Prescription, Compliance, and Burden Associated with Salt-Restricted Diets in Heart Failure Patients: Results from the French National OFICSel Observatory.

(1) Background: There is much debate about the use of salt-restricted diet for managing heart failure (HF). Dietary guidelines are inconsistent and lack evidence. (2) Method: The OFICSel observatory collected data about adults hospitalised for HF. The data, collected using study-specific surveys, were used to describe HF management, including diets, from the cardiologists' and patients' perspectives. Cardiologists provided the patients' clinical, biological, echocardiography, and treatment data, while the patients provided dietary, medical history, sociodemographic, morphometric, quality of life, and burden data (burden scale in restricted diets (BIRD) questionnaire). The differences between the diet recommended by the cardiologist, understood by the patient, and the estimated salt intake (by the patient) and diet burden were assessed. (3) Results: Between March and June 2017, 300 cardiologists enrolled 2822 patients. Most patients (90%) were recommended diets with <6 g of salt/day. Mean daily salt consumption was 4.7 g (standard deviation (SD): 2.4). Only 33% of patients complied with their recommended diet, 34% over-complied, and 19% under-complied (14% unknown). Dietary restrictions in HF patients were associated with increased burden (mean BIRD score of 8.1/48 [SD: 8.8]). (4) Conclusion: Healthcare professionals do not always follow dietary recommendations, and their patients do not always understand and comply with diets recommended. Restrictive diets in HF patients are associated with increased burden. An evidence-based approach to developing and recommending HF-specific diets is required.

Short-Term Effects of Salt Restriction via Home Dishes Do Not Persist in the Long Term: A Randomized Control Study.

Salt intake reduction is crucial to prevent non-communicable diseases (NCDs) globally. This study aimed to investigate the short- and long-term effects of monitoring salt concentration in homemade dishes on reducing salt intake in a Japanese population. A double-blind randomized controlled trial using a 2 × 2 factorial design with two interventions was conducted in 195 participants; they were assigned to both interventions for a group monitoring salt concentration in soups (control: no monitoring) and a group using low-sodium seasoning (control: regular seasoning). We evaluated 24-hour urinary sodium excretions at baseline and after a three-month intervention for the changes as major outcomes, at six- and twelve-months after baseline as long-term follow-up surveys. Urinary sodium excretion decreased in both intervention and control groups after the intervention. However, differences in the change for both monitoring and low-sodium seasoning interventions were statistically non-significant (p = 0.29 and 0.52, respectively). Urinary sodium excretion returned to the baseline level after twelve-months for all groups. Monitoring of salt concentration is ineffective in reducing salt intake for short- and long-term among the people studied in this cohort.

Evidence related to sodium restriction in patients with heart failure.

OBJECTIVES: to analyze the scientific production about sodium restriction in patients with heart failure. METHODS: integrative literature review from articles published from 2007 to 2017, located in the CINAHL and Scopus databases. RESULTS: thirteen studies were analyzed. Sodium intake restriction was associated with lower unfavorable clinical outcomes in patients with marked symptomatology. The 24-hour urine sodium dosage was the main tool to assess adherence to the low sodium diet. CONCLUSIONS: based on the studies included in this review, in symptomatic patients, dietary sodium restriction should be encouraged in clinical practice as a protective measure for health. However, in asymptomatic patients, it should be well studied.

Sources of dietary sodium and implications for a statewide salt reduction initiative in Victoria, Australia.

In Victoria, Australia, a statewide salt reduction partnership was launched in 2015. The aim was to measure Na intake, food sources of Na (level of processing, purchase origin) and discretionary salt use in a cross-section of Victorian adults prior to a salt reduction initiative. In 2016/2017, participants completed a 24-h urine collection (n 338) and a subsample completed a 24-h dietary recall (n 142). Participants were aged 41·2 (sd 13·9) years, and 56 % were females. Mean 24-h urinary excretion was 138 (95 % CI 127, 149) mmol/d for Na. Salt equivalent was 8·1 (95 % CI 7·4, 8·7) g/d, equating to about 8·9 (95 % CI 8·1, 9·6) g/d after 10 % adjustment for non-urinary losses. Mean 24-h intake estimated by diet recall was 118 (95 % CI 103, 133) mmol/d for Na (salt 6·9 (95 % CI 6·0, 7·8 g/d)). Leading dietary sources of Na were cereal-based mixed dishes (12 %), English muffins, flat/savoury/sweet breads (9 %), regular breads/rolls (9 %), gravies and savoury sauces (7 %) and processed meats (7 %). Over one-third (38 %) of Na consumed was derived from discretionary foods. Half of all Na consumed came from ultra-processed foods. Dietary Na derived from foods was obtained from retail stores (51 %), restaurants and fast-food/takeaway outlets (28 %) and fresh food markets (9 %). One-third (32 %) of participants reported adding salt at the table and 61 % added salt whilst cooking. This study revealed that salt intake was above recommended levels with diverse sources of intake. Results from this study suggest a multi-faceted salt reduction strategy focusing on the retail sector, and food reformulation would most likely benefit Victorians and has been used to inform the ongoing statewide salt reduction initiative.

[Sodium restriction in heart failure: where are the data?] / Zoutbeperking bij hartfalen.

Mahtani et al. review the evidence for sodium restriction in heart failure. The paucity of solid studies is striking, but deplorably in line with the paucity of high-quality studies on lifestyle management in general. One hard endpoint study (Sodium-HF) is underway. Promising results were obtained in the GOURMET study, which integrated sodium restriction into a broader nutritional approach that simultaneously targeted malnutrition, a major problem in heart failure. Targeting overall nutritional status - rather than single nutrients - matches current trends in nutrition guidelines, and deserves further exploration. Using fresh products and avoiding processed foods is the main step towards an overall healthier diet with less sodium. Dietary improvement, with its clinical benefit, is feasible in most patients by means of adequate support and feedback. Hopefully, the emergence of 'lifestyle medicine' will, with clinical and scientific effort, allow for the health potential of nutrition to be translated into clinical benefit for patients.

Conflicting Evidence on Health Effects Associated with Salt Reduction Calls for a Redesign of the Salt Dietary Guidelines.

Ninety-five percent of the World's populations have a mean salt intake between 6 and 12 g, which is much lower than the tolerated daily level of up to 55 g/d. In spite of this, the recommended upper level by many health institutions is as low as 5.8 g/day. When reviewing the evidence for an upper level of 5.8 g/day, it becomes apparent that neither the supporting studies selected by the health institutions, nor randomized controlled trials and prospective observational studies disregarded by the health institutions, document that a salt intake below this 5.8 g, has beneficial health effects. Although there is an association between salt intake and blood pressure, both in randomized controlled trials and in observational studies, this association is weak, especially in non-obese individuals with normal blood pressure. Furthermore a salt intake below 5.8 g is associated with the activation of the renin-angiotensin-aldosteron system, an increase in plasma lipids and increased mortality. A redesign of the salt dietary guidelines, therefore, seems to be needed.

Protocol for the Process Evaluation of a Complex, Statewide Intervention to Reduce Salt Intake in Victoria, Australia.

Systematic reviews of trials consistently demonstrate that reducing salt intake lowers blood pressure. However, there is limited evidence on how interventions function in the real world to achieve sustained population-wide salt reduction. Process evaluations are crucial for understanding how and why an intervention resulted in its observed effect in that setting, particularly for complex interventions. This project presents the detailed protocol for a process evaluation of a statewide strategy to lower salt intake in Victoria, Australia. We describe the pragmatic methods used to collect and analyse data on six process evaluation dimensions: reach, dose or adoption, fidelity, effectiveness, context and cost, informed by Linnan and Steckler's framework and RE-AIM. Data collection methods include routinely collected administrative data; surveys of processed foods, the population, food industry and organizations; targeted campaign evaluation and semi-structured interviews. Quantitative and qualitative data will be triangulated to provide validation or context for one another. This process evaluation will contribute new knowledge about what components of the intervention are important to salt reduction strategies and how the interventions cause reduced salt intake, to inform the transferability of the program to other Australian states and territories. This protocol can be adapted for other population-based, complex, disease prevention interventions.

The History of the Salt Wars.

The "Salt-Blood Pressure Hypothesis" states that an increase in the intake of salt leads to an increased in blood pressure and subsequently increases the risk for cardiovascular events, which has been a point of contention for decades. This article covers the history and some of the key players pertaining to "The Salt Wars" during the first half of the 1900s, both in Europe and in the United States. Early studies finding benefits with salt restriction in those with hypertension were based on uncontrolled case reports. The overall evidence in the first half of the 1900s suggests that a low-salt diet was not a reasonable strategy for treating hypertension.

Is Salt a Culprit or an Innocent Bystander in Hypertension? A Hypothesis Challenging the Ancient Paradigm.

For decades the notion that an excessive consumption of salt (NaCl) leads to hypertension has persisted. However, this idea is based on opinion, not scientific proof. Despite this, every health organization, agency, and clinicians around the world have been advising salt restriction, especially to hypertensive patients. The present review article suggests that the consumption of a high-salt diet is not the cause of hypertension and that there are other factors, such as added sugars, which are causative for inducing hypertension and cardiovascular disease.

Espironolactona versus placebo, bisoprolol y doxazosina para determinar el tratamiento óptimo de hipertensión resistente a fármacos / Spironolactone versus placebo, bisoprolol and doxazosin to determine the optimal treatment for drug-resistant hypertension

Introducción: El tratamiento farmacológico óptimo para pacientes con hipertensión resistente no está definido. Objetivo: Evaluar la hipótesis de que la hipertensión resistente es a menudo causada por la excesiva retención de sodio, y que la espironolactona sería superior a fármacos no diuréticos. Métodos: Ensayo clínico doble ciego, controlado con placebo, en el que se incluyen pacientes de 18-79 años con presión arterial (PA) sistólica (PAS), clínica igual o mayor de 140mmHg y PA domiciliaria (18 lecturas en 4 días) igual o mayor de 130mmHg, tratados durante al menos 3 meses con dosis máximas toleradas de 3 fármacos. Los pacientes proceden de 12 centros hospitalarios y 2 centros de atención primaria del Reino Unido. Los pacientes fueron asignados a recibir de forma rotatoria durante 12 semanas, una vez al día, espironolactona (25-50mg) o bisoprolol (5-10mg) o doxazosina liberación retardada (4-8mg) o placebo añadidos a su tratamiento farmacológico antihipertensivo. La aleatorización se hizo mediante un sistema centralizado informático. La intervención fue enmascarada para médicos y pacientes. Las dosis se doblaron después de 6 semanas. La variable principal del estudio fue la diferencia en el promedio de PA domiciliaria entre el grupo de espironolactona y placebo, entre el grupo de espironolactona y los otros grupos de fármacos y entre espironolactona y cada uno de los grupos de fármacos del ensayo. Resultados: Entre mayo de 2009 y julio de 2014 fueron evaluados 436 pacientes, de los que 335 fueron aleatorizados. Después de excluir a 21 pacientes, 285 recibieron tratamiento con espironolactona, 282 con doxazosina, 285 con bisoprolol y 274 placebo; 230 pacientes completaron todos los ciclos del tratamiento. El promedio de reducción de PAS domiciliaria con espironolactona fue superior a placebo (−8,7mmHg; IC 95%: −9,7 a −7,6; p<0,0001), también superior al promedio de descenso de los otros grupos farmacológicos de doxazosina y bisoprolol (−4,6; IC 95%: −5,1 a −3,3; p<0,0001) y superior cuando se comparó de forma individual con los otros grupos farmacológicos, doxazosina (−4; IC 95%: −5 a −3; p<0,0001) y bisoprolol (−4,4; IC 95%: −5,5 a −3,4; p<0.0001). Espironolactona fue el tratamiento más efectivo para reducir la PAS. Todos los fármacos fueron bien tolerados. En 6 de los 285 pacientes que recibieron espironolactona, el potasio sérico excedió los 6mmol/l en alguna ocasión. Conclusiones: Espironolactona fue el fármaco más efectivo en el tratamiento de la hipertensión resistente. La superioridad de este fármaco apoya la importancia de la retención de sodio como mecanismo etiopatogénico (AU)

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Comparison of nutrient intakes from two selected diet plans considered healthful versus the cutoff points for green lights as defined by the UK's multiple traffic light scheme.

This study compared nutrient intakes from 7-day menus for the US MyPlate and DASH Eating Plan versus the cutoff points for green lights defined by the UK's multiple traffic light (MTL) scheme. For both diets, the foods achieved green lights for saturated fat and salt, and for beverages for total fat, saturated fat and salt. The other nutrients achieved amber lights but were within the range of the two diets. By contrast, the MTL threshold for salt in beverages was outside the range of the diets. The values for salt in beverages in the MyPlate and Dash diet plans were 0.06±0.07 and 0.19±0.01 (s.d.) g/100 ml, which are both considerably lower compared with the cutoff of 0.3 g/100 ml for an MTL green light. Adjusting the green MTL threshold values to the median values for a healthful diet could help make MTL labelling a more valid way of helping consumers choose a healthful diet.

Food Reformulation, Responsive Regulation, and "Regulatory Scaffolding": Strengthening Performance of Salt Reduction Programs in Australia and the United Kingdom.

Strategies to reduce excess salt consumption play an important role in preventing cardiovascular disease, which is the largest contributor to global mortality from non-communicable diseases. In many countries, voluntary food reformulation programs seek to reduce salt levels across selected product categories, guided by aspirational targets to be achieved progressively over time. This paper evaluates the industry-led salt reduction programs that operate in the United Kingdom and Australia. Drawing on theoretical concepts from the field of regulatory studies, we propose a step-wise or "responsive" approach that introduces regulatory "scaffolds" to progressively increase levels of government oversight and control in response to industry inaction or under-performance. Our model makes full use of the food industry's willingness to reduce salt levels in products to meet reformulation targets, but recognizes that governments remain accountable for addressing major diet-related health risks. Creative regulatory strategies can assist governments to fulfill their public health obligations, including in circumstances where there are political barriers to direct, statutory regulation of the food industry.

Drop the Salt! Assessing the impact of a public health advocacy strategy on Australian government policy on salt.

OBJECTIVE: In 2007 the Australian Division of World Action on Salt and Health (AWASH) launched a campaign to encourage the Australian government to take action to reduce population salt intake. The objective of the present research was to assess the impact of the Drop the Salt! campaign on government policy. DESIGN: A review of government activities related to salt reduction was conducted and an advocacy strategy implemented to increase government action on salt. Advocacy actions were documented and the resulting outcomes identified. An analysis of stakeholder views on the effectiveness of the advocacy strategy was also undertaken. Settings Advocacy activities were coordinated through AWASH at the George Institute for Global Health in Sydney. SUBJECTS: All relevant State and Federal government statements and actions were reviewed and thirteen stakeholders with known interests or responsibilities regarding dietary salt, including food industry, government and health organisations, were interviewed. RESULTS: Stakeholder analysis affirmed that AWASH influenced the government's agenda on salt reduction and four key outputs were attributed to the campaign: (i) the Food Regulation Standing Committee discussions on salt, (ii) the Food and Health Dialogue salt targets, (iii) National Health and Medical Research Council partnership funding and (iv) the New South Wales Premier's Forum on Fast Foods. CONCLUSIONS: While it is not possible to definitively attribute changes in government policy to one organisation, stakeholder research indicated that the AWASH campaign increased the priority of salt reduction on the government's agenda. However, a coordinated government strategy on salt reduction is still required to ensure that the potential health benefits are fully realised.

The effect of sodium reduction with and without potassium chloride on the survival of Listeria monocytogenes in Cheddar cheese.

Sodium chloride (NaCl) in cheese contributes to flavor and texture directly and by its effect on microbial and enzymatic activity. The salt-to-moisture ratio (S/M) is used to gauge if conditions for producing good-quality cheese have been met. Reductions in salt that deviate from the ideal S/M range could result in changing culture acidification profiles during cheese making. Lactococcus lactis ssp. lactis or Lc. lactis ssp. cremoris are both used as cultures in Cheddar cheese manufacture, but Lc. lactis ssp. lactis has a higher salt and pH tolerance than Lc. lactis ssp. cremoris. Both salt and pH are used to control growth and survival of Listeria monocytogenes and salts such as KCl are commonly used to replace the effects of NaCl in food when NaCl is reduced. The objectives of this project were to determine the effects of sodium reduction, KCl use, and the subspecies of Lc. lactis used on L. monocytogenes survival in stirred-curd Cheddar cheese. Cheese was manufactured with either Lc. lactis ssp. lactis or Lc. lactis ssp. cremoris. At the salting step, curd was divided and salted with a concentration targeted to produce a final cheese with 600 mg of sodium/100 g (control), 25% reduced sodium (450 mg of sodium/100 g; both with and without KCl), and low sodium (53% sodium reduction or 280 mg of sodium/100 g; both with and without KCl). Potassium chloride was added on a molar equivalent to the NaCl it replaced to maintain an equivalent S/M. Cheese was inoculated with a 5-strain cocktail of L. monocytogenes at different times during aging to simulate postprocessing contamination, and counts were monitored over 27 or 50 d, depending on incubation temperature (12 or 5 °C, respectively). In cheese inoculated with 4 log10 cfu of L. monocytogenes/g 2 wk after manufacture, viable counts declined by more than 3 log10 cfu/g in all treatments over 60 d. When inoculated with 5 log10 cfu/g at 3mo of cheese age, L. monocytogenes counts in Cheddar cheese were also reduced during storage, but by less than 1.5 log10 cfu/g after 50 d. However, cheese with a 50% reduction in sodium without KCl had higher counts than full-sodium cheese at the end of 50 d of incubation at 4 °C when inoculated at 3 mo. When inoculated at 8 mo postmanufacture, this trend was only observed in 50% reduced sodium with KCl, for cheese manufactured with both cultures. This enhanced survival for 50% reduced-sodium cheese was not seen when a higher incubation temperature (12 °C) was used when cheese was inoculated at 3 mo of age and monitored for 27 d (no difference in treatments was observed at this incubation temperature). In the event of postprocessing contamination during later stages of ripening, L. monocytogenes was capable of survival in Cheddar cheese regardless of which culture was used, whether or not sodium had been reduced by as much as 50% from standard concentrations, or if KCl had been added to maintain the effective S/M of full-sodium Cheddar cheese.