The current state of evidence for sodium and fluid restriction in heart failure.

The field of heart failure has evolved in terms of the therapies that are available including pharmaceutical and device therapies. There is now substantial randomized trial data to indicate that dietary sodium restriction does not provide the reduction in clinical events with accepted heterogeneity in the clinical trial results. Dietary sodium restriction should be considered for some but not all patients and with different objectives than clinical outcomes but instead for potential quality of life benefit. In addition, fluid restriction, once the mainstay of clinical practice, has not shown to be of any additional benefit for patients in hospital or in the ambulatory care setting and therefore should be considered to be used cautiously (if at all) in clinical practice. Further developments and clinical trials are needed in this area to better identify patients who may benefit or have harm from these lower cost interventions and future research should focus on large scale, high quality, clinical trials rather than observational data to drive clinical practice.

Changes in the Sodium Content of Foods Sold in Four Latin American Countries: 2015 to 2018.

In 2015, the Pan American Health Organization (PAHO) published sodium targets for packaged foods, which included two distinct levels: one "regional" and one "lower" target. Changes to the sodium content of the food supply in Latin American Countries (LAC) has not been evaluated. A repeated cross-sectional study used food label data from 2015 (n = 3859) and 2018 (n = 5312) to determine changes in the proportion of packaged foods meeting the PAHO sodium targets and the distribution in the sodium content of foods in four LAC (Argentina, Costa Rica, Paraguay, Peru). Foods were classified into the 18 food categories in the PAHO targets. The proportion of foods meeting the regional targets increased from 82.9% to 89.3% between 2015 and 2018 (p < 0.001). Overall, 44.4% of categories had significant decreases in mean sodium content. Categories with a higher proportion of foods meeting the regional and lower targets in 2018 compared to 2015 (p < 0.05) were breaded meat and poultry, wet and dry soups, snacks, cakes, bread products, flavored cookies and crackers, and dry pasta and noodles. While positive progress has been made in reducing the sodium content of foods in LAC, sodium intakes in the region remain high. More stringent targets are required to support sodium reduction in LAC.

Design and Region-Specific Adaptation of the Dietary Intervention Used in the SODIUM-HF Trial: A Multicentre Study.

BACKGROUND: Restricting dietary sodium consumption has been considered a major component of self-care management in heart failure (HF); however, the evidence supporting this recommendation has not been conclusive. The Study of Dietary Intervention Under 100 MMOL in Heart Failure (SODIUM-HF) trial aims to assess the effects of dietary sodium reduction on clinical outcomes in a HF population using a pragmatic design to provide empirical evidence to guide dietary sodium intake recommendations in patients with chronic HF. METHODS: SODIUM-HF is a multicentre, open-label, blinded adjudicated endpoint, randomized controlled trial in ambulatory patients with chronic HF. This trial involves participants recruited from sites in Canada, Australia, New Zealand, Mexico, Colombia, and Chile, who are followed up to 24 months. Rationale and methods of the SODIUM-HF trial were published elsewhere. As an international pragmatic dietary trial, SODIUM-HF was designed to address several challenges, such as defining the most suitable intervention to account for country-specific variations in food intake and availability. In SODIUM-HF, we implemented the Nutrition-Care Model to provide a comprehensive intervention delivered directly to patients, focusing on modifying the nutrient composition of the diet (sodium restriction), using a personalized counselling and close follow-up. RESULTS: Available upon completion of the trial. CONCLUSIONS: This long-term dietary trial is one of the first in its type in the HF field. This article describes in detail the rationale and methods for the dietary intervention employed and the region-specific adaptation of the SODIUM-HF intervention, so that the learning and processes taken in this trial can be applied to future multicountry dietary clinical trials.

CONTEXTE: La restriction de l'apport en sodium alimentaire est considérée comme étant un élément important de l'auto-prise en charge de l'insuffisance cardiaque (IC); or, les données à l'appui de cette recommandation ne sont pas concluantes. L'étude SODIUM-HF ( S tudy o f D ietary I ntervention U nder 100 M MOL in H eart F ailure) vise à évaluer en contexte réel les effets de la réduction de l'apport en sodium alimentaire sur les résultats cliniques au sein d'une population de patients atteints d'IC, afin d'obtenir des données empiriques qui serviront à orienter les recommandations en matière d'apport en sodium alimentaire chez les patients atteints d'IC chronique. MÉTHODOLOGIE: L'étude SODIUM-HF est un essai multicentrique contrôlé avec répartition aléatoire et mené en mode ouvert auprès de patients ambulatoires atteints d'IC chronique, dont les paramètres sont évalués à l'insu. Les participants sont recrutés dans des centres situés au Canada, en Australie, en Nouvelle-Zélande, au Mexique, en Colombie et au Chili, et font l'objet d'un suivi pendant 24 mois. La raison d'être et la méthodologie de l'étude SODIUM-HF sont présentées ailleurs. Comme il s'agit d'une étude internationale sur l'alimentation menée en contexte réel, l'étude SODIUM-HF a été conçue de manière à résoudre plusieurs difficultés, dont la façon la plus appropriée de tenir compte des variations entre pays en matière d'apport alimentaire et de disponibilité des aliments. L'étude met en œuvre le processus de soins en nutrition, afin d'assurer directement auprès des patients une intervention exhaustive axée sur la modification de la composition en nutriments de l'alimentation (restriction de l'apport en sodium) et faisant appel à des conseils personnalisés et à un suivi étroit. RÉSULTATS: Les résultats seront publiés à la fin de l'étude. CONCLUSIONS: Cette étude de longue durée sur l'alimentation est l'une des premières en son genre dans le domaine de l'IC. Les auteurs décrivent en détail la raison d'être et la méthodologie des mesures d'intervention alimentaire employées ainsi que les adaptations propres à chaque région mises en œuvre dans le cadre de l'étude SODIUM-HF, afin que les apprentissages et les processus issus de l'étude puissent être utilisés dans d'autres études cliniques multinationales sur l'alimentation.

Development of an online tool for sodium intake assessment in Mexico

[ABSTRACT]. Excess sodium intake is associated with adverse health effects, and reducing its intake is a strategy that improves population health. However, estimating sodium intake is challenging and new options for assessment are needed. This review describes the design and development of a web-based, publicly-accessible, dietary sodium intake screening tool (Calculadora de Sodio) for individuals in Mexico. Sodium data from 2017 – 2018 for 3 429 packaged foods, 655 restaurant and cafeteria foods, and 320 home-style meals and street foods (determined by chemical analysis) comprised the 71-question tool. It was piloted with 10 nutrition experts for feedback on content and face validity; and with 30 potential users to test its usability and interface. Improvements were made to content, language, and formatting following the pilot. Its predictive validity will be established in the future. The Calculadora de Sodio provides instant feedback on an individual’s average daily sodium intake, computed by frequency of intake, average number of servings, and sodium content per serving of each sodium-focused food category. This is the first web-based dietary sodium screening tool developed for the general population of Mexico. It is an efficient and practical way to assess sodium intake and can serve as a model for similar tools for other countries and regions.

[RESUMEN]. La ingesta excesiva de sodio se asocia a efectos nocivos para la salud y su reducción constituye una estrategia para mejorar la salud de la población. Sin embargo, es complicado estimar la ingesta de sodio y se necesitan nuevas alternativas para evaluarla. En este examen se describe el diseño y la creación de una herramienta en línea y de acceso público con el fin de establecer la ingesta de sodio en la alimentación (denominada la “calculadora de sodio”) para la población de México. La herramienta, consistente en 71 preguntas, incluye los datos de sodio correspondientes al 2017-2018 de 3 429 alimentos envasados, 655 alimentos de restaurantes y cafeterías y 320 comidas caseras y alimentos de puestos de venta de la calle (determinados mediante análisis químicos). Se hizo una prueba piloto con diez nutricionistas que aportaron su opinión experta en materia de validez del contenido y diseño, además de 30 usuarios potenciales que probaron la facilidad de uso y su interfaz. Tras la prueba piloto, se incluyeron mejoras de contenido, idioma y formato. En el futuro se podrá determinar su valor predictivo. La calculadora de sodio ofrece una evaluación instantánea sobre la ingesta de sodio promedio diaria de una persona, calculada según la frecuencia de la ingesta, la cantidad promedio de raciones y el contenido de sodio por ración de cada categoría de alimentos con sodio. Esta es la primera herramienta en línea de detección de sodio en los alimentos creada para la población general de México. Es una manera eficaz y práctica de evaluar la ingesta de sodio, y puede servir de modelo para herramientas similares en otros países y regiones.

[RESUMO]. A ingestão de sódio em excesso está associada a efeitos adversos à saúde, e a redução do consumo alimentar de sódio é uma estratégia que contribui para a melhoria da saúde das pessoas. Porém, como é difícil estimar a ingestão de sódio, são necessários novos métodos de avaliação. Neste estudo são apresentados o projeto e o desenvolvimento de um instrumento on-line e aberto ao público (denominado ‘’calculadora de sódio’’) para a triagem da ingestão alimentar de sódio por indivíduos no México. O instrumento contém 71 perguntas preparadas com base em dados do teor de sódio, coletados no período de 2017 a 2018, de 3.429 alimentos embalados, 655 alimentos comercializados em restaurantes e lanchonetes e 320 refeições do tipo caseiro e comidas de rua (medidos com análises químicas). Um testepiloto foi realizado com 10 especialistas em nutrição, que fizeram observações sobre a validade de conteúdo e a validade aparente do instrumento, e 30 possíveis usuários que avaliaram sua usabilidade e interface. O conteúdo, os enunciados e o formato foram aperfeiçoados após o teste-piloto. A validade preditiva do instrumento será determinada futuramente. A ‘’calculadora de sódio’’ proporciona uma avaliação imediata da ingestão alimentar média de sódio de uma pessoa, calculada pela frequência de consumo, número médio de porções e teor de sódio por porção de cada categoria de alimento que contém sódio. Este é o primeiro instrumento on-line para a triagem de sódio alimentar desenvolvido para a população do México. É um recurso eficiente e prático para avaliar a ingestão de sódio e pode servir de modelo para o desenvolvimento de instrumentos semelhantes em outros países e regiões.

An Evaluation of the Sodium Content and Compliance with the National Sodium Reduction Targets among Packaged Foods Sold in Costa Rica in 2015 and 2018.

High blood pressure is a leading cause of death in Costa Rica, with an estimated mortality rate of 30%. The average household sodium intake is two times higher than the World Health Organization recommendation. The consumption of processed foods is an important and growing contributor to sodium intake. The objective of this study was to describe the sodium content of packaged foods (mg/100 g) sold in Costa Rica in 2015 (n = 1158) and 2018 (n = 1016) and to assess their compliance with the national sodium reduction targets. All 6 categories with national targets were analyzed: condiments, cookies and biscuits, bread products, processed meats, bakery products, and sauces. A significant reduction in mean sodium content was found in only 3 of the 19 subcategories (cakes, tomato-based sauces, and tomato paste). No subcategories had statistically significant increases in mean sodium levels, but seasonings for sides/mains, ham, and sausage categories were at least 15% higher in sodium. Compliance with the national sodium targets among all foods increased from 80% in 2015 to 87% in 2018. The results demonstrate that it is feasible to reduce the sodium content in packaged foods in Costa Rica, but more work is needed to continually support a gradual reduction of sodium in packaged foods, including more stringent sodium targets.

The Science of Salt: A global review on changes in sodium levels in foods.

This review aims to summarize and synthesize studies reporting on changes in sodium levels in packaged food products, restaurant foods, and hospital or school meals, as a result of salt reduction interventions. Studies were extracted from those published in the Science of Salt Weekly between June 2013 and February 2018. Twenty-four studies were identified: 17 assessed the changes in packaged foods, four in restaurant foods, two in hospital or school meals, and one in both packaged and restaurant foods. Three types of interventions were evaluated as part of the studies: voluntary reductions (including targets), labeling, and interventions in institutional settings. Decreases in sodium were observed in all studies (n = 8) that included the same packaged foods matched at two time points, and in the studies carried out in hospitals and schools. However, there was little to no change in mean sodium levels in restaurant foods. The pooled analysis of change in sodium levels in packaged foods showed a decrease in sodium in unmatched food products (-36 mg/100 g, 95% CI -51 to -20 mg/100 g) and in five food categories-breakfast cereals, breads, processed meats, crisps and snacks, and soups. Twenty-two of the 24 studies were from high-income countries, limiting the applicability of the findings to lower resource settings.

The Science of Salt: Updating the evidence on global estimates of salt intake.

The Global Burden of Disease (GBD) 2010 study estimated national salt intake for 187 countries based on data available up to 2010. The purpose of this review was to identify studies that have measured salt intake in a nationally representative population using the 24-hour urine collection method since 2010, with a view to updating evidence on population salt intake globally. Studies published from January 2011 to September 2018 were searched for from MEDLINE, Scopus, and Embase databases using relevant terms. Studies that provided nationally representative estimates of salt intake among the healthy adult population based on the 24-hour urine collection were included. Measured salt intake was extracted and compared with the GBD estimates. Of the 115 identified studies assessed for eligibility, 13 studies were included: Four studies were from Europe, and one each from the United States, Canada, Benin, India, Samoa, Fiji, Barbados, Australia, and New Zealand. Mean daily salt intake ranged from 6.75 g/d in Barbados to 10.66 g/d in Portugal. Measured mean population salt intake in Italy, England, Canada, and Barbados was lower, and in Fiji, Samoa, and Benin was higher, in recent surveys compared to the GBD 2010 estimates. Despite global targets to reduce population salt intake, only 13 countries have published nationally representative salt intake data since the GBD 2010 study. In all countries, salt intake levels remain higher than the World Health Organization's recommendation, highlighting the need for additional global efforts to lower salt intake and monitor salt reduction strategies.

Development of an online tool for sodium intake assessment in Mexico.

Excess sodium intake is associated with adverse health effects, and reducing its intake is a strategy that improves population health. However, estimating sodium intake is challenging and new options for assessment are needed. This review describes the design and development of a web-based, publicly-accessible, dietary sodium intake screening tool (Calculadora de Sodio) for individuals in Mexico. Sodium data from 2017 - 2018 for 3 429 packaged foods, 655 restaurant and cafeteria foods, and 320 home-style meals and street foods (determined by chemical analysis) comprised the 71-question tool. It was piloted with 10 nutrition experts for feedback on content and face validity; and with 30 potential users to test its usability and interface. Improvements were made to content, language, and formatting following the pilot. Its predictive validity will be established in the future. The Calculadora de Sodio provides instant feedback on an individual's average daily sodium intake, computed by frequency of intake, average number of servings, and sodium content per serving of each sodium-focused food category. This is the first web-based dietary sodium screening tool developed for the general population of Mexico. It is an efficient and practical way to assess sodium intake and can serve as a model for similar tools for other countries and regions.

La ingesta excesiva de sodio se asocia a efectos nocivos para la salud y su reducción constituye una estrategia para mejorar la salud de la población. Sin embargo, es complicado estimar la ingesta de sodio y se necesitan nuevas alternativas para evaluarla. En este examen se describe el diseño y la creación de una herramienta en línea y de acceso público con el fin de establecer la ingesta de sodio en la alimentación (denominada la "calculadora de sodio") para la población de México. La herramienta, consistente en 71 preguntas, incluye los datos de sodio correspondientes al 2017-2018 de 3 429 alimentos envasados, 655 alimentos de restaurantes y cafeterías y 320 comidas caseras y alimentos de puestos de venta de la calle (determinados mediante análisis químicos). Se hizo una prueba piloto con diez nutricionistas que aportaron su opinión experta en materia de validez del contenido y diseño, además de 30 usuarios potenciales que probaron la facilidad de uso y su interfaz. Tras la prueba piloto, se incluyeron mejoras de contenido, idioma y formato. En el futuro se podrá determinar su valor predictivo. La calculadora de sodio ofrece una evaluación instantánea sobre la ingesta de sodio promedio diaria de una persona, calculada según la frecuencia de la ingesta, la cantidad promedio de raciones y el contenido de sodio por ración de cada categoría de alimentos con sodio. Esta es la primera herramienta en línea de detección de sodio en los alimentos creada para la población general de México. Es una manera eficaz y práctica de evaluar la ingesta de sodio, y puede servir de modelo para herramientas similares en otros países y regiones.

A ingestão de sódio em excesso está associada a efeitos adversos à saúde, e a redução do consumo alimentar de sódio é uma estratégia que contribui para a melhoria da saúde das pessoas. Porém, como é difícil estimar a ingestão de sódio, são necessários novos métodos de avaliação. Neste estudo são apresentados o projeto e o desenvolvimento de um instrumento on-line e aberto ao público (denominado ''calculadora de sódio'') para a triagem da ingestão alimentar de sódio por indivíduos no México. O instrumento contém 71 perguntas preparadas com base em dados do teor de sódio, coletados no período de 2017 a 2018, de 3.429 alimentos embalados, 655 alimentos comercializados em restaurantes e lanchonetes e 320 refeições do tipo caseiro e comidas de rua (medidos com análises químicas). Um teste-piloto foi realizado com 10 especialistas em nutrição, que fizeram observações sobre a validade de conteúdo e a validade aparente do instrumento, e 30 possíveis usuários que avaliaram sua usabilidade e interface. O conteúdo, os enunciados e o formato foram aperfeiçoados após o teste-piloto. A validade preditiva do instrumento será determinada futuramente. A ''calculadora de sódio'' proporciona uma avaliação imediata da ingestão alimentar média de sódio de uma pessoa, calculada pela frequência de consumo, número médio de porções e teor de sódio por porção de cada categoria de alimento que contém sódio. Este é o primeiro instrumento on-line para a triagem de sódio alimentar desenvolvido para a população do México. É um recurso eficiente e prático para avaliar a ingestão de sódio e pode servir de modelo para o desenvolvimento de instrumentos semelhantes em outros países e regiões.

Food Sources of Sodium Intake in an Adult Mexican Population: A Sub-Analysis of the SALMEX Study.

Excessive dietary sodium intake increases blood pressure and cardiovascular risk. In Western diets, the majority of dietary sodium comes from packaged and prepared foods (≈75%); however, in Mexico there is no available data on the main food sources of dietary sodium. The main objective of this study was to identify and characterize the major food sources of dietary sodium in a sample of the Mexican Salt and Mexico (SALMEX) cohort. Adult male and female participants of the SALMEX study who provided a complete and valid three-day food record during the baseline visit were included. Overall, 950 participants (mean age 38.6 ± 10.7 years) were analyzed to determine the total sodium contributed by the main food sources of sodium identified. Mean daily sodium intake estimated by three-day food records and 24-h urinary sodium excretion was 2647.2 ± 976.9 mg/day and 3497.2 ± 1393.0, in the overall population, respectively. Processed meat was the main contributor to daily sodium intake, representing 8% of total sodium intake per capita as measured by three-day food records. When savory bread (8%) and sweet bakery goods (8%) were considered together as bread products, these were the major contributor to daily sodium intake, accounting for the 16% of total sodium intake, followed by processed meat (8%), natural cheeses (5%), and tacos (5%). These results highlight the need for public health policies focused on reducing the sodium content of processed food in Mexico.

Dietary Self-management in Heart Failure: High Tech or High Touch?

OPINION STATEMENT: Dietary management of heart failure (HF) has largely been focused on sodium and fluid restrictions. Although safety and efficacy of these interventions in HF remain unclear, a daily sodium intake between 2000 and 3000 mg/day appears to be safe in these patients. Ongoing clinical research will inform on the safety and efficacy of a more restrictive sodium intake to less than 1500 mg/day. Data shows that routine fluid restriction in HF regardless of symptoms may be unnecessary; however, in patients with signs of congestion, fluid restriction to 2.0 L/day may be advisable. Recently, more attention has been paid to other nutritional aspects of HF beyond sodium and fluid intake, although there is still little evidence available to guide nutritional management of HF. Assuring that patients meet daily requirements for key micronutrients, such as calcium, magnesium, potassium, folate, vitamin E, vitamin D, zinc, and thiamine, is essential in order to prevent deficiencies. More appropriate macronutrient composition of the diet is still to be determined; however, a diet containing 50-55% carbohydrates, 25-30% fat, and 15-20% protein seems acceptable for patients with HF with or without non-end-stage renal disease. Additionally, increased protein intake may be considered in malnourished/cachectic patients. Consulting a registered dietitian is especially helpful for patients with recent HF exacerbations or for patients with multiple comorbidities who may need to follow several dietary restrictions and may benefit of individualized dietary counseling in order to ensure appropriate intake of energy, protein, and micronutrients. Today, there are still several knowledge gaps in guiding the dietary management of HF. In this article, we review current recommendations for the dietary management of HF and the evidence supporting this practice.

Estimates of Dietary Sodium Consumption in Patients With Chronic Heart Failure.

Estimating dietary sodium intake is a key component of dietary assessment in the clinical setting of HF to effectively implement appropriate dietary interventions for sodium reduction and monitor adherence to the dietary treatment. In a research setting, assessment of sodium intake is crucial to an essential methodology to evaluate outcomes after a dietary or behavioral intervention. Current available sodium intake assessment methods include 24-hour urine collection, spot urine collections, multiple day food records, food recalls, and food frequency questionnaires. However, these methods have inherent limitations that make assessment of sodium intake challenging, and the utility of traditional methods may be questionable for estimating sodium intake in patients with HF. Thus, there are remaining questions about how to best assess dietary sodium intake in this patient population, and there is a need to identify a reliable method to assess and monitor sodium intake in the research and clinical setting of HF. This paper provides a comprehensive review of the current methods for sodium intake assessment, addresses the challenges for its accurate evaluation, and highlights the relevance of applying the highest-quality measurement methods in the research setting to minimize the risk of biased data.