A Heart-Healthy Diet for Cardiovascular Disease Prevention: Where Are We Now?

Effect of Nuts on Anthropometric and Glycemic Indexes and Blood Pressure in Secondary Cardiovascular Prevention: A Systematic Review and Meta-analysis of Randomized Controlled Trials

CONTEXT

Nut-enriched diets have a positive impact on cardiovascular risk factors, such as body mass, blood pressure, and fasting blood glucose. However, studies in individuals undergoing secondary cardiovascular prevention show controversial results.

OBJECTIVE

This systematic review with meta-analysis assessed the effect of nut supplementation on anthropometric, glycemic, and blood pressure indices in patients with atherosclerotic cardiovascular disease, as well as the frequency of adverse events.

DATA SOURCES

Six databases were used for the search-PubMed, Cochrane Library, EMBASE, BVS (Biblioteca Virtual da Saude), Web of Science, and ClinicalTrials.gov-until February 2023, with no language restrictions.

DATA EXTRACTION

The Cochrane Handbook for Systematic Reviews of Interventions methodology and the PICOS (Population, Intervention, Comparison, Outcome, Setting/design) strategy were used. Seven independent reviewers were involved in data extraction and resolution of disagreements. Certainty of the evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

DATA ANALYSIS

From 5187 records identified, 6 publications containing data referring to 5 randomized clinical trials (n = 436) were included in the final analyses. The nuts evaluated were almonds, pecans, Brazil nuts, and mixed nuts, with portions that varied between 5 g and 85 g (median: 30 g/day). The intervention period varied between 6 and 12 weeks. The nuts had no effect on fasting glucose and anthropometric indices, although the certainty of the evidence for most of these outcomes was low or very low. They also had no effect on systolic (mean difference [MD]: -1.16 mmHg [95% CI, -5.68 to 3.35], I2 = 0%-moderate certainty of evidence) or diastolic (MD: 0.10 mmHg [95% CI, -2.30 to 2.51], I2 = 0%-high certainty of evidence) blood pressure. It was not possible to aggregate data on adverse events.

CONCLUSION

Nut supplementation had no effect on blood pressure, fasting glucose, or anthropometric profile in the context of atherosclerotic cardiovascular disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020163456.

The long-term effects of cardiometabolic risk factors on mortality and life expectancy: evidence from a health check-up cohort study

OBJECTIVE

Cardiometabolic risk factors significantly contribute to disease burden. This study explored the effects of hypertension (HTN), diabetes mellitus (DM), and hyperlipidemia (HLP) on mortality. It stratified findings by age group and comorbidity severity using the Charlson Comorbidity Index (CCI) score. Additionally, it assessed the compounded effects of comorbid conditions to estimate life expectancy (LE) and years of life lost (YLL) in individuals with various cardiometabolic risk factor combinations.

METHODS

Using data from the MJ Health Check-up Database (2002-2017), linked with the National Health Insurance Research Database (2000-2017) and the Death Registry (2002-2019), this study employed Cox proportional hazards models to determine mortality risk associated with various cardiometabolic risk factors. Adjusted Kaplan-Meier curves were constructed to evaluate survival rates across different risk factors and CCI scores. Survival rates were extrapolated to estimate confounder-adjusted LE and YLL for age-comorbidity combinations.

RESULTS

Among the three age groups (20-39, 40-59, 60-79), HLP was the most common single risk factor, followed by HTN. In participants with dual risk factors, HTN and HLP were the most frequent pair, with diabetes and HLP second. An increased number of cardiometabolic risk factors elevated mortality risk, particularly in the 20-39 age group. LE, adjusted for confounders, declined with age, higher CCI scores, and more risk factors. YLL decreased with age but increased with higher CCI scores and more risk factors.

CONCLUSIONS

Promoting health awareness, early disease detection, and timely medical access can reduce cardiometabolic risk factors and associated comorbidities, thereby alleviating disease burden.

The Influence of Lifestyle Modifications on Cardiovascular Outcomes in Older Adults: Findings from a Cross-Sectional Study

Background: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among older adults. Lifestyle modifications, including diet, physical activity, and smoking cessation, are key to reducing cardiovascular risk. This study examines the combined effects of these behaviors on cardiovascular outcomes and their mediating mechanisms. Methods: A cross-sectional study was conducted among older adults (aged ≥ 60 years) in Riyadh, Saudi Arabia. Data on dietary quality, physical activity, and smoking status were collected using validated questionnaires. Cardiovascular outcomes, including low-density lipoprotein cholesterol (LDL), systolic blood pressure (SBP), and body mass index (BMI), were measured. A composite cardiovascular risk score was computed. Path analysis was employed to assess direct and indirect effects of lifestyle factors on cardiovascular outcomes. Results: Participants adhering to a healthy diet, engaging in regular physical activity, and avoiding smoking had significantly lower composite cardiovascular risk scores. Non-smoking status showed the strongest direct effect (β = -0.20, p = 0.006), while dietary quality and physical activity exhibited significant indirect effects mediated by LDL, SBP, and BMI. Combined adherence to multiple healthy behaviors resulted in the greatest reductions in cardiovascular risk. The path analysis highlighted dietary quality and physical activity as critical mediators of cardiovascular health improvements. Conclusions: Lifestyle modifications significantly reduce cardiovascular risk in older adults, with cumulative benefits observed for combined adherence to healthy behaviors. These findings emphasize the importance of comprehensive lifestyle interventions targeting diet, physical activity, and smoking cessation to promote cardiovascular health in aging populations.

Prevalence of Vitamin K2 Deficiency and Its Association with Coronary Artery Disease: A Case-Control Study

BACKGROUND/OBJECTIVES

Vitamin K2 analogs are associated with decreased vascular calcification, which may provide protective benefits for individuals with coronary artery disease (CAD) by stimulating anti-calcific proteins like matrix Gla protein and adjusting innate immune responses. This study addresses a significant gap in understanding the association between serum levels of vitamin K2 analogs in different CAD types and examines their correlations with clinical risk parameters in CAD patients.

METHODS

This case-control study enrolled CAD patients and healthy controls to assess and compare serum concentrations of two vitamin K2 analogs including menaquinone-4 (MK-4) and menaquinone-7 (MK-7) via ultra-performance liquid chromatography with tandem mass spectrometry (UPLC-MS/MS). CAD risk factors were evaluated and related to serum levels of vitamin K2 analogs. The CAD group was further subdivided into stable angina, STEMI, NSTEMI, and unstable angina groups to investigate potential differences in vitamin K2 analog levels.

RESULTS

Patients experiencing acute coronary syndrome exhibited notably reduced serum levels of MK-4 and MK-7 (1.61 ± 0.66, and 1.64 ± 0.59 ng/mL, respectively) in comparison to the control group (2.29 ± 0.54, and 2.16 ± 0.46 ng/mL, respectively), with MK-4 and MK-7 displaying stronger associations with CAD risk indicators. Notable variations in vitamin K2 analog levels were found between CAD patients and control groups (p < 0.001). Unstable angina patients showed the lowest serum levels of MK-4 and MK-7.

CONCLUSIONS

The present study demonstrated a higher prevalence rate of vitamin K2 deficiency among patients with CAD. The most pronounced decrease in MK-4 and MK-7 was observed in unstable angina patients. Moreover, these outcomes indicate the imperative requirement for an integrative approach that incorporates metabolic, lipid, and vitamin K2-related pathways in the risk stratification and management of CAD.

Microcardia and cardiomegaly screening using postero-anterior chest X-ray (PA CXR) across university students in Ghana - a retrospective study

BACKGROUND

Microcardia and cardiomegaly are good diagnostic and prognostic tools for several diseases. This study investigated the distribution of microcardia and cardiomegaly among students of the University of Health and Allied Sciences (UHAS) in Ghana to determine the prevalence of microcardia and cardiomegaly across gender, and to evaluate the correlation between the presence of these heart conditions and age.

METHODS

This retrospective study involved a review of 4519 postero-anterior (PA) chest X-rays (CXRs) between 2020 and 2023. The CXRs were taken using a digital radiography machine. The CXRs were obtained on PA projection, with the students upright, on arrested inspiration and a source-to-detector distance of 180 cm. Only CXR images with no significant rotation (assessed using the distance between the medial ends of the clavicles and the vertebral spinous processes) and lung abnormalities were included in the study. The transverse cardiac diameter (TCD) and transverse thoracic diameter (TTD) were measured and cardiothoracic ratio (CTR) calculated for each CXR. The CTR was calculated as a ratio of TCD/TTD and categorised as microcardia (CTR < 0.42), normal heart size (0.42 < CTR ≤ 0.50) and cardiomegaly (0.50 < CTR ≤ 0.60). The data was analysed using the Statistical Package for the Social Sciences (SPSS) version 26 and descriptive and inferential statistics were conducted. The Mann-Whitney U Test was conducted to determine statistically significant differences in TCD, TTD and CTR across female and male students. Spearman's rho correlation was conducted to investigate the relationships between age and TCD, TTD and CTR.

RESULTS

The students were aged 15-37 years (mean = 19.60 ± 2.20) with a modal age of 18 years. The study included 2930 (64.84%) females and 1589 (35.16%) males. Most of the students [3384 (74.88%)] had normal heart sizes. However, 647 (14.32%) had microcardia whereas 488 (10.80%) had cardiomegaly. Out of the students suffering from cardiomegaly, 478 (97.95%) and 10 (2.05%) had mild/moderate and severe cardiomegaly respectively. Cardiomegaly was more common among the female students (p < 0.05) and those aged 15-22 years [418 (85.66%)]. There was no correlation between TCD, TTD and CTR and age [ r = 0.01, p = 0.42; r = 0.02, p = 0.17; r = 0.01, p = 0.66, respectively].

CONCLUSION

The majority of the students had normal heart sizes, but a few had microcardia and cardiomegaly. Cardiomegaly was more common among the female students. The presence of microcardia and cardiomegaly could have health implications for the students and increase their risks of cardiovascular diseases hence these students should be further screened medically for the underlying causes though they may be asymptomatic. Stakeholders in higher education and public health may find this study useful in developing strategies to minimise the prevalence of cardiac diseases and also improve treatment.

Coffee and Cardiovascular Health: A Review of Literature

Cardiovascular disease is the leading cause of death worldwide and is on the rise. Diet is considered to be a key modifiable risk factor for reducing the incidence of cardiovascular disease. Dietary approaches have proved advantageous for preventing disease morbidity and mortality but tend to focus on fruit, vegetables, fiber, lean protein and healthy fats. Coffee is one of the most popular beverages worldwide but is often surrounded by controversy with regard to its impact on health. This review aims to explore the relationship between coffee consumption and cardiovascular disease. The evidence from observational trials as well as randomized controlled trials is discussed. By focusing on specific bioactive compounds in coffee, potential mechanisms are explored, and future directions of research in the field are considered.

Leukocytosis as a Risk Factor for Coronary Artery Disease: Pathophysiology and Epidemiology

Coronary artery disease (CAD) is a significant health concern characterized by reduced blood flow to the heart muscle, primarily due to the buildup of atherosclerotic plaques in the coronary arteries. This process begins with endothelial injury, leading to a cascade of biological responses contributing to plaque formation. Endothelial injury attracts the migration of monocytes which differentiate into macrophages upon uptake of oxidized low-density lipoproteins, changing into lipid-laden macrophage or “foam cells.” The process of plaque formation is influenced by many factors which have been studied extensively in literature such as smoking, hypertension, and diabetes mellitus. Chronic inflammatory illnesses are often associated with a high prevalence of coronary artery syndromes, prompting the evaluation of markers of inflammation such as white blood cell count and inflammatory markers as independent risk factors for CAD. White blood cells play a remarkable role in the pathophysiology of disease formation and progression. The article below aims to discuss the pathophysiology and epidemiology of leukocytosis as a risk factor for CAD.

Adherence to EAT-Lancet reference diet and risk of premature coronary artery diseases: a multi-center case-control study

BACKGROUND

In 2019, a globally sustainable dietary pattern that primarily emphasizes the consumption of plant-based foods was proposed by the EAT-Lancet Commission. However, there is limited evidence regarding the association of this diet with coronary events.

OBJECTIVES

To determine the association between the EAT-Lancet Reference Diet (ELD) and premature coronary artery disease (PCAD) risk and its severity.

METHODS

This multi-center, case-control study was conducted within the framework of the Iran premature coronary artery disease (I-PAD). A total of 3185 participants aged under 70 years in women and 60 years in men were included. Cases were those whose coronary angiography showed stenosis ≥ 75% in at least one vessel or ≥ 50% in the left main artery (n = 2033), while the controls had normal angiography results (n = 1152). Dietary intake was assessed using a validated food frequency questionnaire. Logistic regression was utilized to examine the association between ELD and presence of PCAD.

RESULTS

Compared with individuals in the first quartile, those in the highest quartile of ELD (OR = 0.29, 95% CI: 0.21, 0.39; P for trend < 0.001) and ELD calculated with minimum intake (OR = 0.39, 95% CI: 0.29, 0.52; P < 0.001) had lower risk of PCAD. Individuals in the highest quartile of adherence to the ELD and ELD with minimum intake had 78% and 72% lower risk of having severe PCAD compared with those in the lowest quartile, respectively.

CONCLUSION

An inverse association was observed between adherence to the ELD and PCAD risk and its severity. Large-scale prospective cohort studies are required to confirm these findings.

Unexplored Opportunities of Utilizing Food Waste in Food Product Development for Cardiovascular Health

PURPOSE OF REVIEW

Global food production leads to substantial amounts of agricultural and food waste that contribute to climate change and hinder international efforts to end food insecurity and poverty. Food waste is a rich source of vitamins, minerals, fibers, phenolic compounds, lipids, and bioactive peptides. These compounds can be used to create food products that help reduce heart disease risk and promote sustainability. This review examines the potential cardiovascular benefits of nutrients found in different food waste categories (such as fruits and vegetables, cereal, dairy, meat and poultry, and seafood), focusing on animal and clinical evidence, and giving examples of functional food products in each category.

RECENT FINDINGS

Current evidence suggests that consuming fruit and vegetable pomace, cereal bran, and whey protein may lower the risk of cardiovascular disease, particularly in individuals who are at risk. This is due to improved lipid profile, reduced blood pressure and increased flow-mediated dilation, enhanced glucose and insulin regulation, decreased inflammation, as well as reduced platelet aggregation and improved endothelial function. However, the intervention studies are limited, including a low number of participants and of short duration. Food waste has great potential to be utilized as cardioprotective products. Longer-term intervention studies are necessary to substantiate the health claims of food by-products. Technological advances are needed to improve the stability and bioavailability of bioactive compounds. Implementing safety assessments and regulatory frameworks for functional food derived from food waste is crucial. This is essential for maximizing the potential of food waste, reducing carbon footprint, and improving human health.

Dietary patterns and premature coronary artery disease: result from the Iran premature coronary artery disease (IPAD) study

BACKGROUND

Premature coronary artery disease (PCAD) is one of the major health concerns leading to considerable death and disabilities. This study aimed to evaluate the relationship of dietary patterns with risk of PCAD.

METHODS

Iran premature coronary diseases (IPAD) is a case-control study consists of 3159 participants. Obstructive CAD in ≥ 75% of at least one coronary artery or ≥ 50% in the left main artery based on coronary angiography in women under 70 and men under 60 years old was considered PCAD. The habitual dietary intake of participants was collected using a semi-quantitative validated food frequency questionnaire (SFFQ). Principal Component Analysis (PCA) was used to extract dietary patterns.

RESULTS

Three main dietary patterns including healthy, Western and high-fat, high-sugar were identified. Patients categorized in the last tertile of the healthy dietary pattern had a decreased risk of PCAD (OR = 0.77, 95% CI: 0.64-0.93), while those in the top tertile of Western (OR = 2.38, 95 CI:1.97-2.86) and High-fat simple carbohydrate (HFSC) (OR = 3.10, 95% CI:2.57-3.75) diets had increased risk of PCAD.

CONCLUSIONS

A healthy dietary pattern was significantly related to a decreased risk of PCAD presence, whereas Western and HFSC diets were connected to a higher risk of PCAD.

Intermittent fasting reduces inflammation and joint damage in a murine model of rheumatoid arthritis: insights from transcriptomic and metagenomic analyses

BACKGROUND

Intermittent fasting (IF) has shown benefits in various pathological conditions. Although its anti-inflammatory potential has been recognized, its effects on the mechanism underlying rheumatoid arthritis (RA) remain insufficiently characterized. This study aimed to investigate the effects of IF in a murine model of RA.

METHODS

Collagen-induced arthritis (CIA) was developed in sixteen male DBA/1 mice, randomly assigned to two groups, with one undergoing IF every other day for four weeks. The effects of IF on joint inflammation and remodeling were evaluated clinically, histologically, and through tomography. Transcriptomic changes were characterized using expression microarrays, validated by RT-qPCR, and confirmed by immunohistochemistry. Additionally, modifications in gut microbiota were assessed through 16 S sequencing.

RESULTS

Mice subjected to IF significantly reduced the incidence and severity of clinical arthritis. Histological and radiographic assessments confirmed a decrease in inflammation and joint damage. Transcriptomic analysis revealed that IF led to the upregulation of 364 genes and the downregulation of 543 genes, with notable reductions in inflammatory signaling pathways associated with RA-related genes, including Cd72, Cd79a, Ifna, Il33, and Bglap 2. Notably, IL33 emerged as a pivotal mediator in the inflammatory processes mitigated by fasting. Key regulators associated with IF effects, such as CEBPA, FOXO1, HIF1A, PPARG, and PPARA, were identified, indicating a complex interplay between metabolic and inflammatory pathways. Furthermore, differential expression of microRNAs and lncRNAs, including miR-15b, miR-103-2, miR-302a, miR-6985, and miR- 5624, was observed. Metagenomic analysis indicated that IF enhanced the abundance and diversity of the gut microbiome, explicitly promoting anti-inflammatory bacterial populations, notably within the genus Ruminococcaceae.

CONCLUSION

Our findings suggest that IF exerts significant anti-inflammatory and immunoregulatory effects in the context of CIA. Given its non-risky nature, further investigation into the potential benefits of IF in patients with RA is warranted.

CLINICAL TRIAL NUMBER

Not applicable.

Qualitative exploration of awareness about risk factors and transformative behaviours among Pakistani patients with coronary artery disease

OBJECTIVES

To explore patients' awareness of risk factors for coronary artery disease (CAD) and experiences of the behavioural modifications, they made during their recovery through in-depth semistructured interviews.

DESIGN

Qualitative exploration was undertaken as part of a larger project to answer the study questions.

SETTING

Participants were recruited from a public-sector tertiary care hospital in Lahore Pakistan.

PARTICIPANTS

A total of 20 participants, men and women, who had more than 6 months of experience living with CAD, were recruited using a purposive sampling technique.

RESULTS

The data were organised and analysed using NVIVO software. An inductive coding approach was used to generate codes, categories and themes. Three themes emerged from participants' data: lifestyle choices and behavioural factors, reflective awareness and lifestyle changes, holistic perspectives and health management.

CONCLUSIONS

The present study's findings align with recent literature, emphasising the complex nature of risk factors contributing to heart disease. The participants' understanding and behavioural changes show the importance of health awareness and preventive measures in reducing cardiovascular risks.

Culturally Tailored Lifestyle Modification Strategies for Hypertension Management: A Narrative Review

Hypertension (HTN) is a significant global health challenge affecting billions of individuals worldwide. The prevalence of HTN varies considerably across the globe due to diverse factors, such as lifestyle influenced by culture, genetics, health care access, and socioeconomic conditions. Lifestyle modification has a substantial impact on blood pressure management; however, some cultural practices and behaviors affect recommended lifestyle modification strategies for HTN management. The purpose of this review was to explore lifestyle modification strategies for HTN management from a cultural perspective. Lifestyle modification, including physical activity, stress reduction, changes in dietary patterns (adopting a low-sodium diet and intake of fruit and vegetables), and weight management, provide an effective non-pharmacologic intervention for the management of hypertension. Individual's cultural practices have the potential to determine their diet, physical activity levels, knowledge, and perception about HTN, adherence to treatment and medications, and the use of local herbal preparations for HTN management. Culture focuses on individuals' belief, practices and how these beliefs and practices influence their lifestyle behaviors for HTN management. It is important to consider patients' cultural beliefs before recommending lifestyle behaviors for HTN management.

Food for Thought: Nourishing Cardiovascular Health Amidst the Exposome

The cumulative exposures of an individual during their lifetime, known as the exposome, encompass environmental exposures and lifestyle factors that significantly impact cardiovascular health. The exposome concept aims to provide a comprehensive framework for understanding how various exposures combine to influence disease risk and health outcomes over a lifetime. Diet is a well-studied aspect of the exposome, recognized as a critical contributor to cardiovascular health and influencing various other health metrics and behaviors. Furthermore, understanding agricultural food systems and their interrelationships with dietary choice and impacts on environmental and human health requires a systems approach. Through a review of the literature, this publication will (1) elucidate the interconnections between the exposome and cardiovascular diseases through the lens of agricultural systems and environmental health; (2) examine the effect of diet on cardiovascular health; (3) examine the influence of socioeconomic and cultural factors on the agricultural food system and dietary choices; and (4) highlight the importance of adopting a systems approach that integrates dietary interventions with sustainable agricultural practices, emphasizing the need for holistic strategies to address the root causes of cardiovascular health issues through balanced human and environmental health interventions.

Ablation of Akt2 rescues chronic caloric restriction-provoked myocardial remodeling and dysfunction through a CDK1-mediated regulation of mitophagy

Chronic caloric restriction triggers unfavorable alterations in cardiac function albeit responsible scenarios remain unclear. This work evaluated the possible involvement of Akt2 in caloric restriction-evoked cardiac geometric and functional changes and responsible processes focusing on autophagy and mitophagy. Akt2 knockout and WT mice were subjected to caloric restriction for 30 weeks prior to assessment of myocardial homeostasis. Caloric restriction compromised echocardiographic parameters (decreased LV wall thickness, LVEDD, stroke volume, cardiac output, ejection fraction, fractional shortening, and LV mass), cardiomyocyte contractile and intracellular Ca2+ capacity, myocardial atrophy, interstitial fibrosis and mitochondrial injury associated with elevated blood glucocorticoids, autophagy (LC3B, p62, Atg7, Beclin-1), and mitophagy (Pink1, Parkin, TOM20), dampened cardiac ATP levels, mitochondrial protein PGC1α and UCP2, anti-apoptotic protein Bcl2, intracellular Ca2+ governing components Na+-Ca2+ exchanger, phosphorylation of SERCA2a, mTOR (Ser2481) and ULK1 (Ser757), and upregulated Bax, phospholamban, phosphorylation of Akt2, AMPK, and ULK1 (Ser555), the responses except autophagy markers (Beclin-1, Atg7), phosphorylation of AMPK, mTOR and ULK1 were negated by Akt2 ablation. Levels of CDK1 and DRP1 phosphorylation were overtly upregulated with caloric restriction, the response was reversed by Akt2 knockout. Caloric restriction-evoked changes in cardiac remodeling and cardiomyocyte function were alleviated by glucocorticoid receptor antagonism, Parkin ablation and Mdivi-1. In vitro experiment indicated that serum deprivation or glucocorticoids evoked GFP-LC3B accumulation and cardiomyocyte dysfunction, which was negated by inhibition of Akt2, CDK1 or DRP1, whereas mitophagy induction reversed Akt2 ablation-evoked cardioprotection. These observations favor a protective role of Akt2 ablation in sustained caloric restriction-evoked cardiac pathological changes via correction of glucocorticoid-induced mitophagy defect in a CDK1-DRP1-dependent manner.

Feasibility of the MIND+SOUL Culturally Tailored Brain Healthy Diet: A Pilot Study

Alzheimer's disease (AD) disproportionately impacts Black Americans, who are three times more likely to develop AD. While heart-healthy diets have shown potential in reducing AD risk, research on adapted dietary interventions for Black American communities remains limited. This pilot study assessed the feasibility and acceptability of an adapted brain healthy diet intervention (MIND + SOUL) and explored changes in cardiometabolic risk and cognition. Twenty-nine participants completed the 12-week intervention, which included culturally tailored health education, cooking classes, health coaching, and groceries. Feasibility was assessed by attendance and retention rates, while acceptability was measured by two questionnaires. Participants had a mean age of 70.3, with 10.3% male. The intervention demonstrated high feasibility (89.3% retention) and acceptability (mean = 71.9, SD = 8.59), with meaningful improvements in body mass index (estimate = -0.54, P = 0.009), dietary intake (estimate = 28.39, P = 0.042), and executive function (estimate = 3.32, P < 0.001). However, no significant changes in blood-based biomarkers were observed. The MIND + SOUL intervention demonstrated high feasibility and acceptability, improvements in body composition, cognitive function, and dietary behaviors, despite no significant changes in blood-based biomarkers. Findings suggest potential benefits for reducing AD risk factors and promoting healthy aging. Clinical Trials Registry: ClinicalTrials.Gov; NCT05414682.

Digital Education on Hospital Nutrition Diets: What Do Patients Want to Know?

INTRODUCTION

Therapeutic nutrition plays an imperative role during a patient's hospital course. There is a tremendous body of literature that emphasizes the systematic delivery of information regarding hospital nutrition diets. A major component of delivering healthcare information is the principle of providing quality healthcare information, but this has not yet been investigated on hospital nutrition diets. This study aimed to evaluate the comprehension and readability of patient education materials regarding therapeutic hospital diets.

METHODOLOGY

The methodology employed the use of publicly available questions regarding hospital nutrition diets and categorized them per Rothwell's Classification of Questions. Additionally, the questions were extracted online and have an associated digital article linked to the question. These articles underwent analysis for readability scores.

RESULTS

This study's findings reveal that most hospital diets do not meet the recommended grade-reading levels.

CONCLUSIONS

This underscores the need for healthcare providers to enhance patient education regarding hospital diets. The prevalence of "Fact" questions showcases the importance of clearly explaining diets and dietary restrictions to patients.

Alcohol Consumption and Cardiovascular Disease: A Narrative Review of Evolving Perspectives and Long-Term Implications

Cardiovascular illnesses remain the primary cause of death, accounting for at least 17.9 million fatalities per year and posing a significant public health problem because of its extensive predominance and effect on healthcare systems. The etiology of cardiovascular disease is complex and involves several environmental and lifestyle factors. Alcohol use is a highly important determinant because of its dual-edged effect on cardiovascular health. Multiple studies indicate that moderate alcohol consumption may have certain advantages, such as slight enhancements in lipid profiles. Conversely, excessive alcohol intake is associated with serious negative consequences, including cardiomyopathy, hypertension, arrhythmias, and even mortality. The aim of this study is to provide a comprehensive analysis of the several effects of alcohol on cardiovascular health and their understanding within the medical field over time. It uses an interpretative narrative review methodology and analyzes studies that focus on genetic risk factors, gender differences, and shifts in paradigms in recent years. This article highlights the need for obtaining a thorough understanding of the effects of alcohol on cardiovascular health to support public health guidelines and clinical practice, and it underscores the significance of including alcohol consumption into the broader context of cardiovascular risk management and identifies important subjects for further study.

A Comprehensive Review of Cardiovascular Disease Management: Cardiac Biomarkers, Imaging Modalities, Pharmacotherapy, Surgical Interventions, and Herbal Remedies

Cardiovascular diseases (CVDs) continue to be a major global health concern, representing a leading cause of morbidity and mortality. This review provides a comprehensive examination of CVDs, encompassing their pathophysiology, diagnostic biomarkers, advanced imaging techniques, pharmacological treatments, surgical interventions, and the emerging role of herbal remedies. The review covers various cardiovascular conditions such as coronary artery disease, atherosclerosis, peripheral artery disease, deep vein thrombosis, pulmonary embolism, cardiomyopathy, rheumatic heart disease, hypertension, ischemic heart disease, heart failure, cerebrovascular diseases, and congenital heart defects. The review presents a wide range of cardiac biomarkers such as troponins, C-reactive protein, CKMB, BNP, NT-proBNP, galectin, adiponectin, IL-6, TNF-α, miRNAs, and oxylipins. Advanced molecular imaging techniques, including chest X-ray, ECG, ultrasound, CT, SPECT, PET, and MRI, have significantly enhanced our ability to visualize myocardial perfusion, plaque characterization, and cardiac function. Various synthetic drugs including statins, ACE inhibitors, ARBs, β-blockers, calcium channel blockers, antihypertensives, anticoagulants, and antiarrhythmics are fundamental in managing CVDs. Nonetheless, their side effects such as hepatic dysfunction, renal impairment, and bleeding risks necessitate careful monitoring and personalized treatment strategies. In addition to conventional therapies, herbal remedies have garnered attention for their potential cardiovascular benefits. Plant extracts and their bioactive compounds, such as flavonoids, phenolic acids, saponins, and alkaloids, offer promising cardioprotective effects and enhanced cardiovascular health. This review underscores the value of combining traditional and modern therapeutic approaches to improve cardiovascular outcomes. This review serves as a vital resource for researchers by integrating a broad spectrum of information on CVDs, diagnostic tools, imaging techniques, pharmacological treatments and their side effects, and the potential of herbal remedies.

Effects of Migration on Nutritional Habits: From Turkey to Germany

Background

Dietary habits are influenced by environmental factors. Among these environmental factors are the place of residence, cultural characteristics, food accessibility, and economic status, which can all contribute to changes in the dietary pattern. Migration is another factor that can influence changes in the aspects mentioned above. We aimed to assess the dietary habits of individuals who have migrated from Turkey to Germany in comparison to those living in Turkey.

Methods

In this descriptive and cross-sectional study, 254 individuals were enrolled with 102 individuals in Germany and 152 individuals in Turkey between April 2022 and July 2023. The data collection tools included Socio-demographic Characteristics Forms, Dietary Habits and Health Status Forms, and Food Consumption Frequency Forms. The data was collected online via Google Forms.

Results

There were statistically significant differences in the consumption frequency of processed meats, meat and poultry, sweetened beverages, sugar, desserts and pastries, vegetables, fruits, eggs and grains, olive oil, sunflower oil, hazelnut oil, grains, dairy products, coffee, starch, and carbonated beverages between the two groups (P<0.05). Statistically significant differences were not found in terms of butter and tea consumption frequency.

Conclusion

Overall, the study results have revealed significant differences in dietary habits between Turks living in Germany and those living in Turkey. The most noteworthy dimension of these differences is that individuals living in Turkey exhibit a stronger adherence to the Mediterranean dietary pattern, while those living in Germany tend to follow a Western dietary pattern.

Navigating the crossroads: cardiometabolic risks in cancer survivorship - a comprehensive review

The landscape of cancer survivorship is increasingly populated by individuals facing a spectrum of cardiometabolic risks, attributed to both their oncological history and treatment regimens. This manuscript synthesizes findings from various studies, highlighting the prevalence of traditional risk factors-hypertension, dyslipidemia, diabetes-as well as emergent concerns like obesity and metabolic syndrome among survivors. The impact of demographic variables, specific cancer types, and treatment modalities on cardiometabolic health is explored. Through a lens of multidisciplinary management and future research directives, we advocate for an integrative approach to cardiometabolic health in cancer survivors, aiming to ensure their victory over cancer extends into long-term well-being. Furthermore, we discuss the outcome implications of these cardiometabolic risk factors on cardiovascular disease development, future cardiovascular events, and overall survival, supported by studies showing improved outcomes through exercise and risk factor control.

Optimizing Cardiovascular Health: A Comprehensive Review of Risk Assessment Strategies for Primary Prevention

Cardiovascular disease (CVD) is a leading global health concern, and effective primary prevention strategies are essential to mitigate its impact. This comprehensive review examines current risk assessment strategies for primary prevention of CVD, emphasizing the importance of early identification and intervention to reduce disease incidence. Traditional risk factors such as hypertension, hyperlipidemia, smoking, and lifestyle choices are discussed alongside emerging factors, including genetic predispositions and biomarkers. The review evaluates various risk assessment tools and models, such as the Framingham risk score, atherosclerotic CVD risk calculator, QRISK, and Reynolds risk score, highlighting their methodologies, strengths, and limitations. Additionally, the review explores lifestyle modifications, including dietary changes, physical activity, weight management, smoking cessation, and pharmacological interventions like statins and antihypertensives. Special considerations for different populations, including the elderly, women, and those with a family history of CVD, are addressed. Future directions in cardiovascular risk assessment are also discussed, focusing on technological advancements and personalized medicine. This review aims to enhance the implementation of effective primary prevention measures and improve cardiovascular health outcomes by providing a thorough analysis of risk assessment strategies.

Association between Diet Quality and Eating Behavior in Type 2 Diabetes Adults: A Cross-Sectional Study

Type 2 diabetes mellitus (T2DM) has become a global epidemic. To effectively control T2DM, individuals must adhere to a high-quality diet that encompasses not only healthy dietary patterns but also promotes positive eating behaviors. We conducted a cross-sectional study on 314 patients with T2DM, and we evaluated the diet quality and also examined the associations between eating behavior, diet quality, and anthropometric and clinical factors in T2DM patients. We used the Diet Quality Index-International and Dutch Eating Behavior Questionnaire to assess dietary characteristics. We found that women had a significantly higher diet quality than men (61.40 vs. 58.68, p = 0.002) but were also more prone to emotional eating (2.00 vs. 1.53, p < 0.001) and restrained eating (2.39 vs. 2.05, p = 0.002). Restrained eating correlated with duration of diabetes (r = -0.169, p = 0.003), body mass index (r = 0.182, p = 0.001), and external eating with glycated hemoglobin (r = 0.114, p = 0.044). Patients with emotional eating had a higher vitamin C adequacy score (β = 0.117, p = 0.045). External eating was positively associated with grain adequacy (β = 0.208, p < 0.001) and negatively associated with empty-calorie food moderation score (β = -0.125, p = 0.032). For restrained eating, we found associations with vitamin C adequacy (β = -0.138, p = 0.017) and fruit adequacy (β = 0.125, p = 0.033). In conclusion, the results of this study provide valuable insight into dietary behavior and emphasize the importance of promoting healthy eating habits for T2DM patients.

Navigating the crossroads: cardiometabolic risks in cancer survivorship - a comprehensive review

The landscape of cancer survivorship is increasingly populated by individuals facing a spectrum of cardiometabolic risks, attributed to both their oncological history and treatment regimens. This manuscript synthesizes findings from various studies, highlighting the prevalence of traditional risk factors-hypertension, dyslipidemia, diabetes-as well as emergent concerns like obesity and metabolic syndrome among survivors. The impact of demographic variables, specific cancer types, and treatment modalities on cardiometabolic health is explored. Through a lens of multidisciplinary management and future research directives, we advocate for an integrative approach to cardiometabolic health in cancer survivors, aiming to ensure their victory over cancer extends into long-term well-being.

Selected Psychosocial Factors, Nutritional Behavior, and the Analysis of Concentrations of Selected Vitamins in Patients with Cardiovascular Diseases

Cardiovascular diseases (CVD) are the leading cause of death worldwide, influenced by the interaction of factors, including age, sex, genetic conditions, overweight/obesity, hypertension, an abnormal lipid profile, vitamin deficiencies, diabetes, and psychological factors. This study aimed to assess the relationships between psychosocial and nutritional factors in a group of 61 patients with CVD (i.e., atherosclerosis, hypertension, ischemic heart disease, and myocardial infarction) and their possible impact on the course of the disease. The plasma concentrations of vitamins A, E, D, and β-carotene were determined using validated HPLC-MS/MS, while the lipid profile was analyzed enzymatically. Psychosocial factors and nutritional behaviors were assessed using author-designed questionnaires. Over 50% of patients had 25-OH-D3 and retinol deficiencies, while >85% of patients exhibited significant deficiencies in α-tocopherol and β-carotene. The lipid profile showed no specific relationship with any particular CVD. Dietary behavior minimally impacted biochemical parameters except for higher β-carotene concentrations in the group with higher fruit and vegetable intake. The negative impact of the CVD on selected parameters of quality of life was noticed. To increase the effectiveness of the prevention and treatment of CVD, the need for interdisciplinary cooperation observed between doctors, psychologists, and specialists in human nutrition seems to be justified.

The Polypill: A New Alternative in the Prevention and Treatment of Cardiovascular Disease

Cardiovascular disease (CVD) is the primary cause of death and disability worldwide. Although age-standardized CVD mortality rates decreased globally by 14.5% between 2006 and 2016, the burden of CVD remains disproportionately higher in low- and middle-income countries compared to high-income countries. Even though proven, effective approaches based on multiple-drug intake aimed at the prevention and treatment of CVD are currently available, poor adherence, early discontinuation of treatment, and suboptimal daily execution of the prescribed therapeutic regimes give rise to shortfalls in drug exposure, leading to high variability in the responses to the prescribed medications. Wald and Law, in their landmark paper published in BMJ 2003, hypothesized that the use of a fixed-dose combination of statins, β-blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and aspirin (classic Polypill composition) may increase adherence and decrease CVD by up to 80% when prescribed as primary prevention or in substitution of traditional protocols. Since then, many clinical trials have tested this hypothesis, with comparable results. This review aims to describe the available clinical trials performed to assess the impact of fixed-dose combinations on adherence, cost-effectiveness, and the risk factors critical to the onset of CVD.

Molecular Aspects of Cardiometabolic Diseases: From Etiopathogenesis to Potential Therapeutic Targets

Cardiometabolic diseases (CMDs) encompass a range of prevalent, often preventable, non-communicable illnesses, including myocardial infarction, stroke, cardiac insufficiency, arterial hypertension, obesity, type 2 diabetes mellitus, insulin resistance, chronic renal dysfunction, non-alcoholic fatty liver disease, and rare metabolic disorders [...].

Bile Acids and Bilirubin Role in Oxidative Stress and Inflammation in Cardiovascular Diseases

Bile acids (BAs) and bilirubin, primarily known for their role in lipid metabolism and as heme catabolite, respectively, have been found to have diverse effects on various physiological processes, including oxidative stress and inflammation. Indeed, accumulating evidence showed that the interplay between BAs and bilirubin in these processes involves intricate regulatory mechanisms mediated by specific receptors and signaling pathways under certain conditions and in specific contexts. Oxidative stress plays a significant role in the development and progression of cardiovascular diseases (CVDs) due to its role in inflammation, endothelial dysfunction, hypertension, and other risk factors. In the cardiovascular (CV) system, recent studies have suggested that BAs and bilirubin have some opposite effects related to oxidative and inflammatory mechanisms, but this area of research is still under investigation. This review aims to introduce BAs and bilirubin from a biochemical and physiological point of view, emphasizing their potential protective or detrimental effects on CVDs. Moreover, clinical studies that have assessed the association between BAs/bilirubin and CVD were examined in depth to better interpret the possible link between them.

Towards Optimal Cardiovascular Health: A Comprehensive Review of Preventive Strategies

Heart disease remains a prominent global health concern, with cardiovascular disease (CVD) standing as a leading cause of death worldwide. Preventing heart disease not only decreases the risk of premature death but also mitigates complications like heart attacks, strokes, and arrhythmias, thereby enhancing overall health and quality of life. The economic burden of heart disease treatment highlights the importance of implementing preventive measures, such as lifestyle changes and early interventions, which can alleviate healthcare costs. These strategies, targeting risk factors like hypertension (HTN), diabetes mellitus (DM), dyslipidemia, and obesity, not only prevent heart disease but also reduce the risk of other health issues. Herein, this review covers various preventive measures, including dietary interventions, exercise, controlling HTN, DM, cholesterol, and weight, smoking cessation, and pharmacological interventions. By critically analyzing the guidelines and leveraging robust data alongside variations in recommendations, this review aims to elucidate effective primary prevention strategies for CVD.

The Effect of a Program to Improve Adherence to the Mediterranean Diet on Cardiometabolic Parameters in 7034 Spanish Workers

BACKGROUND

Cardiovascular and metabolic diseases include a large group of pathologies and constitute one of the most serious chronic health problems facing the 21st century, with high rates of morbidity and mortality worldwide. Unhealthy diets influence the development of these pathologies. The Mediterranean diet can be an important part in the treatment of these diseases. The objective of this study was to assess the effect of a program that aims to increase adherence to the Mediterranean diet on the improvement of different cardiometabolic risk parameters.

METHODS

A prospective intervention study was carried out on 7034 Spanish workers. Prior to the intervention, 22 cardiometabolic risk scales were evaluated. Participants in this study were informed both orally and in writing of the characteristics and benefits of the Mediterranean diet and were given the website of the Ministry of Health, Consumption and Social Welfare of Spain, which provides advice on nutrition. Adherence to the Mediterranean diet was reinforced by sending a monthly SMS to their mobile phones. After six months of follow-up, the 22 risk scales were re-evaluated to assess changes. Means and standard deviations were calculated using Student's t test to analyse quantitative variables. Prevalence was calculated using the Chi-square test when the variables were qualitative.

RESULTS

All the cardiometabolic risk scales studied decreased after implementing a program to improve and enhance adherence to the Mediterranean diet. The number of losses in the sample was very low, standing at 4.31%.

CONCLUSIONS

The Mediterranean diet is effective in reducing all cardiovascular risk scales evaluated. The mean values and prevalence of high values of the different cardiometabolic risk scales analysed led to lower values after the implementation of the program to increase adherence to the Mediterranean diet. We observed a significant positive difference in metabolic age in both sexes. We have obtained a significant improvement in the insulin resistance index, especially in the SPISE-IR index, data that we have not found in previous publications. Easy access to the Internet and new information and communication technologies facilitate adherence to a diet and can reduce the number of losses.

Genetic, lifestyle and metabolic factors contributing to cardiovascular disease in the Italian population: a literature review

Cardiovascular diseases (CVD) represent a major health problem worldwide. In Italy, despite the decline in CVD mortality and disability-adjusted life years recently observed, CVD remains the leading cause of death. The development of CVD has a complex and multifactorial etiology that involves environmental, lifestyle/behavioral (e.g., unhealthy diet, physical inactivity, smoking, and alcohol abuse), metabolic, and genetic factors. Although a large number of CVD susceptibility genetic variants have been identified, some seem to confer risk according to the genetic background or ethnicity of the population. Some CVD-associated polymorphisms with appreciable frequency in the Italian population may be important contributors to the development and progression of the most prevalent CVD in the population. This literature review aims to provide an overview of the epidemiology of CVD in Italy, as well as to highlight the main genetic, lifestyle/behavioral, and metabolic factors contributing to CVD risk in this population.

Dietary Behavior and Determinants of Diet Quality among Primary Health Care Patients in Poland

BACKGROUND

The aim of the present research was to determine the factors influencing the prevalence of eating behaviors, diet quality, and unhealthy eating among primary healthcare patients in Poland.

METHODS

The cross-sectional study included 896 adult primary care patients in Łódź. The study was conducted from January 2020 to December 2021 among thirty-four primary healthcare facilities. A survey recorded the sociodemographic data of the respondents as well as data regarding their health condition and diet.

RESULTS

The majority of the respondents (57.6%) had average dietary habits, while 40% had unhealthy eating habits. The univariable logistic regression found that primary care patients with medium/secondary education had a 1.5 times greater risk of unhealthy eating habits, and those with post-secondary vocational education had a 1.75 times greater risk of unhealthy eating habits than those with higher education (OR = 1.46; 95% CI: 1.08-1.97, p ≤ 0.01, and OR = 1.75; 95% CI: 1.04-2.94, p ≤ 0.05). The multivariable logistic regression confirmed that the level of education had a significant impact on dietary habits: for medium/secondary education, OR = 1.40; 95% CI: 1.03-1.91 (p ≤ 0.01); for post-secondary vocational education, OR = 1.69; 95% CI: 1.0-2.85 (p ≤ 0.05).

CONCLUSIONS

The education level was significantly correlated with the prevalence of unhealthy eating behaviors in the studied population. This factor should be considered in the promotion of healthy eating behaviors and nutritional counseling interventions conducted by family physicians in primary health care.

Advances in Understanding the Interplay between Dietary Practices, Body Composition, and Sports Performance in Athletes

The dietary practices of athletes play a crucial role in shaping their body composition, influencing sports performance, training adaptations, and overall health. However, despite the widely acknowledged significance of dietary intake in athletic success, there exists a gap in our understanding of the intricate relationships between nutrition, body composition, and performance. Furthermore, emerging evidence suggests that many athletes fail to adopt optimal nutritional practices, which can impede their potential achievements. In response, this Special Issue seeks to gather research papers that delve into athletes' dietary practices and their potential impacts on body composition and sports performance. Additionally, studies focusing on interventions aimed at optimizing dietary habits are encouraged. This paper outlines the key aspects and points that will be developed in the ensuing articles of this Special Issue.

Estimated Intake of Potassium, Phosphorus and Zinc with the Daily Diet Negatively Correlates with ADP-Dependent Whole Blood Platelet Aggregation in Older Subjects

The aggregation of blood platelets is the pivotal step that leads to thrombosis. The risk of thrombotic events increases with age. Available data suggest that minerals taken with diet can affect the course of thrombosis. However, little is known about the relationship between platelet aggregability and mineral intake with diet among elderly people. Thus, we evaluated the associations between the reactivities of platelets to arachidonic acid, collagen or ADP and the estimated quantities of minerals consumed as a part of the daily diet in 246 subjects aged 60-65 years (124 men and 122 women). The found simple (not-adjusted) Spearman's rank negative correlations are as follows: 1. arachidonate-dependent aggregation and the amounts of potassium, zinc, magnesium, phosphorus, iron, copper and manganese; 2. collagen-dependent aggregation and the amounts of potassium, phosphorus, iron and zinc; and 3. ADP-dependent aggregation and the amounts of potassium, phosphorus and zinc. The negative associations between ADP-dependent platelet reactivity and the amount of potassium, phosphorus and zinc and between collagen-dependent aggregability and the amount of phosphorus were also noted after adjusting for a bunch of cardiovascular risk factors. Overall, in older subjects, the intake of minerals with diet is negatively related to blood platelet reactivity, especially in response to ADP. Diet fortification with some minerals may possibly reduce the thrombotic risk among elderly patients.

Legumes: A Vehicle for Transition to Sustainability

Legumes are an excellent source of protein and have been used in the human diet for centuries. Consumption of legumes has been linked to several health benefits, including a lower risk of cardiovascular diseases, type 2 diabetes mellitus, and certain types of cancer, while legumes' high fiber content promotes digestive health. Aside from the positive health benefits, one of the most significant advantages of legumes is the low environmental footprint of their cultivation. They can be grown in a variety of climates and soil types, and they require less water and fertilizer than other crops, making them a sustainable option for farmers. Thanks to their nutritional and physicochemical properties, they are widely used by the food industry since the growing popularity of plant-based diets and the increasing demand for alternatives to meat offers the opportunity to develop legume-based meat substitutes. As the use of legumes as a source of protein becomes widespread, new market opportunities could be created for farmers and food industries, while the reduction in healthcare costs could have a potential economic impact. Achieving widespread adoption of legumes as a sustainable source of protein requires coordinated efforts by individuals, governments, and the private sector. The objective of this narrative review is to present the benefits coming from legume consumption in terms of health and environmental sustainability, and underline the importance of promoting their inclusion in the daily dietary pattern as well as their use as functional ingredients and plant-based alternatives to animal products.

Examining the Nutrition of Cardiological Patients in Hospitals: Evaluating the Discrepancy between Received Diets and Reference Diet Based on ESC 2021 Guidelines-Hospital Diet Medical Investigation) (HDMI) Study

Cardiovascular diseases (CVDs) are the leading causes of death worldwide. CVDs have become the dominant cause of death and have been a significant health challenge since the second half of the 20th century in the Polish population. The aim of our HDMI (hospital diet medical investigation) study was to examine the quality of the hospital diets given to cardiac patients and assess how much they adhere to the European Society of Cardiology (ESC) 2021 guidelines. By comparing the diets received by patients with the recommended dietary patterns outlined in the ESC 2021 guidelines, we sought to identify discrepancies. The study was conducted in two steps: creating a 7-day model menu and comparing it with the received diets and then making comparisons with ESC 2021 guidelines. Additionally, we designed a survey to obtain the characteristics of the hospitals. The results show that the nutrition in hospitals remains substandard. None of the diets had an appropriate salt supply or predominance of plant-based food patterns. Only 1/7 diets avoided sweetened beverages, and 2/7 diets had an appropriate amount of fiber. This underscores a gap in the healthcare system to improve patients' health by implementing dietary interventions that foster the development of healthy eating habits.

Initiatives to Reduce the Content of Sodium in Food Products and Meals and Improve the Population's Health

Table salt is the main source of sodium (Na) in the human diet. Excessive supply of Na in a diet is strongly linked to many non-communicable human diseases, such as hypertension, obesity and stomach cancer. The World Health Organization recommends that daily intake of salt in adult diets should be kept below 5 g/person/day, which corresponds to 2 g Na/person/day. However, on average, adults consume about 9-10 g/person/day, and children and young people about 7-8 g/person/day. Initiatives to reduce salt intake include modifications of food composition in collaboration with the food industry, education of consumers, salt marking on foodstuff labels and taxation of salt. A need also exists to educate society so that they choose low-sodium products. In view of the food technology and amount of salt intake, the most important and the easiest change to make is to reduce the content of salt in baked goods. This paper analyses the results of surveys regarding strategies to reduce salt content in food products and considers multifaceted initiatives to reduce salt intake as a possible efficient method of improving the population's health status.