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Effects of Reduced Sodium Intake on Hypertension Control in Older Individuals
Results From the Trial of Nonpharmacologic Interventions in the Elderly (TONE)
Lawrence J. Appel, MD, MPH;
Mark A. Espeland, PhD;
Linda Easter, MS, RD;
Alan C. Wilson, PhD;
Steven Folmar, PhD;
Clifton R. Lacy, MD
Arch Intern Med. 2001;161:685-693.
Background Few trials have evaluated the effects of reduced sodium intake in older
individuals, and no trial has examined the effects in relevant subgroups such
as African Americans.
Patients and Methods The effects of sodium reduction on blood pressure (BP) and hypertension
control were evaluated in 681 patients with hypertension, aged 60 to 80 years,
randomly assigned to a reduced sodium intervention or control group. Participants
(47% women, 23% African Americans) had systolic BP less than 145 mm Hg and
diastolic BP less than 85 mm Hg while taking 1 antihypertensive medication.
Three months after the start of intervention, medication was withdrawn. The
primary end point was occurrence of an average systolic BP of 150 mm Hg or
more, an average diastolic BP of 90 mm Hg or more, the resumption of medication,
or a cardiovascular event during follow-up (mean, 27.8 months).
Results Compared with control, mean urinary sodium excretion was 40 mmol/d less
in the reduced sodium intervention group (P<.001);
significant reductions in sodium excretion occurred in subgroups defined by
sex, race, age, and obesity. Prior to medication withdrawal, mean reductions
in systolic and diastolic BPs from the reduced sodium intervention, net of
control, were 4.3 mm Hg (P<.001) and 2.0 mm Hg
(P = .001). During follow-up, an end point occurred
in 59% of reduced sodium and 73% of control group participants (relative hazard
ratio = 0.68, P<.001). In African Americans, the
corresponding relative hazard ratio was 0.56 (P =
.005); results were similar in other subgroups. In dose-response analyses,
end points were progressively less frequent with greater sodium reduction
(P for trend = .002).
Conclusion A reduced sodium intake is a broadly effective, nonpharmacologic therapy
that can lower BP and control hypertension in older individuals.
From the Welch Center for Prevention, Epidemiology, and Clinical Research,
Johns Hopkins Medical Institutions, Baltimore, Md (Dr Appel); Departments
of Public Health Sciences (Dr Espeland), General Clinical Research Center
(Ms Easter), and Anthropology (Dr Folmar), Wake Forest University, Winston-Salem,
NC; and Division of Cardiovascular Diseases and Hypertension, University of
Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School,
New Brunswick (Drs Wilson and Lacy).
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