Consumer knowledge and attitudes to salt intake and labelled salt information

Dietary Salt-Related Knowledge, Attitudes and Behaviors in Healthy and Hypertensive Turkish Adults from Food Choice Perspective

Food choices are influenced by knowledge, attitudes, and behaviors (KABs); therefore, determining KABs regarding salt is a key point for salt reduction, which is a primary public health problem in Turkey. This study aimed to assess salt-related KABs in Turkey. This cross-sectional study was conducted on 415 adults in a hospital in Turkey. A structured questionnaire assessing salt-related KABs was administered, and blood pressure was measured. The majority of participants were aware of the health risks associated with high salt intake. Higher overall attitude scores increased the odds of performing most behaviors to reduce salt, except for checking food labels, using spices instead of salt, and purchasing foods labeled as low-sodium, by almost three-fold. These results suggest that both normotensive and hypertensive adults need to improve their knowledge of the health effects and dietary sources of salt, and how to reduce it. Salt-related KABs were not found to be aligned with all positive attitudes toward salt consumption; this indicates the need for regulations that operate independently of public perceptions, such as policies for reducing salt in the food industry and making reduced-salt products more affordable to encourage healthier food choices.

"Microplastic seasoning": A study on microplastic contamination of sea salts in Bangladesh

This study investigated microplastics (MPs) in commercial sea salts from Bangladesh. The presence of MPs in the 18 sea salt bands was 100 %, where the mean MPs abundance was 471.67 MPs/kg, ranging between 300 and 670 MPs/kg. The maximum number of MPs in the 300-1500 μm size class was significantly higher than the 1500-3000 μm and 3000-5000 μm size class. The most dominant color was black. Fibers and foams were the dominant shapes. The highest number of MPs was 41 %, obtained from coarse salt grains. Four types of polymers were mainly identified from the analyzed samples: PP, PE, PET, and PA. The mean polymer risk index value among these sea salts was 539 to 1257. The findings of this study can be helpful for consumers, salt industries, and policymakers to be aware of or reduce MP contamination levels in sea salts during production and consumption.

Characterization of the Biofilms Formed by Histamine-Producing Lentilactobacillus parabuchneri Strains in the Dairy Environment

Lentilactobacillus parabuchneri, a lactic acid bacterium, is largely responsible for the production and accumulation of histamine, a toxic biogenic amine, in cheese. L. parabuchneri strains can form biofilms on the surface of industry equipment. Since they are resistant to cleaning and disinfection, they may act as reservoirs of histamine-producing contaminants in cheese. The aim of this study was to investigate the biofilm-producing capacity of L. parabuchneri strains. Using the crystal violet technique, the strains were first categorized as weak, moderate or strong biofilm producers. Analysis of their biofilm matrices revealed them to be mainly composed of proteins. Two strains of each category were then selected to analyze the influence on the biofilm-forming capacity of temperature, pH, carbon source, NaCl concentration and surface material (i.e., focusing on those used in the dairy industry). In general, low temperature (8 °C), high NaCl concentrations (2–3% w/v) and neutral pH (pH 6) prevented biofilm formation. All strains were found to adhere easily to beech wood. These findings increase knowledge of the biofilm-forming capacity of histamine-producing L. parabuchneri strains and how their formation may be prevented for improving food safety.

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

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

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.

Influence of Dietary Salt Intake on T2D Treatment

Backgrounds

To what extent patients undergoing long-term T2D treatment are affected by dietary salt intake has not been completely investigated.

Objectives

We aimed to investigate the influence of dietary salt intakes on T2D treatment, including glucose-lowering effect and indices related to T2D progression.

Methods

The study recruited 1090 patients with T2D at Ningbo City First Hospital from January 1, 2018, to December 30, 2021. We compared their one-year follow-up outcomes in terms of fasting blood glucose (FBG), glycated hemoglobin (HbA1c), blood pressure, obesity, and prevalence of retinopathy and neuropathy among groups with different dietary salt intakes.

Results

The 1090 patients consisted of 287(26.3%) decreasing-, 190(17.4%) increasing-, 175(16.0%) steadily low-, 243(22.3%) steadily medium-, and 195(17.9%) steadily high-dietary salt intake patients. Compared to increasing-, steadily medium-, and steadily high-dietary salt intake patients, decreasing and steadily low salt intake led to lower baseline FBG, HbA1c, systolic blood pressure (SBP), BMI, and visceral fat area (VFA) (all p<0.05), to a larger decrease in FBG, HbA1c, SBP, BMI, and VFA after one-year treatment (all p<0.05), as well as to a slightly lower prevalence of retinopathy and a significantly lower prevalence of neuropathy. The steadily low salt patients had lower urine albumin/creatinine ratio (UAR) both at baseline and after treatment. Notably, the fasting insulin in the steadily low salt group was higher than the remaining groups after treatment (p<0.01).

Conclusions

The present study concludes that lowered dietary salt intake benefits T2D treatment in multiple aspects, including main treatment targets such as FBG and HbA1c, and indices reflecting potential complications of T2D, including BMI, VFA, SBP, UAR, retinopathy, and neuropathy.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: NCT03811470.

Perceived Associations between Excessive Sugar Intake and Health Conditions

Excessive sugar intake represents an increased risk of developing non-communicable diseases (e.g., obesity, cardiometabolic diseases, and dental diseases). Still, it is unclear whether people are aware of these adverse health outcomes. The current study systematically examined the extent to which people associate health conditions with excessive sugar intake. Participants (N = 1010 Portuguese volunteers) freely reported all health conditions they associated with excessive sugar consumption and rated the strength of these associations for eight specific health conditions. All participants reported health conditions associated with excessive sugar intake, with the most frequent being risk factors for cardiometabolic diseases (e.g., diabetes), cardiovascular diseases, oral problems, oncological and mental health conditions. Moreover, participants considered diabetes, overweight/obesity, and oral problems as being the conditions most related to excessive sugar intake. Women, participants with children in the household, and experts in health/nutrition rated excessive sugar intake as being more strongly linked to some of the health conditions. The identification of the health conditions that people associate with excessive sugar consumption may inform policymakers, educators, and health professionals and support interventions targeting the general public or specific groups (e.g., overweight people) in raising awareness of potential adverse health outcomes and, ultimately, contribute to reducing sugar intake.

Age, time orientation and risk perception are major determinants of discretionary salt usage

The present work explored the relationship between discretionary salt usage and personal characteristics, using boosted regression trees (BRT). Specifically, the focus was on how socio-demographic characteristics and personality traits linked to risk perception and time orientation impact on discretionary salt consumption patterns. For this purpose, an online cross-sectional survey with a convenience sample of 498 Uruguayan participants was carried out. Participants completed the consideration of future consequences (CFC) scale adapted for eating behaviour, a short survey about discretionary salt consumption patterns and indicated their degree of agreement with statements measuring perceived risk of sodium consumption. Finally, socio-demographic data were collected. BRT were applied to build predictive models that related discretionary salt usage to socio-demographic characteristics, the two factors of the CFC-Food scale (consideration of the future and consideration of the immediate consequences of eating behaviour), and the two factors of the perceived risk of sodium consumption scale (severity of perceived risks and risk compensation). Age, time orientation and perceived risk were the most relevant explanatory variables for discretionary salt usage. Older people had a lower likelihood of adding salt to food, either at home or when eating out. In addition, individuals who tend to be present rather than future oriented, as well as those with low perception of risk severity and susceptibility were more likely to add salt to foods. Results from the present work suggest that communication campaigns to reduce discretionary salt intake should mainly focus on stressing the short-term health benefits of reducing sodium intake and raising perceived susceptibility.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Parental practices, preferences, skills and attitudes on food consumption of pre-school children: Results from Nutriscience Project

The association between family environment and child’s eating behaviors is well established but a multidimensional approach to study this relation is lacking. This study aimed to assess the proprieties of a questionnaire created to evaluate parental practices, preferences, skills and attitudes regarding fruit and vegetables (F&V), sugar and salt. Participants (n = 714) were families of pre-school children (aged 2–6 years old) of the Nutriscience Project–a web-based gamification program–who answered a questionnaire assessing socio-demographic characteristics, nutrition knowledge, and a scale evaluating parental practices, preferences, skills and attitudes, at the baseline of the project. Exploratory factorial analysis was applied to the scale: 21 items and 5 factors were extracted (52.4% of explained variance) with a Kaiser-Meyer-Olkin (KMO) value of 0.770: 1. Modelling/active promotion of F&V consumption (α = 0.73), 2. Skills for choosing/preparing healthy food (α = 0.75), 3. Food preferences and satiety perception (α = 0.70), 4. Awareness regarding sugar/salt intake (α = 0.61), 5. Allowance regarding F&V consumption (α = 0.55). Kruskal-Wallis and Mann-Whitney tests were conducted to compare factors according to socio-demographic characteristics. Higher scores for parental modelling and active promotion of F&V consumption were observed in older parents, those with higher nutrition knowledge and who reported to live without income difficulties. Regarding food preferences, higher scores were observed in mothers, with higher nutrition knowledge and from higher educated groups. Higher awareness regarding salt and sugar consumption were observed in older parents, with higher education, higher nutrition knowledge and with female children. Older parents and with female children also registered higher scores of skills for choosing/preparing healthy food. The scale showed satisfactory proprieties and may contribute to assess family food environment using a multidimensional approach. It also highlighted the importance of considering socio-demographic characteristics in interventions to promote healthy eating.

Microparticles and microplastics contamination in African table salts

The presence of micro/plastic particles has been reported in various seafood products. However, information on microplastics contamination in salts from African continent is very limited. This study analysed 23 brands of table salts from 8 African countries for microplastics using microscopic/spectroscopic techniques. South Africa showed the highest microplastics concentration (0-1.33 ± 0.32 particles/kg), Nigeria, Cameroun, and Ghana (0-0.33 ± 0.38 particles/kg each); characterized as polyvinyl acetate, polypropylene, and polyethylene. Other countries have no detectable microplastics at 0.3 μm filter pore size. To our best knowledge, this is the first study to characterize micro-fibres/plastics in table salts across African countries, confirming that it is an emission source of micro-fibres/plastics into the human food chain, highlighting the overarching need to understand their effects on human health.

Factors Affecting Salt Reduction Measure Adoption among Chinese Residents

China has the highest mortality rate caused by diseases and conditions associated with its high-salt diet. Since 2016, China has initiated a national salt reduction campaign that aims at promoting the usage of salt information on food labels and salt-restriction spoons and reducing condiment and pickled food intake. However, factors affecting individuals’ decisions to adopt these salt reduction measures remain largely unknown. By comparing the performances of logistic regression, stepwise logistic regression, lasso logistic regression and adaptive lasso logistic regression, this study aims to fill this gap by analyzing the adoption behaviour of 1610 individuals from a nationally representative online survey. It was found that the practices were far from adopted and only 26.40%, 22.98%, 33.54% and 37.20% reported the adoption of labelled salt information, salt-restriction spoons, reduced condiment use in home cooking and reduced pickled food intake, respectively. Knowledge on salt, the perceived benefits of salt reduction, participation in nutrition education and training programs on sodium reduction were positively associated with using salt information labels. Adoption of the other measures was largely explained by people’s awareness of hypertension risks and taste preferences. It is therefore recommended that policy interventions should enhance Chinese individuals’ knowledge of salt, raise the awareness of the benefits associated with a low-salt diet and the risks associated with consuming excessive salt and reshape their taste choices.

Knowledge, Attitudes, and Practices Regarding Dietary Sodium in College Students

OBJECTIVE

Test a dietary sodium survey in a US adult population of college students using a survey previously validated in a non-US adult population.

METHODS

Cross-sectional study of a convenience sample of college students from a Midwest (n = 168) and Pacific Island (n = 152) university. Main outcome measures were knowledge, attitudes, and practices regarding dietary sodium (38 items). Sum scores and percentages for constructs were calculated. A score <75% was considered unfavorable; t test or ANOVA were used to examine group differences.

RESULTS

Midwest students were primarily non-Hispanic White individuals (81%) and 65% female. Pacific Island students were predominantly Asian (51%) and 66% female. Mean ± SD construct scores (percentage) for knowledge, attitudes, and practices were 58.69 ± 10.62, 63.96 ± 16.18, 66.00 ± 12.34 (Midwest) and 57.54 ± 10.93, 64.84 ± 14.96, 64.94 ± 13.18 (Pacific Island), respectively; there were no significant differences between schools or race.

CONCLUSIONS AND IMPLICATIONS

College students scored low in knowledge, attitudes, and practices regarding sodium. Results from this formative study may inform assessment strategies in future dietary sodium interventions.

Effectiveness and Feasibility of Taxing Salt and Foods High in Sodium: A Systematic Review of the Evidence

Diets high in salt are a leading risk for death and disability globally. Taxing unhealthy food is an effective means of influencing what people eat and improving population health. Although there is a growing body of evidence on taxing products high in sugar, and unhealthy foods more broadly, there is limited knowledge or experience of using fiscal measures to reduce salt consumption. We searched peer-reviewed databases [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews] and gray literature for studies published between January 2000 and October 2019. Studies were included if they provided information on the impact on salt consumption of: taxes on salt; taxes on foods high in salt, and taxes on unhealthy foods defined to include foods high in salt. Studies were excluded if their definition of unhealthy foods did not specify high salt or sodium. We found 18 relevant studies, including 15 studies reporting the effects of salt taxes through modeling (8), real-world evaluation (4), experimental design (2), or review of cost-effectiveness (1); 6 studies providing information relevant to country implementation of salt taxes; and 2 studies reporting stakeholder perceptions toward salt taxation. Although there is some evidence on the potential effectiveness and cost-effectiveness of salt taxation, especially from modeling studies, uptake of salt taxation is limited in practice. Some modeling studies suggested that food taxes can have unintended outcomes such as reduced consumption of healthy foods, or increased consumption of unhealthy, untaxed substitutes. In contrast, modeling studies that combined taxes for unhealthy foods with subsidies found that the benefits were increased. Modeling suggests that taxing all foods based on their salt content is likely to have more impact than taxing specific products high in salt given that salt is pervasive in the food chain. However, the limited experience we found suggests that policy-makers favor taxing specific products.

Understanding Vietnamese Urban Consumers' Nutrition Label Use, Health Concerns, and Consumption of Food and Beverages with Added Sugars

Vietnam is experiencing a diet and nutrition transition. Increasing consumption of food and beverages with added sugars is a significant public health concern. Policies and interventions, such as mandatory nutrition labelling, are being considered to improve consumers’ awareness and understanding of diet and health implications of added sugars in food and beverages. The effectiveness of various policy approaches relies on an improved understanding of the interrelationships between urban Vietnamese consumers’ health concerns, nutrition label use, and intake of sugars. We empirically disentangle these relationships for urban Vietnamese households using novel intra-household data covering 4047 adults and 737 adolescents from 1590 households in Hanoi and Ho Chi Minh City. The data are from comprehensive household surveys and 24-hour food diaries. Simultaneous equation regression models are estimated using three-stage least squares (3SLS) to account for possible endogeneity. Nutrition label use is significantly associated with a lower share of calories from foods and beverages with added sugars. These findings suggest that nutrition labelling programs may be an effective policy mechanism to reduce the negative health implications of increasing availability and consumption of food and beverages with added sugars in urban Vietnam.

Effects of a Novel Contextual Just-In-Time Mobile App Intervention (LowSalt4Life) on Sodium Intake in Adults With Hypertension: Pilot Randomized Controlled Trial

BACKGROUND

High dietary sodium intake is a significant public health problem in the United States. High sodium consumption is associated with high blood pressure and high risk of cardiovascular disease.

OBJECTIVE

The aim of this study was to evaluate the effect of a just-in-time adaptive mobile app intervention, namely, LowSalt4Life, on reducing sodium intake in adults with hypertension.

METHODS

In this study, 50 participants aged ≥18 years who were under treatment for hypertension were randomized (1:1, stratified by gender) into 2 groups, namely, the App group (LowSalt4Life intervention) and the No App group (usual dietary advice) in a single-center, prospective, open-label randomized controlled trial for 8 weeks. The primary endpoint was the change in the 24-hour urinary sodium excretion estimated from spot urine by using the Kawasaki equation, which was analyzed using unpaired two-sided t tests. Secondary outcomes included the change in the sodium intake measured by the food frequency questionnaire (FFQ), the 24-hour urinary sodium excretion, blood pressure levels, and the self-reported confidence in following a low-sodium diet.

RESULTS

From baseline to week 8, there was a significant reduction in the Kawasaki-estimated 24-hour urinary sodium excretion calculated from spot urine in the App group compared to that in the No App group (-462 [SD 1220] mg vs 381 [SD 1460] mg, respectively; P=.03). The change in the 24-hour urinary sodium excretion was -637 (SD 1524) mg in the App group and -322 (SD 1485) mg in the No App group (P=.47). The changes in the estimated sodium intake as measured by 24-hour dietary recall and by FFQ in the App group were -1537 (SD 2693) mg and -1553 (SD 1764) mg while those in the No App group were -233 (SD 2150) mg and -515 (SD 1081) mg, respectively (P=.07 and P=.01, respectively). The systolic blood pressure change from baseline to week 8 in the App group was -7.5 mmHg while that in the No App group was -0.7 mmHg (P=.12), but the self-confidence in following a low-sodium diet was not significantly different between the 2 groups.

CONCLUSIONS

This study shows that a contextual just-in-time mobile app intervention resulted in a greater reduction in the dietary sodium intake in adults with hypertension than that in the control group over a 8-week period, as measured by the estimated 24-hour urinary sodium excretion from spot urine and FFQ. The intervention group did not show a significant difference from the control group in the self-confidence in following a low sodium diet and in the 24-hour urinary sodium excretion or dietary intake of sodium as measured by the 24-hour dietary recall. A larger clinical trial is warranted to further elucidate the effects of the LowSalt4Life intervention on sodium intake and blood pressure levels in adults with hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03099343; https://clinicaltrials.gov/ct2/show/NCT03099343.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11282.

Salt-Related Knowledge, Attitudes and Behaviors (KABs) among Victorian Adults Following 22-Months of a Consumer Awareness Campaign

The Australian population consumes more salt than recommended and this increases the risk of raised blood pressure and cardiovascular disease. In 2015, a state-wide initiative was launched in the Australian state of Victoria to reduce population salt intake. This study examines whether salt-related knowledge, attitudes and behaviors (KABs) of Victorian adults changed following the first 22 months of a consumer awareness campaign targeting parents. Repeated cross-sectional surveys of adults (18–65 years) recruited from research panels. Analyses were weighted to reflect the Victorian population. In both surveys mean age of participants (1584 in 2015 and 2141 in 2018) was 41 years, and 51% were female. This includes 554 parents/caregivers in 2015 and 799 in 2018. Most indicators of KAB remained unchanged. Among parents/caregivers the percentage who agreed limiting salt in their child’s diet was important increased by 8% (p = 0.001), and there was a 10% reduction in the percentage who reported placing a saltshaker on the table and a 9% reduction in those who reported their child added salt at the table (both p < 0.001). Some small adverse effects on other indicators were also observed. During the first 22 months of a salt reduction consumer awareness campaign, there were limited changes in KAB overall, however the target audience reported positive changes regarding their children, which aligned with the campaign messages.

Selected Predictors of the Importance Attached to Salt Content Information on the Food Packaging (a Study among Polish Consumers)

This paper aims to identify selected antecedents of the importance attached to salt content information (ISCI) placed on food labels, on the basis of a representative survey of 1051 Polish consumers. The study was conducted with the use of the CAWI (Computer Assisted Web Interviews) method in 2018. Quota sampling was applied with reference to the following five criteria: sex, age, education, place of living (urban and rural areas), and region. In a multiple regression model, ISCI depends on the respondent’s: sex, age, evaluation of the quantity of nutrition claims, importance attached to nutrition claims, willingness to pay a price premium for products with nutrition claims, attention paid to health and nutrition claims, agreeing with the opinion that unreliable nutrition claims are a serious problem, evaluation of healthiness of one’s diet, self-rated knowledge about healthy nutrition, buying organic food, and reading front-of-package (FOP) labels during and after the purchase. The strongest effects on the importance attached to salt content information on the food packaging were displayed by the importance of nutrition claims, attention paid to nutrition and health claims, respondent’s age, FOP label reading at home, and agreeing that the use of unreliable nutrition claims is a serious problem.

Knowledge, Attitudes and Behaviours Related to Dietary Salt Intake in High-Income Countries: a Systematic Review

PURPOSE OF REVIEW

The purpose of this review was to examine the knowledge, attitudes and behaviours (KAB) related to dietary salt intake among adults in high-income countries.

RECENT FINDINGS

Overall (n = 24 studies across 12 countries), KAB related to dietary salt intake are low. While consumers are aware of the health implications of a high salt intake, fundamental knowledge regarding recommended dietary intake, primary food sources, and the relationship between salt and sodium is lacking. Salt added during cooking was more common than adding salt to food at the table. Many participants were confused by nutrition information panels, but food purchasing behaviours were positively influenced by front of package labelling. Greater emphasis of individual KAB is required from future sodium reduction programmes with specific initiatives focusing on consumer education and awareness raising. By doing so, consumers will be adequately informed and empowered to make healthier food choices and reduce individual sodium intake.

Determinants of intention to reduce salt intake and willingness to purchase salt-reduced food products: Evidence from a web survey

To study consumers' intention to reduce their dietary salt intake and willingness to purchase salt-reduced food products, as well as the determinants of these, this research relies on data collected through a web survey of 1030 participants in Denmark. The majority of respondents (66.8%) express no intentions to change their dietary salt intake, but 12.6% indicate such intentions, and 20.6% claim to have already implemented a change. Willingness to purchase salt-reduced food products is high but varies across product categories, ranging from 52% for olives to 72% for meat spreads. Personal and social norms reveal the strongest influences on intention to change dietary habits, whereas personal norms, knowledge, and awareness of health consequences exert the strongest influences on willingness to purchase salt-reduced food products. These results suggest that most consumers are willing to purchase salt-reduced food products, even without having a salt reduction goal. These results are relevant for stakeholders and policy makers, as evidence of how consumers respond to salt-reduced food products and their intention to lower their dietary salt intake.

Comparison of salt-related knowledge, attitudes and behaviours between parents and caregivers of children under 18 years of age and other adults who do not care for children under 18 years of age in Victoria, Australia

Background/Aims

Salt intake among Australian adults exceeds recommendations, increasing the risk of cardiovascular disease. Knowledge, attitudes and behaviours (KABs) are modifiable factors that may influence salt consumption. It is not known whether salt-related KABs among parents and caregivers of children under 18 years of age differ from other adults who do not care for children under 18 years of age. Therefore, we aimed to determine whether salt-related KABs differed between parents and caregivers and other adults. This information can be used to inform messages included in salt reduction consumer awareness campaigns.

Methods

Adults, aged 18–65 years, were recruited from four shopping centres, Facebook and a consumer research panel in the state of Victoria, Australia. Participants indicated if they were a parent or a caregiver of a child/children <18 years (‘parents/caregivers’) or not (‘other adults’). Regression models, adjusted for covariates, assessed differences in KABs between the two groups. Construct scores for KABs were developed, with high scores for knowledge indicative of high salt-related knowledge, for attitude indicative of lower importance of using salt to enhance the taste of food, and for behaviours indicative of higher frequency of engaging in behaviours to reduce salt in the diet.

Results

A total of 840 parents/caregivers and 1558 other adults completed the survey. Just over half of the parents/caregivers and other adults were female, with a mean (SD) age of 41.1 (10.3) years and 44.3 (15.3) years, respectively. Mean construct scores for salt-related KABs were similar between the two groups. Parents/caregivers were less likely to be aware of the relationship between salt and sodium (OR=0.73, p=0.002) and more likely to report difficulty in interpreting sodium information displayed on food labels (OR=1.36, p=0.004). Parents/caregivers were more likely to be concerned about a range of food-related issues, including the amount of saturated fat, sugar and salt in food. Parents/caregivers were more likely to report that they were trying to reduce their salt intake (OR=1.27, p=0.012) and more likely to report adding salt at the table (OR=1.28, p=0.008).

Conclusions

There were some differences in salt-related KABs between parents/caregivers and other adults. These findings provide insight into particular messages that could be focused on in consumer awareness campaigns that seek to improve parents’/caregivers’ KABs related to salt intake. Specifically, messages targeted at parents/caregivers should include practical guidance to reduce table salt and resources to assist in interpreting sodium information on food labels and the relationship of sodium to salt.

Economic assessment of nutritional recommendations: A comment

This is a comment on the paper by Irz et al. (2015) in this journal, on nutritional recommendations. Irz et al. (2015) propose to compute the cost of a nutritional constraint as the consumer loss of surplus, derived from their observed choices. Introducing behavioral biases into an extended version of their model, I show that their proposed methodology implicitly assumes that consumer dietary choices do not involve any health considerations. The cost per quality-adjusted life year that they compute should be corrected by the size of the bias of consumers to be compared with benchmark evaluations.

Knowledge, Attitude, and Practice on Salt and Assessment of Dietary Salt and Fat Intake among University of Sharjah Students

BACKGROUND

Cardiovascular diseases are the main cause of deaths in the United Arab Emirates and reducing dietary salt intake is recommended to improve the population's health.

METHODS

a cross-sectional survey was given to 401 students from the University of Sharjah to investigate knowledge, attitudes, and practices related to dietary salt intake and a 24-h dietary recall among a subsample of 122 students, to assess the dietary intake of total fat, cholesterol, saturated fat, trans fat, and sodium.

RESULTS

findings indicated low salt-related knowledge scores among students (17 out of 30), high prevalence of overweight (28%), obesity (14%), hypertension stage 1 (31%), and hypertension stage 2 (20%). The results also revealed a high percentage of students exceeding the recommended intake of total fat (48%), saturated fat (90%), trans fat (64%), and sodium (89%), and all students not meeting potassium recommendations.

CONCLUSIONS

culture-specific awareness campaigns on salt and fat intake and their association with health are needed.

The Digital Education to Limit Salt in the Home Program Improved Salt-Related Knowledge, Attitudes, and Behaviors in Parents

Background

Currently, Australian children and adults are eating too much salt, increasing their risk of cardiovascular-related conditions. Web-based programs provide an avenue to engage the parents of primary schoolchildren in salt-specific messages, which may positively impact their own salt-related knowledge, attitudes, and behaviors (KABs).

Objective

This pilot study aimed to determine whether parents’ salt-related KABs improved following participation in the Digital Education to LImit Salt in the Home (DELISH) Web-based education program.

Methods

The DELISH program was a 5-week, home-delivered, Web-based intervention, with a pre- and posttest design, targeting schoolchildren aged 7 to 10 years and their parents. Parents received weekly Web-based educational newsletters and text messages and completed online pre- and postprogram surveys assessing salt-related KABs. Upon completion of the program, all parents were also invited to complete an online evaluation survey. Changes in KABs outcomes were assessed using McNemar tests and paired t tests.

Results

Of the 80 parents that commenced the program, 73 parents (mean age 41.0, SD 7.0 years; 86% (63/73) females) completed both pre- and postsurveys. Overall, mean score for salt-related knowledge improved (+3.6 [standard error (SE) 0.41] points), and mean behavior score also improved (+4.5 [SE 0.61] points), indicating a higher frequency of engaging in behaviors to reduce salt in the diet, and mean attitude score decreased (−0.7 [SE 0.19] points), representing lower importance of using salt to enhance the taste of food (all P<.001). Following participation, the proportion of parents aware of the daily salt intake recommendation increased from 40% (29/73) to 74% (54/73) (P<.001), and awareness of bread as the main source of salt increased from 58% (42/73) to 95% (69/73) (P<.001). The proportion of parents who agreed that salt should be used in cooking to enhance the flavor of food decreased from 30% (22/73) to 11% (8/73) (P=.002) and the proportion who agreed that sodium information displayed on food labels was difficult to understand decreased from 52% (38/73) to 32% (23/73) (P=.009). There was a reduction in the proportion of parents who reported adding salt during cooking (55% [40/73] vs 41% [30/73]; P=.03) and at the table (32% [23/73] vs 18% [13/73]; P=.002). Of the 16 parents who completed the evaluation survey, 75% (12/16) enjoyed the program, and all parents found the newsletters to be useful. Almost all parents (15/16, 94%) agreed that the DELISH program would be useful to other parents.

Conclusions

The improvement in salt-related KABs in the DELISH program indicates the potential for online technology, to disseminate simple salt reduction education messages to families with primary school–aged children. Future work should seek to improve the quality of data collected by including a larger sample size and a control group to integrate the program within the school setting to enable wider dissemination.

A Meta-Analysis of Food Labeling Effects on Consumer Diet Behaviors and Industry Practices

CONTEXT

The influence of food and beverage labeling (food labeling) on consumer behaviors, industry responses, and health outcomes is not well established.

EVIDENCE ACQUISITION

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Ten databases were searched in 2014 for studies published after 1990 evaluating food labeling and consumer purchases/orders, intakes, metabolic risk factors, and industry responses. Data extractions were performed independently and in duplicate. Studies were pooled using inverse-variance random effects meta-analysis. Heterogeneity was explored with I2, stratified analyses, and meta-regression; and publication bias was assessed with funnel plots, Begg's tests, and Egger's tests. Analyses were completed in 2017.

EVIDENCE SYNTHESIS

From 6,232 articles, a total of 60 studies were identified, including 2 million observations across 111 intervention arms in 11 countries. Food labeling decreased consumer intakes of energy by 6.6% (95% CI= -8.8%, -4.4%, n=31), total fat by 10.6% (95% CI= -17.7%, -3.5%, n=13), and other unhealthy dietary options by 13.0% (95% CI= -25.7%, -0.2%, n=16), while increasing vegetable consumption by 13.5% (95% CI=2.4%, 24.6%, n=5). Evaluating industry responses, labeling decreased product contents of sodium by 8.9% (95% CI= -17.3%, -0.6%, n=4) and artificial trans fat by 64.3% (95% CI= -91.1%, -37.5%, n=3). No significant heterogeneity was identified by label placement or type, duration, labeled product, region, population, voluntary or legislative approaches, combined intervention components, study design, or quality. Evidence for publication bias was not identified.

CONCLUSIONS

From reviewing 60 intervention studies, food labeling reduces consumer dietary intake of selected nutrients and influences industry practices to reduce product contents of sodium and artificial trans fat.

A Novel Just-in-Time Contextual Mobile App Intervention to Reduce Sodium Intake in Hypertension: Protocol and Rationale for a Randomized Controlled Trial (LowSalt4Life Trial)

Background

High sodium intake is a significant public health problem in the United States. Interventions that lower sodium intake can decrease blood pressure and improve cardiovascular outcomes. Restaurants and grocery stores are prime targets for intervention with about 77% of all sodium intake in the average US diet coming from processed and restaurant foods.

Objective

This study proposes that a mobile app intervention that promotes low-sodium alternatives at grocery stores and restaurants will reduce dietary intake of sodium and improve confidence following a low-sodium diet in hypertension.

Methods

In this single-center, prospective, open-label study, patients will be randomized to a mobile app or usual care for 8 weeks. We will randomize 50 patients (age>18 years) diagnosed with hypertension and on antihypertensive therapy for at least 3 months in a 1:1 manner stratified by gender. Study subjects will receive the mobile app, LowSalt4Life, or usual dietary advice for 8 weeks. LowSalt4Life provides a multifaceted intervention based on just-in-time contextual tailored messages at grocery stores and restaurants. The primary endpoint is the change in the estimated 24-hour urinary excretion of sodium from spot urine. Secondary outcomes include change in the sodium content of the food frequency questionnaire, confidence in following a low-sodium diet, urine chloride and creatinine dipsticks, and blood pressure.

Results

The project was funded in May 2016 until April 2018. This trial is currently enrolling patients. To date, 26 of the 50 patients needed have been enrolled. Results will be available in the Spring of 2019.

Conclusions

This randomized controlled trial will test the efficacy of just-in-time contextual tailored messages through a novel mobile app 8-week intervention on urinary sodium excretion in patients with hypertension. We will address a critical evidence gap in the care of patients with hypertension. If effective, this intervention could be scaled to assess effects on blood pressure and cardiovascular events in hypertension.

Trial Registration

ClinicalTrials.gov NCT03099343; https://clinicaltrials.gov/ct2/show/NCT03099343 (Archived by WebCite at http://www.webcitation.org/735HNzKlQ)

International Registered Report Identifier (IRRID)

PRR1-10.2196/11282

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.

Impact of a hospital-based educational intervention on dietary salt-related knowledge and behaviour in a cardiac care unit population in Lebanon

Background

Cardiovascular disease is the most common cause of morbidity and mortality worldwide. Numerous strategies have been effective in reducing cardiovascular disease risk, from pharmacological approaches to lifestyle modification interventions. One of these strategies includes the reduction in dietary sodium which in turn reduces cardiovascular risk by reducing high blood pressure, perhaps the most important cardiovascular risk factor.

Methods

We evaluated an educational dietary salt reduction intervention in a cardiac care unit population in Lebanon, assessing salt related knowledge and behaviours before and after administering an evidence-based educational leaflet to patients.

Results

Salt-related knowledge improved significantly immediately post-intervention and subsequently fell on 4-week follow-up, but remained above baseline. Three of the four salt-related behaviours measured improved on 4-week follow-up: trying to buy low-salt foods increased from 54% to 74% (P=0.007), adding salt at the table reduced from 44% to 34% (P=0.03) and trying to buy food with no added salt increased from 24% to 52% (P=0.02) of the cohort. Adding salt during cooking did not differ significantly. A trend towards improved behavioural risk category in the cohort overall was observed on follow-up (P=0.07), 32% of participants were categorised as high behavioural risk pre-intervention, reducing to 17% on follow-up. Multi-ordered regression modelling identified being in the high-risk behavioural category at baseline as a predictor of being in the high-risk or moderate-risk category on follow-up.

Conclusions

This hospital-based educational intervention had a modestly positive impact on salt-related knowledge and behaviour, with participants in the highest behavioural risk category at baseline being most resistant to behavioural improvement.

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).

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

Salt consumption is high in Africa and the continent also shares the greatest burden of hypertension. This study examines salt-related knowledge, attitude and self-reported behaviours (KAB) amongst adults from two African countries—Ghana and South Africa—which have distributed different public health messages related to salt. KAB was assessed in the multinational longitudinal World Health Organisation (WHO) study on global AGEing and adult health (WHO-SAGE) Wave 2 (2014–2015). Respondents were randomly selected across both countries—Ghana (n = 6746; mean age 58 years old; SD 17; 41% men; 31% hypertensive) and South Africa (n = 3776, mean age 54 years old; SD 17; 32% men; 45% hypertensive). South Africans were more likely than Ghanaians to add salt to food at the table (OR 4.80, CI 4.071–5.611, p < 0.001) but less likely to add salt to food during cooking (OR 0.16, CI 0.130–0.197, p < 0.001). South Africans were also less likely to take action to control their salt intake (OR 0.436, CI 0.379–0.488, p < 0.001). Considering the various salt reduction initiatives of South Africa that have been largely absent in Ghana, this study supports additional efforts to raise consumer awareness on discretionary salt use and behaviour change in both countries.

Stages of Behavioral Change for Reducing Sodium Intake in Korean Consumers: Comparison of Characteristics Based on Social Cognitive Theory

High sodium intake increases the risk of cardiovascular disease. Given the importance of behavioral changes to reducing sodium intake, this study aims to investigate the stages of change and the differences in cognitive and behavioral characteristics by stage in Korean consumers. Adult participants (N = 3892) completed a questionnaire on the stages of behavioral change, recognition of social efforts, outcome expectancy, barriers to practice, nutrition knowledge and dietary behaviors, and self-efficiency related to reduced sodium intake. The numbers of participants in each stage of behavioral change for reducing sodium intake was 29.5% in the maintenance stage, 19.5% in the action stage, and 51.0% in the preaction stage that included the precontemplation, contemplation, and preparation stages. Multiple logistic regression showed that the factors differentiating the three stages were recognizing a supportive social environment, perceived barriers to the practice of reducing sodium intake, and self-efficacy to be conscious of sodium content and to request less salt when eating out. Purchasing experience of sodium-reduced products for salty foods, knowledge of the recommended intake of salt and the difference between sodium and salt, and improving dietary habits of eating salted fish, processed food, and salty snacks were factors for being in the action stage versus the preaction stage. These findings suggest that tailored intervention according to the characteristics of each stage is helpful in reducing sodium intake.

Knowledge, attitudes and behaviours related to dietary salt among adults in the state of Victoria, Australia 2015

Background

Information on consumer’s knowledge, attitudes and behaviours (KABs) related to salt can be used to inform awareness and education campaigns and serve as a baseline measure to monitor changes in KABs over time. The aim of this study was to determine KABs related to salt intake among Victorian adults.

Methods

Cross-sectional survey conducted in Victorian adults aged 18–65 years. Participants were recruited from shopping centres located in Melbourne and Geelong and via online methods (Facebook and Consumer Research Panel) to complete an online survey assessing KABs related to dietary salt. Descriptive statistics (mean (SD) or n (%)) were used to report survey findings.

Results

A total of 2398 participants provided a valid survey (mean age 43 years (SD 13), 57% female). The majority (80%) were born in Australia and 63% were the main household grocery shopper. The majority (89%) were aware of the health risks associated with a high salt intake. Eighty three percent believed that Australians eat too much salt. Three quarters (75%) correctly identified salt from processed foods as being the main source of salt in the diet. Less than a third (29%) of participants believed their own individual salt intake exceeded dietary recommendations and only 28% could correctly identify the maximum recommended daily intake for salt. Just under half (46%) of participants were concerned about the amount of salt in food. Almost two thirds (61%) of participants believed that there should be laws which limit the amount of salt added to manufactured foods and 58% agreed that it was difficult to find lower salt options when eating out.

Conclusions

The findings of this study serve as a baseline assessment of KABs related to salt intake in Victorian adults and can be used to assess changes in salt related KABs over time. Public concern about salt is low as many people remain unaware of their own salt intake. An increased awareness of the excessive amount of salt consumed and increased availability of lower salt foods are likely to reduce population salt intake.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4451-0) contains supplementary material, which is available to authorized users.

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

Consumer knowledge is understood to play a role in managing risk factors associated with cardiovascular disease and may be influenced by level of education. The association between population knowledge, behaviours and actual salt consumption was explored overall, and for more-educated compared to less-educated individuals. A cross-sectional survey was done in an age-and sex-stratified random sample of 1395 participants from urban and rural areas of North and South India. A single 24-h urine sample, participants' physical measurements and questionnaire data were collected. The mean age of participants was 40 years, 47% were women and mean 24-h urinary salt excretion was 9.27 (8.87-9.69) g/day. Many participants reported favourable knowledge and behaviours to minimise risks related to salt. Several of these behaviours were associated with reduced salt intake-less use of salt while cooking, avoidance of snacks, namkeens, and avoidance of pickles (all p < 0.003). Mean salt intake was comparable in more-educated (9.21, 8.55-9.87 g/day) versus less-educated (9.34, 8.57-10.12 g/day) individuals (p = 0.82). There was no substantively different pattern of knowledge and behaviours between more-versus less-educated groups and no clear evidence that level of education influenced salt intake. Several consumer behaviours related to use of salt during food preparation and consumption of salty products were related to actual salt consumption and therefore appear to offer an opportunity for intervention. These would be a reasonable focus for a government-led education campaign targeting salt.

Quality standards versus nutritional taxes: Health and welfare impacts with strategic firms

The goal of this paper is to better understand firms' strategic reactions to nutritional policies targeting food quality improvements and to derive optimal policies. We propose a model of product differentiation, taking into account the taste and health characteristics of products. We study how two firms react to alternative policies: an MQS policy, linear taxation of the two goods on the market, and taxation of the low-quality good. The MQS and the taxation of the low-quality product are the preferred options by a social planner. If taste is moderately important, the MQS policy is chosen by a populist and a paternalist social planner. If taste is a major component of choice, the populist planner chooses to tax the low-quality product whereas the paternalist planner prefers the MQS policy. Finally, for a paternalist social planner, an MQS-based policy always allows for higher levels of welfare than an information policy alone.

Earmarking and the political support of fat taxes

An unhealthy good causes health issues in the long run. It creates a misperceived utility loss and increases health care costs. Conversely, a healthy good provides misperceived utility gains and reduces health care costs. Individuals differ in income and in their degree of misperception; they vote over a fat tax according to their misperceived utility. A fraction of the tax proceeds is "earmarked" to reduce health insurance premiums; the remainder finances a subsidy on the healthy good. This earmarking rule is determined to maximize welfare, anticipating the induced political equilibrium. The equilibrium fat tax is always lower than the utilitarian level. This is not necessarily true with a Rawlsian objective. The determination of the earmarking rule is complex. Even in the utilitarian case, it is not just used to boost political support for the fat tax. Instead, it may involve a tradeoff between fat tax and healthy good subsidy.

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

Background

Salt reduction is a public health priority but there are few studies testing the efficacy of plausible salt reduction programs.

Methods

A 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.

Results

Survey participants were on average 56 years old and 58 % female. Mean salt intake estimated from 24-h urine samples fell from 8.8 g/day (SD = 3.6 g/day) in 2011 to 8.0 (3.6) g/day in 2014 (−0.80, 95 % confidence interval −1.2 to −0.3;p < 0.001). There were significant increases in the proportion of participants that knew the recommended upper limit of salt intake (18 % vs. 29 %; p < 0.001), knew the importance of salt reduction (64 % vs. 78 %; p < 0.001) and reported changing their behaviors to reduce their salt intake by using spices (5 % vs. 28 %; p < 0.001) and avoiding eating out (21 % vs. 34 %; p < 0.001). However, the proportions that checked food labels (30 % vs. 25 %; p = 0.02) fell, as did the numbers avoiding processed foods (44 % vs. 35 %; p = 0.006). Twenty-six percent reported using salt substitute at the end of the intervention period and 90 % had heard about the program. Findings were robust to multivariable adjustment.

Conclusions

Implementation of this multi-faceted community-based program was associated with a ~10 % 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 registration

NCT02105727.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3064-3) contains supplementary material, which is available to authorized users.

Impact of Health Labels on Flavor Perception and Emotional Profiling: A Consumer Study on Cheese

The global increase of cardiovascular diseases is linked to the shift towards unbalanced diets with increasing salt and fat intake. This has led to a growing consumers' interest in more balanced food products, which explains the growing number of health-related claims on food products (e.g., "low in salt" or "light"). Based on a within-subjects design, consumers (n = 129) evaluated the same cheese product with different labels. Participants rated liking, saltiness and fat flavor intensity before and after consuming four labeled cheeses. Even though the cheese products were identical, inclusion of health labels influenced consumer perceptions. Cheese with a "light" label had a lower overall expected and perceived liking compared to regular cheese. Although cheese with a "salt reduced" label had a lower expected liking compared to regular cheese, no lower liking was found when consumers actually consumed the labeled cheese. All labels also influenced the perceived intensities of the attributes related to these labels, e.g., for example salt intensity for reduced salt label. While emotional profiles of the labeled cheeses differed before tasting, little differences were found when actual tasting these cheeses. In conclusion, this study shows that health-related labels might influence the perceived flavor and emotional profiles of cheese products.

Consumer attitudes, barriers, and meal satisfaction associated with sodium-reduced meal intake at worksite cafeterias

BACKGROUND/OBJECTIVES

Targeting consumers who consume lunches at their worksite cafeterias would be a valuable approach to reduce sodium intake in South Korea. To assess the relationships between socio-demographic factors, consumer satisfaction, attitudes, barriers and the frequency of sodium-reduced meal intake.

SUBJECTS/METHODS

We implemented a cross-sectional research, analyzing data from 738 consumers aged 18 years or older (327 males and 411 females) at 17 worksite cafeterias in South Korea. We used the ordinary least squares regression analysis to determine the factors related to overall satisfaction with sodium-reduced meal. General linear models with LSD tests were employed to examine the variables that differed by the frequency of sodium-reduced meal intake.

RESULTS

Most subjects always or usually consumed the sodium-reduced meal (49%), followed by sometimes (34%) and rarely or never (18%). Diverse menus, taste and belief in the helpfulness of the sodium-reduced meal significantly increased overall satisfaction with the sodium-reduced diet (P < 0.05). We found importance of needs in the following order: 1) 'menu diversity' (4.01 points), 2) 'active promotion' (3.97 points), 3) 'display of nutrition labels in a visible location' (3.96 points), 4) 'improvement of taste' (3.88 points), and 5) 'education of sodium-reduction self-care behaviors' (3.82 points).

CONCLUSION

Dietitians could lead consumers to choose sodium-reduced meals by improving their taste and providing diverse menus for the sodium-reduced meals at worksite cafeterias.

Does school health and home economics education influence adults' food knowledge?

Home economics and health teachers are to be found in many parts of the world. They teach students about food in relation to its nutritional, safety and environmental properties. The effects of such teaching might be expected to be reflected in the food knowledge of adults who have undertaken school education in these areas. This study examined the food knowledge associations of school home economics and health education among Australian adults. Two separate online surveys were conducted nationwide among 2022 (November 2011) and 2146 Australian adults (November-December 2012). True/false and multiple choice questions in both surveys were used to assess nutrition, food safety and environmental knowledge. Knowledge scores were constructed and compared against respondents' experience of school health or home economics education via multiple regression analyses. The results from both studies showed that home economics (and similar) education was associated with higher levels of food knowledge among several age groups. The associations of home economics education with food knowledge differed across several Australian states and recall of home economics themes differed across the age groups. These findings suggest that home economics education may bring about long-lasting learning of food knowledge. Further research is required, however, to confirm the findings and to test the causal influence of home economics education on adults' food knowledge.

Influence of Interpretation Aids on Attentional Capture, Visual Processing, and Understanding of Front-of-Package Nutrition Labels

OBJECTIVE

To study the influence of 2 interpretational aids of front-of-package (FOP) nutrition labels (color code and text descriptors) on attentional capture and consumers' understanding of nutritional information.

DESIGN

A full factorial design was used to assess the influence of color code and text descriptors using visual search and eye tracking.

PARTICIPANTS

Ten trained assessors participated in the visual search study and 54 consumers completed the eye-tracking study.

MAIN OUTCOME MEASURES

In the visual search study, assessors were asked to indicate whether there was a label high in fat within sets of mayonnaise labels with different FOP labels. In the eye-tracking study, assessors answered a set of questions about the nutritional content of labels.

ANALYSIS

The researchers used logistic regression to evaluate the influence of interpretational aids of FOP nutrition labels on the percentage of correct answers. Analyses of variance were used to evaluate the influence of the studied variables on attentional measures and participants' response times.

RESULTS

Response times were significantly higher for monochromatic FOP labels compared with color-coded ones (3,225 vs 964 ms; P < .001), which suggests that color codes increase attentional capture. The highest number and duration of fixations and visits were recorded on labels that did not include color codes or text descriptors (P < .05). The lowest percentage of incorrect answers was observed when the nutrient level was indicated using color code and text descriptors (P < .05).

CONCLUSIONS AND IMPLICATIONS

The combination of color codes and text descriptors seems to be the most effective alternative to increase attentional capture and understanding of nutritional information.

Salt reduction in Australia: from advocacy to action

BACKGROUND

As part of its endorsement of the World Health Organization's Global Action Plan to prevent non-communicable diseases, the Federal Government of Australia has committed to a 30% reduction in average population salt intake by 2025. Currently, mean daily salt intake levels are 8-9 g, varying by sex, region and population group. A number of salt reduction initiatives have been established over the last decade, but key elements for a co-ordinated population-level strategy are still missing. The objective of this review is to provide a comprehensive overview of existing population-level salt reduction activities in Australia and identify opportunities for further action.

METHODS

A review of the published literature and stakeholder activities was undertaken to identify and document current activities. The activities were then assessed against a pre-defined framework for salt reduction strategies.

RESULTS

A range of initiatives were identified from the review. The Australian Division of World Action on Salt and Health (AWASH) was established in 2005 and in 2007 launched its Drop the Salt! Campaign. This united non-governmental organisations (NGOs), health and medical and food industry organisations in a co-ordinated advocacy effort to encourage government to develop a national strategy to reduce salt. Subsequently, in 2010 the Federal Government launched its Food and Health Dialogue (FHD) with a remit to improve the health of the food supply in Australia through voluntary partnerships with food industry, government and non-government public health organisations. The focus of the FHD to date has been on voluntary reformulation of foods, primarily through salt reduction targets. More recently, in December 2014, the government's Health Star Rating system was launched. This front of pack labelling scheme uses stars to highlight the nutritional profile of packaged foods. Both government initiatives have clear targets or criteria for industry to meet, however, both are voluntary and the extent of industry uptake is not yet clear. There is also no parallel public awareness campaign to try and influence consumer behaviour relating to salt and no agreed mechanism for monitoring national changes in salt intake. The Victorian Health Promotion Foundation (VicHealth) has recently instigated a State-level partnership to advance action and will launch its strategy in 2015.

CONCLUSIONS

In conclusion, salt reduction activities are currently being implemented through a variety of different programs but additional efforts and more robust national monitoring mechanisms are required to ensure that Australia is on track to achieve the proposed 30% reduction in salt intake within the next decade.

Sodium content on processed foods for snacks

OBJECTIVE

To assess the Na content reported on the labels of processed foods sold in Brazil that are usually consumed as snacks by children and adolescents.

DESIGN

Cross-sectional study that assessed Na content and serving size reporting on processed food labels.

SETTING

A supermarket that is part of a large chain in Brazil.

SUBJECTS

All foods available for sale at the study's location and reported in the literature as snacks present in the diets of Brazilian children and adolescents.

RESULTS

Of the 2945 processed foods, 87 % complied with the reference serving sizes, although variability in reporting was observed in most of the food subgroups. In addition, 21 % of the processed foods had high Na levels (>600 mg/100 g) and 35 % had medium Na levels (>120 and ≤600 mg/100 g). The meats, oils, fats and seeds groups as well as the prepared dishes had higher percentages of foods classified as high Na (81 %, 58 % and 53 %, respectively).

CONCLUSIONS

Most of the processed foods had high or medium Na content. We emphasize the importance of revising Brazilian nutrition labelling legislation to standardize reference serving sizes to avoid variation. Besides, we point out the potential for reducing Na levels in most processed foods, as evidenced by the variability in Na content within subgroups. Finally, we have identified the need to develop a method to classify Na levels in processed foods with specific parameters for children and adolescents.

The effects of nutrition knowledge on food label use. A review of the literature

Nutrition information on food labels is an important source of nutrition information but is typically underutilized by consumers. This review examined whether consumer nutrition knowledge is important for communication of nutrition information through labels on packaged foods. A cognitive processing model posits that consumers with prior knowledge are more likely to use label information effectively, that is, focus on salient information, understand information, and make healthful decisions based on this information. Consistent with this model, the review found that nutrition knowledge provides support for food label use. However, nutrition knowledge measures varied widely in terms of the dimensions they included and the extensiveness of the assessment. Relatively few studies investigated knowledge effects on the use of ingredient lists and claims, compared to nutrition facts labels. We also found an overreliance on convenience samples relying on younger adults, limiting our understanding of how knowledge supports food label use in later life. Future research should 1) investigate which dimensions, or forms, of nutrition knowledge are most critical to food label use and dietary decision making and 2) determine whether increases in nutrition knowledge can promote great use of nutrition information on food labels.