Dietary sodium, sodium-to-potassium ratio, and risk of stroke: A systematic review and nonlinear dose-response meta-analysis

Clin Nutr. 2019 Jun;38(3):1092-1100. doi: 10.1016/j.clnu.2018.05.017. Epub 2018 Jun 1.


Background & aims: The association of high sodium intake with risk of stroke has been accepted. But considering the proposed J/U-shaped association between sodium intake and risk of all-cause mortality, the shape of the dose-response relationship has not been determined yet. This study aimed to test the dose-response association of dietary sodium and sodium-to-potassium ratio with risk of stroke in adults aged 18 years or older.

Methods: We performed a systematic search using PubMed and Scopus, from database inception up to October 2017. Prospective and retrospective observational studies reporting risk estimates of stroke for three or more quantitative categories of dietary sodium or sodium-to-potassium ratio were included. Studies that reported results as continuous were also included. Two independent authors extracted the information and assessed the quality of included studies. Pooled relative risk (RR) was calculated using a random-effects model. Publication bias was tested. Sensitivity and subgroup analyses were done.

Results: Of initial 20,412 studies identified, 14 prospective cohort studies, one case-cohort study, and one case-control study (total n = 261,732) with 10,150 cases of stroke were included. The Pooled RRs of stroke were 1.06 (95%CI: 1.02, 1.10; I2 = 60%, n = 14 studies) for a 1 gr/d increment in dietary sodium intake, and 1.22 (95%CI: 1.04, 1.41; I2 = 60%, n = 5 studies) for a one-unit increment in dietary sodium-to-potassium ratio (mmol/mmol). The risk of stroke increased linearly with increasing dietary sodium intake, and also along with the increase in dietary sodium-to-potassium ratio. No evidence of a J/U-shaped association was found in the analyses of total stroke, stroke incidence, and stroke mortality. High sodium intake was associated with a somewhat worse prognosis among Asian countries as compared to westerns.

Conclusion: Higher sodium intake and higher dietary sodium-to-potassium ratio were associated with a higher risk of stroke. Reducing dietary sodium-to-potassium ratio can be considered as a supplementary approach in parallel with the decrease in sodium intake in order to decrease stroke risk. The interpretation of the results is limited by observational nature of studies examined.

Keywords: Cardiovascular disease; Dietary sodium; Hypertension; Meta-analysis; Stroke.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Aged
  • Diet / statistics & numerical data*
  • Female
  • Humans
  • Hypertension
  • Male
  • Middle Aged
  • Potassium, Dietary*
  • Risk Factors
  • Sodium, Dietary*
  • Stroke / epidemiology*


  • Potassium, Dietary
  • Sodium, Dietary