Combating CV Diseases: The Salt Reduction Path

H. Isma’eel, MD, FSCCT, FESC

Assistant Professor of Medicine

Co-Director, Vascular Medicine Program

American University of Beirut

Outline

• Why this presentation here?

• International CVD Data versus local?

• Why Salt?

• Time for action: introduce the Lebanese Action on Salt and Health (LASH) Group a member of WASH

0

5

10

15

20

25

30

1990 2020

Millio

ns o

f D

eath

s

fro

m C

ard

iovascu

lar

Cau

ses

Western countries Non-Western (developing) countries

5 million

Death from CVD Worldwide

KS Reddy et al, N Engl J Med 2004

Fuster V et al, Lancet 2005

9 million

19 million

6 million

Over

70%

of the

global

burden of

heart

attack and

stroke is

on poor

countries.

~15m

>25m

Fuster, V. et al. Circulation 2007;116:1966-1970

CVD mortality in various age groups and countries across the globe

0 20 40 60 80 100

Portugal

USA

Brazil

India

South Africa

35-44 45-54 55-64 65-74 75+

Men

Women

0 10 20 30 40 50 60 70

42

62

Patients Diagnosed with CHD (%) Murabito et al Circulation 1993

Myocardial Infarction or Sudden Cardiac

Death as Initial Presentation of CHD

Trends in Age-standardized mortality &

incidence of Acute MI Infarction (NHANES)

Per 100, 000 Person

Ergin A, An J Med 2004

49.7 49.2

10

20

30

40

50

60

30.4

18.6

Acute MI Mortality Acute MI incidence

1971-1982 1982-1992

Where do we stand in Lebanon?

Women Men Overall

Cigarette

smokers

31.6% 46.8% 38.5%

HTN 14.2% 13.2% 13.8%

DM2 4.8% 7.2% 5.9%

Raised

Cholesterol

15.2% 18.0% 16.5%

On meds for

Chol.

45.5% 36.9% 41.2%

Family History of

CAD

52.4% 48.3% 50.5%

Obese 26.5% 28.7% 27.4% % with 3-4 risk

factors

27.1% 42.9% 34.1%

Data on a Nationally representative sample of 2000 adults in Lebanon ages 25-64

Hwalla & Sibai et al, 2009

Nasreddine L. et al, 2012 LMJ In press

Corresponding %in USA

33.7%

11.9%

33%

28.3%

CDC Stats and Facts

0%

10%

20%

30%

40%

50%

60%

70%

1995 2000 2005 2010 2015 2020

Obesity

Diabetes

Hypertension

Linear trend (Obesity)

Linear trend (Diabetes)

Linear trend (HTN)

Figure 1: Secular linear trends in the prevalence (%) of obesity, diabetes and hypertension

among Lebanese adults* (Nasreddine L. et al, 2012 LMJ In Press)

And if this continues in a linear manner then we’re heading towards a disaster.

GBACC: Great Beirut Area CV Cohort

What has happened over 5 years?

HTN & SES in Lebanon HTN No/Yes

No Yes N ColPctN N ColPctN p-value

DEMO_GENDER 0.52 Male 104 33.99 66 36.87 Female 202 66.01 113 63.13 Age 41.64 ± 12.94 53.39 ± 13.85 <0.0001 Socioeconomic_5_education_n 0.0006 Less then elementary 90 29.7 85 47.49 Elementary 91 30.03 44 24.58 Secondary - technical 80 26.4 38 21.23 Higher education 42 13.86 12 6.7 Income <0.0001 < 600$ 71 25 81 50.94 600-999.9$ 119 41.9 47 29.56 1000-2000$ 65 22.89 24 15.09 >2000$ 29 10.21 7 4.4 Crowd_index_c 0.11 Not crowded 52 16.99 44 24.58 Crowded 129 42.16 72 40.22 Severely crowded 125 40.85 63 35.2

HTN No Yes Definite diabetes <0.0001

No 285 93.14 125 69.83 Yes 21 6.86 54 30.17 BMI_c <0.0001

Normal 98 32.03 14 7.82 Overweight 111 36.27 57 31.84 Obese 97 31.7 108 60.34 Obesity <0.0001

Non obese 209 68.3 71 39.66 Obese 97 31.7 108 60.34 MetS_WC <0.0001

0 167 54.58 44 24.58 1 139 45.42 135 75.42 SMOKE_CN_NY 0.0003

No 92 30.07 83 46.37 Yes 214 69.93 96 53.63 SMOKE_CN_NEY 0.0011

Never 69 22.55 58 32.4 Ex 23 7.52 25 13.97 Current 214 69.93 96 53.63 LDL (mg/dL) 106.91 33.86 112.88 43.4 0.11

HDL (mg/dL) 51.33 15.56 46.69 13.03 0.0005

Triglyceride (mg/dL) 128.34 106.74 165.68 88.49 <0.0001

Glucose(mg/dL) 103.43 30.71 128.19 57.01 <0.0001

HbA1C (%) 5.63 0.98 6.5 1.72 <0.0001

Waist circumference (cm) 91.95 13.35 103.6 16.1 <0.0001

Hence: POLICY CHANGES

• Highly Commend the Tobacco Working Group and we look forward to emulating them

Lebanese Action on Salt and Health

Na Reduction Working Grp 1. Why? 2. Who? 3. What are we doing? 4. When?

List of FACTS: 1.Despite some “noise”, salt is associated with

HTN, CVD and others

2.Reducing salt intake is associated with

reduced CVD outcomes

3.Reducing salt intake policy is among the

most cost-effective interventions as per the

WHO

4.Reducing salt intake is beyond an

individual’s effort – it requires a cultural

change and MAJOR FORCE

5.Reducing salt needs to be gradual with

realistic goals

List of Myths

1. most of the salt is added via the shaker

2. Salt is needed as a preservative TODAY

3. People who are used to salt cannot cut it

4. It’s an individual’s choice

From Knowledge to Policy

• Where are the major sources of salt in our diet?

• Who are the major stakeholders?

• How are we moving forward?

Lebanese Action on Salt and Health

• Adel Berbari

• Kamal Badr

• Hussain Isma’eel – VMP assigned Group Facilitator

• Lara Nasreddine

• Haya Hamadeh

• Imad El Haj

•Samir Arnaout •Abir Barhoumi •Mariam Olaik •Mohamad Medawar •Nathalie Khoueiry •Sami Sanjad •George Saade •Hani Tamim •Abla Sibai

Vascular Medicine Program at American University of Beirut

from all faculties

Goals

VMP- Na Intake optimization working Group

Research Clinical

Internal Education

and Training

External Education

and Training

Health Policy

Health Communication Plan

Na in Leb. Food 54.7% of the adult Lebanese population was found to exceed the maximum intake level of 2300 mg/day.

25%

12%

10%

9%

8%

8%

5%

4%

4%

3%

2% 2%

2% 2%

2% 1% 1% 1%

Major food group contributors to sodium intake

Bread, other bread-like products and breakfast cereals

Processed meats

Cheese and labneh

Salads

Vegetable based dishes and moughrabieh

Potato chips and salty snacks

Isma’eel H. et al, CDT 2015

47% of Na

CDC Morbidity and Mortality Weekly Report

40% of sodium consumed in the U.S. comes from 10 food categories, with bread and poultry among the top 5 (47% among Leb.) 88% are above the 2300 mg/d recommendation (55%)

How do we compare to the USA?

StakeHolders:

• All healthcare providers

• Governmental Bodies

• Food industry and Catering Services

Salt Shopping Guide:

Food Labels

Radio Messages &

Social Media

• 2-year Plan is pending approval in 2 weeks

• World Action on Salt and Health _ Lebanon (all working grp)

http://www.worldactiononsalt.com/

• First “Doctors to Coach Change” workshop (Coaching & Career Counseling Ltd. to train health care workers (HCW) adopt a coaching style to change lifestyle habits and Improve Compliance with Meds)

• Validate Na Food Frequency Questionnaire

• Launch Survey on Consumer Awareness of Health Hazards of Salt and Major sources of Salt in diet

• Launch Survey on HCW Awareness of Health Hazards of Salt and major sources of salt in diet

• Na Calculator Webpage

Time Line: Only KEY ongoing projects will be mentioned

• Research project “Establishment of Salt Intake and Range of PWV within Leb.”

• Initiate Health Comm. Plan Steps (Awareness, Interventions and impact measuring Research)

• Expect our invitation soon to the first HCW Salt Monitoring Workshop

• Replicate all the above in Pediatrics

• Feb 2013 (Credit Hx): Ready to launch National LASH Working Group

Time Line: Only KEY ongoing projects will be mentioned

What CCU patients know about salt intake and their health?

Does raising awareness improve knowledge?

Does patient awareness raising lead to behavioral changes?

Limitations

• Is the reported change in behavior true?

• Should we have used urinary sodium collection?

• Does this change lead to reduction in salt intake?

• Does this change lead to reduction in HTN?

• Does this change lead to reduction in CV outcomes?

Take home messages

• CVD are increasing in developing world countries

• HTN (similar to all CVD risk factors) is on the rise

• Higher prevalence of HTN are present in lower SES groups

• Lebanese consume high amounts of salt

• Bread and processed food are No. 1 source of salt

• Awareness raising about need/how to reduce salt intake is associated with ‘reported’ behavioral changes

• Health Policy Changes are more effective/efficient

GBACC Working Group; special

thanks to participants, students and

volunteers

Lebanese Action on Salt and Health

• Adel Berbari

• Kamal Badr

• Hussain Isma’eel – VMP assigned Group Facilitator

• Lara Nasreddine

• Haya Hamadeh

• Imad El Haj

•Samir Arnaout •Abir Barhoumi •Mariam Olaik •Mohamad Medawar •Nathalie Khoueiry •Sami Sanjad •George Saade •Hani Tamim •Abla Sibai

Vascular Medicine Program at American University of Beirut

from all faculties

Thank you