Sodium and Potassium Intake: NHANES and Other Data

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Sodium and Potassium Intake: NHANES and Other Data Sodium Mary (Molly) E. Cogswell, RN, DrPH Senior Scientist Division for Heart Disease and Stroke Prevention Centers for Disease Control and Prevention National Academies of Science, Engineering, and Medicine March 7, 2018 National Center for Chronic Disease Prevention and Health Promotion Division for Heart Disease and Stroke Prevention

Objectives Inform Review of the Dietary Reference Intakes (DRI) for Sodium and Potassium Describe Canadian and US sodium and potassium intakes Understand Strengths and limitations of population intake estimates

Data Sources - Overview Canadian Community Health Survey (CCHS) 24-hour dietary recalls US National Health and Nutrition Examination Survey (NHANES) 24-hour dietary recalls 24-hour urine collection Salt Sources Study 24-hour dietary recalls Duplicate salt sample collection Supplements/antacids Home tap water

Canadian Community Health Survey Sample - 2004 Nationally-representative, non-institutionalized persons All ages (diet data 1+ years, n=32,776) Two 24-hour dietary recalls Interviewer administered Day 1: in-person at home Day 2: ~1/3 random sample by telephone (3-10 days later) Bilingual dietary interviewers English\French Conducted all days of week Based on USDA s Automated Multiple-Pass Method Computerized instrument 5-step multiple pass approach Nutrient values Canadian Nutrient File, 2001b Population estimates Excluded salt added at the table, supplements/antacids Account for survey design, non-response Percentiles of usual intake, C-SIDE

What We Eat in America, NHANES Sample continuous Nationally-representative, non-institutionalized persons All ages (dietary data 2009-2014, n=26,446) Two 24-hour dietary recalls Interviewer-administered Day 1: in-person Day 2: telephone (3-10 days later) Bilingual dietary interviewers English\Spanish Conducted all days of week USDA Automated Multiple-Pass Method Computerized instrument 5-step multiple pass approach Nutrient values Food and Nutrient Database for Dietary Studies Population estimates Exclude salt added at the table, supplements/antacids Account for survey design and non-response Usual intake estimation, NCI Method, 2009-2014 Population proportions by WWEIA food categories, 2013-2014 Step 1 Quick List... Listing of all foods/beverages Step 2 Forgotten Foods... Probes for forgotten foods/ beverages Step 3 Time & Occasion... Ask for each food/beverage Step 4 Detail Cycle... Standardized questions for each food /beverage Step 5 Final Probe... A final probe for anything else Source: Modified from slide from Alanna Moshfegh, with permission. Validity of Na, K, or energy intakes in AMPM: Moshfegh et al, AJCN 2008;88:324-32; Rhodes et al, AJCN 2013;97:958-64; Freedman et al., Am J Epidemiol 2015;181:473-487; Mercado et al., AJCN 2015;101:376-86.

NHANES 24-Hour Urine Collection Sample - 2014 Nationally-representative, non-institutionalized persons Random-half sample Non-pregnant adults aged 20-69 years Two 24-hour urine collections In-person start / stop (most) First collection: post-examination Second collection,~ ½ sample: 3-10 days later Verbal, written, pictorial instructions English/Spanish Conducted all days of the week Laboratory analysis Complete specimens Roche Ion-Selective Electrode technique Population estimates First 24-hour urine collection Account for complex survey design and non-response Flow Chart First 24-h Urine

Results Sodium Sources

Mean Daily Sodium Intake by DRI Age-Sex Group, Canada, 2004 Milligrams 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Both Sexes Male Female 1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+ Age in Years Source: Statistics Canada, Canadian Community Health Survey, 2004, n=32,776

Mean Daily Sodium Intake by DRI Age-Sex Group, United States, 2009-2014 Milligrams 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Both Sexes Male Female 0-6 7-12 1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+ Age in Months Age in Years Source: CDC, unpublished analyses, What We Eat in America, NHANES 2009-2014, n=26,446

Cogswell ME, Loria CM, Terry AL, et al. Estimated 24-Hour Urinary Sodium and Potassium Excretion in US Adults Published online March 7, 2018 Available at jama.com and on The JAMA Network Reader at mobile.jamanetwork.com jamanetwork.com

5000 Mean 24-Hour Urinary Sodium Excretion, Adults 20-69 years, United States, 2014 Milligrams 4500 4000 3500 3608 4205 3000 3039 2500 Overall (827) Men (421) Women (406) Sex (No. of Participants) Source: Cogswell, Loria, Terry, et al., JAMA. 2018;319(12):1-12. doi:10.1001/jama.2018.1156.

Mean Estimated Daily Sodium Intake by Method, United States 5000 4500 Milligrams 4000 3500 3608 3607 4205 4175 3000 3039 3044 2500 Urine (827) 2014 Diet (4246) 2013-2014 Urine (421) Diet (2056) Urine (406) Diet (2190) Overall Men Women Sex and Measurement Method (No. of Participants) Source: Cogswell, Loria, Terry, et al., JAMA. 2018;319(12):1-12. doi:10.1001/jama.2018.1156. Non-pregnant adults aged 20-69 years. Diet data based on WWEIA, NHANES, 2013-2014.

Sodium Intake Distributions, Adults 19+ Years by Sex, United States, 2009-2014 8000 7000 Usual Daily Intake, Milligrams 6000 5000 4000 3000 2000 1000 0 Men Women 0 10 20 30 40 50 60 70 80 90 100 Percentiles Source: CDC, unpublished analyses, What We Eat in America, NHANES 2009-2014, n=15,678

Sodium Density Distributions, Adults 19+ Years by Sex, United States, 2009-2014 3000 2500 Usual Daily Intake, Milligrams per 1000 kcal 2000 1500 1000 500 Men Women 0 0 10 20 30 40 50 60 70 80 90 100 Percentiles Source: CDC, unpublished analyses, What We Eat in America, NHANES 2009-2014, n=15,678

Results Sodium Sources

Salt Sources Study Sample Convenience sample, Dec 2013-Dec 2014 450 Non-pregnant adults, aged 18-74 years Validation Sub Study: 4 race/ethnic groups, 3 geographic locations (MN, CA, AL) Baseline clinic visit Four record-assisted 24-h dietary recalls Interviewer-administration by telephone Non-consecutive over 11 days 1 weekend day, 3 weekdays Bilingual dietary interviews English\Spanish Other sodium sources Duplicate salt samples Dietary supplements/non-prescription antacids Home tap water Data collection and nutrient values UMN Nutrition Data System for Research (NDSR) Automated data collection and nutrient coding Estimates Mean proportions (4 days per person) Various sources, e.g., inherent, salt added at the table, supplements/antacids

Mean Proportions of Sodium Intake from Various Sources (n=450) Mean total sodium intake: 3501 mg per day Added outside the home, 71% Inherent to food, 14% Added at table, 5% Added in home preparation, 6% Dietary supplements/antacids and tap water, <1% Source: Harnack LJ, et al. Sources of Sodium in US Adults from 3 Geographic Regions. Circulation. 2017;135:1775-1783.

Top 10 Food Types Contributing to Sodium Intake United States, 2013-2014 Rank Food Type % 1 Yeast breads 6.2 2 Pizza 5.9 3 Single code sandwiches 5.7 4 Cold cuts and cured meats 5.4 5 Soups 3.8 6 Burritos and Tacos 3.8 7 Savory snacks 3.7 8 Chicken, whole pieces 3.8 9 Cheese 3.5 10 Eggs and Omelets 3.1 Source: Quader et al., MMWR. 2017;66(12):324-328. NHANES 2013-2014, US persons 2 years and older, n=8,067

Results Potassium Sources

Mean Daily Potassium Intake by DRI Age-Sex Group, Canada, 2004 4000 3500 Both Sexes Male Female 3000 Milligrams 2500 2000 1500 1000 500 0 1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+ Age in Years Source: Statistics Canada, Canadian Community Health Survey, 2004, n=32,776

Mean Daily Potassium Intake by DRI Age-Sex Group, United States, 2009-2014 4000 3500 3000 Both Sexes Male Female Milligrams 2500 2000 1500 1000 500 0 0-6 7-12 1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+ Age in Months Age in Years Source: CDC, unpublished analyses, What We Eat in America, NHANES 2009-2014, n=26,446

3500 Mean 24-Hour Urinary Potassium Excretion Adults 20-69 years, United States, 2014 3000 Milligrams 2500 2000 2155 2399 1922 1500 1000 Overall (827) Men (421) Women (406) Sex (No. of Participants) Source: Cogswell, Loria, Terry, et al., JAMA. 2018;319(12):1-12. doi:10.1001/jama.2018.1156

Mean Estimated Daily Potassium Intake by Method, United States 3500 3000 3029 Milligrams 2500 2000 2155 2671 2399 1922 2317 1500 1000 Urine (827) 2014 Diet (4246) 2013-2014 Urine (421) Diet (2056) Urine (406) Diet (2190) Overall Men Women Sex and Measurement Method (No. of Participants) Source: Cogswell, Loria, Terry, et al., JAMA. 2018;319(12):1-12. doi:10.1001/jama.2018.1156 and CDC, unpublished data (Diet), WWEIA, NHANES, 2013-2014, non-pregnant adults aged 20-69 y.

Potassium Intake Distributions, Adults 19+ years by Sex, United States, 2009-2014 6000 5000 Usual Daily Intake, Milligrams 4000 3000 2000 1000 Men Women 0 0 10 20 30 40 50 60 70 80 90 100 Percentiles Source: CDC, unpublished analyses, What We Eat in America, NHANES 2009-2014, n=15,678

Top 10 Food Types Contributing to Potassium Intake United States, 2005-2006 Rank Food Type % 1 Reduced fat milk 5.9 2 Coffee 5.2 3 Chicken and chicken mixed dishes 4.5 4 Beef and beef mixed dishes 3.6 5 100% Orange/grapefruit juice 3.4 6 Fried white potatoes 3.3 7 Potato/corn/other chips 3.2 8 Whole milk 2.9 9 Other white potatoes 2.9 10 Pasta and pasta dishes 2.7 See https://epi.grants.cancer.gov/diet/foodsources/potassium/table1a.html, NHANES 2005-2006 data, US population aged 2+ years, n=8549 For foods ranked by the amount of potassium per standard food portions see 2015-2020 Dietary Guidelines for Americans, Appendix 10.

Results Sodium:Potassium Ratio

Mean Sodium:Potassium Ratio, by DRI Age-Sex Group, United States, 2009-2014 Molar Ratio Sdoium:Potassium 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Both Sexes Male Female 0-6 7-12 1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+ Age in Months Age in Years Source: CDC, unpublished analyses, What We Eat in America, NHANES 2009-2014, n=26,446

5 Mean 24-Hour Urinary Sodium:Potassium Excretion, Adults 20-69 years, United States, 2014 Molar Ratio Sodium:Potassium 4.5 4 3.5 3 2.5 2 1.5 3.17 3.32 3.03 1 Overall (827) Men (421) Women (406) Sex (No. of Participants) Source: Cogswell, Loria, Terry, et al., JAMA. 2018;319(12):1-12. doi:10.1001/jama.2018.1156

Mean Estimated Sodium:Potassium Ratio by Method, United States 5 Molar ratio of sodium:potassium 4.5 4 3.5 3 2.5 2 1.5 1 3.17 Urine (827) 2014 2.47 Diet (4246) 2013-2014 3.32 2.5 3.03 2.43 Urine (421) Diet (2056) Urine (406) Diet (2190) Both Sexes Male Female Sex and Measurement Method (No. of Participants) Source: Cogswell, Loria, Terry, et al., JAMA. 2018;319(12):1-12. doi:10.1001/jama.2018.1156 and CDC, unpublished data (Diet), WWEIA, NHANES, 2013-2014, non-pregnant adults aged 20-69 y.

Sodium:Potassium Distributions, Adults 19+ years by Sex, United States, 2009-2014 5 4.5 4 Usual Molar Ratio 3.5 3 2.5 2 1.5 Men Women 1 0.5 0 0 10 20 30 40 50 60 70 80 90 100 Percentiles Source: CDC, unpublished analyses, What We Eat in America, NHANES 2009-2014, n=15,678

Strengths and Limitations

Strengths NHANES / CCHS Dietary Recalls Short-term recall Low reactivity Automated interview All seasons / days of the week Limitations Random error within-person variability Under-reporting Excludes salt / salt substitutes* added at the table Relies on accurate nutrient composition *Quader et al., Trends and determinants of discretionary salt use: National Health and Nutrition Examination Survey 2003-2012. Public Health Nutr 2016;19:2195-2203.

Strengths NHANES/CCHS Nutrient Composition Up-to-date, select laboratory values National sampling Brands represent ~70%-80% market Standard recipe files Brand-specific values (increasing) Limitations Variability by brand, location, time Laboratory / label values can differ Limited label values for potassium USDA National Food and Nutrient Analysis Program USDA National Nutrient Database for Standard Reference (SR) USDA Food and Nutrient Database for Dietary Studies

Strengths In person start and stop Captures All seasons / days of the week All sources of intake Limitations Selection bias Sample size Random error Within-individual Inaccurate timing NHANES - 24-Hour Urine Underestimation Incomplete collection % excreted, ~90% sodium, 50%-90% potassium etable 2. 24-Hour Urine Collection Completion Rates by Participant Characteristics, NHANES 2014 Participant characteristic Asked to Participate (n=1103), No. Completed (n=827), No. (%) P Value Sex Male 542 421 (77.7) 0.04 Female 561 406 (72.4) Age range, years 20-44 584 432 (74.0) 0.41 45-69 519 395(76.1) Race and Hispanic origin Non-Hispanic white 448 339 (75.7) Non-Hispanic black 281 225 (80.1) 0.001 Non-Hispanic Asian 160 100 (62.5) Hispanic 178 137 (77.0)

Intake Conclusions Sodium and potassium intake vary by age and sex Usual sodium intake varied widely within population subgroups. Dietary and urinary sodium assessment are similar & underestimate intake 24-hour urinary potassium excretion significantly lower than dietary estimates Sources Commonly consumed foods contribute to sodium and potassium intake Most sodium consumed is not naturally occurring Sodium

Thank You CDC Draft Tables Lixia Zhao Zefeng Zhang Katherine Overwyk Kirsten Herrick NIH Janet De Jesus Catherine Loria USDA Alanna Moshfegh Jaspreet Ahuja Pamela Pehrsson Health Canada Amanda MacFarlane

Questions CDC website: cdc.gov/salt EMAIL: mcogswell@cdc.gov For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Mean Daily Sodium Density by DRI Age-Sex Group, United States, 2009-2014 3000 Both Sexes Male Female 2500 Milligrams Per 1000 Kilocalories 2000 1500 1000 500 0 0-6 7-12 1-3 4-8 9-13 14-18 19-30 31-50 51-70 71+ Age in Months Age in Years Data Source: What We Eat in America, NHANES 2009-2014

Mean Daily Sodium Density by Age-Sex Group, United States, 2013-2014 3000 Male Female Milligrams per 1000 kcal 2500 2000 1500 1000 500 0 2-5 6-11 12-19 20-29 30-39 40-49 50-59 60-69 70+ Age in Years Source: What We Eat in America, NHANES 2013-2014, https://www.ars.usda.gov/arsuserfiles/80400530/pdf/1314/table_41_den_gen_13.pdf

Mean Daily Potassium Density by Age-Sex Group, United States, 2013-2014 3000 Male Female Milligrams per 1000 kcal 2500 2000 1500 1000 500 0 2-5 6-11 12-19 20-29 30-39 40-49 50-59 60-69 70+ Age in Years Source: What We Eat in America, NHANES 2013-2014, https://www.ars.usda.gov/arsuserfiles/80400530/pdf/1314/table_41_den_gen_13.pdf

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