Background In times of seawater inundation in coastal deltas, unprotected drinking water sources, such as ponds and
shallow tube wells, take on salt water with each inundation. Daily consumption of these saline sources contributes to
overall sodium intake. Although there is evidence that a high dietary salt intake is an important risk factor for
hypertension, little is known about the eff ect of high concentrations of sodium in drinking water on population
health. In this longitudinal study, we aimed to measure the eff ect of high concentrations of sodium in drinking water
on blood pressure and to assess the reversibility of raised blood pressure when conventional drinking water sources
were replaced by low-saline water.
Methods We used a multistage sampling process to recruit participants aged 18 years or older from the salinityaffected
sub-districts of Dacope, Batiagatha, and Paikgatchha in coastal Bangladesh. Most participants consumed
drinking water from highly saline sources, such as ponds and tube-wells, while a small percentage had access to
rainwater. In March, 2013, we recorded: baseline concentrations of sodium in drinking water; participants’ blood
pressure; and personal, lifestyle, and environmental characteristics. During the study period, some study participants
gained access to low-saline drinking water alternatives that were installed for use in the dry season, when water from
ponds becomes more saline. In March, 2014, and May, 2014, we made follow-up assessments of drinking water
sodium, blood pressure, and repeated the questionnaire about personal, lifestyle, and environmental characteristics.
We used generalised linear mixed methods to model the eff ect of drinking water sodium on blood pressure and
assess reversibility of raised blood pressure when participants switched from conventional drinking water sources to
low-saline alternatives.
Findings We included data from 581 participants in analysis, of which 277 (48%) were male. Median age was 38 years
(IQR 30–49). Systolic blood pressures at baseline varied greatly with drinking water sodium: mean systolic blood
pressure in the lowest water sodium quintile was 119·4 (SD 13·7) and 138·4 mmHg (SD 25·0) (for particpants
younger than 60 years and participants 60 year and older, respectively) and in the highest sodium quintile 126·7 mm Hg
(18·0) and 147·0 mm Hg (22·3), respectively. Drinking water sodium concentrations remained, after controlling for
personal, lifestyle and environmental factors, highly associated with blood pressures. Furthermore, for a 100 mg/L
decrease in sodium concentration in drinking water, blood pressure was reduced, on average, by 0·95/0·57 mm Hg
and the odds of hypertension reduced by 16% (95% CI 8%–26%).
Interpretation Drinking water is an important contributor to daily sodium intake in salinity-affected areas and,
therefore, a risk factor for hypertension. Alternative low-sodium drinking water sources could help to prevent
hypertension-related morbidity and mortality for the large number of people living in these coastal areas. The
practicalities of supply of such alternative sources, including safeguarding the microbial quality, should be further
studied.