Weight loss, minimal sodium intake reduces cardiometabolic risk

BOSTON — Participating in a weight-loss program and managing sodium intake can help reduce the risk for and effects of cardiometabolic disease, according to presentations at the Cardiometabolic Health Conference in Boston.

Micronutrients, BP

“The dietary intake of micronutrients, individually as well as in combinations, can have significant impacts on blood pressure,” Jamy D. Ard, MD, professor in the department of epidemiology and prevention at Wake Forest School of Medicine in Winston-Salem, North Carolina, said during a presentation.

Ard said micronutrients including sodium, potassium, calcium and magnesium in addition to a limited intake of added sugar can help control BP, which can be achieved with a Dietary Approaches to Stop Hypertension (DASH) diet.

Although sodium is highly debated, clinicians agree that those who have a diet high in sodium typically have higher BPs, and reducing it in a diet can help reduce BP.

“No matter where start, if you have someone reduce their sodium intake by about 1,000 mg per day, you can see clinically meaningful reductions in blood pressure,” Ard said.

The INTERSALT study published in the BMJ in 1988 analyzed sodium intake across different populations. Researchers found that as sodium intake increased, BP increased, and the age-related BP increase was greater in those with a higher intake.

In the DASH-Sodium trial published in The New England Journal of Medicine in 2001, patients were assigned to receive specific diets of varying sodium levels. Increased consumption of sodium was also linked to increased BP, but once the sodium intake decreased from 8 grams of salt per day to 4 grams per day, systolic BP decreased by 7 mm Hg and diastolic BP declined by 3 mm Hg. The decreases were seen in patients with high BP and high normal BP.

“This is showing that this method of lowering blood pressure with sodium reduction is not just for people with hypertension, but also for people who have early signs of prehypertension or early increases in blood pressure,” Ard said.

Both the INTERSALT and DASH-Sodium studies helped develop sodium intake recommendations, including those in the American Heart Association/American College of Cardiology Guideline on Lifestyle Management to Reduce Cardiovascular Risk, which suggest an intake of less than 2,400 mg per day, with an ideal intake of 1,500 mg per day.

Potassium is a key secondary micronutrient, according to the presentation.

“Potassium may be a really critical micronutrient because it can blunt the effects of sodium,” whose intake is not easy to control due to it being pervasive in the food supply, Ard said.

Patients who excrete more potassium have lower BP, but typically it is not consumed as much as it should be, according to the presentation. The DASH diet calls for 4,700 mg of potassium per 2,000 kcal, and patients often consume less than that.

Although there is not enough evidence to formulate recommendations on potassium intake, it is recommended to increase the intake of fruits and vegetables, Ard said.

Calcium and magnesium are also part of the DASH diet and can be found in nuts, low-fat dairy, fruits, vegetables and legumes. There is a lack of evidence to support that calcium and magnesium decrease BP by a certain amount, but it is known that it does contribute to a decrease, according to Ard.

Decreasing sodium intake can be difficult since 70% or more of intake is baked into the food supply, but a shift from processed to fresh foods can help in reducing sodium in a patient’s diet, and frozen foods and low-sodium alternatives can also reduce intake, according to the presentation.

“If someone picks up a label and says well this has 220 mg of sodium per serving, and they start to get scared away because 200 sounds like a big number, in the grand scheme of things, if you can make that dish yourself using that item and you can control all the other components of it, that’s a much better option than going out to the restaurant and having that same dish in a setting where you don’t control any of the components that go into it,” Ard said.

Macronutrients, CVD

Diet can greatly affect lipids and BP, Janet M. de Jesus, MS, RD, nutritionist in the Center for Translation Research and Implementation Science at the NHLBI, said during a presentation.

The DASH trial looked at dietary patterns and their effects on lowering BP. Patients assigned the DASH diet had a greater decrease in systolic and diastolic BP vs. those assigned a control diet, even with a similar sodium intake in both diets. LDL was reduced by 11 mg in patients assigned the DASH diet. There was no change in triglycerides and a minimal decrease in HDL. A similar lipid decrease was also seen in the DASH-Sodium trial, and a low saturated fat diet as seen in the DELTA trial reduced LDL by 11%.

The OMNI-Heart trial aimed to improve the DASH diet to reduce triglycerides. Ten percent of carbohydrates were replaced with protein in one arm and unsaturated fat in another arm. Triglycerides in the protein arm were reduced by 16.4 mg/dL and by 9.3 mg/dL in the unsaturated fat arm. HDL in the protein group was reduced more (2.6 mg/dL) vs. the unsaturated fat group (0.3 mg/dL).

“This is an improvement over DASH, but all of them are beneficial for LDL, but the protein arm ... had a more beneficial profile,” de Jesus said.

Researchers in the PREDIMED trial reviewed the effects of a Mediterranean diet on cardiac outcomes. Olive oil or nuts were supplemented in addition to behavioral counseling. The risk for the primary endpoint, which was stroke, acute MI or death from other CV causes, decreased by 30%.

The American population has a dietary intake of saturated fat, sugars and sodium above the recommended amounts, de Jesus said, noting the American Heart Association published a presidential advisory this year on dietary fat and CVD, and it emphasized that coconut oil has the most saturated oil.

“It’s kind of become a boutique oil,” de Jesus said. “I see it in my grocery stores in these lovely containers. It’s being used in all kinds of baked goods, but really it is the most saturated, more saturated than our palm oils, our butter, beef fat.”

Saturated fat is found in many foods, but mainly in fatty meats, cheese, desserts, high-fat items and pizza. Trans fats have been recognized as being unsafe and will not be added to foods starting 2018.

Reducing sugar intake can play a role in losing weight and reducing CV risk, she said.

“If someone asks me how can I lose weight, the first thing I ask them is what are you drinking,” de Jesus said. “Sugar-sweetened beverages are a major problem in the U.S. Almost half the added sugars that we eat come from drinks.”

Diet can greatly affect lipids and BP, Janet M. de Jesus, MS, RD, nutritionist in the Center for Translation Research and Implementation Science at the NHLBI, said during a presentation.

The DASH trial looked at dietary patterns and their effects on lowering BP. Patients assigned the DASH diet had a greater decrease in systolic and diastolic BP vs. those assigned a control diet, even with a similar sodium intake in both diets. LDL was reduced by 11 mg in patients assigned the DASH diet. There was no change in triglycerides and a minimal decrease in HDL. A similar lipid decrease was also seen in the DASH-Sodium trial, and a low saturated fat diet as seen in the DELTA trial reduced LDL by 11%.

The OMNI-Heart trial aimed to improve the DASH diet to reduce triglycerides. Ten percent of carbohydrates were replaced with protein in one arm and unsaturated fat in another arm. Triglycerides in the protein arm were reduced by 16.4 mg/dL and by 9.3 mg/dL in the unsaturated fat arm. HDL in the protein group was reduced more (2.6 mg/dL) vs. the unsaturated fat group (0.3 mg/dL).

“This is an improvement over DASH, but all of them are beneficial for LDL, but the protein arm … had a more beneficial profile,” de Jesus said.

Researchers in the PREDIMED trial tested the effects of a Mediterranean diet on cardiac outcomes. Olive oil or nuts were supplemented in addition to behavioral counseling. The risk for the primary endpoint, which was stroke, acute MI or death from other CV causes, decreased by 30%.

The American population has a dietary intake of saturated fat, sugars and sodium above the recommended amounts, de Jesus said, noting the American Heart Association published a presidential advisory this year on dietary fats and CVD, and it emphasized that coconut oil contains a high amount of saturated fat and increases LDL cholesterol.

“It’s kind of become a boutique oil,” de Jesus said. “I see it in my grocery stores in these lovely containers. It’s being used in all kinds of baked goods and in cooking, but really it contains a high amount of saturated, more saturated than palm oil, butter, beef fat.”

Saturated fat is found in many foods, but mainly in fatty meats, cheese, desserts and pizza. Trans fats have been recognized as being unsafe and will not be added to foods starting in June 2018.

Reducing sugar intake can play a role in losing weight and reducing CV risk, she said.

“If someone asks me how can I lose weight, the first thing I ask them is what are you drinking,” de Jesus said. “Sugar-sweetened beverages are a major problem in the U.S. Almost half the added sugars that we eat come from drinks.”

Weight management

Finding a successful weight-loss approach can help a patient throughout the process.

“For most of your patients, the way to do it is to go slowly,” John P. Foreyt, PhD, professor of medicine at Baylor College of Medicine in Houston, said in a presentation. “It makes the most sense. So what are the most successful behavioral strategies that will help you do that? You start with about a 10-pound weight loss in your 200-pound patient, so about a 5% weight loss will reduce cardiovascular, cardiometabolic risk factors in most of your patients, so over 6 months, focus on that first 10 pounds.”

Seeing patients more often can lead to successful weight loss. The clinician, commercial weight-loss group, dietician or nurse practitioner should see the patient about 14 times throughout the first 6 months, according to the presentation. This can be achieved through apps, phone calls and online meetings.

Although diets provide different approaches to weight loss, most of the diets that moderately reduce caloric intake are the same, but the main issue is adherence, Foreyt said.

Behavioral strategies can help patients adhere to their diet, including self-monitoring, stimulus control, stress management and social support, he said.

Self-monitoring includes the patient keeping a food diary, even though it is only a good independent variable. Patients often underreport their calories and overreport their exercise. Evidence shows that self-monitoring strategies are necessary, even if they are not always sufficient, he said.

“It’s a way to raise awareness of what your patient is eating, and that’s why you do it,” Foreyt said. “A monitoring system is to observe, record and feed back. The feedback can be fat, grams, calories, food groups or point systems.”

In data from the Look AHEAD study published in Obesity in 2014, patients kept a food diary for 2 weeks, and after 1 year, those who wrote more words had significantly greater weight loss compared with those who did not write as much.

Identifying triggers that cause binge eating, night eating or other nonadherent strategies can help control environmental stimuli, according to the presentation.

Nonadherence is also linked to stress, tension, anxiety, loneliness, depression, anger and boredom.

“All of these interact with eating too much or underexercising, so setting realistic goals, starting with that first 10 pounds, focusing on small changes make all the difference in the world,” Foreyt said.

Some examples of cognitive restructuring to aid in relieving stress include meditation, physical activity and progressive relaxation.

Social support systems are critical and can include health care professionals, 10-step weight loss programs, family members, peers and commercial groups, he said.

Significant factors in the first year of weight loss in patients from the Look AHEAD study published in Obesity in 2009 included physical activity, treatment attendance and meal replacements. Patients in the highest quartile of weekly physical activity lost 11.9% of their weight, and those in the lowest quartile lost 4.4%. Those in the highest quartile of meal replacements had 11% weight loss vs. 6% for the lowest quartile. Patients in the highest quartile of scheduled visits had a 11% weight reduction vs. 4.6% for those in the lowest quartile. Weight loss was maintained after 10 years.

In a Finnish diabetes prevention trial published in The New England Journal of Medicine in 2001, researchers found that the risk for diabetes was reduced by 58% in patients with impaired glucose intolerance who received individualized counseling on lifestyle changes vs. the control group.

“Focus on health, energy, fitness, well-being and functional definitions,” Foreyt said. “My success factor with a patient is the ability for my patient to play on the floor with their kids or their grandkids or walk up a flight of stairs without being out of breath. These are functional changes, and that improves with small changes in weight.” – by Darlene Dobkowski

References:

Ard JD.

de Jesus JM.

Foreyt JP. Cardiometabolic Disorders: Diet Quality, Quantity and Beyond. All presented at: Cardiometabolic Health Conference; Oct. 4-7, 2017; Boston.

Disclosure: Ard, de Jesus and Foreyt report no relevant financial disclosures.