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The Health Effects of Reducing Sodium and Improving Overall Diet
 

The Health Effects of Reducing Sodium and Improving Overall Diet

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  • The meeting in Chicago did not provide time enough to discuss the ongoing controversy among medical experts over the scientific questions. This presentation was offered as a presumably accurate and balanced review of the science. The opening slide proclaims no conflict of interest and the author responded to a question (not mine, incidentally) by denying he is a member of the anti-salt activist group WASH. See #273 at http://www.worldactiononsalt.com/home/docs/wash_members.xls

    For balance, I've downloaded a recent PPT by Dr. Hillel Cohen, author of several health outcomes studies of the NHANES database. You can find it at

    http://www.slideshare.net/rhanneman/salt-and-cardiovascular-mortality



    Dick Hanneman, Salt Institute
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The Health Effects of Reducing Sodium and Improving Overall Diet The Health Effects of Reducing Sodium and Improving Overall Diet Presentation Transcript

  • The Health Effects of Reducing Sodium and Improving Overall Diet Lawrence J Appel, MD, MPH Professor of Medicine, Epidemiology and International Health (Human Nutrition) July 9, 2008 Disclosures and Conflicts of Interest: None
  • Bottom Line on Salt (Sodium Chloride)
    • On average, reducing salt intake lowers blood pressure and subsequent risk of cardiovascular disease
    • Other potential health benefits
      • reduced risk of gastro-esophageal cancer
      • reduced left ventricular mass
      • preserved bone mass
  • Bottom Line of Diet Quality
    • Several distinct diets are associated with increased survival and a reduced risk of chronic disease, especially cardiovascular disease (CVD)
    • Such diets are typically:
      • Reduced in saturated fat, trans fat, and cholesterol
      • Rich in fruits, vegetables, and whole grains
  • www.nap.edu www.iom.edu/fnb Dietary Reference Intakes from the Institute of Medicine (IOM)
  • 2005 US Dietary Guidelines
    • Scientific Advisory Committee Report
    • “ Technical Report”
    • Dietary Guidelines for Americans , 2005
    • “ Policy Document”
    • Finding Your Way to a Healthier You: Based on the Dietary Guidelines for Americans
    • “ Public Document”
    • Implementation Tools
      • DASH eating plan
      • Food Label
      • My Pyramid
    • www.healthierus.gov/dietaryguidelines
  • Reducing Sodium Intake
  • Useful Conversions Adequate Intake (AI) Upper Level (UL) Sodium (mg) 1,500 2,300 Sodium (mmol) 65 100 Sodium Chloride (g) 3.8 5.8
  • Forms of Sodium
    • 90% of sodium consumed as sodium chloride (salt)
    • Other forms:
      • sodium bicarbonate
      • sodium in processed foods, such as sodium benzoate and sodium phosphate
  • Sources of Dietary Sodium Inherent 12% Food Processing 77% At the Table 6% During Cooking 5% Mattes and Donnelly, JACN, 1991; 10: 383 (62 adults who completed 7 day dietary records)
  •  
  • Adverse Effects Attributed to Excess Sodium Intake
    • Increased urinary calcium excretion (but no trials with bone mineral density or fractures)
    • Increased left ventricular mass in cross-sectional studies (and one randomized trial)
    • Increased risk of gastric cancer (ecologic studies, case-control studies)
    • Primary effect of sodium that drives policy: Increased blood pressure (and subsequent blood pressure related CVD renal disease)
  • Deaths from Stomach Cancer (per 100,000 Per year) Adapted from Joossens, Int J Epi 1996;25:494-504 KOR r=0.702 P<0.001 JAPAN CHI POL COL HUN POR GDR ITA SPA FRG CAN FIN NET MAL E.W ARG DEN BEL USA N.I MEX TOB 190 170 150 130 110 90 70 50 30 10 0 6 7 8 9 10 11 12 13 14 Salt Intake (grams/day) ICE Salt and Stomach Cancer: Ecological Analysis
  • BP Classification (JNC VII, 2003) Category Systolic BP Diastolic BP Normal < 120 and < 80 Pre-Hypertensive 120 - 139 or 80 – 89 Hypertension Stage 1 Stage 2 140 – 159 > 160 or or 90 – 99 > 100
  • Magnitude of the BP Problem
    • 62% of strokes and 49% of CHD events attributed to elevated BP*
    • 26% of adults worldwide (971 million) have hypertension**
    *WHO, World Health Report 2002: Reducing Risks, Promoting Healthy Life, **Kearney Lancet 2005;305:217,
  • Important Concepts
    • The lower your blood pressure, the lower your risk of heart disease and stroke ( EVEN IF YOU DO NOT HAVE HYPERTENSION )
    • In most but not all countries, blood pressure rises with age
    • Your lifetime risk of developing hypertension is 90%
  • Stroke Mortality by Level of Usual Systolic BP* *Prospective Studies Collaboration, Lancet, 2002: Meta-analysis of 61 prospective studies with 2.7m person-yrs, 11.9k deaths
  • Distribution of BP Levels in US Adults, Ages 18 and Older (NHANESIII) “ Normal” <120/80 Prehypertension SBP 120-39 or DBP 80-89 Hypertension SBP > 140 or DBP > 90 Source: Wang, Hypertension, 2004 42% 27% 31%
  • Established Market Economies Men 116 Women 123 Latin America & Caribbean Men 60 Women 54 Middle Eastern Crescent Men 36 Women 38 Former Socialist Economies Men 41 Women 53 China Men 99 Women 83 India Men 60 Women 58 Sub-Saharan Africa Men 38 Women 42 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Lancet 2005;365:217-223 2000: Number (millions) of Hypertensives, by World Region Other Asia & islands Men 38 Women 33 Overall = 971 million Economically Developed Countries = 333 million Economically Developing Countries = 639 million SBP≥140 mm Hg DBP≥ 90 mm Hg BP lowering med
  • Mean SBP and DBP by Age and Race/Ethnicity for Women, Age 18 Years and Older 150 140 130 120 110 100 90 80 70 mm Hg 18-29 30-39 40-49 50-59 60-69 70-79 80+ Diastolic Systolic Source: Burt V, et al. Hypertension, 1995 SBP Rise with Age = ~0.6 mmHg per year Age Black White Mexican-American
  • Mean Systolic and Diastolic BP * Pediatrics, 2004;114:555-576 (for 50th Percentile Height) ** J Human HTN, 1989, 3:331-407 Age (yrs) SBP Rise with Age boys: 1.9 mmHg / yr girls: 1.5 mmHg / yr Yanomami**, ages 20-59 Men Women U.S. Children*, ages 1- 17 ♦ (101) ♦ (91) ♦ (65) ♦ (56) 20 - 59 Age (yrs) Systolic Diastolic
  • Population-Based Strategy SBP Distributions Stamler R. Hypertension 1991;17:I-16–I-20. % Reduction in Mortality Reduction in BP After Intervention Before Intervention Stroke CHD Total -6 -4 -3 -8 -5 -4 -14 -9 -7 Reduction in SBP mmHg 2 3 5
  • Effect of Reduced Sodium Intake on Blood Pressure
    • > 50 trials of sodium reduction on blood pressure
    • 10 dose response trials
    • 3 trials of sodium reduction as a means to prevent hypertension
  • Sodium: Dose Response Trials Luft, 1979 (14 non-hypertensive)
  • Sodium: Dose Response Trials MacGregor, 1989 (20 hypertensive)
  • Sodium: Dose Response Trials Johnson, 2001 (n=17 non-hypertensive elderly)
  • Sodium: Dose Response Trials Johnson, 2001 (n=15 elderly with isolated systolic hypertension)
  • Sodium: Dose Response Trials Johnson, 2001 (n=8 elderly with systolic-diastolic hypertension)
  • Sodium Dose Response Trials: DASH-Sodium Trial* Systolic Blood Pressure Control Diet DASH Diet 1.5 (65) 2.4 (106) 3.3 (143) Sodium Level: gm/d (mmol) per day +2.1 +1.3 +1.7 +4.6 +6.7 p<.0001 +3.0 P<.0001 *Sacks, 2001 (412 pre- and stage 1 hypertensive adults)
  • Factors Associated with Increased BP Response to Salt
    • Fixed factors
      • Middle and older-aged persons
      • African-Americans
      • Genetic Factors
      • Individuals with:
        • Hypertension
        • Diabetes
        • Chronic Renal Insufficiency
    • Modifiable
      • Low potassium intake
      • Poor quality diet
  • Effect of Sodium Reduction (Higher to Lower) in African-Americans and Non-African-Americans on the Control Diet African-Americans Non-African-Americans - 8.0 † P<.001 - 4.5 † P<.001 - 5.1 P<.001 - 2.2 P<.001 0 † P-interaction < 0.05
  • Effects of Reduced Na on CVD Events: Results from 3 Randomized Trials INTERVENTION OUTCOME FU TONE (2001) 639 Elderly ↓ Na 21% ↓ CVD events 2.3 yrs Taiwan Veterans (2006) 1,981 Elderly ↓ Na /↑ K Salt 41%* ↓ CVD Mortality 2.6 yrs TOHP Follow-up (2007) 3,126 Prehypertensives ↓ Na 30%* ↓ CVD events 10-15 yrs *p<0.05
  • Sodium Recommendations from the 2005 US Dietary Guidelines Report
    • Limit for general population
    • < 100 mmol/d (2,300 mg/d)
    • Limit of < 65 mmol/d (1,500 mg/d) for those who are most likely to benefit from sodium reduction
      • middle- and older-aged persons
      • blacks
      • persons with hypertension, diabetes or CKD
  • Organizations and Countries Recommending Major Reductions in Sodium Organizations National Research Council 1 National Institutes of Health 1 National HBP Education Program CC 1 Joint National Committee 7 1 U.S. Department of Health and Human Services 1 U.S. Department of Agriculture 1 National Academy of Sciences American Medical Association 3 American Heart Association 1 American Public Health Association 3 Center for Science in the Public Interest 3 World Health Organization 4 World Hypertension League Countries Finland 1 United Kingdom 3 Australia 1 Ireland New Zealand 1 < 2300 mg/day; 2 < 2300 mg day under age 50; < 1500 mg/day for 50-70, hypertensives, and blacks; < 1200 mg/day for age 70 and higher; 3 Minimum 50% reduction in processed and restaurant foods; 4 < 2000 mg/day
  • Improving Overall Diet Quality
  • Three Stories (Diets)
    • Traditional Okinawan Diet
    • Traditional Mediterranean-style Diets
    • DASH-style Diets
  • Okinawa
    • Poorest of Japanese prefectures
    • Prior to World War II (and Westernization), Okinawa had:
      • The largest population of centenarians in Japan (and likely the world)
      • Highest average survival
  • Traditional Okinawan Diet
    • Emphasizes:
      • Green-yellow vegetables, sweet potatoes, soy bean products, bonito flakes (shaved fish)
    • Includes:
      • Some pork
    • Reduced in:
      • Dairy products, salt
  • Age-adjusted Mortality in 1995 (Deaths per 100,000) from Coronary Heart Disease (CHD) and Cancer in Okinawa, Japan, and US* *Willcox BJ, Ann NYAS, 2007
  • Mediterranean Dietary Pattern(s)
    • 16 countries border the Mediterranean Sea
    • Substantial variation in diet by country and region
    • Many regions of Greece (e.g. Crete) and Southern Italy have an extremely low risk of CHD
  • Mediterranean Dietary Pattern
    • Emphasizes:
      • Fruits, Vegetables, Bread, Cereals, Potatoes, Beans, Nuts, and Seeds
    • Includes:
      • Olive Oil, Dairy Products, Fish, and Poultry, Wine
    • Reduced in:
      • Red Meat
  • Effects of Mediterranean Diet † on Mortality Over 44 months in Greek Patients with Coronary Heart Disease Trichopoulou, Arch Int Med, 2005 * * † Per 2 unit increase in Mediterranean Diet Score * p < .05 Total CHD Other
  • Effects of Mediterranean Diet † on Mortality Over 44 months in Greek Population (Primary Prevention) Trichopoulou, NEJM, 2003 † Per 2 unit increase in Mediterranean Diet Score Total CHD Cancer 25%* * * * p < .05
  • Effects of Mediterranean Diet † on 10 Year Mortality in 2,339 Elderly European Men and Women (HALE Project) † Score of 4 or higher on modified version of Trichopoulou Knoops, JAMA, 2004 *p < .05 Total CHD CVD Cancer Other * 23%* * *
  • D ietary A pproaches to S top H ypertension
  • Nutrient Targets By Diet
  • Servings per Day of Food Groups Servings/Day Fruits/ Vegetables Dairy Products Meat/Fish Poultry Fats/ Oils
  • THE DASH DIETARY PATTERN: Foods
    • Emphasizes:
      • Fruits, Vegetables, Low-fat Dairy Foods
    • Includes:
      • Whole Grains, Nuts, Poultry, Fish
    • Reduced in:
      • Fats, Red Meat, Sweets, and Sugar-containing Beverages
  • The DASH diet
  • Weekly BP by Diet During Intervention Feeding WEEKS B 1 2 3 4 5 6 7,8 DIASTOLIC SYSTOLIC Appel, NEJM, 2007
  • Effect of DASH Combination Diet by BP Status Hypertensives Non-Hypertensives * † * * * * p< 0.05 (main effect) † p< 0.05 (BP status interaction)
  • Effect of DASH Combination Diet By Race African-Americans Non-African-Americans * † * * * * p< 0.05 (main effect) † p< 0.05 (race interaction)
  • Relative Risk* of Coronary Heart Disease and Stroke by Quintile of DASH Score (Nurses Health Study, Fung, 2008) * Adjusted for age, BMI, menopause, hormone use, energy intake, multivit Use, Etoh, fam Hx, physical activity and aspirin *
  • Estimated Nutrient Composition by Diet 1 Willcox, Ann NYAS, 2007; 2 Sacks, NEJM 2001; 3 Kromhout, AJCN, 1989 Okinawan 1 DASH 2 Mediterranean 3 Carb (% kcal) 85% 55% 43% Protein (% kcal) 9% 18% 13% Fat (% kcal) 6% 27% 42% Sat Fat (% kcal) 2% 6% 9% Cholesterol (mg/1000 kcal) 72 mg 75 mg Sodium (mg/d) 1,113 mg 1,150 mg - Potassium (mg/d) 5,199 mg 4,700 mg -
  • Summary
    • Several distinct dietary patterns are associated with longevity and a reduced risk of chronic disease, particularly cardiovascular disease
    • Common features:
      • rich in fruit, vegetables, and grains
      • reduced in sodium, saturated fat, trans fat and cholesterol