CVD

Question 0

WHO Report 2010

Causes of death

Answer 0

60% approx for men and women

IHD, stroke, copd, lrti

Question 1

Time-trends: CVD associated death rate in USA

Answer 1

Overall decreasing trend from:
1900-1997 cooper et al, circulation 2009
--- all genders and black and whites) cooper et al, CHD epidem
1970-2002 Jemal et al, JAMA 2005
~2009 Kochanek et al 2009 

Although variation e.g. Highest stroke rate in south west Oklahoma, Mississippi and Alabama (mokdad et al 1999)

But increased in Eastern Europe (Levi et al, Haart) from 1980-97

Question 2

Blood pressure and age

NB. 69% of all strokes and 49% of all heart disease attributable to raised BP (ezzati et al 2002) major RF for developing and developed

Answer 2

NHANES III phase I (1988-91)

Increased Bp with age (black women most, black > white)

Question 3

Evidence of how lifestyle affects health

Answer 3

Framingham study
Started in 1950s, concept of RF was born, now on third generation of participants

MONICA
Multinational monitoring of trends and determinants in CVD - worlds largest study of heart disease and stroke risk populations

Rose et al, 1985
Increases BP amongst London civil servants than Kenyan nomads - indicative of lifestyle variation especially diet

Question 4

Htn and CVD mortality (increased 25yr risk of death from CHD and stroke)

Answer 4

Adapted from Elliot and stamler 2005, multiple rf ix trial or MRFIT

randomised primary prevention trial showed that htn led to increase CVD mortality- just under 350k men used (347978)

Question 5

Smoking and health

Answer 5

Doll et al 2004
Smoking adverse effect on life expectancy

Pell et al 2008
Deceased admission for ACS according to month before and after smoking free legislation in Scotland

Question 6

Statin use to decrease cholesterol

Longitudinal studies of cholesterol show prognostic validity

Answer 6

Ford et al 2007

Pravastin
Statin treatment for an average 5 years provided an ongoing reduction in the risk if coronary events for an additional period of up to 10 years

Question 7

CVD mortality and gender

Answer 7

Nb NHANES is blood pressure

Jones-Webb et al, 2004
CVD mortality rates for men and women (45-64 years)
Highest in men, highest in blacks

Question 8

Intersalt (epidemiological study)

Answer 8

The Intersalt study was an observational study that showed an association between dietary salt, measured by urinary excretion, and blood pressure.[1] The study was based on a sample of 10 079 men and women age 20-59 sampled from 52 populations spread across the world.

Subsequent analyses showed that different BP in different populations e.g. Kenyan nomads and lower than London civil servants - due to environmental factors (rose et al, 1985)

Similarly Kenyan Lou migrants BP increased with length of stay in Nairobi (industrialised, different lifestyle)
- poulter et al, BMJ 1990

Question 9

Tone study

Answer 9

Appel, 1995

Trial of Nonpharmacologic Interventions in Elderly (TONE) showed loss of weight and decreased sodium intake can eliminate need for medication in the elderly to control BP in 585 overweight elderly individuals

Background:
National and international policy-making organizations advocate nonpharmacologic therapies to reduce blood pressure (BP). However, data to support such recommendations in older persons are virtually nonexistent. The Trials of Nonpharmacologic Intervention in the Elderly (TONE) is a randomized, controlled trial that will test whether weight loss or a reduced sodium (Na) intake or both can maintain satisfactory BP control, without unacceptable side effects, after withdrawal of antihypertensive drug therapy.

Question 10

Dash diet

Answer 10

Dietary approaches to stop htn (DASH) Appel et al 1997

Promoted US based national heart lung and blood institute
Reduced sbp by 6 and dbp by 3mmHg in those with pre-HTN

Sanchez-Castillo et al 1987
75% vs 10% (processed vs natural)

But hanneman of salt institute said the diet works not because of salt decrease but necause diet is good DIETARY QUALITY, NOT DIETARY SALT,
MOST RESPONSIBLE
FOR HEALTHY BLOOD PRESSURE

WHO: <2g/day of sodium and less for children

Question 11

Salt intakes in children’s diets

Answer 11

Marrero et al, 2014
13% of 5-6 and 35% of 13-17 year olds were over their maximum intake by scientific advisory committee on nutrition - 3G vs 6g

Question 12

Intermap (food sources of sodium, n= 501) Anderson et al 2010

Answer 12

49% breads, grains and cereals

INTERMAP (INTERnational collaborative study of MAcronutrients, micronutrients and blood Pressure) is a multi-centre cross-sectional epidemiologic investigation designed to help clarify unanswered questions regarding the role of dietary factors in the development of unfavourable blood pressure (BP) levels in adults.

Question 13

High BP is the leading RF for mortality worldwide especially LmIc

Answer 13

Ezzati and riboli 2013

Question 14

“Genetics load the gun, but environment pulls the trigger”

Answer 14

Pioneering American diabetologist,

Question 15

Salt reduction vs tobacco control

Answer 15

Asaria et al, 2007

Cheaper and more cost effective to limit salt

• more deaths averted
• costs less per person

Question 16

Action against salt in the UK

Answer 16

Consensus action on salt and health
CASH was set up in 1996 as a response to the refusal of the Chief Medical Officer to endorse the COMA recommendations to reduce salt intake, following the threat of withdrawal of funds by the food industry to the Conservative Party. This view was contrary to the current medical and scientific consensus and we aim to counter these claims with the wealth of scientific evidence, which clearly links high salt intake to ill health

The current target is to reduce salt intake to an average of 6g a day (by 2012) for adults and even less for children, from the current average of 8.1g a day. This reduction will have a large impact on reducing strokes by approximately 22% and heart attacks by 16% saving 17,000 lives in the UK as well as other health benefits for the population.

• See more at: http://www.actiononsalt.org.uk/about/index.html#.dpuf

UK Salt Campaign
Asda became the first in the UK to beat the FSAs target of reducing salt content in its food ahead of 2010 deadline. It has cut 396 tonnes of salt from it’d 12000 own brand products,

Traffic light label

Question 17

Danaei G et al 2011. GA, Lim SS, Riley LM, Ezzati M on behalf of the Global Burden of Metabolic Risk Factor of Chronic Diseases Collaborating Group (Blood Pressure). National, regional, and global trends in systolic blood pressure since 1980: Systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participant

Answer 17

Overall – Global population SBP decreased slightly (~1 mm Hg/decade) since 1980, but trends varied significantly across regions and countries; SBP currently highest in LMICs. Uncontrolled HTN prevalence declined, but number of people with UHTN increased (population growth & ageing)

Lowest SBP – Overall Women in Australasia

Highest SBP – Overall Central + Eastern Europe, SSA; Men in every subregion except West Africa
Men – Baltic + East and West African countries

Decreases – Largest in men and women in Australasia, North America, Western Europe

Increases – Oceania, East Africa, South & Southeast Asia for both sexes; West Africa for women

Question 18

Elliott et al 1996. Intersalt revisited: Further analyses of 24 hour sodium excretion and blood pressure within and across populations

Answer 18

Results: In within population analyses (n=10 074), individual 24 hour urinary sodium excretion higher by 100 mmol (for example, 170 v 70 mmol) was associated with systolic/diastolic blood pressure higher on average by 3/0 to 6/3 mm Hg (with and without body mass in analyses). Associations were larger at ages 40-59. In cross population analyses (n=52), sample median 24 hour sodium excretion higher by 100 mmol was associated with median systolic/diastolic pressure higher on average by 5-7/2-4 mm Hg, and estimated mean difference in systolic/diastolic pressure at age 55 compared with age 25 greater by 10-11/6 mm Hg.

Conclusions: The strong, positive association of urinary sodium with systolic pressure of individuals concurs with Intersalt cross population findings and results of other studies. Higher urinary sodium is also associated with substantially greater differences in blood pressure in middle age compared with young adulthood. These results support recommendations for reduction of high salt intake in populations for prevention and control of adverse blood pressure levels.

Key Messages
o The within population findings were previously underestimated because of incomplete correction for the regression dilution problem
o Revised estimates of the within population association of sodium to blood pressure in Intersalt are concordant with the cross population findings for 52 samples
o Estimates of the effect of median sodium excretion higher by 100 mmol/day over a 30 year period (age 55 minus age 25) were a greater difference of 10-11 mm Hg in systolic blood pressure and 6 mm Hg in diastolic blood pressure
o These results lend further support to recommendations for mass reduction of high salt intake for the prevention and control of adverse blood pressure levels and high blood pressure in populations

Question 19

Reducing Population Salt Intake Worldwide: From Evidence to Implementation
(Feng 2010)

Answer 19

o with the recent large increase in the consumption of highly salted processed foods, salt intake is now increasing again.
o Humans are genetically programmed to a salt intake of less than 0.25 g/d. The recent changes (in evolutionary terms) to a high salt intake present a major challenge to the physiologic systems to excrete these large amounts of salt through the kidneys
o The average salt intake in most countries around the world is approximately 9 to 12 g/d, with many Asian countries having mean intakes more than 12 g/d
o The consequence is that the high salt intake causes a rise in blood pressure (BP), thereby, increasing the risk of cardiovascular disease (CVD), and renal disease.
o There is also increasing evidence that salt intake is indirectly related to obesity through soft drink consumption salt comprises 40% sodium and 60% chloride.
o It was estimated that an increase of 6 g/d in salt intake over 30 years would lead to an increase in systolic BP by 9 mm Hg
o Population-based intervention studies have shown that when salt intake was successfully decreased, there was a reduction in population BP randomized trials have studied the effects of modest reductions in salt intake, that is, from the current intake of approximately 9 to 12 g/d to approximately 5 to 6 g/d and have shown that the falls in BP were equivalent to single drug therapy
o The fall in BP with a reduction in salt intake has been shown to be related to age, that is, the older the individual, the greater that fall in BP with salt reduction.
o Reducing salt from the current intake of 9 to 12 g/d to the recommended level of 5 to 6 g/d will have a major effect on BP and thereby CVD and may have other beneficial effects on health
o approximately 80% of salt is developed countries: hidden in foods, that is, added by the food industry
o In many developing countries, where most of the salt consumed comes from salt either added during cooking or comes from sauces, public health campaigns are needed to encourage consumers to use less salt.

Question 20

Dunford et al (2012). The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction

Answer 20

Findings
o Salt content of fast foods varies substantially, not only by type of food, but by company and country in which the food is produced
o
o Reasons for this variation are not clear, the marked differences in salt content of very similar products suggest that technical reasons are not a primary explanation
o In the right regulatory environment, it is likely that fast food companies could substantially reduce the salt in their products, translating to large gains for population health
o environment, it is likely that fast food companies could substantially reduce salt in their products.
o Reductions could be made incrementally over several years, so that substantial cumulative decreases in salt content could be achieved without consumers being aware of changes in formulation.
o Evidence from the UK shows agreement between governments & food industry can drive down salt levels of processed foods. An incremental, sector-wide approach has the greatest impact from a public health perspective as small reductions in risk for a larger population will increase overall benefits. One can exploit that because fast food companies already have dynamic ongoing reformulation programs, cost of incorporating salt-reduction targets should be minimal
o Much greater variation in salt content seen comparisons were made per serving than per 100g, This provides evidence to reduce and standardise serving sizes, which has the added advantage of reducing consumption of other adverse nutrients – good strategy for obesity epidemic. Trend that serving sizes of fast food have substantially increased

Question 21

Brown et al (2009). Salt intakes around the world: Implications for public health

Answer 21

Findings
o Sodium intake worldwide well in excess of physiological need (i.e. 10-20 mmol/day)
o Commonly >100 mmol/day, sometimes >200 mmol/day
o Distribution
• North America + Europe à Sodium intake dominated by sodium added to manufactured foods (~75% of intake) à Cereals + baked goods mainly in US/UK
• Japan + China à Salt added at home + soy sauce largest contributors
o Implications
• Shifting population BP levels to more optimal levels will have profound effects. In the UK, for example, it was estimated that a population-wide reduction in sodium intake of 100 mmol/day would lead to mean systolic and diastolic BP falls, preventing nearly 22 000 deaths from CHD and 15 000 deaths from stroke
• Policy need to be directed at main source of dietary sodium in various populations
• Personal efforts to reduce salt intake may be hampered by the large quantities of salt found in processed foods: unpublished INTERMAP data show that for individuals who made a conscious effort to reduce salt intake compared to others, sodium excretion was greatly reduced only among the rural PRC samples. Therefore, public health initiatives to limit salt consumption can only be effective in tandem with government/industry initiatives to reduce the salt content of processed foods. Therefore, public health initiatives to limit salt consumption can only be effective in tandem with government/industry initiatives to reduce the salt content of processed foods.