Trends in Dietary Sodium Intake in the United States and the Impact of USDA Guidelines: NHANES 1999-2016



      Moderation in sodium consumption is recommended to reduce morbidity and mortality; however, trends in intake and the impact of guidelines have not been examined.


      Sodium intake data collected from 1999-2016 in the National Health and Nutrition Examination Surveys were analyzed. Trends in sodium intake for individuals aged 18 years or over and in subgroups based on age, sex, race and ethnicity, and sodium-sensitive chronic diseases were examined. Adherence to US Department of Agriculture guidelines was assessed. Multivariable regression analysis was performed to identify predictors of sodium intake from 2011-2016.


      A total of 47,509 individuals (median age = 44.0 years, 48.3% male) were included in the study. Median sodium consumption was 3232 mg per day (95% confidence interval [CI], 3210-3255), increasing from 3156 mg per day (95% CI 3,038-3,273) in 1999-2000 to 3273 mg per day (95% CI, 3218-3328) in 2015-2016 (P < .001). Intake declined with age (3427 mg per day for individuals aged 18-50 years, 3101 mg per day for individuals aged 51-70 years, and 2620 mg per day for individuals aged ≥71 years; P < .001) and was greater in males than in females (3827 mg per day vs 2778 mg per day; P < .001). Caucasians, Hispanics, and African Americans consumed 3278, 3117, and 3027 mg of dietary sodium per day respectively (P < .001). Individuals with hypertension, diabetes mellitus, and chronic kidney disease consumed 3073, 3062, and 2658 mg of dietary sodium per day respectively. Population adherence to US Department of Agriculture recommendations declined from 34% to 23% and all high-risk subgroups had < 10% adherence. Daily total calories was the strongest predictor of sodium consumption (overall r2 = 0.680).


      Sodium intake has remained above recommended levels in all segments of the adult population and adherence to guidelines is poor. Novel interventions are needed to reduce sodium intake.


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      1. Gottlieb S. US Food and Drug Administration. Reducing the burden of chronic disease. Available at: Accessed September 1st, 2018.

        • Feng J.H.
        • MacGregor G.A.
        Salt, blood pressure and cardiovascular disease.
        Curr Opin Cardiol. 2007; 22: 298-305
      2. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ. 1988;297:319-328.

        • He F.J.
        • MacGregor G.A.
        Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials.
        Lancet. 2011; 378: 380-382
        • Strazullo P.
        • E'Elia L.
        • Kandala N.-B.
        • Cappucio F.
        Salt intake, stroke and cardiovascular disease: meta-analysis of prospective studies.
        BMJ. 2009; 339: b4567
        • Cappucio F.P.
        • Markandu N.D.
        • Carney C.
        • Sagnella G.A.
        • MacGregor G.A.
        Double-blind randomized trial of modest salt restriction in older people.
        Lancet. 1997; 350: 850-854
        • He F.J.
        • Li J.
        • MacGregor G.A.
        Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials.
        BMJ. 2013; 346: f1325
        • He F.J.
        • MacGregor G.A.
        How far should salt intake be reduced?.
        Hypertension. 2003; 42: 1093-1099
        • He F.J.
        • Marciniak M.
        • Visagie E.
        • et al.
        Effect of modest salt reduction on blood pressure, urinary albumin and pulse wave velocity in white, black and Asian mild hypertensives.
        Hypertension. 2009; 54: 482-488
        • Joffres M.R.
        • Campbell N.R.
        • Manns B.
        Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related healthcare costs in Canada.
        Can J Cardiol. 2007; 23: 437-443
        • Micha R.
        • Penalvo J.L.
        • Cudhea F.
        • Imamura F.
        • Rehm C.D.
        • Mozaffarian D.
        Association between dietary factors and mortality from heart disease, stroke and type 2 diabetes in the United States.
        JAMA. 2017; 317: 912-924
        • Rysz J.
        • Franczyk B.
        • Cialkowska-Rysz A.
        • Gluba-Brzozka A.
        The effect of diet on the survival of patients with chronic kidney disease.
        Nutrients. 2017; 9: 1-17
        • Sacks F.M.
        • Svetkey L.P.
        • Vollmer W.M.
        • et al.
        Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet.
        N Engl J Med. 2001; 344: 3-11
        • Selmer R.M.
        • Kristiansen I.S.
        • Haglerod A.
        • et al.
        Cost and health consequences of reducing the population salt intake.
        J Epidemiol Community Health. 2000; 54: 697-702
        • Swift P.A.
        • Marandu N.D.
        • Sagnella G.A.
        • He F.J.
        • MacGregor G.A.
        Modest salt reduction reduces blood pressure and urine protein excretion in black hypertensives: a randomized control trial.
        Hypertension. 2005; 46: 308-312
        • Vollmer W.M.
        • Sacks F.M.
        • Ard J.
        • et al.
        Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial.
        Ann Intern Med. 2001; 135: 1019-1028
      3. Office of Disease Prevention and Health Promotion. Dietary guidelines for Americans, 1995. 4th edition. Available at: Accessed August 10, 2018.

      4. Office of Disease Prevention and Health Promotion. Dietary guidelines for Americans, 2005. 6th edition. Available at: Accessed August 10, 2018.

      5. Office of Disease Prevention and Health Promotion. Dietary guidelines for Americans, 2010. 7th edition. Available at: Accessed August 10, 2018.

      6. Office of Disease Prevention and Health Promotion. Dietary guidelines for Americans, 2015-2020: 8th edition. Available at: Accessed August 10, 2018.

        • Alderman M.H.
        • Cohen H.
        • Madhavan S.
        Dietary sodium intake and mortality: the National Health and Nutrition Examination Survey (NHANES I).
        Lancet. 1998; 351: 781-785
        • Cogswell M.E.
        • Loria C.M.
        • Terry A.L.
        • et al.
        Estimated 24-hour urinary sodium and potassium excretion in US adults.
        JAMA. 2018; 319: 1209-1220
        • Cogswell M.E.
        • Zhang Z.
        • Carriquiry A.L.
        • et al.
        Sodium and potassium intakes among US adults: NHANES 2003-2008.
        Am J Clin Nutr. 2012; 96: 647-657
        • Cohen H.W.
        • Hailpern S.M.
        • Alderman M.H.
        Sodium intake and mortality follow-up in the third National Health and Nutrition Examination Survey (NHANES III).
        J Gen Intern Med. 2008; 23: 1297-1302
        • Cohen H.W.
        • Hailpern S.M.
        • Fang J.
        • Alderman M.H.
        Sodium intake and mortality in the NHANES II follow-up study.
        Am J Med. 2006; 119: e7-e14
        • Jackson S.L.
        • King S.M.
        • Zhao L.
        • Cogswell M.E.
        Prevalence of excess sodium intake in the United States - NHANES, 2009-2012.
        MMWR Morb Mortal Wkly Rep. 2016; 64: 1393-1397
        • Ko J.
        • Kim K.B.
        • Timmerman G.M.
        • Clark A.P.
        • Kim M.
        Factors predicting sodium intake of Korean Americans with type 2 diabetes.
        J Immigr Minor Health. 2018; 20: 641-650
      7. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey: MEC In-Person Dietary Interviewers Procedures Manual. Available at: Accessed August 9, 2018.

        • Cogswell M.E.
        • Elliott P.
        • Wang C.-Y.
        • Rhodes D.G.
        • Pfeiffer C.M.
        • Loria C.M.
        Assessing US sodium intake through dietary data and urine biomarkers.
        Adv Nutr. 2013; 4: 560-562
        • Rhodes D.G.
        • Murayi T.
        • Clemens J.C.
        • Baer D.J.
        • Sebastian R.S.
        • Moshfegh A.J.
        The USDA automated multiple-pass method accurately assesses population sodium intakes.
        Am J Clin Nutr. 2013; 97: 958-964
        • Palar K.
        • Sturm R.
        Potential societal savings from reduced sodium consumption in the US adult population.
        Am J Health Promot. 2009; 24: 49-57
        • Yang Q.
        • Liu T.
        • Kuklina E.V.
        • et al.
        Sodium and potassium intake and mortality among US adults: prospective data from the Third National Health and Nutrition Examination Survey.
        Arch Intern Med. 2011; 171: 1183-1191
        • He F.J.
        • MacGregor G.A.
        Reducing population salt intake worldwide: from evidence to implementation.
        Prog Cardiovasc Dis. 2010; 52: 363-382
        • Bibbins-Domingo K.
        • Chertow G.
        • Coxson P.G.
        • et al.
        Projected effect of dietary salt reductions on future cardiovascular disease.
        N Engl J Med. 2010; 362: 590-599
        • Smith-Spangler C.M.
        • Juusola J.L.
        • Enns E.A.
        • Owens D.K.
        • Garber A.M.
        Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis.
        Ann Intern Med. 2010; 152: 481-487
        • Havas S.
        • Dickinson B.D.
        • Wilson M.
        The urgent need to reduce sodium consumption.
        JAMA. 2007; 298: 1439-1441
        • Harnack L.J.
        • Cogswell M.E.
        • Shikany J.M.
        • et al.
        Sources of sodium in US adults from 3 geographic regions.
        Circulation. 2017; 135: 1775-1783
        • Girgis S.
        • Neal B.
        • Prescott J.
        • et al.
        A one-quarter reduction in the salt content of bread can be made without detection.
        Eur J Clin Nutr. 2003; 57: 616-620
      8. National Academy of Sciences. Strategies to Reduce Sodium Intake in the United States. Available at: Accessed September 1, 2018.

        • Jacobson M.F.
        • Krieger J.
        • Brownell K.D.
        Potential policy approaches to address diet-related diseases.
        JAMA. 2018; 320: 341-342
        • Hu F.B.
        • Willett W.C.
        Current and future landscape of nutritional epidemiologic research.
        JAMA. 2018; 320: 2073-2074
        • Estruch R.
        • Ros E.
        • Salas-Salvadó J.
        • et al.
        Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts.
        N Engl J Med. 2018; 378: e34
        • Merino J.
        • Guasch-Ferré M.
        • Martínez-González M.A.
        • et al.
        Is complying with the recommendations of sodium intake beneficial for health in individuals at high cardiovascular risk?.
        findings from the PREDIMED study. Am J Clin Nutr. 2015; 101: 440-448
        • Toledo E.
        • Hu F.B.
        • Estruch R.
        • et al.
        Effect of the Mediterranean diet on blood pressure in the PREDIMED trial: results from a randomized controlled trial.
        BMC Med. 2013; 11: 207
        • Mozaffarian D.
        Dietary policy priorities for cardiovascular disease, diabetes and obesity: a comprehensive review.
        Circulation. 2016; 133: 187-225
        • Burnier M.
        • Wuerzner G.
        • Bochud M.
        Salt, blood pressure and cardiovascular risk: what is the most adequate preventive strategy? a Swiss perspective.
        Front Physiol. 2015; 6: 227
        • Rehm C.D.
        • Peñalvo J.L.
        • Afshin A.
        • Mozaffarian D.
        Dietary intake among US adults, 1999-2012.
        JAMA. 2016; 315: 2542-2553