Sodium-Linked Heart Disease Falls in Rates but Rises in Numbers Across China, G20 and Southeast Asia

A high-sodium diet remains one of the most consequential modifiable risks for cardiovascular disease, and a new multinational analysis now shows just how unevenly its cardiac toll is distributed. Drawing on the Global Burden of Disease (GBD) 2023 database, researchers tracked two sodium-attributable conditions—high sodium diet-related hypertensive heart disease (HNaD-HHD) and high sodium diet-related ischemic heart disease (HNaD-IHD)—across China, the G20 member countries and Southeast Asian nations from 1990 to 2023. Their central finding is a paradox that public health officials cannot afford to ignore: age-standardized rates of death, disability-adjusted life years (DALYs) and years of life lost (YLLs) for both diseases generally declined over the 34-year window, yet the absolute numbers of cases kept climbing.

The divergence between relative and absolute measures is not a statistical curiosity but the arithmetic consequence of demographic change. As populations grow and age, even falling per-person rates can translate into rising totals of deaths and disability. The study’s authors, writing in Artery Research, argue that assessments of disease burden must therefore weigh both indicator types simultaneously, because relying on a single metric risks misleading prevention and control decisions. Their projections, built with autoregressive integrated moving average (ARIMA) models, suggest the twin pattern of declining or plateauing standardized rates alongside rising absolute numbers may persist for a long time.

The two diseases told strikingly different stories. HNaD-HHD showed a continuous and stable downward trend in its age-standardized rates (ASRs) across all three regions, with strong consistency across regional and gender subgroups. HNaD-IHD, by contrast, declined more slowly and unevenly, fluctuating with significant heterogeneity and punctuated by local rebounds. China emerged as the core region for HNaD-IHD risk and heterogeneity, a finding the authors link to persistently high dietary sodium intake among Chinese residents, low hypertension control rates and an accelerated aging process. Southeast Asia displayed the most gradual trends in both ASRs and absolute numbers, with the least heterogeneity among age subgroups, while the G20 countries fell between the two extremes.

Quantitatively, the gap between the diseases is stark. For HNaD-HHD, the average annual percentage changes (AAPCs) in China were −4.19 for deaths, −4.35 for DALYs and −4.50 for YLLs in both sexes combined; the corresponding G20 figures were −2.38, −2.53 and −2.61, and Southeast Asia recorded −1.52, −1.45 and −1.47. HNaD-IHD also declined, but far more gently: AAPCs for deaths were −0.88 in China, −0.94 in the G20 and −1.13 in Southeast Asia. China thus experienced the fastest improvement in hypertensive heart disease burden, followed by the G20 and Southeast Asia, yet it simultaneously carried the heaviest ischemic risk profile.

One metric broke the general pattern of improvement. Years lived with disability (YLDs) for HNaD-IHD in China rose significantly, with a both-sexes AAPC of 0.21 (95% confidence interval 0.09–0.34), while the same measure fell in Southeast Asia and the G20. YLDs of HNaD-HHD in the G20 remained essentially stable, at an AAPC of 0.02 (95% CI −0.10–0.13). The authors note that existing epidemiological interventions such as salt reduction and blood pressure control have not yet shown a mitigating effect on the disability burden in China, possibly reflecting insufficient intervention coverage and poor patient adherence. They cite evidence that 74.6% of elderly individuals exceed recommended sodium intake, and 87.8% of them believe their intake is low or appropriate—a perception gap that complicates management in the very age groups where the burden concentrates.

Age stratification reinforced that concentration. For both conditions and in all three regions, ASRs increased markedly with advancing age, with the burden predominantly borne by elderly and very elderly populations, and absolute case counts among the oldest cohorts rising more sharply in most regions. Gender differences were equally consistent: in every country and region studied, male ASRs and case numbers significantly exceeded female values, with a male-to-female ratio of roughly 1.5 to 2.0. The authors attribute this to men’s greater propensity for adverse lifestyle habits—high-salt diets, smoking and alcohol consumption—alongside the cardiovascular protective effect of estrogen in women before menopause. Yet the trajectories diverged by disease: in China, deaths from HNaD-HHD fell faster in males (male AAPC −4.60 versus female −3.77), whereas deaths from HNaD-IHD fell faster in females (female −1.35 versus male −0.73), hinting at distinct gender-specific driving mechanisms.

Decomposition analysis revealed why the two burdens moved so differently. For HNaD-HHD, epidemiological change—alterations in age-specific rates—was the dominant factor driving remission across all indicators and regions, consistent with improved risk factor control and advances in diagnosis and treatment. The increases that did occur were driven demographically: population size was the primary contributor in Southeast Asia and the G20, with aging second, while in China aging was the primary contributor and population growth secondary. For HNaD-IHD, the hierarchy inverted. Population growth was the main driver of rising burden in Southeast Asia and the G20, and the primary driver of DALYs, YLDs and YLLs in China, while aging was the main driver of deaths in China and a secondary driver elsewhere. Epidemiological change generally alleviated HNaD-IHD burden, though its contribution was markedly smaller than for HNaD-HHD—and it actually contributed positively to YLDs in China.

The methodological machinery behind these conclusions is substantial. The GBD framework defines a high-sodium diet as daily intake exceeding the World Health Organization’s recommended maximum of 2 grams of sodium, equivalent to 5 grams of salt. Exposure was estimated by converting dietary survey data into a gold-standard measure of 24-hour urinary sodium excretion using the MR-BRT model, with Spatial-Temporal Gaussian Process Regression filling measurement gaps and an Ensemble Distribution Model fitting the continuous, non-linear exposure distribution. Uncertainty intervals were derived from 1,000 Monte Carlo posterior samplings of exposure, relative risk and theoretical minimum risk levels, propagating errors through to the population attributable fraction. Trend analysis used Joinpoint regression to estimate annual and average annual percentage changes with 95% confidence intervals, and all analyses ran in R version 4.4.1 and Joinpoint version 5.1.0.0.

Looking forward, the ARIMA projections extend today’s paradox into the coming decades. Predicted ASRs for HNaD-HHD continue downward, though with notably wide 95% confidence intervals indicating poor prediction stability; for HNaD-IHD the intervals are narrower, suggesting higher certainty. Absolute numbers, however, generally rise: HNaD-HHD totals creep upward in Southeast Asia and the G20 while declining in China, whereas HNaD-IHD increases substantially exceed those of HNaD-HHD, with Chinese DALYs rising fastest among all three regions and indicators. The ASR of YLDs for HNaD-IHD shows a slight rebound trend in all three regions, underscoring disability as an emerging frontier of the sodium problem.

The study’s limitations temper these conclusions. GBD data may contain regional gaps or estimation biases, particularly for dietary sodium measurement in low-income countries; the analysis did not distinguish sodium sources such as processed foods versus salt added in home cooking; and the predictive model depends on historical trends, so future policies or technologies could shift the trajectory. Even so, the authors’ prescription is targeted rather than uniform: standardized salt-reduction legislation, food-industry standards and nationwide health education for the stable HNaD-HHD burden, leveraging China’s community-based hypertension management and family doctor contract services as adaptable models, while for HNaD-IHD—especially in aging China—integrated multi-risk interventions combining salt reduction, lipid regulation and smoking cessation, with screening and comorbidity management focused on the elderly. Southeast Asia, they suggest, can sustain its current measures while continuing to improve dietary patterns, building on policies such as Sri Lanka’s and Thailand’s sodium-reduction programs and Malaysia’s maximum salt limits for processed foods.

Subject of Research: Temporal trends, driving factors and projections of high-sodium-diet-related hypertensive and ischemic heart disease burden in China, the G20 and Southeast Asia from 1990 to 2023

Article Title: Regional Disparities in Sodium-Related Cardiac Disease Burden: A Multinational Analysis From 1990 to 2023

Article References: Zhang, M., Kang, G., Miao, H., & Dong, C. (2026). Regional Disparities in Sodium-Related Cardiac Disease Burden: A Multinational Analysis From 1990 to 2023. Artery Research, 32(1), Article 16. https://doi.org/10.1007/s44200-026-00117-y

Image Credits: AI Generated

DOI: 10.1007/s44200-026-00117-y

Keywords: high sodium diet, hypertensive heart disease, ischemic heart disease, Global Burden of Disease, age-standardized rates, disability-adjusted life years, China, G20, Southeast Asia, population aging, ARIMA forecasting, salt reduction