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1.
Sodium Reduction: How Big Might the Risks and Benefits Be?
Yin, X, Tian, M, Neal, B
Heart, lung & circulation. 2021;(2):180-185
Abstract
Cardiovascular diseases are the leading cause of death worldwide and raised blood pressure is the leading risk for these conditions. Excess sodium intake clearly elevates blood pressure though the association of sodium intake with cardiovascular outcomes has been disputed. Nonetheless, it was estimated that in 2017 excess dietary sodium caused between 1.4 and 5.4 million deaths. Key underlying assumptions for those estimates were that the association between sodium intake and cardiovascular disease is direct and linear, and that a daily consumption level of 2.0 g of sodium minimised risk. Recent data indicating that reported U-shaped associations of sodium with risk are the result of confounding provide strong support for the first assumption. Cardiovascular risks may, however, continue to decline below intake levels of 2.0 g per day. Further, because excess sodium intake appears to drive a progressive rise in blood pressure with age, the magnitude of the disease burden avoidable by sodium reduction may have been under-estimated. Regardless, health benefits will only be achieved if safe, effective and scalable interventions can be defined and none have been identified to date. Salt substitution, which switches regular salt for a reduced-sodium, added-potassium alternative offers a significant opportunity. Falls in blood pressure with salt substitution are comparable to single-drug therapy and salt substitutes are low cost, simple to use, well-tolerated and could be applied community-wide. Data that prove clinical benefits and exclude risks will be required to support widespread use. An ongoing large-scale randomised trial of the effects of salt substitution on stroke, major cardiovascular events and death will complete soon and define the role of salt substitutes in public health.
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Priority Actions to Advance Population Sodium Reduction.
Ide, N, Ajenikoko, A, Steele, L, Cohn, J, J Curtis, C, Frieden, TR, Cobb, LK
Nutrients. 2020;(9)
Abstract
High sodium intake is estimated to cause approximately 3 million deaths per year worldwide. The estimated average sodium intake of 3.95 g/day far exceeds the recommended intake. Population sodium reduction should be a global priority, while simultaneously ensuring universal salt iodization. This article identifies high priority strategies that address major sources of sodium: added to packaged food, added to food consumed outside the home, and added in the home. To be included, strategies needed to be scalable and sustainable, have large benefit, and applicable to one of four measures of effectiveness: (1) Rigorously evaluated with demonstrated success in reducing sodium; (2) suggestive evidence from lower quality evaluations or modeling; (3) rigorous evaluations of similar interventions not specifically for sodium reduction; or (4) an innovative approach for sources of sodium that are not sufficiently addressed by an existing strategy. We identified seven priority interventions. Four target packaged food: front-of-pack labeling, packaged food reformulation targets, regulating food marketing to children, and taxes on high sodium foods. One targets food consumed outside the home: food procurement policies for public institutions. Two target sodium added at home: mass media campaigns and population uptake of low-sodium salt. In conclusion, governments have many tools to save lives by reducing population sodium intake.
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3.
Potassium-Enriched Salt Substitutes as a Means to Lower Blood Pressure: Benefits and Risks.
Greer, RC, Marklund, M, Anderson, CAM, Cobb, LK, Dalcin, AT, Henry, M, Appel, LJ
Hypertension (Dallas, Tex. : 1979). 2020;(2):266-274
Abstract
Use of salt substitutes containing potassium chloride is a potential strategy to reduce sodium intake, increase potassium intake, and thereby lower blood pressure and prevent the adverse consequences of high blood pressure. In this review, we describe the rationale for using potassium-enriched salt substitutes, summarize current evidence on the benefits and risks of potassium-enriched salt substitutes and discuss the implications of using potassium-enriched salt substitutes as a strategy to lower blood pressure. A benefit of salt substitutes that contain potassium chloride is the expected reduction in dietary sodium intake at the population level because of reformulation of manufactured foods or replacement of sodium chloride added to food during home cooking or at the dining table. There is empirical evidence that replacement of sodium chloride with potassium-enriched salt substitutes lowers systolic and diastolic blood pressure (average net Δ [95% CI] in mm Hg: -5.58 [-7.08 to -4.09] and -2.88 [-3.93 to -1.83], respectively). The risks of potassium-enriched salt substitutes include a possible increased risk of hyperkalemia and its principal adverse consequences: arrhythmias and sudden cardiac death, especially in people with conditions that impair potassium excretion such as chronic kidney disease. There is insufficient evidence regarding the effects of potassium-enriched salt substitutes on the occurrence of hyperkalemia. There is a need for additional empirical research on the effect of increasing dietary potassium and potassium-enriched salt substitutes on serum potassium levels and the risk of hyperkalemia, as well as for robust estimation of the population-wide impact of replacing sodium chloride with potassium-enriched salt substitutes.
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4.
[Sodium restriction in heart failure: where are the data?].
Navis, GJ
Nederlands tijdschrift voor geneeskunde. 2019
Abstract
Mahtani et al. review the evidence for sodium restriction in heart failure. The paucity of solid studies is striking, but deplorably in line with the paucity of high-quality studies on lifestyle management in general. One hard endpoint study (Sodium-HF) is underway. Promising results were obtained in the GOURMET study, which integrated sodium restriction into a broader nutritional approach that simultaneously targeted malnutrition, a major problem in heart failure. Targeting overall nutritional status - rather than single nutrients - matches current trends in nutrition guidelines, and deserves further exploration. Using fresh products and avoiding processed foods is the main step towards an overall healthier diet with less sodium. Dietary improvement, with its clinical benefit, is feasible in most patients by means of adequate support and feedback. Hopefully, the emergence of 'lifestyle medicine' will, with clinical and scientific effort, allow for the health potential of nutrition to be translated into clinical benefit for patients.
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[Increased mortality on a daily salt intake below six grammes].
Graudal, N
Ugeskrift for laeger. 2018;(33)
Abstract
Randomised controlled trials of healthy individuals show that the effect of reduced dietary salt intake (SR) on blood pressure (BP) is less than 1 mmHg. Still, health authorities use BP effects obtained in studies of participants with high BP to simulate reduced mortality in computer modeling studies. These simulations are in contrast to real data from observational studies, which show that a low salt intake is associated with an increased mortality of about 15% in healthy as well as in hypertensive individuals. Consequently, SR at the population level should not be a public health priority.
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6.
Salt and hypertension: what do we know?
DiNicolantonio, JJ, O'Keefe, JH
Current opinion in cardiology. 2018;(4):377-381
Abstract
PURPOSE OF REVIEW To evaluate the evidence for population-wide sodium restriction. RECENT FINDINGS The recommendations for population-wide sodium restriction largely rely on one surrogate marker (blood pressure). However, recent evidence suggests that when looking beyond blood pressure (e.g. heart rate, aldosterone, renin, cholesterol, triglycerides, noradrenaline and adrenaline), the net effect of sodium restriction is likely harmful. Prospective studies support the notion that those consuming the lowest amounts of salt are at the highest risk of cardiovascular events and premature death. SUMMARY There is no definitive proof that sodium restriction reduces cardiovascular events or death. It is time for the dietary guidelines to look at the totality of the evidence and reconsider the advice around population-wide sodium restriction.
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Can We End the Salt Wars With a Randomized Clinical Trial in a Controlled Environment?
Jones, DW, Luft, FC, Whelton, PK, Alderman, MH, Hall, JE, Peterson, ED, Califf, RM, McCarron, DA
Hypertension (Dallas, Tex. : 1979). 2018;(1):10-11
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The Science of Salt: A regularly updated systematic review of the implementation of salt reduction interventions (September 2016-February 2017).
Johnson, C, Santos, JA, McKenzie, B, Thout, SR, Trieu, K, McLean, R, Petersen, KS, Campbell, NRC, Webster, J
Journal of clinical hypertension (Greenwich, Conn.). 2017;(10):928-938
Abstract
This periodic review aims to identify, summarize, and appraise studies relating to the implementation of salt reduction strategies that were published between September 2016 and February 2017. A total of 41 studies were included as relevant to the design, assessment, and implementation of salt reduction strategies, and a detailed appraisal was conducted on the seven studies that evaluated the impact of salt reduction strategies. Of these, three were national studies or included large populations and four were conducted in communities with small participant sample sizes. Each study used a different strategy for reducing salt intake varying from category-specific sodium targets for packaged food to use of a low-sodium salt substitute to behavior change interventions. Four studies found statistically significant decreases in dietary salt intake and one study showed statistically significant decreases in mean sodium density of packaged food products. Four of the seven studies used either spot or 24-hour urine samples to measure dietary salt intake and five were conducted in East or Southeast Asia-two of which were in low- and middle-income countries. Study quality varied among the seven studies and all except one had one or more risks related to bias.
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9.
Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review.
Schorling, E, Niebuhr, D, Kroke, A
Public health nutrition. 2017;(11):1993-2003
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Abstract
OBJECTIVE To analyse and compare the cost-effectiveness of different interventions to reduce salt consumption. DESIGN A systematic review of published cost-effectiveness analyses (CEA) and cost-utility analyses (CUA) was undertaken in the databases EMBASE, MEDLINE (PubMed), Cochrane and others until July 2016. Study selection was limited to CEA and CUA conducted in member countries of the Organisation for Economic Co-operation and Development (OECD) in English, German or French, without time limit. Outcomes measures were life years gained (LYG), disability-adjusted life years (DALY) and quality-adjusted life years (QALY). Relevant aspects in modelling were analysed and compared. Quality assessments were conducted using the Drummond and Jefferson/British Medical Journal checklist. SETTING OECD member countries. SUBJECTS Mainly adults. RESULTS Fourteen CEA and CUA were included in the review which analysed different strategies: salt reduction or substitution in processed foods, taxes, labelling, awareness campaigns and targeted dietary advice. Fifty-nine out of sixty-two scenarios were cost-saving. The incremental cost-effectiveness ratio in international dollars (Intl.$; 2015) was particularly low for taxes, a salt reduction by food manufacturers and labelling (303 900 Intl.$/DALY). However, only six studies analysed cost-effectiveness from a societal perspective and quality assessments showed flaws in conducting and a lack of transparency in reporting. CONCLUSIONS A population-wide salt reduction could be cost-effective in prevention of hypertension and CVD in OECD member countries. However, comparability between study results is limited due to differences in modelling, applied perspectives and considered data.
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The Science of Salt: A regularly updated systematic review of the implementation of salt reduction interventions (March-August 2016).
Santos, JA, Trieu, K, Raj, TS, Arcand, J, Johnson, C, Webster, J, McLean, R
Journal of clinical hypertension (Greenwich, Conn.). 2017;(4):439-451
Abstract
This review aims to identify, summarize, and appraise studies reporting on the implementation of salt reduction interventions that were published between March and August 2016. Overall, 40 studies were included: four studies evaluated the impact of salt reduction interventions, while 36 studies were identified as relevant to the design, assessment, and implementation of salt reduction strategies. Detailed appraisal and commentary were undertaken on the four studies that measured the impact of the interventions. Among them, different evaluation approaches were adopted; however, all demonstrated positive health outcomes relating to dietary salt reduction. Three of the four studies measured sodium in breads and provided consistent evidence that sodium reduction in breads is feasible and different intervention options are available. None of the studies were conducted in low- or lower middle-income countries, which stresses the need for more resources and research support for the implementation of salt reduction interventions in these countries.