1
|
Abstract
BACKGROUND Member states of the WHO, including India, have adopted a target 30% reduction in mean population salt consumption by 2025 to prevent noncommunicable diseases. Our aim was to support this initiative by summarizing existing data that describe mean salt consumption in India. METHOD Electronic databases - MEDLINE via Ovid, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews - were searched up to November 2015 for studies that reported mean or median dietary salt intake in Indian adults aged 19 years and older. Random effects meta-analysis was used to obtain summary estimates of salt intake. RESULTS Of 1201 abstracts identified, 90 were reviewed in full text and 21 were included: 18 cross-sectional surveys (n = 225 024), two randomized trials (n = 255) and one case-control study (n = 270). Data were collected between 1986 and 2014, and reported mean salt consumption levels were between 5.22 and 42.30 g/day. With an extreme outlier excluded, overall mean weighted salt intake was 10.98 g/day (95% confidence interval 8.57-13.40). There was significant heterogeneity between the estimates for contributing studies (I = 99.97%) (P homogeneity ≤0.001), which was likely attributable to the different measurement methods used and the different populations studied. There was no evidence of a change in intake over time (P trend = 0.08). CONCLUSION The available data leave some uncertainty about exact mean salt consumption in India but there is little doubt that population salt consumption far exceeds the WHO-recommended maximum of 5 g per person per day.
Collapse
|
2
|
Salt Use Behaviours of Ghanaians and South Africans: A Comparative Study of Knowledge, Attitudes and Practices. Nutrients 2017; 9:nu9090939. [PMID: 28846641 PMCID: PMC5622699 DOI: 10.3390/nu9090939] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/30/2022] Open
Abstract
Salt consumption is high in Africa and the continent also shares the greatest burden of hypertension. This study examines salt-related knowledge, attitude and self-reported behaviours (KAB) amongst adults from two African countries—Ghana and South Africa—which have distributed different public health messages related to salt. KAB was assessed in the multinational longitudinal World Health Organisation (WHO) study on global AGEing and adult health (WHO-SAGE) Wave 2 (2014–2015). Respondents were randomly selected across both countries—Ghana (n = 6746; mean age 58 years old; SD 17; 41% men; 31% hypertensive) and South Africa (n = 3776, mean age 54 years old; SD 17; 32% men; 45% hypertensive). South Africans were more likely than Ghanaians to add salt to food at the table (OR 4.80, CI 4.071–5.611, p < 0.001) but less likely to add salt to food during cooking (OR 0.16, CI 0.130–0.197, p < 0.001). South Africans were also less likely to take action to control their salt intake (OR 0.436, CI 0.379–0.488, p < 0.001). Considering the various salt reduction initiatives of South Africa that have been largely absent in Ghana, this study supports additional efforts to raise consumer awareness on discretionary salt use and behaviour change in both countries.
Collapse
|
3
|
Han W, Hu Y, Tang Y, Xue F, Hou L, Liang S, Zhang B, Wang W, Asaiti K, Pang H, Wang Z, Wang Y, Zhang M, Jiang J. Relationship between urinary sodium with blood pressure and hypertension among a Kazakh community population in Xinjiang, China. J Hum Hypertens 2017; 31:333-340. [PMID: 28054572 DOI: 10.1038/jhh.2016.83] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/02/2016] [Accepted: 10/21/2016] [Indexed: 01/11/2023]
Abstract
Urinary sodium levels are reported to be associated with blood pressure in clinical trials and epidemiology studies. Nevertheless, the public health message of reducing sodium intake in free-living community populations remains under debate. Based on an ongoing prospective study initiated in 2012 with a community-based design in Xinjiang, China, 1668 adults (⩾30 years old) were assessed in the current study for associations between urinary sodium and blood pressure and hypertension in a free-living population of Kazakh people. After excluding 223 people on antihypertensive medication, 1445 participants were analyzed. Second urine samples after waking were used to estimate 24-h urinary sodium excretion, which is a marker for sodium intake. Following analyses, we found that the distribution of systolic and diastolic blood pressures moved upward with increasing quartiles of urinary sodium. After adjusting for age, differences in median systolic blood pressure were 8.5 mm Hg for men and 8.0 mm Hg for women between the top and bottom urinary sodium quartiles, and differences for diastolic blood pressure were 4.7 mm Hg for men and 4.3 mm Hg for women. A significant increased risk for hypertension was observed for the top quartile of urinary sodium after adjusting for age, body mass index, smoking, alcohol consumption, fruit and vegetable consumption, with corresponding odds ratios being 1.61 (95% confidence interval (CI): 1.02-2.54) for men and 1.92 (95% CI: 1.13-3.27) for women. Improving education about reducing salt intake is of particular public importance to reduce blood pressure and the risk for hypertension among the Kazakh people.
Collapse
Affiliation(s)
- W Han
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Y Hu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Y Tang
- The People's Hospital of Altay Prefecture, Xinjiang, China
| | - F Xue
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - L Hou
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - S Liang
- The People's Hospital of Altay Prefecture, Xinjiang, China
| | - B Zhang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - W Wang
- The People's Hospital of Altay Prefecture, Xinjiang, China
| | - K Asaiti
- Hong Dun Town Hospital, Xinjiang, China
| | - H Pang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Z Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Y Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| | - M Zhang
- The People's Hospital of Altay Prefecture, Xinjiang, China
| | - J Jiang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/School of Basic Medicine Peking Union Medical College, Beijing, China
| |
Collapse
|
4
|
Johnson C, Mohan S, Rogers K, Shivashankar R, Thout SR, Gupta P, He FJ, MacGregor GA, Webster J, Krishnan A, Maulik PK, Reddy KS, Prabhakaran D, Neal B. The Association of Knowledge and Behaviours Related to Salt with 24-h Urinary Salt Excretion in a Population from North and South India. Nutrients 2017; 9:E144. [PMID: 28212309 PMCID: PMC5331575 DOI: 10.3390/nu9020144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/24/2017] [Accepted: 02/03/2017] [Indexed: 11/16/2022] Open
Abstract
Consumer knowledge is understood to play a role in managing risk factors associated with cardiovascular disease and may be influenced by level of education. The association between population knowledge, behaviours and actual salt consumption was explored overall, and for more-educated compared to less-educated individuals. A cross-sectional survey was done in an age-and sex-stratified random sample of 1395 participants from urban and rural areas of North and South India. A single 24-h urine sample, participants' physical measurements and questionnaire data were collected. The mean age of participants was 40 years, 47% were women and mean 24-h urinary salt excretion was 9.27 (8.87-9.69) g/day. Many participants reported favourable knowledge and behaviours to minimise risks related to salt. Several of these behaviours were associated with reduced salt intake-less use of salt while cooking, avoidance of snacks, namkeens, and avoidance of pickles (all p < 0.003). Mean salt intake was comparable in more-educated (9.21, 8.55-9.87 g/day) versus less-educated (9.34, 8.57-10.12 g/day) individuals (p = 0.82). There was no substantively different pattern of knowledge and behaviours between more-versus less-educated groups and no clear evidence that level of education influenced salt intake. Several consumer behaviours related to use of salt during food preparation and consumption of salty products were related to actual salt consumption and therefore appear to offer an opportunity for intervention. These would be a reasonable focus for a government-led education campaign targeting salt.
Collapse
Affiliation(s)
- Claire Johnson
- The George Institute for Global Health, Box M201 Missenden Rd, Sydney 2006, Australia.
- School of Public Health, Department of Medicine, The University of Sydney, Sydney 2006, Australia.
| | - Sailesh Mohan
- Public Health Foundation of India, New Delhi 110070, India.
| | - Kris Rogers
- The George Institute for Global Health, Box M201 Missenden Rd, Sydney 2006, Australia.
| | - Roopa Shivashankar
- Public Health Foundation of India, New Delhi 110070, India.
- Centre for Chronic Disease Control, New Delhi 122002, India.
| | | | - Priti Gupta
- Public Health Foundation of India, New Delhi 110070, India.
| | - Feng J He
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London EC1M 6BQ, UK.
| | - Graham A MacGregor
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London EC1M 6BQ, UK.
| | - Jacqui Webster
- The George Institute for Global Health, Box M201 Missenden Rd, Sydney 2006, Australia.
- School of Public Health, Department of Medicine, The University of Sydney, Sydney 2006, Australia.
| | - Anand Krishnan
- All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Pallab K Maulik
- George Institute for Global Health, Hyderabad 500034, India.
- George Institute for Global Health, University of Oxford, Oxford OX1 3PA, UK.
| | | | - Dorairaj Prabhakaran
- Public Health Foundation of India, New Delhi 110070, India.
- Centre for Chronic Disease Control, New Delhi 122002, India.
| | - Bruce Neal
- The George Institute for Global Health, Box M201 Missenden Rd, Sydney 2006, Australia.
- School of Public Health, Department of Medicine, The University of Sydney, Sydney 2006, Australia.
- Charles Perkins Centre, University of Sydney, Sydney 2050, Australia.
- School of Public Health, Imperial College, London SW7 2AZ, UK.
- Royal Prince Alfred Hospital, Sydney 2050, Australia.
| |
Collapse
|
5
|
Johnson C, Mohan S, Rogers K, Shivashankar R, Thout SR, Gupta P, He FJ, MacGregor GA, Webster J, Krishnan A, Maulik PK, Reddy KS, Prabhakaran D, Neal B. Mean Dietary Salt Intake in Urban and Rural Areas in India: A Population Survey of 1395 Persons. J Am Heart Assoc 2017; 6:e004547. [PMID: 28062480 PMCID: PMC5523637 DOI: 10.1161/jaha.116.004547] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/02/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The scientific evidence base in support of population-wide salt reduction is strong, but current high-quality data about salt intake levels in India are mostly absent. This project sought to estimate daily salt consumption levels in selected communities of Delhi and Haryana in north India and Andhra Pradesh in south India. METHODS AND RESULTS In this study, 24-hour urine samples were collected using an age- and sex-stratified sampling strategy in rural, urban, and slum areas. Salt intake estimates were made for the overall population of each region and for major subgroups by weighting the survey data for the populations of Delhi and Haryana, and Andhra Pradesh. Complete 24-hour urine samples were available for 637 participants from Delhi and Haryana and 758 from Andhra Pradesh (65% and 68% response rates, respectively). Weighted mean population 24-hour urine excretion of salt was 8.59 g/day (95% CI 7.68-9.51) in Delhi and Haryana and 9.46 g/day (95% CI 9.06-9.85) in Andhra Pradesh (P=0.097). Estimates inflated to account for the minimum likely nonurinary losses of sodium provided corresponding estimates of daily salt intake of 9.45 g/day (95% CI 8.45-10.46) and 10.41 g/day (95% CI 9.97-10.84), respectively. CONCLUSIONS Salt consumption in India is high, with mean population intake well above the World Health Organization recommended maximum of 5 g/day. A national salt reduction program would likely avert much premature death and disability.
Collapse
Affiliation(s)
- Claire Johnson
- The George Institute for Global Health, Sydney, Australia
- The University of Sydney, Australia
| | | | - Kris Rogers
- The George Institute for Global Health, Sydney, Australia
- The University of Sydney, Australia
| | - Roopa Shivashankar
- Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | | | - Priti Gupta
- Public Health Foundation of India, New Delhi, India
| | - Feng J He
- Wolfson Institute of Preventive Medicine Queen Mary University of London, United Kingdom
- Barts and the London School of Medicine & Dentistry Queen Mary University of London, United Kingdom
| | - Graham A MacGregor
- Wolfson Institute of Preventive Medicine Queen Mary University of London, United Kingdom
- Barts and the London School of Medicine & Dentistry Queen Mary University of London, United Kingdom
| | - Jacqui Webster
- The George Institute for Global Health, Sydney, Australia
- The University of Sydney, Australia
| | - Anand Krishnan
- All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Dorairaj Prabhakaran
- Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Bruce Neal
- The George Institute for Global Health, Sydney, Australia
- The University of Sydney, Australia
- Charles Perkins Centre, University of Sydney, Australia
- Imperial College, London, United Kingdom
- Royal Prince Alfred Hospital, Sydney, Australia
| |
Collapse
|
6
|
Okeahialam BN, Ogbonna C, Joseph DE, Chuhwak EK, Isiguzoro IO. Relationship of blood pressure with some cardiovascular disease risk factors in a rural population of Plateau State, North Central Nigeria. Niger Med J 2015; 56:208-12. [PMID: 26229231 PMCID: PMC4518339 DOI: 10.4103/0300-1652.160400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Hypertension is associated with certain cardiovascular disease (CVD) risk factors which vary from one place to the other depending on community sophistication. We decided to obtain the situation as it affects this rural Nigerian community to be in an evidence-based position to initiate individual and group prevention strategies. Design: Cross-sectional population survey. Materials and Methods: We surveyed for CVD risk factors among subjects 15 years and above in this rural community using a questionnaire requesting personal, medical and anthropometric information. One in three of them were randomly assigned to laboratory investigations. Results: Of the 840 subjects studied, 25% were males. The population mean age was 45.5 (18.2) standard deviation (SD), with 1.8% smokers and 4.1% using alcohol. Systolic blood pressure (SBP) correlated with age, body mass index (BMI), total cholesterol (TC) and uric acid (UA); while diastolic blood pressure (DBP) correlated with age, BMI, TC, UA and atherogenic index (AI). SBP and DBP improved with exercise but not salt intake. The local seasonings used in cooking had no impact on blood pressure. Conclusion: To reduce cardiovascular morbidity in this and probably other rural sub-Saharan African communities, BMI, TC, UA and salt intake in diet should be targeted for reduction. Physical activity should be encouraged. Interestingly, these fall into the sphere of healthy lifestyle which should be encouraged and re-inforced.
Collapse
Affiliation(s)
- Basil N Okeahialam
- Department of Medicine, Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Chikaike Ogbonna
- Department of Community Health, Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Dele E Joseph
- Department of Haematology, Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Evelyn K Chuhwak
- Department of Medicine, Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Ikechukwu O Isiguzoro
- Department of Medical Laboratory Science, Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| |
Collapse
|
7
|
Campbell N, Legowski B, Legetic B, Nilson E, L'Abbé M. Inaugural Maximum Values for Sodium in Processed Food Products in the Americas. J Clin Hypertens (Greenwich) 2015; 17:611-3. [PMID: 25903047 DOI: 10.1111/jch.12553] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/08/2015] [Indexed: 11/30/2022]
Abstract
Reducing dietary salt/sodium is one of the most cost-effective interventions to improve population health. There are five initiatives in the Americas that independently developed targets for reformulating foods to reduce salt/sodium content. Applying selection criteria, recommended by the Pan American Health Organization (PAHO)/World Health Organization (WHO) Technical Advisory Group on Dietary Salt/Sodium Reduction, a consortium of governments, civil society, and food companies (the Salt Smart Consortium) agreed to an inaugural set of regional maximum targets (upper limits) for salt/sodium levels for 11 food categories, to be achieved by December 2016. Ultimately, to substantively reduce dietary salt across whole populations, targets will be needed for the majority of processed and pre-prepared foods. Cardiovascular and hypertension organizations are encouraged to utilize the regional targets in advocacy and in monitoring and evaluation of progress by the food industry.
Collapse
Affiliation(s)
- Norm Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | | | - Branka Legetic
- Unit of Noncommunicable Diseases and Disability, Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization-World Health Organization, Washington, DC
| | | | - Mary L'Abbé
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
8
|
Progress on salt reduction in the Pacific Islands: from strategies to action. Heart Lung Circ 2014; 24:503-9. [PMID: 25577701 DOI: 10.1016/j.hlc.2014.11.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/25/2014] [Accepted: 11/27/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Most populations are consuming too much salt which is the main contributor of high blood pressure, a leading risk factor of cardiovascular disease and stroke. The South Pacific Office of the World Health Organization has been facilitating the development of salt reduction strategies in Pacific Island Countries and areas (PICs). The objective of this analysis was to review progress to date and identify regional actions needed to support PICs and ensure they achieve the global target to reduce population salt intake by 30% by 2025. METHODS Relevant available national food, health and non-communicable disease (NCD) plans from all 22 PICs were reviewed. NCD co-ordinators provided updates and relayed experiences through semi-structured interviews. All activities were systematically categorised according to an existing salt reduction framework for the development of salt reduction strategies. RESULTS Salt reduction consultations had been held in 14 countries and final strategies or action plans developed in nine of these, with drafts available in a further three. Three other countries had integrated salt reduction into NCD strategic plans. Baseline monitoring of salt intake had been undertaken in three countries, salt levels in foods in nine countries and salt knowledge, attitude and behaviour surveys in four countries. Most countries were at early stages of implementation and identified limited resources as a barrier to action. Planned salt reduction strategies included work with food industry or importers, implementing regional salt reduction targets, reducing salt levels in school and hospital meals, behaviour change campaigns, and monitoring and evaluation. CONCLUSIONS There had been good progress on salt reduction planning in PICs. The need for increased capacity to effectively implement agreed activities, supported by regional standards and the establishment of improved monitoring systems, were identified as important steps to ensure the potential cardiovascular health benefits of salt reduction could be fully realised in the region.
Collapse
|
9
|
Johnson C, Mohan S, Praveen D, Woodward M, Maulik PK, Shivashankar R, Amarchand R, Webster J, Dunford E, Thout SR, MacGregor G, He F, Reddy KS, Krishnan A, Prabhakaran D, Neal B. Protocol for developing the evidence base for a national salt reduction programme for India. BMJ Open 2014; 4:e006629. [PMID: 25344488 PMCID: PMC4212187 DOI: 10.1136/bmjopen-2014-006629] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 10/01/2014] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION The scientific evidence base in support of salt reduction is strong but the data required to translate these insights into reduced population salt intake are mostly absent. The aim of this research project is to develop the evidence base required to formulate and implement a national salt reduction programme for India. METHODS AND ANALYSIS The research will comprise three components: a stakeholder analysis involving government, industry, consumers and civil society organisations; a population survey using an age-stratified and sex-stratified random samples drawn from urban (slum and non-slum) and rural areas of North and South India; and a systematic quantitative evaluation of the nutritional components of processed and restaurant foods. The stakeholder interviews will be analysed using qualitative methods to summarise the main themes and define the broad range of factors influencing the food environment in India. The population survey will estimate the mean daily salt consumption through the collection of 24 h urine samples with concurrent dietary surveys identifying the main sources of dietary sodium/salt. The survey of foods will record the nutritional composition of the chief elements of food supply. The findings from this research will be synthesised and proposals for a national salt reduction strategy for India will be developed in collaboration with key stakeholders. ETHICS AND DISSEMINATION This study has been approved by the Human Research Ethics Committees of the University of Sydney and the Centre for Chronic Disease Control in New Delhi, and also by the Indian Health Ministry's Screening Committee. The project began fieldwork in February 2014 and will report the main results in 2016. The findings will be targeted primarily at public health policymakers and advocates, but will be disseminated widely through other mechanisms including conference presentations and peer-reviewed publications, as well as to the participating communities.
Collapse
Affiliation(s)
- Claire Johnson
- George Institute for Global Health, Oxford University, Oxford, UK
- University of Sydney, Sydney, Australia
| | | | - Deversetty Praveen
- George Institute for Global Health, Oxford University, Oxford, UK
- University of Sydney, Sydney, Australia
| | - Mark Woodward
- George Institute for Global Health, Oxford University, Oxford, UK
- University of Sydney, Sydney, Australia
| | - Pallab K Maulik
- George Institute for Global Health, Oxford University, Oxford, UK
| | - Roopa Shivashankar
- Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, Gurgaon, India
| | | | - Jacqui Webster
- George Institute for Global Health, Oxford University, Oxford, UK
| | | | - Sudhir Raj Thout
- George Institute for Global Health, Oxford University, Oxford, UK
| | | | - Feng He
- Wolfson Institute of Preventative Medicine, London, UK
| | | | - Anand Krishnan
- All India Institute of Medical Science, New Delhi, India
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, New Delhi, India
- Centre for Chronic Disease Control, Gurgaon, India
| | - Bruce Neal
- George Institute for Global Health, Oxford University, Oxford, UK
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Imperial College London, London, UK
| |
Collapse
|
10
|
Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods. Nutrients 2014; 6:3274-87. [PMID: 25195640 PMCID: PMC4145308 DOI: 10.3390/nu6083274] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/07/2014] [Accepted: 08/11/2014] [Indexed: 01/03/2023] Open
Abstract
Reducing population salt intake has been identified as a priority intervention to reduce non-communicable diseases. Member States of the World Health Organization have agreed to a global target of a 30% reduction in salt intake by 2025. In countries where most salt consumed is from processed foods, programs to engage the food industry to reduce salt in products are being developed. This paper provides a comprehensive overview of national initiatives to encourage the food industry to reduce salt. A systematic review of the literature was supplemented by key informant questionnaires to inform categorization of the initiatives. Fifty nine food industry salt reduction programs were identified. Thirty eight countries had targets for salt levels in foods and nine countries had introduced legislation for some products. South Africa and Argentina have both introduced legislation limiting salt levels across a broad range of foods. Seventeen countries reported reductions in salt levels in foods—the majority in bread. While these trends represent progress, many countries have yet to initiate work in this area, others are at early stages of implementation and further monitoring is required to assess progress towards achieving the global target.
Collapse
|
11
|
Woo KS, Kwok TCY, Celermajer DS. Vegan diet, subnormal vitamin B-12 status and cardiovascular health. Nutrients 2014; 6:3259-73. [PMID: 25195560 PMCID: PMC4145307 DOI: 10.3390/nu6083259] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/06/2014] [Accepted: 08/08/2014] [Indexed: 12/31/2022] Open
Abstract
Vegetarian diets have been associated with atherosclerosis protection, with healthier atherosclerosis risk profiles, as well as lower prevalence of, and mortality from, ischemic heart disease and stroke. However, there are few data concerning the possible cardiovascular effects of a vegan diet (with no meat, dairy or egg products). Vitamin B-12 deficiency is highly prevalent in vegetarians; this can be partially alleviated by taking dairy/egg products in lact-ovo-vegetarians. However, metabolic vitamin B-12 deficiency is highly prevalent in vegetarians in Australia, Germany, Italy and Austria, and in vegans (80%) in Hong Kong and India, where vegans rarely take vitamin B-12 fortified food or vitamin B-12 supplements. Similar deficiencies exist in northern Chinese rural communities consuming inadequate meat, egg or dairy products due to poverty or dietary habits. Vascular studies have demonstrated impaired arterial endothelial function and increased carotid intima-media thickness as atherosclerosis surrogates in such metabolic vitamin B-12 deficient populations, but not in lactovegetarians in China. Vitamin B-12 supplementation has a favourable impact on these vascular surrogates in Hong Kong vegans and in underprivileged communities in northern rural China. Regular monitoring of vitamin B-12 status is thus potentially beneficial for early detection and treatment of metabolic vitamin B-12 deficiency in vegans, and possibly for prevention of atherosclerosis-related diseases.
Collapse
Affiliation(s)
- Kam S Woo
- Room 186, Science Centre South Block, Biochemistry Programme, School of Life Sciences, The Chinese University of Hong Kong, Shatin NT, Hong Kong.
| | - Timothy C Y Kwok
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
| | - David S Celermajer
- Sydney Medical School, The University of Sydney, Sydney 2050, Australia.
| |
Collapse
|
12
|
Marakis G, Tsigarida E, Mila S, Panagiotakos DB. Knowledge, attitudes and behaviour of Greek adults towards salt consumption: a Hellenic Food Authority project. Public Health Nutr 2014; 17:1877-93. [PMID: 24171893 PMCID: PMC10282474 DOI: 10.1017/s1368980013002255] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 06/05/2013] [Accepted: 07/25/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To investigate the knowledge, attitudes and behaviour of Greek adults towards salt as well as their differences with respect to gender, age and level of education. DESIGN Cross-sectional, observational survey. SETTING Voluntary participation to a telephone interview, using a seventeen-item questionnaire. SUBJECTS Greek adults aged over 25 years (n 3609), nationally representative according to age, gender and geographical distribution of the Greek population, were interviewed. RESULTS More women of all age groups compared with men reported adding salt during cooking (P < 0·001), while less reported adding salt on the plate (P < 0·001). Also, more women believed that salt added during cooking was the main source of salt in the diet (P < 0·001). Participants aged 25-34, 35-44 and 45-54 years old had better knowledge of the harmful effects of salt on health compared with the 55+ years age group (P = 0·002, P = 0·001, P < 0·001, respectively); respondents in the aforementioned age groups also knew that children should consume less salt than adults compared with 55+ years age group (P = 0·004, P < 0·001, P < 0·001, respectively). Respondents with secondary and higher educational status were more likely to avoid consumption of processed foods (P < 0·001) and to check the nutrition information on food packaging as compared with respondents having basic education status (P < 0·001). CONCLUSIONS Awareness needs to be raised regarding salt recommendations for adults and children, sources of sodium in the diet and adding less salt during cooking, as well as reading food labels. Future campaigns for salt reduction should consider gender, age and level of education differences regarding knowledge, attitudes and behaviour towards salt.
Collapse
Affiliation(s)
- Georgios Marakis
- Hellenic Food Authority, Nutrition Policy and Research Directorate, 124 Kifisias Avenue and 2 Iatridou Street, Athens, TK 11526, Greece
| | - Eirini Tsigarida
- Hellenic Food Authority, Nutrition Policy and Research Directorate, 124 Kifisias Avenue and 2 Iatridou Street, Athens, TK 11526, Greece
| | - Spyridoula Mila
- Hellenic Food Authority, Nutrition Policy and Research Directorate, 124 Kifisias Avenue and 2 Iatridou Street, Athens, TK 11526, Greece
| | | |
Collapse
|
13
|
Campbell N, Legowski B, Legetic B, Ferrante D, Nilson E, Campbell C, L'Abbé M. Targets and Timelines for Reducing Salt in Processed Food in the Americas. J Clin Hypertens (Greenwich) 2014; 16:619-23. [DOI: 10.1111/jch.12379] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 06/30/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Norm Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences and Libin Cardiovascular Institute of Alberta; University of Calgary; Calgary AB Canada
| | - Barbara Legowski
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences and Libin Cardiovascular Institute of Alberta; University of Calgary; Ottawa ON Canada
| | - Branka Legetic
- Unit of Noncommunicable Diseases and Disability; Department of Noncommunicable Diseases and Mental Health; Pan American Health Organization-World Health Organization; Washington DC
| | | | | | | | - Mary L'Abbé
- Department of Nutritional Sciences; Faculty of Medicine; University of Toronto; Toronto ON Canada
| |
Collapse
|
14
|
Trevena H, Dunford E, Neal B, Webster J. The Australian Food and Health Dialogue - the implications of the sodium recommendation for pasta sauces. Public Health Nutr 2014; 17:1647-53. [PMID: 23830096 PMCID: PMC10282366 DOI: 10.1017/s1368980013001791] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Revised: 05/12/2013] [Accepted: 05/29/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the change in Na content of Australian pasta sauces between 2008 and 2011. A secondary objective was to project the mean Na content of these same products in 2014 using the Australian Food and Health Dialogue Na commitment and compare projections with the 2012 UK Na target for pasta sauce. DESIGN Na data were collected from the product labels of pasta sauce products. Mean Na content was calculated for 2008 and 2011 and change assessed. Projected mean values for 2014 were derived by applying a 15 % reduction to the 2011 products above the 'action point' of 420 mg Na/100 g, consistent with the Food and Health Dialogue commitment (scenario 1). A 15 % reduction was applied to products already below the 'action point' (scenario 2). Projections were compared with the 2012 UK target. SETTING Na data for pasta sauce products in Australian supermarkets (July-September) in 2008 and 2011. SUBJECTS Not applicable. RESULTS Data were available for 124 (2008) and 187 (2011) products, and mean Na levels were not significantly different (451 mg/100 g v. 423 mg/100 g; P = 0·16). The projected means (381 mg Na/100 g in scenario 1; 375 mg Na/100 g in scenario 2) exceeded the 2012 UK target (330 mg Na/100 g) and to attain this would require a 22 % reduction from 2011 levels. CONCLUSIONS There is little evidence that all Australian manufacturers of pasta sauces systematically reduced the Na content of their products between 2008 and 2011. Even if all manufacturers achieve the current voluntary commitment by 2014, average salt levels in Australian products would still be above the 2012 UK target.
Collapse
Affiliation(s)
- Helen Trevena
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia
- School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Victoria, Australia
| | - Elizabeth Dunford
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia
| | - Jacqueline Webster
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia
| |
Collapse
|
15
|
Webster J, Snowdon W, Moodie M, Viali S, Schultz J, Bell C, Land MA, Downs S, Christoforou A, Dunford E, Barzi F, Woodward M, Neal B. Cost-effectiveness of reducing salt intake in the Pacific Islands: protocol for a before and after intervention study. BMC Public Health 2014; 14:107. [PMID: 24495646 PMCID: PMC3933378 DOI: 10.1186/1471-2458-14-107] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 01/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is broad consensus that diets high in salt are bad for health and that reducing salt intake is a cost-effective strategy for preventing chronic diseases. The World Health Organization has been supporting the development of salt reduction strategies in the Pacific Islands where salt intakes are thought to be high. However, there are no accurate measures of salt intake in these countries. The aims of this project are to establish baseline levels of salt intake in two Pacific Island countries, implement multi-pronged, cross-sectoral salt reduction programs in both, and determine the effects and cost-effectiveness of the intervention strategies. METHODS/DESIGN Intervention effectiveness will be assessed from cross-sectional surveys before and after population-based salt reduction interventions in Fiji and Samoa. Baseline surveys began in July 2012 and follow-up surveys will be completed by July 2015 after a 2-year intervention period.A three-stage stratified cluster random sampling strategy will be used for the population surveys, building on existing government surveys in each country. Data on salt intake, salt levels in foods and sources of dietary salt measured at baseline will be combined with an in-depth qualitative analysis of stakeholder views to develop and implement targeted interventions to reduce salt intake. DISCUSSION Salt reduction is a global priority and all Member States of the World Health Organization have agreed on a target to reduce salt intake by 30% by 2025, as part of the global action plan to reduce the burden of non-communicable diseases. The study described by this protocol will be the first to provide a robust assessment of salt intake and the impact of salt reduction interventions in the Pacific Islands. As such, it will inform the development of strategies for other Pacific Island countries and comparable low and middle-income settings around the world.
Collapse
Affiliation(s)
- Jacqui Webster
- George Institute for Global Health, (affiliated with the University of Sydney), Level 10, King George V Building, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales 2050, Australia.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Webster J, Dunford E, Kennington S, Neal B, Chapman S. Drop the Salt! Assessing the impact of a public health advocacy strategy on Australian government policy on salt. Public Health Nutr 2014; 17:212-8. [PMID: 23171657 PMCID: PMC10282269 DOI: 10.1017/s1368980012004806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 07/23/2012] [Accepted: 09/03/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In 2007 the Australian Division of World Action on Salt and Health (AWASH) launched a campaign to encourage the Australian government to take action to reduce population salt intake. The objective of the present research was to assess the impact of the Drop the Salt! campaign on government policy. DESIGN A review of government activities related to salt reduction was conducted and an advocacy strategy implemented to increase government action on salt. Advocacy actions were documented and the resulting outcomes identified. An analysis of stakeholder views on the effectiveness of the advocacy strategy was also undertaken. Settings Advocacy activities were coordinated through AWASH at the George Institute for Global Health in Sydney. SUBJECTS All relevant State and Federal government statements and actions were reviewed and thirteen stakeholders with known interests or responsibilities regarding dietary salt, including food industry, government and health organisations, were interviewed. RESULTS Stakeholder analysis affirmed that AWASH influenced the government's agenda on salt reduction and four key outputs were attributed to the campaign: (i) the Food Regulation Standing Committee discussions on salt, (ii) the Food and Health Dialogue salt targets, (iii) National Health and Medical Research Council partnership funding and (iv) the New South Wales Premier's Forum on Fast Foods. CONCLUSIONS While it is not possible to definitively attribute changes in government policy to one organisation, stakeholder research indicated that the AWASH campaign increased the priority of salt reduction on the government's agenda. However, a coordinated government strategy on salt reduction is still required to ensure that the potential health benefits are fully realised.
Collapse
Affiliation(s)
- Jacqui Webster
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Elizabeth Dunford
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Kennington
- Independent Consultant, Sydney, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon Chapman
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
17
|
Bonita R, Magnusson R, Bovet P, Zhao D, Malta DC, Geneau R, Suh I, Thankappan KR, McKee M, Hospedales J, de Courten M, Capewell S, Beaglehole R. Country actions to meet UN commitments on non-communicable diseases: a stepwise approach. Lancet 2013; 381:575-84. [PMID: 23410607 DOI: 10.1016/s0140-6736(12)61993-x] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Strong leadership from heads of state is needed to meet national commitments to the UN political declaration on non-communicable diseases (NCDs) and to achieve the goal of a 25% reduction in premature NCD mortality by 2025 (the 25 by 25 goal). A simple, phased, national response to the political declaration is suggested, with three key steps: planning, implementation, and accountability. Planning entails mobilisation of a multisectoral response to develop and support the national action plan, and to build human, financial, and regulatory capacity for change. Implementation of a few priority and feasible cost-effective interventions for the prevention and treatment of NCDs will achieve the 25 by 25 goal and will need only few additional financial resources. Accountability incorporates three dimensions: monitoring of progress, reviewing of progress, and appropriate responses to accelerate progress. A national NCD commission or equivalent, which is independent of government, is needed to ensure that all relevant stakeholders are held accountable for the UN commitments to NCDs.
Collapse
Affiliation(s)
- Ruth Bonita
- University of Auckland, Auckland, New Zealand.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
There is overwhelming evidence that a reduction in salt intake from the current level of approximately 9-12 g/d in most countries of the world to the recommended level of 5-6 g/d lowers blood pressure (BP) in both hypertensive and normotensive individuals. A further reduction to 3-4 g/d has a greater effect. Prospective studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of cardiovascular disease. Cost-effectiveness analyses have documented that salt reduction is more or at the very least just as cost-effective as tobacco control in reducing cardiovascular disease, the leading cause of death and disability worldwide. The mechanisms whereby salt raises blood pressure and increases cardiovascular risk are not fully understood. The existing concepts focus on the tendency for an increase in extracellular fluid volume. Increasing evidence suggests that small increases in plasma sodium may have a direct effect on BP and the cardiovascular system, independent of extracellular volume. All countries should adopt a coherent and workable strategy to reduce salt intake in the whole population. Even a modest reduction in population salt intake will have major beneficial effects on health, along with major cost savings.
Collapse
Affiliation(s)
- Feng J He
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, UK.
| | | |
Collapse
|
19
|
Dunford EK, Eyles H, Mhurchu CN, Webster JL, Neal BC. Changes in the sodium content of bread in Australia and New Zealand between 2007 and 2010: implications for policy. Med J Aust 2011; 195:346-9. [PMID: 21929500 DOI: 10.5694/mja11.10673] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To define the effectiveness of recent efforts by the Australian Division of World Action on Salt and Health, and the Heart Foundation in New Zealand to reduce sodium levels in breads in Australia and New Zealand. DESIGN AND SETTING Data on the sodium contents of packaged sliced bread products sold in Australian and New Zealand supermarkets were collected from the product labels of 157 breads in 2007 and 167 breads in 2010, and were compared overall, by bread type, by manufacturer, and between nations. MAIN OUTCOME MEASURES Mean sodium values in bread and proportions of breads meeting the targets of 400 mg/100 g in Australia and 450 mg/100 g in New Zealand. RESULTS Overall mean sodium content in bread in Australia was 434 mg/100 g in 2007 and 435 mg/100 g in 2010; corresponding values for New Zealand were 469 mg/100 g and 439 mg/100 g. The proportion of Australian breads meeting the national target increased from 29% in 2007 to 50% in 2010; the proportion of New Zealand breads meeting the national target increased from 49% in 2007 to 90% in 2010. There were clear differences between the results achieved by different companies. CONCLUSIONS Voluntary efforts by non-governmental organisations have had some impact on sodium levels in bread, particularly in New Zealand. However, substantial room for further improvement remains. If additional reductions are not achieved under the current voluntary arrangements, legislated approaches may be required.
Collapse
|