Million Hearts® and Sodium:
Best Practices and Opportunities
August 22, 2013
2:00pm - 3:00pm
Welcome & Overview
Jill Birnbaum, JD
Vice President, State Advocacy & Public Health
American Heart Association
Agenda
Time
Agenda Item / Topic
Speaker / Facilitator
3:00
Welcome, Overview
Jill Birnbaum, JD, Vice President, State Advocacy & Public Health,
American Heart Association
3:05
AHA Sodium Conference Highlights
Emily Ann Miller, Emily Ann Miller, MPH, RD, National Program
Lead, Sodium Reduction Initiative, American Heart Association
3:20
Sodium Intake in Populations:
Assessment of Evidence, 2013 IOM
Report
Cheryl Anderson, Cheryl A. M. Anderson, PhD, MPH, MS,
Associate Professor, Department of Family and Preventive
Medicine, University of California San Diego School of Medicine
3:35
Future Direction of Procurement
Policy
Laurie Whitsel, Ph.D., Director of Policy Research, American
Heart Association
3:45
Million Hearts Support and
Engagement
John Clymer, Executive Director, National Forum for Heart
Disease and Stroke Prevention
3:55
Q and A
Facilitated by Jill Birnbaum, JD, Vice President, State Advocacy &
Public Health, American Heart Association
AHA Sodium Conference Highlights
Emily Ann Miller, MPH, RD
National Program Lead, Sodium Reduction Initiative
American Heart Association
• Date: June 19-20, 2013; Arlington, VA
• Attendees: 140 stakeholders from various sectors
• Purpose:
– Create an interactive and collaborative environment to
discuss the status and future implications of reducing
sodium in the food supply and to identify opportunities for
stakeholder collaboration.
– Not intended to debate the appropriate level of sodium
intake, i.e. 2,300mg vs. 1,500mg, rather, to coalesce
around our common ground
Planning Committee
• Elliott Antman, MD, Brigham and Women’s Hospital
and Harvard Medical School – AHA President-Elect
• Larry Appel, MD, MPH, Johns Hopkins University –
Chair, Sodium Reduction Advisory Task Force
• Doug Balentine, PhD, Unilever – Chair, Industry
Nutrition Advisory Panel
• Rachel Johnson, PhD, MPH, RD, University of Vermont
– Chair, Nutrition Committee
• Lyn Steffen, PhD, MPH, RD, University of Minnesota –
EPI Council Liaison to Nutrition Committee
Objectives
• Assess the current status and future implications of efforts to reduce
sodium in the food supply.
• Leverage expertise from different disciplines to identify and evaluate
sodium reduction strategies; address opportunities and challenges.
• Discuss ways to translate sodium reduction strategies into practical
application.
• Identify short-term and long-term goals sodium reduction goals and
factors that impact timelines for achieving these goals.
• Identify collaboration opportunities among stakeholders.
• Identify metrics and methodologies for evaluating the collective
impact of sodium reduction efforts on the food supply and on health
outcomes.
Agenda
• Plenary Sessions
– Science behind sodium reduction and public health
recommendations
– Measurement of sodium intakes
– Consumer knowledge, attitudes, and behaviors re:
sodium
– Food technology and solutions for sodium reduction
– Food industry experiences and perspectives
– Potential policy and education strategies for sodium
reduction
• Breakout sessions
Breakout Sessions
• Opportunity for participants to contribute their
expertise and thoughts
• Intended to identify areas that are ripe for further
investigation and possibly, future action
• 4 facilitator-led breakout groups
• Major takeaways from presentations; key
determinants of success; guiding principles for
future actions; most promising solutions and how
to overcome their potential barriers; roles for
various sectors
Themes from Breakout Sessions
•
•
•
•
•
•
Complexity
Commitment
Collaboration
Communication
Consistency
Common Ground
Themes from Breakout Sessions
• Complexity
– Sodium reduction involves much more than just taking out the salt
• Commitment
– It will be a long term effort; some progress has been made but there is
much more work ahead; lowering sodium in the food supply is critical
• Collaboration
– It is imperative to have simultaneous, multi-sector efforts
• Communication/Consistency
– We need simple, positive, consistent messages that are culturallyappropriate and come from multiple voices
• Common Ground
– Incorporate sodium as part of a total health/total diet approach and
reap multiple benefits for cardiovascular health
Conference Proceedings
• Proceedings to be published in an AHA journal
• Estimated timing: January 2014
THANK YOU!
Emily Ann Miller, MPH, RD
emilyann.miller@heart.org
Sodium Intake in Populations: Assessment of
Evidence, 2013 IOM Report
Cheryl Anderson, PhD, MPH, MS
Associate Professor, Department of Family
and Preventive Medicine
University of California San Diego School of Medicine
Sodium Intake in
Populations:
Assessment of Evidence
Statement of Task
Evaluate the results, study design, and methodological
approaches to assessing the relationship between sodium
and health outcomes in the literature since 2003.
• Evaluate potential benefits/adverse impacts of reduced
population sodium intake (i.e. 1,500 – 2,300 mg/day) in
the population generally and for population subgroups
(those with hypertension and prehypertension, those 51
years of age and older, African Americans, and those
with diabetes, chronic kidney disease, and congestive
heart failure).
• Comment on the implications for population-based
strategies to reduce sodium intake.
• Identify data and methods gaps and suggest ways to
address them.
15
Step 1: Literature Search
Citations identified in Embase, MEDLINE, PubMed,
Web of Science, and Cochrane Database of Systematic
Reviews database search for primary studies, published
between January 2003 and December 18, 2012
(more than 2,000)
Reviewed abstracts and
removed those that failed to
meet criteria1
Retrieved full-text of primary articles for review
(more than 200)
Removed articles that failed to
meet criteria1
Study articles reviewed (n=38)
4 randomized, controlled trials (RCTs)
34 observational (cohort or case-control)
studies
By health outcome
4
CVD, Stroke, and
Mortality (n=25)2
Kidney Disease
(n=2)2
Metabolic Syndrome
(n=2)
Diabetes
(n=2)
Gastrointestinal
Cancer (n=8)
4 RCTs, 21
observational studies
2 observational
2 observational
2 observational
8 observational
Step 2: Review and Evaluation of
Studies
Criteria:
1. Generalizability to the populations of interest
a. General U.S. population
b. Subgroups (hypertensive/prehypertensive, 51 years and
older, African American, those with diabetes, chronic
kidney disease, and congestive heart failure)
2. Methodological appropriateness
a.
b.
c.
d.
Study design
Quantitative measures of dietary sodium intake
Confounder adjustment
Number and consistency of relevant studies available
17
Factors that Impacted Evaluation
• Variability in the types and quality of measures used
in observational studies and clinical trials
• Lack of consistency among studies in the methods
used for defining sodium intakes at both high and low
ends of the range of typical intakes
• Extreme variability in intake levels between and
among population groups
• precluded the committee from establishing a
“healthy” intake range.
• Committee could consider sodium intake levels only
within the context of each individual study.
18
Overarching Findings
• Many populations evaluated were outside the US
• included groups that consumed mean levels of sodium much
higher than the average amount consumed by adults in the
US
• The quantity and quality of relevant studies was less than
optimal
• limitations associated with the quantitative measures of
sodium intake
• potential for spurious findings related to incorrect
measurement and reverse causality
• Variability in the types and quality of measures used, so that
measures could not be reliably calibrated across studies
19
Findings and Conclusions
General Population
Finding 1: Results from studies linking dietary sodium intake with
direct health outcomes were highly variable in methodological
quality, particularly in assessing sodium intake. The range of
limitations included over- or under-reporting of intakes or
incomplete collection of urine samples. In addition, variability in
data collection methodologies limited the committee’s ability to
compare results across studies.
Conclusion 1: Given the methodological flaws and limitations,
when considered collectively, the evidence indicates a positive
relationship between higher levels of sodium intake and risk of
CVD. This evidence is consistent with existing evidence on blood
pressure as a surrogate indicator of CVD risk.
20
General Population
Finding 2: Evidence from studies on direct health outcomes was
insufficient and inconsistent regarding an association between
sodium intake below 2,300 mg per day and benefit or risk of CVD
outcomes (including stroke and CVD mortality) or all-cause
mortality in the general US population.
Conclusion 2: Evidence from studies on direct health outcomes is
inconsistent and insufficient to conclude that lowering sodium
intakes below 2,300 mg/day either increases or decreases risk of
CVD outcomes (including stroke and CVD mortality) or all-cause
mortality in the general U.S. population.
21
Population Subgroups
Finding 1: Evidence from multiple randomized controlled trials (RCTs)
that were conducted by a single investigative team indicated that low
sodium intake (e.g., to 1,840 mg/day) may lead to greater risk of
adverse events in congestive heart failure (CHF) patients with reduced
ejection fraction and who are receiving certain aggressive therapeutic
regimens. This association also is supported by one observational
study where low sodium intake levels in patients with CVD and
diabetes were associated with higher risk of CHF events.
Conclusion 1: Evidence suggests that low sodium intakes may lead to
higher risk of adverse events in mid- to late-stage CHF patients with
reduced ejection fraction and who are receiving aggressive therapeutic
regimens. Because these therapeutic regimens were very different than
current standards of care in the US, the results may not be
generalizable. Similar studies in other settings and using regimens
more closely resembling those in standard U.S. clinical practice are still
needed.
22
Population Subgroups
Finding 2: Data among prehypertensive participants from two
related studies provided some evidence suggesting a continued
benefit of lowering sodium intake in these patients down to
2,300 mg per day (and lower, although based on small numbers
in the lower range). No evidence was found for benefit and
some evidence suggesting risk of adverse health outcomes
associated with sodium intake levels in ranges approximating
1,500 to 2,300 mg per day in other disease-specific population
subgroups (those with diabetes, chronic kidney disease (CKD),
or pre-existing CVD).
23
Population Subgroups
Finding 2: In addition to inconsistencies in sodium intake
measures, methodological flaws included the possibility
of confounding and reverse causality. No relevant
evidence was found on health outcomes for other
population subgroups considered (i.e., persons 51 years
of age and older, and African Americans). In studies that
explored interactions, race, age, or the presence of
hypertension or diabetes did not change the effect of
sodium on health outcomes.
24
Population Subgroups
Conclusion 2: With the exception of CHF patients, the
current body of evidence addressing the association between
low sodium intake and health outcomes in the population
subgroups considered is limited. The evidence available is
inconsistent and limited in its approaches to measuring
sodium intake. The evidence also is limited by small numbers
of health outcomes and the methodological constraints of
observational study designs, including the potential for
reverse causality and confounding.
25
Population Subgroups
Conclusion 2: While the current literature provides some
evidence for adverse health effects of low sodium intake
among individuals with diabetes, CKD, or pre-existing CVD,
the evidence on both the benefit and harm is not strong
enough to indicate that these subgroups should be treated
differently from the general U.S. population. Thus, the
evidence on direct health outcomes does not support prior
recommendations to lower sodium intake within these
subgroups to, or even below, 1,500 mg/day.
26
Implications for Population-based
Strategies
• The available evidence on associations between sodium
intake and direct health outcomes is consistent with
population-based efforts to lower excessive dietary sodium
intakes, but it is not consistent with efforts that encourage
lowering of dietary sodium in the general population to 1,500
mg/day.
• The evidence reviewed also suggests that dietary sodium
intake may affect heart disease risk through pathways in
addition to blood pressure.
27
Implications for Population-based
Strategies
• Further research may shed more light on the association
between lower (1,500 to 2,300 mg) levels of sodium and
health outcomes in the general population and
subpopulations.
• The committee was not asked to draw conclusions about
a specific target range of dietary sodium. Other factors
also precluded specifying a such range. These included
methodologic problems in assessing sodium intake and
difficulty calibrating those measures across different
approaches to measuring intake and different study
designs.
28
Committee
BRIAN L. STROM (Chair), University of Pennsylvania
CHERYL A.M. ANDERSON, University of California San Diego
JAMY ARD, Wake Forest Baptist Health
KIRSTEN BIBBINS-DOMINGO, University of California San Francisco
NANCY R. COOK, Brigham & Women’s Hospital
MARY KAY FOX, Mathematica Policy Research
NIELS GRAUDAL, Copenhagen University Hospital
JIANG HE, Tulane University
JOACHIM IX, Veterans Affairs San Diego Healthcare System
STEPHEN E. KIMMEL, University of Pennsylvania
ALICE H. LICHTENSTEIN, Tufts University
MYRON WEINBERGER, Indiana University
29
Future Direction of Procurement Policy
Laurie Whitsel, PhD
Director of Policy Research
American Heart Association
Decrease deaths from CVD and Stroke
Improve the overall CV health of
Americans
31
Procurement
Increasing attention on the importance
of creating healthier work
environments and healthier food
options to the public in different
settings.
32
Procurement
• Potential Environments
–
–
–
–
–
–
–
–
–
–
government buildings
hospital systems
college/university campuses
Schools/child care centers
assisted living facilities
faith-based organizations
private corporations
theme parks/resorts
prisons
non-profit organizations
33
Procurement
• Targets for nutrition
standards for food and
beverage procurement
–
–
–
–
–
Vending machines
Cafeterias
Concession stands
Meetings/conferences
Organizational events
34
Procurement
• Numerous existing
model standards
– AHA
– HHS/Federal
Government
– Municipal governments
– National Alliance for
Nutrition and Activity
– Alliance for a Healthier
Generation
35
Forthcoming AHA Paper
• Will address such issues as:
– Existing model standards
– Barriers to implementation
– Legal issues
– Case studies
– Importance of Evaluation
36
The Future of Procurement
Policy
Where do we go from here?
37
Procurement
• A relatively new area of policy development
• Will require an assessment of the impact of
the numerous existing policies across the U.S.
• Consistent evaluation for
– Purchasing behavior
– Availability of healthy food in purchasing
– Affordability/Cost Issues
– Health impact
– Levels of adoption
– Industry response
38
Million Hearts® Support and Engagement
John Clymer
Executive Director
National Forum for Heart Disease
and Stroke Prevention
The Million Hearts®
Initiative
Goal: Prevent 1 million heart attacks
and strokes in 5 years
• National initiative co-led by CDC and CMS
• Partners across federal, state, and local government
and private organizations
CDC Million Hearts®
Collaboration
• American Heart Association
• National Forum for Heart Disease & Stroke Prevention
• Association of State and Territorial Health Officials
• National Association of City County Health Officials
• National Association of Chronic Disease Directors
Key Components
• Improve care for people who need treatment by
encouraging a targeted focus on the “ABCS”
• Empower Americans to make healthy choices such as
not using tobacco and reducing sodium and trans fat
consumption
Actions You Can Take
1. Align existing initiatives and programs with Million
Hearts® goals
2. Convene partners, stakeholders, and policy makers
for Million Hearts® for planning purposes
3. Share success stories on Million Hearts®
Ways to Use Million
Hearts® to Achieve Your
0rganizations goals
1. Join Community Commons – Connect, Share, and
Collaborate on Million Hearts® Activities
2. Become a Million Hearts® Partner
3. Pledge Support on the Million® Hearts Website – Be
One in a Million Hearts®
State Engagement Guide
1. Includes information on the initiative
2. Ways to use Million Hearts® to achieve your
organization’s goals
3. Lessons learned and key recommendations,
Workshop descriptions
4. Examples, resources, and information on how the
Collaboration organizations can assist in working
with Million Hearts®
National Forum Members /
Million Hearts® Partners
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•
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•
•
•
•
•
•
American College of Cardiology
American Heart Association
American Medical Group Foundation
Association of Black Cardiologists, Inc.
Association of State and Territorial
Health Officials
Centers for Disease Control and
Prevention
Health Resources and Services
Administration
Indian Health Service
National Association of Chronic Disease
Directors
National Association of County and City
•
•
•
•
•
•
•
•
Health Officials
National Heart, Lung, and Blood Institute
National Lipid Association
Preventive Cardiovascular Nurses
Association
U.S. Department of Health and Human
Services
U.S. Department of Veterans Affairs,
Ischemic Heart Disease Quality
Enhancement Research Initiative
U.S. Food and Drug Administration,
Office of Women's Health
WomenHeart
YMCA
Questions & Answers
Jill Birnbaum, JD
Vice President, State Advocacy & Public Health
American Heart Association
AHA Activities
Thank You!
For more information, please visit millionhearts.hhs.gov
www.nationalforum.org
www.heart.org