Major Underlying Factors causing Death Worldwide Raised Blood

Major Underlying Factors causing Death - Worldwide Raised Blood Pressure 7 million Tobacco High cholesterol Underweight Unsafe sex Low fruit & vegetables intake High BMI Developed region Physical inactivity Developing region Alcohol Unsafe water, sani & hygiene 0 www. worldactiononsalt. com 1 2 3 4 Millions of Deaths 5 6 7 Ezzati et al. Lancet 2002: 360: 1347 -60.

ﻋﻮﺍﻣﻞ ﻣﻮﺛﺮ ﺗﻐﺬیﻪ ﺍی ﺩﺭکﺎﻫﺶ ﻓﺸﺎﺭ ﺧﻮﻥ • • • Weight loss Reduced sodium intake Increased potassium intake Moderation of alcohol intake DASH style dietary pattern Supplementations

AT HIGHEST LEVELS OF RISK. . .

Weight loss • Direct association • 45% of Iranian adults are overweight/obese¹ • 5 kg weight loss is associated with a 5/4 mm. Hg reduction in BP² • Modest weight loss is more effective in BP in pre-hypertensive patients ¹Tehran Glucose & Lipid Study, 2003 Mashad Metabolic Synd Study, 2008 ²Neter JE, Hypertension 2003

www. worldactiononsalt. com

Salt Until 5000 yrs ago 0. 1 grams of salt per day Now 10 to 12 grams per day Why this big increase? (a) Magical property of preserving food (b) Cleans up tainted and/or unpalatable food Deep freeze refrigerator Therefore now no need But still eating 10 to 12 gram per day courtesy of the food industry Processed 80% (9. 6 grams) of salt hidden in food Only 15% (1. 8 grams) added by consumer www. worldactiononsalt. com Fast Restaurant Canteen Salt, diet & health. 1998, Camb Uni Press

Double-Blind study of modest salt reduction (n=19) Randomised double-blind crossover Usual Salt 4 wks Supine SBP (mm. Hg) 168 166 164 162 160 158 156 154 152 Reduced Salt 4 wks P=0. 001 Mean fall = 9. 5 mm. Hg P=0. 004 Mean fall = P=0. 001 Mean fall = 4. 5 g/day of salt 92 91 Supine DBP (mm. Hg) 90 89 88 5. 3 mm. Hg 87 86 175 Urinary Sodium (mmol/24 h) 150 125 100 75 50 25 0 Lancet. 1982; 1: 351 -355

Reduced salt intake • A reduction of 1. 8 g/d lowered BP by 2. 0/1. 0 (nml) mm. Hg and 5. 0/3. 0 in hypertensive ¹ • Relative risk reduction of high BP (20%) • More effective in Asians, Blacks and elderly • Recommendations: 4 g in general population, less in blacks ¹He FJ, Hypertension, 2006

Predicted effect on Stroke and Heart Attack Deaths (BP fall from Meta-analysis) • Reducing salt by 1 gram / day would reduce strokes by 5% heart attacks by 3% • Reducing salt by 6 gram / day would reduce strokes by 24% heart attacks by 18% • Reducing salt by 9 gram / day would reduce strokes by 34% heart attacks by 25% Hypertension 2003; 42: 1093 -99

Benefits of Reducing Population Salt Intake Salt 4. 6 g/d ↓ Hypertension prevalence 30% ↓ Forrester etal. J Human Hypertens 2005: 19: 55 -60.

ﺧﻼﺻﻪ Salt intake (10 – 12 g/day) • Population BP, rise in BP with age, hypertension • Other effects e. g. stomach cancer, stroke, LVH, kidney disease, osteoporosis etc Reduce salt intake • from 10 - 12 g/day to 5 - 6 g/day

ﺍﺯ ﻏﺬﺍﻫﺎی ﻣﺨﺘﻠﻒ 100 ﻣیﺰﺍﻥ ﻧﻤک ﺩﺭ Cheese & Tomato Pizza 1. 25 g Processed Cheese 6 g Meat role 7 g Sausages 1. 25 g Smoked Fish 7 g Crisps 3 g Savoury Biscuits 3 g www. worldactiononsalt. com White bread Digestive Cornflakes Tomato Ketchup Brown Sauce 1. 25 g 2. 2 g

Japan 1960 intake Overall: Government campaign to reduce salt 13. 5 → 12. 1 g/day (1. 4 g/day ↓ ) Akita (North): 18 → 14 g/day (4 g/day ↓ ) BP 80% in stroke mortality At this time Japan rapidly Westernised e. g. saturated fat, smoking, weight, exercise Sasaki N. The salt factor in apoplexy and hypertension: epidemiological studies in Japan. In: Yamori Y, editor. Prophylactic Approach to Hypertensive Diseases. New York: Raven Press; 1979. p. 467 -74.

Finland Salt intake (g/day) Diastolic BP (mm. Hg) Stroke mortality (1/100000) Men Women Year Karppanen & Mervaala. Prog Cardiovasc Dis 2006; 49: 59 -75.

Potassium • • • High K⁺ is associated with lower BP Effective in normotensive and hypertensives 2 g/d is associated with 5. 0/2. 5 mm. Hg¹ K⁺ supplementation? Safe dose: 5 g/d Concerns in renal failure ¹Geleinjse JM, J Hum Hypertens, 2003

Alcohol intake • Direct dos-dependent relationship • French pardox

DASH diet • Dietary Approach for Stopping Hypertension • Includes: – Fruits – Vegetables – Low foods esp dairy – Nuts – Fish – poultry • Reduces BP by 5. 5/3. 0 mm. Hg

DASH-Sodium Trial (All participants N=412) Salt intake (g/day) 8 6 4 Systolic BP (mm. Hg) Control Diet DASH Diet Diastolic BP (mm. Hg) Control Diet DASH Diet Urinary Sodium (mmol/24 h) www. worldactiononsalt. com Sacks et al. NEJM 2001; 344: 3 -10.

AT HIGHER LEVELS OF RISK. . . • Advice and assistance • Specific interventions: » weight reduction class » exercise referral » smoking cessation clinic