Estimated dietary sodium intake in Thailand: A nationwide population survey with 24-hour urine collections

Health literacy and high blood pressure among Myanmar migrant workers in Northeastern Thailand

Hypertension, related to serious consequences unless diagnosed and treated, is a global concern, also affecting migrant workers. Due to the high prevalence of hypertension among migrant workers in Thailand, the influences of health literacy and other factors on blood pressure were needed to explore among Myanmar migrant workers in Northeastern Thailand. Hence, this study aimed to identify the prevalence of high blood pressure (HBP), its association with health literacy and other factors among Myanmar migrant workers in Northeastern Thailand. A cross-sectional analytical study was conducted in Northeastern Thailand. A multistage sampling procedure was applied. Data was gathered through interviews utilizing validated and reliable structured questionnaire. Descriptive statistics and inferential statistics with multiple logistic regression were used. Among 406 participants, about 60% were male and about 70% of them were married. The prevalence of overall HBP was 63.3% (95% CI: 58.49-67.86), 52% in females and 71.86% in males. Participants with limited health literacy were 79% more likely to have HBP than those with excellent and adequate health literacy (AOR = 1.79, 95% CI: 1.13-2.84). Other factors substantially linked with having HBP were being male gender (AOR = 4.68, 95% CI: 2.81-7.78), being overweight (AOR = 2.23, 95% CI: 1.18-4.23), being obese (AOR = 5.69, 95% CI: 2.96-10.96), not having health insurance (AOR = 2.01, 95% CI: 1.11-3.66), staying in Thailand for more than 48 months (AOR = 2.4, 95% CI: 1.48-3.9), and having family history of hypertension (AOR = 2.07, 95% CI: 1.28-3.35). In conclusion, more than half of Myanmar migrant workers had HBP. Factors associated with HBP were limited health literacy, male gender, overnutrition, lack of health insurance, longer duration of stay in Thailand and having family history of hypertension. Therefore, there is a need for a multifaceted strategy to prevent hypertension and its consequences by promoting health literacy as well as by enhancing good behavioural practice among this community.

How an agreement with restriction of unhealthy food marketing and sodium taxation influenced high fat, salt or sugar (HFSS) food consumption

BACKGROUND

Food taxation and food marketing policy are very cost-effectiveness to improve healthy diets among children. The objective of this study was to investigate the socio-demographic characteristics of Thais and attitude towards on policy unhealthy food marketing restriction and sodium taxation which influence high fat, sodium, and sugar (FHSS) food eating.

METHODS

The data were obtained from the 2021 Health Behavior of Population Survey, four-stage sampling method of the Thai people, aged 15 years and above, using a offline survey application-assisted face-to-face interview. Logistic Regression were used to analyze the explanatory variables on agreement and HFSS food intake.

RESULTS

Almost half (48.4%) of samples disagreed with sodium taxation, and 42.7% of the samples disagreed with food marketing restriction. Most (99.6%) of Thai respondents consumed HFSS food, including sugar sweetened beverages (SSB). Gender, age, education, income, BMI, and health status were associated with agreement with food marketing restriction policy and sodium taxation policy. There is no association between agreement with policy on sodium taxation and food marketing and HFSS food consumption.

CONCLUSION

Nearly half of Thais indicated that they disagreed with policy on food marketing restriction and sodium taxation. Therefore, understanding and awareness of the two policies among Thais should be further investigated in order to develop better policy communication for increased public understanding and engagement.

Characteristics and clinical outcomes of people with hypertension receiving continuous care in Thailand: a cross-sectional study

Background

Hypertension (HT) is a major global health concern, including in Thailand. The present study aimed to identify the characteristics and clinical outcomes of people with HT receiving continuous care in Thailand in 2018.

Methods

We conducted a nationwide cross-sectional study in 2018. People with HT aged 20 years and older receiving medical care at outpatient clinics in the targeted hospitals for at least 12 months were included.

Findings

A total of 36,557 people with HT nationwide were enrolled in the current study. 61.5% of the participants were women, and the average age of the participants was 64.7 years. Most participants (53.3%) required two or more antihypertensive medications to control blood pressure (BP). The overall prevalence of BP control (systolic BP, <140 mmHg; diastolic BP, <90 mmHg) was 66.6% and 49.4% at the latest visit and the latest two consecutive times, respectively. BP control rate was lower for people with HT residing in the southern region compared to other regions. The prevalence of achieving the target goal of LDL cholesterol level (<100 mg/dL) was 39.9%, and that of BMI ≥ 25 kg/m2 was 47.6%. Only 15.2% of participants received a 12-lead electrocardiogram (ECG) screening; among them, 2.8% had atrial fibrillation and 2.2% had left ventricular hypertrophy. The prevalence of the history of cerebrovascular, cardiovascular, and renal complications was 4.2%, 4.3%, and 13.1%, respectively, among people with HT.

Interpretation

The findings indicated a potential for further improvement in the quality of HT care in Thailand. Accessibility to continuous care among males with HT requires additional responsiveness. BP control rate should be enhanced, especially in the southern region. A coverage of 12-lead ECG screening in people with HT should be increased. Weight management and reduction of LDL cholesterol levels should be encouraged to prevent cardiovascular complications.

Funding

National Health Security Office (NHSO) in Thailand.

Estimation of 24-hour urinary sodium and potassium excretion among Chinese adults: a cross-sectional study from the China National Nutrition Survey

BACKGROUND

High-sodium intake is one of the most important risk factors for hypertension and cardiovascular disease, yet reliable national estimates of sodium intake in Chinese adults have not been reported.

OBJECTIVES

We estimated 24-h urinary sodium and potassium excretion and population daily sodium and potassium intake of Chinese adults for the first time at a national level.

METHODS

A nationally representative cross-sectional survey was conducted to collect 24-h urine specimens from Chinese adults aged ≥18 y as part of the China National Nutrition Survey 2015. Finally, 10,114 participants (4932 males and 5182 females) with complete 24-h urine specimens were included in the analysis. Estimates of mean urinary electrolyte excretion and demographic, socioeconomic, and health characteristics were used with weighted coefficients that accounted for sample selection probabilities, poststratification weighting, and nonresponse rates.

RESULTS

The estimation of overall weighted mean 24-h urinary sodium excretion was 4121 mg (95% confidence interval [CI]: 3993, 4250), 4155 mg (95% CI: 3993, 4317) in males and 4081 mg (95% CI: 3953, 4209) in females (P for sex difference = 0.36). Overall mean 24-h urinary potassium excretion was 1534 mg (95% CI: 1492, 1577), 1468 mg (95% CI: 1424, 1513) in males and 1614 mg (95% CI: 1569-1660) in females (P for sex difference <0.001). Mean 24-h urinary sodium excretion was significantly higher in rural adults (4350 mg; 95% CI: 4217, 4483) than in urban residents (3909 mg; 95% CI: 3739, 4080; P < 0.001), and in northern residents (4388 mg; 95% CI: 4237, 4539) than in southern residents (3998 mg; 95% CI: 3832, 4163; P = 0.002).

CONCLUSIONS

The first nationwide survey with 24-h urine collection confirmed that mean sodium intake in Chinese adults was more than twice the upper limit, whereas mean potassium intake was <60% of the lower limit, recommended by the World Health Organization. Urgent measures should be taken to reduce sodium intake and increase potassium intake in China.

Choosing an effective food classification system for promoting healthy diets in Thailand: a comparative evaluation of three nutrient profiling-based food classification systems (government, WHO, and Healthier Choice Logo) and a food-processing-based food classification system (NOVA)

Introduction

This study aimed to assess the nutritional quality of food and beverage products in Thailand by comparing four different food classification systems: the nutrient profiling-based food classification systems by the Department of Health (DOH), the WHO South-East Asia Region (WHO SEA), the Healthier Choice Logo (HCL), and the food-processing-based food classification system, NOVA.

Methods

This study used secondary data from the Mintel Global New Products Database (N = 17,414). Food subgroups were classified differently based on these four systems. The DOH classified food products into three groups: Group A-healthy pass or meeting standard, Group B-not meeting the standard, and Group C-far below standard. The WHO SEA classified food products into two groups: marketing prohibited products and marketing permitted products. The HCL classified food products into two groups: eligible products for the logo; and ineligible products for the logo. The NOVA classified food products into four groups: unprocessed or minimally processed foods (MP), processed culinary ingredients (PCI), processed foods (P), and ultra-processed foods (UPF). Descriptive statistics (percentage and frequency) were used for analysis. Agreement analysis was conducted using Cohen's kappa statistic between each pair of food classification systems.

Results

Of the total sample that could be classified by any of the four classification systems (n = 10,486), the DOH, the WHO SEA and the HCL systems classified products as healthy (Group A, marketing permitted or eligible for HCL logo) at 10.4, 11.1, and 10.9%, respectively. Only 5.6% were classified as minimally processed foods using NOVA and 83.1% were ultra-processed foods (UPFs). Over 50% of products classified as healthy by the nutrient profiling systems were classified as UPF according to the NOVA system. Products that were eligible for the HCL had the highest proportion of UPF products (84.4%), followed by the Group A products (69.2%) and the WHO marketing-permitted products (65.0%).

Conclusion

A hybrid food classification approach taking both nutrients and food processing into account is needed to comprehensively assess the nutritional quality of food and beverage products in Thailand.

Availability and Price of Low-Sodium Condiments and Instant Noodles in the Bangkok Metropolitan Region

INTRODUCTION

Excess sodium consumption can cause hypertension. One component of Thailand's 5-part strategy to reduce sodium intake is reform of the food environment to increase access to low-sodium foods. Our research aimed to describe the availability and price of low-sodium food products in retail stores in the Bangkok Metropolitan Region.

METHODS

In June and July 2021, we used multistage cluster sampling to conduct a cross-sectional study of the availability of low-sodium foods. Availability referred to a retail store offering at least 1 version of low-sodium condiment or instant noodles. We applied the Thai Healthier Choice criteria and World Health Organization (WHO) global benchmark as the low-sodium criteria for these products. We surveyed 248 retail stores in 30 communities in 6 districts in the Bangkok Metropolitan Region. We observed store shelf availability and price by using a survey form and used the Fisher exact test and independent t test to compare availability and price by sodium content and store size.

RESULTS

All subcategories of low-sodium condiments, except black soy sauce in small stores, were less available than regular-sodium condiments. The proportional difference ranged from 11.3% to 90.6% (P < .001). We found no difference in the 4 condiment subcategories, including fish sauce, thin soy sauce, seasoning sauce, and oyster sauce in large stores. Low-sodium versions of instant noodles were unavailable in either large or small stores. The price of low-sodium condiments was 2 to 3 times higher than that of regular-sodium condiments (P < .05).

CONCLUSION

Low-sodium food options are not generally available in the Bangkok Metropolitan Region, and access to them is inequitable because of pricing. Instant noodles, a popular food, were unavailable in low-sodium versions. Their reformulation should be promoted. Government subsidies of the price of commonly used low-sodium condiments could increase their use and reduce sodium consumption overall.

Nutritional Content of Popular Menu Items from Online Food Delivery Applications in Bangkok, Thailand: Are They Healthy?

The rise in online food delivery (OFD) applications has increased access to a myriad of ready-to-eat options, which may lead to unhealthier food choices. Our objective was to assess the nutritional profile of popular menu items available through OFD applications in Bangkok, Thailand. We selected the top 40 popular menu items from three of the most commonly used OFD applications in 2021. Each menu item was collected from the top 15 restaurants in Bangkok for a total of 600 items. Nutritional contents were analysed by a professional food laboratory in Bangkok. Descriptive statistics were employed to describe the nutritional content of each menu item, including energy, fat, sodium, and sugar content. We also compared nutritional content to the World Health Organization's recommended daily intake values. The majority of menu items were considered unhealthy, with 23 of the 25 ready-to-eat menu items containing more than the recommended sodium intake for adults. Eighty percent of all sweets contained approximately 1.5 times more sugar than the daily recommendation. Displaying nutrition facts in the OFD applications for menu items and providing consumers with filters for healthier options are required to reduce overconsumption and improve consumer food choice.

Food Choices and Hypertension Among Rural Thais: Evidence From a Discrete Choice Experiment

Objective: The rural northern region of Thailand exhibits the highest rate of hypertension. This study explored hypertensive-related food choices between normotensive and hypertensive people residing in rural northern Thailand to determine which food attributes influence their choices.

Methods: The study conducted a discrete choice experiment (DCE) survey among Thai adults residing in rural northern Thailand (n = 403) to estimate the relative importance of four food attributes, including food preparation, price, taste, and amount of salt. A mixed logit model was used to analyze the data from the DCE.

Results: The first and second most important attributes in both hypertensive and normotensive groups were the amount of salt and food preparation at home, respectively, followed by price and taste. Specifically, the normotensive group was more attentive to the amount of salt in their food than their hypertensive counterparts.

Conclusion: Intervention programs in rural communities may benefit from focusing their attention on embracing low-salt cultural foods and providing guidance on how to add flavor without additional salt or reduce high sodium seasonings without losing flavor when cooking.

Estimation of sodium consumption by novel formulas derived from random spot and 12-hour urine collection

The gold standard for estimating sodium intake is 24h urine sodium excretion. Several equations have been used to estimate 24h urine sodium excretion, however, a validated formula for calculating 24h urine sodium excretion from 12h urine collection has not yet been established. This study aims to develop novel equations for estimating 24h urine sodium excretion from 12h and random spot urine collection and also to validate existing spot urine equations in the Thai population. A cross-sectional survey was carried out among 209 adult hospital personnel. Participants were asked to perform a 12h daytime, 12h nighttime, and a random spot urine collection over a period of 24 hours. The mean 24h urine sodium excretion was 4,055±1,712 mg/day. Estimated urine sodium excretion from 3 different equations using random spot urine collection showed moderate correlation and agreement with actual 24h urine sodium excretion (r = 0.54, P<0.001, ICC = 0.53 for Kawasaki; r = 0.57, P<0.001, ICC = 0.44 for Tanaka; r = 0.60, P<0.001, ICC = 0.45 for INTERSALT). Novel equations for predicting 24h urine sodium excretion were then developed using variables derived from 12h daytime urine collection, 12h nighttime urine collection, random spot urine collection, 12h daytime with random spot urine collection, and 12h nighttime with random spot urine collection which showed strong correlation and agreement with actual measured values (r = 0.88, P<0.001, ICC = 0.87; r = 0.83, P<0.001, ICC = 0.81; r = 0.67, P<0.001, ICC = 0.62; r = 0.90, P<0.001, ICC = 0.90; and r = 0.83, p<0.001, ICC = 0.82 respectively). Bland-Altman plots indicated good agreement between predicted values and actual 24h urine sodium excretion using the new equations. Newly derived equations from 12h daytime and 12h nighttime urine collection with or without casual spot urine collection were able to accurately predict 24h urine sodium excretion.

Impact of self-monitoring of salt intake by salt meter in hypertensive patients: A randomized controlled trial (SMAL-SALT)

Salt intake over reference level would result in elevated blood pressure (BP) and long‐term morbidity. Salt meter is a device used to detect sodium content in daily food. This study aimed to evaluate the efficacy of salt‐meter addition to dietary education. The authors conducted a randomized‐controlled trial in hypertensive patients with uncontrolled BP (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg). Patients were randomized to receive salt meter plus dietary education (group A) or education only (group B), and followed up for 8 weeks. The primary endpoint was change in 24‐h urinary sodium excretion. Changes in BP, salt taste sensitivity, cardio‐ankle vascular index (CAVI) were also analyzed. There were total number of 90 patients who had complete follow‐up, 45 in each group. Mean age was 62.9 years and 53% were females. Mean baseline 24‐h urine sodium was 151.6 mmol/24 h and mean SBP and DBP were 152.8 and 83.4 mmHg, respectively. Baseline characteristics were similar between two groups. At 8 weeks, mean change in urine sodium were –31.83 mmol/24 h and 0.36 mmol/24 h in group A and group B, respectively (p = .006). Mean decrease in BP were SBP, 14.44 versus 8.22 mmHg (p = .030), and DBP 5.53 versus 1.93 mmHg (p = .032). The salt sensitivity was improved more in group A. There was no different between change in CAVI. From this study, salt meter in conjunction with dietary education, for self‐monitoring of salt intake is superior to education alone in hypertensive patients, and provided better blood pressure control. Salt meter should be considered in uncontrolled hypertensive patients.