Salt Reduction Dedicated to World Hypertension Day 2015 Edited by Hussain Isma'eel and Jacqui Webster June 2015

ISSN 2223-3652 Vol 5, No 3 June 2015 Cardiovascular Diagnosis and Therapy Diagnosis and Cardiovascular www.thecdt.org Focused Issue: Salt Reduction Dedicated to World Hypertension Day 2015 Edited by Hussain Isma'eel and Jacqui Webster June 2015. Volume 5 Number 3 Pages 169-248 ed Editorial Correspondence: Eunice X. Xu. Managing Editor, Cardiovascular Diagnosis and Therapy. HK office: Room 604, 6/F Hollywood Center, 77-91 Queen's road, Sheung Wan, Indexed in Pub Hong Kong. Tel: +852 3188 5078; Fax: +852 3188 5078. Email: [email protected] Editor-In-Chief Deputy Editor-in-Chief Associate and Guest Editors Paul Schoenhagen, MD Shao-Ping Nie, MD, FESC Julia Buntaine Ana Olga H Mocumbi, MD, PhD, Cleveland Clinic, Ohio, USA Beijing, China New York, USA FESC Grimm Lee Maputo, Mozambique Los Angeles, USA Editorial Board Suhny Abbara, MD Hussain Isma’eel, MD, FSCCT, Stephen J Nicholls, MD, PhD, Adriano R. Tonelli, MD Boston, USA FESC FRACP, FACC, FESC, FAHA, Cleveland, USA Carlos Aguiar, MD Beirut, Lebanon FCSANZ Shengxian Tu, PhD Carnaxide, Portugal Hasan Jilaihawi Adelaide, Australia Shanghai, China Wael AlJaroudi, MD Los Angeles, USA Hiroyuki Niinuma, MD, PhD Clemens von Birgelen, MD, PhD, New York, USA Christof Karmonik, PhD Tokyo, Japan FSCAI, FESC Thomas Bartel, MD, PhD, FESC Houston, USA Sasan Partovi, MD Enschede, The Netherlands Innsbruck, Austria Yu Kataoka, MD Cleveland, USA Ping Wang, MD, PhD Ozgur Bayturan, MD Osaka, Japan Gerard Pasterkamp, PhD, MD, Boston, USA Manisa, Turkey Jonathon Leipsic, MD, FRCPC FESC Harvey D. White, MB, ChB, Stefan C. Bertog, MD Vancouver, Canada Utrecht, The Netherlands DSc, FRACP, FACC, FESC, Minneapolis, USA Pedro A. Lemos, MD, PhD Prabhakar Rajiah, MD, FRCR FAHA, FHKCC (Hon), John C Burnett Jr, MD Sao Paulo, Brazil Cleveland, USA FCSANZ, FRSNZ Rochester, USA Tong Liu, MD, PhD Johan H.C. Reiber, PhD Auckland, New Zealand Marc Dewey, MD Tianjin, China Leiden, The Netherlands Dennis Wong Berlin, Germany Hua Luo, MD, FPVRI Jun Ren, MD, PhD, FAHA Melbourne, Australia Milind Desai, MD Shenzhen, China Laramie, USA Yunlong Xia, MD, PhD Cleveland, USA Xiaohai Ma, MD, PhD Luca Saba, MD Dalian, China Yi-mei Du, MD, PhD Beijing, China Cagliari, Italy Li Yang, MD, PhD Wuhan, China Warner Mampuya, MD U. Joseph Schoepf, MD, Prof. Beijing, China Raimund Erbel, MD, FAHA, Sherbrooke, Canada (h.c.), FAHA, FSCBT-MR, Xiaoping Yang, PhD FESC, FACC, FASE Peter A. McCullough, MD, FNASCI, FSCCT Denver, USA Essen, Germany MPH, FACC, FACP, FAHA, Charleston, USA Jose L. Zamorano, MD, FESC Sameer Gafoor, MD FCCP, FNKF Mehdi Shishebhor, MD Madrid, Spain Frankfurt, Germany Warren, USA Cleveland, USA Stephan Haulon, MD, PhD Eike Nagel, MD, PhD Srikanth Sola, MD Lille Cedex, France London, UK Bangalore, India Hans Ibsen, Professor, MD, DMSc Zhonghua Sun, PhD, MB Holbæk, Denmark Curtin, Australia Editorial Consultants Olcay Aksoy, MD Carlos David Escobedo Uribe, Heba Elsaegh Mounir, MD Yingmei Zhang, MD, PhD Los Angeles, USA MD Cairo, Egypt Laramie, USA João L. Cavalcante Ignacio Chávez, México Alper Ozkan, MD Lei Zhao, MD Pittsburgh, USA Alexander Kharlamov Cleveland, USA Beijing, China Yekaterinburg, Russia Arjang Ruhparwar, MD, PhD Heidelberg, Germany Statistical Editor Senior Editors Science Editors Executive Copyeditor Binhuan Wang, PhD Eunice X. Xu Silvia L. Zhou Oreo Zhao New York, USA (Corresponding Editor) Helen X. Seliman Grace S. Li Executive Typesetting Editor Elva S. Zheng Production Editor Chuyuan Xie Nancy Q. Zhong Emily M. Shi Aims and Scope online at: www.thecdt.org The journal ‘Cardiovascular Diagnosis and Therapy’ (Print ISSN: 2223- 3652; Online ISSN: 2223-3660) accepts basic and clinical science Disclaimer submissions related to Cardiovascular Medicine and Surgery. The The Publisher and Editors cannot be held responsible for errors mission of the journal is the rapid exchange of scientific information or any consequences arising from the use of information contained between clinicians and scientists worldwide. in this journal; the views and opinions expressed do not necessarily reflect those of the Publisher and Editors, neither does the publication Note to NIH Grantees of advertisements constitute any endorsement by the Publisher and Pursuant to NIH mandate, AME Publishing Company will post the Editors of the products advertised. accepted version of contributions authored by NIH grant-holders to PubMed Central upon acceptance. This accepted version will be made © 2015 Cardiovascular Diagnosis and Therapy publicly available 2 months after publication. For further information, see www.thecdt.org Cover image: Salt Labyrinth. (see page 248 in this issue). Conflict of Interest Policy for Editors For submission instructions, subscription and all other information The full policy and the Editors’ disclosure statements are available visit www.thecdt.org Table of Contents Preface 169 Salt intake reduction efforts: advances and challenges Hussain Isma’eel, Paul Schoenhagen, Jacqui Webster Review Article 172 An overview of salt intake reduction efforts in the Gulf Cooperation Council countries Nawal Alhamad, Elsayed Almalt, Najeeba Alamir, Monica Subhakaran 178 Sodium intake reduction efforts in Lebanon Mohamad M. Almedawar, Lara Nasreddine, Ammar Olabi, Haya Hamade, Elie Awad, Imad Toufeili, Samir Arnaout, Hussain A. Isma’eel 186 WHO’s supported interventions on salt intake reduction in the sub-Saharan Africa region Chandralall Sookram, Davison Munodawafa, Peter Malekele Phori, Benoit Varenne, Abdikamal Alisalad 191 Salt reduction and hypertension in China: a concise state-of-the-art review Yue Liu, Huiyan Li, Siting Hong, Xinhua Yin Original Article 197 Sodium content in processed foods in Argentina: compliance with the national law Lorena Allemandi, María Victoria Tiscornia, Miguel Ponce, Luciana Castronuovo, Elizabeth Dunford, Verónica Schoj 207 Salt reduction in Australia: from advocacy to action Jacqui Webster, Kathy Trieu, Elizabeth Dunford, Caryl Nowson, Kellie-Ann Jolly, Rohan Greenland, Jenny Reimers, Bruce Bolam 219 Artificial neural network modeling using clinical and knowledge independent variables predicts salt intake reduction behavior Hussain A. Isma’eel, George E. Sakr, Mohamad M. Almedawar, Jihan Fathallah, Torkom Garabedian, Savo Bou Zein Eddine, Lara Nasreddine, Imad H. Elhajj 229 Developing a national salt reduction strategy for Mongolia Batsaikhan Enkhtungalag, Jamayan Batjargal, Ochir Chimedsuren, Bayandorj Tsogzolmaa, Craig S. Anderson, Jacqui Webster Brief Report 238 The World Hypertension League: where now and where to in salt reduction Norm R. C. Campbell, Daniel T. Lackland, Liu Lisheng, Xin-Hua Zhang, Peter M. Nilsson, Mark L. Niebylski; the World Hypertension League Executive Perspective 243 The strides to reduce salt intake in Brazil: have we done enough? Eduardo Augusto Fernandes Nilson Arts and Medicine 248 Salt Labyrinth Motoi Yamamoto © Cardiovascular Diagnosis and Therapy. All rights reserved. Cardiovasc Diagn Ther Vol 5, No 3 June 2015 Preface Salt intake reduction efforts: advances and challenges The articles in this special issue of Cardiovascular Diagnosis and Therapy describe the efforts to reduce salt intake in different parts of the world, including South America, Africa, the Middle East, the Far East (China and Mongolia) and Australia, in addition to an overview of the work of the World Hypertension League in this domain. Sharing experiences from diverse regions and countries, these data will contribute to better understanding the challenges and opportunities encountered by the groups working in the field. The alarming increase in cardiovascular diseases (CVD) in the world has led to numerous calls for preventive measures. One of the cost effective measures, identified as a ‘best-buy’, by the WHO, is salt intake reduction (1). Accordingly, local governmental and non-governmental bodies are working together to develop programs to lower salt intake at the population level by 30% towards the WHO guideline of <5 g/day (2). The evidence linking salt intake to hypertension and data demonstrating a decrease in blood pressure with salt intake reduction is widely available in the medical literature (3-5). It is based on observational data and also well designed clinical trials. However, ascertaining that salt intake reduction leads to a decrease in hard cardiovascular outcomes (death, stroke, or myocardial infarction) remains a contentious issue. On the one hand, there are members of the scientific community, who continue to demand more rigorous scientific evidence for effectiveness of salt reduction in reducing hard CVD outcomes (6,7). On the other hand, are the majority of pragmatic public health experts who find the existing evidence is strong enough to warrant action and are already advancing. Of note, the latter group is not only supported by the WHO, but also by many other respectable scientific bodies (8-10). These opposing stands were noted by the editorial team during the preparation of this issue, having being raised by several reviewers of the articles presented here. Whilst the impact on blood pressure is undisputed, the question of clinical effectiveness (impact on CVD) of salt reduction is still unanswered in some scientists’ minds and therefore merits continued attention. On the ground, tremendous progress has been made in relation to the development and implementation of salt reduction strategies. Several regional organizations, such as the World Health Organization Collaborating Centre on Population Salt Reduction at the George Institute in Sydney, the World

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