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Yu J, Arnott C, Li Q, Di Tanna GL, Tian M, Huang L, Yin X, Zhang X, Pearson SA, Labarthe DR, Elliott P, Yan LL, Zhou B, Wu Y, Neal B. Secondary Analysis of the Salt Substitute and Stroke Study (SSaSS): Effects of Potassium-Enriched Salt on Cardiac Outcomes. Hypertension 2024; 81:1031-1040. [PMID: 38465623 DOI: 10.1161/hypertensionaha.123.22410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The SSaSS (Salt Substitute and Stroke Study) has shown that use of a potassium-enriched salt lowers the risk of stroke, total cardiovascular events, and premature death. The effects on cause-specific cardiac outcomes are reported here. METHODS SSaSS was an unblinded, cluster-randomised trial assessing the effects of potassium-enriched salt compared with regular salt among 20 995 Chinese adults with established stroke and older age and uncontrolled hypertension. Post hoc efficacy analyses were performed using an intention-to-treat method and a hierarchical Poisson regression model adjusting for clustering to obtain rate ratios and 95% CIs. We assessed acute coronary syndrome, heart failure, arrhythmia, and sudden death. RESULTS Over a mean 4.74 years follow-up, there were 695 acute coronary syndrome events, 454 heart failure events, 230 arrhythmia events, and 1133 sudden deaths recorded. The rates of events were lower in potassium-enriched salt group for all outcomes but CIs were wide for most: acute coronary syndrome (6.32 versus 7.65 events per 1000 person-years; rate ratio, 0.80 [95% CI, 0.65-0.99]); heart failure (9.14 versus 11.32 events per 1000 person-years; rate ratio, 0.88 [95% CI, 0.60-1.28]); arrhythmia (4.43 versus 6.20 events per 1000 person-years; rate ratio, 0.59 [95% CI, 0.35-0.98]); and sudden death (11.01 versus 11.76 events per 1000 person-years; rate ratio, 0.94 [95% CI, 0.82-1.07]; all P>0.05 with adjustment for multiple comparisons). CONCLUSIONS These results suggest that use of potassium-enriched salt is more likely to prevent than cause cardiac disease but the post hoc nature of these analyses precludes definitive conclusions. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02092090.
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Affiliation(s)
- Jie Yu
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- Faculty of Medicine (J.Y., C.A.), University of New South Wales, Sydney, Australia
| | - Clare Arnott
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- Faculty of Medicine (J.Y., C.A.), University of New South Wales, Sydney, Australia
- University of Sydney, Australia (C.A.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.A.)
| | - Qiang Li
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
| | - Maoyi Tian
- School of Public Health, Harbin Medical University, Harbin, China (M.T., X.Z.)
| | - Liping Huang
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
| | - Xuejun Yin
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (X.Y.)
| | - Xinyi Zhang
- School of Public Health, Harbin Medical University, Harbin, China (M.T., X.Z.)
| | - Sallie-Anne Pearson
- School of Population Health, Faculty of Medicine and Health (S.-A.P.), University of New South Wales, Sydney, Australia
| | - Darwin R Labarthe
- Northwestern University Feinberg School of Medicine, Chicago, United States (D.R.L.)
| | - Paul Elliott
- School of Public Health (P.E.), Imperial College London, United Kingdom
| | - Lijing L Yan
- The George Institute for Global Health at Peking University Health Science Centre, Beijing, China (L.L.Y., Y.W.)
- Global Health Research Centre, Duke Kunshan University, Kunshan, China (L.L.Y.)
| | - Bo Zhou
- First Hospital of China Medical University, Shenyang, China (B.Z.)
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Centre, Beijing, China (L.L.Y., Y.W.)
- Peking University Clinical Research Institute, Beijing, China (Y.W.)
| | - Bruce Neal
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China. The Charles Perkins Centre (B.N.)
- Department of Epidemiology and Biostatistics (B.N.), Imperial College London, United Kingdom
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Bullen J, Kissock K, Yin X, Mkambula P, Trieu K, Hastings B, Neal B, Paige E. The potential for current sodium and potassium production to support a global switch to the use of potassium-enriched salt: a desktop research study. Public Health Nutr 2024:1-23. [PMID: 38644629 DOI: 10.1017/s1368980024000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
OBJECTIVE Switching regular salt (sodium chloride) for salt enriched with potassium chloride (25% potassium chloride, 75% sodium chloride) has been shown to reduce blood pressure and the risk of cardiovascular diseases. We sought to define the potential for current production of sodium chloride and potassium chloride to support a global switch to the use of potassium-enriched salt. DESIGN We summarised data from geological surveys, government reports and trade organisations describing the global production and supply of sodium chloride and potash (the primary source of potassium chloride) and compared this to potential requirements for potassium-enriched salt. SETTING Global. SUBJECTS N/A. RESULTS Approximately 280 million tonnes of sodium chloride were produced in 2020 with China and the United States the main producers. Global production of potash from which potassium chloride is extracted was about 44 million tonnes with Canada, Belarus, Russia and China providing 77% of the world's supply. There were 48 countries in which potassium-enriched salt is currently marketed with 79 different brands identified. Allowing for loss of salt between manufacture and consumption, a full global switch from regular salt to potassium-enriched salt would require about 9.7 million tonnes of sodium chloride to be replaced with 9.7 million tonnes of potassium chloride annually. CONCLUSIONS Significant up-scaling of the production of potassium chloride and the capacity of companies able to manufacture potassium-enriched salt, as well as a robust business case for the switch to potassium chloride, would be required.
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Affiliation(s)
- James Bullen
- The George Institute for Global Health, Sydney, Australia
| | - Katrina Kissock
- The George Institute for Global Health, Sydney, Australia
- The University of New South Wales, Sydney, Australia
| | - Xuejun Yin
- The George Institute for Global Health, Sydney, Australia
- The University of New South Wales, Sydney, Australia
| | | | - Kathy Trieu
- The George Institute for Global Health, Sydney, Australia
- The University of New South Wales, Sydney, Australia
| | | | - Bruce Neal
- The George Institute for Global Health, Sydney, Australia
- The University of New South Wales, Sydney, Australia
| | - Ellie Paige
- The George Institute for Global Health, Sydney, Australia
- The University of New South Wales, Sydney, Australia
- The National Centre for Epidemiology and Population Health, the Australian National University, Canberra, Australia
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Khan MS, Januzzi JL, Liu Y, Xu J, Shaw W, Sattar N, Mahaffey KW, Neal B, Hansen MK, Butler J. Natriuretic Peptides and Prognosis in Patients with Type 2 Diabetes Mellitus and High Risk for Cardiovascular Events. J Card Fail 2024:S1071-9164(24)00119-2. [PMID: 38614444 DOI: 10.1016/j.cardfail.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/16/2024] [Accepted: 03/13/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Prognosis of individuals with and without an established heart failure (HF) diagnosis and similarly elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels is not well known. METHODS CANVAS (Canagliflozin Cardiovascular Assessment Study) trial participants were stratified according to baseline NT-proBNP quartiles and history of HF at baseline. Adjusted event rates per 1000 patient-years follow-up for hospitalizations for HF (HHF), cardiovascular mortality, and kidney events were assessed, and hazard ratios (HR) were calculated using Cox proportional hazard models. RESULTS Of the 3507 participants with available NT-proBNP concentrations, 471 (13.4%) had history of HF. Incidence rate per 1000 patient-years for HHF increased across the NT-proBNP quartiles in patients with (0, 2.8, 13.4 and 40.1; P<0.001) and without (1.8, 3.1, 6.0 and 19.1; P<0.001) HF, with significantly higher risk in patients with HF compared to those without (with HF: quartile 3 HR 9.28 [1.15, 75.05]; P=0.04; without HF: quartile-4 HR 4.86, [2.08, 11.35]; P<0.001). Similar higher risk for kidney events was seen in HF patients (with HF: quartile-4 HR 6.94, [2.66, 18.08]; P=0.001; without HF: quartile-4th HR 4.85 [3.02, 7.80]; P=0.001). Similar trends were seen for cardiovascular mortality. CONCLUSIONS Among patients with type 2 diabetes and cardiovascular risk, an elevated NT-proBNP level was associated with worse HF and kidney outcomes in general regardless of history of HF, however presence of a clinical diagnosis of HF at baseline was associated with incrementally higher risk particularly in higher NT-proBNP quartiles.
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Affiliation(s)
| | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, Massachusetts
| | - Yuxi Liu
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, Massachusetts
| | - Jialin Xu
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | - Wayne Shaw
- Janssen Research & Development, LLC, Raritan, New Jersey
| | - Naveed Sattar
- Glasgow Cardiovascular Research, Glasgow, United Kingdom
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia; Charles Perkins Centre, University of Sydney, Sydney, Australia; Imperial College London, London, United Kingdom
| | | | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; University of Mississippi, Jackson, Mississippi.
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Patel SM, Kang YM, Im K, Neuen BL, Anker SD, Bhatt DL, Butler J, Cherney DZI, Claggett BL, Fletcher RA, Herrington WG, Inzucchi SE, Jardine MJ, Mahaffey KW, McGuire DK, McMurray JJV, Neal B, Packer M, Perkovic V, Solomon SD, Staplin N, Vaduganathan M, Wanner C, Wheeler DC, Zannad F, Zhao Y, Heerspink HJL, Sabatine MS, Wiviott SD. Sodium Glucose Co-transporter 2 Inhibitors and Major Adverse Cardiovascular Outcomes: A SMART-C Collaborative Meta-Analysis. Circulation 2024. [PMID: 38583093 DOI: 10.1161/circulationaha.124.069568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/30/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Sodium glucose co-transporter 2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular events (MACE) across different patient populations are less clear. METHODS This was a collaborative trial-level meta-analysis from the SGLT2i meta-analysis cardio-renal trialists consortium, which includes all phase 3, placebo-controlled, outcomes trials of SGLT2i across three patient populations (diabetes at high risk for atherosclerotic cardiovascular disease [ASCVD], heart failure [HF], or chronic kidney disease [CKD]). The outcomes of interest were MACE (composite of CV death, myocardial infarction [MI], or stroke), individual components of MACE (inclusive of fatal and non-fatal events), all-cause mortality, and death subtypes. Effect estimates for SGLT2i vs. placebo were meta-analyzed across trials and examined across key subgroups (established ASCVD, prior MI, diabetes, prior HF, albuminuria, CKD stages and risk groups). RESULTS A total of 78,607 patients across 11 trials were included: 42,568 (54.2%), 20,725 (26.4%), and 15,314 (19.5%) were included from trials of patients with diabetes at high risk for ASCVD, HF, or CKD, respectively. SGLT2i reduced the rate of MACE by 9% (HR 0.91 [95% CI 0.87-0.96], p<0.0001) with a consistent effect across all three patient populations (I2=0%) and across all key subgroups. This effect was primarily driven by a reduction in CV death (HR 0.86 [0.81-0.92], p<0.0001), with no significant effect for MI in the overall population (HR 0.95 [0.87-1.04], p=0.29), and no effect on stroke (HR 0.99 [0.91-1.07], p=0.77). The benefit for CV death was driven primarily by reductions in HF death and sudden cardiac death (HR 0.68 [0.46-1.02] and HR 0.86 [0.78-0.95], respectively) and was generally consistent across subgroups, with the possible exception of being more apparent in those with albuminuria (Pint=0.02). CONCLUSIONS SGLT2i reduce the risk of MACE across a broad range of patients irrespective of ASCVD, diabetes, kidney function or other major clinical characteristics at baseline. This effect is driven primarily by a reduction of CV death, particularly HF and sudden cardiac death, without a significant effect on MI in the overall population, and no effect on stroke. These data may help inform selection for SGLT2i therapies across the spectrum of cardiovascular-kidney-metabolic disease.
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Affiliation(s)
- Siddharth M Patel
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Yu Mi Kang
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - KyungAh Im
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Brendon L Neuen
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, Ontario, Canada
| | - Brian L Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - William G Herrington
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | - Meg J Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR), Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Parkland Health, Dallas, TX
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX and Imperial College, London United Kingdom
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Natalie Staplin
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Christoph Wanner
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center (CHFC), University Hospital, Würzburg, Germany
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Faiez Zannad
- Université de Lorraine, Inserm Centre d'Investigations Cliniques Plurithématique 1433, and CHRU, Nancy, France
| | | | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Huang L, Li Q, Wu JH, Tian M, Yin X, Yu J, Liu Y, Zhang X, Wu Y, Paige E, Trieu K, Marklund M, Rodgers A, Neal B. The contribution of sodium reduction and potassium increase to the blood pressure lowering observed in the Salt Substitute and Stroke Study. J Hum Hypertens 2024; 38:298-306. [PMID: 38379029 PMCID: PMC11001572 DOI: 10.1038/s41371-024-00896-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 01/07/2024] [Accepted: 01/15/2024] [Indexed: 02/22/2024]
Abstract
The Salt Substitute and Stroke Study (SSaSS) demonstrated significant reductions in systolic blood pressure (SBP), and the risk of stroke, major cardiovascular events and total mortality with the use of potassium-enriched salt. The contribution of sodium reduction versus potassium increase to these effects is unknown. We identified four different data sources describing the association between sodium reduction, potassium supplementation and change in SBP. We then fitted a series of models to estimate the SBP reductions expected for the differences in sodium and potassium intake in SSaSS, derived from 24-h urine collections. The proportions of the SBP reduction separately attributable to sodium reduction and potassium supplementation were calculated. The observed SBP reduction in SSaSS was -3.3 mmHg with a corresponding mean 15.2 mmol reduction in 24-h sodium excretion and a mean 20.6 mmol increase in 24-h potassium excretion. Assuming 90% of dietary sodium intake and 70% of dietary potassium intake were excreted through urine, the models projected falls in SBP of between -1.67 (95% confidence interval: -4.06 to +0.73) mmHg and -5.33 (95% confidence interval: -8.58 to -2.08) mmHg. The estimated proportional contribution of sodium reduction to the SBP fall ranged between 12 and 39% for the different models fitted. Sensitivity analyses assuming different proportional urinary excretion of dietary sodium and potassium intake showed similar results. In every model, the majority of the SBP lowering effect in SSaSS was estimated to be attributable to the increase in dietary potassium rather than the fall in dietary sodium.
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Affiliation(s)
- Liping Huang
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.
| | - Qiang Li
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jason Hy Wu
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- School of Population Health, UNSW Sydney, Sydney, NSW, Australia
| | - Maoyi Tian
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Xuejun Yin
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Yu
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Yishu Liu
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xinyi Zhang
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Yangfeng Wu
- Peking University Clinical Research Institute and School of Public Health, Peking University, Beijing, China
| | - Ellie Paige
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- National Centre for Epidemiology and Population Health, The Australian National University, Canberra, ACT, Australia
| | - Kathy Trieu
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Matti Marklund
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Anthony Rodgers
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- Imperial College London, London, UK
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Xu X, Zeng L, Jha V, Cobb LK, Shibuya K, Appel LJ, Neal B, Schutte AE. Potassium-Enriched Salt Substitutes: A Review of Recommendations in Clinical Management Guidelines. Hypertension 2024; 81:400-414. [PMID: 38284271 PMCID: PMC10863666 DOI: 10.1161/hypertensionaha.123.21343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Excess dietary sodium intake and insufficient dietary potassium intake are both well-established risk factors for hypertension. Despite some successful initiatives, efforts to control hypertension by improving dietary intake have largely failed because the changes required are mostly too hard to implement. Consistent recent data from randomized controlled trials show that potassium-enriched, sodium-reduced salt substitutes are an effective option for improving consumption levels and reducing blood pressure and the rates of cardiovascular events and deaths. Yet, salt substitutes are inconsistently recommended and rarely used. We sought to define the extent to which evidence about the likely benefits and harms of potassium-enriched salt substitutes has been incorporated into clinical management by systematically searching guidelines for the management of hypertension or chronic kidney disease. We found incomplete and inconsistent recommendations about the use of potassium-enriched salt substitutes in the 32 hypertension and 14 kidney guidelines that we reviewed. Discussion among the authors identified the possibility of updating clinical guidelines to provide consistent advice about the use of potassium-enriched salt for hypertension control. Draft wording was chosen to commence debate and progress consensus building: strong recommendation for patients with hypertension-potassium-enriched salt with a composition of 75% sodium chloride and 25% potassium chloride should be recommended to all patients with hypertension, unless they have advanced kidney disease, are using a potassium supplement, are using a potassium-sparing diuretic, or have another contraindication. We strongly encourage clinical guideline bodies to review their recommendations about the use of potassium-enriched salt substitutes at the earliest opportunity.
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Affiliation(s)
- Xiaoyue Xu
- School of Population Health (X.X., L.Z., A.E.S.), University of New South Wales Sydney, Kensington, Australia
- The George Institute for Global Health (X.X., B.N., A.E.S.), University of New South Wales Sydney, Kensington, Australia
| | - Ling Zeng
- School of Population Health (X.X., L.Z., A.E.S.), University of New South Wales Sydney, Kensington, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales, New Delhi, India (V.J.)
- School of Public Health, Imperial College London, United Kingdom (V.J., B.N.)
- Prasanna School of Public Health, Manipal Academy of Higher Education, India (V.J.)
| | | | | | - Lawrence J. Appel
- Department of Epidemiology, Bloomberg School of Public Health and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Bruce Neal
- The George Institute for Global Health (X.X., B.N., A.E.S.), University of New South Wales Sydney, Kensington, Australia
- School of Public Health, Imperial College London, United Kingdom (V.J., B.N.)
| | - Aletta E. Schutte
- School of Population Health (X.X., L.Z., A.E.S.), University of New South Wales Sydney, Kensington, Australia
- The George Institute for Global Health (X.X., B.N., A.E.S.), University of New South Wales Sydney, Kensington, Australia
- Hypertension in Africa Research Team, Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa (A.E.S.)
- Department of Paediatrics, Medical Research Council/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (A.E.S)
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7
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Haghdoost F, Gnanenthiran SR, Shan S, Kaistha P, Huang L, Tian M, Liu Y, Yin X, Zhang X, Hao Z, Wu Y, Di Tanna GL, Neal B, Rodgers A. The effect of salt substitution on frequency and severity of headache: results from the SSaSS cluster-randomised controlled trial of 20,995 participants. Eur J Clin Nutr 2024:10.1038/s41430-024-01419-7. [PMID: 38402353 DOI: 10.1038/s41430-024-01419-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Headache is one of the most common neurological symptoms. Headache disorders are associated with a high global burden of disease. Prior studies indicate that short-to-medium term sodium reduction reduces headache symptom. This study evaluated the effects of long-term reduced-sodium, added-potassium salt on headache frequency and severity in rural China. METHODS The Salt substitute and stroke study (SSaSS) was an open-label cluster-randomised trial in rural China designed to evaluate the effect of salt substitution on mortality and cardiovascular events. Participants included adults with a history of prior stroke and those aged ≥60 years with uncontrolled high blood pressure (BP). Villages were randomly assigned in a 1:1 ratio either to intervention with salt substitute (75% sodium chloride and 25% potassium chloride by mass) or to control with continued use of regular salt (100% sodium chloride). In this pre-specified analysis, between-group differences in headache frequency and severity were evaluated. The study was registered with ClinicalTrials.gov (identifier number: NCT02092090). RESULTS A total of 20,995 participants were included in the trial (mean age 64.3 years, 51% female, mean follow-up 4.7 years). At final follow-up at the end of the study, headache outcome data including frequency and severity of headaches was available for 16,486 (98%) of 16,823 living participants. Overall, 4454/16,486 (27%) individuals reported having headache: 27.4% in the intervention group (2301/8386) vs 26.6% in the control group (2153/8100) (RR 1.04, 95% CI: 0.93, 1.16, p = 0.48). There was no difference in headache severity between intervention and control groups (p = 0.90). CONCLUSION Long term salt substitution did not reduce the frequency or severity of headaches in this population.
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Affiliation(s)
- Faraidoon Haghdoost
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia.
| | - Sonali R Gnanenthiran
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Concord West, New South Wales, Australia
| | - Sana Shan
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | | | - Liping Huang
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Yishu Liu
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Xuejun Yin
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Xinyi Zhang
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Zhixin Hao
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Yangfeng Wu
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
- School of Public Health, Imperial College London, London, UK
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
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8
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Neuen BL, Heerspink HJL, Vart P, Claggett BL, Fletcher RA, Arnott C, de Oliveira Costa J, Falster MO, Pearson SA, Mahaffey KW, Neal B, Agarwal R, Bakris G, Perkovic V, Solomon SD, Vaduganathan M. Estimated Lifetime Cardiovascular, Kidney, and Mortality Benefits of Combination Treatment With SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Nonsteroidal MRA Compared With Conventional Care in Patients With Type 2 Diabetes and Albuminuria. Circulation 2024; 149:450-462. [PMID: 37952217 DOI: 10.1161/circulationaha.123.067584] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Sodium glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and the nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone all individually reduce cardiovascular, kidney, and mortality outcomes in patients with type 2 diabetes and albuminuria. However, the lifetime benefits of combination therapy with these medicines are not known. METHODS We used data from 2 SGLT2i trials (CANVAS [Canagliflozin Cardiovascular Assessment] and CREDENCE [Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation]), 2 ns-MRA trials (FIDELIO-DKD [Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease] and FIGARO-DKD [Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease]), and 8 GLP-1 RA trials to estimate the relative effects of combination therapy versus conventional care (renin-angiotensin system blockade and traditional risk factor control) on cardiovascular, kidney, and mortality outcomes. Using actuarial methods, we then estimated absolute risk reductions with combination SGLT2i, GLP-1 RA, and ns-MRA in patients with type 2 diabetes and at least moderately increased albuminuria (urinary albumin:creatinine ratio ≥30 mg/g) by applying estimated combination treatment effects to participants receiving conventional care in CANVAS and CREDENCE. RESULTS Compared with conventional care, the combination of SGLT2i, GLP-1 RA, and ns-MRA was associated with a hazard ratio of 0.65 (95% CI, 0.55-0.76) for major adverse cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). The corresponding estimated absolute risk reduction over 3 years was 4.4% (95% CI, 3.0-5.7), with a number needed to treat of 23 (95% CI, 18-33). For a 50-year-old patient commencing combination therapy, estimated major adverse cardiovascular event-free survival was 21.1 years compared with 17.9 years for conventional care (3.2 years gained [95% CI, 2.1-4.3]). There were also projected gains in survival free from hospitalized heart failure (3.2 years [95% CI, 2.4-4.0]), chronic kidney disease progression (5.5 years [95% CI, 4.0-6.7]), cardiovascular death (2.2 years [95% CI, 1.2-3.0]), and all-cause death (2.4 years [95% CI, 1.4-3.4]). Attenuated but clinically relevant gains in event-free survival were observed in analyses assuming 50% additive effects of combination therapy, including for major adverse cardiovascular events (2.4 years [95% CI, 1.1-3.5]), chronic kidney disease progression (4.5 years [95% CI, 2.8-5.9]), and all-cause death (1.8 years [95% CI, 0.7-2.8]). CONCLUSIONS In patients with type 2 diabetes and at least moderately increased albuminuria, combination treatment of SGLT2i, GLP-1 RA, and ns-MRA has the potential to afford relevant gains in cardiovascular and kidney event-free and overall survival.
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Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia (B.L.N.)
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, The Netherlands (H.J.L.H., P.V.)
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, The Netherlands (H.J.L.H., P.V.)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.A.)
| | - Julianna de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Epidemiology and Biostatistics, Imperial College London, United Kingdom (B.N.)
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis (R.A.)
| | - George Bakris
- Department of Medicine, University of Chicago, IL (G.B.)
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
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9
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Jain SS, Yu J, Arnott C, Neal B, Perkovic V, Neuen BL, Jardine M, Mahaffey KW. Treatment effect of canagliflozin for patients on therapy for heart failure: Pooled analysis of the CANVAS program and CREDENCE trial. Int J Cardiol 2024; 395:131444. [PMID: 37844669 DOI: 10.1016/j.ijcard.2023.131444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 09/12/2023] [Accepted: 10/12/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Canagliflozin is a sodium-glucose cotransporter 2 inhibitor that has been shown to reduce cardiovascular events in diabetic patients with and without heart failure (HF). Whether the clinical benefits and safety profile of canagliflozin are different in those on a beta blocker and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (BB + RAASi) is unknown. METHODS We pooled participants with HF at baseline from the CANVAS Program and CREDENCE trial and assessed major adverse cardiovascular events and its components; hospitalization for heart failure (HHF); HHF or CV death; all-cause mortality; a renal composite; and a combined renal and CV composite. RESULTS Of 14,543 participants, 2113 had HF at baseline, and 1280 were on BB + RAASi. In those with a history of HF, participants on BB + RAASi therapy were more likely to have coronary atherosclerotic disease (82 vs 72%, p < 0.001), history of myocardial infarction (42 vs 29%, p < 0.001), higher mean body mass index (34 vs 32 kg/m2, p < 0.001), and lower mean estimated glomerular filtration rate (67 vs 70 mL/min/1.73 m2, p < 0.01). They were also more likely to be on insulin, a statin, antithrombotic agent, and a diuretic (all p < 0.001). In unadjusted analysis and when adjusted for selected baseline factors, there was no heterogeneity in canagliflozin treatment effect except for HHF/CV death in those on baseline BB + RAASi vs. those not on baseline BB + RAASi (Pheterogeneity = 0.02). CONCLUSION Canagliflozin mostly improved CV and kidney outcomes in participants with a history of HF irrespective of use of BB + RAASi at baseline, with possible greater benefit on HHF/CV death in participants on BB + RAASi.
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Affiliation(s)
- Sneha S Jain
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, United States of America
| | - Jie Yu
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia; Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Clare Arnott
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; The Charles Perkins Centre, University of Sydney, Sydney, Australia; Faculty of Clinical Epidemiology, Imperial College London, London, UK
| | - Vlado Perkovic
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia
| | - Brendon L Neuen
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia
| | - Meg Jardine
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Concord Repatriation General Hospital, Sydney, New South Wales, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, United States of America; Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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10
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Barrett EM, Afrin H, Rayner M, Pettigrew S, Gaines A, Maganja D, Jones A, Mozaffarian D, Beck EJ, Neal B, Taylor F, Munn E, Wu JH. Criterion validation of nutrient profiling systems: a systematic review and meta-analysis. Am J Clin Nutr 2024; 119:145-163. [PMID: 37863430 DOI: 10.1016/j.ajcnut.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/21/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Nutrient profiling systems (NPSs) use algorithms to evaluate the nutritional quality of foods and beverages. Criterion validation, which assesses the relationship between consuming foods rated as healthier by the NPS and objective measures of health, is essential to ensure the accuracy of NPSs. OBJECTIVE We examined and compared NPSs that have undergone criterion validity testing in relation to diet-related disease risk and risk markers. METHODS Academic databases were searched for prospective cohort and cross-sectional studies published before November, 2022. NPSs were eligible if they incorporated multiple nutrients or food components using an algorithm to determine an overall summary indicator (e.g., a score or rank) for individual foods. Studies were included if they assessed the criterion validity of an eligible NPS. Validation evidence was first summarized in narrative form by NPS, with random effects meta-analysis where ≥2 prospective cohort studies assessed the same NPS and outcomes. RESULTS Of 4519 publications identified, 29 describing 9 NPSs were included in the review. The Nutri-Score NPS was assessed as having substantial criterion validation evidence. Highest compared with lowest diet quality as defined by the Nutri-Score was associated with significantly lower risk of cardiovascular disease (hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.59, 0.93; n = 6), cancer (HR: 0.75; 95% CI: 0.59, 0.94; n = 5), all-cause mortality (HR: 0.74; 95% CI; 0.59, 0.91; n = 4) and change in body mass index (HR: 0.68; 95% CI: 0.50, 0.92; n = 3). The Food Standards Agency NPS, Health Star Rating, Nutrient Profiling Scoring Criterion, Food Compass, Overall Nutrition Quality Index, and the Nutrient-Rich Food Index were determined as having intermediate criterion validation evidence. Two other NPSs were determined as having limited criterion validation evidence. CONCLUSIONS We found limited criterion validation studies compared with the number of NPSs estimated to exist. Greater emphasis on conducting and reporting on criterion validation studies across varied contexts may improve the confidence in existing NPSs.
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Affiliation(s)
- Eden M Barrett
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
| | - Habiba Afrin
- School of Public Health, University of California, Berkeley, CA, United States
| | - Mike Rayner
- Oxford Martin Programme on the Future of Food and Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Simone Pettigrew
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Allison Gaines
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Damian Maganja
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Alexandra Jones
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Dariush Mozaffarian
- Food is Medicine Institute, Friedman School of Nutrition Science & Policy, Tufts University, Boston, MA, United States; Tufts School of Medicine and Division of Cardiology, Tufts Medical Center, Boston, MA, United States
| | - Eleanor J Beck
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Fraser Taylor
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Elizabeth Munn
- Population and Public Health, New South Wales Ministry of Health, Sydney, NSW, Australia
| | - Jason Hy Wu
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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11
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Kissock KR, Garrett GS, Mkambula P, Bullen JD, Trieu K, Fisher LJ, Paige E, Gary MS, Neal B. Switching the World's Salt Supply-Learning from Iodization to Achieve Potassium Enrichment. Adv Nutr 2024; 15:100148. [PMID: 37977326 PMCID: PMC10730351 DOI: 10.1016/j.advnut.2023.100148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/23/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023] Open
Abstract
Sodium is an essential dietary component, but excess sodium intake can lead to high blood pressure and an increased risk of cardiovascular disease. Many national and international bodies, including the World Health Organization, have advocated for population-wide sodium reduction interventions. Most have been unsuccessful due to inadequate sodium reduction by food industry and difficulties in persuading consumers to add less salt to food. Recent research highlights potassium-enriched salt as a new, feasible, acceptable, and scalable approach to reducing the harms caused by excess sodium and inadequate potassium consumption. Modeling shows that a global switch from regular salt to potassium-enriched salt has the potential to avert millions of strokes, heart attacks, and premature deaths worldwide each year. There will be many challenges in switching the world's salt supply to potassium-enriched salt, but the success of universal salt iodization shows that making a global change to the manufacture and use of salt is a tractable proposition. This in-depth review of universal salt iodization identified the importance of a multisectoral effort with strong global leadership, the support of multilateral organizations, engagement with the salt industry, empowered incountry teams, strong participation of national governments, understanding the salt supply chain, and a strategic advocacy and communication plan. Key challenges to the implementation of the iodization program were costs to government, industry, and consumers, industry concerns about consumer acceptability, variance in the size and capabilities of salt producers, inconsistent quality control, ineffective regulation, and trade-related regulatory issues. Many of the opportunities and challenges to universal salt iodization will likely also be applicable to switching the global salt supply to iodized and potassium-enriched salt.
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Affiliation(s)
- Katrina R Kissock
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia.
| | | | | | - James D Bullen
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia
| | - Laura J Fisher
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia
| | - Ellie Paige
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia; National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
| | | | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia; School of Public Health, Imperial College London, United Kingdom
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12
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Crosby S, Malavisi A, Huang L, Jan S, Holden R, Neal B. Factors influencing the time to ethics and governance approvals for clinical trials: a retrospective cross-sectional survey. Trials 2023; 24:779. [PMID: 38041126 PMCID: PMC10693024 DOI: 10.1186/s13063-023-07802-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND The findings from multi-centre trials are central to the practice of evidence-based medicine, enabling the development and implementation of new treatments. The time it takes to commence clinical trials at sites can be long, and ethics and governance approvals are key steps on the pathway to site activation. The goal of this study was to explore factors influencing the times to ethics approval, governance approval and site activation for multi-centre clinical trials. METHODS This paper assessed the associations of trial characteristics (disease area and trial phase), site characteristics (government or private ownership, country) and characteristics of the ethics and governance processes (scope guidelines, mutual acceptance requirements and triage of projects by risk) with times to approvals and activation. Median times were compared between site initiations that were and were not exposed to each characteristic using non-parametric tests in univariable and multivariable regressions. RESULTS There were data from 150 site activations done across 91 sites, 16 trials and 5 countries from November 2013 to November 2021. The overall median time to activation was 234 days (range 74 to 657), with ethics approval taking a median of 48 days (0 to 369) and governance approval a median of 34 days (0 to 489). Both the univariable and multivariable analyses identified associations of disease area, particularly oncology (p univariable = 0.012, p multivariable = 0.044), use of scope guidelines (p < 0.001, p = 0.020) and use of a triage process (p < 0.001, 0.043) with shorter median times for governance approval. These characteristics (all p < 0.001) plus early trial phase (p = 0.028) were also predictive of shorter median times for ethics approval in univariable analyses, but none remained predictive in multivariable models (all p > 0.054). The only factors associated with reduced overall time to site activation in both univariable and multivariable analyses were the early trial phase (p < 0.001, p = 0.013) and mutual acceptance of ethics approvals (p = 0.031, p = 0.030). INTERPRETATION Times to ethics and governance approvals were only one third of total trial start-up time. Factors influencing times to approval and activation were somewhat inconsistent across analyses, but it seems likely that the introduction of selected governance and ethics processes can reduce approval times.
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Affiliation(s)
- Sam Crosby
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia.
| | - Adriana Malavisi
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Liping Huang
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Richard Holden
- UNSW Business School, Faculty of Economics, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Imperial College London, London, UK
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13
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Rao S, Nazarzadeh M, Canoy D, Li Y, Huang J, Mamouei M, Salimi-Khorshidi G, Schutte AE, Neal B, Smith GD, Rahimi K. Sodium-based paracetamol: impact on blood pressure, cardiovascular events, and all-cause mortality. Eur Heart J 2023; 44:4448-4457. [PMID: 37611115 PMCID: PMC10635668 DOI: 10.1093/eurheartj/ehad535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND AND AIMS Effervescent formulations of paracetamol containing sodium bicarbonate have been reported to associate with increased blood pressure and a higher risk of cardiovascular diseases and all-cause mortality. Given the major implications of these findings, the reported associations were re-examined. METHODS Using linked electronic health records data, a cohort of 475 442 UK individuals with at least one prescription of paracetamol, aged between 60 and 90 years, was identified. Outcomes in patients taking sodium-based paracetamol were compared with those taking non-sodium-based formulations of the same. Using a deep learning approach, associations with systolic blood pressure (SBP), major cardiovascular events (myocardial infarction, heart failure, and stroke), and all-cause mortality within 1 year after baseline were investigated. RESULTS A total of 460 980 and 14 462 patients were identified for the non-sodium-based and sodium-based paracetamol exposure groups, respectively (mean age: 74 years; 64% women). Analysis revealed no difference in SBP [mean difference -0.04 mmHg (95% confidence interval -0.51, 0.43)] and no association with major cardiovascular events [relative risk (RR) 1.03 (0.91, 1.16)]. Sodium-based paracetamol showed a positive association with all-cause mortality [RR 1.46 (1.40, 1.52)]. However, after further accounting of other sources of residual confounding, the observed association attenuated towards the null [RR 1.08 (1.01, 1.16)]. Exploratory analyses revealed dysphagia and related conditions as major sources of uncontrolled confounding by indication for this association. CONCLUSIONS This study does not support previous suggestions of increased SBP and an elevated risk of cardiovascular events from short-term use of sodium bicarbonate paracetamol in routine clinical practice.
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Affiliation(s)
- Shishir Rao
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Dexter Canoy
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Yikuan Li
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Jing Huang
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing, China
| | - Mohammad Mamouei
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Gholamreza Salimi-Khorshidi
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
| | - Aletta E Schutte
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - George Davey Smith
- Medical Research Council Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, University of Bristol, Bristol, UK
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, University of Oxford, 34 Broad St, Oxford, OX1 3BD Oxfordshire, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre (Level 3), John Radcliffe Hospital, Oxford, OX3 9DU Oxfordshire, UK
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
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14
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Atkins ER, Chye A, Lung T, Nolde JM, Billot L, Burke M, Chalmers J, Figtree GA, Hay P, Hillis GS, Jansen S, Marschner S, Neal B, Nelson MR, Reid CM, Usherwood T, Schlaich M, Chow CK, Rodgers A. Cost-effectiveness of ultra-low-dose quadruple combination therapy for high blood pressure. Heart 2023; 109:1698-1705. [PMID: 37553138 DOI: 10.1136/heartjnl-2022-322300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/17/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE To determine the cost-effectiveness and cost-utility of a quadpill containing irbesartan 37.5 mg, amlodipine 1.25 mg, indapamide 0.625 mg and bisoprolol 2.5 mg in comparison with irbesartan 150 mg for people with hypertension who are either untreated or receiving monotherapy. METHODS We conducted a within-trial and modelled economic evaluation of the Quadruple UltrA-low-dose tReaTment for hypErTension trial. The analysis was preplanned, and medications and health service use captured during the trial. The main outcomes were incremental cost-effectiveness ratios (ICERs) for cost per mm Hg systolic blood pressure (BP) reduction at 3 months, and modelled cost per quality-adjusted life year (QALY) over a lifetime. RESULTS The within-trial analysis showed no clear difference in cost per mm Hg BP lowering between randomised treatments at 3 months ($A10 (95% uncertainty interval (UI) $A -18 to $A37) per mm Hg per person) for quadpill versus monotherapy. The modelled cost-utility over a lifetime projected a mean incremental cost of $A265 (95% UI $A166 to $A357) and a mean 0.02 QALYs gained (95% UI 0.01 to 0.03) per person with quadpill therapy compared with monotherapy. Quadpill therapy was cost-effective in the base case (ICER of $A14 006 per QALY), and the result was sensitive to the quadpill cost in one-way sensitivity analysis. CONCLUSIONS Quadpill in comparison with monotherapy is comparably cost-effective for short-term BP lowering. In the long-term, quadpill therapy is likely to be cost-effective. TRIAL REGISTRATION NUMBER ANZCTRN12616001144404.
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Affiliation(s)
- Emily R Atkins
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Alexander Chye
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Thomas Lung
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, The University of Western Australia, Perth, Western Australia, Australia
| | - Laurent Billot
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Michael Burke
- Kildare Road Medical Centre, Blacktown, New South Wales, Australia
| | - John Chalmers
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, The University of Sydney Northern Clinical School, St Leonards, New South Wales, Australia
- Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Peter Hay
- Castle Hill Medical Centre, Castle Hill, New South Wales, Australia
| | - Graham S Hillis
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Shirley Jansen
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Simone Marschner
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Mark R Nelson
- Discipline of General Practice, Menzies Research Institute Tasmania, Hobart, Tasmania, Australia
| | - Christopher M Reid
- Centre for Clinical Research and Education, Curtin University, Perth, Western Australia, Australia
| | - Tim Usherwood
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
| | - Markus Schlaich
- Dobney Hypertension Centre, The University of Western Australia, Perth, Western Australia, Australia
- Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
- Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Clara K Chow
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, The University of Sydney, Westmead, New South Wales, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
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15
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Bolton KA, Santos JA, Rosewarne E, Trieu K, Reimers J, Nowson C, Neal B, Webster J, Woodward M, Dunford E, Armstrong S, Bolam B, Grimes C. Outcomes of a state-wide salt reduction initiative in adults living in Victoria, Australia. Eur J Nutr 2023; 62:3055-3067. [PMID: 37493681 PMCID: PMC10468945 DOI: 10.1007/s00394-023-03210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE To assess any effects of a state-wide sodium reduction intervention on sodium intake, sources of dietary sodium and discretionary salt use at a population level. METHODS Data (24-h urinary sodium excretion, self-report survey, a 24-h dietary recall) were collected cross-sectionally at baseline (2016/2017) and follow-up (2020) from adults in Victoria, Australia. Intervention activities included consumer awareness advertising campaign, public debate generation via mass media, strengthening existing policy initiatives and supporting food innovation with industry. RESULTS There were 339 participants at baseline and 211 at follow-up, with 144 and 90 of participants completing a 24-h dietary recall, respectively. There was no difference in adjusted 24-h urinary sodium excretion between baseline and follow-up (134 vs 131 mmol/24 h; p = 0.260). There were no differences in the percentage of participants adding salt during cooking (63% vs 68%; p = 0.244), adding salt at the table (34% vs 37%; p = 0.400) or regularly taking action to control salt/sodium intake (22% vs 21%; p = 0.793). There were large differences in the quantity of dietary sodium sourced from retail stores (57% vs 77%, p < 0.001), and less sodium was sourced from foods at fresh food markets (13% vs 2%; p ≤ 0.001) at follow-up. No large differences were apparent for foods with different levels of processing or for food groups. CONCLUSION There was no clear population-level effect of the 4-year multi-component Victorian Salt Reduction Intervention on sodium intake with Victorian adults continuing to consume sodium above recommended levels. The findings indicate that more intensive and sustained efforts aiming at the retail and food industry with national level support are likely to be required to achieve a measurable improvement in sodium intake at a state level.
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Affiliation(s)
- Kristy A Bolton
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia.
| | - Joseph Alvin Santos
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Emalie Rosewarne
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Jenny Reimers
- Victorian Health Promotion Foundation (VicHealth), Melbourne, VIC, Australia
| | - Caryl Nowson
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Public Health, Imperial College London, London, UK
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Public Health, Imperial College London, London, UK
| | - Elizabeth Dunford
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Department of Nutrition, Gillings Global School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | - Bruce Bolam
- School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Carley Grimes
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
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16
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Sen T, Ju W, Nair V, Ladd P, Menon R, Otto EA, Pyle L, Vigers T, Nelson RG, Arnott C, Neal B, Hansen MK, Kretzler M, Bjornstad P, Heerspink HJL. Sodium glucose co-transporter 2 inhibition increases epidermal growth factor expression and improves outcomes in patients with type 2 diabetes. Kidney Int 2023; 104:828-839. [PMID: 37543256 DOI: 10.1016/j.kint.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 06/30/2023] [Accepted: 07/21/2023] [Indexed: 08/07/2023]
Abstract
Underlying molecular mechanisms of the kidney protective effects of sodium glucose co-transporter 2 (SGLT2) inhibitors are not fully elucidated. Therefore, we studied the association between urinary epidermal growth factor (uEGF), a mitogenic factor involved in kidney repair, and kidney outcomes in patients with type 2 diabetes (T2D). The underlying molecular mechanisms of the SGLT2 inhibitor canagliflozin on EGF using single-cell RNA sequencing from kidney tissue were examined. Urinary EGF-to-creatinine ratio (uEGF/Cr) was measured in 3521 CANagliflozin cardioVascular Assessment Study (CANVAS) participants at baseline and week 52. Associations of uEGF/Cr with kidney outcome were assessed using multivariable-adjusted Cox regression models. Single-cell RNA sequencing was performed using protocol kidney biopsy tissue from ten young patients with T2D on SGLT2i, six patients with T2D on standard care only, and six healthy controls (HCs). In CANVAS, each doubling in baseline uEGF/Cr was associated with a 12% (95% confidence interval 1-22) decreased risk of kidney outcome. uEGF/Cr decreased after 52 weeks with placebo and remained stable with canagliflozin (between-group difference +7.3% (2.0-12.8). In young persons with T2D, EGF mRNA was primarily expressed in the thick ascending loop of Henle. Expression in biopsies from T2D without SGLT2i was significantly lower compared to HCs, whereas treatment with SGLT2i increased EGF levels closer to the healthy state. In young persons with T2D without SGLT2i, endothelin-1 emerged as a key regulator of the EGF co-expression network. SGLT2i treatment was associated with a shift towards normal EGF expression. Thus, decreased uEGF represents increased risk of kidney disease progression in patients with T2D. Canagliflozin increased kidney tissue expression of EGF and was associated with a downstream signaling cascade linked to tubular repair and reversal of tubular injury.
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Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Wenjun Ju
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Viji Nair
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Patricia Ladd
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rajasree Menon
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Edgar A Otto
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura Pyle
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA; Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tim Vigers
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA; Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Robert G Nelson
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona, USA
| | - Clare Arnott
- The George Institute for Global Health, University New South Wales (UNSW), Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Michael K Hansen
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA.
| | - Petter Bjornstad
- Section of Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA; Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands; The George Institute for Global Health, University New South Wales (UNSW), Sydney, New South Wales, Australia.
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17
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Law KK, Coyle DH, Neal B, Huang L, Barrett EM, Arnott C, Chow CK, Di Tanna GL, Lung T, Mozaffarian D, Berkowitz SA, Wong J, Wu T, Twigg S, Gauld A, Simmons D, Piya MK, MacMillan F, Khoo CL, Tian M, Trieu K, Wu JHY. Protocol for a randomized controlled trial of medically tailored meals compared to usual care among individuals with type 2 diabetes in Australia. Contemp Clin Trials 2023; 132:107307. [PMID: 37516164 DOI: 10.1016/j.cct.2023.107307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND 'Food is medicine' strategies aim to integrate food-based nutrition interventions into healthcare systems and are of growing interest to healthcare providers and policy makers. 'Medically Tailored Meals' (MTM) is one such intervention, which involves the 'prescription' by healthcare providers of subsidized, pre-prepared meals for individuals to prevent or manage chronic conditions, combined with nutrition education. OBJECTIVE This study will test the efficacy of an MTM program in Australia among participants with type 2 diabetes (T2D) and hyperglycemia, who experience difficulties accessing and eating nutritious food. METHODS This study will be a two-arm parallel trial (goal n = 212) with individuals randomized in a 1:1 ratio to a MTM intervention group or a control group (106 per arm). Over 26 weeks, the intervention group will be prescribed 20 MTM per fortnight and up to 3 sessions with an accredited dietitian. Controls will continue with their usual care. The primary outcome is glycated hemoglobin (HbA1c, %) and secondary outcomes include differences in blood pressure, blood lipids and weight, all measured at 26 weeks. Process and economic data will be analyzed to assess the feasibility, acceptability, scalability, and cost-effectiveness of the intervention. Recruitment commenced in the first quarter of 2023, with analyses and results anticipated to be available by March 2025. DISCUSSION Few randomized controlled trials have assessed the impact of MTM on clinical outcomes. This Australian-first trial will generate robust data to inform the case for sustained, large-scale implementation of MTM to improve the management of T2D among vulnerable populations. ANZCTR ACTRN12622000852752. PROTOCOL VERSION Version 1.1, July 2023.
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Affiliation(s)
- Kristy K Law
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
| | - Daisy H Coyle
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
| | - Liping Huang
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Eden M Barrett
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Clare Arnott
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Clara K Chow
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Westmead, NSW, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | - Thomas Lung
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States of America
| | - Seth A Berkowitz
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Jencia Wong
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Faculty of Medicine and Health, Sydney Medical School, Central Clinical School, Central Sydney (Patyegarang) Precinct, University of Sydney, NSW, Australia
| | - Ted Wu
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Stephen Twigg
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Faculty of Medicine and Health, Sydney Medical School, Central Clinical School, Central Sydney (Patyegarang) Precinct, University of Sydney, NSW, Australia
| | - Amanda Gauld
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - David Simmons
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia; Macarthur Diabetes Endocrinology and Metabolism Service, Camden and Campbelltown Hospitals, Campbelltown, NSW, Australia
| | - Milan K Piya
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia; Macarthur Diabetes Endocrinology and Metabolism Service, Camden and Campbelltown Hospitals, Campbelltown, NSW, Australia
| | - Freya MacMillan
- Macarthur Diabetes Endocrinology and Metabolism Service, Camden and Campbelltown Hospitals, Campbelltown, NSW, Australia.; School of Health Sciences, Western Sydney University, Campbelltown, NSW, Australia
| | - Chee L Khoo
- Healthfocus Family Practice, Sydney, NSW, Australia
| | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; School of Public Health, Harbin Medical University, Harbin, China
| | - Kathy Trieu
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Jason H Y Wu
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; School of Population Health, University of New South Wales, Sydney, NSW, Australia
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18
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Januzzi JL, Mohebi R, Liu Y, Sattar N, Heerspink HJL, Tefera E, Vaduganathan M, Butler J, Yavin Y, Li J, Pollock CA, Perkovic V, Neal B, Hansen MK. Cardiorenal Biomarkers, Canagliflozin, and Outcomes in Diabetic Kidney Disease: The CREDENCE Trial. Circulation 2023; 148:651-660. [PMID: 37603600 DOI: 10.1161/circulationaha.123.065251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND People with type 2 diabetes and albuminuria are at an elevated risk for cardiac and renal events. The optimal biomarkers to aid disease prediction and to understand the benefits of sodium-glucose cotransporter-2 inhibition remain unclear. METHODS Among 2627 study participants in the CREDENCE trial (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation), concentrations of NT-proBNP (N-terminal pro-B-type natriuretic peptide), high-sensitivity cardiac troponin T, growth differentiation factor-15, and IGFBP7 (insulin-like growth factor binding protein 7) were measured. The effect of canagliflozin on biomarker concentrations was evaluated. The prognostic potential of each biomarker on the primary outcome (a composite of end-stage kidney disease [dialysis, transplantation, or a sustained estimated glomerular filtration rate of <15 mL·min-1·1.73 m-2], doubling of the serum creatinine level, or renal death or cardiovascular death) was assessed. RESULTS The median (quartiles 1 and 3) concentration of each biomarker was generally elevated: NT-proBNP, 180 ng/L (82, 442 ng/L); high-sensitivity cardiac troponin T, 19 ng/L (12, 29 ng/L); growth differentiation factor-15, 2595 ng/L (1852, 3775 ng/L); and IGFBP7, 121.8 ng/mL (105.4, 141.5 ng/mL). At 1 year, the biomarkers all rose by 6% to 29% in the placebo arm but only by 3% to 10% in the canagliflozin arm (all P<0.01 in multivariable linear mixed-effect models). Baseline concentrations of each biomarker were strongly predictive of cardiac and renal outcomes. When the biomarkers were analyzed together in a multimarker panel, individuals with high risk scores (hazard ratio [HR], 4.01 [95% CI, 2.52-6.35]) and moderate risk scores (HR, 2.39 [95% CI, 1.48-3.87]) showed a higher risk for the primary outcome compared with those with low risk scores. By 1 year, a 50% increase in NT-proBNP (HR, 1.11 [95% CI, 1.08-1.15]), high-sensitivity cardiac troponin T (HR, 1.86 [95% CI, 1.64-2.10]), growth differentiation factor-15 (HR, 1.45 [95% CI, 1.24-1.70]), and IGFBP7 (HR, 3.76 [95% CI, 2.54-5.56]) was associated with risk of the primary outcome. CONCLUSIONS Multiple cardiorenal stress biomarkers are strongly prognostic in people with type 2 diabetes and albuminuria. Canagliflozin modestly reduced the longitudinal trajectory of rise in each biomarker. Change in the biomarker level in addition to the baseline level augments the primary outcome prediction. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02065791.
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Affiliation(s)
- James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (J.L.J., R.M., Y.L.)
- Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, MA (J.L.J.)
| | - Reza Mohebi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (J.L.J., R.M., Y.L.)
| | - Yuxi Liu
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (J.L.J., R.M., Y.L.)
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, UK (N.S.)
| | - Hiddo J L Heerspink
- Department Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, the Netherlands (H.J.L.H.)
| | - Eshetu Tefera
- Janssen Research & Development, LLC, Spring House, PA (E.T., Y.Y., M.K.H.)
| | - Muthiah Vaduganathan
- Cardiology Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.V.)
| | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
- Baylor Scott & White Institute, Dallas, TX (J.B.)
| | - Yshai Yavin
- Janssen Research & Development, LLC, Spring House, PA (E.T., Y.Y., M.K.H.)
| | - Jingwei Li
- Department of Cardiology, People's Liberation Army General Hospital, Beijing, China (J.L.)
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China (J.L.)
- The George Institute for Global Health (J.L., V.P., B.N.), UNSW Sydney, Australia
| | - Carol A Pollock
- Kolling Institute, Royal North Shore Hospital University of Sydney, NSW, Australia (C.A.P.)
| | - Vlado Perkovic
- The George Institute for Global Health (J.L., V.P., B.N.), UNSW Sydney, Australia
- Faculty of Medicine (V.P.), UNSW Sydney, Australia
- The Royal North Shore Hospital, Sydney, Australia (V.P.)
| | - Bruce Neal
- The George Institute for Global Health (J.L., V.P., B.N.), UNSW Sydney, Australia
- Charles Perkins Centre, University of Sydney, NSW, Australia (B.N.)
- Imperial College London, UK (B.N.)
| | - Michael K Hansen
- Janssen Research & Development, LLC, Spring House, PA (E.T., Y.Y., M.K.H.)
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Shahid M, Gaines A, Coyle D, Alessandrini R, Finnigan T, Frost G, Marklund M, Neal B. The effect of mycoprotein intake on biomarkers of human health: a systematic review and meta-analysis. Am J Clin Nutr 2023; 118:141-150. [PMID: 37407163 DOI: 10.1016/j.ajcnut.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/27/2023] [Accepted: 03/20/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Mycoprotein is a fungal source of protein that is increasingly consumed as an ingredient in meat analogs. OBJECTIVES This study aimed to systematically review and meta-analyze the effects of mycoprotein intake on selected biomarkers of human health. METHODS This study was registered in PROSPERO (CRD42022308980). We searched the PubMed, Scopus, and Embase databases to identify randomized control trials in any language until 16 August, 2022. Trials were included if they administered a mycoprotein intervention against a nonmycoprotein control arm and if reported outcomes included blood lipids, blood glucose, insulin, blood pressure, or body weight. Eligible trials were assessed for risk of bias using the Cochrane risk-of-bias tool for randomized trials. An inverse-variance-weighted, random-effects meta-analysis model was used to assess the effects of intake across each biomarker. RESULTS Nine trials that included 178 participants with a mean follow-up of 13 d were included, with 4 reporting on blood lipids and 5 reporting on postprandial blood glucose or insulin. The overall reduction of total cholesterol was -0.55 mmol/L (95% CI: -0.85 to -0.26; P < 0.001) in the mycoprotein group compared to control, but no clear effects on HDL cholesterol, LDL cholesterol, or TGs were found (all P > 0.05). There were no reductions in postprandial blood glucose concentrations at 30, 60, 90 or 120 min. Postprandial blood insulin concentration was reduced by -76.51 pmol/L (95% CI: -150.75 to -2.28; P = 0.043) at 30 min, with no detectable effects at 60, 90, or 120 min. CONCLUSIONS Mycoprotein intake may have important effects on blood lipids, but the evidence base is limited by the small sample sizes and short intervention periods of the contributing trials. The protocol for this systematic review has been registered in PROSPERO as CRD42022308980.
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Affiliation(s)
- Maria Shahid
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.
| | - Allison Gaines
- The George Institute for Global Health, University of New South Wales, Sydney, Australia; Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Daisy Coyle
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Roberta Alessandrini
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | | | - Gary Frost
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Matti Marklund
- The George Institute for Global Health, University of New South Wales, Sydney, Australia; Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia; Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
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Yi TW, Smyth B, Di Tanna GL, Arnott C, Cardoza K, Kang A, Pollock C, Agarwal R, Bakris G, Charytan DM, de Zeeuw D, Heerspink HJL, Neal B, Wheeler DC, Cannon CP, Zhang H, Zinman B, Perkovic V, Levin A, Mahaffey KW, Jardine M. Kidney and Cardiovascular Effects of Canagliflozin According to Age and Sex: A Post Hoc Analysis of the CREDENCE Randomized Clinical Trial. Am J Kidney Dis 2023; 82:84-96.e1. [PMID: 36889425 DOI: 10.1053/j.ajkd.2022.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/21/2022] [Indexed: 03/08/2023]
Abstract
RATIONALE & OBJECTIVE It is unclear whether the effect of canagliflozin on adverse kidney and cardiovascular events in those with diabetic kidney disease varies by age and sex. We assessed the effects of canagliflozin among age group categories and between sexes in the Canagliflozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) study. STUDY DESIGN Secondary analysis of a randomized controlled trial. SETTING & PARTICIPANTS Participants in the CREDENCE trial. INTERVENTION Participants were randomly assigned to receive canagliflozin 100mg/d or placebo. OUTCOMES Primary composite outcome of kidney failure, doubling of serum creatinine concentration, or death due to kidney or cardiovascular disease. Prespecified secondary and safety outcomes were also analyzed. Outcomes were evaluated by age at baseline (<60, 60-69, and≥70 years) and sex in the intention-to-treat population using Cox regression models. RESULTS The mean age of the cohort was 63.0±9.2 years, and 34% were female. Older age and female sex were independently associated with a lower risk of the composite of adverse kidney outcomes. There was no evidence that the effect of canagliflozin on the primary outcome (a composite of kidney failure, a doubling of serum creatinine concentration, or death from kidney or cardiovascular causes) differed between age groups (HRs, 0.67 [95% CI, 0.52-0.87], 0.63 [0.48-0.82], and 0.89 [0.61-1.29] for ages<60, 60-69, and≥70 years, respectively; P=0.3for interaction) or sexes (HRs, 0.71 [95% CI, 0.54-0.95] and 0.69 [0.56-0.84] in women and men, respectively; P=0.8for interaction). No differences in safety outcomes by age group or sex were observed. LIMITATIONS This was a post hoc analysis with multiple comparisons. CONCLUSIONS Canagliflozin consistently reduced the relative risk of kidney events in people with diabetic kidney disease in both sexes and across age subgroups. As a result of greater background risk, the absolute reduction in adverse kidney outcomes was greater in younger participants. FUNDING This post hoc analysis of the CREDENCE trial was not funded. The CREDENCE study was sponsored by Janssen Research and Development and was conducted collaboratively by the sponsor, an academic-led steering committee, and an academic research organization, George Clinical. TRIAL REGISTRATION The original CREDENCE trial was registered at ClinicalTrials.gov with study number NCT02065791.
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Affiliation(s)
- Tae Won Yi
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia; Department of Medicine, Clinician Investigator Program, University of British Columbia, Vancouver, British Columbia
| | - Brendan Smyth
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney Medical School, New South Wales, Australia; Department of Renal Medicine, St George Hospital, Kogarah, New South Wales, Australia; National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia
| | - Clare Arnott
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney Medical School, New South Wales, Australia
| | - Kathryn Cardoza
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Amy Kang
- Department of Renal Medicine, Prince of Wales Hospital, New South Wales, Australia
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, New South Wales, Australia; Department of Renal Medicine, Royal North Shore Hospital, New South Wales, Australia
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis, IN
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - David M Charytan
- Nephrology Division, New York University Langone Medical Center, New York University School Grossman of Medicine, New York, NY
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia; Charles Perkins Centre, University of Sydney, New South Wales, Australia; School of Public, Imperial College London, London, United Kingdom
| | - David C Wheeler
- Department of Renal Medicine, University College London Medical School, London, United Kingdom
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, China
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia; Department of Renal Medicine, Royal North Shore Hospital, New South Wales, Australia
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Meg Jardine
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia; Department of Nephrology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Grimes CA, Bolton KA, Trieu K, Reimers J, Armstrong S, Bolam B, Beckford K, Santos JA, Rosewarne E, Dunford EK, Jan S, Webster J, Neal B, Nowson C, Woodward M. Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia. Public Health Nutr 2023; 26:1456-1467. [PMID: 36785876 PMCID: PMC10346046 DOI: 10.1017/s1368980023000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/11/2023] [Accepted: 01/30/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention. DESIGN Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models. SETTING Victoria, Australia. PARTICIPANTS Children aged 4-12 years. RESULTS Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged. CONCLUSION These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.
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Affiliation(s)
- Carley A Grimes
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Geelong, VIC3216, Australia
| | - Kristy A Bolton
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Geelong, VIC3216, Australia
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Jenny Reimers
- Victorian Health Promotion Foundation (VicHealth), Melbourne, VIC, Australia
| | | | - Bruce Bolam
- Department of Health and Human Services, Melbourne, VIC, Australia
| | - Kelsey Beckford
- Deakin University, School of Exercise and Nutrition Sciences, Geelong, VIC, Australia
| | - Joseph Alvin Santos
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Emalie Rosewarne
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Elizabeth K Dunford
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Department of Nutrition, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Caryl Nowson
- Deakin University, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Geelong, VIC3216, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
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22
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Fletcher RA, Arnott C, Rockenschaub P, Schutte AE, Carpenter L, Vaduganathan M, Agarwal R, Bakris G, Chang TI, Heerspink HJL, Jardine MJ, Mahaffey KW, Neal B, Pollock C, Jun M, Rodgers A, Perkovic V, Neuen BL. Canagliflozin, Blood Pressure Variability, and Risk of Cardiovascular, Kidney, and Mortality Outcomes: Pooled Individual Participant Data From the CANVAS and CREDENCE Trials. J Am Heart Assoc 2023:e028516. [PMID: 37345834 DOI: 10.1161/jaha.122.028516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Background Sodium glucose cotransporter-2 inhibitors reduce systolic blood pressure (SBP), but whether they affect SBP variability is unknown. There also remains uncertainty regarding the prognostic value of SBP variability for different clinical outcomes. Methods and Results Using individual participant data from the CANVAS (Canagliflozin Cardiovascular Assessment Study) Program and CREDENCE (Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation) trial, we assessed the effect of canagliflozin on SBP variability in people with type 2 diabetes across 4 study visits over 1.5 years as measured by standard deviation, coefficient of variation, and variability independent of the mean. We used multivariable Cox regression models to estimate associations of SBP variability with cardiovascular, kidney, and mortality outcomes. In 11 551 trial participants, canagliflozin modestly lowered the standard deviation of SBP variability (-0.25 mm Hg [95% CI, -0.44 to -0.06]), but there was no effect on coefficient of variation (0.02% [95% CI, -0.12 to 0.16]) or variability independent of the mean (0.08 U [95% CI, -0.11 to 0.26]) when adjusting for correlation with mean SBP. Each 1 standard deviation increase in standard deviation of SBP variability was independently associated with higher risk of hospitalization for heart failure (hazard ratio [HR], 1.19 [95% CI, 1.02-1.38]) and all-cause mortality (HR, 1.12 [95% CI, 1.01-1.25]), with consistent results observed for coefficient of variation and variability independent of the mean. Increases in SBP variability were not associated with kidney outcomes. Conclusions In people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease, higher visit-to-visit SBP variability is independently associated with risks of hospitalization for heart failure and all-cause mortality. Canagliflozin has little to no effect on SBP variability, independent of its established SBP-lowering effect. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01032629, NCT01989754, NCT02065791.
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Affiliation(s)
- Robert A Fletcher
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Department of Cardiology Royal Prince Alfred Hospital New South Wales Sydney Australia
- Sydney Medical School University of Sydney New South Wales Australia
| | - Patrick Rockenschaub
- Charité Lab for Artificial Intelligence in Medicine Charité Universitätsmedizin Berlin Berlin Germany
- QUEST Center for Transforming Biomedical Research Berlin Institute of Health (BIH) Berlin Germany
| | - Aletta E Schutte
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Faculty of Medicine and Health UNSW New South Wales Sydney Australia
| | - Lewis Carpenter
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | | | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center IN Indianapolis USA
| | - George Bakris
- Department of Medicine University of Chicago Medicine IL Chicago USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine Stanford University School of Medicine CA Stanford USA
- Stanford Hypertension Center Stanford University School of Medicine CA Stanford USA
| | - Hiddo J L Heerspink
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Department of Clinical Pharmacy and Pharmacology University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Meg J Jardine
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- NHMRC Clinical Trials Centre University of Sydney New South Wales Australia
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford Center for Clinical Research Stanford University School of Medicine CA Stanford USA
| | - Bruce Neal
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Imperial College London London UK
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School University of Sydney, Royal North Shore Hospital Sydney Australia
| | - Min Jun
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
| | - Anthony Rodgers
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Department of Renal Medicine Royal North Shore Hospital New South Wales Sydney Australia
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23
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Rosewarne E, Santos JA, Di Tanna GL, Shahid M, Grimes C, Bolton KA, Webster J, Neal B, Woodward M, Coyle D, Trieu K. Changes in sodium levels in Australian packaged foods between 2014 and 2019: an interrupted time series analysis of the impact of the Victorian Salt Reduction Partnership's media advocacy strategy. Int J Behav Nutr Phys Act 2023; 20:71. [PMID: 37316889 DOI: 10.1186/s12966-023-01475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 06/01/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND The Victorian Salt Reduction Partnership (VSRP) implemented a media advocacy strategy (intervention) to stimulate food manufacturers to reduce sodium levels across targeted Australian packaged foods between 2017 and 2019. This study assessed changes in sodium levels of targeted and non-targeted packaged foods during the intervention (2017 to 2019) compared to before the intervention (2014 to 2016) in Australia. METHODS Annually collected branded-food composition data from 2014 to 2019 were used. Interrupted time series analyses was conducted to compare the trend in sodium levels in packaged foods during the intervention (2017-2019) to the trend in the pre-intervention period (2014-2016). The difference between these trends was derived to estimate the effect of the intervention. RESULTS A total of 90,807 products were included in the analysis, of which 14,743 were targeted by the intervention. The difference in before and during intervention trends between targeted and non-targeted food categories was 2.59 mg/100 g (95% CI: -13.88 to 19.06). There was a difference in the pre-intervention slope (2014, 2015, 2016) and intervention slope (2017, 2018, 2019) for four of 17 targeted food categories. There was a decrease in sodium levels (mg/100 g) in one food category: frozen ready meals (-13.47; 95% CI: -25.40 to -1.53), and an increase in three categories: flat bread (20.46; 95% CI: 9.11 to 31.81), plain dry biscuits (24.53; 95% CI: 5.87 to 43.19), and bacon (44.54; 95% CI: 6.36 to 82.72). For the other 13 targeted categories, the difference in slopes crossed the line of null effect. CONCLUSIONS The VSRP's media advocacy strategy did not result in a meaningful reduction in sodium levels of targeted packaged food products during the intervention years compared to trends in sodium levels before the intervention. Our study suggests media advocacy activities highlighting the differences in sodium levels in packaged food products and industry meetings alone are not sufficient to lower average sodium levels in packaged foods in the absence of government leadership and measurable sodium targets.
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Affiliation(s)
- Emalie Rosewarne
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia.
| | - Joseph Alvin Santos
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
| | - Maria Shahid
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
| | - Carley Grimes
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Kristy A Bolton
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Jacqui Webster
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Mark Woodward
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Daisy Coyle
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
| | - Kathy Trieu
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia
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24
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Karlsson K, Rådholm K, Dunford E, Wu JHY, Neal B, Sundström J. Sodium content in processed food items in Sweden compared to other countries: a cross-sectional multinational study. Front Public Health 2023; 11:1182132. [PMID: 37361177 PMCID: PMC10287089 DOI: 10.3389/fpubh.2023.1182132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/17/2023] [Indexed: 06/28/2023] Open
Abstract
Background Dietary sodium has a dose-response relationship with cardiovascular disease, and sodium intake in Sweden exceeds national and international recommendations. Two thirds of dietary sodium intake comes from processed foods, and adults in Sweden eat more processed foods than any other European country. We hypothesized that sodium content in processed foods is higher in Sweden than in other countries. The aim of this study was to investigate sodium content in processed food items in Sweden, and how it differs from Australia, France, Hong Kong, South Africa, the United Kingdom and the United States. Methods Data were collected from retailers by trained research staff using standardized methods. Data were categorized into 10 food categories and compared using Kruskal-Wallis test of ranks. Sodium content in the food items was compared in mg sodium per 100 g of product, based on the nutritional content labels on the packages. Results Compared to other countries, Sweden had among the highest sodium content in the "dairy" and "convenience foods" categories, but among the lowest in "cereal and grain products," "seafood and seafood products" and "snack foods" categories. Australia had the overall lowest sodium content, and the US the overall highest. The highest sodium content in most analyzed countries was found in the "meat and meat products" category. The highest median sodium content in any category was found among "sauces, dips, spreads and dressings" in Hong Kong. Conclusion The sodium content differed substantially between countries in all food categories, although contrary to our hypothesis, processed foods overall had lower sodium content in Sweden than in most other included countries. Sodium content in processed food was nonetheless high also in Sweden, and especially so in increasingly consumed food categories, such as "convenience foods".
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Affiliation(s)
- Karin Karlsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Karin Rådholm
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Elizabeth Dunford
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Department of Nutrition, Gillings Global School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jason H. Y. Wu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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25
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Charytan DM, Mahaffey KW, Jardine MJ, Cannon CP, Neal B, Lambers Heerspink HJ, Agarwal R, Bakris GL, de Zeeuw D, Levin A, Pollock C, Zhang H, Zinman B, Rosenthal N, Perkovic V, Di Tanna GL, Yu J, Rogers K, Arnott C, Wheeler DC. Cardiorenal protective effects of canagliflozin in CREDENCE according to glucose lowering. BMJ Open Diabetes Res Care 2023; 11:e003270. [PMID: 37311602 DOI: 10.1136/bmjdrc-2022-003270] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/21/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Relationships between glycemic-lowering effects of sodium glucose co-transporter 2 inhibitors and impact on kidney and cardiovascular outcomes are uncertain. RESEARCH DESIGN AND METHODS We analyzed 4395 individuals with prebaseline and postbaseline hemoglobin A1c (HbA1c) randomized to canagliflozin (n=2193) or placebo (n=2202) in The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation trial. Effects on HbA1c were assessed using mixed models. Mediation of treatment effects by achieved glycemic control was analyzed using proportional hazards regression with and without adjustment for achieved HbA1c. End points included combined kidney or cardiovascular death, end-stage kidney disease or doubling of serum creatinine (primary trial outcome), and individual end point components. RESULTS HbA1c lowering was modified by baseline estimated glomerular filtration rate (eGFR). For baseline eGFR 60-90, 45-59, and 30-44 mL/min/1.73 m2, overall HbA1c (canagliflozin vs placebo) decreased by -0.24%, -0.14%, and -0.08% respectively and likelihood of >0.5% decrease in HbA1c decreased with ORs of 1.47 (95% CI 1.27 to 1.67), 1.12 (0.94 to 1.33) and 0.99 (0.83 to 1.18), respectively. Adjustment for postbaseline HbA1c marginally attenuated canagliflozin effects on primary and kidney composite outcomes: unadjusted HR 0.67 (95% CI 0.57 to 0.80) and 0.66 (95% CI 0.53 to 0.81); adjusted for week 13 HbA1c, HR 0.71 (95% CI 0.060 to 0.84) and 0.68 (95% CI 0.55 to 0.83). Results adjusted for time-varying HbA1c or HbA1c as a cubic spline were similar and consistent with preserved clinical benefits across a range of excellent and poor glycemic control. CONCLUSIONS The glycemic effects of canagliflozin are attenuated at lower eGFR but effects on kidney and cardiac end points are preserved. Non-glycemic effects may be primarily responsible for the kidney and cardioprotective benefits of canagliflozin.22.
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Affiliation(s)
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Meg J Jardine
- The University of Sydney, Sydney, New South Wales, Australia
| | | | - Bruce Neal
- The University of Sydney, Sydney, New South Wales, Australia
| | | | | | | | - Dick de Zeeuw
- Clinical Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Adeera Levin
- Nephrology, St. Paul's Hospital, Newtown, New South Wales, Australia
| | - Carol Pollock
- Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Hong Zhang
- Renal Division of Peking University First Hospital, Beijing, China
| | | | | | - Vlado Perkovic
- George Institute for Global Health, Sydney, New South Wales, Australia
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | | | - Jie Yu
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kris Rogers
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, Newtown, New South Wales, Australia
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26
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Arnott C, Neal B. Good for your heart and safe for your toes - a patient-level meta-analysis of DAPA-HF and DELIVER. Eur Heart J 2023:7161387. [PMID: 37220173 DOI: 10.1093/eurheartj/ehad315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/10/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
- Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Imperial College London, London, UK
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27
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Sundström J, Lind L, Nowrouzi S, Hagström E, Held C, Lytsy P, Neal B, Marttala K, Östlund O. Heterogeneity in Blood Pressure Response to 4 Antihypertensive Drugs: A Randomized Clinical Trial. JAMA 2023; 329:1160-1169. [PMID: 37039792 PMCID: PMC10091169 DOI: 10.1001/jama.2023.3322] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/21/2023] [Indexed: 04/12/2023]
Abstract
Importance Hypertension is the leading risk factor for premature death worldwide. Multiple blood pressure-lowering therapies are available but the potential for maximizing benefit by personalized targeting of drug classes is unknown. Objective To investigate and quantify the potential for targeting specific drugs to specific individuals to maximize blood pressure effects. Design, Setting, and Participants A randomized, double-blind, repeated crossover trial in men and women with grade 1 hypertension at low risk for cardiovascular events at an outpatient research clinic in Sweden. Mixed-effects models were used to assess the extent to which individuals responded better to one treatment than another and to estimate the additional blood pressure lowering achievable by personalized treatment. Interventions Each participant was scheduled for treatment in random order with 4 different classes of blood pressure-lowering drugs (lisinopril [angiotensin-converting enzyme inhibitor], candesartan [angiotensin-receptor blocker], hydrochlorothiazide [thiazide], and amlodipine [calcium channel blocker]), with repeated treatments for 2 classes. Main Outcomes and Measures Ambulatory daytime systolic blood pressure, measured at the end of each treatment period. Results There were 1468 completed treatment periods (median length, 56 days) recorded in 270 of the 280 randomized participants (54% men; mean age, 64 years). The blood pressure response to different treatments varied considerably between individuals (P < .001), specifically for the choices of lisinopril vs hydrochlorothiazide, lisinopril vs amlodipine, candesartan vs hydrochlorothiazide, and candesartan vs amlodipine. Large differences were excluded for the choices of lisinopril vs candesartan and hydrochlorothiazide vs amlodipine. On average, personalized treatment had the potential to provide an additional 4.4 mm Hg-lower systolic blood pressure. Conclusions and Relevance These data reveal substantial heterogeneity in blood pressure response to drug therapy for hypertension, findings that may have implications for personalized therapy. Trial Registration ClinicalTrials.gov Identifier: NCT02774460.
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Affiliation(s)
- Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Lars Lind
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Shamim Nowrouzi
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Claes Held
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Lytsy
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kerstin Marttala
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Yuan Y, Jin A, Neal B, Feng X, Qiao Q, Wang H, Zhang R, Li J, Duan P, Cao L, Zhang H, Hu S, Li H, Gao P, Xie G, Yuan J, Cheng L, Wang S, Zhang H, Niu W, Fang H, Zhao M, Gao R, Chen J, Elliott P, Labarthe D, Wu Y. Salt substitution and salt-supply restriction for lowering blood pressure in elderly care facilities: a cluster-randomized trial. Nat Med 2023; 29:973-981. [PMID: 37055566 DOI: 10.1038/s41591-023-02286-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 03/02/2023] [Indexed: 04/15/2023]
Abstract
There is a paucity of high-quality evidence on the effectiveness and safety of salt reduction strategies, particularly for older people, who have the most to benefit but are at higher risk of adverse effects. Here, we conducted a clinical trial in which 48 residential elderly care facilities in China (1,612 participants including 1,230 men and 382 women, 55 years or older) were cluster-randomized using a 2 × 2 factorial design to provision of salt substitute (62.5% NaCl and 25% KCl) versus usual salt and to a progressively restricted versus usual supply of salt or salt substitute for 2 years. Salt substitute compared with usual salt lowered systolic blood pressure (-7.1 mmHg, 95% confidence interval (CI) -10.5 to -3.8), meeting the primary outcome of the trial, whereas restricted supply compared with usual supply of salt or salt substitute had no effect on systolic blood pressure. Salt substitute also lowered diastolic blood pressure (-1.9 mmHg, 95% CI -3.6 to -0.2) and resulted in fewer cardiovascular events (hazard ratio (HR) 0.60, 95% CI 0.38-0.96), but had no effect on total mortality (HR 0.84, 95% CI 0.63-1.13). From a safety standpoint, salt substitute increased mean serum potassium and led to more frequent biochemical hyperkalemia, but was not associated with adverse clinical outcomes. In contrast, salt restriction had no effect on any study outcome. The results of this trial indicate that use of salt substitute, but not efforts to restrict salt supply, may achieve blood pressure lowering and deliver health benefits to residents of elderly care facilities in China. Clinicaltrials.gov registration: NCT03290716.
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Affiliation(s)
- Yifang Yuan
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | - Aoming Jin
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Public Health, Imperial College London, London, UK
| | | | - Qianku Qiao
- Yangcheng Ophthalmic Hospital, Shanxi, China
| | - Hongxia Wang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Inner Mongolia, China
| | - Ruijuan Zhang
- Department of Public Health, Xi'an Jiaotong University, Shaanxi, China
| | - Jiayu Li
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | | | - La'e Cao
- Yangcheng Ophthalmic Hospital, Shanxi, China
| | - Hui Zhang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Inner Mongolia, China
| | - Senke Hu
- Department of Public Health, Xi'an Jiaotong University, Shaanxi, China
| | - Huijuan Li
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | - Pei Gao
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
| | - Gaoqiang Xie
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
| | | | - Lili Cheng
- Yangcheng Ophthalmic Hospital, Shanxi, China
| | - Sujuan Wang
- Department of Nutrition and Food Safety, Hohhot Center for Disease Control and Prevention, Inner Mongolia, China
| | - Haijun Zhang
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Wenyi Niu
- Department of Social Medicine and Health Education, Peking University School of Public Health, Beijing, China
| | - Hai Fang
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, Peking Union Medical College, Beijing, China
| | - Junshi Chen
- China National Food Safety Risk Assessment Center, Beijing, China
| | - Paul Elliott
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- UK Dementia Research Institute at Imperial College London, London, UK
- British Heart Foundation Centre for Research Excellence, Imperial College London, London, UK
| | - Darwin Labarthe
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Yangfeng Wu
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China.
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China.
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Bowman L, Weidinger F, Albert MA, Fry ETA, Pinto FJ, Bowman L, Casadei B, Collins R, Devereaux PJ, Douglas PS, Frobert O, Goto S, Grines C, Harrington RA, Haynes R, Hochman JS, Charney LH, James S, Kirchhof P, Komajda M, Lam CSP, Landray M, Maggioni A, McMurray J, Medhurst N, Mehran R, Neal B, Rydén L, Thiele H, Van Gelder I, Wallentin L, Yusuf S, Zannad F. Randomized trials fit for the 21st century. A joint opinion from the European Society of Cardiology, American Heart Association, American College of Cardiology, and the World Heart Federation. Eur Heart J 2023; 44:931-934. [PMID: 36525339 PMCID: PMC10011328 DOI: 10.1093/eurheartj/ehac633] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Louise Bowman
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Franz Weidinger
- President, European Society of Cardiology, 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse, Vienna, Austria
| | - Michelle A Albert
- President, American Heart Association. Walter A. Haas-Lucie Stern Endowed Chair in Cardiology and Admissions Dean, University of California San Francisco Medical School. Director, CeNter for the StUdy of AdveRsiTy and CardiovascUlaR DiseasE (NURTURE Center), San Francisco, CA, USA
| | - Edward T A Fry
- President, American College of Cardiology, Washington, DC, USA.,Chair, Ascension Health Cardiovascular Service Line, Indianapolis, IN, USA
| | - Fausto J Pinto
- President, World Heart Federation, Geneva, Switzerland.,Department of Cardiology, Santa Maria University Hospital, CHULN E.P.E., CCUL, University of Lisbon, Lisbon, Portugal
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Eyles H, Grey J, Jiang Y, Umali E, McLean R, Te Morenga L, Neal B, Rodgers A, Doughty RN, Ni Mhurchu C. Effectiveness of a Sodium-Reduction Smartphone App and Reduced-Sodium Salt to Lower Sodium Intake in Adults With Hypertension: Findings From the Salt Alternatives Randomized Controlled Trial. JMIR Mhealth Uhealth 2023; 11:e43675. [PMID: 36892914 PMCID: PMC10037177 DOI: 10.2196/43675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/13/2022] [Accepted: 01/19/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Even modest reductions in blood pressure (BP) can have an important impact on population-level morbidity and mortality from cardiovascular disease. There are 2 promising approaches: the SaltSwitch smartphone app, which enables users to scan the bar code of a packaged food using their smartphone camera and receive an immediate, interpretive traffic light nutrition label on-screen alongside a list of healthier, lower-salt options in the same food category; and reduced-sodium salts (RSSs), which are an alternative to regular table salt that are lower in sodium and higher in potassium but have a similar mouthfeel, taste, and flavor. OBJECTIVE Our aim was to determine whether a 12-week intervention with a sodium-reduction package comprising the SaltSwitch smartphone app and an RSS could reduce urinary sodium excretion in adults with high BP. METHODS A 2-arm parallel randomized controlled trial was conducted in New Zealand (target n=326). Following a 2-week baseline period, adults who owned a smartphone and had high BP (≥140/85 mm Hg) were randomized in a 1:1 ratio to the intervention (SaltSwitch smartphone app + RSS) or control (generic heart-healthy eating information from The Heart Foundation of New Zealand). The primary outcome was 24-hour urinary sodium excretion at 12 weeks estimated via spot urine. Secondary outcomes were urinary potassium excretion, BP, sodium content of food purchases, and intervention use and acceptability. Intervention effects were assessed blinded using intention-to-treat analyses with generalized linear regression adjusting for baseline outcome measures, age, and ethnicity. RESULTS A total of 168 adults were randomized (n=84, 50% per group) between June 2019 and February 2020. Challenges associated with the COVID-19 pandemic and smartphone technology detrimentally affected recruitment. The adjusted mean difference between groups was 547 (95% CI -331 to 1424) mg for estimated 24-hour urinary sodium excretion, 132 (95% CI -1083 to 1347) mg for urinary potassium excretion, -0.66 (95% CI -3.48 to 2.16) mm Hg for systolic BP, and 73 (95% CI -21 to 168) mg per 100 g for the sodium content of food purchases. Most intervention participants reported using the SaltSwitch app (48/64, 75%) and RSS (60/64, 94%). SaltSwitch was used on 6 shopping occasions, and approximately 1/2 tsp per week of RSS was consumed per household during the intervention. CONCLUSIONS In this randomized controlled trial of a salt-reduction package, we found no evidence that dietary sodium intake was reduced in adults with high BP. These negative findings may be owing to lower-than-anticipated engagement with the trial intervention package. However, implementation and COVID-19-related challenges meant that the trial was underpowered, and it is possible that a real effect may have been missed. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12619000352101; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377044 and Universal Trial U1111-1225-4471.
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Affiliation(s)
- Helen Eyles
- National Institute for Health Innovation, The University of Auckland, Auckland, New Zealand
| | - Jacqueline Grey
- National Institute for Health Innovation, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- National Institute for Health Innovation, The University of Auckland, Auckland, New Zealand
| | - Elaine Umali
- National Institute for Health Innovation, The University of Auckland, Auckland, New Zealand
| | - Rachael McLean
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Lisa Te Morenga
- Research Centre for Hauora and Health, Massey University Wellington, Wellington, New Zealand
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Robert N Doughty
- Department of Medicine, The University of Auckland, Auckland, New Zealand
| | - Cliona Ni Mhurchu
- National Institute for Health Innovation, The University of Auckland, Auckland, New Zealand
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Trieu K, Coyle DH, Rosewarne E, Shahid M, Yamamoto R, Nishida C, Neal B, He FJ, Marklund M, Wu JHY. Estimated Dietary and Health Impact of the World Health Organization's Global Sodium Benchmarks on Packaged Foods in Australia: a Modeling Study. Hypertension 2023; 80:541-549. [PMID: 36625256 DOI: 10.1161/hypertensionaha.122.20105] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND In 2021, the World Health Organization (WHO) set sodium benchmarks for packaged foods to guide countries in setting feasible and effective sodium reformulation programs. We modeled the dietary and health impact of full compliance with the WHO's sodium benchmarks in Australia and compared it to the potential impact of Australia's 2020 sodium reformulation targets. METHODS We used nationally representative data on food and sodium intake, sodium levels in packaged foods, and food sales volume to estimate sodium intake pre- and post-implementation of the WHO and Australia's sodium benchmarks for 24 age-sex groups. Using comparative risk assessment models, we then estimated the potential deaths, incidence, and disability-adjusted life years averted from cardiovascular disease, chronic kidney disease, and stomach cancer based on the reductions in sodium intake. RESULTS Compliance with the WHO's sodium benchmarks for packaged foods in Australia could lower mean adult sodium intake by 404 mg/day, corresponding to a 12% reduction. This could prevent about 1770 deaths/year (95% uncertainty interval 1168-2587), corresponding to 3% of all cardiovascular disease, chronic kidney disease, and stomach cancer deaths in Australia, and prevent some 6900 (4603-9513) new cases, and 25 700 (17 655-35 796) disability-adjusted life years/year. Compared with Australian targets, the WHO benchmarks will avert around 3 and a half times more deaths each year (1770 versus 510). CONCLUSIONS Substantially greater health impact could be achieved if the Australian government strengthened its current sodium reformulation program by adopting WHO's more stringent and comprehensive sodium benchmarks.
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Affiliation(s)
- Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (K.T., D.H.C., E.R., M.S., B.N., M.M., J.H.Y.W.)
| | - Daisy H Coyle
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (K.T., D.H.C., E.R., M.S., B.N., M.M., J.H.Y.W.)
| | - Emalie Rosewarne
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (K.T., D.H.C., E.R., M.S., B.N., M.M., J.H.Y.W.)
| | - Maria Shahid
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (K.T., D.H.C., E.R., M.S., B.N., M.M., J.H.Y.W.)
| | - Rain Yamamoto
- World Health Organization, Geneva, Switzerland (R.Y., C.N.)
| | | | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (K.T., D.H.C., E.R., M.S., B.N., M.M., J.H.Y.W.).,Department of Epidemiology and Biostatistics, Imperial College London, United Kingdom (B.N.)
| | - Feng J He
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (F.J.H.)
| | - Matti Marklund
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (K.T., D.H.C., E.R., M.S., B.N., M.M., J.H.Y.W.).,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.M.)
| | - Jason H Y Wu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (K.T., D.H.C., E.R., M.S., B.N., M.M., J.H.Y.W.).,School of Population Health, University of New South Wales, Australia (J.H.Y.W.)
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Marklund M, Cherukupalli R, Pathak P, Neupane D, Krishna A, Wu JH, Neal B, Kaur P, Moran AE, Appel LJ, Matsushita K. Hypertension treatment capacity in India by increased workforce, greater task-sharing, and extended prescription period: a modelling study. Lancet Reg Health Southeast Asia 2023; 10:100124. [PMID: 37383361 PMCID: PMC10306017 DOI: 10.1016/j.lansea.2022.100124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 06/30/2023]
Abstract
Background The worldwide control rate for hypertension is dismal. An inadequate number of physicians to treat patients with hypertension is one key obstacle. Innovative health system approaches such as delegation of basic tasks to non-physician health workers (task-sharing) might alleviate this problem. Massive scale up of population-wide hypertension management is especially important for low- and middle-income countries such as India. Methods Using constrained optimization models, we estimated the hypertension treatment capacity and salary costs of staff involved in hypertension care within the public health system of India and simulated the potential effects of (1) an increased workforce, (2) greater task-sharing among health workers, and (3) extended average prescription periods that reduce treatment visit frequency (e.g., quarterly instead of monthly). Findings Currently, only an estimated 8% (95% uncertainty interval 7%-10%) of ∼245 million adults with hypertension can be treated by physician-led services in the Indian public health system (assuming the current number of health workers, no greater task-sharing, and monthly visits for prescriptions). Without task-sharing and with continued monthly visits for prescriptions, the least costly workforce expansion to treat 70% of adults with hypertension would require ∼1.6 (1.0-2.5) million additional staff (all non-physicians), with ∼INR 200 billion (≈USD 2.7 billion) in additional annual salary costs. Implementing task-sharing among health workers (without increasing the overall time on hypertension care) or allowing a 3-month prescription period was estimated to allow the current workforce to treat ∼25% of patients. Joint implementation of task-sharing and a longer prescription period could treat ∼70% of patients with hypertension in India. Interpretation The combination of greater task-sharing and extended prescription periods could substantially increase the hypertension treatment capacity in India without any expansion of the current workforce in the public health system. By contrast, workforce expansion alone would require considerable, additional human and financial resources. Funding Resolve to Save Lives, an initiative of Vital Strategies, was funded by grants from Bloomberg Philanthropies; the Bill and Melinda Gates Foundation; and Gates Philanthropy Partners (funded with support from the Chan Zuckerberg Foundation).
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Affiliation(s)
- Matti Marklund
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | | | - Priya Pathak
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dinesh Neupane
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jason H.Y. Wu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Imperial College London, London, UK
| | - Prabhdeep Kaur
- National Institute of Epidemiology, The Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Andrew E. Moran
- Resolve to Save Lives, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Lawrence J. Appel
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tye S, Oshima M, Arnott C, Neuen BL, Fletcher RA, Neal B, Heerspink HJL. The importance of targeting multiple risk markers in patients with type 2 diabetes: A post-hoc study from the CANVAS programme. Diabetes Obes Metab 2023; 25:1638-1645. [PMID: 36782264 DOI: 10.1111/dom.15018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
AIMS To investigate the extent to which improvements in multiple cardiovascular risk markers are associated with a lower risk of cardiovascular and kidney outcomes in patients with type 2 diabetes and high cardiovascular risk participating in the CANVAS programme. MATERIALS AND METHODS Clinically relevant improvements in cardiovascular risk factors were defined as a reduction in glycated haemoglobin ≥1.0%, systolic blood pressure ≥10 mmHg, body weight ≥3 kg, urinary-albumin-creatinine ratio ≥30%, uric acid ≥0.5 mg/dl, and an increase in haemoglobin of ≥1.0 g/dl from baseline to week 26. Participants were categorized according to the number of improvements in cardiovascular risk markers: zero, one, two, three, or four or more risk marker improvements. The Cox proportional hazard regression adjusted for treatment assignment, demographic variables and laboratory measurements was performed to determine the association between the number of risk marker improvements and risk of a composite cardiovascular, heart failure or kidney outcomes. RESULTS We included 9487 (93.5%) participants with available data at baseline and week 26. After week 26, 566 composite cardiovascular, 370 heart failure/cardiovascular death and 153 composite kidney outcomes occurred. The multivariable adjusted hazard ratios associated with four or more improvements in risk markers versus no risk marker improvement were 0.67 (95% CI 0.48, 0.92), 0.58 (95% CI 0.39, 0.87) and 0.49 (95% CI 0.25, 0.96) for the three outcomes respectively. We observed a trend of decreased hazard ratios across subgroups of increasing number of risk marker improvements (p for trend = .008, .02 and .047, respectively). CONCLUSIONS In patients with type 2 diabetes, improvements in multiple risk markers were associated with a reduced risk of cardiovascular and kidney outcomes as compared with no risk marker improvement.
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Affiliation(s)
- SokCin Tye
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
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Yin X, Paige E, Tian M, Li Q, Huang L, Yu J, Rodgers A, Elliott P, Wu Y, Neal B. The Proportion of Dietary Salt Replaced With Potassium-Enriched Salt in the SSaSS: Implications for Scale-Up. Hypertension 2023; 80:956-965. [PMID: 36628969 DOI: 10.1161/hypertensionaha.122.20115] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The SSaSS (Salt Substitute and Stroke Study) recently reported definitive effects of a potassium-enriched salt on cardiovascular outcomes and death. Quantifying the amount of potassium-enriched salt used by trial participants is important for understanding the magnitude of the effect of potassium-enriched salt on risk reduction and how population-wide scale-up might be achieved. METHODS Baseline and annual 24-hour urine samples were collected from subgroups of participants in SSaSS throughout the 5-year follow-up. The mean difference in 24-hour potassium excretion between the 2 groups was used to estimate the quantity of potassium-enriched salt consumed in the intervention group. The corresponding projected difference in sodium intake between groups was calculated and compared with the observed difference. RESULTS The potassium-enriched salt group, compared to the regular salt group, had a mean increase in 24-hour urinary potassium excretion of 0.80 g/d (95% CI, 0.71-0.90), which equates to consumption of 8.8 g/d (95% CI, 7.8-9.9) of potassium-enriched salt. Based on 8.8 g/d potassium-enriched salt consumption, the projected difference in 24-hour urinary sodium excretion was -0.79 g/d. This compares to an observed difference of -0.35 g/d (95% CI, -0.55 to -0.15) and suggests that 72% of baseline regular salt intake was replaced by potassium-enriched salt. CONCLUSIONS The smaller than anticipated between-group difference in sodium excretion likely results from the joint use of regular salt and potassium-enriched salt in the intervention group. Our findings suggest that even an incomplete replacement of regular salt with potassium-enriched salt can deliver significant health gains. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02092090.
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Affiliation(s)
- Xuejun Yin
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.)
| | - Ellie Paige
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.)
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.).,School of Public Health, Harbin Medical University, China (M.T.)
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.)
| | - Liping Huang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.)
| | - Jie Yu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.).,Department of Cardiology, Peking University Third Hospital, Beijing, China (J.Y.)
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.)
| | - Paul Elliott
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia (E.P.).,School of Public Health, Imperial College London, UK (P.E., B.N.)
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China (Y.W.).,Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China (Y.W.)
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (X.Y., E.P., M.T., Q.L., L.H., J.Y., A.R., B.N.).,School of Public Health, Imperial College London, UK (P.E., B.N.)
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Sanuade OA, Alfa V, Yin X, Liu H, Ojo AE, Shedul GL, Ojji DB, Huffman MD, Orji IA, Okoli RCB, Akor B, Ripiye NR, Eze H, Okoro CE, Van Horn L, Tripathi P, Ojo TM, Trieu K, Neal B, Hirschhorn LR. Stakeholder perspectives on Nigeria's national sodium reduction program: Lessons for implementation and scale-up. PLoS One 2023; 18:e0280226. [PMID: 36638099 PMCID: PMC9838847 DOI: 10.1371/journal.pone.0280226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/26/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To reduce excess dietary sodium consumption, Nigeria's 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders' knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions. METHODS From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions. RESULTS Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum. CONCLUSION We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.
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Affiliation(s)
- Olutobi A. Sanuade
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, United States of America
| | - Vanessa Alfa
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Xuejun Yin
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Adedayo E. Ojo
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Gabriel L. Shedul
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Dike B. Ojji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Mark D. Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Cardiovascular Division and Global Health Center, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Ikechukwu A. Orji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | | | - Blessing Akor
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Nanna R. Ripiye
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Helen Eze
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Clementina Ebere Okoro
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Linda Van Horn
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Priya Tripathi
- Stanley Manne Children’s Research Institute, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States of America
| | - Tunde M. Ojo
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Robert J Havey Institute for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- * E-mail:
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Coyle DH, Huang L, Shahid M, Gaines A, Di Tanna GL, Louie JCY, Pan X, Marklund M, Neal B, Wu JHY. Socio-economic difference in purchases of ultra-processed foods in Australia: an analysis of a nationally representative household grocery purchasing panel. Int J Behav Nutr Phys Act 2022; 19:148. [PMID: 36503612 PMCID: PMC9742014 DOI: 10.1186/s12966-022-01389-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Consumption of ultra-processed foods is associated with increased risk of obesity and non-communicable diseases. Little is known about current patterns of ultra-processed foods intake in Australia. The aim of this study was to examine the amount and type of ultra-processed foods purchased by Australian households in 2019 and determine whether purchases differed by socio-economic status (SES). We also assessed whether purchases of ultra-processed foods changed between 2015 and 2019. METHODS: We used grocery purchase data from a nationally representative consumer panel in Australia to assess packaged and unpackaged grocery purchases that were brought home between 2015 to 2019. Ultra-processed foods were identified according to the NOVA system, which classifies foods according to the nature, extent and purpose of industrial food processing. Purchases of ultra-processed foods were calculated per capita, using two outcomes: grams/day and percent of total energy. The top food categories contributing to purchases of ultra-processed foods in 2019 were identified, and differences in ultra-processed food purchases by SES (Index of Relative Social Advantage and Disadvantage) were assessed using survey-weighted linear regression. Changes in purchases of ultra-processed foods between 2015 to 2019 were examined overall and by SES using mixed linear models. RESULTS In 2019, the mean ± SD total grocery purchases made by Australian households was 881.1 ± 511.9 g/d per capita. Of this, 424.2 ± 319.0 g/d per capita was attributable to purchases of ultra-processed foods, which represented 56.4% of total energy purchased. The largest food categories contributing to total energy purchased included mass-produced, packaged breads (8.2% of total energy purchased), chocolate and sweets (5.7%), biscuits and crackers (5.7%) and ice-cream and edible ices (4.3%). In 2019, purchases of ultra-processed foods were significantly higher for the lowest SES households compared to all other SES quintiles (P < 0.001). There were no major changes in purchases of ultra-processed foods overall or by SES over the five-year period. CONCLUSIONS Between 2015 and 2019, ultra-processed foods have consistently made up the majority of groceries purchased by Australians, particularly for the lowest SES households. Policies that reduce ultra-processed food consumption may reduce diet-related health inequalities.
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Affiliation(s)
- Daisy H. Coyle
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia
| | - Liping Huang
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia
| | - Maria Shahid
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia
| | - Allison Gaines
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia ,grid.7445.20000 0001 2113 8111Department of Epidemiology and Biostatistics, Faculty of Medicine, School of Public Health, Imperial College London, London, SW7 2AZ UK
| | - Gian Luca Di Tanna
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia
| | - Jimmy Chun Yu Louie
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia ,grid.194645.b0000000121742757School of Biological Science, Faculty of Science, The University of Hong Kong, Hong Kong, 999077 China
| | - Xiongfei Pan
- grid.461863.e0000 0004 1757 9397Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
| | - Matti Marklund
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia
| | - Bruce Neal
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia ,grid.7445.20000 0001 2113 8111Department of Epidemiology and Biostatistics, Faculty of Medicine, School of Public Health, Imperial College London, London, SW7 2AZ UK
| | - Jason H. Y. Wu
- grid.1005.40000 0004 4902 0432Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042 Australia
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Rasmussen DGK, Hansen MK, Blair J, Jatkoe TA, Neal B, Karsdal MA, Genovese F. Endotrophin is a risk marker of complications in CANagliflozin cardioVascular Assessment Study (CANVAS): a randomized controlled trial. Cardiovasc Diabetol 2022; 21:261. [PMID: 36443792 PMCID: PMC9706889 DOI: 10.1186/s12933-022-01666-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Enhanced de-novo collagen type VI (COL VI) formation has been associated with kidney and cardiovascular fibrosis. We hypothesized that endotrophin (ETP), a product specifically generated during collagen type VI formation, may be prognostic for heart failure (HF), cardiovascular death (CVD), kidney endpoints, and all-cause mortality in patients with type 2 diabetes. METHODS We measured ETP in plasma (P-ETP) and urine (U-ETP) samples collected at baseline and follow-up (year 3) from the randomized controlled trial, CANagliflozin cardioVascular Assessment Study (CANVAS), by use of the PRO-C6 ELISA measuring COL VI formation and ETP. At baseline, plasma and urine samples were available for 3531 and 3423 patients, respectively. At year 3, plasma and urine samples were available for 2178 (61.7%) and 2070 (60.5%) patients, respectively Patients were followed for a median of 6.1 years, and endpoints included: incident HF, CVD, three kidney composite endpoints, and all-cause mortality. Backward selection was used to identify variables to be included in the analyses. Robustness of the association with outcome was assessed by bootstrap analyses. RESULTS In univariable analysis, P-ETP predicted all investigated outcomes (all p < 0.0001), remained independently associated with all outcomes after adjustment for conventional risk factors (all p < 0.004), and increased C-statistics of the models for the outcomes HF, CVD, HFCVD, all-cause mortality, and kidney composite 2 (ΔC ≥ 0.002). In bootstrap analysis, P-ETP was retained with a frequency ranging from 41.0 to 98.4% for all outcomes. Levels of U-ETP were associated with outcomes in univariable analysis, but associations with most outcomes were lost after adjustment for conventional risk factors. The increase in P-ETP over time was greater with increasing albuminuria stage (p < 0.0001) and was independently associated with the kidney endpoints (p < 0.03). In the placebo arm, the increase in P-ETP was prognostic for all-cause mortality (HR [95% CI]; 1.14 [1.05-1.23], p = 0.003). Whereas levels of P-ETP were not impacted by treatment, levels of U-ETP significantly increased with canagliflozin treatment. CONCLUSIONS P-ETP generated during COL VI formation predicts cardiovascular, kidney and mortality outcomes in patients with type 2 diabetes. As ETP identifies patients at increased risk of experiencing relevant outcomes, it may be used for patient enrichment in future clinical trials. Trial Registry Number (ClinicalTrials.gov Identifier): NCT01032629.
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Affiliation(s)
| | - Michael K. Hansen
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, Spring House, Raritan, PA USA
| | - Joseph Blair
- grid.436559.80000 0004 0410 881XNordic Bioscience A/S, Herlev, Denmark
| | - Timothy A. Jatkoe
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, Raritan, NJ USA
| | - Bruce Neal
- grid.415508.d0000 0001 1964 6010The George Institute for Global Health, UNSW Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XThe Charles Perkins Centre, University of Sydney, Sydney, NSW Australia ,grid.7445.20000 0001 2113 8111Imperial College London, London, UK
| | - Morten A. Karsdal
- grid.436559.80000 0004 0410 881XNordic Bioscience A/S, Herlev, Denmark
| | - Federica Genovese
- grid.436559.80000 0004 0410 881XNordic Bioscience A/S, Herlev, Denmark
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Baigent C, Emberson J, Haynes R, Herrington WG, Judge P, Landray MJ, Mayne KJ, Ng SY, Preiss D, Roddick AJ, Staplin N, Zhu D, Anker SD, Bhatt DL, Brueckmann M, Butler J, Cherney DZ, Green JB, Hauske SJ, Haynes R, Heerspink HJ, Herrington WG, Inzucchi SE, Jardine MJ, Liu CC, Mahaffey KW, McCausland FR, McGuire DK, McMurray JJ, Neal B, Neuen BL, Packer M, Perkovic V, Sabatine MS, Solomon SD, Vaduganathan M, Wanner C, Wheeler DC, Wiviott SD, Zannad F. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022; 400:1788-1801. [PMID: 36351458 PMCID: PMC7613836 DOI: 10.1016/s0140-6736(22)02074-8] [Citation(s) in RCA: 200] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Large trials have shown that sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure or chronic kidney disease, or with type 2 diabetes and high risk of atherosclerotic cardiovascular disease. None of the trials recruiting patients with and without diabetes were designed to assess outcomes separately in patients without diabetes. METHODS We did a systematic review and meta-analysis of SGLT2 inhibitor trials. We searched the MEDLINE and Embase databases for trials published from database inception to Sept 5, 2022. SGLT2 inhibitor trials that were double-blind, placebo-controlled, performed in adults (age ≥18 years), large (≥500 participants per group), and at least 6 months in duration were included. Summary-level data used for analysis were extracted from published reports or provided by trial investigators, and inverse-variance-weighted meta-analyses were conducted to estimate treatment effects. The main efficacy outcomes were kidney disease progression (standardised to a definition of a sustained ≥50% decrease in estimated glomerular filtration rate [eGFR] from randomisation, a sustained low eGFR, end-stage kidney disease, or death from kidney failure), acute kidney injury, and a composite of cardiovascular death or hospitalisation for heart failure. Other outcomes were death from cardiovascular and non-cardiovascular disease considered separately, and the main safety outcomes were ketoacidosis and lower limb amputation. This study is registered with PROSPERO, CRD42022351618. FINDINGS We identified 13 trials involving 90 413 participants. After exclusion of four participants with uncertain diabetes status, we analysed 90 409 participants (74 804 [82·7%] participants with diabetes [>99% with type 2 diabetes] and 15 605 [17·3%] without diabetes; trial-level mean baseline eGFR range 37-85 mL/min per 1·73 m2). Compared with placebo, allocation to an SGLT2 inhibitor reduced the risk of kidney disease progression by 37% (relative risk [RR] 0·63, 95% CI 0·58-0·69) with similar RRs in patients with and without diabetes. In the four chronic kidney disease trials, RRs were similar irrespective of primary kidney diagnosis. SGLT2 inhibitors reduced the risk of acute kidney injury by 23% (0·77, 0·70-0·84) and the risk of cardiovascular death or hospitalisation for heart failure by 23% (0·77, 0·74-0·81), again with similar effects in those with and without diabetes. SGLT2 inhibitors also reduced the risk of cardiovascular death (0·86, 0·81-0·92) but did not significantly reduce the risk of non-cardiovascular death (0·94, 0·88-1·02). For these mortality outcomes, RRs were similar in patients with and without diabetes. For all outcomes, results were broadly similar irrespective of trial mean baseline eGFR. Based on estimates of absolute effects, the absolute benefits of SGLT2 inhibition outweighed any serious hazards of ketoacidosis or amputation. INTERPRETATION In addition to the established cardiovascular benefits of SGLT2 inhibitors, the randomised data support their use for modifying risk of kidney disease progression and acute kidney injury, not only in patients with type 2 diabetes at high cardiovascular risk, but also in patients with chronic kidney disease or heart failure irrespective of diabetes status, primary kidney disease, or kidney function. FUNDING UK Medical Research Council and Kidney Research UK.
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Wu JH, Trieu K, Coyle D, Huang L, Wijesuriya N, Nallaiah K, Lung T, Di Tanna GL, Zheng M, Mozaffarian D, MacMillan F, Simmons D, Wu T, Twigg S, Gauld A, Constantino M, McGill M, Wong J, Neal B. Testing the Feasibility and Dietary Impact of a "Produce Prescription" Program for Adults with Undermanaged Type 2 Diabetes and Food Insecurity in Australia. J Nutr 2022; 152:2409-2418. [PMID: 36774107 DOI: 10.1093/jn/nxac152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/06/2022] [Accepted: 07/06/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND There is growing interest in Food is Medicine programs that incorporate food-based interventions into health care for patients with diet-related conditions. OBJECTIVES We aimed to test the feasibility of a "produce prescription" program and its impact on diet quality for people with type 2 diabetes (T2D) experiencing food insecurity in Australia. METHODS We conducted a pre-post intervention study in n = 50 adults experiencing food insecurity with T2D and glycated hemoglobin (HbA1c) ≥8%. Once enrolled, participants received healthy food boxes weekly free of charge, with the contents sufficient to create 2 meals/d, 5 d/wk for the entire household, over 12 wk. Participants were also provided with tailored recipes and behavioral change support. The primary outcome was change in diet quality assessed by 24-h diet recalls. Secondary outcomes included differences in cardiovascular disease risk factors; blood micronutrients; and feasibility indicators. Differences in the baseline and 12-wk mean primary and secondary outcomes were assessed by paired t tests. RESULTS Participants were older adults with mean ± SD age 63 ± 9 y (range: 40-87 y), HbA1c 9.8% ± 1.5%, and 46% were female. Overall, 92% completed the final study follow-up for the primary outcome. Compared with baseline, diet quality improved at week 12, with an increase in the mean overall diet quality (Alternate Healthy Eating Index score) of 12.9 (95% CI: 8.7, 17.1; P < 0.001), driven by significant improvements in vegetables, fruits, whole grains, red/processed meat, trans fat, sodium, and alcohol consumption. Blood lipids also improved (total:HDL cholesterol: -0.48; 95% CI: -0.72, -0.24; P < 0.001), and there was significant weight loss (-1.74 kg; 95% CI: -2.80, -0.68 kg, P = 0.002), but no changes in other clinical outcomes. Participants reported high levels of satisfaction with the program. CONCLUSIONS These findings provide strong support for an adequately powered randomized trial to assess effects of produce prescription as an innovative approach to improve clinical management among individuals with T2D experiencing food insecurity. This trial was registered at https://anzctr.org.au/ as ACTRN12621000404820.
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Affiliation(s)
- Jason Hy Wu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
| | - Kathy Trieu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Daisy Coyle
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Liping Huang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nirupama Wijesuriya
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Kellie Nallaiah
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Thomas Lung
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Gian L Di Tanna
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Miaobing Zheng
- Institute for Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Freya MacMillan
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia; Diabetes, Obesity and Metabolism Translational Research Unit (DOMTRU), School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia; Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - David Simmons
- Diabetes, Obesity and Metabolism Translational Research Unit (DOMTRU), School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia; Macarthur Diabetes Service, Camden and Campbelltown Hospital, Campbelltown, New South Wales, Australia
| | - Ted Wu
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Royal Prince Alfred Clinic, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Stephen Twigg
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Royal Prince Alfred Clinic, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gauld
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Royal Prince Alfred Clinic, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Maria Constantino
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Royal Prince Alfred Clinic, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Margaret McGill
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Royal Prince Alfred Clinic, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Jencia Wong
- Diabetes Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Royal Prince Alfred Clinic, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Imperial College London, School of Public Health, London, United Kingdom
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Koshino A, Schechter M, Sen T, Vart P, Neuen BL, Neal B, Arnott C, Perkovic V, Ridker PM, Tuttle KR, Hansen MK, Heerspink HJL. Interleukin-6 and Cardiovascular and Kidney Outcomes in Patients With Type 2 Diabetes: New Insights From CANVAS. Diabetes Care 2022; 45:2644-2652. [PMID: 36134918 PMCID: PMC9862371 DOI: 10.2337/dc22-0866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The inflammatory cytokine interleukin-6 (IL-6) is associated with cardiovascular (CV) and kidney outcomes in various populations. However, data in patients with type 2 diabetes are limited. We assessed the association of IL-6 with CV and kidney outcomes in the Canagliflozin Cardiovascular Assessment Study (CANVAS) and determined the effect of canagliflozin on IL-6. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes at high CV risk were randomly assigned to canagliflozin or placebo. Plasma IL-6 was measured at baseline and years 1, 3, and 6. The composite CV outcome was nonfatal myocardial infarction, nonfatal stroke, or CV death; the composite kidney outcome was sustained ≥40% estimated glomerular filtration rate decline, end-stage kidney disease, or kidney-related death. Multivariable-adjusted Cox proportional hazards regression was used to estimate the associations between IL-6 and the outcomes. The effect of canagliflozin on IL-6 over time was assessed with a repeated-measures mixed-effects model. RESULTS The geometric mean IL-6 at baseline, available in 3,503 (80.2%) participants, was 1.7 pg/mL. Each doubling of baseline IL-6 was associated with 14% (95% CI 4, 24) and 21% (95% CI 1, 45) increased risk of CV and kidney outcomes, respectively. Over 6 years, IL-6 increased by 5.8% (95% CI 3.4, 8.3) in the placebo group. Canagliflozin modestly attenuated the IL-6 increase (absolute percentage difference vs. placebo 4.4% [95% CI 1.3, 9.9; P = 0.01]). At year 1, each 25% lower level of IL-6 compared with baseline was associated with 7% (95% CI 1, 22) and 14% (95% CI 5, 22) lower risks for the CV and kidney outcome, respectively. CONCLUSIONS In patients with type 2 diabetes at high CV risk, baseline IL-6 and its 1-year change were associated with CV and kidney outcomes. The effect of IL-6-lowering therapy on CV, kidney, and safety outcomes remains to be tested.
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Affiliation(s)
- Akihiko Koshino
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Meir Schechter
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Bruce Neal
- The George Institute for Global Health, Sydney, Australia
| | - Clare Arnott
- The George Institute for Global Health, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Paul M Ridker
- Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, and Nephrology Division, University of Washington, Spokane, WA
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,The George Institute for Global Health, Sydney, Australia.,University of New South Wales, Sydney, Australia
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Sarraju A, Bakris G, Cannon CP, Cherney D, Damaraju C, Figtree GA, Gogate J, Greene T, Heerspink HJ, Januzzi JL, Neal B, Jardine MJ, Blais J, Kosiborod M, Levin A, Lingvay I, Weir MR, Perkovic V, Mahaffey KW. Cardiovascular Effects of Canagliflozin in Relation to Renal Function and Albuminuria. J Am Coll Cardiol 2022; 80:1721-1731. [DOI: 10.1016/j.jacc.2022.08.772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 07/20/2022] [Accepted: 08/12/2022] [Indexed: 10/31/2022]
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Maganja D, Trieu K, Reading M, Huang L, Hart AC, Taylor F, Stamatellis S, Arnott C, Feng X, Schutte AE, Di Tanna GL, Ni Mhurchu C, Cameron AJ, Huffman MD, Neal B, Wu JH. Protocol for a novel sodium and blood pressure reduction intervention targeting online grocery shoppers with hypertension - the SaltSwitch Online Grocery Shopping randomized trial. Am Heart J 2022; 252:70-83. [PMID: 35777455 DOI: 10.1016/j.ahj.2022.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/30/2022] [Accepted: 06/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND High dietary sodium intake is a leading cause of hypertension. A major source of dietary sodium is salt added to processed food products available in retail food environments. The fast-growing online grocery shopping setting provides new opportunities for salt reduction interventions that support consumers in choosing healthier options. METHODS The SaltSwitch Online Grocery Shopping randomized controlled trial is investigating the feasibility, acceptability, and effectiveness of a novel intervention for lowering salt consumption and blood pressure amongst people with hypertension who shop for groceries online. The intervention is based on a bespoke web browser extension that interfaces with a major retailer's online store to highlight and interpret product sodium content and suggest similar but lower-sodium alternatives. The primary outcome of interest is change in mean systolic blood pressure between individuals randomized (1:1) to the intervention and control (usual online shopping) arms at 12 weeks. Secondary outcomes are diastolic blood pressure, spot urinary sodium and sodium:potassium ratio, sodium purchases, and dietary intake. Intervention implementation and lessons for future uptake will be assessed using a mixed methods process evaluation. Participants with hypertension who shop online for groceries and exhibit high sodium purchasing behavior are being recruited across Australia. A target sample size of 1,966 provides 80% power (2-sided alpha = 0.05) to detect a 2 mm Hg difference in systolic blood pressure between groups, assuming a 15 mm Hg standard deviation, after allowing for a 10% dropout rate. DISCUSSION This trial will provide evidence on an innovative intervention to potentially reduce salt intake and blood pressure in people with hypertension. The intervention caters to individual preferences by encouraging sustainable switches to similar but lower-salt products. If effective, the intervention will be readily scalable at low cost by interfacing with existing online retail environments.
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Affiliation(s)
- Damian Maganja
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michelle Reading
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Liping Huang
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ashleigh Chanel Hart
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Fraser Taylor
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Steve Stamatellis
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Xiaoqi Feng
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Aletta E Schutte
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Cliona Ni Mhurchu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Adrian J Cameron
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Melbourne, Victoria, Australia
| | - Mark D Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Cardiovascular Division and Global Health Center, Washington University, St. Louis, MO
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Epidemiology and Biostatistics, Imperial College London, South Kensington, London, United Kingdom
| | - Jason Hy Wu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Li C, Yu J, Hockham C, Perkovic V, Neuen BL, Badve SV, Houston L, Lee VYJ, Barraclough JY, Fletcher RA, Mahaffey KW, Heerspink HJL, Cannon CP, Neal B, Arnott C. Canagliflozin and atrial fibrillation in type 2 diabetes mellitus: A secondary analysis from the CANVAS Program and CREDENCE trial and meta-analysis. Diabetes Obes Metab 2022; 24:1927-1938. [PMID: 35589614 DOI: 10.1111/dom.14772] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/07/2022] [Accepted: 05/17/2022] [Indexed: 01/10/2023]
Abstract
AIM To assess the effects of canagliflozin on the incidence of atrial fibrillation/atrial flutter (AF/AFL) and other key cardiorenal outcomes in a pooled analysis of the CANVAS and CREDENCE trials. MATERIALS AND METHODS Participants with type 2 diabetes and high risk of cardiovascular disease or chronic kidney disease were included and randomly assigned to canagliflozin or placebo. We explored the effects of canagliflozin on the incidence of first AF/AFL events and AF/AFL-related complications (ischaemic stroke/transient ischaemic attack/hospitalization for heart failure). Major adverse cardiovascular events and a renal-specific outcome by baseline AF/AFL status were analysed using Cox regression models. RESULTS Overall, 354 participants experienced a first AF/AFL event. Canagliflozin had no detectable effect on AF/AFL (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.67-1.02) compared with placebo. Subgroup analysis, however, suggested a possible reduction in AF/AFL in those with no AF/AFL history (HR 0.78, 95% CI 0.62-0.99). Canagliflozin was also associated with a reduction in AF/AFL-related complications (HR 0.74, 95% CI 0.65-0.86). There was no evidence of treatment heterogeneity by baseline AF/AFL history for other key cardiorenal outcomes (all Pinteraction > 0.14). Meta-analysis of five sodium-glucose cotransporter-2 (SGLT2) inhibitor trials demonstrated a 19% reduction in AF/AFL events with active treatment (HR 0.81, 95% CI 0.72-0.92). CONCLUSIONS Overall, a significant effect of canagliflozin on the incidence of AF/AFL events could not be shown, however, a possible reduction in AF/AFL events in those with no prior history requires further investigation. Meta-analysis suggests SGLT2 inhibition reduces AF/AFL incidence.
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Affiliation(s)
- Chao Li
- Cardiovascular Centre, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jie Yu
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Carinna Hockham
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sunil V Badve
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Nephrology, St George Hospital, Sydney, Australia
| | - Lauren Houston
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Vivian Y J Lee
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Robert A Fletcher
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Hiddo J L Heerspink
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christopher P Cannon
- Cardiovascular Division, Brigham & Women's Hospital and Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Imperial College London, London, UK
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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44
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Sen T, Koshino A, Neal B, Bijlsma MJ, Arnott C, Li J, Hansen MK, Ix JH, Heerspink HJL. Mechanisms of action of the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin on tubular inflammation and damage: A post hoc mediation analysis of the CANVAS trial. Diabetes Obes Metab 2022; 24:1950-1956. [PMID: 35635326 PMCID: PMC9546391 DOI: 10.1111/dom.14779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/09/2022] [Accepted: 05/25/2022] [Indexed: 01/10/2023]
Abstract
AIMS To test the hypothesis that the reduction in urinary kidney injury molecule-1 (KIM-1) observed with the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin is mediated through its effects on urine albumin to creatinine ratio (UACR) and monocyte chemoattractant protein-1 (MCP-1) by assessing the proportion of the effect of canagliflozin on KIM-1 that is mediated through its effects on MCP-1 and UACR in patients with type 2 diabetes and albuminuric kidney disease. MATERIAL AND METHODS We measured KIM-1 and MCP-1 levels in urine samples from the CANVAS trial at baseline and Week 52 with the Mesoscale QuickPlex SQ 120 platform. KIM-1 and MCP-1 were standardized by urinary creatinine (Cr). The proportion of the effect of canagliflozin that is mediated through UACR and MCP-1/Cr on KIM-1/Cr was estimated with G-computation. RESULTS In total, 763 patients with micro- or macroalbuminuria (17.6% of the total cohort) were included. Baseline characteristics were well balanced between the canagliflozin and placebo group. At Year 1, canagliflozin compared to placebo reduced UACR, MCP-1/Cr and KIM-1/Cr by 40.4% (95% CI 31.0, 48.4), 18.1% (95% CI 8.9, 26.4) and 30.9% (95% CI 23.0, 38.0), respectively. The proportion of the effect of canagliflozin on KIM-1/Cr mediated by its effect on UACR and in turn on MCP-1/Cr was 15.2% (95% CI 9.4, 24.5). CONCLUSION Canagliflozin reduces urinary KIM-1, suggesting decreased tubular damage. This effect was partly mediated through a reduction in MCP-1, indicative of reduced tubular inflammation, which was in turn mediated by a reduction in UACR. This post hoc analysis suggests that urinary albumin leakage may lead to tubular inflammation and induction of injury, and provide mechanistic insight for how canagliflozin may ameliorate tubular damage, but further research is required to confirm these findings.
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Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Akihiko Koshino
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
- Department of Nephrology and Laboratory MedicineKanazawa UniversityKanazawaJapan
| | - Bruce Neal
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
| | - Maarten J. Bijlsma
- Unit PharmacoTherapy, Epidemiology, and Economics (PTEE), Groningen Research Institute of PharmacyUniversity of GroningenGroningenThe Netherlands
| | - Clare Arnott
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
| | - Jingwei Li
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
| | | | - Joachim H. Ix
- Nephrology SectionVeterans Affairs San Diego Healthcare SystemLa JollaCaliforniaUSA
- Division of Nephrology‐Hypertension, Department of MedicineUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
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Marklund M, Tullu F, Raj Thout S, Yu J, Brady TM, Appel LJ, Neal B, Wu JHY, Gupta R. Estimated Benefits and Risks of Using a Reduced-Sodium, Potassium-Enriched Salt Substitute in India: A Modeling Study. Hypertension 2022; 79:2188-2198. [PMID: 35880525 DOI: 10.1161/hypertensionaha.122.19072] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Salt substitution (ie, replacement of table and cooking salt with potassium-enriched salt substitutes) is a promising strategy to reduce blood pressure and prevent cardiovascular disease, particularly in countries like India where there is high sodium intake, mainly from discretionary salt, and low potassium intake. Life-threatening hyperkalemia from increased potassium intake is a postulated concern for individuals with chronic kidney disease. METHODS We used comparative risk assessment models to estimate the number of (1) cardiovascular deaths averted due to blood pressure reductions; (2) potential hyperkalemia-related deaths from increased potassium intake in individuals with advanced chronic kidney disease; and (3) net averted deaths from nationwide salt substitution in India. We evaluated a conservative scenario, based on a large, long-term pragmatic trial in rural China; and an optimistic scenario informed by our recent trial in India. Sensitivity analyses were conducted to assess the robustness of the findings. RESULTS In the conservative scenario, a nationwide salt substitution intervention was estimated to result in ≈214 000 (95% uncertainty interval, 92 764-353 054) averted deaths from blood pressure reduction in the total population and ≈52 000 (22 961-80 211) in 28 million individuals with advanced chronic kidney disease, while ≈22 000 (15 221-31 840) hyperkalemia-deaths might be caused by the intervention. The corresponding estimates for the optimistic scenario were ≈351 000 (130 470-546 255), ≈66 000 (24 925-105 851), and ≈9000 (4251-14 599). Net benefits were consistent across sensitivity analyses. CONCLUSIONS Modeling nationwide salt substitution in India consistently estimated substantial net benefits, preventing around 8% to 14% of annual cardiovascular deaths. Even allowing for potential hyperkalemia risks there were net benefits estimated for individuals with chronic kidney disease.
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Affiliation(s)
- Matti Marklund
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.M., J.Y., B.N., J.H.Y.W.)
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.M., L.J.A.)
- Department of Public Health and Caring Sciences, Uppsala University, Sweden (M.M.)
| | - Fikru Tullu
- World Health Organization, Country Office India, New Delhi (F.T., R.G.)
| | - Sudhir Raj Thout
- Research and Development Division, The George Institute for Global Health, Hyderabad, India (S.R.T.)
- Indian Institute of Technology Hyderabad, Kandi, Sangareddy, Telangana, India (S.R.T.)
| | - Jie Yu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.M., J.Y., B.N., J.H.Y.W.)
- Department of Cardiology, Peking University Third Hospital, Beijing, China (J.Y.)
| | - Tammy M Brady
- Johns Hopkins University School of Medicine, Baltimore, MD (T.M.B., L.J.A.)
| | - Lawrence J Appel
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.M., L.J.A.)
- Johns Hopkins University School of Medicine, Baltimore, MD (T.M.B., L.J.A.)
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.M., J.Y., B.N., J.H.Y.W.)
| | - Jason H Y Wu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.M., J.Y., B.N., J.H.Y.W.)
- Imperial College London, London, United Kingdom (B.N.)
| | - Rachita Gupta
- World Health Organization, Country Office India, New Delhi (F.T., R.G.)
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Nadkarni GN, Takale D, Neal B, Mahaffey KW, Yavin Y, Hansen MK, Fleming F, Heerspink HJ, Coca SG. A Post Hoc Analysis of KidneyIntelX and Cardiorenal Outcomes in Diabetic Kidney Disease. Kidney360 2022; 3:1599-1602. [PMID: 36245651 PMCID: PMC9528375 DOI: 10.34067/kid.0002172022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/12/2022] [Indexed: 01/05/2023]
Abstract
KidneyIntelX, a bioprognostic test for assessing risk of CKD progression, risk stratified individuals for kidney, heart failure, and death outcomes in the Canagliflozin Cardiovascular Assessment Study.Individuals scored as high risk seemed to derive more of benefit from treatment with canagliflozin versus placebo.These findings may serve to increase adoption of underutilized therapies for cardiorenal risk reduction in patients with diabetic kidney disease.
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47
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Yin X, Rodgers A, Perkovic A, Huang L, Li KC, Yu J, Wu Y, Wu JHY, Marklund M, Huffman MD, Miranda JJ, Di Tanna GL, Labarthe D, Elliott P, Tian M, Neal B. Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis. Heart 2022; 108:1608-1615. [PMID: 35945000 DOI: 10.1136/heartjnl-2022-321332] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/06/2022] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES The Salt Substitute and Stroke Study (SSaSS) recently reported blood pressure-mediated benefits of a potassium-enriched salt substitute on cardiovascular outcomes and death. This study assessed the effects of salt substitutes on a breadth of outcomes to quantify the consistency of the findings and understand the likely generalisability of the SSaSS results. METHODS We searched PubMed, Embase and the Cochrane Library up to 31 August 2021. Parallel group, step-wedge or cluster randomised controlled trials reporting the effect of salt substitute on blood pressure or clinical outcomes were included. Meta-analyses and metaregressions were used to define the consistency of findings across trials, geographies and patient groups. RESULTS There were 21 trials and 31 949 participants included, with 19 reporting effects on blood pressure and 5 reporting effects on clinical outcomes. Overall reduction of systolic blood pressure (SBP) was -4.61 mm Hg (95% CI -6.07 to -3.14) and of diastolic blood pressure (DBP) was -1.61 mm Hg (95% CI -2.42 to -0.79). Reductions in blood pressure appeared to be consistent across geographical regions and population subgroups defined by age, sex, history of hypertension, body mass index, baseline blood pressure, baseline 24-hour urinary sodium and baseline 24-hour urinary potassium (all p homogeneity >0.05). Metaregression showed that each 10% lower proportion of sodium choloride in the salt substitute was associated with a -1.53 mm Hg (95% CI -3.02 to -0.03, p=0.045) greater reduction in SBP and a -0.95 mm Hg (95% CI -1.78 to -0.12, p=0.025) greater reduction in DBP. There were clear protective effects of salt substitute on total mortality (risk ratio (RR) 0.89, 95% CI 0.85 to 0.94), cardiovascular mortality (RR 0.87, 95% CI 0. 81 to 0.94) and cardiovascular events (RR 0.89, 95% CI 0.85 to 0.94). CONCLUSIONS The beneficial effects of salt substitutes on blood pressure across geographies and populations were consistent. Blood pressure-mediated protective effects on clinical outcomes are likely to be generalisable across population subgroups and to countries worldwide. TRIAL REGISTRATION NUMBER CRD42020161077.
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Affiliation(s)
- Xuejun Yin
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Adam Perkovic
- School of Health Science, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Liping Huang
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Ka-Chun Li
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Jie Yu
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China.,Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - J H Y Wu
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Matti Marklund
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Mark D Huffman
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.,Cardiovascular Division and Global Health Center, Washington University in St. Louis, St. Louis, Missouri, USA
| | - J Jaime Miranda
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.,CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Darwin Labarthe
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Paul Elliott
- School of Public Health, Imperial College of Science Technology and Medicine, London, UK
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia .,School of Public Health, Harbin Medical University, Harbin, China
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.,School of Public Health, Imperial College of Science Technology and Medicine, London, UK
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48
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Tye SC, Jongs N, Coca SG, Sundström J, Arnott C, Neal B, Perkovic V, Mahaffey KW, Vart P, Heerspink HJL. Initiation of the SGLT2 inhibitor canagliflozin to prevent kidney and heart failure outcomes guided by HbA1c, albuminuria, and predicted risk of kidney failure. Cardiovasc Diabetol 2022; 21:194. [PMID: 36151557 PMCID: PMC9508745 DOI: 10.1186/s12933-022-01619-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of kidney and heart failure events independent of glycemic effects. We assessed whether initiation of the SGLT2 inhibitor canagliflozin guided by multivariable predicted risk based on clinical characteristics and novel biomarkers is more efficient to prevent clinical outcomes compared to a strategy guided by HbA1c or urinary-albumin-creatinine ratio (UACR) alone. METHODS We performed a post-hoc analysis of the CANVAS trial including 3713 patients with available biomarker measurements. We compared the number of composite kidney (defined as a sustained 40% decline in eGFR, chronic dialysis, kidney transplantation, or kidney death) and composite heart failure outcomes (defined as heart failure hospitalization or cardiovascular (CV) death) prevented per 1000 patients treated for 5 years when canagliflozin was initiated in patients according to HbA1c ≥ 7.5%, UACR, or multivariable risk models consisting of: (1) clinical characteristics, or (2) clinical characteristics and novel biomarkers. Differences in the rates of events prevented between strategies were tested by Chi2-statistic. RESULTS After a median follow-up of 6.1 years, 144 kidney events were recorded. The final clinical model included age, previous history of CV disease, systolic blood pressure, UACR, hemoglobin, body weight, albumin, estimated glomerular filtration rate, and randomized treatment assignment. The combined biomarkers model included all clinical characteristics, tumor necrosis factor receptor-1, kidney injury molecule-1, matrix metallopeptidase-7 and interleukin-6. Treating all patients with HbA1c ≥ 7.5% (n = 2809) would prevent 33.0 (95% CI 18.8 to 43.3 ) kidney events at a rate of 9.6 (95% CI 5.5 to 12.6) events prevented per 1000 patients treated for 5 years. The corresponding rates were 5.8 (95% CI 3.4 to 7.9), 16.6 (95% CI 9.5 to 22.0) (P < 0.001 versus HbA1c or UACR approach), and 17.5 (95% CI 10.0 to 23.0) (P < 0.001 versus HbA1c or UACR approach; P = 0.54 versus clinical model). Findings were similar for the heart failure outcome. CONCLUSION Initiation of canagliflozin based on an estimated risk-based approach prevented more kidney and heart failure outcomes compared to a strategy based on HbA1c or UACR alone. There was no apparent gain from adding novel biomarkers to the clinical risk model. These findings support the use of risk-based assessment using clinical markers to guide initiation of SGLT2 inhibitors in patients with type 2 diabetes.
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Affiliation(s)
- Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands. .,The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.
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49
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Liu Y, Xiao S, Yin X, Gao P, Wu J, Xiong S, Hockham C, Hone T, Wu JHY, Pearson SA, Neal B, Tian M. Nation-Wide Routinely Collected Health Datasets in China: A Scoping Review. Public Health Rev 2022; 43:1605025. [PMID: 36211230 PMCID: PMC9532513 DOI: 10.3389/phrs.2022.1605025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives: The potential for using routinely collected data for medical research in China remains unclear. We sought to conduct a scoping review to systematically characterise nation-wide routinely collected datasets in China that may be of value for clinical research. Methods: We searched public databases and the websites of government agencies, and non-government organizations. We included nation-wide routinely collected databases related to communicable diseases, non-communicable diseases, injuries, and maternal and child health. Database characteristics, including disease area, data custodianship, data volume, frequency of update and accessibility were extracted and summarised. Results: There were 70 databases identified, of which 46 related to communicable diseases, 20 to non-communicable diseases, 1 to injury and 3 to maternal and child health. The data volume varied from below 1000 to over 100,000 records. Over half (64%) of the databases were accessible for medical research mostly comprising communicable diseases. Conclusion: There are large quantities of routinely collected data in China. Challenges to using such data in medical research remain with various accessibility. The potential of routinely collected data may also be applicable to other low- and middle-income countries.
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Affiliation(s)
- Yishu Liu
- George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Shaoming Xiao
- The George Institute for Global Health, Health Science Centre, Peking University, Beijing, China
| | - Xuejun Yin
- George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Pei Gao
- School of Public Health, Health Science Center, Peking University, Beijing, China
| | - Jing Wu
- National Center for Chronic and Non-Communicable Diseases Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Shangzhi Xiong
- George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Carinna Hockham
- The George Institute for Global Health, UK, London, United Kingdom
| | - Thomas Hone
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jason H. Y. Wu
- George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Sallie Anne Pearson
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Bruce Neal
- George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Maoyi Tian
- George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
- School of Public Health, Harbin Medical University, Harbin, China
- *Correspondence: Maoyi Tian,
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50
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Crosby S, Rajadurai E, Jan S, Neal B, Holden R. The effects on clinical trial activity of direct funding and taxation policy interventions made by government: A systematic review. PLoS One 2022; 17:e0269021. [PMID: 36084155 PMCID: PMC9462683 DOI: 10.1371/journal.pone.0269021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/23/2022] [Indexed: 11/19/2022] Open
Abstract
Context
Governments have attempted to increase clinical trial activity in their jurisdictions using a range of methods including targeted direct funding and industry tax rebates. The effectiveness of the different approaches employed is unclear.
Objective
To systematically review the effects of direct government financing interventions by allowing companies to reduce their tax payable on clinical trial activity.
Data sources
Pub Med, Scopus, Sage, ProQuest, Google Scholar and Google were searched up to the 11th of April 2022. In addition, the reference lists of all potentially eligible documents were hand searched to identify additional reports. Following feedback from co-authors, information on a small number of additional interventions were specifically sought out and included.
Data extraction
Summary information about potentially eligible reports were reviewed independently by two researchers, followed by extraction of data into a structured spreadsheet for eligible studies. The primary outcomes of interest were the number of clinical trials and the expenditure on clinical trials but data about other evaluations were also collected.
Results
There were 1694 potentially eligible reports that were reviewed. Full text assessments were done for 304, and 30 reports that provided data on 43 interventions were included– 29 that deployed targeted direct funding and 14 that provided tax rebates or exemptions. There were data describing effects on a primary outcome for 25/41 of the interventions. The most common types of interventions were direct funding to researchers via special granting mechanisms and tax offsets to companies and research organisations. All 25 of the studies for which data were available reported a positive impact on numbers and/or expenditure on clinical trials though the robustness of evaluations was limited for many. Estimates of the magnitude of effects of interventions were reported inconsistently, varied substantially, and could not be synthesised quantitatively, though targeted direct funding interventions appeared to be associated with more immediate impact on clinical trial activity.
Conclusion
There is a high likelihood that governments can increase clinical trial activity with either direct or indirect fiscal mechanisms. Direct funding may provide a more immediate and tangible return on investment than tax rebates.
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Affiliation(s)
- Sam Crosby
- The George Institute for Global Health, Newtown, NSW, Australia
- * E-mail:
| | | | - Stephen Jan
- The George Institute for Global Health, Newtown, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, Newtown, NSW, Australia
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