Vol. 147 No. 0708 (2017)
Associations of sodium, potassium and protein intake with blood pressure and hypertension in Switzerland
Nutritional factors play an important role in the regulation of blood pressure and in the development of hypertension. In this analysis, we explored the associations of 24-hour urinary Na+, K+ and urea excretion with blood pressure levels and the risk of hypertension in the Swiss population, taking regional linguistic differences into account.
The Swiss Survey on Salt is a population based cross-sectional study that included 1336 subjects from the three main linguistic regions (French, German and Italian) of Switzerland. Blood pressure was measured with a validated oscillometric Omron HEM 907 device. Hypertension was defined as current antihypertensive treatment or a mean systolic blood pressure >140 mm Hg and/or diastolic >90 mm Hg, based on eight blood pressure measurements performed at two visits. Na+, K+ and urea excretion were assessed in 24-hour urine collections. We use multiple logistic/linear regressions to explore the associations of urine Na+, K+ and urea with blood pressure / hypertension, taking into account potential confounders and effect modifiers.
The prevalence of hypertension was 30%, 26% and 17% in the German-, French- and Italian- speaking regions respectively, (p-value across regions <0.001). In the Swiss adult population, besides age, sex, and body mass index, urinary Na+ excretion was positively associated with systolic blood pressure and hypertension. Urinary K+ excretion tended to be negatively associated with blood pressure but this was not significant (p = 0.08). Hypertensive people had a higher 24-hour urinary Na+/K+ ratio than normotensive people (p = 0.003). Urinary urea excretion was associated with neither blood pressure nor hypertension. Participants from the German-speaking region had a higher likelihood of having a high systolic blood pressure.
We confirm a high prevalence of elevated blood pressure in Swiss adults, including regional differences. In Switzerland, urinary Na+ excretion is associated positively with blood pressure and hypertension, independently of urinary K+ and urea excretion. The observed differences in blood pressure levels across linguistic regions are independent of the urinary Na+, K+ and urea excretion.
- Mente A, O’Donnell MJ, Rangarajan S, McQueen MJ, Poirier P, Wielgosz A, et al.; PURE Investigators. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med. 2014;371(7):601–11. doi:.https://doi.org/10.1056/NEJMoa1311989
- McFadden CB, Brensinger CM, Berlin JA, Townsend RR. Systematic review of the effect of daily alcohol intake on blood pressure. Am J Hypertens. 2005;18(2 Pt 1):276–86. doi:.https://doi.org/10.1016/j.amjhyper.2004.07.020
- Kotsis V, Nilsson P, Grassi G, Mancia G, Redon J, Luft F, et al.; WG on Obesity, Diabetes, the High Risk Patient, European Society of Hypertension. New developments in the pathogenesis of obesity-induced hypertension. J Hypertens. 2015;33(8):1499–508. doi:.https://doi.org/10.1097/HJH.0000000000000645
- Teunissen-Beekman KF, van Baak MA. The role of dietary protein in blood pressure regulation. Curr Opin Lipidol. 2013;24(1):65–70. doi:.https://doi.org/10.1097/MOL.0b013e32835b4645
- Myers VH, Champagne CM. Nutritional effects on blood pressure. Curr Opin Lipidol. 2007;18(1):20–4. doi:.https://doi.org/10.1097/MOL.0b013e328012d911
- Du H, Li L, Bennett D, Guo Y, Key TJ, Bian Z, et al.; China Kadoorie Biobank Study. Fresh fruit consumption and major cardiovascular disease in china. N Engl J Med. 2016;374(14):1332–43. doi:.https://doi.org/10.1056/NEJMoa1501451
- Altorf-van der Kuil W, Engberink MF, Brink EJ, van Baak MA, Bakker SJ, Navis G, et al. Dietary protein and blood pressure: a systematic review. PLoS One. 2010;5(8):e12102. doi:.https://doi.org/10.1371/journal.pone.0012102
- Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al.; DASH Collaborative Research Group. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336(16):1117–24. doi:.https://doi.org/10.1056/NEJM199704173361601
- Santesso N, Akl EA, Bianchi M, Mente A, Mustafa R, Heels-Ansdell D, et al. Effects of higher- versus lower-protein diets on health outcomes: a systematic review and meta-analysis. Eur J Clin Nutr. 2012;66(7):780–8. doi:.https://doi.org/10.1038/ejcn.2012.37
- Appel LJ, Sacks FM, Carey VJ, Obarzanek E, Swain JF, Miller ER, 3rd, et al.; OmniHeart Collaborative Research Group. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA. 2005;294(19):2455–64. doi:.https://doi.org/10.1001/jama.294.19.2455
- Gijsbers L, Dower JI, Mensink M, Siebelink E, Bakker SJ, Geleijnse JM. Effects of sodium and potassium supplementation on blood pressure and arterial stiffness: a fully controlled dietary intervention study. J Hum Hypertens. 2015;29(10):592–8. doi:.https://doi.org/10.1038/jhh.2015.3
- He FJ, Markandu ND, Coltart R, Barron J, MacGregor GA. Effect of short-term supplementation of potassium chloride and potassium citrate on blood pressure in hypertensives. Hypertension. 2005;45(4):571–4. doi:.https://doi.org/10.1161/01.HYP.0000158264.36590.19
- Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M, et al.; ESH/ESC Task Force for the Management of Arterial Hypertension. 2013 practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC task force for the management of arterial hypertension. J Hypertens. 2013;31(10):1925–38. doi:.https://doi.org/10.1097/HJH.0b013e328364ca4c
- Krause T, Lovibond K, Caulfield M, McCormack T, Williams B ; Guideline Development Group. Management of hypertension: summary of NICE guidance. BMJ. 2011;343(aug25 2):d4891. doi:.https://doi.org/10.1136/bmj.d4891
- Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al.; Task Force Members. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31(7):1281–357. doi:.https://doi.org/10.1097/01.hjh.0000431740.32696.cc
- Mozaffarian D, Fahimi S, Singh GM, Micha R, Khatibzadeh S, Engell RE, et al.; Global Burden of Diseases Nutrition and Chronic Diseases Expert Group. Global sodium consumption and death from cardiovascular causes. N Engl J Med. 2014;371(7):624–34. doi:.https://doi.org/10.1056/NEJMoa1304127
- Marques-Vidal P, Paccaud F. Regional differences in self-reported screening, prevalence and management of cardiovascular risk factors in Switzerland. BMC Public Health. 2012;12(1):246. doi:.https://doi.org/10.1186/1471-2458-12-246
- Dufour MC. What is moderate drinking? Defining “drinks” and drinking levels. Alcohol Res Health. 1999;23(1):5–14.
- El Assaad MA, Topouchian JA, Darné BM, Asmar RG. Validation of the Omron HEM-907 device for blood pressure measurement. Blood Press Monit. 2002;7(4):237–41. doi:.https://doi.org/10.1097/00126097-200208000-00006
- Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen intake of patients with chronic renal failure. Kidney Int. 1985;27(1):58–65. doi:.https://doi.org/10.1038/ki.1985.10
- Bingham SA, Cummings JH. Urine nitrogen as an independent validatory measure of dietary intake: a study of nitrogen balance in individuals consuming their normal diet. Am J Clin Nutr. 1985;42(6):1276–89.
- Bingham SA. Urine nitrogen as a biomarker for the validation of dietary protein intake. J Nutr. 2003;133(Suppl 3):921S–4S.
- Tasevska N, Runswick SA, Bingham SA. Urinary potassium is as reliable as urinary nitrogen for use as a recovery biomarker in dietary studies of free living individuals. J Nutr. 2006;136(5):1334–40.
- Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ. 1988;297(6644):319–28. doi:.https://doi.org/10.1136/bmj.297.6644.319
- Smith WC, Crombie IK, Tavendale RT, Gulland SK, Tunstall-Pedoe HD. Urinary electrolyte excretion, alcohol consumption, and blood pressure in the Scottish heart health study. BMJ. 1988;297(6644):329–30. doi:.https://doi.org/10.1136/bmj.297.6644.329
- Whelton PK, He J, Cutler JA, Brancati FL, Appel LJ, Follmann D, et al. Effects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA. 1997;277(20):1624–32. doi:.https://doi.org/10.1001/jama.1997.03540440058033
- Aburto NJ, Hanson S, Gutierrez H, Hooper L, Elliott P, Cappuccio FP. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. BMJ. 2013;346(apr03 3):f1378. doi:.https://doi.org/10.1136/bmj.f1378
- Smyth A, Dunkler D, Gao P, Teo KK, Yusuf S, O’Donnell MJ, et al.; ONTARGET and TRANSCEND investigators. The relationship between estimated sodium and potassium excretion and subsequent renal outcomes. Kidney Int. 2014;86(6):1205–12. doi:.https://doi.org/10.1038/ki.2014.214
- Hedayati SS, Minhajuddin AT, Ijaz A, Moe OW, Elsayed EF, Reilly RF, et al. Association of urinary sodium/potassium ratio with blood pressure: sex and racial differences. Clin J Am Soc Nephrol. 2012;7(2):315–22. doi:.https://doi.org/10.2215/CJN.02060311
- Yang Q, Liu T, Kuklina EV, Flanders WD, Hong Y, Gillespie C, et al. Sodium and potassium intake and mortality among US adults: prospective data from the Third National Health and Nutrition Examination Survey. Arch Intern Med. 2011;171(13):1183–91. doi:.https://doi.org/10.1001/archinternmed.2011.257
- Kwok TC, Chan TY, Woo J. Relationship of urinary sodium/potassium excretion and calcium intake to blood pressure and prevalence of hypertension among older Chinese vegetarians. Eur J Clin Nutr. 2003;57(2):299–304. doi:.https://doi.org/10.1038/sj.ejcn.1601553
- Perez V, Chang ET. Sodium-to-potassium ratio and blood pressure, hypertension, and related factors. Adv Nutr. 2014;5(6):712–41. doi:.https://doi.org/10.3945/an.114.006783
- Buendia JR, Bradlee ML, Singer MR, Moore LL. Diets higher in protein predict lower high blood pressure risk in Framingham Offspring Study adults. Am J Hypertens. 2015;28(3):372–9. doi:.https://doi.org/10.1093/ajh/hpu157
- Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, et al.; Writing Group of the PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA. 2003;289(16):2083–93.
- Wang YF, Yancy WS Jr, Yu D, Champagne C, Appel LJ, Lin PH. The relationship between dietary protein intake and blood pressure: results from the PREMIER study. J Hum Hypertens. 2008;22(11):745–54. doi:.https://doi.org/10.1038/jhh.2008.64
- Hajjar I, Kotchen T. Regional variations of blood pressure in the United States are associated with regional variations in dietary intakes: the NHANES-III data. J Nutr. 2003;133(1):211–4.
- Kiefe CI, Williams OD, Bild DE, Lewis CE, Hilner JE, Oberman A. Regional disparities in the incidence of elevated blood pressure among young adults: the CARDIA study. Circulation. 1997;96(4):1082–8. doi:.https://doi.org/10.1161/01.CIR.96.4.1082
- Chammartin F, Probst-Hensch N, Utzinger J, Vounatsou P. Mortality atlas of the main causes of death in Switzerland, 2008-2012. Swiss Med Wkly. 2016;146:w14280.. doi: http://dx.doi.org/10.4414/smw.2016.14280