While the US Department of Health and Human Services recommends a sodium intake of less than 2,300 mg/day, about 9 of 10 American adults exceed that limit. Increased sodium intake is believed to have a direct effect on a variety of negative cardiovascular outcomes such as coronary heart disease, left ventricular hypertrophy, and stroke. Recognizing the impact of dietary sodium on diseases like hypertension and CVD, the FDA recently released voluntary guidance for industry on the target mean and upper concentrations for sodium in commercially processed, packaged, and prepared foods. The guidance was intended to provide a measurable voluntary goal to help Americans to reduce their average sodium intake by 12% over the next 2.5 years, and plans for further iterative reductions in the future. In addition to daily dietary (food and drink) sodium, both prescription and over-the-counter medications can contribute to increasing patients’ total sodium intake per day. Additionally, other risk factors—such as smoking the absence of physical activity, and poor sleep hygiene—that contribute to developing cardiovascular conditions can be modified by maintaining a healthy and balanced lifestyle.
In episode 5, listen as Sleep Review’s Sree Roy and cardiologist-sleep specialist Barbara Hutchinson, MD, PhD, FACC, discuss:
- The FDA recently released guidance on voluntary target concentrations for sodium, in commercially processed packaged and prepared foods. What are your thoughts on this reduced goal for sodium intake, in terms of impact on cardiovascular risk?
- What are some links between high sodium intake and adverse cardiovascular outcomes?
- What should people be aware of with regard to medication use and sodium intake?
- How should cardiovascular risk be discussed when determining the management plan for sleep disorders?
- Can you share an example of modifying a sleep disorder patient’s management plan, due to an emerging cardiovascular risk or disease?
- Beyond sodium intake, what are some of the other modifiable cardiovascular risk factors that everyone, regardless of whether they have a sleep disorder or not, should be aware of?
You can revisit all episodes here:
- Episode 1 on Narcolepsy Across the Lifespan
- Episode 2 on Developing A Narcolepsy Management Plan
- Episode 3 on Handling Comorbities Linked With Narcolepsy
- Episode 4 on Reducing Risk of Cardiovascular Comorbidities
- Episode 5 on Sodium Intake and Other Modifiable Cardiovascular Risk Factors
Sree Roy: Hello and welcome. I’m Sree Roy with Sleep Review and I’m thrilled to be here with cardiologist sleep specialist, Barbara Hutchinson, MD, PhD, FACC. Hutchinson is the owner and managing partner at Chesapeake Cardiac Care in Maryland.
This episode is sponsored by Jazz Pharmaceuticals.
Today, we are chatting about sodium intake. The FDA recently released guidance on voluntary target concentrations for sodium, in commercially processed package and prepared foods. These targets were designed to support a 12% reduction in the average American daily sodium intake, from approximately 3,400 milligrams daily to 3,000 milligrams. What are your thoughts on this reduced goal for sodium intake, in terms of impact on cardiovascular risk?
Dr. Barbara Hutchinson: Well, I think it’s a good start as we talk about sodium, because we know how important it is in terms of predisposing to a lot of cardiovascular risk factors. But when you think of the main source of sodium, it comes from packets processed, restaurant, and just store-bought foods.
I think this is a good start and 12% reduction, it’s okay, but that 3,000 milligrams, according to the dietary guidelines, actually dietary guidelines takes it down to 2,300 milligrams. And if we look at some of the other organizations such as the American College of Cardiology, the American Heart Association, it’s even down to as much as 1,500 milligrams. So obviously the lower it is the better, but there are other factors we often have to take into consideration because on one end of the spectrum, you have some people that need salt. And we don’t want people to leave this conversation today, thinking that sodium is all bad because we need sodium in our bodies, it serves an important place as a mineral.
But what we’re talking about here is high concentrations on how high concentrations can impact. So I would say it’s a good start because in the packaged foods, if we could start decreasing that, that would impact all cardiovascular risks.
The other thing that I would also emphasize is that the lower we start think about it, our taste buds now get used to a lower amount. And in addition to these packaged foods, remember there are other sources of sodium, there’s natural sodium that we take in, there’s table sodium the one that we add at the table, then there’s one that they add when they are cooking. So there are other sources of sodium that we also have to consider, so the lower we start with these processed foods, which we said 71% of people that’s the source of sodium.
Sree Roy: What are some links between high sodium intake and adverse cardiovascular outcomes?
Dr. Barbara Hutchinson: Sure. And by the way, when we talk about high sodium intake, it’s usually in the form of salt which is sodium chloride. And then on the other hand, you have the mineral sodium but high sodium intake can have effects on cardiovascular outcomes.
We know that high sodium intake can lead to elevated blood pressure levels. It can also lead to coronary artery disease, to stroke, congestive heart failure, high sodium levels predisposed to CHF exacerbation in patients. And there have been studies that also point to the fact that high sodium levels can also cause increased thickening of the heart muscle itself. And as you have increased thickening of the heart muscle that could lead to other conditions, whether it’s cardiomyopathy and even elevated blood pressure levels.
Sree Roy: In addition to sodium in our food, medications can also be a source of sodium intake that people may be unaware of. For example, prescription and over the counter medications can contribute to increase a person’s total sodium intake per day.
In fact, one study found rates of cardiovascular disease to be higher in people who were taking sodium containing acetaminophen, versus those taking non-sodium containing acetaminophen. What should people be aware of with regard to medication use and sodium intake?
Dr. Barbara Hutchinson: Well, I guess it goes back to what we just talked about in terms of the mineral, in terms of… The basic awareness here should be the fact that, there are hidden sources of sodium. Whether it is in medication or whether it is in… We talked about the foods that we eat. And so as we look at medications, if you have one of the cardiovascular risk factors we talked about, the high blood pressure, congestive heart failure, you should be alerted to reading the labels. Just like you go to the grocery store and would read the labels, read the labels in terms of finding out what is the carrier in that medication? Is it sodium? Is it potassium? So it’s very important to read the labels and also to know what’s the base in terms of the medication. Because this study that you just alluded, show that those patients that had the sodium containing acetaminophen, they had higher rates of cardiovascular disease, certainly.
Sree Roy: We’ll be back with Dr. Hutchinson after this short break.
This episode is sponsored by Jazz Pharmaceuticals. Jazz Pharmaceuticals is a global biopharmaceutical company with a focus in neuroscience and sleep medicine committee to improving the lives of patients and their families. Jazz is also the proud creator of Narcolepsy Link. The Narcolepsy Link mission is to increase narcolepsy awareness, help patients receive a proper diagnosis of narcolepsy, and to support long-term disease management. Narcolepsy Link creates innovative, evidence-based educational materials and resources for healthcare professionals to improve communication between healthcare professionals and their patients. Visit Jazzpharma.com and NarcolepsyLink.com for more information.
Sree Roy: Researchers are revealing more about the connections between sleep disorders, including obstructive sleep apnea, insomnia, and narcolepsy, and cardiovascular risk. How, if at all, should cardiovascular risk be discussed when determining the management plan for sleep disorders?
Dr. Barbara Hutchinson: Well, when we talk about management of sleep, we have to remember, we have to not see patients in silos. Yes, they may have a sleep breathing problem or sleep disorder, but what else is going on? Because what I have found over the years is sometimes, if they have other cardiovascular problems, they can often be triggered by the sleep problem or it is bidirectional. For example, when we talk about patients with resistant hypertension, resistant hypertension and they take five, six medications.
There comes a point in time where you have to ask yourself: Is there something else that’s driving that high blood pressure? And now we know that obstructive sleep apnea, almost 50% of patients with resistant hypertension and sometimes even up to 85% can have obstructive sleep apnea? And we know that treating that obstructive sleep apnea, could often result in them taking less medications than they are on. So that’s one thing.
Again, in cardiovascular disease, arrhythmia is a big thing. Many patients have atrial fibrillation or they may have some atrial or ventricular arrhythmias. And instead of just focusing on the cardiovascular, could there be some other sleep related problem, insomnia whether it’s sleep breathing disorder, that could again be driving that. So as we talk about risk factors, it’s always good to think outside the, I like to call it the cardiovascular box and look at other drivers that could be driving some of the cardiovascular problems.
For example, exacerbation of congestive heart failure, every time it’s 2:00, 3:00 in the morning, we have to stop and think: Is there something going on while we are sleeping that is driving that? So I always like to think of sleep, as the sleeper in cardiovascular disease that we always have to think about, as we treat these patients. And as we treat patients with cardiovascular disease, it’s good to think outside the box and look at other things, I like to call them other drivers of their cardiovascular problems.
Sree Roy: Can you share an example of modifying a sleep disorder patient’s management plan, due to an emerging cardiovascular risk or disease?
Dr. Barbara Hutchinson: Oh, sure. I’ll share two. I often see patients that come, like I mentioned with cardiovascular disease, well, many high blood pressure and they come because their doctors have… They’re now on four or five medications and they still can’t get their blood pressure down. They’ve tried dietary changes, low sodium, everything. And they say, “Well, I’ve always tell them I feel tired all the time.”
But no one has gone beyond that. What could be causing the fatigue? And just screening them for obstructive sleep apnea or just sleep breathing disorders. And often I can’t tell you how many times, I’ve found that several of these patients have, between moderate to severe obstructive sleep apnea. They get treated for the obstructive sleep apnea and on follow-up, blood pressure that previously was uncontrolled on four medications now within range. Now, better controlled once you’ve started treating the obstructive sleep apnea.
And that’s just one example, but I’ve seen similar examples in patients with atrial fibrillation. Once a month they’re in the hospital waking up at 2:00, 3:00 in the morning with atrial fibrillation. And no one has ever related atrial fibrillation with obstructive sleep apnea. They’re screened, they have moderate to severe obstructive sleep apnea, the sleep apnea is treated. And all of a sudden now they have less frequent hospitalization or less frequent exacerbation of these atrial fibrillation episodes, that they seem to be getting.
So again, thinking outside the box and recognizing the link between atrial fibrillation and there’s clear data that points to the fact that, although we have all the fancy techniques of treating atrial fibrillation whether it’s ablation, medication.
We now know that despite all of that, if we don’t treat one of the drivers like obstructive sleep apnea, we’re just spinning our wheels because they’ll just need more ablation, more medication. And clearly studies have shown, if we’re able to treat the obstructive sleep apnea, there’s less recurrence of the atrial fibrillation.
Sree Roy: We’ve talked a lot about sodium and heart health. Beyond sodium intake, what are some of the other modifiable cardiovascular risk factors that everyone, regardless of whether they have a sleep disorder or not, should be aware of?
Dr. Barbara Hutchinson: Sure. That’s a great question because sometimes we could get so focused and missed the basics. And of course there’s some risk factors that we can’t change, we can’t give away our parents, although some people may want to and we can’t change our sex. Although now there’s surgical techniques that can happen, but for the most part, but there are other risk factors that can be controlled. And those are some of the ones that I want to talk a little bit about blood pressure. We know that there are certain things that can affect blood pressure, that can lower blood pressure, we talked about salt intake but cholesterol levels, we know cholesterol can predispose to heart attacks, stroke, and coronary artery disease. So controlling our cholesterol levels, physical activity, being active, exercising at least 30 minutes five days a week can go a long way.
So these are all things that we could modify because as we modify these things that can impact on overall cardiovascular risk. Or weight, obesity, knowing what our BMI is, do we need to do portion control? Do we need to exercise? Do we need to watch our intake of saturated and unsaturated fats? So all these controlling our weight, our BMI, sleep hygiene, we just talked about sleep and cardiovascular disease, that’s the sleeper in cardiovascular disease. So attending to good sleep hygiene, because we know, sleep related, sleep disorders can affect our cardiovascular diseases. Smoking, tobacco intake, overall diet, we talked about sodium. But although we talk about sodium because sodium drives the sodium potassium ATP is pump, but we cannot forget other minerals such as potassium, watching potassium levels because the higher the potassium level the better it is, and the magnesium. So other minerals that we can look at, that we can control can also help in this area too.
Sree Roy: Well, thank you so much for chatting with us today. You can find Sleep Review at sleepreviewmag.com. Thank you so much for tuning in to this episode.
Dr. Barbara Hutchinson: Thanks for having me.
To dive even deeper:
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force . Hypertension. 2018;71(6):1269-1324.
Jackson SL, King SM, Zhao L, Cogswell ME. Prevalence of excess sodium intake in the United States—NHANES, 2009-2012. MMWR Morb Mortal Wkly Rep. 2016;64(52):1393-7.
Benjamin EJ, Muntner P, Alonso A, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528.
Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;121(4):586-613.
Salehi-Abargouei A, Maghsoudi Z, Shirani F, Azadbakht L. Effects of Dietary Approaches to Stop Hypertension (DASH)-style diet on fatal or nonfatal cardiovascular diseases—incidence: a systematic review and meta-analysis on observational prospective studies. Nutrition. 2013;29(4):611-8.
Quan SF. Sleep disturbances and their relationship to cardiovascular disease. Am J Lifestyle Med. 2009;3(1 Suppl):55s-9s.
Centers for Disease Control and Prevention. Sleep and Sleep Disorders. Sleep and Chronic Disease.
Ma Y, He FJ, Sun Q, et al. 24-Hour urinary sodium and potassium excretion and cardiovascular risk. N Engl J Med. 2022;386(3):252-63.
US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans, 2020-2025. 9th ed. December 2020.
World Health Organization. WHO Guideline: Sodium Intake for Adults and Children. World Health Organization; 2012.
Quader ZS, Zhao L, Gillespie C, et al. Sodium intake among persons aged ≥2 years—United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2017;66(12):324-8.
Jackson SL, King SM, Zhao L, Cogswell ME. Prevalence of excess sodium intake in the United States—NHANES, 2009-2012. MMWR Morb Mortal Wkly Rep. 2016;64(52):1393-7.
Elliott P, Stamler J, Nichols R, et al. Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. BMJ. 1996;312(7041):1249-53.
Mente A, O’Donnell MJ, Rangarajan S, et al; PURE Investigators. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med. 2014;371(7):601-11.
Voluntary Sodium Reduction Goals: Target Mean and Upper Bound Concentrations for Sodium in Commercially Processed, Packaged, and Prepared Foods: Guidance for Industry. US Department of Health and Human Services, Food and Drug Administration, Center for Food Safety and Applied Nutrition; 2021.
Zeng C, Rosenberg L, Li X, et al. Sodium-containing acetaminophen and cardiovascular outcomes in individuals with and without hypertension. Eur Heart J. 2022 May 7;43(18):1743-55.
Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010;362(7):590-9.
Institute of Medicine. Sodium Intake in Populations: Assessment of Evidence. Washington, DC: National Academies Press; 2013.
Gardener H, Rundek T, Wright CB, et al. Dietary sodium and risk of stroke in the Northern Manhattan study. Stroke. 2012;43(5):1200-5.
Rodriguez CJ, Bibbins-Domingo K, Jin Z, et al. Association of sodium and potassium intake with left ventricular mass: coronary artery risk development in young adults. Hypertension. 2011;58(3):410-6.
Strazzullo P, D’Elia L, Kandala NB, Cappuccio FP. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ. 2009;339:b4567.