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Hypertension, Diet and Dietary Sodium in Canada. Why is sodium reduction Controversial? 1 Norm Campbell.

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Presentation on theme: "Hypertension, Diet and Dietary Sodium in Canada. Why is sodium reduction Controversial? 1 Norm Campbell."— Presentation transcript:

1 Hypertension, Diet and Dietary Sodium in Canada. Why is sodium reduction Controversial? 1 Norm Campbell

2 Financial interests in sodium Salary support from HSF-CIHR to lead efforts to prevent and control hypertension Only recent salt based grant was a $25,000 one year grant (2012-2013) from the NCE Canadian Stroke Network to develop and implement a weekly med-line search and review on dietary salt I have received $750 to talk on unhealthy eating from a Internal Medicine meeting in 2013 2

3 Academic interests Professor of Medicine, Community Health Sciences and Physiology and Pharmacology, Libin Cardiovascular Institute, O’Brien Institute of Public Health at the University of Calgary -HSFC CIHR Chair in Hypertension Prevention and Control -Chair of the Canadian Hypertension Advisory Committee (of national health and scientific organizations) to lead the nongovernmental effort to prevent and control hypertension -President of the World Hypertension League -Co-Chair of the PAHO/WHO Technical Advisory Group on Cardiovascular Disease Prevention through Dietary Salt Reduction -Member of the WHO Nutrition Advisory Group Focus on salt was based on assessment of evidence of benefit. 3

4 HSFC CIHR Chair in Hypertension Prevention and control Mandate 2011-2016 to align government and non governmental organizations on a Pan Canadian Hypertension Framework vision and objectives. – Develop a systematic approach and committee structure for the health care sector to successfully advocate for policy changes to reduce blood pressure in the Canadian population. – Aligning Canadian public health food policy with global best practices.

5 Systolic blood pressure greater than 115 mmHg Figure obtained by cropping a downloaded figure from http://www.healthdata.org July 8 2014,http://www.healthdata.org

6 Burden of hypertension in Canada 7.4 million adult Canadians with hypertension In 2007/8 1100 Canadians a day were diagnosed with hypertension > 90% of us are estimated to develop hypertension in a average lifespan Antihypertensive drug costs of 3 billion dollars/year Almost half of all people in Canada over age 60 are taking drugs to control blood pressure 20-25 million physicians visits for hypertension/year Direct health care costs approximately 10% of overall health costs Societal burden (including indirect costs) are estimated to be 4.5 to 15% of GDP in high income countries 6

7 Attributable Risk of Lifestyle to Hypertension Risk factor Approximate attributable risk for hypertension Increased salt in diet 32% Decreased potassium in diet17% Overweight32% Sedentary lifestyle17% Excess alcohol3% Dietary fats?%

8 CHMS: Canadian Health Measures Survey CHMS: Canadian Heart Health Survey Wilkins et al. Health Reports Feb 2010 The past and current situation for hypertension in Canada CHHS 1985-1992 2007 / 2008 Treated and BP controlled Not Aware Aware and BP not treated Treated and BP not controlled 43% 13% 22% 21% 16% 66% 4% 14% No impact on prevalence No impact of lifestyle

9 Pan Canadian Hypertension Framework An opportunity to discuss how to improve the prevention and control of hypertension in Canada 2011-2020

10 Canadian Hypertension Advisory Committee  Committee structure formed to support HSF/CIHR Chair mandate  Comprised of 15 national organizations to advance/operationalize Hypertension Framework Canadian Hypertension Advisory Committee Membership Canadian Association of Cardiovascular Prevention and Rehabilitation Canadian Cardiovascular Society Canadian Council of Cardiovascular Nurses Canadian Diabetes Association Canadian Medical Association Canadian Nurses Association Canadian Pharmacists Association Canadian Society of Internal Medicine Canadian Society of Nephrology Canadian Stroke Network College of Family Physicians of Canada Heart and Stroke Foundation of Canada Hypertension Canada Public Health Physicians of Canada

11 Recommendation Priorities Recommendation 1.Build Healthy Public Policy (1) 2. Re-orient/redesign the health services delivery system 3.Build partnerships to create supportive environments and evolve the healthcare system (2) 4.Strengthen community action (3) 5.Develop personal skills for better self-management 6.Improve decision support (4) 7.Optimize information systems (5) Provincial Priority, Hypertension Canada, C-CHANGE, Hypertension experts CHAMP Initiative PHAC, Hypertension Canada and new Chair priority Hypertension Canada/HSF

12 Priority Areas of Focus Important & Urgent Important but less urgent Reduce the impact of financial interests on healthy public food policies Policy Statement on Marketing to Kids Defining Healthy Food Sodium Policy & Advocacy Healthy food procurement Standardized front of package food labels that contain health connotations Healthy Food in Canada Fiscal Policies (Taxation/Subsidies)

13 Policy Positions

14

15 Highlights of recent national health and scientific organizations actions on dietary sodium 2006: Blood Pressure Canada (BPC), a coalition of 27 organizations and the Canadian Stroke Network prioritize actions to reduce dietary sodium 2006-8: BPC strategic planning committee formed 2006-7: BPC policy statement on dietary sodium endorsed by 17 national health and scientific organizations 2007: Health and scientific organizations collaborate in Health Canada Sodium Working Group 2007: Health and scientific organizations conduct work on the impact of dietary sodium on the health of Canadians 2007-: Extensive education programs for health care professionals and the public- BPC, Hypertension Canada and Canadian Stroke Network 2011: Health and scientific organizations write public letter of concern to the Prime Minister and all elected FPT officials regarding the Harper governments lack of support for the Sodium Reduction Strategy for Canada created by SWG 2013: Strong national health and scientific organizations support for L Davies parliamentary bill for sodium reduction 15 CSPI PHAC/Health Canada PT’s Food Processing Industry

16 WHO supports sodium reduction Internationally, in 2012, the World Health Organization following an exhaustive and comprehensive review of the clinical interventions and cohort studies of populations United Nations (independent national reviews, political and based on advice of the WHO). All but 1 comprehensive scientific organization review. 31 of 31 surveyed national hypertension societies. Numerous scientific and health NGOs Global Burden of Disease Study estimated 1.65 million deaths in 2010 from high dietary sodium/year. - 486 authors from 302 institutions in 50 countries, indicated to be the strongest evidence-based assessment of people’s health problems around the world. WHO supported GATES funded. 16

17 There is no credible national or international health or scientific organization, I am aware of that has stated opposition to sodium reduction to < 2400mg/day and most support <2000mg/day. Canada’s upper limit of <2300 mg sodium/day is broadly supported within the Canadian health and scientific community. Hypertension Canada supports 2000 mg sodium/day 17

18 Who does not support sodium reduction The Salt Institute. Some of the food processing industry especially in the United States. Several scientists and clinicians who have long histories of close relationships with the salt or food industries. A few dissident scientists most of whom have personally performed research (usually with major methodological weaknesses) that do not support sodium reduction. 18

19 Generating controversy The studies that have created controversy are based on weak research design – Unreliable assessment of sodium intake (e.g. spot urine) – Using extreme variation in dietary sodium over a duration of a few days – Do not address known confounding factors (explanations) for the outcomes being tested, – Control for blood pressure (the main mechanism of sodium induced harm), – Conducted in populations with diseases where reverse causality is likely (i.e. sick people eat less and die more) 19

20 Generating controversy Several controversial studies have been conducted by consultants of the Salt Institute (an umbrella organization of the salt industry) The results of the weak studies have been highly leveraged into public attention by the food and salt industries 20

21 Sodium Science Challenges IOM reports Institute of Medicine of the National Academies. Sodium Intake in Populations: Assessment of Evidence. Strom BL, Yaktine AL, Oria M, editors. Report, V-F-44. 2013. Washington, D.C. USA, The Academies Press. 21

22 Contextual issues in IOM report IOM and the IOM committee are highly respected and not perceived or likely to have any bias against sodium reduction. Hypertension was not considered a primary outcome. Rapid review requested likely resulted in the incomplete review of the quality of evidence. Only recent studies, 2003 and after were reviewed (hence not comprehensive). Focused on high risk people. Most of the studies were based on cohort designs in people with disease where reverse causality is an expected major weakness (sick people eat less and die more). Most of the speakers at the public session of IOM were those who had expressed positions against sodium reduction and some had COI. 22

23 IOM report: Cohort studies that DO NOT support reducing dietary sodium on CVD, renal or death TrialsBP adjusted Inadequate baseline sodium assessment Inadequate adjustment of confounding factors Likely reverse causality One or more authors with perceived COI Cohen 2006124hr dietPhysical activity, SES1 Cohen 2008124 hr dietPhysical activity, SES1 Dong 201013 days1 Ekinci 2011124 hr urine1 Geleijinse 2007 overnight Larsson 2008 1FFQ O’Donnell*+/-Spot urine with many on diuretic 1 23

24 IOM report: Cohort studies that DO NOT support reducing dietary sodium on CVD, renal or death TrialBP adjusted Inadequate baseline sodium assessment Inadequate adjustment of confounding factors Likely reverse causality One or more authors with COI Stolarz- Skrzypek 2011 124 hr Tikellis 2013 24 hr11 Lennie 2011 24 hr11 Total6/102/104/105/102/10 Number with at least 1 fatal flaw – 10/10 Number with 2 fatal flaws- 7/10 * Trials with J curve with sodium 24

25 IOM report: Cohort studies that DO support reducing dietary sodium on CVD, or death TrialBP adjusted Inadequate baseline sodium assessment Inadequate adjustment of confounding factors Likely reverse causality * Not applicable to positive studies One or more authors with COI Cook 2007Repeated 24hr Cook 2009*Repeated 24hr Costa 2012FFQ1 Gardener 2012 FFQ Heerspink 2012 Repeated 24 hr1 Jafar 2006FFQ1 Kono 2011Multiple urines1 * Supports sodium reduction when adjusted for K intake 25

26 IOM report: Cohort studies that DO support reducing dietary sodium on CVD, renal or death TrialBP adjustedInadequate Baseline sodium assessment Inadequate adjustment of confounding factors Likely reverse causality *Not applicable to positive studies One or more authors with COI Arcand 2011Multiple day and methods McCausland 2012 Multiday diary1 Nagata 2004FFQ Takachi 2010FFQ Thomas 201124 hr Umesawa 2008 FFQ Yang 201124 hr recall 26

27 IOM report: Cohort studies that DO support reducing dietary sodium on CVD, renal or death TrialBP adjustedInadequate Baseline sodium assessment Inadequate adjustment of confounding factors Likely reverse causality * Not applicable to positive studies One or more authors with COI Total0/14 5/140/14 Reverse causation does not impact positive findings hence 5/14 would have 1 fatal flaw and none more than 1 27

28 Cohort studies- conclusion If the studies that have fatal flaws are excluded then all cohort studies find sodium intake associated with CVD, renal or death. Through selection of confounding factors and their adjustment, the results can be selected. Both studies with the senior author who had COI have been refuted. IOM contrasts with WHO-Cochrane meta analysis of cohort studies that used quality indicators to exclude methodologically weak and irrelevant studies found higher sodium intake was associated with a 24% higher risk of stroke, a 63% higher risk of stroke death and a 32% higher risk of coronary heart disease death. Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerpohl JJ. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ 2013; 346:f1326 28

29 Heart failure RCT in IOM report Series of 6 single centre study publications Extreme doses of diuretic used to sodium deplete people with heart failure prior to sodium reduction Meta analysis of studies withdrawn as 4 publications contain duplicate data It was claimed the data was lost for two 2 studies when verifying data was requested Only 1 trial registered No safety monitoring board 5 complex studies with over 1000 participants -no stated funding The academic institute where the investigator resides declined a formal investigation 29

30 Sodium science 1)The use of weak methods indicate the need for research standards to be set. 2)There is a need for a high quality RCT. 3)To me the enthusiastic claims to media that sodium is not important for health based on frail methods is endangering programs designed to save millions of lives/year. 30

31 Science of Salt Weekly Science of Salt Weekly is an initiative of the (CIHR/HSFC) Chair in Hypertension Prevention and Control. Funding for this 2-year initiative has been provided by the Canadian Stroke Network and the George Institute for Global Health.Canadian Stroke NetworkGeorge Institute for Global Health This weekly newsletter features short summaries of relevant Medline-retrieved articles related to dietary sodium. To download issues or to sign-up for automated email updates, visit: http://www.hypertensiontalk.com http://www.hypertensiontalk.com 31

32 Setting Research standards An international coalition of organizations lead by the World Hypertension League is forming to set research standards and maintain regular systematic reviews of the literature 32

33 Some Best Global Practices to achieve the WHO target (<5 g salt/day) and United Nations target (30% decrease in dietary salt by 2025). Regulatory approaches that set targets and timelines on sodium content of processed foods (South Africa and Argentina) Voluntary approaches that set targets and timelines on sodium content of processed foods with close government oversight and monitoring (Finland, England, Ireland, Brazil, Chile (expected soon to be regulatory) 33

34 Changes in DBP, salt intake and stroke deaths in Finland 5600 mg 3360 mg DBP Salt Stroke Karppanen H et al Progress, Cardiovascular Disease 2006;49:59-75

35 Changes in CVD, blood pressure and salt consumption in the England 2003-2011 Japan not well evaluated but reduced salt intake, reduced population BP and reduced stroke

36 Sodium science: A substantive but incomplete evidence base indicates the widespread addition of large amounts of sodium to food is one of the largest public health disasters of industrialization killing 1.65 million/yr. in 2010 Current controversy is largely fueled by weak research methods, and financial interests. 36


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