Heart failure and salt: The great debate

Originally Posted Here: https://www.health.harvard.edu/blog/heart-failure-and-salt-the-great-debate-2018121815563

“Let there be work, bread, water, and salt for all.”
— Nelson Mandela

Salt: without it, food can seem tasteless. It is the reason sea water burns our eyes and skin. Some people enjoy salt water baths. Is it good for us? Is it not? Do we really know?

In modern medicine, we tend to have a generally negative feeling about sodium, the element found in salt. Excessive sodium intake is linked to water retention, and it is also a risk factor for high blood pressure. Both excessive sodium intake and high blood pressure are major risk factors for developing heart failure, and for causing complications in those with existing heart failure. Given that 6.5 million American adults have heart failure, restricting salt intake might profoundly reduce risk for this major medical scourge.

Indeed, we advise our patients with heart failure to restrict the amount of salt they consume per day. For years we have been telling them to stay away from salty fries and Chinese takeout, which may have up to 7,000 mg of sodium in a single meal. We consign patients hospitalized for heart failure to a bland “low salt, heart healthy” diet until discharge. But what do we base the low-salt recommendation on? Is this just anecdotal? Or do we have evidence that guides our recommendations?

In the spirit of open-mindedness, let’s debate this question.

Point: Moderate sodium intake is harmful for people with heart failure

Sodium intake is associated with fluid retention, hence the puffiness and bloating that may follow a very salty meal. And excessive sodium intake may worsen high blood pressure, or hypertension. High blood pressure increases the risk of developing heart failure and can worsen existing heart failure. Hypertension may also lead to other types of heart disease, stroke, or kidney failure. A low-sodium diet may help lower or prevent high blood pressure, and may reduce the risk of such diseases.

High-sodium diets are also usually high in total fat and calories, which may lead to obesity and its many associated complications. Some studies also suggest that there may be a link between sodium intake and osteoporosis and stomach cancer. Additionally, consuming salty foods over a long period of time can accustom your taste buds to the taste, and in turn make you more likely to reach for saltier foods.

Counterpoint: Moderate sodium intake is not harmful for people with heart failure

Cardiologists tend to practice evidence-based medicine, yet many of our recommendations regarding sodium intake for people with heart failure are based on assumptions. Surprisingly, it is hard to say there is enough evidence to state beyond a shadow of a doubt that patients with heart failure should be restricted to the 2,000 mg of salt per day most physicians recommend. And realistically speaking, how many patients abide by this restriction remains unclear, because sodium is in almost everything we consume.

In a systematic review of nine studies recently published in JAMA Internal Medicine, only limited and inconsistent evidence was found supporting any benefit of salt-restricted diets for non-hospitalized people with heart failure. The evidence for salt restriction was inconclusive in patients admitted to the hospital for heart failure. This was a well-done study; only nine of 2,655 studies evaluated were rigorous enough to include in the review. So perhaps most importantly, this review illustrates that regardless of the conclusion, rigorous, evidence-based data regarding sodium restriction in heart failure are not available.

The lives of our heart failure patients are complicated enough as it is. It is imperative that whatever we recommend for our patients does not further worsen the quality of their already difficult lives. Since patients often struggle to maintain adherence to therapies in heart failure, our focus as physicians should be on stressing the things that are evidence-based. This includes adherence to guideline-directed medical therapies and favorable lifestyle interventions, such as more exercise, and care of other relevant medical conditions, such as diabetes.

The verdict: Until we have more evidence, it’s a draw

Take some of what we say with a grain of salt (pun intended). There is not yet enough evidence for either side of the great salt debate to win. And our discussion should not lead patients to consume salt in excess until we know for sure. Indeed, in the absence of good clinical data, one must accept the need for good clinical judgment: avoiding excessive amounts of sodium is a healthy move for all of us, including those with heart failure.

It’s also highly likely that some patients are more salt-sensitive than others. Thus, directing salt restriction to those most vulnerable might be better than a one-size-fits-all approach. Studies in this area are very much needed. Fortunately, clinical trials to address this question are ongoing, so stay tuned!

Follow Dr. Januzzi on Twitter @JJheart_doc and Dr. Ibrahim @IAmDrIbrahim

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Seasons of grief

Originally Posted Here: https://www.health.harvard.edu/blog/seasons-of-grief-2018121715343

While speaking as a panelist on substance use disorder (SUD), I felt it necessary to remind the audience that addiction is a family disease. While family members may not themselves be tethered to use of a substance, we all share in the anger, guilt, despair, and all too often grief that ripple back and forth in a family’s encounter with SUD. I learned early on, “Addiction isn’t a spectator sport, eventually the whole family gets to play.”

What may be harder for some to understand is that the “sport” gets played for a lifetime, even by generations to come. I am reminded of a line near the end of Robert Woodruff Anderson’s play I Never Sang for My Father, “Death ends a life, but it does not end a relationship, which struggles on in the survivor’s mind toward some final resolution, some clear meaning, which it perhaps never finds.”

The struggle to find some resolution to loss due to SUD may take the form of rotating graveside arrangements, memorial gardens or park benches, sponsored public talks, races, and fundraising benefits. These are but a few of the ways families devise to remember a loved one and contribute to the common good in their name.

Unfortunately, the struggle toward resolution can also result in blame, alienation, family disruption, and divorce. The disease has a way of finding its way into the weak spots of a family fabric and causing rot, unless and until the aftereffects are tended to and we find some way to make meaning from a loved one’s overdose death.

One disruption that is almost certain to appear is the alteration of a family’s calendar. While always a constant, grief finds a way to manifest itself in anniversaries new and old — certainly on birthdays, or with an empty chair at holiday tables (a practice some families observe not only in name but in deed), but also the memory of the day someone overdosed, or the last memory of sobriety. The scar of a horrifying discovery or a dreaded telephone call now mars Christmas Day, a wedding anniversary, or what would ordinarily be a celebratory family event.

For me the fall was always a happy time, ever since my early adolescence when I began to play soccer. I’ve played, coached, or been a referee every fall for 50 years. Exactly six years ago, even the same day of the week as I write this, I refereed a game on a bright October Saturday morning. That evening I discovered our son, William, overdosed in our living room. His last words to me as he shut the door were, “I’m going to watch some TV.” There was no mention of injecting heroin. Six weeks of comatose hospitalization followed before he died in our arms.

Every year since, the fall darkens not just with the loss of daylight, but also with the loss of a beautiful light in our lives. William’s November birthday, Thanksgiving, the day he died, the date of his memorial service — all combine to create a season of grief for our family. Nieces who will know him only through photographs and stories will sing him “Happy Birthday” on a day that is anything but happy for those who knew and loved William. Soccer, a sport I love, now competes with a deep seasonal gloom.

The philosopher Arthur Schopenhauer famously said, “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” Despite all the loss and suffering, all the beautiful memorials, and all the work of many grieving families and advocacy groups to enlighten us, I fear our society lingers too near stage one, ridicule. Ridicule prolongs shame and stigma, and serves to perpetuate our seasons of grief.

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The new exercise guidelines: Any changes for you?

Originally Posted Here: https://www.health.harvard.edu/blog/the-new-exercise-guidelines-any-changes-for-you-2018121415623

It’s likely you already know that regular exercise helps prevent chronic disease, such as diabetes and heart problems, while improving your overall health, mood, and quality of life. It can sharpen mental function, boost concentration, and help you sleep. And the new exercise and physical activity guidelines issued by the federal government’s Office of Disease Prevention and Health Promotion show that the dose required to gain these benefits is not hard to achieve. The new guidelines are better tailored for age and ability, too.

What should your exercise goals be?

The amount of exercise and mix of activities recommended varies depending on age and ability, as described more fully below. It ranges from a high of three hours daily — for preschoolers, who tend to love activity — to 150 minutes a week.

Unfortunately, 80% of the population is not meeting the guidelines. Each year in the US, an estimated 10% of premature deaths and $117 billion in healthcare costs are associated with inadequate physical activity.

Besides saving money on healthcare, there are many personal benefits to staying active. The new guidelines highlight other new evidence-based findings related to physical activity and exercise.

What changed in the new exercise guidelines? Overall, move more, sit less. Work toward reducing the amount of time you spend sitting every day. If you have a desk job, get up to walk around regularly, or try chair yoga or a few desk exercises. All activity counts toward the recommended goals — not just 10-minute bouts of activity, as past guidelines recommended. Younger people and older people may benefit in different ways from exercise. It facilitates normal growth and development for preschoolers through teens, strengthening bones and muscles and improving cardiovascular health. Older adults who participate in regular exercise have better balance, and lower risks of falling and injury, thus improving their ability to remain independent.

The new guidelines base your dose of physical activity on relative intensity: how much effort a given exercise takes compared with your capacity for exercise. A brisk walk counts as moderate physical activity (think: fast enough so that you can speak comfortably, but not sing). The speed of this walk will be much faster for someone who is in shape than for someone who is just starting to exercise or getting back to activity after a break. But no matter where the starting line is, most people can safely improve their fitness and health. Begin with lower amounts of exercise and slowly increase duration, intensity, and frequency.

For example, if you:

Have been bed-bound, start by walking two minutes every 10 to 15 minutes (during commercial breaks when watching TV or listening to the radio). Typically walk for exercise, try adding an extra block to your regimen once a week. Jog, try going at your regular pace for five minutes, then increasing it for one minute. What stayed the same in the new exercise guidelines? Exercise is safe for almost everyone — even people with chronic disease and disabilities. Different types of exercise have complementary benefits: Aerobic activity, like walking, running, or cycling, improves cardiovascular health. It involves movement of the large muscles of the body for sustained periods of time. Muscle-strengthening activity, like resistance training with elastic bands or weight lifting, improves muscle strength, endurance, power, and mass. Bone-strengthening activity, like running, playing basketball, resistance training, or jumping rope, improves bone health and strength. Balance activity, like walking backwards, standing on one leg, yoga, and tai chi, can reduce fall risk. Multicomponent physical activity, like running, dancing, or playing tennis includes at least two of the above types of activity. Rating the intensity of activities is simple. During: Light activity, you don’t feel like you’re exerting yourself. Moderate activity, you can talk comfortably, but not sing. Intense activity, you can say a few words, but not full sentences. Within the guidelines, one minute of intense activity is roughly equivalent to two minutes of moderate activity. New exercise recommendations by age and ability Preschool-age (3 through 5 years): physically active throughout the day with the goal of three hours of activity daily Children and teens (6 through 17 years): at least 60 minutes daily of moderate-to-vigorous physical activity; include vigorous activity, muscle-strengthening, and bone-strengthening activity three times a week Adults:at least 150 to 300 minutes weekly of moderate-intensity aerobic activity, or 75 to 150 minutes weekly of vigorous-intensity aerobic activity, or an equivalent combination of both, plus muscle-strengthening activities on at least two days a week Older adults:multicomponent physical activities that mix balance activities, aerobic activities, and strength training can help prevent falls and injuries; reduce overall sitting and replace it with light (or when possible, moderate) activity Pregnant and postpartum women:at least 150 minutes weekly of moderate-intensity aerobic activity Adults with chronic conditions or disabilities:follow adult guidelines as able, including both aerobic and muscle-strengthening activities

 

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