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Prospective Data From the Third National Health and Nutrition Examination Survey

Quanhe Yang, PhD; Tiebin Liu, MSPH; Elena V. Kuklina, MD, PhD; W. Dana Flanders, MD, ScD; Yuling Hong, MD, PhD; Cathleen Gillespie, MS; Man-Huei Chang, MPH; Marta Gwinn, MD; Nicole Dowling, PhD; Muin J. Khoury, MD, PhD; Frank B. Hu, MD, PhD

Arch Intern Med. 2011;171(13):1183-1191. doi:10.1001/archinternmed.2011.257

Background  Several epidemiologic studies suggested that higher sodium and lower potassium intakes were associated with increased risk of cardiovascular diseases (CVD). Few studies have examined joint effects of dietary sodium and potassium intake on risk of mortality.

Methods  To investigate estimated usual intakes of sodium and potassium as well as their ratio in relation to risk of all-cause and CVD mortality, the Third National Health and Nutrition Examination Survey Linked Mortality File (1988-2006), a prospective cohort study of a nationally representative sample of 12 267 US adults, studied all-cause, cardiovascular, and ischemic heart (IHD) diseases mortality.

Results  During a mean follow-up period of 14.8 years, we documented a total of 2270 deaths, including 825 CVD deaths and 443 IHD deaths. After multivariable adjustment, higher sodium intake was associated with increased all-cause mortality (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.03-1.41 per 1000 mg/d), whereas higher potassium intake was associated with lower mortality risk (HR, 0.80; 95% CI, 0.67-0.94 per 1000 mg/d). For sodium-potassium ratio, the adjusted HRs comparing the highest quartile with the lowest quartile were HR, 1.46 (95% CI, 1.27-1.67) for all-cause mortality; HR, 1.46 (95% CI, 1.11-1.92) for CVD mortality; and HR, 2.15 (95% CI, 1.48-3.12) for IHD mortality. These findings did not differ significantly by sex, race/ethnicity, body mass index, hypertension status, education levels, or physical activity.

Conclusion  Our findings suggest that a higher sodium-potassium ratio is associated with significantly increased risk of CVD and all-cause mortality, and higher sodium intake is associated with increased total mortality in the general US population.

Author Affiliations: Office of Public Health Genomics (Drs Yang, Gwinn, Dowling, and Khoury, Mr Liu, and Ms Chang) and Division for Heart Disease and Stroke Prevention (Drs Kuklina and Hong and Ms Gillespie), Centers for Disease Control and Prevention, and Department of Epidemiology, Rollins School of Public Health, Emory University (Dr Flanders) Atlanta, Georgia; and Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, Massachusetts (Dr Hu).

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RELATED LETTERS

Reanalysis of NHANES III Data on Sodium Association With Mortality: Appropriate Adjustment for Potassium Not Performed
Hillel W. Cohen, Michael Aldermann, and Niels Graudal
Arch Intern Med. 2011;171(22):2063.
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Method of Estimating Sodium Intake and Its Possible Influence on NHANES III Outcome
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Arch Intern Med. 2011;171(22):2063-2064.
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Method of Estimating Sodium Intake and Its Possible Influence on NHANES III Outcome—Reply
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Arch Intern Med. 2011;171(22):2064.
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Arch Intern Med. 2011;171(13):1191-1192.
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