1. Salt, Heart Disease, and Stroke Norm Campbell

2. 1) The role of increased blood pressure as a determinant of adverse outcomes 2) The health risks of high dietary salt

3. Global Leading Risk Factors for Death 2004 Global Health Risks. Mortality and burden of disease attributable to selected major risks WHO 2009 Systolic blood pressure greater than 115 mmHg

4. The Burden of Hypertension Blood Pressure* As A Cardiovascular Risk Attributable Risk –Overall ½ of heart and stroke* –Stroke 60-70%* –Heart failure 50% –Heart attack 25% –Kidney failure 20% –Dementia –Many other vascular diseases * Systolic blood pressure greater than 115 mmHg

5. The Burden of Hypertension Lifetime risk of Hypertension (in Normotensive Women and Men aged 55-65 years) Risk of Hypertension % 0 2 4681012 14161820 Years to Follow-up Women Risk of Hypertension % Years to Follow-up 0 2 4681012 14161820 Men JAMA 2002: Framingham data. 100 80 60 40 20 0 100 80 60 40 20 0

6. BP is well known to rise with age in modern industrialized societies.BP is well known to rise with age in modern industrialized societies. If people move from an area that does not have hypertension to an area that does, they develop hypertensionIf people move from an area that does not have hypertension to an area that does, they develop hypertension Societies that eat unprocessed foods, are physical active and lean do not develop hypertension Meneton et al, 2005

7. Salt and Hypertension

8. Salt and Sodium CONFUSING TERMINOLOGY !!!! 5 gm salt is 2000 mg sodium 2300 mg sodium is about  a teaspoon of salt (sodium chloride)  100 mmol of sodium or salt  5.8 gm (5800 mg) of salt (NaCl)

9. Salt, hypertension and vascular disease A vast array of evidence involving 1000s of studies Animal studies; hypertension and vascular disease Migration studies Epidemiological studies; cross sectional and cohort; hypertension and vascular disease Clinical trials; hypertension and some vascular disease

10. Salt: Meta-analyses The Cochrane Library 2006;3:1-41 ; Key features: random allocation; >2.3 g/day reduction in salt; >4 weeks duration; isolated intervention Hypertensive Median age 50 (range 24-73) Reduction of BP 5.1 (5.8 – 4.3) / 2.7 (3.2-2.2) mmHg; Reduction of 4.5g salt/day, Baseline salt intake 7g – 11g Treatment salt intake 3.25g – 7.2g Normotensive median age 47 (range 22-67) Reduction of BP 2.0 (2.6 –1.5) / 1.0 (1.4-0.6) mmHg; Reduction of salt 4.25g/day Baseline salt intake 7.25g – 11.5g Treatment salt intake 3.25g – 7.75g

11. Meta analysis on different levels of reduction in dietary salt on blood pressure Hypertension 2003;42:1093-1099

12. Effect of 'small' reductions in systolic blood pressure on cardiovascular and total death From Whelton, P. K. et al. JAMA 2002;288:1882-1888

13. Estimated effects on hypertension, CVD and related costs if dietary salt reduced 30% reduction in prevalence of hypertension by reducing salt to recommended levels 8.5 million deaths averted worldwide over 10 years by reducing salt intake 15% Slightly more cost effective than efforts to reduce tobacco use in low to middle income countries. In the USA cost savings of 10-30 billion dollars/yr and reduced CVD events by up to 260,000/yr, deaths up to 90,000/yr from reducing salt by 3 g/day

14. Salt and other health issues Reversibility, aging and in utero effects Direct (non BP related) vascular and cardiac damage Obesity and related diseases (e.g. diabetes) Asthma Kidney stones Osteoporosis Gastric Cancer (promoter)

15. How much salt is unhealthy? Difficult to answer accurately as BP increases as dietary salt increases Small amounts are in primitive diets relative to current intake (about 1/10 th ) Rapid or extensive reductions in dietary salt are associated with increases in lipid and glucose values In those not yet acclimatized, physical activity in hot dry climates increases salt losses in sweat and the amount of dietary salt required

16. Salt intake recommendations WHO: less than 5 g salt (sodium <2000 mg)/day

17. How much salt do you consume? 1) Far too much 2) Too much 3) Just about right 4) Too little

18. THE SALT YOU EAT COMES FROM PROCESSED FOODS

19. Salt intakes around the world With few exceptions the average consumption of populations is over 5.8 g/day after age 5 and many over 10 g/day In developed economies the vast majority of salt is added in food processing (~80%) In undeveloped economies most salt is added at home in cooking and at table In transition economies, salt at home and in food processing is an issue. Int J Epi 2009;38:791-813

20. Discussion Salt intakes around the world are much higher than physiological levels that humans evolved on The high intakes are linked to major causes of death and disability throughout the world Reducing dietary salt is estimated to be one of the most effective and cost effective interventions to improve health.

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