Health and Wellness

Lower Sodium Intake Recommendation for Almost 70% of US Adults in 2005 to 2006

Laurie Barclay, MD
Information from Industry
The Institute for Advances in Point-of-Care Testing
Keep up with emerging trends in glycemic control, anticoagulation management, and other areas of point-of-care testing, to help reduce costs, enhance the efficacy of healthcare management, and improve patient outcomes.

March 27, 2009 — In 2005 to 2006, the lower sodium recommendation made in 2005 by the US Department of Health and Human Services (HHS) and US Department of Agriculture (USDA) was applicable to 69.2% of US adults, according to the results of a study reported in the March 27 issue of the Morbidity and Mortality Weekly Report.

“In 2005–2006, an estimated 29% of U.S. adults had hypertension (i.e., high blood pressure), and another 28% had prehypertension,” write C. Ayala, PhD, and colleagues from Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, US Centers for Disease Control and Prevention (CDC). “Hypertension increases the risk for heart disease and stroke, the first and third leading causes of death in the United States. Greater consumption of sodium can increase the risk for hypertension.”

In the United States in 2005 to 2006, the estimated average daily intake of sodium in people older than 2 years was 3436 mg, despite HHS/USDA recommendations in 2005 for lower sodium intake. In US adults, recommendations are for not more than 2300 mg/day of sodium (about 1 tsp of salt), or not more than 1500 mg/day of sodium for high-risk groups (persons with hypertension, middle-aged and older adults, and blacks).

On the basis of data from the National Health and Nutrition Examination Survey (NHANES) from 4 annual survey periods from 1999 to 2006, the CDC determined that in 2005 to 2006, the lower sodium recommendation was applicable to 69.2% of US adults (approximately 145.5 million persons). Three nonoverlapping populations were defined for the analysis: all adults older than 20 years with hypertension, all adults older than 40 years without hypertension, and blacks aged 20 to 39 years without hypertension. During the 4 NHANES study periods, the overall percentage of persons in these risk groups increased significantly.

“Consumers and health-care providers should be aware of the lower sodium recommendation, and health-care providers should inform their patients of the evidence linking greater sodium intake to higher blood pressure,” the study authors write.

In an accompanying editorial note, public health actions are described that could lower sodium intake, such as reducing the sodium content of processed foods; promoting intake of fruits, vegetables, and other low-sodium foods; and making food labeling changes to provide more pertinent information regarding sodium.

Limitations of this study include that NHANES data were restricted to the noninstitutionalized population, excluding persons who reside in long-term care facilities or correctional facilities. If these groups were included, the percentage of the population for whom the recommended 1500 mg/day sodium limit is applicable would likely increase.

“The World Health Organization has set a global target for maximum intake of salt for adults at 5 g/day (i.e., 2,000 mg/day of sodium) or lower if specified by national targets, such as the recommendation in the United States,” the editorial concludes. “Eleven countries in the European Union have agreed to reduce salt intake by 16% over the next 4 years. In the United States, Healthy People 2010 calls for increasing to 95% the proportion of adults with high blood pressure who are taking action (e.g., reducing sodium intake) to help control their blood pressure (objective 12-11).”

Morb Mortal Wkly Rep. 2009;58:281–283.

Red and Processed Meat Intake Linked to Mortality CME/CE

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP

March 26, 2009 — Eating red and processed meat is associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality rates, according to the results of a large, prospective study reported in the March 23 issue of the Archives of Internal Medicine.

“High intakes of red or processed meat may increase the risk of mortality,” write Rashmi Sinha, PhD, from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services in Rockville, Maryland, and colleagues. “Our objective was to determine the relations of red, white, and processed meat intakes to risk for total and cause-specific mortality.”

The National Institutes of Health–AARP Diet and Health Study enrolled approximately half a million people aged 50 to 71 years at baseline. A food frequency questionnaire administered at baseline allowed estimation of meat intake, and Cox proportional hazards regression models allowed calculation of hazard ratios (HRs) and 95% confidence intervals (CIs) within quintiles of meat intake.

Red meat included all types of beef and pork such as bacon, beef, cold cuts, hamburgers, hotdogs, steak, and meats in pizza, lasagna, and stew. White meat included chicken, turkey, and fish along with poultry cold cuts, canned tuna, and low-fat hotdogs. Processed meats could include either red or white meats in the form of sandwich meats or cold cuts as well as bacon, red meat and poultry sausages, and regular hotdogs and low-fat hotdogs made from poultry. The authors note that some of the meats may overlap in the 3 categories, but they were not duplicated or used in the same models in the study analysis.

The models considered covariates of age, education, marital status, presence or absence of family history of cancer (for cancer mortality only), race, body mass index, smoking history, physical activity, energy intake, alcohol drinking, use of vitamin supplements, fruit consumption, vegetable consumption, and use of menopausal hormone therapy in women. Primary endpoints of the study were total mortality and deaths caused by cancer, cardiovascular disease, injury and sudden deaths, and all other causes.

During 10 years of follow-up, 47,976 men and 23,276 women died. Overall mortality risks were increased for men and women in the highest vs the lowest quintile of red meat intake (HR, 1.31; 95% CI, 1.27 - 1.35; and HR, 1.36; 95% CI, 1.30-1.43, respectively) and processed meat intake (HR, 1.16; 95% CI, 1.12 - 1.20; and HR, 1.25; 95% CI, 1.20 - 1.31, respectively). Men and women with higher intake also had increased risks for cancer mortality for red meat (HR, 1.22; 95% CI, 1.16 - 1.29; and HR, 1.20; 95% CI, 1.12 - 1.30, respectively) and processed meat (HR, 1.12; 95% CI, 1.06 - 1.19; and HR, 1.11; 95% CI 1.04 - 1.19, respectively).

Cardiovascular disease risk was increased for men and women in the highest quintile of intake of red meat (HR, 1.27; 95% CI, 1.20 - 1.35; and HR, 1.50; 95% CI, 1.37 - 1.65, respectively) and processed meat (HR, 1.09; 95% CI, 1.03 - 1.15; and HR, 1.38; 95% CI, 1.26 - 1.51, respectively). For the highest vs the lowest quintile of white meat intake for both men and women, there was an inverse association for total mortality, cancer mortality, and mortality from all other causes.

“Red and processed meat intakes were associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality,” the study authors write. “In contrast, high white meat intake and a low-risk meat diet was associated with a small decrease in total and cancer mortality.”

Limitations of this study include possible residual confounding by smoking; possible measurement error; and cohort predominantly non-Hispanic white, more educated, with less smoking, less fat and red meat intake, and more intake of fiber and fruit and vegetables than similarly aged adults in the US population, limiting generalizability.

“These results complement the recommendations by the American Institute for Cancer Research and the World Cancer Research Fund to reduce red and processed meat intake to decrease cancer incidence,” the study authors write. “Future research should investigate the relation between subtypes of meat and specific causes of mortality.”

In an accompanying editorial, Barry M. Popkin, PhD, from the University of North Carolina, Chapel Hill, discusses how the implications of reducing excessive meat intake would relate to several major global concerns.

“Of equal importance is the role of clinicians as public health advocates,” Dr. Popkin writes. “Far too few clinicians speak out on topics such as this. What the public hears is the side of the profession that is preaching vegetarian diets and not the side of the profession that is discussing moderation as a healthy option.”

The Intramural Research Program of the National Institute of Health, National Cancer Institute supported this study in part. The study authors have disclosed no relevant financial relationships. Dr. Popkin is not a vegetarian and has no financial conflict of interest related to any food product as it affects health.

Arch Intern Med. 2009;169:543-545, 562-571.
Clinical Context

Dietary patterns are changing around the globe, and an editorial by Popkin, which accompanies the current article, describes these patterns. Individuals in higher-income countries continue to consume meat and dairy products at 2 to 3 times the rate of lower-income countries. However, meat and dairy products are becoming a more common dietary staple in some developing countries, particularly India, China, and Brazil.

In part, higher consumption of meat is the result of a lower cost of beef vs several decades ago. At the same time, the cost of grains and rice has increased significantly on the world market in the last 6 years. This has important environmental consequences, as the need for water and feedstock is much higher in raising animals vs raising basic crops.

Meat consumption can have significant effects on rates of obesity and overall health as well. The current study examines a large cohort of adults to determine the effect of meat intake on mortality rates.

Chronic Pain Linked to Low Vitamin D

Allison Gandey
Information from Industry
Find out about a head-to-head comparison of MS treatment options
Dr. Daniel Mikol discusses the findings from the multicenter REGARD study.Click here.

March 25, 2009 — Inadequate vitamin D may represent an underrecognized source of nociperception and impaired neuromuscular functioning, say researchers.

“Physicians who care for patients with chronic, diffuse pain that seems musculoskeletal — and involves many areas of tenderness to palpation — should strongly consider checking vitamin-D level,” Michael Turner, MD, from the Mayo Clinic in Rochester, Minnesota, said in a news release issued Friday.

“For example,” he added, “many patients who have been labeled with fibromyalgia are, in fact, suffering from symptomatic vitamin-D inadequacy. Vigilance is especially required when risk factors are present, such as obesity, darker pigmented skin, or limited exposure to sunlight.”

Dr. Turner was lead investigator of a study published in the journal Pain Medicine in November 2008. The work suggests a correlation between inadequate vitamin-D levels and the amount of narcotic medication taken by chronic pain patients.

Required Nearly Twice As Much Pain Medication

The researchers found that patients who had inadequate vitamin-D levels and required narcotic pain medication were taking much higher doses — nearly twice as much — as those with adequate levels. These patients also reported worse physical function and worse overall health perception.

Dr. Turner told Medscape Neurology & Neurosurgery his group was surprised by the finding. “We didn’t anticipate that the difference would be so high.”

The investigators retrospectively studied 267 patients admitted to the Mayo Comprehensive Pain Rehabilitation Center. They compared serum 25-hydroxyvitamin-D levels at the time of admission with other parameters such as the amount and duration of narcotic pain medication used, self-reported levels of pain, emotional distress, physical functioning, health perception, and demographic information such as sex, age, diagnosis, and body-mass index.

Patients with vitamin-D levels below 20 ng/mL were considered to have inadequate amounts. The prevalence of low vitamin D was 26% (95% CI, 20.6% – 31.1%).

Among patients using opioids, the mean morphine-equivalent dose for the inadequate vitamin-D group was 133.5 mg/day compared with 70.0 mg/day for the adequate group (P = .001). The mean duration of opioid use for the inadequate and adequate groups was 71.1 months and 43.8 months, respectively (P = .023).

The researchers also observed a link between increasing body-mass index and decreasing levels of vitamin D.

Inadequate Vitamin D May Create or Sustain Pain

The preliminary results suggest that inadequate vitamin D may play a role in creating or sustaining chronic pain. During an interview, Dr. Turner suggested that patients with inadequate vitamin D may benefit from cholecalciferol 50,000 international units dosed according to the level of deficiency.

But he urged caution for patients with calcium- or phosphate-processing disorders. “Increasing vitamin-D levels could be problematic in patients with kidney failure or stones or primary hyperparathyroidism or sarcoidosis. This doesn’t preclude increasing levels, but it might warrant discussion with an endocrinologist,” he said.

For patients with adequate vitamin D looking to maintain levels, he recommends10 to 15 minutes of sun exposure with no sunscreen on the trunk and arms and legs 3 times a week.

Sun Exposure or Diet and Supplements?

It is a recommendation often made by proponents of vitamin D but hotly contested by the American Academy of Dermatology. The academy recommends that vitamin D be obtained from a healthy diet and supplements and not from unprotected exposure to ultraviolet (UV) radiation.

“Unprotected UV exposure to the sun or indoor tanning devices is a known risk factor for the development of skin cancer,” dermatologists write in the academy’s position statement.

Dr. Turner and his team conclude: “Prospective trials utilizing a repeated-measures design are warranted to assess the effects of vitamin-D repletion on pain outcomes and physiological measures of neuromuscular functioning among patients with chronic pain and comorbid vitamin-D inadequacy.”

The researchers have disclosed no relevant financial relationships.

Pain Med. 2008;9:979-984. Abstract

Health to All