The 6 studies included in this special issue were conducted in China, Indonesia, the Netherlands, Taiwan, and the United States, providing an international perspective on nutrition-related problems. The samples in these studies are equally diverse including those with hypertension, heart failure, and acute myocardial infarction and those undergoing cardiac surgery and transcatheter aortic valve implantation, as well as women with a history of weight cycling. These diverse studies provide an appreciation of the global need for more research to develop nutritional interventions to promote optimal health.

Although it has been more than 75 years since dietary sodium was identified as playing a role in cardiovascular conditions, decreasing sodium in diets of people with chronic cardiovascular disease remains a challenge. Our understanding of how to best intervene remains incomplete, particularly in countries where less research has been conducted. The study by Wickham et al showed that the Theory of Planned Behavior can be used to understand issues related to decreasing dietary sodium intake in people with hypertension in Indonesia. As in previous studies, men had greater difficulty following a low-sodium diet. Similar to studies in other countries, positive attitudes toward sodium restriction and belief that peers approved of restricting dietary sodium were predictors of lower sodium intake.

The role appetite plays in both diet quantity and quality is underappreciated across many groups with chronic conditions. Andrea et al analyzed data from 734 patients with heart failure in the Netherlands enrolled in the Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure study in which changes in appetite were followed for 18 months after index hospital discharge. Half of the patients reported decreased appetite at discharge, demonstrating this as a major issue in this population. Although appetite improved over time for many, 20% reported still having decreased appetite at 18 months. Comorbid symptoms of fatigue tripled the risk of decreased appetite, and depressive symptoms were associated with a 1.7 times higher risk of decreased appetite.

Inadequate food intake in chronic conditions does not occur in isolation. Teng et al examined the relationship of insufficient caloric intake and related comorbidities to mortality in patients undergoing cardiac surgery in Taiwan. Delirium, slow gait speed, frailty, and insufficient caloric intake were all independently associated with higher 3-month mortality. When combined, the presence of each additional risk factor increased risk of death by 2.6 times. This is among the first studies to examine the interrelationships among these risk factors. It is likely we would see similar findings in other patient populations.

The Nutritional Risk Screening 2002 scale has been used across multiple populations to identify patients who might be at risk for malnutrition. Li et al screened 2307 patients hospitalized for treatment of an acute myocardial infarction in China. A risk score of 3 or higher, indicating being at nutritional risk, assessed during hospitalization was associated with more than double the risk of death within the first 14 months. Although the Nutritional Risk Screening 2002 scale is not a measure of nutritional status, it is an easily administered scale that can be used to identify people who may need nutritional intervention to decrease risk of rehospitalization or death.

Sarcopenia, a distinct condition associated with muscle loss, is common among older adults. Hsu et al examined 81 patients with severe atrial valve stenosis who underwent transcatheter aortic valve implantation from Taiwan. The patients were divided into those with and without suspected sarcopenia. Patients with suspected sarcopenia were more than 5.5 times more likely to be at a high risk for malnutrition than those without sarcopenia. Lower risk of malnutrition was seen in patients who received a greater degree of family support.

Both bodyweight cycling and poor sleep have been associated with cardiovascular risk. People who are overweight can experience sleep apnea and other sleep disorders. They are also more likely to undergo diet-related cycles of weight loss and regain. Cao et al are among the first to examine whether weight cycling and altered sleep patterns are related. Most of 506 women in their US sample reported at least 1 episode of weight cycling. Experiencing at least 1 episode of weight cycling was associated with poor sleep quality, shorter sleep, risk of sleep apnea, and longer time to fall asleep. Thus, weight cycling and altered sleep seem to be co-risk factors for cardiovascular disease.

I commend the authors for their thoughtful treatment of each subject. The research reported in this issue shows that most nutrition-related problems are similar across international borders and across different patient populations. I am sure you will gain insight from these studies that can be applied to your population of interest.