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TRANSCRIPT
Combating CV Diseases: The Salt Reduction Path
H. Isma’eel, MD, FSCCT, FESC
Assistant Professor of Medicine
Co-Director, Vascular Medicine Program
American University of Beirut
Outline
• Why this presentation here?
• International CVD Data versus local?
• Why Salt?
• Time for action: introduce the Lebanese Action on Salt and Health (LASH) Group a member of WASH
0
5
10
15
20
25
30
1990 2020
Millio
ns o
f D
eath
s
fro
m C
ard
iovascu
lar
Cau
ses
Western countries Non-Western (developing) countries
5 million
Death from CVD Worldwide
KS Reddy et al, N Engl J Med 2004
Fuster V et al, Lancet 2005
9 million
19 million
6 million
Over
70%
of the
global
burden of
heart
attack and
stroke is
on poor
countries.
~15m
>25m
Fuster, V. et al. Circulation 2007;116:1966-1970
CVD mortality in various age groups and countries across the globe
0 20 40 60 80 100
Portugal
USA
Brazil
India
South Africa
35-44 45-54 55-64 65-74 75+
Men
Women
0 10 20 30 40 50 60 70
42
62
Patients Diagnosed with CHD (%) Murabito et al Circulation 1993
Myocardial Infarction or Sudden Cardiac
Death as Initial Presentation of CHD
Trends in Age-standardized mortality &
incidence of Acute MI Infarction (NHANES)
Per 100, 000 Person
Ergin A, An J Med 2004
49.7 49.2
10
20
30
40
50
60
30.4
18.6
Acute MI Mortality Acute MI incidence
1971-1982 1982-1992
Where do we stand in Lebanon?
Women Men Overall
Cigarette
smokers
31.6% 46.8% 38.5%
HTN 14.2% 13.2% 13.8%
DM2 4.8% 7.2% 5.9%
Raised
Cholesterol
15.2% 18.0% 16.5%
On meds for
Chol.
45.5% 36.9% 41.2%
Family History of
CAD
52.4% 48.3% 50.5%
Obese 26.5% 28.7% 27.4% % with 3-4 risk
factors
27.1% 42.9% 34.1%
Data on a Nationally representative sample of 2000 adults in Lebanon ages 25-64
Hwalla & Sibai et al, 2009
Nasreddine L. et al, 2012 LMJ In press
Corresponding %in USA
33.7%
11.9%
33%
28.3%
CDC Stats and Facts
0%
10%
20%
30%
40%
50%
60%
70%
1995 2000 2005 2010 2015 2020
Obesity
Diabetes
Hypertension
Linear trend (Obesity)
Linear trend (Diabetes)
Linear trend (HTN)
Figure 1: Secular linear trends in the prevalence (%) of obesity, diabetes and hypertension
among Lebanese adults* (Nasreddine L. et al, 2012 LMJ In Press)
And if this continues in a linear manner then we’re heading towards a disaster.
GBACC: Great Beirut Area CV Cohort
What has happened over 5 years?
HTN & SES in Lebanon HTN No/Yes
No Yes N ColPctN N ColPctN p-value
DEMO_GENDER 0.52 Male 104 33.99 66 36.87 Female 202 66.01 113 63.13 Age 41.64 ± 12.94 53.39 ± 13.85 <0.0001 Socioeconomic_5_education_n 0.0006 Less then elementary 90 29.7 85 47.49 Elementary 91 30.03 44 24.58 Secondary - technical 80 26.4 38 21.23 Higher education 42 13.86 12 6.7 Income <0.0001 < 600$ 71 25 81 50.94 600-999.9$ 119 41.9 47 29.56 1000-2000$ 65 22.89 24 15.09 >2000$ 29 10.21 7 4.4 Crowd_index_c 0.11 Not crowded 52 16.99 44 24.58 Crowded 129 42.16 72 40.22 Severely crowded 125 40.85 63 35.2
HTN No Yes Definite diabetes <0.0001
No 285 93.14 125 69.83 Yes 21 6.86 54 30.17 BMI_c <0.0001
Normal 98 32.03 14 7.82 Overweight 111 36.27 57 31.84 Obese 97 31.7 108 60.34 Obesity <0.0001
Non obese 209 68.3 71 39.66 Obese 97 31.7 108 60.34 MetS_WC <0.0001
0 167 54.58 44 24.58 1 139 45.42 135 75.42 SMOKE_CN_NY 0.0003
No 92 30.07 83 46.37 Yes 214 69.93 96 53.63 SMOKE_CN_NEY 0.0011
Never 69 22.55 58 32.4 Ex 23 7.52 25 13.97 Current 214 69.93 96 53.63 LDL (mg/dL) 106.91 33.86 112.88 43.4 0.11
HDL (mg/dL) 51.33 15.56 46.69 13.03 0.0005
Triglyceride (mg/dL) 128.34 106.74 165.68 88.49 <0.0001
Glucose(mg/dL) 103.43 30.71 128.19 57.01 <0.0001
HbA1C (%) 5.63 0.98 6.5 1.72 <0.0001
Waist circumference (cm) 91.95 13.35 103.6 16.1 <0.0001
Hence: POLICY CHANGES
• Highly Commend the Tobacco Working Group and we look forward to emulating them
Lebanese Action on Salt and Health
Na Reduction Working Grp 1. Why? 2. Who? 3. What are we doing? 4. When?
List of FACTS: 1.Despite some “noise”, salt is associated with
HTN, CVD and others
2.Reducing salt intake is associated with
reduced CVD outcomes
3.Reducing salt intake policy is among the
most cost-effective interventions as per the
WHO
4.Reducing salt intake is beyond an
individual’s effort – it requires a cultural
change and MAJOR FORCE
5.Reducing salt needs to be gradual with
realistic goals
List of Myths
1. most of the salt is added via the shaker
2. Salt is needed as a preservative TODAY
3. People who are used to salt cannot cut it
4. It’s an individual’s choice
From Knowledge to Policy
• Where are the major sources of salt in our diet?
• Who are the major stakeholders?
• How are we moving forward?
Lebanese Action on Salt and Health
• Adel Berbari
• Kamal Badr
• Hussain Isma’eel – VMP assigned Group Facilitator
• Lara Nasreddine
• Haya Hamadeh
• Imad El Haj
•Samir Arnaout •Abir Barhoumi •Mariam Olaik •Mohamad Medawar •Nathalie Khoueiry •Sami Sanjad •George Saade •Hani Tamim •Abla Sibai
Vascular Medicine Program at American University of Beirut
from all faculties
Goals
VMP- Na Intake optimization working Group
Research Clinical
Internal Education
and Training
External Education
and Training
Health Policy
Health Communication Plan
Na in Leb. Food 54.7% of the adult Lebanese population was found to exceed the maximum intake level of 2300 mg/day.
25%
12%
10%
9%
8%
8%
5%
4%
4%
3%
2% 2%
2% 2%
2% 1% 1% 1%
Major food group contributors to sodium intake
Bread, other bread-like products and breakfast cereals
Processed meats
Cheese and labneh
Salads
Vegetable based dishes and moughrabieh
Potato chips and salty snacks
Isma’eel H. et al, CDT 2015
47% of Na
CDC Morbidity and Mortality Weekly Report
40% of sodium consumed in the U.S. comes from 10 food categories, with bread and poultry among the top 5 (47% among Leb.) 88% are above the 2300 mg/d recommendation (55%)
How do we compare to the USA?
StakeHolders:
• All healthcare providers
• Governmental Bodies
• Food industry and Catering Services
Salt Shopping Guide:
Food Labels
Radio Messages &
Social Media
• 2-year Plan is pending approval in 2 weeks
• World Action on Salt and Health _ Lebanon (all working grp)
http://www.worldactiononsalt.com/
• First “Doctors to Coach Change” workshop (Coaching & Career Counseling Ltd. to train health care workers (HCW) adopt a coaching style to change lifestyle habits and Improve Compliance with Meds)
• Validate Na Food Frequency Questionnaire
• Launch Survey on Consumer Awareness of Health Hazards of Salt and Major sources of Salt in diet
• Launch Survey on HCW Awareness of Health Hazards of Salt and major sources of salt in diet
• Na Calculator Webpage
Time Line: Only KEY ongoing projects will be mentioned
• Research project “Establishment of Salt Intake and Range of PWV within Leb.”
• Initiate Health Comm. Plan Steps (Awareness, Interventions and impact measuring Research)
• Expect our invitation soon to the first HCW Salt Monitoring Workshop
• Replicate all the above in Pediatrics
• Feb 2013 (Credit Hx): Ready to launch National LASH Working Group
Time Line: Only KEY ongoing projects will be mentioned
What CCU patients know about salt intake and their health?
Does raising awareness improve knowledge?
Does patient awareness raising lead to behavioral changes?
Limitations
• Is the reported change in behavior true?
• Should we have used urinary sodium collection?
• Does this change lead to reduction in salt intake?
• Does this change lead to reduction in HTN?
• Does this change lead to reduction in CV outcomes?
Take home messages
• CVD are increasing in developing world countries
• HTN (similar to all CVD risk factors) is on the rise
• Higher prevalence of HTN are present in lower SES groups
• Lebanese consume high amounts of salt
• Bread and processed food are No. 1 source of salt
• Awareness raising about need/how to reduce salt intake is associated with ‘reported’ behavioral changes
• Health Policy Changes are more effective/efficient
GBACC Working Group; special
thanks to participants, students and
volunteers
Lebanese Action on Salt and Health
• Adel Berbari
• Kamal Badr
• Hussain Isma’eel – VMP assigned Group Facilitator
• Lara Nasreddine
• Haya Hamadeh
• Imad El Haj
•Samir Arnaout •Abir Barhoumi •Mariam Olaik •Mohamad Medawar •Nathalie Khoueiry •Sami Sanjad •George Saade •Hani Tamim •Abla Sibai
Vascular Medicine Program at American University of Beirut
from all faculties
Thank you