For more information, visit www.restaurant.org/events/nutrition.

1. The Health Effects of Reducing Sodium and Improving Overall Diet Lawrence J Appel, MD, MPH Professor of Medicine, Epidemiology and International Health (Human Nutrition) July 9, 2008 Disclosures and Conflicts of Interest: None

4. www.nap.edu www.iom.edu/fnb Dietary Reference Intakes from the Institute of Medicine (IOM)

6. Reducing Sodium Intake

7. Useful Conversions Adequate Intake (AI) Upper Level (UL) Sodium (mg) 1,500 2,300 Sodium (mmol) 65 100 Sodium Chloride (g) 3.8 5.8

9. Sources of Dietary Sodium Inherent 12% Food Processing 77% At the Table 6% During Cooking 5% Mattes and Donnelly, JACN, 1991; 10: 383 (62 adults who completed 7 day dietary records)

12. Deaths from Stomach Cancer (per 100,000 Per year) Adapted from Joossens, Int J Epi 1996;25:494-504 KOR r=0.702 P<0.001 JAPAN CHI POL COL HUN POR GDR ITA SPA FRG CAN FIN NET MAL E.W ARG DEN BEL USA N.I MEX TOB 190 170 150 130 110 90 70 50 30 10 0 6 7 8 9 10 11 12 13 14 Salt Intake (grams/day) ICE Salt and Stomach Cancer: Ecological Analysis

13. BP Classification (JNC VII, 2003) Category Systolic BP Diastolic BP Normal < 120 and < 80 Pre-Hypertensive 120 - 139 or 80 – 89 Hypertension Stage 1 Stage 2 140 – 159 > 160 or or 90 – 99 > 100

16. Stroke Mortality by Level of Usual Systolic BP* *Prospective Studies Collaboration, Lancet, 2002: Meta-analysis of 61 prospective studies with 2.7m person-yrs, 11.9k deaths

17. Distribution of BP Levels in US Adults, Ages 18 and Older (NHANESIII) “ Normal” <120/80 Prehypertension SBP 120-39 or DBP 80-89 Hypertension SBP > 140 or DBP > 90 Source: Wang, Hypertension, 2004 42% 27% 31%

18. Established Market Economies Men 116 Women 123 Latin America & Caribbean Men 60 Women 54 Middle Eastern Crescent Men 36 Women 38 Former Socialist Economies Men 41 Women 53 China Men 99 Women 83 India Men 60 Women 58 Sub-Saharan Africa Men 38 Women 42 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Lancet 2005;365:217-223 2000: Number (millions) of Hypertensives, by World Region Other Asia & islands Men 38 Women 33 Overall = 971 million Economically Developed Countries = 333 million Economically Developing Countries = 639 million SBP≥140 mm Hg DBP≥ 90 mm Hg BP lowering med

19. Mean SBP and DBP by Age and Race/Ethnicity for Women, Age 18 Years and Older 150 140 130 120 110 100 90 80 70 mm Hg 18-29 30-39 40-49 50-59 60-69 70-79 80+ Diastolic Systolic Source: Burt V, et al. Hypertension, 1995 SBP Rise with Age = ~0.6 mmHg per year Age Black White Mexican-American

20. Mean Systolic and Diastolic BP * Pediatrics, 2004;114:555-576 (for 50th Percentile Height) ** J Human HTN, 1989, 3:331-407 Age (yrs) SBP Rise with Age boys: 1.9 mmHg / yr girls: 1.5 mmHg / yr Yanomami**, ages 20-59 Men Women U.S. Children*, ages 1- 17 ♦ (101) ♦ (91) ♦ (65) ♦ (56) 20 - 59 Age (yrs) Systolic Diastolic

21. Population-Based Strategy SBP Distributions Stamler R. Hypertension 1991;17:I-16–I-20. % Reduction in Mortality Reduction in BP After Intervention Before Intervention Stroke CHD Total -6 -4 -3 -8 -5 -4 -14 -9 -7 Reduction in SBP mmHg 2 3 5

23. Sodium: Dose Response Trials Luft, 1979 (14 non-hypertensive)

24. Sodium: Dose Response Trials MacGregor, 1989 (20 hypertensive)

25. Sodium: Dose Response Trials Johnson, 2001 (n=17 non-hypertensive elderly)

26. Sodium: Dose Response Trials Johnson, 2001 (n=15 elderly with isolated systolic hypertension)

27. Sodium: Dose Response Trials Johnson, 2001 (n=8 elderly with systolic-diastolic hypertension)

28. Sodium Dose Response Trials: DASH-Sodium Trial* Systolic Blood Pressure Control Diet DASH Diet 1.5 (65) 2.4 (106) 3.3 (143) Sodium Level: gm/d (mmol) per day +2.1 +1.3 +1.7 +4.6 +6.7 p<.0001 +3.0 P<.0001 *Sacks, 2001 (412 pre- and stage 1 hypertensive adults)

30. Effect of Sodium Reduction (Higher to Lower) in African-Americans and Non-African-Americans on the Control Diet African-Americans Non-African-Americans - 8.0 † P<.001 - 4.5 † P<.001 - 5.1 P<.001 - 2.2 P<.001 0 † P-interaction < 0.05

31. Effects of Reduced Na on CVD Events: Results from 3 Randomized Trials INTERVENTION OUTCOME FU TONE (2001) 639 Elderly ↓ Na 21% ↓ CVD events 2.3 yrs Taiwan Veterans (2006) 1,981 Elderly ↓ Na /↑ K Salt 41%* ↓ CVD Mortality 2.6 yrs TOHP Follow-up (2007) 3,126 Prehypertensives ↓ Na 30%* ↓ CVD events 10-15 yrs *p<0.05

33. Organizations and Countries Recommending Major Reductions in Sodium Organizations National Research Council 1 National Institutes of Health 1 National HBP Education Program CC 1 Joint National Committee 7 1 U.S. Department of Health and Human Services 1 U.S. Department of Agriculture 1 National Academy of Sciences American Medical Association 3 American Heart Association 1 American Public Health Association 3 Center for Science in the Public Interest 3 World Health Organization 4 World Hypertension League Countries Finland 1 United Kingdom 3 Australia 1 Ireland New Zealand 1 < 2300 mg/day; 2 < 2300 mg day under age 50; < 1500 mg/day for 50-70, hypertensives, and blacks; < 1200 mg/day for age 70 and higher; 3 Minimum 50% reduction in processed and restaurant foods; 4 < 2000 mg/day

34. Improving Overall Diet Quality

38. Age-adjusted Mortality in 1995 (Deaths per 100,000) from Coronary Heart Disease (CHD) and Cancer in Okinawa, Japan, and US* *Willcox BJ, Ann NYAS, 2007

41. Effects of Mediterranean Diet † on Mortality Over 44 months in Greek Patients with Coronary Heart Disease Trichopoulou, Arch Int Med, 2005 * * † Per 2 unit increase in Mediterranean Diet Score * p < .05 Total CHD Other

42. Effects of Mediterranean Diet † on Mortality Over 44 months in Greek Population (Primary Prevention) Trichopoulou, NEJM, 2003 † Per 2 unit increase in Mediterranean Diet Score Total CHD Cancer 25%* * * * p < .05

43. Effects of Mediterranean Diet † on 10 Year Mortality in 2,339 Elderly European Men and Women (HALE Project) † Score of 4 or higher on modified version of Trichopoulou Knoops, JAMA, 2004 *p < .05 Total CHD CVD Cancer Other * 23%* * *

44. D ietary A pproaches to S top H ypertension

45. Nutrient Targets By Diet

46. Servings per Day of Food Groups Servings/Day Fruits/ Vegetables Dairy Products Meat/Fish Poultry Fats/ Oils

48. The DASH diet

49. Weekly BP by Diet During Intervention Feeding WEEKS B 1 2 3 4 5 6 7,8 DIASTOLIC SYSTOLIC Appel, NEJM, 2007

50. Effect of DASH Combination Diet by BP Status Hypertensives Non-Hypertensives * † * * * * p< 0.05 (main effect) † p< 0.05 (BP status interaction)

51. Effect of DASH Combination Diet By Race African-Americans Non-African-Americans * † * * * * p< 0.05 (main effect) † p< 0.05 (race interaction)

52. Relative Risk* of Coronary Heart Disease and Stroke by Quintile of DASH Score (Nurses Health Study, Fung, 2008) * Adjusted for age, BMI, menopause, hormone use, energy intake, multivit Use, Etoh, fam Hx, physical activity and aspirin *

53. Estimated Nutrient Composition by Diet 1 Willcox, Ann NYAS, 2007; 2 Sacks, NEJM 2001; 3 Kromhout, AJCN, 1989 Okinawan 1 DASH 2 Mediterranean 3 Carb (% kcal) 85% 55% 43% Protein (% kcal) 9% 18% 13% Fat (% kcal) 6% 27% 42% Sat Fat (% kcal) 2% 6% 9% Cholesterol (mg/1000 kcal) 72 mg 75 mg Sodium (mg/d) 1,113 mg 1,150 mg - Potassium (mg/d) 5,199 mg 4,700 mg -