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Low dietary sodium in heart failure: time for a re-evaluation of guidelines?
  1. Min Jun,
  2. Bruce Neal
  1. The George Institute for Global Health, The University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Min Jun, The George Institute for Global Health, The University of Sydney, PO Box 201, Missenden Road, Sydney, NSW 2050, Australia; mjun{at}

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There is much evidence that higher sodium intake is associated with elevated blood pressure and there is a strong likelihood that the relationship between excess dietary sodium intake and hypertension is causal.1–3 Corresponding evidence from clinical trials shows that significant reductions in blood pressure can be achieved by lowering dietary sodium consumption in groups with hypertension as well as among normotensive individuals.4 With high blood pressure identified as the leading cause of cardiovascular disease in the world, responsible for more than 60% of stroke events and almost 50% of coronary heart disease,5 efforts to control blood pressure levels have been a global priority for decades. In addition to very well established clinical hypertension control programmes, many of the world's leading scientific and health organisations recommend the widespread reduction of sodium intake for blood pressure lowering. In the USA, the US dietary guidelines recommend reducing the daily intake of sodium to less than 2300 mg/day for the general population, which equates to about one teaspoon or 6 g of salt.6 The US dietary guidelines also advise that higher risk individuals, such as African Americans or people with hypertension, diabetes, or chronic kidney disease, should aim for a daily intake of 1500 mg/day or less.6

A key challenge for these guidelines has been the absence of definitive evidence that reduced dietary sodium translates into lower risks of ‘hard’ clinical outcomes such as stroke and heart attack. This has been the focus of much recent debate. On the one hand, investigators have projected that population-wide reductions in dietary sodium intake will deliver very large benefits because the blood pressure reductions that would ensue would produce substantial reductions in cardiovascular disease.7 It is estimated that reducing population salt intake in the USA by 3 g/day could prevent between 60 000 and 120 000 new …

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  • Contributors MJ wrote the first draft of the manuscript and performed critical revision of the manuscript as the corresponding author. BN contributed to critical revision and improvements to the manuscript.

  • Competing interests MJ reports no conflicts of interest. BN reports, over the past 5 years, receiving grant support from the Australian Food and Grocery Council, Baxter, Bupa Australia, Johnson and Johnson, Medtronic, Merck Shering Plough, Novartis, Respironics, Roche, Servier; consulting fees from Roche and Takeda; and lecture fees or reimbursements of travel expenses from Abbott, AstraZeneca, Novartis, Pepsico, Pfizer, Pharmacy Guild of Australia, and Roche. He is also the chair of the Australian Division of World Action on Salt and Health.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Editor's note Since this editorial has been published the original paper (reference 16, DiNicolantonio JJ, Di Pasquale P, Taylor RS, et al. Low sodium versus normal sodium diets in systolic heart failure: systematic review and meta-analysis. Heart 2012; 10.1136/heartjnl-2012-302337) has been retracted due to unreliable source data. Please find the retraction notice here;

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    BMJ Publishing Group Ltd and British Cardiovascular Society