Salt (sodium chloride) content of retail samples of Nigerian white bread: implications for the daily salt intake of normotensive and hypertensive adults

Stakeholder perspectives on Nigeria's national sodium reduction program: Lessons for implementation and scale-up

BACKGROUND

To reduce excess dietary sodium consumption, Nigeria's 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders' knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions.

METHODS

From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions.

RESULTS

Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum.

CONCLUSION

We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.

Salt Intake from Traditional Breads: A Public Health Challenge for Decreasing Non-communicable Diseases in Iran

Background:

In recent decades, a decrease of sodium chloride (NaCl) salt in diets such as breads has raised public attention for control of non-communicable diseases (NCDs) in developed and developing countries. Bread is an important food in public diets in Iran as well as many other countries.

Aim:

The aim of this study was to assess salt (NaCl) content of the Iranian traditional breads and to estimate daily salt intake through consumption of these foodstuffs. The study was carried out in five major cities of Iran in 2016.

Methods:

In total, 237 traditional bread samples (including Sangak, Taftoon, Lavash and Barbari) were collected and the sample NaCl content was assessed using published methods by the International Organization for Standardization (ISO) and Association of Official Analytical Chemists (AOAC). Values were compared to Iranian standard limit values.

Results:

Salt content of the traditional breads ranged from 0.03 g to 2.99 g per 100 g of dry weight (D.W.). Overall, 49.2% of the traditional bread samples in Tehran and 47.2% of the traditional bread samples in other cities exceeded the standard limit. Since 93.8% of Sangak breads from Tehran met the salt limit criteria of national standards, this traditional bread includes a more favorable nutritional status compared to that other breads do.

Conclusion:

Awareness of salt level in breads and monitoring salt use in bakeries can help update food policies and improve public lifestyle. A decrease in the ratio of salt is recommended as the major nutritional intervention for the prevention and control of NCDs.

Salt and potassium intake among adult Ghanaians: WHO-SAGE Ghana Wave 3

Though Ghana has high hypertension prevalence, the country lacks current national salt consumption data required to build and enhance advocacy for salt reduction. We explored the characteristics of a randomly selected sub sample that had valid urine collection, along with matched survey, anthropometric and BP data (n = 839, mean age = 60y), from the World Health Organization's Study on global AGEing and adult health (WHO-SAGE), Ghana Wave 3, n = 3053). We also investigated the relationship between salt intake and blood pressure (BP) among the cohort. BP was measured in triplicate and 24 h urine was collected for the determination of urinary sodium (Na), potassium (K), creatinine (Cr) and iodine levels. Hypertension prevalence was 44.3%. Median salt intake was 8.3 g/day, higher in women compared to men (8.6, interquartile range (IQR) 7.5 g/day vs 7.5, IQR 7.4 g/day, p <  0.01), younger participants (18-49 y) compared to older ones (50+ y) (9.7, IQR 7.9 g/day vs 8.1, IQR 7.1 g/day, p <  0.01) and those with higher Body Mass Index (BMI) (> 30 kg/m2) compared to a healthy BMI (18.5-24.9 kg/m2) (10.04, IQR 5.1 g/day vs 6.2, IQR 5.6 g/day, p <  0.01). More than three quarters (77%, n = 647) of participants had salt intakes above the WHO maximum recommendation of 5 g/d, and nearly two thirds (65%, n = 548) had daily K intakes below the recommended level of 90 mmol. Dietary sodium to potassium (Na: K) ratios above 2 mmol/mmol were positively associated with increasing BP with age. Population-based interventions to reduce salt intake and increase K consumption are needed.

Monitoring and implementation of salt reduction initiatives in Africa: A systematic review

This systematic review aims to document salt consumption patterns and the implementation status and potential impact of salt reduction initiatives in Africa, from studies published between January 2009 and November 2019. Studies were sourced using MEDLINE, Embase, Cochrane Library electronic databases, and gray literature. Of the 887 records retrieved, 38 studies conducted in 18 African countries were included. Twelve studies measured population salt intake, 11 examined salt level in foods, 11 assessed consumer knowledge, attitudes, and behaviors, 1 study evaluated a behavior change intervention, and 3 studies modeled potential health gains and cost savings of salt reduction interventions. The population salt intake studies determined by 24‐hour urine collections showed that the mean (SD) salt intake in African adults ranged from 6.8 (2.2) g to 11.3 (5.4) g/d. Salt levels in foods were generally high, and consumer knowledge was fairly high but did not seem to translate into salt lowering behaviors. Modeling studies showed that interventions for reducing dietary sodium would generate large health gains and cost savings for the health system. Despite this evidence, adoption of population salt reduction strategies in Africa has been slow, and dietary consumption of sodium remains high. Only South Africa adopted legislation in 2016 to reduce population salt intake, but success of this intervention has not yet been fully evaluated. Thus, rigorous evaluation of the salt reduction legislation in South Africa and initiation of salt reduction programs in other African countries will be vital to achieving the targeted 30% reduction in salt intake by 2025.

Comparative Analysis of Selected Physicochemical and Textural Properties of Bread Substitutes

In the present study, the physicochemical, textural and sensorial properties of crackerbread (made from rye, maize and wheat flour) and rice waffles, the most popular on the Polish market bread substitutes, were determined. It was shown that values of several mechanical properties of rice waffles, including ultimate fracture force, strain and stress differed significantly from that of crackerbread. Texture profile analysis showed that the highest hardness and springiness was exhibited by rice waffles with sesame seeds and wheat-rye, respectively. The concentration of salt was the lowest in rice bread with sunflower. The most acceptable was the rice bread with sea salt (8.26 in a 9-point scale) and overall consumer acceptance of crispbreads was highly correlated with sensory attribute of saltiness.

Dietary Sources of Salt in Low- and Middle-Income Countries: A Systematic Literature Review

Rapid urbanization in low- and middle-income countries (LMICs) is transforming dietary patterns from reliance on traditional staples to increased consumption of energy-dense foods high in saturated fats, trans fats, sugars, and salt. A systematic literature review was conducted to determine major food sources of salt in LMICs that could be targeted in strategies to lower population salt intake. Articles were sourced using Medline, Web of Science, Scopus, and grey literature. Inclusion criteria were: reported dietary intake of Na/salt using dietary assessment methods and food composition tables and/or laboratory analysis of salt content of specific foods in populations in countries defined as low or middle income (LMIC) according to World Bank criteria. Of the 3207 records retrieved, 15 studies conducted in 12 LMICs from diverse geographical regions met the eligibility criteria. The major sources of dietary salt were breads, meat and meat products, bakery products, instant noodles, salted preserved foods, milk and dairy products, and condiments. Identification of foods that contribute to salt intake in LMICs allows for development of multi-faceted approaches to salt reduction that include consumer education, accompanied by product reformulation.

Salt Use Behaviours of Ghanaians and South Africans: A Comparative Study of Knowledge, Attitudes and Practices

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.

High salt diet impairs memory-related synaptic plasticity via increased oxidative stress and suppressed synaptic protein expression

Scope

A high salt (HS) diet is detrimental to cognitive function, in addition to having a role in cardiovascular disorders. However, the method by which an HS diet impairs cognitive functions such as learning and memory remains open.

Methods and results

In this study, we found that mice on a 7 week HS diet demonstrated disturbed short‐term memory in an object‐place recognition task, and both 4 week and 7 week HS treatments impaired long‐term memory, as evidenced in a fear conditioning test. Mechanistically, the HS diet inhibited memory‐related long‐term potentiation (LTP) in the hippocampus, while also increasing the levels of reactive oxygen species (ROS) in hippocampal cells and downregulating the expression of synapsin I, synaptophysin, and brain‐derived neurotrophic factor in specific encephalic region.

Conclusion

This suggests that oxidative stress or synaptic protein/neurotrophin deregulation was involved in the HS diet‐induced memory impairment. Thus, the present study provides novel insights into the mechanisms of memory impairment caused by excessive dietary salt, and underlined the importance of controlling to salt absorb quantity.

Influence of sodium consumption and associated knowledge on poststroke hypertension in Uganda

OBJECTIVE

We assessed 24-hour urine sodium levels as an index of dietary salt consumption and its association with dietary salt knowledge and hypertension among poststroke patients with and without a history of hypertension in Uganda.

METHODS

A case-control study in which poststroke patients with a history of hypertension (cases, n = 123) were compared to poststroke patients without known hypertension (controls, n = 112). Dietary salt intake was assessed by 24-hour urine sodium, a valid measure of dietary salt consumption. Dietary salt knowledge was determined by questionnaire. The independent relationships among salt knowledge, 24-hour urine sodium, and blood pressure control were assessed using multiple regression analysis.

RESULTS

High 24-hour urine sodium (≥8.5 g/d) was 2 times more prevalent among hypertensive poststroke patients than controls (p = 0.002). Patients with minimal poststroke disability who had a choice in determining their diets had higher urine sodium than their more disabled counterparts. Only 43% of the study population had basic dietary salt knowledge, 39% had adequate diet-disease-related knowledge, and 37% had procedural knowledge (report of specific steps being taken to reduce salt consumption). Dietary salt knowledge was similarly poor among cases and controls (p = 0.488) and was not related to education level (p = 0.205).

CONCLUSIONS

High urine sodium and high salt-diet preferences were more frequent among poststroke hypertensive patients in Uganda than in their nonhypertensive counterparts. There was, however, no difference in dietary salt knowledge between these groups. The development of educational strategies that include salt-diet preferences may lead to better blood pressure control in this high-risk population.

Low sodium and high potassium intake for cardiovascular prevention: evidence revisited with emphasis on challenges in sub-Saharan Africa

Reduction in dietary salt intake and increase in potassium intake can make a major contribution to the prevention and control of hypertension and consequential cardiovascular disease, especially in sub-Saharan Africa (SSA) where prevalence rates are highest. African populations are going through a westernization of their traditional eating patterns, with a shift towards a US/Western-style diet, which contains an excessive amount of salt. Currently, the mean sodium intake in SSA populations is far above the recommended daily allowance. Besides, potassium intake is low, and, particularly, the supply of fruits and vegetables that are important sources of potassium is insufficient to meet current and growing population needs in SSA countries. Context-relevant strategies are needed for population-wide sodium intake reduction and increase in potassium intake.

Sodium content of bread from bakeries and traditional markets in Maputo, Mozambique

Objective

The Na content of bread is one of the most common targets of initiatives to reduce Na intake worldwide. Assessing the Na content of staple foods is of major relevance in Mozambique, given the high burden of hypertension in this setting. We aimed to estimate the Na content of white bread available in different bakeries and markets in Maputo.

Design

A cross-sectional study of the Na content of white bread available for sale at twenty-five bakeries and markets in Mozambique. Flame photometry was used to quantify the Na content of the bread. The percentage of samples meeting manufacturer Na targets from South Africa and six countries from other regions, selected as benchmarks, was computed.

Setting

Maputo, Mozambique.

Subjects

Three loaves of white bread from each selected bakery/market.

Results

The mean Na content of bread was 450·3 mg/100 g (range: 254·9–638·3 mg/100 g), with no significant differences between bakeries and traditional markets. Most samples (88 %) did not meet the regulation in South Africa (≤380 mg/100 g). When considering the targets from other countries (range: ≤360–550 mg/100 g), the prevalence of non-compliance varied between 8 % and 92 %. There were no significant differences in the price of bread with Na content below and above the targets.

Conclusions

The content of Na in bread varies widely in Mozambique, reaching high values in a high proportion of the bakeries and markets in Maputo. Measures to regulate the Na content in bread may contribute to a reduction in Na intake and improved health at the population level.