Global projections indicate that, by 2020, non-communicable diseases (NCDs) such as cardiovascular diseases (CVD), cancers, chronic respiratory diseases and diabetes will account for three out of every four deaths. CVDs are currently the number one cause of death globally. An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global deaths. More than three quarters of CVD deaths take place in low- and middle-income countries, and it’s a major cause of poverty, loss of productivity and poor quality of life worldwide.
Most CVDs can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and the harmful use of alcohol. Individuals with CVD or who are at high risk (owing to the presence of one or more risk factors such as hypertension, diabetes, hyperlipidaemia or an already established disease) have a greater need of early detection and management. Improving diet and lifestyle has a critical role to play in reducing the burden of CVDs.
Hypertension
Hypertension, or elevated arterial blood pressure, defined as a systolic blood pressure of >150mmHg or a diastolic blood pressure of >90mmHg is the most preventable contributor to CVD and deaths in the world.1 According to the World Health Organization (WHO), one in three adults has high blood pressure. Raised blood pressure is estimated to cause 7.5 million deaths worldwide, accounting for 12.8% of all deaths. Individuals with hypertension are often asymptomatic. This is a dangerous disease that silently damages the heart and arteries and can cause myocardial infarction, heart failure, stroke and end-stage renal disease. The causes of essential hypertension are not known. The key risk factors for hypertension include
- age
- ethnicity
- family history
- lower socioeconomic status
- overweight or obesity
- dietary pattern inconsistent with the DASH (Dietary Approaches to Stop Hypertension), such as an inadequate intake of fruits, vegetables and low-fat dairy foods, and excessive intake of saturated fat and cholesterol
- high sodium intake
- inadequate level of physical activity
- excessive alcohol intake.
Screening for high blood pressure is important to reduce complications and mortality from untreated hypertension. Morbidity from hypertension includes left ventricular hypertrophy, heart failure, atherosclerosis, myocardial infarction, kidney failure and stroke.2
Mozzaffarian, et al. quantified the global consumption of sodium according to age, sex and country based on the urinary excretion and diet of individuals from 66 countries (74.1% of adults throughout the world).3 They estimated that in 2010, the mean level of global sodium consumption was 3.95g/d, and regional mean levels ranged from 2.18–5.51g/d. Globally, 1.65 million annual deaths from cardiovascular causes were attributed to sodium intake above the reference level of 2g/d. These deaths accounted for nearly one of every ten deaths from cardiovascular causes (9.5%).
Using a systematic review of the literature and evidence-based methodology, the Eighth Joint National Committee (JNC 8) drafted evidence statements and guidelines for treatment of high blood pressure.1 Evidence suggests that reducing sodium intake reduces blood pressure and the risk for CVD and stroke. The JNC 8 endorsed the lifestyle modification recommendations by the Lifestyle Work Group; that is, a healthy lifestyle is important in the prevention of CVD. Healthful diet, weight control and regular exercise are all lifestyle treatments with great potential for improved blood pressure control and reducing the need for medication in individuals with hypertension.1,4
Nutrition interventions to lower the risk of hypertension
The current recommended nutrition therapy in the DASH Eating Plan is less than 2400mg of sodium per day.5 The DASH Eating Plan is designed to reduce sodium, include fruits, vegetables and whole grains, and limit fats.6 The ideal dietary pattern emphasises vegetable, fruit and whole grain intake, the incorporation of low-fat dairy items, poultry, fish, legumes, vegetable oils (non-tropical) and nuts, and minimises the intake of red meats, sweets and sugar-sweetened beverages.
The DASH eating plan is high in potassium, calcium, magnesium and fibre, while limiting sodium to levels 1500–2400mg per day. In addition to following the DASH Eating Plan, individuals with hypertension are encouraged to engage in heart-healthy lifestyle activities and behaviours.4 This includes 2 hours and 30 minutes of moderate-intensity physical activity per week, 1 hour and 15 minutes of vigorous-intensity aerobic physical activity per week, or some combination of both types of physical activity to help attain and maintain a healthy weight.
Efficacy of nutrition therapy
Although many individuals with hypertension eventually require medication to control their blood pressure, lifestyle modifications serve as the foundation for treatment. Strong evidence supports the use of the DASH Eating Plan to control blood pressure. The DASH Eating Plan reduces systolic blood pressure by 8–14mmHg on average.6–9 In patients following a DASH Eating Plan, lower sodium intake (levels of 1500 or 2400mg/d) produced greater reductions in blood pressure than a sodium level of 3000mg/d.10
Reducing dietary sodium intake to less than 2400mg/d lowered blood pressure on average by 2–8mmHg. TONE investigated the benefits of intensive nutrition therapy to modify lifestyles of patients, aged 60 to 80 years, receiving a single medication for control of hypertension. At a median of 3.2 months, patients were able to discontinue pharmacologic treatment because of the effectiveness of lifestyle modifications.11
Food and beverage industry: a powerful platform for change
Growing awareness about what constitutes healthy eating patterns has started to produce a shift in consumption habits among mainstream consumers. The food and beverage industry can play a vital role in educating consumers and empowering them to make better food and beverage choices and lead healthier lives.
Sodium is an essential micronutrient playing a vital role in many physiological functions, while also contributing to food functionality, food safety and quality, and taste. In industrialised countries, about 75% of sodium in the diet comes from manufactured foods and foods eaten away from home. In an effort to combat CVDs, international authorities such as WHO are encouraging the food and beverage industry to reduce sodium levels in their products.
Significant sodium reduction is not without complications. Reducing sodium in processed foods can be challenging because of the specific functionality it has in terms of taste and the associated palatability of foods (increased saltiness, reduced bitterness, enhanced sweetness and other congruent flavours). Using sodium replacers and gradually reducing the sodium level (time consuming) can help to maintain palatability while addressing the high sodium intakes. Currently available approaches allow successful sodium reductions of 20–30% without changing the quality of the eating experience. Further reduction will require new scientific research and development. Research into the physiology of taste perception and salt receptors is an emerging area of science that is crucial to the goal of reducing sodium in processed foods even more.
Tools for sodium reduction
The effectiveness of sodium reduction tools depends on factors such as the food or beverage in question, the targeted level of reduction and the expectation of the consumer. Strategies for sodium reduction in food and beverages could include the use of alternative tastants capable of increasing the perception of saltiness, manipulation of the food matrix so that salt can be delivered more directly to the taste buds as well as consumer education regarding the negative impact on health to help shift saltiness preferences gradually.
For instance, reformulating using Kerry’s Taste Modulation Technology tools provides customers with an ideal way to improve the overall taste of their products, whilst meeting or exceeding consumer taste expectations and without compromising key attributes such as nutrition, shelf-life and cost of manufacture. Our Taste Modulation Technology tools comprise a customised combination of building blocks that deliver the required taste functionality in the application, thereby achieving a more desirable nutritional profile. Using Taste Modulation Technology tools for salt reduction, we can enhance the perception of saltiness whilst declaring only natural flavour systems on the final consumer label.
Other sodium reduction tools include salt replacers, such as potassium chloride and other mineral salts, phosphates, herbs and spices, umami ingredients, restructuring of the recipe to maximise salt perception by reducing competitive tastants and optimising synergies. All of these solutions have their benefits and limitations based on the food and beverage application. For example, some can only be used in limited concentrations owing to undesirable taste effects such as bitter or metallic tastes and decreased palatability. To help individuals achieve their sodium intake targets, a combination of solutions is required.
Functional food market trends addressing cardiovascular health
With 46% of consumers regularly consuming functional foods as opposed to medications for health benefits, the demand for multifunctional and targeted products is high. Global retail sales of functional food and beverages (defined categories are beverages, soft drinks, packaged food, dairy, oils and fats) claiming a 'heart health' benefit grew by €388m from 2010–2015.
Breakfast cereals are proven vehicles for fortification and this category has seen the largest number of product launches in recent years in developing markets. Oat-rich brands take advantage of the beta-glucan cholesterol lowering claim (FDA and EFSA approved claims). Low sodium and high fibre claims are also commonly seen in this category. We are increasingly seeing oats added to other categories to add functionality. Oats have even been repositioned as a meal side dish in the USA: 'Tomato Risotto Steel Cut Oats Meal Mate' products are available in multiple flavours and can be used as part of a larger meal. Chia and linseeds, touted for their omega-3 content, are increasingly being added to breads (multigrain bread with linseed in Colombia and 'Chia & Hemp Breakfast Mix' in the USA).
As healthy snacks are increasingly demanded by consumers, baked varieties and vegetables snacks are gaining traction in the market. Promoted for their low fat and high fibre content (and also following the gluten free trend), examples include pea snaps (baked marrowfat peas with rapeseed oil), red pepper pitta chips in Ireland, ready to eat Dried Green Peas in Vietnam, ginger chunks in Canada, Masala Flavour Jowar Crispys (baked crisps) in India, and Crackers with Puffed Rice in Italy. Dairy alternatives such as soy and almond milks are promoted for their low saturated fat profile, and antioxidant and high fibre go hand in hand with a CVD claim.
Conclusion
Improving diet and lifestyle continues to be a vital component in the strategy to prevent CVD. The new guidelines emphasize the importance of lifestyle modification as part of the therapeutic treatment programme for CVD risk factors. The food and beverage industry, along with healthcare professionals, have a significant role to play in helping individuals to understand and incorporate dietary advice and encourage physical activity to achieve optimum clinical outcomes, as well as reduce the deleterious effects of diabetes and CVD.
References
1. P.A. James, et al., 'Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8),' JAMA 311(5), 507–520 (2014).
2. C. Rosendorff, et al. on behalf of the American Heart Association, American College of Cardiology and American Society of Hypertension, 'Treatment of Hypertension in Patients with Coronary Artery Disease: A Scientific Statement from the American Heart Association, American College of Cardiology and American Society of Hypertension,' J. Am. Soc. Hypertens. 65(6), 1372–1407 (2015).
3. D. Mozaffarian, et al. for the Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NUTRICODE), 'Global Sodium Consumption and Death from Cardiovascular Causes,' N. Engl. J. Med. 371, 624–634 (2014).
4. R.H. Eckel, et al., '2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines,' Circulation. 129(25 suppl. 2), S76–S99 (2014).
5. Academy of Nutrition and Dietetics. Evidence Analysis Library Hypertension Project: www.andeal.org/topic.cfm?menu=5285.
6. L.J. Appel, et al., 'A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure,' N. Engl. J. Med. 336, 1117–1124 (1997).
7. L.P. Svetkey, et al., 'Effects of Dietary Patterns on Blood Pressure: Subgroup Analysis of the Dietary Approaches to Stop Hypertension (DASH) Randomized Clinical Trial,' Arch. Intern. Med. 159, 285–293 (1999).
8. L.J. Appel, et al., 'Effects of Comprehensive Lifestyle Modification on Blood Pressure Control. Main Results of the PREMIER Clinical Trial,' JAMA 289, 2083–2093 (2003).
9. P.J. Elmer, et al. for the PREMIER Collaborative Research Group, 'Effects of Comprehensive Lifestyle Modification on Diet, Weight, Physical Fitness and Blood Pressure Control: 18-Month Results of a Randomized Trial,' Ann. Intern. Med. 144, 485–495 (2006).
10. F.M. Sacks, et al. for the DASH-Sodium Collaborative Research Group. 'Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet,' N. Engl. J. Med. 344, 3–10 (2001).
P.K. Whelton, et al., 'Sodium Reduction and Weight Loss in the Treatment of Hypertension in Older Persons: A Randomized Controlled Trial of Nonpharmacologic Interventions in the Elderly (TONE),' JAMA 279, 839–846 (1998).
