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

Mineral content in commercially branded and local salt in selected villages from Bahi, Iramba, Manyoni, and Singida urban districts, Tanzania

The study examines the mineral content of table salts used by households in villages adjacent to the production areas. A total of 210 samples from commercial and local salts were collected, and analyzed using iodometry titration, spectrophotometry, colorimetry, and atomic absorption spectroscopy (AAS) techniques, followed by a household interview for salt type preference. The lowest detectable concentration LOD, lowest quantifiable concentration LOQ and, recovery of methods ranged (0.32-2.155 μg/kg), (0.117-6.387 μg/kg) and, (94.2-103.6 %), respectively. Significant differences in mineral contents were observed within and between local and commercially branded salts (p < 0.001). The mean iodine in the local salt samples from Kitangiri (SA), Singidani (SB), Kindai (SC), Chibumagwa (SD), and Sulunga (SE) ranged from 10.5 ± 0,02 to 16.9 ± 0.01 mg/Kg, with only SA and SC in the World Health Organization (WHO) limits, while commercially branded salt samples SF (Malindi), and SG (Dar es salaam) ranged from 23.4 ± 0.01 to 35.9 ± 0,02 mg/kg that were in the Tanzania Bureau of Standards (TBS) and WHO agreed range. Other ions recorded were nitrate (3.3-4.4 mg/kg, 5.45-7.40 mg/kg), phosphate (0.02-0.48 mg/kg, 0.03 mg/kg), sulphate (0.31-0.42 mg/kg, 0.03-0.07 mg/kg), ammonia (0.5 mg/kg, 0.5 mg/kg to 0.6 mg/kg), copper (1.0-2.0 mg/kg, 0.9-2.0 mg/kg), iron (0.5-1.8 mg/kg, 0.9 mg/kg), and manganese (0.5-1.8 mg/kg, 0.9 mg/kg) for local and commercially branded salt, respectively. Households preferred local to commercial-branded salts: Nkonkilangi 163 (69.9, 32.1 %), Mangwanjuki 96 (17.2, 82.8 %), Unyanga 54 (26.7, 73.3 %), Chibumagwa 106 (63.0, 37.0 %), and Chali Igongo 51 (74.6, 25.4 %), respectively. Public health interventions are recommended to promote the consumption of adequately iodized salt for informed dietary choices.

Dietary salt intake and kidney function in rural Senegalese populations: a cross-sectional study

INTRODUCTION

High salt intake is a major risk factor for hypertension and its complications such as chronic kidney disease (CKD) and cardiovascular diseases. The present study aimed to determine level of sodium consumption and its relation with kidney function in the rural populations of Ferlo (centre of Senegal).

SUBJECTS AND METHODS

We performed a cross-sectional study including 400 volunteers aged > 18 years. Clinical, biological and dietary data were collected during household visits. Daily sodium intake was measured in the 24 h-urine outpout and CKD was defined as eGFR < 60 ml/min. Linear regression analysis was used to assess association between sodium intake and covariates.

RESULTS

Mean age was 46.42 ± 15.60 and sex-ratio was 1.05. Prevalence of hypertension, CKD and overweight were 21.5, 11.7 and 20.5%, respectively. The median daily salt intake was 11.7 g with interquartile range of 14.8 g. Only 11.25% of participants consumed less than 5 g/day. After multivariate analysis, high salt intake was associated with age > 60 years, overweight and CKD. However, gender and hypertension were not significantly associated with salt intake. Industrial broths (91.5%) and bread (85%) represented the main sources of dietary salt.

CONCLUSION

This study revealed high levels of daily salt intake contrasting with low potassium intakes in the majority of participants. Participants with CKD, overweight and age > 60 years presented higher salt consumption. Stategies to reduce salt consumption are urgently needed to reduce burden of CKD in rural Senegalese populations.

Consumption of Discretionary Salt and Salt from Bouillon among Households, Women, and Young Children in Northern Region, Ghana: A Mixed-Methods Study with the Condiment Micronutrient Innovation Trial (CoMIT) Project

Background

Information on salt consumption patterns is needed to inform the need for and design of salt reduction strategies.

Objectives

In northern Ghana, this study aimed to estimate household consumption of salt, including salt from bouillon, and compare (estimated) women and children's salt intake to global recommendations; to estimate the proportion of salt consumed from bouillon; and to identify factors, including knowledge, attitudes, and practices, associated with household salt consumption.

Methods

Employing mixed-methods methodology, we conducted a pilot survey (n = 369 households enrolled) and focus group discussions (FGDs; n = 20) in Tolon and Kumbungu districts (14 urban, 14 rural clusters) (clinicaltrials.gov registry: NCT04632771). Households reported purchases of discretionary salt (DS, "table salt") and bouillon cubes. DS and total salt (TS; DS+salt from bouillon) consumption for women (15-49 y) and children (2-5 y) were estimated using the Adult Male Equivalent method and compared with global recommendations (<5 g/d women; <3.75 g/d children). Women's salt intake was also predicted from urinary sodium excretion (INTERSALT equation). Associations between DS and TS consumption, as well as household and women's characteristics, were tested with minimally adjusted and multivariable linear mixed-effects models. Qualitative FGD themes were generated using the Framework Method.

Results

From household purchase data, estimated TS consumption exceeded global recommendations for 44% of children [median: 2.9 (IQR: 1.9, 5.2) g/d] and 60% of women [6.0 (4.0, 10.2) g/d]; 35% of children and 50% of women exceeded recommendations from DS alone. Bouillon contributed <25% of households' TS consumption. Few characteristics were associated with DS or TS consumption. Salient qualitative themes that shaped salt consumption behaviors included salt's ubiquity as a seasoning, key household members' influence on food procurement and preparation, and perceptions about health.

Conclusions

Purchase data suggest salt consumption among women and children exceeds recommendations, even when excluding salt from bouillon; food prepared outside the home likely further contributes. Salt reduction interventions may be warranted in this context.

Prevalence of Risk Factors for Hypertension Among Faculty at an Urban University in Uganda

Purpose

Hypertension is a major contributor to morbidity and mortality worldwide. Many people however are not aware of their possession of risk factors for hypertension. There is a paucity of literature in Uganda describing the risk profile of faculty at public universities. The purpose of this study was to determine the prevalence of hypertension risk factors among university teaching staff.

Methods

This study was conducted among faculty at Makerere University in Uganda. The modified World Health Organization STEP-wise approach for non-communicable disease surveillance was used in data collection. Hypertension was defined as having a systolic blood pressure of ≥140mmHg and/or a diastolic blood pressure of ≥90mmHg, or being on antihypertensive medications. Participants were enrolled from the faculty lists by proportionate to size systematic sampling until the sample size for each college was obtained. Data was collected from January to March 2018. Multivariate logistic regression was used to determine factors associated with hypertension.

Results

A total of 141 participants were recruited into the study. The prevalent risk factors for hypertension include physical inactivity (78.7%), overweight (46.8%), obesity (20.6%), addition of extra salt to food (46.8%), current alcohol consumption (33.3%), history of smoking (10.6%), inadequate fruit and vegetable servings per day (100%), family history of hypertension (40.4%) and a family history of diabetes (22.7%). Hypertension was prevalent at 26.2% (95% CI 18.94-33.46%). The risk factors significantly associated with hypertension included a family history of hypertension (p=0.009), obesity (p=0.008) and male gender (p = 0.029).

Conclusion

The prevalence of known hypertension risk factors among university teaching staff in urban Uganda is high. Majority of these risk factors are modifiable highlighting the need for continuous screening as well as introduction of prevention and health promotion strategies to reduce the risk burden.

Socio-demographic and economic factors associated with the consumption of processed foods in South Africa - Evidence from Demographic and Health Survey VII

OBJECTIVE

The primary objective of this study was to examine the socio-demographic and economic factors associated with the consumption of processed foods in South Africa.

STUDY DESIGN

This is an empirical study where secondary data analysis was performed from the South African Demographic and Health Survey VII.

METHODS

A nationally representative sample of 10,336 participants (aged ≥15 years) was included in the analysis. Using regression models, we studied the association between socio-demographic and economic predictors and the intake of processed foods.

RESULTS

The regression models found that the odds of consumption of any type of processed foods were significantly high in all South African provinces but specifically higher in urban settings, those with any level of education, and young adults. The odds of processed meat consumption were significantly higher among the coloured population, while that of fried food, fast food, and salty snacks was significant in the white population. The odds of consumption increased irrespective of marital status and were higher among males, specifically among those in the poorer and poorest wealth quintiles.

CONCLUSION

These findings warrant advocacy and action for healthy food choices in the population. The role of industry, ethnic vulnerability, and gender stereotypes in food preparation are areas that need priority attention.

Dietary factors and hypertension risk in West Africa: a systematic review and meta-analysis of observational studies

BACKGROUND

Contrary to North America and Europe, the prevalence of hypertension is rising in West Africa. Although diet is implicated as a contributor to this trend, nutritional guidelines in West Africa are not tailored to address this concern. This study aimed to address this limitation by investigating dietary factors common to West Africa and evaluating their association with hypertension.

METHODS

PubMed, Scopus, Web of Science, and Medline were searched to identify studies that investigated diet and hypertension in West African adults. All meta-analyses used a generic inverse-variance random effects model, with subgroup analyses by age, BMI, and study location, and were performed in R.

RESULTS

Three thousand, two hundred ninety-eight studies were identified, of which 31 ( n  = 48 809 participants) satisfied inclusion criteria - all cross-sectional. Meta-analyses of the association between dietary factors and hypertension included dietary fat [odds ratio (OR) = 1.76; 95% confidence interval (95% CI) 1.44-2.14; P  < 0.0001], red meat (OR = 1.51; 95% CI: 1.04-2.18; P  = 0.03), junk-food (OR = 1.41; 95% CI: 1.19-1.67; P  < 0.0001), dietary salt (OR = 1.25; 95% CI: 1.12-1.40; P  < 0.0001), alcohol (OR = 1.17; 95% CI: 1.03-1.32; P  = 0.013), and 'fruits and vegetables' (OR = 0.80; 95% CI: 0.24-1.17; P  < 0.0001). Subgroup analyses suggested that 'fruit and vegetable' consumption is less protective in the elderly.

CONCLUSION

High consumption of dietary salt, red meat, dietary fat, junk food, and alcohol are associated with increased odds of hypertension, whereas high fruit and vegetable appear protective. This region-specific evidence will support the development of nutritional assessment tools for clinicians, patients, and researchers aiming to reduce hypertension in West Africa.

Reducing Dietary Sodium Intake among Young Adults in Ghana: A Call to Action

The positive association between excessive dietary sodium intake, hypertension, and cardiovascular disease (CVD) has been widely investigated in observational studies and clinical trials. Reducing sodium intake is a proven strategy to prevent hypertension and the onset of CVD, a major cause of morbidity and mortality globally. Africa has the youngest population globally, which is key to the continent's sustainable development. However, in Africa, the epidemics of hypertension and CVD negatively impact life expectancy and economic growth. Ghana, like other African countries, is no exception. The factors contributing to the increasing burden of CVD and excessive sodium consumption are multi-faceted and multi-level, including individual lifestyle, neighborhood and built environments, and socio-economic and health policies. Thus, the implementation of evidence-based interventions such as the World Health Organization Best Buys that target the multi-level determinants of sodium consumption is urgently needed in Ghana and other African countries. The aim of this commentary is to highlight factors that contribute to excessive sodium consumption. Second, the commentary will showcase lessons of successful implementation of sodium reduction interventions in other countries. Such lessons may help avert CVD in young adults in Ghana and Africa.

Early evidence for the effectiveness of South Africa's legislation on salt restriction in foods: the African-PREDICT study

South Africa was among the first countries to adopt mandatory regulation in 2016 to lower the salt content in processed foods, aiming to reduce population salt intake to <5 g/day. To assess the effectiveness of this regulation in 20-30 year-old adults, we determined the change in salt intake over a mean follow-up time of 4.56-years spanning the implementation of the regulation. This observational study included baseline (2013-2016; N = 668; 24.9 ± 3 years; 47.8% black; 40.7% men) and follow-up data (2018-ongoing; N = 311; 25.4 ± 3.05 years; 51.1% black; 43.4% men) for participants of the African-PREDICT study. Salt intake was estimated from 24-h urinary sodium excretion. Median salt intake at baseline (N = 668) was 7.88 g/day (IQR: 5.67). In those followed (N = 311), salt intake reduced from baseline [median (IQR): 7.91 g/day (5.83)] to follow-up [7.26 g/day (5.30)] [unadjusted median: -0.82 g/day]. After adjusting for baseline salt intake to address regression to the mean, the mean salt reduction was -1.2 g/day. The greatest reductions were in men [mean difference: -1.47 g/day], black adults [mean difference: -2.04 g/day], and participants from low [mean difference: -1.89 g/day] or middle [mean difference: -1.84 g/day] socio-economic status groups, adjusting for baseline salt intake. Our preliminary findings suggest that South Africa's salt regulation has been effective in lowering salt intake in young adults by ~1.2 g salt/day. Our study supports the effectiveness of upstream interventions to lower population salt intake, particularly for vulnerable groups who may typically consume more processed foods. It needs to be determined if the legislation has the anticipated population health gains.

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.

Frequency of adding salt at the table and risk of incident cardiovascular disease and all-cause mortality: a prospective cohort study

BACKGROUND

Adding salt at the table is a prevalent eating habit, but its long-term relationship with cardiovascular disease (CVD) and all-cause mortality remains unclear. We evaluated the associations of adding salt at the table with the risk of incident CVD and all-cause mortality.

METHODS

Among 413,109 middle- and old-aged adults without cancer or CVD, all participants reported the frequency of adding salt at the table at baseline. The associations between adding salt at the table and incident CVD (the composite endpoint of coronary heart disease, stroke, heart failure, and CVD deaths) and all-cause mortality were investigated using Cox proportional hazards models.

RESULTS

Of the study population, the mean age was 55.8 years and 45.5% were men; 44.4% reported adding salt at the table; 4.8% reported always adding salt at the table. During a median follow-up of 12 years, there were 37,091 incident CVD cases and 21,293 all-cause deaths. After adjustment for demographic, lifestyle, and cardiometabolic risk factors, the multivariable-adjusted hazard ratios (HRs) for participants who always added salt at the table versus never/rarely added salt at the table were 1.21 (95% confidence interval [CI]: 1.16-1.26) for CVD, 1.19 (95%CI: 1.05-1.35) for CVD mortality, and 1.22 (95%CI: 1.16-1.29) for all-cause mortality, respectively.

CONCLUSIONS

In this prospective cohort study, a higher frequency of adding salt at the table was associated with a greater risk of incident CVD and mortality. Our findings support the benefits of restricting the habit of adding salt at the table in promoting cardiovascular health.

The Healthy Aging Adult South Africa report card: a systematic review of the evidence between 2013 and 2020 for middle-aged South African men and women

Due to the increasing non-communicable disease burden in Africa, several strategies that target the major lifestyle and physiological risk factors have been implemented to combat such diseases. The Healthy Aging Adult South Africa report card systematically reviews national and regional prevalence data of middle-aged South African adults (45-65 years) published between 2013 and 2020 on diet, physical activity, tobacco use and alcohol consumption, obesity, hypertension, dyslipidaemia and diabetes mellitus. Each indicator was assigned two grades, (1) based on the availability of prevalence data, and (2) based on whether policies have been proposed and implemented for the respective indicators. Alcohol consumption, obesity, hypertension and diabetes received an A grade for the availability of prevalence data. Tobacco use and diet received an A grade for policy and implementation. Gaps have been identified that need to be filled by future research focusing on continued surveillance of all indicators in order to inform and implement effective policies.

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.

Sodium Reduction in Bouillon: Targeting a Food Staple to Reduce Hypertension in Sub-saharan Africa

Bouillon cubes are a staple ingredient used in Sub-saharan African countries providing flavor enhancement to savory foods. Bouillon has been identified as a vehicle for fortification to overcome micronutrient deficiencies in Sub-saharan Africa. However, bouillon has a high sodium content (and in addition with other foods) contributes to dietary sodium intake above recommended guidelines. High dietary sodium intake is a key risk factor for hypertension and cardiovascular disease (CVD). Africa has the highest rates of hypertension and CVD globally with nearly half the adult population above 25 years affected. This review presents current state of research on sodium reduction strategies in bouillon. The key challenge is to reduce sodium levels while maintaining optimal flavor at the lowest possible production cost to ensure bouillon continues to be affordable in Sub-saharan Africa. To produce lower sodium bouillon with acceptable flavor at low cost will likely involve multiple sodium reduction strategies; direct reduction in sodium, sodium replacement and saltiness boosting flavor technologies. Efforts to reduce the sodium content of bouillon in Sub-saharan Africa is a worthwhile strategy to: (i) lower the overall sodium consumption across the population, and (ii) deliver population-wide health benefits in a region with high rates of hypertension and CVD.

Rural and urban migration to Europe in relation to cardiovascular disease risk: does it matter where you migrate from?

OBJECTIVES

To assess whether the environmental context (i.e. rural vs urban) in which individuals in low- and middle-income countries have resided most of their lives is associated with estimated cardiovascular disease (CVD) risk after migration to a high-income country.

STUDY DESIGN

Data from the Research on Obesity and Diabetes among African Migrants (RODAM) study were used including 1699 Ghanaian participants aged 40-79 years who had migrated to Europe from Ghana (1549 of urban origin, 150 of rural origin).

METHODS

Ten-year CVD risk was estimated using the Pooled Cohort Equation, with estimates ≥7.5% defining elevated CVD risk. Comparisons between urban and rural origin migrant groups were made using proportions and adjusted odds ratios (ORs).

RESULTS

The proportion of migrants with an elevated CVD-risk score was substantially higher among rural migrants than among urban migrants (45% vs. 37%, OR = 1.44, 95% confidence interval [CI]:1.03-2.02), which persisted after adjustment for education level, site of residence in Europe (London, Amsterdam or Berlin), length of stay in Europe, physical activity, energy intake and alcohol consumption (OR = 1.67, 95% CI: 1.05-2.67).

CONCLUSION

Our findings indicate that migrants who spent most of their lives in a rural setting before migration to Europe may have a higher CVD risk than those of urban origins. Further work is needed to confirm these findings in other migrant populations and to unravel the mechanisms driving the differential CVD risk between urban and rural migrants.

Effect of South Africa's interim mandatory salt reduction programme on urinary sodium excretion and blood pressure

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Thirty percent reduction in population salt intake by 2025 is recommended by WHO.

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South Africa introduced mandatory maximum sodium limits in processed foods in 2016.

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A countrywide impact evaluation assessed change in salt intake after two years.

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Salt intake measured using 24hr Na excretion dropped by 1.15 g per day.

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Ongoing evaluation is necessary as more stringent targets were implemented in 2019.

South Africa implemented legislation in June 2016 mandating maximum sodium (Na) levels in processed foods. A pre-post impact evaluation assessed whether the interim legislative approach reduced salt intake and blood pressure. Baseline Na intake was assessed in a nested cohort of the WHO Study on global AGEing and adult health (WHO-SAGE) Wave 2 (Aug-Dec 2015). 24-hour urine samples were collected in a random subsample (n = 1,299; of which n = 750 were considered valid (volume ≥ 300 mL and creatinine ≥ 4 mmol/day (women) or ≥ 6 mmol/day (men))). Follow-up urine samples were collected in Wave 3 (Jun 2018-Jun 2019), with replacements included for those lost to follow-up (n = 1,189; n = 548 valid). In those aged 18 − 49y, median salt intake was 7.8 (4.7, 12.0) g/day in W2 (n = 274), remaining similar in the W3 sample (7.7 (4.9, 11.3) g salt/day (n = 92); P = 0.569). In older adults (50 + y), median salt intake was 5.8 (4.0, 8.5) g/day (n = 467) in W2, and 6.0 (4.0, 8.6) g/day (n = 455) in W3 (P = 0.721). Controlling for differences in background characteristics, overall salt intake dropped by 1.15 g/day (P = 0.028). 24hr urinary Na concentrations from a countrywide South African sample suggest that salt intakes have dropped during the interim phase of mandatory sodium legislation. Further measurement of population level salt intake following stricter Na targets, enforced from June 2019, is necessary.

Knowledge, attitude and behaviour of university students regarding salt and iodine: a multicentre cross-sectional study in six countries in Europe and Asia

Background

Strategies to reduce salt intake are encouraged to be implemented in parallel with those that aim to ensure iodine adequacy at the population level. The aim of the present study was to assess and compare knowledge, attitudes and behaviours related to salt and iodine among students in Europe and Asia.

Methods

A multicentre cross-sectional study was conducted with 2459 university students in total (42.7% males, median age 21 years) from four countries in Europe and two countries in Asia. Data were collected with the use of a self-administered questionnaire, and univariate and multivariate statistical analyses were performed to explore any association between variables.

Results

Only 6.5% of all participants knew the correct salt recommendations. Nearly a quarter of them (24.4%) found salt recommendations confusing and/or contradictory. There were significant differences between European and Asian participants, with those from Europe being better informed about salt recommendations, but significantly less knowledgeable about iodine. The reported frequency of use of salt and salt-containing sauces either at the table or for cooking, as well as knowledge about ways to reduce salt intake among those who indicated to make conscious efforts to do so, differed significantly between countries. Significant differences between countries were also observed with respect to the type of salt used, with about one third of all participants (34%) not being aware of the kind of salt they used.

Conclusion

The results of this survey highlight serious salt- and iodine-related knowledge gaps among university students in Europe and Asia. Raising awareness and conducting information campaigns is needed to promote changes in behaviour that would result in a reduction of salt intake and conscious use of iodised salt at the individual level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00593-5.

Prevalence, awareness and control of hypertension in Ghana: A systematic review and meta-analysis

BACKGROUND

Hypertension is a major health problem in Ghana, being a leading cause of admissions and deaths in the country. In the context of a changing food and health policy environment, we undertook a systematic review (PROSPERO registration number: CRD42020177174) and a meta-analysis of the prevalence of adult hypertension, and its awareness and control in Ghana.

METHODS

We searched major databases including PubMed, Embase as well as Google Scholar and online digital collections of public universities of Ghana to locate relevant published and unpublished community-based articles up till April 2020.

FINDINGS

Eighty-five articles involving 82,045 apparently-healthy subjects aged 15-100 years were analyzed. In individual studies, the prevalence of hypertension, defined in most cases as blood pressure ≥ 140/90 mmHg, ranged from 2.8% to 67.5%. The pooled prevalence from the meta-analysis was 27.0% (95% CI 24.0%-30.0%), being twice as high in the coastal (28%, 95% CI: 24.0%-31.0%) and middle geo-ecological belts (29%, 95% CI: 25.0%-33.0%) as in the northern belt (13%, 95% CI: 7.0%-21.0%). The prevalence was similar by sex, urban-rural residence or peer-review status of the included studies. It did not appear to vary over the study year period 1976-2019. Of the subjects with hypertension, only 35% (95% CI: 29.0%-41.0%) were aware of it, 22% (95% CI: 16.0%-29.0%) were on treatment and 6.0% (95% CI: 3.0%-10.0%) had their blood pressure controlled. Sensitivity analyses corroborated the robust estimates. There was, however, high heterogeneity (I2 = 98.7%) across the studies which was partly explained by prevalent obesity in the subjects.

CONCLUSION

More than one in four adults in Ghana have hypertension. This high prevalence has persisted for decades and is similar in rural and urban populations. With the low awareness and poor control of hypertension, greater investments in cardiovascular health are required if Ghana is to meet the global target for hypertension.

Projected effects on salt purchases following implementation of a national salt reduction policy in South Africa

OBJECTIVE

To assess the contribution of different food groups to total salt purchases and to evaluate the estimated reduction in salt purchases if mandatory maximum salt limits in South African legislation were being complied with.

DESIGN

This study conducted a cross-sectional analysis of purchasing data from Discovery Vitality members. Data were linked to the South African FoodSwitch database to determine the salt content of each food product purchased. Food category and total annual salt purchases were determined by summing salt content (kg) per each unit purchased across a whole year. Reductions in annual salt purchases were estimated by applying legislated maximum limits to product salt content.

SETTING

South Africa.

PARTICIPANTS

The study utilised purchasing data from 344 161 households, members of Discovery Vitality, collected for a whole year between January and December 2018.

RESULTS

Vitality members purchased R12·8 billion worth of food products in 2018, representing 9562 products from which 264 583 kg of salt was purchased. The main contributors to salt purchases were bread and bakery products (23·3 %); meat and meat products (19 %); dairy (12·2 %); sauces, dressings, spreads and dips (11·8 %); and convenience foods (8·7 %). The projected total quantity of salt that would be purchased after implementation of the salt legislation was 250 346 kg, a reduction of 5·4 % from 2018 levels.

CONCLUSIONS

A projected reduction in salt purchases of 5·4 % from 2018 levels suggests that meeting the mandatory maximum salt limits in South Africa will make a meaningful contribution to reducing salt purchases.

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

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

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

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

Towards Population Salt Reduction to Control High Blood Pressure in Ghana: A Policy Direction

Although population salt reduction is considered a "best buy" in addressing hypertension and cardiovascular disease, Ghana shares a high hypertension burden with a seemingly high salt consumption. This article discusses best practices in reducing population salt intake and provides preliminary data on salt and potassium intake, as well as the process to develop a road map and identification of actions needed to support the development of a strategic national document towards salt reduction in Ghana. In February 2019, a 2-d stakeholder meeting was held with government agencies, researchers, nongovernmental organizations, civil society organizations, and international partners to deliberate on salt reduction strategies and interventions needed in the face of rising hypertension and other noncommunicable diseases (NCDs) in Ghana. Recommendations were developed from the stakeholder meeting and are being considered for inclusion in the revision of Ghana's national NCD policy.

Behavioral beliefs of reducing salt intake from the perspective of people at risk of hypertension: An exploratory study

BACKGROUND

The average salt intake in Iran is 12 g per day and it is reported to be about 10 g per day in Yazd City, Iran. This study was conducted to explain the behavioral beliefs toward salt intake reduction in people at risk of hypertension (HTN) based on Theory of Planned Behavior (TPB) guideline.

METHODS

This study was a TPB-based exploratory research. The participants were 25 married individuals at risk of developing HTN, with a mean age of 42.9 ± 7.2 years. They were selected by purposive maximum variation sampling continued until data saturation. The data collection method was a semi-structured interview. Study lasted from January 2017 to April 2017.

RESULTS

Concerning the advantages and disadvantages of reducing daily salt intake, data analysis yielded 52 primary codes, 19 subcategories, and 5 categories. Advantages in two categories included disease prevention and misconceptions about the benefits, and disadvantages in three categories included physical health disorder, difficulty following a low-salt diet, and false beliefs about the disadvantages of salt intake reduction.

CONCLUSION

According to the findings of this study, prevention of high blood pressure and cardiovascular diseases (CVDs) was among the most important advantages of reducing salt intake, and undesirable taste of low-salt foods and family members' disagreement were among the most important disadvantages of reducing salt intake. The misconceptions of our participants included blood lipids reduction and creation of difficulty contracting the muscles. It is recommended to correct misconceptions and strengthen behavioral beliefs to promote salt intake reduction behavior in educational interventions.