults and children

Final considerations of the evidence

In the systematic review of RCTs, WHO grouped the studies by blood pressure status at baseline, to explore the potential need for separate guidelines based on blood pressure status. The meta-analysis of the six studies with seven comparisons in individuals with normal blood pressure found that reduced sodium intake reduced systolic blood pressure by 1.38 mmHg (95%CI: 0.02, 2.74) (quality of evidence moderate). The meta analysis of 24 studies with 31 comparisons in individuals with hypertension found that reduced sodium intake reduced systolic blood pressure by 4.06 mmHg (95%CI: 2.96, 5.15) (quality of evidence high). The meta analysis of eight studies with 13 comparisons in mixed populations of individuals both with or without hypertension found that reduced sodium intake reduced systolic blood pressure by 3.41 mmHg (95%CI: 1.69, 5.13) (quality of evidence high). Although the reduction in blood pressure was statistically significantly less in individuals without hypertension, it was still evident. The effect of sodium reduction on blood pressure in individuals without high blood pressure is relatively small. Nevertheless, the high prevalence of hypertension in adult populations globally (2), and the clear benefit of reduced sodium in individuals with high blood pressure and in populations of individuals with and without high blood pressure, means that reducing sodium intake is likely to be broadly beneficial to populations around the world. The body of evidence suggests that reducing sodium is beneficial for most individuals, regardless of current sodium consumption level. In the set of RCTs, the intake in the higher sodium group ranged from 2.07 to 4.77 g/day (mean 3.79 ±0.61 g/ day), and the reduced sodium intake ranged from 1.13 to 3.34 g/day (mean 2.04 ±0.54 g/day). The overall effect estimate of reducing sodium on blood pressure was significant across this broad range of baseline intake. Furthermore, WHO grouped studies based on baseline sodium intake level, and found a significant decrease in systolic blood pressure in all subgroups. In the four studies with a baseline sodium intake of <3 g/ day, the decrease was 1.79 mmHg (95%CI: 0.07, 3.52); in the studies with a baseline sodium intake of 3.0–3.5 g/day, the decrease was 2.97 mmHg (95%CI: 1.21, 4.73); in the studies with a baseline sodium intake of 3.5–4.0 g/day, the decrease was 3.07 mmHg (95%CI: 1.43, 4.71); in the studies with a baseline sodium intake of 4.0–4.5 g/day, the decrease was 3.91 mmHg (95%CI: 1.72,6.10); and in the studies with a baseline sodium intake of >4.5 g/day, the decrease was 5.74 mmHg (95%CI: 3.03, 8.45). The test of subgroup differences suggested no difference in the change in systolic blood pressure by subgroup (P=0.17). This guideline is based on a review of the literature and on three new systematic reviews. The new meta-analyses found that reduced sodium intake decreased resting and ambulatory systolic and diastolic blood pressure in individuals with or without hypertension. These results are consistent with five previous systematic reviews that reported a decrease in blood pressure with reduced sodium in adults both with or without hypertension (30-34). Although a meta-analysis of two RCTs was inconclusive regarding the effect of decreased sodium on risk of cardiovascular disease, stroke and coronary heart disease, the systematic review and meta-analysis of cohort studies found a significant direct association between sodium intake and stroke. These results are consistent with the previous review and meta-analysis that the current review updated, which found a significant direct association between sodium and risk of both stroke and cardiovascular disease (35).

WHO| Guideline

Sodium intake for adults and children

The results from the new systematic review and meta-analyses regarding cardiovascular disease and coronary heart disease did not find a significant positive relationship between sodium and those outcomes; nonetheless, there was no adverse effect of decreased sodium intake on risk of cardiovascular disease or coronary heart disease. There was no indication from the RCTs of a duration of 4 weeks or more that reduced sodium intake had any adverse effects on blood lipids and catecholamine levels. These results were consistent with a previous systematic review when only the studies in that review of 4 weeks or more were considered (33). There was also no indication of an adverse effect of reduced sodium on renal function, and the results were even suggestive of a beneficial effect. A systematic review and meta-analyses also showed that reduced sodium intake decreases systolic and diastolic blood pressure in children. These results were consistent with two previous systematic reviews of the literature in children (55, 56). Finally, the modest reduction in resting systolic blood pressure (3.39 mmHg) and in diastolic blood pressure (1.54 mmHg) would have important public health benefits. Elevated blood pressure is the leading risk factor for mortality, accounting for almost 13% of deaths globally (1). In the USA, a decrease of 2 mmHg in diastolic blood pressure in the population could result in an estimated 17% decrease in the prevalence of hypertension, 6% decrease in risk of coronary heart disease and 15% decrease in risk of stroke. It could also prevent an estimated 67,000 coronary heart disease events and 34,000 stroke events every year (57). In the United Kingdom, researchers estimate that a 5 mmHg reduction in systolic blood pressure could reduce the prevalence of hypertension by 50% (58). Additionally, the relationship between blood pressure and risk of vascular mortality is positive, strong and linear down to a systolic blood pressure of 115 mmHg, below which there is no evidence (53). Thus, almost all reduction in blood pressure is beneficial for health, and modest population-wide reductions in blood pressure result in important reductions in mortality, substantial health benefits and meaningful savings in health-care costs (1, 3, 13).

WHO| Guideline

Sodium intake for adults and children

Recommendations and remarks Recommendations • WHO recommends a reduction in sodium intake to reduce blood pressure and risk of cardiovascular disease, stroke and coronary heart disease in adults (strong recommendation 1). WHO recommends a reduction to <2 g/day sodium (5 g/day salt) in adults (strong recommendation). WHO recommends a reduction in sodium intake to control2 blood pressure in children (strong recommendation). The recommended maximum level of intake of 2 g/day sodium in adults should be adjusted downward based on the energy requirements of children relative to those of adults.

•

Remarks

•

These recommendations apply to all individuals, with or without hypertension (including pregnant or lactating women), except for individuals with illnesses or taking drug therapy that may lead to hyponatraemia or acute build-up of body water, or require physician-supervised diets (e.g. patients with heart failure and those with type I diabetes). In these subpopulations, there may be a particular relationship between sodium intake and the health outcomes of interest (10, 11). Hence, these subpopulations were not considered in the review of the evidence and generation of the guideline. For this recommendation, “adults” includes individuals ≥16 years of age. For this recommendation, “children” includes individuals 2–15 years of age inclusive. The recommendation for children does not address the recommended period of exclusive breastfeeding (0–6 months) or the period of complementary feeding with continued breastfeeding (6–24 months). These recommendations were based on the totality of evidence regarding the relationship between sodium intake and blood pressure, all-cause mortality, cardiovascular disease, stroke and coronary heart disease, as well as potential adverse effects on blood lipids, catecholamine levels and renal function. The evidence regarding the relationship between sodium intake and blood pressure was of high quality, whereas the evidence regarding sodium intake and all-cause mortality, cardiovascular disease, stroke and coronary heart disease was of lower quality. Therefore, these recommendations should be reviewed when more evidence on the relationship between sodium intake and all-cause mortality and cardiovascular disease outcomes becomes available.

• • •

•

A strong recommendation is one for which the guideline development group is confident that the desirable effects of adherence outweigh the undesirable effects. The recommendation can be either in favour of or against an intervention. Implications of a strong recommendation are as follows: for patients, most people in their situation would desire the recommended course of action, only a small proportion would not; for clinicians, most patients should receive the recommended course of action, and adherence to this recommendation is a reasonable measure of good-quality care; for policy-makers, the recommendation can be adopted as a policy in most situations. 2 “Control” for this recommendation refers to the prevention of a deleterious rise in blood pressure with age 1

WHO| Guideline

Sodium intake for adults and children

•

These recommendations recognize that salt reduction and salt iodization are compatible. Monitoring of salt intake and salt iodization at country level is needed so that salt iodization can be adjusted over time, depending on observed salt intake in the population, so that individuals consuming the recommended amount of sodium will continue to consume sufficient iodine. These recommendations complement the WHO guideline on potassium consumption and should not be interpreted to replace or supersede that guideline. Public health interventions should aim to reduce sodium intake and simultaneously increase potassium intake through foods. These recommendations do not address the optimal sodium to potassium ratio; however, if this guideline and the WHO guideline on potassium intake are achieved, the molar ratio of sodium to potassium would be approximately one to one. The recommended intake level in children is lower than that of adults when children’s energy requirements are less than adults. The adjustment of recommended sodium intake based on energy requirements is recommended because of the positive association between energy requirements and sodium intake. Each country should determine the energy requirements of various age categories of the paediatric population relative to adults approximately 20–50 years of age, to lower the recommended maximum intake value of 2 g/day. If country-specific data are not available, data from another country with similar population demographics and dietary habits can be used to make this adjustment.

•

WHO| Guideline

Sodium intake for adults and children

Translation and implementation This nutrient guideline on sodium can aid the logical, systematic, and scientific development of nutrition interventions taking into account the best available scientific evidence. This guideline should be used in conjunction with potassium and other nutrient guidelines to guide public health nutrition programmes and policies. The recommendations in this guideline can be used by programme and policy planners to assess current sodium intake relative to a benchmark and develop measures to decrease sodium intake, where necessary, through public health interventions including, but not limited to, food and product labelling and consumer education. Additionally, this guideline can be translated at the country-level into culturally and contextually specific FBDGs that take into account locally available food and dietary customs. Providing overall dietary guidance is outside the scope of this guideline because such dietary guidance should be based on overall dietary goals, which consider all required nutrients. It is recognized that it is feasible to achieve this recommendation while respecting national dietary customs because a wide variety of fresh foods are naturally low in sodium (Annex 2). Additionally incremental sodium reduction in processed foods is feasible without consumer complaint.

Research gaps and future initiatives Implications for future research • Further high-quality RCTs testing the effect of reducing sodium to <1.2 g/ day on blood pressure and adverse effects (e.g. changes in blood lipids and catecholamine levels in adults) are warranted to increase the evidence base. Further high-quality RCTs testing the effect of sodium reduction on blood pressure and adverse effects (e.g. changes in blood lipids and catecholamine levels in children) are warranted to increase the evidence base. Further high-quality RCTs with multiple intervention arms directly testing the effect of multiple levels of sodium on health outcomes are warranted to strengthen the evidence base for the target sodium intake level. Further high-quality RCTs with all-cause mortality, cardiovascular disease, stroke and coronary heart disease as outcomes are warranted to strengthen the evidence base on the effect of sodium intake on these patient-relevant outcomes.

•

Dissemination

The current guideline will be disseminated through: • • • electronic media such as slide presentations; mailing lists of the WHO Department of Nutrition for Health and Development and the UN Standing Committee on Nutrition; the web site of the WHO Department of Nutrition for Health and Development.

WHO| Guideline

Sodium intake for adults and children

A summary of this guideline will also be available in all six UN languages through the WHO Department of Nutrition for Health and Development’s electronic Library of Evidence for Nutrition Actions. The library displays WHO guidelines related to nutrition, and complementary documents such as systematic reviews and other evidence informing the guidelines, biological and behavioural rationales for the effectiveness of a guideline, and other relevant resources produced by Member States and global partners.

Updating the guideline

The recommendations in this guideline will be reviewed by the end of 2017. If new information is available by that date, a guideline review group will be convened to evaluate the new evidence and revise the recommendation. However, if a large amount of new evidence becomes available before that date, a guideline review group may be convened earlier. The Department of Nutrition for Health and Development at the WHO Headquarters in Geneva, together with partners in other departments within the WHO Secretariat, will be responsible for coordinating the updating of the guideline, following the formal WHO Handbook for guideline development (8) procedures. When the guideline is due for review, WHO will welcome suggestions for additional questions that could be addressed in the guideline.

WHO| Guideline

Sodium intake for adults and children

Annex 1 GRADE summary of findings tables What is the effect of decreased sodium intake relative to higher intake in adults (≥16 years of age)? Effect Number of participants Quality of the evidence Outcomes (95 % CI) (studies) (GRADE) Comments RR: 1,12 46 483 ⊕⊝⊝⊝ Data from cohort studies begin with a GRADE of low. Cardiovascular disease 1 (directly assessed; RR greater than 1 (0.93 to 1.34) (9 studies) very low Downgraded due to imprecision because 95%CI crossed threshold of relevance of benefit or harm. indicates increased risk with increased sodium intake) RR: 0.84 720 ⊕⊕⊕⊝ Data from randomized-controlled trials. Only two Cardiovascular disease 1 studies. Downgraded due to imprecision because (directly assessed; RR less than 1 (0.57, 1.23) (2 studies) moderate indicates decreased risk with decreased sodium intake) 95%CI crossed threshold of relevance of benefit or harm. Stroke RR: 1.24 72 878 ⊕⊝⊝⊝ Data from cohort studies begin with a GRADE of low. (directly assessed: RR greater than 1 indicates increase (1.08 to 1.43) (10 studies) very low Downgraded due to inconsistency. risk with increased sodium intake) Coronary heart disease RR: 1,04 37 343 ⊕⊝⊝⊝ (directly assessed: RR greater than 1 indicates (0.86 to 1.24) (6 studies) very low increased risk with increased sodium intake) RR: 1,06 21 515 ⊕⊝⊝⊝ All cause mortality (directly assessed: RR greater than 1 indicates (0.94 to 1.20) (7 studies) very low increased risk with increased sodium intake) MD 3.39 lower 3 6 736 ⊕⊕⊕⊕ Resting systolic blood pressure 2 (36 studies) high (follow-up 1-36 months; units (4.31 to 2.46 lower) mmHg; better indicated by lower values) Data from cohort studies begin with a GRADE of low. Downgraded due to imprecision because 95%CI crossed threshold of relevance of benefit or harm. Data from cohort studies begin with a GRADE of low. Downgraded due to inconsistency.

WHO| Guideline

22 Sodium intake for adults and children

Evidence suggests a dose response with greater benefit to blood pressure as sodium intake decreases

For details on studies included in the reviews, see references (49, 50).

(Continued overleaf)

WHO| Guideline

(Continued from previous page) What is the effect of decreased sodium intake relative to higher intake in adults (≥16 years of age)? Effect Number of participants Quality of the evidence Outcomes (95 % CI) (studies) (GRADE) MD 0.02 higher 2 339 ⊕⊕⊕⊕ Total cholesterol 4 (11 studies) high 95%CI(follow-up 1 - 2 months; units mmol/L; Better (0.03 lower to 0.07 higher) indicated by lower values) MD 8.23 higher 265 ⊕⊕⊕⊕ Plasma noradrenaline 5 high (follow-up 1 - 2.5 months; units pg/mL; (27.84 lower to 44.29 higher) (7 studies) better indicated by lower values) MD 76.6 lower 189 ⊕⊕⊕⊕ Urinary protein excretion 6 high (follow-up mean 1.5 months; units (154.2 lower to 0.97 higher) (1 study) ng/mL filtrate; better indicated by lower values) Minor side effects 7 249 ⊕⊝⊝⊝ (better indicated by lower values) (3 studies) very low

Comments Not downgraded due to imprecision because did not cross threshold of relevance of benefit or harm. Not downgraded due to imprecision because did not cross threshold of relevance of benefit or harm.e Only one study with three comparisons included in the meta-analysis to produce effect estimate No quantitative data available

23 Sodium intake for adults and children

CI, Confidence interval; RR, Risk ratio; MD, Mean difference. GRADE Working Group grades of evidence: High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We have moderate confidence in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect. Consistent with no effect of reduced sodium intake on total cholesterol levels, four additional RCTs qualitatively reported no statistically significant difference between reduced sodium and control groups in total cholesterol levels. A meta-analysis of 9 RCTs with 11 comparisons reporting high-density lipoprotein (HDL) concentration was consistent with a slight decrease in HDL which did not indicate a decrease of biological importance (MD 0.01 mmol/L lower (0.03 lower to 0.00)) (quality of evidence moderate). A meta-analysis of six RCTs with eight comparisons reporting low-density lipoprotein (LDL) concentration was consistent with no effect of low sodium intake on LDL (MD 0.03 mmol/L higher (0.02 lower to 0.08 higher))(quality of evidence high). A meta-analysis of eight RCTs with 10 comparisons reporting total triglyceride concentration was consistent with no effect of low sodium on triglyceride concentration (MD 0.04 mmol/L lower (0.01 lower to 0.09 higher))(quality of evidence high). 5 A meta-analysis of four RCTS with four comparisons reporting plasma adrenaline is supportive of no effect of reduced sodium on catecholamine levels (MD 6.90 pg/mL higher (2.17 lower to 15.96 higher)) (quality of evidence high). 6 Consistent with a beneficial effect of reduced sodium on renal function, one study, which could not be combined in the meta-analysis due to the form of results, reported a reduction in urinary protein excretion with reduced sodium. Consistent with a beneficial effect of reduced sodium, one study with 169 low sodium and 169 control participants reported a significant reduction in urinary albumin levels with low sodium intake, one study with 46 low sodium and 46 control participants reported a non-significant decrease in urinary albumin with reduced sodium, and one study with 17 low sodium and 17 control participants reported no change. Consistent with a beneficial effect of reduced sodium, two studies reported reduced urinary albumin:creatinine ratio with low sodium intake. 7 Minor adverse effects such as headache, edema, dizziness and muscle aches were reported in three studies and there was no difference in reported minor adverse effects between low sodium and control groups. 4

For details on studies included in the reviews, see references (49, 50).

WHO| Guideline

What is the effect of a decrease in sodium intake to <2 g/day relative to an intake of ≥2 g/day in adults? Quality of the evidence Effect Number of participants Outcomes (95 % CI) (studies) (GRADE) Cardiovascular disease 1 (directly assessed) Stroke (directly assessed) Coronary heart disease (directly assessed) All cause mortality (directly assessed) MD 3.47 lower 3 820 ⊕⊕⊕⊕ Resting systolic blood pressure 2 (2 studies) high 1-36 months; units mmHg; better indicated by lower values) (6.18 to 0.76 lower) MD 0.05 higher 1 560 ⊕⊕⊕⊕ Total cholesterol 4 high (follow-up 1 - 2 months; units mmol/L; (0.00 lower to 0.11 higher) (1 study) Better indicated by lower values) Plasma noradrenaline MD 107 lower 24 ⊕⊕⊕⊕ (1 study) high (follow-up 1 - 2.5 months; units pg/mL; (437 lower to 223 higher) Better indicated by lower values) Urinary protein excretion Minor side effects

Comments There were no studies with cardiovascular disease as an outcome which addressed this question. There were no studies with cardiovascular disease as an outcome which addressed this question. There were no studies with cardiovascular disease as an outcome which addressed this question. There were no studies with cardiovascular disease as an outcome which addressed this question.

24 Sodium intake for adults and children 1

Only one study with three comparisons included in the meta-analysis to produce effect estimate Only one study with three comparisons included in the meta-analysis to produce effect estimate There were no studies with cardiovascular disease as an outcome which addressed this question. There were no studies with cardiovascular disease as an outcome which addressed this question.

CI, Confidence interval; RR, Risk ratio; MD, Mean difference. GRADE Working Group grades of evidence: High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We have moderate confidence in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect. Composite cardiovascular disease as reported by original study authors. This variable included some or all of the following: fatal and non-fatal stroke, coronary heart disease, myocardial infarction, and/or congestive cardiac failure, or episode of coronary revascularization, bypass grafting, and/or angioplasty. 2 Additional evidence from a meta-analysis of 36 randomized-controlled trials (RCTs) subgrouped by those studies in which the intervention group achieved an absolute intake of <2 g/day compared to those studies in which the intervention group achieved an absolute intake of ≥2 g/day was compatible with a greater reduction in blood pressure when intake was <2g/day (<2 g/day, MD = 3.39 lower (4.69 to 2.09 lower) vs ≥2/day intake, MD = 2.68 lower (3.66 to 1.70 lower)). 3 A MD described as ‘lower’ signifies a reduction in the outcome in the decreased sodium versus the higher sodium group. 4 Additional evidence from a meta-analysis of 12 RCTs with 17 total comparisons subgrouped by those studies in which the intervention group achieved an absolute intake of <2 g/day compared to those studies in which the intervention group achieved an absolute intake of ≥2 g/day was compatible with no differential effect of varying sodium intake levels on total cholesterol (l <2 g/day, mean difference = 0.02 lower (0.03 lower to 0.08 higher) vs ≥2g/day intake, MD = 0.02 lower (0.08 lower to 0.03 higher)). A meta-analysis of results from one RCT with two comparisons is consistent with no differential effect of varying sodium intake levels on high-density lipoprotein (HDL) concentration (MD = 0.00 lower (0.02 lower to 0.01 higher) or low-density lipoprotein (LDL) concentration (MD = 0.04 higher (0.03 lower to 0.12 higher). For details on studies included in the reviews, see references (49, 50).

WHO| Guideline

What is the effect of decreased sodium intake relative to higher intake in children (2–15 years of age)? Effect Number of participants Quality of the evidence Outcomes (95 % CI) (studies) (GRADE) Comments MD 0.87 lower 2 1 245 ⊕⊕⊕⊝ 2 studies with 4 comparisons were not Resting systolic blood pressure 1 (8 studies) moderate randomized. Downgraded due to high risk of bias. (assessed in children, follow-up 1-36 months; (1.47 to 0.26 lower) units mmHg; better indicated by lower values) MD 3.39 lower 2 6 736 ⊕⊕⊕⊝ Downgraded due to indirectness Resting systolic blood pressure 1 (36 studies) moderate (assessed in adults, follow-up 1-36 months; (4.31 to 2.46 lower) units mmHg; better indicated by lower values) Total cholesterol No studies assessed this outcome in children (assessed in children) MD 0.02 higher 2 339 ⊕⊕⊕⊝ Downgraded due to indirectness Total cholesterol 3 moderate (assessed in adults; follow-up 1 - 2 months; (0.03 lower to 0.07 higher) (11 studies) units mmol/L; Better indicated by lower values) Plasma noradrenaline No studies assessed this outcome in children (assessed in children) MD 8.23 higher 265 ⊕⊕⊕⊝ Downgraded due to indirectness Plasma noradrenaline 3 moderate (27.84 lower to 44.29 higher) (7 studies) (assessed in adults; follow-up 1 - 2.5 months; units pg/mL; better indicated by lower values) Minor side effects No studies assessed this outcome in children (assessed in children) Minor side effects 3 (assessed in adults) 249 (3 studies) No quantitative results available

25 Sodium intake for adults and children

For details on studies included in the reviews, see reference (51).

Annex 2

Examples of sodium content in various foods and food groups

Approximate amount of sodium content in various food groups Food group Table salt, baking soda, baking powder Bouillon cubes, powdered broths, soups, gravies Soy sauce Snack foods (e.g. pretzels, cheese puffs, popcorn) Bacon Sauces and spreads Cheese, hard Processed vegetables Butter/margarine Cheese, soft Processed fish Cereals and cereal products (e.g. bread, breakfast cereals, biscuits, cakes, pastries) Fish, raw or frozen Eggs Milk and cream Vegetables, fresh or frozen Fruits, fresh or frozen 250 100 80 50 10 5 Sodium content mg/100 g 38,000 20,000 7,000 1,500 1,500 1,200 800 600 500 400 400

1000 mg = 43.5 mmol Note: The information in this table is based on approximate calculations of an average mg of sodium per 100 g food from diverse, iconic foods taken from food composition databases from around the globe. The sodium content varies substantially within the food groups and the table provides a relative comparison of average levels of sodium only. The information provided can be used only for approximate comparisons of food groups, and should not be used to estimate daily intake. Sources: (23, 59-62)

WHO| Guideline

Sodium intake for adults and children

Comparison of the sodium content of an example of foods in unprocessed (i.e. “natural”) and processed states Description Food item Sodium content (mg/100 g)

Beef Topside, roast, lean and fat 48 Corned beef, canned 950 Bran Bran, wheat 28 Bran flakes 1,000 Cheese Hard cheese, average 620 Processed 1,320 Chick-peas Dried, boiled in unsalted water 5 Canned, re-heated, drained 220 Crab Boiled 370 Canned 550 Cod Cod, in batter, fried in blended oil 100 Fish fingers, fried in blended oil 350 Raw, boiled in unsalted water 9 New potatoes Canned, re-heated, drained 250 2 Peanuts Plain Dry roasted 790 Roasted and salted 400 Raw, boiled in unsalted water Trace Peas Canned, re-heated, drained 250 Potato chips Homemade, fried in blended oil 12 (French fries) Oven chips, frozen, baked 53 Salmon Raw, steamed 110 Canned 570 Smoked 1,880 Sweet corn On-the-cob, whole, boiled in unsalted water 1 Kernels, canned, re-heated, drained 270 Tuna Raw 47 Canned in oil, drained 290 Canned in brine, drained 320 1000 mg = 43.5 mmol Source: (6)

WHO| Guideline

Sodium intake for adults and children

Annex 3

WHO Secretariat WHO Headquarters Dr Francesco Branca Director Department of Nutrition for Health and Development Dr Chizuru Nishida Coordinator Nutrition Policy and Scientific Advice Unit Department of Nutrition for Health and Development Dr Nancy Aburto Scientist Nutrition Policy and Scientific Advice Unit Department of Nutrition for Health and Development Dr John Beard Director, Ageing and Life Course Family and Community Health Dr Shanthi Mendis Coordinator Chronic Diseases Prevention and Management Department of Chronic Diseases and Health Promotion Dr Poul Erik Petersen Dental Officer Health Promotion Department of Chronic Diseases and Health Promotion Ms Mariana Widmer Technical Officer Improving Maternal and Perinatal Health Reproductive Health and Research Dr Godfrey Xuereb Technical Officer Surveillance and Population-based Prevention Department of Chronic Diseases and Health Promotion Dr Cynthia Souza Guidelines Review Committee Secretariat Dr Regina Kulier Guidelines Review Committee Secretariat Dr Margaret Harris Guidelines Review Committee Secretariat WHO regional offices Dr Abel Dushimimana Medical Officer WHO Regional Office for Africa Brazzaville, the Congo Dr Chessa Lutter Regional Adviser Unit on Child and Adolescent Health WHO Regional Office for the Americas/ Pan American Health Organization Washington, USA Dr Kunal Bagchi Regional Adviser Nutrition and Food Safety WHO Regional Office for South-East Asia New Delhi, India Dr Joao Breda Scientist WHO Regional Office for Europe Copenhagen, Denmark Dr Ayoub Al-Jawaldeh Regional Adviser Nutrition WHO Regional Office for the Eastern Mediterranean Cairo, Egypt Dr Tommaso Cavalli-Sforza Regional Adviser Nutrition WHO Regional Office for the Western Pacific Manila, the Philippines

WHO| Guideline

Sodium intake for adults and children

Annex 4

Members of the WHO Steering Committee for Nutrition Guideline Development 2010 - 2011 WHO Headquarters Dr Francesco Branca Director, Nutrition for Health and Development Department Dr Tikki Pang (Pangestu) Director, Research Policy and Cooperation Dr Elizabeth Mason Director, Child and Adolescent Health and Development Alternate: Dr Nigel Rollins Scientist, Newborn and Child Health and Development Dr Ala Alwan Acting Director, Chronic Diseases and Health Promotion Alternate: Dr Godfrey Xuereb Technical Officer Chronic Disease and Health Promotion Dr Ruediger Krech Director, Ethics, Equity, Trade and Human Rights Alternate: Ms Nicole Valentine Technical Officer, Ethics, Equity, Trade and Human Rights Dr Maged Younes Director, Food Safety, Zoonoses and Foodborne Diseases Dr Robert D. Newman Director, Global Malaria Programme Alternate: Dr Sergio Spinaci Associate Director, Global Malaria Programme Dr Aafje Rietveld Medical Officer, Global Malaria Programme Dr Willem Van Lerberghe Director, Health Policy, Development and Services Dr Gottfried Otto Hirnschall Director, HIV/AIDS Alternate: Mr Craig Michael McClure Senior Technical Officer, HTM/HIV Dr Jean-Marie Okwo-Bele Director, Immunization, Vaccines and Biologicals Dr Michael Mbizvo Director, Reproductive Health and Research Dr Mario Raviglione Director, Stop Tuberculosis Alternate: Dr Knut Lonnroth Medical Officer, Stop Tuberculosis Dr Daniel Eduardo Lopez Acuna Director, Strategy, Policy and Resource Management Dr Nevio Zagaria Acting Director, Emergency Response & Recovery Operations International Agency for Research on Cancer Dr Isabelle Romieu Director, Nutrition Department

WHO| Guideline

Sodium intake for adults and children

Annex 5

Members of the NUGAG Subgroup on Diet and Health and external resource persons 2010 - 2011 Members of the NUGAG Subgroup on Diet and Health (Note: the areas of expertise of each guideline group member are given in italics)

Professor Pascal Bovet University Institute of Social and Preventive Medicine, Lausanne University Hospital Switzerland and Ministry of Health Seychelles Programme manager, noncommunicable diseases Professor Michael Clarke School of Nursing and Midwifery Trinity College, Ireland and United Kingdom Cochrane Centre United Kingdom Methods, systematic review Professor John H Cummings Centre for Oncology and Molecular Medicine Division of Medical Sciences University of Dundee United Kingdom Carbohydrates, dietary fibre Professor Ibrahim Elmadfa Institution of Nutritional Sciences University of Vienna Austria Human nutrition, nutrient requirements, fats and fatty acids, dietary diversity Professor Nahla Hwalla Faculty of Agricultural and Food Sciences American University of Beirut Lebanon Dietetics, nutrition, food-based dietary guidelines, diet and health Associate Professor Rachel Huxley Division of Epidemiology & Community Health University of Minnesota USA Epidemiology, physiology, biostatistics, meta-analysis, obesity WHO| Guideline

Professor Shiriki Kumanyika Center for Clinical Epidemiology & Biostatistics University of Pennsylvania School of Medicine USA Human nutrition, epidemiology, obesity, salt/sodium Professor Mary L’Abbe Department of Nutritional Sciences Faculty of Medicine University of Toronto Canada Nutrition science, trans-fatty acids, risk assessment and risk management, diet and health Professor Duo Li Department of Food Science and Nutrition Zhejiang University China Nutritional epidemiology, fats and fatty acids Professor Jim Mann Department of Medical and Surgical Sciences University of Otago New Zealand Carbohydrates, sugars, diabetes, fats and fatty acids Professor Carlos Monteiro Department of Nutrition, School of Public Health University of Sao Paulo Brazil Human nutrition, epidemiology, double-burden of malnutrition Professor Dariush Mozaffarian Harvard School of Public Health Harvard University USA Cardiology, epidemiology, diet and health

Sodium intake for adults and children

Professor Srinath Reddy Public Health Foundation of India India Cardiovascular diseases, obesity, noncommunicable diseases Professor Murray Skeaff University of Otago New Zealand Fats and fatty acids, biomarkers, diet and health, human nutrition

Professor H.H. (Esté) Vorster Faculty of Health Sciences North-West University South Africa Nutrition physiology, public health nutrition, food-based dietary guidelines

External resource persons Professor Francesco Cappuccio University of Warwick Warwick Medical School United Kingdom Professor Paul Elliott MRC-HPA Centre for Environment and Health and Department of Epidemiology and Biostatistics School of Public Health Imperial College London United Kingdom Dr Caroline Lee Hooper School of Medicine, Health Policy and Practice University of East Anglia United Kingdom Dr Sarah Kelly Institute for Ageing and Health School of Dental Sciences University of Newcastle United Kingdom Dr Cho-il Kim Department of Food and Nutrition Industry Korea Health Industry Development Institute The Republic of Korea Dr Joerg Meerpohl German Cochrane Centre Institute of Medical Biometry and Medical Informatics University Medical Center Freiburg Germany Professor Paula Moynihan Institute for Ageing and Health School of Dental Sciences University of Newcastle United Kingdom

WHO| Guideline

Sodium intake for adults and children

Annex 6

External Expert and Stakeholder Panel Members commenting on priority questions (February 2011) Comments received from Eduard Baladia (on behalf of Maria Manera, Julio Basulto and Eduard Baladia) Gerda Feunekes Suzanne Harris Mark Huffman Siobhan Jennings Erika Ketterer Anatoliy Khudaiberganov Branka Legetic (on behalf of the Pan American Health Organization Expert Group on Salt Reduction) Graham MacGregor Bruce Neal Aileen Robertson Barbara Schneeman

Affiliation Spanish Association of Dietitians & Nutritonists, Spain Unilever, the Netherlands International Life Sciences Institute, USA (with offices around the world) Northwestern University Feinberg School of Medicine, USA Health Service Executive, Ireland Heart and Stroke Foundation, South Africa Ministry of Health, Uzbekistan Pan American Health Organization Expert Group on Salt Reduction, Americas Consensus Action on Salt and Health, United Kingdom The George Institute for Global Health, Australia Metropolitan University College Copenhagen, Denmark U.S. Food and Drug Administration; U.S. Delegate to the Codex Committee on Nutrition and Foods for Special Dietary Uses and the Codex Committee on Food Labelling, USA National Institute for Public Health and the Environment (RIVM), the Netherlands The George Institute for Global Health, Australia

Hans Verhagen Jacqueline Webster

WHO| Guideline

Sodium intake for adults and children

Members commenting on the draft guidelines (February 2012) Comments received from Nebal Aboul Ella Michael Alderman Leila Alouane Salmeh Bahmanpour Amber Bastian Wulf Becker Lucie Bohac Norm Campbell Jalila el Ati Sheila Fleischhacker Gihan Fouad Isabel Gaertner Mark Huffman Antti Jula Chor San Khoo Marzia Lazzerini Sandrine Lauret Graham MacGregor

Affiliation National Nutrition Institute, Egypt The Albert Einstein College of Medicine, USA National Institute of Nutrition and Food Technology, Tunisia Shiraz University of Medical Sciences, Iran (Islamic Republic of ) Health Promotion Board, Singapore National Food Agency, Sweden Network for Sustained Elimination of Iodine Deficiency, Canada University of Calgary, Canada National Institute of Nutrition and Food Technology, Tunisia Institute of Food Technologists, USA National Nutrition Institute, Egypt German Federation for Food Law and Food Science, Germany Northwestern University Department of Preventive Medicine, USA National Institute for Health and Welfare, Finland ILSI North America, USA WHO Collaborating Center for Maternal and Child Health, IRCCS Burlo Trieste, Italy EuSalt (European Salt Producers’ Association), Belgium Wolfson Institute, Queen Mary University of London, United Kingdom

WHO| Guideline

Sodium intake for adults and children

Comments received from Kathryn McMurry Viola Michael Gulsen Saleh Rusidah Selamat BT Letty Shiu Pasquale Strazzullo

Affiliation National Heart, Lung, and Blood Institute, United States of America Non Communicable Disease Section, Disease Control Division, Ministry Of Health, Malaysia National Nutrition Institute, Egypt Nutrition Division, Ministry of Health, Malaysia Health Promotion Board, Singapore Department of Clinical and Experimental Medicine, University of Naples Medical School, Italy National Nutrition Institute, Egypt Department of Health, England, United Kingdom Institute of Public Health of Vojvodina / School of Medicine University of Novi Sad, Republic of Serbia The George Institute for Global Health, Australia Health Promotion Board, Singapore National Nutrition Institute, Egypt

Eman Sultan Alison Tedstone Ljiljana Trajkovic Pavlovic

Jacqueline Webster Clare Whitton Sahar Zaghloul

WHO| Guideline

Sodium intake for adults and children

Annex 7

Priority questions in the format of population, intervention, control and outcomes (PICO) Adults What is the effect of reduced sodium intake compared with higher intake on health outcomes? What is the target level of intake for maximum health benefit? Participants Adults (≥16 years of age) with or without hypertension, or a population of adults (some with and some without hypertension), with or without type 2 diabetes, previous cardiovascular disease, previous cancer, etc. Intervention: decreased sodium intake via advice, specific foods, supplements or whole diet provided, and unconfounded by other dietary, weight, lifestyle or pharmaceutical interventions. Diet with sodium level higher than in the intervention (may be usual intake or specific sodium intake) via advice or specific foods or supplements or whole diet provided. • • • • Reduced sodium intake (any level) versus higher sodium intake (usual sodium intake). Reduced sodium intake by ≥1/3 of usual or higher intake level versus reduced sodium intake by <1/3 of usual or higher. Consuming <2 g sodium/day versus consuming ≥2 g sodium/day. Consuming <1.2 g sodium/day versus consuming ≥1.2 g sodium/day versus consuming 1.2–2.0 g sodium/day.

Intervention (or exposure)

Control

Specific comparisons

Outcomes

All-cause mortality, cardiovascular disease, stroke, coronary heart disease, blood pressure, renal function, adverse effects (blood lipids, catecholamine levels and any other adverse events reported by study authors). All countries

Settings

WHO| Guideline

Sodium intake for adults and children

Children What is the effect of reduced sodium intake compared with higher intake on health outcomes? What is the target level of intake for maximum health benefit? Participants Children or adolescents (2–15 years inclusive), not acutely ill, with or without type 2 diabetes, previous cardiovascular disease, previous cancer, etc. Intervention: decreased sodium intake via advice, specific foods, supplements or whole diet provided, and unconfounded by other dietary, weight, lifestyle or pharmaceutical interventions. Exposure: single baseline or repeated sodium intake measurement Control Diet with sodium level higher than in the intervention (may be usual intake or specific sodium intake) via advice or specific foods or supplements or whole diet provided. • • • Outcomes Reduced sodium intake (any level) versus higher sodium intake (usual sodium intake) Reduced sodium intake by ≥1/3 usual or higher intake level versus reduced sodium intake by <1/3 of usual or higher. Consuming <2 g sodium/day versus consuming ≥2 g sodium/day.

Intervention (or exposure)

Specific comparisons

Blood pressure (systolic and/or diastolic), adverse effects (blood lipids, catecholamine levels and any other adverse events reported by study authors) All countries

Settings

WHO| Guideline

Sodium intake for adults and children

Annex 8

Summary of considerations for determining the strength of the recommendations Quality of evidence: • • • • • • • • • • • • High-quality evidence that decreasing sodium is beneficial for blood pressure in adults. High-quality evidence that decreasing sodium has no harmful effect on blood lipids, catecholamine levels, renal function or any minor side effects (e.g. headache and dizziness) in adults. Moderate-quality evidence that reduced sodium is consistent with a benefit to renal function in adults. Because of the well-established relationship between blood pressure and cardiovascular disease outcomes, the evidence of an effect of sodium on blood pressure was also considered moderate-quality evidence that reduced sodium is beneficial for reducing risk of cardiovascular disease, stroke and coronary heart disease. Moderate-quality evidence that reduced sodium is beneficial for controlling blood pressure in children. Moderate-quality evidence that reduced sodium has no harmful effect on blood lipids, catecholamine levels or any minor side effects (e.g. headache and dizziness) in children. High and moderate-quality evidence that consuming <2 g sodium/ day compared with consuming ≥2 g sodium/day is beneficial for reducing blood pressure and risk of cardiovascular disease, stroke and coronary heart disease in adults. High-quality evidence that consuming <2 g sodium/day compared with consuming ≥2 g sodium/day has no effect on blood lipids or catecholamine levels; however, recognizing that these data come from a limited number of studies, directly testing the effect of <2 g sodium/day compared with consuming ≥2 g sodium/day on these outcomes. This recommendation places a high value on reduction of blood pressure, cardiovascular disease, stroke, coronary heart disease and related NCDs. NCDs affect countries in all regions and all income levels, thus rendering interventions to reduce the burden of NCDs valuable in all contexts. Recognizing that some persons have taste preference for higher sodium foods. Recognizing that reformulation of processed foods would be necessary to provide consumers with choices of lower-sodium products that continue to be palatable to the consumer and marketable for producers.

Values and preferences:

WHO| Guideline

Sodium intake for adults and children

Trade-off between benefits and harm:

• • •

High-quality evidence in adults and moderate-quality evidence in children of benefit of decreasing sodium intake on blood pressure. Blood pressure is a good proxy indicator for risk of cardiovascular disease, stroke and coronary heart disease outcomes. Though inconclusive, there was evidence from the meta-analyses of cohort studies measuring cardiovascular disease or coronary heart disease that reduced sodium has potential benefits. The cohort data supported a reduction in risk of stroke with decreased sodium intake. High-quality evidence in adults and moderate-quality evidence in children indicates no negative effect on blood lipids or catecholamine levels with decreased sodium intake for 4 weeks or more.

Costs and feasibility:

• Cost–benefit analyses have consistently identified reduced sodium intake as one of the most cost-effective public health interventions available. • In many countries, this recommendation will require: – the cooperation of the food industry to reduce sodium content in processed foods and to make reduced sodium products widely available and accessible, to provide consumer choice; – activities to raise consumer awareness; – improvements in food labelling. • Experience in some countries has demonstrated that reduction of sodium content of processed foods is feasible and achievable for food manufacturers working in close cooperation with government agencies, and that these efforts can result in marked reductions in sodium content of products without adverse consumer reaction. • Additional strategies for the implementation of these recommendations will include public education, health promotion, and behavioural change. These strategies are even more important in contexts where most sodium intake comes from addition in the home.

WHO| Guideline

Sodium intake for adults and children

Annex 9

Management of conflict of interest NUGAG members Professor John Cummings, Professor Shiriki Kumanyika and Professor Este Vorster declared that they received support from the local organizers of the third meeting of the Subgroup on Diet and Health; that is, the Korean Food and Drug Administration (KFDA)/Korea Health Industry Development Institute (KHIDI). It was considered that the declared interests did not constitute any conflict of interest for their roles as members of the NUGAG Subgroup on Diet and Health, nor did they represent any conflict of interest for the work being undertaken by the NUGAG Subgroup on Diet and Health. Professor Ibrahim Elmadfa declared that he has received research grants from the Ministry of Health, Austria; the European Commission; the European Food Standard Agency; and Nutrisciencia, Switzerland. The grants were received by his university, and funds were mainly used for staff costs for those working in the research projects and fieldwork. Further information obtained from Professor Elmadfa regarding Nutrisciencia indicated that it is a Liechtenstein for-profit foundation, registered with the Public Registry of the Principality of Liechtenstein under number FL-0002.251.294-8. The purpose of the foundation is to support research, education and science to universities in Germany. It also contributes to charitable and humanitarian organizations. No commercially operating companies are involved in the operation of the foundation, either directly or indirectly. The declared interests were not considered to constitute any conflict of interest for Professor Elmadfa’s role as a member of the NUGAG Subgroup on Diet and Health, nor did they represent any conflict of interest for the work being undertaken by the NUGAG Subgroup on Diet and Health. Professor Nahla Hwalla declared that she has received research support including grants, collaborations, sponsorships and other funding from WHO, the International Atomic Energy Agency (IAEA), the Lebanese National Council for Scientific Research, the UN University (UNU) and Nestle Middle East. Further information obtained from Professor Hwalla regarding the declared grant received from Nestle Middle East indicated that the grant supports two types of projects at the American University of Beirut (AUB): intervention activities to promote healthy eating in schools, and research activities of three faculty members in the Faculty of Agriculture and Food Sciences, where Professor Hwalla, as the Dean of the Faculty, oversees the implementation of these activities. Professor Hwalla also indicated that there is an agreement between AUB and Nestle Middle East that all intellectual property (including technology, method, know-how or data rights) produced during the course of the projects will belong to AUB. Professor Hwalla’s declared interests do not present any conflict of interest for the work of the NUGAG because the funds she received for her own research were from UN agencies (i.e. WHO, IAEA and UNU) and a governmental institution (i.e. the Lebanese National Council for Scientific Research). It was agreed that Professor Hwalla could participate in the March 2011 meeting as a member of the NUGAG Subgroup on Diet and Health, especially since:

WHO| Guideline

Sodium intake for adults and children

• • •

the interest is not personal; the amount received is not significant in view of the total budget of the faculty; funding is going to a programme that was already established before the Nestle contribution and that has governmental support. It was suggested that an appropriate disclosure statement be prepared to indicate her declared interest. Professor Hwalla participated in the March 2011 NUGAG meeting but was not able to attend the November 2011 meeting when the current guideline was developed.

Professor Mary L’Abbe declared that she received research grants from the Canadian Institutes of Health Research, to evaluate the impact of Canada’s sodium reduction policy; the Public Health Agency of Canada, to prepare a report on public food procurement policies related to sodium; and the Beef Information Centre (a non-profit research foundation funded, but administered at arm’s length, by the Canadian beef industry), to examine the iron bioavailability of the diets of Canadians. Professor L’Abbe also receives other funding for research in NCD prevention and health promotion. She also declared that she has spoken at the annual meeting of the Canadian Meat Council to explain Canada’s Sodium Working Group report recommendations, and the process being used to develop Canada’s sodium targets for foods. Her travel expenses were paid by the Canadian Meat Council, but no honorarium was received. Professor L’Abbe appeared as a witness to the Canadian Parliament’s Standing Committee on Health, as Chair of Canada’s Sodium Working Group, to advocate for action to reduce sodium in Canadian foods and to increase consumer awareness of sodium, and to support research in the sodium field. The research grant received from the Beef Information Centre was for a study to examine the iron availability of the diets among the Canadian populations; this activity was not related to the area of recommendations being reviewed and updated by the NUGAG Subgroup on Diet and Health. Hence, it was suggested that the declared interest be reported in the process and the meeting report with details, but that no action be taken and Professor L’Abbe be accepted as a member of the NUGAG Subgroup on Diet and Health. Professor Jim Mann declared that he is employed by a university that has an interest in nutrition as it relates to human health, and receives research grants from New Zealand governmental agencies. He also declared that, as an individual and as advisory committee member, he has provided expert advice relating to nutrition and human health to innumerable national and international bodies including WHO, FAO, the World Cancer Research Fund and the media. The declared interests were not considered to constitute any conflict of interest for Professor Mann’s role as a member of the NUGAG Subgroup on Diet and Health, nor did they represent any conflict of interest for the work being undertaken by that subgroup. Professor Dariush Mozaffarian declared that he has received a significant number of research grants to study the effects of dietary factors on chronic diseases from the US National Institutes of Health; the Searle Scholar Award from the Searle Funds at the Chicago Community Trust; the Genes and Environment Initiative at the Harvard School of Public Health; the Gates Foundation/WHO Global Burden of Diseases, Injuries and Risk Factors Study; and GlaxoSmith Kline, Sigma-Tau and Pronova for an investigator-initiated, not-for-profit trial of fish oil to prevent post-surgical arrhythmia. He has also received modest honoraria and travel reimbursement for WHO| Guideline

Sodium intake for adults and children

speaking at scientific conferences and reviewing on topics related to diet and cardiovascular disease, including from the US Food and Drug Administration, International Life Sciences Institute, Aramark, Unilever, SPRIM, Nutrition Impact, WHO, UpToDate, and several universities and scientific organizations. He has no ownership, patents, stocks, advisory board membership or speaking board membership. The trial of fish oil, for which Professor Mozaffarian received grants from GlaxoSmith Kline, Sigma-Tau and Pronova, is not related to the work of the NUGAG Subgroup on Diet and Health. Given Professor Mozaffarian’s honoraria, travel reimbursement and speaking and reviewing engagements, it was agreed that the declared interest in the process be documented in the meeting report and that no action be taken. It was decided he could participate as member of the NUGAG and his participation in the guideline development meetings would be reviewed for each meeting topic in the future. Professor Murray Skeaff declared various memberships as follows: • Serving as a member of the Public Health Scientific Advisory Group and the chair of the Food and Nutrition Working Group of the New Zealand National Heart Foundation. These groups advise the Heart Foundation, a nongovernmental organization, about the scientific basis of its public health efforts to reduce the burden of heart disease in New Zealand. He is not an employee of the Heart Foundation and receives no remuneration for work related to the Advisory Group. Appointed in 2008 as a Scientific Fellow of Food Standards Australia New Zealand (FSANZ). “The FSANZ Fellows Program aims to establish a network of distinguished scientists and experts from key disciplines in areas relevant to food regulation. The network is intended to promote close collaborative relations between FSANZ staff, the Fellows, and their affiliated institutions to the benefit of all parties.” No remuneration is given to Fellows. Serving as a member of the New Zealand Food Safety Academy (NZFSA). The NZFSA is a governmental department within the Ministry of Agriculture and Fisheries. From time to time, NZFSA seeks the advice of experts in areas where its staff do not have the required expertise or where it requires confirmation of the advice provided by its staff. NZFSA also establishes expert groups to seek more specific assistance in relation to particular issues, drawing experts from the members of the academy. A $1000 honorarium is paid to Professor Skeaff’s university each year.

•

The declared interests were not considered to constitute any conflict of interest for his role as a member of the NUGAG Subgroup on Diet and Health, nor did they represent any conflict of interest for the work being undertaken by that subgroup. External experts and resource persons Professor Francesco Cappuccio declared that he provided expert testimony on salt and cardiovascular disease as part of the Guidance Development group of the National Institute of Health and Clinical Excellence of England in 2009. He is an unpaid member of Consensus Action on Salt and Health (2000–present), the World Action on Salt and Health (WASH) (2003–present), the National Heart Forum (2010–present), the Pan American Health Organization/WHO Salt Group (2009–2011), and the European Salt Action Group (2007–present). WHO| Guideline

Sodium intake for adults and children

Professor Paul Elliott declared that he is a member of WASH. He also declared that his university is currently receiving research funds for the INTERMAP study from the US National Institutes of Health, and that he received research support for a sodium intake study from the US Centers for Disease Control and Prevention (CDC) in 2010. He declared that he provided an expert opinion related to: • population sodium intake to the US National Heart, Lung, and Blood Institute National Health and Nutrition Examination Survey Sodium Working Group, Bethesda, USA in January 2011; sodium intake measurement methods and efficacy for the Epidemiology & Surveillance Branch of CDC, USA during 2010–2011.

•

Dr Lee Hooper declared that she has received research funding from Barry Callebaut (to her university) to carry out a systematic review on the effects of chocolate and cocoa on markers of oxidative stress; the review was completed in August 2010. She has also received research funding from Soy Nutrition Institute (to her university) to carry out a systematic review on the effects of soy and isoflavones on hormonal status in women; the review was completed in July 2008. Dr Sarah Kelly declared the support for her participation at the third meeting of the NUGAG Subgroup on Diet and Health from the local organizers of the third meeting of the Subgroup on Diet and Health; that is, the KFDA/KHIDI. Dr Cho-il Kim declared that, in 2009, she provided an expert opinion to the KFDA when they were developing a guideline to identify “energy-dense and nutritient-poor” foods according to the Special Act on Food Safety Management for Children. Since 2009, the sale of such food has been prohibited within school premises and in designated stores in the vicinity of schools (referred to as the “Green Food Zone”). Since 2010, television advertisements for such food are prohibited between 5:00 pm and 7:00 pm every day. Dr Kim thought that this information was relevant because the regulations on energy-dense and nutrition-poor foods deal with the fat and sugar content of food, and the meeting of the NUGAG Subgroup on Diet and Health was also reviewing recommendations related to total fat and sugars. Professor Paula Moynihan declared that she received a research grant (to her university) that included reviewing the intake of sugars in care homes as a small component of a large dietary study from the United Kingdom Food Standard Agency/Department of Health; the study was completed in January 2011. She also declared that her travel costs for the third meeting of the NUGAG Subgroup on Diet and Health were covered by research funds from her university. External experts and resource persons were involved in the discussions of the evidence, but did not vote at the NUGAG meetings at which the recommendations were formulated. The final wording and determination of the strength of the recommendations were based on the consensus of the NUGAG members only. Members of the External Expert and Stakeholder Panel were also required to submit a signed declaration of interests form and a current curriculum vitae before commenting on the draft recommendations and guideline document.

WHO| Guideline

Sodium intake for adults and children

References

1. WHO. Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization (WHO), 2009 (http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf ). 2. WHO. Preventing chronic disease: a vital investment. Geneva, World Health Organization (WHO), 2005 (http://www.who.int/chp/chronic_disease_report/contents/en/index.html). 3. Murray CJ, Lauer JA, Hutubessy RC et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet, 2003, 361(9359):717–725 (http://www.ncbi.nlm.nih.gov/pubmed/12620735). 4. WHO. Prevention of recurrent heart attacks and strokes in low and middle income populations: Evidence-based recommendations for policy makers and health professionals. Geneva, World Health Organization (WHO), 2003 (http://www.who.int/cardiovascular_diseases/resources/pub0402/en/). 5. Bibbins-Domingo K, Chertow GM, Coxson PG et al. Projected effect of dietary salt reductions on future cardiovascular disease. New England Journal of Medicine, 2010, 362(7):590–599 (http://www.ncbi.nlm.nih.gov/pubmed/20089957). 6. Elliott P. Sodium intakes around the world. Background document prepared for the Forum and Technical meeting on Reducing Salt Intake in Populations (Paris 5–7 October 2006). Geneva, World Health Organization, 2007. 7. WHO. Prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. Geneva, World Health Organization (WHO), 2007 (http://whqlibdoc.who.int/publications/2007/9789241547178_eng.pdf ). 8. WHO’s Guidelines Review Committee. WHO Handbook for guideline development. Geneva, World Health Organization (WHO), 2012 (http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf ). 9. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008, 336(7650):924–926 (http://www.ncbi.nlm.nih.gov/pubmed/18436948). 10. Paterna S, Gaspare P, Fasullo S et al. Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? Clin Sci (Lond), 2008, 114(3):221-230 (http://www.ncbi.nlm.nih.gov/pubmed/17688420). 11. Thomas MC, Moran J, Forsblom C et al. The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Diabetes Care, 2011, 34(4):861-866 (http://www.ncbi.nlm.nih.gov/pubmed/21307382). 12. WHO. Diet, nutrition and the prevention of chronic disease. Report of a Joint WHO/ FAO Expert Consultation. Geneva, World Health Organization (WHO), 2003 (http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf ). 13. Mackay J, Mensah G. The Atlas of Heart Disease and Stroke. Geneva, World Health Organization (WHO), 2004 (http://www.who.int/cardiovascular_diseases/resources/atlas/en/). 14. WHO. Global status report on noncommunicable diseases. Geneva, World Health Organization (WHO), 2010 (http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf ). 15. Strong K, Mathers C, Leeder S et al. Preventing chronic diseases: how many lives can we save? Lancet, 2005, 366(9496):1578–1582 (http://www.ncbi.nlm.nih.gov/pubmed/16257345). 16. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and metaregression analysis. Circulation, 2008, 117(25):3171–3180 (http://www.ncbi.nlm.nih.gov/pubmed/18559702).

WHO| Guideline

Sodium intake for adults and children

17. Daniels SR, Loggie JM, Khoury P et al. Left ventricular geometry and severe left ventricular hypertrophy in children and adolescents with essential hypertension. Circulation, 1998, 97(19):1907–1911 (http://www.ncbi.nlm.nih.gov/pubmed/9609083). 18. Holbrook JT, Patterson KY, Bodner JE et al. Sodium and potassium intake and balance in adults consuming self-selected diets. American Journal of Clinical Nutrition, 1984, 40(4):786–793 (http://www.ncbi.nlm.nih.gov/pubmed/6486085). 19. Fukumoto T, Tanaka T, Fujioka H et al. Differences in composition of sweat induced by thermal exposure and by running exercise. Clin Cardiol, 1988, 11(10):707–709 (http://www.ncbi.nlm.nih.gov/pubmed/3224454). 20. Sawka MN, Montain SJ. Fluid and electrolyte supplementation for exercise heat stress. American Journal of Clinical Nutrition, 2000, 72(2 Suppl):564S–572S (http://www.ncbi.nlm.nih.gov/pubmed/10919961). 21. American College of Sports Medicine, Sawka MN, Burke LM et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Medicine and Science in Sports Exercise, 2007, 39(2):377–390 (http://www.ncbi.nlm.nih.gov/pubmed/17277604). 22. Brown IJ, Tzoulaki I, Candeias V et al. Salt intakes around the world: implications for public health. Int J Epidemiol, 2009, 38(3):791–813 (http://www.ncbi.nlm.nih.gov/pubmed/19351697). 23. Wu Leung W, Butrum R, Chang F et al. Food composition table for use in East Asia. Rome and Washington, D.C., FAO and US Department of Health, Education, and Welfare, 1972. 24. Webster JL, Dunford EK, Neal BC. A systematic survey of the sodium contents of processed foods. Am J Clin Nutr, 2010, 91(2):413-420 (http://www.ncbi.nlm.nih.gov/pubmed/19955402). 25. Ni Mhurchu C, Capelin C, Dunford EK et al. Sodium content of processed foods in the United Kingdom: analysis of 44,000 foods purchased by 21,000 households. Am J Clin Nutr, 2011, 93(3):594-600 (http://www.ncbi.nlm.nih.gov/pubmed/21191142). 26. Centers for Disease Control and Prevention. Vital signs: Food categories contributing the most to sodium consumption — United States, 2007–2008. Morbidity and Mortality Weekly, 2011, 61:92–98. 27. He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. Journal of Human Hypertension, 2009, 23(6):363–384 (http://www.ncbi.nlm.nih.gov/pubmed/19110538). 28. Cutler JA, Follmann D, Allender PS. Randomized trials of sodium reduction: an overview. American Journal of Clinical Nutrition, 1997, 65(2 Suppl):643S–651S (http://www.ncbi.nlm.nih.gov/pubmed/9022560). 29. He FJ, MacGregor GA. How far should salt intake be reduced? Hypertension, 2003, 42(6):1093–1099 (http://www.ncbi.nlm.nih.gov/pubmed/14610100). 30. He FJ, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database of Systemic Reviews, 2004, (3):CD004937 (http://www.ncbi.nlm.nih.gov/pubmed/15266549). 31. Dickinson HO, Mason JM, Nicolson DJ et al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. J Hypertens, 2006, 24(2):215–233 (http://www.ncbi.nlm.nih.gov/pubmed/16508562). 32. Dietary Guidelines Advisory Committee. Adults and sodium: what is the relationship between sodium and blood pressure in adults aged 19 years and older? Washington, D.C., Department of Health and Human Services and Department of Agriculture, 2010 (http://www.nutritionevidencelibrary.com/evidence. cfm?evidence_summary_id=250164&highlight=adults%20and%20sodium&home=1).

WHO| Guideline

Sodium intake for adults and children

33. Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride. Cochrane Database of Systemic Reviews, 2011, (11):CD004022 (http://www.ncbi.nlm.nih.gov/pubmed/22071811). 34. Hooper L, Bartlett C, Davey SG et al. Advice to reduce dietary salt for prevention of cardiovascular disease. Cochrane Database of Systemic Reviews, 2004, (1):CD003656 (http://www.ncbi.nlm.nih.gov/ pubmed/14974027). 35. Strazzullo P, D’Elia L, Kandala NB et al. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ, 2009, 339:b4567 (http://www.ncbi.nlm.nih.gov/pubmed/19934192). 36. Taylor RS, Ashton KE, Moxham T et al. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database of Systemic Reviews, 2011, (7):CD009217 (http://www.ncbi.nlm.nih.gov/ pubmed/21735439). 37. O’Donnell MJ, Yusuf S, Mente A et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA, 2011, 306(20):2229–2238 (http://www.ncbi.nlm.nih.gov/pubmed/22110105). 38. Stolarz-Skrzypek K, Kuznetsova T, Thijs L et al. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA, 2011, 305(17):1777–1785 (http://www.ncbi.nlm.nih.gov/pubmed/21540421). 39. Brenner BM, Taal MW, Chertow GM et al. Brenner and Rector’s the kidney. Philadelphia, Saunders Elsevier, 2011. 40. Meade T. Review: Plasma renin and the incidence of cardiovascular disease. Journal of the Renin-AngiotensinAldosterone System, 2010, 11(2):91–98 (http://www.ncbi.nlm.nih.gov/pubmed/20418354). 41. Volpe M, Battistoni A, Chin D et al. Renin as a biomarker of cardiovascular disease in clinical practice. Nutrition, Metabolism and Cardiovascular Diseases, 2012, 22(4):312–317 (http://www.ncbi.nlm.nih.gov/ pubmed/22402063). 42. Alderman MH, Madhavan S, Ooi WL et al. Association of the renin-sodium profile with the risk of myocardial infarction in patients with hypertension. New England Journal of Medicine, 1991, 324(16):1098–1104 (http://www.ncbi.nlm.nih.gov/pubmed/1759997). 43. Gonzalez MC, Cohen HW, Sealey JE et al. Enduring direct association of baseline plasma renin activity with all-cause and cardiovascular mortality in hypertensive patients. Am J Hypertens, 2011, 24(11):1181–1186 (http://www.ncbi.nlm.nih.gov/pubmed/21938071). 44. Meade TW, Cooper JA, Peart WS. Plasma renin activity and ischemic heart disease. New England Journal of Medicine, 1993, 329(9):616–619 (http://www.ncbi.nlm.nih.gov/pubmed/8341336). 45. Volpe M, Francia P, Tocci G et al. Prediction of long-term survival in chronic heart failure by multiple biomarker assessment: a 15-year prospective follow-up study. Clin Cardiol, 2010, 33(11):700–707 (http://www.ncbi.nlm.nih.gov/pubmed/21089115). 46. Desai M, Stockbridge N, Temple R. Blood pressure as an example of a biomarker that functions as a surrogate. American Association of Pharmaceutical Scientists, 2006, 8(1):E146–152 (http://www.ncbi.nlm.nih.gov/pubmed/16584122). 47. WHO. Basic documents (Edition 47). Geneva, World Health Organization (WHO), 2009 (http://apps.who.int/gb/bd/). 48. WHO. Guidelines for declaration of interests for WHO experts. Geneva, World Health Organization (WHO), 2010

WHO| Guideline

Sodium intake for adults and children

49. WHO. Effect of reduced sodium intake on blood pressure, renal function, blood lipids and other potential adverse effects. Geneva, World Health Organization (WHO), 2012. 50. WHO. Effect of reduced sodium intake on cardiovascular disease, coronary heart disease, and stroke. Geneva, World Health Organization (WHO), 2012. 51. WHO. Effect of reduced sodium intake on blood pressure and potential adverse effects in children. Geneva, World Health Organization (WHO), 2012. 52. Chobanian AV, Bakris GL, Black HR et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA, 2003, 289(19):2560– 2572 (http://www.ncbi.nlm.nih.gov/pubmed/12748199). 53. Lewington S, Clarke R, Qizilbash N et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet, 2002, 360(9349):1903–1913 (http://www.ncbi.nlm.nih.gov/pubmed/12493255). 54. Vasan RS. Biomarkers of cardiovascular disease: molecular basis and practical considerations. Circulation, 2006, 113(19):2335–2362 (http://www.ncbi.nlm.nih.gov/pubmed/16702488). 55. Dietary Guidelines Advisory Committee. What is the effect of a reduced sodium intake on blood pressure in children from birth to age 18 years? Washington, D.C., Department of Health and Human Services and Department of Agriculture, 2010 (http://www.nutritionevidencelibrary.com/tmp/NEL_500569E6081A316DDCEB9EBDC66165AC.pdf ). 56. He FJ, MacGregor GA. Importance of salt in determining blood pressure in children: meta-analysis of controlled trials. Hypertension, 2006, 48(5):861–869 (http://www.ncbi.nlm.nih.gov/pubmed/17000923). 57. Cook NR, Cohen J, Hebert PR et al. Implications of small reductions in diastolic blood pressure for primary prevention. Arch Intern Med, 1995, 155(7):701-709 (http://www.ncbi.nlm.nih.gov/pubmed/7695458). 58. McPherson K, Britton A, Causer L. Coronary heart disease: estimating the impact of changes in risk factors. National Heart Forum. Norwich, The Stationery Office, 2002. 59. United States Department of Agriculture. USDA national nutrient database for standard reference. 2011 (http://www.ars.usda.gov/Services/docs.htm?docid=8964). 60. FAO. INFOODS food composition database for biodiversity, version 1.1. Rome, Food and Agricultural Organization of the United Nations (FAO), 2011. 61. Wu Leung W. Food composition table for use in Africa. Rome and Bethesda, MD, FAO and US Department of Health, Education, and Welfare, 1968. 62. Cashel K, English R, Lewis J. Composition of foods Australia. Canberra, Nutrition Section, Department of Community Services and Health, 1989.

WHO| Guideline

Sodium intake for adults and children

For more information, please contact: Department of Nutrition for Health and Development World Health Organization 20, Avenue Appia, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4156 E-mail: nutrition@who.int www.who.int/nutrition ISBN 978 92 4 150483 6

WHO| Guideline

Sodium intake for adults and children

‫ين‬ ‫للبالغ�‬ ‫مدخول الصوديوم‬ ‫أ‬ ‫والطفال‬ ‫موجز‬

‫‪:‬يهيجوتلا أدبملا‬

‫للبالغ� أ‬ ‫ين‬ ‫والطفال‬ ‫مدخول الصوديوم‬

‫‪i‬‬

‫‪ | OMS‬ملخص‬

‫‪WHO/NMH/NHD/13.2‬‬

‫© منظمة الصحة العالمية ‪2013‬‬ ‫جميع الحقوق محفوظة‪ .‬يمكن الحصول عىل مطبوعات منظمة الصحة العالمية من عىل موقع المنظمة إ ت ن‬ ‫و�‬ ‫اللك� ي‬ ‫�اءها من قسم الطباعة ش‬ ‫(‪ )www.who.int‬أو ش‬ ‫والن�‪ ،‬منظمة الصحة العالمية ‪20 Avenue Appia, 1211 Geneva‬‬ ‫ال�يد إ ت ن‬ ‫و�‪:‬‬ ‫‪( 27, Switzerland‬هاتف رقم‪+41 22 791 3264 :‬؛ فاكس رقم‪+14 22 791 4857 :‬؛ عنوان ب‬ ‫اللك� ي‬ ‫الذن باستنساخ أو ترجمة منشورات منظمة الصحة‬ ‫‪ .)bookorders@who.int‬وينبغي توجيه طلبات الحصول عىل إ‬ ‫ن‬ ‫ت‬ ‫ش‬ ‫و�‬ ‫ع� موقع المنظمة إ‬ ‫غ� تجاري ‪ -‬إىل قسم الطباعة والن� ب‬ ‫العالمية ‪ -‬سواء كان ذلك لبيعها أو لتوزيعها توزيعاً ي‬ ‫اللك� ي‬ ‫(‪.)http://www.who.int/about/licensing/copyright_form/en/index.html‬‬ ‫ف‬ ‫تع� إطالقاً عن رأي منظمة الصحة العالمية‬ ‫� هذا المطبوع‪ ،‬وطريقة عرض المواد الواردة فيه‪ ،‬ال ب‬ ‫والتسميات المستخدمة ي‬ ‫القانو� أ‬ ‫ن‬ ‫لي بلد‪ ،‬أو إقليم‪ ،‬أو مدينة‪ ،‬أو منطقة‪ ،‬أو لسلطات أي منها‪ ،‬أو بشأن تحديد حدودها أو تخومها‪.‬‬ ‫بشأن الوضع‬ ‫ي‬ ‫وتشكل الخطوط المنقوطة عىل الخرائط خطوطاً حدودية تقريبية قد ال يوجد بعد اتفاق كامل عليها‪.‬‬ ‫ن‬ ‫يع� أن هذه ش‬ ‫ش‬ ‫ال�كات والمنتجات معتمدة‪ ،‬أو موىص بها من قبل‬ ‫وذكر �كات بعينها أو منتجات جهات صانعة معينة ال ي‬ ‫منظمة الصحة العالمية‪ ،‬تفضيال ً لها عىل سواها مما يماثلها ولم يرد ذكره‪ .‬وفيما عدا الخطأ والسهو‪ ،‬ي ز‬ ‫تم� أسماء المنتجات‬ ‫المسجلة الملكية بوضع خط تحتها‪.‬‬ ‫ف‬ ‫� هذا المطبوع‪ .‬ومع‬ ‫وقد اتخذت منظمة الصحة العالمية كل االحتياطات المعقولة للتحقق من صحة المعلومات الواردة ي‬ ‫تفس� واستعمال‬ ‫فإن المواد المنشورة توزع دون أي ضمان من أي نوع رصيحاً كان أو ضمنياً‪ .‬والقارئ هو المسؤول عن ي‬ ‫ذلك ّ‬ ‫أ‬ ‫�ض‬ ‫ال� ت‬ ‫ت‬ ‫ت�تب عىل استعمال هذه المواد‪.‬‬ ‫المواد المنشورة‪ .‬والمنظمة ليست مسؤولة بأي حال عن ال ار ي‬

‫‪Design and layout: Alberto March‬‬ ‫‪Printed by the WHO Document Production Services, Geneva Switzerland‬‬

‫للبالغ� أ‬ ‫ين‬ ‫والطفال‬ ‫مدخول الصوديوم‬

‫‪ii‬‬

‫‪ | OMS‬ملخص‬

‫أ‬ ‫ف‬ ‫� العالم (‪ )2 ،1‬وتنفيذ التدخالت الرامية إىل تخفيف عبئها يعود‬ ‫المراض ي‬ ‫ئيس للوفيات والمراضة ي‬ ‫غ� السارية هي السبب الر ي‬ ‫أ‬ ‫غ� السارية (ومنها ارتفاع ضغط الدم‬ ‫بمردودية عالية للغاية (‪ .)3‬ويرتبط ارتفاع مدخول الصوديوم إ‬ ‫بالصابة بعدد من المراض ي‬ ‫وأمراض القلب أ‬ ‫والوعية الدموية والجلطة الدماغية)‪ ،‬وقد يؤدي تخفيض مدخول الصوديوم إىل تقليل ضغط الدم والخطورة‬ ‫أ‬ ‫ج ِمعت حديثاً عن مدخول الصوديوم إىل أن سكان العالم‬ ‫الناجمة عن إ‬ ‫غ� السارية (‪ .)5 ،4‬ي‬ ‫الصابة بالمراض ي‬ ‫وتش� بيانات ُ‬ ‫أك� بكث� مما يحتاجونه من الناحية الفسيولوجية (‪ ،)6‬إذ يستهلكون ف‬ ‫ث‬ ‫كث� من الحاالت كميات‬ ‫�‬ ‫الصوديوم‬ ‫من‬ ‫كميات‬ ‫يستهلكون‬ ‫ي ي‬ ‫ي‬ ‫ن‬ ‫ن‬ ‫ام�‬ ‫بكث� التوصية الحالية لمنظمة الصحة العالمية (المنظمة) بشأن استهالك‬ ‫حدد بمقدار غر ي‬ ‫الم ّ‬ ‫ي‬ ‫منه تفوق ي‬ ‫البالغ� للصوديوم ُ‬ ‫ً‬ ‫من الصوديوم يوميا (أي ما يعادل ‪ 5‬غرامات من ملح الطعام يومياً) (‪.)7‬‬

‫موجز‬

‫المعلومات‬ ‫أ‬ ‫الساسية‬

‫ومنذ صدور دليل المنظمة السابق بشأن مدخول الصوديوم (‪ ،)7‬نُ ِش‬ ‫البينات العلمية عن مدخول‬ ‫� كم جدير بالثناء من ّ‬ ‫أ‬ ‫الصوديوم وارتفاع ضغط الدم وخطورة الصابة بأمراض القلب أ‬ ‫والوعية الدموية‪ .‬لذا طلبت الدول العضاء ش‬ ‫وال�كاء الدوليون‬ ‫إ‬ ‫للبالغ� وتعد أيضا دليال آخر عن مدخول الصوديوم أ‬ ‫ين‬ ‫للطفال‪.‬‬ ‫الحال عن مدخول الصوديوم‬ ‫من المنظمة أن تستعرض الدليل‬ ‫ً‬ ‫ّ‬ ‫ي‬ ‫أ‬ ‫ت‬ ‫ين‬ ‫البالغ�‬ ‫ال� تصيب معظم‬ ‫الغرض من هذا الدليل هو تقديم توصيات عن استهالك الصوديوم للحد من المراض ي‬ ‫غ� السارية ي‬ ‫أ‬ ‫ف‬ ‫� تقييم المعدالت الحالية لمدخول الصوديوم‬ ‫والطفال‪ ،‬وهي توصيات يمكن أن تستفيد منها ب‬ ‫ال�امج والسياسات المتطورة ي‬ ‫ف‬ ‫تداب� لخفض مدخول الصوديوم‬ ‫� وضع ي‬ ‫بالقياس إىل معيار مرجعي ما‪ .‬كما يمكن االستفادة من تلك التوصيات‪ ،‬عند اللزوم‪ ،‬ي‬ ‫ف‬ ‫� مجال الصحة العمومية‪ ،‬من قبيل توسيم المواد الغذائية والمنتجات‪ ،‬وتثقيف المستهلك‪ ،‬وإعداد‬ ‫من خالل تنفيذ تدخالت ي‬ ‫أ‬ ‫مبادئ توجيهية عن النظم الغذائية القائمة عىل أنواع الطعمة‪.‬‬ ‫ف‬ ‫� دليل منظمة الصحة العالمية بشأن وضع المبادئ‬ ‫بالبينات باالستعانة إ‬ ‫بالجراءات ّ‬ ‫أعدت المنظمة هذا الدليل المسند ّ‬ ‫المبينة ي‬ ‫التوجيهية (‪ .)8‬وفيما يل الخطوات المتبعة ف‬ ‫� هذه العملية‪:‬‬ ‫ي‬ ‫ي‬ ‫تحديد المسائل والحصائل ذات أ‬ ‫الولوية؛‬ ‫• ‬ ‫ت‬ ‫البينات؛‬ ‫• ‬ ‫اس�جاع ّ‬ ‫البينات وتوليفها؛‬ ‫تقييم‬ ‫•‬ ‫ ‬ ‫ّ‬ ‫صياغة التوصيات؛‬ ‫• ‬ ‫تحديد الفجوات البحثية؛‬ ‫• ‬ ‫التخطيط ش‬ ‫لن� الدليل وتطبيقه وتقييم نتائجه وتحديثه‬ ‫• ‬ ‫للبينات عن مواضيع مختارة مسبقاً‪ ،‬وذلك استناداً‬ ‫وقد ط ُِّبقت منهجية تصنيف التوصيات وتقييمها وتطويرها (‪ )9‬إ‬ ‫لعداد مرتسمات ّ‬ ‫ف‬ ‫� ثالث مشاورات‬ ‫دول متعدد التخصصات من ب‬ ‫الخ�اء ي‬ ‫إىل استعراضات منهجية أجريت مؤخراً للمصنفات العلمية‪ .‬وشارك فريق ي‬ ‫ف‬ ‫ف‬ ‫� سول‪ ،‬جمهورية كوريا‪ ،‬من ‪29‬‬ ‫تقنية أجرتها المنظمة‪ُ ،‬‬ ‫� جنيف‪ ،‬سويرسا‪ ،‬من ‪ 14‬إىل ‪ 18‬آذار‪ /‬مارس ‪2011‬؛ والثانية ي‬ ‫ع ِقدت أوالها ي‬ ‫الثا�‪ /‬نوفم� إىل ‪ 2‬كانون أ‬ ‫الول‪ /‬ديسم� ‪2011‬؛ والثالثة ف‬ ‫ن‬ ‫ش‬ ‫� جنيف‪ ،‬سويرسا‪ ،‬من ‪ 27‬إىل ‪ 30‬آذار‪ /‬مارس ‪ .2012‬وقد قام فريق‬ ‫ب‬ ‫ب‬ ‫ت�ين ي‬ ‫ي‬ ‫آ‬ ‫ف‬ ‫ف‬ ‫� الراء حول رصانة التوصيات‪.‬‬ ‫ب‬ ‫� تلك االجتماعات باستعراض ومناقشة ّ‬ ‫البينات‪ ،‬وصياغة التوصيات‪ ،‬وتوصل اىل توافق ي‬ ‫الخ�اء ي‬ ‫وأخذ الفريق ف‬ ‫البينات المتاحة‪ ،‬والقيم‬ ‫وجودة‬ ‫مستهجنة‪،‬‬ ‫وأخرى‬ ‫مستحسنة‬ ‫نتائج‬ ‫من‬ ‫التوصيات‬ ‫من‬ ‫تحقيقه‬ ‫المرجو‬ ‫حسبانه‬ ‫�‬ ‫ّ‬ ‫ي‬ ‫للمسؤول� ف‬ ‫والتفضيالت المتعلقة بالتوصيات الواردة ف‬ ‫ين‬ ‫� مجال الصحة العمومية‬ ‫المتاحة‬ ‫ات‬ ‫ر‬ ‫الخيا‬ ‫وتكلفة‬ ‫مختلفة‪،‬‬ ‫مواضع‬ ‫�‬ ‫ي‬ ‫ي‬ ‫ومديري ال�امج ف� مختلف أ‬ ‫ن‬ ‫المع� بوضع الدليل استمارة إعالن بشأن عدم تضارب‬ ‫الوساط‪ .‬واستكمل جميع أعضاء الفريق‬ ‫ب‬ ‫ي‬ ‫ي‬ ‫المصالح قبل عقد كل اجتماع‪ ،‬وشارك ف‬ ‫خب� خارجي وأصحاب المصلحة‪.‬‬ ‫� هذه العملية برمتها فريق مكون من ي‬ ‫ي‬ ‫البالغ� أ‬ ‫ين‬ ‫والطفال‪ .‬وجرى الكشف عن‬ ‫كث� ًا من ضغط الدم االنقبا�ض ي واالنبساطي لدى‬ ‫تقليل مدخول الصوديوم يخفّض ي‬ ‫أ‬ ‫ف‬ ‫ساس‪ .‬فتقليل‬ ‫� طائفة واسعة من معدالت مدخول الصوديوم‪ ،‬وهي معدالت مستقلة عن مدخوله‬ ‫تخفيض ضغط الدم ي‬ ‫ال ي‬ ‫ف‬ ‫هذا المدخول إىل ن‬ ‫ت‬ ‫ام� ي ن‬ ‫أد� من غر ي ن‬ ‫� إطار المواظبة‬ ‫اثن� يومياً يعود بفائدة عىل ضغط الدم ب‬ ‫ال� يعود بها تقليله ي‬ ‫أك� من تلك ي‬ ‫عىل استهالك ث‬ ‫ن‬ ‫كب� عىل نسبة الدهون‬ ‫ام� من الصوديوم يومياً‪ .‬وال يخلّف تقليل مدخول الصوديوم أي ي‬ ‫أك� من غر ي‬ ‫سل� ي‬ ‫تأث� ب ي‬ ‫ف‬ ‫ين‬ ‫الصابة بالجلطة الدماغية‬ ‫� الدم أو مستويات‬ ‫الكاتيكوالم� أو وظائف الكىل‪ .‬ويرتبط ارتفاع مدخول الصوديوم بزيادة خطورة إ‬ ‫ي‬ ‫للبالغ� أ‬ ‫ين‬ ‫والطفال‬ ‫مدخول الصوديوم‬

‫الغرض من الدليل‬

‫أساليب وضع‬ ‫الدليل‬

‫الب ّينات المطروحة‬

‫‪1‬‬

‫‪ | OMS‬ملخص‬

‫والسكتة الدماغية المميتة وأمراض القلب التاجية القاتلة‪ .‬وال يرتبط مدخول الصوديوم بالوفيات الناجمة عن جميع أ‬ ‫السباب‬ ‫أ‬ ‫أ‬ ‫اليجابية الوثيقة ي ن‬ ‫ب�‬ ‫غ� المميتة‪ .‬عىل أن العالقة إ‬ ‫الخرى إ‬ ‫والصابة بأمراض القلب والوعية الدموية وبأمراض القلب التاجية ي‬ ‫غ� ش‬ ‫يحسن هذه الحصائل من خالل‬ ‫بينات ي‬ ‫ضغط الدم وهذه الحصائل تقدم ّ‬ ‫مبا�ة تثبت أن تقليل مدخول الصوديوم يمكن أن ّ‬ ‫أعدت المنظمة التوصيات التالية بشأن مدخول الصوديوم‬ ‫البينات ّ‬ ‫ي‬ ‫تأث�ه المفيد عىل ضغط الدم‪ .‬واستناداً إىل كامل مجموعة ّ‬ ‫أ‬ ‫ن‬ ‫البالغ� والطفال‪.‬‬ ‫لدى‬ ‫ي‬ ‫توص المنظمة بتقليل مدخول الصوديوم لتخفيض ضغط الدم والحد من خطورة الصابة بأمراض القلب أ‬ ‫والوعية‬ ‫إ‬ ‫ي‬ ‫‪1‬‬ ‫ين‬ ‫ين‬ ‫البالغ�‬ ‫توص بتقليل مدخول‬ ‫الدموية والسكتة الدماغية وأمراض القلب التاجية لدى‬ ‫البالغ� (توصية قوية )‪ .‬كما ي‬ ‫من الصوديوم إىل ن‬ ‫أد� من غر ي ن‬ ‫ام� يومياً (أي ‪ 5‬غرامات من ملح الطعام يومياً) (توصية قوية)‬ ‫توص المنظمة بتقليل مدخول الصوديوم للتحكم‪ 2‬ف� ضغط الدم لدى أ‬ ‫الطفال (توصية قوية)‪ .‬وينبغي أن يُخفّض‬ ‫ي‬ ‫ي‬ ‫الحد أ‬ ‫المحدد بمقدار غر ي ن‬ ‫ين‬ ‫ام� يومياً عىل أساس متطلبات الطفل من الطاقة‬ ‫البالغ� من الصوديوم‬ ‫القىص لمدخول‬ ‫ّ‬ ‫ين‬ ‫البالغ�‪.‬‬ ‫مقارنة بمتطلبات‬ ‫• ‬

‫البينات‬

‫• ‬

‫وتنطبق هذه التوصيات عىل جميع أ‬ ‫ين‬ ‫ين‬ ‫المصاب� به (بما فيهم الحوامل‬ ‫وغ�‬ ‫الفـراد‬ ‫المصاب� منهم بارتفاع ضغط الدم ي‬ ‫ف‬ ‫ف‬ ‫� سوائل الجسم أو‬ ‫� نقص الصوديوم ي‬ ‫والمرضعات)‪ ،‬باستثناء الذين يعانون من أمراض أو يأخذون عالجاً بأدوية قد تتسبب ي‬ ‫ف‬ ‫ف‬ ‫ت‬ ‫� حالة اتباع نظم غذائية تستدعي ش‬ ‫إ�اف الطبيب (مثل المر�ض الذين يعانون من عجز‬ ‫� الجسم‪ ،‬أو ي‬ ‫ال�اكم الحاد للسوائل ي‬ ‫أ‬ ‫والمصاب� بداء السكري من النوع الول)‪ .‬وقد تكون هناك عالقة خاصة ي ن‬ ‫ين‬ ‫ب� مدخول الصوديوم والنتائج الصحية المهمة‬ ‫القلب‬ ‫ف‬ ‫البينات وإعداد الدليل‪.‬‬ ‫� هذه الفئات الفرعية من السكان (‪ ،)11 ،01‬عليه لم تُؤخذ هذه الفئات بنظر االعتبار لدى استعراض ّ‬ ‫ي‬ ‫وتكمل هذه التوصيات دليل المنظمة بشأن مدخول البوتاسيوم‪ ،‬وينبغي أن تستخدم جنباً إىل جنب مع ذاك الدليل‬ ‫ ‬ ‫ّ‬ ‫أ‬ ‫ف‬ ‫ت‬ ‫� وضع برامج وسياسات الصحة العمومية المتعلقة بالتغذية‪.‬‬ ‫وسواه من الدلة والتوصيات المعنية بالمواد المغذية اس�شاداً بها ي‬ ‫وال تندرج معالجة الحد أ‬ ‫المثل من نسبة مدخول الصوديوم إىل البوتاسيوم ضمن نطاق هذا الدليل؛ ولكن إذا كان الفرد يستهلك‬ ‫يوص به دليل المنظمة بشأن مدخول البوتاسيوم فإن من شأن‬ ‫يوص به هذا الدليل وآخر من‬ ‫البوتاسيوم ي‬ ‫قدراً من الصوديوم ي‬ ‫أ‬ ‫عت� مفيداً للصحة (‪.)21‬‬ ‫نسبة الصوديوم إىل البوتاسيوم أن تكون بالتساوي تقريباً‪ ،‬المر الذي يُ ب‬ ‫وتسلّم هذه التوصيات بأن ثمة تطابق ي ن‬ ‫ب� تقليل كمية ملح الطعام وإضافة اليود إىل الملح‪ .‬ويلزم إجراء رصد عىل‬ ‫ ‬ ‫المضاف إليه من اليود بمرور الزمن حسب االقتضاء‪ ،‬إذ‬ ‫كمية‬ ‫تعديل‬ ‫أجل‬ ‫من‬ ‫إليه‬ ‫اليود‬ ‫وإضافة‬ ‫الملح‬ ‫لمدخول‬ ‫القطري‬ ‫الصعيد‬ ‫ُ‬ ‫المر عىل الملحوظ من مدخول السكان من ملح الطعام‪ ،‬وذلك ضماناً لمواظبة أ‬ ‫يتوقف أ‬ ‫الموىص‬ ‫القدر‬ ‫يستهلكون‬ ‫الذين‬ ‫اد‬ ‫ر‬ ‫ف‬ ‫ال‬ ‫ُ‬ ‫به من الصوديوم عىل استهالك اليود بكمية كافية‪.‬‬ ‫البينات بشأن العالقة ي ن‬ ‫ب� مدخول الصوديوم وضغط الدم ومعدل الوفيات‬ ‫ ‬ ‫واستندت هذه التوصيات إىل مجمل ّ‬ ‫الخرى والصابة بأمراض القلب أ‬ ‫السباب أ‬ ‫الناجمة عن جميع أ‬ ‫والوعية الدموية والسكتة الدماغية وأمراض القلب التاجية‪ ،‬وكذلك‬ ‫إ‬ ‫آ‬ ‫ال� يحتمل أن يخلفها مدخول الصوديوم عىل نسبة الدهون ف‬ ‫ين‬ ‫الكاتيكوالم� ووظائف الكىل‪ .‬وقد‬ ‫� الدم ومستويات‬ ‫الثار الضارة ت ي ُ‬ ‫ي‬ ‫البينات المجمعة عن العالقة ي ن‬ ‫ب� مدخول الصوديوم وضغط الدم عالية الجودة‪ ،‬فيما تدنّت جودة تلك المجمعة عن‬ ‫كانت ّ‬ ‫أ‬ ‫أ‬ ‫أ‬ ‫والصابة بأمراض القلب والوعية الدموية والسكتة‬ ‫خرى‬ ‫ال‬ ‫سباب‬ ‫ال‬ ‫جميع‬ ‫عن‬ ‫الناجمة‬ ‫الوفيات‬ ‫بمعدل‬ ‫الصوديوم‬ ‫مدخول‬ ‫عالقة‬ ‫إ‬ ‫ن‬ ‫ب�‬ ‫البينات عن حصائل العالقة ي‬ ‫الدماغية وأمراض القلب التاجية‪ .‬لذا ينبغي استعراض هذه التوصيات عندما يُتاح المزيد من ّ‬ ‫الخرى والصابة بأمراض القلب أ‬ ‫السباب أ‬ ‫مدخول الصوديوم والوفيات الناجمة عن جميع أ‬ ‫والوعية الدموية‪.‬‬ ‫إ‬ ‫ف‬ ‫� مجال الصحة العمومية من خالل تخفيض معدل‬ ‫ ‬ ‫ومن شأن تنفيذ هذه التوصيات بنجاح أن يحقق نتائج مهمة ي‬ ‫ن‬ ‫ن‬ ‫كب� (‪.)31 ،3 ،1‬‬ ‫بشكل‬ ‫الصحية‬ ‫الرعاية‬ ‫تكاليف‬ ‫وتخفيض‬ ‫الناس‪،‬‬ ‫من‬ ‫المالي�‬ ‫حياة‬ ‫نوعية‬ ‫وتحس�‬ ‫والوفيات‪،‬‬ ‫االعتالالت‬ ‫ي‬ ‫ي‬ ‫ي‬ ‫‪1‬‬ ‫ف‬ ‫ن‬ ‫� أن نتائجها المستحسنة ستفوق تلك المستهجنة‬ ‫‪.‬التوصية القوية هي توصية يثق الفريق‬ ‫المع� بوضع الدليل ي‬ ‫ي‬ ‫‪2‬‬ ‫ف‬ ‫� هذه التوصية إىل الوقاية من ارتفاع ضغط الدم الضار مع تقدم العمر‬ ‫ي‬ ‫‪.‬يش� مصطلح «تحكم» ي‬

‫للبالغ� أ‬ ‫ين‬ ‫والطفال‬ ‫مدخول الصوديوم‬

‫‪2‬‬

‫‪ | OMS‬ملخص‬

‫المراجع‬ 1. WHO. Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization (WHO), 2009 (http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf ). 2. WHO. Preventing chronic disease: a vital investment. Geneva, World Health Organization (WHO), 2005 (http://www.who.int/chp/chronic_disease_report/contents/en/index.html). 3. Murray CJ, Lauer JA, Hutubessy RC et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet, 2003, 361(9359):717–725 (http://www.ncbi.nlm.nih.gov/pubmed/12620735). 4. WHO. Prevention of recurrent heart attacks and strokes in low and middle income populations: Evidence-based recommendations for policy makers and health professionals. Geneva, World Health Organization (WHO), 2003 (http://www.who.int/cardiovascular_diseases/resources/pub0402/en/). 5. Bibbins-Domingo K, Chertow GM, Coxson PG et al. Projected effect of dietary salt reductions on future cardiovascular disease. New England Journal of Medicine, 2010, 362(7):590–599 (http://www.ncbi.nlm.nih.gov/pubmed/20089957). 6. Elliott P. Sodium intakes around the world. Background document prepared for the Forum and Technical meeting on Reducing Salt Intake in Populations (Paris 5–7 October 2006). Geneva, World Health Organization, 2007. 7. WHO. Prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. Geneva, World Health Organization (WHO), 2007 (http://whqlibdoc.who.int/publications/2007/9789241547178_eng.pdf ). 8. WHO’s Guidelines Review Committee. WHO Handbook for guideline development. Geneva, World Health Organization (WHO), 2012 (http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf ). 9. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008, 336(7650):924–926 (http://www.ncbi.nlm.nih.gov/pubmed/18436948). 10. Paterna S, Gaspare P, Fasullo S et al. Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? Clin Sci (Lond), 2008, 114(3):221-230 (http://www.ncbi.nlm.nih.gov/pubmed/17688420). 11. Thomas MC, Moran J, Forsblom C et al. The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Diabetes Care, 2011, 34(4):861-866 (http://www.ncbi.nlm.nih.gov/pubmed/21307382). 12. WHO. Diet, nutrition and the prevention of chronic disease. Report of a Joint WHO/ FAO Expert Consultation. Geneva, World Health Organization (WHO), 2003 (http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf ). 13. Mackay J, Mensah G. The Atlas of Heart Disease and Stroke. Geneva, World Health Organization (WHO), 2004 (http://www.who.int/cardiovascular_diseases/resources/atlas/en/).

‫للبالغ� أ‬ ‫ين‬ ‫والطفال‬ ‫مدخول الصوديوم‬

‫ | ملخص‬OMS

‫‪:‬تامولعملا نم ديزمل‬ ‫ةيمنتلاو ةحصلا لجأ نم ةيذغتلا ةرادإ‬ ‫ةيملاعلا ةحصلا ةمظنم‬ ‫‪20, Avvenue Appia, CH-1211 Genève 27, Suisse‬‬ ‫‪Télécopie : +41 22 791 4156‬‬ ‫‪Courriel : nutrition@who.int‬‬ ‫‪www.who.int/nutrition‬‬

‫للبالغ� أ‬ ‫ين‬ ‫والطفال‬ ‫مدخول الصوديوم‬

‫‪4‬‬

‫‪ | OMS‬ملخص‬

指南:

成人和儿童钠摄入量内容摘要

WHO | 内容摘要

成人和儿童钠摄入量

版权所有。世界卫生组织出版物可从世卫组织网站 (www.who.int) 获得，或者自 WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (电话：+41 22 791 3264；传真：+41 22 791 4857；电子邮件：bookorders@who.int) 购买。要获得复制许可或翻译世界卫生组织出版物的许可 – 无论是为了出售或非商业性分发，应通过世卫组织网站 (http://www.who.int/about/licensing/copyright_ form/en/index.html) 向世界卫生组织出版处提出申请。本出版物采用的名称和陈述的材料并不代表世界卫生组织对任何国家、领地、城市或地区或其当局的合法地位，或关于边界或分界线的规定有任何意见。地图上的虚线表示可能尚未完全达成一致的大致边界线。凡提及某些公司或某些制造商的产品时，并不意味着它们已为世界卫生组织所认可或推荐，或比其它未提及的同类公司或产品更好。除差错和疏忽外，凡专利产品名称均冠以大写字母，以示区别。世界卫生组织已采取一切合理的预防措施来核实本出版物中包含的信息。但是，已出版材料的分发无任何明确或含蓄的保证。解释和使用材料的责任取决于读者。世界卫生组织对于因使用这些材料造成的损失不承担责任。 Design and layout: Alberto March Printed by the WHO Document Production Services, Geneva Switzerland

WHO | 内容摘要

成人和儿童钠摄入量

内容摘要背景非传染性疾病是造成全球发病率和死亡率的主要因素(1, 2) ，而采取干预措施减轻非传染性疾病负担具有很高的成本效益 ( 3 ) 。钠摄入量过高会引起一些非传染性疾病（如高血压、心血管疾病和中风等) ，而减少钠摄入量可以降低血压以及与此相关的非传染性疾病风险(4, 5)。最近收集的钠摄入量数据显示全球人口钠摄入量大大高于生理需要水平(6)。许多人群的钠摄入量大大高于世界卫生组织（世卫组织）目前推荐的成人钠摄入量（每日2克钠，相当于每日5克盐 )(7)。自从上次发表世卫组织钠摄入量指南(7)以来，收集并公布了关于钠摄入量、高血压和心血管疾病风险的大量科学证据。各会员国以及国际伙伴为此要求世卫组织审查现行的成人钠摄入量指南，并制定儿童钠摄入量指南。

目的

本指南的目的是就钠摄入量提供建议，以减少多数成人和儿童罹患非传染性疾病。负责制定规划和政策者可以根据这里的建议，对照基准评估目前的钠摄入水平。如有必要，还可根据这些建议制定有关措施，通过公共卫生干预措施（如食品和产品标签、消费者教育以及制定以食品为基础的饮食指南等 ) ，减少钠摄入量。

方法

世卫组织根据《WHO Handbook for guideline development 》 (8)。中列举的程序，制订了本知证指南。该过程包括的步骤是： •

确定重点问题和结果；

• 检索获取证据； • 评估和归纳证据； • 制订建议； • 确定研究空白； • 就指南的发布、实施、影响评估和更新制订相应的计划。

WHO | 内容摘要

成人和儿童钠摄入量

世卫组织采用“建议评估、制定和评价的分级”(Grading of Recommendations Assessment, Development and Evaluation) (GRADE) 法 (9) ，根据对科学文献最新的系统综述结果，针对预先选定的主题汇总了相应的证据。于2011年3月14日至18日在瑞士日内瓦、于2011年11月29日至12月2日在韩国首尔以及于2012年3月27日至 30日在瑞士日内瓦召开了三次世卫组织技术咨询会议，与会专家来自全球各地，涉及多个学科。专家们在这些会议上审议和讨论了现有证据和建议草案，并针对建议的强度达成了共识。在确定建议的强度时，专家们考虑了有关建议的合意效果 (desirable effects) 和不合意效果 (undesirable effects)、现有证据的质量、在不同环境下与建议相关的益处和选择问题以及在不同环境下可供公共卫生官员和规划管理人员选用方案的成本。指南编写小组的全体成员在每次参加会议前均填写《利益申报表》。外部专家和利益相关方小组全程参与。

证据

减少钠摄入量能够大幅降低成人和儿童的收缩压和舒张压。经检测，不管基线钠摄入量如何，在广泛的摄入水平上减少钠摄入量能够降低血压。将钠摄入量降至每日<2克对血压的益处大于钠摄入量虽然减少、但仍高于每日>2克的情况。减少钠摄入量对血脂、儿茶酚胺水平或肾功能并无显著不良影响。增加钠摄入量会加剧发生中风、致命性中风和致命性冠心病的风险。虽未发现钠摄入量与全因死亡率、发生心血管疾病或非致命性冠心病之间的关联，但血压与这些结果密切相关，这些间接证据表明，减少钠摄入量通过对血压的有益作用，可以改善这些结果。基于总体证据，世卫组织就成人和儿童钠摄入量提出以下建议。

建议

• 世卫组织建议成人减少钠摄入量，以便降低血压以及发生心血管疾病、中风和冠心病的风险（强烈建议1 )。世卫组织建议将成人钠摄入量降至每日 <2克（即每日盐摄入量<5克 )（强烈建议 )。

• 世卫组织建议儿童减少钠摄入量，以控制2血压（强烈建议 )。应根据儿童不同于成人的能量需求，参照所推荐的成人每日2克钠摄入最高限量，酌减儿童钠摄入最高限量。

1 2

“强烈建议”指的是指南制订小组确信合意效果将超过不合意效果的建议。在本建议中，“控制”系指预防随着年龄的增加血压升高并造成不良影响。

WHO | 内容摘要

成人和儿童钠摄入量

这些建议适用于所有人，对有高血压或无高血压的人（包括孕妇和哺乳期妇女）均适用，但不适用于患有疾病的人或正接受药物治疗的、可能会导致低钠血症或体液激增的人或需要医生监督饮食的人（如心脏衰竭或I型糖尿病患者 )。在这些亚人群中，钠摄入量与引起关注的健康结果之间可能存在某种关系（10, 11)。因此，在审查证据和制订本指南时未考虑这些亚人群。这些建议是对世卫组织钾摄入量指南的补充，应将这些建议与世卫组织钾摄入量指南以及其它营养指南和建议一道使用，以指导制定公共卫生营养规划和政策。确定钠摄入量与钾摄入量的最佳比例不属于本指南的范围。如果个人按照本指南的建议摄入钠，并按照世卫组织钾摄入量指南的建议摄入钾，钠与钾的比例约为1:1 ，这被视为有益于健康(12)。这些建议确认减少盐摄入量和食盐碘化并无冲突。需要在国家级监测盐摄入量和碘化食盐情况，以便根据所观测到的人口盐摄入量逐渐对碘化盐进行必要的调整，确保按推荐水平摄入钠的人继续摄入足量碘。这些建议基于钠摄入量与血压、全因死亡率、心血管疾病、中风和冠心病之间关系以及对血脂、儿茶酚胺水平和肾功能的潜在不良影响的总体证据。关于钠摄入量与血压之间关系的证据质量很高，而关于钠摄入量与全因死亡率、心血管疾病、中风和冠心病之间关系的证据质量则较低。因此，应在获得关于钠摄入量与全因死亡率和心血管疾病结果之间关系的更多证据后审查这些建议。妥善落实这些建议将大大增进公众健康，降低发病率和死亡率，改善数以百万计人的生活质量，并能大幅减少医疗保健费用 (1, 3, 13)。

WHO | 内容摘要

成人和儿童钠摄入量

参考文献 1. WHO. Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization (WHO), 2009 (http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf ). 2. WHO. Preventing chronic disease: a vital investment. Geneva, World Health Organization (WHO), 2005 (http://www.who.int/chp/chronic_disease_report/contents/en/index.html). 3. Murray CJ, Lauer JA, Hutubessy RC et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet, 2003, 361(9359):717–725 (http://www.ncbi.nlm.nih.gov/pubmed/12620735). 4. WHO. Prevention of recurrent heart attacks and strokes in low and middle income populations: Evidence-based recommendations for policy makers and health professionals. Geneva, World Health Organization (WHO), 2003 (http://www.who.int/cardiovascular_diseases/resources/pub0402/en/). 5. Bibbins-Domingo K, Chertow GM, Coxson PG et al. Projected effect of dietary salt reductions on future cardiovascular disease. New England Journal of Medicine, 2010, 362(7):590–599 (http://www.ncbi.nlm.nih.gov/pubmed/20089957). 6. Elliott P. Sodium intakes around the world. Background document prepared for the Forum and Technical meeting on Reducing Salt Intake in Populations (Paris 5–7 October 2006). Geneva, World Health Organization, 2007. 7. WHO. Prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. Geneva, World Health Organization (WHO), 2007 (http://whqlibdoc.who.int/publications/2007/9789241547178_eng.pdf ). 8. WHO’s Guidelines Review Committee. WHO Handbook for guideline development. Geneva, World Health Organization (WHO), 2012 (http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf ). 9. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008, 336(7650):924–926 (http://www.ncbi.nlm.nih.gov/pubmed/18436948). 10. Paterna S, Gaspare P, Fasullo S et al. Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? Clin Sci (Lond), 2008, 114(3):221-230 (http://www.ncbi.nlm.nih.gov/pubmed/17688420). 11. Thomas MC, Moran J, Forsblom C et al. The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Diabetes Care, 2011, 34(4):861-866 (http://www.ncbi.nlm.nih.gov/pubmed/21307382). 12. WHO. Diet, nutrition and the prevention of chronic disease. Report of a Joint WHO/ FAO Expert Consultation. Geneva, World Health Organization (WHO), 2003 (http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf ). 13. Mackay J, Mensah G. The Atlas of Heart Disease and Stroke. Geneva, World Health Organization (WHO), 2004 (http://www.who.int/cardiovascular_diseases/resources/atlas/en/).

WHO | 内容摘要

成人和儿童钠摄入量

如欲获取更多信息，请联系： Department of Nutrition for Health and Development World Health Organization 20, Avenue Appia, 1211 Geneva, Switzerland Fax: +41 22 791 4156 Email: nutrition@who.int www.who.int/nutrition

WHO | 内容摘要

成人和儿童钠摄入量

Руководство:

Потреблении натрия для взрослых и детей Резюме

WHO | Резюме

Руководство о потреблении натрия для взрослых и детей

Все права защищены. Публикации Всемирной организации здравоохранения имеются на веб-сайте ВОЗ (www.who.int) или могут быть приобретены в Отделе прессы ВОЗ, Всемирная организация здравоохранения, 20 Avenue Appia, 1211 Geneva 27, Switzerland (тел.: +41 22 791 3264; факс: +41 22 791 4857; эл. почта: bookorders@who.int). Запросы на получение разрешения на воспроизведение или перевод публикаций ВОЗ - как для продажи, так и для некоммерческого распространения следует направлять в Отдел прессы ВОЗ через веб-сайт ВОЗ (http://www.who.int/about/licensing/ copyright_form/en/index.html). Обозначения, используемые в настоящей публикации, и приводимые в ней материалы не отражают какого-либо мнения Всемирной организации здравоохранения относительно юридического статуса какой-либо страны, территории, города или района или их органов власти, либо относительно делимитации их границ. Пунктирные линии на географических картах обозначают приблизительные границы, в отношении которых пока еще может быть не достигнуто полное согласие. Упоминание конкретных компаний или продукции некоторых изготовителей не означает, что Всемирная организация здравоохранения поддерживает или рекомендует их, отдавая им предпочтение по сравнению с другими компаниями или продуктами аналогичного характера, не упомянутыми в тексте. За исключением случаев, когда имеют место ошибки и пропуски, названия патентованных продуктов выделяются начальными прописными буквами. Всемирная организация здравоохранения приняла все разумные меры предосторожности для проверки информации, содержащейся в настоящей публикации. Тем не менее, опубликованные материалы распространяются без какой-либо четко выраженной или подразумеваемой гарантии. Ответственность за интерпретацию и использование материалов ложится на пользователей. Всемирная организация здравоохранения ни в коем случае не несет ответственности за ущерб, возникший в результате использования этих материалов. Design and layout: Alberto March Printed by the WHO Document Production Services, Geneva Switzerland

WHO | Резюме

Руководство о потреблении натрия для взрослых и детей

Исполнительное резюме Справочная информация Неинфекционные заболевания (НИЗ) являются одним из основных факторов смертности и заболеваемости в глобальных масштабах (1, 2), а вмешательства по сокращению бремени НИЗ являются высокоэффективными с точки зрения затрат (3). Повышенное потребление натрия ассоциируется с рядом НИЗ (включая гипертензию, сердечно-сосудистые заболевания и инсульт), а сокращение потребления натрия может снизить кровяное давление и риск связанных НИЗ (4, 5). Как показывают последние данные о потреблении натрия, в различных группах населения в мире потребление натрия значительно превышает физиологическую потребность (6). Во многих случаях уровень потребления значительно превышает существующий рекомендованный Всемирной организацией здравоохранения (WHO) уровень потребления натрия для взрослых, который составляет 2 г натрия в сутки (эквивалентно 5 г соли в сутки) (7). В период после выхода предыдущего руководства ВОЗ по потреблению натрия (7) опубликован существенный объем научных данных в отношении употребления соли, гипертензии и риска сердечно-сосудистых заболеваний. Государства-члены и международные партнеры поэтому просили ВОЗ пересмотреть существующее руководство по потреблению натрия для взрослых, а также разработать руководство по потреблению натрия для детей.

Цель

Цель настоящего руководства – представить рекомендации о потреблении натрия для сокращения НИЗ среди большинства взрослых и детей. Рекомендации, содержащиеся в настоящем руководстве, могут быть использованы при разработке программ и политики для оценки существующего уровня потребления натрия по сравнению с базовым уровнем. В случае необходимости эти рекомендации можно также использовать для разработки мер по сокращению потребления натрия в ходе таких связанных с общественным здравоохранением мер, как маркировка продуктов питания, просвещение потребителей, а также установление основанных на конкретных продуктах руководящих принципов питания. ВОЗ разработала данное основанное на фактах руководство с использованием процедур, изложенных в « WHO Handbook for guideline development » (8). Данный процесс предусматривает следующие шаги: • • • • • • определение первоочередных вопросов и конечных результатов; поиск данных; оценку и синтез данных; выработку рекомендаций; выявление пробелов в исследованиях; составление планов распространения, осуществления, оценки воздействия и обновления руководств.

Методология

WHO | Резюме

Руководство о потреблении натрия для взрослых и детей

Методология (GRADE) (Grading of Recommendations Assessment, Development and Evaluation) (9) была применена для подготовки характеристик данных по предварительно отобранным темам на основе недавнего систематического обзора научной литературы. В трех технических консультативных совещаниях ВОЗ принимала участие международная междисциплинарная группа экспертов. Первое совещание состоялось в Женеве, Швейцария, 14–18 марта 2011 г.; второе – в Сеуле, Республика Корея, 29 ноября – 2 декабря 2011 г.; а третье – в Женеве, Швейцария, 27–30 марта 2012 года. На этих совещания группа экспертов рассмотрела и обсудила данные, подготовила проект рекомендаций и достигла консенсуса о силе каждой рекомендации. При определении силы рекомендаций учитывались желательные и нежелательные последствия применения рекомендаций, качество имеющихся данных, показателей и преференций в связи с использованием конкретной рекомендации в различных обстоятельствах, а также стоимость вариантов, имеющихся у сотрудников общественного здравоохранения и руководителей программ в различных условиях. Перед каждым совещанием все члены группы по разработке руководства заполняли формуляр декларации интересов. В ходе всего процесса была задействована Группа внешних экспертов и заинтересованных сторон.

Данные

Сокращение потребления натрия вело к существенному сокращению систолического и диастолического кровяного давления у взрослых и детей. Сокращение кровяного давления отмечалось по широкому диапазону уровней потребления и не зависело от исходного уровня потребления натрия. Сокращение потребления натрия до <2 г в сутки было более благоприятным для кровяного давления, чем сокращение потребления натрия при сохранении уровня потребления >2 г в сутки. Сокращение потребления натрия не оказывало заметного негативного воздействия на липиды в крови, уровни катехоламина или почечную функцию. Увеличение потребления натрия ассоциируется с повышением риска инцидентного инсульта, фатального инсульта и фатального коронарно-сердечного заболевания. Не отмечалось какой-либо связи между потреблением натрия и смертностью от всех причин, инцидентными сердечно-сосудистыми заболеваниями и несмертельными коронарно-сердечными заболеваниями. Однако сильная позитивная взаимосвязь между кровяным давлением и такими исходами косвенно свидетельствует о том, что сокращение потребления натрия может сократить такие исходы за счет благоприятного воздействия на кровяное давление. Опираясь на всю совокупность данных, ВОЗ разработала следующие рекомендации относительно потребления натрия взрослыми и детьми. • ВОЗ рекомендует сократить потребление натрия для снижения кровяного давления и риска сердечно-сосудистых заболеваний, инсульта и коронарных сердечных заболеваний у взрослых (сильная рекомендация1). ВОЗ рекомендует сократить потребление натрия до <2 г в сутки (5 г соли в сутки) для взрослых (сильная рекомендация). ВОЗ рекомендует сократить потребление натрия для обеспечения контроля2 за кровяным давлением у детей (сильная рекомендация). Рекомендованный максимальный уровень потребления в размере 2 г

Рекомендации

•

Сильной называется рекомендация, в отношении которой группа разработки рекомендаций уверена, что желательный эффект выполнения перевешивает нежелательные последствия. 1

«Контроль» в данной рекомендации означает предотвращение вредного для здоровья повышения кровяного давления с возрастом. 2

WHO | Резюме

Руководство о потреблении натрия для взрослых и детей

натрия в сутки для взрослых следует корректировать в сторону понижения на основе энергетических потребностей детей по сравнению с такими потребностями у взрослых. Эти рекомендации применимы ко всем лицам, страдающим или не страдающим от гипертензии (включая беременных и кормящих женщин), за исключением тех лиц, заболевание или принимаемые лекарства которых могут привести к гипонатремии, резкому повышению содержания воды в организме или потребовать соблюдения диеты под наблюдением врача (например, у пациентов с инфарктом или диабетом типа I). В этих подгруппах может отмечаться особая взаимосвязь между потреблением натрия и соответствующими медицинскими исходами (10, 11). Поэтому эти подгруппы не учитывались при рассмотрении данных и выработке руководства. Данные рекомендации дополняют руководство ВОЗ по потреблению калия и должны использоваться с учетом этих и других руководящих принципов и рекомендаций по питательным веществам при разработке программ и политики общественного здравоохранения в области питания. Вопрос об оптимальном соотношении натрия и калия не рассматривается в рамках этого руководства; однако если человек будет употреблять то количество натрия, которое рекомендовано в данном руководстве, а также то количество калия, которое рекомендуется в руководстве ВОЗ по потреблению калия, то соотношение натрия к калию будет примерно один к одному, что считается полезным для здоровья (12). В этих рекомендациях признается, что сокращение потребления соли и йодирование соли совместимы. Необходим мониторинг на страновом уровне в том, что касается потребления соли и йодирования соли, с тем чтобы со временем корректировать, по мере необходимости, йодирование соли в зависимости от регистрируемого потребления соли населением, с тем чтобы обеспечить потребление не только рекомендованного количества натрия, но и сохранение поступления йода в достаточном количестве. Данные рекомендации основаны на совокупности данных о взаимосвязи между потреблением натрия и кровяным давлением, смертностью от всех причин, сердечно-сосудистыми заболеваниями, инсультами и коронарно-сердечными заболеваниями, а также потенциально негативными последствиями для липидов в крови, уровнями катехоламинов и почечной функцией. Данные в отношении взаимосвязи между потреблением натрия и кровяным давлением являются надежными, а вот данные, касающиеся потребления натрия и смертности от всех причин, сердечно-сосудистых заболеваний, инсульта и коронарно-сердечных заболеваний характеризуются более низким качеством. Поэтому данные рекомендации следует пересмотреть, когда появятся дополнительные данные о взаимосвязи между потреблением натрия и смертностью от всех причин и исходами в случае сердечно-сосудистых заболеваний. Успешное осуществление данных рекомендаций окажет важное влияние на состояние общественного здравоохранения в результате сокращения заболеваемости и смертности, повышения качества жизни миллионов людей, а также значительного сокращения расходов на здравоохранение (1, 3, 13).

WHO | Резюме

Руководство о потреблении натрия для взрослых и детей

Библиография 1. WHO. Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization (WHO), 2009 (http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf ). 2. WHO. Preventing chronic disease: a vital investment. Geneva, World Health Organization (WHO), 2005 (http://www.who.int/chp/chronic_disease_report/contents/en/index.html). 3. Murray CJ, Lauer JA, Hutubessy RC et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet, 2003, 361(9359):717–725 (http://www.ncbi.nlm.nih.gov/pubmed/12620735). 4. WHO. Prevention of recurrent heart attacks and strokes in low and middle income populations: Evidence-based recommendations for policy makers and health professionals. Geneva, World Health Organization (WHO), 2003 (http://www.who.int/cardiovascular_diseases/resources/pub0402/en/). 5. Bibbins-Domingo K, Chertow GM, Coxson PG et al. Projected effect of dietary salt reductions on future cardiovascular disease. New England Journal of Medicine, 2010, 362(7):590–599 (http://www.ncbi.nlm.nih.gov/pubmed/20089957). 6. Elliott P. Sodium intakes around the world. Background document prepared for the Forum and Technical meeting on Reducing Salt Intake in Populations (Paris 5–7 October 2006). Geneva, World Health Organization, 2007. 7. WHO. Prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. Geneva, World Health Organization (WHO), 2007 (http://whqlibdoc.who.int/publications/2007/9789241547178_eng.pdf ). 8. WHO’s Guidelines Review Committee. WHO Handbook for guideline development. Geneva, World Health Organization (WHO), 2012 (http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf ). 9. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008, 336(7650):924–926 (http://www.ncbi.nlm.nih.gov/pubmed/18436948). 10. Paterna S, Gaspare P, Fasullo S et al. Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? Clin Sci (Lond), 2008, 114(3):221-230 (http://www.ncbi.nlm.nih.gov/pubmed/17688420). 11. Thomas MC, Moran J, Forsblom C et al. The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Diabetes Care, 2011, 34(4):861-866 (http://www.ncbi.nlm.nih.gov/pubmed/21307382). 12. WHO. Diet, nutrition and the prevention of chronic disease. Report of a Joint WHO/ FAO Expert Consultation. Geneva, World Health Organization (WHO), 2003 (http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf ). 13. Mackay J, Mensah G. The Atlas of Heart Disease and Stroke. Geneva, World Health Organization (WHO), 2004 (http://www.who.int/cardiovascular_diseases/resources/atlas/en/).

WHO | Резюме

Руководство о потреблении натрия для взрослых и детей

Для получения дополнительной информации: Département Nutrition pour la santé et le développement Organisation mondiale de la Santé 20, Avvenue Appia, CH-1211 Genève 27, Suisse Télécopie : +41 22 791 4156 Courriel : nutrition@who.int www.who.int/nutrition

WHO | Резюме

Руководство о потреблении натрия для взрослых и детей

Key facts

Organisation World Health Organization (WHO)

Document type Publications

Adoption date December 31, 2012

Source World Health Organization