The combined effect of air pollution and non-optimal temperature on mortality in Shandong Province, China: establishment of air health index.

PURPOSE: The air health index (AHI) captures the combined effects of air pollution and non-optimal temperatures and helps assess the atmospheric environment's overall health risk. Shandong Province is a crucial industrial base in China, and the health effects of air pollution and non-optimal temperature cannot be ignored. To construct an AHI for Shandong Province and assess the district-level mortality burden due to AHI in the study area. METHODS: Daily district-specific mortality, meteorological, and air pollution data over 2013-2018 were collected in Shandong Province, China. The AHI construction eventually incorporated PM2.5 and NO2, O3, and non-optimal temperatures. Attributable fraction (AF) and attributable number (AN) were used to estimate the district-specific mortality burden attributable to AHI. RESULTS: The average AHI value observed in Shandong Province was 6. Our research revealed a positive association between the total AHI and total mortality, with an overall trend of a slow increase followed by a rapid increase. The exposure-response curves, when stratified by gender, age, and cause of death, were approximately consistent with the overall trend. The provincial attributable fraction (AF) was 5.31% (95% CI 4.58%, 5.91%), and the attributable number (AN) was 188,246 (95% CI 162,396, 209,533). Overall, higher ANs mainly appeared in the southwestern area, while higher values of AF were observed in the central-eastern and central-northern areas. CONCLUSIONS: The air health index performs well in predicting death burden and can convey health risks related to exposure to the ambient environment to the public.

Iodine nutritional status in the adult population of Shandong Province (China) prior to salt reduction program.

PURPOSE: Tremendous differences in iodine status and daily iodine intake persist across provinces of China. The objective of the present study was to evaluate the iodine status and dietary iodine intake of Shandong adults before the implementation of the salt reduction program and a new salt iodization standard. METHODS: Data from a baseline survey of the Shandong and Ministry of Health Action on Salt Reduction and Hypertension project (2011) were analyzed. The iodine contents of 1949 24-h urine samples and 136 drinking water samples were assayed. Daily urinary iodine excretion and daily iodine intake were calculated, analyzed, stratified by different analytical variables and compared with Chinese Dietary Reference Values. RESULTS: The median urinary iodine concentration and median daily iodine intake of Shandong adults were 248.5 µg/L and 368.2 µg/day, respectively. The median iodine intake of different groups was between the estimated average requirements and the upper limit, except group in water iodine >300 µg/L with median iodine intake of 1200.7 µg/L. Salt intake and iodine levels in drinking water related to iodine intake significantly. CONCLUSIONS: Shandong adults had more than adequate iodine nutrition, and the dietary iodine intake of the population was generally appropriate and safe except residents in high water iodine areas. In the context of the implementation of a salt reduction program and a new salt iodization standard, the iodine status of high water iodine areas may remain in the recommended level, but in low water iodine areas, the risk of inadequate iodine intake may increase, needing monitoring of urine iodine excretion, dietary iodine intake and iodized salt consumption regularly.

[Prevalence of dyslipidemia among residents aged 18-69 years in Shandong province of China, 2011].

OBJECTIVE: To investigate the prevalence and distribution characteristics of dyslipidemia among Shandong residents aged 18-69 years. METHODS: The levels of triglyceride (TG), low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), and total cholesterol (TC) were determined in fasting serum of 5 ml venous blood for subjects aged 18-69 years who were selected by multi-stage stratified cluster random sampling from 20 counties in July, 2011 in 140 counties of Shandong province. The prevalence of dyslipidemia, hypercholesterolemia, high blood LDL-C, low blood HDL-C and hypertriglyceridemia were analyzed by the complex weighting. The prevalence of dyslipidemia, hypercholesterolemia, high blood LDL-C, low blood HDL-C and hypertriglyceridemia were compared for different characteristics by Rao-Scott χ(2). RESULTS: The prevalence of dyslipidemia among 15 350 subjects was 22.70% (3 572), with higher in males (26.91% (2 110/7 683)) than in females (18.41% (1 462/7 667)). The prevalence of hypercholesterolemia was 3.39% (n=582), with higher in Eastern Shandong (4.59% (185/3 704)). The prevalence of high blood LDL-C was 0.56% (n=94), with higher in Eastern Shandong (0.79% (32/3 074)). The prevalence of low blood HDL-C was 11.41% (n=1 789). The prevalence of hypertriglyceridemia was 13.02% (n=2 059), higher in urban residents (16.54% (814/4 804)) than in rural (11.52% (1 245/10 546)) (χ(2)=71.54, P<0.001). The difference between the prevalence of low blood HDL-C and hypertriglyceridemia was not significant among Eastern Shandong, Central-South and Northwest. CONCLUSION: Dyslipidemia rate was higher among adult residents in Shandong province. The rate was higher for men than for women. The prevalence of hypercholesterolemia and high blood LDL-C were higher in Eastern Shandong than the other areas. The hypertriglyceridemia and low blood HDL-C were two major types of dyslipidemia.

Association between 24 h urinary sodium and potassium excretion and the metabolic syndrome in Chinese adults: the Shandong and Ministry of Health Action on Salt and Hypertension (SMASH) study.

The association of 24 h urinary Na and potassium excretion with the risk of the metabolic syndrome (MetS) has not been studied in China. The aim of the present study was to examine this association by analysing the data from 1906 study participants living in north China. To this end, 24 h urine samples were collected. Of the 1906 participants, 471 (24·7 %) had the MetS. The mean urinary Na and K excretion was 228·7 and 40·8 mmol/d, respectively. After multivariate adjustment, the odds of the MetS significantly increased across the increasing tertiles of urinary Na excretion (1·00, 1·40 and 1·54, respectively). For the components of the MetS, the odds of central obesity, elevated blood pressure and elevated TAG, but not the odds of low HDL-cholesterol and elevated fasting glucose, significantly increased with the successive tertiles of urinary Na excretion. Furthermore, for every 100 mmol/d increase in urinary Na excretion, the odds of the MetS, central obesity, elevated blood pressure and elevated TAG was significantly increased by 29, 63, 22 and 21 %, respectively. However, urinary K excretion was not significantly associated with the risk of the MetS. These findings suggest that high Na intake might be an important risk factor for the MetS in Chinese adults.

Urinary albumin excretion and prevalence of microalbuminuria in a general Chinese population: a cross-sectional study.

BACKGROUND: Microalbuminuria has been shown to be a risk factor for cardiovascular and renal disease in patients with hypertension and diabetes as well as in the general population. Urinary albumin excretion over 24 h is considered a 'gold standard' to detect microalbuminuria. Few studies have used 24-h urinary albumin excretion to analyze the prevalence of and related factors for microalbuminuira in a general Chinese population. METHODS: This study included 1980 adults aged 18-69 years from the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) Project 2011 survey. Blood pressure, height, weight and waist circumference were measured, and a venous blood and timed 24-h urine samples were collected from each participant. Linear and logistic regression analyses were used to test associations between established cardiovascular risk factors and microalbuminuria. RESULTS: The median (25th-75th percentile) of 24-h urinary albumin excretion was 6.1 mg/d (4.5-8.7 mg/d) for all adults, 6.0 mg/d (4.4-8.5 mg/d) for men and 6.2 mg/d (4.6-8.9 mg/d) for women. The overall prevalence of microalbuminuria was 4.1% (95% confidence interval [CI]: 3.2-5.0%), 3.7% (95% CI: 2.9-4.5%) for men and 4.6% (95% CI: 3.7-5.5%) for women. Microalbuminuria was present in 8.1% (95% CI: 6.9-9.3%) of individuals with hypertension, 11.4% (95% CI: 10.0-12.8%) of those with diabetes and 15.6% (95% CI: 14.0-17.2%) of those with both. Multiple logistic regression analysis indicated that systolic blood pressure (odds ratio [OR] 1.02; 95% CI: 1.01-1.03) and fasting blood glucose (OR 1.19; 95% CI: 1.05-1.35) were the independent risk factors for microalbuminuria. CONCLUSIONS: Adults in the general population of Shandong Province have a moderate prevalence of microalbuminuria. Those with hypertension and diabetes are at high risk of having microalbuminuria, suggesting the need for screening and early intervention for microalbuminuria among these individuals.

Hypertension prevalence, awareness, treatment, and control and sodium intake in Shandong Province, China: baseline results from Shandong-Ministry of Health Action on Salt Reduction and Hypertension (SMASH), 2011.

INTRODUCTION: In China, population-based blood pressure levels and prevalence of hypertension are increasing. Meanwhile, sodium intake, a major risk factor for hypertension, is high. In 2011, to develop intervention priorities for a salt reduction and hypertension control project in Shandong Province (population 96 million), a cross-sectional survey was conducted to collect information on sodium intake and hypertension prevalence, awareness, treatment, and control. METHODS: Complex, multistage sampling methods were used to select a provincial-representative adult sample. Blood pressure was measured and a survey conducted among all participants; condiments were weighed in the household, a 24-hour dietary recall was conducted, and urine was collected. Hypertension was determined by blood pressure measured on a single occasion and self-reported use of antihypertension medications. RESULTS: Overall, 23.4% (95% confidence interval [CI], 20.9%-26.0%) of adults in Shandong were estimated to have hypertension. Among those classified as having hypertension, approximately one-third (34.5%) reported having hypertension, approximately one-fourth (27.5%) reported taking medications, and one-seventh (14.9%) had their blood pressure controlled (<140/<90 mm Hg). Estimated total average daily dietary sodium intake was 5,745 mg (95% CI, 5,428 mg-6,063 mg). Most dietary sodium (80.8%) came from salt and high-salt condiments added during cooking: a sodium intake of 4,640 mg (95% CI, 4,360 mg-4,920 mg). The average daily urinary sodium excretion was 5,398 mg (95% CI, 5,112 mg-5,683 mg). CONCLUSION: Hypertension and excessive sodium intake in adults are major public health problems in Shandong Province, China.

[Comparison of dietary survey, frequency and 24 hour urinary Na methods in evaluation of salt intake in the population].

OBJECTIVE: To compare the difference and correlation between dietary salt intakes assessed by 24 hours urinary Na method, food weighted record method and food frequency questionnaire method. METHODS: All 2 184 subjects aged 18 to 69 were selected by multi stage stratified cluster random sampling method in Shandong province in June to September, 2011. Dietary salt intakes were measured by 24 hours urinary Na method, food weighted record method and food frequency questionnaire method. The information on gender, age, dining locations and labour intensity of members dining at home for 3 days were recorded. And the dietary habits were surveyed by questionnaire. RESULTS: Salt intakes were 14.0, 12.0 and 10.5 g/d assessed by 24 hours urinary Na method, food weighted record method and food frequency questionnaire, respectively. Comparing with 24 hours urinary Na method, salt intakes assessed by food weighted record method and food frequency questionnaire method were 2.0 g (14.3% undervalued) and 3.4 g (24.3% undervalued) less, respectively. Comparing with 24 hours urinary Na method, the proportion of individuals with salt intake over-reported and under-reported were 42.4% (856/2 020) and 55.3% (1 117/2 020) by food weighted record method, and were 20.7% (418/2 020) and 16.3% (329/2 020) by food frequency questionnaire method, respectively; the proportion of individuals with salt intakes within ± 25% of 24 hours urinary Na method were 36.9% (745/2 020) and 28.4% (574/2 020), respectively. Salt intakes assessed by 24 hours urinary method correlated significantly with both salt intakes assessed by food weighted record method and food frequency questionnaire method; the correlation coefficients were 0.13 and 0.07, respectively. With the increasing of salt intakes by subjects' self-judgment, salt intakes were all rising significantly using three survey methods. Salt intakes of three group population of light, moderate and partial taste salty were 13.6, 13.6 and 14.7 g/d by 24 hours urinary Na method (F = 0.47, P < 0.05); 11.0, 12.0 and 12.7 g/d by food weighted record method (F = 5.83, P < 0.05), and 9.3, 10.2 and 11.9 g/d by food frequency questionnaire method (F = 5.83, P < 0.05), respectively. CONCLUSION: Comparing with 24 hours urinary method, food weighted record method and food frequency questionnaire method would undervalue dietary salt intake. Salt intake status can be more accurately assessed by adjusting the underestimation rate.

Chronic obstructive pulmonary disease and the airway microbiome: A review for clinicians.

Chronic obstructive pulmonary disease (COPD) is a complex heterogeneous disease characterized by progressive airflow limitation and chronic inflammation. The progressive development and long-term repeated acute exacerbation of COPD make many patients still unable to control the deterioration of the disease after active treatment, and even eventually lead to death. An increasing number of studies have shown that the occurrence and development of COPD are closely related to the composition and changes of airway microbiome. This article reviews the interaction between COPD and airway microbiome, the potential mechanisms of interaction, and the treatment methods related to microbiome. We elaborated the internal correlation between airway microbiome and different stages of COPD, inflammatory endotypes, glucocorticoid and antibiotic treatment, analyze the pathophysiological mechanisms such as the "vicious cycle" hypothesis, abnormal inflammation-immune response of the host and the "natural selection" of COPD to airway microbiome, introduce the treatment of COPD related to microbiome and emphasize the predictive value of airway microbiome for the progression, exacerbation and prognosis of COPD, as well as the guiding role for clinical management of patients, in order to provide a new perspective for exploring the pathogenesis of COPD, and also provide clues and guidance for finding new treatment targets.

Association between spot urinary sodium-to-potassium ratio and blood pressure among Chinese adults aged 18-69 years: the SMASH study.

Background: Excessive sodium and low potassium intake are involved in the development of hypertension. Growing evidence showed that the sodium-to-potassium ratio (Na/K) was significantly associated with blood pressure (BP). However, studies on the dose-response relationship of spot urinary Na/K ratio with hypertension and BP in the general population are scarce, especially in the Chinese population. Materials and methods: Data from the post-intervention survey of the Shandong Ministry of Health Action on Salt and Hypertension (SMASH) project was analyzed. Associations between Na/K molar ratio and hypertension prevalence and between Na/K molar ratio and BP indices were analyzed using multivariable logistic and linear regression, respectively, followed by subgroup analysis and interaction analysis. The restricted cubic spline model was used to explore the dose-response relationship. Informed by existing literature, we adjusted for potential confounding factors, including temperature and renal function, to assess the association and dose-response relationship. Results: There was a non-linear positive association between Na/K and hypertension (OR:1.09, 95%CI: 1.08-1.11) and a linear positive association between Na/K and systolic BP, diastolic BP, and mean arterial pressure (ß 0.53, 95%CI: 0.45-0.60; ß 0.36, 95%CI: 0.31-0.41; and ß 0.42, 95%CI: 0.36-0.47, respectively). The association was stronger in individuals with hypertension, female patients, those in the 50-59-year age group, and those who were obese. Environmental temperatures had little impact on associations. Conclusion: Our findings provide further evidence that the spot urinary Na/K ratio is a simple, useful, and convenient indicator for monitoring salt reduction and potassium increase, which could be used in clinical and public health practices.

Case report: Interstitial implantation radiotherapy combined with immunotherapy and GM-CSF in oligometastatic platinum-resistant ovarian cancer.

Background: Treatment for platinum-resistant ovarian cancer is challenging. Currently, platinum-resistant ovarian cancer is typically treated with non-platinum single-agent chemotherapy ± bevacizumab, but the prognosis is often extremely poor. In the treatment of platinum-resistant ovarian cancer patients, reports of triple therapy with interstitial implantation radiotherapy combined with immunotherapy and granulocyte-macrophage colony-stimulating factor (GM-CSF) (PRaG for short) are relatively rare. Case description: Here, we report a patient with oligometastatic platinum-resistant ovarian cancer. The patient achieved partial response (PR) of the lesion and sustained benefit for more than six months after receiving interstitial implantation radiotherapy combined with immunotherapy along with GM-CSF. Conclusion: This triple therapy may provide additional options for these patients.

Estimated Burden of Stroke in China in 2020.

Importance: Stroke is the leading cause of death in China. However, recent data about the up-to-date stroke burden in China are limited. Objective: To investigate the urban-rural disparity of stroke burden in the Chinese adult population, including prevalence, incidence, and mortality rate, and disparities between urban and rural populations. Design, Setting, and Participants: This cross-sectional study was based on a nationally representative survey that included 676 394 participants aged 40 years and older. It was conducted from July 2020 to December 2020 in 31 provinces in mainland China. Main Outcomes and Measures: Primary outcome was self-reported stroke verified by trained neurologists during a face-to-face interviews using a standardized protocol. Stroke incidence were assessed by defining first-ever strokes that occurred during 1 year preceding the survey. Strokes causing death that occurred during the 1 year preceding the survey were considered as death cases. Results: The study included 676 394 Chinese adults (395 122 [58.4%] females; mean [SD] age, 59.7 [11.0] years). In 2020, the weighted prevalence, incidence, and mortality rates of stroke in China were 2.6% (95% CI, 2.6%-2.6%), 505.2 (95% CI, 488.5-522.0) per 100 000 person-years, and 343.4 (95% CI, 329.6-357.2) per 100 000 person-years, respectively. It was estimated that among the Chinese population aged 40 years and older in 2020, there were 3.4 (95% CI, 3.3-3.6) million incident cases of stroke, 17.8 (95% CI, 17.5-18.0) million prevalent cases of stroke, and 2.3 (95% CI, 2.2-2.4) million deaths from stroke. Ischemic stroke constituted 15.5 (95% CI, 15.2-15.6) million (86.8%) of all incident strokes in 2020, while intracerebral hemorrhage constituted 2.1 (95% CI, 2.1-2.1) million (11.9%) and subarachnoid hemorrhage constituted 0.2 (95% CI, 0.2-0.2) million (1.3%). The prevalence of stroke was higher in urban than in rural areas (2.7% [95% CI, 2.6%-2.7%] vs 2.5% [95% CI, 2.5%-2.6%]; P = .02), but the incidence rate (485.5 [95% CI, 462.8-508.3] vs 520.8 [95% CI, 496.3-545.2] per 100 000 person-years; P < .001) and mortality rate (309.9 [95% CI, 291.7-328.1] vs 369.7 [95% CI, 349.1-390.3] per 100 000 person-years; P < .001) were lower in urban areas than in rural areas. In 2020, the leading risk factor for stroke was hypertension (OR, 3.20 [95% CI, 3.09-3.32]). Conclusions and Relevance: In a large, nationally representative sample of adults aged 40 years or older, the estimated prevalence, incidence, and mortality rate of stroke in China in 2020 were 2.6%, 505.2 per 100 000 person-years, and 343.4 per 100 000 person-years, respectively, indicating the need for an improved stroke prevention strategy in the general Chinese population.

The NLP toxin family in Phytophthora sojae includes rapidly evolving groups that lack necrosis-inducing activity.

Necrosis- and ethylene-inducing-like proteins (NLP) are widely distributed in eukaryotic and prokaryotic plant pathogens and are considered to be important virulence factors. We identified, in total, 70 potential Phytophthora sojae NLP genes but 37 were designated as pseudogenes. Sequence alignment of the remaining 33 NLP delineated six groups. Three of these groups include proteins with an intact heptapeptide (Gly-His-Arg-His-Asp-Trp-Glu) motif, which is important for necrosis-inducing activity, whereas the motif is not conserved in the other groups. In total, 19 representative NLP genes were assessed for necrosis-inducing activity by heterologous expression in Nicotiana benthamiana. Surprisingly, only eight genes triggered cell death. The expression of the NLP genes in P. sojae was examined, distinguishing 20 expressed and 13 nonexpressed NLP genes. Real-time reverse-transcriptase polymerase chain reaction results indicate that most NLP are highly expressed during cyst germination and infection stages. Amino acid substitution ratios (Ka/Ks) of 33 NLP sequences from four different P. sojae strains resulted in identification of positive selection sites in a distinct NLP group. Overall, our study indicates that expansion and pseudogenization of the P. sojae NLP family results from an ongoing birth-and-death process, and that varying patterns of expression, necrosis-inducing activity, and positive selection suggest that NLP have diversified in function.

The RxLR effector Avh241 from Phytophthora sojae requires plasma membrane localization to induce plant cell death.

• The Phytophthora sojae genome encodes hundreds of RxLR effectors predicted to manipulate various plant defense responses, but the molecular mechanisms involved are largely unknown. Here we have characterized in detail the P. sojae RxLR effector Avh241. • To determine the function and localization of Avh241, we transiently expressed it on different plants. Silencing of Avh241 in P. sojae, we determined its virulence during infection. Through the assay of promoting infection by Phytophthora capsici to Nicotiana benthamiana, we further confirmed this virulence role. • Avh241 induced cell death in several different plants and localized to the plant plasma membrane. An N-terminal motif within Avh241 was important for membrane localization and cell death-inducing activity. Two mitogen-activated protein kinases, NbMEK2 and NbWIPK, were required for the cell death triggered by Avh241 in N. benthamiana. Avh241 was important for the pathogen's full virulence on soybean. Avh241 could also promote infection by P. capsici and the membrane localization motif was not required to promote infection. • This work suggests that Avh241 interacts with the plant immune system via at least two different mechanisms, one recognized by plants dependent on subcellular localization and one promoting infection independent on membrane localization.

Application of Metagenomic Next-Generation Sequencing in the Diagnosis of Pneumonia Caused by Chlamydia psittaci.

Psittacosis is an uncommon disease which mainly presents as community-acquired pneumonia (CAP). We aim to apply metagenomic next-generation sequencing (mNGS) as a promising tool in the diagnosis of psittacosis pneumonia and to describe its clinical spectrum to provide physicians with a better understanding and recognition of this disease. Thirteen cases of psittacosis pneumonia were diagnosed by using mNGS. A retrospective analysis of the data on clinical manifestations, laboratory data, computed tomography (CT) images, new diagnosis tools, treatments, and outcomes was summarized. These patients had common symptoms of fever and weakness; some had poor appetite, cough, myalgia, and headache. Ten patients developed acute respiratory distress syndrome (ARDS), among which six patients were severe pneumonia cases and needed ventilator therapy. Most patients got psittacosis pneumonia during the cold season. Ten cases were sporadic, but three were family clustering. All of the 13 patients were traced to an exposure history to birds, cat, or poultry, among which 2 only touched the innards of killed poultry before cooking, which may be an atypical exposure history not been reported before, to our knowledge. Most patients had various degrees of liver dysfunction. Air-space consolidations, along with ground-glass opacities and reticular shadows, were detected on chest CT scan. mNGS takes 48 to 72 h to provide results and helps to diagnose psittacosis. After being diagnosed by mNGS, with effective medicines, all patients finally had complete recoveries. The use of mNGS can improve the diagnostic rate of psittacosis pneumonia and shorten the course of disease control. IMPORTANCE Psittacosis pneumonia is easily underdiagnosed and misdiagnosed. In this study, we use mNGS in the diagnosis of psittacosis pneumonia. We found this disease is prone in the cold season, and touching the innards of killed poultry during cooking may be an atypical exposure history which has not been reported before to our knowledge. There are sporadic cases and family outbreak cases as well. Except for typical symptoms of fever and weakness, headache may be the main and only symptom in some patients. The rate of severe pneumonia is high among inpatients with psittacosis pneumonia, and the incidence of hepatic involvements is also high. Psittacosis pneumonia can be cured if the diagnosis is accurate and in time, even if it is severe pneumonia on admission. Some problems worthy of our attention about psittacosis pneumonia were put forward, such as its sick season, special exposure history, the rate of severe disease, and the high cure rate. mNGS can quickly and objectively detect more rare pathogenic microorganisms in clinical specimens without the need for specific amplification and has an advantage in the diagnosis of rare pathogenic bacteria in difficult cases such as psittacosis pneumonia. The use of mNGS can improve the accuracy and reduce the delay in the diagnosis of psittacosis, which shortens the course of disease control.

[Deaths and life expectancy losses attributed to high-salt diet in Shandong province].

Objective: To estimate the deaths and life expectancy losses attributed to diet with high salt in Shandong province. Methods: Based on 24 h urinary sodium and blood pressure levels from the final evaluation survey of Shandong-Ministry of Health Action on Salt and Hypertension Project (SMASH) in 2016 and death cause data from Shandong Mortality Surveillance System, the population attributable fractions (PAF) and the deaths due to high-salt diet were calculated based on the framework of comparative risk assessment and the life expectancy loss was calculated by life table method. Results: A total of 32 987 deaths caused by high-salt diets were reported in 2016, accounting for 11.74% of related disease deaths and 4.95% of all deaths. The proportion of deaths due to high-salt diet in men (13.51%) was higher than that in women (9.17%). Cardiovascular diseases were the major causes of deaths due to high salt diet, accounting for 90.82% of all disease deaths caused by high-salt diets. The other causes were gastric cancer (8.10%) and chronic kidney disease (1.08%). The PAF in urban residents (13.87%) was higher than that in rural residents (10.87%). A loss of 0.58 years of the life expectancy were attributed to the high-salt diet. The different diseases caused by high-salt diet had different effects on life expectancy loss, ischemic heart disease ranked first, followed by cerebral hemorrhage and cerebral infarction. Conclusions: The proportion of deaths attributed to high-salt diets was high in Shandong. Cardiovascular diseases were the most important causes of deaths caused by high-salt diets. High-salt diet is still seriously affecting the health of residents in Shandong, indicating that salt reduction interventions need to be strengthened.

Associations Between Salt-Restriction Spoons and Long-Term Changes in Urinary Na+/K+ Ratios and Blood Pressure: Findings From a Population-Based Cohort.

Background There have been few studies on the relationship between long-term changes in sodium intake and blood pressure. A method of reducing sodium intake in a population that is known for high-sodium intake based on homemade cooking is also needed. Methods and Results Our study was based on a baseline survey of 15 350 individuals aged 18 to 69 years with multistage random sampling and a 3-year salt-restriction campaign across Shandong Province, China. We included 339 individuals from six districts/counties in this cohort study, and the 24-hour urinary sodium-potassium ratio (Na+/K+) served as an indicator of sodium intake. The average change in ratio was 2.39 (95% CI, 2.17-2.61) from 6.81 (95% CI, 6.41-7.21) at baseline to 4.41 (95% CI, 4.18-4.64) during the resurvey. Following a reduction from low to high quartiles of urinary Na+/K+ ratio, the average increases were 10.9 (95% CI, 8.9-12.9), 9.2 (95% CI, 6.9-11.5), 6.3 (95% CI, 4.0-8.6), and 5.3 (95% CI, 2.9-7.7) mm Hg for systolic blood pressure (P for trend=0.019) and 3.8 (95% CI, 2.4-5.2), 2.9 (95% CI, 1.7-4.2), 1.6 (95% CI, 0.4-2.8), and -0.3 (95% CI, -1.4-0.8) mm Hg for diastolic blood pressure (P for trend=0.002), respectively. A reduction in salt intake was evident for people using a 2-g salt-restriction spoon for cooking (-3.49 versus -2.22; P=0.027) after adjustment of confounding factors, compared with nonusers. Similar findings were obtained for other salt-restriction spoon-based indicators. Conclusions Our study indicated that using a salt-restriction spoon for cooking was associated with reduced salt intake that led to a blunting of blood pressure deterioration. This finding further supports the salt-restriction spoon-based strategy for people whose primary salt intake is from homemade cooking.

Association of a Province-Wide Intervention With Salt Intake and Hypertension in Shandong Province, China, 2011-2016.

Importance: High salt intake is associated with hypertension, which is a leading modifiable risk factor for cardiovascular disease. Objective: To assess the association of a government-led, multisectoral, and population-based intervention with reduced salt intake and blood pressure in Shandong Province, China. Design, Setting, and Participants: This cross-sectional study used data from the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) program, a 5-year intervention to reduce sodium consumption in Shandong Province, China. Two representative samples of adults (aged 18-69 years) were surveyed in 2011 (15 350 preintervention participants) and 2016 (16 490 postintervention participants) to examine changes in blood pressure, and knowledge, attitudes, and behaviors related to sodium intake. Urine samples were collected from random subsamples (2024 preintervention participants and 1675 postintervention participants) for measuring sodium and potassium excretion. Data were analyzed from January 20, 2017, to April 9, 2019. Interventions: Media campaigns, distribution of scaled salt spoons, promotion of low-sodium products in markets and restaurants, and activities to support household sodium reduction and school-based sodium reduction education. Main Outcomes and Measures: The primary outcome was change in urinary sodium excretion. Secondary outcomes were changes in potassium excretion, blood pressure, and knowledge, attitudes, and behaviors. Outcomes were adjusted for likely confounders. Means (95% CIs) and percentages were weighted. Results: Among 15 350 participants in 2011, 7683 (50.4%) were men and the mean age was 40.7 years (95% CI, 40.2-41.2 years); among 16 490 participants in 2016, 8077 (50.7%) were men and the mean age was 42.8 years (95% CI, 42.5-43.1 years). Among participants with 24-hour urine samples, 1060 (51.8%) were men and the mean age was 40.9 years (95% CI, 40.5-41.3 years) in 2011 and 836 (50.7%) were men and the mean age was 40.7 years (95% CI, 40.1-41.4 years) in 2016. The 24-hour urinary sodium excretion decreased 25% from 5338 mg per day (95% CI, 5065-5612 mg per day) in 2011 to 4013 mg per day (95% CI, 3837-4190 mg per day) in 2016 (P < .001), and potassium excretion increased 15% from 1607 mg per day (95% CI, 1511-1704 mg per day) to 1850 mg per day (95% CI, 1771-1929 mg per day) (P < .001). Adjusted mean systolic blood pressure among all participants decreased from 131.8 mm Hg (95% CI, 129.8-133.8 mm Hg) to 130.0 mm Hg (95% CI, 127.7-132.4 mm Hg) (P = .04), and diastolic blood pressure decreased from 83.9 mm Hg (95% CI, 82.6-85.1 mm Hg) to 80.8 mm Hg (95% CI, 79.4-82.1 mm Hg) (P < .001). Knowledge, attitudes, and behaviors associated with dietary sodium reduction and hypertension improved significantly. Conclusions and Relevance: The findings suggest that a government-led and population-based intervention in Shandong, China, was associated with significant decreases in dietary sodium intake and a modest reduction in blood pressure. The results of SMASH may have implications for sodium reduction and blood pressure control in other regions of China and worldwide.

Cardiovascular Diseases Deaths Attributable to High Sodium Intake in Shandong Province, China.

Background High sodium intake elevates blood pressure and thereby raises cardiovascular diseases ( CVD s). Sodium intake is high in northern China, including Shandong province where the SMASH (Shandong-Ministry of Health Action on Sodium and Hypertension) is currently underway. Methods and Results Blood pressure values and sodium intake measurements using 24-hour urinary excretion were collected from the 2011 SMASH baseline survey, which was conducted in 20 counties/districts using a multistage stratified cluster random sampling method. We derived cause-specific mortality from the Shandong Death Registration System ( SDRS ) during the same year and used population-attributable fraction to estimate annual CVD s deaths attributable to high sodium intake (mediated through elevated systolic blood pressure) and CVD deaths averted by achieving different sodium-reduction targets. Overall, 16 100 (95% uncertainty intervals, 11 000-22 600) CVD deaths among adults aged 25 to 69 years, including 5600 (4000-6500) for ischemic heart disease and 9000 (6700-11 600) for stroke, were attributable to higher sodium intake (2000 mg/day or 5.0 g/day of salt as a reference) in Shandong in 2011, accounting for 19.9% (13.7-25.0%) of total CVD deaths. The benefit of CVD deaths from sodium reduction is considerable with 8800 (6400-13 600), 6700 (4900-11 600), and 8500 (6000-10 800) averted, respectively, if sodium intake was reduced from the 2011 baseline to 3500 mg/day, 4000 mg/day, or reduced by 30%. Conclusions Nearly 20% of CVD deaths among adults aged 25 to 69 years could be attributable to the systolic blood pressure-raising effect of high sodium intake in Shandong in 2011. Potential benefits from population reduction of sodium intake are considerable.

Population-based association between urinary excretion of sodium, potassium and its ratio with albuminuria in Chinese.

BACKGROUND AND OBJECTIVES: Albuminuria is a risk factor for cardiovascular and renal disease. However, little is known about the association of 24 h urinary sodium and potassium excretion with albuminuria in China. The aim of this study was to examine this association by analyzing the data from 1,975 Chinese adults living in north China. METHODS AND STUDY DESIGN: Excretion of urinary sodium, potassium and albumin was assessed in a single 24-h urine sample for each participant. Height, weight, waist circumference and blood pressure were measured and body mass index was determined as weight divided by square height. Fasting blood sample was collected and fasting glucose was measured. RESULTS: The average 24-h urinary sodium and potassium excretion were 232 mmol and 40.8 mmol, resulting a mean sodium to potassium ratio of 6.7. The median (Q1-Q3) 24-h urinary albuminuria excretion was 6.1 mg (4.5-8.7 mg). Overall, urinary sodium excretion was positively associated with albumin excretion (ß=0.029, p<0.001). This association was independent of major cardiovascular risk factors including age, gender, systolic blood pressure, body mass index, fasting glucose, waist circumference, hypertensive drug treatment, and smoking. Moreover, the relation of sodium and albumin was similar in the subgroups stratified by gender, adiposity and diabetic status. No significant associations of potassium excretion or sodium to potassium ratio with urinary albumin excretion were observed. CONCLUSIONS: In cross-sectional analyses, high sodium intake was shown to be associated with increased urinary albuminuria in the general Chinese adult population, supporting salt restriction for renal and cardiovascular health benefit.

[Association between 24 h urinary sodium to potassium ratio and metabolic syndrome in Chinese adults].

OBJECTIVE: To examine the association between 24 h urinary sodium to potassium ratio and metabolic syndrome (MS) in Chinese adults. METHODS: A population-based cross-sectional study was conducted among Chinese adults aged 18-69 years in Shandong province in 2011. Data on 24 h urinary excretion of sodium and potassium and components of MS were examined. Participants were divided into four groups according to the quartile of 24 h urinary sodium to potassium ratio. RESULTS: Of the 1 906 Chinese adults eligible for final data analysis, 471 (24.7%) were with MS. After completion of multivariate logistic regression analysis, when compared to the participants with 24 h urinary sodium to potassium ratio < 4.3, the OR (95% CI) of participants with 24 h urinary sodium to potassium ratio during 4.3-5.6, 5.7-8.1, and ≥ 8.1 were 1.27 (0.93-1.71), 1.06 (0.78-1.46), and 1.45 (1.06-1.97), respectively (P values for linear trend < 0.05). As for the components of MS, the odds of central obesity and elevated blood pressure but not the odds of elevated triglycerides, low high density lipoprotein cholesterol and elevated fasting glucose, had significantly increases with successive 24 h urinary sodium to potassium ratio quartiles (P values for linear trends < 0.05). CONCLUSION: The 24 h urinary sodium to potassium ratio appeared significantly associated with the odds of MS.