JC2011-12 Salt - Dr. Branch

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To Salt or Not to Salt:

To Salt or Not to Salt Candice Branch, MD MPH

Reduced dietary salt for the prevention of cardiovascular disease:

Reduced dietary salt for the prevention of cardiovascular disease By Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim S

Outline:

Outline Objectives for the study Study requirements Results Conclusions What do we do now?

Objectives:

Objectives What are the long term effects of low salt diet interventions on mortality and cardiovascular morbidity? Will a reduced BP as an effect of low salt diet cause better mortality and cardiovascular outcomes?

Inclusion requirements:

Inclusion requirements Randomized control trials Adults Intervention = reduced salt diet or advice to reduce salt intake Outcomes Primary – mortality (overall and cardiovascular), morbidity Secondary – SBP, DBP, urinary salt excretion, QOL

Interventions:

Interventions Dietary program provided by kitchen Dietary advice Nutritional and behavioral counseling Written daily dietary sheets

Study populations:

Study populations Normotensive patients HPT, TOPH I, TOPH II Hypertensive patients Morgan, TONE Mixed Normo and hypertensive patients Chang Heart failure patients Paterna

Bias of studies:

Bias of studies Performance and detection bias Attrition bias Follow up bias Small study bias Unclear Selection Allocation Reporting

End points:

End points Mortality Cardiovascular morbidity Included: MI, stroke, CABG, PTCA, death Blood pressure Urinary sodium excretion Quality of life

Conclusion:

Conclusion Review limited by lack of CV events, though it is more than previous study in 2004. To gain power of 80% and alpha 5%, the study would need 2,500 cv events and over 18,000 participants to show RR reduction of 0.90 Only one study was completely randomized with blinding May have lead to no difference between the 2 groups as participants may have made positive life changes Observational bias through extension of study time after the study had been completed Unclear if intervention and control groups remained true to their diets

Discussion Question:

Discussion Question Is salt reduction a medical problem or a public health problem?

The controversy :

The controversy Salt reduction does improve BP in normotensive and hypertensive patient, but only modestly Starzzullo 2009 Observational study RR of stroke 1.23; RR of CV 1.14 Confounders – low salt diet, better diet, exercise, smoke less

On the flip side:

On the flip side Further confounders: Excessive use of salt in processed foods

So where does this leave us?:

So where does this leave us? $$$ NEJM article in 2010 estimated 10 to 24 billion dollar decrease in costs if salt reduced by 1g to 3g/day in our diets UK Voluntary Campaign to reduce salt Started 2006, reached goal of decrease of 1g by 2010 Breads decrease by 35%, cereals by 45% Achieved 1.5 billion pound savings annually to date

What are we doing?:

What are we doing? Alabama limits school snacks to 360mg sodium Vermont school breakfast and lunches limit sodium to 230mg In NY…

National salt reduction initiative :

National salt reduction initiative NY

Participants:

Participants Au Bon Pain Bertucci’s Italian Restaurant Black Bear European Style Deli Boar’s Head Provisions Co. Butterball Campbell Soup Company Delhaize America Dietz & Watson FreshDirect Furmano’s Goya Foods Hain Celestial Heinz Hostess Brands Ken’s Foods Kraft Foods LiDestri Foods / Francesco Rinaldi Mars Food US McCain Foods Premio Red Gold, Inc. Snyder’s-Lance, Inc. Starbucks Coffee Company Subway® Target Corporation Unilever Uno Chicago Grill White Rose

References:

References Taylor RS, Ashton KE,Moxham T, Hooper L, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD009217. DOI: 10.1002/14651858.CD009217. Kirsten Bibbins -Domingo, Ph.D., M.D., Glenn M. Chertow , M.D., M.P.H., Pamela G. Coxson , Ph.D., Andrew Moran, M.D., James M. Lightwood, Ph.D., Mark J. Pletcher , M.D., M.P.H., and Lee Goldman, M.D., M.P.H. N Engl J Med 2010; 362:590-599 http://www2.cdc.gov/phlp/winnable/sodium_reduction.asp http://www.cihr.ca/e/41968.html#s8 www.cdc.gov/ salt /pdfs/ sodium _ reduction _in_hospitals.pdf http://www.food.gov.uk/news/pressreleases/2009/may/salttargets

But first…:

But first… Thank you…

References:

References Taylor RS, Ashton KE,Moxham T, Hooper L, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD009217. DOI: 10.1002/14651858.CD009217. Kirsten Bibbins -Domingo, Ph.D., M.D., Glenn M. Chertow , M.D., M.P.H., Pamela G. Coxson , Ph.D., Andrew Moran, M.D., James M. Lightwood, Ph.D., Mark J. Pletcher , M.D., M.P.H., and Lee Goldman, M.D., M.P.H. N Engl J Med 2010; 362:590-599 http://www2.cdc.gov/phlp/winnable/sodium_reduction.asp http://www.cihr.ca/e/41968.html#s8 www.cdc.gov/ salt /pdfs/ sodium _ reduction _in_hospitals.pdf http://www.food.gov.uk/news/pressreleases/2009/may/salttargets

Thank you:

Thank you AGAIN..

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