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Dedicated to the Assessment, Prevention, and Control of Hypertension Globally A Call for Quality

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally A Call for Quality Research on Salt Intake and Health: From the World Hypertension League and Supporting Organizations Campbell, N, Appel L, Cappuccio, F, Correa-Rotter, R, Hankey, G, Lackland, D, Mac. Gregor, G, Neal B, Niebylski, M, Webster, J, Willis, K, Woodward, M. "A call for quality research on salt intake and health: From the World Hypertension League and Supporting Organizations" Journal of Clinical Hypertension 2014; 16: 469 -71 DOI: 10. 1111/jch. 12364 http: //onlinelibrary. wiley. com/doi/10. 1111/jch. 12364/abstract The WHL is a charitable organization comprised of national and regional hypertension societies 1

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally The Journal of Clinical

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally The Journal of Clinical Hypertension • The Official Journal of the World Hypertension League offers free access which can be signed up for by: 1. Go to the Journal of Clinical Hypertension Homepage http: //onlinelibrary. wiley. com/journal/10. 1111/(ISSN)1751 -7176 2. Click on the down arrow next to the Log In/Register Option in the upper right corner of the screen 1. Choose the register option from the lower left corner of the dropdown box 1. On the log in page enter your e-mail address—which will become your user name –and select a password, enter your personal information (This information is not shared with outside parties), select promotional information you might like to receive and hit the submit registration button The WHL is a charitable organization comprised of national and regional hypertension societies 2

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Organizations Supporting the Call

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Organizations Supporting the Call For Quality Research on Salt Intake and Health The WHL is a charitable organization comprised of national and regional hypertension societies 3

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Research Supports the Harmful

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Research Supports the Harmful Effects of High Dietary Sodium: • In several animal species, including chimpanzees, diets with added sodium result in increased blood pressure (BP) and cardiovascular disease • In some of the animal models, increased dietary sodium directly causes inflammation and vascular, cardiac and renal target organ damage independent of BP • Increased dietary sodium is a procarcinogen for gastric cancer in animals studied and is a probable procarcinogen in humans, is associated with renal cancer, recurrent kidney stones, increased severity of multiple sclerosis with new plaque formation, osteoporosis, and Meniere’s disease The WHL is a charitable organization comprised of national and regional hypertension societies 4

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Problems Attributed to High

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Problems Attributed to High Levels of Dietary Sodium: • Increased dietary sodium increases blood pressure and is estimated to cause 300 million people to have hypertension 1 • Increased dietary sodium is also associated with increased vascular events in healthy populations 1 • It has been estimated that 1. 65 million deaths occurred related to salt consumption above 5 g/day (sodium 2000 mg/day) in 20101 The WHL is a charitable organization comprised of national and regional hypertension societies 5

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Reducing Dietary Sodium Decreases

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Reducing Dietary Sodium Decreases BP in Adults and Children: • Reducing dietary sodium is projected to be one of the most effective, and cost effective, interventions to improve health. 2 • Based on repeated comprehensive systematic reviews of the evidence major health and scientific organizations around the world have recommended that dietary sodium levels be reduced. 2 The WHL is a charitable organization comprised of national and regional hypertension societies 6

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Opposing Sides to the

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Opposing Sides to the Dietary Salt Debate: • There are several studies which report that reducing dietary sodium is not beneficial while others have produced results suggesting harm • These studies have created substantive controversy and have drawn significant criticism from the scientific community • Criticism is based on weakness in research design and methods, misinterpretation of study results, and potential conflicts of interest of the authors • The Institute of Medicine commented that weak research design was a major factor in its inability to determine the health impact of sodium intake in the range of 1500 mg/d to 2300 mg/d 3 • A systematic review of the literature examining methodological issues in cohort studies that relate sodium intake to outcomes found that nearly all studies had major methodological issues that could impact the outcomes or create bias 4 The WHL is a charitable organization comprised of national and regional hypertension societies 7

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Table I: Important Issues

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Table I: Important Issues That Could Be Addressed in Setting Standards for Research on Sodium (Salt) Intake and Health The assessment of dietary sodium intake for populations or for individuals is precise and reliable The method for assessing outcomes (e. g. blood pressure and cardiovascular disease) is robust and there is a minimum loss to follow-up Intervention studies have a substantive and sustained impact on sodium intake, and in observational studies there is substantive difference between low and high sodium intake The study has a duration relevant to the health and disease outcomes under investigation The study has adequate statistical power to address the reported outcomes Relevant confounding factors are assessed, reasonably balanced, and accounted for in design and analysis Blood pressure, which is on the causal pathway, is not adjusted for in analyses of effects on clinical outcomes The WHL is a charitable organization comprised of national and regional hypertension societies 8

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Table I: Important Issues

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Table I: Important Issues That Could Be Addressed in Setting Standards for Research on Sodium (Salt) Intake and Health The right study designs are used to assess the question under-evaluation. Specifically, it is not clear that further retrospective studies of the relationship between sodium and either blood pressure or vascular events are warranted. Likewise, further cohort studies of the relationship between sodium and either blood pressure or vascular outcomes may not be helpful. This is particularly so when the studies are done in populations with pre-existing disease where the risks of reverse causality are profound. Steps are taken to minimize the impact of reverse causality in cohort studies including people who have existing disease. In such settings, reverse causality is always discussed as a major limitation precluding definitive conclusions. Drugs (especially diuretics) and other factors that interact with dietary sodium to reduce blood pressure and or intravascular volume are fully accounted for in the study design to avoid confounding the assessment of adverse events relating to hypotension or hypovolemia. The findings are reported and interpreted in the context of other published research on dietary sodium and health outcomes. Potential conflicts of interest are disclosed and acknowledged as a limitation in discussion of results and are considered in funding and publication decisions. Discussion accounts for known published research on dietary sodium and similar relevant outcomes. Research data are maintained and are accessible for independent external review, if necessary. The WHL is a charitable organization comprised of national and regional hypertension societies 9

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Research Needed to End

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Research Needed to End the Debate: • Rigorous research study design and conduct is needed for all future research on the health impacts of reducing dietary sodium • The publication of further studies with weak designs and methods is likely to produce misleading and inconsistent results • This will lead to further controversy and confusion • Controversy will often attract unwarranted media attention, which undermines the public health message and casts doubt on solid evidence-based results The WHL is a charitable organization comprised of national and regional hypertension societies 10

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Conclusion: For these reasons,

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Conclusion: For these reasons, the World Hypertension League (WHL) and supporting organizations make an urgent call for: • The setting of standards for research examining sodium intake and health • These standards need: • To be considered by researchers designing studies, by funding bodies, and by journal editors and reviewers • To ensure consensus and the use of best available evidence in setting the standards, the standards setting process should be aided by systematic reviews of the evidence and overseen by respected international and national health and scientific organizations • To accomplish this the WHL is actively creating a working group dedicated to establishing these standards and hopes efforts will be underway before the end of 2014 The WHL is a charitable organization comprised of national and regional hypertension societies 11

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally References: 1. “Institute for

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally References: 1. “Institute for Health Metrics and Evaluation” http: //vizhub. healthdata. org/gbd-compare/ 2. Campbell, N, Lackland, D, Niebylski, M. “ 2014 Dietary Salt Fact Sheet of the World Hypertension League, International Society of Hypertension, Pan American Health Organization Technical Advisory Group on Cardiovascular Disease Prevention Through Dietary Salt Reduction, the World Health Organization Collaborating Centre on Population Salt Reduction and World Action on Salt & Health. " The Journal of Clinical Hypertension http: //onlinelibrary. wiley. com/doi/10. 1111/jch. 12402/ abstract 3. Institute of Medicine of the National Academies. Sodium Intake in Populations: Assessment of Evidence. 2013. 4. Circulation. 2014; 129: 1173 -1186 The WHL is a charitable organization comprised of national and regional hypertension societies 12

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally This Power. Point Presentation

Dedicated to the Assessment, Prevention, and Control of Hypertension Globally This Power. Point Presentation is Based on the Article: “A Call for Quality Research on Salt Intake and Health: From the World Hypertension League and Supporting Organizations” By Norm R. C. Campbell, Larry J. Appel, Francesco P. Cappuccio, Ricardo Correa. Rotter, Graeme J. Hankey, Daniel T. Lackland, Graham Mac. Gregor, Bruce Neal, Mark L. Niebylski, Jacqui Webster, Kevin J. Willis, and mark Woodward. Journal of Clinical Hypertension 2014; 16: 469 -71 DOI: 10. 1111/jch. 12364 http: //onlinelibrary. wiley. com/doi/10. 1111/jch. 12364/abstract Power. Point Created By: Kimbree Redburn Power. Point Reviewed By: Norm R. C. Campbell The WHL is a charitable organization comprised of national and regional hypertension societies 13