Salt intake, hypertension and diabetes mellitus

Association of triglyceride-glucose index with incident hypertension among non-overweight healthy adults: A cohort study in China

BACKGROUND AND AIMS

Overweight and obesity are well recognized as important and traditional risk factors for hypertension (HTN), but the prevalence of HTN tends to increase in non-overweight people. Triglyceride-glucose (TyG) index has been observed to be associated with HTN. However, whether such association still persists in non-overweight people remains unclear. The aim of our cohort study was to explore the link between TyG index and incident HTN in non-overweight Chinese population.

METHODS AND RESULTS

As many as 4678 individuals without HTN at baseline were involved, who underwent at least two years of health check-ups in the eight-year study period and maintained non-overweight at follow-up. According to baseline TyG index quintiles, participants were classified into five groups. Compared with the 1st quantile, those in the 5th quantile of TyG index had a 1.73-fold (HR 95% CI 1.13-2.65) risk of incident HTN. The results remained consistent when analyses were restricted to participants without abnormal TG or FPG level at baseline (HR 1.62, 95% CI 1.17-2.26). Furthermore, the subgroup analyses were conducted, the risk of incident HTN was still significantly increased with increasing TyG index for subgroups of older participants (age≥ 40 years), males, females and higher BMI group (BMI≥ 21 kg/m²).

CONCLUSIONS

The risk of incident HTN increased with increasing TyG index among Chinese non-overweight adults, so TyG index might be a reliable predictor of incident HTN among adults maintaining non-overweight.

Dietary pattern scores in relation to pre-diabetes regression to normal glycemia or progression to type 2 diabetes: a 9-year follow-up

BACKGROUND

We aimed to assess potential associations of habitual dietary pattern scores in relation to the risk of pre-diabetes (Pre-DM) progression to type 2 diabetes mellitus (T2DM) or the chance of returning to normal glycemia.

METHODS

This cohort study included 334 Pre-DM individuals (mean age of 49.4 years, and 51.5% men) who participated in the third phase of the Tehran Lipid and Glucose Study (2006-2008) and followed up for a median of 9 years. A validated food frequency questionnaire at baseline assessed usual intakes of the participants. Major dietary patterns were identified using principal component analysis. The DASH score and Mediterranean diet score (MDS) were also calculated. Multinomial logistic regression analysis was used to estimate the odds ratios (95% confidence intervals (CIs)) of developing T2DM and returning to normal glycemia in relation to dietary pattern scores.

RESULTS

During the study follow-up, 39.8% progressed to T2DM, and 39.8% returned to normal glycemia. Three following major dietary patterns, including Western-style (with a higher load of red meats, hydrogenated fats, sodium, and total fat intakes), healthy pattern (with a higher load of whole grains, vegetables, and dairy products), and processed-foods pattern (with a higher load of processed-meats, fast-foods, salty snakes, and sweets and candies) were identified. The Western-style dietary pattern increased the risk of progressing to T2DM by 38% (OR = 1.38; 95% CI = 1.00 to 1.89, P = 0.050). Other dietary pattern scores were not related to regression or progression from Pre-DM.

CONCLUSION

The Western-style dietary pattern (characterized by higher load of red meats, hydrogenated fats, sodium intake, and high-GI foods) may accelerate the progression of Pre-DM to T2DM.

Dietary pH Enhancement Improves Metabolic Outcomes in Diet-Induced Obese Male and Female Mice: Effects of Beef vs. Casein Proteins

(1) Consumption of diets that are caloric dense but not nutrient dense have been implicated in metabolic diseases, in part through low-grade metabolic acidosis. Mitigation strategies through dietary intervention to alleviate acidosis have not been previously reported. Our objective is to determine the effects of pH enhancement (with ammonia) in high fat diet-induced obese mice that were fed beef or casein as protein sources compared to low fat diet-fed mice. (2) Methods: B6 male and female mice were randomized (n = 10) into eight diets that differ in protein source, pH enhancement of the protein, and fat content, and fed for 13 weeks: low fat (11% fat) casein (LFC), LF casein pH-enhanced (LFCN), LF lean beef (LFB), LFBN, high fat (46%) casein (HFC), HFCN, HF beef (HFB), and HFBN. Body weights and composition, and glucose tolerance tests were conducted along with terminal serum analyses. Three-way ANOVA was performed. (3) Results: A significant effect of dietary fat (LF vs. HF) was observed across all variables in both sexes (final body weight, fat mass, glucose clearance, and serum leptin). Importantly, pH enhancement significantly reduced adiposity (males only) and final body weights (females only) and significantly improved glucose clearance in both sexes. Lastly, clear sex differences were observed across all variables. (4) Conclusions: Our findings demonstrate metabolic benefits of increasing dietary pH using ammonia, while high fat intake per se (not protein source) is the major contributor to metabolic dysfunctions. Additional research is warranted to determine mechanisms underlying the beneficial effects of pH enhancement, and interactions with dietary fat content and proteins.

Clinical effect of nonsteroidal mineralocorticoid receptor (MR) antagonists in the treatment of diabetic kidney disease: expectations as a new therapeutic strategy

Diabetes mellitus is the main cause of chronic kidney disease (CKD) in Japan and worldwide. Although angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor blockers (ARBs) are basic drugs for the treatment of CKD with diabetes (diabetic kidney disease, DKD) with albuminuria and/or proteinuria, it has also become clear that the use of an ACE inhibitor or ARB alone is not fully sufficient. We have previously reported the clinical effects of mineralocorticoid receptor (MR) antagonists and recommended their use in addition to renin-angiotensin system inhibitors. Recently, new types of nonsteroidal MR antagonists have been developed, and the results of a large-scale study are expected. Nonsteroidal MR antagonists are distributed in the heart, lungs, liver, and kidneys when administered orally and are characterized by their equivalent distribution between the heart (nonepithelial tissue) and kidneys (epithelial tissue). We summarize the latest evidence regarding the use of nonsteroidal MR antagonists in the treatment of DKD. Hyperkalemia and renal dysfunction are frequent during MR antagonist treatment. However, with careful and combined monitoring of these two conditions, the effectiveness of MR antagonists will not be diminished; conversely, it is apparent that patients at such risk will benefit more from the addition of an MR antagonist to the treatment regimen. The most important measure against hyperkalemia is the regular monitoring of serum potassium levels and renal function. The safest and most reliable measure against hyperkalemia is the combined use of a new oral potassium adsorbent that has high potassium selectivity and few side effects. In DKD treatment, it is important to continue using MR antagonists without interruption as much as possible.

Prevalence and associated factors of diabetes mellitus among Governmental Civil Servants at Guji Zone, Oromia Region, Ethiopia, 2021. A community-based cross-sectional study

Background

Despite it being easily preventable, still diabetes mellitus is found in every population in the world and all regions, with the greatest escalation in low and middle-income countries. Moreover, undiagnosed or poorly controlled diabetes can lead to lower limb amputation, blindness, and kidney disease. However, there is a paucity of information on the magnitude and associated factors among adult populations in rural pastoral areas. Therefore, this study aimed to assess the magnitude of diabetes mellitus and associated factors among Guji Zone Government Civil Servants, Southern Ethiopia.

Methods

Cross-sectional study was conducted from March 1-14/2018, among 437 randomly selected Government employees of Guji Zone. A self-administered questionnaire was used to collect data. Data were coded and entered using Epi-data version 3.1 and exported to SPSS version 20 for analysis. Multivariable logistic regression analysis was done to identify significant factors associated with the magnitude of DM. P<0.05 was used to declare statistical significance and odds ratio with 95% confidence interval were calculated.

Result

The median (±IQR) age of participants was 33 (±14) years of age. Overall, the prevalence of DM in the study population was found to be 16 (3.9%) [95% CI: 2.2–5.6%]. The prevalence of DM among males and females was 3.8% and 4.2% respectively. Age (<35 years) [0.21 (0.04–0.94)], increasing salt amount in dietary feeding [14.31(1.28–159.2)], Consumption of vegetable &fruit once per week [23.38(2.01–269.17)], diagnosed with HTN [21.35(2.28–199.37)], and Family history of DM [9.42(1.72–51.42)] were significantly associated with DM.

Conclusion

Comparably lower prevalence of previously undiagnosed DM was found by this study. Being old, excess salt consumption, intake of vegetables & fruit once per week, hypertension, and family history of DM were significantly associated with DM. Therefore, the zonal Health department should enhance and strengthen the provision of health education programs and counseling about nutrition, weight control, and appropriate physical activity and advised the communities for mass screening for diabetes.

Impact of Sociodemographic Characteristics, Lifestyle, and Obesity on Coexistence of Diabetes and Hypertension: A Structural Equation Model Analysis amongst Chinese Adults

Background

In general, given the insufficient sample size, considerable literature has been found on single studies of diabetes and hypertension and few studies have been found on the coexistence of diabetes and hypertension (CDH) and its influencing factors with a large range of samples. This study aimed to establish a structural equation model for exploring the direct and indirect relationships amongst sociodemographic characteristics, lifestyle, obesity, and CDH amongst Chinese adults.

Methods

A cross-sectional study was conducted in a representative sample of 25356 adults between June 1, 2015, and September 30, 2018, in Hubei province, China. Confirmatory factor analysis was initially conducted to test the latent variables. A structural equation model was then performed to analyse the association between latent variables and CDH.

Results

The total prevalence of CDH was 2.8%. The model paths indicated that sociodemographic characteristics, lifestyle, and obesity were directly associated with CDH, and the effects were 0.187, 0.739, and 0.353, respectively. Sociodemographic characteristics and lifestyle were also indirectly associated with CDH, and the effects were 0.128 and 0.045, respectively. Lifestyle had the strongest effect on CDH (β = 0.784, P < 0.001), followed by obesity (β = 0.353, P < 0.001) and sociodemographic characteristics (β = 0.315, P < 0.001). All paths of the model were significant (P < 0.001).

Conclusion

CDH was significantly associated with sociodemographic characteristics, lifestyle, and obesity amongst Chinese adults. The dominant predictor of CDH was lifestyle. Targeting these results might develop lifestyle and weight loss intervention to prevent CDH according to the characteristics of the population.

Association of Estimated Salt and Miso Intake with the Prevalence of Obesity in People with Type 2 Diabetes: A Cross-Sectional Study

Salt intake is often estimated by the amount of sodium excreted in urine, and miso has been reported to increase it. This cross-sectional study investigated the relationship between obesity and high estimated salt intake with and without habitual miso consumption. Estimates of salt intake (g/day) were calculated using urinary sodium excretion, and a high estimated intake was defined as greater than the median amount of 9.5 g/day. Participants were divided into four groups based on estimated salt intake and miso consumption. Among 300 people, the proportions of obesity were 77.8% (n = 14/18), 40.2% (n = 53/132), 26.0% (n = 33/127), and 34.8% (n = 8/23) in the (+/-), (+/+), (-/+), and (-/-) groups of high estimated salt intake/habitual miso consumption, respectively. Compared with the (+/-) group, the adjusted odds ratios for obesity were 0.07 (95% confidence interval (CI): 0.02-0.26, p < 0.001), 0.16 (95% CI: 0.03-0.76, p = 0.022), and 0.14 (95% CI: 0.04-0.51, p = 0.003) in the (-/+), (-/-), and (+/+) groups, respectively. The presence of obesity was not much higher in people with high estimated salt intake with habitual miso consumption than that in people without. Clinicians should be aware that miso consumption promotes salt excretion, which may lead to an apparently higher estimated salt intake than actual.

Preference for High Dietary Salt Intake Is Associated With Undiagnosed Type 2 Diabetes: The Henan Rural Cohort

Background: Diabetes continues to be a serious disease burden globally. Nutrition plays a vital role in human life and health, and both inadequate and over nutrition have been implicated in cause the of disease. Objective: We explored the role of preference for high dietary salt intake and diabetes in a rural population. We also looked at possible mediating factors in the relationship between diabetes and preference for high dietary salt intake. Methods/Participants: Data from the Henan rural cohort in China were analyzed. Using multinomial regression models, the association between diabetes diagnosis type and reported preference for dietary salt was assessed. Adjusted odds ratios (aORs) with confidence interval (CI) at a 95% level are reported. Mediation analyses using structural equation models in Stata were performed. Results: Of the 39,183 participants included in the analyses, 4.07% were previously diagnosed with diabetes, and 5.80% with undiagnosed diabetes. Eighteen percent had a preference for salty meals, the mean age was 55.45 years, and 60% were women. Preference for salty meals was associated with undiagnosed diabetes (aOR = 1.17, 95% CI 1.03, 1.32), but not with previously diagnosed diabetes. Stratified analysis revealed that the association with undiagnosed diabetes was only significant in men (aOR = 1.36, 95% CI 1.13, 1.70) but not in women (aOR = 1.06, 95% CI 0.81, 1.38). BMI and central obesity fully mediated the association. Dietary salt intake was self-reported and therefore presents a limitation. Conclusion: Our study demonstrated that preference for high dietary salt intake is associated with undiagnosed diabetes but not prevalent diabetes.

Direct Cardiac Actions of Sodium Glucose Cotransporter 2 Inhibitors Target Pathogenic Mechanisms Underlying Heart Failure in Diabetic Patients

Sodium glucose cotransporter 2 inhibitors (SGLT2i) are the first antidiabetic compounds that effectively reduce heart failure hospitalization and cardiovascular death in type 2 diabetics. Being explicitly designed to inhibit SGLT2 in the kidney, SGLT2i have lately been investigated for their off-target cardiac actions. Here, we review the direct effects of SGLT2i Empagliflozin (Empa), Dapagliflozin (Dapa), and Canagliflozin (Cana) on various cardiac cell types and cardiac function, and how these may contribute to the cardiovascular benefits observed in large clinical trials. SGLT2i impaired the Na⁺/H⁺ exchanger 1 (NHE-1), reduced cytosolic [Ca²⁺] and [Na⁺] and increased mitochondrial [Ca²⁺] in healthy cardiomyocytes. Empa, one of the best studied SGLT2i, maintained cell viability and ATP content following hypoxia/reoxygenation in cardiomyocytes and endothelial cells. SGLT2i recovered vasoreactivity of hyperglycemic and TNF-α-stimulated aortic rings and of hyperglycemic endothelial cells. Anti-inflammatory actions of Cana in IL-1β-treated HUVEC and of Dapa in LPS-treated cardiofibroblast were mediated by AMPK activation. In isolated mouse hearts, Empa and Cana, but not Dapa, induced vasodilation. In ischemia-reperfusion studies of the isolated heart, Empa delayed contracture development during ischemia and increased mitochondrial respiration post-ischemia. Direct cardiac effects of SGLT2i target well-known drivers of diabetes and heart failure (elevated cardiac cytosolic [Ca²⁺] and [Na⁺], activated NHE-1, elevated inflammation, impaired vasorelaxation, and reduced AMPK activity). These cardiac effects may contribute to the large beneficial clinical effects of these antidiabetic drugs.

Diabetes knowledge and its association with the weight status among residents of Jeddah City, Saudi Arabia

Objective

To examine the association of weight status with level of diabetes knowledge (symptoms and complications) among residents of Jeddah City, Saudi Arabia.

Methods

In a cross-sectional study, a questionnaire assessing sociodemographic and health characteristics and knowledge about diabetes and its symptoms and complications was utilized. Data of 3978 adults, 18 years of age or older, were collected from public mall sites in Jeddah city and surrounding areas. Participants were divided into three tertiles based on their knowledge scores. Weight and height were measured following standardized procedures, and body weight categories were defined based on body mass index (BMI). The association between weight status and tertiles of diabetes knowledge was examined using multinomial logistic regression analysis.

Results

Compared to normal-weight participants, participants who were underweight, overweight, or obese, did not differ with regards to knowledge about diabetes symptoms. Adjusted models showed that overweight and obese participants had lower odds of being in the lowest tertile of knowledge about diabetes complications compared to normal-weight participants (OR: 0.71, 95% CI: 0.58–0.86 and OR: 0.64, 95% CI: 0.51–0.79, respectively). With regards to general knowledge about diabetes, the knowledge of participants who were underweight did not differ when compared to normal-weight participants. Overweight and obese participants had lower odds of being in the lowest tertile of general knowledge about diabetes compared to normal-weight participants (OR: 0.78, 95% CI: 0.62–0.97 and OR: 0.60, 95% CI: 0.47–0.76, respectively).

Conclusions

Overweight and obese individuals have better knowledge about diabetes compared to normal-weight individuals. Public health programs need to take into account the level of diabetes knowledge and tailor interventions to aid behavior and lifestyle change.

The relationship between diabetic risk factors, diabetic complications and salt intake

The relationship between salt and hypertension is the focus of a large amount of research, there are few reviews of the relationship between salt and diabetes, despite the increasing incidence of diabetes. By searching PubMed and the Cochrane Library, we summarized the relationships between diabetic risk factors, diabetic complications and salt intake. The pathophysiological mechanisms underlying the effects of salt on diabetes risk factors and diabetic complications are also discussed. Our findings should assist experts and scholars to understand the current research of salt intake and to pay more attention to the prevention and treatment of related diseases caused by excessive salt intake; guide treatment for patients with diabetes mellitus; and provide a reference for government departments to formulate a reasonable salt restriction policy. We also recommend future research directions.

Blood Pressure Regulation: Reviewing Evidence for Interplay Between Common Dietary Sugars and Table Salt

A popular concept is that the significant global progression in prevalence and intensification of elevated blood pressure (BP) levels is due in part to dietary indiscretions. Excess intake of several food sources causing overweight/obesity plays an important role in BP perturbations. However, certain nutrients are involved in ways other than via body fat accumulation, particularly table salt (sodium chloride) and popular refined carbohydrates like dietary sugars (sucrose, fructose, high fructose corn syrup). In nondiabetics and diabetics, several functions of salt and sugar influence BP and metabolism. For example, salt intake is linked to volume expansion, insulin resistance, and hypertension, while sugar intake is associated with enhanced salt sensitivity via urinary sodium retention, insulin resistance, and hypertension. The key postulate evaluated here is that when two popular nutrients-salt and dietary sugars-are consumed together in adequate amounts, their respective individual BP effects are significantly amplified. In previous laboratory studies, a sugar challenge did not increase BP in the face of marked sodium depletion, and combining sugar and salt challenges caused a synergistic BP elevation. Among examples of amplification on the clinical side, the greatest increases in BP following sugar challenges were seen in diabetic subjects having the highest sodium excretion. Interplay between table salt and common dietary sugars in BP regulation is a reasonable postulate and should be carefully considered when developing optimal prevention and treatment regimens to ameliorate the worldwide crisis arising from harmful elevated BP levels.

Dietary Sodium Intake in People with Diabetes in Korea: The Korean National Health and Nutrition Examination Survey for 2008 to 2010

BACKGROUND

Diabetics are likely to receive advice from their physicians concerning lifestyle changes. To understand how much sodium is consumed by diabetics in Korea, we compared the average daily sodium intake between diabetics and non-diabetics after controlling for confounding factors.

METHODS

We obtained the sodium intake data for 13,957 individuals who participated in the Korean National Health and Nutrition Examination Survey (KNHANES), 2008 to 2010, which consisted of a health interview and behavioral and nutritional surveys. The KNHANES uses a stratified, multistage, probability-sampling design, and weighting adjustments were conducted to represent the entire population.

RESULTS

Our analysis revealed that, overall, diabetics tended to have lower sodium intake (4,910.2 mg) than healthy individuals (5,188.2 mg). However, both diabetic and healthy individuals reported higher sodium intake than is recommended by the World Health Organization (WHO). Stratified subgroup analyses revealed that the sodium intake (4,314.2 mg) among newly diagnosed diabetics was higher among women when compared to patients with known diabetes (3,812.5 mg, P=0.035). Female diabetics with cardiovascular disease had lower average sodium intake compared to those without cardiovascular disease after adjusting for sex, age, body mass index, and total energy intake (P=0.058). Sodium intake among male diabetics with hypercholesterolemia (P=0.011) and female diabetics with hypertriglyceridemia (P=0.067) tended to be higher than that among those who without dyslipidemia.

CONCLUSION

The average sodium intake of diabetics in Korea was higher than the WHO recommends. Sodium intake in newly diagnosed diabetics was significantly higher than that in non-diabetics and previously diagnosed diabetics among females. Prospective studies are needed to identify the exact sodium intake.

Increased Insulin following an Oral Glucose Load, Genetic Variation near the Melatonin Receptor MTNR1B, but No Biochemical Evidence of Endothelial Dysfunction in Young Asian Men and Women

Aim

To identify biochemical and genetic variation relating to increased risk of developing type 2 diabetes mellitus and cardiovascular disease in young, lean male and female adults of different ethnicities.

Method

Fasting blood and urine and non-fasting blood following oral glucose intake were analysed in 90 Caucasians, South Asians and South East/East Asians.

Results

There were no differences in age, birthweight, blood pressure, body mass index, percent body fat, total energy, percentage of macronutrient intake, microalbumin, leptin, cortisol, adrenocorticotropic hormone, nitric oxide metabolites, C-reactive protein, homocysteine, tumor necrosis factor-α, interleukin-6, von Willebrand factor, vascular cell adhesion molecule-1, plasminogen activator inhibitor-1, and tissue plasminogen activator. Fasting total cholesterol (P = .000), triglycerides (P = .050), low density lipoprotein (P = .009) and non-fasting blood glucose (15 min) (P = .024) were elevated in South Asians compared with Caucasians, but there was no significant difference in glucose area under curve (AUC). Non-fasting insulin in South Asians (15–120 min), in South East/East Asians (60–120 min), and insulin AUC in South Asians and South East/East Asians, were elevated compared with Caucasians (P≤0.006). The molar ratio of C-peptide AUC/Insulin AUC (P = .045) and adiponectin (P = .037) were lower in South Asians compared with Caucasians. A significant difference in allele frequency distributions in Caucasians and South Asians was found for rs2166706 (P = 0.022) and rs10830963 (P = 0.009), which are both near the melatonin receptor MTNR1B.

Conclusions

Elevated non-fasting insulin exists in young South Asians of normal fasting glucose and insulin. Hepatic clearance of insulin may be reduced in South Asians. No current biochemical evidence exists of endothelial dysfunction at this stage of development. MTNR1B signalling may be a useful therapeutic target in Asian populations in the prevention of type 2 diabetes mellitus.

Kidney involvement in a nongenetic rat model of type 2 diabetes

BACKGROUND

Rats fed a high fat diet and given a low dose of streptozotocin (STZ) (35 mg/kg) develop type 2 diabetes with insulin resistance, hyperinsulinemia, moderate hyperglycemia, hyperlipidemia, and salt-sensitive hypertension. We postulated that rats with noninsulinopenic (type 2) diabetes develop lesions of diabetic nephropathy significantly more prominent than those seen in classic insulinopenic (type 1) diabetic rats.

METHODS

Rats were fed regular chow or high fat diet (60% calories from fat and 70% animal fat). After 5 weeks, rats fed regular chow received vehicle (controls) or 55 mg/kg STZ (type 1 diabetes mellitus). Rats fed high fat diet received vehicle (high fat) or low dose STZ, 35 mg/kg (type 2 diabetes mellitus). Rats were sacrificed 14 weeks after STZ/vehicle injection.

RESULTS

Blood glucose, systolic blood pressure, and urinary protein excretion were significantly higher in both diabetes groups than in controls. Serum insulin levels (ng/mL) were higher in type 2 diabetes than in type 1 diabetes groups (0.49 +/- 0.12 vs. 0.07 +/- 0.07) (P= 0.01). Percentage of sclerosed glomeruli was significantly higher in type 2 diabetes group than in control and type 1 diabetes groups. Fibronectin expression was significantly increased in high fat, type 1 and type 2 diabetes groups compared to controls. The expression of type IV collagen, connective tissue growth factor (CTGF), and transforming growth factor-beta (TGF-beta) was significantly increased in high fat and type 2 diabetes groups compared to controls.

CONCLUSION

Rats fed a high fat diet and given a low dose of STZ developed diabetes (with normal/high insulin levels), hypertension, and proteinuria. Kidney lesions in this type 2 model appear to be more pronounced than in type 1 diabetic rats despite lower blood glucose levels and proteinuria. We present a nongenetic rat model of type 2 diabetes mellitus and nephropathy.

The implementation of nutritional advice for people with diabetes

These consensus-based recommendations emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of services required to provide the information. Important changes from previous recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy provided that this is eaten in the context of a healthy diet and distributed throughout the day [corrected]. Evidence is presented for the effectiveness of advice provided by trained dieticians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented.

Prevention of hypertension and its complications: theoretical basis and guidelines for treatment

Hypertension is a nutritional-hygienic disease. Long-term caloric intake in excess of energy expenditures, chronic supraphysiological intake of dietary sodium, excessive alcohol consumption, and psychosocial stressors all contribute to the development of hypertension throughout the world. Elevated BP, particularly systolic BP, has been linked to multiple adverse clinical outcomes including stroke, heart failure, myocardial infarction, renal insufficiency/failure, peripheral vascular disease, retinopathy, dementia, and premature mortality. These undesirable clinical outcomes are typically, although not invariably, preceded by pressure-related target-organ injury such as left ventricular hypertrophy, renal insufficiency and proteinuria. The relation of BP and CKD and, in turn, the prevention of CKD or forestalling its progression by hypertension treatment, will be the focus of this manuscript. In hypertensive persons with reduced kidney function and/or proteinuria, lowering BP with multidrug therapy that is inclusive of pharmacologic modulators of the renin-angiotensin-aldosterone-kinin system is an effective strategy to forestall the progressive loss of kidney function. The totality of data support low therapeutic BP targets for persons with proteinuria >1 g/d. Nevertheless, in persons with CKD, even those with proteinuria below the dipstick positive level (approximately 300 mg/d or urine protein to creatinine ratio of 0.22), aggressive BP control also may be warranted because of the high risk of nonrenal cardiovascular disease. Multiple antihypertensive drugs will be required in the vast majority of patients with diabetes and/or reduced kidney function to attain BP goal. Renin-angiotensin system (RAS) modulator therapy is indicated among persons with diabetes mellitus and CKD. Available data support the use of angiotensin receptor blockers in persons with type 2 diabetes and overt nephropathy for preservation of kidney function. Among persons with type I diabetes with or without overt nephropathy, type 2 diabetes without overt nephropathy and in nondiabetic CKD, the available clinical data support the use of angiotensin-converting enzyme inhibitors as the RAS modulator of choice. Low therapeutic target BP levels <130/80 mmHg in persons with type 2 diabetes mellitus also appear warranted based on available data mostly for reducing the risk of nonrenal cardiovascular disease and overall mortality.