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Dietary Sodium and Potassium Intake and Their Association with Blood Pressure in a Non-Hypertensive Iranian Adult Population: Isfahan Salt Study

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Dietary Sodium and Potassium Intake and Their Association with Blood Pressure in a Non-Hypertensive Iranian Adult Population: Isfahan Salt Study View metadata, citation and similar papers at core.ac.uk brought to you by CORE Nutrition & Dietetics 2016 DOI: 10.1111/1747-0080.12304provided by shahrekord university of medical scinces Australia Dietitians f of o Association A A D ORIGINAL RESEARCH Dietary sodium and potassium intake and their association with blood pressure in a non-hypertensive Iranian adult population: Isfahan salt study Noushin MOHAMMADIFARD,1,2 Arsalan KHALEDIFAR,3,4 Alireza KHOSRAVI,2,4 Fatemeh NOURI,1 Ali POURMOGHADAS,4 Awat FEIZI,5,6 Ahmad ESMAILLZADEH7,8,9 and Nizal SARRAFZADEGAN1 1Isfahan Cardiovascular Research Centre, 2Hypertension Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan and 3Department of Cardiology, School of Medicine, Hajar Hospital, Modeling in Health Research Centre, Shahrekord University of Medical Sciences, Shahrekord, 4Interventional Cardiology Research Centre, 5Epidemiology and Biostatistics Department, 6Cardiac Rehabilitation Research Centre, Cardiovascular Research Institute, 7Food Security Research Centre, 8Department of Community Nutrition, Isfahan University of Medical Sciences, Isfahan, and 9Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran Abstract Aim: The association of sodium (Na) and potassium (K) intake with blood pressure (BP) is an ongoing debate, espe- cially in central Iran. We aimed to examine the mean Na and K intake, major sources of Na and the relationship between BP and dietary and urinary Na and K. Methods: This cross-sectional study was performed in central Iran in 2013–2014. A total of 796 non-hypertensive adults aged >18 years were randomly recruited. The semi-quantitative food frequency questionnaire was used to assess dietary Na and K intake. Moreover, 24-hour urine samples were collected to measure 24-hour urinary Na (UNa) and K (UK) as biomarkers. BP was measured twice on each arm using a standard protocol. Results: The mean Na and K intake were 4309.6 Æ 1344.4 and 2732.7 Æ 1050.5 mg/day, respectively. Table and cooking salt were the main sources of Na. Odds ratio (OR) (95% confidence interval (CI)) of the crude model in the highest quartile of UNa indicated a significant association with the higher risk of prehypertension (OR (95% CI): 2.09 (1.09–4.05); P for trend = 0.007). After adjustment for potential confounders, prehypertension was significantly associated with increasing dietary Na/K ratio (OR (95% CI): 1.28 (1.01–1.57); P for trend = 0.046) and UNa/UK ratio (OR (95% CI): 2.15(1.08-4.55); P for trend = 0.029). Conclusions: Increasing dietary and urinary Na/K ratios and UNa were associated with elevated BP and prehyperten- sion occurrence. These findings support the necessity of developing a salt reduction programme in our country. Key words: blood pressure, diet, urine, Iran, potassium, sodium. Introduction rapid rise in developing countries1 and has reached 17.3% among Iranian adult population.2 Hypertension control Hypertension is a major public health issue affecting almost has, hence, turned into a global public health priority.3 Die- one quarter of adults worldwide. Its prevalence is on a tary modifications may regulate blood pressure (BP) and subsequently control hypertension.4 Among dietary factors, N. Mohammadifard, MSc, PhD Candidate high sodium (Na) and low potassium (K) intakes are associ- 5 A. Khaledifar, MD, Associate Professor ated with higher BP and have been reported to increase A. Khosravi, MD, Associate Professor overall mortality and the risk of cardiovascular diseases in F. Nouri, MSc, Statistician the American population.6 Na reduction may thus be the A. Pourmoghadas, MD, Associate Professor most cost-effective approach to hypertension control in A. Feizi, PhD, Associate Professor both low- and high-income countries.7 Although several A. Esmaillzadeh, PhD, Professor epidemiological and interventional studies have shown BP N. Sarrafzadegan, MD, Professor 8,9 Correspondence: A. Khaledifar, Department of Cardiology, School of to be independently associated with Na and K levels, a Medicine, Hajar Hospital, Modeling in Health Research Center, population-based study rejected the relationship between K 8 Shahrekord University of Medical Sciences, P.O. Box 8813833435, levels and BP. However, two recent meta-analyses on Shahrekord, Iran Tel: +98-3833333448, Fax: +98-3833351040, 22 randomised clinical trials (RCTs) and population-based Email: [email protected] studies in 21 countries reported an inverse relationship 10,11 Accepted June 2016 between K levels and BP. While most studies have © 2016 Dietitians Association of Australia 1 N. Mohammadifard et al. measured Na and K intake through dietary assessment the Joint National Committee7 (JNC7) and WHO guide- methods, such as 24-hour dietary recall or semi-quantitative lines, prehypertension was defined as an SBP of food frequency questionnaire (FFQ), evaluating the urinary 130–139 mmHg and/or a DBP of 80–89 mmHg.1 excretion of Na and K using 24-hour urine collection is still Dietary assessment was carried out by a 136-item semi- considered the most valid and reliable method to determine quantitative FFQ. The FFQ was validated against the gold daily intake of these two elements.12 Furthermore, standards of 24-hour urine samples and 12-monthly 24- population-based studies have failed to establish obvious hour dietary recalls in 113 participants. The FFQ was also relationships between Na and K levels and hypertension. recompleted with a one-year interval to examine its repro- Because of the ongoing debate over these relationships,13,14 ducibility. The criterion validity and reproducibility were especially in Eastern Mediterranean and Middle East presented by correlation and intra-class correlation coeffi- regions, the present study aimed to evaluate the associa- cients, respectively. The criterion validity of FFQ for assess- tions between dietary Na and K intake and BP using data ment of Na and K was 0.60 and 0.56 compared with 24- from the Isfahan salt study in 2013–2014.15 hour dietary recall and 0.31 and 0.38 against 24-hour urine Na and K excretions, respectively. The reproducibility was Methods 0.43 and 0.40 for Na and K intake, respectively. The FFQ was coded by giving a gram weight to every portion The present study was performed on healthy adults aged reported. All dietary data were entered into the Iranian >18 years in Isfahan city, Iran in 2013–2014. In order to Food Consumption Program (IFCP), designed by ICRC,17 select the participants using multi-stage cluster sampling, a and analysed. The IFCP calculated nutrient intake and food number of households were first selected, and the study group servings for all foods reported in the FFQ. It had a objectives and procedures were explained to them. One research quality nutrient database analysing Na and K for a adult from each household was then recruited. Sample size variety of food items using the Iranian Food Composition was determined according to a previous study,15 and a total Table,18 which was modified based on the US Department of 796 healthy individuals were enrolled. While the only of Agriculture National Nutrient Database. Trained nutri- inclusion criteria was age greater than 18 years, the exclu- tionists assisted in the design and validation of the dietary sion criteria were a history of diabetes insipidus, diabetes questionnaire. The FFQ included some questions about die- mellitus, hypertension, a special dietary regimen or fasting tary supplements and five questions regarding discretionary at the time of sampling, history of using diuretics, renal salt consumption, including salt used at the table and salt insufficiency, menstruation or pregnancy and excessive for food preparation at home. The salt intake questions sweating on the day of urine collection. In addition, we comprised using the salt shaker, the weight of the salt pack- excluded the participants with less than 500 mL urine/day, age that they usually use, how long before the salt package reporting more than one missed voiding. Male and female was consumed, the total number of family members and subjects who were younger than 50 years with 24-hour their age to estimate salt consumption by each participant. urine creatinine (UCr) to body weight ratios of less than Urine samples were collected from 7 a.m. to 7 a.m. the 20 and 15 mg/kg/day, respectively, along with those who next day (after excluding the first sample of the first day). were aged 50 years and over with UCr to body weight The samples were poured into sterile plastic containers ratios of less than 10 and 7.5 mg/kg/day, respectively. The labelled with the participants’ name and a special code. study was approved by the Research Council of Isfahan Inappropriately collected samples along with those with a Cardiovascular Research Centre (ICRC), a World Health low volume of urine were excluded from the analysis. If a Organization (WHO) collaborative centre, ethics committee. person was unable to deliver the urine sample to the labora- Written informed consent was obtained from all partici- tory, we collected it at his/her home. Venous blood samples pants. This paper was prepared based on the strengthening were taken on the same day to measure serum biochemical the reporting of observational studies in epidemiology indices, including fasting blood sugar, serum albumin level (STROBE) statement for cross-sectional studies. and lipid profile. Total 24-hour urinary Na (UNa) was cal- The medical history of all subjects was taken, and clinical culated by multiplying Na concentration by the urine vol- examinations followed by blood and urine tests were per- ume in litres. Urinary chemical parameters including UNa, formed. Height and weight were measured using standard 24-hour urinary K (UK) and 24-hour UCr were measured. methods. Body mass index (BMI) was calculated as weight In order to assess the accuracy of urinary samples as 24- divided by height squared (kg/m2).
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