Self-management behavior strategy based on behavioral economics in patients with hypertension: a scoping review

Hypertensive patients often do not make the most favorable choices and behaviors for managing disease. Behavioral economics strategies offer new ideas for guiding patients toward health behavior. The scoping review aimed to summarize behavioral economics strategies designed to improve hypertension self-management behaviors. A literature search was conducted in September 2022 using the following electronic databases: Embase, Medline, CINAHL, PsycINFO, Web of Science, Cochrane Library, CNKI, Wan Fang Database for Chinese Periodicals, and CBM-SinoMed. We screened the literature for experimental studies written in Chinese or English reporting on BE strategies designed to improve self-management behavior in hypertension. We searched 17 820 records and included 18 articles in the final scoping review. We performed qualitative synthesis by the categories of choice architecture. The most common BE strategies were those targeting decision information and decision assistance, such as changing the presentation of information, making information visible, and providing reminders for actions. Most strategies targeted BP, diet, medication adherence, and physical activity behavior. Ten out of 18 studies reported statistically significant improvement in self-management behavior. Further research on BE strategies should focus on addressing the challenges, including changing the decision structure, encompassing a more comprehensive range of target behaviors, and examining the long-term effects of BE strategies.

Technology-supported behavior change interventions for reducing sodium intake in adults: a systematic review and meta-analysis

The effects of technology-supported behavior change interventions for reducing sodium intake on health outcomes in adults are inconclusive. Effective intervention characteristics associated with sodium reduction have yet to be identified. A systematic review and meta-analysis were conducted, searching randomized controlled trials (RCTs) published between January 2000 and April 2023 across 5 databases (PROSPERO: CRD42022357905). Meta-analyses using random-effects models were performed on 24-h urinary sodium (24HUNa), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Subgroup analysis and meta-regression of 24HUNa were performed to identify effective intervention characteristics. Eighteen RCTs involving 3505 participants (51.5% female, mean age 51.6 years) were included. Technology-supported behavior change interventions for reducing sodium intake significantly reduced 24HUNa (mean difference [MD] -0.39 gm/24 h, 95% confidence interval [CI] -0.50 to -0.27; I2 = 24%), SBP (MD -2.67 mmHg, 95% CI -4.06 to -1.29; I2 = 40%), and DBP (MD -1.39 mmHg, 95% CI -2.31 to -0.48; I2 = 31%), compared to control conditions. Interventions delivered more frequently (≤weekly) were associated with a significantly larger effect size in 24HUNa reduction compared to less frequent interventions (>weekly). Other intervention characteristics, such as intervention delivery via instant messaging and participant-family dyad involvement, were associated with larger, albeit non-significant, effect sizes in 24HUNa reduction when compared to other subgroups. Technology-supported behavior change interventions aimed at reducing sodium intake were effective in reducing 24HUNa, SBP, and DBP at post-intervention. Effective intervention characteristics identified in this review should be considered to develop sodium intake reduction interventions and tested in future trials, particularly for its long-term effects.

Efficacy of an Educational Intervention for Sodium Restriction in Patients with Hypertension: A Randomized Controlled Trial

There is sound evidence showing the efficacy of non-pharmacological interventions in lowering blood pressure (BP); however, adherence is usually poor. Interventions to induce behavioral changes aim to improve the ability to read labels, choose foods, and eat low-sodium meals, reinforcing adherence to sodium restriction. In this randomized parallel-controlled trial, we assessed the effectiveness of an educational intervention using the Dietary Sodium Restriction Questionnaire (DSRQ) scores. A follow-up period of 6 months was conducted. Participants were randomized into (1) an educational intervention provided by a registered dietitian on individual visits and dietary planning; (2) a control group with the usual care and dietary recommendations. Patients underwent 24-h ambulatory BP monitoring, 12-h fasting blood tests, spot urine collection, and assessment using DSRQ. We randomized 120 participants (67.5% women and 68.3% Caucasians), and 25 participants were lost to follow-up. The 24-h sodium urinary excretion changed in the control (Δ -1610 mg/day; 95% confidence interval [CI] -1800 to -1410) and intervention groups (Δ -1670 mg/day; 95% CI -1800 to -1450) over time. There was no significant difference in the 24-h estimated sodium between groups. In hypertensive patients, DSRQ-based educational intervention is effective for improving the ability to detect and overcome obstacles to a low-sodium restriction diet but is as effective as dietary recommendations for lowering sodium.

24-hour sodium and potassium excretion in the Americas: a systematic review and meta-analysis

Objective

To determine the 24-hour urinary sodium and potassium excretions in the Americas.

Methods

A systematic review and meta-analysis were performed seeking for studies conducted between 1990 and 2021 in adults living in any sovereign state of the Americas in Medline, Embase, Scopus, SciELO, and Lilacs. The search was first run on October 26th, 2020 and was updated on December 15th, 2021. Of 3 941 abstracts reviewed, 74 studies were included from 14 countries, 72 studies reporting urinary sodium (27 387 adults), and 42 studies reporting urinary potassium (19 610 adults) carried out between 1990 and 2020. Data were pooled using a random-effects meta-analysis model.

Results

Mean excretion was 157.29 mmol/24h (95% CI, 151.42-163.16) for sodium and 57.69 mmol/24h (95% CI, 53.35-62.03) for potassium. When only women were considered, mean excretion was 135.81 mmol/24h (95% CI, 130.37-141.25) for sodium and 51.73 mmol/24h (95% CI, 48.77-54.70) for potassium. In men, mean excretion was 169.39 mmol/24h (95% CI, 162.14-176.64) for sodium and 62.67 mmol/24h (95% CI, 55.41-69.93) for potassium. Mean sodium excretion was 150.09 mmol/24h (95% CI, 137.87-162.30) in the 1990s and 159.79 mmol/24h (95% CI, 151.63-167.95) in the 2010s. Mean potassium excretion was 58.64 mmol/24h (95% CI, 52.73-64.55) in the 1990s and 56.33 mmol/24/h (95% CI, 48.65-64.00) in the 2010s.

Conclusions

These findings suggest that sodium excretions are almost double the maximum level recommended by the World Health Organization and potassium excretions are 35% lower than the minimum requirement; therefore, major efforts to reduce sodium and to increase potassium intakes should be implemented.

Primary and secondary cardiovascular disease prevention interventions targeting lifestyle risk factors in women: A systematic review and meta-analysis

Background and aims

Over seven million women die from cardiovascular disease (CVD) annually. While lifestyle modification is recommended for CVD prevention, there are no systematic reviews evaluating the effectiveness of interventions targeted to women. The primary aim of this systematic review is to determine the efficacy of primary and secondary CVD prevention interventions targeting lifestyle risk factors in women.

Methods

Six electronic databases were searched up to January 2022. Eligible studies included randomized controlled trials of primary or secondary CVD prevention interventions targeting CVD lifestyle risk factors (diet, physical activity, sedentary behavior, smoking, alcohol, sleep, and weight management) in women (≥18 years) that reported CVD risk markers or lifestyle risk factors. Meta-analyses were conducted on CVD risk markers and body mass index (BMI), and the level of evidence was applied to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria and reported.

Results

Thirty-five RCTs were included (24 primary and 11 secondary prevention). Meta-analyses demonstrated that lifestyle CVD prevention interventions achieved statistically significant reductions in BMI at ≤ 6 months (0.95 kg/m2, 95% CI = 0.54 to 1.35, p < 0.0001), 12 months (0.61 kg/m2, 95% CI = 0.07 to 1.16, p = 0.03) and >12 months (0.58 kg/m2, 95% CI = 0.01 to 1.16, p = 0.05), and systolic blood pressure (mmHg) at ≤ 6 months (3.51, p < 0.001).

Conclusions

Lifestyle interventions are important for the prevention of CVD in women, specifically to reduce systolic blood pressure in the short term (≤ 6 months) and BMI long term (>12 months).

Systematic review registration

https://osf.io/bkwqm, identifier: osf-registrations-bkwqm-v1.

A mobile phone application intervention to promote healthy salt intake among adults: Protocol for a randomized controlled study (Preprint)

Background

There is sound evidence associating high salt intake and a greater risk of cardiovascular and noncardiovascular diseases. High salt intake has been observed in several populations worldwide. Therefore, promoting healthier salt consumption has been encouraged as a low-cost strategy to reduce this risk factor. However, these strategies need to be sound, built on theoretical and methodological bases, and consider the target population’s context.

Objective

This protocol aims to describe a mobile phone app intervention to promote healthy salt intake among adults.

Methods

This is an experimental and longitudinal study protocol conducted in three modules. Module 1 refers to the planning of the intervention based on the Behaviour Change Wheel framework. Module 2 is the development of the mobile phone app intervention based on the date of module 1. In module 3, the intervention will be evaluated using a randomized controlled study, with three steps of data collection in a 2-month follow-up in a sample of 86 adults (43 participants for each group: the control group and intervention group) recruited from the primary health care centers of a Brazilian town. The discretionary salt intake questionnaire will assess salt consumption, the app usability will be assessed using the System Usability Scale, and psychosocial variables (habit, intention, and self-efficacy) will also be measured.

Results

Recruitment began in October 2021, and the follow-up will end in August 2022. The results of this study are expected to be published in 2023.

Conclusions

Results from this study will help people to control salt intake when cooking at home, will stimulate self-care, will work as an alternative or supportive method in the relationship between health care professionals and patients, and will contribute to implementing the app intervention to promote healthy salt intake on a large scale.

Trial Registration

The Brazilian Clinical Trials Registry RBR-4s8qyyq; https://ensaiosclinicos.gov.br/rg/RBR-4s8qyyq

International Registered Report Identifier (IRRID)

DERR1-10.2196/37853

Reducing salt intake: a systematic review and meta-analysis of behavior change interventions in adults

CONTEXT

Prolonged high salt (sodium) intake can increase the risk of hypertension and cardiovascular disease. Behavioral interventions may help reduce sodium intake at the population level.

OBJECTIVE

The effectiveness of behavior change interventions to reduce sodium intake in adults was investigated in this systematic review and meta-analysis.

DATA SOURCE

The PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and EMBASE databases were searched.

DATA EXTRACTION

Narrative synthesis and random-effects meta-analyses were used to determine intervention efficacy. A total of 61 trials (46 controlled trials and 15 quasi-experimental studies) were included.

RESULTS

Behavior change interventions resulted in significant improvements in salt consumption behavior (eg, decrease in purchase of salty foods; increase in use of salt substitutes), leading to reductions in sodium intake as measured by urinary sodium in 32 trials (N = 7840 participants; mean difference, -486.19 mg/d [95%CI, -669.44 to -302.95]; P < 0.001; I2 = 92%) and dietary sodium in 19 trials (N = 3750 participants; mean difference -399.86 mg/d [95%CI, -581.51 to -218.20]; P < 0.001; I2 = 96%), equivalent to a reduction of >1 g of salt intake daily. Effects were not significantly different based on baseline sodium intakes, blood pressure status, disease status, the use of behavior change theories, or the main method of intervention delivery (ie, online vs face-to-face).

CONCLUSION

Behavior change interventions are effective at improving salt consumption practices and appear to reduce salt intake by >1 g/d.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020185639.

Interventions That Successfully Reduced Adults Salt Intake-A Systematic Review

Background: Adequate sodium intake is important for lowering blood pressure and thus reducing cardiovascular disease risk and other complications. The aim of this review is to identify recent interventions around the world that have been successful in reducing salt intake. Methods: A search in the PubMed, Web of Science and Scopus databases was performed. We include studies published in the last 10 years; randomized trials, pilot intervention without a control arm or experimental study; adult participants; and interventions that successfully reduced salt intake. Study quality was assessed. Results: We included 21 studies, 16 randomized intervention trials and five nonrandomized intervention studies. Eleven interventions described health and nutritional education, seven interventions described nutritional education plus other interventions, and three studies used salt meters to reduce sodium intake. Conclusion: Health and nutritional education, nutritional education plus other interventions and estimates of salt intake showed success in the reduction of salt consumption. There is no evidence that one type of intervention analyzed is more effective than other in reducing salt consumption, so we must analyze each in which individuals or subpopulations will have the intervention performed and use the most suitable approaches to lead to better results.

Strengthening Knowledge to Practice on Effective Salt Reduction Interventions in Low- and Middle-Income Countries

PURPOSE OF REVIEW

The objective of this review was to consolidate available published information on the implementation and evaluation of salt reduction interventions in low- and middle-income countries (LMICs).

RECENT FINDINGS

The Science of Salt database (made up of studies identified in a weekly Medline search) was used to retrieve articles related to the implementation of salt reduction interventions from June 2013 to February 2020. Studies that measured the effects of the interventions in LMICs, based on four outcome measures-salt intake; sodium levels in foods; knowledge, attitudes, and behaviours (KABs) towards salt; and blood pressure-were included. Results were summarised overall and according to subgroups of intervention type, duration, sample size, country's income class, and regional classification. The review identified 32 studies, representing 13 upper middle-income and four lower middle-income countries. The main salt reduction interventions were education, food reformulation, and salt substitution; and many interventions were multi-faceted. More studies reported a positive effect of the interventions (decreased salt intake (12/17); lower sodium levels in foods or compliance with agreed targets (6/6); improved KAB (17/19); and decreased blood pressure (10/14)) than a null effect, and no study reported a negative effect of the intervention. However, many studies were of small scale and targeted specific groups, and none was from low-income countries. Consumer education, food reformulation, and salt substitution, either alone or in combination, were effective in their target populations. Supporting scale-up of salt reduction interventions in LMICs is essential to cover broader populations and to increase their public health impact.

The association between dietary sodium intake, adiposity and sugar-sweetened beverages in children and adults: a systematic review and meta-analysis

Higher intakes of Na may contribute to weight gain. The primary aim of this systematic review and meta-analysis was to examine the relationship between dietary Na intake and measures of adiposity in children and adults. Given the previous link between Na intake and the consumption of sugar-sweetened beverages (SSB), which are a known risk factor for obesity, a secondary aim examining the relationship between Na intake and SSB consumption was assessed. A systematic literature search identified cross-sectional and longitudinal studies and randomised controlled trials (RCT) which reduced dietary Na (≥3 months). Meta-analysis was performed for outcomes with ≥3 studies. Cross-sectionally higher Na intakes were associated with overweight/obesity in adults (five studies; n 11 067; OR 1·74; 95 % CI 1·43, 2·13) and in children (three studies; n 3625, OR 3·29; 95 % CI 2·25, 4·80), and abdominal obesity (five studies; n 19 744; OR 2·04; 95 % CI 1·72, 2·42) in adults. Overall, associations remained in sensitivity analyses which adjusted for energy. Findings from longitudinal studies were inconsistent. RCT in adults indicated a trend for lower body weight on reduced-Na compared with control diets (fifteen studies; n 5274; -0·29 kg; 95 % CI -0·59, 0·01; P = 0·06); however, it is unclear if energy intakes were also altered on reduced-Na diets. Among children higher Na intakes were associated with higher intake of SSB (four studies, n 10 329, b = 22, 16 and 26 g/d); no studies were retrieved for adults. Overall, there was a lack of high-quality studies retrieved. While cross-sectional evidence indicates Na intake was positively associated with adiposity, these findings have not been clearly confirmed by longitudinal studies or RCT.

Developing and Testing an Instrument to Measure the Factors Affecting the Salt Restriction Behaviors among Women

Background: High salt intake is considered as one of the most important causes of hypertension and cardiovascular diseases. Measuring and identifying factors contributing to people's salt intake behaviors is important to evaluate effectiveness of interventions focusing on salt reduction behaviors. The purpose of this study was to develop and test a new theory of planned behavior (TPB)- based instrument to measure factors influencing three different salt intake behaviors (adding salt during cooking, at the table, purchasing salty food) among women.

Study design: A mixed-method study.

Methods: After the face and content validity of developed instrument were established, a representative sample of women (N= 300, age (SD):42.82(12.10)) were recruited to assess the construct validity using Partial Least Square confirmatory factor analysis. Coefficient alpha and composite reliability (CR) were used to establish reliability of instrument. The content validity index (CVI) and content validity ratio (CVR) were used to assess the content validity.

Results: Assessing validity and reliability of instrument led to 56-item questionnaire. CVI was more than 0.70 and CVR more than 0.56. Internal consistency as assessed by Cronbach's alpha was acceptable. Convergent and discriminant validity were established. The GOF index for behavior one was 0.250, for behavior two was 0.414 and behavior three was 0.374. The results of confirmatory factor analysis indicate that TPB model has an acceptable fit with data.

Conclusion: Our instrument provides a validated and reliable tool for assessing different aspects of salt intake behaviors in women to evaluate effectiveness of interventions focusing on salt reduction behaviors.

Effectiveness of Educational Interventions on Adherence to Lifestyle Modifications Among Hypertensive Patients: An Integrative Review

Controlling blood pressure is a global concern as it is a major risk factor for cardiometabolic diseases and stroke. A flattened control rate was noted in recent decades, which highlighted an issue of adherence to medications and lifestyle modifications. Effectiveness of educational intervention on medication adherence and blood pressure control had been reviewed, but reviews on lifestyle modifications are lacking. This review with meta-analysis aimed to identify the effect of educational interventions on blood pressure control and adherence to lifestyle modifications. In accordance with the PRISMA statement, a search of CINAHL Complete, PubMed, Medline, Embase and Scopus for randomized control trials published between 2009 and 2019 was conducted. Data were extracted for quality synthesis and meta-analysis. Thirteen studies were included. Two forms of educational intervention, individual and group education, were commonly used. Phone calls, message reminders and reading materials after education were identified in the studies as supportive methods, which showed a moderate to large effect on adherence to lifestyle modifications and blood pressure control. Monthly group education lasting 45 min was suggested. Health professionals could integrate the education with supportive methods into community health promotion to improve and reinforce the adherence behavior on medications and lifestyle modifications among hypertensive patients.

What methods have been used to estimate salt intake? A systematic review

The relationship between salt intake and cardiovascular diseases is a contemporary scientific controversy, which has been attributed to the limits of the measures of salt intake used in the studies. Thus, this article sought to systematically review the literature on the methods used to estimate salt intake in different study designs. Of the 124 articles, 60.5% used only biochemical measures, 26.6% only self-report measures and 12.9% reported the combined use of both methods. The 24-hour urinary sodium excretion was the predominant biochemical method (79.1%) and the Food Frequency Questionnaire was the predominant self-report measure (36.4%). Interventional studies used mostly 24-hour urinary sodium excretion; while longitudinal studies used self-report measures. The question guiding the study and its design, as well as constraints related to costs, sample size and feasibility seems to influence the choice of the type of measurement.

Dietary sources of salt intake in adults and older people: a population-based study in a Brazilian town

OBJECTIVE

To assess salt intake and its dietary sources using biochemical and self-report methods and to characterize salt intake according to sociodemographic and disease-related variables in a sample of the Brazilian population.

DESIGN

Population-based cross-sectional survey.

SETTING

Salt intake was assessed by biochemical (24 h urinary Na excretion) and self-report methods (sodium FFQ, 24 h dietary recall, seasoned-salt questionnaire, discretionary-salt questionnaire and total reported salt intake).ParticipantsAdults and older people (n 517) aged 20-80 years, living in Artur Nogueira, São Paulo, Brazil.

RESULTS

Mean salt intake based on 24 h urinary Na excretion and total reported salt intake was 10·5 and 11·0 g/d, respectively; both measures were significantly correlated. Discretionary salt and seasoned salt were the most important sources of salt intake (68·2 %). Men in the study consumed more salt than women as estimated by 24 h urinary Na excretion (11·7 v. 9·6 g salt/d; P&lt;0·0001). Participants known to be hypertensive added more salt to their meals but consumed less salty ultra-processed foods. Waist circumference in both sexes and BMI were positively correlated with salt intake estimated by 24 h urinary Na excretion. In addition, regression analysis revealed that being a young male or having a high waist circumference was a predictor of higher salt intake.

CONCLUSIONS

Salt intake in this population was well above the recommended amount. The main source of salt intake came from salt added during cooking. Salt intake varied according to sex and waist circumference.

The Science of Salt: A focused review on salt-related knowledge, attitudes and behaviors, and gender differences

The aim of the current review was to examine the scope of studies published in the Science of Salt Weekly that contained a measure of self-reported knowledge, attitudes, and behavior (KAB) concerning salt. Specific objectives were to examine how KAB measures are used to evaluate salt reduction intervention studies, the questionnaires used, and whether any gender differences exist in self-reported KAB. Studies were reviewed from the commencement of Science of Salt Weekly, June 2013 to the end of August 2017. Seventy-five studies had relevant measures of KAB and were included in this review, 13 of these were salt-reduction intervention-evaluation studies, with the remainder (62) being descriptive KAB studies. The KAB questionnaires used were specific to the populations studied, without evidence of a best practice measure. 40% of studies used KAB alone as the primary outcome measure; the remaining studies used more quantitative measures of salt intake such as 24-hour urine. Only half of the descriptive studies showed KAB outcomes disaggregated by gender, and of those, 73% showed women had more favorable KAB related to salt. None of the salt intervention-evaluation studies showed disaggregated KAB data. Therefore, it is likely important that evaluation studies disaggregate, and are appropriately powered to disaggregate all outcomes by gender to address potential disparities.