The Association of Knowledge and Behaviours Related to Salt with 24-h Urinary Salt Excretion in a Population from North and South India

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.

Understanding knowledge, attitudes and behaviours related to dietary sodium intake in a multi-ethnic population in Singapore

OBJECTIVE

This study aimed to fill the current gap in the understanding of the knowledge, attitudes and behaviours (KAB) related to dietary Na among adult residents in Singapore.

DESIGN

A cross-sectional online survey was conducted between October and December 2020 on 955 participants selected through random sampling.

SETTING

The survey was conducted in Singapore.

PARTICIPANTS

Participants were recruited from the Singapore Population Health Study Online Panel.

RESULTS

Participants' mean age was 46·6 ± 14·1 years old and 58 % of them were females. Most of the participants were Chinese (82·1 %), 10·5 % were Indian and 4·5 % were Malay. Findings from the weighted data showed that most participants were aware of the health impact of high Na consumption. However, many participants were unaware of the recommended intake for salt (68%) and Na (83%), had misconceptions, and were unable to correctly use food labels to assess NA content (69%). Findings also alluded to the presence of knowledge gaps in the sources of Na in their diet. While 59 % of the participants reported to be limiting their consumption of Na, many reported facing barriers such as not knowing how to limit their Na intake. Participants also felt that there were limited options for low-Na foods when eating out and were lacking awareness of low-Na products.

CONCLUSIONS

Findings highlighted substantial gaps in participants' knowledge and skills in managing their Na consumption. This suggests the need for more public education and improvements in the food environment.

Pertinence of Salt-Related Knowledge and Reported Behaviour on Salt Intake in Adults: A Cross-Sectional Study

The association between salt-related knowledge, attitude, behaviour (KAB) and actual salt consumption in Greek adults is uncertain. This study investigates the correlation between salt intake, gauged by 24-h urinary sodium excretion, with salt-related KAB. It further explores how socio-demographic factors influence these behaviors. Salt consumption was evaluated using a 24-h urinary sodium test, and compared to self-reported KAB data. Knowledge and behavior scores related to salt were computed. An overall cohort-adjusted model examined the relationship between daily salt consumption, knowledge and behavior scores, and certain covariates. Through the stratification by the cohort random effect, two models were established (Cohort I Adults; Cohort II Students) examining the same relationships of the overall cohort model. 463 Greek adults participated. The average salt intake was 9.54 g/day, nearly double the WHO recommendation. Significant differences in knowledge scores were noted based on sex, age, education, and BMI. A trend suggesting lower discretionary salt use with increased salt intake was observed (p = 0.06). However, comprehensive analysis revealed no direct correlation between salt intake and either knowledge (p = 0.562) or behavior scores (p = 0.210). The results emphasize the need for food product reforms by industry stakeholders and accelerated efforts towards reducing salt intake.

Awareness, behavior, and determinants of dietary salt intake in adults: results from the National NCD Monitoring Survey, India

A diet high in sodium contributes to a significant proportion of Disability Adjusted Life Years (DALYs) due to cardiovascular diseases. This paper describes the awareness, behaviour and determinants related to dietary salt intake in an adult population of 18-69 years that were assessed as part of the National NCD Monitoring Survey (NNMS) in India. A sub-sample of 3000 adults selected through simple random sampling from 150 nationally representative Primary Sampling Units (PSUs) was included. Data regarding awareness and behaviour related to dietary salt intake were collected. Urinary sodium excretion in spot urine samples was estimated and used to calculate dietary salt intake. The dietary salt intake's sociodemographic, behavioural and metabolic determinants were also analysed. Less than one-third of the adults of both genders in all age groups in rural and urban areas were aware that daily high salt intake could affect health. The estimated mean daily salt intake was 8.0 g (8.9 g/day for men and 7.1 g/day for women). The salt intake was significantly higher in men [Adjusted OR = 17.66 (5.24-59.46)], rural areas [Adjusted OR = 6.14 (1.83-20.60)], overweight and obese respondents [Adjusted OR = 17.62 (3.17-98.07)]. The perception of the harmful effects of high salt intake and practices to limit salt intake was low in the study population. The mean daily salt intake was higher than the WHO recommendation of up to 5 g daily. The mean dietary salt intake is high in the Indian population, which calls for planning and implementing control of dietary salt consumption measures.

Eater-oriented knowledge framework for reducing salt and dietary sodium intake (scoping review)

Salt and dietary sodium are ubiquitously present in daily food practices and, at the same time, reducing salt intake presents an important public health issue. Given such an ambivalent position of salt in human diet, we argue that public health guidelines toward dietary sodium reduction require an eater-oriented knowledge framework. In this article we are making the first steps toward a flexible interdisciplinary database which would include nutritional, socio-economic, cultural, material, and socio-psychological determinants of salt consumption for comprehensive public health campaigns. We employ an explorative scoping review of academic articles and reports, limiting our review to the original data on salt or sodium consumption published in English or French between 2000 and 2022. We describe salt consumption as research object, identifying its representation in different research fields, data sources, methodologies, samples, and links with nutritional recommendations. We synthesize existing approaches via four eater-oriented categories: Socio-demographic and cultural descriptors of salt consumers; Knowledge, attitudes, and beliefs on nutritional norms; Salt practices associated with dietary or medical regimes; Salt materialities: interactions and contexts. In each category, we identify the dominant relational features, i.e., what kind of 'eater-salt' relation is being put forward. We thus build an interdisciplinary documentary base of dietary sodium consumption factors. We discuss the results, suggesting that comprehensive nutritional policies for global salt reduction require interdisciplinary eater-oriented data frameworks.

Salt-related practices and its association with 24-hour urinary sodium excretion in an Uruguayan population cohort

Objectives.

To evaluate the association between knowledge, attitudes, and behavior (KAB) towards sodium use and sodium intake measured by 24-hour urinary collection in an adult cohort from Uruguay (Genotype Phenotype and Environment of Hypertension Study, GEFA-HT-UY).

Methods.

In a cross-sectional study (n = 159), a single 24-hour urinary sample, participants' physical, biochemical and blood pressure measurements and questionnaire data were collected. The association between KAB and 24-hour urinary sodium excretion was assessed using general linear models.

Results.

Mean age of participants was 49.8±15.5 years, 67.9% were women, and mean 24-hour urinary sodium excretion was 3.6±1.7 g/day. Although 90.6% of participants exceeded the maximum recommended intake as indicated by urinary sodium excretion, more than half misperceived their actual intake, reporting consuming “the right amount.” Almost three-quarters of the participants reported being concerned about the amount of sodium in their diet, but only 52.8% reported taking action to control it. Lack of procedural knowledge was observed. There was no association between KAB and sodium use and intake assessed by 24-hour urinary sodium excretion.

Conclusions.

The lack of association between KAB towards the use of sodium and intake measured by 24-hour urinary excretion reflects the need to support people with opportunities and motivations to reduce sodium consumption. Structural actions to promote an adequate food environment, such as the effective implementation of the front-of-package nutrition labeling in Uruguay, are positive steps.

The association of knowledge, attitudes and behaviors related to salt with 24-h urinary sodium, potassium excretion and hypertensive status

To understand the association between sodium and potassium consumption levels, hypertension and knowledge, attitudes and behaviors (KAB) toward salt and the commitment to effective sodium reduction and potassium supplementation to achieve the purpose of suppressing hypertension. A stratified multistage random sampling method was used to obtain a representative provincial sample of 7512 residents aged 18-69 years through a cross-sectional survey by the Salt Reduction and Hypertension Prevention Project (SRHPP) in Zhejiang Province of China in 2017-2018. A screening including demographic, anthropometric, salt-related KAB and physical measurements was implemented, and 24-h urine of approximately 1/5 of the participants was collected and tested. The mean age was 44.8 years, 50.1% were women, 44.0% lived in urban areas, and hypertension or prehypertension accounted for approximately 35.0%. The mean 24-h urinary sodium and potassium excretion were 3848.5 (1661.1) mg/d and 1491.1 (710.9) mg/d, respectively. KAB in urban areas was generally more favorable than in rural areas, women were better than men, and the optimal blood pressure group was better than the other two groups (P < 0.05). However, the awareness and correct use rate of salt-restricted spoons, low-sodium salt and nutrition labeling were lower. A multivariable linear regression model indicated that KAB had a smaller effect on sodium (two indicators effective for promoting sodium reduction) and a greater effect on potassium (six indicators effective for promoting potassium supplementation) and mainly focused on knowledge and behavior indicators. A multivariable logistic regression model indicated that mastering more knowledge and taking active measures could effectively reduce the transition to hypertension, even if the individual was already in prehypertension. There is much room for improvement of salt-related KAB in the Chinese population. A clear association indicates that KAB can help to reduce sodium and supplement potassium, especially potassium, and help to suppress the development of hypertension. The role of beliefs in KAB should be fully valued and improved, similar to knowledge and behaviors. This study provides important evidence and insight into China's efforts to meet the targets of salt reduction and hypertension prevention.

The Magnitude of Salt Intake Behaviors and Its Predictors among Saqez Urban Population of Kurdistan District in Iran: A Cross-Sectional Study

Background

Controlling and reducing salt intake are one of the solutions to overcome hypertension. This study aimed at determining the predictors related to salt control methods in Saqez urban population.

Methods and Materials

In the present cross-sectional study, the sample population was randomly selected through cluster sampling. Data collection was performed using valid questionnaires, demographic, family economic status, knowledge, perception, intention, salt intake behaviors, and salt control methods, along with measuring body mass index (BMI) and hypertension levels. Descriptive, analytical statistical methods and multivariate logistic regression analysis were used to determine the predictors of desirable salt control methods. The variables of sex, age, family economic status, knowledge, perception, perceived social support, self-efficacy, and intention were analyzed as independent variables. Data analysis was performed using SPSS software version 24 at a significance level of 0.05.

Results

Out of 766 participants, 73% were women, with mean (M) 32.83, standard deviation (SD) 9.52 years, and 77.2% were married. There were significant sex differences in employment (P=0.01) and economic status (P=0.016). The M (SD) of blood pressure (systolic/diastolic) was 110.65 (0.0212) (P=0.441). The salt intake control methods between men and women did not show significant differences (P=0.368). Among totally 88.5%, 87.7% men and 88.9% women followed desirable behaviors. The predictors that determine the adoption of salt control methods were sex (man) (OR = 0.71, 95% CI (0.38–1.29)), age (OR = 1.02, 95% CI = (0.99–1.05)), SES/FAS (medium, high level) (OR = 1.37, 95% CI = (0.754–2.47); OR = 0.46, 95% CI = (0.047–4.55)), blood pressure (OR = 1.33, 95% CI = (0.16–11.23)), knowledge (have) (OR = 1.01, 95% CI = (0.39–1.63)), intent to reduce salt (OR = 1.047, 95% CI = (1.03–1.06)), perceived salt reduction importance (OR = 1.02, 95% CI = (1.01–1.04)), perceived emotional support (health staff) (OR = 1.02, 95% CI = (1.01–1.04)), media (OR = 1.01, 95% CI = 0.99–1.02), perceived practical support (spouse) (OR = 1.02, 95% CI = 0.99–1.04)), and perceived self-efficacy (OR = 1.01, 95% CI = (0.99–1.03)).

Conclusion

The support of health staff and spouse seems to be effective in controlling the salt intake behaviors of healthy individuals. In parallel with the development and change of people's lifestyles, new approaches (legal and services) for salt control based on the support of media and social media were expected.

Validity of predictive equations for 24-h urinary sodium excretion at the population and individual levels among Chinese adults aged 18-69 years

Spot urine (SU) collection is a convenient method commonly used for sodium estimation, but its validity in predicting 24-h urinary sodium (24-hUNa) excretion has not been thoroughly evaluated among the general population. The aim of this study was to comprehensively assess the validity of eight existing methods in predicting 24-hUNa excretion by using SU samples among Chinese adults. We analyzed 1424 representative individuals aged 18 to 69 years. We compared the measured and estimated measurements of 24-hUNa at the population level by examining bias, the correlation, intraclass correlation coefficients (ICCs), receiver operating characteristic (ROC) curves and Bland–Altman plots and analyzed the relative and absolute differences and misclassification at the individual level. The bias for all methods was significant (all p < 0.001), among which the smallest bias was − 7.9 mmol for the Toft formula and the largest bias was − 53.8 mmol for the Mage formula. Correlation coefficients were all less than 0.380, all formulas exhibited an area under the ROC curve below 0.683, and the Bland–Altman plots indicated slightly high dispersion of the estimation biases at higher sodium levels regardless of the formula. The proportions of relative differences > 40% for the eight methods were all over one-third, the proportions of absolute differences > 51.3 mmol/24 h (3 g/day NaCl) were all over 40%, and the misclassification rates (7, 10, and 13 g/day NaCl as cutoff points) were all over 65%. Caution remains due to poor validity between estimated and actual measurements when using the eight formulas to obtain a plausible estimation for surveillance of the Chinese population sodium excretion, and the results do not support the application of SU to estimate sodium intake at the individual level due to its poor performance with respect to classification.

The Complex Role of Cognitive and Behavioral Factors in Salt Intake Levels of Women

Background

High salt intake is responsible for some serious health consequences. This study aims to investigate the interrelationship between salt intake cognitive and behavioral factors and urinary sodium excretion levels in women.

Methods

A descriptive analytical cross-sectional study was conducted in two residential complexes in Ahvaz city, Iran. 260 female participants were selected using systematic random sampling. Data on salt-related cognitive factors, including knowledge, perceived susceptibility, perceived severity, attitude, intention, self-efficacy, and behavior, were collected using a validated questionnaire. To determine true salt intake, 24-hour urinary sodium excretion level was measured. Data was analyzed using Pearson correlation, one-way Anova, and linear regression tests.

Results

81.2% of the participants’ salt intake was higher than the WHO recommended value (5 grams/day). A significant relationship between sodium excretion level and knowledge (r = –0.332, p < 0.001), attitude (r = –0.144, p = 0.02), behavior (r = –0.130, p = 0.036), and perceived severity (r = –0.135, p = 0.03) was found. An R² of 0.134 demonstrates a 13.4% variation in urinary sodium excretion, associated with knowledge and perceived severity.

Conclusion

Future interventions should aim to improve all the salt-related cognitive factors with placing an emphasis on increasing salt-related knowledge and perceived severity.

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.

Use of Salt-Restriction Spoons and Its Associations with Urinary Sodium and Potassium in the Zhejiang Province of China: Results of a Population-Based Survey

In China, a major source of sodium is salt added during cooking. In this context, use of a salt-restriction spoon (SRS) has been promoted in public health campaigns and by health care providers. To describe use of and factors associated with SRS use, knowledge of correct use, and actual correct use. This study is a population-based, representative survey of 7512 residents, aged 18 to 69 years, of China’s Zhejiang Province. The survey, which was conducted in 2017 using a multistage random sampling strategy, collected demographic information, SRS use, and physical measurements; a 24-h urine collection was obtained from 1,496 of the participants. The mean age of the participants was 44.8 years, 50.1% were females, and over 1/3 (35.3%) were classified as hypertensive. Mean 24-h urinary sodium and potassium excretions were 167.3(72.2) mmol/24 h and 38.2(18.2) mmol/24 h, respectively. Only 12.0% (899/7512) of participants once used or were currently using SRS; of the 899 users, 73.4% knew how to use the SRS correctly, and just 46.5% actually used it correctly. SRS use was more commonly associated with behavioral factors rather than socio-demographic factors. Initiation of SRS use by health care providers was associated with correct technical knowledge of SRS. Lower sodium-to-potassium ratio was associated with SRS use, while SRS use was not associated with urinary sodium and potassium excretion. Use of SRS was uncommon in Zhejiang Province of China. Given that a common source of sodium in China is salt added during cooking, use of SRS is an appealing strategy, ideally as part of a multi-component campaign.

Association between 24-h urinary sodium and potassium excretion and blood pressure among Chinese adults aged 18-69 years

The direction and magnitude of the association between sodium and potassium excretion and blood pressure (BP) may differ depending on the characteristics of the study participant or the intake assessment method. Our objective was to assess the relationship between BP, hypertension and 24-h urinary sodium and potassium excretion among Chinese adults. A total of 1424 provincially representative Chinese residents aged 18 to 69 years participated in a cross-sectional survey in 2017 that included demographic data, physical measurements and 24-h urine collection. In this study, the average 24-h urinary sodium and potassium excretion and sodium-to-potassium ratio were 3811.4 mg/day, 1449.3 mg/day, and 4.9, respectively. After multivariable adjustment, each 1000 mg difference in 24-h urinary sodium excretion was significantly associated with systolic BP (0.64 mm Hg; 95% confidence interval [CI] 0.05-1.24) and diastolic BP (0.45 mm Hg; 95% CI 0.08-0.81), and each 1000 mg difference in 24-h urinary potassium excretion was inversely associated with systolic BP (- 3.07 mm Hg; 95% CI - 4.57 to - 1.57) and diastolic BP (- 0.94 mm Hg; 95% CI - 1.87 to - 0.02). The sodium-to-potassium ratio was significantly associated with systolic BP (0.78 mm Hg; 95% CI 0.42-1.13) and diastolic BP (0.31 mm Hg; 95% CI 0.10-0.53) per 1-unit increase. These associations were mainly driven by the hypertensive group. Those with a sodium intake above about 4900 mg/24 h or with a potassium intake below about 1000 mg/24 h had a higher risk of hypertension. At higher but not lower levels of 24-h urinary sodium excretion, potassium can better blunt the sodium-BP relationship. The adjusted odds ratios (ORs) of hypertension in the highest quartile compared with the lowest quartile of excretion were 0.54 (95% CI 0.35-0.84) for potassium and 1.71 (95% CI 1.16-2.51) for the sodium-to-potassium ratio, while the corresponding OR for sodium was not significant (OR, 1.28; 95% CI 0.83-1.98). Our results showed that the sodium intake was significantly associated with BP among hypertensive patients and the inverse association between potassium intake and BP was stronger and involved a larger fraction of the population, especially those with a potassium intake below 1000 mg/24 h should probably increase their potassium intake.

Dietary sodium and potassium intake: knowledge, attitude and behaviour towards dietary salt intake among adults in Addis Ababa, Ethiopia

OBJECTIVE

The present study aimed to estimate the consumption of Na and K and to assess salt-related knowledge, attitude and behaviour among adults in Addis Ababa, Ethiopia.

DESIGN

A community-based cross-sectional study was conducted. Estimates of Na and K intake were made using repeated multiple-pass 24-h dietary recall as well as using random urine. The usual intake of Na and K from the 24-h dietary recall was determined using the National Cancer Institute methodology. Estimated 24-h Na and K excretion was calculated using International Cooperative Study on Salt, Other Factors, and Blood Pressure and Tanaka formula.

SETTINGS

Addis Ababa, the capital city of Ethiopia.

PARTICIPANTS

Individuals aged 20 years and above residing in the city.

RESULT

The mean Na and K intake estimated using the diet recall data was 3·0 (0·9) g/d and 1·9 (0·6) g/d, respectively. Based on the urine analysis, the estimated mean Na and K intakes were 3·3 (0·7) g/d and 1·9 (0·4) g/d, respectively. Moreover, the analysis showed that the mean Na:K ratio was 2·5 (1·4). The daily intake of K was below the recommended amount for all study participants. More than 98 % and 90 % of participants had an excess intake of Na and Na:K ratio, respectively.

CONCLUSION

We found a high prevalence of inadequate K intake as well as excess intake of Na resulting in an increased prevalence of excess Na:K ratio. Thus, interventions targeting to decrease Na intake and to increase K intake are needed.

The Predictors of High Dietary Salt Intake among Hypertensive Patients in Iran

Background

Hypertension and its complications are among the major health problems all over the world, particularly in developing countries. The aims of this study were to show that, weather the hypertensive patients follow the expertise recommendations and differences between men and women in their levels of knowledge and behavior in salt taking.

Methods

The present cross-sectional study was conducted among all hypertensive patients in rural health centers of Tabriz, Iran, in Feb-May; 2016. Data were collected by an interviewer-administrated questionnaire, along with anthropometric, blood pressure, and 24-hour urinary sodium excretion measurements. Multivariate logistic regression analysis was used to compute adjusted odds ratio (OR).

Results

In all 205 patients, 62.9% female, 40.5% aged over 60 years, and 53.7% with low or moderate socioeconomic status, 49.3% body mass index (BMI) 30 kg/m² and above, 10.2% of the patients had systolic/diastolic equal and above (≥) 40/90 mmHg, participated in the study. In total, 16.6% were aware of the daily salt allowance for healthy people with sex difference (P < 0.001). Significant predictors of adding salt beyond the dietary recommendations in food preparation were occupation (unemployed) (OR = 4.05, 95% CI = 1.041-15.78, (P = 0.044)) and blood pressure level (systolic/diastolic ≥140/90) (OR = 2.76, 95% CI = 1.28-5.96 (P = 0.010)), while adding salt at the table correlated with sex (men) (OR = 4.47, 95% CI = 1.21-16.57 (P = 0.025)), age (54-59) (OR = 0.05 95% CI = 0.01-0.39, (P = 0.005)), and knowledge (general) (OR = 1.06, 95% CI = 0.99-1.13 (P = 0.05)).

Conclusion

The different pattern of salt intake was observed between men and women. In general, the amount of salt taken by hypertensive patients is higher than recommended allowances. Both men and women add extra amount of salt to food, women when preparing food and men at the table. Salt intake level both during preparing and eating food may be associated with occupation (unemployed), blood pressure level (systolic/diastolic ≥140/90), sex (men), age (54-59), and also patient knowledge (general).

Sources of Dietary Salt in North and South India Estimated from 24 Hour Dietary Recall

Recent data on salt intake levels in India show consumption is around 11 g per day, higher than the World Health Organization's (WHO) recommended intake of 5 g per day. However, high-quality data on sources of salt in diets to inform a salt reduction strategy are mostly absent. A cross-sectional survey of 1283 participants was undertaken in rural, urban, and slum areas in North (n = 526) and South (n = 757) India using an age-, area-, and sex-stratified sampling strategy. Data from two 24-h dietary recall surveys were transcribed into a purpose-built nutrient database. Weighted salt intake was estimated from the average of the two recall surveys, and major contributors to salt intake were identified. Added salt contributed the most to total salt intake, with proportions of 87.7% in South India and 83.5% in North India (p < 0.001). The main food sources of salt in the south were from meat, poultry, and eggs (6.3%), followed by dairy and dairy products (2.6%), and fish and seafood (1.6%). In the north, the main sources were dairy and dairy products (6.4%), followed by bread and bakery products (3.3%), and fruits and vegetables (2.1%). Salt intake in India is high, and this research confirms it comes mainly from added salt. Urgent action is needed to implement a program to achieve the WHO salt reduction target of a 30% reduction by 2025. The data here suggest the focus needs to be on changing consumer behavior combined with low sodium, salt substitution.

Knowledge and behaviors related to dietary salt and sources of dietary sodium in north India

Sodium, an element needed for the normal human physiology is known to be associated with high blood pressure and other consequences if consumed in excess. The assessment of knowledge and behavior related to sodium that is consumed in the form of salt plays an important role in the control of cardiovascular diseases. To control the intake of sodium, dietary sources of sodium need to be identified. To address this, a community-based cross-sectional study was conducted among women aged 20 to 59 years in north India, where knowledge, attitude, and behavior questionnaire given by the World Health Organization and 24-h dietary recall were used. The mean age of the participants was 34.5 years, and the majority of them were homemakers. Approximately, 80% of the participants believed that high salt diet causes serious health problems, and only 5% of the participants were aware of the existence of a recommendation for daily salt intake. Less than 20% of the participants took measures to control their salt intake. Vegetable-based dishes were found to be the major contributors to the daily salt intake followed by pulse-based and cereal-based dishes. This is because of the high quantity in which they are consumed. Food cooked at home contributed to 90% of the daily salt intake. To control the salt intake, we should cut- down the discretionary salt use. Dietary advice should be customized to the individual, and the family physician plays an important role in this. Behavioral change is the need of the hour to control the epidemic of non-communicable diseases.

Knowledge, attitudes and practices related to dietary salt intake among adults in North India

OBJECTIVE

To assess the knowledge, attitudes and practices related to salt consumption among adults in rural and urban North India.

DESIGN

Data for the study were obtained from a community-based cross-sectional survey using an interviewer-administered questionnaire and 24 h urine samples.

SETTING

Data collection was conducted during March-October 2012 in rural Haryana and urban Delhi in North India.

PARTICIPANTS

Adults (n 1635) aged ≥20 years (701 in rural Haryana; 934 in urban Delhi).

RESULTS

Twenty-four per cent of rural and 40·5 % of urban participants knew that a high-salt diet causes high blood pressure. Nearly one-fifth of both rural and urban participants knew that there should be a maximum daily limit for consumption of salt. In rural and urban areas, 46·6 and 45·1 %, respectively, perceived it important to reduce the salt content of their diet; however, only 3·7 and 10·2 %, respectively, reported taking some actions. Participants reported they were consuming 'too little salt', 'just the right amount of salt' or 'too much salt', but their corresponding mean (95 % CI) actual salt consumption (g/d; as measured by 24 h urinary Na excretion) was higher, especially among rural participants (rural: 9·2 (8·13, 10·22), 8·5 (8·19, 8·77) or 8·4 (7·72, 8·99); urban: 5·6 (4·67, 6·57), 5·7 (5·32, 6·01) or 4·6 (4·10, 5·14), respectively).

CONCLUSIONS

Knowledge about the deleterious health impact of excess salt consumption is low in this population. Tailored public education for salt reduction is warranted with a particular focus on rural residents.

Stakeholders' perceptions regarding a salt reduction strategy for India: Findings from qualitative research

Background

Scientific evidence indicates that high dietary salt intake has detrimental effects on blood pressure and associated cardiovascular disease (CVD). However, limited information is available on how to implement salt reduction in low and middle-income countries (LMICs) such as India, where the burden of hypertension and CVD is increasing rapidly. As part of a large study to create the evidence base required to develop a salt reduction strategy for India, we assessed the perspectives of various stakeholders regarding developing an India specific salt reduction strategy.

Methods

A qualitative research design was deployed to elicit various stakeholder’s (government and policy-related stakeholders, industry, civil Society, consumers) perspectives on a salt reduction strategy for India, using in-depth interviews (IDIs) and focus group discussions (FGDs). We used an inductive approach for data analysis. Data were analyzed using thematic content analysis method.

Results

Forty-two IDIs and eight FGDs were conducted with various stakeholders of interest and relevance. Analysis indicated three major themes: 1. Barriers for salt reduction 2. Facilitators for salt reduction; 3. Strategies for salt reduction. Most of the stakeholders were in alignment with the need for a salt reduction programme in India to prevent and control hypertension and related CVD. Major barriers indicated by the stakeholders for salt reduction in India were social and cultural beliefs, a large unorganized food retail sector, and the lack of proper implementation of even existing food policies. Stakeholders from the food industry reported that there might be decreased sales due to salt reduction. Major facilitators included the fact that: salt reduction is currently a part of the National Multi-Sectoral Action Plan for the prevention and control of NCDs, salt reduction and salt iodine programme are compatible, and that few of the multinational food companies have already started working in the direction of initiating efforts for salt reduction. Based on the barriers and facilitators, few of the recommendations are to generate awareness among consumers, promote salt reduction by processed food industry, and implement consumer friendly food labelling.

Conclusions

In this study of multiple key influential stakeholders in India, most of the stakeholders were in alignment with the need for a salt reduction programme in India to prevent and control hypertension and related CVD. The development and adoption of the National Multi-sectoral Action Plan to reduce premature non-communicable diseases (NCDs) in India, provides a potential platform that can be leveraged to drive, implement and monitor salt reduction efforts.

Knowledge and Attitudes Are Related to Selected Salt-Specific Behaviours among Australian Parents

Salt intake in adults and children exceeds recommended levels. Salt-related knowledge, attitudes, and behaviours (KABs) may influence the amount of salt consumed. The aims of this study were to assess salt-related KABs among parents, and investigate whether salt-related knowledge and attitudes are associated with salt-specific behaviours. Parents with children <18 years were recruited from four shopping centers across Victoria, Australia; Facebook; and an online consumer research panel; they then completed an online questionnaire assessing salt-related KABs and salt use in children. Eight hundred and thirty-seven parents (mean age 41.0 (10.0) (SD) years) provided valid responses. Most (77%) parents were aware that eating too much salt damages children’s health and that reducing the amount of salt in their children’s diet was important (70%), and 46% reported adding salt to food prepared for their children. Parents who were aware that eating too much salt damages children’s health were less likely to report that their child added salt at the table (OR = 0.51, p < 0.001), and that they added salt to food prepared for the child (OR = 0.46, p < 0.001). Educational messages that highlight the adverse health effects of salt during childhood are likely to be useful in reducing discretionary salt use in the home environment.

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.

Knowledge and behaviors regarding salt intake in Mozambique

BACKGROUND/OBJECTIVES

Health education and regulatory measures may contribute to lower population salt intake. Therefore, we aimed to describe knowledge and behaviors related to salt intake in Mozambique.

SUBJECTS/METHODS

A cross-sectional evaluation of a representative sample of the population aged 15-64 years (n = 3116) was conducted in 2014/2015, following the Stepwise Approach to Chronic Disease Risk Factor Surveillance, including a 12-question module for evaluation of dietary salt.

RESULTS

Three dimensions were identified in the questionnaire, named "self-reported salt intake", "knowledge of health effects of salt intake", and "behaviors for control of salt intake". A total of 7.4% of the participants perceived that they consumed too much/far too much salt and 25.9% reported adding salt/salty seasoning often/always to prepared foods. The proportion considering that it was not important to decrease the salt contents of their diet was 8%, and 16.9% were not aware that high salt intake could be deleterious for health. Prevalences of lack of behaviors for reducing salt intake ranged from 74.9% for not limiting consumption of processed foods, to 95% for not buying low salt alternatives. There were few differences according to socio-demographic variables, but awareness of hypertension was, in general, associated with better knowledge and less frequent behaviors likely to contribute to a high salt intake.

CONCLUSIONS

Most Mozambicans were aware that high salt intake can cause health problems, but the self-reported salt intake and behaviors for its control show an ample margin for improvement. This study provides evidence to guide population level salt-reducing policies.

The relationship of health/food literacy and salt awareness to daily sodium and potassium intake among a workplace population in Switzerland

BACKGROUND AND AIMS

High sodium (Na) and low potassium (K) intake are associated with hypertension and CVD risk. This study explored the associations of health literacy (HL), food literacy (FL), and salt awareness with salt intake, K intake, and Na/K ratio in a workplace intervention trial in Switzerland.

METHODS AND RESULTS

The study acquired baseline data from 141 individuals, mean age 44.6 years. Na and K intake were estimated from a single 24-h urine collection. We applied validated instruments to assess HL and FL, and salt awareness. Multiple linear regression was used to investigate the association of explanatory variables with salt intake, K intake, and Na/K. Mean daily salt intake was 8.9 g, K 3.1 g, and Na/K 1.18. Salt intake was associated with sex (p < 0.001), and K intake with sex (p < 0.001), age (p = 0.02), and waist-to-height ratio (p = 0.03), as was Na/K. HL index and FL score were not significantly associated with salt or K intake but the awareness variable "salt content impacts food/menu choice" was associated with salt intake (p = 0.005).

CONCLUSION

To achieve the established targets for population Na and K intake, health-related knowledge, abilities, and skills related to Na/salt and K intake need to be promoted through combined educational and structural interventions. Clinical Trials Registry number: DRKS00006790 (23/09/2014).