salt reduction resource slides

8/10/2019 Salt Reduction Resource Slides

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Outline


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Hypertension:

A leading risk factor for death

and disability


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Proportion of deaths attributable to leading risk

factors worldwide (WHO 2000)

Ezzati et al. WHO 2000 Report. Lancet.2002;360:1347-60.

Attributable Mortality(In millions; total 55,861,000)

0 87654321


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Organ damage related to

hypertensionCerebrovascular disease

- transient ischemic attacks- ischemic or hemorrhagic stroke- vascular dementia

Hypertensive retinopathyLeft ventricular dysfunction

Coronary artery disease

- myocardial infarction- angina pectoris- congestive heart failure

Chronic kidney disease- hypertensive nephropathyGFR < 60 ml/min/1.73 m2)- albuminuria- ESRD/dialysis

Peripheral artery disease

- intermittent claudication


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High blood pressure

as a cardiovascular risk factor

Systolic blood pressure > 115 mmHg causes:

overall 50% of heart and stroke 60-70% of strokes

Hypertension > 140/90 mmHg causes:

heart Failure 50% heart attack 25%

kidney failure 20%


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Risk of hypertension

increases with age

Risk of Hypertension %

0 2 4 6 8 10 12 14 16 18 20

Years to Follow-up

Women

Risk of Hypertension %

Years to Follow-up

0 2 4 6 8 10 12 14 16 18 20

Men

JAMA.2002: Framingham data.

100

80

60

40

20

0

100

80

60

40

20

0

Future risk in normotensive women and men aged 65 years


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In summary

Hypertension is a leading risk factor fordeath and disability.

Hypertension is a major cardiovascularrisk factor.

Hypertension is very prevalent and has alarge impact on health care resource use.

Lifestyle factors influence blood pressureincluding dietary salt.


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Salt , Sodium & Hypertension


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Higher dietary salt increases death

from stroke in the EU

Adapted from Perry IJ et al. J Hum Hypertens. 1992;6:23-25.


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High salt intake increases

risk of death

CHD

Death

CVD

Death

All

Death1.75

1.50

1.25

1.00

0.75

0.50

H

azardRatio

High saltintake

Lower saltintake

He FJ, MacGregor GA. J Hum Hypertens. 2002;16:761-70.


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International scientific and healthorganizations conclude that high

dietary salt:

increases blood pressure

is a health risk

WHO/FAO technical report recommendsless than 5 g of salt per day

Nishida C et al. Public Health Nutr. 2003;7:245-50.


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Animal studies suggest:

Van Vliet et al, 2006

Excess salt intake can cause aslow and progressive increasein blood pressure.

In time, salt restriction may notfully restore blood pressure tooriginal levels.

Acute salt restriction mayunderestimate the accumulatedeffects of lifelong salt exposure.


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Excess salt intake increases

morbidity and mortality in animals

Morbiditiescardiac hypertrophy

vascular hypertrophyvascular stiffening renal damagehyperlipidaemia insulin resistance

Mortalityhypertensive encephalopathystrokeheart failure

premature death

Progressive (left to right) effect of salt exposure on

LVH in salt sensitive (DS, top row) vs salt resistant

(DR, bottom row) rats.

From InokoAm J Physiol. 1994;267:H2471-82.


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Animal studies summary

The ability of excess salt toraise blood pressure appears tobe a general characteristic inmammals, including humans.

The effects of salt on bloodpressure are complex, havingseveral distinct components:- acute vs slow-progressive;

- reversible vs irreversible.

Many individual systems andmechanisms contribute to theeffect of salt on blood pressure.


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Renal Mechanisms

for Salt-DependentHypertension


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Acute salt sensitivity

of blood pressure

Salt sensitivity is well

defined by the steadystate relationshipbetween salt intake andblood pressure(chronic pressure

natriuresis relationship,or renal function

curve).


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intrauterine growth retardation (IUGR) low nephron mass renal disease

inflammation, injury, etc genetic abnormalities exogenous agents (e.g. DOCA) ageing - salt excretion

Factors that lead to salt sensitivityof blood pressure


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Evidence in Humans for a Link

betweenHigh Dietary Salt & Hypertension


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Lower salt reduces

systolic blood pressure4

2

0

-2

-4

-6

-8

-10

-12

-30 -50 -70 -90 -110 -130Change in Urinary Salt

(mmol/24h)

ChangeinSystolicB

loodPressure

(mmHg

)

Normotensives

Hypertensives

He FJ, MacGregor GA. J Hum Hyptens.2002;16:761-70.


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Lower dietary salt reduced blood

pressure in hypertensive adults

20 trials, 802 individuals

dietary salt lowered by 4.5 g/dayfrom baseline of 7 - 11 g/d to 3.257.2 g/d

blood pressure lowered by 5.1/2.7 mm Hg

He FJ, MacGregor GA. Cochrane Database of Syst

Rev. 2004;Issue 1. Art. No.: CD004937.


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Lower dietary salt reduces blood pressure innormotensive adults

11 trials, 2,220 subjects

dietary salt lowered by 4.25 g/dayfrom baseline of 7.2511.5 g/d to 3.257.75 g/d

blood pressure lowered by 2.0/1.0 mm Hg

He FJ, MacGregor GA. Cochrane Database of Syst Rev.

2004;Issue 1. Art. No.: CD004937.


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Effects of salt reduction on

blood pressure over time

Obarzanek E et al. Hypertension.2003;42:459-67.


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Lower salt as part of a healthy diet

Methodology randomized 412 adults (mixed blood pressure status, racial

groups, sexes) to:

control diet - lowin fruit, vegetables and dairy, fat content typicalof US diet

DASH diet - highin fruit, vegetables and low-fat dairy, reduced

fat content

consume diet for consecutive 30 day periods in random order ateach of 3 levels of salt

DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344:3-10.


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Results: diet and salt intake

DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344:3-10.

In tervent ion Change in mean blood pressure vs con tro l

(systol ic)

Control diet DASH diet

9 g/d salt control level - 6 mmHg

6 g/d salt - 2 mmHg - 7 mmHg

3 g/d salt - 7 mmHg - 9 mmHg


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Salt restriction reduces

blood pressurein children and infants

Children (average age 13)reduced dietary salt 42%reduced blood pressure 1.17/1.29 mmHg

Infants (less than one year)reduced dietary salt 54%reduced systolic blood pressure 2.47 mmHg

Hypertension.2006;48:861-9.


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In summary

High dietary salt increases blood pressure, which

is a health risk. Lower salt consumption decreases blood

pressure.

Other dietary factors can also reduce bloodpressure.


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The Importance ofLower Salt Intake


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Healthcare cost savings in Canadaby reducing dietary sodium

Using the Cochrane Review data

a reduction in average dietary sodium intake by4.5g/d (from 8.8g to 4.3g in Canada) would result in

30% fewer people with hypertension

almost double the blood pressure treatment and controlrate

hypertension care cost savings of $430 to $538 million/yr

Can J Cardiol. 2007;23:437-43.


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Impact of reducing blood pressurethrough dietary sodium

Annual reduction in incidence of

myocardial infarction (5%) strokes (13%)

heart failure (17%)

Reduction in health care costs associated with

the overall predicted 8.6% reduction in CVD

$1.7 billion per year in Canada and $18 billion inthe United States

Can J Cardiol. 2008;24:497-501.


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Observed effect of lower saltintake on cardiovascular events in

TOHP trials

25-30% lower risk of cardiovascular eventsin those who had been in the low saltgroups

1.9 -2.5 g/day reduction in dietary saltduring intervention

BMJ.2007;334:885-92.


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Changes in diastolic blood pressure,

salt intake and stroke deaths in Finland5600 mg

3360 mg

DBP Salt StrokeKarppanen H et al. Progress, Cardiovascular Disease. 2006;49:59-75.


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Salt intake and obesity

High dietary salt increases thirst and fluidconsumption.

Many of the fluids consumed contain simple sugarsor alcohol and contribute to caloric intake.

20-30% of the excess calories consumed by childrenand adolescents are through increased beverageconsumption associated with high salt intake.

Therefore high salt diets are likely to be a significantfactor in the obesity epidemic.

He FJ et al. Hypertension. 2008;51:629-34.


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Relationship between salt intake and fluid

consumption in children and adolescents

R=0.40p


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Salt and other health effects

obesity and related diseases (e.g. diabetes)

asthma

kidney stones

osteoporosis

gastric cancer


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Dietary salt intake for adults

In Canada and the USA

3.25 - 3.75 g/day (age dependant) is estimated to

be adequate for most adults (adequate intake (AI))

5.75 g/day is above the upper limit recommendedfor health (upper limit (UL))

WHO/FAO technical report has indicated dietary salt

intake should be less than 5 g/day

DRI, IM 2003


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Prevalence of excessive intakes:What we eat in America, NHANES 2001-2002


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Where in our diet does salt come from?

12% natural content offoods

hidden salt: 77% from

processed foodmanufactured andrestaurants

conscious salt:11%

added at the table (5%)and in cooking (6%)

J Am College of Nutrition. 1991;10:383-93.

11%

12%

77%

Occurs Naturally in Foods

Added at the Table or in Cooking

Restaurant/Processed Food

In regions where most food

is processed or eaten in

restaurants


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Where in our diet does salt come

from?

In regions where most food is prepared

and eaten at home, large amounts of saltmay be added in cooking or at the table.


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Salt in our food: why?

boosts flavor, texture and shelf life of foods

salt and sodium phosphates increase waterbinding capacity of meat products

salty snacks make you thirsty!


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Our taste for salt:

would we miss it ?

Taste buds get used to high salt levels.

As salt levels are gradually reduced tastebuds adapt.

Only takes a few weeks to enjoy food withless salt and reveal subtle flavors.


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In summary

In the Americas, people consume an unhealthyamount of salt.

This can cause hypertension, a leading risk for

death and disability. The solution is to reduce salt in commercially

manufactured food and promote healthy eating.

We need to educate the public and patients.

We need to provide leadership in ourcommunities.

The outlook for improvement is cautiously

optimistic.


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Key messages

Dietary salt is an important contributor to highblood pressure.

Reducing salt lowers blood pressure andprevents cardiovascular disease.

Salt intake in the Americas is higher than thelevels recommended for health.


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Key messages

Policies to reduce population-wide saltintake are most effective and can have a

high impact.

Healthcare professionals can play a key rolein educating people of all ages regarding

their optimal dietary salt intake.


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Success stories for reducing dietary salt

Finland (1970) Karppanen H, Mervaala E. Sodium intake and hypertension. Prog Cardiovasc Dis

2006; 49: 5975; Laatikainen T et al. Sodium in the Finnish diet: 20-year trends inurinary sodium excretion among the adult population. Eur J Clin Nutr 2006; 60: 96570.

UK (1996)

Food Standards Agency http://www.food.gov.uk/healthiereating/salt/

CASHConsensus Action on Salt and Health http://www.actiononsalt.org.uk/

WASH (2005)World Action on Salt andHealth http://www.worldactiononsalt.com/
http://www.actiononsalt.org.uk/http://www.actiononsalt.org.uk/


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Global initiatives

Success of WASHraising public, political andmanufacturers awareness

WHO Technical Meeting statement on Reducing

salt intake in populations

Agreement of major global food and beveragemanufacturers to cut salt in their foods products

World Hypertension Day 2009 theme Salt and

Hypertensiona massive global public healthcampaign to reduce dietary salt through a varietyof initiatives including food sector and other

stakeholders participation


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Reducing salt intake

Most dramatic impact will be to reducehidden salt in manufactured foods

Reduction can be achieved by gradual reduction of salt by food manufacturers

and restaurateurs

a public campaign on health benefits of salt

reduction raising consumer attention to salt levels on food

labels


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Anticipated outcomes

increased consumer awareness of the healthdangers of high dietary salt

increased consumer demand for lower salt foods increased development of lower salt foods by the

food sector

increased government monitoring of dietary saltas a health parameter

gradual reduction in dietary salt such that mostpeople are below the upper limit (by 2020)


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PAHO/WHO

Cardiovascular Disease Prevention

through Dietary Salt Reduction

PAHO has established a Regional Experts

Group international leaders in nutrition and chronic

diseases

developed a policy statement

with a view to commitment and implementation bystakeholders

who is willing to do what

what resources are required


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Policy GoalA gradual and sustained drop in dietary salt intake toreach national targets or the internationallyrecommended target of less than 5g/day/person by2020.

Recommendat ions for Pol icy and Ac t ion

Consistent with the three pillarsfor successful dietarysalt reduction published by WHO: productreformulation; consumer awareness and educationcampaigns; and environmental changes to makehealthy choices the easiest and most affordableoptions for all people.


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To nat ional governments

Seek endorsement for the PAHO dietary salt

reduction policy statement from ministries ofhealth, agriculture and trade, from foodregulatory agencies, national public healthleaders, non-governmental organizations,academia, and relevant food industries.


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To nat ional governments

Develop sustainable, securely funded, scientificallybased salt reduction programs that are integrated intoexisting food, nutrition and health education programs.

The programs should be socially inclusive and includemajor socioeconomic, racial, cultural, gender and agesubgroups and specifically children. Components shouldinclude:

Standardized food labels that easily identify high andlow salt foods.

Educating people including children about the healthrisks of high dietary salt and how to reduce salt intake

as part of a healthy diet.


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To national governments

Initiate collaboration with relevant domestic foodindustries to set gradually decreasing targets, withtimelines, for salt levels according to food categories,by regulation or through economic incentives or

disincentives with government oversight.

Regulate or otherwise encourage domestic andmultinational food enterprises to adopt a)best in

class (salt content to match the lowest in the specificfood category) and b) best in world (salt content tomatch the lowest in a specific food produced by thecompany elsewhere in the world) formulations forproducts in national markets.


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To nat ional governm ents

Develop a national surveillance system with

regular reporting of dietary salt intake levelsand the major sources of dietary salt. Monitorprogress towards reducing intake to the reachthe international target or a national one.


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To national governments

Review national salt fortification policies andrecommendations to be in concordance with therecommended salt intake.

Extend official support to the Codex AlimentariusCommittee on Food Labeling for salt/sodium to beincluded as a mandatory component of nutritionlabels.

Develop legislative or regulatory frameworks toimplement the WHO recommendations on advertisingof food products and beverages to children.


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To nongovernm ental organizat ions , heal thcare

organizations , assoc iat ions of heal thprofessionals, consumers associations

Endorse the PAHO dietary salt reduction policystatement.

Educate memberships on the health risks of highdietary salt and how to reduce salt intake. Encourageinvolvement in advocacy. Monitor and promotepresentations on dietary salt at national meetings and

the publication of articles on dietary salt reduction. Promote and advocate media releases on dietary salt

reduction to reach the public, including children andparticularly women given their integral roles in familyhealth and food preparation.


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To nongovernmental organizations,

healthcare organizat ions, associat ions of

health professionals, consumers

associat ions

Broadly disseminate relevant literature.

Educate policy and decision makers on the healthbenefits of lowering blood pressure amongnormotensive and hypertensive people, regardless ofage.

Advocate policies and regulations that will contributeto population-wide reductions in dietary salt.

Promote coalition-building, increase organizationalcapacity for advocacy and develop advocacy tools to

promote civil society actions.


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To the food indus t ry

Endorse the PAHO dietary salt reduction policy statement.

Make current best in class and best in world low saltproducts and practices universal across global markets assoon as possible. Make salt substitutes readily available ataffordable prices.

Institute reformulation schedules for a gradual andsustained reduction in the salt content of all existing salt-containing food products, restaurant and ready-mademeals to contribute to achieving the policy goal. Make all

new food product formulations inherently low in salt. Use standardized, clear and easy-to-understand food

labels that include information on salt content.

Promote the health benefits of low salt diets to all peoples

of the Americas.


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To PAHO

Ensure good communications and information sharing

between regional and international initiatives to foster bestpractices.

Develop a template for national report cards and report toMember States on comparative national baselines and

progress at pre specified time points (e.g. in 2010 thebaseline, progress in 2015 and 2020).

Work with Member States to monitor dietary saltconsumption.

Develop and foster a network of endorsing governments,NGOs, and expert champions on dietary salt in the region.

Develop a web based toolbox with educational materials

and programs on dietary salt for the public, patients,healthcare professionals that are culturally appropriate to

subregions of the Americas.


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Where can I get resources?

www.lowersodium.ca www.sodium101.ca

Hypertension website

www.hypertension.ca

Consensus Action on Salt & Health (CASH)

www.actiononsalt.org.uk

World Action on Salt &Health (WASH)

www.worldactiononsalt.com/ World Health Organization (WHO)

www.who.int/dietphysicalactivity/reducingsalt/en

Pan American Health Organizaiton (PAHO)

www.paho.org/cncd_cvd/salt
http://www.lowersodium.ca/http://www.sodium101.ca/http://www.hypertension.ca/http://www.actiononsalt.org.uk/http://www.worldactiononsalt.com/http://www.who.int/dietphysicalactivity/reducingsalt/enhttp://www.paho.org/cncd_cvd/salthttp://www.paho.org/cncd_cvd/salthttp://www.who.int/dietphysicalactivity/reducingsalt/enhttp://www.worldactiononsalt.com/http://www.actiononsalt.org.uk/http://www.hypertension.ca/http://www.sodium101.ca/http://www.lowersodium.ca/


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Resources


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Resources

1. Sodium chloride, dietaryadverse effects2. Hypertensionprevention and control3. Iodinedeficiency

4. Nutrition policy5. National health programsorganization and administration

I. World Health OrganizationII. WHO Technical Meeting on Reducing Salt Intake in Populations (2006: Paris, France)III. Title

ISBN 978 92 4 159537 7 (NLM classification: QU 145)

WHO Forum on Reducing Salt Intake inPopulations (2006: Paris, France)Reducing salt intake in populations:

Report of a WHO Forum and Technical

Meeting.

5-7 October 2006, Paris, France.
http://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdfhttp://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdfhttp://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdfhttp://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdfhttp://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdfhttp://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdfhttp://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdfhttp://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdf


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Resources

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