Unexpected associations between nocturia and salt intake and post dinner exercise: A case report

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He had a history of a salt-restrictive diet. Patient presentation : A normal-weight middle-aged male patient had at least one nocturnal void during the main sleep period for more than 5 years, which increased to 2 nocturnal voids in 2023 when he developed symptoms of diabetes mellitus. He adopted low–moderate-intensity postdinner physical exercise for self-management of diabetic symptoms in 2024, which reduced nocturnal voids from 2–1 per night, but these regular residual voids were coupled with urgency and still bothersome. Recently, he awoke at daybreak without having had any such nocturnal void and recalled that he had unusually more salty late dinner just before bedtime. He hypothesized that the association between a more salty dinner and reduced nocturnal voids prompted him to add salt to his dinner plate in six subsequent dinners, confirming the association. Thereafter, he resolved to ensure that he had optimal amounts of salt on his dinner plate to prevent or have at most one nocturnal void during the main sleep period. This resolution significantly reduced the frequency of residual nocturnal voids during the main sleep period and ended urgent voids. Conclusions : Sufficient salt intake for dinner and low–moderate-intensity postdinner physical exercise were associated with reduced nocturnal voids. Postdinner physical exercise is an affordable, feasible and largely safe option for the management of nocturia if shown to be effective in powered randomized crossover or controlled studies. Sufficient amounts of salt for dinner may be infrequent but not routinely beneficial for reducing nocturnal voids. Urology & Nephrology diabetes mellitus dietary salt lower urinary tract symptoms nocturnal enuresis nocturnal polyuria sodium chloride sleep disorders nonpharmacological treatment Background Nocturia is defined by the International Continence Society as a condition typically characterized by frequent waking during the main sleep period to discharge urine. 1 A significant proportion of adults are bothered by nocturia; for example, one-third of adults in the U.S. above the age of 30 years have at least 2 voids per night, and approximately 70% of them are bothered by it. 2 Nocturia impairs the quality of life of patients and is usually bothersome to patients when nocturnal voids occur more than twice per night, which increases the severity of sleep impairment, disturbs bed partners and increases the risk of falls and fractures in elderly patients. Impaired sleep causes daytime fatigue, poor concentration, memory impairment, and reduced productivity at work. Mortality risk is also positively correlated with the number of nocturnal voids. 3 In individuals with normal renal function, urine is concentrated at night with reduced volumes in response to the antidiuretic hormone arginine vasopressin (AVP). AVP is the primary hormone that regulates renal water retention; it is stimulated by high plasma osmolality, angiotensin II and hypovolemia to augment water retention and is inhibited by atrial natriuretic peptide, hypercalcemia and prostaglandin E2, leading to diuresis. 4 Plasma osmolality, which is largely mediated by increased sodium chloride concentrations, is the major stimulus for AVP release. 5 However, excessive salt intake is associated with nocturia. Patients with excessive salt intake were sensitized by written guidelines on implementing measures for salt intake restriction in a prospective study. A responsive group of patients successfully reduced their daily salt intake from 10 to 8 g/day, which was accompanied by improvements in nocturia, urgency, nocturnal polyuria and quality of life, whereas the remaining patients whose daily salt intake was not reduced did not experience any improvement. 6 A study on the efficacy of salt intake restriction on overactive bladder symptoms in patients with excessive salt intake revealed that a responsive group of those whose salt intake decreased from 10.4 to 7.7 g/day experienced significant decreases in their mean 24-hour voiding frequency following nutritional guidance, whereas the nonresponsive group whose mean daily salt intake increased from 9.6 to 11.5 g/day had increases in their mean 24-hour voiding frequency. 7 The Canadian Urological Association (CUA) recommended restricting evening and total daily fluids, reducing dietary salt and evening protein, and restricting caffeine and alcohol for the management of nocturia from fluid intake. CUA refers to physical activity, weight loss, dietary modifications and glycemic control for the treatment of nocturia associated with obesity and diabetes. 10 The ICS recommended lifestyle interventions such as weight loss, dietary changes, salt restriction, and protein restriction for the treatment of nocturia and specifically indicated salt, protein, and caloric restrictions for patients with renal failure. 8 However, no study has investigated whether changes in the amount of salt consumed for dinner and postdinner exercise are associated with the frequency of nocturnal voids. This study highlights the roles that having a sufficient or optimal amount of salt for dinner and maintaining glycemic control by engaging in low–moderate-intensity postdinner physical exercise may play in reducing the frequency of nocturnal voids. Clinical presentation A middle-aged male patient referred to in this report presented with a long history of having 1 or more nighttime voids after bedtime for more than 7 years. He never sought any medical attention despite being bothered by this condition. The patient was well educated and was able to collect relevant information over an extended period of years. He had a normal body mass index (BMI) of 22.7, consumed mostly minimally processed home-cooked food and did not smoke or consume alcohol. He was cautious not to add table salt to his plate even when deemed necessary since learning of the link between salt and hypertension several years back in time but was not duly sensitized to the risks of salt restriction. He had a consistent sleep schedule running from 11:00 pm to 7:00 am and a family history of type 2 diabetes mellitus. In September 2023, he developed symptoms of diabetes mellitus, which included an increase in nocturnal voids of 2 or more times per night, blurry vision, nighttime thirst, numbness or tingling of the feet and a hypoglycemic event in April 2024. These symptoms emerged following a period of 9 months of marked reduction in walking exercise. His nighttime voids after developing diabetic symptoms commonly occurred as early as 2:00 am and were characterized by urgency. He adopted dietary and lifestyle changes such as physical exercise for self-management and reversal of these symptoms, which were effective. Dietary changes included avoidance or reduced consumption of simple carbohydrates that cause postprandial glycemic excursions in favor of fiber-rich complex carbohydrates with moderate increases in postprandial blood glucose. In August 2024, he adopted postdinner low–moderate-intensity walking exercise of 10–12 minutes for controlling postprandial excursions of blood glucose, which he found to be effective in reducing nocturnal voids after bedtime from 2–1 or rarely zero. He had 1 nocturnal void regularly after bedtime since then, except when he could not conduct postdinner exercise for one month; then, his nocturnal voids rose to 2 again. The patient initially attempted to restrict fluid intake in the evening, but the outcomes of postdinner exercise were superior to the outcomes of fluid restriction and complemented the latter. Recently, he had late dinner that was unusually salty, then went to bed in less than an hour just after postdinner exercise and never had any nocturnal void during the main sleep period. He subsequently tried to determine whether making his dinner unusually more salty than before in six consecutive dinners could prevent or reduce his bothersome residual nocturnal voids that normally occurred before 5:00 am. He chose to maintain a limited intake of salt in other meals taken earlier in the day to avoid exceeding the daily consumption limit of 5 g as much as possible. He observed that this intervention consistently prevented or reduced such voids despite taking half or one glass of water to accompany his saltier dinners. In the week of the trial, he had only 2 convenience voids that occurred at approximately 5:00 am, where the primary cause of waking was not to void, whereas in the previous weeks, he awoke once every night before 5:00 am, primarily to void. He did not experience any serious adverse effects during the course of the week of the trial. However, on one night, he had a dry mouth or felt thirsty, and on one of the last nights of the week, he felt slightly more pressure on his pulse than before. Thereafter, he resolved to ensure that his dinner included only a sufficient or optimal amount of salt coupled with taking only half a glass of water or less, unlike before, when he did not attempt to replete if there was a suboptimal amount of salt in his dinner. In the third week, he had zero nocturnal voids during the main sleep period for 3 nights, which was unprecedented over several years, and only 1 nocturnal void per night for the remaining 4 nights; however, the amount of salt in 1 of the 4 dinners was suboptimal. In the fourth week, he had zero nocturnal voids during the main sleep period for 4 nights and only 1 nocturnal void per night for the remaining 3 nights. In the fifth week, he had zero nocturnal voids during the main sleep period for 6 nights and 2 nocturnal voids in one night. He no longer had any urgency that he usually experienced before voids during the main sleep period and first morning voids. However, he had recurring incidents of dry mouth that were indicative of mild dehydration and one episode of abdominal discomfort or bloating in the fifth week, which raised the need to reconsider how frequently he should have sufficiently salted dinners to prevent nocturnal voids. Dry mouth, constipation and abdominal discomfort effects, which were uncommon in the previous months, were probably linked to fluid intake restrictions following saltier dinners. Treatment with sufficient intake of salt for dinner ceased at the end of the fifth week. The follow-up period in the sixth and seventh weeks of reversion to pretreatment dinner had a record of 3 nights without nocturnal voids and 4 nights with only 1 nocturnal void during the main sleep period. Additionally, over the last 2 years, he reported that taking dinner early, i.e., more than 3 hours before bedtime, or taking only very light dinner later reduced nocturnal voids after bedtime. He found postdinner exercise to be tolerable and sustainable since it involves low–moderate-intensity exercise, such as walking or stationary marching, for only 10–12 minutes. Stationary marching involves lifting one leg after another with the feet raised nearly as high as one’s knees (400 steps); walking or stationary marching is conducted within 30 minutes after dinner. Upon observing that the latter seemed to be more effective than the former and required less space, he switched from postdinner walks to stationary marches in June 2025. The unusually more salty dinners were not tolerable for long periods of time beyond one week. However, these findings raised awareness of the necessity of having a sufficient amount of salt for dinner to reduce nocturnal voids, which should be applied only infrequently or occasionally in circumstances where bathrooms are not readily available but not routinely available, to prevent mild dehydration symptoms caused by dry mouth and constipation or bloating. Discussion and Conclusions The patient had a family history of type 2 diabetes mellitus and probably had prediabetes or impaired glucose tolerance (IGT) unknowingly for many years until he developed symptoms of diabetes mellitus in September 2023. Most individuals with prediabetes are not aware of their status. The global prevalence of IGT in 2021 was 9.1%, and it was highest in high-income countries. 9 Among the 38,093 respondents to the U.S. nationally representative survey, 26.2% had prediabetes; 46.1% of young adults (aged 20–54) in that survey, who constituted 65% of the total respondents, were found to have prediabetes. 10 The patient took a long time to find the underlying cause of his nocturnal voids, partly because he had not been screened for prediabetes, which was shown by the development of symptoms of diabetes mellitus in 2023. A systematic review revealed an association of diabetes mellitus with a 1.49-fold greater risk of nocturia, which was more common in male subjects or patients with a lower nocturia cutoff. 11 The experts’ recommendations on the use of physical exercise as an option for the management of nocturia were vague 4 , 8 or indicated increased physical activity but not too close to bedtime, for example, having afternoon walks 2 and avoidance of nighttime physical exercise. 2 , 4 However, the patient reported that 10–12 minutes of low–moderate-intensity nighttime exercise involving walking or stationary marching, conducted just after dinner, reduced the frequency of his nocturnal voids from 2 to 1. In a nationally representative study in the U.S., investigators revealed that total physical activity and leisure-time physical activity, in particular, were associated with a reduced risk of nocturia in adults. 12 Low levels of physical activity, such as step counts and moderate-vigorous activities, are associated with increased nocturia and nocturnal enuresis (NE) in older adult women with urinary incontinence. 13 An intervention study revealed that brisk walking for 30 minutes or more in the evening or night by elderly participants significantly reduced episodes of nocturia from 3.3 to 1.9 and improved sleep. However, the timing of this exercise did not specifically target the management of postprandial glycemic excursions for efficiency, and the noncompliance rate of 36% in this study was very high. 14 There are steep increases in blood glucose just after meals 15 , which induce frequent urination as a major symptom of uncontrolled diabetes mellitus in a bid to eliminate excess glucose. Various studies have demonstrated that postmeal physical exercise reduces postprandial increases in blood glucose. 16 – 20 None of these studies specifically investigated the association between postdinner physical exercise and nocturia. Nonetheless, regular postdinner walks or stationary marches, in this instance, reduced nocturnal voids in the patient on the basis of pre-post analysis, which is supported by the relevant literature cited herein. If an individual is incapable of performing postmeal walks or stationary marches to control postprandial glycemic excursions, conducting soleus push-ups or bilateral plantar flexion, sometimes called leg fidgeting, may be an option. Postmeal leg fidgeting has been shown to improve limb blood flow and postprandial glycemic control in people with an average BMI of 37.5 21 , in diverse demographic volunteers 22 , and mitigate the deleterious effects of high-fat and refined sugar diets on cerebrovascular and cardiovascular functions as opposed to prolonged sitting. 23 , 24 Leg fidgeting involves intermittent plantarflexion activity of rapidly bouncing the knees with angular movements of the ankles when comfortably seated on a chair with the toes firmly resting on the ground for at least 1 minute with breaks of 3–4 minutes. The primary dietary strategies for controlling postprandial glycemic excursions and nocturnal voids include avoiding or restricting the consumption of highly refined simple carbohydrates with high glycemic indices in favor of complex minimally processed high-fiber carbohydrates with low glycemic indices. The replacement of high-glycemic-index carbohydrates with low-glycemic-index carbohydrates improved glycemic control in diabetic patients. 25 These dietary changes involved replacing products made of white flour and potatoes with minimally refined cereal products and whole grains, and these diet changes were also associated with lower risks of cardiovascular disease 25 , insomnia 26 and menopause symptoms. 27 The management of insomnia is known to reduce nocturia 4 , 8 , and lifestyle interventions are also indicated for the management of menopause-related nocturia. 8 A group of children with primary monosymptomatic NE who took the first-line drug indicated for it and followed the recommendations to avoid or restrict the intake of foods consumed with added sugars (fruit juice, tea, carbonated drinks, chocolate, milk and yogurt) and fruits that are rich in simple sugars had a higher response rate and a lower number of relapses than controls who took only the drug. 28 The other dietary strategies are fluid intake restrictions in the evening and control of meal-sizes, that is, avoiding heavy meals closer to bedtime 4 and avoiding alcohol and caffeine in the evening. 3 , 4 Consistent with the portion control of meals, the ICS recommended calorie restriction for treating nocturia associated with fluid intake and renal disease. 8 The patient in this report reported that having only very light or no meals in the 3 hours preceding bedtime reduced the incidence of nocturia. However, fluid intake restriction in the evening or during dinner may increase the risk of mild dehydration, hyperosmality and hypertension, particularly if an individual experiences symptoms such as constipation or dry mouth at night. Ingesting food without taking adequate water increases osmotic pressure and triggers vasopressin-secreting neurons in the brain to release vasopressin, which controls renal water excretion. 29 A study of 407,187 adults revealed that healthy individuals with a serum sodium level of 140 mmol/L or higher were associated with an elevated risk of developing hypertension and heart failure, although this level is still within the normal range of 135–146 mmol/L. Investigators have cited serum vasopressin as an indicator of poor hydration and have proposed optimal fluid intake guidance for affected individuals to resolve poor hydration, as shown by elevated sodium and tonicity levels in their sera. 30 Moreover, drinking water lowers plasma vasopressin. 29 The CUA recommended reduced dietary salt intake for the management of nocturia. 4 The ICS indicates salt restrictions for the management of nocturia associated with fluid intake, renal failure and cardiovascular disease. 8 These guidelines are based on the widely held assumption that increasing salt intake increases fluid intake and urine volume in the general population. Conversely, the patient reported that he prevented or significantly reduced nocturnal voids during the main sleep periods by increasing the amount of salt intake for dinners. Consistent with this finding, a study revealed that a 6 g/d increase in salt intake increased urine sodium excretion but reduced the urine volume by 540 ml/d, which indicated increased renal water reabsorption according to the urine concentration in 10 of the 10 healthy men who were exposed to 3 salt intake levels (12, 9, or 6 g/d). The volume of water intake was 293 ml/d greater at the 6-g/d salt intake level than at the 12-g/d salt intake level. 31 The changes in the amount of salt intake in the diet of 12 healthy male volunteers from 6 g/d to 12 g/d increased their total-body sodium, extracellular water and body weight in the short term within the first week. 32 The mechanism by which saltier dinners prevent or reduce the incidence of nocturia has been explained in other studies. Arginine vasopressin (AVP) is the primary hormone that regulates renal water retention and excretion in the body. The release of AVP occurs during sleep at night to promote water retention, and its release is strongly stimulated by plasma osmolality, which is predominantly increased by the sodium chloride concentration. 4 , 5 Desmopressin, a synthetic analog of AVP, is indicated for the treatment of nocturia 8 and nocturnal polyuria 3 , 4 in adults and nocturnal enuresis in children 28 , 33 , 34 because it reduces the volume of urine produced at night. The clinical guidelines that indicated salt intake restrictions for the management of nocturia did not consider studies on the adverse effects of salt intake restrictions. A low-salt diet with a urine sodium concentration of less than 1.2 g/day for 1 week was associated with an increase in insulin resistance in 152 subjects compared with a high-salt diet with a urine sodium concentration of more than 6 g/d. 35 Urinary sodium excretion of less than 3 g/day reveals low dietary sodium intake. High levels of renin and catecholamines, which are associated with increased cardiovascular disease events, have been reported in populations with poor sodium intake. 36 However, the World Health Organization (WHO) strongly recommended a reduction to less than 2 g/day of sodium (5 g/day salt) in adults to reduce blood pressure and the risk of cardiovascular disease, stroke and coronary heart disease. 37 There is evidence that black individuals are more sensitive to changes in salt intake than white individuals are. Patients with hypertension are more sensitive to changes in salt intake than are individuals without hypertension, and older adults are more sensitive to changes in salt intake than younger adults are. The effects of salt on BP are greater in the setting of low-potassium intake and a poor-quality diet than in the setting of the Dietary Approaches to Stop Hypertension (DASH) diet. However, studies suggest that the BPs of women might be more salt sensitive than those of men are less consistent. 38 Potassium is an essential nutrient and electrolyte that increases water retention in the bloodstream, lowers BP by countering the negative effects of elevated sodium intake on BP, and it is largely found in minimally processed or whole foods such as fruits and vegetables. Examples of foods that contain potassium include beans, peas, nuts, green vegetables (spinach, cabbage, parsley), fruits (bananas, papayas, dates), other vegetables (tomatoes, cucumbers, pumpkins) and root vegetables (carrots, onions, beetroots). 39 Limiting daily salt intake within the recommended limit of less than 5 g should be paired with increasing potassium intake to maintain the blood plasma volume. Although the ICS recommends salt restriction for the management of nocturia in heart failure (HF) patients 8 , recent data contradict the beneficial role of salt and fluid restrictions in HF. Hence, the European Society of Cardiology recommended limiting salt intake to no more than 5 g/day in patients with HF and considering a fluid intake restriction of 1.5–2 L/day in selected HF patients. 40 Patients should be informed of safe options available to strike a balance between a long life that is devoid of hypertension and a dignified and happy life that is largely free from nocturia or incontinence. This balance may be attained by limiting the number of meals constituting salt to only 2 meals per day, including dinner, such that other meals or snacks may be flavored with only spices. It is important to have dinner consisting of salt to improve water retention during sleep, prevent dehydration in elderly individuals and improve the quality of sleep. However, if dinner is made more salty purposely to improve water retention during sleep, it should be matched with the intake of adequate water or fluids and antioxidant-rich foods to mitigate the adverse effects of salty meals. Impaired vasodilatation of the small vessels was shown to occur under conditions of high salt intake in healthy adults, which was improved by the intake of the antioxidant ascorbic acid or by acute exercise. 36 The other drawback of saltier meals is increased risks for abdominal discomfort or bloating 41 , which may worsen premenstrual symptoms in some female individuals. A high-salt diet was found to be associated with a decreased population of Lactobacillus spp., a microbe that was shown to be beneficial for gastrointestinal health 41 , which underscores the need to avoid indulgence in high-salt diets. The patient developed gastrointestinal side effects in the fifth week, namely, dry mouth, abdominal discomfort, bloating and constipation. Similarly, dry mouth and constipation have been documented as side effects of desmopressin in the treatment of children with NE. 42 The findings of this study have clinical applications that may improve the clinical management of nocturia and NE considering the reduced risk of these conditions associated with physical exercise. 13 Additionally, I have unpublished reports on an 8–10-year-old child with monosymptomatic NE who had only 1 episode of NE in 6 weeks following adherence to guidance on sufficient salt intake for dinner as opposed to a baseline of 2–3 episodes of NE per week. The changes in the amount of salt consumed for dinner and/or the timing of dinner may be confounding factors that were overlooked in previous studies that evaluated the efficacy and safety of desmopressin for the treatment of nocturia and NE, which may be considered when designing future studies and in clinical practice. This study has several strengths. First, this is the first study to investigate the associations between nocturia and the amount of salt consumed for dinner and postdinner exercise. Second, it reflects observations made in a real-world setting, which is suitable for studying the dietary and lifestyle exposures of patients. Third, an association between postdinner exercise and nocturia was observed over an extended period of one year. Finally, the patient was well educated, health literate and a knowledgeable source of reliable data. However, this study had several limitations. First, this was a retrospective study, and data were obtained from self-reports by patients who identified factors associated with nocturia. Second, a bladder diary was not maintained by the patient as needed for the diagnosis of nocturia. 1 Third, the patient was diagnosed on the basis of a family history and symptoms of diabetes mellitus instead of requesting a blood test for hemoglobin A1C. Fourth, the follow-up period for the association of the amount of salt intake with nocturia after treatment ceased in the fifth week was limited to one fortnight. Fifth, this study lacked urine and blood analyses of electrolytes and renal function biomarkers such as uric acid, blood urea nitrogen and creatinine. Sixth, the amount of salt intake for dinner and per day were not precisely measured apart from estimations using a teaspoon. Most of these weaknesses were caused by factors beyond our control, such as a lack of funding for hiring other experts and a functional research laboratory. Conclusions Sufficient amounts of salt intake for dinner and low-moderate-intensity physical exercise were associated with reduced nocturnal voids. Postdinner exercise is an affordable, feasible and largely safe option for the management of nocturia and nocturnal enuresis if shown to be effective in powered randomized crossover or controlled studies. Prospective studies are needed to evaluate the effects of different forms of low–moderate-intensity exercise postdinner exercise on the frequency of nocturnal voids. Adults may occasionally consume salty dinners to reduce nocturnal voids when sleeping away from home where bathrooms are not readily accessible or to prevent nocturnal enuresis during such visits. The changes in the amount of salt consumed for dinner may be considered a confounding factor when assessing the effectiveness and side effects of drugs such as desmopressin in the treatment of nocturia or NE. Clinical guidelines may be improved to include screening for prediabetes and type 2 diabetes mellitus concurrently for precise identification of conditions associated with nocturia. Abbreviations AVP, arginine vasopressin; BMI, body mass index; BP, blood pressure; CUA, Canadian Urological Association; HF, heart failure; ICS, International Continence Society; IGT, impaired glucose tolerance; LUTS, lower urinary tract symptoms; NE, nocturnal enuresis; WHO, World Health Organization. Declarations Funding The author was not awarded any grants or funding for this project. Data availability No datasets were generated or analyzed during the current study. Consent to participate and ethics approval Consent to participate in this study was obtained from the patients via written informed consent. This study was conducted retrospectively and ethically in the best interest of patients with nocturia, although ethical approval could not be obtained because of the lack of a research ethics committee for our startup organization, which has not yet been funded. A waiver was needed in light of the retrospective nature of this study. Consent for publication Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/relative of the patient. A copy of the consent form is available for review by the Editor of this journal. Supplementary material The CARE checklist has been added as needed for a case report in the form of an additional file (CHECK_LIST.docx). Competing interests This case study has nonfinancial competing interests related to personal relationships with the patient. Clinical trial number: not applicable. Acknowledgment I am profoundly grateful to all the family members, especially my parents, Mr. Piston Eporu and Mrs. Grace Eporu, for the generous support they have always extended to me for my scholarly projects. References Hashim H, Blanker MH, Drake MJ, et al. International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function. 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Pflugers Arch. 2020 Feb;472(2):271-280. doi: 10.1007/s00424-019-02300-4. Epub 2019 Aug 8. PMID: 31396757; PMCID: PMC7035221. Babir FJ, Riddell MC, Adamo LM, Richards DL, Gibala MJ. The effect of bodyweight exercise on 24-h glycemic responses determined by continuous glucose monitoring in healthy inactive adults: a randomized crossover study. Sci Rep. 2023 Nov 28;13(1):20884. doi: 10.1038/s41598-023-48063-y. PMID: 38017140; PMCID: PMC10684602. Pettit-Mee RJ, Ready ST, Padilla J, Kanaley JA. Leg Fidgeting During Prolonged Sitting Improves Postprandial Glycemic Control in People with Obesity. Obesity (Silver Spring). 2021;29(7):1146-1154. doi:10.1002/oby.23173. Hamilton MT, Hamilton DG, Zderic TW. A potent physiological method to magnify and sustain soleus oxidative metabolism improves glucose and lipid regulation. iScience. 2022;25(9):104869. Published 2022 Aug 5. doi:10.1016/j.isci.2022.104869. Fryer S, Paterson C, Turner L, et al. Localized activity attenuates the combined impact of a high fat meal and prolonged sitting on arterial stiffness: A randomized, controlled crossover trial. Front Physiol. 2023;14:1107456. Published 2023 Feb 1. doi:10.3389/fphys.2023.1107456. Fryer S, Paterson C, Stoner L, et al. Leg Fidgeting Improves Executive Function following Prolonged Sitting with a Typical Western Meal: A Randomized, Controlled Cross-Over Trial. Int J Environ Res Public Health. 2022;19(3):1357. Published 2022 Jan 26. doi:10.3390/ijerph19031357. Willett W, Manson J, Liu S. Glycemic index, glycemic load, and risk of type 2 diabetes. Am J Clin Nutr. 2002;76(1):274S-80S. doi:10.1093/ajcn/76/1.274S. Gangwisch JE, Hale L, St-Onge MP, et al. High glycemic index and glycemic load diets as risk factors for insomnia: analyses from the Women's Health Initiative. Am J Clin Nutr. 2020;111(2):429-439. doi:10.1093/ajcn/nqz275. Elibol E, Eski S, Gez E, Çamdeviren G. The impact of carbohydrate quality index on menopausal symptoms and quality of life in postmenopausal women. BMC Womens Health. 2025;25(1):262. Published 2025 May 28. doi:10.1186/s12905-025-03822-z. Ferrara P, Del Volgo V, Romano V, Scarpelli V, De Gara L, Miggiano GA. Combined Dietary Recommendations, Desmopressin, and Behavioral Interventions May Be Effective First-Line Treatment in Resolution of Enuresis. Urol J. 2015;12(4):2228-2232. Published 2015 Sep 4. Mandelblat-Cerf Y, Kim A, Burgess CR, et al. Bidirectional Anticipation of Future Osmotic Challenges by Vasopressin Neurons. Neuron. 2017;93(1):57-65. doi:10.1016/j.neuron.2016.11.021. Rabinowitz J, Darawshi M, Burak N, Boehm M, Dmitrieva NI. Risk for hypertension and heart failure linked to high normal serum sodium and tonicity in general healthcare electronic medical records. Eur J Prev Cardiol. Published online April 11, 2025. doi:10.1093/eurjpc/zwaf232. Peng AW, Juraschek SP, Appel LJ, Miller ER 3rd, Mueller NT. Effects of the DASH Diet and Sodium Intake on Bloating: Results From the DASH-Sodium Trial. Am J Gastroenterol. 2019;114(7):1109-1115. doi:10.14309/ajg.0000000000000283 Rakova N, Jüttner K, Dahlmann A, et al. Long-term space flight simulation reveals infradian rhythmicity in human Na(+) balance. Cell Metab. 2013;17(1):125-131. doi:10.1016/j.cmet.2012.11.013. Sun M, Li S, Sun X, Deng Z, Xu Y. Association between winter season and desmopressin treatment efficiency in children with monosymptomatic nocturnal enuresis: a pilot study. Int Braz J Urol. 2022;48(2):275-281. doi:10.1590/S1677-5538.IBJU.2021.0236. Ferrara P, Cammisa I, Zona M, Gatto A, Sacco R, Verrotti Di Pianella AV. Traditional and innovative interventions in the management of Enuresis. Cent European J Urol. 2024; 77: 42-57. Garg R, Williams GH, Hurwitz S, Brown NJ, Hopkins PN, Adler GK. Low-salt diet increases insulin resistance in healthy subjects. Metabolism. 2011;60(7):965-968. doi:10.1016/j.metabol.2010.09.005. Grillo A, Salvi L, Coruzzi P, Salvi P, Parati G. Sodium Intake and Hypertension. Nutrients. 2019;11(9):1970. Published 2019 Aug 21. doi:10.3390/nu11091970. WHO. Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), 2012. Elijovich F, Weinberger MH, Anderson CA, et al. Salt Sensitivity of Blood Pressure: A Scientific Statement From the American Heart Association. Hypertension. 2016;68(3):e7-e46. doi:10.1161/HYP.0000000000000047. WHO. Guideline: Potassium intake for adults and children. Geneva, World Health Organization (WHO), 2012. Mullens W, Damman K, Dhont S, et al. Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Eur J Heart Fail. 2024;26(4):730-741. doi:10.1002/ejhf.3244. Peng AW, Juraschek SP, Appel LJ, Miller ER 3rd, Mueller NT. Effects of the DASH Diet and Sodium Intake on Bloating: Results From the DASH-Sodium Trial. Am J Gastroenterol. 2019;114(7):1109-1115. doi:10.14309/ajg.0000000000000283. Paola Nigri, Luigi Nigri, Lucia Peccarisi, Overview on the management of nocturnal enuresis in children in general pediatrics, Global Pediatrics, Volume 9, 2024, 100207, ISSN 2667-0097, https://doi.org/10.1016/j.gpeds.2024.100207. Additional Declarations The authors declare potential competing interests as follows: This case study has nonfinancial competing interests related to personal relationships with the patient. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7549533","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":519817994,"identity":"f2fd1de1-ed8e-4826-85eb-41f251060992","order_by":0,"name":"Ronald Eporu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYNCCAhCR2PAhgcEGyGBsPEBYi4EBSEvjjASGNJCWBmK1JDDOYGA4DObj1cLf3nv4M4/Bn2h+9uTGhgc15+3Wth8G2lJjE41Li8SZc2nSPAYGuTN7HjY2JBy7nbztTCJQy7G03AZcTpLIMWMGadlwI7H9QWLD7WSzA0AtjA2H8Wkx/gzSsv9GYmNDYsO5ZLPzDwlqMQA7bIMEWMsBO7MbBGyROHPGTHKOgXHujDNgvyQnmN0A2pKAxy/87T3GH95UyOX2t6c/bPxRY2dvdj794YMPNTY4tWCARLDKBGKVg4A9KYpHwSgYBaNgZAAAR1BnhBmqfNMAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0008-5498-0426","institution":"Medificwise-SMC Limited","correspondingAuthor":true,"prefix":"","firstName":"Ronald","middleName":"","lastName":"Eporu","suffix":""}],"badges":[],"createdAt":"2025-09-06 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09:54:18","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104303,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7549533/v1/3c2c0ca5e8acc4bf06c64170.html"},{"id":92247918,"identity":"395510f7-6e3e-4816-b801-e46c597e483f","added_by":"auto","created_at":"2025-09-26 10:02:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":414700,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7549533/v1/1f15eb83-47f4-4cd6-b79c-82c191b8f535.pdf"}],"financialInterests":"The authors declare potential competing interests as follows: This case study has nonfinancial competing interests related to personal relationships with the patient.","formattedTitle":"\u003cp\u003eUnexpected associations between nocturia and salt intake and post dinner exercise: A case report\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eNocturia is defined by the International Continence Society as a condition typically characterized by frequent waking during the main sleep period to discharge urine.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e A significant proportion of adults are bothered by nocturia; for example, one-third of adults in the U.S. above the age of 30 years have at least 2 voids per night, and approximately 70% of them are bothered by it.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eNocturia impairs the quality of life of patients and is usually bothersome to patients when nocturnal voids occur more than twice per night, which increases the severity of sleep impairment, disturbs bed partners and increases the risk of falls and fractures in elderly patients. Impaired sleep causes daytime fatigue, poor concentration, memory impairment, and reduced productivity at work. Mortality risk is also positively correlated with the number of nocturnal voids.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn individuals with normal renal function, urine is concentrated at night with reduced volumes in response to the antidiuretic hormone arginine vasopressin (AVP). AVP is the primary hormone that regulates renal water retention; it is stimulated by high plasma osmolality, angiotensin II and hypovolemia to augment water retention and is inhibited by atrial natriuretic peptide, hypercalcemia and prostaglandin E2, leading to diuresis.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Plasma osmolality, which is largely mediated by increased sodium chloride concentrations, is the major stimulus for AVP release.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHowever, excessive salt intake is associated with nocturia. Patients with excessive salt intake were sensitized by written guidelines on implementing measures for salt intake restriction in a prospective study. A responsive group of patients successfully reduced their daily salt intake from 10 to 8 g/day, which was accompanied by improvements in nocturia, urgency, nocturnal polyuria and quality of life, whereas the remaining patients whose daily salt intake was not reduced did not experience any improvement.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e A study on the efficacy of salt intake restriction on overactive bladder symptoms in patients with excessive salt intake revealed that a responsive group of those whose salt intake decreased from 10.4 to 7.7 g/day experienced significant decreases in their mean 24-hour voiding frequency following nutritional guidance, whereas the nonresponsive group whose mean daily salt intake increased from 9.6 to 11.5 g/day had increases in their mean 24-hour voiding frequency.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe Canadian Urological Association (CUA) recommended restricting evening and total daily fluids, reducing dietary salt and evening protein, and restricting caffeine and alcohol for the management of nocturia from fluid intake. CUA refers to physical activity, weight loss, dietary modifications and glycemic control for the treatment of nocturia associated with obesity and diabetes.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e The ICS recommended lifestyle interventions such as weight loss, dietary changes, salt restriction, and protein restriction for the treatment of nocturia and specifically indicated salt, protein, and caloric restrictions for patients with renal failure.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHowever, no study has investigated whether changes in the amount of salt consumed for dinner and postdinner exercise are associated with the frequency of nocturnal voids. This study highlights the roles that having a sufficient or optimal amount of salt for dinner and maintaining glycemic control by engaging in low\u0026ndash;moderate-intensity postdinner physical exercise may play in reducing the frequency of nocturnal voids.\u003c/p\u003e"},{"header":"Clinical presentation","content":"\u003cp\u003eA middle-aged male patient referred to in this report presented with a long history of having 1 or more nighttime voids after bedtime for more than 7 years. He never sought any medical attention despite being bothered by this condition. The patient was well educated and was able to collect relevant information over an extended period of years. He had a normal body mass index (BMI) of 22.7, consumed mostly minimally processed home-cooked food and did not smoke or consume alcohol. He was cautious not to add table salt to his plate even when deemed necessary since learning of the link between salt and hypertension several years back in time but was not duly sensitized to the risks of salt restriction. He had a consistent sleep schedule running from 11:00 pm to 7:00 am and a family history of type 2 diabetes mellitus. In September 2023, he developed symptoms of diabetes mellitus, which included an increase in nocturnal voids of 2 or more times per night, blurry vision, nighttime thirst, numbness or tingling of the feet and a hypoglycemic event in April 2024. These symptoms emerged following a period of 9 months of marked reduction in walking exercise. His nighttime voids after developing diabetic symptoms commonly occurred as early as 2:00 am and were characterized by urgency.\u003c/p\u003e\u003cp\u003eHe adopted dietary and lifestyle changes such as physical exercise for self-management and reversal of these symptoms, which were effective. Dietary changes included avoidance or reduced consumption of simple carbohydrates that cause postprandial glycemic excursions in favor of fiber-rich complex carbohydrates with moderate increases in postprandial blood glucose. In August 2024, he adopted postdinner low–moderate-intensity walking exercise of 10–12 minutes for controlling postprandial excursions of blood glucose, which he found to be effective in reducing nocturnal voids after bedtime from 2–1 or rarely zero. He had 1 nocturnal void regularly after bedtime since then, except when he could not conduct postdinner exercise for one month; then, his nocturnal voids rose to 2 again. The patient initially attempted to restrict fluid intake in the evening, but the outcomes of postdinner exercise were superior to the outcomes of fluid restriction and complemented the latter.\u003c/p\u003e\u003cp\u003eRecently, he had late dinner that was unusually salty, then went to bed in less than an hour just after postdinner exercise and never had any nocturnal void during the main sleep period. He subsequently tried to determine whether making his dinner unusually more salty than before in six consecutive dinners could prevent or reduce his bothersome residual nocturnal voids that normally occurred before 5:00 am. He chose to maintain a limited intake of salt in other meals taken earlier in the day to avoid exceeding the daily consumption limit of 5 g as much as possible. He observed that this intervention consistently prevented or reduced such voids despite taking half or one glass of water to accompany his saltier dinners. In the week of the trial, he had only 2 convenience voids that occurred at approximately 5:00 am, where the primary cause of waking was not to void, whereas in the previous weeks, he awoke once every night before 5:00 am, primarily to void. He did not experience any serious adverse effects during the course of the week of the trial. However, on one night, he had a dry mouth or felt thirsty, and on one of the last nights of the week, he felt slightly more pressure on his pulse than before.\u003c/p\u003e\u003cp\u003eThereafter, he resolved to ensure that his dinner included only a sufficient or optimal amount of salt coupled with taking only half a glass of water or less, unlike before, when he did not attempt to replete if there was a suboptimal amount of salt in his dinner. In the third week, he had zero nocturnal voids during the main sleep period for 3 nights, which was unprecedented over several years, and only 1 nocturnal void per night for the remaining 4 nights; however, the amount of salt in 1 of the 4 dinners was suboptimal. In the fourth week, he had zero nocturnal voids during the main sleep period for 4 nights and only 1 nocturnal void per night for the remaining 3 nights. In the fifth week, he had zero nocturnal voids during the main sleep period for 6 nights and 2 nocturnal voids in one night. He no longer had any urgency that he usually experienced before voids during the main sleep period and first morning voids. However, he had recurring incidents of dry mouth that were indicative of mild dehydration and one episode of abdominal discomfort or bloating in the fifth week, which raised the need to reconsider how frequently he should have sufficiently salted dinners to prevent nocturnal voids. Dry mouth, constipation and abdominal discomfort effects, which were uncommon in the previous months, were probably linked to fluid intake restrictions following saltier dinners. Treatment with sufficient intake of salt for dinner ceased at the end of the fifth week. The follow-up period in the sixth and seventh weeks of reversion to pretreatment dinner had a record of 3 nights without nocturnal voids and 4 nights with only 1 nocturnal void during the main sleep period.\u003c/p\u003e\u003cp\u003eAdditionally, over the last 2 years, he reported that taking dinner early, i.e., more than 3 hours before bedtime, or taking only very light dinner later reduced nocturnal voids after bedtime.\u003c/p\u003e\u003cp\u003eHe found postdinner exercise to be tolerable and sustainable since it involves low–moderate-intensity exercise, such as walking or stationary marching, for only 10–12 minutes. Stationary marching involves lifting one leg after another with the feet raised nearly as high as one’s knees (400 steps); walking or stationary marching is conducted within 30 minutes after dinner. Upon observing that the latter seemed to be more effective than the former and required less space, he switched from postdinner walks to stationary marches in June 2025.\u003c/p\u003e\u003cp\u003eThe unusually more salty dinners were not tolerable for long periods of time beyond one week. However, these findings raised awareness of the necessity of having a sufficient amount of salt for dinner to reduce nocturnal voids, which should be applied only infrequently or occasionally in circumstances where bathrooms are not readily available but not routinely available, to prevent mild dehydration symptoms caused by dry mouth and constipation or bloating.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThe patient had a family history of type 2 diabetes mellitus and probably had prediabetes or impaired glucose tolerance (IGT) unknowingly for many years until he developed symptoms of diabetes mellitus in September 2023. Most individuals with prediabetes are not aware of their status. The global prevalence of IGT in 2021 was 9.1%, and it was highest in high-income countries.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Among the 38,093 respondents to the U.S. nationally representative survey, 26.2% had prediabetes; 46.1% of young adults (aged 20–54) in that survey, who constituted 65% of the total respondents, were found to have prediabetes.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e The patient took a long time to find the underlying cause of his nocturnal voids, partly because he had not been screened for prediabetes, which was shown by the development of symptoms of diabetes mellitus in 2023. A systematic review revealed an association of diabetes mellitus with a 1.49-fold greater risk of nocturia, which was more common in male subjects or patients with a lower nocturia cutoff.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe experts’ recommendations on the use of physical exercise as an option for the management of nocturia were vague\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e or indicated increased physical activity but not too close to bedtime, for example, having afternoon walks\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and avoidance of nighttime physical exercise.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, the patient reported that 10–12 minutes of low–moderate-intensity nighttime exercise involving walking or stationary marching, conducted just after dinner, reduced the frequency of his nocturnal voids from 2 to 1. In a nationally representative study in the U.S., investigators revealed that total physical activity and leisure-time physical activity, in particular, were associated with a reduced risk of nocturia in adults.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Low levels of physical activity, such as step counts and moderate-vigorous activities, are associated with increased nocturia and nocturnal enuresis (NE) in older adult women with urinary incontinence.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e An intervention study revealed that brisk walking for 30 minutes or more in the evening or night by elderly participants significantly reduced episodes of nocturia from 3.3 to 1.9 and improved sleep. However, the timing of this exercise did not specifically target the management of postprandial glycemic excursions for efficiency, and the noncompliance rate of 36% in this study was very high.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThere are steep increases in blood glucose just after meals\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, which induce frequent urination as a major symptom of uncontrolled diabetes mellitus in a bid to eliminate excess glucose. Various studies have demonstrated that postmeal physical exercise reduces postprandial increases in blood glucose.\u003csup\u003e\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e None of these studies specifically investigated the association between postdinner physical exercise and nocturia. Nonetheless, regular postdinner walks or stationary marches, in this instance, reduced nocturnal voids in the patient on the basis of pre-post analysis, which is supported by the relevant literature cited herein.\u003c/p\u003e\u003cp\u003eIf an individual is incapable of performing postmeal walks or stationary marches to control postprandial glycemic excursions, conducting soleus push-ups or bilateral plantar flexion, sometimes called leg fidgeting, may be an option. Postmeal leg fidgeting has been shown to improve limb blood flow and postprandial glycemic control in people with an average BMI of 37.5\u003csup\u003e21\u003c/sup\u003e, in diverse demographic volunteers\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, and mitigate the deleterious effects of high-fat and refined sugar diets on cerebrovascular and cardiovascular functions as opposed to prolonged sitting.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Leg fidgeting involves intermittent plantarflexion activity of rapidly bouncing the knees with angular movements of the ankles when comfortably seated on a chair with the toes firmly resting on the ground for at least 1 minute with breaks of 3–4 minutes.\u003c/p\u003e\u003cp\u003eThe primary dietary strategies for controlling postprandial glycemic excursions and nocturnal voids include avoiding or restricting the consumption of highly refined simple carbohydrates with high glycemic indices in favor of complex minimally processed high-fiber carbohydrates with low glycemic indices. The replacement of high-glycemic-index carbohydrates with low-glycemic-index carbohydrates improved glycemic control in diabetic patients.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e These dietary changes involved replacing products made of white flour and potatoes with minimally refined cereal products and whole grains, and these diet changes were also associated with lower risks of cardiovascular disease\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, insomnia\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e and menopause symptoms.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e The management of insomnia is known to reduce nocturia\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003c/sup\u003e and lifestyle interventions are also indicated for the management of menopause-related nocturia.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e A group of children with primary monosymptomatic NE who took the first-line drug indicated for it and followed the recommendations to avoid or restrict the intake of foods consumed with added sugars (fruit juice, tea, carbonated drinks, chocolate, milk and yogurt) and fruits that are rich in simple sugars had a higher response rate and a lower number of relapses than controls who took only the drug.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe other dietary strategies are fluid intake restrictions in the evening and control of meal-sizes, that is, avoiding heavy meals closer to bedtime\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e and avoiding alcohol and caffeine in the evening.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Consistent with the portion control of meals, the ICS recommended calorie restriction for treating nocturia associated with fluid intake and renal disease.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The patient in this report reported that having only very light or no meals in the 3 hours preceding bedtime reduced the incidence of nocturia. However, fluid intake restriction in the evening or during dinner may increase the risk of mild dehydration, hyperosmality and hypertension, particularly if an individual experiences symptoms such as constipation or dry mouth at night. Ingesting food without taking adequate water increases osmotic pressure and triggers vasopressin-secreting neurons in the brain to release vasopressin, which controls renal water excretion.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e A study of 407,187 adults revealed that healthy individuals with a serum sodium level of 140 mmol/L or higher were associated with an elevated risk of developing hypertension and heart failure, although this level is still within the normal range of 135–146 mmol/L. Investigators have cited serum vasopressin as an indicator of poor hydration and have proposed optimal fluid intake guidance for affected individuals to resolve poor hydration, as shown by elevated sodium and tonicity levels in their sera.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Moreover, drinking water lowers plasma vasopressin.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe CUA recommended reduced dietary salt intake for the management of nocturia.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The ICS indicates salt restrictions for the management of nocturia associated with fluid intake, renal failure and cardiovascular disease.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e These guidelines are based on the widely held assumption that increasing salt intake increases fluid intake and urine volume in the general population. Conversely, the patient reported that he prevented or significantly reduced nocturnal voids during the main sleep periods by increasing the amount of salt intake for dinners. Consistent with this finding, a study revealed that a 6 g/d increase in salt intake increased urine sodium excretion but reduced the urine volume by 540 ml/d, which indicated increased renal water reabsorption according to the urine concentration in 10 of the 10 healthy men who were exposed to 3 salt intake levels (12, 9, or 6 g/d). The volume of water intake was 293 ml/d greater at the 6-g/d salt intake level than at the 12-g/d salt intake level.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e The changes in the amount of salt intake in the diet of 12 healthy male volunteers from 6 g/d to 12 g/d increased their total-body sodium, extracellular water and body weight in the short term within the first week.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe mechanism by which saltier dinners prevent or reduce the incidence of nocturia has been explained in other studies. Arginine vasopressin (AVP) is the primary hormone that regulates renal water retention and excretion in the body. The release of AVP occurs during sleep at night to promote water retention, and its release is strongly stimulated by plasma osmolality, which is predominantly increased by the sodium chloride concentration.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Desmopressin, a synthetic analog of AVP, is indicated for the treatment of nocturia\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and nocturnal polyuria\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e in adults and nocturnal enuresis in children\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e because it reduces the volume of urine produced at night.\u003c/p\u003e\u003cp\u003eThe clinical guidelines that indicated salt intake restrictions for the management of nocturia did not consider studies on the adverse effects of salt intake restrictions. A low-salt diet with a urine sodium concentration of less than 1.2 g/day for 1 week was associated with an increase in insulin resistance in 152 subjects compared with a high-salt diet with a urine sodium concentration of more than 6 g/d.\u003csup\u003e35\u003c/sup\u003e Urinary sodium excretion of less than 3 g/day reveals low dietary sodium intake. High levels of renin and catecholamines, which are associated with increased cardiovascular disease events, have been reported in populations with poor sodium intake.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHowever, the World Health Organization (WHO) strongly recommended a reduction to less than 2 g/day of sodium (5 g/day salt) in adults to reduce blood pressure and the risk of cardiovascular disease, stroke and coronary heart disease.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e There is evidence that black individuals are more sensitive to changes in salt intake than white individuals are. Patients with hypertension are more sensitive to changes in salt intake than are individuals without hypertension, and older adults are more sensitive to changes in salt intake than younger adults are. The effects of salt on BP are greater in the setting of low-potassium intake and a poor-quality diet than in the setting of the Dietary Approaches to Stop Hypertension (DASH) diet. However, studies suggest that the BPs of women might be more salt sensitive than those of men are less consistent.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Potassium is an essential nutrient and electrolyte that increases water retention in the bloodstream, lowers BP by countering the negative effects of elevated sodium intake on BP, and it is largely found in minimally processed or whole foods such as fruits and vegetables. Examples of foods that contain potassium include beans, peas, nuts, green vegetables (spinach, cabbage, parsley), fruits (bananas, papayas, dates), other vegetables (tomatoes, cucumbers, pumpkins) and root vegetables (carrots, onions, beetroots).\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Limiting daily salt intake within the recommended limit of less than 5 g should be paired with increasing potassium intake to maintain the blood plasma volume.\u003c/p\u003e\u003cp\u003eAlthough the ICS recommends salt restriction for the management of nocturia in heart failure (HF) patients\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, recent data contradict the beneficial role of salt and fluid restrictions in HF. Hence, the European Society of Cardiology recommended limiting salt intake to no more than 5 g/day in patients with HF and considering a fluid intake restriction of 1.5–2 L/day in selected HF patients.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePatients should be informed of safe options available to strike a balance between a long life that is devoid of hypertension and a dignified and happy life that is largely free from nocturia or incontinence. This balance may be attained by limiting the number of meals constituting salt to only 2 meals per day, including dinner, such that other meals or snacks may be flavored with only spices. It is important to have dinner consisting of salt to improve water retention during sleep, prevent dehydration in elderly individuals and improve the quality of sleep.\u003c/p\u003e\u003cp\u003eHowever, if dinner is made more salty purposely to improve water retention during sleep, it should be matched with the intake of adequate water or fluids and antioxidant-rich foods to mitigate the adverse effects of salty meals. Impaired vasodilatation of the small vessels was shown to occur under conditions of high salt intake in healthy adults, which was improved by the intake of the antioxidant ascorbic acid or by acute exercise.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e The other drawback of saltier meals is increased risks for abdominal discomfort or bloating\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e, which may worsen premenstrual symptoms in some female individuals. A high-salt diet was found to be associated with a decreased population of \u003cem\u003eLactobacillus\u003c/em\u003e spp., a microbe that was shown to be beneficial for gastrointestinal health\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e, which underscores the need to avoid indulgence in high-salt diets. The patient developed gastrointestinal side effects in the fifth week, namely, dry mouth, abdominal discomfort, bloating and constipation. Similarly, dry mouth and constipation have been documented as side effects of desmopressin in the treatment of children with NE.\u003csup\u003e42\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe findings of this study have clinical applications that may improve the clinical management of nocturia and NE considering the reduced risk of these conditions associated with physical exercise.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Additionally, I have unpublished reports on an 8–10-year-old child with monosymptomatic NE who had only 1 episode of NE in 6 weeks following adherence to guidance on sufficient salt intake for dinner as opposed to a baseline of 2–3 episodes of NE per week.\u003c/p\u003e\u003cp\u003eThe changes in the amount of salt consumed for dinner and/or the timing of dinner may be confounding factors that were overlooked in previous studies that evaluated the efficacy and safety of desmopressin for the treatment of nocturia and NE, which may be considered when designing future studies and in clinical practice.\u003c/p\u003e\u003cp\u003eThis study has several strengths. First, this is the first study to investigate the associations between nocturia and the amount of salt consumed for dinner and postdinner exercise. Second, it reflects observations made in a real-world setting, which is suitable for studying the dietary and lifestyle exposures of patients. Third, an association between postdinner exercise and nocturia was observed over an extended period of one year. Finally, the patient was well educated, health literate and a knowledgeable source of reliable data. However, this study had several limitations. First, this was a retrospective study, and data were obtained from self-reports by patients who identified factors associated with nocturia. Second, a bladder diary was not maintained by the patient as needed for the diagnosis of nocturia.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Third, the patient was diagnosed on the basis of a family history and symptoms of diabetes mellitus instead of requesting a blood test for hemoglobin A1C. Fourth, the follow-up period for the association of the amount of salt intake with nocturia after treatment ceased in the fifth week was limited to one fortnight. Fifth, this study lacked urine and blood analyses of electrolytes and renal function biomarkers such as uric acid, blood urea nitrogen and creatinine. Sixth, the amount of salt intake for dinner and per day were not precisely measured apart from estimations using a teaspoon. Most of these weaknesses were caused by factors beyond our control, such as a lack of funding for hiring other experts and a functional research laboratory.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eSufficient amounts of salt intake for dinner and low-moderate-intensity physical exercise were associated with reduced nocturnal voids. Postdinner exercise is an affordable, feasible and largely safe option for the management of nocturia and nocturnal enuresis if shown to be effective in powered randomized crossover or controlled studies. Prospective studies are needed to evaluate the effects of different forms of low–moderate-intensity exercise postdinner exercise on the frequency of nocturnal voids. Adults may occasionally consume salty dinners to reduce nocturnal voids when sleeping away from home where bathrooms are not readily accessible or to prevent nocturnal enuresis during such visits. The changes in the amount of salt consumed for dinner may be considered a confounding factor when assessing the effectiveness and side effects of drugs such as desmopressin in the treatment of nocturia or NE. Clinical guidelines may be improved to include screening for prediabetes and type 2 diabetes mellitus concurrently for precise identification of conditions associated with nocturia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAVP, arginine vasopressin; BMI, body mass index; BP, blood pressure; CUA, Canadian Urological Association; HF, heart failure; ICS, International Continence Society; IGT, impaired glucose tolerance; LUTS, lower urinary tract symptoms; NE, nocturnal enuresis; WHO, World Health Organization.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author was not awarded any grants or funding for this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate and ethics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to participate in this study was obtained from the patients via written informed consent. This study was conducted retrospectively and ethically in the best interest of patients with nocturia, although ethical approval could not be obtained because of the lack of a research ethics committee for our startup organization, which has not yet been funded. A waiver was needed in light of the retrospective nature of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/relative of the patient. A copy of the consent form is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CARE checklist has been added as needed for a case report in the form of an additional file (CHECK_LIST.docx).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case study has nonfinancial competing interests related to personal relationships with the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI am profoundly grateful to all the family members, especially my parents, Mr. Piston Eporu and Mrs. Grace Eporu, for the generous support they have always extended to me for my scholarly projects.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHashim H, Blanker MH, Drake MJ, et al. International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function. Neurourol Urodyn. 2019;38(2):499-508. doi:10.1002/nau.23917.\u003c/li\u003e\n \u003cli\u003eLeslie SW, Sajjad H, Singh S. Nocturia. [Updated 2024 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518987/.\u003c/li\u003e\n \u003cli\u003ePrince D, Pedler K, Rashid P. Nocturia--a guide to assessment and management. Aust Fam Physician. 2012;41(6):399-402.\u003c/li\u003e\n \u003cli\u003eNguyen LN, Randhawa H, Nadeau G, et al. Canadian Urological Association best practice report: Diagnosis and management of nocturia. Can Urol Assoc J 2022;16(7):E336-49.\u003ca href=\"http://dx.doi.org/10.5489/cuaj.7970\"\u003ehttp://dx.doi.org/10.5489/cuaj.7970\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eBirder LA, Van Kerrebroeck PEV. Pathophysiological Mechanisms of Nocturia and Nocturnal Polyuria: The Contribution of Cellular Function, the Urinary Bladder Urothelium, and Circadian Rhythm. Urology. 2019;133S:14-23. doi:10.1016/j.urology.2019.07.020.\u003c/li\u003e\n \u003cli\u003eMatsuo T, Miyata Y, Sakai H. Effect of salt intake reduction on nocturia in patients with excessive salt intake. Neurourol Urodyn. 2019;38(3):927-933. doi:10.1002/nau.23929.\u003c/li\u003e\n \u003cli\u003eMatsuo T, Miyata Y, Otsubo A, et al. Efficacy of salt reduction for managing overactive bladder symptoms: a prospective study in patients with excessive daily salt intake. Sci Rep. 2021;11(1):4046. Published 2021 Feb 18. doi:10.1038/s41598-021-83725-9.\u003c/li\u003e\n \u003cli\u003eEveraert K, Herv\u0026eacute; F, Bosch R, et al. International Continence Society consensus on the diagnosis and treatment of nocturia. Neurourol Urodyn. 2019;38(2):478-498. doi:10.1002/nau.23939.\u003c/li\u003e\n \u003cli\u003eRooney MR, Fang M, Ogurtsova K, et al. Global Prevalence of Prediabetes. Diabetes Care. 2023;46(7):1388-1394. doi:10.2337/dc22-2376.\u003c/li\u003e\n \u003cli\u003eEkwunife O, Wang X, Fraser R, et al. Demographics, Lifestyle, Comorbidities, Prediabetes, and Mortality. JAMA Netw Open. 2025;8(8):e2526219. Published 2025 Aug 1. doi:10.1001/jamanetworkopen.2025.26219.\u003c/li\u003e\n \u003cli\u003eFu Z, Wang F, Dang X, Zhou T. The association between diabetes and nocturia: A systematic review and meta-analysis. Front Public Health. 2022;10:924488. Published 2022 Oct 3. doi:10.3389/fpubh.2022.924488.\u003c/li\u003e\n \u003cli\u003eJia Y, Shen R, Dong X, Yang F, Zhou L, Long H. Association of domain-specific physical activity with nocturia: a population-based study. Sci Rep. 2025;15(1):2768. Published 2025 Jan 22. doi:10.1038/s41598-025-86182-w.\u003c/li\u003e\n \u003cli\u003eChu CM, Khanijow KD, Schmitz KH, Newman DK, Arya LA, Harvie HS. Physical Activity Patterns and Sedentary Behavior in Older Women With Urinary Incontinence: an Accelerometer-based Study. Female Pelvic Med Reconstr Surg. 2019;25(4):318-322. doi:10.1097/SPV.0000000000000552.\u003c/li\u003e\n \u003cli\u003eSugaya K, Nishijima S, Owan T, Oda M, Miyazato M, Ogawa Y. Effects of walking exercise on nocturia in elderly individuals. Biomed Res. 2007;28(2):101-105. doi:10.2220/biomedres.28.101.\u003c/li\u003e\n \u003cli\u003eDote-Montero M, Sanchez-Delgado G, Ravussin E. Effects of Intermittent Fasting on Cardiometabolic Health: An Energy Metabolism Perspective. Nutrients. 2022;14(3):489. Published 2022 Jan 23. doi:10.3390/nu14030489.\u003c/li\u003e\n \u003cli\u003eEngeroff T, Groneberg DA, Wilke J. After Dinner Rest a While After Supper Walk a Mile? A Systematic Review with Meta-analysis on the Acute Postprandial Glycemic Response to Exercise Before and After Meal Ingestion in Healthy Subjects and Patients with Impaired Glucose Tolerance. Sports Med. 2023 Apr;53(4):849-869. doi: 10.1007/s40279-022-01808-7. Epub 2023 Jan 30. PMID: 36715875; PMCID: PMC10036272.\u003c/li\u003e\n \u003cli\u003ePeddie MC, Bone JL, Rehrer NJ, Skeaff CM, Gray AR, Perry TL. Breaking prolonged sitting reduces postprandial glycemia in healthy, normal-weight adults: a randomized crossover trial. Am J Clin Nutr. 2013;98(2):358-366. doi:10.3945/ajcn.112.051763.\u003c/li\u003e\n \u003cli\u003eDunstan DW, Kingwell BA, Larsen R, et al. Breaking up prolonged sitting reduces postprandial glucose and insulin responses. Diabetes Care. 2012;35(5):976-983. doi:10.2337/dc11-1931.\u003c/li\u003e\n \u003cli\u003eSolomon TPJ, Tarry E, Hudson CO, Fitt AI, Laye MJ. Immediate postbreakfast physical activity improves interstitial postprandial glycemia: a comparison of different activity-meal timings. Pflugers Arch. 2020 Feb;472(2):271-280. doi: 10.1007/s00424-019-02300-4. Epub 2019 Aug 8. PMID: 31396757; PMCID: PMC7035221.\u003c/li\u003e\n \u003cli\u003eBabir FJ, Riddell MC, Adamo LM, Richards DL, Gibala MJ. The effect of bodyweight exercise on 24-h glycemic responses determined by continuous glucose monitoring in healthy inactive adults: a randomized crossover study. Sci Rep. 2023 Nov 28;13(1):20884. doi: 10.1038/s41598-023-48063-y. PMID: 38017140; PMCID: PMC10684602.\u003c/li\u003e\n \u003cli\u003ePettit-Mee RJ, Ready ST, Padilla J, Kanaley JA. Leg Fidgeting During Prolonged Sitting Improves Postprandial Glycemic Control in People with Obesity. Obesity (Silver Spring). 2021;29(7):1146-1154. doi:10.1002/oby.23173.\u003c/li\u003e\n \u003cli\u003eHamilton MT, Hamilton DG, Zderic TW. A potent physiological method to magnify and sustain soleus oxidative metabolism improves glucose and lipid regulation. iScience. 2022;25(9):104869. Published 2022 Aug 5. doi:10.1016/j.isci.2022.104869.\u003c/li\u003e\n \u003cli\u003eFryer S, Paterson C, Turner L, et al. Localized activity attenuates the combined impact of a high fat meal and prolonged sitting on arterial stiffness: A randomized, controlled crossover trial. Front Physiol. 2023;14:1107456. Published 2023 Feb 1. doi:10.3389/fphys.2023.1107456.\u003c/li\u003e\n \u003cli\u003eFryer S, Paterson C, Stoner L, et al. Leg Fidgeting Improves Executive Function following Prolonged Sitting with a Typical Western Meal: A Randomized, Controlled Cross-Over Trial. Int J Environ Res Public Health. 2022;19(3):1357. Published 2022 Jan 26. doi:10.3390/ijerph19031357.\u003c/li\u003e\n \u003cli\u003eWillett W, Manson J, Liu S. Glycemic index, glycemic load, and risk of type 2 diabetes. Am J Clin Nutr. 2002;76(1):274S-80S. doi:10.1093/ajcn/76/1.274S.\u003c/li\u003e\n \u003cli\u003eGangwisch JE, Hale L, St-Onge MP, et al. High glycemic index and glycemic load diets as risk factors for insomnia: analyses from the Women\u0026apos;s Health Initiative. Am J Clin Nutr. 2020;111(2):429-439. doi:10.1093/ajcn/nqz275.\u003c/li\u003e\n \u003cli\u003eElibol E, Eski S, Gez E, \u0026Ccedil;amdeviren G. The impact of carbohydrate quality index on menopausal symptoms and quality of life in postmenopausal women. BMC Womens Health. 2025;25(1):262. Published 2025 May 28. doi:10.1186/s12905-025-03822-z.\u003c/li\u003e\n \u003cli\u003eFerrara P, Del Volgo V, Romano V, Scarpelli V, De Gara L, Miggiano GA. Combined Dietary Recommendations, Desmopressin, and Behavioral Interventions May Be Effective First-Line Treatment in Resolution of Enuresis. Urol J. 2015;12(4):2228-2232. Published 2015 Sep 4.\u003c/li\u003e\n \u003cli\u003eMandelblat-Cerf Y, Kim A, Burgess CR, et al. Bidirectional Anticipation of Future Osmotic Challenges by Vasopressin Neurons. Neuron. 2017;93(1):57-65. doi:10.1016/j.neuron.2016.11.021.\u003c/li\u003e\n \u003cli\u003eRabinowitz J, Darawshi M, Burak N, Boehm M, Dmitrieva NI. Risk for hypertension and heart failure linked to high normal serum sodium and tonicity in general healthcare electronic medical records. Eur J Prev Cardiol. Published online April 11, 2025. doi:10.1093/eurjpc/zwaf232.\u003c/li\u003e\n \u003cli\u003ePeng AW, Juraschek SP, Appel LJ, Miller ER 3rd, Mueller NT. Effects of the DASH Diet and Sodium Intake on Bloating: Results From the DASH-Sodium Trial. Am J Gastroenterol. 2019;114(7):1109-1115. doi:10.14309/ajg.0000000000000283\u003c/li\u003e\n \u003cli\u003eRakova N, J\u0026uuml;ttner K, Dahlmann A, et al. Long-term space flight simulation reveals infradian rhythmicity in human Na(+) balance. Cell Metab. 2013;17(1):125-131. doi:10.1016/j.cmet.2012.11.013.\u003c/li\u003e\n \u003cli\u003eSun M, Li S, Sun X, Deng Z, Xu Y. Association between winter season and desmopressin treatment efficiency in children with monosymptomatic nocturnal enuresis: a pilot study. Int Braz J Urol. 2022;48(2):275-281. doi:10.1590/S1677-5538.IBJU.2021.0236.\u003c/li\u003e\n \u003cli\u003eFerrara P, Cammisa I, Zona M, Gatto A, Sacco R, Verrotti Di Pianella AV. Traditional and innovative interventions in the management of Enuresis. Cent European J Urol. 2024; 77: 42-57.\u003c/li\u003e\n \u003cli\u003eGarg R, Williams GH, Hurwitz S, Brown NJ, Hopkins PN, Adler GK. Low-salt diet increases insulin resistance in healthy subjects. Metabolism. 2011;60(7):965-968. doi:10.1016/j.metabol.2010.09.005.\u003c/li\u003e\n \u003cli\u003eGrillo A, Salvi L, Coruzzi P, Salvi P, Parati G. Sodium Intake and Hypertension. Nutrients. 2019;11(9):1970. Published 2019 Aug 21. doi:10.3390/nu11091970.\u003c/li\u003e\n \u003cli\u003eWHO. Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), 2012.\u003c/li\u003e\n \u003cli\u003eElijovich F, Weinberger MH, Anderson CA, et al. Salt Sensitivity of Blood Pressure: A Scientific Statement From the American Heart Association. Hypertension. 2016;68(3):e7-e46. doi:10.1161/HYP.0000000000000047.\u003c/li\u003e\n \u003cli\u003eWHO. Guideline: Potassium intake for adults and children. Geneva, World Health Organization (WHO), 2012.\u003c/li\u003e\n \u003cli\u003eMullens W, Damman K, Dhont S, et al. Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Eur J Heart Fail. 2024;26(4):730-741. doi:10.1002/ejhf.3244.\u003c/li\u003e\n \u003cli\u003ePeng AW, Juraschek SP, Appel LJ, Miller ER 3rd, Mueller NT. Effects of the DASH Diet and Sodium Intake on Bloating: Results From the DASH-Sodium Trial. Am J Gastroenterol. 2019;114(7):1109-1115. doi:10.14309/ajg.0000000000000283.\u003c/li\u003e\n \u003cli\u003ePaola Nigri, Luigi Nigri, Lucia Peccarisi, Overview on the management of nocturnal enuresis in children in general pediatrics, Global Pediatrics, Volume 9, 2024, 100207, ISSN 2667-0097, https://doi.org/10.1016/j.gpeds.2024.100207.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"diabetes mellitus, dietary salt, lower urinary tract symptoms, nocturnal enuresis, nocturnal polyuria, sodium chloride, sleep disorders, nonpharmacological treatment","lastPublishedDoi":"10.21203/rs.3.rs-7549533/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7549533/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: A patient’s repeated addition of salt to his dinner plate and postdinner exercise were instantly followed by reductions in nocturnal voids, which had been his nightly occurrence for several years, contrary to advise indicated in clinical guidelines that recommended salt restriction and avoidance of late evening exercise. He had a history of a salt-restrictive diet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient presentation\u003c/strong\u003e: A normal-weight middle-aged male patient had at least one nocturnal void during the main sleep period for more than 5 years, which increased to 2 nocturnal voids in 2023 when he developed symptoms of diabetes mellitus. He adopted low–moderate-intensity postdinner physical exercise for self-management of diabetic symptoms in 2024, which reduced nocturnal voids from 2–1 per night, but these regular residual voids were coupled with urgency and still bothersome. Recently, he awoke at daybreak without having had any such nocturnal void and recalled that he had unusually more salty late dinner just before bedtime. He hypothesized that the association between a more salty dinner and reduced nocturnal voids prompted him to add salt to his dinner plate in six subsequent dinners, confirming the association. Thereafter, he resolved to ensure that he had optimal amounts of salt on his dinner plate to prevent or have at most one nocturnal void during the main sleep period. This resolution significantly reduced the frequency of residual nocturnal voids during the main sleep period and ended urgent voids.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Sufficient salt intake for dinner and low–moderate-intensity postdinner physical exercise were associated with reduced nocturnal voids. Postdinner physical exercise is an affordable, feasible and largely safe option for the management of nocturia if shown to be effective in powered randomized crossover or controlled studies. Sufficient amounts of salt for dinner may be infrequent but not routinely beneficial for reducing nocturnal voids.\u003c/p\u003e","manuscriptTitle":"Unexpected associations between nocturia and salt intake and post dinner exercise: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-26 09:54:07","doi":"10.21203/rs.3.rs-7549533/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba854e70-4d17-4bb6-9cd1-33ccfb397c02","owner":[],"postedDate":"September 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55244378,"name":"Urology \u0026 Nephrology"}],"tags":[],"updatedAt":"2025-09-26T09:54:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-26 09:54:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7549533","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7549533","identity":"rs-7549533","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}