Nutrition and Cardiovascular Disease (CVD) 4 September 2015

Nutrition and Cardiovascular Disease (CVD) 4 September 2015 DEAKIN MEDICAL SCHOOL HME102 Public Health Medicine Prof Caryl Nowson Slide 1 Deakin University CRICOS Provider Code: 00113B Learning Objectives Describe the nutritional risk factors contributing to CVD risk Understand the evidence base indicating that lifestyle risk factors contribute to CVD risk including: Dyslipidemia Hypertension Type 2 diabetes

(Obesity covered elsewhere) Describe the nutritional population approaches being implemented worldwide to reduce CVD risk Understand the systemic factors that prevent individual nutritional behaviour change Describe the recommended dietary approaches to reduce CVD risk at the individual and population level in Australia Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 2 Deakin University CRICOS Provider Code: 00113B Cardiovascular Disease Heart, Stroke & Vascular Disease 30% of 58 million deaths globally (2005) equal to infectious diseases, nutritional deficiencies, maternal and perinatal conditions combined 46% deaths < 70 years Kills more Australians than any other disease group 3.67 million Australians affected

1.10 million long term disability as a result Increased by 18.2% over last decade Aboriginal &Torres Strait Islanders 2.6x likely to die More disadvantaged groups more likely to die Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 3 Deakin University CRICOS Provider Code: 00113B CVD Risk factors 90% of all Australians have at least 1 risk factor for heart, stroke and vascular disease 60% overweight or obese 54% insufficiently active 51% high blood cholesterol 30% high blood pressure 13% drink at levels harmful to health 8% have diabetes (AIHW NHS 2004-2005) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 4 Deakin University CRICOS Provider Code: 00113B

Dyslipidemia Abnormal: Total cholesterol >5.5 mmol/L HDL cholesterol <1.0 mmol/L men,< 1.3 mmol/L women LDL cholesterol > 3.5 mmol/L Serum total cholesterol = LDL + HDL + Triglycerides High serum LDL cholesterol atherogenic High serum Triglycerides atherogenic Low HDL cholesterol atherogoneic http://www.abs.gov.au/ausstats/[email protected]/Lookup/4364.0.55.005Chapter3002011-12 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 5 Deakin University CRICOS Provider Code: 00113B Dyslipidemia: Australia 201112: 1/3 adults (32.8% or 5.6 million people) high

total cholesterol levels and high LDL levels Only 10.1% self-reported having high cholesterol as a current long-term health condition Further 19.1%: total cholesterol level close to the abnormal cut off (5.05.4 mmol/L range) Proportion of people with high total cholesterol peaked at 5564 years (47.8%) Overall there was no significant difference in rates of total cholesterol for men and women. http://www.abs.gov.au/ausstats/[email protected]/Lookup/4364.0.55.005Chapter3002011-12 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 6 Deakin University CRICOS Provider Code: 00113B Dyslipidemia: lifestyle risk factors Current smokers more likely high cholesterol (38.1% v never smoked 30.4%)

Obese adults (37.0% v 25.8% normal weight or underweight) 84.7% with high total cholesterol also high LDL cholesterol, and high triglycerides (22.9% compared with 9.5%) Hypertensives: higher total cholesterol that those with normal blood pressure (40.8% v 31.0%) High levels of LDL cholesterol were more common among men (35.0%) than women (31.6%) Those with high LDL cholesterol were more likely to have high triglycerides than those with normal LDL levels (15.7% compared with 11.7%) No association between high LDL cholesterol and lower than normal HDL 'good' cholesterol. http://www.abs.gov.au/ausstats/[email protected]/Lookup/4364.0.55.005Chapter3002011-12 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 7 Deakin University CRICOS Provider Code: 00113B Dyslipidemia: lifestyle factors serum cholesterol - CHD 0.5mmol/L (about 10%) mean population serum cholesterol results in 12.6% coronary events 0.6 mmol/l serum cholesterol - IHD: 54% at 40 years, 39% 50yrs (Law) Saturated fats & Trans fats: Total - LDL cholesterol Cochrane review: Small, potentially important CVD risk reduction with saturated

fat Replacing saturated fat with polyunsaturated fat: useful strategy Obesity: Total - LDL cholesterol Exercise: HDL cholesterol Moderate Alcohol: HDL cholesterol BUT !! Omega-3 fatty acids: inversely related: arrhythmia, sudden cardiac death, thrombosis Cochrane Database Syst Rev. 2015 Jun 10;6:CD011737. Reduction in saturated fat intake for cardiovascular disease. (15 randomised controlled trials (RCTs)) Reviews lipid level alterations on cardiovascular morbidity and mortality indicating that changes in blood lipids do affect cardiovascular risk (Briel 2009; De Caterina 2010; Robinson 2009; Rubins 1995; Walsh 1995) Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ. 1994; 308:3 BMJ. 1994 Feb 5;308(6925):367-72. Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 8 Deakin University CRICOS Provider Code: 00113B 1. Which of the following foods does NOT contain significant amounts of saturated fatty acids? A. B. C.

D. E. Public Health Medicine DEAKIN MEDICAL SCHOOL Whole roasted chicken Shortbread biscuits Full cream milk Cheddar Cheese Home cooked chips in Canola oil Nutrition and Cardiovascular Disease (CVD) Slide 9 Deakin University CRICOS Provider Code: 00113B Saturated Fats Stearic acid: C18:O saturated fat Solid at room temperature. mainly found in animal products

Animal-based sources of saturated fats: Dairy foods such as butter, cream, regular-fat milk and cheese Oleic acid:C18:1w9 Meat such as fatty cuts of beef, pork and mono unsaturated fat lamb, processed meats like salami, and chicken (especially chicken skin) Plant-derived saturated fats: Palm oil, Cooking margarine, Coconut, Coconut milk and cream Oleic acid:C18:2w6 Deep fried take away foods, Cakes, poly unsaturated fat Biscuits, Pastries and pies http://www.heartfoundation.org.au/healthy-eating/fats/Pages/saturated-fats.aspx Public Health Medicine

DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 10 Deakin University CRICOS Provider Code: 00113B Trans fatty acids (TFA) in Australia Unsaturated fat that behaves like a saturated fat. Naturally occurring TFA: dairy products, beef, veal, lamb Artificial, synthetic, industrial or manufactured trans fats: hydrogenated or partially hydrogenated vegetable fats Since 2007, manufactured TFA intakes declined 25-45% Mean manufactured TFA intake < 0.4 g/day Mean total TFA from both ruminant and manufactured ~ 0.5-0.6% of total dietary energy:, >90% Aust. population TFA intakes <1% (WHO) pop. goal 60% to 75% of TFA intake derived from ruminant foods: low fat options reduce intake

To Avoid trans fat Choose polyunsaturated and monounsaturated spreads and margarines, lean meat trimmed all visible fat. low or no fat dairy foods limit foods and take-away meals (deep-fried and baked foods: biscuits, pastries, pies) Avoid hydrogenated oils or partially hydrogenated vegetable oils in the ingredients list. unsaturated fatty acid molecule: trans double bond between carbon atoms, which makes the molecule kinked. http://www.heartfoundation.org.au/healthy-eating/fats/Pages/trans-fats.aspx http://www.health.gov.au/internet/main/publishing.nsf/Content/F5F93016C243672FCA2578A20019F090/$File/Trans-Fatty-Acids-in-the-Australia-and-NewZealand-Food-Supply%20-%20Att1.pdf Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 11 Deakin University CRICOS Provider Code: 00113B Diabetes Prevention: Lifestyle Diabetes Prevention Program (DPP)

3,234 subjects, age 51, BMI 34.0 kg/m2 impaired glucose tolerance Randomised to intensive lifestyle modification, metformin or placebo: follow-up 2.8 yrs Diabetes incidence: 11.0% placebo 7.8% metformin 4.8% lifestyle intervention (58% reduction) Weight loss was only 7% of initial body weight >30mins per day activity <30% energy from fat <10% energy from saturated fat Fibre >15g/1000kj Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 12 Deakin University CRICOS Provider Code: 00113B Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 13 Deakin University CRICOS Provider Code: 00113B 13

Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 14 Deakin University CRICOS Provider Code: 00113B 14 Meta-analysis: Lifestyle Interventions 49% decrease in incidence of T2DM for lifestyle intervention vs standard advice Gillies et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and metaanalysis BMJ 2007; 334 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 15 Deakin University CRICOS Provider Code: 00113B 2. How often do you add salt in cooking? A. B.

C. D. Public Health Medicine DEAKIN MEDICAL SCHOOL Never Rarely Sometimes Often Nutrition and Cardiovascular Disease (CVD) Slide 16 Deakin University CRICOS Provider Code: 00113B 3. How often do you add salt at the table? A. Never B. Rarely C. Sometimes D. Often Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 17 Deakin University CRICOS Provider Code: 00113B 4. What are the dietary recommendations for the

number of grams of salt per day for the general population? A. 1 gram (~17mmol sodium) B. 2 grams (~35mmol sodium) C. 3 grams (~52mmol sodium) D. 4 grams (~70mmol sodium) E. 5 grams (~86mmol sodium) F. 6 grams (~100mmol sodium) G. 7 grams (~120mmol sodium) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 18 Deakin University CRICOS Provider Code: 00113B 5. Which of the following the major food groups make the largest contribution to average intakes of dietary sodium in Australia? A. B. C. D. Public Health Medicine DEAKIN MEDICAL SCHOOL Vegemite and savoury spreads

Soft Drinks Breads and Cereals Fish and Seafood Nutrition and Cardiovascular Disease (CVD) Slide 19 Deakin University CRICOS Provider Code: 00113B Hypertension Australia (>140/90mmHg) Men more likely to have hypertension than women (23.4% v 19.5%) Hypertension: 42.6% aged 65 years 5.5% aged 18-24 years http://www.abs.gov.au/ausstats/[email protected]/Lookup/4364.0.55.005Chapter3002011-12 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 20 Deakin University CRICOS Provider Code: 00113B Effects of High Blood Pressure Stroke and usual BP Relationship between BP and CVD is

continuous, graded, independent, & causative CVD by 2 - 4 times Relative Risk Hardening of the arteries of Stroke Stroke Myocardial infarction Congestive Heart Failure Peripheral arterial disease Kidney damage: Chronic Renal Failure Retinopathy Blindness 4.00 2.00 1.00 0.50 0.25

Usual SBP 123 136 148 162 175 Usual DBP 76 84 91 99 105 Approximate mean usual BP (mmHg)

No signs or symptoms until dangerously high MMcMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J. Blood pressure, stroke, and coronary heart disease. Lancet 1990;335:765-73. Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 21 Deakin University CRICOS Provider Code: 00113B Stroke & Hypertension: Australia Strokes 40,000 stroke each year 70% first ever stroke leading cause of long-term disability in Adults Strokes cause 9% all deaths Risk of stroke (& CHD) increases with BP Hypertension Most common chronic disease 1 in 4 males & 1 in 6 females (25-65yrs) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 22 Deakin University CRICOS Provider Code: 00113B

Evidence based Guidelines Treat hypertensive persons > 60 yrs: BP <150/90 mm Hg 30 - 59 yrs diastolic goal < 90 mm Hg; Others BP < 140/90 mm Hg (based on expert opinion) Same goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014;311(5):507-520.http://www.nhlbi.nih.gov/guidelines/hyperte nsion/express.pdf Public Health Medicine Nutrition and Cardiovascular Disease (CVD) Slide 23 DEAKIN MEDICAL SCHOOL Deakin University CRICOS Provider Code: 00113B

Definition of Hypertension > 140/90 mmHg Lifestyle modifications Abolition of age-adjusted targets: but treatment of elderly individualised 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013 Jul;31(7):1281-357 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 24 Deakin University CRICOS Provider Code: 00113B Prevention: to reverse increasing prevalence Changes in the Prevalence and Control of Hypertension in the United States (19882004). Chobanian AV. Shattuck Lecture. The hypertension paradox--more uncontrolled disease despite improved therapy. N Engl J Med. 2009 Aug 27;361(9):878-87. Public Health Medicine

DEAKIN MEDICAL SCHOOL 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013 Jul;31(7):1281-357 Nutrition and Cardiovascular Disease (CVD) Slide 25 Deakin University CRICOS Provider Code: 00113B US Guidelines: management of Hypertension Lifestyle modification Endorsed the recommendations of the Lifestyle Work Group: : 1. Combine Dietary Approaches to Stop Hypertension (DASH) diet with reduced sodium intake < 2,400 mg of sodium (6g salt) per day, noting that limiting intake to 1,500 mg (4g salt/d) can result in even greater reduction in BP 2. Even without achieving these goals, reducing sodium intake by 1,000 mg (2.5g salt)/day lowers blood pressure. Physical activity. Moderate to vigorous physical activity for approximately 160 minutes per week (three to four sessions a week, lasting ~40 minutes per session). Weight loss. The JNC 8 panel endorsed maintaining a healthy weight in controlling blood pressure Alcohol intake received no specific recommendations Eckel RH, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06029-4. doi:

10.1016/j.jacc.2013.11.003. Thomas G1, Shishehbor M, Brill D, Nally JV Jr New hypertension guidelines: one size fits most? Cleve Clin J Med. 2014 Mar;81(3):178-88. doi: 10.3949/ccjm.81a.14003. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013;doi:10.1001/jama.2013.284427. Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 26 Deakin University CRICOS Provider Code: 00113B Key Evidence-based AHA/ACC Guideline on Lifestyle Management to Reduce BP Eckel RH, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06029-4. doi: 10.1016/j.jacc.2013.11.003. Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 27 Deakin University CRICOS Provider Code: 00113B Relationship between body weight, exercise

and BP in Australia Of those with hypertension: three-quarters (76.3%) were overweight/obese 42.7% reported doing no exercise in the last week Of those without hypertension: one-half (53.1%) were overweight/obese 32.5% reported doing no exercise in the last week. Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 28 Deakin University CRICOS Provider Code: 00113B Lifestyle modifications: BP BP-lowering effects of targeted lifestyle modifications can be equivalent to drug monotherapy Major drawback: low level of adherence over time Lifestyle changes may safely and effectively: delay or prevent hypertension in those without hypertension delay/prevent medical therapy in grade 1 hypertensive patients contribute to BP reduction in hypertensives already on medication reduce number and doses of antihypertensive agents

2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013 Jul;31(7):1281-357 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 29 Deakin University CRICOS Provider Code: 00113B 20 salt free societies Intersalt study: average (mean) blood pressure of about 200 people of all ages from three of the salt free societies Yanomama, Brazil 96/61mmHg Xingu, Brazil 99/62 mmHg Asaro, Papua-New Guinea 108/63 mmHg Courtesy Dr. Trevor Beard (deceased) Public Health Medicine DEAKIN MEDICAL SCHOOL

Nutrition and Cardiovascular Disease (CVD) Slide 30 Deakin University CRICOS Provider Code: 00113B Tukisenta in PNG have lifelong normal BP living at home Courtesy Dr. Trevor Beard (deceased) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 31 Deakin University CRICOS Provider Code: 00113B Prehypertension in Port Moresby Courtesy Dr. Trevor Beard (deceased) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 32 Deakin University CRICOS Provider Code: 00113B Link to video summary http://www.nejm.org/doi/full/10.1056/NEJMoa1304127?query=TOC

Sodium to salt To convert sodium to salt, multiply the sodium figure in milligrams (mg) by 2.5 and then divide by 1,000. sodium (mg) salt (g) sodium (mmol) 100.0 sodium (mg) 2300 salt (g) 5.8 87.0 2000 5.0 65.2 1500 3.8 43.5 1000 2.5 26.1 600

1.5 17.4 400 1.0 6000 15.0 13.0 300 0.8 8.7 200 0.5 Recommended intake general population ~<6g salt/day Recommended intake at risk population ~<5g salt/day Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 33 Deakin University CRICOS Provider Code: 00113B Salt and cardiovascular outcomes 10-15yr follow-up of patients

in the Trials of Hypertension Prevention I and II (TOHP I and TOHP: effects of lifestyle modifications including salt restriction 10-15yrs post trial: salt reduction 25% lower incidence CV events The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels: results of the Trials of Hypertension Prevention, phase I. JAMA 1992;267:1213-20. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure: the Trials of Hypertension Prevention, phase II. Arch Intern Med 1997;157:657- 67. Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the Trials of Hypertension Prevention (TOHP).BMJ 2007;334:885-92. Cumulative incidence CVD by salt intervention group (TOHP) I and II adjusted for age, sex, and clinic. Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 34 Deakin University CRICOS Provider Code: 00113B Salt-Sensitivity

A family history of high blood pressure high resting heart rate >15% of ideal body weight Elevated blood pressure (older) >50% those over age 60 hypertensive black Americans low plasma renin activity 35 Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 35 Deakin University CRICOS Provider Code: 00113B Nutrients associated with BP Sodium Potassium Calcium Magnesium Chloride

Alcohol Vegetarian diet Fibre Fat (total) P:S ratio Fish oils Caffeine Variety of vitamins eg. Vit C ? Other dietary factors eg. Garlic ? Public Health Medicine DEAKIN MEDICAL SCHOOL Appel, et al. Effects of Protein, Monounsaturated Fat, and Carbohydrate Intake on Blood Pressure and Serum Lipids: Results of the OmniHeart Randomized Trial. JAMA 2005:294(19), p 24552464 Nutrition and Cardiovascular Disease (CVD) Slide 36 Deakin University CRICOS Provider Code: 00113B Past Diet versus Current Diets 300 Na & K mmol/day 282

250 200 150 150 K (mmol) 100 50 Na (mmol) 70 30 0 Past Public Health Medicine DEAKIN MEDICAL SCHOOL Present Nutrition and Cardiovascular Disease (CVD) Slide 37 Deakin University CRICOS Provider Code: 00113B

DASH (Study 1) Dietary patterns, rather than of individual nutrients (NEJM, 1997): significantly and quickly lowered blood pressure (n=459) Hypertensives: Fall 11/5 mmHg Normotensives: Fall 6/3 mmHg DASH diet: low in saturated fat, total fat, and cholesterol more fruits, vegetables, and low fat dairy foods, includes whole grains, poultry, fish, and nuts. Reduced in red meat, sweets, and sugar- containing beverages, rich in K, Ca, Mg, protein, fibre BP reductions: no change in weight, alcohol or Na intake

3,000mg sodium/day 7.5g salt Na(130mmol/day) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 38 Deakin University CRICOS Provider Code: 00113B Dietary Pattern: DASH SERVES PER DAY 2-3 serves Mono/poly oils (avoid butter) 3 serves Low Fat Dairy (3 cups) 3-4 Fruit 4-5 Vegetables 8-10 serves wholegrain bread/cereals Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 39

Deakin University CRICOS Provider Code: 00113B Dietary Pattern: DASH SERVES PER WEEK 3 red meat (max) 3 fish 4 nuts/seeds 1 legume Public Health Medicine DEAKIN MEDICAL SCHOOL Maximum: 2 alcohol drinks/day Maximum: 4 caffeine drinks/day Nutrition and Cardiovascular Disease (CVD) Slide 40 Deakin University CRICOS Provider Code: 00113B DASH-sodium (Study 2) 2 different eating patterns 412 participants 57% women, 57% African Americans SBP 120-159 mmHg, DBP 80-95 mmHg (41% hypertensive) Usual diet or the DASH diet

3,300mg (143mmol) sodium (~8g salt) 2,400mg (104mmol) sodium (~6g salt) 1,500mg (65mmol) sodium (~4g salt) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 41 Deakin University CRICOS Provider Code: 00113B Sacks FM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approachesto Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2000 DASH-Sodium 135 -7*** SBP (mmHg) Control 130

-2*** -6*** -5*** DASH -2** -3 143 8g salt DEAKIN MEDICAL SCHOOL -2* -1* 125 Public Health Medicine -5*** 104

65 6g salt 4g salt Na (mmol) Nutrition and Cardiovascular Disease (CVD) Slide 42 Deakin University CRICOS Provider Code: 00113B Salt & Health: Population Approach Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 43 Deakin University CRICOS Provider Code: 00113B Effect of processing on salt content/100g bacon 5g salt lean ham

25 times 4g salt lean pork 20 times 0.2g salt Range 0.7-1.5g salt bread 500 times 1.5g salt wheat 0g salt processed cheese 4 g salt milk

0.1 g salt cornflakes 0g salt corn 0 DEAKIN MEDICAL SCHOOL 2.0 g 500 times 0g salt mg sodium/100g Public Health Medicine 40 times 500 1000

1500 2000 2500 Nutrition and Cardiovascular Disease (CVD) Slide 44 Deakin University CRICOS Provider Code: 00113B Salt in foods Low salt product <120mg/100gm have a look at Bread Pasta sauces Cheese slices Breakfast cereals Biscuits Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 45

Deakin University CRICOS Provider Code: 00113B Sodium/ salt targets: Adults (4-6g/day) World Health Organization < 5 g salt/d (<87 mmol Na+) as a population nutrient intake goal Australian division of World Action on Salt & Health (AWASH) - less than 6g salt/d (< 100 mmol Na+) National Heart Foundation less than 6g salt/d (< 100 mmol Na+) less than 4g salt/d (< 70 mmol Na+) if high BP or existing CVD Suggested Dietary target (NH&MRC) - less than 4g salt/day (< 70 mmol Na+) http://www.who.int/dietphysicalactivity/publications/trs916/ download/en/ Upper Limit (NH&MRC) Diet Nutrition and the Prevention of Chronic Disease Report of the joint WHO/FAO expert consultation WHO + Technical Report Series, No. 916 (TRS 916 - less than 6g/d (100mmol Na ) NHMRC. Nutrient Reference Values for Australia and New Zealand including Recommended Dietary Intakes. National Health and Medical Research Council, 2004 National Heart Foundation of Australia Position Statement The relationships between dietary electrolytes and cardiovascular disease

November 2006) Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 46 Deakin University CRICOS Provider Code: 00113B % meeting salt/sodium targets MCC study (2008/09) Men 178 (67) ~ 10g salt N=376 6g salt/d 31 11 4g salt/d 0 5 N=407

men women 8 2 10 15 women 134 (51) ~ 8g salt 20 25 30 35 AWASH & NHF < 6g salt/d (< 100 mmol Na ) Huggins et al. MJA 2011;195(3):128-32. Suggested Dietary target (NH&MRC) & NHF: high BP or existing CVD <4g salt/ + d (< 70 mmol Na+, (~2000mg Na+)

Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 47 Deakin University CRICOS Provider Code: 00113B Salt: Population Effect Average Australian/NZ Intake: >9.0g salt 5g salt (2300mg Na+) reduction 5mmHg SBP 3mmHg DBP (J Hum Hyper 2000;18(4s)s126 3 g/day (51mmol Na) reduction in salt: In hypertensives: stroke deaths 14% coronary deaths 9% In normotensives: stroke deaths 6% coronary deaths 4% Public Health Medicine DEAKIN MEDICAL SCHOOL

http://www.salt.gov.uk/in_the_body.shtml He F, MacGregor G. Effect of longer-term modest reduction on blood pressure. A meta-analysis. Implications for public health. J Human Hypertens 2000;18 (Suppl. 4):S126 Nutrition and Cardiovascular Disease (CVD) Slide 48 Deakin University CRICOS Provider Code: 00113B Mean Salt intake (g/day) UK Trend of mean estimated salt intake (g/day) and 95% confidence intervals 12 Australia The UK Food Standards Agency (FSA) started working with the food industry in 2003 and launched its consumer education campaign in 2005 Salt intake (g/day) 2011/12 11

10 Both 9.1 men 9.8 women 7.1 9.5g 9 8.6g 8 8.1g The mean and 95% confidence limits for each point are as calculated according to the protocol in place at the time. Different methods of assessment of completeness of 24 hour urine collections may contribute slightly (1- 3%) to the decrease from 2006 to 2011. These differences fall within the 95% confidence limits for each point. The

slope of the trend is not substantially affected by these differences. a 7 Target 6 Aug-00 Public Health Medicine DEAKIN MEDICAL SCHOOL 5 years Nov-01 Jan-03 4 years Apr-04 Jul-05 Oct-06 Time Jan-08 3 years

Mar-09 Jun-10 12 years Sep-11 Nutrition and Cardiovascular Disease (CVD) Slide 49 Deakin University CRICOS Provider Code: 00113B Recent Australian Initiatives The Victorian Health Promotion Foundation: Salt Reduction Partnership Group - George Institute for Global Health, The Heart Foundation, Deakin University, and the Victorian Department of Health, The action plan has the ambitious goal of reducing the average daily salt intake of Victorian adults and children by 1 gram by 2018 with four intervention strategies: generating public debate, raising consumer awareness, strengthening policy initiatives, and supporting food industry innovation. The action plan,

launched in March 2014, is supported by significant investment and a robust evaluation strategy. Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 50 Deakin University CRICOS Provider Code: 00113B Public Health Medicine DEAKIN MEDICAL SCHOOL Nutrition and Cardiovascular Disease (CVD) Slide 51 Deakin University CRICOS Provider Code: 00113B Key Lifestyle Changes: reduce CVD

Low intake trans fats, saturated fats Saturated fat <10% Energy, Monounsaturated fat 7-10% Energy <1% energy trans fats Omega-6 Fatty acids 5-8% Energy, Omega-3 Fatty acids 1-2% Energy Fish 1-2 serves/week Reduce Daily Salt by 1/3 Maximum 5g/day or 100mmol Na+ Eat at least 7 serves/day (400g fruit/vegetables) Wholegrain breads/cereals & pulses >20g dietary fibre Maintain body weight in normal range: Reduce body weight if overweight Maximum of 3 standard alcohol drinks/day Physical Activity at least 30min/day moderate level most days Public Health Medicine DEAKIN MEDICAL SCHOOL Population wide approaches Food supply low trans fats, saturated fats Food supply lower sodium content Cheap readily available

fruit/vegetables/education Systems approach: healthy environments for eating and physical activity Nutrition and Cardiovascular Disease (CVD) Slide 52 Deakin University CRICOS Provider Code: 00113B

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    Theories of Health & Illness Behaviour ... This experiment explained behaviour. In health psychology we wish to find out about health behaviours: How they decide they are ill, their lifestyle choices, whether they seek medical help, whether they seek complimentary...