Mary Anne Land

The association of knowledge, attitudes and behaviours related to salt with 24-hour urinary sodium excretion

AimSalt reduction efforts usually have a strong focus on consumer education. Understanding the association between salt consumption levels and knowledge, attitudes and behaviours towards salt should provide insight into the likely effectiveness of education-based programs.MethodsA single 24-hour urine sample and a questionnaire describing knowledge, attitudes and behaviours was obtained from 306 randomly selected participants and 113 volunteers from a regional town in Australia.ResultsMean age of all participants was 55xa0years (range 20–88), 55% were women and mean 24-hour urinary salt excretion was 8.8(3.6) g/d. There was no difference in salt excretion between the randomly selected and volunteer sample. Virtually all participants (95%) identified that a diet high in salt can cause serious health problems with the majority of participants (81%) linking a high salt diet to raised blood pressure. There was no difference in salt excretion between those who did 8.7(2.1) g/d and did not 7.5(3.3) g/d identify that a diet high in salt causes high blood pressure (pu2009=u20090.1). Nor was there a difference between individuals who believed they consumed “too much” 8.9(3.3) g/d “just the right amount” 8.4(2.6) g/d or “too little salt” 9.1(3.7) g/d (pu2009=u20090.2). Likewise, individuals who indicated that lowering their salt intake was important 8.5(2.9) g/d vs. not important 8.8(2.4) g/d did not have different consumption levels (pu2009=u20090.4).ConclusionThe absence of a clear association between knowledge, attitudes and behaviours towards salt and actual salt consumption suggests that interventions focused on knowledge, attitudes and behaviours alone may be of limited efficacy.

An Update on the Salt Wars—Genuine Controversy, Poor Science, or Vested Interest?

There is unequivocal evidence that increased sodium intake is associated with increased blood pressure, and that increased blood pressure leads to increased risk of vascular diseases. Unfortunately, the published evidence directly linking sodium intake to vascular risk is inconsistent and confusing. This review, emphasising recent developments in national and international settings, considers why this is the case and how vested interests – particularly the food industry – have exploited the vacuum. We argue that legislation is the only tool that is likely to reverse the current situation wherein many millions of lives are put at risk through an unnecessary dietary additive, the reduction of which would be eminently feasible and have no conceivable disadvantage to health.

Cost-effectiveness of reducing salt intake in the Pacific Islands: protocol for a before and after intervention study

BackgroundThere is broad consensus that diets high in salt are bad for health and that reducing salt intake is a cost-effective strategy for preventing chronic diseases. The World Health Organization has been supporting the development of salt reduction strategies in the Pacific Islands where salt intakes are thought to be high. However, there are no accurate measures of salt intake in these countries. The aims of this project are to establish baseline levels of salt intake in two Pacific Island countries, implement multi-pronged, cross-sectoral salt reduction programs in both, and determine the effects and cost-effectiveness of the intervention strategies.Methods/DesignIntervention effectiveness will be assessed from cross-sectional surveys before and after population-based salt reduction interventions in Fiji and Samoa. Baseline surveys began in July 2012 and follow-up surveys will be completed by July 2015 after a 2-year intervention period.A three-stage stratified cluster random sampling strategy will be used for the population surveys, building on existing government surveys in each country. Data on salt intake, salt levels in foods and sources of dietary salt measured at baseline will be combined with an in-depth qualitative analysis of stakeholder views to develop and implement targeted interventions to reduce salt intake.DiscussionSalt reduction is a global priority and all Member States of the World Health Organization have agreed on a target to reduce salt intake by 30% by 2025, as part of the global action plan to reduce the burden of non-communicable diseases. The study described by this protocol will be the first to provide a robust assessment of salt intake and the impact of salt reduction interventions in the Pacific Islands. As such, it will inform the development of strategies for other Pacific Island countries and comparable low and middle-income settings around the world.

Dietary Salt Intake and Discretionary Salt Use in Two General Population Samples in Australia: 2011 and 2014

The limited Australian measures to reduce population sodium intake through national initiatives targeting sodium in the food supply have not been evaluated. The aim was, thus, to assess if there has been a change in salt intake and discretionary salt use between 2011 and 2014 in the state of Victoria, Australia. Adults drawn from a population sample provided 24 h urine collections and reported discretionary salt use in 2011 and 2014. The final sample included 307 subjects who participated in both surveys, 291 who participated in 2011 only, and 135 subjects who participated in 2014 only. Analysis included adjustment for age, gender, metropolitan area, weekend collection and participation in both surveys, where appropriate. In 2011, 598 participants: 53% female, age 57.1(12.0)(SD) years and in 2014, 442 participants: 53% female, age 61.2(10.7) years provided valid urine collections, with no difference in the mean urinary salt excretion between 2011: 7.9 (7.6, 8.2) (95% CI) g/salt/day and 2014: 7.8 (7.5, 8.1) g/salt/day (p = 0.589), and no difference in discretionary salt use: 35% (2011) and 36% (2014) reported adding salt sometimes or often/always at the table (p = 0.76). Those that sometimes or often/always added salt at the table and when cooking had 0.7 (0.7, 0.8) g/salt/day (p = 0.0016) higher salt excretion. There is no indication over this 3-year period that national salt reduction initiatives targeting the food supply have resulted in a population reduction in salt intake. More concerted efforts are required to reduce the salt content of manufactured foods, together with a consumer education campaign targeting the use of discretionary salt.

How much salt do adults consume in climate vulnerable coastal Bangladesh

BackgroundEvidence from numerous studies suggests that salt intake is an important determinant of elevated blood pressure. Robust data about salt consumption among adults in Bangladesh is sparse. However, much evidence suggests saline intrusion due to sea level rise as a result of climate change exposes more than 20 million people to adverse effects of salinity through the food and water supply. The objective of our study was to assess salt consumption among adults in a coastal region of Bangladesh.MethodsOur study was cross sectional and conducted during October-November 2011. A single 24xa0hour urine was collected from 400 randomly selected individuals over 18xa0years of age from Chakaria, a rural, coastal area in Southeastern Bangladesh. Logistic regression was conducted to identify the determinants of high salt consumption.ResultsThe mean urinary sodium excretion was 115xa0mmol/d (6.8xa0g salt). Based on logistic regression using two different cutoff points (IOM and WHO), housewives and those living in the coastal area had a significantly higher probability of high salt intake compared with people who were engaged in labour-intensive occupations and who lived in hilly areas.ConclusionIt is important to create awareness about the implication of excessive salt intake on health and to develop strategies for reducing salt intake that can be implemented at the community-level. A sustainable policy for salt reduction in the Bangladeshi diet should be formulated with special emphasis on coastal areas.

Mean population salt consumption in India: a systematic review

Background: Member states of the WHO, including India, have adopted a target 30% reduction in mean population salt consumption by 2025 to prevent noncommunicable diseases. Our aim was to support this initiative by summarizing existing data that describe mean salt consumption in India. Method: Electronic databases – MEDLINE via Ovid, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews – were searched up to November 2015 for studies that reported mean or median dietary salt intake in Indian adults aged 19 years and older. Random effects meta-analysis was used to obtain summary estimates of salt intake. Results: Of 1201 abstracts identified, 90 were reviewed in full text and 21 were included: 18 cross-sectional surveys (nu200a=u200a225u200a024), two randomized trials (nu200a=u200a255) and one case–control study (nu200a=u200a270). Data were collected between 1986 and 2014, and reported mean salt consumption levels were between 5.22 and 42.30u200ag/day. With an extreme outlier excluded, overall mean weighted salt intake was 10.98u200ag/day (95% confidence interval 8.57–13.40). There was significant heterogeneity between the estimates for contributing studies (I2u200a=u200a99.97%) (P homogeneity ⩽0.001), which was likely attributable to the different measurement methods used and the different populations studied. There was no evidence of a change in intake over time (P trendu200a=u200a0.08). Conclusion: The available data leave some uncertainty about exact mean salt consumption in India but there is little doubt that population salt consumption far exceeds the WHO-recommended maximum of 5u200ag per person per day.

Effects of a community-based salt reduction program in a regional Australian population

BackgroundSalt reduction is a public health priority but there are few studies testing the efficacy of plausible salt reduction programs.MethodsA multi-faceted, community-based salt reduction program using the Communication for Behavioral Impact framework was implemented in Lithgow, Australia. Single 24-h urine samples were obtained from 419 individuals at baseline (2011) and from 572 at follow-up (2014). Information about knowledge and behaviors relating to salt was also collected.ResultsSurvey participants were on average 56xa0years old and 58xa0% female. Mean salt intake estimated from 24-h urine samples fell from 8.8xa0g/day (SDu2009=u20093.6xa0g/day) in 2011 to 8.0 (3.6) g/day in 2014 (−0.80, 95xa0% confidence interval −1.2 to −0.3;pu2009<u20090.001). There were significant increases in the proportion of participants that knew the recommended upper limit of salt intake (18xa0% vs. 29xa0%; pu2009<u20090.001), knew the importance of salt reduction (64xa0% vs. 78xa0%; pu2009<u20090.001) and reported changing their behaviors to reduce their salt intake by using spices (5xa0% vs. 28xa0%; pu2009<u20090.001) and avoiding eating out (21xa0% vs. 34xa0%; pu2009<u20090.001). However, the proportions that checked food labels (30xa0% vs. 25xa0%; pu2009=u20090.02) fell, as did the numbers avoiding processed foods (44xa0% vs. 35xa0%; pu2009=u20090.006). Twenty-six percent reported using salt substitute at the end of the intervention period and 90xa0% had heard about the program. Findings were robust to multivariable adjustment.ConclusionsImplementation of this multi-faceted community-based program was associated with a ~10xa0% reduction in salt consumption in an Australian regional town. These findings highlight the potential of well-designed health promotion programs to compliment other population-based strategies to bring about much-needed reductions in salt consumption.Clinical trial registrationNCT02105727.

Protocol for the implementation and evaluation of a community-based intervention seeking to reduce dietary salt intake in Lithgow, Australia

BackgroundExcess dietary salt is a leading risk for health. Multiple health, government, industry and community organisations have identified the need to reduce consumption of dietary salt. This project seeks to implement and evaluate a community-based salt reduction intervention.MethodsThe study comprises a baseline assessment followed by a targeted intervention and then an evaluation of efficacy. The study location is Lithgow, a regional town in New South Wales, Australia. The salt reduction intervention is based upon the Communication for Behavioural Impact framework which utilises an integrated communication model to enact community advocacy and impact by providing tools that enable the translation of knowledge into behavioural change. The duration of the intervention will be between 6 and 12xa0months. The primary evaluation will be through measurement of 24-hr urinary sodium excretion in independent population samples aged >u200920xa0years, drawn before and after the intervention period. The study is designed to detect a difference in mean sodium excretion of 0.7 grams per day or greater with 80% power and pu2009=u20090.05.DiscussionThis study will provide a robust evaluation of the effectiveness of a community-based intervention seeking to reduce dietary salt intake using the Communication for Behavioural Impact framework. The results will provide important new evidence to inform the design and implementation of current and future salt reduction policies in Australia. The results will also have important international implications because, following the recent World Health Organization recommendations for the control of non-communicable diseases, many countries are now seeking to achieve a reduction in average population salt consumption.Trial registrationClinicalTrials.gov, NCT02105727

A systematic review of the prevalence of nutrition labels and completeness of nutrient declarations on pre-packaged foods in China

BACKGROUNDnThe Chinese government launched a voluntary nutrition labelling code in 2007 and made it mandatory since 1 January 2013. This article aims to quantify the prevalence of nutrition labels and the completeness of nutrient declarations on pre-packaged foods in China and to explore the impact of the 2007 code.nnnMETHODSnA systematic search of the published and grey literature was done, and a random-effects meta-analysis was used to obtain summary estimates.nnnRESULTSnThere were 15 surveys identified from 13 reports. For 44% (95% confidence interval: 37-51%) of the 22 636 food items, the product label provided information on one or more nutrients. There was significant heterogeneity between the surveys (I(2) = 99%, P < 0.001) raising some uncertainty about the reliability of the estimate. The heterogeneity was in part explained by differences in labelling between food categories (P < 0.001) but not by changes in the prevalence of nutrition labels over time (P = 0.36).nnnCONCLUSIONSnMost pre-packaged foods in this survey had a nutrition label non-compliant with current Chinese nutrition labelling standards. The voluntary code launched in 2007 had limited impact on nutrition labelling. There is significant scope for the recently introduced mandatory labelling requirements to improve nutrition labelling in China.

24 Hour urinary excretion of salt in Mongolians

Background: Hypertension is a main risk factor for cardiovascular diseases in Mongolia. There is strong evidence for a direct relationship between dietary sodium consumption and blood pressure. Salt intake can be estimated by measuring urinary excretion of sodium. Methods: 24-hour urine samples were collected from 983 adults 25–64 years of age from Ulaanbaatar, the capital city of Mongolia and four provinces. The urinary level of sodium was determined using the ion-selective method, and the amount of salt was calculated based on the urinary concentration of Na. Results: The mean urinary concentration of salt was 11.1 g/day. There was no statistically significant difference in the excreted amount of salt detected between males and females (11.3 g/day vs. 10.8 g/day, p > 0.05) or between adults living in the capital city and those living in the rural provinces (11.5 g/day vs. 10.7 g/day, p > 0.05) or between the age groups (9.8 g/day in the 25 to 34 year age group; 11.5 g/day in adults aged 35 to 44; 11.5 g/day in 45–54-year-old participants and 11.7 g/day in the 55 to 64 age group, p > 0.01). Conclusions: The survey results demonstrate that the salt intake per day of Mongolians is higher than that of other populations and is more than twice the WHO target intake of 5 g of salt per day. This highlights the need for a population salt reduction strategy and provides a solid baseline from which to monitor future change.