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Yin X, Tian M, Sun L, Webster J, Trieu K, Huffman MD, Miranda JJ, Marklund M, Wu JHY, Cobb LK, Chu H, Pearson SA, Neal B, Liu H. Barriers and Facilitators to Implementing Reduced-Sodium Salts as a Population-Level Intervention: A Qualitative Study. Nutrients 2021; 13:nu13093225. [PMID: 34579109 PMCID: PMC8471368 DOI: 10.3390/nu13093225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/06/2021] [Accepted: 09/13/2021] [Indexed: 11/16/2022] Open
Abstract
Widespread use of reduced-sodium salts can potentially lower excessive population-level dietary sodium intake. This study aimed to identify key barriers and facilitators to implementing reduced-sodium salt as a population level intervention. Semi-structured interviews were conducted with key informants from academia, the salt manufacturing industry, and government. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to inform our interview guides and data analysis. Eighteen key informants from nine countries across five World Health Organization regions participated in the study from January 2020 to July 2020. Participants were concerned about the lack of robust evidence on safety for specific populations such as those with renal impairment. Taste and price compared to regular salt and an understanding of the potential health benefits of reduced-sodium salt were identified as critical factors influencing the adoption of reduced-sodium salts. Higher production costs, low profit return, and reduced market demand for reduced-sodium salts were key barriers for industry in implementation. Participants provided recommendations as potential strategies to enhance the uptake. There are presently substantial barriers to the widespread use of reduced-sodium salt but there are also clear opportunities to take actions that would increase uptake.
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Affiliation(s)
- Xuejun Yin
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
- The George Institute for Global Health, Peking University Health Science Center, Beijing 100600, China;
- School of Public Health, Harbin Medical University, Harbin 150081, China
- Correspondence: ; Tel.: +86-(0)451-8750-2881
| | - Lingli Sun
- The George Institute for Global Health, Peking University Health Science Center, Beijing 100600, China;
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
| | - Mark D. Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - J. Jaime Miranda
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima 15074, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima 15074, Peru
| | - Matti Marklund
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Department of Public Health and Caring Sciences, Uppsala University, 75236 Uppsala, Sweden
| | - Jason H. Y. Wu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
| | - Laura K. Cobb
- Resolve to Save Lives, an Initiative of Vital Strategies, New York, NY 10005, USA;
| | - Hongling Chu
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100083, China;
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW 2052, Australia;
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
- School of Public Health, Imperial College London, London SW7 2BX, UK
| | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2050, Australia; (X.Y.); (J.W.); (K.T.); (M.D.H.); (J.J.M.); (M.M.); (J.H.Y.W.); (B.N.); (H.L.)
- Sydney Institute for Women, Children and Their Families, Sydney Local Health District, Sydney, NSW 2050, Australia
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Yin X, Liu H, Webster J, Trieu K, Huffman MD, Miranda JJ, Marklund M, Wu JHY, Cobb LK, Li KC, Pearson SA, Neal B, Tian M. Availability, Formulation, Labeling, and Price of Low-sodium Salt Worldwide: Environmental Scan. JMIR Public Health Surveill 2021; 7:e27423. [PMID: 33985938 PMCID: PMC8319774 DOI: 10.2196/27423] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/19/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background Regular salt is about 100% sodium chloride. Low-sodium salts have reduced sodium chloride content, most commonly through substitution with potassium chloride. Low-sodium salts have a potential role in reducing the population's sodium intake levels and blood pressure, but their availability in the global market is unknown. Objective The aim of this study is to assess the availability, formulation, labeling, and price of low-sodium salts currently available to consumers worldwide. Methods Low-sodium salts were identified through a systematic literature review, Google search, online shopping site searches, and inquiry of key informants. The keywords “salt substitute,” “low-sodium salt,” “potassium salt,” “mineral salt,” and “sodium reduced salt” in six official languages of the United Nations were used for the search. Information about the brand, formula, labeling, and price was extracted and analyzed. Results A total of 87 low-sodium salts were available in 47 out of 195 (24%) countries worldwide, including 28 high-income countries, 13 upper-middle-income countries, and 6 lower-middle-income countries. The proportion of sodium chloride varied from 0% (sodium-free) to 88% (as percent of weight; regular salt is 100% sodium chloride). Potassium chloride was the most frequent component with levels ranging from 0% to 100% (potassium chloride salt). A total of 43 (49%) low-sodium salts had labels with the potential health risks, and 33 (38%) had labels with the potential health benefits. The median price of low-sodium salts in high-income, upper-middle-income, and lower-middle-income countries was US $15.00/kg (IQR 6.4-22.5), US $2.70/kg (IQR 1.7-5.5), and US $2.90/kg (IQR 0.50-22.2), respectively. The price of low-sodium salts was between 1.1 and 14.6 times that of regular salts. Conclusions Low-sodium salts are not widely available and are commonly more expensive than regular salts. Policies that promote the availability, affordability, and labeling of low-sodium salts should increase uptake, helping populations reduce blood pressure and prevent cardiovascular diseases. International Registered Report Identifier (IRRID) RR2-10.1111/jch.14054
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Affiliation(s)
- Xuejun Yin
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark D Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Feinberg School of Medicine, Northwestern University, Evanston, IL, United States
| | - J Jaime Miranda
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Matti Marklund
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.,Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Jason H Y Wu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laura K Cobb
- Resolve to Save Lives, Initiative of Vital Strategies, New York City, NY, United States
| | - Ka Chun Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,School of Public Health, Imperial College London, London, United Kingdom
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,The George Institute for Global Health at Peking University Health Science Center, Beijing, China
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