salt intake, sugar-sweetened soft drink consumption, and blood pressure

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Accepted Manuscript Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure Feng J. He , PhD Graham A. MacGregor , MD PII: S0002-9149(14)01089-3 DOI: 10.1016/j.amjcard.2014.05.004 Reference: AJC 20452 To appear in: The American Journal of Cardiology Received Date: 1 May 2014 Accepted Date: 6 May 2014 Please cite this article as: He FJ, MacGregor GA, Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure, The American Journal of Cardiology (2014), doi: 10.1016/j.amjcard.2014.05.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Page 1: Salt Intake, Sugar-Sweetened Soft Drink Consumption, and Blood Pressure

Accepted Manuscript

Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure

Feng J. He , PhD Graham A. MacGregor , MD

PII: S0002-9149(14)01089-3

DOI: 10.1016/j.amjcard.2014.05.004

Reference: AJC 20452

To appear in: The American Journal of Cardiology

Received Date: 1 May 2014

Accepted Date: 6 May 2014

Please cite this article as: He FJ, MacGregor GA, Salt Intake, Sugar-sweetened Soft Drink Consumptionand Blood Pressure, The American Journal of Cardiology (2014), doi: 10.1016/j.amjcard.2014.05.004.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.

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Salt Intake, Sugar-sweetened Soft Drink

Consumption and Blood Pressure

In their interesting review article, Malik et al1 do not seem to consider the

underlying mechanism by which sugar-sweetened soft drink consumption is

associated with increased blood pressure. For instance, there is clear evidence for a

causal relation between salt intake and total fluid consumption,2 as well as sugar-

sweetened soft drink consumption,3 an important and very relevant point which Malik

et al failed to acknowledge. A carefully controlled metabolic study in adult humans

where salt intake was changed, has quantified the relation between the change in

salt intake and the subsequent change in fluid consumption.2 A study in 10,074 free

living individuals across the world showed an identical relation between usual salt

and fluid intake.2 An analysis of the National Diet and Nutrition Survey dataset

showed that, in free living children in Great Britain, the same relation held true.3

Similar findings have also been reported in the USA and Australia.4 5 There is,

therefore, no doubt that in humans, like other mammals, salt is a major drive to thirst

and, an increase in salt intake will increase the amount of fluid consumed, and if part

of this fluid is in the form of soft drinks, they will be increased proportionately. It is

therefore likely that the increased salt intake is, at least, partially responsible for the

increase in blood pressure and the increase in soft drink consumption. In other

words, the observed association between sugar-sweetened soft drink consumption

and blood pressure may be, in part, mediated by salt intake.

As Malik et al rightly pointed out, sugar-sweetened soft drinks are the largest

source of added sugar in our diet. Added sugar is a major hidden source of calories

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and contributes to obesity and type 2 diabetes.6-8 Some studies also suggest that the

role of sugar in soft drinks in obesity might be key because it provides no feeling of

satiation.9 It is well established that obesity is associated with an increased blood

pressure. Additionally, sugar in soft drinks stimulates insulin secretion which could

lead to sodium and water retention10 and, thereby, possibly increasing blood

pressure. The suggested mechanism for the links between salt intake, sugar-

sweetened soft drink consumption and blood pressure is shown in Figure.

Raised blood pressure throughout its range is a major cause of cardiovascular

disease, accounting for 62% of strokes and 49% of coronary heart disease.11 A

reduction in population salt intake which can easily be made by slowly reducing the

amounts of salt added to foods by the food industry, will lead to a reduction in

population blood pressure and cardiovascular mortality, as demonstrated in the UK12

and Finland.13 Furthermore, a reduction in salt intake will cause a reduction in sugar-

sweetened soft drink consumption and, thereby, a decrease in obesity and type II

diabetes.

Efforts to reduce soft drink consumption combined with a gradual reduction in

the amounts of sugar added to soft drinks will provide additional beneficial effects on

health. An action group (Action on Sugar)14 was recently set up with a mission to

achieve a gradual and sustained reduction in the amounts of sugar added to foods

and drinks, following a similar model to the UK salt reduction programme15 pioneered

by Consensus Action on Salt and Health (CASH).16 This model has become one of

the most successful nutritional policies in the UK since the Second World War,17 by

setting progressively lower salt targets for over 80 categories of foods for the food

industry to achieve within a certain time frame.15 As this is done slowly, people do

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not notice the difference in taste. A reduction in population salt and sugar intake,

even by a small amount, will have a major beneficial effect on health along with

major cost savings.

Feng J He, PhD.

Graham A MacGregor, MD

London, UK

1 May 2014

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1. Malik AH, Akram Y, Shetty S, Malik SS, Yanchou Njike V. Impact of Sugar-

Sweetened Beverages on Blood Pressure. Am J Cardiol 2014;113:1574-1580.

2. He FJ, Markandu ND, Sagnella GA, MacGregor GA. Effect of salt intake on renal

excretion of water in humans. Hypertension 2001;38:317-320.

3. He FJ, Marrero NM, MacGregor GA. Salt intake is related to soft drink

consumption in children and adolescents: a link to obesity? Hypertension

2008;51:629-634.

4. Grimes CA, Wright JD, Liu K, Nowson CA, Loria CM. Dietary sodium intake is

associated with total fluid and sugar-sweetened beverage consumption in US

children and adolescents aged 2-18 y: NHANES 2005-2008. Am J Clin Nutr

2013;98:189-196.

5. Grimes CA, Riddell LJ, Campbell KJ, Nowson CA. Dietary salt intake, sugar-

sweetened beverage consumption, and obesity risk. Pediatrics 2013;131:14-21.

6. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on

nutrition and health: a systematic review and meta-analysis. Am J Public Health

2007;97:667-675.

7. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic

review and meta-analyses of randomised controlled trials and cohort studies.

BMJ 2013;346:e7492.

8. Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, Sacks F,

Steffen LM, Wylie-Rosett J, American Heart Association Nutrition Committee of

the Council on Nutrition PA, Metabolism, the Council on E, Prevention. Dietary

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sugars intake and cardiovascular health: a scientific statement from the

American Heart Association. Circulation 2009;120:1011-1020.

9. DiMeglio DP, Mattes RD. Liquid versus solid carbohydrate: effects on food intake

and body weight. Int J Obes Relat Metab Disord 2000;24:794-800.

10. Rocchini AP, Katch V, Kveselis D, Moorehead C, Martin M, Lampman R,

Gregory M. Insulin and renal sodium retention in obese adolescents.

Hypertension 1989;14:367-374.

11. World Health Report 2002: Reducing risks, promoting healthy life. Geneva,

Switzerland: World Health Organisation, 2002. www.who.int/whr/2002 (Accessed

3 June 2013).

12. He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from

2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart

disease mortality. BMJ Open 2014;4:e004549.

13. Karppanen H, Mervaala E. Sodium intake and hypertension. Prog Cardiovasc

Dis 2006;49:59-75.

14. MacGregor GA, Hashem KM. Action on sugar--lessons from UK salt reduction

programme. Lancet 2014;383:929-931.

15. He FJ, Brinsden HC, Macgregor GA. Salt reduction in the United Kingdom: a

successful experiment in public health. J Hum Hypertens 2013:advance online

publication, 31 October 2013; doi:2010.1038/jhh.2013.2105.

16. Consensus Action on Salt and Health. www.actiononsalt.org.uk/ (Access verified

July 23, 2012).

17. Winkler JT. Obesity exposé offers slim pickings. BMJ 2012;345:e4465.

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Figure caption: Mechanism for the links between salt intake, sugar-sweetened soft

drink consumption and blood pressure (BP).

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Sodium and water retention

BP ↑↑↑↑

Calorie ↑↑↑↑

Soft drinks ↑↑↑↑

Salt Intake ↑↑↑↑

Gut sodium

absorption

Insulin ↑↑↑↑

Obesity ↑↑↑↑