Safety and efficacy of salt substitution with a low sodium-potassium enriched dietary salt in patients with heart failure with reduced ejection fraction: A pilot study

Effect of partial substitution of NaCl by KCl on aggregation behavior and gel properties of beef myosin

Based on the three typical gels under KCl substitution groups, the effect of partial substitution of NaCl by KCl (groups: T 1:0.6 M NaCl; T 2: 0.3 M NaCl +0.3 M KCl; T 3: 0.2 M NaCl +0.4 M KCl; T 4:0.6 M KCl) on the aggregation behavior and gel characteristics of myosin was evaluated. The significant changes in hydrophobicity and sulfhydryl content (P < 0.05) indicate KCl substitution enhances myosin aggregation through hydrophobic interactions and disulfide bonds. According to Ca2+-ATP, scanning electron microscopes (SEM) and the rheological results, T2 had a smoother network structure at about 75 °C. Noticeably, T3 had high water holding capacity (WHC), but its gel had some visible cavities. T4 had a gel structure with several irregular aggregates due to a greater aggregation rate. Thus, appropriate partial substitution of NaCl by KCl could enhance beef myosin gel properties and heat-induced aggregation behavior.

Incorporation of cross-linked/acetylated tapioca starches on the gelling properties, rheological behaviour, and microstructure of low-salt myofibrillar protein gels: Perspective on phase transition

This study investigated the gelling properties, rheological behaviour, and microstructure of heat-induced, low-salt myofibrillar protein (MP) gels containing different levels (2%, 4%, 6%, and 8%, w/w) of cross-linked (CTS) or acetylated (ATS) tapioca starch. The results indicated that either CTS or ATS significantly enhanced the gel strength and water-holding capacity of low-salt MP gels (P < 0.05), an outcome verified by the rheological behaviour test results under different modes. Furthermore, iodine-staining images indicated that the MP-dominated continuous phase gradually transited to a starch-dominated phase with increasing CTS or ATS levels, and 4% was the critical point for this phase transition. In addition, hydrophobic interactions and disulphide bonds constituted the major intermolecular forces of low-salt MP gels, effectively promoting phase transition. In brief, modified tapioca starches possess considerable potential application value in low-salt meat products.

Salt substitute recommendations for heart failure patients may influence guideline-directed medical therapies titration

AIMS

Reducing sodium intake is necessary for patients with chronic heart failure (CHF). Salt substitutes (saltSubs) have become increasingly popular as recommendations by healthcare professionals (HCPs) as well as options for patients and their caregivers. However, their consumption is generally potassium based and remains poorly evaluated in CHF management. Their impact on guideline-directed medical therapies (GDMTs) also remains unknown. The primary objective of this study was to provide a description and estimate of HCP recommendations and reported use of saltSubs in France. Secondary objectives were to identify if there was an association between these recommendations by HCPs and the use of GDMTs.

METHODS AND RESULTS

A nationwide, questionnaire-based, cross-sectional, epidemiological study was conducted from September 2020 to July 2021. Data collection included baseline characteristics, the use and recommendations of saltSubs, and the use of GDMTs, which included (i) angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNis), (ii) mineralocorticoid receptor antagonists (MRAs), and/or (iii) beta-blockers (BBs). In total, 13% of HCPs advised saltSubs and 17% of patients and 22% of caregivers reported their consumption. CHF patients advised to take saltSubs did not differ in terms of left ventricular ejection fraction (EF) <40%, ischaemic origin, and New York Heart Association III-IV class, but were more recently hospitalized for acute HF (P = 0.004). HCPs who recommended saltSubs to patients were more likely to advise an anti-diabetic diet (P < 0.001), cholesterol-lowering diet (P < 0.001), and exercise (P = 0.018). In the overall population, ACEi/ARB/ARNi use was less frequent in case of saltSub recommendations (74% vs. 82%, P = 0.012). The concomitant prescription of none, one, two, or three GDMTs was less favourable in case of saltSub recommendations (P = 0.046). There was no significant difference for the presence of MRA (56% vs. 58%) and/or BB (78% vs. 82%). The under-prescription of ACEi/ARB/ARNi was found when patients had EF < 40% (P = 0.029) and/or EF ≥ 40% (P = 0.043). In the subgroup with left ventricular EF ≥ 40%, we found a higher thiazide use (P = 0.014) and a less frequent use of low EF GDMTs (P = 0.044) in case of being recommended saltSubs.

CONCLUSIONS

Beyond the well-established risk for hyperkalaemia, our preliminary results suggest a potentially negative impact of saltSubs on GDMT use, especially for ACEis/ARBs/ARNis in CHF management. saltSub recommendations and their availability from open sale outlets should be considered to avoid possible misuse or deference from GDMTs in the future. Informed advice to consumers should also be considered from HCPs or pharmacists.

Effect of Ultrasound-Assisted Sodium Bicarbonate Treatment on Aggregation and Conformation of Reduced-Salt Pork Myofibrillar Protein

To study the effects of an ultrasound (0, 30, and 60 min) and sodium bicarbonate (0% and 0.2%) combination on the reduced-salt pork myofibrillar protein, the changes in pH, turbidity, aggregation, and conformation were investigated. After the ultrasound-assisted sodium bicarbonate treatment, the pH increased by 0.80 units, the absolute value of Zeta potential, hydrophobic force, and active sulfhydryl group significantly increased (p < 0.05), and the turbidity and particle size significantly decreased (p < 0.05). Meanwhile, the fluorescence intensity decreased from 894 to 623, and the fluorescence peak showed a significant redshift, which indicated that the ultrasound-assisted sodium bicarbonate treatment exposed the non-polarity of the microenvironment in which the fluorescence emission group was located, leading to the microenvironment and protein structure of myofibrillar tryptophan being changed. Overall, an ultrasound-assisted sodium bicarbonate treatment could significantly improve pork myofibrillar protein solubility and change the protein structure under a reduced-salt environment.

Estimated Benefits and Risks of Using a Reduced-Sodium, Potassium-Enriched Salt Substitute in India: A Modeling Study

BACKGROUND

Salt substitution (ie, replacement of table and cooking salt with potassium-enriched salt substitutes) is a promising strategy to reduce blood pressure and prevent cardiovascular disease, particularly in countries like India where there is high sodium intake, mainly from discretionary salt, and low potassium intake. Life-threatening hyperkalemia from increased potassium intake is a postulated concern for individuals with chronic kidney disease.

METHODS

We used comparative risk assessment models to estimate the number of (1) cardiovascular deaths averted due to blood pressure reductions; (2) potential hyperkalemia-related deaths from increased potassium intake in individuals with advanced chronic kidney disease; and (3) net averted deaths from nationwide salt substitution in India. We evaluated a conservative scenario, based on a large, long-term pragmatic trial in rural China; and an optimistic scenario informed by our recent trial in India. Sensitivity analyses were conducted to assess the robustness of the findings.

RESULTS

In the conservative scenario, a nationwide salt substitution intervention was estimated to result in ≈214 000 (95% uncertainty interval, 92 764-353 054) averted deaths from blood pressure reduction in the total population and ≈52 000 (22 961-80 211) in 28 million individuals with advanced chronic kidney disease, while ≈22 000 (15 221-31 840) hyperkalemia-deaths might be caused by the intervention. The corresponding estimates for the optimistic scenario were ≈351 000 (130 470-546 255), ≈66 000 (24 925-105 851), and ≈9000 (4251-14 599). Net benefits were consistent across sensitivity analyses.

CONCLUSIONS

Modeling nationwide salt substitution in India consistently estimated substantial net benefits, preventing around 8% to 14% of annual cardiovascular deaths. Even allowing for potential hyperkalemia risks there were net benefits estimated for individuals with chronic kidney disease.

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

OBJECTIVES

The Salt Substitute and Stroke Study (SSaSS) recently reported blood pressure-mediated benefits of a potassium-enriched salt substitute on cardiovascular outcomes and death. This study assessed the effects of salt substitutes on a breadth of outcomes to quantify the consistency of the findings and understand the likely generalisability of the SSaSS results.

METHODS

We searched PubMed, Embase and the Cochrane Library up to 31 August 2021. Parallel group, step-wedge or cluster randomised controlled trials reporting the effect of salt substitute on blood pressure or clinical outcomes were included. Meta-analyses and metaregressions were used to define the consistency of findings across trials, geographies and patient groups.

RESULTS

There were 21 trials and 31 949 participants included, with 19 reporting effects on blood pressure and 5 reporting effects on clinical outcomes. Overall reduction of systolic blood pressure (SBP) was -4.61 mm Hg (95% CI -6.07 to -3.14) and of diastolic blood pressure (DBP) was -1.61 mm Hg (95% CI -2.42 to -0.79). Reductions in blood pressure appeared to be consistent across geographical regions and population subgroups defined by age, sex, history of hypertension, body mass index, baseline blood pressure, baseline 24-hour urinary sodium and baseline 24-hour urinary potassium (all p homogeneity >0.05). Metaregression showed that each 10% lower proportion of sodium choloride in the salt substitute was associated with a -1.53 mm Hg (95% CI -3.02 to -0.03, p=0.045) greater reduction in SBP and a -0.95 mm Hg (95% CI -1.78 to -0.12, p=0.025) greater reduction in DBP. There were clear protective effects of salt substitute on total mortality (risk ratio (RR) 0.89, 95% CI 0.85 to 0.94), cardiovascular mortality (RR 0.87, 95% CI 0. 81 to 0.94) and cardiovascular events (RR 0.89, 95% CI 0.85 to 0.94).

CONCLUSIONS

The beneficial effects of salt substitutes on blood pressure across geographies and populations were consistent. Blood pressure-mediated protective effects on clinical outcomes are likely to be generalisable across population subgroups and to countries worldwide.

TRIAL REGISTRATION NUMBER

CRD42020161077.

Effect of ultrasound-assisted sodium bicarbonate treatment on gel characteristics and water migration of reduced-salt pork batters

To study the potential usefulness of ultrasound (0, 30, and 60 min) and sodium bicarbonate (0 % and 0.2 %) combination on the reduced-salt pork batters, the changes in water holding capacity, gel properties, and microstructure were investigated. The pH, salt-soluble proteins solubility, cooking yield, and b* values of reduced-salt pork batters significantly increased (P < 0.05) with the increase in ultrasound time and the addition of sodium bicarbonate, leading to the hardness, springiness, cohesiveness, and chewiness significantly increased (P < 0.05). Furthermore, the use of ultrasound-assisted sodium bicarbonate treatment caused the reduced-salt pork batters to form a typical spongy structure with more evenly cavities. Due to the initial relaxation time of T₂₁ and T₂₂ were shorter, and the peak ratio of P₂₁ was increased and P₂₂ was decreased after ultrasound-assisted sodium bicarbonate treatment, implying that the mobility of water was reduced. Thus, the use of ultrasound-assisted sodium bicarbonate treatment enabled reduced-salt pork batters to have better gel characteristics and higher cooking yield.

Impact of salt concentration on bacterial diversity and changes in biogenic amines during fermentation of farmhouse soybean paste in Northeast China

Farmhouse soybean paste in Northeast China is a traditional fermented product made from soybean, and more than 11% (w/w) salt is usually added during production to control the fermentation process. In this study, the variations in bacterial diversity, biogenic amines(BAs) and physicochemical properties during the natural fermentation of soybean paste with different salt concentrations (8%, 9%, 10%, 11%, and 12%) were studied. The results show that at 0 days (0 d) of fermentation in soybean paste, the dominant genera included Staphylococcus, unidentified Clostridiales, and Sporolactobacillus. During fermentation from 30 d to 90 d, the dominant genera were Tetragenococcus and Staphylococcus. However, the proportions of the dominant genera were different depending on the salt concentration. Putrescine(Put), tryptamine(Try), β-phenethylamine(Phe), cadaverine(Cad), histamine(His), and tyramine(Tyr) showed negative correlations with salt concentration. The amino type nitrogen(ANN), titratable acidity(TTA) and total number of colonies were also negatively correlated with salt concentration. Analysis of the correlation between genera and BAs showed that 12 genera were positively correlated with BAs, and 4 genera were negatively correlated with BAs. The results of this study indicated that salt has a significant impact on bacterial diversity during the fermentation of soybean paste, which in turn affects the changes in bacterial metabolites. From the perspective of food safety, the amount of salt added in the soybean paste can be reduced to 10% under the existing fermentation conditions.

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The effect of salt concentration on soybean paste was studied.

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Salt concentration affected the bacterial diversity and BAs in soybean paste.

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There was a species succession process in the initial 30 days of fermentation.

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There was correlation between the BAs and some bacteria in soybean paste.

Effect of sodium bicarbonate and sodium chloride on aggregation and conformation of pork myofibrillar protein

To investigate the effect of sodium bicarbonate instead of sodium chloride, the changes in pH, turbidity, aggregation, and conformation of myofibrillar protein solution with various amounts of sodium chloride and sodium bicarbonate were studied. When the sodium bicarbonate was increased from 0% to 0.4%, accompanied by the sodium chloride being decreased from 2.0% to 0.8%, the pH increased about 1.20 unites; the absolute values of the Zeta potential, active sulfhydryl, and surface hydrophobicity increased significantly (p < 0.05); and the turbidity, particle size, and Ca²⁺-ATPase activity decreased significantly (p < 0.05). In addition, the Mg²⁺-ATPase activity was not significantly different (p > 0.05) when increasing sodium bicarbonate, implying that sodium bicarbonate did not affect the actin. Overall, the results indicated that an increase in sodium bicarbonate could improve solubility, expose more hydrophobic residues and sulfhydryl groups, and induce Ca²⁺-ATPase inactivation and protein unfolding, leading the myofibrillar protein to denaturation easily.