Originl Article Epidemiology Dietes Met J 2016;40:290-296 http://dx.doi.org/10.4093/dmj.2016.40.4.290 pissn 2233-6079 eissn 2233-6087 DIABETES & METABOLISM JOURNAL Dietry Sodium Intke in People with Dietes in Kore: The Koren Ntionl Helth nd Nutrition Exmintion Survey for 2008 to 2010 Myung Shin Kng 1, Chong Hw Kim 1, Su Jin Jeong 1, Te Sun Prk 2 1 Deprtment of Internl Medicine, Sejong Generl Hospitl, Bucheon, 2 Deprtment of Endocrinology nd Metolism, Chonuk Ntionl University Medicl School nd Reserch Institute of Clinicl Medicine, Chonuk Ntionl University Hospitl, Jeonju, Kore Bckground: Dietics re likely to receive dvice from their physicins concerning lifestyle chnges. To understnd how much sodium is consumed y dietics in Kore, we compred the verge dily sodium intke etween dietics nd non-dietics fter controlling for confounding fctors. Methods: We otined the sodium intke dt for 13,957 individuls who prticipted in the Koren Ntionl Helth nd Nutrition Exmintion Survey (KNHANES), 2008 to 2010, which consisted of helth interview nd ehviorl nd nutritionl surveys. The KNHANES uses strtified, multistge, proility-smpling design, nd weighting djustments were conducted to represent the entire popultion. Results: Our nlysis reveled tht, overll, dietics tended to hve lower sodium intke (4,910.2 mg) thn helthy individuls (5,188.2 mg). However, oth dietic nd helthy individuls reported higher sodium intke thn is recommended y the World Helth Orgniztion (WHO). Strtified sugroup nlyses reveled tht the sodium intke (4,314.2 mg) mong newly dignosed dietics ws higher mong women when compred to ptients with known dietes (3,812.5 mg, P=0.035). Femle dietics with crdiovsculr disese hd lower verge sodium intke compred to those without crdiovsculr disese fter djusting for sex, ge, ody mss index, nd totl energy intke (P=0.058). Sodium intke mong mle dietics with hypercholesterolemi (P=0.011) nd femle dietics with hypertriglyceridemi (P=0.067) tended to e higher thn tht mong those who without dyslipidemi. Conclusion: The verge sodium intke of dietics in Kore ws higher thn the WHO recommends. Sodium intke in newly dignosed dietics ws significntly higher thn tht in non-dietics nd previously dignosed dietics mong femles. Prospective studies re needed to identify the exct sodium intke. Keywords: Crdiovsculr diseses; Dietes mellitus, type 2; Hypercholesterolemi; Hypertriglyceridemi; Sodium, dietry INTRODUCTION Mny studies hve investigted sodium intke in non-dietic ptients. Higher sodium intke is ssocited with higher lood pressure [1], wheres lower sodium intke cn reduce lood pressure in hypertensive ptients [2-5]. The likelihood Corresponding uthors: Chong Hw Kim http://orcid.org/0000-0002-4563-7772 Division of Endocrinology nd Metolism, Deprtment of Internl Medicine, Sejong Generl Hospitl, 28 Hohyeon-ro 489eon-gil, Sos-gu, Bucheon 14754, Kore E-mil: drngelkr@hnmil.net Te Sun Prk http://orcid.org/0000-0001-7216-8468 Deprtment of Endocrinology nd Metolism, Chonuk Ntionl University Medicl School nd Reserch Institute of Clinicl Medicine, Chonuk Ntionl University Hospitl, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Kore E-mil: pts@chonuk.c.kr Received: Sep. 14, 2015; Accepted: Oct. 20, 2015 This is n Open Access rticle distriuted under the terms of the Cretive Commons Attriution Non-Commercil License (http://cretivecommons.org/licenses/y-nc/4.0/) which permits unrestricted non-commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 2016 Koren Dietes Assocition
Sodium intke in people with dietes in Kore of developing type 2 dietes mellitus (T2DM) is lmost 2.5 times higher in persons with hypertension (HTN) thn in normotensive individuls [6]. However, reserch investigting the potentil ssocition etween dietes nd sodium intke re rre. According to the met-nlysis y Suckling et l. [7], reduced sodium intke leds to lower lood pressure in type 1 dietes mellitus (T1DM) nd T2DM. Uzu et l. [8] reveled tht higher sodium intke ws ssocited with msked HTN in ptients with T2DM. On the other hnd, in cohort study out sodium intke nd mortlity in T2DM, lower 24-hour urinry sodium excretion ws, prdoxiclly, ssocited with incresed ll-cuse nd crdiovsculr mortlity [9]. In Kore, there hve een no stndrdized epidemiologicl studies on ntionwide sodium intke to dte. Using dt from the Koren Ntionl Helth nd Nutrition Exmintion Survey (KNHANES, 2008 to 2010), we investigted sodium intke in Kore nd the chrcteristics ssocited with sodium intke in ptients with T2DM. METHODS Study popultion The dt nlyzed in this study were otined from the KNHANES IV nd V (2008 to 2010). In totl, 29,235 people prticipted in this study. We nlyzed the dt from mle nd femle sujects who were more thn 30 yers of ge. Prticipnts who did not hve dt regrding their diet, demogrphic chrcteristics, nd lortory, nd/or physicl chrcteristics were excluded. People without dt regrding the tretment of their HTN, dietes mellitus (DM), hyperlipidemi, nd/or mediction history were lso excluded. In ddition, pregnnt women nd people whose totl energy intke ws less thn 500 kcl or greter thn 5,000 kcl were excluded, s were ptients with dietes whose glycosylted hemogloin (HA1c) ws not recorded. After pplying the exclusion criteri, 13,957 prticipnts were enrolled. Dignosis of DM It ws impossile to distinguish T1DM nd T2DM in the KNHANES dtset. DM is dignosed y the Americn Dietes Assocition (ADA), Koren Dietes Assocition, nd KNHANES criteri (fsting lood sugr 126 mg/dl, or ptients with orl hypoglycemic gents [OHA] or insulin, or ptients who were lredy dignosed y physicin). The ptients who were not dignosed y physicin, ut whose fsting lood glucose ws over 126 mg/dl without OHA nd insulin tretment, were considered s newly dignosed dietes. Dignosis of hypercholesterolemi Prticipnts whose fsting totl cholesterol ws 240 mg/dl or who were tking lipid-lowering mediction were considered to hve hypercholesterolemi. Dignosis of hypertriglyceridemi Prticipnts whose fsting triglyceride ws 200 mg/dl were considered to hve hypertriglyceridemi. Sttisticl nlyses All dt re presented s men±stndrd error (SE) or s prevlence (% nd SE). Smpling weights were used to tke the complex smpling into ccount, nd sttisticl nlyses were conducted using SAS version 9.3 softwre with the survey procedure (SAS Institute Inc., Cry, NC, USA). Becuse KNHANES uses complex smple design method, we used the PROC SURVEY procedure of SAS, which uses weight, strtifiction vriles, nd cluster vriles to otin estimted results without is. Sttisticl significnce ws defined s P<0.05. RESULTS Bseline chrcteristics of non-dietic nd dietic ptients Bseline chrcteristics of non-dietic nd dietic individuls re shown in Tle 1. In totl, there were 12,477 individuls without dietes nd 1,480 individuls with dietes. The percentge of those tht took prt in smoking, drinking, nd regulr physicl ctivity were similr in oth groups. However, there were severl notle differences. Eductionl ttinment nd income levels were lower mong dietics compred to non-dietic individuls. The proportion of people hving ody mss index (BMI) >25.0 kg/m 2 ws higher mong dietic ptients thn non-dietic ptients. The prevlence of HTN, hypercholesterolemi, nd hypertriglyceridemi ws lso higher mong ptients with DM. Sodium intke in DM nd non-dm Sodium intke mong ptients with nd without dietes is shown in Tle 2, Fig. 1. Averge sodium intke per dy mong non-dietic nd dietic ptients ws 5,188.2 nd Dietes Met J 2016;40:290-296 291
Kng MS, et l. Tle 1. Bseline chrcteristics in DM nd non-dm Chrcteristic Sex Norml, % (n=12,477) Dietes, % (n=1,480) P vlue Mle 48.9 56.0 <0.001 Femle 51.1 44.0 Age group, yr 30 44 44.5 13.1 <0.001 45 64 35.7 40.1 65 74 15.5 35.8 75 4.2 11.0 Eduction Elementry 20.8 42.4 <0.001 Lower secondry 12.4 15.0 Upper secondry 36.1 27.8 College or more 30.6 14.8 Income Lowest 15.0 29.1 <0.001 Medium-low 24.8 28.4 Medium-high 30.1 22.3 Highest 30.1 20.2 Body mss index, kg/m 2 <18.5 3.4 1.7 <0.001 18.5 25.0 64.9 46.3 25.0 31.6 52.0 Current smokers, yes 24.8 23.5 0.394 Alcohol use, yes 57.8 48.0 <0.001 Regulr physicl ctivity, yes 13.2 12.6 0.615 Prevlence of hypertension, yes Prevlence of hypercholesterolemi, yes Prevlence of hypertriglyceridemi, yes Totl energy intke, kcl 29.0 59.4 <0.001 11.0 24.5 <0.001 16.1 31.5 <0.001 1,970.2±10.1 1,847.6±25.9 <0.001 %CHO 68.4±0.1 71.3±0.3 <0.001 %Ft 17.0±0.1 14.6±0.3 <0.001 %Protein 14.7±0.1 14.1±0.1 0.001 Vlues re presented s men±stndrd error. DM, dietes mellitus; CHO, crohydrte. P vlue from Ro-Scott chi-squre test using PROC SURVEYFREQ, P vlue from PROC SURVEYFREG. Sodium intke (mg) Sodium intke (mg) 6,200 6,000 5,800 5,600 5,400 5,200 4,400 4,200 4,000 3,800 3,600 3,400 6,127.1 Norml Dietes Formerly Newly dignosed dignosed dietes dietes 4,290.5 5,676.3 3,933.3 P=0.022 c,e 5,547.3 P=0.035d,f P=0.991 P=0.279 3,812.5 5,957.6 4,314.2 Norml Dietes Formerly Newly dignosed dignosed dietes dietes Fig. 1. (A) Comprison of sodium intke in mle with known dietes mellitus (DM) nd newly dignosed DM. (B) Comprison of sodium intke in femle with known DM nd newly dignosed DM. P vlue ws otined from PROC SUR- VEYREG fter djustment for (sex), ge group, eduction, income, ody mss index, smoking, lcohol use, physicl ctivity, nd totl energy intke. Norml vs. dietes, Norml vs. formerly dignosed, c Norml vs. newly dignosed, d Formerly vs. newly, e,f Sttisticlly significnt P vlue. 4,910.2 mg, respectively. Among mles, sodium intke ws 6,127.1 mg in non-dietics nd 5,676.3 mg in dietics. Among femles, sodium intke ws 4,290.5 mg in non-dietics nd 3,933.3 mg mong dietics. However, fter djusting for sex, ge, BMI, nd totl energy intke, those with dietes did not hve significntly lower verge sodium intke (P=0.868) thn non-dietics. Sodium intke in those with known or newly dignosed DM The comprison of sodium intke etween previously dignosed dietic ptients nd those with newly dignosed dietes is shown in Fig. 1. Anlysis of this dt revels trend tht sodium intke mong newly dignosed dietics is greter thn those with estlished dignoses. Prticulrly mong femles, this difference ws sttisticlly significnt. A B 292 Dietes Met J 2016;40:290-296
Sodium intke in people with dietes in Kore Tle 2. Comprison of sodium intke in people with dietes mellitus nd non-dietes mellitus Vrile Norml Dietes Dietes formerly dignosed Dietes newly dignosed P vlue Totl (n=13,957) 12,477 1,480 1,137 343 Sodium, mg 5,188.2±39.1 4,910.2±116.1 4,741.0±133.6 5,340.8±230.6 >0.1,c,d,e Mle (n=5,661) 4,930 731 543 188 Sodium, mg 6,127.1±55.4 5,676.3±174.0 5,547.3±210.0 5,957.6±320.0 >0.1,c,d,e Femle (n=8,296) 7,547 749 594 155 Sodium, mg 4,290.5±41.5 3,933.3±136.6 3,812.5±150.7 4,314.2±270.4 0.022 d, 0.035 e Vlues re presented s men±stndrd error. P vlue ws otined from PROC SURVEYREG fter djustment for (sex), ge group, eduction, income, ody mss index, smoking, lcohol use, physicl ctivity, nd totl energy intke, Norml vs. dietes, c Norml vs. formerly dignosed, d Norml vs. newly dignosed, e Formerly vs. newly. Tle 3. Comprison of sodium intke in DM ptients with or without CVD, hypercholesterolemi, hypertriglyceridemi Vrile N, mg P vlue Totl (n=1,480) DM lone 4,929.4±126.8 DM c CVD 4,727.1±350.5 0.786 DM lone 4,711.2±132.6 DM c hypercholesterolemi 5,525.2±250.9 0.021 DM lone 4,726.8±134.7 DM c hypertriglyceridemi 5,294.1±7,187.5 0.201 Mle (n=731) DM lone 5,669.4±185.1 DM c CVD 5,738.6±499.4 0.439 DM lone 5,294.1±182.0 DM c hypercholesterolemi 7,187.5±432.3 0.011 DM lone 5,507.1±217.9 DM c hypertriglyceridemi 5,994.4±291.3 0.891 Femle (n=749) DM lone 3,998.2±148.4 DM c CVD 3,262.2±246.9 0.058 DM lone 3,865.1±162.5 DM c hypercholesterolemi 4,093.4±230.5 0.777 DM lone 3,833.4±127.4 DM c hypertriglyceridemi 4,199.6±347.9 0.067 Vlues re presented s men±stndrd error. DM, dietes mellitus; CVD, crdiovsculr disese; c, with. P vlue ws otined from PROC SURVEYREG fter djustment for (sex), ge group, ody mss index (BMI), nd totl energy intke, P vlue ws otined from PROC SURVEYREG fter djustment for (sex), ge group, eduction, income, BMI, smoking, lcohol use, physicl ctivity, nd totl energy intke. Sodium intke in dietic ptients with crdiovsculr disese, HTN, hypercholesterolemi, nd hypertriglyceridemi Femle dietics with crdiovsculr disese (Tle 3) hd significntly lower verge sodium intke compred to those without crdiovsculr disese fter djusting for sex, ge, BMI, nd totl energy intke (3,262 mg/dy vs. 3,998 mg/dy, P=0.058). A comprison of sodium intke ccording to whether or not the individul hd hypercholesterolemi is shown in Tle 3. All sujects, mles in prticulr, showed significnt differences. After djusting for sex, ge group, eduction, income, BMI, smoking, lcohol use, physicl ctivity, nd totl energy intke, in ll sujects nd prticulrly mles, those individuls with dietes nd hypercholesterolemi hd significntly higher sodium intke. A similr trend ws oserved mong femles, ut ws not sttisticlly significnt. A comprison of sodium intke mong those with nd without hypertriglyceridemi is shown in Tle 3. Femles with hypertriglyceridemi hd higher sodium intke compred to those without hypertriglyceridemi. The resulting P vlue ws 0.067 fter djusting for sex, ge group, eduction, income, BMI, smoking, lcohol use, physicl ctivity, nd totl energy intke. The reltionships etween the qurtiles of sodium intke, high lood pressure, hypercholesterolemi, nd HA1c re shown in Tle 4. Compred to the seline sodium intke of the reference group (1,637 mg/dy), greter seline sodium intke ws ssocited with n incresed risk of hypercholesterolemi (3,113 mg/dy: odds rtio [OR], 1.16; 95% CI, 0.74 to 1.80; 4,751 mg/dy: OR, 0.99; 95% CI, 0.62 to 1.56; 9,260 mg/dy: OR, 1.83; 95% CI, 1.12 to 2.97). This trend ws even more pprent mong mles (Tle 4). Dietes Met J 2016;40:290-296 293
Kng MS, et l. Tle 4. Odds rtio of dyslipidemi ccording to the qurtile of sodium intke Vrile Q1 Q2 Q3 Q4 OR 95% CI OR 95% CI OR 95% CI OR 95% CI Totl (n=1,480) 370 370 370 370 Hypercholesterolemi (n=364) 1.00-1.16 0.74 1.80 0.99 0.62 1.56 1.83 1.12 2.97 0.028 Hypertriglyceridemi (n=432) 1.00-0.83 0.55 1.25 1.03 0.68 1.58 1.02 0.67 1.56 0.629 Mle (n=731) 182 183 183 183 Hypercholesterolemi (n=134) 1.00-1.02 0.47 2.20 1.29 0.60 2.77 2.46 1.20 5.05 0.006 Hypertriglyceridemi (n=229) 1.00-0.66 0.37 1.18 0.94 0.52 1.68 1.03 0.55 1.91 0.548 Femle (n=749) 187 187 188 187 Hypercholesterolemi (n=230) 1.00-0.77 0.44 1.34 1.27 0.68 2.39 1.20 0.64 2.22 0.301 Hypertriglyceridemi (n=203) 1.00-1.72 0.96 3.09 1.97 1.13 3.44 1.52 0.82 2.82 0.144 P vlue OR, odds rtio. P for trend ws otined from PROC SURVEYLOGISTIC fter djustment for sex, ge group, eduction, income, ody mss index, smoking, lcohol use, physicl ctivity, nd totl energy intke. DISCUSSION Few studies hve investigted sodium intke mong ptients with nd without dietes in Kore. Huh et l. [10] reveled tht verge sodium intke estimted sed on 24-hour urinry sodium excretion ws 6,528.8 mg/dy in mle dietic ptients nd 5,073.6 mg/dy in femle ptients. Lee et l. [11] showed tht sodium intke in dietic ptients ged 65 nd over ws 6,135.5 mg/dy. Similrly, study y Lim et l. [12] with dietic ptients ged 65 nd over found tht sodium intke sed on 24-hour dietry recll ws 4,719.6 mg/dy in mles nd 3,461 mg/dy in femles. However, ll of these studies re limited y the fct tht their smples were very smll. In our study, sodium intke mong non-dietics ws greter thn in dietics (5,188.2 nd 4,910.2 mg, respectively). Although this difference ws not sttisticlly significnt, trend with dietic individuls sodium intke eing lower thn tht of non-dietic individuls ws oserved. These findings were reported in previous study [13] sed on the Ntionl Helth nd Nutrition Exmintion Survey dt in the United Sttes. One explntion for this trend is physicin recommendtions regrding life-style modifictions, prticulrly mong individuls with dietes [14-16]. Almost ll dults in the United Sttes exceeded the recommended sodium intke s stted y the 2013 ADA position sttement for sodium intke [17] ( totl of 99.4% of United Sttes dults consumed more thn 1,500 mg/dy of sodium [13]). Howev- er, dults in Kore still consume more sodium thn Americns. Given the plethor of studies documenting the ssocition etween sodium intke nd T2DM risk [18], crdiovsculr nd chronic kidney disese risk [19-24], nd links etween sodium restriction nd reduction in proteinuri, stroke protection, nd enhncement of ntihypertensive gents [10,25], limiting nd mnging sodium intke is centrl to pulic helth. Becuse inititives to reduce sodium intke hve een implemented y vrious orgniztions, it is necessry to determine more ccurte, helthy mount of sodium intke. KNHANES dt used in this study ws otined through 24-hour dietry recll. Becuse this method is less ccurte, considering the dietry hits of Korens [26], there is need to develop more ccurte method for estimting sodium intke in susequent KNHANES surveys. In similr mnner to sodium intke mong those with nd without dietes, we speculte tht those with n estlished dietes dignosis my hve lower overll sodium intke thn those newly dignosed with dietes, due to lifestyle modifictions. Anlysis of our dt reveled tht sodium intke ws not ssocited with crdiovsculr events (dt not shown). However, femle dietics with crdiovsculr disese hd lower overll sodium intke compred to those without crdiovsculr disese. A single-center, rndomized control tril [27] reported lower sodium intke in ptients with dietes nd crdiovsculr disese compred to those with dietes with- 294 Dietes Met J 2016;40:290-296
Sodium intke in people with dietes in Kore out crdiovsculr disese. Reduced intke nd enhnced dietry modifictions, which re integrl to crdiovsculr disese cre [28], were ssumed to hve contriuted to this oservtion. Sodium intke ws higher mong people with dietes ccompnied y hypercholesterolemi nd/or hypertriglyceridemi. In qurtiles of sodium intke, those with greter sodium intke tend to hve higher risk of hypercholesterolemi. Thus, there remins possiility tht sodium intke could lso ffect lood lipid concentrtion in the Koren popultion. However, given the cross-sectionl nture of this study, we remin skepticl of this possiility. Moreover, prior study reported tht chnges in dietry sodium intke over 50 to 150 mmol/dy did not ffect lood lipid concentrtions [29]. If results similr to our results re found in susequent studies from KNHANES dt, there will e greter need for more relile studies on whether sodium intke ffects lood lipid concentrtion. This study hs severl strengths, including lrge smple with diverse helth nd sociodemogrphic dt from the Koren popultion nd nlysis tht interrogtes the potentil ssocitions etween sodium intke nd lood lipids mong those with nd without dietes. The study is most limited y the fct tht the KNHANES otined dt y 24-hour dietry recll, so the ccurcy of sodium intke is not gurnteed. Our reserch is lso limited y its cross-sectionl nture ecuse we could not elucidte the cusl reltionship etween sodium intke nd DM or hypercholesterolemi. In summry, our study reveled tht the overll sodium intke mong Koren dults ws very high. Second, individuls with n estlished dignosis of dietes, especilly femles, hd lower sodium intke thn did individuls with newly dignosed dietes or helthy individuls. In ddition, femle dietics with crdiovsculr disese hd lower overll sodium intke thn did those without crdiovsculr disese. Third, mong dietics with hypercholesterolemi nd hypertriglyceridemi, trend towrd higher sodium intke ws oserved in comprison to those with dietes lone. Finlly, we determined tht mong those with dietes, sodium intke lso incresed the risk of hypercholesterolemi. Future studies will require more ccurte tools to record sodium intke. Moreover, further prospective reserch is needed to elucidte cuse-nd-effect reltionships etween sodium intke nd lood lipid profiles. CONFLICTS OF INTEREST No potentil conflict of interest relevnt to this rticle ws reported. ACKNOWLEDGMENTS We would like to thnk memers of Committee of Food nd Nutrition, Koren Dietes Assocition. REFERENCES 1. Interslt Coopertive Reserch Group. Interslt: n interntionl study of electrolyte excretion nd lood pressure. Results for 24 hour urinry sodium nd potssium excretion. BMJ 1988;297:319-28. 2. Midgley JP, Mtthew AG, Greenwood CM, Logn AG. Effect of reduced dietry sodium on lood pressure: met-nlysis of rndomized controlled trils. JAMA 1996;275:1590-7. 3. He FJ, McGregor GA. Effect of modest slt reduction on lood pressure: met-nlysis of rndomized trils. Implictions for pulic helth. J Hum Hypertens 2002;16:761-70. 4. Cutler JA, Follmnn D, Allender PS. Rndomized trils of sodium reduction: n overview. Am J Clin Nutr 1997;65(2 Suppl): 643S-51S. 5. Lw MR, Frost CD, Wld NJ. By how much does dietry slt reduction lower lood pressure? III. Anlysis of dt from trils of slt reduction. BMJ 1991;302:819-24. 6. Gress TW, Nieto FJ, Shhr E, Wofford MR, Brncti FL. Hypertension nd ntihypertensive therpy s risk fctors for type 2 dietes mellitus. Atherosclerosis Risk in Communities Study. N Engl J Med 2000;342:905-12. 7. Suckling RJ, He FJ, Mcgregor GA. Altered dietry slt intke for preventing nd treting dietic kidney disese. Cochrne Dtse Syst Rev 2010;(12):CD006763. 8. Uzu T, Nko K, Kume S, Arki H, Isshiki K, Arki S, Kwi H, Ugi S, Kshiwgi A, Megw H. High sodium intke is ssocited with msked hypertension in Jpnese ptients with type 2 dietes nd treted hypertension. Am J Hypertens 2012;25:1170-4. 9. Ekinci EI, Clrke S, Thoms MC, Morn JL, Cheong K, McIsc RJ, Jerums G. Dietry slt intke nd mortlity in ptients with type 2 dietes. Dietes Cre 2011;34:703-9. 10. Huh KY, Suh I, Kim KR, Nm CM, Oh KW. The reltionship etween slt perception nd slt intke in dietic ptients. J Dietes Met J 2016;40:290-296 295
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