1. The Health Effects of Reducing Sodium and Improving Overall Diet Lawrence J Appel, MD, MPH Professor of Medicine, Epidemiology and International Health(Human Nutrition) July 9, 2008 Disclosures and Conflicts of Interest: None

2. Bottom Line on Salt(Sodium Chloride)

On average, reducing salt intake lowers blood pressure and subsequent risk of cardiovascular disease

Other potential health benefits

• reduced risk of gastro-esophageal cancer

• reduced left ventricular mass

• preserved bone mass

3. Bottom Line of Diet Quality

Several distinct diets are associated with increased survival and a reduced risk of chronic disease, especially cardiovascular disease (CVD)

Such diets are typically:

• Reduced in saturated fat, trans fat, and cholesterol

• Rich in fruits, vegetables, and whole grains

4. www.nap.edu www.iom.edu/fnb Dietary Reference Intakes from the Institute of Medicine (IOM) 5. 2005 US Dietary Guidelines

Scientific Advisory Committee Report

Technical Report

Dietary Guidelines for Americans , 2005

Policy Document

Finding Your Way to a Healthier You: Based on theDietary Guidelines for Americans

Public Document

Implementation Tools

• DASH eating plan

• Food Label

• My Pyramid

www.healthierus.gov/dietaryguidelines

6. Reducing Sodium Intake 7. Useful Conversions Adequate Intake (AI) Upper Level (UL) Sodium (mg) 1,500 2,300 Sodium (mmol) 65 100 Sodium Chloride (g) 3.8 5.8 8. Forms of Sodium

90% of sodium consumed as sodium chloride (salt)

Other forms:

• sodium bicarbonate

• sodium in processed foods, such as sodium benzoate and sodium phosphate

9. Sources of Dietary Sodium Inherent 12% Food Processing 77% At the Table 6% During Cooking 5% Mattes and Donnelly, JACN, 1991; 10: 383 (62 adults who completed 7 day dietary records) 10. 11. Adverse Effects Attributed to Excess Sodium Intake

Increased urinary calcium excretion (but no trials with bone mineral density or fractures)

Increased left ventricular mass in cross-sectional studies (and one randomized trial)

Increased risk of gastric cancer (ecologic studies, case-control studies)

Primary effect of sodium that drives policy:Increased blood pressure (and subsequent blood pressure related CVD renal disease)

12. Deaths from Stomach Cancer (per 100,000 Per year) Adapted from Joossens, Int J Epi 1996;25:494-504KOR r=0.702 P 160or or 90 99 >100 14. Magnitude of the BP Problem

62% of strokes and 49% of CHD events attributed to elevated BP*

26% of adults worldwide (971 million) have hypertension**

*WHO, World Health Report 2002: Reducing Risks, Promoting Healthy Life, **Kearney Lancet 2005;305:217, 15. Important Concepts

The lower your blood pressure, the lower your risk of heart disease and stroke ( EVEN IF YOU DO NOT HAVE HYPERTENSION )

In most but not all countries, blood pressure rises with age

Your lifetime risk of developing hypertension is 90%

16. Stroke Mortality by Level of Usual Systolic BP* *Prospective Studies Collaboration, Lancet, 2002: Meta-analysis of 61 prospective studies with 2.7m person-yrs, 11.9k deaths 17. Distribution of BP Levels in US Adults, Ages 18 and Older (NHANESIII) Normal 140 or DBP> 90 Source:Wang, Hypertension, 2004 42% 27% 31% 18. Established Market Economies Men116 Women 123 Latin America & Caribbean Men60 Women 54Middle Eastern Crescent Men36 Women38 Former Socialist Economies Men41 Women 53 China Men99 Women 83 India Men60 Women 58 Sub-Saharan Africa Men38 Women42 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J.Lancet 2005;365:217-223 2000: Number (millions) of Hypertensives, by World Region Other Asia & islands Men38 Women 33 Overall = 971 million Economically Developed Countries = 333 million Economically Developing Countries = 639 million SBP140 mm Hg DBP90 mm Hg BP lowering med 19. Mean SBP and DBP by Age and Race/Ethnicity for Women, Age 18 Years and Older 150 140 130 120 110 100 90 80 70 mm Hg 18-29 30-39 40-49 50-59 60-69 70-79 80+ Diastolic Systolic Source:Burt V, et al.Hypertension, 1995 SBP Rise with Age = ~0.6 mmHg per year Age Black White Mexican-American 20. Mean Systolic and Diastolic BP * Pediatrics, 2004;114:555-576 (for 50th Percentile Height) ** J Human HTN, 1989, 3:331-407 Age (yrs) SBP Rise with Age boys: 1.9 mmHg / yr girls: 1.5 mmHg / yr Yanomami**, ages 20-59 Men Women U.S. Children*, ages 1- 17 (101) (91) (65) (56) 20 - 59 Age (yrs) Systolic Diastolic 21. Population-Based Strategy SBP Distributions Stamler R.Hypertension 1991;17:I-16I-20. % Reduction in MortalityReduction in BP After Intervention Before Intervention Stroke CHD Total -6 -4 -3 -8 -5 -4 -14 -9 -7 Reduction in SBP mmHg 2 3 5 22. Effect of Reduced Sodium Intake on Blood Pressure

> 50 trials of sodium reduction on blood pressure

10 dose response trials

3 trials of sodium reduction as a means to prevent hypertension

23. Sodium: Dose Response Trials Luft, 1979 (14 non-hypertensive) 24. Sodium: Dose Response Trials MacGregor, 1989 (20 hypertensive) 25. Sodium: Dose Response Trials Johnson,2001 (n=17 non-hypertensive elderly) 26. Sodium: Dose Response Trials Johnson,2001 (n=15 elderly with isolated systolic hypertension) 27. Sodium: Dose Response Trials Johnson,2001 (n=8 elderly with systolic-diastolic hypertension) 28. Sodium Dose Response Trials:DASH-Sodium Trial* Systolic BloodPressure Control Diet DASH Diet 1.5 (65)2.4 (106) 3.3 (143) Sodium Level: gm/d (mmol) per day +2.1 +1.3 +1.7 +4.6 +6.7 p