kjhp Korean Journal of Health Promotion Korean J Health Promot 2234-2141 2093-5676 The Korean Society of Health Promotion and Disease Prevention 10.15384/kjhp.2015.15.4.175 kjhp-15-175 Original Article The Relationship between Daily Sodium Intake and Obesity in Korean Adults KimJung-hoon LimGyeong Eun KangSunyoung LeeKayoung ParkTae-jin KimJinseung Department of Family Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea ￭ Corresponding author：Jinseung Kim, MD Department of Family Medicine, Busan Paik Hospital, Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 47392, Korea Tel: +82-51-890-6729, Fax: +82-51-894-7554 E-mail: jinseungkim@inje.ac.kr, jinseungkim@hanmail.net 122015 19122015 154 175184 16092015 06112015 Copyright © 2015 The Korean Society of Health Promotion and Disease Prevention 2015 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

World health organization (WHO) recommended daily sodium intake less than 2 g. To assess the validity of WHO recommendation, we investigated the relationship between daily sodium intake and obesity.

 Methods

A total of 14,694 participants aged ≥19 years who had no missing data for nutrition, chronic disease, health behavior, economic status and laboratory findings from the 5th Korean National Health and Nutrition Examination Survey (KNHANES-V), which was performed from 2010 to 2012. Obesity was defined as having a body mass index of 25 kg/m2 or higher. Daily sodium intake was calculated from 24 hour recall and divided into five categories (< 2 g, 2-4 g, 4-6 g, 6-8 g, ≥8 g). The association between daily sodium intake and obesity was analyzed using multiple logistic regressions.

 Results

Higher sodium intake in men had an increased risk of obesity with odds ratios (ORs) of 1.27 for 2-4 g intake (95% confidence interval [CI], 0.97-1.67), 1.40 for 4-6 g intake (95% CI, 1.07-1.85), 1.41 for 6-8 g intake (95% CI, 1.05-1.89), and 1.61 for ≥8 g intake (95% CI, 1.19-2.18), compared to men with less than 2 g intake, after adjusting for confounding factors. The P value for trend of ORs in each group for men was 0.020. In women, compared to the lesser than 2 g intake, only ≥8 g intake group had an OR of 1.28 (95% CI, 1.02-1.62) without showing significant P for trend (P value for trend＝0.221)

 Conclusions

We found that sodium intake more than 2 g per day was independently related to the increased risk of obesity in men. Therefore, to minimize the risk of obesity, we suggest taking sodium less than 2 g per day.

 Sodium Obesity Energy intake World Health Organization REFERENCES Ministry of Health and Welfare The National Health Plan 2020 Korea Ministry of Health and Welfare 2011 National Institutes of Health Consensus Development Panel on the Health Implications of Obesity Health implications of obesity: National Institutes of Health consensus development conference statement Ann Intern Med 19851036 Part 2 10737 World Health Organization Global status report on noncommunicable disease 2014 Geneva WHO Global Strategy on Diet, Physical Activity and Health 2015 [Accessed Mon Day, Year]. http://www.who.int/mediacentre/factsheets/fs311/en/ Hubert HB Feinleib M McNamara PM Castelli WP Obesity ac an independent risk factor for cardiovascular disease: A 26-year follow up of participants in the Framingham Heart Study Circulation 1983675 96877 McInnis KJ Franklin BA Rippe JM Counseling for Physical Activity in Overweight and Obese Patients Am Fam Physician 2003676 124956 Lau DC Douketis JD Morrison KM Hramiak IM Sharma AM Ur E Obesity Canada Clinical Practice Guidelines Expert Panel 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children CMAJ 20071768 S113 Lenz M Richter T Mühlhauser I The morbidity and mortality associated with overweight and obesity in adulthood: a systematic review Dtsch Arztebl Int 200910640 6418 Guh DP Zhang W Bansback N Amarsi Z Birmingham CL Anis AH The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis BMC Public Health 20099 88 Tsigos C Hainer V Basdevant A Finer N Fried M Mathus-Vliegen E Management of obesity in adults: European clinical practice guidelines Obes Facts 200812 10616 Strazzullo P D'Elia L Cairella G Garbagnati F Cappuccio FP Scalfi L Excess body weight and incidence of stroke: meta-analysis of prospective studies with 2 million participants Stroke 2010415 e41826 Oh SW Yoon YS Shin SA Effects of excess weight on cancer incidences depending on cancer sites and histologic findings among men: Korea National Health Insurance Corporation Study J Clin Oncol 20052321 474254 Navia B Aparicio A Perea JM Pérez-Farinós N Villar-Villalba C Labrado E Sodium intake may promote weight gain; results of the FANPE study in a representative sample of the adult Spanish population Nutr Hosp 2014296 12839 Libuda L Kersting M Alexy U Consumption of dietary salt measured by urinary sodium excretion and its association with body weight status in healthy children and adolescents Public Health Nutr 2012153 43341 Yoon YS Oh SW Sodium density and obesity; the Korea National Health and Nutrition Examination Survey 2007-2010 Eur J Clin Nutr 2013672 1416 Song HJ Cho YG Lee HJ Dietary sodium intake and prevalence of overweight in adults Metabolism 2013625 7038 Larsen SC Ängquist L Sørensen TI Heitmann BL 24h urinary sodium excretion and subsequent change in weight, waist circumference and body composition PLoS One 201387 e69689 Ministry for Health, Welfare and Family Affairs; Korea Centers for Disease Control and Prevention National Health Nutrition Examination Survey Report Cheongwon Korea Centers for Disease Control and Prevention 2013 WHO Guideline: Sodium intake for adults and children Geneva World Health Organization 2012 Babor TF Higgins-Biddle JC Saunders JB Monteiro MG AUDIT - The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care 2nd ed. Geneva World Health Organization 2001 International Physical Activity Questionnaire Guidelines for data processing and analysis of the International Physical Activity Questionnaire (IPAQ) International Physical Activity Questionnaire 2005 [Accessed March 2, 2012]. http://www.ipaq.ki.se WHO/IASO/IOTF The Asia-Pacific perspective: redefining obesity and its treatment Health communications Australia Melbourne 2000 Yon M Lee Y Kim D Lee J Koh E Nam E Major sources of sodium intake of the Korean population at prepared dish level-based on the KNHANES 2008 & 2009 Korean J Community Nutr 2011164 47387 Hoffmann IS Cubeddu LX Salt and the metabolic syndrome Nutr Metab Cardiovasc Dis 2009192 1238 Deglaire A Méjean C Castetbon K Kesse-Guyot E Hercberg S Schlich P Associations between weight status and liking scores for sweet, salt and fat according to the gender in adults (The Nutrinet-Santé study) Eur J Clin Nutr 2015691 406 Gibson S Neate D Sugar intake, soft drink consumption and body weight among British children: further analysis of National Diet and Nutrition Survey data with adjustment for under-reporting and physical activity Int J Food Sci Nutr 2007586 44560 He FJ Marrero NM MacGregor GA Salt intake is related to soft drink consumption in children and adolescents: a link to obesity? Hypertension 2008513 62934 Fonseca-Alaniz MH Brito LC Borges-Silva CN Takada J Andreotti S Lima FB High dietary sodium intake increases white adipose tissue mass and plasma leptin in rats Obesity (Silver Spring) 2007159 22008 Fonseca-Alaniz MH Takada J Andreotti S de Campos TB Campaña AB Borges-Silva CN High sodium intake enhances insulin-stimulated glucose uptake in rat epididymal adipose tissue Obesity (Silver Spring) 2008166 118692 Nunez MF Mollard RC Luhovyy BL Wong CL Anderson GH Acute sodium ingestion has no effect on short-term food and water intake, subjective appetite, thirst, or glycemic response in healthy young men Appl Physiol Nutr Metab 2013387 74652 Dalmasso C Amigone JL Vivas L Serotonergic system involvement in the inhibitory action of estrogen on induced sodium appetite in female rats Physiol Behav 20111043 398407 Figures and Tables

Flow chart of subjects’ selection.

Trend of odds ratio for obesity according to daily sodium intake in men.

General characteristics of subjects according to sex

Characteristics Total (n＝14,694) Men (n＝5,969) Women (n＝8,725) P-valuea
Age, y 50.78±0.13 51.66±0.21 50.18±0.17 ＜0.001
Daily energy intake, Kcal 1,977.19±7.05 2,373.70±12.33 1,705.92±7.02 ＜0.001
Daily sodium intake, mg 4,866.02±27.03 5,874.65±46.18 2,863.04±30.65 ＜0.001
Systolic blood pressure, mmHg 120.00±0.14 122.82±0.21 118.08±0.19 ＜0.001
Diastolic blood pressure, mmHg 76.12±0.09 78.86±0.14 74.25±0.12 ＜0.001
Fasting blood sugar, mg/dL 97.84±0.18 100.79±0.31 95.83±0.22 ＜0.001
Total cholesterol, mg/dL 189.62±0.30 187.26±0.47 191.23±0.39 ＜0.001
HDL cholesterol, mg/dL 52.66±0.11 49.32±0.16 54.94±0.14 ＜0.001
LDL cholesterol, mg/dL 111.66±0.27 108.93±32.02 113.50±0.34 ＜0.001
Triglyceride, mg/dL 130.09±0.85 152.38±1.62 114.84±0.86 ＜0.001
Obesity (BMI≥25), % (N) 31.7 (4,659) 34.9 (2,084) 29.5 (2,575) ＜0.001
Central obesityb, % (N) 25.9 (3,812) 26.3 (1,570) 25.7 (2,242) 0.410
Chronic disease, %
Hypertension 33.9 (4,976) 39.1 (2,236) 30.3 (2,640) ＜0.001
Dyslipidemia 36.5 (5,369) 42.8 (2,557) 32.2 (2,812) ＜0.001
Diabetes mellitus 10.8 (1,589) 13.4 (801) 9.0 (788) ＜0.001
Cerebral vascular disease 2.0 (300) 2.7 (160) 1.6 (140) ＜0.001
Angina pectoris 2.4 (357) 2.7 (164) 2.2 (193) 0.038
Myocardial infarction 1.0 (140) 1.4 (85) 0.6 (55) ＜0.001
Health related behavior
Smoking, % (N) ＜0.001
Non-smoker 60.9 (8,944) 18.6 (1,109) 89.8 (7,835)
Past smoker 20.5 (3,015) 42.8 (2,554) 5.3 (461)
Current smoker 18.6 (2,735) 38.6 (2,306) 4.9 (429)
Alcohol use, % (N) ＜0.001
Non drinking 14.0 (2,054) 5.3 (317) 19.9 (1,737)
Normal drinking 60.3 (8,856) 46.6 (2,779) 69.7 (6,077)
Problem drinking 16.6 (2,440) 29.1 (1,736) 8.1 (704)
Alcohol use disorder 4.8 (708) 10.0 (595) 1.3 (113)
Alcohol dependence 4.3 (636) 9.1 (542) 1.1 (94)
Physical activity, METs/wk 2,176.68±28.03 2,648.04±48.53 1,854.22±33.12 ＜0.001
Household income, % (N) 0.022
Low 19.4 (2,848) 18.2 (1,088) 20.2 (1,760)
Low-middle 25.8 (3,794) 25.9 (1,544) 25.8 (2,250)
High-middle 27.4 (4,026) 28.2 (1,684) 26.8 (2,342)
High 27.4 (4,026) 27.7 (1,653) 27.2 (2,373)
Education level, % (N) ＜0.001
Less than elementary school 25.8 (3,794) 18.3 (1,092) 31.0 (2,702)
Middle school 11.1 (1,633) 12.2 (730) 10.3 (903)
High school 33.3 (4,886) 35.4 (2,115) 31.8 (2,771)
College or higher 29.8 (4,381) 34.0 (2,032) 26.9 (2,349)

Abbreviations: BMI, body mass index; METs, metabolic equivalents. Values are presented as mean±standard error or percent (number).

Continuous variables were calculated by general linear model and categorical variables were calculated by chi-square test.

Central obesity was defined as waist circumference ≥90 cm in men and ≥85 cm in women.

Chronic diseases and health related behaviors according to daily sodium intake in men

Group Group of daily sodium intake (N＝5,969)
＜2 g (394) 2-4 g (1,581) 4-6 g (1,695) 6-8 g (1,091) ≥ 8 g (1,208) P valuea
Daily energy intake, Kcal 1,449.58±29.15 1,892.89±15.44 2,280.27±16.40 2,675.45±25.12 3,162.92±33.07 ＜0.001
Total cholesterol, mg/dL 182.95±2.14 185.18±0.87 188.95±0.86 186.85±1.13 189.36±1.00 0.001
HDL cholesterol, mg/dL 48.14±0.61 48.98±0.32 49.59±0.29 49.59±0.35 49.56±0.33 0.019
LDL cholesterol, mg/dL 105.87±1.84 108.96±0.79 110.04±0.79 107.83±0.99 109.33±0.90 0.144
Triglyceride, mg/dL 149.74±6.93 142.52±2.46 154.47±3.05 153.98±4.09 161.79±4.08 0.020
Fasting blood glucose, mg/dL 101.85±1.19 101.15±0.57 101.02±0.60 99.99±0.66 100.38±0.75 0.159
Systolic blood pressure, mmHg 125.46±0.87 123.44±0.41 122.76±0.40 121.98±0.49 122.00±0.44 ＜0.001
Diastolic blood pressure, mmHg 76.68±0.52 77.94±0.26 79.26±0.26 79.19±0.33 79.91±0.30 ＜0.001
Obesity (BMI≥25), % (N) 26.1 (101) 31.4 (497) 35.8 (606) 35.7 (389) 40.5 (489) ＜0.001
Central obesityb, % (N) 23.9 (94) 23.8 (377) 27.7 (469) 25.6 (279) 29.1 (351) 0.005
Chronic disease, % (N)
Hypertension 48.5 (191) 42.9 (679) 38.1 (646) 34.4 (375) 36.8 (445) ＜0.001
Dyslipidemia 47.2 (186) 41.9 (662) 42.9 (728) 41.5 (453) 43.7 (528) 0.789
Diabetes mellitus 20.8 (82) 15.4 (243) 12.6 (214) 11.3 (968) 11.5 (139) ＜0.001
Cerebral vascular disease 6.1 (24) 3.5 (56) 2.6 (44) 1.5 (16) 1.7 (20) ＜0.001
Angina pectoris 4.1 (16) 3.3 (52) 2.8 (47) 2.4 (26) 1.9 (23) 0.005
Myocardial infarction 2.5 (10) 1.5 (23) 1.5 (25) 1.1 (12) 1.2 (15) 0.123
Health related behavior
Smoking, % (N) 0.770
Non-smoker 19.3 (76) 19.6 (310) 19.5 (331) 17.2 (188) 16.9 (204)
Past smoker 43.4 (171) 44.8 (708) 41.4 (701) 42.9 (468) 41.9 (506)
Current smoker 37.3 (147) 35.6 (563) 39.1 (663) 39.9 (435) 41.2 (498)
Alcohol use, % (N) ＜0.001
Non drinking 6.9 (27) 55.8 (220) 22.3 (88) 6.3 (25) 8.6 (34)
Normal drinking 7.0 (111) 52.7 (833) 25.2 (398) 8.5 (135) 6.6 (104)
Problem drinking 4.8 (81) 45.1 (764) 31.3 (531) 9.9 (168) 8.9 (151)
Alcohol use disorder 4.4 (48) 45.2 (493) 28.7 (313) 12.0 (131) 9.7 (106)
Alcohol dependence 4.1 (50) 38.8 (469) 33.6 (406) 11.3 (136) 12.2 (147)
Physical activity, METs/wk 2,263.81±173.60 2,419.75±92.49 2,530.51±88.26 3,013.61±119.57 2,906.89±111.41 ＜0.001

Abbreviations: HDL, high density lipoprotein; LDL, low density lipoprotein; BMI, body mass index; METs, metabolic equivalents; wk, week. Values are presented as mean±standard error or percent (number).

Calculated by general linear model or chi-square test.

Central obesity was defined waist circumference ≥90 cm in men.

Laboratory data, chronic diseases, and health related behaviors according to daily sodium intake in women

Group Group of daily sodium intake (N＝8725)
＜2 g (1,563) 2-4 g (3,568) 4-6 g (1,990) 6-8 g (914) ≥ 8 g (690) P valuea
Daily energy intake, Kcal 1,170.77±10.79 1,584.57±9.3 1,906.45±12.56 2,134.37±20.93 2,399.82±32.99 ＜0.001
Total cholesterol, mg/dL 194.44±1.00 190.82±0.61 189.79±0.81 190.85±1.17 190.71±1.33 0.041
HDL cholesterol, mg/dL 53.65±0.33 54.85±0.22 55.35±0.28 56.06±0.43 55.68±0.47 ＜0.001
LDL cholesterol, mg/dL 115.67±0.86 113.61±0.53 112.21±0.72 112.58±1.04 113.04±1.20 0.047
Triglyceride, mg/dL 127.07±2.75 112.63±1.22 112.19±1.65 111.86±2.34 110.17±2.47 ＜0.001
Fasting blood glucose, mg/dL 97.43±0.52 95.65±0.34 95.32±0.48 94.79±0.59 95.95±0.74 0.058
Systolic blood pressure, mmHg 121.52±0.48 117.80±0.31 116.60±0.39 117.48±0.59 116.74±0.67 ＜0.001
Diastolic blood pressure, mmHg 74.35±0.25 74.01±0.16 74.17±0.22 74.88±0.33 74.58±0.39 0.176
Obesity (BMI≥25), % (N) 32.0 (500) 28.8 (1,028) 28.4 (566) 28.4 (260) 32.0 (221) 0.571
Central obesityb, % (N) 30.4 (475) 25.2 (898) 24.0 (477) 24.3 (222) 24.6 (170) 0.001
Chronic disease, % (N)
Hypertension 39.3 (615) 29.9 (1,067) 26.8 (534) 26.9 (246) 25.7 (177) ＜0.001
Dyslipidemia 39.3 (614) 31.2 (1,112) 30.3 (603) 30.1 (275) 30.1 (208) ＜0.001
Diabetes mellitus 12.9 (201) 8.8 (314) 7.6 (151) 6.9 (63) 8.6 (59) ＜0.001
Cerebral vascular disease 2.5 (39) 1.7 (62) 1.1 (22) 1.0 (9) 1.2 (8) 0.001
Angina pectoris 3.1 (48) 2.4 (84) 1.7 (34) 1.6 (15) 1.7 (12) 0.005
Myocardial infarction 1.3 (20) 0.5 (19) 0.6 (11) 0 (0) 0.7 (5) 0.011
Health related behavior
Smoking, % (N) 0.391
Non-smoker 89.5 (1,399) 90.2 (3,219) 89.6 (1,783) 89.5 (818) 89.3 (616)
Past smoker 4.9 (76) 5.2 (186) 5.4 (107) 5.5 (50) 6.1 (42)
Current smoker 5.6 (88) 4.6 (163) 5.0 (100) 5.0 (46) 4.6 (32)
Alcohol use, % (N) ＜0.001
Non drinking 27.1 (423) 19.2 (684) 18.0 (358) 17.2 (157) 16.7 (115)
Normal drinking 64.3 (1,005) 70.7 (2,521) 70.7 (1,407) 71.0 (649) 71.7 (495)
Problem drinking 6.8 (106) 7.9 (282) 8.7 (174) 9.0 (82) 8.7 (60)
Alcohol use disorder 1.0 (16) 1.2 (43) 1.2 (24) 2.0 (18) 1.7 (12)
Alcohol dependence 0.8 (13) 1.1 (38) 1.4 (27) 0.9 (8) 1.2 (8)
Physical activity, METs/wk 1,721.69±75.50 1,840.59±51.07 1,869.91±68.49 1,879.46±99.92 2,146.18±140.48 0.004

Abbreviations: HDL, High density lipoprotein; LDL, low density lipoprotein; BMI, body mass index; METs, metabolic equivalents; wk, week. Values are presented as mean±standard error or percent (number).

Calculated by general linear model or chi-square test.

Central obesity was defined waist circumference ≥ 85 cm in women.

Odds ratios for obesity according to daily sodium intake by logistic regression

Outcome Daily sodium intake Adjusted OR (95% CI)a Adjusted OR (95% CI)b Adjusted OR (95% CI)c
Obesity (BMI≥25 kg/m2)
Men (N＝5,969) ＜2 g (394) 1 1 1
2-4 g (1,581) 1.24 (0.96-1.59) 1.26 (0.97-1.64) 1.27 (0.97-1.67)
4-6 g (1,695) 1.45 (1.13-1.87) 1.44 (1.11-7.88) 1.40 (1.07-1.85)
6-8 g (1,091) 1.42 (1.08-1.86) 1.44 (1.08-1.91) 1.41 (1.05-1.89)
≥8 g (1,208) 1.72 (1.30-2.27) 1.67 (1.25-2.23) 1.61 (1.19-2.18)
P value for trendd 0.001 0.003 0.020
Women (N＝8725) ＜2 g (1,563) 1 1 1
2-4 g (3,568) 1.00 (0.88-1.15) 1.04 (0.90-1.20) 1.01 (0.87-1.17)
4-6 g (1,990) 1.03 (0.88-1.21) 1.07 (0.91-1.26) 1.04 (0.87-1.23)
6-8 g (914) 1.04 (0.86-1.27) 1.08 (0.87-1.32) 1.02 (0.82-1.26)
≥8 g (690) 1.26 (1.01-1.58) 1.28 (1.02-1.62) 1.21 (0.96-1.54)
P value for trendd 0.249 0.221 0.494

Abbreviations: OR, odds ratio; CI, confidence interval; BMI, body mass index.

Logistic regression for obesity with daily sodium intake after adjustment for age and daily energy intake.

Logistic regression for obesity with daily sodium intake after adjustment for age, daily energy intake, chronic disease, and social behaviors (smoking status, drinking status (AUDIT score), physical activity (METs-min/week)), economic status, and education level.

Logistic regression for obesity with daily sodium intake after adjustment for daily energy intake, chronic disease, social behaviors, economic status, education level, lipid profile (total cholesterol, triglyceride, low density lipoprotein cholesterol, high density lipoprotein cholesterol), fasting blood glucose, and blood pressure.

Tests for linear trends across categories were conducted by treating the median of each category as a continuous variable.