The contribution of sodium reduction and potassium increase to the blood pressure lowering observed in the Salt Substitute and Stroke Study.

The Salt Substitute and Stroke Study (SSaSS) demonstrated significant reductions in systolic blood pressure (SBP), and the risk of stroke, major cardiovascular events and total mortality with the use of potassium-enriched salt. The contribution of sodium reduction versus potassium increase to these effects is unknown. We identified four different data sources describing the association between sodium reduction, potassium supplementation and change in SBP. We then fitted a series of models to estimate the SBP reductions expected for the differences in sodium and potassium intake in SSaSS, derived from 24-h urine collections. The proportions of the SBP reduction separately attributable to sodium reduction and potassium supplementation were calculated. The observed SBP reduction in SSaSS was -3.3 mmHg with a corresponding mean 15.2 mmol reduction in 24-h sodium excretion and a mean 20.6 mmol increase in 24-h potassium excretion. Assuming 90% of dietary sodium intake and 70% of dietary potassium intake were excreted through urine, the models projected falls in SBP of between -1.67 (95% confidence interval: -4.06 to +0.73) mmHg and -5.33 (95% confidence interval: -8.58 to -2.08) mmHg. The estimated proportional contribution of sodium reduction to the SBP fall ranged between 12 and 39% for the different models fitted. Sensitivity analyses assuming different proportional urinary excretion of dietary sodium and potassium intake showed similar results. In every model, the majority of the SBP lowering effect in SSaSS was estimated to be attributable to the increase in dietary potassium rather than the fall in dietary sodium.

Salt restriction for treatment of hypertension - current state and future directions.

PURPOSE OF REVIEW: Given the adverse effects of excess dietary sodium chloride (also known as table salt) on blood pressure (BP) and cardiovascular disease (CVD), restriction of dietary sodium is recommended by numerous guidelines. The strictest of these recommend no more than 1.5 g/day of dietary sodium among hypertensive persons. However, average dietary sodium intake in the population is closer to 5 g/day and there is debate about whether too much sodium restriction may be associated with increased CVD risk. Herein, we aim to provide a balanced update on this topic. RECENT FINDINGS: In 2021, the Salt Substitute and Stroke Study (SSaSS) demonstrated a significant reduction in BP, CVD, and death among Chinese adults randomized to a low sodium salt-substitute supplemented with potassium. This trial largely puts to rest any remaining debate about the benefits of dietary sodium restriction among persons with excess baseline intake (dietary sodium intake fell from approximately 5 down to 4 g/day in the active arm of SSaSS). However, whether achieving and maintaining a dietary sodium of less than1.5 g/day is feasible in real-world settings and whether this low an intake is harmful remain open questions. SUMMARY: Aiming for sodium intakes of 2--3 g/day in the general population and as low as 2 g/day in persons with hypertension or CVD seems most reasonable, but there is some uncertainty around lower targets.

Potassium intake: the Cinderella electrolyte.

Dietary guidelines recommend intake targets for some essential minerals, based on observational and experimental evidence relating mineral intake levels to health outcomes. For prevention of cardiovascular disease, reducing sodium intake and increasing potassium intake are the principal tools. While reducing sodium intake has received greatest public health priority, emerging evidence suggests that increasing potassium intake may be a more important target for cardiovascular prevention. Increased potassium intake reduces blood pressure and mitigates the hypertensive effects of excess sodium intake, and the recent large Phase III SSaSS trial reported that increasing potassium intake (and reducing sodium intake) in populations with low potassium intake and high sodium intake, through salt substitution (25% KCl, 75%NaCl), reduces the risk of stroke in patients at increased cardiovascular risk. As key sources of potassium intake include fruit, vegetables, nuts, and legumes, higher potassium intake may be associated with healthy dietary patterns. The current review makes the case that increasing potassium intake might represent a more advantageous dietary strategy for prevention of cardiovascular disease. Future research should focus on addressing the independent effect of potassium supplementation in populations with low or moderate potassium intake, and determine effective strategies to increase potassium intake from diet.

Effects of Sodium-Specific Medical Nutrition Therapy from a Registered Dietitian Nutritionist in Individuals with Chronic Kidney Disease: An Evidence Analysis Center Systematic Review and Meta-Analysis.

Dietary sodium intake can increase risk of hypertension, a leading cause of kidney failure in individuals with chronic kidney disease. The objective of this systematic review was to examine the effect of sodium-specific medical nutrition therapy provided by a registered dietitian nutritionist or international equivalent on blood pressure and urinary sodium excretion in individuals with chronic kidney disease, stages 2 through 5, receiving maintenance dialysis and posttransplant. Medline, the Cumulative Index to Nursing and Allied Health Literature, Cochrane Cochrane Central Register of Controlled Trials, and other databases were searched to identify eligible controlled trials published in the English language from January 2000 until June 2020 that addressed the research question. Risk of bias was assessed using the RoB 2.0 tool and quality of evidence was examined by outcome using the Grading of Recommendations Assessment, Development, and Evaluation method. Of the 5,642 articles identified, eight studies were included in the final analyses. Six studies targeted clients who were not dialyzed, including one with clients who were posttransplantation, and two studies with clients receiving maintenance hemodialysis. Sodium-specific medical nutrition therapy from a registered dietitian nutritionist significantly reduced clinic systolic blood pressure (mean difference -6.7, 95% CI -11.0 to -2.4 mm Hg; I2 = 51%) and diastolic blood pressure (mean difference -4.8, 95% CI, -7.1 to -2.4 mm Hg; I2 = 23%) as well as urinary sodium excretion (mean difference -67.6, 95% CI -91.6 to -43.6 mmol/day; I2 = 84.1%). Efficacy was limited to individuals who were not dialyzed, including posttransplantation, but the intervention did not significantly improve blood pressure in individuals receiving maintenance hemodialysis. Adults with chronic kidney disease should begin to work with registered dietitian nutritionist early in the course of disease to receive individualized, effective counseling to improve risk factors and, ultimately, health outcomes.

Nutrition and the Covid-19 pandemic: Three factors with high impact on community health.

AIMS: In the course of the COVID-19 pandemic, multiple suggestions have been delivered through websites and social media referring to natural substances and various kinds of supplements with thaumaturgical properties in preventing and/or fighting the coronavirus infection. Indeed, there is no clinical trial evidence that a dietary or pharmacological supplementation of any particular substance will increase the effectiveness of the immune defences. There are however three nutritional issues that deserve special attention under the present circumstances, namely vitamin D deficiency, excess salt intake and inappropriate alcohol consumption. Here is a short review of the current knowledge about the possible role of these factors in the immunity defence system and their potential impact on the modulation of the immune response to SARS-COV2 infection. DATA SYNTHESIS: For all of these factors there is convincing evidence of an impact on the immune defence structure and function. In the absence of RCT demonstration that increased ingestion of any given substance may confer protection against the new enemy, special attention to correction of these three nutritional criticisms is certainly warranted at the time of COVID pandemic. CONCLUSIONS: We propose that the inappropriate intake of salt and alcohol and the risk of inadequate vitamin D status should be object of screening, in particular in subjects at high mortality risk from SARS-COV 2 infection, such as institutionalised elderly subjects and all those affected by predisposing conditions.

[Nutrition in the prevention and control of osteoporosis]. / Nutrición en la prevención y el control de la osteoporosis.

INTRODUCTION: Objective: although osteoporosis develops in advanced stages of life, it must be prevented and stopped from the pediatric age, acting on modifiable factors, especially diet and lifestyle. The objective of this work is to review the latest evidence on nutritional improvements that can help in the prevention and control of the disease. Methods: bibliographic search related to the topic. Results: it is advisable to avoid energy restrictions, especially in postmenopausal women and particularly if they have osteopenia/osteoporosis since, in relation to these pathologies, excess weight may be preferable, rather than underweight. Protein intake higher than the recommended one is beneficial for the bone, provided that the calcium intake is adequate. Excessive intake of sugar and saturated fat should be avoided, but attempts should be made to achieve the nutritional goals set for ω-3 polyunsaturated fatty acids and fiber. It is important to monitor vitamin D status and calcium intake, which is inadequate in high percentages of individuals, as well as improving the contribution of vitamins K, C and group B, and also magnesium, potassium, iron, zinc, copper, fluorine, manganese, silicon and boron, and avoiding the excessive contribution of phosphorus and sodium. Conclusions: osteoporosis is an underdiagnosed pathology and of increasing prevalence. Due to its high morbidity and mortality, prevention is important and, from a nutritional point of view, it is convenient to bring the diet closer to the theoretical ideal. In general, increasing the consumption of dairy products, fish, vegetables and fruits, as well as reducing the consumption of salt, during childhood and throughout life, seems convenient for the bone improvement of most of the population.

INTRODUCCIÓN: Introducción y objetivos: la osteoporosis, aunque se manifiesta en etapas avanzadas de la vida, se debe prevenir y frenar desde la edad pediátrica, actuando sobre los factores modificables, especialmente la alimentación y el estilo de vida. El objetivo del presente trabajo es revisar las últimas evidencias sobre las mejoras nutricionales que pueden ayudar en la prevención y el control de la enfermedad. Métodos: búsqueda bibliográfica en relación con el tema. Resultados: conviene evitar las restricciones energéticas, especialmente en mujeres posmenopáusicas, sobre todo si tienen osteopenia/osteoporosis dado que, en relación con estas patologías, puede ser preferible un exceso de peso frente a un peso insuficiente. Una ingesta proteica superior a la recomendada es beneficiosa para el hueso siempre que la ingesta de calcio sea adecuada. Se debe evitar una ingesta excesiva de azúcar y de grasa saturada, pero se deben intentar alcanzar los objetivos nutricionales marcados para los ácidos grasos poliinsaturados ω-3 y la fibra. Es importante vigilar la situación en vitamina D y la ingesta de calcio, que es inadecuada en elevados porcentajes de individuos. También conviene mejorar el aporte de vitaminas K, C y del grupo B, así como de magnesio, potasio, hierro, zinc, cobre, flúor, manganeso, silicio y boro, y evitar el aporte excesivo de fósforo y sodio. Conclusiones: la osteoporosis es una patología infradiagnosticada y de prevalencia creciente. Por su elevada morbilidad y mortalidad es importante la prevención y desde el punto de vista nutricional conviene aproximar la dieta al ideal teórico. En general, el incremento en el consumo de lácteos, pescado, verduras, hortalizas y frutas, así como la reducción del consumo de sal, durante la infancia y a lo largo de la vida parecen convenientes para la mejora ósea de la mayor parte de la población.

The Influence of Dietary Salt on the Osseointegration of Implants in Aging Rats

Introduction: The bone-implant interface has been studied extensively, but only few papers focused on the nutritional aspects that may affect bone quality, especially salt intake. Objective: To study the osseointegration of implants in salt-loaded rats with low mineral bone content. Methods: A total of 60 4-month-old male rats were divided in 2 groups ( n = 30), being these groups divided in 2 periods, (2 and 4 months). The control group received a normal diet, while the test group received a diet supplemented with 1% sodium chloride (NaCl). Implants were placed in the tibia of both groups. A total of 15 animals of each group were sacrificed at the 2 nd month of the experiment, while the remaining animals were sacrificed at the 4 th month. Results: No statistically significant difference was found in food intake between the groups on any experimental period, but a statistically significant difference was found in the liquid intake in the saline group in both periods. For all groups, osseointegration was observed in both groups. The mean percentage of osseointegration in the cortical bone, in the trabecular bone, and in the total osseointegrated surface between the control (46.38 ± 16.17%) and saline (49.13 ± 11.52%) groups at 2 months was not statistically different ( p = 0.61). The total osseointegration areas of the control (53.98 ± 12.06%) and saline (51.40 ± 13.01%) groups at the 4 th month of the study were not statistically ( p = 0.61). Conclusion: Ingestion of salt did not affect directly the osseointegration process during the period of the experiment. The results suggest that mineral losses may not affect the achievement of good osseointegration in aging rats. (AU)

Maximising benefits and minimising adverse effects of micronutrient interventions in low- and middle-income countries.

Micronutrient deficiencies are widespread and disproportionately affect women and children in low- and middle-income countries (LMIC). Among various interventions, food fortification and supplementation with micronutrients have been proven to be cost-effective. The aim of the present paper is to review existing literature to assess risks of excessive intake in LMIC to then highlight programmatic changes required to maximise benefits of micronutrient interventions while minimising risks of adverse effects. While very few LMIC have national food consumption surveys that can inform fortification programmes, many more are implementing mandatory fortification programmes. The risks of inadequate micronutrient intakes were common, but risks of excessive intakes were also present for iodine, vitamin A, folic acid and iron. Excessive salt consumption, high concentrations of iodine in ground-water and excessive levels of iodisation were linked with excessive iodine intake. For vitamin A, overlapping interventions were the main risk for excessive intake; whereas for iron, contamination with iron from soil and screw-wares of millers and high iron concentration in drinking-water increased the risk of excessive intake, which could be further exacerbated with fortification. Before implementing micronutrient interventions, adherence to the basic principles of documenting evidence confirming that the deficiency in question exists and that fortification will correct this deficiency is needed. This can be supported with dietary intake assessments and biochemical screening that help diagnose nutrient deficiencies. Targeting micronutrient interventions, although programmatically challenging, should be considered whenever possible. Moreover, closer monitoring of appropriate fortification of foods and overlapping interventions is needed.

Renal tubule insulin receptor modestly promotes elevated blood pressure and markedly stimulates glucose reabsorption.

Although the cause of hypertension among individuals with obesity and insulin resistance is unknown, increased plasma insulin, acting in the kidney to increase sodium reabsorption, has been proposed as a potential mechanism. Insulin may also stimulate glucose uptake, but the contributions of tubular insulin signaling to sodium or glucose transport in the setting of insulin resistance is unknown. To directly study the role of insulin signaling in the kidney, we generated inducible renal tubule-specific insulin receptor-KO mice and used high-fat feeding and mineralocorticoids to model obesity and insulin resistance. Insulin receptor deletion did not alter blood pressure or sodium excretion in mice on a high-fat diet alone, but it mildly attenuated the increase in blood pressure with mineralocorticoid supplementation. Under these conditions, KO mice developed profound glucosuria. Insulin receptor deletion significantly reduced SGLT2 expression and increased urinary glucose excretion and urine flow. These data demonstrate a direct role for insulin receptor-stimulated sodium and glucose transport and a functional interaction of insulin signaling with mineralocorticoids in vivo. These studies uncover a potential mechanistic link between preserved insulin sensitivity and renal glucose handling in obesity and insulin resistance.

Integrative Medicine for Cardiovascular Disease and Prevention.

Cardiovascular disease (CVD) is traditionally treated through medications and lifestyle modifications, yet adherence to these treatments is often poor. The use of complementary therapies is increasing, and it is vital for physicians to be aware of the risks and benefits of these options. This article summarizes the current evidence base on integrative therapies for the prevention and treatment of CVD, including hypertension, hyperlipidemia, coronary artery disease, heart failure, and arrhythmias. Where applicable, recommendations are included for therapies that may be used as an adjunct to traditional medical care to improve cardiovascular health and quality of life.

Warnings as a directive front-of-pack nutrition labelling scheme: comparison with the Guideline Daily Amount and traffic-light systems.

OBJECTIVE: Warnings have recently been proposed as a new type of directive front-of-pack (FOP) nutrition labelling scheme to flag products with high content of key nutrients. In the present work, this system was compared with the two most common FOP nutrition labelling schemes (Guideline Daily Amounts (GDA) and traffic-light system) in terms of goal-directed attention, influence on perceived healthfulness and ability to differentiate between products. Design/Setting/Subjects Goal-directed attention to FOP labels was evaluated using a visual search task in which participants were presented with labels on a computer screen and were asked to indicate whether labels with high sodium content were present or absent. A survey with 387 participants was also carried out, in which the influence of FOP labels on perceived healthfulness and ability to identify the healthful alternative were evaluated. RESULTS: Warnings improved consumers' ability to correctly identify a product with high content of a key nutrient within a set of labels compared with GDA and received the highest goal-directed attention. In addition, products with high energy, saturated fat, sugar and/or sodium content that featured warnings on the label were perceived as less healthful than those featuring the GDA or traffic-light system. Warnings and the traffic-light system performed equally well in the identification of the most healthful product. CONCLUSIONS: Results from the present work suggest that warnings have potential as directive FOP nutrition labels to improve consumer ability to identify unhealthful products and highlight advantages compared with the traffic-light system.

[Role of the diet in urinary stone formation and prevalence]. / Az étrend szerepe a húgyúti kövek kialakulásában és megelozésében.

In Hungary and in the developed countries urinary stones occur more often due to nutritional habits, obesity and sedentary lifestyle beside the endocrine and metabolic causes. In the daily urological and family doctor practice prevention should have an important role. Prevention is based not only on body weight control, physical exercise and medical treatment, but on proper diet as well. The nutritional components can change the consistence of urine, causing supersaturation, which is essential in stone formation. Specific nutritional components can either prevent stone formation (increased fluid intake, citrate, magnesium, fruits and vegetables) or either increase stone formation (decreased fluid intake, proteins, carbohydrates, oxalate, salt, increased calcium intake, ascorbic-acid etc). We summarized evidence-based practical dietary suggestions on the primary and secondary prevention of urinary stones. Orv Hetil. 2017; 158(22): 851-855.

Hypertension in Chronic Kidney Disease.

Hypertension, a global public health problem, is currently the leading factor in the global burden of disease. It is the major modifiable risk factor for heart disease, stroke and kidney failure. Chronic kidney disease (CKD) is both a common cause of hypertension and CKD is also a complication of uncontrolled hypertension. The interaction between hypertension and CKD is complex and increases the risk of adverse cardiovascular and cerebrovascular outcomes. This is particularly significant in the setting of resistant hypertension commonly seen in patient with CKD. The pathophysiology of CKD associated hypertension is multi-factorial with different mechanisms contributing to hypertension. These pathogenic mechanisms include sodium dysregulation, increased sympathetic nervous system and alterations in renin angiotensin aldosterone system activity. Standardized blood pressure (BP) measurement is essential in establishing the diagnosis and management of hypertension in CKD. Use of ambulatory blood pressure monitoring provides an additional assessment of diurnal variation in BP commonly seen in CKD patients. The optimal BP target in the treatment of hypertension in general and CKD population remains a matter of debate and controversial despite recent guidelines and clinical trial data. Medical therapy of patients with CKD associated hypertension can be difficult and challenging. Additional evaluation by a hypertension specialist may be required in the setting of treatment resistant hypertension by excluding pseudo-resistance and treatable secondary causes. Treatment with a combination of antihypertensive drugs, including appropriate diuretic choice, based on estimated glomerular filtration rate, is a key component of hypertension management in CKD patients. In addition to drug treatment non-pharmacological approaches including life style modification, most important of which is dietary salt restriction, should be included in the management of hypertension in CKD patients.

Effects of a high salt intake and potassium supplementation on QT interval dispersion in normotensive healthy subjects.

OBJECTIVE: To evaluate the effects of dietary sodium intake on QT interval dispersion (QTd) in normotensive healthy subjects and assess the protective effects of dietary potassium. Methods All subjects were sequentially maintained on a protocol with a three-day baseline investigation, seven-day low-salt period (3 g/day (d), NaCL), seven-day salt loading period (18 g/d, NaCL) and a seven-day salt loading with potassium supplementation period (4.5 g/d, KCL). On the last day of each period, 24-hour urine samples were collected, the blood pressure values were measured and an electrocardiogram was recorded. The QT interval, QTd and T peak-T end interval (Tp-Te) were subsequently measured and calculated. Patients Sixty-four normotensive subjects, men and women, ranging from 28 to 60 years of age, were enrolled. Results There were no great fluctuations in heart rate after salt loading, whereas the systolic blood pressure (SBP, mmHg) and diastolic blood pressure (DBP, mmHg) increased and the corrected QT interval (QTc), corrected QT interval dispersion (QTdc) and Tp-Te values were significantly prolonged compared to that observed in the low-salt period (SBP, 118.6 ± 13.5 vs. 111.7 ± 11.3, p<0.01; DBP, 76.9 ± 8.6 vs. 71.7 ± 7.7, p<0.01; QTdc, 60.3 ± 19.4 vs. 55.6 ± 19.4, p<0.05; Tp-Te, 83.0 ± 10.1 vs. 79.8 ± 8.5, p<0.01). Surprisingly, all of these changes were reversed by potassium supplementation (SBP, 114.5 ± 12.3 vs.118.6 ± 13.5, p<0.01; DBP, 72.2 ± 7.9 vs.76.9 ± 8.6, p<0.01;QTd, 42.6 ± 15.1 vs. 47.4 ± 19.0, p<0.05; QTdc, 52.2 ± 18.0 vs. 60.3 ± 19.4, p<0.05; Tp-Te, 79.1 ± 8.5 vs. 83.0 ± 10.1, p<0.01). Conclusion Salt loading prolongs the QT interval, QTd and Tp-Te, while dietary potassium supplementation reverses these alterations. These findings suggest that potassium supplementation may improve variation in the healing time and prevent arrhythmia.

LCZ696, Angiotensin II Receptor-Neprilysin Inhibitor, Ameliorates High-Salt-Induced Hypertension and Cardiovascular Injury More Than Valsartan Alone.

BACKGROUND: LCZ696, an angiotensin receptor-neprilysin inhibitor, has recently been demonstrated to exert more beneficial effects on hypertensive or heart failure patients than conventional renin-angiotensin system blockers. However, the mechanism underlying the benefit of LCZ696 remains to be understood. The present study was undertaken to examine the effect of LCZ696 compared with valsartan on hypertension and cardiovascular injury. METHODS: (i) Using telemetry, we compared the hypotensive effect of LCZ696 and valsartan in spontaneously hypertensive rats (SHR) that were fed a high-salt diet followed by a low-salt diet. (ii) We also examined the comparative effect of LCZ696 and valsartan on salt loaded SHRcp, a model of metabolic syndrome. RESULTS: (i) LCZ696 exerted a greater blood pressure (BP) lowering effect than valsartan in SHR regardless of high-salt or low-salt intake. Additive BP reduction by LCZ696 was associated with a significant increase in urinary sodium excretion and sympathetic activity suppression. (ii) LCZ696 significantly ameliorated cardiac hypertrophy and inflammation, coronary arterial remodeling, and vascular endothelial dysfunction in high-salt loaded SHRcp compared with valsartan. CONCLUSIONS: LCZ696 caused greater BP reduction than valsartan in SHR regardless of the degree of salt intake, which was associated with a significant enhancement in urinary sodium excretion and sympathetic activity suppression. Furthermore, an additive BP lowering effect of LCZ696 led to greater cardiovascular protection in hypertensive rats.

The relation of potassium and sodium intakes to diet cost among U.S. adults.

The 2010 Dietary Guidelines recommended that Americans increase potassium and decrease sodium intakes to reduce the burden of hypertension. One reason why so few Americans meet the recommended potassium or sodium goals may be perceived or actual food costs. This study explored the monetary costs associated with potassium and sodium intakes using national food prices and a representative sample of US adults. Dietary intake data from the 2001-2002 National Health and Nutrition Examination Survey were merged with a national food prices database. In a population of 4744 adults, the association between the energy-adjusted sodium and potassium intakes, and the sodium-to-potassium ratio (Na:K) and energy-adjusted diet cost was evaluated. Diets that were more potassium-rich or had lower Na:K ratios were associated with higher diet costs, while sodium intakes were not related to cost. The difference in diet cost between extreme quintiles of potassium intakes was $1.49 (95% confidence interval: 1.29, 1.69). A food-level analysis showed that beans, potatoes, coffee, milk, bananas, citrus juices and carrots are frequently consumed and low-cost sources of potassium. Based on existing dietary data and current American eating habits, a potassium-dense diet was associated with higher diet costs, while sodium was not. Price interventions may be an effective approach to improve potassium intakes and reduce the Na:K ratio of the diet. The present methods helped identify some alternative low-cost foods that were effective in increasing potassium intakes. The identification and promotion of lower-cost foods to help individuals meet targeted dietary recommendations could accompany future dietary guidelines.