Long-term effects of neonatal sodium restriction on blood pressure

Clinical guidelines for the diagnosis, evaluation, and management of hypertension for Korean children and adolescents: the Korean Working Group of Pediatric Hypertension

Pediatric hypertension (HTN) is a significant, growing health concern worldwide and also in Korea. Diagnosis, evaluation, and treatment of HTN in Korean children and adolescents are uncertain due to limitations in using the current international guidelines, since the recommendations by the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) guidelines differ. Furthermore, these are guidelines for Western youth, who are racially and ethnically different from Koreans. In addition, reference blood pressure values for all pediatric age groups, which are essential for the diagnosis of HTN according to these two guidelines, are absent in Korea. Therefore, HTN guidelines for Korean children and adolescents should be established. The Korean Working Group of Pediatric Hypertension established clinical guidelines for the diagnosis, evaluation, and management of HTN in Korean children and adolescents. These guidelines were based on reported clinical evidence, expert recommendations, and AAP and ESH guidelines. The characteristics of Korean youth and the Korean medical and insurance system were considered during the establishment of the guidelines. By providing recommendations suitable for Korean youth, these guidelines will help in the prevention and management of childhood HTN, thus relieving the burden of cardiovascular disease in adulthood in Korea.

Development of a Culinary Intervention (Cooking Class) for Salt Reduction in Japanese Home Cooking: Strategies and Assessment

Introduction

Culinary interventions (cooking classes) are a potential educational tool for salt reduction in the home diet, but their content has never been reported in detail. This study aimed to develop a cooking class for salt reduction, describe its rationale and structure so that other parties could replicate it, and preliminarily assess its impact on salt intake.

Methods

A multidisciplinary research team developed a cooking class package to reduce salt content in the Japanese home diet. The package comprised its developmental policy, teaching methodology, a menu and recipes, and an implementation manual and aimed to allow third parties to replicate and modify the content. The team took the following step-by-step developmental approach. First, traditional home meals were modeled to create strategies contributing to a target of 2 g salt/meal. Then, educational topics were developed through these strategies, and finally, a dietitian produced menus and prepared documents for the class. The impact of the cooking class was assessed in a nonrandomized study of community residents. The outcome was differences in urinary salt excretion before and after the intervention. General linear models were used to account for the possible confounders.

Results

The authors assumed 4-7 g salt/meal from analyzing typical Japanese home diets and developed 3 strategies: (1) restricting salt content in the main dish, (2) maintaining good tastes without salty dishes, and (3) balancing nutrition with low-salt dishes. On the basis of these strategies, the authors selected a total of 5 educational topics that participants could learn and apply at home: 1a, a simple and reliable technique to limit salt in a serving; 2a, excluding salty dishes; 2b, staple foods with notable flavor and aroma; 3a, flavoring without salt in side dishes; and 3b, ingredients that should be used intentionally. The team dietitian translated these educational topics into a menu and recipes for hands-on training and prepared a manual for conducting the class. The class developed using this approach was successfully overseen by a dietitian outside the research team. In the validation study, the intervention group (n=52) showed a greater decrease in urinary salt excretion than the control group (n=46), with an adjusted difference of -1.38 g (p=0.001).

Conclusions

The authors developed a cooking class package for salt reduction so that third parties could replicate and modify the class. The significant salt reduction noted in this study warrants further studies to apply this cooking class to other populations.

Dietary Sodium Reduction Is Best for Reducing Blood Pressure: Controversies in Hypertension

The global burden of cardiovascular disease (CVD) continues to grow, as does the incidence of hypertension, one of the most important modifiable risk factors of CVD. Non-pharmacologic, population level interventions are critically needed to halt the hypertension pandemic, but there is an ongoing debate as to whether public policy efforts should focus more on dietary sodium reduction or increasing potassium. In this commentary, we summarize arguments in favor of policy geared towards reduced sodium intake. Recognizing increasing dietary sodium as one of the drivers of the hypertension pandemic is critical to developing public policy to reduce population level sodium exposure and blood pressure. We draw from a robust field of evidence to show that reducing sodium intake improves blood pressure in a linear fashion, across the lifespan, at an individual level and a population level, and may even reduce CVD events. While potassium plays an important role in blood pressure regulation, potassium interventions are less effective at reducing blood pressure, carry risk of hyperkalemia in select populations, and are more logistically challenging. There is an urgent need for nation-wide policies to reduce sodium intake to help stem the hypertension pandemic and prevent CVD.

Prenatal Household Air Pollution Exposure and Childhood Blood Pressure in Rural Ghana

BACKGROUND

The association between prenatal household air pollution (HAP) exposure and childhood blood pressure (BP) is unknown.

OBJECTIVE

Within the Ghana Randomized Air Pollution and Health Study (GRAPHS) we examined time-varying associations between a) maternal prenatal and b) first-year-of-life HAP exposure with BP at 4 years of age and, separately, whether a stove intervention delivered prenatally and continued through the first year of life could improve BP at 4 years of age.

METHODS

GRAPHS was a cluster-randomized cookstove intervention trial wherein n = 1,414 pregnant women were randomized to one of two stove interventions: a) a liquefied petroleum gas (LPG) stove or improved biomass stove, or b) control (open fire cooking). Maternal HAP exposure over pregnancy and child HAP exposure over the first year of life was quantified by repeated carbon monoxide (CO) measurements; a subset of women (n = 368 ) also performed one prenatal and one postnatal personal fine particulate matter (PM 2.5 ) measurement. Systolic and diastolic BP (SBP and DBP) were measured in n = 667 4-y-old children along with their PM 2.5 exposure (n = 692 ). We examined the effect of the intervention on resting BP z -scores. We also employed reverse distributed lag models to examine time-varying associations between a) maternal prenatal and b) first-year-of-life HAP exposure and resting BP z -scores. Among those with PM 2.5 measures, we examined associations between PM 2.5 and resting BP z -scores. Sex-specific effects were considered.

RESULTS

Intention-to-treat analyses identified that DBP z -score at 4 years of age was lower among children born in the LPG arm (LPG β = - 0.20 ; 95% CI: - 0.36 , - 0.03 ) as compared with those in the control arm, and females were most susceptible to the intervention. Higher CO exposure in late gestation was associated with higher SBP and DBP z -score at 4 years of age, whereas higher late-first-year-of-life CO exposure was associated with higher DBP z -score. In the subset with PM 2.5 measurements, higher maternal postnatal PM 2.5 exposure was associated with higher SBP z -scores.

DISCUSSION

These findings suggest that prenatal and first-year-of-life HAP exposure are associated with child BP and support the need for reductions in exposure to HAP, with interventions such as cleaner cooking beginning in pregnancy. https://doi.org/10.1289/EHP13225.

Blood Pressure at Different Life Stages Over the Early Life Course and Intima-Media Thickness

Importance

Although cardiovascular disease (CVD) begins in early life, the extent to which blood pressure (BP) at different life stages contributes to CVD is unclear.

Objective

To determine the relative contribution of BP at different life stages across the early-life course from infancy to young adulthood with carotid intima-media thickness (IMT).

Design, setting, and participants

The analyses were performed in 2022 using data gathered from July 1989 through January 2018 within the Special Turku Coronary Risk Factor Intervention Project, a randomized, infancy-onset cohort of 534 participants coupled with annual BP (from age 7 months to 20 years), biennial IMT measurements (from ages 13 to 19 years), who were followed up with again at age 26 years.

Exposures

BP measured from infancy (aged 7 to 13 months), preschool (2 to 5 years), childhood (6 to 12 years), adolescence (13 to 17 years), and young adulthood (18 to 26 years).

Main outcomes and measures

Primary outcomes were carotid IMT measured in young adulthood at age 26 years. Bayesian relevant life-course exposure models assessed the relative contribution of BP at each life stage.

Results

Systolic BP at each life stage contributed to the association with young adulthood carotid IMT (infancy: relative weight, 25.3%; 95% credible interval [CrI], 3.6-45.8; preschool childhood: relative weight, 27.0%; 95% CrI, 3.3-57.1; childhood: relative weight, 18.0%; 95% CrI, 0.5-40.0; adolescence: relative weight, 13.5%; 95% CrI, 0.4-37.1; and young adulthood: relative weight, 16.2%; 95% CrI, 1.6-46.1). A 1-SD (at single life-stage) higher systolic BP accumulated across the life course was associated with a higher carotid IMT (0.02 mm; 95% CrI, 0.01-0.03). The findings for carotid IMT were replicated in the Cardiovascular Risk in Young Finns Study that assessed systolic BP from childhood and carotid IMT in adulthood (33 to 45 years).

Conclusion and relevance

In this cohort study, a life-course approach indicated that accumulation of risk exposure to BP levels at all life stages contributed to adulthood carotid IMT. Of those, the contribution attributed to each observed life stage was approximately equal. These results support prevention efforts that achieve and maintain normal BP levels across the life course, starting in infancy.

Sodium - a systematic review for Nordic Nutrition Recommendations 2023

Blood pressure (BP) rises along with increasing sodium intake from early childhood to late adulthood, and leads to hypertension among most men and women living in Nordic and Baltic countries. Elevated BP is the leading global risk factor for premature deaths and disability-adjusted life-years. A reduction in sodium intake is essential in the prevention of hypertension in individuals, in the lowering of BP levels, in the treatment of hypertensive individuals, and in decreasing risks associated with elevated BP. There is a progressive linear dose-response relationship between sodium intake and BP beginning from a sodium intake of less than 0.8 g/day. Sodium reduction decreases BP linearly by a dose-response manner down to a sodium intake level of less than 2 g/day. Randomised intervention studies with a duration of at least 4 weeks confirm the efficiency and safety of reducing blood sodium intake to a level of less than 2 g/day. Results from prospective cohort studies show that higher sodium intake is positively associated with an increased risk of stroke and cardiovascular events and mortality among the general adult population, and the associations are linear in studies using proper sodium assessment methods. Analyses assessing sodium intake using at least two 24-h urine samples have shown a linear positive relationship between sodium intake and the risk of a cardiovascular event or death. Based on an overall evaluation of the available data, a limitation of the sodium intake to 2.0 g/day is suggested for adults. The optimal sodium intake level would be probably about 1.5 g/day. Sodium intake recommended for children can be extrapolated from the recommended sodium intake for adults. According to national dietary surveys, the average sodium intakes in Nordic countries range in adult men from 3.6 to 4.4 g/day and in adult women from 2.6. to 3.2 g/day, and in Baltic countries in men from 2.6 to 5.1 g/day and in women from 1.8 to 3.6 g/day.

The role of intra- and interdialytic sodium balance and restriction in dialysis therapies

The relationship between sodium, blood pressure and extracellular volume could not be more pronounced or complex than in a dialysis patient. We review the patients' sources of sodium exposure in the form of dietary salt intake, medication administration, and the dialysis treatment itself. In addition, the roles dialysis modalities, hemodialysis types, and dialysis fluid sodium concentration have on blood pressure, intradialytic symptoms, and interdialytic weight gain affect patient outcomes are discussed. We review whether sodium restriction (reduced salt intake), alteration in dialysis fluid sodium concentration and the different dialysis types have any impact on blood pressure, intradialytic symptoms, and interdialytic weight gain.

Avoidance of added salt for 6-12-month-old infants: A narrative review

Most nutrition guidelines recommend avoiding foods with added salt for infants aged 6-12 months. However, the reason for no added salt lacks enough and reliable evidence. We re-searched and re-studied the relevant evidence. We searched PubMed and the Cochrane database for English-language studies published from 1904 through 2021. We also searched the databases of the websites of different national institutions. Randomized clinical trials (RCTs), systematic reviews, observational studies, and dietary guidelines were included in this review. The kidneys of infants aged 6-12 months have adequate sodium excretion capacity. There is insufficient evidence that high salt (sodium) intake early in life might lead to hypertension or salty diet preference in adults. Infants aged 6-12 months might be at risk of low sodium intake of only 150-300 mg of sodium/day, which may not meet the body's needs, if their supplementary food is not adequately salted.

Less sodium, more potassium, or both: population-wide strategies to prevent hypertension

Hypertension is among the most prevalent medical conditions globally and a major contributor to chronic kidney disease, cardiovascular disease, and death. Prevention through nonpharmacological, population-level interventions is critically needed to halt this worldwide epidemic. However, there are ongoing disagreements as to where public policy efforts should focus. Recently the Salt Substitute and Stroke Study demonstrated the efficacy of substituting table salt with potassium salt to reduce the risk of stroke, major cardiovascular events, and death. However, this sparked debate over whether sodium or potassium should be prioritized in countries where table salt substitution was less feasible. In this commentary, we summarize arguments in favor of either strategy: reduced sodium or increased potassium intake. Moreover, we discuss evidence and policy approaches related to either or combined approaches relevant to cultural context. Ultimately, there is an urgent need for policies that both reduce sodium and increase potassium intake; however, identifying a strategy that fits cultural context will be key to improve population-wide blood pressures.

Hypertension in Children and Young Adults

Primary hypertension (PH) is most common during adolescence with increasing prevalence globally, alongside the epidemic of obesity. Unlike in adults, there are no data on children with uncontrolled hypertension and their future risk of hard cardiovascular and cerebrovascular outcomes. However, hypertension in childhood is linked to hypertensive-mediated organ damage (HMOD) which is often reversible if treated appropriately. Despite differing guidelines regarding the threshold for defining hypertension, there is consensus that early recognition and prompt management with lifestyle modification escalating to antihypertensive medication is required to ameliorate adverse outcomes. Unfortunately, many unknowns remain regarding pathophysiology and optimum treatment of childhood hypertension.

Salt sensitivity of blood pressure in childhood and adolescence

Although moderation of sodium intake is recommended population-wide, it remains uncertain who benefits from salt restriction. Salt sensitivity refers to changes in blood pressure in response to sodium intake and may occur with or without hypertension. Unfortunately, there is no practical way to assess salt sensitivity in daily practice. Assessment of salt sensitivity even in research studies is challenging with varying protocols utilized which may contribute to differing results. Building on studies in animals and adults, risk factors and conditions associated with salt sensitivity have been identified in the pediatric and young adult populations. This review presents the limited evidence linking obesity, low birth weight, diabetes, chronic kidney disease, and race/ethnicity with salt sensitivity in children, adolescents, and young adults. The impact of stress on sodium handling is also reviewed. The influence of age on the timing of introduction of dietary salt restriction and the long-term influence of salt sensitivity on risk for hypertension are considered. Lastly, interventions other than salt restriction that may improve salt sensitivity and may inform recommendations to families are reviewed.

Treatment of congenital adrenal hyperplasia in children aged 0-3 years: a retrospective multicenter analysis of salt supplementation, glucocorticoid and mineralocorticoid medication, growth and blood pressure

Objectives

International guidelines recommend additional salt supplementation during infancy in classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. The influence of corticoid medication and growth has not been assessed.

Aim

To investigate the current use of salt supplementation, fludrocortisone (FC) and hydrocortisone (HC) dosage as well as weight, height, BMI and blood pressure (BP) in CAH children aged 0-3 years.

Methods

Retrospective multicentre analysis using data from the I-CAH registry. Salt-treated (ST) and non-salt-treated (NST) children were compared regarding FC and HC dosage, weight, height and BP at 0, 3, 6, 9, 12, 18, 24, 30, and 36 months.

Results

We analysed 2483 visits of 331 patients born after year 2000 in 13 countries (male, n = 145) with 203 ST patients (61%). NST children had significantly higher FC dosages at 1.5-4.5 months and higher HC dosages until 1.5 months of age. No differences in weight, length and BP between subgroups were observed. Children of the whole cohort showed increased BMI-SDS during the study period and about half of the reported BP readings were >P95.

Conclusion

In children treated with additional salt supplementation, FC and HC dosages are lower during the first months of life but without differences in weight, length and BP until 3 years of age compared to NST children. All children showed an increase in BMI-SDS and a high rate of BP readings >P95 until 3 years, indicating the start of weight gain and negative effects on blood pressure already in very early life.

High blood pressure in children and adolescents: current perspectives and strategies to improve future kidney and cardiovascular health

Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.

Sodium found in processed cow milk and estimated intake by infants

OBJECTIVE

To determine the sodium concentration in cow milk available for sale and to estimate its consumption by infants up to 6 months of age.

METHODS

Sodium level was determined by flame emission spectrophotometry in eight different lots of five brands of liquid ultra-high temperature milk and three brands of powdered milk. To estimate sodium consumption via cow milk, orientations for exceptional situations when neither breastfeeding nor infant formula is possible were considered. Inferential statistics were performed and results were compared with critical parameters at a 5% significance level.

RESULTS

The mean sodium content per portion found in liquid milk (162.5±16.2) mg/200mL was higher than that in powdered milk (116.8±3.0) mg/26g. Estimated sodium consumption by infants through powdered milk varied from 149.8 to 224.7% of adequate intake, and via liquid milk can be more than 500% of the adequate intake, reaching 812.4% of it if dilution is not applied. Seven of the eight brands of milk studied had declared, on their labels, that the sodium content was 13-30% lower than that found in chemical analysis.

CONCLUSION

Liquid and powdered whole cow milk have high sodium content, and the content per portion is higher in liquid milk than in powdered milk. The estimated consumption of sodium through these products can far exceed the adequate intake for infants from 0 to 6 months old, even when the recommended dilution and maximum daily volumes are followed.

Biomarkers of high salt intake

High salt intake is associated with hypertension, which is a leading modifiable risk factor for cardiovascular disease (CVD) and chronic kidney disease (CKD). International Guidelines recommend a large reduction in the consumption of sodium to reduce blood pressure, organ damage, and mortality. In its early stages, the symptoms of CKD are generally not apparent. CKD proceeds in a "silent" manner, necessitating the need for urinary biomarkers to detect kidney damage at an early stage. Since traditional renal biomarkers, such as serum creatinine, are not sufficiently sensitive, difficulties are associated with detecting kidney damage induced by a high salt intake, particularly in normotensive individuals. Several new biomarkers for renal tubular damage, such as neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), vanin-1, liver-type fatty acid-binding protein (L-FABP), and monocyte chemotactic protein-1 (MCP-1), have recently been identified. However, few studies have investigated early biomarkers for CKD progression associated with a high salt diet. This chapter provides insights into novel biomarkers for CKD in normo- and hypertensive individuals with a high salt intake. Recent studies using spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats (WKY) fed a high salt diet identified urinary vanin-1 and NGAL as early biomarkers for renal tubular damage in SHR and WKY, whereas urinary KIM-1 was a useful biomarker for salt-induced renal injury in SHR only. Clinical studies are needed to confirm these findings.

Breastfeeding in the First Days of Life Is Associated With Lower Blood Pressure at 3 Years of Age

Background

Breastfeeding in infancy is associated with lower cardiovascular disease risk in adulthood; however, the amount of breastfeeding required to achieve this benefit is unknown.

Methods and Results

In the CHILD (Canadian Healthy Infant Longitudinal Development) Cohort Study, we analyzed 2382 children with complete data on early life feeding and blood pressure. Infant feeding was documented from hospital records in the first few days of life and reported by mothers throughout infancy. Blood pressure was measured at 3 years of age. Analyses controlled for birth weight, gestational age, socioeconomic status, maternal body mass index, and other potential confounders. We found that nearly all children (2333/2382; 97.9%) were ever breastfed, of whom 98 (4.2%) only briefly received breast milk during their birth hospitalization (“early limited breastfeeding”). At 3 years of age, blood pressure was higher in children who were never breastfed (mean systolic/diastolic 103/60 mm Hg) compared with those who were ever breastfed (99/58 mm Hg), including those who received only early limited breastfeeding (99/57 mm Hg). These differences in systolic blood pressure persisted in adjusted models (ever breastfed: −3.47 mm Hg, 95% CI, −6.14 to −0.80; early limited breastfeeding: −4.24 mm Hg, 95% CI, −7.45 to −1.04). Among breastfed children, there was no significant dose‐response association according to the duration or exclusivity of breastfeeding. Associations were not mediated by child body mass index.

Conclusions

Although the benefits of sustained and exclusive breastfeeding are indisputable, this study indicates any breastfeeding, regardless of duration or exclusivity, is associated with lower blood pressure at 3 years of age. Further research examining the bioactive components of early breast milk, underlying mechanisms, and long‐term associations is warranted.

Necessity of salt intake reduction education beginning in youth: a cross-sectional survey of sodium-to-potassium ratios in mothers and their preschool children

Urinary sodium-to-potassium ratios are known to be high in preschoolers, but there are no reports comparing these ratios with those of the children's mothers. The aim of this study was to investigate the association between the urinary sodium-to-potassium ratios of mothers and their preschool children under the hypothesis that the ratio is equivalent between the two. We evaluated 297 preschoolers aged four to five attending six kindergartens (four in northern Japan, two in southern Japan), and we also evaluated the children's mothers. We asked the participants to take morning first urine samples for 2 consecutive days in the spring and autumn of the same year (four samples per participant) and to fill out a dietary questionnaire. There was a correlation between the urinary sodium-to-potassium ratios of preschoolers and those of their mothers. However, in a comparison between the preschoolers and their mothers overall, higher values were found in the preschoolers [preschoolers: 4.6 (3.5-6.3) mmol/L/g·Cr; mothers: 4.3 (3.9-4.7) mmol/L/g·Cr, p = 0.003]. These results correlated with the urinary sodium-to-potassium ratios estimated from the dietary questionnaire. The preschoolers showed high sodium and low potassium intake consumption compared to the mothers. Interestingly, these were found to differ by region and gender. In conclusion, the urinary sodium-to-potassium ratio in Japanese preschoolers is related to and higher than that of their mothers. It is important to educate children, their parents, childcare professionals, and society as a whole about proper salt restriction and potassium supplementation, as well as to improve the food environment.

Long-Term Effect of Salt Substitute on All-Cause and Cardiovascular Disease Mortality: An Exploratory Follow-Up of a Randomized Controlled Trial

Background: Salt substitute, a strategy for salt reduction, has been shown to decrease blood pressure and the incidence of hypertension. However, whether its hypotensive effect will reduce long-term mortality remains unclear. Our study reported an exploratory follow-up of mortality outcomes from previous randomized controlled trial to assess the long-term effect of low-sodium salt on total and cardiovascular disease (CVD) mortality. Methods: Participants who completed a previous 3-year double-blind randomized controlled trial were followed up from 2009 to 2019 to collect mortality data. Multivariable Cox regression models were used to evaluate the association between low-sodium salt intervention and all-cause and CVD mortality. Results: Four hundred and forty participants completed the intervention trial, of which 428 participants had death outcome data recorded after 10 years follow-up: 209 in a salt substitute group and 219 in a normal salt group. Fifty participants died during follow-up, 25 died due to CVD. No significant differences in relative risks were found for all-cause mortality [HR = 0.81, 95% confidence interval (CI): 0.46-1.42] and CVD mortality (HR = 0.58, 95% CI: 0.26-1.32) in unadjusted analyses. After adjusted with age and alcohol drinking status, there were significant reductions for stroke mortality among all participants (HR = 0.26, 95% CI: 0.08-0.84) and for CVD mortality (HR = 0.38, 95% CI: 0.16-0.92) and stroke mortality (HR = 0.25, 95% CI: 0.08-0.82) among hypertensive participants. Conclusions: Compared to normal salt, salt substitute might reduce the risk of CVD death, especially stroke among hypertensive patients. Our exploratory follow-up results provide potential evidence that low-sodium salt may be an accessible and effective strategy for prevention of CVD events, but definitive randomized controlled trials are warranted.

Diet as a tool for primordial cardiovascular prevention in developing countries

There is a rising burden of non-communicable disease (NCD), especially cardiovascular diseases (CVD) in the developing nations to an extent that they are sometimes terms as NCD epidemics. If unchecked, these NCD epidemics, can impact the healthcare systems and adversely affect the development of the whole country. While CVD is a matter of concern worldwide, it is even more so in low- and middle-income countries, where the incidence and prevalence of these diseases are much worse than developed countries, owning to their large population. According to the WHO, CVDs cause 28.5% of all deaths, in the developing nations. Even within the developing countries, the profile of CVD varies greatly, depending on the phase of epidemiological transition the country is currently undergoing. While primary prevention is about treating risk factors to prevent CVD, primordial prevention refers to avoiding the development of risk factors in the first place. As we now know, atherosclerosis starts in youth and is related to dyslipidemia, smoking, and hypertension, Body Mass Index and blood glucose levels. Therefore, the primordial prevention must start early in life. High-quality clinical trials have traditionally been mainly focusing on primary and secondary prevention settings. There are some key studies that evaluated the role of diet in primordial setting that were discussed in this review.

Salt and Sugar: Two Enemies of Healthy Blood Pressure in Children

The prevalence of essential arterial hypertension in children and adolescents has grown considerably in the last few decades, making this disease a major clinical problem in the pediatric age. The pathogenesis of arterial hypertension is multifactorial, with one of the components being represented by incorrect eating habits. In particular, excessive salt and sugar intake can contribute to the onset of hypertension in children, particularly in subjects with excess weight. Babies have an innate predisposition for sweet taste, while that for salty taste manifests after a few weeks. The recent modification of dietary styles and the current very wide availability of salt and sugar has led to an exponential increase in the consumption of these two nutrients. The dietary intake of salt and sugar in children is in fact much higher than that recommended by health agencies. The purpose of this review is to explore the mechanisms via which an excessive dietary intake of salt and sugar can contribute to the onset of arterial hypertension in children and to show the most important clinical studies that demonstrate the association between these two nutrients and arterial hypertension in pediatric age. Correct eating habits are essential for the prevention and nondrug treatment of essential hypertension in children and adolescents.

Urinary sodium and potassium excretions in young adulthood and blood pressure by middle age: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

OBJECTIVE

Data are sparse regarding the impact of sodium and potassium intakes on serial blood pressure (BP) levels during long-term follow-up.

METHODS

Among 1007 Coronary Artery Risk Development in Young Adults participants (mean age, 30.2 years; 53% blacks; 57% women) who had at least two 24-h urine samples collected at year 5 (Y5) examination, we assessed associations of urinary sodium and potassium excretions with BP trends and incident hypertension in the subsequent 25 years. Participants were classified by sex-specific medians for averaged 24-h urinary excretions: lower sodium and higher potassium (Na-Lo-K-Hi); higher sodium and lower potassium (Na-Hi-K-Lo); and others.

RESULTS

In the adjusted generalized estimating equation model, SBP and DBP greatly increased in the Na-Hi-K-Lo group (n = 185) compared with the Na-Lo-K-Hi group (n = 185), with statistically significant BP differences at Y20, Y25, and Y30 (mean SBP, 3.93, 4.94, and 4.88 mmHg, respectively; and mean DBP, 4.70, 4.95, and 4.59 mmHg, respectively). During 25-year follow-up, among 926 participants without prevalent hypertension by Y5, 381 (41.1%) developed hypertension. In the adjusted Cox proportional hazards model, the Na-Hi-K-Lo group had hazard ratio (95% confidence interval), 1.45 (1.00-2.10) for incident hypertension compared with the Na-Lo-K-Hi group. The association with incident hypertension was predominant in blacks and white women (race--sex interaction, P = 0.03). Sodium-to-potassium ratio and sodium excretion were positively, whereas potassium excretion was inversely, associated with incident hypertension (all P trend <0.05).

CONCLUSION

Our findings highlight the importance of dietary sodium reduction and higher potassium intake for hypertension prevention among young adults.

Factors Associated with Primary Hypertension in Pediatric Patients: An Up-to-Date

BACKGROUND

Arterial hypertension in children is considered a common alteration nowadays, mainly because obesity is a growing worldwide problem closely related to increased blood pressure. Childhood hypertension can be classified as primary or secondary, depending on the etiology. Primary or essential hypertension still has its pathophysiology not fully elucidated, and there is no consensus in the literature on most underlying mechanisms. In this review, genetic and environmental factors, including sodium and potassium intake, socioeconomic status, ethnicity, family structure, obesity, sedentary lifestyle, prematurity and low birth weight, prenatal and postnatal exposures are highlighted.

OBJECTIVE

The present study aimed to perform an update on primary hypertension in childhood, providing clinicians and researchers an overview of the current state of the literature regarding the influence of genetic and environmental factors.

METHODS

This integrative review searched for articles on genetic and environmental factors related to primary hypertension in pediatric patients. The databases evaluated were PubMed and Scopus.

RESULTS

The studies have provided insights regarding many genetic and environmental factors, in addition to their association with the pathophysiology of primary hypertension in childhood. Findings corroborated the idea that primary hypertension is a multifactorial disease. Further studies in the pediatric population are needed to elucidate the underlying mechanisms.

CONCLUSION

The study of primary hypertension in pediatrics has utmost importance for the adoption of preventive measures and the development of more efficient treatments, therefore reducing childhood morbidity and the incidence of cardiovascular diseases and other health consequences later in life.

Is too much salt harmful? Yes

The contribution of high sodium intake to hypertension and to the severity of immune-mediated diseases is still being heatedly debated in medical literature and in the lay media. This review aims to demonstrate two conflicting views on the topic, with the first part citing the detrimental effects of excessive salt consumption. Sodium plays a central role in volume and blood pressure homeostasis, and the positive correlation between sodium intake and blood pressure has been extensively researched. Despite the fact that the average of global daily salt consumption exceeds recommendations of international associations, health damage from excessive salt intake is still controversial. Individual differences in salt sensitivity are in great part attributed to this contradiction. Patients suffering from certain diseases as well as other vulnerable groups-either minors or individuals of full age-exhibit more pronounced blood pressure reduction when consuming a low-sodium diet. Furthermore, findings from the last two decades give insight into the concept of extrarenal sodium storage; however, the long-term consequences of this phenomenon are lesser known. Evidence of the relationship between sodium and autoimmune diseases are cited in the review, too. Nevertheless, further clinical trials are needed to clarify their interplay. In conclusion, for salt-sensitive risk groups in the population, even stricter limits of sodium consumption should be set than for young, healthy individuals. Therefore, the question raised in the title should be rephrased as follows: "how much salt is harmful" and "for whom is elevated salt intake harmful?"

Salt sensitivity and hypertension

Salt sensitivity refers to the physiological trait present in mammals, including humans, by which the blood pressure (BP) of some members of the population exhibits changes parallel to changes in salt intake. It is commoner in elderly, females, Afro-Americans, patients with chronic kidney disease (CKD) and insulin resistance. Increased salt intake promotes an expansion of extracellular fluid volume and increases cardiac output. Salt-sensitive individuals present an abnormal kidney reaction to salt intake; the kidneys retain most of the salt due to an abnormal over-reactivity of sympathetic nervous system and a blunted suppression of renin-angiotensin axis. Moreover, instead of peripheral vascular resistance falling, salt-sensitive subjects present increased vascular resistance due mainly to impaired nitric oxide synthesis in endothelium. Recent studies have shown that part of the dietary salt loading accumulates in skin. Hypertensive and patients with CKD seem to have more sodium in skin comparing to healthy ones. However, we still have not fully explained the link between skin sodium, BP and salt sensitivity. Finally, although salt sensitivity plays a meaningful role in BP pathophysiology, it cannot be used by the physician in everyday patient's care, mainly due to lack of a simple and practical diagnostic test.

Cumulative Blood Pressure Exposure During Young Adulthood and Mobility and Cognitive Function in Midlife

BACKGROUND

High blood pressure (BP) is a known risk factor for mobility and cognitive impairment in older adults. This study tested the association of cumulative BP exposure from young adulthood to midlife with gait and cognitive function in midlife. Furthermore, we tested whether these associations were modified by cerebral white matter hyperintensity (WMH) burden.

METHODS

We included 191 participants from the CARDIA study (Coronary Artery Risk Development in Young Adults), a community-based cohort of young individuals followed over 30 years. Cumulative BP was calculated as the area under the curve (mm Hg×years) from baseline up to year 30 examination. Gait and cognition were assessed at the year 30 examination. Cerebral WMH was available at year 30 in a subset of participants (n=144) who underwent magnetic resonance imaging. Multiple linear regression models were used to assess the association of cumulative BP exposure with gait and cognition. To test effect modification by WMH burden, participants were stratified at the median of WMH and tested for interaction.

RESULTS

Higher cumulative systolic and diastolic BPs were associated with slower walking speed (both P=0.010), smaller step length (P=0.011 and 0.005, respectively), and higher gait variability (P=0.018 and 0.001, respectively). Higher cumulative systolic BP was associated with lower cognitive performance in the executive (P=0.021), memory (P=0.015), and global domains (P=0.010), and higher cumulative diastolic BP was associated with lower cognitive performance in the memory domain (P=0.012). All associations were independent of socio-demographics and vascular risk factors (body mass index, smoking, diabetes mellitus and total cholesterol). The association between cumulative BP and gait was moderated by WMH burden (interaction P<0.05). However, the relation between cumulative BP and cognitive function was not different based on the WMH burden (interaction P>0.05).

CONCLUSIONS

Exposure to higher BP levels from young to midlife is associated with worse gait and cognitive performance in midlife. Furthermore, WMH moderates the association of cumulative BP exposure with gait, but not with cognitive function in midlife. The mechanisms underpinning the impact of BP exposure on brain structure and function must be investigated in longitudinal studies using a life course approach.

Effect of a salt-reduction strategy on blood pressure and acceptability among customers of a food concessionaire in Lima, Peru

AIM

Limited information exists regarding the implementation of salt reduction strategies on collective food services, such as restaurants and food concessionaires. The present study aimed to assess the effect of a salt reduction strategy on blood pressure levels and food acceptability among customers of a food concessionaire.

METHODS

A quasi-experimental study with two phases was conducted. In the pre-intervention phase, the amount of salt used in food preparation was determined. In the intervention phase, a reduction of 20% in salt added to food preparations was implemented. Four hedonic tests and two blood pressure measurements were performed before and after the intervention implementation using standardised techniques. In addition, an evaluation of uneaten food was conducted daily on all customers' plates. Mixed linear regression models were generated to assess the effect of the intervention on blood pressure and acceptability.

RESULTS

A total of 71 workers were evaluated, mean age of 37.5 years, 57.8% females, who consumed the food of the concessionaire, on average, 4.4 (SD: 0.7) days per week. Systolic and diastolic blood pressure were reduced by 3.1 (P < 0.001) and 2.9 (P < 0.001) mmHg at the end of the study, respectively. The results of the hedonic tests and the uneaten food before and after the intervention did not vary significantly.

CONCLUSIONS

The reduction of 20% of salt added to food from a concessionaire had a positive impact on the reduction of customers' blood pressure without reducing food acceptability. This strategy could be implemented in other contexts.

Sodium intake and blood pressure in children and adolescents: a systematic review and meta-analysis of experimental and observational studies

Background

High sodium intake is a cause of elevated blood pressure in adults. In children and adolescents, less evidence is available and findings are equivocal. We systematically reviewed the evidence from experimental and observational studies on the association between sodium intake and blood pressure in children and adolescents.

Methods

A systematic search of the Medline, Embase, CINAHL and CENTRAL databases up to March 2017 was conducted and supplemented by a manual search of bibliographies and unpublished studies. Experimental and observational studies involving children or adolescents between 0 and 18 years of age were included. Random-effects meta-analyses were performed by pooling data across all studies, separately for experimental and observational studies, and restricting to studies with sodium intake and blood pressure measurement methods of high quality. Subgroup meta-analyses, sensitivity analyses and meta-regressions were conducted to investigate sources of heterogeneity and confounding. The dose-response relationship was also investigated.

Results

Of the 6572 publications identified, 85 studies (14 experimental; 71 observational, including 60 cross-sectional, 6 cohort and 5 case-control studies) with 58 531 participants were included. In experimental studies, sodium reduction interventions decreased systolic blood pressure by 0.6 mm Hg [95% confidence interval (CI): 0.5, 0.8] and diastolic blood pressure by 1.2 mm Hg (95% CI: 0.4, 1.9). The meta-analysis of 18 experimental and observational studies (including 3406 participants) with sodium intake and blood pressure measurement methods of high quality showed that, for every additional gram of sodium intake per day, systolic blood pressure increased by 0.8 mm Hg (95% CI: 0.4, 1.3) and diastolic blood pressure by 0.7 mm Hg (95% CI: 0.0, 1.4). The association was stronger among children with overweight and with low potassium intake. A quasi-linear relationship was found between sodium intake and blood pressure.

Conclusions

Sodium intake is positively associated with blood pressure in children and adolescents, with consistent findings in experimental and observational studies. Since blood pressure tracks across the life course, our findings support the reduction of sodium intake during childhood and adolescence to lower blood pressure and prevent the development of hypertension.

Organ memory: a key principle for understanding the pathophysiology of hypertension and other non-communicable diseases

In recent years, several post-interventional analyses of large-scale randomized controlled clinical trials have given us a new concept regarding the risk management of hypertension and cardiovascular diseases. The beneficial effects of intensive treatments were extended even after the interventions ended. This phenomenon is known as "metabolic memory" or "legacy effect", and we recognized its clinical significance. A certain level of evidence in human and animal studies employing organ transplantation techniques has indicated that this type of "memory" resides in each organ and could be transferrable, erasable, and rewritable, which is similar to neuronal and immune "memory". In this review, we define this memory as "organ memory" and summarize the current picture and future direction of this concept. "Organ memory" can be observed in many clinical settings, including in the control of hypertension, diabetes mellitus, and dyslipidemia. Several intensive treatments were demonstrated to have the potential to rewrite "organ memory", leading to the curability of targeted diseases. "Organ memory" is the engraved phenotype of altered organ responsiveness acquired by a time-dependent accumulation of organ stress responses. Not only is the epigenetic change of key genes involved in the formation of "organ memory" but the alteration of multiple factors, including low molecular weight energy metabolites, immune mediators, and tissue structures, is involved as well. These factors intercommunicate during every stress response and carry out incessant remodeling in a certain direction in a spiral fashion through positive feedback mechanisms. Future studies should be directed toward the identification of the core unit of "organ memory" and its manipulation.

Effect of early postnatal nutrition on chronic kidney disease and arterial hypertension in adulthood: a narrative review

Intrauterine growth restriction (IUGR) has been identified as a risk factor for adult chronic kidney disease (CKD), including hypertension (HTN). Accelerated postnatal catch-up growth superimposed to IUGR has been shown to further increase the risk of CKD and HTN. Although the impact of excessive postnatal growth without previous IUGR is less clear, excessive postnatal overfeeding in experimental animals shows a strong impact on the risk of CKD and HTN in adulthood. On the other hand, food restriction in the postnatal period seems to have a protective effect on CKD programming. All these effects are mediated at least partially by the activation of the renin-angiotensin system, leptin and neuropeptide Y (NPY) signaling and profibrotic pathways. Early nutrition, especially in the postnatal period has a significant impact on the risk of CKD and HTN at adulthood and should receive specific attention in the prevention of CKD and HTN.

HABITS AND ATTITUDES OF MOTHERS OF INFANTS IN RELATION TO BREASTFEEDING AND ARTIFICIAL FEEDING IN 11 BRAZILIAN CITIES

Objective:

To analyze the relationship between habits and attitudes of mothers and the types of milk offered to their children in their first two years of life.

Methods:

Retrospective study including 773 interviews of mothers from 11 Brazilian cities with children under 2 years of age. Interviews were conducted in 11 cities of Brazil. The following factors were analyzed: breastfeeding method planned during pregnancy and the method actually applied after birth; type(s) of milk(s) used on the day of the interview and earlier; age at which the child was introduced to whole milk; and source of advice used to choose a certain type of milk.

Results:

Breast milk was offered to 81.7% of infants during their first six months of life, to 52.2% of infants during their second semester (p<0.001) and to 32.9% of infants during their second year of life (p<0.001). In contrast, cow’s milk consumption increased from 31.1 to 83.8% (p<0.001) and 98.7% (p=0.05), respectively, for these three age groups. Infant (15.0%) and follow-on (also known as toddler’s) (2.3%) formulas were used by a much smaller number of infants than whole cow’s milk. Most mothers were not prescribed whole cow’s milk. Pediatricians were the health care professionals who most often recommended infant formulas.

Conclusions:

Rates of breastfeeding in Brazil remain below recommended levels. Brazilian mothers often decide to feed their infants with whole cow’s milk on their own initiative. The use of infant formulas after weaning is still too low.

Salt sensitivity of blood pressure at age 8 years in children born preterm

Preterm birth and low birth weight have been associated with an increased risk of hypertension; postnatal growth and dietary salt intake may contribute to these associations. In adults, the change of blood pressure (BP) in response to modifications in salt intake, i.e., salt sensitivity of BP, has been independently associated with cardiovascular disease. Little is known about salt sensitivity in children. We hypothesize that it may partly explain the association between preterm birth and higher BP in later life. We assessed salt sensitivity of BP at age 8 years in 63 preterm-born children, and explored its association with postnatal growth, sodium intake, and body composition from infancy onwards. BP was measured at baseline and after a 7-day high-salt diet. The difference in mean arterial pressure (MAP) was calculated; salt sensitivity was defined as an increase in MAP of ≥5%. Ten children (16%) showed salt sensitivity of BP, which was associated with neonatal growth restriction as well as with lower fat mass and BMI from infancy onwards. At age 8 years, children classified as salt sensitive had a lower weight-for-age SD-score (-1.5 ± 1.3 vs. -0.6 ± 1.1) and BMI (13.8 ± 1.7 vs. 15.5 ± 1.8 kg/m²) compared to their salt resistant counterparts. Sodium intake was not associated with (salt sensitivity of) BP. Salt sensitivity of BP was demonstrated in preterm-born children at age 8 years and may contribute to the development of cardiovascular disease at later age. Long-term follow-up studies are necessary to assess reproducibility of our findings and to explore clustering with other cardiovascular risk factors.

Life with one kidney

Life with a solitary functioning kidney (SFK) may be different from that when born with two kidneys. Based on the hyperfiltration hypothesis, a SFK may lead to glomerular damage with hypertension, albuminuria and progression towards end-stage renal disease. As the prognosis of kidney donors was considered to be very good, having a SFK has been considered to be a benign condition. In contrast, our research group has demonstrated that being born with or acquiring a SFK in childhood results in renal injury before adulthood in over 50% of those affected. Most congenital cases will be detected during antenatal ultrasound screening, but up to 38% of cases of unilateral renal agenesis are missed. In about 25-50% of cases of antenatally detected SFK there will be signs of hypertrophy, which could indicate additional nephron formation and is associated with a somewhat reduced risk of renal injury. Additional renal and extrarenal anomalies are frequently detected and may denote a genetic cause for the SFK, even though for the majority of cases no explanation can (yet) be found. The ongoing glomerular hyperfiltration results in renal injury, for which early markers are lacking. Individuals with SFK should avoid obesity and excessive salt intake to limit additional hyperfiltration. As conditions like hypertension, albuminuria and a mildly reduced glomerular filtration rate generally do not result in specific complaints but may pose a threat to long-term health, screening for renal injury in any individual with a SFK would appear to be imperative, starting from infancy. With early treatment, secondary consequences may be diminished, thereby providing the optimal life for anyone born with a SFK.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Divergent secular trends in blood pressure and body mass index in children and adolescents in Hong Kong

Secular trends in blood pressure (BP) and body mass index (BMI) during childhood and adolescence are sentinels for the future population cardiovascular disease burden. We examined trends in BP z-score (ages 9-18 years from 1999 to 2014) and BMI z-score (ages 6-18 years from 1996 to 2014) in Hong Kong, China. Overall, BP z-score fell, systolic BP from 0.08 to -0.01 in girls and from 0.31 to 0.25 in boys. However, the trends were not consistent, for both sexes, systolic BP z-score was stable from 1999, decreased slightly from 2002 to 2005 and increased slightly to 2014, diastolic BP z-score decreased slightly from 1999 to 2004 and then remained stable to 2014. In contrast, BMI z-score rose from -0.15 to -0.01 in girls and from 0.14 to 0.34 in boys, mainly during 1997 to 2010. The upper tail of the systolic (except boys) and diastolic BP distribution shifted downwards, whereas the entire BMI distribution shifted upward. BP declined slightly whereas BMI rose in Hong Kong children and adolescents during the last 20 years, with systolic BP and BMI in boys above the reference. This warrants dual action in tackling rising BMI and identifying favorable determinants of BP, particularly targeting boys.

Complementary Feeding Strategies to Facilitate Acceptance of Fruits and Vegetables: A Narrative Review of the Literature

Complementary feeding (CF), which should begin after exclusive breastfeeding for six months, according to the World Health Organization (WHO), or after four months and before six months according to the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), is a period when the infant implicitly learns what, when, how, and how much to eat. At the onset of CF, the brain and the gut are still developing and maturing, and food experiences contribute to shaping brain connections involved in food hedonics and in the control of food intake. These learning processes are likely to have a long-term impact. Children’s consumption of fruit and vegetables (FV) is below recommendations in many countries. Thus, it is crucial to establish preferences for FV early, when infants are learning to eat. The development of food preferences mainly starts when infants discover their first solid foods. This narrative review summarizes the factors that influence FV acceptance at the start of the CF period: previous milk feeding experience; timing of onset of CF; repeated exposures to the food; variety of foods offered as of the start of the CF period; quality and sensory properties of the complementary foods; quality of the meal time context; and parental responsive feeding.

[Effectiveness of the National Strategy for Healthy Complementary Feeding to improve complemantary feeding of infants in a municipality in Southern Brazil]

The aim of this study was to assess the effectiveness of the National Strategy for Healthy Complementary Feeding (ENPACS) in improving complementary feeding in the first year of life in a Brazilian municipality (county). This was an impact evaluation study that enrolled 340 infants from 6 to 12 months of age, followed at primary healthcare units. The target outcomes were prevalence rates for the consumption of vegetables, legumes, fruits, and unhealthy foods, and the prevalence of foods with adequate consistency for age. Poisson regression showed that the strategy was associated with reductions of 32% in the consumption of sodas and/or industrialized juices, 35% of industrialized foods, and 5% of unhealthy foods. There was no increase in the consumption of fruits, legumes, vegetables, or foods with adequate consistency for age. In conclusion, the strategy's positive effect was partial, but it has the potential to help improve infant nutrition, based on its effectiveness in reducing the consumption of unhealthy foods.

Brazilian infant and preschool children feeding: literature review

OBJECTIVE

To assess the feeding profile of Brazilian infants and preschool children aged 6 months to 6 years, based on the qualitative and quantitative analysis of food and nutrient intake.

DATA SOURCE

This review analyzed studies carried out in Brazil that had food survey data on infants and preschool children. The search was limited to publications from the last 10 years included in the LILACS and MEDLINE electronic databases.

DATA SUMMARY

The initial search identified 1480 articles, of which 1411 were excluded after the analysis of abstracts, as they were repeated or did not meet the inclusion criteria. Of the 69 articles assessed in full, 31 articles contained data on food survey and were selected. Only three studies concurrently assessed children from different Brazilian geographical regions. Of the assessed articles, eight had qualitative data, with descriptive analysis of food consumption frequency, and 23 had predominantly quantitative data, with information on energy and nutrient consumption.

CONCLUSIONS

The articles assessed in this review showed very heterogeneous results, making it difficult to compare findings. Overall, the feeding of infants and preschool children is characterized by low consumption of meat, fruits, and vegetables; high consumption of cow's milk and inadequate preparation of bottles; as well as early and high intake of fried foods, candies/sweets, soft drinks, and salt. These results provide aid for the development of strategies that aim to achieve better quality feeding of Brazilian infants and preschoolers.

Salt intake and eating habits of school-aged children

Salt restriction is important for the prevention and treatment of hypertension; however, salt consumption is still high in Japan. Improvements in dietary habits, including salt reduction in childhood, may contribute to the prevention of hypertension. The aim of the present study was to investigate the salt intake of school-aged children and the relationship between their diet diary and actual salt intake. The subjects comprised 580 schoolchildren (471 elementary school pupils and 109 junior high school pupils) who wanted to evaluate their salt intake in Kuji, a northeast coastal area in Japan. We estimated salt intake using spot urine samples and a formula. Lifestyle was assessed using a questionnaire. We also evaluated the salt intake and the lifestyles of 440 parents. The estimated salt intakes of elementary school pupils, junior high school pupils and their parents were 7.1±1.5, 7.6±1.5 and 8.0±1.7 g per day, respectively. The proportion of lower-grade children who achieved the recommended salt intake was low. In the multivariate analysis, the estimated salt intake of school-aged children correlated with their age, estimated salt intake of their parents and the menu priorities of the household. The estimated salt intake of the parents was associated with female gender, obesity, age and the habitual consumption of bread and noodles. In conclusion, the estimated salt intake of school-aged children positively correlated with the estimated salt intake of their parents, and the proportion of lower-grade children who achieved the recommended salt intake was low. Guidance on salt restriction for children and their parents may reduce the salt intake of school-aged children.

Infant Feeding Practices in a Multi-Ethnic Asian Cohort: The GUSTO Study

The optimal introduction of complementary foods provides infants with nutritionally balanced diets and establishes healthy eating habits. The documentation of infant feeding practices in multi-ethnic Asian populations is limited. In a Singapore cohort study (GUSTO), 842 mother-infant dyads were interviewed regarding their feeding practices when the infants were aged 9 and 12 months. In the first year, 20.5% of infants were given dietary supplements, while 5.7% took probiotics and 15.7% homeopathic preparations. At age 9 months, 45.8% of infants had seasonings added to their foods, increasing to 56.3% at 12 months. At age 12 months, 32.7% of infants were given blended food, although 92.3% had begun some form of self-feeding. Additionally, 87.4% of infants were fed milk via a bottle, while a third of them had food items added into their bottles. At both time points, more than a third of infants were provided sweetened drinks via the bottle. Infants of Indian ethnicity were more likely to be given dietary supplements, have oil and seasonings added to their foods and consumed sweetened drinks from the bottle (p < 0.001). These findings provide a better understanding of variations in infant feeding practices, so that healthcare professionals can offer more targeted and culturally-appropriate advice.

Gender and obesity modify the impact of salt intake on blood pressure in children

BACKGROUND

Most modifiable risk factors for high blood pressure (BP), such as obesity and salt intake, are imprinted in childhood and persist into adulthood. The aim of our study was to evaluate the intake of salt in children and to assess its impact on BP taking into account gender and nutritional status.

METHODS

A total of 298 children aged 8-9 years were evaluated in a cross-sectional study. Anthropometric measurements and 24-h ambulatory monitoring were performed, and salt intake was determined by 24-h urinary sodium excretion.

RESULTS

The average estimated salt intake among the entire cohort of children enrolled in the study was 6.5 ± 2.2 g/day, and it was significantly higher in boys than in girls (6.8 ± 2.4 vs. 6.1 ± 1.9 g/day, respectively; p = 0.018) and in overweight/obese children than in normal weight children (6.8 ± 2.4 vs. 6.1 ± 2.0 g/day, respectively; p = 0.006). Salt intake exceeded the upper limit of the US Dietary Reference Intake in 72% of children. Daytime systolic BP increased by 1.00 mmHg (95% confidence interval 0.40-1.59) per gram of daily salt intake in overweight/obese boys, but not in normal weight boys or in girls.

CONCLUSIONS

Our results demonstrate an extremely high salt intake among 8- to 9-year-old Portuguese children. Higher salt intake was associated with higher systolic BP in boys, specifically in those who were overweight/obese. Longitudinal studies are needed to further evaluate the causal relationship between obesity and high BP and the mechanism by which salt intake modulates this relationship. Nonetheless, based on our results, we urge that dietary salt reduction interventions, along with measures to fight the global epidemic of obesity, be implemented as early in life as possible.

Salt intake in children and its consequences on blood pressure

Sodium is the most abundant extracellular cation and therefore pivotal in determining fluid balance. At the beginning of life, a positive sodium balance is needed to grow. Newborns and preterm infants tend to lose sodium via their kidneys and therefore need adequate sodium intake. Among older children and adults, however, excessive salt intake leads to volume expansion and arterial hypertension. Children who are overweight, born preterm, or small for gestational age and African American children are at increased risk of developing high blood pressure due to a high salt intake because they are more likely to be salt sensitive. In the developed world, salt intake is generally above the recommended intake also among children. Although a positive sodium balance is needed for growth during the first year of life, in older children, a sodium-poor diet seems to have the same cardiovascular protective effects as among adults. This is relevant, since: (1) a blood pressure tracking phenomenon was recognized; (2) the development of taste preferences is important during childhood; and (3) salt intake is often associated with the consumption of sugar-sweetened beverages (predisposing children to weight gain).