From Policy to Action: Next Steps in Achieving Population-Wide Reduction in Sodium Intake


  • Lawrence J. Appel MD, MPH

    Corresponding author
    1. Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
    2. Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD
    3. Department of Epidemiology, Johns Hopkins University, Baltimore, MD
    • Address for correspondence: Lawrence J. Appel, MD, MPH, Johns Hopkins University, 2024 East Monument Street, Suite 2-642, Baltimore, MD 21205-2223


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The burden of blood pressure (BP)–related disease is substantial and unacceptable. Elevated BP is the leading preventable cause of death worldwide, in low- and middle-income countries as well as high-income countries.[1] Medication treatment of elevated BP is currently the mainstay of efforts to prevent BP-related cardiovascular disease (CVD), but sole reliance on medication treatment for patients with elevated BP is an incomplete solution. Treatment has no impact on individuals with prehypertension who remain at elevated risk for CVD[2] but who are not yet candidates for medication therapy. More importantly, treatment for middle- and older-aged individuals has no impact on the age-related rise in BP, a phenomenon that begins early in life and that underlies the problem of elevated BP. Indeed, the clinical problem of elevated BP reflects a lifelong health process with clinical manifestations at older ages. Addressing the underlying causes of elevated BP remains the best hope for interrupting this lifelong process. To this end, excess sodium intake has an important, if not predominant, role in the pathogenesis of elevated BP.[3]

As reported in this issue of the Journal, the World Hypertension League and International Society of Hypertension have developed a joint policy statement that calls on governments, nongovernment organizations, and the food industry to reduce sodium intake.[4] This statement and other calls to action from leading professional organizations[5-8] are important intermediate steps between the accumulated evidence on the harmful effects of excess sodium intake and the eventual attainment of population-wide reductions in sodium intake.

The statement from the World Hypertension League and International Society of Hypertension has identified several action items. A more comprehensive roadmap, at least for the United States, is the Institute of Medicine's Strategies to Reduce Sodium in the United States.[9] Accomplishing sodium reduction is largely a matter of changing the environment such that sodium reduction is a passive process for most individuals.[10] The alternative, an active process in which billions of persons receive education and behavioral counseling to reduce their sodium intake, is an unrealistic approach to the public health pandemic of elevated BP.

While the medical and public health communities advocate for regulatory and other environmental strategies to reduce sodium intake, the concurrent support of clinicians is vital. To assist their patients in reducing BP and thus their risk for CVD, clinicians need to support both public health approaches and the individual efforts of their patients. Now is a time for action, not hesitation.


Dr Appel has received grant support from the McCormick Science Foundation, and has received royalties from the sales of a book on the Dietary Approaches to Stop Hypertension diet.