Attitudes and beliefs of health risks associated with sodium intake in diabetes

Knowledge, attitudes, and behaviors related to dietary salt intake and the acceptability of salt substitute among the Australian culturally and linguistically diverse community: An online survey

The Australian culturally and linguistically diverse (CALD) communities may be at higher risk of salt intake than recommended given the use of a combination of discretionary sources and exposure to processed foods within a western country. This survey aimed to understand the knowledge, attitudes, and behaviors toward dietary salt and the acceptability of salt substitutes in the CALD communities. An online cross-sectional survey was conducted among adults who self-reported being a part of a CALD community, which was defined as non-Indigenous cultural groups in Australia having cultural or linguistic connections with their overseas place of birth, ancestry or ethnic origin, religion, preferred language or language spoken at home. A total of 218 respondents opened the survey link. A total of 196 completed the entire survey. The majority of respondents (162, 83%) were aware that high salt intake causes serious health problems. Altogether 134 (69%) respondents were aware that there is a recommended amount for daily salt consumption although only 59 (44%) knew precise recommendations as <5 g salt per day. Around one quarter of the respondents rarely or never looked for ‟low in salt'' or ‟reduced salt'' messages on food labels when shopping. Over half specified they always or often added salt during cooking or preparing foods in the household. Almost 4 in 5 CALD respondents were willing to reduce their salt intake for health and 3 in 4 were open to trying a salt substitute. Further research into the utility of a salt substitute intervention in the Australian CALD community is warranted.

'Feta is obviously very dangerous stuff looking at all those reds': Can nutrition labelling help people living with type 2 diabetes to self-manage their condition?

BACKGROUND

The consumption of a healthy balanced diet is the cornerstone of treatment for people living with type 2 diabetes (PLWT2DM). The United Kingdom recommends a standardised voluntary front-of-pack food labelling system which uses the green-amber-red colour coding to indicate the presence of nutrients in a food item. Research with PLWT2DM suggests that they may find it challenging to interpret the information on food labels. This paper draws from a larger study exploring nutrition information practices for PLWT2DM. The aim of this paper is to explore the experiences of using nutrition information found on food labels among PLWT2DM and their partners/carers.

METHODS

This study used a qualitative and mixed methods design, using a solicited 4-week unstructured diary followed by a qualitative interview with each participant. The theoretical framework drew on practice theory. Data were analysed using thematic analysis.

RESULTS

Nineteen PLWT2DM and one partner took part. Data consisted of 19 diaries and interviews. Almost all participants used food labels to help manage their condition; however, the colour-coding link with traffic lights appeared to overemphasise the need to avoid foods with red labels. Participants' beliefs about sugar influenced their food choices which in turn could impact on their nutritional intake. Highly developed mathematical skills were needed to interpret information about portion sizes.

CONCLUSIONS

Healthcare professionals and patient support groups should focus more on educating PLWT2DM about how to interpret food labels so that they are able to apply these to their own food choices. Future research and development of subsequent versions of the food labelling system should include PLWT2DM to ensure that labels are both clear and relevant to them.

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.

Preference for High Dietary Salt Intake Is Associated With Undiagnosed Type 2 Diabetes: The Henan Rural Cohort

Background: Diabetes continues to be a serious disease burden globally. Nutrition plays a vital role in human life and health, and both inadequate and over nutrition have been implicated in cause the of disease. Objective: We explored the role of preference for high dietary salt intake and diabetes in a rural population. We also looked at possible mediating factors in the relationship between diabetes and preference for high dietary salt intake. Methods/Participants: Data from the Henan rural cohort in China were analyzed. Using multinomial regression models, the association between diabetes diagnosis type and reported preference for dietary salt was assessed. Adjusted odds ratios (aORs) with confidence interval (CI) at a 95% level are reported. Mediation analyses using structural equation models in Stata were performed. Results: Of the 39,183 participants included in the analyses, 4.07% were previously diagnosed with diabetes, and 5.80% with undiagnosed diabetes. Eighteen percent had a preference for salty meals, the mean age was 55.45 years, and 60% were women. Preference for salty meals was associated with undiagnosed diabetes (aOR = 1.17, 95% CI 1.03, 1.32), but not with previously diagnosed diabetes. Stratified analysis revealed that the association with undiagnosed diabetes was only significant in men (aOR = 1.36, 95% CI 1.13, 1.70) but not in women (aOR = 1.06, 95% CI 0.81, 1.38). BMI and central obesity fully mediated the association. Dietary salt intake was self-reported and therefore presents a limitation. Conclusion: Our study demonstrated that preference for high dietary salt intake is associated with undiagnosed diabetes but not prevalent diabetes.

Dietary sodium and potassium intake in people with diabetes: are guidelines being met?

OBJECTIVE

Despite public health bodies advocating for lowering dietary sodium and increasing potassium intake to improve cardiovascular outcomes, people with diabetes are not meeting these targets. We hypothesize that (i) both at an individual level and within the cohort, there will be a low adherence to the guidelines and (ii) sodium and potassium intake will remain stable over time.

METHODS

We conducted this prospective study in a cohort of 904 participants with diabetes who provided 24-h urine collections from 2009 to 2015. Dietary sodium and potassium intake were estimated from 24-h urinary sodium (uNa) and potassium (uK) measurements. Additional data were collected for: 24-h urinary volume (uVol), creatinine (uCr),; serum creatinine, urea, estimated glomerular filtration rate (eGFR), glycated haemoglobin (HbA1c), fasting glucose, lipids); clinical characteristics (age, blood pressure (BP), body mass index (BMI) and duration of diabetes). Adherence to recommended dietary sodium (uNa < 2300 mg/24 h (100mmol/24 h)) and potassium (uK > 4680 mg/24 h(120 mmol/24)) intake were the main outcome measures.

RESULTS

Participants (n = 904) completed 3689 urine collections (average four collections/participant). The mean ± SD (mmol/24 h) for uNa was 181 ± 73 and uK was 76 ± 25. After correcting uNa for uCr, 7% and 5% of participants met dietary sodium and potassium guidelines respectively. Males were less likely to meet sodium guidelines (OR 0.40, p < 0.001) but were more likely to meet potassium guidelines (OR 6.13, p < 0.001). Longer duration of diabetes was associated with higher adherence to sodium and potassium guidelines (OR 1.04, p < 0.001 and OR 0.96, p = 0.006 respectively). Increasing age was significantly associated with adherence to potassium guidelines (OR 0.97, p = 0.007).

CONCLUSIONS

People with diabetes do not follow current dietary sodium and potassium guidelines and are less likely to change their dietary intake of sodium and potassium over time.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impaired pressure natriuresis and non-dipping blood pressure in rats with early type 1 diabetes mellitus

KEY POINTS

Type 1 diabetes mellitus increases cardiovascular risk; hypertension amplifies this risk, while pressure natriuresis regulates long-term blood pressure. We induced type 1 diabetes in rats by streptozotocin injection and demonstrated a substantial impairment of pressure natriuresis: acute increases in blood pressure did not increase renal medullary blood flow, tubular sodium reabsorption was not downregulated, and proximal tubule sodium reabsorption, measured by lithium clearance, was unaffected. Insulin reduced blood glucose in diabetic rats, and rescued the pressure natriuresis response without influencing lithium clearance, but did not restore medullary blood flow. Radiotelemetry showed that diastolic blood pressure was increased in diabetic rats, and its diurnal variation was reduced. Increases in medullary blood flow and decreases in distal tubule sodium reabsorption that offset acute rises in BP are impaired in early type 1 diabetes, and this impairment could be a target for preventing hypertension in type 1 diabetes.

ABSTRACT

Type 1 diabetes mellitus (T1DM) substantially increases cardiovascular risk, and hypertension amplifies this risk. Blood pressure (BP) and body sodium homeostasis are linked. T1DM patients have increased total exchangeable sodium, correlating directly with BP. Pressure natriuresis is an important physiological regulator of BP. We hypothesised that pressure natriuresis would be impaired, and BP increased, in the early phase of T1DM. Male Sprague-Dawley rats were injected with streptozotocin (30-45 mg/kg) or citrate vehicle. After 3 weeks, pressure natriuresis was induced by serial arterial ligation. In non-diabetic controls, this increased fractional excretion of sodium from ∼1% to ∼25% of the filtered load (P < 0.01); in T1DM rats, the response was significantly blunted, peaking at only ∼3% (P < 0.01). Mechanistically, normal lithium clearance suggested that distal tubule sodium reabsorption was not downregulated with increased BP in T1DM rats. The pressure dependence of renal medullary perfusion, considered a key factor in the integrated response, was abolished. Insulin therapy rescued the natriuretic response in diabetic rats, restoring normal downregulation of tubular sodium reabsorption when BP was increased. However, the pressure dependence of medullary perfusion was not restored, suggesting persistent vascular dysfunction despite glycaemic control. Radiotelemetry showed that T1DM did not affect systolic BP, but mean diastolic BP was ∼5 mmHg higher than in non-diabetic controls (P < 0.01), and normal diurnal variation was reduced. In conclusion, functional impairment of renal sodium and BP homeostasis is an early manifestation of T1DM, preceding hypertension and nephropathy. Early intervention to restore pressure natriuresis in T1DM may complement reductions in cardiovascular risk achieved with glycaemic control.

The Science of Salt: A focused review on salt-related knowledge, attitudes and behaviors, and gender differences

The aim of the current review was to examine the scope of studies published in the Science of Salt Weekly that contained a measure of self-reported knowledge, attitudes, and behavior (KAB) concerning salt. Specific objectives were to examine how KAB measures are used to evaluate salt reduction intervention studies, the questionnaires used, and whether any gender differences exist in self-reported KAB. Studies were reviewed from the commencement of Science of Salt Weekly, June 2013 to the end of August 2017. Seventy-five studies had relevant measures of KAB and were included in this review, 13 of these were salt-reduction intervention-evaluation studies, with the remainder (62) being descriptive KAB studies. The KAB questionnaires used were specific to the populations studied, without evidence of a best practice measure. 40% of studies used KAB alone as the primary outcome measure; the remaining studies used more quantitative measures of salt intake such as 24-hour urine. Only half of the descriptive studies showed KAB outcomes disaggregated by gender, and of those, 73% showed women had more favorable KAB related to salt. None of the salt intervention-evaluation studies showed disaggregated KAB data. Therefore, it is likely important that evaluation studies disaggregate, and are appropriately powered to disaggregate all outcomes by gender to address potential disparities.

Salt Restriction in Diabetes

There are no long-term interventions examining the effects of salt reduction in people with diabetes, and these are urgently required. Sodium reduction is controversial as it appears that an intake below 2.5 g and above 6 g/day of salt is associated with increased cardiovascular disease risk. However, pre-existing illness leading to a lower salt intake may confound the findings. Only a few studies have prospectively collected data on the sodium intake and excretion of people with diabetes and examined hard end points. In addition, future studies need to collect more data on food intake as well as coexistent illnesses to address potential confounding. The World Health Organization recommends a reduction to less than 5 g/day salt in adults. Given that the available evidence suggests that the salt intake of people with type 2 diabetes is generally well above 6 g/day it seems reasonable to ensure individuals with diabetes have an intake below 6 g/day. However, such recommendations need to be individualized.