Letter by DiNicolantonio et al Regarding Article, “Reducing Sodium Intake to Prevent Stroke: Time for Action, Not Hesitation”
To the Editor:
In a recent review in Stroke, Appel1 states that the evidence supporting population-wide reduction in sodium intake is compelling; the time for action is now. Appel concludes that reducing sodium intake would be both safe and effective for preventing cardiovascular disease, stroke, and deaths. We take strong issue with several of Appel’s points and urge caution when considering his conclusions.
Most of arguments of Appel focus on evidence relating sodium intake to blood pressure (BP). Starting with the weakest evidence, Appel mentions that Kenyans who migrated to urban areas had higher mean sodium intakes and BPs than those who remained in rural areas. Such ecological association hardly implicates sodium. Urban living is also associated with other dietary factors (eg, refined-carbohydrate consumption) and lifestyle changes (eg, sedentary work) that are also likely to increase BP independent of sodium.
With respect to experimental evidence, Appel invokes the Dietary Approaches to Stop Hypertension (DASH)-Sodium trial. He notes that, in the trial, sodium reduction to a level of ≈1500 mg/d lowered BP. …