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May 22, 1996, Vol 275, No. 20 >
ARTICLE | May 22, 1996

Effect of Reduced Dietary Sodium on Blood Pressure: Title and subTitle BreakA Meta-analysis of Randomized Controlled Trials FREE

Julian Paul Midgley, BM BCh; Andrew Glenday Matthew; Celia Margaret T. Greenwood, MMath; Alexander Gordon Logan, MD
[+] Author Affiliations

Presented in part at the American Society of Nephrology 27th annual meeting, Orlando, Fla, October 27, 1994.

Reprints: Alexander G. Logan, MD, Suite 850, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario, Canada M5G 1X5.


JAMA. 1996;275(20):1590-1597. doi:10.1001/jama.1996.03530440070039
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Published online
Article
References

Objective.  —To ascertain whether restriction of dietary sodium lowers blood pressure in hypertensive and normotensive individuals.

Data Sources.  —An English-language computerized literature search, restricted to human studies with Medical Subject Heading terms, "hypertension," "blood pressure," "vascular resistance," "sodium and dietary," "diet and sodium restricted," "sodium chloride," "clinical trial," "randomized controlled trial," and "prospective studies," was conducted. Bibliographies of review articles and personal files were also searched.

Trial Selection.  —Trials that had randomized allocation to control and dietary sodium intervention groups, monitored by timed sodium excretion, with outcome measures of both systolic and diastolic blood pressure were selected by blinded review of the methods section.

Data Extraction.  —Two observers extracted data independently, using purposedesigned forms, and discrepancies were resolved by discussion.

Data Synthesis.  —The 56 trials that met our inclusion criteria showed significant heterogeneity. Publication bias was also evident. The mean reduction (95% confidence interval) in daily urinary sodium excretion, a proxy measure of dietary sodium intake, was 95 mmol/d (71-119 mmol/d) in 28 trials with 1131 hypertensive subjects and 125 mmol/d (95-156 mmol/d) in 28 trials with 2374 normotensive subjects. After adjustment for measurement error of urinary sodium excretion, the decrease in blood pressure for a 100-mmol/d reduction in daily sodium excretion was 3.7 mm Hg (2.35-5.05 mm Hg) for systolic (P<.001) and 0.9 mm Hg (-0.13 to 1.85 mm Hg) for diastolic (P=.09) in the hypertensive trials, and 1.0 mm Hg (0.51-1.56 mm Hg) for systolic (P<.001) and 0.1 mm Hg (-0.32 to 0.51 mm Hg) for diastolic (P=.64) in the normotensive trials. Decreases in blood pressure were larger in trials of older hypertensive individuals and small and nonsignificant in trials of normotensive individuals whose meals were prepared and who lived outside the institution setting.

Conclusion.  —Dietary sodium restriction for older hypertensive individuals might be considered, but the evidence in the normotensive population does not support current recommendations for universal dietary sodium restriction.(JAMA. 1996;275:1590-1597)

REFERENCES

1 +
References 8, 10, 35-44, 50, 55, 72, 75, 76, 81-83.
2 +
References 27-32, 45, 46, 52-54, 60, 74, 77-79, 81, 83, 87.
3 +
References 7, 45-48, 51-54, 56, 57, 60, 68, 74, 85, 87.
4 +
References 8, 10, 35-44, 50, 55, 72, 75, 76, 81-83.
5 +
Logan AG.  Sodium manipulation in the management of hypertension: the view against its general use. Can J Physiol Pharmacol . 1986;;64:793-802.
6 +
Cutler JA, Follmann D, Elliott P, Suh I.  An overview of randomized trials of sodium reduction and blood pressure. Hypertension . 1991;;17:I-27—I-33.
7 +
Muntzel M, Drueke T.  A comprehensive review of the salt and blood pressure relationship. Am J Hypertens . 1992;;5:1S-42S.
8 +
Stamler J.  Dietary salt and blood pressure. Ann N Y Acad Sci . 1993;;676:122-156.
9 +
 Food labeling: health claims and label statements; sodium/hypertension. Federal Register . 1991;;56: 60825-60855.
10 +
Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for the Americans, 1995 . Washington, DC: US Dept of Agriculture, US Dept of Health and Human Services.
11 +
Cooper R, Van Horn L, Liu K, et al.  A randomized trial on the effect of decreased dietary sodium intake on blood pressure in adolescents. J Hypertens . 1984;;2:361-366.
12 +
Fuchs FD, Wannmacher CM, Wannmacher L, et al.  Effect of sodium intake on blood pressure, serum levels and renal excretion of sodium and potassium in normotensives with and without familial predisposition to hypertension. Braz J Med Biol Res . 1987;;20:25-34.
13 +
Gillum RF, Elmer PJ, Prineas RJ.  Changing sodium intake in children: the Minneapolis Children's Blood Pressure Study. Hypertension . 1981;; 3:698-703.
14 +
Mascioli S, Grimm R, Launer C, et al.  Sodium chloride raises blood pressure in normotensive subjects: the study of sodium and blood pressure. Hypertension . 1991;;17:I-21—I-26.
15 +
Tonascia J, Donithan M, Tonascia S, Hiller J, Hall WD, Langford HG. Hypertension Prevention Trial: Estimation of 24-Hour Sodium and Potassium Excretion From Overnight Urine Collections . Baltimore, Md: Dept of Biostatistics, The Johns Hopkins University; 1989;. Technical report 703.
16 +
Jula A, Ronnemaa T, Rastas M, Karvetti RL, Maki J.  Long-term nonpharmacological treatment for mild to moderate hypertension. J Intern Med . 1990;;227:413-421.
17 +
Jula AM, Ronnemaa TE, Piha SJ, Maki JP.  Response of diastolic blood pressure to long-term sodium restriction is posture related. Scand J Clin Lab Invest . 1992;;52:159-167.
18 +
Koopman H, Spreeuwenberg C, Westerman RF, Donker AJ.  Dietary treatment of patients with mild to moderate hypertension in a general practice: a pilot intervention study, I: the first three months. J Hum Hypertens . 1990;;4:368-371.
19 +
Koopman H, Spreeuwenberg C, Westerman RF, Donker AJ.  Dietary treatment of patients with mild to moderate hypertension in a general practice: a pilot intervention study, II: beyond three months. J Hum Hypertens . 1990;;4:372-374.
20 +
Chalmers J, Morgan T, Doyle A, et al.  Australian National Health and Medical Research Council dietary salt study in mild hypertension. J Hypertens . 1986;;4( (suppl 6) ):S629-S637.
21 +
Nowson CA, Morgan TO.  Change in blood pressure in relation to change in nutrients effected by manipulation of dietary sodium and potassium. Clin Exp Pharmacol Physiol . 1988;;15:225-242.
22 +
Fagerberg B, Andersson OK, Isaksson B, Bjorntorp P.  Blood pressure control during weight reduction in obese hypertensive men: separate effects of sodium and energy restriction. BMJ . 1984;; 288:11-14.
23 +
Andersson OK, Fagerberg B, Hedner T.  Importance of dietary salt in the hemodynamic adjustment to weight reduction in obese hypertensive men. Hypertension . 1984;;6:814-819.
24 +
Fagerberg B, Andersson OK, Persson B, Hedner T.  Reactivity to norepinephrine and effect of sodium on blood pressure during weight loss. Hypertension . 1985;;7:586-592.
25 +
Andersson OK, Fagerberg B, Hedner T.  Haemodynamic adjustment to weight reduction—separate effects of energy versus salt restriction. J Hypertens . 1983;;1( (suppl 2) ):35-37.
26 +
Fagerberg B, Andersson OK, Lindstedt G, Waldenstrom J, Aurell M.  The sodium intake modifies the renin-aldosterone and blood pressure changes associated with moderately low energy diets. Acta Med Scand . 1985;;218:157-164.
27 +
Australian National Health and Medical Research Council Dietary Salt Study Management Committee.  Fall in blood pressure with modest reduction in dietary salt intake in mild hypertension. Lancet . 1989;;1:399-402.
28 +
Australian National Health and Medical Research Council Dietary Salt Study Management Committee.  Effects of replacing sodium intake in subjects on a low sodium diet: a crossover study. Clin Exp Hypertens . 1989;;11:1011-1024.
29 +
Richards AM, Nicholls MG, Espiner EA, et al.  Blood-pressure response to moderate sodium restriction and to potassium supplementation in mild essential hypertension. Lancet . 1984;;1:757-761.
30 +
Richards AM, Nicholls MG, Espiner EA, et al.  Endogenous angiotensin-aldosterone-pressure relationships during sodium restriction. Hypertension . 1985;;7:681-687.
31 +
MacGregor GA, Markandu ND, Best FE, et al.  Double-blind randomised crossover trial of moderate sodium restriction in essential hypertension. Lancet . 1982;;1:351-355.
32 +
MacGregor GA, Markandu ND, Sagnella GA.  Dietary sodium restriction in normotensive subjects and patients with essential hypertension. Clin Sci . 1982;;63:399S-402S.
33 +
MacGregor GA.  Salt restriction in the treatment of hypertension. Scand J Clin Lab Invest Suppl . 1985;;176:25-37.
34 +
Koolen MI, Bussemaker-Verduyn den Boer E, van Brummelen P.  Clinical biochemical and haemodynamic correlates of sodium sensitivity in essential hypertension. J Hypertens . 1983;;1( (suppl 2) ): 21-23.
35 +
Koolen MI, van Brummelen P.  Adrenergic activity and peripheral hemodynamics in relation to sodium sensitivity in patients with essential hypertension. Hypertension . 1984;;6:820-825.
36 +
Koolen MI, van Brummelen P.  Sodium sensitivity in essential hypertension: role of the renin-angiotensin-aldosterone system and predictive value of an intravenous frusemide test. J Hypertens . 1984;; 2:55-59.
37 +
Watt GC, Edwards C, Hart JT, Hart M, Walton P, Foy CJ.  Dietary sodium restriction for mild hypertension in general practice. BMJ . 1983;;286:432-436.
38 +
Watt G, Hart JT, Foy C.  Effect of moderate dietary sodium restriction on patients with mild hypertension in general practice. J Hypertens Suppl . 1983;;1:18-20.
39 +
Miller JZ, Weinberger MH, Daugherty SA, Fineberg NS, Christian JC, Grim CE.  Blood pressure response to dietary sodium restriction in healthy normotensive children. Am J Clin Nutr . 1988;;47: 113-119.
40 +
Luft FC, Miller JZ, Grim CE, et al.  Salt sensitivity and resistance of blood pressure: age and race as factors in physiological responses. Hypertension . 1991;;17:I102-I108.
41 +
Luft FC, Miller JZ, Weinberger MH, Grim CE, Daugherty SA, Christian JC.  Influence of genetic variance on sodium sensitivity of blood pressure. Klin Wochenschr . 1987;;65:101-109.
42 +
The Trials of Hypertension Prevention Collaborative Research Group.  The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels: results of the Trials of Hypertension Prevention, phase I. JAMA . 1992;; 267:1213-1220.
43 +
Kumanyika SK, Hebert PR, Cutler JA, et al.  Feasibility and efficacy of sodium reduction in the trials of hypertension prevention, phase I. Hypertension . 1993;;22:502-512.
44 +
Watt GC, Foy CJ, Hart JT, et al.  Dietary sodium and arterial blood pressure: evidence against genetic susceptibility. BMJ . 1985;;291:1525-1528.
45 +
Watt GC, Foy CJ, Hart JT.  Dietary sodium and blood pressure in young people with and without familial predisposition to high blood pressure. J Clin Hypertens . 1986;;2:141-147.
46 +
Myers JB.  Reduced sodium chloride intake normalises blood pressure distribution. J Hum Hypertens . 1989;;3:97-104.
47 +
Myers J, Morgan T, Waga S, Manley K.  The effect of sodium intake on blood pressure related to the age of the patients. Clin Exp Pharmacol Physiol Suppl . 1982;;9:287-289.
48 +
Myers JB, Morgan TO.  Effect of alteration in sodium chloride intake on blood pressure of normotensive subjects. J Cardiovasc Pharmacol . 1984;; 6( (suppl 1) ):S204-S209.
49 +
Sharma AM, Arntz HR, Kribben A, Schattenfroh S, Distler A.  Dietary sodium restriction: adverse effect on plasma lipids. Klin Wochenschr . 1990;;68:664-668.
50 +
Ruppert M, Overlack A, Kolloch R, Kraft K, Gobel B, Stumpe KO.  Neurohormonal and metabolic effects of severe and moderate salt restriction in non-obese normotensive adults. J Hypertens . 1993;; 11:743-749.
51 +
Overlack A, Ruppert M, Kolloch R, et al.  Divergent hemodynamic and hormonal responses to varying salt intake in normotensive subjects. Hypertension . 1993;;22:331-338.
52 +
Ruppert M, Overlack A, Kolloch R, Kraft K, Lennarz M, Stumpe KO.  Effects of severe and moderate salt restriction on serum lipids in nonobese normotensive adults. Am J Med Sci . 1994;;307( (suppl 1) ):S87-S90.
53 +
Myers J, Morgan T.  The effect of sodium intake on the blood pressure related to age and sex. Clin Exp Hypertens . 1983;;5:99-118.
54 +
Nestel PJ, Clifton PM, Noakes M, McArthur R, Howe PR.  Enhanced blood pressure response to dietary salt in elderly women, especially those with small waist:hip ratio. J Hypertens . 1993;;11:1387-1394.
55 +
El Ashry A, Heagerty AM, Alton SM, Bing RF, Swales JD, Thurston H.  Effects of manipulation of sodium balance on erythrocyte sodium transport. J Hum Hypertens . 1987;;1:105-111.
56 +
Sharma AM, Ruland K, Spies KP, Distler A.  Salt sensitivity in young normotensive subjects is associated with a hyperinsulinemic response to oral glucose. J Hypertens . 1991;;9:329-335.
57 +
Sharma AM, Schorr U, Distler A.  Insulin resistance in young salt-sensitive normotensive subjects. Hypertension . 1993;;21:273-279.
58 +
Skrabal F, Herholz H, Neumayr M, et al.  Salt sensitivity in humans is linked to enhanced sympathetic responsiveness and to enhanced proximal tubular reabsorption. Hypertension . 1984;;6:152-158.
59 +
Teow BH, Di Nicolantonio R, Morgan TO.  Sodium chloride preference and recognition threshold in normotensive subjects on high and low salt diet. Clin Exp Hypertens . 1986;;7:1681-1695.
60 +
Burnier M, Rutschmann B, Nussberger J, et al.  Salt-dependent renal effects of an angiotensin II antagonist in healthy subjects. Hypertension . 1993;; 22:339-347.
61 +
Bruun NE, Skott P, Damkjaer Nielsen M, et al.  Normal renal tubular response to changes of sodium intake in hypertensive man. J Hypertens . 1990;; 8:219-227.
62 +
MacGregor GA, Markandu ND, Sagnella GA, Singer DR, Cappuccio FP.  Double-blind study of three sodium intakes and long-term effects of sodium restriction in essential hypertension. Lancet . 1989;;2:1244-1247.
63 +
Zoccali C, Mallamaci F, Leonardis D, Romeo M.  Randomly allocated crossover study of various levels of sodium intake in patients with mild hypertension. J Hypertens . 1993;;11( (suppl 5) ):S326-S327.
64 +
Schmid M, Mann JF, Stein G, et al.  Natriuresispressure relationship in polycystic kidney disease. J Hypertens . 1990;;8:277-283.
65 +
Morgan T, Adam W, Gillies A, Wilson M, Morgan G, Carney S.  Hypertension treated by salt restriction. Lancet . 1978;;1:227-230.
66 +
Fleiss JL.  The statistical basis of meta-analysis. Stat Methods Med Res . 1993;;2:121-145.
67 +
Follmann D, Elliott P, Suh I, Cutler J.  Variance imputation for overviews of clinical trials with continuous response. J Clin Epidemiol . 1992;;45:769-773.
68 +
DerSimonian R, Laird N.  Meta-analysis in clinical trials. Control Clin Trials . 1986;;7:177-188.
69 +
Seber GAI. Linear Regression Analysis . New York, NY: John Wiley & Sons Inc; 1977;:155-158.
70 +
Dyer AR, Shipley M, Elliott P, for the Intersalt Cooperative Research Group.  Urinary electrolyte excretion in 24 hours and blood pressure in the Intersalt study, I: estimates of reliability. Am J Epidemiol . 1994;;139:927-939.
71 +
SAS Institute Inc.SAS/STAT User's Guide, Version 6 . 4th ed. Cary, NC: SAS Institute Inc; 1989;.
72 +
Lawton WJ, Sinkey CA, Fitz AE, Mark AL.  Dietary salt produces abnormal renal vasoconstrictor responses to upright posture in borderline hypertensive subjects. Hypertension . 1988;;11:529-536.
73 +
Applegate WB, Miller ST, Elam JT, et al.  Nonpharmacologic intervention to reduce blood pressure in older patients with mild hypertension. Arch Intern Med . 1992;;152:1162-1166.
74 +
Erwteman TM, Nagelkerke N, Lubsen J, Koster M, Dunning AJ.  Beta blockade, diuretics, and salt restriction for the management of mild hypertension: a randomised double blind trial. BMJ . 1984;; 289:406-409.
75 +
Silman AJ, Locke C, Mitchell P, Humpherson P.  Evaluation of the effectiveness of a low sodium diet in the treatment of mild to moderate hypertension. Lancet . 1983;;1:1179-1182.
76 +
Hypertension Prevention Trial Research Group.  The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure. Arch Intern Med . 1990;;150:153-162.
77 +
Mark AL, Lawton WJ, Abboud FM, Fitz AE, Connor WE, Heistad DD.  Effects of high and low sodium intake on arterial pressure and forearm vasular resistance in borderline hypertension: a preliminary report. Circ Res . 1975;;36:194-198.
78 +
Skrabal F, Aubock J, Hortnagl H.  Low sodium/ high potassium diet for prevention of hypertension: probable mechanisms of action. Lancet . 1981;;2:895-900.
79 +
Puska P, Iacono JM, Nissinen A, et al.  Controlled, randomised trial of the effect of dietary fat on blood. Lancet . 1983;;1:1-5.
80 +
Richards AM, Tonolo G, Cleland JGF, et al.  Plasma atrial natriuretic peptide: responses to modest and severe sodium restriction. J Hypertens . 1986;;4( (suppl 6) ):S559-S563.
81 +
Grobbee DE, Hofman A, Roelandt JT, Boomsma F, Schalekamp MA, Valkenburg HA.  Sodium restriction and potassium supplementation in young people with mildly elevated blood pressure. J Hypertens . 1987;;5:115-119.
82 +
Kurtz TW, Al-Bander HA, Morris RC Jr.  'Salt-sensitive' essential hypertension in men: is the sodium ion alone important? N Engl J Med . 1987;: 317:1043-1048.
83 +
Bompiani GD, Cerasola G, Morici ML, et al.  Effects of moderate low sodium/high potassium diet on essential hypertension: results of a comparative study. Int J Clin Pharmacol Ther Toxicol . 1988;; 26:129-132.
84 +
Morgan T, Anderson A.  Interaction in hypertensive man between sodium intake, converting enzyme inhibitor (enalapril), plasma renin, and blood pressure control. J Hum Hypertens . 1988;;1:311-315.
85 +
Hargreaves M, Morgan TO, Snow R, Guerin M.  Exercise tolerance in the heat on low and normal salt intakes. Clin Sci . 1989;;76:553-557.
86 +
Friberg P, Meredith I, Jennings G, Lambert G, Fazio V, Esler M.  Evidence for increased renal norepinephrine overflow during sodium restriction in humans. Hypertension . 1990;;16:121-130.
87 +
Howe PR, Cobiac L, Smith RM.  Lack of effect of short-term changes in sodium intake on blood pressure in adolescent schoolchildren. J Hypertens . 1991;;9:181-186.
88 +
Benetos A, Xiao YY, Cuche JL, Hannaert P, Safar M.  Arterial effects of salt restriction in hypertensive patients: a 9-week, randomized, double-blind, crossover study. J Hypertens . 1992;;10:355-360.
89 +
Gow IF, Dockrell M, Edwards CR, et al.  The sensitivity of human blood platelets to the aggregating agent ADP during different dietary sodium intakes in healthy men. Eur J Clin Pharmacol . 1992;;43:635-638.
90 +
Del Rio A, Rodriguez-Villamil JL.  Metabolic effects of strict salt restriction in essential hypertensive patients. J Intern Med . 1993;;233:409-414.
91 +
Donovan DS, Solomon CG, Seely EW, Williams GH, Simonson DC.  Effect of sodium intake on insulin sensitivity. Am J Physiol . 1993;;264:E730-E734.
92 +
Fotherby MD, Potter JF.  Effects of moderate sodium restriction on clinic and twenty-four-hour ambulatory blood pressure in elderly hypertensive subjects. J Hypertens . 1993;;11:657-663.
93 +
Gill JS, Zezulka AV, Beevers DG, Davies P.  Relation between initial blood pressure and its fall with treatment. Lancet . 1985;;1:567-569.
94 +
Law MR, Frost CD, Wald NJ.  Ill-Analysis of data from trials of salt reduction. BMJ . 1991;;302: 819-824.
95 +
Alderman MH, Madhavan S, Cohen H, Sealey JE, Laragh JH.  Low urinary sodium associated with greater risk of myocardial infarction among treated hypertensive men. Hypertension . 1995;;25: 1144-1152.
96 +
Egan M, Weder AB, Petrin J, Hoffman RG.  Neurohumoral and metabolic effects of short-term dietary restriction in men: relationship to salt-sensitivity status. Am J Hypertens . 1991;;4:416-421.
97 +
Ruppert M, Diehl J, Kolloch R, et al.  Short-term dietary sodium restriction increases serum lipids and insulin in salt-sensitive and salt-resistant normotensive adults. Klin Wochenschr . 1991;;69 ( (suppl 25) ):51-57.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
References 8, 10, 35-44, 50, 55, 72, 75, 76, 81-83.
2 +
References 27-32, 45, 46, 52-54, 60, 74, 77-79, 81, 83, 87.
3 +
References 7, 45-48, 51-54, 56, 57, 60, 68, 74, 85, 87.
4 +
References 8, 10, 35-44, 50, 55, 72, 75, 76, 81-83.
5 +
Logan AG.  Sodium manipulation in the management of hypertension: the view against its general use. Can J Physiol Pharmacol . 1986;;64:793-802.
6 +
Cutler JA, Follmann D, Elliott P, Suh I.  An overview of randomized trials of sodium reduction and blood pressure. Hypertension . 1991;;17:I-27—I-33.
7 +
Muntzel M, Drueke T.  A comprehensive review of the salt and blood pressure relationship. Am J Hypertens . 1992;;5:1S-42S.
8 +
Stamler J.  Dietary salt and blood pressure. Ann N Y Acad Sci . 1993;;676:122-156.
9 +
 Food labeling: health claims and label statements; sodium/hypertension. Federal Register . 1991;;56: 60825-60855.
10 +
Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for the Americans, 1995 . Washington, DC: US Dept of Agriculture, US Dept of Health and Human Services.
11 +
Cooper R, Van Horn L, Liu K, et al.  A randomized trial on the effect of decreased dietary sodium intake on blood pressure in adolescents. J Hypertens . 1984;;2:361-366.
12 +
Fuchs FD, Wannmacher CM, Wannmacher L, et al.  Effect of sodium intake on blood pressure, serum levels and renal excretion of sodium and potassium in normotensives with and without familial predisposition to hypertension. Braz J Med Biol Res . 1987;;20:25-34.
13 +
Gillum RF, Elmer PJ, Prineas RJ.  Changing sodium intake in children: the Minneapolis Children's Blood Pressure Study. Hypertension . 1981;; 3:698-703.
14 +
Mascioli S, Grimm R, Launer C, et al.  Sodium chloride raises blood pressure in normotensive subjects: the study of sodium and blood pressure. Hypertension . 1991;;17:I-21—I-26.
15 +
Tonascia J, Donithan M, Tonascia S, Hiller J, Hall WD, Langford HG. Hypertension Prevention Trial: Estimation of 24-Hour Sodium and Potassium Excretion From Overnight Urine Collections . Baltimore, Md: Dept of Biostatistics, The Johns Hopkins University; 1989;. Technical report 703.
16 +
Jula A, Ronnemaa T, Rastas M, Karvetti RL, Maki J.  Long-term nonpharmacological treatment for mild to moderate hypertension. J Intern Med . 1990;;227:413-421.
17 +
Jula AM, Ronnemaa TE, Piha SJ, Maki JP.  Response of diastolic blood pressure to long-term sodium restriction is posture related. Scand J Clin Lab Invest . 1992;;52:159-167.
18 +
Koopman H, Spreeuwenberg C, Westerman RF, Donker AJ.  Dietary treatment of patients with mild to moderate hypertension in a general practice: a pilot intervention study, I: the first three months. J Hum Hypertens . 1990;;4:368-371.
19 +
Koopman H, Spreeuwenberg C, Westerman RF, Donker AJ.  Dietary treatment of patients with mild to moderate hypertension in a general practice: a pilot intervention study, II: beyond three months. J Hum Hypertens . 1990;;4:372-374.
20 +
Chalmers J, Morgan T, Doyle A, et al.  Australian National Health and Medical Research Council dietary salt study in mild hypertension. J Hypertens . 1986;;4( (suppl 6) ):S629-S637.
21 +
Nowson CA, Morgan TO.  Change in blood pressure in relation to change in nutrients effected by manipulation of dietary sodium and potassium. Clin Exp Pharmacol Physiol . 1988;;15:225-242.
22 +
Fagerberg B, Andersson OK, Isaksson B, Bjorntorp P.  Blood pressure control during weight reduction in obese hypertensive men: separate effects of sodium and energy restriction. BMJ . 1984;; 288:11-14.
23 +
Andersson OK, Fagerberg B, Hedner T.  Importance of dietary salt in the hemodynamic adjustment to weight reduction in obese hypertensive men. Hypertension . 1984;;6:814-819.
24 +
Fagerberg B, Andersson OK, Persson B, Hedner T.  Reactivity to norepinephrine and effect of sodium on blood pressure during weight loss. Hypertension . 1985;;7:586-592.
25 +
Andersson OK, Fagerberg B, Hedner T.  Haemodynamic adjustment to weight reduction—separate effects of energy versus salt restriction. J Hypertens . 1983;;1( (suppl 2) ):35-37.
26 +
Fagerberg B, Andersson OK, Lindstedt G, Waldenstrom J, Aurell M.  The sodium intake modifies the renin-aldosterone and blood pressure changes associated with moderately low energy diets. Acta Med Scand . 1985;;218:157-164.
27 +
Australian National Health and Medical Research Council Dietary Salt Study Management Committee.  Fall in blood pressure with modest reduction in dietary salt intake in mild hypertension. Lancet . 1989;;1:399-402.
28 +
Australian National Health and Medical Research Council Dietary Salt Study Management Committee.  Effects of replacing sodium intake in subjects on a low sodium diet: a crossover study. Clin Exp Hypertens . 1989;;11:1011-1024.
29 +
Richards AM, Nicholls MG, Espiner EA, et al.  Blood-pressure response to moderate sodium restriction and to potassium supplementation in mild essential hypertension. Lancet . 1984;;1:757-761.
30 +
Richards AM, Nicholls MG, Espiner EA, et al.  Endogenous angiotensin-aldosterone-pressure relationships during sodium restriction. Hypertension . 1985;;7:681-687.
31 +
MacGregor GA, Markandu ND, Best FE, et al.  Double-blind randomised crossover trial of moderate sodium restriction in essential hypertension. Lancet . 1982;;1:351-355.
32 +
MacGregor GA, Markandu ND, Sagnella GA.  Dietary sodium restriction in normotensive subjects and patients with essential hypertension. Clin Sci . 1982;;63:399S-402S.
33 +
MacGregor GA.  Salt restriction in the treatment of hypertension. Scand J Clin Lab Invest Suppl . 1985;;176:25-37.
34 +
Koolen MI, Bussemaker-Verduyn den Boer E, van Brummelen P.  Clinical biochemical and haemodynamic correlates of sodium sensitivity in essential hypertension. J Hypertens . 1983;;1( (suppl 2) ): 21-23.
35 +
Koolen MI, van Brummelen P.  Adrenergic activity and peripheral hemodynamics in relation to sodium sensitivity in patients with essential hypertension. Hypertension . 1984;;6:820-825.
36 +
Koolen MI, van Brummelen P.  Sodium sensitivity in essential hypertension: role of the renin-angiotensin-aldosterone system and predictive value of an intravenous frusemide test. J Hypertens . 1984;; 2:55-59.
37 +
Watt GC, Edwards C, Hart JT, Hart M, Walton P, Foy CJ.  Dietary sodium restriction for mild hypertension in general practice. BMJ . 1983;;286:432-436.
38 +
Watt G, Hart JT, Foy C.  Effect of moderate dietary sodium restriction on patients with mild hypertension in general practice. J Hypertens Suppl . 1983;;1:18-20.
39 +
Miller JZ, Weinberger MH, Daugherty SA, Fineberg NS, Christian JC, Grim CE.  Blood pressure response to dietary sodium restriction in healthy normotensive children. Am J Clin Nutr . 1988;;47: 113-119.
40 +
Luft FC, Miller JZ, Grim CE, et al.  Salt sensitivity and resistance of blood pressure: age and race as factors in physiological responses. Hypertension . 1991;;17:I102-I108.
41 +
Luft FC, Miller JZ, Weinberger MH, Grim CE, Daugherty SA, Christian JC.  Influence of genetic variance on sodium sensitivity of blood pressure. Klin Wochenschr . 1987;;65:101-109.
42 +
The Trials of Hypertension Prevention Collaborative Research Group.  The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels: results of the Trials of Hypertension Prevention, phase I. JAMA . 1992;; 267:1213-1220.
43 +
Kumanyika SK, Hebert PR, Cutler JA, et al.  Feasibility and efficacy of sodium reduction in the trials of hypertension prevention, phase I. Hypertension . 1993;;22:502-512.
44 +
Watt GC, Foy CJ, Hart JT, et al.  Dietary sodium and arterial blood pressure: evidence against genetic susceptibility. BMJ . 1985;;291:1525-1528.
45 +
Watt GC, Foy CJ, Hart JT.  Dietary sodium and blood pressure in young people with and without familial predisposition to high blood pressure. J Clin Hypertens . 1986;;2:141-147.
46 +
Myers JB.  Reduced sodium chloride intake normalises blood pressure distribution. J Hum Hypertens . 1989;;3:97-104.
47 +
Myers J, Morgan T, Waga S, Manley K.  The effect of sodium intake on blood pressure related to the age of the patients. Clin Exp Pharmacol Physiol Suppl . 1982;;9:287-289.
48 +
Myers JB, Morgan TO.  Effect of alteration in sodium chloride intake on blood pressure of normotensive subjects. J Cardiovasc Pharmacol . 1984;; 6( (suppl 1) ):S204-S209.
49 +
Sharma AM, Arntz HR, Kribben A, Schattenfroh S, Distler A.  Dietary sodium restriction: adverse effect on plasma lipids. Klin Wochenschr . 1990;;68:664-668.
50 +
Ruppert M, Overlack A, Kolloch R, Kraft K, Gobel B, Stumpe KO.  Neurohormonal and metabolic effects of severe and moderate salt restriction in non-obese normotensive adults. J Hypertens . 1993;; 11:743-749.
51 +
Overlack A, Ruppert M, Kolloch R, et al.  Divergent hemodynamic and hormonal responses to varying salt intake in normotensive subjects. Hypertension . 1993;;22:331-338.
52 +
Ruppert M, Overlack A, Kolloch R, Kraft K, Lennarz M, Stumpe KO.  Effects of severe and moderate salt restriction on serum lipids in nonobese normotensive adults. Am J Med Sci . 1994;;307( (suppl 1) ):S87-S90.
53 +
Myers J, Morgan T.  The effect of sodium intake on the blood pressure related to age and sex. Clin Exp Hypertens . 1983;;5:99-118.
54 +
Nestel PJ, Clifton PM, Noakes M, McArthur R, Howe PR.  Enhanced blood pressure response to dietary salt in elderly women, especially those with small waist:hip ratio. J Hypertens . 1993;;11:1387-1394.
55 +
El Ashry A, Heagerty AM, Alton SM, Bing RF, Swales JD, Thurston H.  Effects of manipulation of sodium balance on erythrocyte sodium transport. J Hum Hypertens . 1987;;1:105-111.
56 +
Sharma AM, Ruland K, Spies KP, Distler A.  Salt sensitivity in young normotensive subjects is associated with a hyperinsulinemic response to oral glucose. J Hypertens . 1991;;9:329-335.
57 +
Sharma AM, Schorr U, Distler A.  Insulin resistance in young salt-sensitive normotensive subjects. Hypertension . 1993;;21:273-279.
58 +
Skrabal F, Herholz H, Neumayr M, et al.  Salt sensitivity in humans is linked to enhanced sympathetic responsiveness and to enhanced proximal tubular reabsorption. Hypertension . 1984;;6:152-158.
59 +
Teow BH, Di Nicolantonio R, Morgan TO.  Sodium chloride preference and recognition threshold in normotensive subjects on high and low salt diet. Clin Exp Hypertens . 1986;;7:1681-1695.
60 +
Burnier M, Rutschmann B, Nussberger J, et al.  Salt-dependent renal effects of an angiotensin II antagonist in healthy subjects. Hypertension . 1993;; 22:339-347.
61 +
Bruun NE, Skott P, Damkjaer Nielsen M, et al.  Normal renal tubular response to changes of sodium intake in hypertensive man. J Hypertens . 1990;; 8:219-227.
62 +
MacGregor GA, Markandu ND, Sagnella GA, Singer DR, Cappuccio FP.  Double-blind study of three sodium intakes and long-term effects of sodium restriction in essential hypertension. Lancet . 1989;;2:1244-1247.
63 +
Zoccali C, Mallamaci F, Leonardis D, Romeo M.  Randomly allocated crossover study of various levels of sodium intake in patients with mild hypertension. J Hypertens . 1993;;11( (suppl 5) ):S326-S327.
64 +
Schmid M, Mann JF, Stein G, et al.  Natriuresispressure relationship in polycystic kidney disease. J Hypertens . 1990;;8:277-283.
65 +
Morgan T, Adam W, Gillies A, Wilson M, Morgan G, Carney S.  Hypertension treated by salt restriction. Lancet . 1978;;1:227-230.
66 +
Fleiss JL.  The statistical basis of meta-analysis. Stat Methods Med Res . 1993;;2:121-145.
67 +
Follmann D, Elliott P, Suh I, Cutler J.  Variance imputation for overviews of clinical trials with continuous response. J Clin Epidemiol . 1992;;45:769-773.
68 +
DerSimonian R, Laird N.  Meta-analysis in clinical trials. Control Clin Trials . 1986;;7:177-188.
69 +
Seber GAI. Linear Regression Analysis . New York, NY: John Wiley & Sons Inc; 1977;:155-158.
70 +
Dyer AR, Shipley M, Elliott P, for the Intersalt Cooperative Research Group.  Urinary electrolyte excretion in 24 hours and blood pressure in the Intersalt study, I: estimates of reliability. Am J Epidemiol . 1994;;139:927-939.
71 +
SAS Institute Inc.SAS/STAT User's Guide, Version 6 . 4th ed. Cary, NC: SAS Institute Inc; 1989;.
72 +
Lawton WJ, Sinkey CA, Fitz AE, Mark AL.  Dietary salt produces abnormal renal vasoconstrictor responses to upright posture in borderline hypertensive subjects. Hypertension . 1988;;11:529-536.
73 +
Applegate WB, Miller ST, Elam JT, et al.  Nonpharmacologic intervention to reduce blood pressure in older patients with mild hypertension. Arch Intern Med . 1992;;152:1162-1166.
74 +
Erwteman TM, Nagelkerke N, Lubsen J, Koster M, Dunning AJ.  Beta blockade, diuretics, and salt restriction for the management of mild hypertension: a randomised double blind trial. BMJ . 1984;; 289:406-409.
75 +
Silman AJ, Locke C, Mitchell P, Humpherson P.  Evaluation of the effectiveness of a low sodium diet in the treatment of mild to moderate hypertension. Lancet . 1983;;1:1179-1182.
76 +
Hypertension Prevention Trial Research Group.  The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure. Arch Intern Med . 1990;;150:153-162.
77 +
Mark AL, Lawton WJ, Abboud FM, Fitz AE, Connor WE, Heistad DD.  Effects of high and low sodium intake on arterial pressure and forearm vasular resistance in borderline hypertension: a preliminary report. Circ Res . 1975;;36:194-198.
78 +
Skrabal F, Aubock J, Hortnagl H.  Low sodium/ high potassium diet for prevention of hypertension: probable mechanisms of action. Lancet . 1981;;2:895-900.
79 +
Puska P, Iacono JM, Nissinen A, et al.  Controlled, randomised trial of the effect of dietary fat on blood. Lancet . 1983;;1:1-5.
80 +
Richards AM, Tonolo G, Cleland JGF, et al.  Plasma atrial natriuretic peptide: responses to modest and severe sodium restriction. J Hypertens . 1986;;4( (suppl 6) ):S559-S563.
81 +
Grobbee DE, Hofman A, Roelandt JT, Boomsma F, Schalekamp MA, Valkenburg HA.  Sodium restriction and potassium supplementation in young people with mildly elevated blood pressure. J Hypertens . 1987;;5:115-119.
82 +
Kurtz TW, Al-Bander HA, Morris RC Jr.  'Salt-sensitive' essential hypertension in men: is the sodium ion alone important? N Engl J Med . 1987;: 317:1043-1048.
83 +
Bompiani GD, Cerasola G, Morici ML, et al.  Effects of moderate low sodium/high potassium diet on essential hypertension: results of a comparative study. Int J Clin Pharmacol Ther Toxicol . 1988;; 26:129-132.
84 +
Morgan T, Anderson A.  Interaction in hypertensive man between sodium intake, converting enzyme inhibitor (enalapril), plasma renin, and blood pressure control. J Hum Hypertens . 1988;;1:311-315.
85 +
Hargreaves M, Morgan TO, Snow R, Guerin M.  Exercise tolerance in the heat on low and normal salt intakes. Clin Sci . 1989;;76:553-557.
86 +
Friberg P, Meredith I, Jennings G, Lambert G, Fazio V, Esler M.  Evidence for increased renal norepinephrine overflow during sodium restriction in humans. Hypertension . 1990;;16:121-130.
87 +
Howe PR, Cobiac L, Smith RM.  Lack of effect of short-term changes in sodium intake on blood pressure in adolescent schoolchildren. J Hypertens . 1991;;9:181-186.
88 +
Benetos A, Xiao YY, Cuche JL, Hannaert P, Safar M.  Arterial effects of salt restriction in hypertensive patients: a 9-week, randomized, double-blind, crossover study. J Hypertens . 1992;;10:355-360.
89 +
Gow IF, Dockrell M, Edwards CR, et al.  The sensitivity of human blood platelets to the aggregating agent ADP during different dietary sodium intakes in healthy men. Eur J Clin Pharmacol . 1992;;43:635-638.
90 +
Del Rio A, Rodriguez-Villamil JL.  Metabolic effects of strict salt restriction in essential hypertensive patients. J Intern Med . 1993;;233:409-414.
91 +
Donovan DS, Solomon CG, Seely EW, Williams GH, Simonson DC.  Effect of sodium intake on insulin sensitivity. Am J Physiol . 1993;;264:E730-E734.
92 +
Fotherby MD, Potter JF.  Effects of moderate sodium restriction on clinic and twenty-four-hour ambulatory blood pressure in elderly hypertensive subjects. J Hypertens . 1993;;11:657-663.
93 +
Gill JS, Zezulka AV, Beevers DG, Davies P.  Relation between initial blood pressure and its fall with treatment. Lancet . 1985;;1:567-569.
94 +
Law MR, Frost CD, Wald NJ.  Ill-Analysis of data from trials of salt reduction. BMJ . 1991;;302: 819-824.
95 +
Alderman MH, Madhavan S, Cohen H, Sealey JE, Laragh JH.  Low urinary sodium associated with greater risk of myocardial infarction among treated hypertensive men. Hypertension . 1995;;25: 1144-1152.
96 +
Egan M, Weder AB, Petrin J, Hoffman RG.  Neurohumoral and metabolic effects of short-term dietary restriction in men: relationship to salt-sensitivity status. Am J Hypertens . 1991;;4:416-421.
97 +
Ruppert M, Diehl J, Kolloch R, et al.  Short-term dietary sodium restriction increases serum lipids and insulin in salt-sensitive and salt-resistant normotensive adults. Klin Wochenschr . 1991;;69 ( (suppl 25) ):51-57.

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