Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention.

Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV

A substantial body of evidence strongly supports the concept that multiple dietary factors affect blood pressure (BP). Well-established dietary modifications that lower BP are reduced salt intake, weight loss, and moderation of alcohol consumption (among those who drink). Over the past decade, increased potassium intake and consumption of dietary patterns based on the "DASH diet" have emerged as effective strategies that also lower BP. Of substantial public health relevance are findings related to blacks and older individuals. Specifically, blacks are especially sensitive to the BP-lowering effects of reduced salt intake, increased potassium intake, and the DASH diet. Furthermore, it is well documented that older individuals, a group at high risk for BP-related cardiovascular and renal diseases, can make and sustain dietary changes. The risk of cardiovascular disease increases progressively throughout the range of BP, beginning at 115/75 mm Hg. In view of the continuing epidemic of BP-related diseases and the increasing prevalence of hypertension, efforts to reduce BP in both nonhypertensive and hypertensive individuals are warranted. In nonhypertensive individuals, dietary changes can lower BP and prevent hypertension. In uncomplicated stage I hypertension (systolic BP of 140 to 159 mm Hg or diastolic BP of 90 to 99 mm Hg), dietary changes serve as initial treatment before drug therapy. In those hypertensive patients already on drug therapy, lifestyle modifications, particularly a reduced salt intake, can further lower BP. The current challenge to healthcare providers, researchers, government officials, and the general public is developing and implementing effective clinical and public health strategies that lead to sustained dietary changes among individuals and more broadly among whole populations.

Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association

Objective To determine the effects of longer term modest salt reduction on blood pressure, hormones, and lipids. Design Systematic review and meta-analysis. Data sources Medline, Embase, Cochrane Hypertension Group Specialised Register, Cochrane Central Register of Controlled Trials, and reference list of relevant articles. Inclusion criteria Randomised trials with a modest reduction in salt intake and duration of at least four weeks. Data extraction and analysis Data were extracted independently by two reviewers. Random effects meta-analyses, subgroup analyses, and meta-regression were performed. Results Thirty four trials (3230 participants) were included. Meta-analysis showed that the mean change in urinary sodium (reduced salt v usual salt) was −75 mmol/24 h (equivalent to a reduction of 4.4 g/day salt), and with this reduction in salt intake, the mean change in blood pressure was −4.18 mm Hg (95% confidence interval −5.18 to −3.18, I 2 =75%) for systolic blood pressure and −2.06 mm Hg (−2.67 to −1.45, I 2 =68%) for diastolic blood pressure. Meta-regression showed that age, ethnic group, blood pressure status (hypertensive or normotensive), and the change in 24 hour urinary sodium were all significantly associated with the fall in systolic blood pressure, explaining 68% of the variance between studies. A 100 mmol reduction in 24 hour urinary sodium (6 g/day salt) was associated with a fall in systolic blood pressure of 5.8 mm Hg (2.5 to 9.2, P=0.001) after adjustment for age, ethnic group, and blood pressure status. For diastolic blood pressure, age, ethnic group, blood pressure status, and the change in 24 hour urinary sodium explained 41% of the variance between studies. Meta-analysis by subgroup showed that in people with hypertension the mean effect was −5.39 mm Hg (−6.62 to −4.15, I 2 =61%) for systolic blood pressure and −2.82 mm Hg (−3.54 to −2.11, I 2 =52%) for diastolic blood pressure. In normotensive people, the figures were −2.42 mm Hg (−3.56 to −1.29, I 2 =66%) and −1.00 mm Hg (−1.85 to −0.15, I 2 =66%), respectively. Further subgroup analysis showed that the decrease in systolic blood pressure was significant in both white and black people and in men and women. Meta-analysis of data on hormones and lipids showed that the mean change was 0.26 ng/mL/h (0.17 to 0.36, I 2 =70%) for plasma renin activity, 73.20 pmol/L (44.92 to 101.48, I 2 =62%) for aldosterone, 187 pmol/L (39 to 336, I 2 =5%) for noradrenaline (norepinephrine), 37 pmol/L (−1 to 74, I 2 =12%) for adrenaline (epinephrine), 0.05 mmol/L (−0.02 to 0.11, I 2 =0%) for total cholesterol, 0.05 mmol/L (−0.01 to 0.12, I 2 =0%) for low density lipoprotein cholesterol, −0.02 mmol/L (−0.06 to 0.01, I 2 =16%) for high density lipoprotein cholesterol, and 0.04 mmol/L (−0.02 to 0.09, I 2 =0%) for triglycerides. Conclusions A modest reduction in salt intake for four or more weeks causes significant and, from a population viewpoint, important falls in blood pressure in both hypertensive and normotensive individuals, irrespective of sex and ethnic group. Salt reduction is associated with a small physiological increase in plasma renin activity, aldosterone, and noradrenaline and no significant change in lipid concentrations. These results support a reduction in population salt intake, which will lower population blood pressure and thereby reduce cardiovascular disease. The observed significant association between the reduction in 24 hour urinary sodium and the fall in systolic blood pressure, indicates that larger reductions in salt intake will lead to larger falls in systolic blood pressure. The current recommendations to reduce salt intake from 9-12 to 5-6 g/day will have a major effect on blood pressure, but a further reduction to 3 g/day will have a greater effect and should become the long term target for population salt intake.

https://www.bmj.com/content/bmj/346/bmj.f1325.full.pdf

Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials

Objective To assess the effect of decreased sodium intake on blood pressure, related cardiovascular diseases, and potential adverse effects such as changes in blood lipids, catecholamine levels, and renal function. Design Systematic review and meta-analysis. Data sources Cochrane Central Register of Controlled Trials, Medline, Embase, WHO International Clinical Trials Registry Platform, the Latin American and Caribbean health science literature database, and the reference lists of previous reviews. Study selection Randomised controlled trials and prospective cohort studies in non-acutely ill adults and children assessing the relations between sodium intake and blood pressure, renal function, blood lipids, and catecholamine levels, and in non-acutely ill adults all cause mortality, cardiovascular disease, stroke, and coronary heart disease. Study appraisal and synthesis Potential studies were screened independently and in duplicate and study characteristics and outcomes extracted. When possible we conducted a meta-analysis to estimate the effect of lower sodium intake using the inverse variance method and a random effects model. We present results as mean differences or risk ratios, with 95% confidence intervals. Results We included 14 cohort studies and five randomised controlled trials reporting all cause mortality, cardiovascular disease, stroke, or coronary heart disease; and 37 randomised controlled trials measuring blood pressure, renal function, blood lipids, and catecholamine levels in adults. Nine controlled trials and one cohort study in children reporting on blood pressure were also included. In adults a reduction in sodium intake significantly reduced resting systolic blood pressure by 3.39 mm Hg (95% confidence interval 2.46 to 4.31) and resting diastolic blood pressure by 1.54 mm Hg (0.98 to 2.11). When sodium intake was 0.05). There were insufficient randomised controlled trials to assess the effects of reduced sodium intake on mortality and morbidity. The associations in cohort studies between sodium intake and all cause mortality, incident fatal and non-fatal cardiovascular disease, and coronary heart disease were non-significant (P>0.05). Increased sodium intake was associated with an increased risk of stroke (risk ratio 1.24, 95% confidence interval 1.08 to 1.43), stroke mortality (1.63, 1.27 to 2.10), and coronary heart disease mortality (1.32, 1.13 to 1.53). In children, a reduction in sodium intake significantly reduced systolic blood pressure by 0.84 mm Hg (0.25 to 1.43) and diastolic blood pressure by 0.87 mm Hg (0.14 to 1.60). Conclusions High quality evidence in non-acutely ill adults shows that reduced sodium intake reduces blood pressure and has no adverse effect on blood lipids, catecholamine levels, or renal function, and moderate quality evidence in children shows that a reduction in sodium intake reduces blood pressure. Lower sodium intake is also associated with a reduced risk of stroke and fatal coronary heart disease in adults. The totality of evidence suggests that most people will likely benefit from reducing sodium intake.

https://www.bmj.com/content/bmj/346/bmj.f1326.full.pdf

Effect of lower sodium intake on health: systematic review and meta-analyses

Purpose: To compare nutrition and health outcomes before and after implementing a standardized enteral feeding protocol on nutrition and health outcomes in very low birth weight preterm infants.Methods: A retrospective chart review was performed evaluating preterm infants, born less than 34 weeks gestation and weighing less than 1500 g, before and after the implementation of a standardized enteral feeding protocol. Outcomes included weaning of parenteral nutrition, initiation and advancement of enteral feeds, initiation of human-milk fortifier (HMF), change in weight z-score and neonatal morbidities.Results: Fifty-six infants (30 in pre-group, 26 in post-group) met the inclusion criteria. Infants in the standardized enteral feeding protocol group started enteral feeds earlier (p = 0.039) and received full HMF fortification at lower weights (p = 0.033) than those in the pre-group. Fewer days on continuous positive airway pressure (p = 0.021) and lower rates of bronchopulmonary dysplasia (p = 0.018) were also observed in the post-group. Weaning of parenteral nutrition and weight z-score were not significantly different between groups. There were no differences in other morbidities.Conclusion: Study results suggest that adopting a standardized enteral feeding protocol may promote early initiation of enteral feeds and fortification.

Benefits of a Standardized Enteral Feeding Protocol on the Nutrition and Health Outcomes of Very Low Birth Weight Preterm Infants.

Two-hundred-and-twelve untreated subjects (mean age 52.3 +/- 0.8 years; 181 males and 31 females) with a diastolic blood pressure between 90 and 100 mmHg were recruited to the study. Subjects were seen fortnightly and, after 4 pre-diet visits, were randomized into a normal diet group (A, 55 subjects), a high-potassium diet group (B, 52 subjects receiving greater than 100 mmol K+/day) a reduced-sodium diet group (C, 52 subjects receiving 50-75 mmol Na+/day) or a high-potassium and low-sodium diet group (D, 53 subjects receiving same Na+ and K+ as groups B and C). Two-hundred subjects completed the diet phase of 12 weeks. Urine sodium fell to 86 +/- 7 mmol/day in group C and 73 +/- 6 mmol/day in group D, while daily potassium excretion rose to 96 +/- 5 mmol in group B and 87 +/- 4 mmol in group C. Systolic and diastolic blood pressure fell by 3.8 +/- 1.0 and 1.6 +/- 0.6 mmHg respectively in the normal diet group. The falls in systolic and diastolic blood pressures (mmHg) in the diet phase were 7.7 +/- 1.1 and 4.7 +/- 0.7 (B), 8.9 +/- 1.0 and 5.8 +/- 0.6 (C) and 7.9 +/- 0.9 and 4.2 +/- 0.7 (D). These falls were all greater than those in the control group on an intention-to-treat analysis (P less than 0.005) but did not differ from each other. Factorial analysis confirmed that the falls in pressure attributable to the low-sodium diet and high-potassium diet were not additive.(ABSTRACT TRUNCATED AT 250 WORDS)

Australian National Health and Medical Research Council dietary salt study in mild hypertension.

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Benefits of a Standardized Enteral Feeding Protocol on the Nutrition and Health Outcomes of Very Low Birth Weight Preterm Infants.

Australian National Health and Medical Research Council dietary salt study in mild hypertension.