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INTRODUCTION: Diet, chronic kidney disease (CKD), and Apolipoprotein L1 (APOL1) (DCA) Study is examining the role of dietary factors in CKD progression and APOL1 nephropathy. We describe enrollment and retention efforts and highlight facilitators and barriers to enrollment and operational challenges, as well as accommodations made in the study protocol. METHODS: The DCA study is enrolling participants in 7 centers in West Africa. Participants who consented were invited to complete dietary recalls and 24-hour urine collections in year 1. We conducted focus groups and semistructured interviews among study personnel to identify facilitators and barriers to enrollment as well as retention and operational challenges in the execution of the study protocol. We analyzed emerging themes using content analyses. RESULTS: A total of 712 participants were enrolled in 18 months with 1256 24-hour urine and 1260 dietary recalls. Barriers to enrollment were the following: (i) a lack of understanding of research, (ii) the burden of research visits, and (iii) incorporating cultural and traditional nuances when designing research protocols. Factors facilitating enrollment were the following: (i) designing convenient research visits, (ii) building rapport and increased communication between the research team and participants, and (iii) cultural sensitivity – adapting research protocols for the populations involved. Offering home visits, providing free dietary counseling, reducing the volume of study blood collection, and reducing the frequency of visits were some changes made in the study protocol that increased participant satisfaction. CONCLUSION: Adopting a participant-centered approach with accommodations in the protocol for cultural adaptability and incorporating participant feedback is vital for carrying out research in low-income and middle-income regions.

PURPOSE To assess and compare birth expectations of younger and older age adolescents and explore if unmet expectations predict psychological birth trauma (PBT). STUDY DESIGN AND METHODS This secondary analysis expands findings of a previous study (N = 303) which classified adolescents' perceptions of birth into four main themes. The previous study used a mixed-methods approach providing data related to birth expectations. For the current study, expectations were determined by themes as met or unmet by three reviewers. Of 116 useable written narrations, responses of younger (ages 13-17) versus older (ages 18-19) adolescents were compared and explored for impact on PBT. RESULTS Birth expectations for both age groups were more often unmet than met. Despite a smaller cohort, younger adolescents provided more remarks than older adolescents. There were no differences between groups on unmet birth expectations (p = .16). Unmet expectations most often related to pain with older adolescents more inclined to state poor pain management. Younger adolescents more often feared dying. Unmet expectations did not predict PBT. CLINICAL IMPLICATIONS Comprehensive prenatal care can allow for early, open conversations to assess labor knowledge and misconceptions, fear of birth, existing supports, and overall birth expectations, with a premier focus on expected labor pain and pain management. Multiparous adolescents should receive prenatal assessments of posttraumatic stress (PTS) symptoms (a recognized predictor of posttraumatic stress syndrome) potentially originating from a previous traumatic birth. Following birth, symptoms of acute stress and PTS should be assessed of all adolescents, especially if experienced numerous unmet labor expectations.

OBJECTIVE: To examine the effect of a telehealth intervention that used a dietary app, educational website, and weekly dietitian tele-counseling) on sodium intake, diet quality, blood pressure and albuminuria among individuals with diabetes and early stage chronic kidney disease. DESIGN AND METHODS: We examined the effects of a dietary app-supported tele-counseling intervention in a single center, single arm study of 44 participants with type 2 diabetes and stage 1–3a chronic kidney disease. Participants recorded and shared dietary data via MyFitnessPal with registered dietitians, who used motivational interviewing to provide telephone counseling weekly for 8 weeks. After the 8-week intensive intervention, participants were followed at 6 months and 12 months. Outcomes included 24-hour urine sodium (2 collections per timepoint), Healthy Eating Index (HEI) 2015 score (three 24-hour dietary recalls per timepoint), 24-hour systolic blood pressure (SBP) and diastolic blood pressure (DBP), and 24-hour urine albumin excretion. RESULTS: Out of 44 consented participants (mean age 60.3 +/− 11.9 years, 43% female, 89% white, median eGFR was 78.5 ml/min/1.73m(2), median urine albumin excretion 52.9 mg/day, 84% hypertension), 32 (73%) completed 8-week follow-up, 27 (61%) completed 6-month follow up, and 25 (57%) completed 12-month follow up. Among participants who completed 12-month follow up, reported sodium intake decreased by 638 mg/day from baseline of 2919 mg/day (p-value

Background In individuals with chronic kidney disease (CKD), healthy dietary patterns are inversely associated with CKD progression. Metabolomics, an approach that measures many small molecules in biofluids, can identify biomarkers of healthy dietary patterns. Objectives We aimed to identify known metabolites associated with greater adherence to 4 healthy dietary patterns in CKD patients. Methods We examined associations between 486 known plasma metabolites and Healthy Eating Index (HEI)-2015, Alternative Healthy Eating Index (AHEI)-2010, the Dietary Approaches to Stop Hypertension (DASH) diet, and alternate Mediterranean diet (aMED) in 1056 participants (aged 21-74 y at baseline) in the Chronic Renal Insufficiency Cohort (CRIC) Study. Usual dietary intake was assessed using a semiquantitative FFQ. We conducted multivariable linear regression models to study associations between healthy dietary patterns and individual plasma metabolites, adjusting for sociodemographic characteristics, health behaviors, and clinical factors. We used principal component analysis to identify groups of metabolites associated with individual food components within healthy dietary patterns. Results After Bonferroni correction, we identified 266 statistically significant diet-metabolite associations (HEI: n = 60; AHEI: n = 78; DASH: n = 77; aMED: n = 51); 78 metabolites were associated with >1 dietary pattern. Lipids with a longer acyl chain length and double bonds (unsaturated) were positively associated with all 4 dietary patterns. A metabolite pattern low in saturated diacylglycerols and triacylglycerols, and a pattern high in unsaturated triacylglycerols was positively associated with intake of healthy food components. Plasmalogens were negatively associated with the consumption of nuts and legumes and healthy fat, and positively associated with the intake of red and processed meat. Conclusions We identified many metabolites associated with healthy dietary patterns, indicative of food consumption. If replicated, these metabolites may be considered biomarkers of healthy dietary patterns in patients with CKD.

Background The Dietary Approaches to Stop Hypertension (DASH) diet, a high-carbohydrate diet, is highly recommended based on its cardiovascular risk benefits, yet adherence remains persistently low. How subjective impressions of this diet contribute to adherence has not been thoroughly explored. The OmniCarb trial, which compared DASH-style diets varying in glycemic index (GI) and carbohydrate amount, surveyed subjective impressions of such diets. Objectives We examined the effects of GI and carbohydrate amount on qualitative aspects of diet acceptability through secondary outcomes in the OmniCarb trial. Methods OmniCarb was a randomized, crossover trial of 4 DASH-style diets varying by GI (≥65 compared with ≤45) and carbohydrate amount (40% compared with 58% kcal) in overweight or obese (BMI ≥25 kg/m2) adults (n = 163). Participants consumed each diet in random order over 5-wk periods, separated by 2-wk washouts. At baseline and the end of each feeding period, participants rated hunger, diet satisfaction, and gastrointestinal symptoms (diarrhea/loose stools, constipation, bloating, nausea, and heartburn). Results Participant mean age was 52 y, with 52% women, 51% non-Hispanic black, and 56% obese (BMI ≥30). Compared with baseline, all intervention diets decreased heartburn, increased diarrhea/loose stools, and increased bloating, but did not significantly affect constipation or nausea. Compared with lower carbohydrate diets, higher carbohydrate diets increased hunger (RR: 1.16; 95% CI: 1.04, 1.30), increased diet satisfaction (RR: 1.10; 95% CI: 1.01, 1.20), and increased heartburn (RR: 1.49; 95% CI: 1.09, 2.04). Compared with lower GI diets, higher GI diets did not affect hunger (RR: 0.92; 95% CI: 0.83, 1.02), decreased diet satisfaction (RR: 0.83; 95% CI: 0.75, 0.92), and did not affect heartburn (RR: 0.89; 95% CI: 0.70, 1.13). There were no between-diet differences for diarrhea/loose stools, constipation, bloating, and nausea. Conclusions Although a higher carbohydrate amount in DASH-style diets can increase diet satisfaction, it can also decrease satiety and increase heartburn in adults with overweight or obesity.This trial is registered at clinicaltrials.gov as NCT00608049.

RATIONALE & OBJECTIVE: Current dietary guidelines recommend that chronic kidney disease (CKD) patients restrict individual nutrients, such as sodium, potassium, phosphorus and protein. This approach can be difficult for patients to implement and ignores important nutrient interactions. Dietary patterns are an alternative method to intervene on diet. Our objective was to define the associations of four healthy dietary patterns with risk of CKD progression and all-cause mortality among people with CKD. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 2,403 participants aged 21–74 years with an estimated glomerular filtration rate (eGFR) of 20–70 mL/min/1.73 m(2) and dietary data in the Chronic Renal Insufficiency Cohort (CRIC) study. EXPOSURES: Healthy Eating Index-2015 (HEI-2015), Alternative Healthy Eating Index-2010 (AHEI-2010), alternate Mediterranean diet (aMed), and Dietary Approaches to Stop Hypertension (DASH) diet scores were calculated from food frequency questionnaires. OUTCOMES: 1) CKD progression defined as ≥50% eGFR decline, kidney transplantation, or dialysis and 2) all-cause mortality. ANALYTICAL APPROACH: Cox proportional hazards regression models adjusted for demographic, lifestyle, and clinical covariates to estimate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: There were 855 cases of CKD progression and 773 deaths over a maximum of 14 years. Compared with participants with the lowest adherence, the most highly adherent tertile of AHEI-2010, aMed, and DASH had lower adjusted risk of CKD progression with the strongest results for aMed (HR: 0.75, 95% CI: 0.62–0.90). Compared with participants with the lowest adherence, the highest adherence tertiles for all scores had lower adjusted risk of all-cause mortality for each index (24–31% lower risk). LIMITATIONS: Self-reported dietary intake. CONCLUSIONS: Greater adherence to several healthy dietary patterns is associated with a lower risk of CKD progression and all-cause mortality among people with CKD. Guidance to adopt healthy dietary patterns can be considered as a strategy for managing CKD. INDEX WORDS: dietary patterns, nutrition, kidney disease, renal, mortality

Two recent studies challenged traditional paradigms of mammalian sodium physiology, suggesting that sodium reduction might cause weight gain by altering metabolism. This new theory has important implications for population-wide dietary recommendations. However, these observations have not been confirmed. In the DASH (Dietary Approaches to Stop Hypertension)-Sodium trial, 412 adults with systolic blood pressure of 120 to 159 mm Hg and diastolic blood pressure of 80 to 95 mm Hg not taking antihypertensive medications were randomly assigned to the DASH diet or a control diet (parallel design). On their assigned diet, participants randomly consumed each of the 3 sodium levels for 4 weeks (crossover design). Participants were provided all meals but could drink noncaloric beverages (eg, water) freely. Throughout the trial, energy intake was adjusted to maintain weight constant. The 3 sodium levels (at 2100 kcal/day) were: low (1150 mg of Na/day), medium (2300 mg of Na/day), and high (3450 mg of Na/day). Energy intake, weight, self-reported thirst, and 24-hour urine volume were assessed after each period. Participants were 57% women and 57% black; mean age was 48 years [SD, 10]). Among those assigned the control, mean weight increased slightly with higher sodium but not among those assigned DASH. Energy intake did not vary across sodium levels in either diet ( P -trends ≥0.36). Higher sodium resulted in more thirst ( P -trends P -trend=0.007). Reducing sodium did not increase energy requirements to maintain stable weights but did decrease thirst and urine volume (control diet only), findings consistent with the traditional understanding of mammalian sodium physiology. Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT00000608.

Use of salt substitutes containing potassium chloride is a potential strategy to reduce sodium intake, increase potassium intake, and thereby lower blood pressure and prevent the adverse consequences of high blood pressure. In this review, we describe the rationale for using potassium-enriched salt substitutes, summarize current evidence on the benefits and risks of potassium-enriched salt substitutes and discuss the implications of using potassium-enriched salt substitutes as a strategy to lower blood pressure. A benefit of salt substitutes that contain potassium chloride is the expected reduction in dietary sodium intake at the population level because of reformulation of manufactured foods or replacement of sodium chloride added to food during home cooking or at the dining table. There is empirical evidence that replacement of sodium chloride with potassium-enriched salt substitutes lowers systolic and diastolic blood pressure (average net Δ [95% CI] in mm Hg: –5.58 [–7.08 to –4.09] and –2.88 [–3.93 to –1.83], respectively). The risks of potassium-enriched salt substitutes include a possible increased risk of hyperkalemia and its principal adverse consequences: arrhythmias and sudden cardiac death, especially in people with conditions that impair potassium excretion such as chronic kidney disease. There is insufficient evidence regarding the effects of potassium-enriched salt substitutes on the occurrence of hyperkalemia. There is a need for additional empirical research on the effect of increasing dietary potassium and potassium-enriched salt substitutes on serum potassium levels and the risk of hyperkalemia, as well as for robust estimation of the population-wide impact of replacing sodium chloride with potassium-enriched salt substitutes.

Engagement in healthy lifestyle behaviors is suboptimal. The vast majority of the US population does not meet current recommendations. A healthy lifestyle is defined by consuming a healthy dietary pattern, engaging in regular physical activity, avoiding exposure to tobacco products, habitually attaining adequate amounts of sleep, and managing stress levels. For all these health behaviors there are well-established guidelines; however, promotion in clinical settings can be challenging. It is critical to overcome these challenges because greater promotion of heathy lifestyle practices in clinical settings effectively motivates and initiates patient behavior change. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with requisite attention to the demands of clinical settings. In this science advisory, we present strategies, based on the 5A Model, that clinicians and other health care professionals can use for efficient lifestyle-related behavior change counseling in patients at all levels of cardiovascular disease risk at every visit. In addition, we discuss the underlying role of psychological health and well-being in lifestyle-related behavior change counseling, and how clinicians can leverage health technologies when providing brief patient-centered counseling. Greater attention to healthy lifestyle behaviors during routine clinician visits will contribute to promoting cardiovascular health.

Avocados are a nutrient-dense plant-food, but limited trial-derived evidence exists about the effects of avocado intake on family nutritional status. We investigated the impact of two levels of avocado allotment, plus a standard nutrition education intervention on the nutritional status of Hispanic/Latino families. Seventy-two families consisting of at least three members of ≥5 years of age and residing in the same home, free of severe chronic disease, not on specific diets, and self-identified of Hispanic heritage, were randomized to one of two levels of avocado allotment (low = 3/week/family or high = 14/week/family) for 6 months plus 12 bi-weekly nutrition education sessions. The primary outcomes included change in a family’s total energy and macro- and micronutrient intakes. Primary analysis was intention-to-treat with unpaired, two-sided t-tests to assess mean changes between groups at 6 months. At 6 months, the high avocado allotment group had a significant reduction in energy intake, carbohydrate, animal and vegetable protein, saturated and polyunsaturated fat, calcium, magnesium, sodium, potassium, iron, and vitamin D intakes (all p &lt, 0.05). A high allotment of avocados significantly reduced self-reported energy intake by 29% kcal/family/day, compared to a 3% kcal/family/day reduction in families who received a low allotment. Culturally-appropriate plant-food interventions may alter the nutritional status of at-risk families.

In the general population, an increased potassium (K) intake lowers blood pressure (BP). The effects of K have not been well-studied in individuals with chronic kidney disease (CKD). This randomized feeding trial with a 2-period crossover design compared the effects of diets containing 100 and 40 mmol K/day on BP in 29 adults with stage 3 CKD and treated or untreated systolic BP (SBP) 120–159 mmHg and diastolic BP (DBP) &lt, 100 mmHg. The primary outcome was 24 hour ambulatory systolic BP. The higher- versus lower-K diet had no significant effect on 24 hour SBP (−2.12 mm Hg, p = 0.16) and DBP (−0.70 mm Hg, p = 0.44). Corresponding differences in clinic BP were −4.21 mm Hg for SBP (p = 0.054) and −0.08 mm Hg for DBP (p = 0.94). On the higher-K diet, mean serum K increased by 0.21 mmol/L (p = 0.003) compared to the lower-K diet, two participants had confirmed hyperkalemia (serum K ≥ 5.5 mmol/L). In conclusion, a higher dietary intake of K did not lower 24 hour SBP, while clinic SBP reduction was of borderline statistical significance. Additional trials are warranted to understand the health effects of increased K intake in individuals with CKD.

BACKGROUND Uromodulin modulates the sodium-potassium-two-chloride transporter in the thick ascending limb of the loop of Henle, and its overexpression in murine models leads to salt-induced hypertension. We hypothesized that individuals with higher baseline levels of urine uromodulin would have a greater increase in systolic blood pressure (SBP) for the same increase in sodium compared with those with lower uromodulin levels. METHODS We used data from 157 subjects randomized to the control diet of the Dietary Approaches to Stop Hypertension (DASH)-Sodium trial who were assigned to 30 days of low (1,500 mg/d), medium (2,400 mg/d), and high salt (3,300 mg/d) diets in random order. Blood pressure was measured prerandomization and then weekly during each feeding period. We evaluated the association of prerandomization urine uromodulin with change in SBP between diets, as measured at the end of each feeding period, using multivariable linear regression. RESULTS Baseline urine uromodulin stratified by tertiles was ≤17.64, 17.65–31.97, and ≥31.98 µg/ml. Across the tertiles, there were no significant differences in SBP at baseline, nor was there a differential effect of sodium diet on SBP across tertiles (low to high, P = 0.81). After adjusting for age, sex, body mass index, and race, uromodulin levels were not significantly associated with SBP change from low to high sodium diet (P = 0.42). CONCLUSIONS In a randomized trial of different levels of salt intake, higher urine uromodulin levels were not associated with a greater increase in blood pressure in response to high salt intake.

Trials of intensive glucose control have not improved cardiovascular disease (CVD) risk in populations with type 2 diabetes; however, in the general population, reports are inconsistent about the effects of maintaining lower glucose levels. Some speculate that low glycemic values are associated with increased glycemic variability, which is in turn associated with higher CVD risk. It has also been suggested that fasting glucose and hemoglobin A1c (HbA1c) in the lower ranges have a different relationship with CVD and mortality. In 4990 participants from the Multi-Ethnic Study of Atherosclerosis, we used logistic regression to investigate associations of low fasting glucose (

Physical inactivity and unhealthy diet are modifiable behaviors that lead to several cancers. Biologically, these behaviors are linked to cancer through obesity-related insulin resistance, inflammation, and oxidative stress. Individual strategies to change physical activity and diet are often short lived with limited effects. Interventions are expected to be more successful when guided by multi-level frameworks that include environmental components for supporting lifestyle changes. Understanding the role of environment in the pathways between behavior and cancer can help identify what environmental conditions are needed for individual behavioral change approaches to be successful, and better recognize how environments may be fueling underlying racial and ethnic cancer disparities. This cross-sectional study was designed to select participants (n = 602 adults, 40% Hispanic, in San Diego County) from a range of neighborhoods ensuring environmental variability in walkability and food access. Biomarkers measuring cancer risk were measured with fasting blood draw including insulin resistance (fasting plasma insulin and glucose levels), systemic inflammation (levels of CRP), and oxidative stress measured from urine samples. Objective physical activity, sedentary behavior, and sleep were measured by participants wearing a GT3X+ ActiGraph on the hip and wrist. Objective measures of locations were obtained through participants wearing a Qstarz Global Positioning System (GPS) device on the waist. Dietary measures were based on a 24-h food recall collected on two days (weekday and weekend). Environmental exposure will be calculated using static measures around the home and work, and dynamic measures of mobility derived from GPS traces. Associations of environment with physical activity, obesity, diet, and biomarkers will be measured using generalized estimating equation models. Our study is the largest study of objectively measured physical activity, dietary behaviors, environmental context/exposure, and cancer-related biomarkers in a Hispanic population. It is the first to perform high quality measures of physical activity, sedentary behavior, sleep, diet and locations in which these behaviors occur in relation to cancer-associated biomarkers including insulin resistance, inflammation, impaired lipid metabolism, and oxidative stress. Results will add to the evidence-base of how behaviors and the built environment interact to influence biomarkers that increase cancer risk. ClinicalTrials.gov NCT02094170 , 03/21/2014.

Introduction: In individuals with chronic kidney disease (CKD), healthy dietary patterns are inversely associated with CKD progression. Metabolomics, an approach which measures many small molecules in biofluids, can identify biomarkers of healthy dietary patterns and elucidate metabolic pathways underlying diet-disease associations. Hypothesis: We hypothesized that adherence to 4 healthy dietary patterns would be associated with a set of known metabolites in CKD patients. Methods: We examined associations between 634 plasma metabolites assessed using the Broad platform at year 1 and Healthy Eating Index (HEI)-2015, Alternative Healthy Eating Index (AHEI)-2010, the Dietary Approaches to Stop Hypertension (DASH) diet, and alternate Mediterranean diet (aMED), and their food components in 1,117 participants in the CRIC Study. Usual dietary intakes were assessed using a food frequency questionnaire at baseline and year 2. We conducted multivariable linear regression models to study associations between diet scores and individual plasma metabolites, adjusting for sociodemographic characteristics, health behaviors, and clinical factors. Results: After Bonferroni correction, we identified a total of 362 diet-metabolite associations (HEI=78; AHEI=127; DASH=97; aMED=60), and 101 metabolites were associated with more than 1 dietary pattern. The most common metabolite categories were triacylglycerols and diacylglycerols. Most lipids were negatively associated with healthy dietary patterns, except for cholesterols esters and triacylglycerols with ≥7 double bonds. Triacylglycerols with high number of double bonds were positively associated with healthy fat intake (e.g., higher monounsaturated and polyunsaturated fatty acid, omega-3 fatty acid, fish) within HEI, AHEI, and aMED ( Table ). Conclusions: We identified many metabolites associated with healthy dietary patterns, indicative of food consumption. If replicated, they may be considered biomarkers of healthy dietary patterns in CKD patients.

This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman’s risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD. Adopting a heart-healthy diet and increasing physical activity among women with APOs, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk. Lactation and breastfeeding may lower a woman’s later cardiometabolic risk. Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs and CVD in non-White women are needed to better understand and address these health disparities. Future studies of aspirin, statins, and metformin may better inform our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.

Purpose of Review The dietary reference intake (DRI) for sodium has been highly debated with persuasive and elegant arguments made for both population sodium reduction and for maintenance of the status quo. After the 2015 Dietary Guidelines Advisory Committee (DGAC) report was published, controversy ensued, and by Congressional mandate, the sodium DRIs were updated in 2019. The 2019 DRIs defined adequate intake (AI) levels by age–sex groups that are largely consistent with the DRIs for sodium that were published in 2005. Given the overall similarities between the 2005 and 2019 DRIs, one may wonder how the recently published research on sodium and health outcomes was considered in determining the DRIs, particularly, the recent studies from very large observational cohort studies. We aim to address this concern and outline the major threats to ascertaining valid estimates of the relationship between dietary sodium and health outcomes in observational cohort studies. We use tools from modern epidemiology to demonstrate how unexpected and inconsistent findings in these relationships may emerge. We use directed acyclic graphs to illustrate specific examples in which biases may occur. Recent Findings We identified the following key threats to internal validity: poorly defined target intervention, poorly measured sodium exposure, unmeasured or residual confounding, reverse causality, and selection bias. Researchers should consider these threats to internal validity while developing research questions and throughout the research process. Summary For the DRIs to inform real-world interventions relating to sodium reduction, it is recommended that more specific research questions be asked that can clearly define potential interventions of interest.

Author(s): Gunn, Robert A; Bellettiere, John; Garfein, Richard S; Long, Kanya C; Binkin, Nancy J; Anderson, Cheryl AM

Introduction: Social connectedness (SC) is an important determinant of maintaining overall health, and the strength of connections with others may influence cardiovascular health (CVH) in part through improvement in cardiovascular disease risk factors. However, there is a lack of research on the role of SC in promoting CVH, as defined by the American Heart Association’s 2020 Impact Goals. The objective of this study is to determine the effect of SC on CVH among adults. Hypothesis: Higher SC will be associated with higher odds of optimal CVH, relative to inadequate CVH. Methods: Data are from the Community of Mine study, a cross-sectional study of 602 participants (42% Hispanic, 56% female, mean age 59 years) living in San Diego County. CVH was based on Life’s Simple 7 using six metrics including smoking, physical activity, body mass index, total cholesterol, blood pressure, and fasting glucose. A 12-point summary score was used to classify participants as having inadequate (0-6), average (7-8), or optimal (9-12) CVH. SC was assessed using a 7-item scale designed to assess social relationships and strength of connections with others (Cronbach’s alpha=0.92). A mean score across all items was generated. Multinomial logistic regression was used to estimate the association between SC and CVH. We adjusted for age, race/ethnicity, governmental cash assistance, income, education, sex, history of medical comorbidities, family history of heart disease, and depressive symptoms. Results: SC was independently associated with CVH (p=0.04). More specifically, a 1-unit increase in mean SC score was associated with a 46% increase in relative odds of having optimal CVH compared to inadequate CVH (OR=1.46, 95% CI: 1.07-1.98), and a 21% increase in relative odds of having average CVH compared to inadequate CVH (OR=1.21, 95% CI: 0.96-1.52). Conclusions: Higher social connectedness is associated with a greater likelihood of having optimal CVH. Individuals’ perceptions of the strength of their relationships could have cardioprotective benefits through promotion of favorable cardiovascular health behaviors and factors.

BACKGROUND: Despite the rising popularity of plant-based alternative meats, there is limited evidence of the health effects of these products. OBJECTIVES: We aimed to compare the effect of consuming plant-based alternative meat (Plant) as opposed to animal meat (Animal) on health factors. The primary outcome was fasting serum trimethylamine-N-oxide (TMAO). Secondary outcomes included fasting insulin-like growth factor 1, lipids, glucose, insulin, blood pressure, and weight. METHODS: SWAP-MEAT (The Study With Appetizing Plantfood—Meat Eating Alternatives Trial) was a single-site, randomized crossover trial with no washout period. Participants received Plant and Animal products, dietary counseling, lab assessments, microbiome assessments (16S), and anthropometric measurements. Participants were instructed to consume ≥2 servings/d of Plant compared with Animal for 8 wk each, while keeping all other foods and beverages as similar as possible between the 2 phases. RESULTS: The 36 participants who provided complete data for both crossover phases included 67% women, were 69% Caucasian, had a mean ± SD age 50 ± 14 y, and BMI 28 ± 5 kg/m(2). Mean ± SD servings per day were not different by intervention sequence: 2.5 ± 0.6 compared with 2.6 ± 0.7 for Plant and Animal, respectively (P = 0.76). Mean ± SEM TMAO concentrations were significantly lower overall for Plant (2.7 ± 0.3) than for Animal (4.7 ± 0.9) (P = 0.012), but a significant order effect was observed (P = 0.023). TMAO concentrations were significantly lower for Plant among the n = 18 who received Plant second (2.9 ± 0.4 compared with 6.4 ± 1.5, Plant compared with Animal, P = 0.007), but not for the n = 18 who received Plant first (2.5 ± 0.4 compared with 3.0 ± 0.6, Plant compared with Animal, P = 0.23). Exploratory analyses of the microbiome failed to reveal possible responder compared with nonresponder factors. Mean ± SEM LDL-cholesterol concentrations (109.9 ± 4.5 compared with 120.7 ± 4.5 mg/dL, P = 0.002) and weight (78.7 ± 3.0 compared with 79.6 ± 3.0 kg, P

Implementation of prevention policies has often been impeded or delayed due to the lack of randomized controlled trials (RCTs) with hard clinical outcomes (eg, incident disease, mortality). Despite the prominent role of RCTs in health care, it may not always be feasible to conduct RCTs of public health interventions with hard outcomes due to logistical and ethical considerations. RCTs may also lack external validity and have limited generalizability. Currently, there is insufficient guidance for policymakers charged with establishing evidence-based policy to determine whether an RCT with hard outcomes is needed before policy recommendations. In this context, the purpose of this article is to assess, in a case study, the feasibility of conducting an RCT of the oft-cited issue of sodium reduction on cardiovascular outcomes and then propose a framework for decision-making, which includes an assessment of the feasibility of conducting an RCT with hard clinical outcomes when such trials are unavailable. We designed and assessed the feasibility of potential individual- and cluster-randomized trials of sodium reduction on cardiovascular outcomes. Based on our assumptions, a trial using any of the designs considered would require tens of thousands of participants and cost hundreds of millions of dollars, which is prohibitively expensive. Our estimates may be conservative given several key challenges, such as the unknown costs of sustaining a long-term difference in sodium intake, the effect of differential cotreatment with antihypertensive medications, and long lag time to clinical outcomes. Thus, it would be extraordinarily difficult to conduct such a trial, and despite the high costs, would still be at substantial risk for a spuriously null result. A robust framework, such as the one we developed, should be used to guide policymakers when establishing evidence-based public health interventions in the absence of trials with hard clinical outcomes.

It is critical that diet quality be assessed and discussed at the point of care with clinicians and other members of the healthcare team to reduce the incidence and improve the management of diet-related chronic disease, especially cardiovascular disease. Dietary screening or counseling is not usually a component of routine medical visits. Moreover, numerous barriers exist to the implementation of screening and counseling, including lack of training and knowledge, lack of time, sense of futility, lack of reimbursement, competing demands during the visit, and absence of validated rapid diet screener tools with coupled clinical decision support to identify actionable modifications for improvement. With more widespread use of electronic health records, there is an enormous unmet opportunity to provide evidence-based clinician-delivered dietary guidance using rapid diet screener tools that must be addressed. In this scientific statement from the American Heart Association, we provide rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.

Background and PurposeChildbirth can have negative consequences; however, measurement tools to assess this event are limited; and none consider the adolescent's birth. This study assessed the psychometric properties of the childbirth trauma index (CTI).MethodsConstruct validity and reliability of the CTI was assessed via a field test involving 160 adolescents 3 days postpartum.ResultsA modified 8-item version of the original CTI exhibited acceptable construct validity and reliability criteria. The CTI was found to link with birth appraisal, but not subjective distress measurements.ConclusionsThe CTI may be a more robust means of assessing birth appraisal than use of single-item measures. Recommendations for practice suggest use of the modified CTI to assess birth appraisal, or use in combination with single-item rating scales

OBJECTIVES: Avocados are nutrient-dense and could be a favorable component of a healthy dietary pattern, yet there are limited data on the effects of avocado intake on nutritional status. To test if avocados impact energy intake, we examined the effects of two levels of avocado intake, plus a standard nutrition education intervention, on energy and nutrient intake in families of Hispanic Heritage. METHODS: Between April 2017 and June 2018, we conducted a cluster randomized controlled trial in families consisting of at least 3 members residing in the same home, at least 5 years of age, free of severe chronic disease, not on specific diets, and self-identified of Hispanic heritage. Seventy-two (n = 72) families were randomized to one of two groups: nutrition education with low avocado allotment (3 avocados/family/week) or nutrition education with high avocado allotment (14 avocados/family/week). Community health workers (i.e., Promotoras) led 12 bi-weekly in-home nutrition education sessions per family and delivered weekly avocado allotments. Dietary patterning, energy and nutrient intake were measured at baseline, and after 3- and 6-months. The primary outcome was change in a family's total energy intake after 6 months. Secondary outcome measures included differences in macro- and micronutrients between groups. RESULTS: Over the 6-month follow-up period, the mean difference in energy intake for the high versus low avocado intervention group was −1884 kcals/family/day (95% CI −3205 to −563 kcals, P

In the field of human nutrition, randomized controlled trials (RCTs) are considered the gold standard for establishing causal relations between exposure to nutrients, foods, or dietary patterns and prespecified outcome measures, such as body composition, biomarkers, or event rates. Evidence-based dietary guidance is frequently derived from systematic reviews and meta-analyses of these RCTs. Each decision made during the design and conduct of human nutrition RCTs will affect the utility and generalizability of the study results. Within the context of limited resources, the goal is to maximize the generalizability of the findings while producing the highest quality data and maintaining the highest levels of ethics and scientific integrity. The aim of this document is to discuss critical aspects of conducting human nutrition RCTs, including considerations for study design (parallel, crossover, factorial, cluster), institutional ethics approval (institutional review boards), recruitment and screening, intervention implementation, adherence and retention assessment, and statistical analyses considerations. Additional topics include distinguishing between efficacy and effectiveness, defining the research question(s), monitoring biomarker and outcome measures, and collecting and archiving data. Addressed are specific aspects of planning and conducting human nutrition RCTs, including types of interventions, inclusion/exclusion criteria, participant burden, randomization and blinding, trial initiation and monitoring, and the analysis plan.

Background Sugar‐sweetened beverage ( SSB ) consumption has been associated with cardiometabolic risk. However, the association between total and type of SSB intake and incident cardiovascular disease ( CVD ) end points such as myocardial infarction, stroke, and revascularization is limited. Methods and Results We examined the prospective association of baseline SSB consumption with incident CVD in 106 178 women free from CVD and diabetes mellitus in the CTS (California Teachers Study), a cohort of female teachers and administrators, followed since 1995. SSB s were defined as caloric soft drinks, sweetened bottled waters or teas, and fruit drinks, and derived from a self‐administered food frequency questionnaire. CVD end points were based on annual linkage with statewide inpatient hospitalization records. Cox proportional hazards models were used to assess the association between SSB consumption and incident CVD . A total of 8848 CVD incident cases were documented over 20 years of follow‐up. After adjusting for potential confounders, we observed higher hazard ratios ( HRs ) for CVD (HR, 1.19; 95% CI, 1.06–1.34), revascularization (HR, 1.26; 95% CI, 1.04–1.54]), and stroke (HR, 1.21; 95% CI, 1.04–1.41) in women who consumed ≥1 serving per day of SSB s compared with rare/never consumers. We also observed a higher risk of CVD in women who consumed ≥1 serving per day of fruit drinks (HR, 1.42; 95% CI, 1.00–2.01 [ P trend=0.021]) and caloric soft drinks (HR, 1.23; 95% CI, 1.05–1.44 [ P trend=0.0002]), compared with rare/never consumers. Conclusions Consuming ≥1 serving per day of SSB was associated with CVD , revascularization, and stroke. SSB intake might be a modifiable dietary target to reduce risk of CVD among women.

Background Healthy diet is essential in the management of chronic kidney disease (CKD) and preventing related comorbidities. Food outlet access has been studied in the general population; however, the influence of the local food environment on dietary intake among people with CKD has not been evaluated. Objectives This study examined the associations of food outlet density and type of outlets with dietary intake in a multicenter cohort of racially and ethnically diverse patients with CKD. Methods The Chronic Renal Insufficiency Cohort Study is a multicenter prospective study of patients with CKD that used a validated food frequency questionnaire to capture dietary intake at the baseline visit. This is a cross-sectional analysis of 2,484 participants recruited in 2003-2006 from seven Chronic Renal Insufficiency Cohort Study centers. Food outlet data were used to construct a count of the number of fast-food restaurants, convenience stores, and grocery stores per 10,000 population for each geocoded census block group. Multivariable linear and logistic regression models were used to evaluate the associations between measures of food outlet availability and dietary factors. Results The proportion of participants living in zero–, low–, and high–food outlet density areas differed by gender, race or ethnicity, and income level. Among male subjects, living in areas with zero or the highest number of outlets was associated with having the highest caloric intakes in multivariable models. Male subjects living in areas with zero outlets consumed the highest levels of sodium and phosphorous. Female subjects living in areas with zero outlets had the lowest average intake of calories, sodium, and phosphorous. Among low-income female subjects, close proximity to more outlets was associated with higher calorie consumption. Among all participants, access to fast-food restaurants was not associated with an unhealthy diet score, and access to grocery stores was not associated with a healthy diet score. Conclusions Average caloric and nutrient intakes differed by outlet availability; however, there were no strong associations with type of food outlet. This should be considered when developing food-focused public health policies.

Introduction: Genome-wide association studies have revealed susceptibility variants for hypertension in the UMOD gene. The encoded protein, uromodulin, modulates NKCC2 transporter in the thick ascending limb of the loop of Henle, and its overexpression in murine models leads to salt-induced hypertension. Hypothesis: Individuals with higher levels of urine uromodulin will have a greater increase in systolic blood pressure compared to those with lower uromodulin levels. Methods: We used data from 157 subjects in the control diet of the DASH-Sodium trial assigned to 30 days of low (1500 mg/d), medium (2400 mg/d), and high salt (3300 mg/d) diets in random order. Blood pressure was measured at baseline and at 5 visits during the last 9 days of each feeding period. We evaluated the association of urine uromodulin with change in systolic blood pressure between diets, as measured by the average at the end of each feeding period, using multivariable linear regression. Results: Baseline urine uromodulin stratified by tertiles was less than or equal to 17.64, 17.65 - 31.97, and greater than or equal to 31.98 μg/mL (overall mean 30.0 μg/mL, SEM 1.85 μg/mL). Across the tertiles, there were no significant differences in systolic blood pressure (SBP) at baseline, nor was there a differential effect of sodium diet on SBP across tertiles (low to high p = 0.81, Figure). After adjusting for age, sex, BMI, and race, uromodulin levels were not significantly associated with SBP change from low to high sodium diet (β = -0.68 per 10 μg/mL increase in urine uromodulin, p = 0.28). Conclusion: In a randomized trial of different levels of salt intake, higher urine uromodulin levels were not associated with a greater increase in blood pressure in response to high salt intake. Further human studies are needed to evaluate the findings seen in animal models, where the expression of higher levels of urine uromodulin has been associated with salt sensitive hypertension.

Each decade, the American Heart Association (AHA) develops an Impact Goal to guide its overall strategic direction and investments in its research, quality improvement, advocacy, and public health programs. Guided by the AHA’s new Mission Statement, to be a relentless force for a world of longer, healthier lives, the 2030 Impact Goal is anchored in an understanding that to achieve cardiovascular health for all, the AHA must include a broader vision of health and well-being and emphasize health equity. In the next decade, by 2030, the AHA will strive to equitably increase healthy life expectancy beyond current projections, with global and local collaborators, from 66 years of age to at least 68 years of age across the United States and from 64 years of age to at least 67 years of age worldwide. The AHA commits to developing additional targets for equity and well-being to accompany this overarching Impact Goal. To attain the 2030 Impact Goal, we recommend a thoughtful evaluation of interventions available to the public, patients, providers, healthcare delivery systems, communities, policy makers, and legislators. This presidential advisory summarizes the task force’s main considerations in determining the 2030 Impact Goal and the metrics to monitor progress. It describes the aspiration that these goals will be achieved by working with a diverse community of volunteers, patients, scientists, healthcare professionals, and partner organizations needed to ensure success.

ObjectiveTo examine the dose-response relation between reduction in dietary sodium and blood pressure change and to explore the impact of intervention duration.DesignSystematic review and meta-analysis following PRISMA guidelines.Data sourcesOvid MEDLINE(R), EMBASE, and Cochrane Central Register of Controlled Trials (Wiley) and reference lists of relevant articles up to 21 January 2019.Inclusion criteriaRandomised trials comparing different levels of sodium intake undertaken among adult populations with estimates of intake made using 24 hour urinary sodium excretion.Data extraction and analysisTwo of three reviewers screened the records independently for eligibility. One reviewer extracted all data and the other two reviewed the data for accuracy. Reviewers performed random effects meta-analyses, subgroup analyses, and meta-regression.Results133 studies with 12 197 participants were included. The mean reductions (reduced sodiumvusual sodium) of 24 hour urinary sodium, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were 130 mmol (95% confidence interval 115 to 145, PConclusionsThe magnitude of blood pressure lowering achieved with sodium reduction showed a dose-response relation and was greater for older populations, non-white populations, and those with higher blood pressure. Short term studies underestimate the effect of sodium reduction on blood pressure.Systematic review registrationPROSPERO CRD42019140812.

The elimination of specific dietary cholesterol target recommendations in recent guidelines has raised questions about its role with respect to cardiovascular disease. This advisory was developed after a review of human studies on the relationship of dietary cholesterol with blood lipids, lipoproteins, and cardiovascular disease risk to address questions about the relevance of dietary cholesterol guidance for heart health. Evidence from observational studies conducted in several countries generally does not indicate a significant association with cardiovascular disease risk. Although meta-analyses of intervention studies differ in their findings, most associate intakes of cholesterol that exceed current average levels with elevated total or low-density lipoprotein cholesterol concentrations. Dietary guidance should focus on healthy dietary patterns (eg, Mediterranean-style and DASH [Dietary Approaches to Stop Hypertension]–style diets) that are inherently relatively low in cholesterol with typical levels similar to the current US intake. These patterns emphasize fruits, vegetables, whole grains, low-fat or fat-free dairy products, lean protein sources, nuts, seeds, and liquid vegetable oils. A recommendation that gives a specific dietary cholesterol target within the context of food-based advice is challenging for clinicians and consumers to implement; hence, guidance focused on dietary patterns is more likely to improve diet quality and to promote cardiovascular health.

Few studies have investigated the association between ectopic fat from different depots and cardiovascular risk scores and their components in the same population, and none have investigated these relations in South Asians. In a cross-sectional analysis of 796 participants in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study who had measurements of visceral, subcutaneous, pericardial, hepatic, and intermuscular fat from abdominal and cardiac computed tomography scans, we used linear regression to determine the associations of 1 standard deviation difference in each ectopic fat depot with pooled cohort risk score and its components. Pericardial and visceral fat were more strongly associated with the pooled cohort risk score (3.1%, 95% confidence interval [CI] 2.5 to 3.7, and 2.7%, 95% CI 2.1 to 3.3, respectively) and components than intermuscular fat (2.3%, 95% CI 1.7 to 3.0); subcutaneous fat was inversely associated with the pooled cohort risk score (-2.6%, 95% CI -3.2 to 1.9) and hepatic fat attenuation was not linearly associated with the pooled cohort risk score when mutually adjusted (-0.3%, 95% CI -0.9 to 0.4). Associations for risk factor components differed by fat depot. In conclusion, subcutaneous and hepatic fat may have different functions than fat stored in other depots in South Asians. Determining whether these relations are heterogeneous by race may help elucidate the mechanisms underlying CVD disparities.

T50 is a novel serum-based marker that assesses the propensity of calcification in serum. Shorter T50 indicates greater propensity to calcify and it has been associated to cardiovascular disease (CVD) and mortality among patients with kidney disease. In the general population, neither the correlates of T50 nor the relationships of T50 with bone mineral density (BMD) are known. We performed a nested cross-sectional study selecting 150 individuals at random among participants from the Osteoporotic Fractures in Men (MrOS) Study, a study of community-living older men. We categorized individuals into tertiles of T50 and compared demographics and disease indicators across tertiles. We utilized linear regression to evaluate the cross-sectional association between T50 and hip and spine BMD in multivariable models. Older age was associated with shorter T50. Kidney function tended to be lower in those with shorter T50 and the prevalence of CVD and peripheral arterial disease in those with shorter T50, albeit these findings did not achieve statistical significance. We found no statistically significant associations between T50 and total hip or total spine BMD in either unadjusted or multivariable adjusted models. T50, a novel indicator of serum calcification propensity, is not associated with BMD in community-living older men. Future larger studies should determine if T50 may give insights to CVD in the general population above and beyond traditional risk factors.

Background Visceral fat has been shown to be associated with increased cardiometabolic risk, but the role of subcutaneous fat remains unclear, and evidence from diverse populations is lacking. We hypothesized that visceral fat, but not subcutaneous fat, would be independently associated with incident cardiovascular disease (CVD) and all-cause mortality. Methods Among 1910 participants from the Multi-Ethnic Study of Atherosclerosis with abdominal fat measurements from computed tomography scans and followed for an average of 9.3 years, we used multivariable Cox proportional hazards models to investigate the relationship of both visceral and subcutaneous fat tertiles with CVD and all-cause mortality. We tested for interaction and performed sensitivity analysis for subgroups and missing values of visceral fat. Results Participants had mean age of 65 years, visceral fat 150 cm2, subcutaneous fat 263 cm2, and 50% were female, 21% African American, 13% Asian, and 26% Hispanic. In models adjusted for age, sex, race/ethnicity, income, education, smoking, and subcutaneous fat, there was a statistically significant positive association between visceral fat and CVD, but not mortality. The association for combined CVD may be driven by incident coronary heart disease [tertile 2: hazard ratio, 2.43 (1.38 to 4.28); tertile 3: hazard ratio, 3.00 (1.66 to 5.43)]. Additionally, we found no substantial associations between subcutaneous fat and CVD or mortality. There were no statistically significant interactions by age, sex, or race/ethnicity. Conclusions Visceral fat, but not subcutaneous fat, is significantly associated with increased risk for CVD in a multiethnic cohort. These data support the need for effective strategies for lifestyle changes that prevent and reduce visceral fat.

ObjectiveThe Farmers’ Market Fresh Fund Incentive Program is a policy, systems and environmental intervention to improve access to fresh produce for participants on governmental assistance in the USA. The current study examined factors associated with ongoing participation in this matched monetary incentive programme.DesignRelationship of baseline factors with number of Fresh Fund visits was assessed using Poisson regression. Mixed-effects modelling was used to explore changes in consumption of fruits and vegetables and diet quality.SettingSan Diego, California.SubjectsRecipients of Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Supplemental Security Income (SSI) who attended participating farmers’ markets from 2010 to 2012 (n 7298).ResultsAmong those with participation for ≤6 months, factors associated with increased visits included reporting more daily servings of fruits and vegetables (F&V) at baseline, being Vietnamese or Asian/Pacific Islander, and eligibility because of SNAP/CalFresh or SSI (v. WIC). Among those who came for 6–12 months, being Asian/Pacific Islander, eligibility because of SNAP/CalFresh and enrolling in the autumn, winter or spring were associated with a greater number of Fresh Fund visits. Among those who came for >12 months, being male and eligibility because of SSI were associated with a greater number of visits. Overall, the odds of increasing number of servings of F&V consumed increased by 2 % per month, and the odds of improved perception of diet quality increased by 10 % per month.ConclusionsSustaining and increasing Fresh Fund-type programme operations should be a top priority for future policy decisions concerning farmers’ market use in low-income neighbourhoods.

Healthful dietary patterns have a major role in healthy lifestyles and are necessary for cardiovascular health promotion. 1 Over the past decade, dietary patterns have been a focus of human nutrition research studies. This is largely because of the well-recognized fact that we do not eat nutrients, we eat foods, and that we do not eat foods in isolation, we eat them in patterns. As a result, evidence is mounting on the effectiveness of multiple dietary patterns in reducing body weight 2-4 and improving cardiovascular risk. 5-7 The specific components of these patterns, including the types of foods they include, macronutrient balance, and amount of energy deficit created (if weight loss is desired), can impact adherence and effectiveness. In this issue of Circulation , Sofi et al 8 report findings from the CARDIVEG trial (Prevention of Cardiovascular Disease With the Vegetarian Diet) conducted in Florence, Italy, from 2014 to 2015. Participants in the trial were overweight (body mass index ≥25 kg/m 2 ) and met one of the following criteria: total cholesterol >190 mg/dL, low-density lipoprotein cholesterol >115 mg/dL, triglyceride levels >150 mg/dL, and glucose levels >110 but

Background Authoritative medical and public health agencies in most countries advise to reduce population dietary salt intake to under 5–6 g/day as a strategy for preventing high blood pressure and cardiovascular disease. However, there is still dispute about whether salt reduction should be adopted by all populations. In addition, the effect of duration of dietary salt reduction has not been sufficiently investigated. Purpose To understand the effect of dietary salt reduction on blood pressure and the impact of intervention duration. Methods A systematic review and meta-analysis was conducted. Randomized controlled trials that allocated participants to low and high salt intake, without confounding from unequal concomitant interventions, were included. We excluded studies done in individuals younger than 18 years, pregnant women, individuals with renal disease or heart failure, and studies with sodium excretion estimated from spot urine. Random effect meta-analysis was used to generate pooled estimates of the effect on 24-hour urinary sodium excretion, systolic and diastolic blood pressure. Multivariate meta-regression was used to quantify the dose response effect of dietary salt on blood pressure change and to understand the impact of the intervention duration. Results 125 studies were included with 162 data points extracted. Ninety-nine data points (61%) had interventions under 4 weeks. Overall, 24-hour urinary sodium excretion changed by −141 mmol (95% CI: −156; −126), systolic blood pressure changed by −4.4 mm Hg (95% CI: −5.2; −3.7) and diastolic blood pressure changed by −2.4 mm Hg (95% CI: −2.9; −1.9). Sodium reduction resulted in a significant decrease of systolic blood pressure in all subgroups except in participants with low baseline sodium intake ( Figure 1 Conclusions Our meta-analysis showed that sodium reduction could reduce blood pressure in all adult populations regardless of age, sex and race. The effect of salt reduction on systolic blood pressure increases with higher baseline blood pressure. Further studies, designed to investigate the impact of intervention duration, are needed to understand the significance of the duration. Acknowledgement/Funding None

Hypertension is the leading risk factor for global disease burden. Self-management of high blood pressure (BP) through self-monitoring and self-titration of medications, has proved to be one successful and cost-effective tool to achieve better BP control in many high-income countries but not much is known about its potential in low- and middle-income countries (LMICs). We used semi-structured questionnaires and focus groups in three LMICs; Peru, Cameroon and Malawi to examine perceptions and attitudes of patients diagnosed with essential hypertension towards living with hypertension, BP measurement and treatment, patient–physician relationship and opinions about self-management of high blood pressure. Results in all three countries were comparable. Patients showed varied levels of health literacy related to hypertension. BP measurement habits were mostly affected by resources available and caregiver support. Treatment and adherence to it were primarily affected by cost. Most patients were welcoming of the idea of self-management but skeptical about the ability to do self-monitoring accurately and the safety involving self-titration of medications.

Current dietary intakes of North Americans are inconsistent with the Dietary Guidelines for Americans . This occurs in the context of a food system that precludes healthy foods as the default choices. To develop a food system that is both healthy and sustainable requires innovation. This science advisory from the American Heart Association describes both innovative approaches to developing a healthy and sustainable food system and the current evidence base for the associations between these approaches and positive changes in dietary behaviors, dietary intakes, and when available, health outcomes. Innovation can occur through policy, private sector, public health, medical, community, or individual-level approaches and could ignite and further public-private partnerships. New product innovations, reformulations, taxes, incentives, product placement/choice architecture, innovative marketing practices, menu and product labeling, worksite wellness initiatives, community campaigns, nutrition prescriptions, mobile health technologies, and gaming offer potential benefits. Some innovations have been observed to increase the purchasing of healthy foods or have increased diversity in food choices, but there remains limited evidence linking these innovations with health outcomes. The demonstration of evidence-based improvements in health outcomes is challenging for any preventive interventions, especially those related to diet, because of competing lifestyle and environmental risk factors that are difficult to quantify. A key next step in creating a healthier and more sustainable food system is to build innovative system-level approaches that improve individual behaviors, strengthen industry and community efforts, and align policies with evidence-based recommendations. To enable healthier food choices and favorably impact cardiovascular health, immediate action is needed to promote favorable innovation at all levels of the food system.