A comprehensive review on salt and health and current experience of worldwide salt reduction programmes

Systematic Review on the Impact of Salt-Reduction Initiatives by Socioeconomic Position to Address Health Inequalities in Adult Populations

CONTEXT

International evidence shows that individuals from low socioeconomic positions (SEPs) consume a greater amount of salt than those from higher SEPs. This health inequality reflects a disproportionate effect of salt-reduction initiatives, and explains a higher prevalence of cardiovascular disease among the most vulnerable populations. Assessing this impact can help tailor implementation strategies in the future for the benefit of the whole population.

OBJECTIVE

The aim was to systematically review the literature and assess the impact of salt-reduction initiatives on health and behavioral outcomes of adults by SEP.

DATA SOURCES

The search strategy was conducted in 6 databases (CINAHL, Scopus, Embase, MEDLINE, PubMed, and Web of Science) using the terms sodium or salt, social class, policy, intervention or campaign. Peer-reviewed articles assessing salt-reduction interventions in adults reporting dietary or behavioral changes on salt consumption measurements by SEP were considered for inclusion. Articles in which salt intake data were not reported by SEP were excluded.

DATA EXTRACTION

Two reviewers collected data independently using a predesigned electronic form. The AXIS and RoB 2 tools were used for critical appraisal.

DATA ANALYSIS

Eight studies containing data from 111 548 adults were interpreted according to study design following a narrative synthesis approach.

RESULTS

Salt-reduction initiatives are effective at reducing the intake of salt and sodium in adults. When reporting the impact of these initiatives, research outcomes are generally not evaluated by SEP, representing a question yet to be explored.

CONCLUSION

A small number of articles that focused on the impact of salt-reduction interventions reported salt consumption measurements by SEP, indicating a critical gap in research. The limited evidence suggests potentially greater health benefits to be gained from the implementation of population-wide initiatives in adults of low SEP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021238055.

Association of Sodium and Sugar-Sweetened Beverage Intake With Cardiovascular Disease Risk Factors in Adolescents and Young Adults With Obesity

Cardiovascular disease (CVD) risk factors in children have increased in prevalence. Dietary intake may modify risk. Data collected during a randomized trial testing the effect of a behavioral intervention on adiposity, blood pressure (BP), and left ventricular mass index (LVMI) were analyzed using multivariable regression to determine independent associations of sodium, sugar-sweetened beverage (SSB), and artificially sweetened beverage (ASB) intake with outcomes. High sodium intake (≥3.5 g) was associated with hypertensive BP (odds ratio 12.8; P = .027) in minimally adjusted models. High SSB intake (≥4 oz) was independently associated with body mass index z-score (β = .34; P = .035) and waist circumference z-score (β = .49; P = .022) in fully adjusted models. Any ASB intake was associated with LVMI in fully adjusted model (% change 38.22; P = .004). There was no effect modification between sodium and SSB on outcomes. Dietary factors explored in this study independently impacted CVD risk. Further effect measure modification should be explored in larger cohorts.

Global guidelines recommendations for dietary sodium and potassium intake

Non-communicable diseases (NCDs) cause a significant global health challenge, with unhealthy diets identified as a major risk factor. Sodium and potassium, which are essential minerals for human health, play important roles in various bodily functions, and an imbalance in their intake can have significant health implications, particularly concerning hypertension and cardiovascular diseases. This review compiles dietary sodium and potassium intake recommendations from prominent global health organizations and compares global guidelines to Japan's Dietary Reference Intake (DRI) guidelines. Sodium and potassium intake guidelines from organizations such as the World Health Organization (WHO), American College of Cardiology (ACC) and American Heart Association (AHA), Dietary Guidelines for Americans (DGA), European Food Safety Authority (EFSA), and DRI for Japanese exhibit variations. Compared to other Asian countries, Japan's historically higher sodium goal aligns with Southeast Asia where traditional preserved foods contribute to high sodium intake. Contrarily, Japan's lower potassium goal contrasts with other countries in Asia promoting a diet rich in fruits and vegetables. The ongoing effort by Japan to align with global recommendations reflects a gradation approach considering social habits. While harmonizing international efforts is essential, appreciating regional diversities is paramount through tailoring guidelines to cultural and dietary habit practices. Implementing context-specific guidelines informed by scientific research can contribute to global efforts in promoting healthy diets and reducing the burden of NCDs. Global guidelines that recommended the daily dietary intake goal for sodium and potassium exhibit variations. These disparities are influenced by diverse factors, including cultural dietary habits, socioeconomic status, health priorities, and available scientific research. Each population should follow the recommendations of their region.

Temporal dynamics of drinking water sodium levels in coastal areas, Cyprus 2009-2020

Around the world, groundwater salinity levels are increasing in coastal areas, as a result of its systematic overexploitation for domestic, agricultural and industrial demand and potentially due to climate change manifestations (such as, sea level rise). We hypothesized that the groundwater quality of many Mediterranean coastal areas is already being perturbed, especially for water salinity, depending on the groundwater distance from the seafront. The objectives of this study were: i) to evaluate the magnitude and temporal variance of drinking water sodium (Na) as a metric of salt intake used for public health purposes using drinking water data in Cyprus; and ii) to examine the degree of Na enrichment in drinking water as defined by the seawater coastline distance of each sampling point. Open access governmental data of drinking water Na (n = 3304), daily max ambient air temperature and total rainfall were obtained for the period of 2009-2020 from governmental repositories. Linear mixed-effect regression models of drinking water Na with unsupervised covariance matrix were used. After adjusting for temperature and rainfall data, there was a significant annual increase in drinking water Na levels over time (beta = 0.01; 95 % CI: 0.00, 0.02; p = 0.02) for the coastal areas (<10 km from coastline, cutoff used by the EU Environment Agency), but this was not the case for non-coastal areas (>10 km distance from coastline). The distance of each sampling point from the coastline in Cyprus was negatively associated with drinking water Na in coastal areas (beta = -0.04, 95%CI: -0.06, -0.01; p = 0.002); this was not the case for non-coastal areas. More research is warranted to better understand the impacts of global environmental change on water quality in association with the burden of disease in coastal areas.

Can sodium and potassium measured in timed voids be used as reference instruments for validating self-report instruments? Results from a urine calibration study

BACKGROUND

Sodium and potassium measured in 24-h urine collections are often used as reference measurements to validate self-reported dietary intake instruments.

OBJECTIVES

To evaluate whether collection and analysis of a limited number of urine voids at specified times during the day ("timed voids") can provide alternative reference measurements, and to identify their optimal number and timing.

METHODS

We used data from a urine calibration study among 441 adults aged 18-39 y. Participants collected each urine void in a separate container for 24 h and recorded the collection time. For the same day, they reported dietary intake using a 24-h recall. Urinary sodium and potassium were analyzed in a 24-h composite sample and in 4 timed voids (morning, afternoon, evening, and overnight). Linear regression models were used to develop equations predicting log-transformed 24-h urinary sodium or potassium levels using each of the 4 single timed voids, 6 pairs, and 4 triples. The equations also included age, sex, race, BMI (kg/m2), and log creatinine. Optimal combinations minimizing the mean squared prediction error were selected, and the observed and predicted 24-h levels were then used as reference measures to estimate the group bias and attenuation factors of the 24-h dietary recall. These estimates were compared.

RESULTS

Optimal combinations found were as follows: single voids-evening; paired voids-afternoon + overnight (sodium) and morning + evening (potassium); and triple voids-morning + evening + overnight (sodium) and morning + afternoon + evening (potassium). Predicted 24-h urinary levels estimated 24-h recall group biases and attenuation factors without apparent bias, but with less precision than observed 24-h urinary levels. To recover lost precision, it was estimated that sample sizes need to be increased by ∼2.6-2.7 times for a single void, 1.7-2.1 times for paired voids, and 1.5-1.6 times for triple voids.

CONCLUSIONS

Our results provide the basis for further development of new reference biomarkers based on timed voids.

CLINICAL TRIAL REGISTRY

clinicaltrials.gov as NCT01631240.

Knowledge, attitudes, and practices related to dietary salt among older adults in Abha, Saudi Arabia

The need to foster successful aging has intensified with the aging of the global population. This study aimed to assess the knowledge, attitudes, and practices (KAP) concerning dietary salt consumption and to investigate the correlations between sociodemographic variables and salt-related KAP. A structured interview was administered to a cohort of 200 older adults in Abha City, Saudi Arabia, recruited through a convenience sampling approach. The evaluation of salt-related KAP revealed widespread low knowledge (91.5%) as participants scored less than 3, negative attitudes (85.5%) scored less than 12, and predominantly unsatisfactory practices (69.5%) with scores less than 26. Noteworthy differences emerged between participants with poor overall KAP (81.5%) and those with good KAP (18.5%). Significantly weak negative correlations were found between age (r=-0.212), marital status (-0.236), and body mass index (-0.243) with overall KAP. Further examination revealed a significantly weak positive correlation between attitude and practice (r = 0.141). KAP scores show a highly significant positive correlation with overall KAP scores (r = 0.169, 0.352, 0.969). The uncovered correlations contribute to a valuable understanding of the complex dynamics surrounding salt-related KAP. This understanding guides the design of targeted interventions, such as health education programs, promoting successful aging and public health outcomes.

Association between Urinary Sodium Excretion and Body Fat in School-Aged Children: Insights from the ARIA Study

Childhood obesity has been associated with increased sodium intake. Nonetheless, evidence linking sodium intake to Body Mass Index (BMI) and Body Fat Mass Percentage (%BF) remains limited, especially in the pediatric age group. Therefore, this study aims to investigate whether there is an association between 24 h urinary sodium excretion with BMI and %BF in a sample group of children from the ARIA study. This cross-sectional analysis included 303 children aged 7 to 12 from across 20 public schools in Porto, Portugal. Weight and %BF were assessed using the Tanita™ BC-418 Segmental Body Analyzer. Children's Total Energy Intake (TEI) was estimated through a single 24 h Recall Questionnaire, and urinary sodium and potassium excretion was estimated by a 24 h urine collection. The association of %BF and BMI with 24 h sodium excretion was estimated by a binary logistic regression adjusted for sex, age, physical activity, total energy intake, parental education, and 24 h urinary excreted potassium. There was a significant positive association between higher levels of urinary sodium excretion and higher %BF values, even after adjusting for confounders. However, the same was not observed for BMI. Our findings suggest that higher sodium intake is associated with higher values of %BF among children, regardless of TEI and potassium intake.

Sex-specific associations between sodium and potassium intake and overall and cause-specific mortality: a large prospective U.S. cohort study, systematic review, and updated meta-analysis of cohort studies

BACKGROUND

The impact of sodium intake on cardiovascular disease (CVD) health and mortality has been studied for decades, including the well-established association with blood pressure. However, non-linear patterns, dose-response associations, and sex differences in the relationship between sodium and potassium intakes and overall and cause-specific mortality remain to be elucidated and a comprehensive examination is lacking. Our study objective was to determine whether intake of sodium and potassium and the sodium-potassium ratio are associated with overall and cause-specific mortality in men and women.

METHODS

We conducted a prospective analysis of 237,036 men and 179,068 women in the National Institutes of Health-AARP Diet and Health Study. Multivariable-adjusted Cox proportional hazard regression models were utilized to calculate hazard ratios. A systematic review and meta-analysis of cohort studies was also conducted.

RESULTS

During 6,009,748 person-years of follow-up, there were 77,614 deaths, 49,297 among men and 28,317 among women. Adjusting for other risk factors, we found a significant positive association between higher sodium intake (≥ 2,000 mg/d) and increased overall and CVD mortality (overall mortality, fifth versus lowest quintile, men and women HRs = 1.06 and 1.10, Pnonlinearity < 0.0001; CVD mortality, fifth versus lowest quintile, HRs = 1.07 and 1.21, Pnonlinearity = 0.0002 and 0.01). Higher potassium intake and a lower sodium-potassium ratio were associated with a reduced mortality, with women showing stronger associations (overall mortality, fifth versus lowest quintile, HRs for potassium = 0.96 and 0.82, and HRs for the sodium-potassium ratio = 1.09 and 1.23, for men and women, respectively; Pnonlinearity < 0.05 and both P for interaction ≤ 0.0006). The overall mortality associations with intake of sodium, potassium and the sodium-potassium ratio were generally similar across population risk factor subgroups with the exception that the inverse potassium-mortality association was stronger in men with lower body mass index or fruit consumption (Pinteraction < 0.0004). The updated meta-analysis of cohort studies based on 42 risk estimates, 2,085,904 participants, and 80,085 CVD events yielded very similar results (highest versus lowest sodium categories, pooled relative risk for CVD events = 1.13, 95% CI: 1.06-1.20; Pnonlinearity < 0.001).

CONCLUSIONS

Our study demonstrates significant positive associations between daily sodium intake (within the range of sodium intake between 2,000 and 7,500 mg/d), the sodium-potassium ratio, and risk of CVD and overall mortality, with women having stronger sodium-potassium ratio-mortality associations than men, and with the meta-analysis providing compelling support for the CVD associations. These data may suggest decreasing sodium intake and increasing potassium intake as means to improve health and longevity, and our data pointing to a sex difference in the potassium-mortality and sodium-potassium ratio-mortality relationships provide additional evidence relevant to current dietary guidelines for the general adult population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Identifier: CRD42022331618.

Potassium-Enriched Salt Substitutes: A Review of Recommendations in Clinical Management Guidelines

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.

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

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

Salt: a narrative review and local policy initiatives in Israel

High salt intake is a well-known risk factor for cardiovascular disease (CVD). Some recent prospective studies have challenged the salt-CVD link. We conducted a narrative review based on a systematic search and provided a national policy update. We reviewed 14 observational prospective studies in healthy adults, reporting the association between sodium intake and excretion or reduction and CVD incidence. Validated by cohort studies, recommended sodium consumption levels (< 1.5-2 gram per day) are still relevant for the prevention of CVD in adults. We discussed the findings and policy initiatives implemented in Israel. Such initiatives included voluntary and mandatory food labeling, and culturally tailored educational programs. The Ministry of Health in Israel initiated a salt reduction policy in recent years-aimed for the future of the industry as well as the population.

Effects of low-sodium bread on dietary compliance and fecal cultivable bacteria in a randomized controlled pilot trial in hypertensive subjects

High salt intake and compliance to low-sodium (LS) diets are critical in hypertension. Salt reduction in processed foods can help to achieve the target sodium intake. To verify the hypothesis that an innovative LS formulation of a traditional bread could result in a reduction of sodium intake and blood pressure, we performed a 6-month randomized controlled pilot trial on hypertensive patients. We additionally explored the effects of sodium restriction on blood pressure and fecal cultivable bacteria.Fifty-seven patients were randomized in three groups. Group A (n = 19) followed a free diet using standard bread (750 mg Na/100 g), group B (n = 18) followed a LS diet (2300 mg Na/die) using standard bread, group C (n = 20) followed a LS diet (2300 mg Na/die) using LS bread (280 mg Na/100 g). We measured 24-h urinary sodium, blood pressure, routine parameters, fecal microbial counts (26 patients).After 6 months, as compared to group A, group C showed a reduction of 24-h urinary sodium excretion (-908 mg/24 h), diastolic pressure (-9 mmHg) and microbial counts of Bacteroides, Porphyromonas, Prevotella, Enterobacteriaceae, Staphylococcus, Micrococcus. These results suggest that LS bread could increase the adherence to a LS diet, reducing sodium excretion, diastolic pressure and abundance of some fecal cultivable bacteria.Trial registration Registration nr. NCT03127553, on 25/04/2017.

Higher Nocturnal Blood Pressure and Blunted Nocturnal Dipping Are Associated With Decreased Daytime Urinary Sodium and Potassium Excretion in Patients With CKD

Introduction

Sodium homeostasis is intimately associated with blood pressure (BP) rhythm, and potassium excretion is closely associated with sodium excretion in the general population. However, the association between circadian sodium and potassium pattern excretion and nocturnal BP in patients with chronic kidney disease (CKD) is not elucidated.

Methods

We evaluated the correlation between the day-to-night ratio of urinary sodium and potassium excretion rate, nocturnal blood pressure, and nocturnal BP dipping in a CKD cohort.

Results

A total of 3152 (56.76% males, mean age 47.63 years) individuals with CKD were included in the study. Patients in quartile 1 (with the lowest ratio) exhibited a 12 mmHg or 9 mmHg higher nocturnal systolic blood pressure (SBP) and blunted SBP dipping than those in quartile 4 when urinary sodium or potassium excretion rate was divided into day-to-night ratios (both P < 0.001). In multivariate analyses, lower day-to-night ratio of urinary sodium was independently linked to higher nocturnal SBP and blunted SBP dipping (linear regression coefficient (95% confidence interval [CI]): -6.89 (-9.48 to -4.31), and -3.64 (-5.48 to -1.80), respectively; both P < 0.001). Similarly, compared with the highest quartile of day-to-night ratio of urinary potassium excretion rate, linear regression coefficient (95% CI) for the lowest quartile was -5.60 (-8.13 to -3.07) for nocturnal SBP, and -2.47 (-4.28 to -0.67) for SBP dipping (both P < 0.001). Moreover, urine flow rate and concentrates of sodium or potassium in the urine were positively associated with urinary sodium or potassium excretion during daytime (P < 0.001).

Conclusion

A higher nocturnal BP and a blunted nocturnal BP dipping were both independently linked to a lower excretion of sodium or potassium during the day in patients with CKD. Furthermore, a decreased urine flow rate and a diminished capacity to concentrate sodium or potassium in the urine appear to be the key contributors to a low day-to-night ratio of urinary sodium excretion or potassium rate.

Utilization of Yeast Extract as a Flavor Enhancer and Masking Agent in Sodium-Reduced Marinated Shrimp

Deepwater pink shrimp (Parapenaus longirostris) has a significantly high catch yield and is a highly important food source for human nutrition in terms of its nutritional value. The reduction of salt content in seafood products while preserving taste poses a significant challenge. The aim of this study is to reduce the NaCl ratio used in the shrimp marination process by substituting it with KCl and masking the resulting bitterness from KCl using natural flavor enhancers, such as yeast extracts. The marinated shrimp were prepared using 50% KCl instead of 50% NaCl. In order to mask the bitter taste caused by KCl and enhance the flavor, two different types of yeast extracts obtained from Saccharomyces cerevisiae were utilized in the formulation. Nutritional composition, Na and K contents, amino acid composition, color measurement, bacteriological quality, pH changes, and sensory evaluations were conducted to assess the impact of salt reduction and yeast extracts on the sensory, chemical, and physical attributes of the products. L-glutamic acid, L-alanine, L-aspartic acid, L-leucine, L-valine, and L-lysine were found to be higher in samples with Levex Terra yeast extract. Despite a 50% reduction in NaCl content, the addition of yeast extract led to an increase in the umami taste due to the elevation of amino acids present. Yeast extracts can offer a promising solution for enhancing the sensory qualities of seafood products with reduced salt content by conducting more detailed sensory development examinations.

Understanding knowledge, attitudes and behaviours related to dietary sodium intake in a multi-ethnic population in Singapore

OBJECTIVE

This study aimed to fill the current gap in the understanding of the knowledge, attitudes and behaviours (KAB) related to dietary Na among adult residents in Singapore.

DESIGN

A cross-sectional online survey was conducted between October and December 2020 on 955 participants selected through random sampling.

SETTING

The survey was conducted in Singapore.

PARTICIPANTS

Participants were recruited from the Singapore Population Health Study Online Panel.

RESULTS

Participants' mean age was 46·6 ± 14·1 years old and 58 % of them were females. Most of the participants were Chinese (82·1 %), 10·5 % were Indian and 4·5 % were Malay. Findings from the weighted data showed that most participants were aware of the health impact of high Na consumption. However, many participants were unaware of the recommended intake for salt (68%) and Na (83%), had misconceptions, and were unable to correctly use food labels to assess NA content (69%). Findings also alluded to the presence of knowledge gaps in the sources of Na in their diet. While 59 % of the participants reported to be limiting their consumption of Na, many reported facing barriers such as not knowing how to limit their Na intake. Participants also felt that there were limited options for low-Na foods when eating out and were lacking awareness of low-Na products.

CONCLUSIONS

Findings highlighted substantial gaps in participants' knowledge and skills in managing their Na consumption. This suggests the need for more public education and improvements in the food environment.

Epigenetic and transcriptional regulation of the human angiotensinogen gene by high salt

Hypertension is caused by a combination of genetic and environmental factors. Angiotensinogen (AGT) is a component of RAAS, that regulates blood pressure. The human angiotensinogen (hAGT) gene has -6A/-6G polymorphism and -6A variant is associated with human hypertension. In this study, we have investigated the epigenetic regulation of the hAGT. To understand transcriptional regulation of the hAGT, we have made transgenic animals containing -6A. We show that HS affects DNA methylation and modulates transcriptional regulation of this gene in liver and kidney. High salt (HS) increases hAGT gene expression in -6A TG mice. We have observed that the number of CpG sites in the hAGT promoter is decreased after HS treatment. In the liver, seven CpG sites are methylated whereas after HS treatment, only three CpG sites remain methylated. In the kidney, five CpG sites are methylated, whereas after HS treatment, only three CpG sites remain methylated. These results suggest that HS promotes DNA demethylation and increasing AGT gene expression. RT-PCR and immunoblot analysis show that hAGT gene expression is increased by HS. Chip assay has shown that transcription factors bind strongly after HS treatment. RNA-Seq identified differentially expressed genes, novel target genes associated with hypertension, top canonical pathways, upstream regulators. One of the plausible mechanisms for HS induced up-regulation of the hAGT gene is through IL-6/JAK/STAT3/AGT axis.

Sodium Content in Pre-Packaged Foods in China: A Food Label Analysis

Sodium intake from pre-packaged foods is increasing in China and is well above the WHO recommendation of 5 g per day. The purpose of this study is to analyze the sodium content of pre-packaged foods collected by the National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention (NINH, China CDC) in 20 provinces of China from 2017 to 2022. The proportion of pre-packaged foods that meet or exceed the low-sodium, medium-sodium, and high-sodium classifications were analyzed. The proportion of pre-packaged foods that meet and do not meet the WHO global sodium benchmarks and the difference in sodium content between these foods was also calculated. High-sodium foods include sauces, dips, and dressings (3896 mg/100 g), convenience foods (1578 mg/100 g), processed fish products (1470 mg/100 g), processed meat products (1323 mg/100 g), processed poultry products (1240 mg/100 g), snack foods (750 mg/100 g), processed egg products (741 mg/100 g), and fine dried noodles (602 mg/100 g). A large number of pre-packaged foods currently collected in China have a sodium content above sodium benchmarks. This study provided data to support the assessment of sodium intake from pre-packaged foods in the Chinese population and the implementation of comprehensive salt reduction strategies.

Effect of sodium salt on meat products and reduction sodium strategies - A review

Sodium salt is one of the important additives in food processing. However, excessive intake of sodium salt may cause a series of cardiovascular diseases. Nowadays, sodium intake in most countries is higher than the World Health Organization recommends maximum consumption (5 g/d). 20% of the sodium intake in diets comes from meat products. Therefore, reducing the content of sodium salt in meat products and developing sodium salt-reduction meat products have attracted more and more attention for consumers. In this paper, the roles of sodium salt in meat product processing were reviewed. At the same time, sodium salt reduction strategies and existing problems were summarized and discussed. Multiple factors need to be considered to improve the salt-reduction meat product's quality. Relying on a single technology has a narrow application area, and it is difficult to achieve salt reduction. Therefore, a combination of multiple strategies could obtain a more ideal effect.

Association between intake of sodium, potassium, sodium-to-potassium ratio, and blood pressure among US adults

High dietary sodium and low potassium intake is associated with high blood pressure (BP). The current study aimed to determine if the sodium-to-potassium ratio is more strongly associated with low (130-139/80-89 mm Hg) and high (≥140/90 mm Hg) BP thresholds among US adults than either sodium or potassium alone. A total of 30,776 patients aged ≥20 years with complete blood pressure participated in the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2018. Demographic information and health characteristics were compared between men and women using the chi-square test for categorical variables and independent samples t-test for continuous variables. Logistic regression was performed to investigate the association of the odds ratios (OR) of different levels of sodium, potassium, and sodium-to-potassium ratio. After multivariable adjustment (age, gender, Body mass index, Smoking, education, Race, Alcohol, total energy intake, and physical activity), no relationship has been observed between high versus low sodium-to-potassium ratio and BP threshold of 130-139/80-89 mm Hg (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 0.92-1.12). Higher sodium-to-potassium ratio (OR=1.24; CI: 1.11-1.38) and dietary intake of potassium (OR=0.66; CI: 0.55-0.80) showed significant association in reducing the BP threshold of ≥140/90 mm Hg. In dose-response analysis, higher BP ≥140/90 mm Hg was inversely associated with higher potassium intake. Furthermore, the sodium-to-potassium ratio showed higher odds in predicting the BP of patients aged ≤60 years, underweight, nonsmokers, and non-alcohol users. The study confirms an inverse association between higher potassium intake and higher BP threshold. The Doses-response analyses showed sodium-to-potassium ratio is a better predictor of BP thresholds than sodium or potassium alone.

Ultra-processed food consumption and nutritional frailty in older age

Frailty is a multidisciplinary public health issue and nutrition is key concern. Given the scientific consistency about inflammation as shared pathway to poor nutrition and frailty, food processing seems a suitable target to gain evidence in frailty prevention nutrition settings. This study aimed to assess diet in relation to nutritional frailty using the NOVA classification. Browsing the dataset of the Salus in Apulia, 2185 older adults were found to have completed the nutritional assessment, providing eligible data for this study goal. A validated construct, based on the co-presence of physical frailty by CHS criteria plus nutritional imbalance, was applied to characterize nutritional frailty phenotypes. Using the NOVA classification, daily food and beverage intakes from an 85-item self-administered FFQ were assigned to three categories, and effect sizes were tested among groups according to nutritional frailty status (presence/absence). Raw and adjusted logistic regression models were run to assess associations between NOVA food categories by quintiles of daily exposure (very-low, low, mild, moderate, high) and nutritional frailty. Nutritional frailty prevalence was 27%, being more frequent in males. Eating more unprocessed or minimally processed foods was inversely related to nutritional frailty, even after adjustment (OR: 0.10, 95%CI 0.07-0.16), showing a downward ORs behavior toward lower consumption quintiles. Listing in the quintile of moderate consumption of processed foods meant a nearly 50% increase in nutritional frailty probability (OR: 1.46, 95%CI 1.03-2.06), while the probability was double for the highest quintile against the lowest (OR: 3.22, 95%CI 2.27-4.58). A growing probability of nutritional frailty was found for increasing consumption of ultra-processed foods, but significance was lacking. The contribution of food processing to poor nutrition needs to be considered when promoting a better understanding of effective nutritional screening in aging. Therefore, food processing should be accounted for when composing diet guidelines for the older population within the framework of multidisciplinary efforts to ease the frailty healthcare burden.

A Proposed Strategy against Obesity: How Government Policy Can Counter the Obesogenic Environment

An epidemic of obesity emerged in the USA in 1976-1980. The epidemic then spread to many other Westernized nations. Many interventions have been carried out with the goal of lowering the prevalence of obesity. These have mostly taken the form of various types of health promotion (i.e., providing people with education, advice, and encouragement). These actions have achieved, at most, only limited success. A strategy with a better chance of success starts with the recognition that the fundamental cause of obesity is that we live in an obesogenic environment. It is therefore necessary to change the environment so that it fosters a generally healthy lifestyle, thereby leading to enhanced health for the population, including improved weight control. A major goal is to increase the intake of healthy foods (especially fruit, vegetables, and whole grains), while decreasing intake of unhealthy foods (especially ultra-processed foods such as sugar). This will require major changes of many government policies. Some of the required policies are as follows. Schools should implement policies that create a healthy environment for children. For example, they should adopt a policy that only foods of high nutritional quality are sold in vending machines or given to students within school meals. Policies need to go well beyond the school setting; a broad strategy is needed that creates a healthy environment for children. Another important policy is the manipulation of food prices in order to shift the diet toward healthy foods. This requires using subsidies to lower the price of healthy foods, while adding a tax to less healthy foods to increase the price. This policy has been implemented in many cities and countries in the form of a tax on sugar-sweetened beverages (SSBs). The advertising of unhealthy foods (including fast-food restaurants) should be banned, especially where children and adolescents are the major target. Such a ban could be extended to a complete ban on all advertising for unhealthy foods, including that directed at adults. The proposed policy measures are likely to be strongly opposed by food corporations.

The role of dietary salt in metabolism and energy balance: Insights beyond cardiovascular disease

Dietary salt (NaCl) is essential to an organism's survival. However, today's diets are dominated by excessive salt intake, which significantly impacts individual and population health. High salt intake is closely linked to cardiovascular disease (CVD), especially hypertension, through a number of well-studied mechanisms. Emerging evidence indicates that salt overconsumption may also be associated with metabolic disorders. In this review, we first summarize recent updates on the mechanisms of salt-induced CVD, the effects of salt reduction and the use of salt substitution as a therapy. Next, we focus on how high salt intake can impact metabolism and energy balance, describing the mechanisms through which this occurs, including leptin resistance, the overproduction of fructose and ghrelin, insulin resistance and altered hormonal factors. A further influence on metabolism worth noting is the reported role of salt in inducing thermogenesis and increasing body temperature, leading to an increase in energy expenditure. While this result could be viewed as a positive metabolic effect because it promotes a negative energy balance to combat obesity, caution must be taken with this frame of thinking given the deleterious consequences of chronic high salt intake on cardiovascular health. Nevertheless, this review highlights the importance of salt as a noncaloric nutrient in regulating whole-body energy homeostasis. Through this review, we hope to provide a scientific framework for future studies to systematically address the metabolic impacts of dietary salt and salt replacement treatments. In addition, we hope to form a foundation for future clinical trials to explore how these salt-induced metabolic changes impact obesity development and progression, and to elucidate the regulatory mechanisms that drive these changes, with the aim of developing novel therapeutics for obesity and CVD.

Estimated 24-Hour urinary sodium and potassium excretion in adults in the Northwest Region of Morocco, 2017

BACKGROUND

Excessive sodium (Na) and insufficient potassium (K) intake contribute to a high risk of cardiovascular events. Morocco lacks data on actual Na and K intake in adults. We estimated mean Na and K intake in a Moroccan population of adults residing in the Northwest region using 24-h urinary excretion and examined their association with blood pressure (BP).

METHODS

A total of 371 adults from this region, who were recruited for the STEPs Survey Morocco 2017, completed demographic, anthropometric as well as BP data and provided a valid 24-h urine collection according to the standard World Health Organization (WHO) protocol. Multiple Linear Regression analysis was used to examine the association between 24-h urinary sodium (24-hUNa) and 24-h potassium excretion (24-hUK) with BP.

RESULTS

Mean Na excretion was 2794 mg/day and mean K excretion was 1898 mg/day. Overall, only 114 (30.7%) adults met the WHO recommendation for Na intake (< 2000 mg/d) and 31 (8.4%) met the adequate level for K intake (⩾3510 mg/d). There was no association between 24-hUNa and 24-hUK with BP (P > 0.05 for all).

CONCLUSION

Na intake was higher and K intake was lower than WHO recommendations in the study population. There was no association between estimated Na and K intake levels with BP in this population.

An mHealth-based school health education system designed to scale up salt reduction in China (EduSaltS): A development and preliminary implementation study

Background

High-salt diet is an important risk factor for several non-communicable diseases. School-based health education has been found effective in reducing salt intake among children and their families in China. However, no such interventions have been scaled up in the real world. For this purpose, a study was launched to support the development and scale-up of an mHealth-based system (EduSaltS) that integrated routine health education and salt reduction and was delivered through primary schools. This study aims to elaborate the framework, development process, features, and preliminary scaling-up of the EduSaltS system.

Methods

The EduSaltS system evolved from previously successfully tested interventions to reduce family salt intake by empowering schoolchildren through school health education. EduSaltS was designed by following the WHO's conceptual framework for developing a scaling-up strategy which accounted for the nature of the innovation, the capacity of the implementing organizations, the characteristics of the environment, the resources available, and type of scaling up. The system was then developed step by step from determination of online platform architecture, definition of component interventions and activities, development of specific educational materials and tools, to the development of the online/offline hybridized system. The system was tested and refined by a pilot in two schools and a preliminary scale-up in two cities in China.

Results

EduSaltS was developed as an innovative health education system, including an online WeChat-based education platform, a set of offline activities, and an actual administrative website showing the progress and setting the system. The WeChat platform could be installed on users' smartphones to automatically deliver 20 sessions of five-minute well-structured cartoon video classes, followed by other online interactive activities. It also helps support project implementation and real-time performance evaluation. As a first-stage roll-out, a one-year course has been successfully implemented among 54,538 children and their families from 209 schools in two cities, and the average course completion rate was 89.1%.

Conclusion

As an innovative mHealth-based health education system, EduSaltS was developed based on successfully tested interventions and an appropriate framework for scaling up. The early-stage roll-out has shown its preliminary scalability, and further evaluation is ongoing.

Modelling health and economic impact of nutrition interventions: a systematic review

Diet related non-communicable diseases (NCDs), as well as micronutrient deficiencies, are of widespread and growing importance to public health. Authorities are developing programs to improve nutrient intakes via foods. To estimate the potential health and economic impact of these programs there is a wide variety of models. The aim of this review is to evaluate existing models to estimate the health and/or economic impact of nutrition interventions with a focus on reducing salt and sugar intake and increasing vitamin D, iron, and folate/folic acid intake. The protocol of this systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016050873). The final search was conducted on PubMed and Scopus electronic databases and search strings were developed for salt/sodium, sugar, vitamin D, iron, and folic acid intake. Predefined criteria related to scientific quality, applicability, and funding/interest were used to evaluate the publications. In total 122 publications were included for a critical appraisal: 45 for salt/sodium, 61 for sugar, 4 for vitamin D, 9 for folic acid, and 3 for iron. The complexity of modelling the health and economic impact of nutrition interventions is dependent on the purpose and data availability. Although most of the models have the potential to provide projections of future impact, the methodological challenges are considerable. There is a substantial need for more guidance and standardization for future modelling, to compare results of different studies and draw conclusions about the health and economic impact of nutrition interventions.

Consumer perception of salt-reduced bread with the addition of brown seaweed evaluated under blinded and informed conditions

BACKGROUND

Many consumers have a high salt intake and bread is a primary source because of its high rate of consumption. The inclusion of seaweeds has been proposed as an ingredient that could help reduce the salt content of food products. As such, the present study aimed to evaluate whether the amount of salt in bread could be reduced and the change in sensory properties be mitigated by the inclusion of brown seaweed. There were two different sensory trials conducted. In the first trial, participants (n = 102) evaluated bread made with brown seaweed (4% substitution for flour) with reduced amounts of salt (10%, 20%, 30%, 40% and 50%). The second trial asked participants (n = 98) to evaluate the control bread and the 20% salt-reduced bread in blinded and informed conditions. In both sensory trials, the breads samples were assessed using hedonic scales, just-about-right scales, and check-all-that-apply.

RESULTS

The results showed that the 10% and 20% salt-reduced breads were acceptable and associated with being soft, chewy and having no aftertaste. The other breads were associated with a dense, dry and strong aftertaste, along with not being salty enough for the consumers. When the breads were evaluated in informed conditions, the salt reduction label had a negative impact on the consumers' liking.

CONCLUSION

The research emphasizes that salt-reduced labels influence consumers' sensory perception. © 2023 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Strategies to Reduce Purge Losses in Meat Products Stuffed in Plastic Casings

Two different meat emulsions were prepared with different physical stability: R1 with 6.28 ± 1.13% total expressible fluid and R2 with 17.7 ± 1.48%. The emulsions were placed in plastic casings at three different surface tensions (ST), expressed as contact angle, and three distinct overstuffing percentages (OS). The stuffed samples were cooked in an industrial oven. After cooling, purge losses (PL) and texture profile analysis (TPA) were measured. The reduced surface tension of the plastic casings significantly decreased the PL of both recipes. In the case of R2, a combination of high OS and low ST was necessary to reduce PL in a 60%. In the case of TPA, OS had a statistical influence on parameters like chewiness, cohesiveness, and hardness. Plastic casings with different surface tension (to increase adherence of meat emulsion to the casing) stuffed at different levels of overstuffing percentages (to reduce free space between meat emulsion and casing) represent a potential tool to reduce PL of products based on low stability meat emulsions.

Altered dietary salt intake for preventing diabetic kidney disease and its progression

BACKGROUND

There is strong evidence that our current consumption of salt is a major factor in the development of increased blood pressure (BP) and that a reduction in our salt intake lowers BP, whether BP levels are normal or raised initially. Effective control of BP in people with diabetes lowers the risk of strokes, heart attacks and heart failure and slows the progression of chronic kidney disease (CKD) in people with diabetes. This is an update of a review first published in 2010.

OBJECTIVES

To evaluate the effect of altered salt intake on BP and markers of cardiovascular disease and of CKD in people with diabetes.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of altered salt intake in individuals with type 1 and type 2 diabetes. Studies were included when there was a difference between low and high sodium intakes of at least 34 mmol/day.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies and resolved differences by discussion. We calculated mean effect sizes as mean difference (MD) and 95% confidence intervals (CI) using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Thirteen RCTs (313 participants), including 21 comparisons (studies), met our inclusion criteria. One RCT (two studies) was added to this review update. Participants included 99 individuals with type 1 diabetes and 214 individuals with type 2 diabetes. Two RCTs (four studies) included some participants with reduced overall kidney function. The remaining studies either reported that participants with reduced glomerular filtration rate (GFR) were excluded from the study or only included participants with microalbuminuria and normal GFR. Five studies used a parallel study design, and 16 used a cross-over design. Studies were at high risk of bias for most criteria. Random sequence generation and allocation concealment were adequate in only three and two studies, respectively. One study was at low risk of bias for blinding of participants and outcome assessment, but no studies were at low risk for selective reporting. Twelve studies reported non-commercial funding sources, three reported conflicts of interest, and eight reported adequate washout between interventions in cross-over studies. The median net reduction in 24-hour urine sodium excretion (24-hour UNa) in seven long-term studies (treatment duration four to 12 weeks) was 76 mmol (range 51 to 124 mmol), and in 10 short-term studies (treatment duration five to seven days) was 187 mmol (range 86 to 337 mmol). Data were only available graphically in four studies. In long-term studies, reduced sodium intake may lower systolic BP (SBP) by 6.15 mm Hg (7 studies: 95% CI -9.27 to -3.03; I² = 12%), diastolic BP (DBP) by 3.41 mm Hg (7 studies: 95% CI -5.56 to -1.27; I² = 41%) and mean arterial pressure (MAP) by 4.60 mm Hg (4 studies: 95% CI -7.26 to -1.94; I² = 28%). In short-term studies, low sodium intake may reduce SBP by 8.43 mm Hg (5 studies: 95% CI -14.37 to -2.48; I² = 88%), DBP by 2.95 mm Hg (5 studies: 95% CI -4.96 to -0.94; I² = 70%) and MAP by 2.37 mm Hg (9 studies: 95% CI -4.75 to -0.01; I² = 65%). There was considerable heterogeneity in most analyses but particularly among short-term studies. All analyses were considered to be of low certainty evidence. SBP, DBP and MAP reductions may not differ between hypertensive and normotensive participants or between individuals with type 1 or type 2 diabetes. In hypertensive participants, SBP, DBP and MAP may be reduced by 6.45, 3.15 and 4.88 mm Hg, respectively, while in normotensive participants, they may be reduced by 8.43, 2.95 and 2.15 mm Hg, respectively (all low certainty evidence). SBP, DBP and MAP may be reduced by 7.35, 3.04 and 4.30 mm Hg, respectively, in participants with type 2 diabetes and by 7.35, 3.20, and 0.08 mm Hg, respectively, in participants with type 1 diabetes (all low certainty evidence). Eight studies provided measures of urinary protein excretion before and after salt restriction; four reported a reduction in urinary albumin excretion with salt restriction. Pooled analyses showed no changes in GFR (12 studies: MD -1.87 mL/min/1.73 m², 95% CI -5.05 to 1.31; I² = 32%) or HbA1c (6 studies: MD -0.62, 95% CI -1.49 to 0.26; I² = 95%) with salt restriction (low certainty evidence). Body weight was reduced in studies lasting one to two weeks but not in studies lasting for longer periods (low certainty evidence). Adverse effects were reported in only one study; 11% and 21% developed postural hypotension on the low-salt diet and the low-salt diet combined with hydrochlorothiazide, respectively.

AUTHORS' CONCLUSIONS

This systematic review shows an important reduction in SBP and DBP in people with diabetes with normal GFR during short periods of salt restriction, similar to that obtained with single drug therapy for hypertension. These data support the international recommendations that people with diabetes with or without hypertension or evidence of kidney disease should reduce salt intake to less than 5 g/day (2 g sodium).

Global, regional, and national burden of chronic kidney disease attributable to high sodium intake from 1990 to 2019

Background

High sodium intake is a crucial risk factor for the development and progression of chronic kidney disease (CKD). However, the latest global spatiotemporal patterns of CKD burden attributable to high sodium intake still remain unclear. We aimed to evaluate the level and trends of the CKD burden associated with high sodium intake according to sex, age, socio-demographic index (SDI), region, and country from 1990 to 2019.

Methods

Data on CKD burden attributable to high sodium intake from 1990 to 2019 were extracted from the Global Burden of Disease (GBD) Study 2019. The CKD-related deaths, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized DALYs rate (ASDR) attributable to high sodium intake were estimated by age, sex, SDI, region, and country. The estimated annual percentage change (EAPC) was calculated to evaluate the secular trends of ASMR and ASDR of CKD attributable to high sodium intake from 1990 to 2019. We further explored the associations of SDI with the ASMR and ASDR of CKD attributable to high sodium intake.

Results

Globally, the number of CKD-related deaths and DALYs attributable to high sodium intake were 45,530 (95% UI: 12,640 to 93,830) and 1.32 million (95% UI: 0.43 to 2.8) in 2019, both twice as many as those in 1990. However, the ASMR and ASDR slightly grew, with an EAPC of 0.22 (95% CI: 0.16 to 0.28) and 0.10 (95% CI: 0.04 to 0.16), respectively. The age-specific numbers and rates of deaths, as well as DALYs of CKD attributable to high sodium intake, rose with age and were greater in males than in females. The rates of deaths and DALYs peaked in the >95 age group for both females and males in 2019. From 1990 to 2019, the trends of both age-specific rates of mortality and DALYs of CKD attributable to high sodium intake were down in people under 60, while in people over 60, the trends were the opposite. The burden of CKD attributable to high sodium intake in 2019 and its temporal trends from 1990 to 2019 varied greatly by SDI quintile and geographic location. The ASMR or ASDR showed a non-linear negative correlation with SDI at the regional level. The EAPC in ASMR or ASDR showed a markedly negative correlation with ASMR or ASDR in 1990, with a coefficient of -0.40. Nevertheless, the EAPC in ASMR rather than ASDR was positively correlated with SDI in 2019, with a coefficient of 0.18.

Conclusion

Our findings suggest that there are significant sexual and geographic variations in the burden of CKD attributable to high sodium intake and its temporal trends. Globally, the high sodium intake-caused CKD burden continues to elevate, posing a major challenge to public health. In response to this, strengthened and tailored approaches for CKD prevention and sodium intake management are needed, especially for elderly populations, males, and the population in the middle SDI regions.

Lifestyles and health-related quality of life in Chinese people: a national family study

BACKGROUND

There were few studies that investigated health-related quality of life (HRQoL) of the general population in China, and many of them reported limitations in sampling.

OBJECTIVE

To investigate the relationship between lifestyles and HRQoL in the Chinese population in both individual and family levels.

METHOD

Online questionnaires were distributed across China to collect demographic information and participants' HRQoL using EuroQoL 5 Dimension scales. The EuroQoL Group's 5 Dimension scale (EQ-5D) index and EuroQoL Group's visual analog scale (EQ VAS) score were calculated to evaluate the HRQoL.

RESULTS

A total of 1305 valid questionnaires were included. Higher HRQoL was found in people with intend to lower oil intake, intend to lower salt intake, intend to lower sugar intake, balanced diet, moderate sports every week, a sport hobby and joining a fitness organization (all p<.05). HRQoL was higher among male (female as reference), healthy weight (unhealthy weight as reference) (both p<.05). Negative correlation was found between HRQoL and clinical medical history and drinking history. Small families (1-2 persons, 83.19 ± 20.14) had poorer HRQoL (EQ VAS score) than big families (≥3 persons, 85.00 ± 17.96, p <.05).

CONCLUSION

In China, people with healthy dietary habits, regular sports habits, healthy weight and male groups tended to have better HRQoL. Clinical medical history and drinking history were negatively related to HRQoL. Small families tend to have poorer HRQoL than big families. The finding implicated influence of the number of family members on people's perception of health and provided scientific evidence for the current policies to encourage birth in China. For a better HRQoL, we suggest people live in big families and take measures to lower salt/sugar/oil intake and exercise regularly in daily life.

Tracking of Dietary Patterns in the Secondary Prevention of Cardiovascular Disease after a Nutritional Intervention Program-A Randomized Clinical Trial

Individuals with a history of previous cardiovascular events have an increased risk of mortality and morbidity, so adherence to a healthy dietary pattern is essential. We aimed to evaluate and compare dietary patterns between the control and the experimental group from the BALANCE Program. A total of 2360 individuals aged 45 years or older with previous cardiovascular disease were included. The individuals were randomized into two groups: intervention (dietary prescription with nutritional recommendations, nutritional education program based on playful strategies, suggestions of typical and accessible Brazilian foods and intensive monitoring) and control (conventional nutritional counseling). The dietary patterns were identified using factor analysis with the principal component extraction method, and the t-Student tests and ANOVA test were performed to evaluate the associated factors. Four dietary patterns were identified for both groups: "Traditional", "Snack", "Western", "Cardioprotective". There was an increase in the variances of the "Cardioprotective" pattern in both groups. Regarding the "Western" pattern, there was a significant reduction in the variances of the experimental group (10.63% vs. 8.14%). Both groups had improvements in eating habits, especially in the first year of follow-up. The greater increase in adherence to the traditional and cardioprotective pattern in the experimental group justifies the initiative of the BALANCE program.

A Town-Level Comprehensive Intervention Study to Reduce Salt Intake in China: Cluster Randomized Controlled Trial

We determined whether a town-level comprehensive intervention program could lower the salt intake of a population. The parallel, cluster randomized controlled trial was carried out between October 2018 and January 2020 in 48 towns from 12 counties across 6 provinces in China. All participants were asked to complete the 24 h urine collections, anthropometric measurements and questionnaires at the baseline and one-year post-intervention survey. A total of 2693 participants aged 18 to 75 years were recruited at the baseline. A total of 1347 individuals in 24 towns were allocated to the intervention group and the others were allocated to the control group. Valid information from 2335 respondents was collected in the follow-up survey. The 24-h urinary sodium excretion was 189.7 mmol/24 h for the intervention group and 196.1 mmol/24 h for the control group at baseline. At a one-year follow-up, the mean effect of salt intake did not show a significant change (p = 0.31) in the intervention group compared to the control group. However, the mean result of potassium excretion in the intervention group increased by 2.18 mmol/24 h (85.03 mg/24 h) (p = 0.004) and systolic blood pressure decreased by 2.95 mmHg (p < 0.001). The salt-related knowledge and attitude toward salt reduction improved significantly in the intervention group (p < 0.05). A longer period of intervention and follow-up assessment might be needed to evaluate the long-term effectiveness of the program on salt reduction.

Mean population salt intake in Iran: A systematic review and meta-analysis

INTRODUCTION

High salt intake has been connected with the increase of many non-communicable diseases (NCDs) worldwide. Like other middle-income countries, Iran is experiencing a considerable increase in NCDs, necessitating attempts to reduce dietary salt intake. As in Iran there is uncertainty about the existing rate of salt intake. The present study aimed to estimate mean salt intake of Iranian population by systematically reviewing existing literature.

METHODS

This research is a systematic review and meta-analysis (PRISMA Protocol) of published article data, with no time constraint until the end of 2020, to estimate mean salt intake of Iranian population. A comprehensive literature search was performed on international databases of Medline, Science Direct, PubMed, Embase, Scopus, Springer, Online Library Wiley, Web of Science, Cochrane, and Google Scholar and domestic data bases of Iranmedex, Magiran, SID, and Medlib. Subgroup analysis was conducted for gender, region, measurement method, and age group. Research homogeneity was evaluated by I ² statistic. We reviewed all studies which met inclusion criteria. STATA Ver.13.1 was used to perform meta-analysis.

RESULTS

Meta-analysis of data from 32 studies showed that the average salt intake in all ages was 9.674 g/day (95% CI, 9.033-10.316 g/day). The lowest estimation of salt intake was 9.33 g/day (95% CI, 7.75-10.91 g/day) which was estimated from studies which used point collection method, and the highest estimate using the food reminder questionnaire was 10.41 g/day (95% CI, 8.49-12.34 g/day). Also, the average weight salt intake for men over 18 years old in different cities was 10.39 g/day (95% CI, 9.01-11.78 g/day), for women over 18 years in different cities 9.52 g/day (95% CI, 8.42-10.62 g/day), and children and adolescents was estimated at 5.664 g/day (95% CI, 2.91-8.41 g/day).

CONCLUSION

The intake of salt in the Iranian population is near twice the WHO recommendation. Therefore, it is necessary to consider effective strategies and interventions to reduce dietary salt intake in Iran as a health priority.

Estimating the changing burden of disease attributable to high sodium intake in South Africa for 2000, 2006 and 2012

Background. Elevated sodium consumption is associated with increased blood pressure, a major risk factor for cardiovascular and chronic kidney disease.Objectives. To quantify the deaths and disability-adjusted life years (DALYs) attributed to high sodium intake in persons aged ≥25 years in South Africa (SA) for 2000, 2006 and 2012.Methods. Comparative risk assessment (CRA) methodology was used and population attributable fractions (PAFs) of high sodium intake, mediated through high blood pressure (BP), for cardiovascular and chronic kidney disease were estimated. This was done by taking the difference between the PAF for elevated systolic BP (SBP) based on the estimated SBP level in the population and the PAF based on the estimated SBP that would result if sodium intake levels were reduced to the theoretical minimum risk exposure level (1 g/day) according to population group and hypertension categories. A meta-regression based on data from nine national surveys conducted between 1998 and 2017 was used to estimate the prevalence of hypertension by age, sex and population group. Relative risks identified from international literature were used and the difference in PAFs was applied to local burden estimates from the second South African National Burden of Disease Study. Age-standardised rates were calculated using World Health Organization (WHO) standard population weights. The attributable burden was also estimated for 2012 using an alternative target of 2 g/day proposed in the National Strategic Plan for the Prevention and Control of Non-communicable Diseases (NSP).Results. High sodium intake as mediated through high SBP was estimated to cause 8 071 (95% uncertainty interval (UI) 6 542 - 15 474) deaths in 2012, a drop from 9 574 (95% UI 8 158 - 16 526) in 2006 and 8 431 (95% UI 6 972 - 14 511) in 2000. In 2012, ischaemic heart disease caused the highest number of deaths in persons (n=1 832), followed by haemorrhagic stroke (n=1 771), ischaemic stroke (n=1 484) and then hypertensive heart disease (n=1 230). Ischaemic heart disease was the highest contributor to deaths for males (27%), whereas for females it was haemorrhagic stroke (23%). In 2012, 1.5% (95% UI 1.3 - 2.9) of total deaths and 0.7% (95% UI 0.6 - 1.2) of total DALYs were attributed to high sodium intake. If the NSP target of <2 g/day sodium intake had been achieved in 2012, ~2 943 deaths and 48 870 DALYs would have been averted.Conclusion. Despite a slight decreasing trend since 2006, high sodium intake mediated through raised BP accounted for a sizeable burden of disease in 2012. Realising SA’s target to reduce sodium intake remains a priority, and progress requires systematic monitoring and evaluation.

Salt, Not Always a Cardiovascular Enemy? A Mini-Review and Modern Perspective

Dietary salt intake is a long-debated issue. Increased sodium intake is associated with high blood pressure, leading to salt-sensitive hypertension. Excessive salt intake leads to arterial stiffness in susceptible individuals via impaired nitric oxide action and increased endothelin-1 expression, overactivity of the renal sympathetic nervous system and also via aldosterone-independent activation of the mineralocorticoid receptor. Salt restriction in such individuals reduces blood pressure (BP) values. The optimal level of salt restriction that leads to improved cardiovascular outcomes is still under debate. Current BP and dietary guidelines recommend low sodium intake for the general population. However, a specific category of patients does not develop arterial hypertension in response to sodium loading. In addition, recent research demonstrates the deleterious effects of aggressive sodium restriction, even in heart failure patients. This mini review discusses current literature data regarding the advantages and disadvantages of salt restriction and how it impacts the overall health status.

The high sodium condiments and pre-packaged food should be the focus of dietary sodium control in the adult Shanghai population

Background

Long-term, excessively high sodium consumption can lead to increased blood pressure, which is a major risk factor for cardiovascular disease. Therefore, we aimed to analyze the dietary sodium intake and food sources to understand the epidemiological characteristics associated with potentially influencing variables in adults from Shanghai.

Methods

Residents aged 15 years and above were randomly selected using multi-stage stratified random sampling in Shanghai. Over 3 days, family condiments were weighed for each 24-h day, and recall surveys were conducted for the same timeframe regarding sodium intake during the spring, summer, autumn, and winter seasons.

Results

The median sodium intake for residents aged 15 years and above was 4.3 g/d in Shanghai, where 55.1% was obtained from cooking salt, 13.2% from sodium condiments, and 22.2% from pre-packaged food. There were no significant differences in total sodium intake or main sources of sodium intake between different seasons. The sodium intake of rural residents > suburban residents > urban residents (P < 0.05). The logistic regression demonstrated that compared to the rural, the people living in urban and suburban consumed less sodium. Compared to the 18–44, the people aged 45–59 and ≥ 60 consumed more sodium (P < 0.05).

Conclusions

Sodium intake is high in Shanghai. The absolute amount of cooking salt is low in Shanghai, and the possibility of further reduction is very little under the existing dietary habit. Limiting high sodium condiments and pre-packaged food is the new key to controlling salt intake in the future.

The association of knowledge, attitudes and behaviors related to salt with 24-h urinary sodium, potassium excretion and hypertensive status

To understand the association between sodium and potassium consumption levels, hypertension and knowledge, attitudes and behaviors (KAB) toward salt and the commitment to effective sodium reduction and potassium supplementation to achieve the purpose of suppressing hypertension. A stratified multistage random sampling method was used to obtain a representative provincial sample of 7512 residents aged 18-69 years through a cross-sectional survey by the Salt Reduction and Hypertension Prevention Project (SRHPP) in Zhejiang Province of China in 2017-2018. A screening including demographic, anthropometric, salt-related KAB and physical measurements was implemented, and 24-h urine of approximately 1/5 of the participants was collected and tested. The mean age was 44.8 years, 50.1% were women, 44.0% lived in urban areas, and hypertension or prehypertension accounted for approximately 35.0%. The mean 24-h urinary sodium and potassium excretion were 3848.5 (1661.1) mg/d and 1491.1 (710.9) mg/d, respectively. KAB in urban areas was generally more favorable than in rural areas, women were better than men, and the optimal blood pressure group was better than the other two groups (P < 0.05). However, the awareness and correct use rate of salt-restricted spoons, low-sodium salt and nutrition labeling were lower. A multivariable linear regression model indicated that KAB had a smaller effect on sodium (two indicators effective for promoting sodium reduction) and a greater effect on potassium (six indicators effective for promoting potassium supplementation) and mainly focused on knowledge and behavior indicators. A multivariable logistic regression model indicated that mastering more knowledge and taking active measures could effectively reduce the transition to hypertension, even if the individual was already in prehypertension. There is much room for improvement of salt-related KAB in the Chinese population. A clear association indicates that KAB can help to reduce sodium and supplement potassium, especially potassium, and help to suppress the development of hypertension. The role of beliefs in KAB should be fully valued and improved, similar to knowledge and behaviors. This study provides important evidence and insight into China's efforts to meet the targets of salt reduction and hypertension prevention.

Labels Affect Food Choices, but in What Ways?

To reduce obesity and thus promote healthy food choices, front-of-pack (FOP) labels have been introduced. Though FOP labels help identify healthy foods, their impact on actual food choices is rather small. A newly developed so-called swipe task was used to investigate whether the type of label used (summary vs. nutrient-specific) had differential effects on different operationalizations of the "healthier choice" measure (e.g., calories and sugar). After learning about the product offerings of a small online store, observers (N = 354) could, by means of a swipe gesture, purchase the products they needed for a weekend with six people. Observers were randomly assigned to one of five conditions, two summary label conditions (Nutri-Score and HFL), two nutrient (sugar)-specific label conditions (manga and comic), or a control condition without a label. Unexpectedly, more products (+7.3 products)-albeit mostly healthy ones-and thus more calories (+1732 kcal) were purchased in the label conditions than in the control condition. Furthermore, the tested labels had different effects with respect to the different operationalizations (e.g., manga reduced sugar purchase). We argue that the additional green-labeled healthy products purchased (in label conditions) "compensate" for the purchase of red-labeled unhealthy products (see averaging bias and licensing effect).

Estimation of Sodium Availability and Food Sources from 2018 to 2019 and Its Trends during the 2004-2019 Period in Costa Rica

Sodium availability and food sources in 2018−2019 were estimated and trends analyzed for 15 years (2004−2019) in Costa Rica. Food purchase records from the National Household Income and Expenditure Survey (ENIGH) 2018−2019 were converted to energy and sodium using food composition tables measuring “apparent consumption”. Foods were classified by sodium content. ENIGH is a probabilistic, stratified, two-stage and replicated national survey, carried out regularly by the national statistics institution. Results from the 2004−2005 and 2012−2013 ENIGHs came from previous analysis. Differences between periods were determined through descriptive and inferential statistics. The available sodium adjusted to 2000 kcal/person/day was 3.40, 3.86, and 3.84 g/person/day (g/p/d) for periods 2004−2005, 2013−2014, and 2018−2019, respectively. In this last period, this was 3.94 urban and 3.60 g/p/d rural (p < 0.05), with a non-linear increase with income. During 2004−2019 sodium from salt and salt-based condiments increased from 69.5 to 75.5%; the contribution of common salt increased, from 60.2 to 64.8% and condiments without added salt from 9.3 to 10.7%. From 2012−2013 to 2018−2019, processed and ultra-processed foods with added sodium intake increased from 14.2 to 16.9% and decreased in prepared meals (7.2 to 2.8%). Costa Rica has been successful in reducing salt/sodium available for consumption; after a 12% increase of salt consumption between 2004−2005 and 2012−2013, to a level almost twice as high as recommended, it has stabilized in the last period.

High salt intake combined with hypertension elevated the risk of primary liver cancer: a prospective cohort study

Background

Hypertension and high-salt intake may act synergistically to increase the risk of primary liver cancer (PLC). We prospectively examined the joint effect of hypertension and salt intake on the risk of PLC incidence.

Methods

A total of 92,978 participants were included in the final analyses. The study population was divided into 4 groups according to the presence or absence of hypertension and salt intake. Cox proportional hazards regression models were used to evaluate the association of hypertension and/or high-salt intake with the risk of incident cancers. The CAUSALMED procedure was used to perform the mediation analyses.

Results

During a median follow-up of 12.69 years, a total of 418 incident cancer cases were identified. Hypertension was a risk factor for PLC in women but not in men. High salt intake was associated with an elevated risk of PLC in men. A significant interaction between salt intake and hypertension was found for the risk of PLC (P for interaction=0.045). Compared with Group 1 (hypertension-, high salt intake-), participants in Group 2 (hypertension-, high salt intake+) and Group 4 (hypertension+, high salt intake+) were associated with an elevated risk of PLC with the corresponding multivariate HRs (95%CIs) of 1.73(0.96,3.10) and 1.96(1.09,3.53) respectively. No significant mediation effect was found for the association between hypertension, salt intake and PLC risk.

Conclusions

The combination of high salt intake and hypertension could significantly increase the risk of PLC. It may be reasonable to recommend a low-salt intake to prevent and control the prevalence of PLC and hypertension.

Trial registration

Kailuan study, ChiCTR–TNRC–11001489. Registered 24 August, 2011-Retrospectively registered, https://www.chictr.org.cn/showprojen.aspx?proj=8050

Could salt intake directly affect the cerebral microvasculature in hypertension?

OBJECTIVES

Excess dietary salt and chronic kidney disease (CKD) are acknowledged stroke risk factors. The development of small vessel disease, similarly affecting the cerebral and renal microvasculatures, may be an important mechanistic link underlying this interaction. Therefore, we aimed to evaluate if the dietary salt intake and markers of CKD (estimated glomerular filtration rate, albuminuria) relate to transcranial Doppler (TCD) markers of cerebral small vessel disease (CSVD) in hypertensive patients.

MATERIALS AND METHODS

Fifty-six hypertensive patients (57% with diabetes) underwent TCD monitoring in the middle (MCA) and posterior (PCA) cerebral arteries for evaluating neurovascular coupling (NVC), dynamic cerebral autoregulation (dCA), and vasoreactivity to carbon dioxide (VRCO₂). We investigated the relation between renal parameters and TCD studies using Pearson's correlation coefficient and linear regression analyses.

RESULTS

There were no associations between dCA, VRCO₂, NVC, and renal function tests. However, there was a negative association between the daily salt intake and the natural frequency during visual stimulation (r²=0.101, ß=-0.340, p=0.035), indicative of increased rigidity of the cerebral resistance vessels that react to cognitive activation.

CONCLUSIONS

In this cross-sectional study, we found an association between excess dietary salt consumption and CSVD in hypertensive patients. Future research is needed to evaluate whether the natural frequency could be an early, non-invasive, surrogate marker for microvascular dysfunction in hypertension.

Validation of 4 Estimating Methods to Evaluate 24-h Urinary Sodium Excretion: Summer and Winter Seasons for College Students in China

Twenty-four-hour urine sample collection is regarded as the gold standard for sodium intake evaluation, but the implementation can be difficult. The objective was to validate and evaluate the accuracy and feasibility of estimating sodium intake by four methods. A group of 268 healthy volunteers aged 18–25 years was enrolled in this study. Twenty-four-hour urine samples as well as timed (morning, afternoon, evening, and overnight) urine samples were randomly collected in summer and winter. The sodium intake was estimated by four published methods—Kawasaki, INTERSALT, Tanaka, and Sun’s. The consistencies between estimated sodium intake and real measured values of 24-h urinary sodium excretion were compared by Bland–Altman plots in each of the methods. The 24-h urinary sodium analysis result indicated that average daily sodium intake was 3048.4 ± 1225.9 mg in summer and 3564.7 ± 1369.9 mg in winter. At the population level, the bias (estimated value-measured value) was the least with the INTERSALT method with afternoon (−39.7 mg; 95%CI: −164.7, 85.3 mg) and evening (−43.5 mg; 95%CI: −166.4, 79.5 mg) samples in summer. In winter, the Kawasaki method (162.1 mg; 95%CI: 13.5, 310.7 mg) was superior to others. Estimation of sodium intake using the four methods is affected by the time and temperature. In summer, the INTERSALT method provides the best estimation of the population’s mean sodium intake. The Kawasaki method is superior to other methods in winter.

Perspective: Darwinian Applications to Nutrition-The Value of Evolutionary Insights to Teachers and Students

Evolutionary biology informs us that the living world is a product of evolution, guided by the Darwinian mechanism of natural selection. This recognition has been fruitfully employed in a number of issues in health and nutrition sciences; however, it has not been incorporated into education. Nutrition and dietetics students generally learn very little or nothing on the subject of evolution, despite the fact that evolution is the process by which our genetically determined physiological traits and needs were shaped. In the present Perspective article, 3 examples of topics (inflammatory diseases, nutrition transition, and food intolerance) that can benefit from evolutionary information and reasoning are given, with relevant lines of research and inquiry provided throughout. It is argued that the application of evolutionary science to these and other areas of nutrition education can facilitate a deeper and more coherent teaching and learning experience. By recognizing and reframing nutrition as an aspect and discipline of biology, grounded in the fundamental principle of adaptation, revelatory light is shed on physiological states and responses, contentious and unresolved issues, genomic, epigenomic, and microbiomic features, and optimal nutrient status and intakes.

Low-Cost Resistive Microfluidic Salinity Sensor for High-Precision Detection of Drinking Water Salt Levels

Rapid, inexpensive, and precise water salinity testing remains indispensable in water quality monitoring applications. Despite many sensors and commercialized devices to monitor seawater salinity, salt detection and quantification at very low levels of drinking water (below 120 ppm) have been overlooked. In this paper, we report on optimization of a low-cost microfluidic sensor to measure water salinity in the range of 1-120 ppm. The proposed design employs two copper microbridge wires suspended orthogonally in a PDMS microchannel to measure salinity based on the electrical resistance between the wires. The preliminary design of the sensor microchannel with a rectangular cross-section width (w) of 900 μm and height (h) of 500 μm could measure the water salinity in the range of 1-20 ppm in less than 1 min with detection sensitivity, limit of detection (LOD), and limit of quantification (LOQ) of 17.1 ohm/ohm·cm_, 0.31 ppm, and 0.37 ppm, respectively. Data from the preliminary design was used for developing and validating a numerical model which was subsequently used for parametric studies and optimization to improve the sensor's performance. The optimized design demonstrated an order of magnitude increase in sensitivity (385 ohm/ohm·cm), a 6-fold wider detection range (1-120 ppm), and a 15-fold enhancement in miniaturization of the microfluidic channel (w = 200 μm and h = 150 μm) with LOD and LOQ of 0.39 and 0.44 ppm, respectively. In the future, the sensor can be integrated into a hand-held device to remove present impediments for low-cost and ubiquitous salinity surveillance of drinking water.

Mechanism-based strategies to prevent salt sensitivity and salt-induced hypertension

High-salt diets are a major cause of hypertension and cardiovascular (CV) disease. Many governments are interested in using food salt reduction programs to reduce the risk for salt-induced increases in blood pressure and CV events. It is assumed that reducing the salt concentration of processed foods will substantially reduce mean salt intake in the general population. However, contrary to expectations, reducing the sodium density of nearly all foods consumed in England by 21% had little or no effect on salt intake in the general population. This may be due to the fact that in England, as in other countries including the U.S.A., mean salt intake is already close to the lower normal physiologic limit for mean salt intake of free-living populations. Thus, mechanism-based strategies for preventing salt-induced increases in blood pressure that do not solely depend on reducing salt intake merit attention. It is now recognized that the initiation of salt-induced increases in blood pressure often involves a combination of normal increases in sodium balance, blood volume and cardiac output together with abnormal vascular resistance responses to increased salt intake. Therefore, preventing either the normal increases in sodium balance and cardiac output, or the abnormal vascular resistance responses to salt, can prevent salt-induced increases in blood pressure. Suboptimal nutrient intake is a common cause of the hemodynamic disturbances mediating salt-induced hypertension. Accordingly, efforts to identify and correct the nutrient deficiencies that promote salt sensitivity hold promise for decreasing population risk of salt-induced hypertension without requiring reductions in salt intake.

Sodium and potassium intakes and adiposity among Iranian pre-adolescents and adolescents: a cross-sectional study

Background

High sodium and low potassium intakes are associated with the early development of chronic diseases (e.g., hypertension, obesity). Taking into account the limited data on sodium and potassium intakes by 24-h excretion in urine in pre-adolescents and adolescents, we wished to determine baseline salt intake in Iranian subjects aged 11–18 years.

Methods

This was an observational study involving 374 pre-adolescents and adolescents (154 boys and 220 girls). Sodium and potassium intakes were ascertained by measuring sodium and potassium excretion in urine over 24 h. Creatinine level was used to validate the completeness of the urine collections. The association between sodium and potassium intake and adiposity was determined based on body fat percentage.

Results

The mean 24-h urine sodium concentration was 3130 ± 2200 mg/day, equal to 7.961 ± 5.596 g/day salt intake. Approximately half of the study participants exceeded the upper limit of Na intake. The mean potassium intake was estimated 1480 ± 1050 mg/day. There was a positive association between urinary sodium excretion and adiposity in crude (OR 1.79; 95% CI: 1.08—2.74) and full adjusted model (OR: 3.15; 95% CI: 2.28–4.63). Also, in subsample analysis, there was a positive correlation between urinary sodium and adiposity in both pre-adolescents (OR: 2.71; 95% CI: 2.29—3.93) and adolescents (OR: 3.55; 95% CI: 2.17—4.74). However, no significant association was found between 24-h urinary potassium and adiposity.

Conclusion

Sodium intake, as estimated by 24-h urinary excretion, was higher than recommended and it was positively associated with adiposity. Also, this study reported low compliance of potassium intake recommendations in 11–18 years’ Iranian pre-adolescents and adolescents. Health promotion interventions are needed in order to broaden public awareness of high sodium intake and potassium inadequacy to reduce chronic diseases.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Estimation of mean population salt intakes using spot urine samples and associations with body mass index, hypertension, raised blood sugar and hypercholesterolemia: Findings from STEPS Survey 2019, Nepal

Background

High dietary salt intake is recognized as a risk factor for several non-communicable diseases (NCDs), in particular cardiovascular diseases (CVDs), including heart attack and stroke. Accurate measurement of population level salt intake is essential for setting targeted goals and plans for salt reduction strategies. We used a spot urine sample to estimate the mean population salt intake in Nepal and evaluated the association of salt intake with excess weight, hypertension, raised blood sugar and hypercholesterolemia, and a number of socio-demographic characteristics.

Methods

A population-based cross-sectional study was carried out from February to May 2019 using a WHO STEPwise approach to surveillance. Spot urine was collected from 4361 participants aged 15–69 years for the analysis of salt intake. We then used the INTERSALT equation to calculate population salt intake. Student’s ‘t’ test, one-way ANOVA and multivariable linear regression were used to assess the association between salt intake and a number of factors. Statistical significance was accepted at P < .05.

Results

The average (±SD) age of participants was 40 (14.1) years. Mean salt intake, derived from spot urine samples, was estimated to be 9.1g/d. A total of 70.8% of the population consumed more than the WHO’s recommended amount of 5g salt per day, with almost one third of the population (29%) consuming more than 10g of salt per day. Higher salt intake was significantly associated with male gender (β for male = 0.98g; 95%CI:0.87,1.1) and younger age groups (β25–39 years = 0.08; 95%CI:-0.08,0.23) and higher BMI (β = 0.19; 95%CI:0.18,0.21). Participants who were hypertensive and had raised blood cholesterol consumed less salt than people who had normal blood pressure and cholesterol levels (P<0.001).

Conclusions

Salt consumption in Nepal is high, with a total of 70.8% of the population having a mean salt intake >5g/d, well above the World Health Organization recommendation. High salt intake was found to be associated with sex, age group, education, province, BMI, and raised cholesterol level of participants These findings build a strong case for action to reduce salt consumption in Nepal in order to achieve the global target of 30% reduction in population salt intake by 2025.