Hidden salt in bread still a challenge for consumers

Australia’s biggest independent bakery chain says it’s unlikely to adopt proposed salt reduction targets aimed at improving the nation’s cardiovascular health, citing factors such as ‘oven spring’.

Stakeholders were given until last week to comment on the Federal Government’s proposed Voluntary Food Reformulation Targets for bread, which have been developed together with industry through the Healthy Foods Partnership.

A maximum target of 380mg of sodium per 100g has been proposed for leavened breads, to be achieved by the end of 2022. A separate target of 450mg/100g has been proposed for flat breads.

The consultation paper notes bread is a major contributor to Australians’ excess dietary sodium intake.

“Reducing sodium intake can reduce blood pressure, thereby reducing the risk of cardiovascular disease,” it says.

However, a spokesman for Bakers Delight, which has 13.6% of the Australian bread market share, told doctorportal the proposed sodium target would have “too much negative impact” on the flavor and structure of its breads.

“Salt is an essential part of [bread’s] delicious flavour, helps regulate the fermentation process and strengthens the gluten matrix. Without salt, the dough becomes very unstable and is unlikely to hold its structure and shape when baked. It can also lead to an uneven crumb structure and less ‘oven spring’,” the spokesman said.

Bakers Delight advertises the kilojoule count for its products in store, but the sodium content can only be found by visiting the company’s website. Its Hi-Fibre Lo-GI block loaf, marketed for school lunches, contains 532mg of sodium/100g, while its healthier Wholemeal Country Grain block loaf contains 475mg of sodium/100g. The company’s lowest salt bread – the Cape Seed loaf – meets the draft targets with 297mg of sodium/100g, but it’s also much more expensive than other products, at $6.30 a loaf.

Bakers Delight said it had reduced the sodium content of its breads in recent years.

“Traditionally, Australian bakers have worked to a ‘2% of flour weight’ ratio however since 2012, we have used a 1.8% ratio,” the spokesman said. “We’ve also implemented an average 15% salt reduction across our Sourdough and Soy and Linseed range.”

Nevertheless, its Sourdough Vienna loaf still contains 625mg of sodium/100g.

It’s a similar story across many other bread brands. In March last year the George Institute for Global Health warned that just one slice of Schwob’s Dark Rye bread contained more than double the amount of salt as a serving of Kettles sea salt crisps (660mg of sodium/100g). More than a year later, Schwob’s website shows no change in the product’s nutritional information.

The same George Institute report highlighted extremely high salt levels in flat breads, naming Coles Tortillas, which contained 920mg of sodium per 100g in 2017 and still do today.

Consumers in the dark

One of the challenges for consumers trying to reduce their dietary salt intake is that sodium is often a hidden and unexpected ingredient.

A study of over 400 people in Lithgow found people tended to underestimate the amount of dietary salt they consumed. Based on dietary recall, people estimated they consumed 6.4g of salt per day on average.

However, 24-hour urine collection revealed the best estimate of daily salt intake was about 9·9 g/day – around twice as much as the World Health Organisation’s recommendation of maximum salt intake of 5g/day.
Consumers may also be left confused by mixed media messages about the potential harms of salt.

For instance, an observational study of over 90,000 people published in the Lancet last month found both low and high sodium intake (below 2g/day or above 5g/day) were associated with an increased risk of cardiovascular disease.

However, experts have criticised that study’s method of measuring salt intake, and aspects of its design, including the potential for reverse causation if people switched to a low-salt diet due to ill health.

Professor Bruce Neal, a Senior Director at The George Institute said: “It remains the case that the totality of the available evidence provides a strong argument for significant harms from excess salt consumption all around the world.”

To help consumers be more aware of their salt intake, the George Institute has produced the FoodSwitch App, which enables users to scan the barcode of supermarket products and quickly identify whether they have low, medium or high sodium content. The app has had 750,000 all-time downloads.

The big retailers

Both Coles and Woolworths are executive members of the Healthy Food Partnership.

Clare Farrand, Senior Project Manager for Salt Reduction at the World Health Organisation Collaborating Centre on Population Salt Reduction told doctorportal:

“Currently Woolworths is leading the way in the retail space in Australia and has committed to improving the nutritional profile of their own brands.”

She added: “There is still a long way to go, but this is a positive first step, which we hope will encourage many more companies to get on board.”

In 2015, Woolworths worked with The George Institute to develop over 150 category targets for sodium, sugar, saturated fat and kilojoules. All products developed under Woolworths Own Brand are required to meet these targets.

A spokeswoman for Coles told doctorportal the retailer intends to work with its suppliers to achieve the final salt-reduction targets, which are due to be released by the Partnership in early 2019.

“Since 2010, the company has annually removed more than 40 tonnes of salt from its Own Brand products,” she added.

New Apple Watch adds heart tracking: here’s why we should welcome ECG for everyone

Leaked details of the new iPhone models were quickly relegated to second tier headlines after Apple’s latest product announcement. More people seem to be excited about the fact that the new Apple Watch will come with a built-in heart monitoring electrocardiogram (ECG) function.

An ECG is a simple test that can be used to check your heart’s rhythm and electrical activity, designed to detect any underlying issues. The Apple Watch 4 will be the first mainstream wearable gadget to integrate this kind of medical diagnostic technology. (Other devices such as the Fitbit typically measure blood flow by shining a light through the skin. This should be an exciting breakthrough, but Apple’s revelation has been met with a mixed reception.

There isn’t yet enough evidence to show that using an ECG in general to screen people for cardiovascular diseases ultimately makes them healthier. In fact, it’s not recommended for screening people who are at low risk of developing problems because it could produce false positive results (indicating a problem where none really exists). This can then lead healthy people to seek unnecessary, invasive and potentially harmful treatments, at a cost to the health service provider, as well as producing increased anxiety. For those who are at high risk of disease, ECG results might suggest medical intervention when lifestyle changes could actually be more beneficial. But does this really mean the technology shouldn’t be made more widely available?

It would be naive to assume that everyone who is at risk of heart problems knows, never mind consults with a doctor, about it. Often, people don’t realise until it is too late and they need emergency treatment and lengthy retrospective investigation – or, at worse, they die. To ignore the current digital health movement, and surging enthusiasm for it among early adopters of devices, health enthusiasts and growing numbers of people more generally would also be foolish.

The industry is booming. The growing numbers paying to monitor their health with fitness trackers and smart watches has shown how engaged and motivated people can become. We shouldn’t be denying people opportunities to take greater responsibility for their health, particularly as health services come under growing pressure from an ageing and increasingly ill population.

The physical risks associated with performing ECGs are minimal. Sensors attached to the skin are used to detect the electrical signals produced by your heart each time it beats. It is quick, safe and painless.

We shouldn’t ignore concerns that an ECG test in a commercially available watch could encourage many people to make additional trips to the doctor when they have recorded any anomalous activity. A rush of gadget-adorned people descending on clinics demanding services is a worry. But many people already self-diagnose conditions or agonise about symptoms unnecessarily, often caused by using the internet and other technology. Those who do use the Apple Watch ECG may well include large numbers of “worried well”. But the impact of uncontrolled use of ECG technology seems likely to be limited for the moment, especially as many people will still simply be unable to afford it.

If ECG is added to the list of readily available health technology applications, it will be little different from enabling people to detect their pulses, count their steps, track their periods and analyse their sleep. An Apple Watch ECG won’t be conducted under controlled conditions, but this is true of so many health consultations.

Personal health tech is already common

Medical staff now give out many interventions that can be performed independently at home. This includes some self-tracking technologies and sensitive diagnostic tests, such as those for sexual health and bowel screening. In some places, you can even swap the GP’s surgery for a smartphone app.

While accuracy may be an issue with the Apple Watch ECG, the same is true for ECG tests performed in clinics and interpreted by professionals, according to many papers published on this topic. Of course, technologies can always be improved, but waiting until a test is close to perfect isn’t necessarily the best way to use it.

Ultimately, we are living in a digital age and healthcare has so far been slow to revolutionise. We should be harnessing technology to improve healthcare. Everyday ECG won’t replace medical care but might help people to spot important warning signs and seek expert opinion. The real-time data the device has already collected may then help inform a medical expert’s interpretation and diagnosis.

What we should really be thinking about is how we can widen appropriate access for this kind of technology to those who it would most benefit, so that it might identify more people at risk, earlier. This would help make health services more efficient, reduce waste and perhaps even save lives.

Heather May Morgan, Lecturer in Applied Health Sciences, University of Aberdeen

This article is republished from The Conversation under a Creative Commons license. Read the original article.

[Articles] Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data

The perivascular FAI enhances cardiac risk prediction and restratification over and above current state-of-the-art assessment in coronary CTA by providing a quantitative measure of coronary inflammation. High perivascular FAI values (cutoff ≥–70·1 HU) are an indicator of increased cardiac mortality and, therefore, could guide early targeted primary prevention and intensive secondary prevention in patients.

[Correspondence] Interpretation of results of pooled analysis of individual patient data

We read with interest the meta-analysis by Stuart J Head and colleagues1 of individual patient data from randomised trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel or left main disease. The authors found variation in outcomes according to the anatomical complexity of coronary artery disease, as gauged by the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score,2 but reported negative tests for interaction between subgroups of patients in the low (<23), middle (23–32), and high (>32) SYNTAX score tertiles and hazard ratios of death.

[Perspectives] Understanding heartbreak: from Takotsubo to Wuthering Heights

Although an enduring subject of art, music, and literature, it was not until the 1990s that medicine concluded that one can succumb to a broken heart. Japanese physician Hikaru Sato characterised the first case reports of Takotsubo cardiomyopathy, a cardiac response to acute emotional stress. The condition was poetically dubbed the “broken heart syndrome”.

‘Ageist’ statin study highlights under prescribing concerns

A leading cardiologist has railed against ageism in prescribing, after a study in the BMJ cast doubt on the value of statins for primary prevention of cardiovascular disease (CVD) in people aged over 74.

Associate Professor David Colquhoun, a clinical cardiologist and academic at the University of Queensland, urged doctors not to engage in ageism or “therapeutic nihilism”. Doctors should be guided by older patients’ individual risk when deciding whether or not to prescribe lipid-lowering therapies.

“It’s true that risk equations are not very effective when people are over 70 because age is such a strong determinant,” he said. “But waiting for people to have their first cardiovascular event before prescribing statins is not good enough either, as dropping dead is the first coronary event in around a third of cases.”

Professor Colquhoun said cardiovascular risk profiling in the elderly was best achieved using a coronary artery calcium score. Around a third of asymptomatic people 75 and older would be found to have a score over ‘400’ based on this test, meaning they should definitely be treated, he said. The patient’s out-of-pocket cost was around $150.

Professor Colquhoun was commenting on the back of a Spanish study published in the BMJ last week which sought to discern the impact of statin therapy among 46,864 people by linking prescriptions to GPs’ medical records.

The researchers compared the recorded incidence of death and atherosclerotic CVD over a decade between people who commenced statin therapy in 2006-7 (16%) and non-statin users.

In this elderly cohort, statin treatment was not associated with a reduction in mortality or atherosclerotic CVD – except if the patient had diabetes and was aged under 85, the study found.

The authors said their findings called into question the age-appropriateness of US and UK guideline recommendations that people with a 10% risk of atherosclerotic CVD at 10 years receive statins, noting the incidence of CVD in the control group was well above 10%.*

Study under fire

The study has been heavily criticised by Australian cardiologists, who still have fresh memories of thousands of Australians discontinuing their statin therapy after controversial criticism of the treatment on ABC’s Catalyst TV series in 2013.

Professor Colquhoun slammed the latest study as “data dredging” and said it was “difficult to understand how a respected medical journal such as the BMJ could publish poor research and allow unsubstantiated statements to be made which have important consequences regarding cardiovascular health.”

Unlike in a well-designed trial, the observational study could not discern whether patients actually took the drugs which were dispensed and whether there was a change in their lipid levels, he said.

“What is clear [from clinical trials, is], in the very elderly, lipid-lowering therapy and more specifically lowering of LDL-cholesterol, decreases heart attacks, but if there is a high competing cause of mortality then there is no decrease in total deaths,” Professor Colquhoun said.

Professor Garry Jennings, executive director, Sydney Health Partners said the study authors had overreached in their conclusions. “As a retrospective cohort study, definitive conclusions regarding the effectiveness of statin treatment cannot be drawn,” Professor Jennings said.

Professor John McNeil, head of the Department of Epidemiology and Preventive Medicine at Monash University said the study “casts some doubt” about the value of statins in non-diabetic adults beyond 75 who did not have a specific reason to be taking them.

However, he added: “It is by no means the last word on the subject and emphasises the importance of large-scale studies such as the [ongoing] Australian STAREE trial to resolve this question more definitively.”

Under-prescribing in aged care

Meanwhile, ageism was recently cited as a possible explanation for under-prescribing of recommended medicines in residential aged care.

According to an Australian study published in the International Journal for Quality in Healthcare last month, up to 48% of residents did not receive the recommended treatment for their condition, based on a review of 17,672 aged care residents in the Australian Government’s Department of Veterans’ Affairs database.

For instance, the study found only 52.9% of residents with a history of ischaemic heart disease or MI were being prescribed statins and only 56.1% of residents with a history of hypertension or congestive heart failure were receiving an ACE inhibitor or ARB.

The authors cited a literature review which found under-prescribing was common in older populations and was due to a multitude of factors including “multi-morbidity, ageism and economic limitations”.

Lead study author Dr Jodie Hillen (PhD) who undertook the study at the Quality Use of Medicines and Pharmacy Research Centre at UniSA told doctorportal some of the findings may reflect GPs “appropriately de-prescribing medicines in patients who require palliative care, have difficulty swallowing or who have end-stage dementia.”

“However, while de-prescribing is recommended for some medications such as statins, it is generally not recommended for patients taking ACE inhibitors or ARBs, which were also underutilised,” she said. “Further research is required to determine the reasons why beneficial medications are not being used in the older population.”

Dr Hillen and colleagues concluded their study by recommending comprehensive geriatric assessment and collaborative medication reviews to improve medication-related quality of care in aged care.

*In Australia, Guidelines for the Management of Absolute Cardiovascular Disease Risk (2012) recommend lipid lowering and BP lowering therapy for people with a greater than 15% absolute risk of CVD events over five years. The guidelines state that in adults over 74, “use clinical judgement to consider benefits and risks of treatment, co-morbidities and values before initiating therapy”.

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[Comment] BASKET-SMALL 2: advancing DCB beyond in-stent restenosis

Drug-coated balloons (DCB) were first used as a new therapeutic option in the treatment of in-stent restenosis, with proven inhibition of restenosis in clinical studies.1–3 DCB have received a class 1 indication in the 2014 European Society of Cardiology guidelines4 for the treatment of both bare metal stent (BMS) and drug-eluting stent (DES) in-stent restenosis. The next question is whether DCB are effective in de-novo coronary lesions, specifically in small coronary vessels.

Dr Bawa-Garba wins appeal

Dr Hadiza Bawa-Garba, who was convicted of manslaughter by gross negligence over the death of a six-year-old boy in the UK in 2015, in August won her appeal to practise medicine again.

She was struck off in January this year over the death of Jack Adcock, who died of sepsis at Leicester Royal Infirmary in 2011.

BBC News reports that the doctor said she was ‘pleased with the outcome’ but wanted to ‘pay tribute and remember Jack Adcock, a wonderful little boy’.

Jack’s mother, Nicola Adcock, said she was ‘disgusted’ and ‘devastated’ by the judgement, and that it made a ‘mockery of the justice system’.

Dr Bawa-Garba said that she wanted to let the parents know that she was sorry for her role in what happened to Jack.

“I also want to acknowledge and give gratitude to people around the world, from the public to the medical community, who have supported me,” Dr Bawa-Garba said.

The doctor’s appeal was funded by medics because they said the ruling would discourage practitioners from being open when reviewing mistakes.

Jack, who had Down’s syndrome and a heart condition, had been admitted to the hospital in Leicester with vomiting and diarrhoea in 2011.

He died 11 hours later from a cardiac arrest caused by sepsis triggered by pneumonia.

The subsequent trial in 2015 heard the boy’s death was caused by ‘serious neglect’ by staff who failed to recognise his body was ‘shutting down’ and close to death, the prosecution claimed.

At one point, Dr Bawa-Garba mistook Jack for another patient who had a ‘do not resuscitate’ order, the court was told.

The paediatric specialist only resumed treatment when a junior doctor pointed out the error, although the prosecution accepted Jack had already been ‘past the point of no return’.

Dr Bawa-Garba said in her defence she had worked a 12-hour shift with no break and there was a lot of miscommunication in the ward.

Dr Bawa-Garba was suspended from the medical register for a year in June 2017.

However, the General Medical Council (GMC) appealed against the decision, claiming it was ‘not sufficient to protect the public’, and she was struck off in January 2018.

Thousands of doctors signed an open letter of support for Dr Bawa-Garba stating the case would ‘lessen our chances of preventing a similar death’.

Earlier, three senior judges quashed the High Court’s decision and restored the lesser sanction of a one-year suspension.

Announcing the ruling, Master of the Rolls, Sir Terence Etherton, said no concerns had ever been raised about the clinical competence of Dr Bawa-Garba, other than in relation to Jack’s death.

“The evidence before the tribunal was that she was in the top third of her specialist trainee cohort,” he said.

He added that the tribunal was satisfied her actions in relation to the boy were neither deliberate nor reckless, and did not present a continuing risk to patients.

Hypertension ‘triple pill’ shows promise

An innovative 3 in 1 pill for blood pressure has proven more effective than standard care, according to a new trial, and could transform the way we manage hypertension.

Lead researcher of the study, Dr Ruth Webster from The George Institute for Global Health, told doctorportal that “our results could help millions of people globally reduce their blood pressure more effectively and reduce their risk of heart attack or stroke.”

The randomised trial, published in JAMA, was conducted in Sri Lanka and enrolled 700 patients with hypertension. Patients either received usual care or a once-daily dose of a triple combination pill, with each drug (telmisartan, amlodipine and chlorthalidone) at a half dose.

The researchers found that treatment with the triple pill led to an increased proportion of patients achieving their target blood pressure compared with usual care. They concluded that the use of this medication as initial therapy, or as replacement for monotherapy, may be an effective way to improve blood pressure control.

Current hypertension management approach not ideal

Professor Garry Jennings, Chief Medical Advisor at the Heart Foundation, told doctorportal that the results of the trial offer a different strategy for managing blood pressure.

“We know we don’t manage high blood pressure that well with present methods, and a lot of the failure is related to adherence to therapy – 3 pills in 1 is a proven way of helping with adherence.”

“What is interesting in this study is that you don’t need the full doses of each medication, and this seems to get some pretty good outcomes.”

Dr Webster said that the current approach for managing high blood pressure – starting one drug at a low dose, and then increasing the dose and adding more drugs – is not ideal.

“Patients are brought back at frequent intervals to see if they are meeting their targets with multiple visits required to tailor their treatments and dosage. This is not only time inefficient, it’s costly.”

“We also know that many doctors and patients find it too complicated and often don’t stick to the process.”

New approach could see better effectiveness

Dr Webster also noted that around 80% of the effectiveness of any blood pressure medication occurs in the first half dose, with side effects mainly occurring at higher doses. As a result, it makes sense to offer patients lower doses of multiple drugs, rather than higher doses of fewer drugs.

She said the George Institute is now looking at strategies to maximise the uptake of the study results.

“This includes examining the acceptability of the triple pill approach to patients and their doctors, as well as cost-effectiveness, which will be important for governments and other payers to consider.”

“We will also look to influence guidelines for the management of hypertension to include the recommendation to start with multiple, low dose blood pressure lowering medications.”

Professor Jennings added that the triple pill would be fairly cheap and therefore suitable for use across the world.

“High blood pressure is the biggest global risk factor for death and disability, so having something that is suitable for use in every scenario is an important development.”

Change unlikely in the near future

However, Professor Jennings said that given hypertension guidelines in Australia have only recently been updated, it is unlikely that they will be significantly overhauled in the near future.

“At this stage, the preparation is not approved for prescription anyway, so there’s a few steps to go through.”

“While this a successful trial, it’s always hard to replicate trial results in the community.”

He also said that hypertension was a complex issue that Australia, and the whole world, is trying to tackle.

“There’s inherently problems in managing a condition which is lifelong, has no symptoms, and where knowledge about the reasons people are having their blood pressure managed is fairly low.”

Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department [Research]

BACKGROUND:

Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department.

METHODS:

We constructed the clinical chemistry score (CCS) (range 0–5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT).

RESULTS:

For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%–100%), with 8.9% (95% CI 8.1%–9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%–100%), with 10.5% (95% CI 9.6%–11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%–97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%–99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%–97.2%; 11.2% [95% CI 10.3%–12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%–94.7%; 13.1% [95% CI 12.1%–14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3–94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3–75.2).

INTERPRETATION:

The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457