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Salt and our health final


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  • Cappuccio FP, Capewell S, Lincoln P, McPherson K. Policy options to reduce population salt intake. BMJ 2011; DOI:10.1136/bmj.d4995. Available here.
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    • 1. Salt and Cardiovascular disease Jafar Al-Said, M.B. CHb. MD. FASN Nephrology and Internal Medicine Consultant Bahrain Specialist Hospital 1
    • 2. Presentation scheme: Introduction. Historical points. Salt effect on health:  HTN.  Stroke.  Kidney disease.  Kidney stones.  Osteoporosis.  Stomach Cancer.  Obesity.  Meniere’s disease.  Alzheimer’s disease Conclusion. 2
    • 3. NaClSource: 1- Mining. 2- Sea Water (brine) 3
    • 4. Boiling Brine into pure salt 4
    • 5. Relation of Salt and Na:Table Salt had 40%-60% Na.1 gm salt has 400mg-600mg Na.One tea spoon of Salt has : -2300 mg Na. -3500-5500 mg Salt. 5
    • 6. Introduction1. Salt played an important part in Civilizations for centuries.2. Its use mentioned since 6050 BC.3. Egyptian were using it for trade between Phoenicians an Mediterraneans.4. It is a major preservative. It was used in preparing conserving the Mummies in Egypt.5. It is mentioned in Assyrian, Babylonian, Chinese and Greek history. 6
    • 7. Historic pointsSalary = Salarium Argentum= Salt rations forroman solders.Salad = Salt. One of the commodities in the past. Used as Currency and trade. Soldiers were paid by Salt. Taxies were put on salt trade.Salt raotes in the Roman times. 7
    • 8. Roman Salt Roats 8
    • 9. Romans Salt Routes. 9
    • 10. Salt in different countries Austria: Salzburg = City of Salt. Tuzla: Bosina-Herzegovina. ( Tuz= Salt). Jordan: As-Salt town. In Byzantine times. Syracuse, New York = Salt City. 10
    • 11. Salt in Wars and Revolutions:  16th Century; Spanish bankruptcy after blockade of Iberian Salt works by Dutch.  1789-1791; French Revolution.  18th century Salt played a role in the American Revolutions when British strategies were to deny American rebels access to salt.  1812; Napoleon retreat from Moscow many soldiers died because of unhealed wound from lack of salt.  1864. American Civil war. Saltville battle in Virginia.  1930, Gandhi Revolution against British salt taxation in India. Walk to the sea to gather tax free salt for nations poor. 11
    • 12. Salt Monopoly and taxation 2200 BC Chinese emperor taxed salt. 1259-1946; “Gabelle” French kings used salt tax. 1785 Salt Taxes support British colonies. 10000 peoples arrested in England for smuggling salt. 1825; Erie Canal in New York. The ditch that salt built. Salt tax revenues paid half cost. Until 1975 Italy taxes the Salt by 70%. World free trade had lead to abolishing of this Monopoly. As in Taiwan. 12
    • 13. 13
    • 14. Salt and religion. Egyptian Mummies. Greek Worshippers. Jewish Temple offering include salt. Catholic Church use salt in Purifying rituals. Buddhist salt repels evil spirit. 1933 Dalai Lama buried sitting up in a bed of Salt. 14
    • 15. Last Supper; Leonardo da Vinci 1495-1498 15
    • 16. Last Supper; Leonardo da Vinci 1495-1498 16
    • 17. Lets go back to our real medical world 17
    • 18. 18
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    • 22. Recommended daily intake of SaltAge Max. Salt intake/ day 0-6 months <1gm 6-12 months 1gm 1-3 years 2gm 4-6 years 3gm 7-10 years 5gm >11 years 6gm 22
    • 23. Average Daily Salt Intake in Male and Female Americans, as Ascertained from 24- Hour Dietary Recall, 2005–2006. Appel LJ, Anderson CA. N Engl J Med 2010;362:650-652. 23
    • 24. Salt and HypertensionAnimal studies : BP in Chimpanzees with modification of salt 10-15gm/day Denton D, Weisinger R, Mundy N I, et al. The effect of increased salt intake on blood pressure of chimpanzees. Nat Med. 1995;1:1009-16. 25
    • 25. Epidemiology  Communities with high salt consumption showed higher BP.Page L B, Damon A, Moellering R C, Jr. Antecedents of cardiovascular disease in sixSolomon Islands societies. Circulation. 1974;49:1132-46.Page L B, Vandevert D E, Nader K, Lubin N K, Page J R. Blood pressure of Qashqaipastoral nomads in Iran in relation to culture, diet, and body form. Am J Clin Nutr.1981;34:527-38. 26
    • 26. Epidemiologic studies Intersalt study:N = 10079.Adults 20-59 years.Global medical centers = 52 from 32 countries.Aim: Investigate the relation of electrolyte excretion to BP. INTERSALT. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. Bmj. 1988;297:319-28. 27
    • 27. Intersalt results 28
    • 28. Dose response salt reductionDose-response relationship between the reduction in salt intake as judged by reduction in 24hurinary sodium and systolic blood pressure.INTERSALT. Intersalt: an international study of electrolyte excretion and blood pressure. Results for24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. British 29Medical Journal. 1988; 297, 319-28
    • 29. Reducing Salt reduce BP Trial of Hypertension Prevention( TOHP I & II)Cumulative incidence of cardiovascular disease (CVD) by sodium intervention group in TOHP Iand II, adjusted for age, sex, and clinic  Interventional study.  N = 3000.  Randomized to salt reduction and control.  In two cohort populations.  Net salt reduction was 33-44mmol/day.  Followed for 10-15years. Results:  Cardiovascular events were 25% less in the interventional group. 30
    • 30. Trial of Hypertension Prevention (TOHP I & II) Cumulative incidence of cardiovascular disease (CVD) by sodium intervention group in TOHP I and II, adjusted for age, sex, and clinicN=3000.TOHP I = 18 monthsTOHP II = 36-48 months.Decreased salt by 25-30%Results:TOHP I decreased BP -1.7/0.9mmHg.TOHP II decreased BP – 1.2/0.7mmHgCook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK Appel LJ & Whelton PK. Longterm effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up ofthe trials of hypertension prevention (TOTP). BMJ, Apr 2007; 334: 885; doi: 10.1136/bmj.39147.604896.55 31
    • 31. Reducing salt reduce BP in South Asian population in UK • Modest salt reduction 4gm/day for 6 wks. • Decreased BP by -5.4/2.2 mmHgHe et al. Effect of Modest Salt reduction on Blood Pressure, Urinary Albumin and pulse Wave velocity inwhite, black and Asian mild hypertensives. Hypertension. 2009; 54, 482-488. 32
    • 32. Salt reduction in new born.Aim: effect of low salt diet on new born BP. N=500 new born. For 6months. Randomized study to moderate salt reduction.Results : At 6 months the systolic BP was lower by 2.1mmHg. The reduction in BP was maintained after 15 years. 33
    • 33. Results:Hofman A, Hazebroek A, Valkenburg H A. A randomized trial of sodium intake and bloodpressure in newborn infants. Jama. 1983;250:370-3.Geleijnse J M, Hofman A, Witteman J C, et al. Long-term effects of neonatal sodiumrestriction on blood pressure. Hypertension. 1997;29:913-7. 35
    • 34. Two Village controlled Low salt study  2 villages in Portugal.  One village had been offered low salt processed food.  It was given information on how to reduce the salt. Results:  After one year BP was less and in two years both systolic and diastolic BP were lower.Forte J G, Miguel J M, Miguel M J, et al.. Salt and blood pressure: a community trial. J HumHypertens. 1989;3:179-84. 36
    • 35. Results:Forte J G, Miguel J M, Miguel M J, et al.. Salt and blood pressure: a community trial.J Hum Hypertens. 1989;3:179-84. 38
    • 36. Population studiesJapan:Reducing salt from 18gm to 14 gm over one decade.Stroke mortality reduced by 80%.Iso H, Shimamoto T, Yokota K, et al. [Changes in 24-hour urinary excretion of sodium andpotassium in a community-based heath education program on salt reduction]. NipponKoshu Eisei Zasshi. 1999;46:894-903.Finland:14000 population with instruction to reduce salt increasefruits and vegetables and stop smoking. Reduced stroke mortality by 66% Reduced CAD mortality by 55%.RR= 0.5 for salt reduction.Vartiainen E, Sarti C, Tuomilehto J, Kuulasmaa K. Do changes in cardiovascular riskfactors explain changes in mortality from stroke in Finland ? Bmj. 1995;310:901-4. 39
    • 37. Mortality and salt intake Finland: increased salt intake showed increase Cardiovascular and total Mortality.Randomized controlled trialIncreased 6 gm of Salt/dayTuomilehto J, Jousilahti P, Rastenyte D, Moltchanov V, Tanskanen A, Pietinen P, Nissinen A.Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study. Lancet. 402001;357:848-51
    • 38. Treatment trialsReduced salt intake from 10-12gm/day to 5-6gm/daywill: 1.Reduce BP as single AntiHTN. 2.Additive to AntiHTN. 3.More in low renin; blacks and elderly.MacGregor G A, Markandu N D, Best F E, et al. Double-blind randomised crossovertrial of moderate sodium restriction in essential hypertension. Lancet. 1982;1:351-5.He F J, Markandu N D, Sagnella G A, MacGregor G A. Importance of the reninsystem in determining blood pressure fall with salt restriction in black and whitehypertensives. Hypertension. 1998;32:820-4. 41
    • 39. Treatment trialsSalt reduction in three levels 12, 6, 3gm/day.In mild untreated essential HTN individuals: Lower BP in lower salt intake. Continued BP control for one year.MacGregor G A, Markandu N D, Sagnella G A, et al. Double-blind study of threesodium intakes and long-term effects of sodium restriction in essential hypertension.Lancet. 1989;2:1244-7. 42
    • 40. Meta-analysis of salt reduction and BP changes 28 RCT trials Salt reduce from 10 to 5gm. 4wks. Results: Reduce salt 6gm/day: 24% decreased stroke death. 20% decrease IHD deathHe F J, MacGregor G A. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens.2002;16:761-70. 46
    • 41. Salt intake and stroke deathPerry IJ, Beevers DG. Salt intake and stroke: a possible direct effect. Journal of HumanHypertension. 1992; 6, 23-25 47
    • 42. NIH report 2010Salt reduction is No.1 Cardiovascular preventivemeasure.Aim to decrease daily salt to:  6gm in 2015.  3gm in 2025.NICE. Prevention of Cardiovascular Disease. Public health guidance 25. Published June2010 48
    • 43. 49
    • 44. As part of the implementation of the WHO Global Strategy on Diet,Physical Activity and Health and the 2008-2013 Action Plan for theGlobal Strategy for the Prevention and Control of NoncommunicableDiseases 50
    • 45. Most Americans Should Consume Less Sodium (1,500 mg/day or lessCurrent dietary guidelines for Americans recommend that adults in general shouldconsume no more than 2,300 mg of sodium per day. At the same time, consumepotassium-rich foods, such as fruits and vegetables. However, if you are in thefollowing population groups, you should consume no more than 1,500 mg of sodiumper day, and meet the potassium recommendation (4,700 mg/day) with food. 51
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    • 48. Relation of Salt to LVH in individualswith systolic BP >121mmHg.Schmeider RE et al. Dietary salt intake. A determinant of cardiac involvement in essentialhypertension. Circulation. 1988; 78, 951-956 54
    • 49. Cochrane review Aim: Salt reduction and Cardiovascular Mortality. Total studies were 7 RCTs. Population was 6489.(758 (11.6 %)were HTN). Follow up was variable 3-13 years. Results: No strong evidence that reduce salt is beneficial. 2.6 folds higher mortality in heart failure with decreased salt intake.Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim SPublished Online: October 5, 2011Advice to reduce the amount of salt eaten reduces blood pressure but there isinsufficient evidence to confirm the predicted reductions in people dying prematurely orsuffering cardiovascular disease 58
    • 50. Salt intake & Proteinuria Decreased Salt intake from 10gm to 5gm decreased urine protein by 19.4%.Swift P A, Markandu N D, Sagnella G A, He F J, Macgregor G A. Modest SaltReduction Reduces Blood Pressure and Urine Protein Excretion in BlackHypertensives. A Randomized Control Trial. Hypertension. 2005; 46:308-12 Decreased Salt from 9.7gm to 6.5gm decrease 24 hour albuminuria.He FJ, Marciniak M, Visagie E, et al: Effect of modest salt reduction on bloodpressure, urinary albumin, and pulse wave velocity in white, black, and Asian mildhypertensives. Hypertension 54: 482-488, 2009 59
    • 51. Water retentionAccess Salt cause more water retention in: Heart failure. Renal failure. Cirrhosis patients. In women cyclical and idiopathic edema. Sitting for long time like long flights.MacGregor G A, de Wardener H E, Idiopathic edema., in Diseases of the kidney.,G.C. Schrier RW, Editor. 1997, Little Brown and Company.: Boston. p. 2343-2352.Perry I J, Beevers D G. Salt intake and stroke: a possible direct effect. J HumHypertens. 1992;6:23-5. 64
    • 52. Salt and vascular dementia Salt HTN Stroke Vascular dementia• Passmore P. Preventing dementia following a stroke. The Journal of Quality Research in Dementia. 2008;Issue 66.• Fratiglioni L et al. Prevention of Alzheimer’s disease and dementia. Major findings from the Kungsholmen project. Physiology & Behaviour.2007; 92;, 98-104.• Stewart R et al. Change in blood pressure and incident dementia. A 32 year prospective study. Hypertension. 2009; 54, 233-240.• Nagai M et al. Hypertension and Dementia. American Journal of Hypertension. 2010; 23(2), 116-12465
    • 53. How to start decreasing the salt in a community?Laws to start to enforce: Establishing and evaluating public-awareness campaigns.“ "Setting progressive salt targets for reformulating existing processed food and engaging with the food industry in setting standards for new foods." "Surveying population salt intake, progress of reformulation, and effectiveness of communication." "Engagement with industry, including regulation, to create a level playing field so as not to disadvantage more enlightened and progressive companies." 69
    • 54. Conclusion: Salt is strongly related to our lives. It is one of the oldest compounds used. It is strongly related with many diseases:  HTN.  Stroke.  Kidney disease.  Kidney stones.  Osteoporosis.  Stomach Cancer.  Obesity.  Meniere’s disease.  Alzheimer’s disease. 70
    • 55. Take Home MessageReducing salt in our diet is recommended.Normotensive: 4-6 gm per day.Hypertensive: 2-4 gm per day. 71
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