Low-Sodium Dietary Perceptions and Experiences of African-American Women with Hypertension.

African-Americans are disproportionately affected by hypertension with lower rates of blood pressure control in comparison to the general population (Brennan et al., 2010). Low-sodium dietary intake is one of the most important lifestyle changes that can help control hypertension (Zhang et al., 2013). This qualitative study aimed to explore and describe the perceptions and experiences of low-sodium dietary practices among African-American women with hypertension. The study used a single-category focus group design. The findings suggest that African-American women are attempting to follow a low-sodium diet; however, they are influenced by personal and environmental factors and lack a clear understanding of what a low-sodium diet entails. Therefore, nurses must understand the factors that influence African-American women's ability to follow a low-sodium diet so that effective interventions can be implemented to improve adherence in this population.

Poor adherence to medication and salt restriction as a barrier to reaching blood pressure control in patients with hypertension: Cross-sectional study from 12 sub-Saharan countries.

BACKGROUND: Sub-Saharan Africa is experiencing a rising burden of hypertension. Antihypertensive medications and diet are the cornerstone of effective hypertension control. AIMS: To assess adherence to medication and salt restriction in 12 sub-Saharan countries, and to study the relationship between adherence and blood pressure control in patients with hypertension. METHODS: We conducted a cross-sectional survey in urban clinics in twelve sub-Saharan countries. Data were collected on demographics, treatment and adequacy of blood pressure control in patients with hypertension attending the clinics. Adherence was assessed by questionnaires completed by the patients. Hypertension grades were defined according to European Society of Cardiology guidelines. Association between adherence and blood pressure control was investigated using multilevel logistic regression analysis, adjusting for age, sex and country. RESULTS: Among the 2198 patients, 77.4% had uncontrolled blood pressure, 34.0% were poorly adherent to salt restriction, 64.4% were poorly adherent to medication and 24.6% were poorly adherent to both. Poor adherence to salt restriction (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.03-1.72), medication (OR 1.56, 95% CI 1.25-1.93) or both (OR 1.91 1.39-2.66) was related to uncontrolled blood pressure. Moreover, poor adherence to both medication and salt restriction was related to a 1.52-fold (95% CI 1.04-2.22), 1.8-fold (95% CI 1.22-2.65) and 3.08-fold (95% CI 2.02-4.69) increased likelihood of hypertension grade 1, 2 and 3, respectively. CONCLUSIONS: High levels of poor adherence to salt restriction and medication were noted in this urban sub-Saharan study; both were significantly associated with uncontrolled blood pressure, representing major opportunities for intervention to improve hypertension control in sub-Saharan Africa.

Elevated Blood Pressure and Associations with Sodium Intake Among Multiethnic Youth in Edmonton, Canada: Findings from WHY ACT NOW.

INTRODUCTION: This study examined the prevalence of pre-hypertension (PHT) and hypertension (HT) in urban youth, and assessed the effects of sodium intake and obesity on blood pressure (BP) by ethnicity. METHODS: A convenience sample of 557 multiethnic youth, aged 11-23 years, was recruited from 12 schools and institutions in Edmonton, Alberta, Canada. Participants were divided by self-identified ethnicity into four groups (Indigenous, African and Middle Eastern (AME), Asian, and European). RESULTS: Between October 2013 and March 2014, one-on-one interviews were conducted to collect data on demographics, physical activity, diet, and Body Mass Index (BMI). BP was obtained at two different times during the interview and measured a third time in cases of high variability. The standard deviation scores (SDS) of systolic BP (SBP) and diastolic BP (DBP) were used to estimate associations with sodium intake (per 1000 mg/day). Overall, 18.2% and 5.4% of the participants had PHT and HT, respectively. Indigenous and AME participants showed the highest rates of PHT (23.1%). Indigenous and European participants showed higher rates of HT (8.3% and 5.3%, respectively) than other ethnic groups (AME = 4.4%, Asian = 3.9%). There was a positive association between 1000 mg/day increase in sodium intake and SDS of SBP by 0.041 (95% CI 0.007-0.083; p = 0.04) among pre-hypertensive participants. Over 85% of participants exceeded the recommended dietary sodium intake. Mean BMI and dietary sodium intake were higher among pre-hypertensive participants (4219 mg/day) than normotensive (3475 mg/day). CONCLUSIONS: The prevalence of HT varied by ethnicity. High dietary sodium intake was of concern. There is a need for culturally-tailored, population-based interventions to reduce sodium intake.

Improving access to phosphorus- and sodium-restricted foods for people living with chronic kidney disease in remote First Nations.

CONTEXT: Food insecurity in northern, remote Canadian communities has become increasingly recognised as a significant issue in rural health research and policy. Over the past decade, numerous government and academic reports have emerged, documenting the severity of this issue for the health people living in the Canadian north. People living in northern and remote Canadian communities experience significant challenges related to the cost, quality, and variety of market (store-bought) foods. These issues may be of particular concern for those living with chronic diseases that require therapeutic diets, such as chronic kidney disease (CKD). ISSUES: There is little to no research that documents the impact of food insecurity on disease management and quality of life for those living with CKD and end-stage renal disease (ESRD). There is also limited literature on food access for people living with ESRD in northern and remote communities. People living with food insecurity and CKD in remote communities might experience significant challenges in accessing the foods necessary for adhering to dietary guidelines. LESSONS LEARNED: This commentary examines northern food insecurity and draws attention to dietary challenges for residents of remote communities who are living on restricted or therapeutic diets due to chronic disease. In particular we point to the needs of those living with late-stage CKD and ESRD. We call attention to the need for clinicians to understand the capacity of patients to adhere to therapeutic dietary guidelines in remote communities.

Process Evaluation and Costing of a Multifaceted Population-Wide Intervention to Reduce Salt Consumption in Fiji.

This paper reports the process evaluation and costing of a national salt reduction intervention in Fiji. The population-wide intervention included engaging food industry to reduce salt in foods, strategic health communication and a hospital program. The evaluation showed a 1.4 g/day drop in salt intake from the 11.7 g/day at baseline; however, this was not statistically significant. To better understand intervention implementation, we collated data to assess intervention fidelity, reach, context and costs. Government and management changes affected intervention implementation, meaning fidelity was relatively low. There was no active mechanism for ensuring food companies adhered to the voluntary salt reduction targets. Communication activities had wide reach but most activities were one-off, meaning the overall dose was low and impact on behavior limited. Intervention costs were moderate (FJD $277,410 or $0.31 per person) but the strategy relied on multi-sector action which was not fully operationalised. The cyclone also delayed monitoring and likely impacted the results. However, 73% of people surveyed had heard about the campaign and salt reduction policies have been mainstreamed into government programs. Longer-term monitoring of salt intake is planned through future surveys and lessons from this process evaluation will be used to inform future strategies in the Pacific Islands and globally.

Higher adherence to the Mediterranean diet is inversely associated with having hypertension: is low salt intake a mediating factor?

Blood pressure (BP) is a major risk factor for population health worldwide and a preventable disease through lifestyle modification. The aim of this study was to assess the association between adherence to the Mediterranean diet (MD) and occurrence of hypertension in a Mediterranean cohort. Demographic and dietary data of 1937 adults were collected in 2014-2015 from the general population of Catania, Sicily (Italy). Food frequency questionnaires and a MD adherence score were used to assess exposure variables. Higher adherence to the MD was inversely associated with hypertension. However, this association was no more significant after adjustment for sodium and potassium intake. These results suggest that salt may exert a mediating effect of high adherence to the MD towards hypertension.

Elevation of Fasting Ghrelin in Healthy Human Subjects Consuming a High-Salt Diet: A Novel Mechanism of Obesity?

Overweight/obesity is a chronic disease that carries an increased risk of hypertension, diabetes mellitus, and premature death. Several epidemiological studies have demonstrated a clear relationship between salt intake and obesity, but the pathophysiologic mechanisms remain unknown. We hypothesized that ghrelin, which regulates appetite, food intake, and fat deposition, becomes elevated when one consumes a high-salt diet, contributing to the progression of obesity. We, therefore, investigated fasting ghrelin concentrations during a high-salt diet. Thirty-eight non-obese and normotensive subjects (aged 25 to 50 years) were selected from a rural community in Northern China. They were sequentially maintained on a normal diet for three days at baseline, a low-salt diet for seven days (3 g/day, NaCl), then a high-salt diet for seven days (18 g/day). The concentration of plasma ghrelin was measured using an immunoenzyme method (ELISA). High-salt intake significantly increased fasting ghrelin levels, which were higher during the high-salt diet (320.7 ± 30.6 pg/mL) than during the low-salt diet (172.9 ± 8.9 pg/mL). The comparison of ghrelin levels between the different salt diets was statistically-significantly different (p < 0.01). A positive correlation between 24-h urinary sodium excretion and fasting ghrelin levels was demonstrated. Our data indicate that a high-salt diet elevates fasting ghrelin in healthy human subjects, which may be a novel underlying mechanism of obesity.

Nutritional impact of sodium reduction strategies on sodium intake from processed foods.

BACKGROUND/OBJECTIVES: Sodium intake in the Netherlands is substantially above the recommended intake of 2400 mg/day. This study aimed to estimate the effect of two sodium reduction strategies, that is, modification of the composition of industrially processed foods toward the technologically feasible minimum level or alteration of consumers' behavior on sodium intake in the Netherlands. SUBJECTS/METHODS: Data from the Dutch National Food Consumption Survey (2007-2010) and the Food Composition Table (2011) were used to estimate the current sodium intake. In the first scenario, levels in processed foods were reduced toward their technologically feasible minimum level (sodium reduction in processed foods scenario). The minimum feasible levels were based on literature searches or expert judgment. In the second scenario, foods consumed were divided into similar food (sub)groups. Subsequently, foods were replaced by low-sodium alternatives (substitution of processed foods scenario). Sodium intake from foods was calculated based on the mean of two observation days for the current food consumption pattern and the scenarios. RESULTS: Sodium levels of processed foods could be reduced in most food groups by 50%, and this may reduce median sodium intake from foods by 38% (from 3042 to 1886 mg/day in adult men). Substitution of foods may reduce sodium intake by 47% (from 3042 to 1627 mg/day in adult men), owing to many low-sodium alternatives within food groups. CONCLUSIONS: In the Netherlands, reduction of sodium intake by modification of food composition or by alteration of behavior may substantially reduce the median sodium intake from foods below the recommended sodium intake.

The salt content of products from popular fast-food chains in Costa Rica.

Salt is a major determinant of population blood pressure levels. Salt intake in Costa Rica is above levels required for good health. With an increasing number of Costa Ricans visiting fast food restaurants, it is likely that fast-food is contributing to daily salt intake. Salt content data from seven popular fast food chains in Costa Rica were collected in January 2013. Products were classified into 10 categories. Mean salt content was compared between chains and categories. Statistical analysis was performed using Welch ANOVA and Tukey-Kramer HSD tests. Significant differences were found between companies; Subway products had lowest mean salt content (0.97 g/100 g; p < 0.05) while Popeye's and KFC had the highest (1.57 g/100 g; p < 0.05). Significant variations in mean salt content were observed between categories. Salads had a mean salt content of 0.45 g/100 g while sauces had 2.16 g/100 g (p < 0.05). Wide variation in salt content was also seen within food categories. Salt content in sandwiches ranged from 0.5 to 2.1 g/100 g. The high levels and wide variation in salt content of fast food products in Costa Rica suggest that salt reduction is likely to be technically feasible in many cases. With an increasing number of consumers purchasing fast foods, even small improvements in salt levels could produce important health gains.

Determinants and consequences of adherence to the dietary approaches to stop hypertension diet in African-American and white adults with high blood pressure: results from the ENCORE trial.

BACKGROUND: Although the Dietary Approaches to Stop Hypertension (DASH) diet is an accepted nonpharmacologic treatment for hypertension, little is known about what patient characteristics affect dietary adherence and what level of adherence is needed to reduce blood pressure (BP). OBJECTIVE: Our aim was to determine what factors predict dietary adherence and the extent to which dietary adherence is necessary to produce clinically meaningful BP reductions. DESIGN: Ancillary study of the ENCORE (Exercise and Nutrition Interventions for Cardiovascular Health) trial--a 16-week randomized clinical trial of diet and exercise. PARTICIPANTS/SETTING: Participants included 144 sedentary, overweight, or obese adults (body mass index 25 to 39.9) with high BP (systolic 130 to 159 mm Hg and/or diastolic 85 to 99 mm Hg). INTERVENTION: Patients were randomized to one of three groups: DASH diet alone, DASH diet plus weight management, and Usual Diet Controls. MAIN OUTCOMES MEASURES: Our primary outcomes were a composite index of adherence to the DASH diet and clinic BP. STATISTICAL ANALYSES PERFORMED: General linear models were used to compare treatment groups on post-treatment adherence to the DASH diet. Linear regression was used to examine potential predictors of post-treatment DASH adherence. Analysis of covariance was used to examine the relation of adherence to the DASH diet and BP. RESULTS: Participants in the DASH diet plus weight management (16.1 systolic BP [SBP]; 95% CI 13.0 to 19.2 mm Hg and 9.9 diastolic BP [DBP]; 95% CI 8.1 to 11.6 mm Hg) and DASH diet alone (11.2 SBP; 95% CI 8.1 to 14.3 mm Hg and 7.5 DBP; 95% CI 5.8 to 9.3 mm Hg) groups showed significant reductions in BP in comparison with Usual Diet Controls participants (3.4 SBP; 95% CI 0.4 to 6.4 mm Hg and DBP 3.8; 95% CI 2.2 to 5.5 mm Hg). Greater post-treatment consumption of DASH foods was noted in both the DASH diet alone (mean = 6.20; 95% CI 5.83 to 6.57) and DASH diet plus weight management groups (mean = 6.23; 95% CI 5.88 to 6.59) compared with Usual Diet Controls (mean = 3.66; 95% CI 3.30 to 4.01; P<0.0001), and greater adherence to the DASH diet was associated with larger reductions in clinic SBP and DBP (P ≤ 0.01). Only ethnicity predicted dietary adherence, with African Americans less adherent to the DASH diet compared with whites (4.68; 95% CI 4.34 to 5.03 vs 5.83; 95% CI 5.50 to 6.11; P<0.001). CONCLUSIONS: Greater adherence to the DASH diet was associated with larger BP reductions independent of weight loss. African Americans were less likely to be adherent to the DASH dietary eating plan compared with whites, suggesting that culturally sensitive dietary strategies might be needed to improve adherence to the DASH diet.

Prevalence rates of hypertension self-care activities among African Americans.

BACKGROUND: A comprehensive understanding of the self-care activities that contribute to blood pressure control may explain health disparities experienced by African Americans with hypertension. This study assessed the prevalence of self-care activities among African Americans with high blood pressure and examined differences between adherers and nonadherers to self-care activities. METHODS: Interviews were conducted with 186 African Americans. Self-care activities were measured using the H-SCALE (Hypertension Self-Care Activity Level Effects), which was developed to assess the behavioral activities recommended for optimal management of high blood pressure. RESULTS: More than half of participants reported adhering to medication recommendations and prescribed physical activity levels (58.6% and 52.2%, respectively). Following practices related to weight management was less frequent, (30.1%) and adherence to low-salt diet recommendations was also low (22.0%). Three-fourths were nonsmokers and 65% abstained from alcohol. Across the self-care activities, adherers were more likely to be older and female. Nonadherers were more likely to be uninsured. CONCLUSIONS: Many African Americans still face challenges related to hypertension self-care, particularly with weight management and salt reduction. The H-SCALE was a valid and reliable measure of hypertension self-care activities. In addition to monitoring blood pressure, health care providers should assess patients' hypertension self-care activities using the H-SCALE.

Barriers and facilitators of dietary sodium restriction amongst Bangladeshi chronic kidney disease patients.

BACKGROUND: People of Bangladeshi origin have the highest mortality ratio from coronary heart disease of any minority ethnic group in UK and their rate of kidney disease is three- to five-fold higher than that of the European UK population. However, there is little information regarding their dietary customs or knowledge, beliefs and attitudes towards health and nutrition. This multi-method qualitative study aimed to identify: (i) barriers and facilitators to dietary sodium restriction; (ii) traditional and current diet in the UK; and (iii) beliefs and attitudes towards development of hypertension, and the role of sodium. METHODS: Methods included focus group discussions, vignettes and food diaries. Twenty female chronic kidney disease patients attended four focus group discussions and maintained food diaries; ten responded to vignettes during telephone interviews. Triangulation of the results obtained from the three methods identified categories and themes from qualitative thematic analysis. RESULTS: Identified barriers to sodium restriction were deeply-rooted dietary beliefs, attitudes and a culturally-established taste for salt. Facilitators of change included acceptable strategies for cooking with less salt without affecting palatability. Dietary practices were culturally determined but modified by participants' prosperity in the UK relative to their previous impoverished agrarian lifestyles in Bangladesh. CONCLUSIONS: Cultural background and orientation were strong determinants of the group's dietary practices and influenced their reception and response to health communication messages. Efforts to understand their cultural mores, interpret and convey health-promotion messages in culturally-appropriate ways met with a positive response.

Lifestyle advice for Korean Americans and native Koreans with hypertension.

AIM: This paper is a report of a comparison of advice on lifestyle given by healthcare providers and subsequent action by recipients between Korean Americans and native Koreans with hypertension. BACKGROUND: High blood pressure is controllable by having a healthy lifestyle, such as weight control, dietary change, exercise, low-sodium diet, alcohol restriction and smoking cessation, and by taking medication. Healthcare providers play an important role in teaching individuals with hypertension on healthy lifestyles. METHOD: This descriptive comparative study was conducted with a convenience sample of 100 Korean Americans and 100 native Koreans with hypertension. They were interviewed between May 2003 and June 2004 on the advice they received from healthcare providers on lifestyle and their subsequent action in terms of taking medication, weight control, dietary change, exercise, low-sodium diet, smoking cessation, alcohol restriction and tension reduction. Nutrient profiles were examined using the 24-hour dietary recall method. FINDINGS: Korean Americans received advice on lifestyle less than did native Koreans, but more Korean Americans followed healthy lifestyle advice on dietary change and exercise than did native Koreans (P<0.001). Weight control was the least adhered to behaviour among the Korean Americans, although almost two-thirds of them were overweight or obese. Both groups exceeded the Dietary Reference Intakes of sodium, but perceived their sodium consumption as low. CONCLUSION: Native Korean participants need to pay closer attention to carrying out the advice, whereas healthcare providers to Korean Americans need to give more advice on culturally acceptable healthy lifestyles, particularly on dietary changes and weight control. Both groups need to monitor their sodium intake more realistically. It is not only advice from healthcare providers that is integral to control of hypertension, but also that patients should follow that advice.

The effect of minority status and rural residence on actions to control high blood pressure in the U.S.

OBJECTIVE: We examined actions to control high blood pressure (HBP) and health-care provider recommendations for blood pressure control among adults by racial/ethnic group and rural/urban residence. METHODS: We examined data from 45,024 participants with HBP in the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey. We used multiple logistic regression analyses to assess the independent association between current actions to control HBP and health-care provider recommendations for blood pressure control by race/ethnicity and rural/urban status after accounting for confounders. RESULTS: Black people, regardless of rural or urban residence, were more likely to report reducing salt and alcohol intake, changing eating habits, and taking medications than both white urban and white rural adults. Black people, regardless of rural or urban status, were more likely to be advised to cut down on salt, reduce alcohol use, and change eating habits. Black rural adults were also more likely to report being advised to take medications than white urban adults, while white rural adults were less likely to be advised to exercise than white urban adults. CONCLUSIONS: Race/ethnicity and rural/urban status have a differential effect on actions to control HBP and provider advice to control HBP.

Social problem solving training for African Americans: effects on dietary problem solving skill and DASH diet-related behavior change.

OBJECTIVE: Hypertension continues to take its toll on millions of African Americans. Adhering to an eating plan called Dietary Approaches to Stop Hypertension (DASH) can significantly lower blood pressure. This study examined whether problem solving training in addition to education on DASH is more effective than education alone to help African Americans in an urban community college setting solve their own dietary problems and change eating behaviors that could affect blood pressure. METHODS: A randomized, two groups, multiple post-test design was used. All participants (N=78, 59% female) completed a Problem Solving Instrument immediately post-intervention and a follow-up Telephone Interview 2 weeks later. RESULTS: Fewer than half had normal blood pressure on screening. The Experimental Group identified and implemented significantly higher quality solutions to the second of their two problems than the Control Group. The intervention effect was the greatest for participants with blood pressure screenings above normal. CONCLUSION: Problem solving training combined with nutrition information may help African Americans to deal more effectively with dietary problems especially when the problems are complex or less well-defined. PRACTICE IMPLICATIONS: Dietary interventions that include a focus on everyday problem solving as well as knowledge acquisition can be developed in clinical, community health, school, and worksite settings.

Dietary sodium restriction alters postprandial ghrelin: implications for race differences in obesity.

OBJECTIVES: To examine the effect of sodium restriction on the appetite-stimulating hormone, ghrelin, as a function of race, salt sensitivity, and obesity. DESIGN: PARTICIPANTS completed two 4-day outpatient dietary interventions (moderate vs low sodium), and blood samples were drawn two hours after a controlled test meal under both conditions. SETTING: A university research laboratory and affiliated General Clinical Research Center. PARTICIPANTS: 37 women (18 Black, 19 White) and 18 men (9 Black, 9 White), aged 36-63 years. MEASURES: Cardiovascular function (blood pressure, heart rate, impedance-derived indices of cardiac output and peripheral resistance) was measured after a 20-minute rest before each test meal. Blood was drawn by intravenous forearm catheter two hours after each test meal and later assayed for ghrelin, leptin, and norepinephrine. RESULTS: After four days of sodium restriction, postprandial ghrelin increased in White men and women and Black men but decreased in Black women. Salt sensitivity, but not obesity, was also related to ghrelin response during sodium restriction; postprandial ghrelin tended to increase among salt-sensitive subjects during salt restriction but decrease among salt-resistant subjects during salt restriction. CONCLUSIONS: Satiety hormone dysregulation may play a role in: 1) the heightened obesity-related morbidity among Black women, in particular; 2) adherence to sodium-restricted diets; and 3) race differences in behavioral weight-loss interventions that include sodium restriction.