Dietary Reference Intakes for Sodium and Potassium (2019) / Chapter Skim
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Appendix D: Indicators Not Relevant for Establishing Dietary Reference Intake Values
Appendix D: Indicators Not Relevant for Establishing Dietary Reference Intake Values
Pages 447-484
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The list was compiled with the intent of determining which indicators not included in the AHRQ Systematic Review would merit further consideration and, as appropriate, supplemental literature searches. By assessing the scope of evidence on the relationship between the identified indicator and potassium and/or sodium intake and through expert judgment, the committee determined which of the identified indicators had the potential to be relevant for establishing potassium and sodium DRI values.
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reports, conducting an abbreviated search of recent systematic reviews, reviewing international reference intake values reports, and circulating a call for relevant grey literature. These efforts informed the comprehensive list of potential indicators.
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Accordingly, fewer than 35 and 18 indicators were identified for sodium and potassium, respectively, through this abbreviated literature search of systematic reviews. 1 The PubMed search was conducted using the systematic review filter and the following search string: ((("Sodium Chloride"[Mesh]
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Indicators revealed through the workshop, public comments, and information-gathering public sessions were compared to the comprehensive list of indicators, and indicators not previously identified were added. Compiling the Comprehensive List of Indicators Not Included in the AHRQ Systematic Review The comprehensive list of indicators not included in the AHRQ Systematic Review was compiled from the information-gathering activities described in the preceding sections (see Table D-1)
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APPENDIX D 451 TABLE D-1 Comprehensive List of Potential Indicators Not Included in the AHRQ Systematic Review That Have Been Recently Assessed in Relation to Sodium and/or Potassium, Presented in Alphabetical Order Indicator Potassium Sodium Age-related cataracts X Age-related macular degeneration X Arterial stiffness X X Ascites X Blood lipidsa X X Bone healthb X X Cancer X Catecholamines X X Creatininec X Depression X Diabetesd X X Diabetic retinopathy X X Endothelial dysfunction X Gastroesophageal reflux X Genitourinary symptoms X Headache X Heart rate X X Hyperhomocysteinemia X Left ventricular mass X Leg cramps X Maternal and birth outcomese X Metabolic syndrome X X Nonalcoholic fatty liver disease X Obesity X X Pulmonary functionf X X Quality of life X Renin-angiotensin-aldosterone system X X Rheumatoid arthritis X Sarcopenia X X continued
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Determining Which Indicators Have Potential Relevance A wide range of indicators have been assessed in the literature as potentially having a relationship with potassium and/or sodium. The committee, therefore, decided to triage the identified indicators to determine which indicators potentially had relevance for establishing potassium or sodium DRI values.
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The committee followed the general approach described in the AHRQ Systematic Review, which consisted of three different types of searches per indicator in PubMed. One search type was to identify systematic reviews for reference mining.
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a Filters: Systematic Reviews Gather evidence (("Sodium Chloride"[Mesh] OR "Sodium Glutamate"[Mesh]
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a Filters: Systematic Reviews ("Potassium, Dietary"[Mesh] OR potassium[tiab]
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The committee reviewed the evidence from previous IOM reports, the March 2018 public workshop and public session, and the scoping searches to make a determination about whether the indicator potentially had relevance for deriving potassium or sodium DRI values. Indicators the committee determined to have evidence to suggest it may be of relevance progressed to a more thorough consideration and, as necessary, comprehensive literature search (see Appendix E)
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Arterial Stiffness Arterial stiffness was identified as a potential sodium and potassium indicator through the abbreviated search of recent systematic reviews. The relationship between sodium and arterial stiffness was not explored in the 2005 DRI Report (IOM, 2005)
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. Given the limited data on the relationship between potassium intake and cardiovascular disease risk, the committee determined that current evidence does not support considering arterial stiffness for the derivation of a potassium DRI based on chronic disease.
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Creatinine (Serum or Plasma) Creatinine was identified as a potential indicator for potassium through the abbreviated search of recent systematic reviews.
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Given the strength of evidence for blood pressure and for the hard endpoint of cardiovascular disease, the committee determined that the evidence currently does not support the use of heart rate as a potential indicator for establishing sodium DRI values. One recent meta-analysis of randomized controlled trials (Gijsbers et al., 2016)
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Through the scoping searches, three articles on crossover clinical trials and two articles on prospective cohort studies were identified as exploring the relationship between sodium intake and left ventricular mass. For the crossover trials, Williams et al.
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Therefore, the evidence currently does not support the use of left ventricular mass as a potential indicator for establishing potassium or sodium DRI values. The committee, however, notes that future clinical trials are warranted to clarify the relationship between sodium intake and left ventricular mass.
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Age-Related Cataracts, Age-Related Macular Degeneration, and Diabetic Retinopathy Three eye-related conditions were identified as being potential indicators for sodium and potassium from the abbreviated search of recent systematic reviews. The potential indicators included age-related cataracts, age-related macular degeneration, and diabetic retinopathy.
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. Based on this scoping search, the committee determined that the evidence currently does not support the use of age-related cataracts, age-related macular degeneration, or diabetic retinopathy as indicators to inform the sodium DRI values.
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. Sodium The scoping searches did not reveal any publications on trials, prospective cohorts, or nested case-control studies on this topic that have been published since January 1, 2012.10 Accordingly, the committee determined that the evidence currently does not support the use of gastroesophageal reflux as an indicator to inform the sodium DRI values.
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, it was concluded that, given the inconsistent methodological approach and results, there was insufficient evidence to draw conclusions regarding the relationship between sodium intake and genitourinary symptoms. The scoping searches did not reveal any new randomized controlled trials, prospective cohorts, or nested case-cohort studies.11 Accordingly, the committee determined that the evidence currently does not support the use of urinary tract infections as an indicator to inform the sodium DRI values.
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Accordingly, the committee determined that the evidence currently does not support the use of hyperhomocysteinemia as an indicator to inform the sodium DRI values. Leg Cramps Leg cramps were identified as a potential indicator for sodium through the abbreviated search of recent systematic reviews.
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The committee determined that the evidence currently does not support the use of maternal or birth outcomes as indicators to inform the sodium DRI values. Metabolic Syndrome Metabolic syndrome as an outcome was identified as a potential indicator for sodium and for potassium through the abbreviated search of recent systematic reviews.
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did not reveal any articles on trials, prospective cohorts, or nested case-control studies exploring the relationship between potassium intake and metabolic syndrome.16 Accordingly, the committee determined that the evidence currently does not support the use of metabolic syndrome as an indicator to inform the potassium DRI values. Nonalcoholic Fatty Liver Disease Nonalcoholic fatty liver disease was identified as a potential indicator for sodium through the abbreviated search of recent systematic reviews.
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for 4 days Location: Denmark • Placebo for 4 days 24-hour urinary sodium measured the day before the study day for each period Prospective Cohort Inoue et al., • 184 pregnant women Measured before 20th week of 2016 gestation: Location: Japan • 24-hour home urine collection • Early morning urine sample Measured after 20th week, at each pregnancy check-up visit: • Early morning urine sample Hassanzadeh • 620 pregnant women Completed at the 11th–15th, 26th, et al., 2016 and 34th–37th weeks of gestation: Location: Iran • 48-hour dietary recalls
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Measured on 7 consecutive • 14 women developed pregnancy-induced hypertension days before 20th week and and 8 developed pregnancy-induced hypertension with after 30th week gestation: proteinuria.a • Home blood pressure • Estimated urinary salt excretion was not significantly correlated with either home blood pressure before the Infant outcome: 20th gestational week or home blood pressure after the • Light-for-date at birth 30th gestational week. • ogistic regression: Neither urinary salt excretion averaged L until the 30th gestational week nor change in urinary salt excretion was associated with the development of pregnancy-induced hypertension.
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The scoping searches and reference mining of one systematic review (Forte et al., 2018) did not reveal any additional articles on trials, pro
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spective cohorts, or nested case-control studies exploring the relationship between sodium intake and pulmonary function as being published since January 1, 2012.18 Accordingly, the committee determined that the evidence currently does not support the use of pulmonary function as an indicator to inform the sodium DRI values. Potassium In the 2005 DRI Report, prevention of impaired pulmonary function was explored as an indicator for estimating the requirement for potassium.
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The com 19 The different scoping searches (see Table D-2) returned 6 results for the systematic review search, 263 results for the association search, and 180 results for the effect search, which were screened for relevance.
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did not reveal any randomized controlled trials, prospective cohorts, or nested case-control studies published since January 1, 2003, on the relationship between sodium intake and sarcopenia.21 The committee, therefore, determined that the evidence currently does not support the use of sarcopenia as an indicator to inform the sodium DRI values. Potassium Through the scoping searches and reference mining of one systematic review (van Dronkelaar et al., 2018)
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Small Vessel Disease Small vessel disease was identified as a potential indicator for sodium through the abbreviated search of recent systematic reviews. The relationships between sodium and small vessel disease was not explored in the 2005 DRI Report (IOM, 2005)
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While each may be of scientific and clinical interest, not all are relevant for the purposes of informing the potassium or sodium DRI values. Through expert judgment and scoping literature searches for recent evidence, the committee determined that several of the potential indictors that exist in the literature do not align with the DRI paradigm or have limited data at present, and as such do not support their use as indicators to inform the potassium or sodium DRI values.
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Cochrane Database of Systematic Reviews (4)
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2015. Effect of dietary sodium and potassium intake on left ventricular diastolic function and mass in adults ≤40 years (from the Strong Heart Study)
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2017. Small vessel disease and dietary salt intake: Cross-sectional study and systematic review.
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2017. Sodium status and the metabolic syndrome: A systematic review and meta-analysis of observational studies.
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The role of calcium, iron, magnesium, phospho rus, potassium, selenium, sodium, and zinc on muscle mass, muscle strength, and physi cal performance in older adults: A systematic review. Journal of the American Medical Directors Association 19(1)
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2017. The science of salt: A regularly updated systematic review of salt and health outcomes (December 2015-March 2016)
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