Priority Actions to Advance Population Sodium Reduction

Salt Reduction and Iodine Fortification Policies Are Compatible: Perspectives for Public Health Advocacy

Cardiovascular diseases account for almost 18 million deaths annually, the most of all non-communicable diseases. The reduction of dietary salt consumption is a modifiable risk factor. The WHO recommends a daily sodium intake of <2000 mg but average consumption exceeds this in many countries globally. Strategies proposed to aid effective salt reduction policy include product reformulation, front of pack labelling, behavioural change campaigns and establishing a low-sodium-supportive environment. Yet, salt for household and processed food use is, in countries wholly or partially adopting a universal salt iodisation policy, the principal vehicle for population-wide iodine fortification. With salt reduction policies in place, there is concern that iodine deficiency disorders may re-emerge. Recognising the urgency to tackle the rising prevalence of NCDs yet not risk the re-emergence and detrimental effect of inadequate iodine intakes, this review lays out the feasibility of integrating both salt reduction and salt iodine fortification strategies. Reducing the burden of health risks associated with an excessive sodium intake or inadequate iodine through population-tailored, cost-effective strategies involving salt is both feasible and achievable, and represents an opportunity to improve outcomes in public health.

Association between Salt-Related Knowledge, Attitudes, and Behaviours and 24 h Urinary Salt Excretion in Nepal

This study examined the association between salt-related knowledge, attitudes, and behaviors (KAB) and salt excretion using the 24-hour (24 h) urinary collection method. Data were utilized from the Community-Based Management of Non-Communicable Diseases in Nepal (COBIN) Salt Survey, a community-based cross-sectional study conducted among a sub-sample of COBIN cohort in Pokhara Metropolitan City, Western Nepal, from July to December 2018, among adults aged 25-70 years. A total of 451 adults participated in the study, and a single 24 h urine sample was collected from each participant. The mean [(standard deviation (SD)] age of the participants was 49.6 (9.82) years, and the majority were female (65%). The mean urinary salt excretion was 13.28 (SD: 4.72) g/day, with 98% of participants consuming ≥5 g of salt/day. Although 83% of participants knew the risks of high salt intake and 87% believed it was important to reduce their intake, only 10% reported doing so. Salt-related attitude i.e., self-perceived salt intake was significantly associated with urinary salt excretion, adding extra salt to food, consuming processed foods, and taking actions to salt control. Participants who perceived themselves as consuming high salt had higher urinary salt excretion [(14.42 g/day; 95% confidence interval (95% CI): 13.45, 15.39, p = 0.03)], were more likely to add extra [(Odds ratio (OR) = 3.59; 95% CI: 2.03, 6.33, p < 0.001)], and consume processed foods more often (OR = 1.90; 95% CI: 1.06, 3.40, p < 0.05) compared to those who self-perceived consuming a normal amount of salt. Conversely, participants who perceived themselves as consuming low salt were more likely to take actions to control salt intake (OR = 4.22; 95% CI: 1.90, 9.37, p < 0.001) compared to their counterparts who perceived consuming a normal amount of salt. There existed a gap between salt-related knowledge, attitudes, and actual behaviors, resulting in a high salt intake among the Nepalese population. Nepal urgently requires tailored national salt reduction programs that comprise both policy and community-level interventions to achieve a 30% reduction in mean population salt intake by 2025. Further validation studies are needed to assess the effectiveness of community-based intervention in Nepal.

Cost-Effectiveness of Salt Substitute and Salt Supply Restriction in Eldercare Facilities: The DECIDE-Salt Cluster Randomized Clinical Trial

Importance

Salt substitution has been reported to be a cost-saving sodium reduction strategy that has not yet been replicated in different contexts.

Objective

To estimate the cost-effectiveness of sodium reduction strategies within the DECIDE-Salt trial.

Design, Setting, and Participants

The DECIDE-Salt trial cluster randomized in a 1:1:1:1 ratio 48 eldercare facilities in China into 4 groups for evaluation of 2 sodium reduction strategies for 2 years: 1 with both strategies, 2 with either strategy, and 1 with neither strategy. The trial was conducted from September 25, 2017, through October 24, 2020.

Interventions

The 2 intervention strategies were replacing regular salt with salt substitute and progressively restricting salt supply to kitchens.

Main Outcomes and Measures

The main outcomes included per-participant costs of intervention implementation and medical treatments for hypertension and major adverse cardiovascular events (MACEs) against mean reductions in systolic blood pressure, hypertension prevalence, MACE incidence, and mortality. The incremental cost-utility ratio was then assessed as the additional mean cost per quality-adjusted life-year gained. Analyses were conducted separately for each strategy, comparing groups assigned and not assigned the test strategy. Disease outcomes followed the intention-to-treat principle and adopted different models as appropriate. One-way and probabilistic sensitivity analyses were conducted to explore uncertainty, and data analyses were performed between August 13, 2022, and April 5, 2023.

Results

A total of 1612 participants (1230 males [76.3%]) with a mean (SD) age of 71.0 (9.5) years were enrolled. Replacing regular salt with salt substitute reduced mean systolic blood pressure by 7.14 (95% CI, 3.79-10.48) mm Hg, hypertension prevalence by 5.09 (95% CI, 0.37-9.80) percentage points, and cumulative MACEs by 2.27 (95% CI, 0.09-4.45) percentage points. At the end of the 2-year intervention, the mean cost was $25.95 less for the salt substitute group than the regular salt group due to substantial savings in health care costs for MACEs (mean [SD], $72.88 [$9.11] vs $111.18 [$13.90], respectively). Sensitivity analysis showed robust cost savings. By contrast, the salt restriction strategy did not show significant results. If the salt substitution strategy were rolled out to all eldercare facilities in China, 48 101 MACEs and 107 857 hypertension cases were estimated to be averted and $54 982 278 saved in the first 2 years.

Conclusions and Relevance

The findings of this cluster randomized clinical trial indicate that salt substitution may be a cost-saving strategy for hypertension control and cardiovascular disease prevention for residents of eldercare facilities in China. The substantial health benefit savings in preventing MACEs and moderate operating costs offer strong evidence to support the Chinese government and other countries in planning or implementing sodium intake reduction and salt substitute campaigns.

Trial Registration

ClinicalTrials.gov Identifier: NCT03290716.

Dietary intakes of hypertensive patients in rural India: Secondary outcomes of a randomised, double-blind, controlled trial

Background

Hypertension is highly prevalent in India; however, little is known about the dietary intakes of those living with hypertension, particularly in rural areas. The primary aim was to assess the dietary intakes of individuals living in rural India with self-reported history of hypertension. As secondary analyses, we explored the dietary impact of a salt substitute in this population group.

Materials and methods

This study used data from a large randomised controlled trial conducted in seven villages across rural India. Participants received either regular salt (100% sodium chloride) or the salt substitute (70% sodium chloride/30% potassium chloride) to replace all home salt use. Dietary intake at baseline and end-of-trial was assessed using 24-h dietary recalls. A range of dietary outcomes were assessed including energy intake, macronutrient intake and overall diet quality according to the Alternate Healthy Eating Index (AHEI).

Results

A total of 454 participants were included in the analysis. At baseline, mean (SE) energy intakes in regular salt group and salt substitute group were similar at 5240 (110) kJ/day and 5120 (106) kJ/day, respectively. This was largely attributable to intakes of carbohydrates (74.4% of total energy intakes for regular salt group vs 75.4% for the salt substitute group) followed by total fat (15.8% vs 15.4%) and protein (10.4% vs 10.3%). Both groups also had similar AHEI scores at baseline, with mean (SE) total scores equating to 33.0 (0.4) (out of a total 90) for the regular salt group and 32.7 (0.4) for the salt substitute group. Both groups received lowest AHEI scores across the following components: vegetables, fruit and wholegrains. At baseline, the mean (SE) intakes of sodium across the regular salt and salt substitute groups were similar at 2349 (67) mg/day and 2396 (64) mg/day, respectively. In the salt substitute group, there was a significant reduction in total sodium intakes over time (-264 mg/day, 95% CI, -442 to -85), driven by the use of the salt substitute.

Conclusion

This study found individuals with hypertension living in rural India had poor dietary intakes, including low intakes of fruits, vegetables and wholegrains, and high intakes of sodium. Salt substitutes may be an effective strategy for reducing sodium intake in this population group.

Setting sodium targets for pre-packaged foods in China - an exploratory study

Introduction

Setting sodium targets for pre-packaged food has been a priority strategy for reducing population sodium intake. This study aims to explore the attitudes and considerations of researchers and key stakeholders toward implementing such policy in China.

Methods

An exploratory study comprising a survey and a focus group discussion was conducted among 27 purposively selected participants including 12 researchers, 5 consumers, 4 administrators, 3 industry association representatives and 3 food producers. The survey/discussion covered the key questions considered when developing/promoting sodium targets. Free-text responses were manually classified and summarized using thematic analysis.

Results

Two-thirds of the participants supported target-setting policy. Researchers and administrators were most supportive, and food producers and associations were least supportive. Adapted WHO food categorization framework was well accepted to underpin target-setting to ensure international comparability and applicability for Chinese products. Maximum values were the most agreed target type. The WHO benchmarks were thought to be too ambitious to be feasible given the current food supply in China but can be regarded as long-term goals. Initially, a reduction of sodium content by 20% was mostly accepted to guide the development of maximum targets. Other recommendations included implementing a comprehensive strategy, strengthening research, engaging social resources, establishing a systematic monitoring/incentive system, maintaining a fair competitive environment, and developing a supportive information system. Target-setting policy was acceptable by most stakeholders and should be implemented alongside strategies to reduce discretionary salt use.

Discussion

Our findings provide detailed guidance for the Chinese government when developing a target-setting strategy. The methods and results of this study also provide meaningful references for other countries to set sodium targets for pre-packaged foods and implement other salt reduction strategies simultaneously.

India's tryst with salt: Dandi march to low sodium salts

Salt plays a critical role in India's past as well as its present, from Dandi March to its role as a vehicle for micronutrient fortification. However, excess salt intake is a risk factor for high blood pressure and cardiovascular diseases (CVDs). Indians consume double the World Health Organization recommended daily salt (<5 g). India has committed to a 30 per cent reduction in sodium intake by 2025. Evidence based strategies for population sodium intake reduction require a moderate reduction in salt in - home cooked foods, packaged foods and outside-home foods. Reducing the sodium content in packaged food includes policy driven interventions such as front-of-package warning labels, food reformulation, marketing restrictions and taxation on high sodium foods. For foods outside of the home, setting standards for foods purchased and served by schemes like mid-day meals can have a moderate impact. For home cooked foods (the major source of sodium), strategies include advocacy for reducing salt intake. In addition to mass media campaigns for awareness generation, substituting regular salt with low sodium salt (LSS) has the potential to reduce salt intake even in the absence of a major shift in consumer behaviour. LSS substitution effectively lowers blood pressure and thus reduces the risk of CVDs. Further research is required on the effect of LSS substitutes on patients with chronic kidney disease. India needs an integrated approach to sodium reduction that uses evidence based strategies and can be implemented sustainably at scale. This will be possible only through scientific research, governmental leadership and a responsive evidence-to-action approach through a multi-stakeholder coalition.

Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia

OBJECTIVE

In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention.

DESIGN

Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models.

SETTING

Victoria, Australia.

PARTICIPANTS

Children aged 4-12 years.

RESULTS

Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged.

CONCLUSION

These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

Sodium content targets for pre-packaged foods, China: a quantitative study and proposal

Objective

To determine the contribution of pre-packaged foods to population sodium intake in China, and to propose sodium content targets for food subcategories used for the World Health Organization's (WHO's) global sodium benchmarks.

Methods

The impact of four different approaches to reducing the sodium content of pre-packaged foods on population sodium intake was estimated using data from national databases covering the nutrient content and ingredients of 51 803 food products and food consumption by 15 670 Chinese adults. We recategorized food products using a food categorization framework developed for WHO's global sodium benchmarks and adapted for China-specific foods.

Findings

Pre-packaged foods, including condiments, contributed 1302.5 mg/day of sodium intake per adult in 2021, accounting for 30.1% of population sodium intake in China. Setting maximum sodium content levels using a 90th-percentile target would reduce sodium intake from pre-packaged foods by 96.2 mg/day, corresponding to a 1.9% reduction in population intake. Using the 75th-percentile, a fixed 20% reduction and WHO benchmark targets would further reduce intake by 262.0 mg/day (5.2% population intake), 302.8 mg/day (6.0% population intake) and 701.2 mg/day per person (13.9% population intake), respectively. Maximum sodium content levels based on revised 20% reduction targets were proposed because they should result in substantial and acceptable reductions in sodium content for most food subcategories: overall sodium intake would decline by 305.0 mg/day per person, and population intake by 6.1%.

Conclusion

This study provides the scientific rationale for government policy on setting targets for food sodium content in China. Simultaneous action on discretionary salt use should also be taken.

A qualitative look at perception and experience of sodium reduction strategies in the food industry through focus groups and individual interviews

The high incidence of sodium overconsumption in the general population has led sodium reduction in commercial food products to become a topic of importance in the food industry. In order to bridge the gap between sodium reduction understanding in the food industry and academia, focus groups and individual interviews of food industry professionals were conducted. Sodium reduction and influence from external entities such as federal regulations and consumer insight were prominent in the nutritional concerns of food industry professionals. A large variety of sodium reduction strategies were introduced with discussion on the many factors that contribute to their potential for success. Flavor modification methods were most prevalent in the discussion, with particular focus on potassium chloride and incorporating umami taste. Factors that frequently positively contributed to a strategy's success include maintaining functionality and/or important sensory attributes, inexpensive to implement, and being perceived as clean label. Conversely, factors that negatively affect success include adversely impacting flavor, being considered not clean label, and high costs of implementation. Foods important for future sodium reduction varied widely, although those were largely products with high sodium density. Future efforts toward reducing sodium overconsumption and sodium content in the food supply fell into three categories: consumer-focused, industry-focused, and research-focused. Of particular importance for future efforts included greater regulatory pressure and more consumer nutritional education. Findings suggest that future efforts to reduce the incidence of sodium overconsumption should be carried out through multiple avenues rather than focusing on the agency of consumers, the food industry, or research alone.

Sodium Management in Kidney Disease: Old Stories, New Tricks

Excessive dietary sodium intake is associated with an increased risk of hypertension, especially in the setting of chronic kidney disease (CKD). Although implementation of a low-sodium diet in patients with CKD generally is recommended, data supporting the efficacy of this practice is mostly opinion-based. Few controlled studies have investigated the specific association of dietary sodium intake and cardiovascular events and mortality in CKD. Furthermore, in epidemiologic studies, the association of sodium intake with CKD progression, cardiovascular risk, and mortality is not homogeneous, and both low- and high-sodium intake has been associated with adverse health outcomes in different studies. In general, the adverse effects of high dietary sodium intake are more apparent in the setting of advanced CKD. However, there is no established definitive target level of dietary sodium intake in different CKD stages based on glomerular filtration rate and albuminuria/proteinuria. This review discusses the current challenges regarding the rationale of sodium restriction, target levels and assessment of sodium intake, and interventions for sodium restrictions in CKD in relation to clinical outcomes.

Evaluation of a Salt-Reduction Consumer Awareness Campaign Targeted at Parents Residing in the State of Victoria, Australia

From 2015 to 2020 a state-wide salt-reduction initiative was launched in Victoria, Australia, including an awareness campaign focused on parents with children <18 years of age. To evaluate the impact of the campaign on salt-related knowledge, attitudes and behaviors (KABs) we have assessed trends in salt-related KAB pre- and post-delivery of the campaign in parents, as well as within the wider adult population. Cross-sectional surveys of adults aged 18-65 years were undertaken pre- (2015: n = 821 parents; n = 1527 general sample) and post-campaign (2019: n = 935 parents; n = 1747 general sample). KABs were assessed via an online survey. Data were analyzed with regression models and adjusted for covariates. Among parents, around one-quarter of salt-related KABs shifted in a positive direction, but changes were small: there was a 6% (95% CI 2, 11%) increase in the percentage who knew the main source of salt in the diet and reductions in the percentage who reported placing a salt shaker on the table (-8% (95%CI -12, -3)) and that their child added salt at the table (-5% (95% -9, -0.2)). Among the wider adult sample, even fewer shifts in KAB were observed, with some behaviors worsening at follow-up. These findings indicate that this consumer awareness campaign had minimum impact.

New perspectives for hypertension management: progress in methodological and technological developments

Hypertension is the most common and preventable risk factor for cardiovascular disease (CVD), accounting for 20% of deaths worldwide. However, 2/3 of people with hypertension are undiagnosed, untreated, or under treated. A multi-pronged approach is needed to improve hypertension management. Elevated blood pressure (BP) in childhood is a predictor of hypertension and CVD in adulthood; therefore, screening and education programmes should start early and continue throughout the lifespan. Home BP monitoring can be used to engage patients and improve BP control rates. Progress in imaging technology allows for the detection of preclinical disease, which may help identify patients who are at greatest risk of CV events. There is a need to optimize the use of current BP control strategies including lifestyle modifications, antihypertensive agents, and devices. Reducing the complexity of pharmacological therapy using single-pill combinations can improve patient adherence and BP control and may reduce physician inertia. Other strategies that can improve patient adherence include education and reassurance to address misconceptions, engaging patients in management decisions, and using digital tools. Strategies to improve physician therapeutic inertia, such as reminders, education, physician-peer visits, and task-sharing may improve BP control rates. Digital health technologies, such as telemonitoring, wearables, and other mobile health platforms, are becoming frequently adopted tools in hypertension management, particularly those that have undergone regulatory approval. Finally, to fight the consequences of hypertension on a global scale, healthcare system approaches to cardiovascular risk factor management are needed. Government policies should promote routine BP screening, salt-, sugar-, and alcohol reduction programmes, encourage physical activity, and target obesity control.

'Love with Less Salt': evaluation of a sodium reduction mass media campaign in China

OBJECTIVE

This study examines the impact of a salt reduction campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change relating to salt consumption in two provinces of China.

METHODS

In 2019, the 'Love with Less Salt' campaign ran on China Central Television and on local television channels in Shandong and Anhui provinces. Data for this study come from two representative household surveys conducted among a sample of adults aged 25-65 years in Shandong and Anhui provinces: precampaign (n=2000) and postcampaign (n=2015). Logistic regression was performed to estimate the effects of the campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change.

RESULTS

Overall, 13% of postcampaign respondents recalled seeing the campaign, and reactions towards the campaign were positive. Postcampaign respondents were more likely to plan to reduce their purchase of foods high in salt than precampaign respondents (OR=1.45, p=<0.05). Campaign-aware respondents were significantly more likely than campaign-unaware respondents to report higher levels of knowledge, attitudes and behaviours regarding salt reduction.

CONCLUSIONS

Findings reveal that salt reduction mass media campaigns can be an effective public health tool to support efforts to reduce salt consumption in China. Continued and sustained mass media investments are likely to be effective in addressing high salt consumption nationwide.

Advancing Health Research Impact through a Systemic Multi-Sectoral Approach: A Protocol for Introducing Reduced-Sodium Salts and Salty Condiments in Vietnam

Better alignment between health research organisations with the needs (and interests) of key stakeholders in the health policy and research system is critical to improving research impact. The George Institute for Global Health's 'Healthier Societies' program focuses on harnessing the power of governments, markets, and communities to improve population level health equity outcomes and maximise research impact. This protocol outlines a systemic multi-sectoral approach to advance health research impact globally applied to a project to reduce population salt intake in Vietnam by introducing reduced-sodium salts and salty condiments. We defined a systemic multi-sectoral approach to be a strategy that involves engaging with government, market and communities in a deliberate and joined-up way to solve a problem in which they all have a role to play. The project objectives are to: (i) produce reduced-sodium fish sauce products and test consumer acceptability; (ii) investigate the market feasibility of introducing reduced-sodium foods (salt, bot canh and fish sauce) into the Vietnamese market; (iii) estimate the cost-effectiveness of three different government strategies to support the implementation of reduced-sodium products; and (iv) develop an advocacy roadmap to maximise potential research impact. Methods will include standard quality and safety assessments, consumer sensory testing for the locally produced reduced-sodium fish sauces, market feasibility assessment (including collating market data and semi-structured interviews with stakeholders), cost-effectiveness modelling (Markov cohort model), multi-sector stakeholder engagement, and the development of a coordinated advocacy strategy using the Kotter Plus framework. Health research organisations are increasingly seeking ways to achieve greater impact with their research. Through the application of a systemic multi-sectoral approach with governments, markets and communities, this protocol provides an example of how health research projects can achieve such impact.

Lower Strength Alcohol Products-A Realist Review-Based Road Map for European Policy Making

This paper reports the result of a realist review based on a theory of change that substitution of higher strength alcohol products with lower strength alcohol products leads to decreases in overall levels of alcohol consumption in populations and consumer groups. The paper summarizes the results of 128 publications across twelve different themes. European consumers are increasingly buying and drinking lower strength alcohol products over time, with some two fifths doing so to drink less alcohol. It tends to be younger more socially advantaged men, and existing heavier buyers and drinkers of alcohol, who take up lower strength alcohol products. Substitution leads to a lower number of grams of alcohol bought and drunk. Although based on limited studies, buying and drinking lower strength products do not appear to act as gateways to buying and drinking higher strength products. Producer companies are increasing the availability of lower strength alcohol products, particularly for beer, with extra costs of production offset by income from sales. Lower strength alcohol products tend to be marketed as compliments to, rather than substitutes of, existing alcohol consumption, with, to date, the impact of such marketing not evaluated. Production of lower strength alcohol products could impair the impact of existing alcohol policy through alibi marketing (using the brand of lower strength products to promote higher strength products), broadened normalization of drinking cultures, and pressure to weaken policies. In addition to increasing the availability of lower strength products and improved labelling, the key policy that favours substitution of higher strength alcohol products with lower strength products is an alcohol tax based on the dose of alcohol across all products.

Using Digital Platform Approach to Reduce Salt Intake in a Sample of UAE Population: An Intervention Study

Background

Non-communicable diseases (NCDs) are the leading causes of mortality globally, accounting for more deaths than all other causes combined. World Health Organization launched its initiative in 2013 to reduce the intake of salt, the number of countries that have national sodium reduction strategies reached to 89 countries in 2017. In 2020, a study conducted in UAE showed more than 65% of the population exceeded WHO recommendations for salt intake. This study aimed to measure effectiveness of using digital platform approach to deliver educational materials to facilitate salt reduction in a sample of UAE population.

Methods

A controlled parallel intervention study was conducted in 2020. A sample of 121 participants completed the study and fulfilled the inclusion criteria with female to male ratio of (0.95:1.05). Participants were distributed randomly into three groups Control group, WhatsApp group, and Electronic Brochures group. Educational materials were distributed among participants of WhatsApp and Electronic brochures groups for 6-weeks. 24-h urinary excretion for sodium, potassium and creatinine, were measured in addition to KAP questionnaire and physical activity on two occasions at baseline and endpoint after 10-weeks (6-weeks of educational intervention).

Results

Both intervention groups showed a reduction in sodium with 278 mg (p < 0.001) for WhatsApp group (n = 41) and 169 mg (p < 0.018) for Electronic brochures group (n = 41), while Control group didn't show any significant change. Moreover, the percentage of participants exceeding WHO recommendation of sodium intake was significantly reduced at the end of intervention, (p = 0.004). WhatsApp group was more efficient in the percentage of reduction of participants exceeding WHO recommendation compared with baseline, with p = 0.023. A significant reduction in the practice toward adding salt during cooking, use of table salt, adding salt before tasting the foods and use of chicken stocks for both intervention groups was noted with p < 0.05. Intervention groups showed a significant improvement (p < 0.001) in Food and Health related knowledge after 6-weeks of intervention.

Conclusion

The digital platform approach such as WhatsApp and Electronic Brochure were effective in salt reduction. This study proves that UAE population is ready to reduce salt intake with appropriate education materials and easy delivery approach.

Cost-effectiveness of a Household Salt Substitution Intervention: Findings From 20,995 Participants of the Salt Substitute and Stroke Study (SSaSS)

Background:: The Salt Substitute and Stroke Study (SSaSS) ─ a five-year cluster randomized controlled trial, demonstrated that replacing regular salt with a reduced-sodium added-potassium salt substitute reduced the risks of stroke, major adverse cardiovascular events and premature death among individuals with prior stroke or uncontrolled high blood pressure living in rural China. This study assessed the cost-effectiveness profile of the intervention. Methods: A within-trial economic evaluation of SSaSS was conducted from the perspective of the healthcare system and consumers. The primary health outcome assessed was stroke and we also quantified effects on quality-adjusted life years (QALYs). Healthcare costs were identified from participant health insurance records and the literature. All costs (Chinese Yuan - CNY ¥) and QALYs were discounted at 5% per annum. Incremental costs, stroke events averted, and QALYs gained were estimated using bivariate multilevel models. Results: Mean follow-up of the 20,995 participants was 4.7 years. Over this period, replacing regular salt with salt substitute reduced the risk of stroke by 14% (rate ratio 0.86, 95% confidence interval 0.77 to 0.96; p=0.006) and the salt substitute group had on average 0.054 more QALYs per person. The average costs (CNY ¥1,538 for the intervention group and CNY ¥1,649 for the control group) were lower in the salt substitute group (CNY ¥110 less). The intervention was dominant (better outcomes at lower cost) for prevention of stroke as well as for QALYs gained. Sensitivity analyses showed that these conclusions were robust, except when the price of salt substitute was increased to the median and highest market prices identified in China. The salt substitute intervention had a 95.0% probability of being cost-saving, and a greater than 99.9% probability of being cost-effective. Conclusions: Replacing regular salt with salt substitute was a cost-saving intervention for the prevention of stroke and improvement of quality of life amongst the SSaSS participants.

Application of a salt substitute in bitter taste suppression and toward better acceptance of cruciferous vegetables in diet

The addition of table salt has been reported to enable better acceptance when consuming the least preferred vegetables belonging to the Cruciferae family. Considering the adverse effect of excessive table salt intake on incidence of hypertension and cardiovascular diseases, it is essential to explore an alternative healthier option for better acceptance and to encourage consumption of these vegetables. In this study, 261 adult participants were evaluated for their preferences toward basic tastes and food as well as sensory evaluation of a meal prepared from cruciferous vegetables with the addition of two different salts, sodium chloride and salt substitute containing a blend of potassium and sodium salts. A general questionnaire was used to assess taste and food preferences, while the Cruciferous Vegetable Food Frequency Questionnaire (CVFFQ) was used for vegetable intake assessment. The Labeled Magnitude Scale (LMS), Just About Right (JAR) scale, and several hedonic scales were used to determine taster status and sensory evaluation. The results show that a low concentration of the salt substitute did not impact bitterness suppression but did result in higher preference of the cruciferous vegetable meal. Although, subjects self-reported to have salty taste preferences were more sensitive to bitter taste, they did not perceive samples as less salty and less acceptable than subjects with lower sensitivity. The results show the necessity for further examination of the effectiveness of different concentrations of the assessed salt substitute in suppressing perceived bitterness of cruciferous vegetables and regarding their overall acceptance for inclusion in diets.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam

OBJECTIVE

To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC).

DESIGN

Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy.

SETTING

Argentina, Mongolia, South Africa and Vietnam.

PARTICIPANTS

Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes.

RESULTS

Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts.

CONCLUSIONS

Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

Estimated reductions in added sugar intake among U.S. children and youth in response to sugar reduction targets

BACKGROUND

In 2021, the National Salt and Sugar Reduction Initiative (NSSRI) released voluntary sugar reduction targets for packaged foods and drinks in the United States (U.S).

OBJECTIVE

The objectives of this study were to describe trends in added sugar intake from NSSRI foods and beverages among children and youth and estimate possible reductions if industry were to meet the targets.

DESIGN

This study consisted of cross-sectional and trend analyses of demographic and 24-hour dietary recall data from eight survey cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey (NHANES).

PARTICIPANTS/SETTING

The study sample included 23,248 children and youth (aged 2-19 years).

MAIN OUTCOME MEASURES

The main outcome measure was the percent of daily calories from added sugar for foods and beverages in NSSRI categories.

STATISTICAL ANALYSES PERFORMED

Foods and beverages reported by participants were mapped to one of the NSSRI's categories or coded as a non-NSSRI item. Trends over time in added sugar intake were assessed using regression models. To assess possible reductions in added sugar intake if industry were to meet the targets, sales-weighted mean percent reductions for 2023 and 2026 targets were applied to NSSRI items in the 2017-2018 NHANES data. Results were examined overall and by demographic characteristics.

RESULTS

From 2003-2004 to 2017-2018, added sugar intake from NSSRI foods and beverages declined, but consumption remained high. In 2017-2018, NSSRI categories accounted for 70% of U.S. child and youth added sugar intake. If industry met the NSSRI targets, U.S. children and youth would consume 7% (2023 targets) to 21% (2026 targets) less added sugar.

CONCLUSIONS

While added sugar intake from NSSRI foods and drinks has declined over the past decade, added sugar intake from all sources remains high and consumption of added sugar from certain NSSRI categories has remained steady over time. If met, the NSSRI targets are expected to result in meaningful reductions in added sugar intake for U.S. children and youth.

Edible Mushrooms as a Natural Source of Food Ingredient/Additive Replacer

Although mushrooms have been exploited since ancient times because of their particular taste and therapeutic properties, the interest in edible species as a source of ingredients and bioactive compounds is recent. Their valuable nutritional contents in protein, dietary fiber and bioactive compounds make them ideal candidates for use in foods in efforts to improve their nutritional profiles. This trend is in line with the consumer's growing demand for more plant-based foods. The present review paper explores different studies focused on the use of common edible mushrooms as an ingredient and additive replacer by using them in fresh, dried, or even extract forms, as meat, fat, flour, salt, phosphates, and antioxidant replacers. The replacement of meat, fat, flour, and salt by mushrooms from commercial species has been successful despite sensorial and textural parameters can be affected. Moderate concentrations of mushrooms, especially in powder form, should be considered, particularly in non-familiarized consumers. In the case of antioxidant and antimicrobial properties, results are variable, and more studies are necessary to determine the chemical aspects involved.

Barriers and Facilitators to Implementing Reduced-Sodium Salts as a Population-Level Intervention: A Qualitative Study

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.

Core Strategies to Increase the Uptake and Use of Potassium-Enriched Low-Sodium Salt

Excess sodium consumption and insufficient potassium intake contribute to high blood pressure and thus increase the risk of heart disease and stroke. In low-sodium salt, a portion of the sodium in salt (the amount varies, typically ranging from 10 to 50%) is replaced with minerals such as potassium chloride. Low-sodium salt may be an effective, scalable, and sustainable approach to reduce sodium and therefore reduce blood pressure and cardiovascular disease at the population level. Low-sodium salt programs have not been widely scaled up, although they have the potential to both reduce dietary sodium intake and increase dietary potassium intake. This article proposes a framework for a successful scale-up of low-sodium salt use in the home through four core strategies: availability, awareness and promotion, affordability, and advocacy. This framework identifies challenges and potential solutions within the core strategies to begin to understand the pathway to successful program implementation and evaluation of low-sodium salt use.

Are there socio-demographic differences in salt behaviours and fruit and vegetable consumption in Australian adults? A nationally representative cross-sectional survey

BACKGROUND

Diets low in fruit and vegetables and high in salt are among the top dietary risk factors for non-communicable diseases (NCDs). Using a nationally representative sample of Australians, this study aimed to describe self-reported intake of fruit and vegetables, and knowledge, attitudes and behaviours related to salt intake, and determine if there were socio-demographic differences between population subgroups.

METHODS

A 2016 cross-sectional survey of Australian adults aged 18 years and over, which comprised 160 questions, including socio-demographic and health-related questions. Descriptive statistics (mean, 95% confidence interval, %) were calculated. Weighted-adjusted logistic regression models were used to determine if there were socio-demographic differences in salt behaviours and fruit and vegetable consumption.

RESULTS

A total of 1217 participants completed the survey (51% female). Less than 8% of participants reported consuming the recommended 2 or more serves of fruit and 5 or more serves of vegetables. Almost 60% of participants frequently added salt during cooking/meal preparation and 42% of respondents frequently placed a salt-shaker on the table at mealtimes. There were no consistent patterns between socio-demographic factors and measures of fruit and vegetable consumption and salt behaviours. Differences in at least one measure were found for sex, age, location, education level and weight category.

CONCLUSIONS

There were no consistent patterns between socio-demographic factors and salt behaviours and fruit and vegetable intake. Less than recommended intakes of fruit and vegetables and frequent discretionary salt use are placing Australians at risk of diet-related NCDs. Broad population-based policies and programs to improve fruit and vegetable intake and salt behaviours are needed to improve Australian's diets.

Receiving advice from a health professional and action taken to reduce dietary sodium intake among adults

OBJECTIVE

Population reductions in Na intake could prevent hypertension, and current guidelines recommend that clinicians advise patients to reduce intake. This study aimed to estimate the prevalence of taking action and receiving advice from a health professional to reduce Na intake in ten US jurisdictions, including the first-ever data in New York state and Guam.

DESIGN

Weighted prevalence and 95 % CI overall and by location, demographic group, health status and receipt of provider advice using self-reported data from the 2017 Behavioral Risk Factor Surveillance System optional Na module.

SETTING

Seven states, the District of Columbia, Puerto Rico and Guam.

PARTICIPANTS

Adults aged ≥ 18 years.

RESULTS

Overall, 53·6 % (95 % CI 52·7, 54·5) of adults reported taking action to reduce Na intake, including 54·8 % (95 % CI 52·8, 56·7) in New York and 61·2 % (95 % CI 57·6, 64·7) in Guam. Prevalence varied by demographic and health characteristic and was higher among adults who reported having hypertension (72·5 %; 95 % CI 71·2, 73·7) v. those who did not report having hypertension (43·9 %; 95 % CI 42·7, 45·0). Among those who reported receiving Na reduction advice from a health professional, 82·6 % (95 % CI 81·3, 83·9) reported action v. 44·4 % (95 % CI 43·4, 45·5) among those who did not receive advice. However, only 24·0 % (95 % CI 23·3, 24·7) of adults reported receiving advice from a health professional to reduce Na intake.

CONCLUSIONS

The majority of adults report taking action to reduce Na intake. Results highlight an opportunity to increase Na reduction advice from health professionals during clinical visits to better align with existing guidelines.

Availability, Formulation, Labeling, and Price of Low-sodium Salt Worldwide: Environmental Scan

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

Guideline-Driven Management of Hypertension: An Evidence-Based Update

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.