Expansion of the National Salt Reduction Initiative: A Mathematical Model of Benefits and Risks of Population-Level Sodium Reduction

Med Decis Making. 2016 Jan;36(1):72-85. doi: 10.1177/0272989X15583846. Epub 2015 Apr 29.


Background: The National Salt Reduction Initiative, in which food producers agree to lower sodium to levels deemed feasible for different foods, is expected to significantly reduce sodium intake if expanded to a large sector of food manufacturers.

Objective: Given recent data on the relationship between sodium intake, hypertension, and associated cardiovascular disease at a population level, we sought to examine risks and benefits of the program.

Design: To estimate the impact of further expanding the initiative on hypertension, myocardial infarction (MI) and stroke incidence, and related mortality, given food consumption patterns across the United States, we developed and validated a stochastic microsimulation model of hypertension, MI, and stroke morbidity and mortality, using data from food producers on sodium reduction among foods, linked to 24-hour dietary recalls, blood pressure, and cardiovascular histories from the National Health and Nutrition Examination Survey.

Results: Expansion of the initiative to ensure all restaurants and manufacturers reach agreed-upon sodium targets would be expected to avert from 0.9 to 3.0 MIs (a 1.6%-5.4% reduction) and 0.5 to 2.8 strokes (a 1.1%-6.2% reduction) per 10,000 Americans per year over the next decade, after incorporating consumption patterns and variations in the effect of sodium reduction on blood pressure among different demographic groups. Even high levels of consumer addition of table salt or substitution among food categories would be unlikely to neutralize this benefit. However, if recent epidemiological associations between very low sodium and increased mortality are causal, then older women may be at risk of increased mortality from excessively low sodium intake.

Conclusions: An expanded National Salt Reduction Initiative is likely to significantly reduce hypertension and hypertension-related cardiovascular morbidity but may be accompanied by potential risks to older women.

Keywords: cardiovascular disease; health disparities; hypertension; sodium.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Blood Pressure
  • Cardiovascular Diseases / chemically induced*
  • Cardiovascular Diseases / epidemiology*
  • Cardiovascular Diseases / mortality
  • Female
  • Food Industry / legislation & jurisprudence*
  • Humans
  • Hypertension / chemically induced
  • Hypertension / epidemiology
  • Incidence
  • Male
  • Middle Aged
  • Models, Theoretical*
  • Myocardial Infarction / chemically induced
  • Myocardial Infarction / epidemiology
  • Nutrition Policy*
  • Risk Assessment
  • Risk Factors
  • Socioeconomic Factors
  • Sodium, Dietary / adverse effects*
  • Stroke / chemically induced
  • Stroke / epidemiology
  • United States
  • Young Adult


  • Sodium, Dietary