Population-wide sodium reduction: the bumpy road from evidence to policy

Eligibility and Prevalence of the American Heart Association Heart Check Certification Program in the US Packaged Food and Beverage Supply: A Cross-Sectional Study

Objective: Consumers in the US make choices within a food supply dominated by processed packaged foods and beverage products. Front-of-package nutrition labels (FOPL) equip consumers to make healthier choices, but further evaluation and regulation regarding FOPL format, scope, and display have been recommended by the World Health Organization. As a leader in consumer FOPL guidance, the American Heart Association's (AHA) Heart Check programme certifies food companies seeking to add an AHA Heart Check logo as a FOPL for qualifying heart healthy products. A cross-sectional assessment of the AHA Heart Check Standard Certification was conducted within the US packaged food and beverage supply to assess the eligibility and prevalence of the programme as a FOPL. Methods: Data were derived from Label Insight's Open Data initiative, which is the largest publicly-available US branded food composition database. The proportions of products that were certified and eligible to be certified for the Standard Certification were reported by nutrient attributes, grocery aisles and food brands. Results: Among 153,453 products examined, fewer than 1% exhibited the Heart Check certification on their label. Among products that were not Heart Check certified,13.8% were eligible for Standard Certification. The most common reason for ineligibility was the saturated fat content (52%), followed by total fat content (47%) and sodium content (47%). Heart Check certification and eligibility differed substantially across grocery aisle categories. Conclusions: The abundance of unhealthy products in the US packaged food and beverage supply and absence of harmonized FOPL policies suggest the need for FOPL like the Heart Check label to promote adherence to healthy diets. There are opportunities for food manufacturers and the AHA to certify more heart healthy foods and beverages. However, more consistent criteria and transparent labelling could enhance Heart Check certification to facilitate consumers' ability to make more informed and healthful purchases.

Strategic Sodium Reduction Initiative Reduces Sodium in Meals Served at Older Adult Congregate Meal Program Sites

Excessive sodium consumption is a public health issue and congregate meal programs provide a unique opportunity to reduce sodium served to a large, at-risk population. A Sodium Reduction Initiative (SRI) was implemented in a congregate meal program that serves over 3,000 older adults. Nutrient analyses conducted at baseline and post-intervention were used to calculate average sodium reduction and the number of low sodium foods; targeted foods were categorized by strategy. Customer satisfaction surveys were collected at baseline and 3- and 6-months post-intervention. Kruskal Wallis and analysis of variance were used to compare sodium reduction differences. Chi-square analysis determined associations among strategies. The SRI impacted 55 foods, low sodium foods increased by 22%, and the average sodium per menu cycle was reduced by 21%. Replacement with a lower sodium food was the most frequently used strategy and had the largest sodium reduction. Sauces and main entrees were most frequently impacted, and thirteen ingredients accounted for 75% of all reduced-sodium foods. Over 50% of the 1,424 survey respondents consumed the reduced-sodium foods and food satisfaction remained stable from baseline to post-intervention. Congregate meals programs that target commonly used foods and key ingredients can significantly reduce sodium served to older adults.

Disparities and spatial variations of high salt intake in Iran: a subnational study of districts based on the small area estimation method

OBJECTIVE

High salt intake is one of the leading diet-related risk factors for several non-communicable diseases. We aimed to estimate the prevalence of high salt intake in Iran.

DESIGN

A modelling study by the small area estimation method, based on a nationwide cross-sectional survey, Iran STEPwise approach to risk factor Surveillance (STEPS) 2016. The modelling estimated the prevalence of high salt intake, defined as a daily salt intake ≥ 5 g in all districts of Iran based on data from available districts. The modelling results were provided in different geographical and socio-economic scales to make the comparison possible across the country.

SETTING

429 districts of all provinces of Iran, 2016.

PARTICIPANTS

18 635 salt intake measurements from individuals 25 years old and above who participated in the Iran STEPS 2016 survey.

RESULTS

All districts in Iran had a high prevalence of high salt intake. The estimated prevalence of high salt intake among females of all districts ranged between 72·68 % (95 % UI 58·48, 84·81) and 95·04 % (95 % UI 87·10, 100). Estimated prevalence for males ranged between 88·44 % (95 % UI 80·29, 96·15) and 98·64 % (95 % UI 94·97, 100). In all categorisations, males had a significantly higher prevalence of high salt intake. Among females, the population with the lower economic status had a higher salt consumption than the participants with higher economic status by investigating the concentration index.

CONCLUSIONS

Findings of this study highlight the high salt intake as a prominent risk factor in all Iran regions, despite some variations in different scales. More suitable population-wide policies are warranted to handle this public health issue in Iran.

Sodium and Health Outcomes: Ascertaining Valid Estimates in Research Studies

PURPOSE OF REVIEW

The dietary reference intake (DRI) for sodium has been highly debated with persuasive and elegant arguments made for both population sodium reduction and for maintenance of the status quo. After the 2015 Dietary Guidelines Advisory Committee (DGAC) report was published, controversy ensued, and by Congressional mandate, the sodium DRIs were updated in 2019. The 2019 DRIs defined adequate intake (AI) levels by age-sex groups that are largely consistent with the DRIs for sodium that were published in 2005. Given the overall similarities between the 2005 and 2019 DRIs, one may wonder how the recently published research on sodium and health outcomes was considered in determining the DRIs, particularly, the recent studies from very large observational cohort studies. We aim to address this concern and outline the major threats to ascertaining valid estimates of the relationship between dietary sodium and health outcomes in observational cohort studies. We use tools from modern epidemiology to demonstrate how unexpected and inconsistent findings in these relationships may emerge. We use directed acyclic graphs to illustrate specific examples in which biases may occur.

RECENT FINDINGS

We identified the following key threats to internal validity: poorly defined target intervention, poorly measured sodium exposure, unmeasured or residual confounding, reverse causality, and selection bias. Researchers should consider these threats to internal validity while developing research questions and throughout the research process. For the DRIs to inform real-world interventions relating to sodium reduction, it is recommended that more specific research questions be asked that can clearly define potential interventions of interest.

Impact of Nisin and Nisin-Producing Lactococcus lactis ssp. lactis on Clostridium tyrobutyricum and Bacterial Ecosystem of Cheese Matrices

Clostridium tyrobutyricum spores survive milk pasteurization and cause late blowing of cheeses and significant economic loss. The effectiveness of nisin-producing Lactococcus lactis ssp. lactis 32 as a protective strain for control the C. tyrobutyricum growth in Cheddar cheese slurry was compared to that of encapsulated nisin-A. The encapsulated nisin was more effective, with 1.0 log10 reductions of viable spores after one week at 30 °C and 4 °C. Spores were not detected for three weeks at 4 °C in cheese slurry made with 1.3% salt, or during week 2 with 2% salt. Gas production was observed after one week at 30 °C only in the control slurry made with 1.3% salt. In slurry made with the protective strain, the reduction in C. tyrobutyricum count was 0.6 log10 in the second week at 4 °C with both salt concentration. At 4 °C, nisin production started in week 2 and reached 97 µg/g after four weeks. Metabarcoding analysis targeting the sequencing of 16S rRNA revealed that the genus Lactococcus dominated for four weeks at 4 °C. In cheese slurry made with 2% salt, the relative abundance of the genus Clostridium decreased significantly in the presence of nisin or the protective strain. The results indicated that both strategies are able to control the growth of Clostridium development in Cheddar cheese slurries.

Scavenger Receptor Class B type 1 (SR-B1) and the modifiable risk factors of stroke

Stroke is a devastating disease that occurs when a blood vessel in the brain is either blocked or ruptured, consequently leading to deficits in neurological function. Stroke consistently ranked as one of the top causes of mortality, and with the mean age of incidence decreasing, there is renewed interest to seek novel therapeutic treatments. The Scavenger Receptor Class B type 1 (SR-B1) is a multifunctional protein found on the surface of a variety of cells. Research has found that that SR-B1 primarily functions in an anti-inflammatory and anti-atherosclerotic capacity. In this review, we discuss the characteristics of SR-B1 and focus on its potential correlation with the modifiable risk factors of stroke. SR-B1 likely has an impact on stroke through its interaction with smoking, diabetes mellitus, diet, physical inactivity, obesity, hypercholesterolemia, atherosclerosis, coronary heart disease, hypertension, and sickle cell disease, all of which are critical risk factors in the pathogenesis of stroke.

Moving the Needle on Hypertension: What Knowledge Is Needed?

This review highlights the gaps in knowledge and methodological challenges discussed during the Experimental Biology 2019 expert panel session titled "Moving the Needle on Hypertension: What Knowledge Is Needed?" Hypertension is a critical public health burden. Despite a demonstrated benefit of blood pressure reduction on measures of hypertension-related morbidity and mortality, rates for successful blood pressure control remain low. Dietary sodium reduction has been shown to reduce both systolic blood pressure by approximately 3.2 mm Hg and diastolic blood pressure by 2.3 mm Hg, depending on baseline blood pressure and degree of sodium reduction. The updated Dietary Reference Intakes for adults released by the National Academies of Sciences, Engineering, and Medicine include a Chronic Disease Risk Reduction sodium intake level of 2300 mg/d, highlighting the importance of dietary sodium intake in reducing elevated blood pressure and indicating that reducing intakes to this level is expected to reduce blood pressure and risk of cardiovascular disease. The average US daily sodium intake of 3400 mg/d is well above the Chronic Disease Risk Reduction of 2300 mg/d, suggesting that dietary sodium reduction has the potential to significantly improve public health. Although the National Academies of Sciences, Engineering, and Medicine report presents intake recommendations based on a systematic, comprehensive, and thorough evaluation of the evidence, several challenges to moving the needle on hypertension remain. Success will require a more advanced understanding of sodium and potassium physiology, as well as development of the tools needed to effectively address existing research gaps and reduce barriers to sodium intake reduction.

Barriers, Attitudes, and Dietary Behaviors Regarding Sodium Reduction in the Elderly Korean-Chinese Population in Yanbian, China

Objectives

This research investigated the barriers, attitudes, and dietary behaviors related to sodium reduction among the elderly Korean–Chinese population in Yanbian, China.

Methods

We conducted this pilot study using both descriptive research and a focus group interview at the elderly community center in Yanbian.

Results

In total, 21 elderly Korean–Chinese (average age, 71 years) were examined. The findings showed that the top three barriers to sodium reduction were 1) the difficulties associated with having meals with others, 2) a preference for liquid based-dishes, and 3) the lack of taste in low-sodium dishes. Although the participants strongly believed that a reduced-sodium diet would improve their health, they were poorly aware of the amount of sodium in various foods and dishes. In particular, the focus group interviews with eight participants (mean age, 67 years) revealed that salt-preserved foods (e.g., Korean pickled cabbage called ‘kimchi’ and soybean paste) were frequently consumed as part of their food culture, and that very salty dishes were served at restaurants, both of which lead to a high sodium intake.

Conclusion

This study provides useful preliminary data to help design a nutrition intervention program for sodium reduction that targets the elderly Korean–Chinese population in China.

Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review

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 Journalchecklist.

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.$; 2015) was particularly low for taxes, a salt reduction by food manufacturers and labelling (<−3072 Intl.$/QALY, −6187 Intl.$/LYG and <584 Intl.$/DALY over the time horizon compared with the status quo or no intervention). Targeted dietary advice was rather not cost-effective (24 600 Intl.$/QALY and >303 900 Intl.$/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.

Stroke Risk Factors, Genetics, and Prevention

Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis of stroke. Risk factors for stroke can be categorized as modifiable and nonmodifiable. Age, sex, and race/ethnicity are nonmodifiable risk factors for both ischemic and hemorrhagic stroke, while hypertension, smoking, diet, and physical inactivity are among some of the more commonly reported modifiable risk factors. More recently described risk factors and triggers of stroke include inflammatory disorders, infection, pollution, and cardiac atrial disorders independent of atrial fibrillation. Single-gene disorders may cause rare, hereditary disorders for which stroke is a primary manifestation. Recent research also suggests that common and rare genetic polymorphisms can influence risk of more common causes of stroke, due to both other risk factors and specific stroke mechanisms, such as atrial fibrillation. Genetic factors, particularly those with environmental interactions, may be more modifiable than previously recognized. Stroke prevention has generally focused on modifiable risk factors. Lifestyle and behavioral modification, such as dietary changes or smoking cessation, not only reduces stroke risk, but also reduces the risk of other cardiovascular diseases. Other prevention strategies include identifying and treating medical conditions, such as hypertension and diabetes, that increase stroke risk. Recent research into risk factors and genetics of stroke has not only identified those at risk for stroke but also identified ways to target at-risk populations for stroke prevention.

Relationship of nutrition knowledge and self-reported dietary behaviors with urinary excretion of sodium and potassium: comparison between dietitians and nondietitians

The effectiveness of better nutrition knowledge and dietary behavior on healthier dietary intake is still controversial. We hypothesized that nutritional knowledge and dietary behavior are associated with sodium and potassium intake in adult women. A cross-sectional study was conducted at welfare facilities located in 20 areas of Japan. Ninety-nine female dietitians and 117 nondietitians aged 20 to 69 years participated. Sodium and potassium intake were assessed with two 24-hour urine collections and 4-day semiweighed diet records. Nutritional knowledge and dietary behavior were accessed with 3 questionnaires. Analysis of covariance was performed to compare sodium and potassium excretion and selected nutrition and food intake between dietitians and nondietitians. After adjustment for age and smoking habit, sodium and potassium excretion did not significantly differ between the 2 groups (3857 vs 3959 mg/d, P = .57, and 2016 vs 1886 mg/d, P = .10, respectively). Sodium/potassium ratio was significantly lower in the dietitians (P = .044). The dietitians used food labels for sodium contents more often than the nondietitians and consumed more fruits and vegetables (P = .048 and P < .0001, respectively) and less sugar and confectionaries and fat and oils (P = .016 and P = .010, respectively). In conclusion, the higher level of nutritional knowledge and better dietary behavior were not associated with either sodium or potassium excretion but were moderately associated with sodium/potassium ratio.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Perceived and objective diet quality in US adults: a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES)

OBJECTIVE

The Dietary Approaches to Stop Hypertension (DASH) dietary pattern has been shown to reduce cardiometabolic risk. Little is understood about the relationship between objective diet quality and perceived diet quality (PDQ), a potential psychosocial barrier to appropriate dietary intake. We compared PDQ and diet quality measured by a nutrient-based DASH index score in the USA.

DESIGN

Cross-sectional study. Participants in the 2005-2006 National Health and Nutrition Examination Survey (NHANES) rated diet quality on a 5-point Likert scale and PDQ scores were generated (low, medium, high). A single 24 h dietary recall was used to estimate DASH index scores (range 0-9 points) by assigning 0, 0·5 or 1 point (optimal) for nine target nutrients: total fat, saturated fat, protein, cholesterol, fibre, Ca, Mg, K and Na.

SETTING

Nationally representative sample of the US population.

SUBJECTS

Adults aged ≥19 years in 2005-2006 NHANES (n 4419).

RESULTS

Participants with high PDQ (33 %) had higher DASH index scores (mean 3·0 (sd 0·07)) than those with low PDQ (mean 2·5 (sd 0·06), P < 0·001), but average scores did not align with targets for intermediate or optimal DASH accordance. Adults with high PDQ reported higher total fat, saturated fat and Na intakes compared with optimal DASH nutrient goals. Differences between those with high v. low PDQ were similar for Whites and Blacks, but there was no difference between PDQ groups for Mexican Americans.

CONCLUSIONS

Among Whites and Blacks, but not Mexican Americans, high PDQ may be associated with higher diet quality, but not necessarily a diet meeting DASH nutrient goals. This disconnect between PDQ and actual diet quality may serve as a target in obesity prevention.

Cost-effectiveness analysis of salt reduction policies to reduce coronary heart disease in Syria, 2010-2020

OBJECTIVES

This study presents a cost-effectiveness analysis of salt reduction policies to lower coronary heart disease in Syria.

METHODS

Costs and benefits of a health promotion campaign about salt reduction (HP); labeling of salt content on packaged foods (L); reformulation of salt content within packaged foods (R); and combinations of the three were estimated over a 10-year time frame. Policies were deemed cost-effective if their cost-effectiveness ratios were below the region's established threshold of $38,997 purchasing power parity (PPP). Sensitivity analysis was conducted to account for the uncertainty in the reduction of salt intake.

RESULTS

HP, L, and R+HP+L were cost-saving using the best estimates. The remaining policies were cost-effective (CERs: R=$5,453 PPP/LYG; R+HP=$2,201 PPP/LYG; R+L=$2,125 PPP/LYG). R+HP+L provided the largest benefit with net savings using the best and maximum estimates, while R+L was cost-effective with the lowest marginal cost using the minimum estimates.

CONCLUSIONS

This study demonstrated that all policies were cost-saving or cost effective, with the combination of reformulation plus labeling and a comprehensive policy involving all three approaches being the most promising salt reduction strategies to reduce CHD mortality in Syria.

A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries

Background

Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey.

Methods and Findings

Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000 and 378439 LYG in Turkey.

Conclusion

Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.

Health Beliefs Related to Salt-Restricted Diet in Patients on Hemodialysis: Psychometric Evaluation of the Turkish Version of the Beliefs About Dietary Compliance Scale

PURPOSE

The aim of this study was to evaluate the reliability and validity of the Turkish version of the Beliefs about Dietary Compliance Scale (BDCS-T).

METHODS

This methodological study enrolled a sample of 140 patients. Data were collected by using a questionnaire form, the BDCS-T, and the Dialysis Diet and Fluid Restrictions Nonadherence Questionnaire. Descriptive statistics, the one-sample Kolmogorov-Smirnov test, Mann-Whitney U test, correlation coefficients, and psychometric tests were used for the analysis of data.

RESULTS

The factor analysis confirmed that the BDCS-T had a two-factor structure (perceived benefits and perceived barriers) explaining 58.7% of the total variance. The BDCS-T had acceptable internal consistency (Cronbach's alpha coefficients: perceived benefits = .91; perceived barriers = .66), test-retest reliability (intraclass correlation coefficients: perceived benefits = .93; perceived barriers = .79), concurrent validity with the Dialysis Diet and Fluid Restrictions Nonadherence Questionnaire scores, and known group validity with intensity of diet nonadherence.

CONCLUSIONS

The BDCS-T was found to be a reliable and valid tool for assessing the beliefs related to salt-restricted diet in patients on hemodialysis.

IMPLICATIONS FOR PRACTICE

Nurses are recommended to make tailored interventions by taking the benefits and barriers that the patients perceive toward low-salt dietary adherence into account.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Challenges in sodium intake reduction and meal consumption patterns among participants with metabolic syndrome in a dietary trial

Background

Dietary guidelines suggest limiting daily sodium intake to <2,300 mg for the general population, and <1,500 mg/d for those with certain cardiovascular risk factors. Despite these recommendations, few Americans are able to achieve this goal. Identifying challenges in meeting these guidelines is integral for successful compliance. This analysis examined patterns and amount of daily sodium intake among participants with metabolic syndrome enrolled in a one-year dietary intervention study.

Methods

Two hundred forty participants with metabolic syndrome enrolled in a dietary intervention trial to lose weight and improve dietary quality. Three 24-hour dietary recalls were collected at each visit which provided meal patterns and nutrient data, including sodium intake. A secondary data analysis was conducted to examine sodium consumption patterns at baseline and at one-year study visits. Sodium consumption patterns over time were examined using linear mixed models.

Results

The percentage of meals reported eaten in the home at both baseline and one-year follow-up was approximately 69%. Follow-up for the one-year dietary intervention revealed that the participants who consumed sodium greater than 2,300 mg/d declined from 75% (at baseline) to 59%, and those that consumed higher than 1,500 mg/d declined from 96% (at baseline) to 85%. Average sodium intake decreased from 2,994 mg at baseline to 2,558 mg at one-year (P < 0.001), and the sodium potassium ratio also decreased from 1.211 to 1.047 (P < 0.001). Sodium intake per meal varied significantly by meal type, location, and weekday, with higher intake at dinner, in restaurants, and on weekends. At-home lunch and dinner sodium intake decreased (P < 0.05), while dinner sodium intake at restaurant/fast food chains increased from baseline to one-year (P < 0.05).

Conclusion

Sodium intake for the majority of participants exceeded the recommended dietary guidelines. Findings support actions that encourage low-sodium food preparation at home and encourage public health policies that decrease sodium in restaurants and prepared foods.

Recent economic evaluations of interventions to prevent cardiovascular disease by reducing sodium intake

Excess intake of sodium, a common problem worldwide, is associated with hypertension and cardiovascular disease (CVD), and hypertension is a major risk factor for CVD. Population-wide efforts to reduce sodium intake have been identified as a promising strategy for preventing hypertension and CVD, and such initiatives are currently recommended by a variety of scientific and public health organizations. By reviewing the literature published from January 2011 to March 2013, we summarized recent economic analyses of interventions to reduce sodium intake. The evidence, derived from estimates of resultant blood pressure decreases and thus decreases in the incidence of CVD events, supports population-wide interventions for reducing sodium intake. Both lowering the salt content in manufactured foods and conducting mass media campaigns at the national level are estimated to be cost-effective in preventing CVD. Although better data on the cost of interventions are needed for rigorous economic evaluations, population-wide sodium intake reduction can be a promising approach for containing the growing health and economic burden associated with hypertension and its sequelae.

The effect of sodium reduction with and without potassium chloride on the survival of Listeria monocytogenes in Cheddar cheese

Sodium chloride (NaCl) in cheese contributes to flavor and texture directly and by its effect on microbial and enzymatic activity. The salt-to-moisture ratio (S/M) is used to gauge if conditions for producing good-quality cheese have been met. Reductions in salt that deviate from the ideal S/M range could result in changing culture acidification profiles during cheese making. Lactococcus lactis ssp. lactis or Lc. lactis ssp. cremoris are both used as cultures in Cheddar cheese manufacture, but Lc. lactis ssp. lactis has a higher salt and pH tolerance than Lc. lactis ssp. cremoris. Both salt and pH are used to control growth and survival of Listeria monocytogenes and salts such as KCl are commonly used to replace the effects of NaCl in food when NaCl is reduced. The objectives of this project were to determine the effects of sodium reduction, KCl use, and the subspecies of Lc. lactis used on L. monocytogenes survival in stirred-curd Cheddar cheese. Cheese was manufactured with either Lc. lactis ssp. lactis or Lc. lactis ssp. cremoris. At the salting step, curd was divided and salted with a concentration targeted to produce a final cheese with 600 mg of sodium/100 g (control), 25% reduced sodium (450 mg of sodium/100 g; both with and without KCl), and low sodium (53% sodium reduction or 280 mg of sodium/100 g; both with and without KCl). Potassium chloride was added on a molar equivalent to the NaCl it replaced to maintain an equivalent S/M. Cheese was inoculated with a 5-strain cocktail of L. monocytogenes at different times during aging to simulate postprocessing contamination, and counts were monitored over 27 or 50 d, depending on incubation temperature (12 or 5 °C, respectively). In cheese inoculated with 4 log₁₀ cfu of L. monocytogenes/g 2 wk after manufacture, viable counts declined by more than 3 log₁₀ cfu/g in all treatments over 60 d. When inoculated with 5 log₁₀ cfu/g at 3mo of cheese age, L. monocytogenes counts in Cheddar cheese were also reduced during storage, but by less than 1.5 log10 cfu/g after 50 d. However, cheese with a 50% reduction in sodium without KCl had higher counts than full-sodium cheese at the end of 50 d of incubation at 4 °C when inoculated at 3 mo. When inoculated at 8 mo postmanufacture, this trend was only observed in 50% reduced sodium with KCl, for cheese manufactured with both cultures. This enhanced survival for 50% reduced-sodium cheese was not seen when a higher incubation temperature (12 °C) was used when cheese was inoculated at 3 mo of age and monitored for 27 d (no difference in treatments was observed at this incubation temperature). In the event of postprocessing contamination during later stages of ripening, L. monocytogenes was capable of survival in Cheddar cheese regardless of which culture was used, whether or not sodium had been reduced by as much as 50% from standard concentrations, or if KCl had been added to maintain the effective S/M of full-sodium Cheddar cheese.

Preliminary validation of the Hypertension Self-Care Activity Level Effects (H-SCALE) and clinical blood pressure among patients with hypertension

This study establishes preliminary validation of a measure that assesses hypertension self-care activities with clinical blood pressure (BP). The Hypertension Self-Care Activity Level Effects (H-SCALE) was administered to patients with hypertension to assess levels of self-care. Patients (n=154) were predominantly female (68.6%) and black (79.2%). Greater adherence to self-care was associated with lower systolic and diastolic BP for 5 of the 6 self-care behaviors. Medication adherence was correlated with systolic BP (r=-0.19, P<.05) and weight management adherence was correlated with diastolic BP (r=-0.22, P<.05) after controlling for other covariates. Increased adherence to recommended dietary practices was strongly correlated with higher systolic (r=0.29, P<.05) and diastolic BP (r=0.32, P<.05). The H-SCALE was acceptable for use in clinical settings, and adherence to self-care was generally aligned with lower BP. Assessment of hypertension self-care is important when working with individuals to control their BP.

Dietary sodium intake: knowledge, attitudes and practices in Shandong Province, China, 2011

Objective

To investigate the knowledge, attitudes and practices (KAP) for dietary sodium intake among adult residents of Shandong Province, China

Methods

In 2011, we conducted a cross sectional survey among a representative sample of 15,350 adults aged 18 to 69 years using a standardized questionnaire to assess their KAP for sodium. Variation in the KAPs by gender, and residence location were compared using the Chi-square tests. Predictors for the ‘intention to’ and ‘currently taking action to’ reduce sodium intake were determined by multivariate logistic regression with adjustment for confounding factors.

Results

KAPs for dietary sodium intake among urban residents was generally more favorable than among rural residents. Women were likely to have more favorable KAPs than men. About four fifth of subjects reported that they favored a low sodium diets. However, 31% reported that consumption of less sodium results in less physical strength. Overall, 70% indicated their intention to reduce sodium intake, although only 39 % reported that they had taken action to reduce sodium. Multiple logistic regression analyses indicated that favorable actions to dietary sodium reduction were more likely to occur among those who were aware of the link between sodium and hypertension, and less likely among those who had unfavorable attitudes towards dietary sodium reduction.

Conclusion

Increasing knowledge levels about the benefits of sodium reduction will be a key success factor for effective sodium reduction initiatives and is linked to favorable behavioral change. Emphasis should be placed on the rural area.

The feasibility of achieving low-sodium intake in diets that are also nutritious, low-cost, and have familiar meal components

OBJECTIVE

Given the importance of high sodium diets as a risk factor for disease burden (ranked 11(th) in importance in the Global Burden of Disease Study 2010), we aimed to determine the feasibility of low-sodium diets that were also low-cost, nutritious and (for some scenarios) included familiar meals.

METHODS

The mathematical technique of "linear programming" was used to model eight optimized daily diets (some with uncertainty), including some diets that contained "familiar meals" for New Zealanders or were Mediterranean-, Asian- and Pacific-style diets. Data inputs included nutrients in foods, food prices and food wastage.

FINDINGS

Using nutrient recommendations for men and a cost constraint of

CONCLUSIONS

These results provide some reassurance for the feasibility of substantially reducing population sodium intake given currently available low-cost foods and while maintaining some level of familiar meals. Policy makers could consider ways to promote such optimized diets and foods, including regulations on maximum salt levels in processed foods, and taxes on alternative foods that are high in salt, sugar and saturated fat.

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MESH Headings

• Adult
• Diet
• Diet, Sodium-Restricted/economics
• Humans
• Male
• Meals
• Models, Theoretical
• Nutritive Value

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Affiliation(s)

Nick Wilson Department of Public Health, University of Otago, Wellington, New Zealand.
Nhung Nghiem
Rachel H Foster

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