Majority of people with heart disease consume too much sodium
Study finds patients on average consume more than twice the recommended daily amount of sodium with little variation across socioeconomic groups
Individuals with heart disease stand to gain the most from a low-sodium diet but, on average, consume over twice the recommended daily sodium intake, according to a study being presented at the American College of Cardiology’s Annual Scientific Session.
Sodium is an essential nutrient, but consuming too much can raise blood pressure, which damages blood vessels and forces the heart to work harder. Excess sodium can also cause the body to retain fluid, exacerbating conditions like heart failure. The current U.S. Dietary Guidelines put out by the U.S. Department of Agriculture recommends most adults limit their sodium intake to less than 2,300 mg/day, which is equivalent to about 1 teaspoon of table salt. For individuals with cardiovascular diseases, the limit is even lower at 1,500 mg/day, according to guideline recommendations from the ACC and the American Heart Association.
This new study found that among a sample of more than 3,100 people with heart disease, 89% consumed more than the recommended daily maximum of 1,500 mg of sodium and, on average, study participants consumed more than twice this amount. Limiting sodium intake is a fundamental lifestyle modification shown to reduce the likelihood of subsequent major adverse cardiovascular events, researchers said. Their findings underscore the challenges many people face in keeping within recommended sodium limits, regardless of other factors such as socioeconomic status.
“Estimating sodium quantities in a meal can be challenging,” said Elsie Kodjoe, MD, MPH, an internal medicine resident at Piedmont Athens Regional Hospital in Athens, Georgia and the study’s lead author. “Food labels aid in dietary sodium estimation by providing sodium quantities in packaged food. Yet, adhering to a low sodium diet remains challenging even for individuals with cardiovascular disease who have a strong incentive to adhere.”
The study used data from patients diagnosed with a heart attack, stroke, heart failure, coronary artery disease or angina who participated in the National Health and Nutrition Examination Survey (NHANES) between 2009–2018.
Researchers estimated sodium intake based on questionnaires in which participants were asked to report everything they had consumed in 24 hours. According to the results, study participants with cardiovascular disease consumed an average of 3,096 mg of sodium per day, which is slightly lower than the national average of 3,400 mg/day reported by the U.S. Centers for Disease Control and Prevention.
“The relatively small difference in sodium intake suggests that people with cardiovascular disease are not limiting their intake very much compared with the general population and are also consuming more than double what is recommended,” Kodjoe said. “To make it easier for patients to adhere to dietary guidelines, we need to find more practical ways for the general public to estimate dietary sodium levels or perhaps consider a reduction in the sodium content of the food we consume right from the source.”
The researchers also compared sodium intake among people in different socioeconomic groups, but they did not find any significant differences between wealthier and less affluent participants after accounting for age, sex, race and educational attainment.
Individuals can take proactive measures to lower their sodium intake, Kodjoe said. This includes preparing more meals at home where they have greater control over the sodium content and paying close attention to food labels, particularly targeting foods with sodium levels of 140 mg or less per serving. Researchers suggested that better education around the benefits of limiting sodium could also help motivate more people to follow the recommendations.
“Cardiovascular disease is real, and it is the number one cause of morbidity and mortality worldwide according to the World Health Organization,” Kodjoe said. “Adhering to sodium guidelines is one of the easier strategies individuals could readily adopt to reduce hospitalizations, health care costs, morbidity and mortality associated with cardiovascular disease.”
One limitation of the study is that sodium intake was estimated based on food recall questionnaires, rather than 24-hour urine sodium measurements, which is considered the gold standard method. NHANES has included 24-hour urine sodium measurements in its data gathering methods in recent survey cycles, so future studies using this data could provide a more accurate assessment of sodium intake among people with cardiovascular disease.
For more information on reducing sodium, visit CardioSmart.org/Sodium.
Kodjoe will present the study, “The Impact of Income to Poverty Ratio on Sodium Intake Among Adults with Cardiovascular Disease,” on Sunday, April 7, 2024, at 3:15 p.m. ET / 19:15 UTC in Hall B4-5.
ACC.24 will take place April 6-8, 2024, in Atlanta, bringing together cardiologists and cardiovascular specialists from around the world to share the newest discoveries in treatment and prevention. Follow @ACCinTouch, @ACCMediaCenter and #ACC24 for the latest news from the meeting.
Want to cut US heart risks? Get more people into primary care, study suggests
Most care to address the “Essential Eight” risk factors for heart disease and stroke happens in general-care settings, but many with high risk don’t go
When someone has a heart attack or a stroke, specialized care can give them the best chance of surviving.
But when it comes to preventing those problems in the first place, most essential care happens in general primary care clinics, a new study suggests. Or it doesn’t happen at all, if someone can’t, won’t or doesn’t take the time to see a primary care doctor or nurse practitioner.
The study finds that a majority of people with any of these key measures for improving and maintaining cardiovascular health, and the majority of those taking medication to control four of those measures, saw only a primary care clinician in the past year, compared with those who saw a cardiologist alone or in addition to seeing a primary care provider.
The study focuses on seven of what the American Heart Association calls “Life’s Essential Eight” controllable risk factors for cardiovascular disease: high cholesterol, high blood pressure, diabetes, very high body mass index, tobacco use, low exercise and sleep problems such as insomnia. The data source used in the study doesn’t include information about the eighth risk factor, healthy food intake.
The study also finds that large percentages of people with these major cardiovascular risk factors didn’t see either type of health care provider in the past year, even if they said they were taking medications to control their blood pressure, cholesterol, blood sugar or stop smoking.
More than 50% of all tobacco users, 44% of those who say they have low levels of physical activity, and 38% of those with severe obesity said they hadn’t seen a primary care provider or cardiologist in the last year. Even among those taking medication to control cardiovascular risk factors, 15% to 20% said they hadn’t seen any provider in the past year.
The study is published in Circulation: Quality and Outcomes by a team from Michigan Medicine, the University of Michigan’s academic medical center, OhioHealth, and Weill Cornell Medicine.
They used data from more than 66,000 adults interviewed in-depth about their health and health care in the last year, through the nationally representative Medical Expenditure Panel Survey conducted by the federal government.
Lead author Jeremy Sussman, M.D., M.Sc., and co-author Madeline Sterling, M.D., M.P.H., serve on the American Heart Association’s Primary Care Science Committee, which is working on a report on the role of primary care in cardiovascular health.
“As a society we need to recognize that preventing common conditions requires providers who can see patients often, and see the whole patient, which is the role of primary care,” said Sussman, a general internist and associate professor in the U-M Department of Internal Medicine. “While cardiovascular care guidelines are often written by specialists and subspecialists, this study shows that access to primary care is crucial to preventing or delaying some of the most common causes of death in the nation.”
The current crisis in access to primary care for American adults does not bode well for making inroads on the “Essential Eight,” Sussman notes. That crisis is caused by both a shortage of, and uneven distribution of, physicians, nurse practitioners and physician assistants who choose to practice general internal medicine, family medicine and geriatrics.
Long waits for appointments, and inability to find a provider who is accepting new patients, could delay identification and management of cardiovascular risk factors, including starting new preventive medications or adjusting doses to control risk factors appropriately.
People who should make sure to see a primary care provider at least once a year – even just via a telehealth appointment – include those who have already been prescribed an antihypertensive medication to bring down high blood pressure, a diabetes drug to bring down blood sugar, a statin to control cholesterol or a prescription quit-smoking medication.
Regular checkups can help ensure they’re getting the most preventive power out of these medicines.
But even if they’re not taking medication, most adults with at least one cardiovascular risk factor on the “Essential Eight” list should be seeing a primary care provider regularly, Sussman said.
“Primary care providers today can manage high blood pressure, high cholesterol, most cases of diabetes, and tobacco cessation without having to refer to a specialist, though of course specialists play a key role in more complex prevention cases and post-incident care,” he said. “They can also be important entry routes to nutrition counseling, weight management and exercise programs, and sleep disorders diagnosis and treatment.”
Policy measures to enhance access to primary care by training more providers and incentivizing them to practice in shortage areas, and efforts to support primary care providers in managing cardiovascular risk factors, will be important, the authors say. But in the immediate timeframe, they urge individuals with any of these risk factors to request an appointment with their clinic or seek one out if they don’t have a regular primary care provider.
In addition to Sussman and Sterling, who is a general internist and researcher at Weill Cornell, the study team includes author Michael Johansen, M.D., a family medicine physician with OhioHealth who trained at U-M.
Sussman is a member of the U-M Institute for Healthcare Policy and Innovation, the VA Center for Clinical Management Research, and the Division of General Medicine.
The AHA committee that Sussman and Sterling serve on is a joint subcommittee of the Council on Quality of Care and Outcomes Research, and the Council on Cardiovascular and Stroke Nursing.
Clinical Care for Life’s Essential 8 by Medical Specialty in the United States, an Observational Cohort Study, Circulation: Cardiovascular Quality and Outcomes, DOI:10.1161/CIRCOUTCOMES.123.010498 https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.123.010498
JOURNAL
Circulation Cardiovascular Quality and Outcomes
METHOD OF RESEARCH
Data/statistical analysis
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Clinical Care for Life’s Essential 8 by Medical Specialty in the United States, an Observational Cohort Study
Mapping heart health: AI illuminates neighborhood impact on well-being
Study leverages Google Street View to assess links between environment and cardiovascular outcomes
AMERICAN COLLEGE OF CARDIOLOGY
Is the view from your doorstep mostly trees and sky or buildings and grass? The answer could influence your cardiovascular health, according to a study presented at the American College of Cardiology’s Annual Scientific Session. Using an analysis of Google Street View images powered by machine learning, researchers found people living in surroundings rich in sidewalks, trees and clear sky saw a significantly lower risk of major adverse cardiac events.
“A lot of research has shown that environmental factors strongly affect our health. If we can find a way to stratify this risk and provide interventions before cardiovascular events happen, then we could save a lot of lives,” said Zhuo Chen, PhD, a postdoctoral researcher at Case Western Reserve University and University Hospitals Health System in Cleveland and the study’s lead author. “Our study shows that with advanced computer vision algorithms and AI, we now have the ability to quantify the built environment more effectively and efficiently. If we can assess the individual’s risk at a granular level, we could provide more personalized interventions.”
The study is part of a growing body of research investigating how greenspace and the built environment influences cardiovascular risk. Previous studies have used a variety of approaches to quantify environmental features, with mixed results. By combining Google Street View images with robust segmentation methods for analyzing “vertical greenspace”—the view along the skyline and not only on the ground—this study offers a more nuanced and granular perspective on the environment at the level of individual streets rather than averaging across entire counties or ZIP codes.
The researchers used a machine learning algorithm trained to distinguish between trees, grass, sky, sidewalks, buildings and roads to analyze Google Street View images of the residences of nearly 50,000 study participants. Participants were part of a program that provides free and low-cost coronary artery calcium tests (a non-invasive screening method to assess heart disease risk), mostly in northeastern Ohio.
Over a median follow-up period of about 27 months, approximately 2,000 of the patients had experienced a major adverse cardiovascular event, such as a heart attack, stroke or death from heart disease. By analyzing participants’ built environment, researchers found that people living in areas with more sidewalks were 9% less likely to suffer major cardiac events than people living in places with fewer or no sidewalks. In addition, people living in places that scored highly for vertical greenspace—trees and clear sky—were 5% less likely to suffer these events than people in areas that scored low for this metric. These associations were independent from each other.
To account for other factors known to influence heart health, the researchers adjusted the models for age, race, sex, social vulnerability, median household income, fine particle air pollution, noise and cardiovascular risk factors, such as high blood pressure, high cholesterol and diabetes.
“The method and the data source that we’re using here is cheap, open source and publicly available,” Chen said. “It can assess anywhere there are Google Street View cars on the road and really provide a refined metric of the environment.”
The results showed no association between the presence of grass and the risk of cardiovascular events, further bolstering the results of previous studies that found a closer association between trees and cardiovascular health than just grass. However, Chen said that trees alone were not found to have an association with cardiovascular outcomes. Rather, it is the combination of trees and clear sky that together appeared to be a better indicator of vertical greenspace. To refine this metric, the researchers incorporated depth information into the machine learning algorithm.
The study design did not allow for the determination of a causal relationship between environmental features and heart disease, Chen said. It also did not include data on residents’ physical activity or travel behaviors, limiting the ability of researchers to directly examine the mechanisms linking greenspace, walkability and cardiovascular outcomes. In addition, researchers said the cohort consisted mostly of individuals in northeast Ohio, which may limit generalizability of the findings to other areas.
Nevertheless, by refining methods for assessing environmental features at scale, Chen said the work can offer useful insights for addressing an important public health issue at the intersection of environment and personal health.
“It doesn’t necessarily mean that if we plant more trees or build more sidewalks, we’ll reduce cardiovascular risk,” Chen said. “But it still gives us preliminary suggestions and indicators that can help us become aware of ways to change behaviors or neighborhood planning in the future to [potentially] lower cardiovascular risk.”
Chen will present the study, “Residential Vertical Greenspace and Sidewalks Impacts on Cardiovascular Risk: Insights from Deep Learning-Enhanced Google Street View,” on Sunday, April 7, 2024, at 3:15 p.m. ET / 19:15 UTC in Hall B4-5.
Heart health declines rapidly after menopause
Study shows women quickly catch up to men in terms of cardiovascular risk; underscores the need for increased awareness and screening
AMERICAN COLLEGE OF CARDIOLOGY
A woman’s cardiovascular risk can rise sharply after she goes through menopause, quickly catching up to men of a similar age and health profile, according to new findings presented at the American College of Cardiology’s Annual Scientific Session. Researchers said the study underscores the importance of recognizing and addressing early warning signs of heart disease risk in women as they lose the protective effects of estrogen after menopause.
“This is a unique study cohort of only post-menopausal statin users that signals that post-menopausal women may have risk of heart disease that is on par with males,” said Ella Ishaaya, MD, an internal medicine physician at Harbor-UCLA Medical Center in Torrance, California, and the study’s lead author. “Women are underscreened and undertreated, especially post-menopausal women, who have a barrage of new risk factors that many are not aware of. This study raises awareness of what those risk factors are and opens the door to indicating the importance of increased screening for coronary artery calcium (CAC).”
In the study, post-menopausal women underwent heart scans to assess their CAC score, a measure of plaque buildup—fat, calcium and other substances—in the heart’s arteries. CAC levels are assessed with a quick, non-invasive scan similar to an X-ray. A higher CAC score indicates a higher risk of a heart attack or other cardiac events.
Researchers analyzed data from 579 post-menopausal women who were taking statins to control their cholesterol and had undergone two CAC scans at least one year apart. Participants did not have heart disease at the time of the first scan. To compare CAC changes in men and women, each female participant was matched with a male of a similar profile in terms of age, race, statin use, blood pressure and diabetes status.
Researchers divided the participants into three groups with CAC levels of 1–99, 100–399, and 400 or higher at baseline. Between their first and second heart scan, women with baseline CAC of 1–99 saw their CAC rise by a median of eight points, double the median of four seen in their male counterparts. Similarly, women with baseline CAC of 100–399 saw their CAC rise by a median of 31 points, about double the median of 16 seen in males. There was no significant difference between sexes for those with baseline CAC of 400 or higher.
The findings suggest plaque buildup is accelerated in post-menopausal women compared to men, indicating that many women experience a steep rise in the risk of heart problems. Ishaaya said this is likely related to the drop in estrogen that women experience during menopause. Estrogen has long been known to have a protective effect on heart health, but researchers said many women and even many clinicians are not aware of what it means to lose that protection during menopause.
“After menopause, women have much less estrogen and shift to a more testosterone-heavy profile,” Ishaaya said. “This affects the way your body stores fat, where it stores fat and the way it processes fat; it even affects the way your blood clots. And all of those [changes] increase your risk for developing heart disease.”
Heart disease is the leading cause of death in both men and women, but women’s cardiovascular risk has traditionally been undertreated because women tend to develop heart disease at an older age than men and may experience different and sometimes more subtle symptoms.
Based on these results, researchers suggested post-menopausal women should talk to their doctor about heart disease risk factors and follow up on any recommended tests or monitoring. More women may benefit from heart scans when compared to the number of women currently receiving them, Ishaaya said.
Since all the women in the study were taking statins but many still saw a substantial rise in CAC, the results may also indicate that statins are not sufficient to keep plaque buildup in check for this population, Ishaaya said. Future studies could investigate the effectiveness of statins or other therapies in reducing plaque burden in post-menopausal women, she said.
ACC/American Heart Association guidelines recommend considering a heart scan to assess CAC when a person’s risk level is ambiguous or borderline based on standard risk factors. In the U.S. and many other countries, CAC scoring is most used to determine recommendations for statins for intermediate-risk and asymptomatic patients.
Visit CardioSmart.org/CAC to learn more about coronary artery calcium.
Ishaaya will present the study “CAC Progression in Men and Women: Is There an Inflection at Menopause?” on Sunday, April 7, 2024 at 12:15 p.m. ET / 16:15 UTC in Hall B4-5.
ACC.24 will take place April 6-8, 2024, in Atlanta, bringing together cardiologists and cardiovascular specialists from around the world to share the newest discoveries in treatment and prevention. Follow @ACCinTouch, @ACCMediaCenter and #ACC24 for the latest news from the meeting.
The American College of Cardiology (ACC) is the global leader in transforming cardiovascular care and improving heart health for all. As the preeminent source of professional medical education for the entire cardiovascular care team since 1949, ACC credentials cardiovascular professionals in over 140 countries who meet stringent qualifications and leads in the formation of health policy, standards and guidelines. Through its world-renowned family of JACC Journals, NCDR registries, ACC Accreditation Services, global network of Member Sections, CardioSmart patient resources and more, the College is committed to ensuring a world where science, knowledge and innovation optimize patient care and outcomes. Learn more at ACC.org.
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