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Evaluation of a Salt-Reduction Consumer Awareness Campaign Targeted at Parents Residing in the State of Victoria, Australia. Nutrients 2023; 15:nu15040991. [PMID: 36839348 PMCID: PMC9964045 DOI: 10.3390/nu15040991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
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.
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Gupta AK, Carroll TE, Chen Y, Liang W, Cobb LK, Wang Y, Zhang J, Chen Y, Guo X, Mullin S, Murukutla N. 'Love with Less Salt': evaluation of a sodium reduction mass media campaign in China. BMJ Open 2022; 12:e056725. [PMID: 36223966 PMCID: PMC9562322 DOI: 10.1136/bmjopen-2021-056725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study examines the impact of a salt reduction campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change relating to salt consumption in two provinces of China. METHODS In 2019, the 'Love with Less Salt' campaign ran on China Central Television and on local television channels in Shandong and Anhui provinces. Data for this study come from two representative household surveys conducted among a sample of adults aged 25-65 years in Shandong and Anhui provinces: precampaign (n=2000) and postcampaign (n=2015). Logistic regression was performed to estimate the effects of the campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change. RESULTS Overall, 13% of postcampaign respondents recalled seeing the campaign, and reactions towards the campaign were positive. Postcampaign respondents were more likely to plan to reduce their purchase of foods high in salt than precampaign respondents (OR=1.45, p=<0.05). Campaign-aware respondents were significantly more likely than campaign-unaware respondents to report higher levels of knowledge, attitudes and behaviours regarding salt reduction. CONCLUSIONS Findings reveal that salt reduction mass media campaigns can be an effective public health tool to support efforts to reduce salt consumption in China. Continued and sustained mass media investments are likely to be effective in addressing high salt consumption nationwide.
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Affiliation(s)
| | - Tom E Carroll
- Vital Strategies, Sydney, New South Wales, Australia
| | - Yu Chen
- Vital Strategies, Beijing, China
| | | | - Laura K Cobb
- Resolve to Save Lives, An Initiative of Vital Strategies, New York, New York, USA
| | - Yichao Wang
- Beijing Haisi Aide Technology Co Ltd, Beijing, China
| | - Juan Zhang
- Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yeji Chen
- Anhui Provincial Center for Disease Control and Prevention, Hefei, Anhui, China
| | - Xiaolei Guo
- Shandong Center for Disease Control and Prevention, Jinan, China
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Augustus E, Haynes E, Guell C, Morrissey K, Murphy MM, Halliday C, Jia L, Iese V, Anderson SG, Unwin N. The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis. Nutrients 2022; 14:nu14173529. [PMID: 36079787 PMCID: PMC9460279 DOI: 10.3390/nu14173529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/09/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022] Open
Abstract
Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000−2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to ‘over’ nutrition versus ‘under’ nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.
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Affiliation(s)
- Eden Augustus
- The Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, P.O. Box 64, Bridgetown BB11000, Barbados
- Correspondence:
| | - Emily Haynes
- European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK
| | - Cornelia Guell
- European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK
| | - Karyn Morrissey
- Division of Sustainability, Society and Economics, Department of Technology, Management and Economics, Technical University of Denmark, Produktionstorvet 358, DK-2800 Kgs. Lyngby, Denmark
| | - Madhuvanti M. Murphy
- The George Alleyne Chronic Disease Research Centre, Caribbean Institute of Health Research, The University of the West Indies, Bridgetown BB11000, Barbados
| | - Cassandra Halliday
- European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK
| | - Lili Jia
- Institute for Manufacturing, University of Cambridge, Cambridge CB3 0FS, UK
| | - Viliamu Iese
- Pacific Centre for Environment and Sustainable Development, University of the South Pacific, Suva 0101, Fiji
| | - Simon G. Anderson
- The George Alleyne Chronic Disease Research Centre, Caribbean Institute of Health Research, The University of the West Indies, Bridgetown BB11000, Barbados
- Glasgow-Caribbean Centre for Development Research, University of the West Indies, Bridgetown BB11000, Barbados
| | - Nigel Unwin
- European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK
- MRC Epidemiology Unit, University of Cambridge, Cambridge CB2 0QQ, UK
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Brown CR, Rocke K, Murphy MM, Hambleton IR. Interventions and policies aimed at improving nutrition in Small Island Developing States: a rapid review. Rev Panam Salud Publica 2022; 46:e33. [PMID: 36042710 PMCID: PMC9409607 DOI: 10.26633/rpsp.2022.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/22/2022] [Indexed: 01/04/2023] Open
Abstract
Objective. To describe features of nutritional interventions implemented in Small Island Developing States (SIDS) in the past 20 years. Methods. A rapid scoping review was conducted by searching PubMed and Web of Science databases for interventions conducted in SIDS that sought to improve the nutrition of their populations between 2000 and 2019 inclusive. The Noncommunicable diseases progress monitor 2020 was also examined to assess nutritional policies in SIDS. Results. A total of 174 interventions were implemented in 49 of the 58 SIDS. The greatest proportion were conducted in the Caribbean (75 interventions; 43%), with the Pacific region, and the Atlantic, Indian Ocean, Mediterranean and South China Sea region each implementing about 30% of interventions. Using the NOURISHING framework, most interventions (67%) were implemented at the community and national or policy level, using multiple components of the framework. The greatest proportion of interventions (35%) were educational and awareness raising. Restrictions on physical availability of and increased taxation on alcohol were the most commonly reported policies that were partially or fully achieved; restrictions on fats were the least commonly reported. These findings were generally consistent across the SIDS regions. Conclusions. There is a paucity of nutritional policies in SIDS; the reasons may be linked to their social, economic, and environmental vulnerabilities. Interventions should be expanded beyond education to encompass multiple components of the NOURISHING framework, with multisectoral inclusion to ensure stronger stakeholder collaboration and buy-in. A systematic review is warranted using a fuller range of sources to assess the effectiveness of interventions.
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Affiliation(s)
- Catherine R. Brown
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Kern Rocke
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Madhuvanti M. Murphy
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Ian R. Hambleton
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
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Sari DW, Noguchi-Watanabe M, Sasaki S, Yamamoto-Mitani N. Dietary Patterns of 479 Indonesian Adults and Their Associations with Sodium and Potassium Intakes Estimated by Two 24-h Urine Collections. Nutrients 2022; 14:nu14142905. [PMID: 35889861 PMCID: PMC9318011 DOI: 10.3390/nu14142905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/07/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
The excess sodium (Na) intake and insufficient potassium (K) intake are frequently observed all over the world, including Indonesia. This study explored the dietary patterns of Indonesian people and evaluated their associations with Na and K intakes. Na and K intakes were assessed by repeated 24-h urine collection. The dietary patterns of the previous month were extracted by factor analysis using the Indonesian Food Frequency Questionnaire. The participants were community-dwelling Indonesian men and women (n = 479) aged 20 years and over. We identified four dietary patterns in each sex. After controlling for confounding factors, the high quantile of ‘Noodle, oil, and salty sea products’ pattern was associated with the high Na intake in both men and women (p = 0.02 and <0.001, respectively). The ‘Meat, vegetable, oil, and fruit’ pattern statistically significantly contributed to the high K intake in men (p = 0.04), but not in women (p = 0.26). The ‘Vegetable, non-oil, and milk’ pattern in men and ‘Meat, vegetable, and fruit’ pattern in women were associated with low Na:K ratios (p = 0.03 and 0.01, respectively). Neither ‘bread’ nor ‘fish’ appeared as a major determinant of any dietary patterns in this population. The ‘Noodle, oil, and salty sea products’ pattern should be avoided to reduce sodium intake.
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Affiliation(s)
- Dianis Wulan Sari
- Department of Gerontological Home Care and Long-term Care Nursing, Division of Health Sciences & Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Faculty of Nursing, Universitas Airlangga, Jln. Mulyorejo, Surabaya, East Java 60115, Indonesia
- Correspondence: or (D.W.S.); (N.Y.-M.); Tel.: +62-31-5913754 (D.W.S.); +81-3-5841-3508 (N.Y.-M.); Fax: +62-31-5913752 (D.W.S.); +81-3-5841-3502 (N.Y.-M.)
| | - Maiko Noguchi-Watanabe
- Department of Gerontological Home Care and Long-term Care Nursing, Division of Health Sciences & Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Department of Home Care Nursing Science, School of Health Care Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Satoshi Sasaki
- Department of Social and Preventive Epidemiology, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
| | - Noriko Yamamoto-Mitani
- Department of Gerontological Home Care and Long-term Care Nursing, Division of Health Sciences & Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Correspondence: or (D.W.S.); (N.Y.-M.); Tel.: +62-31-5913754 (D.W.S.); +81-3-5841-3508 (N.Y.-M.); Fax: +62-31-5913752 (D.W.S.); +81-3-5841-3502 (N.Y.-M.)
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Webster J, Waqa G, Thow AM, Allender S, Lung T, Woodward M, Rogers K, Tukana I, Kama A, Wilson D, Mounsey S, Dodd R, Reeve E, McKenzie BL, Johnson C, Bell C. Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation. Nutr J 2022; 21:8. [PMID: 35105346 PMCID: PMC8807012 DOI: 10.1186/s12937-022-00761-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/19/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. METHODS Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions. DISCUSSION The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.
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Affiliation(s)
- Jacqui Webster
- George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, Sydney, New South Wales, 2046, Australia.
| | - Gade Waqa
- Pacific Research Centre for the Prevention of Obesity and Non-Communicable Diseases, Fiji National University, Suva, Fiji
| | - Anne-Marie Thow
- Menzies Centre for Health Policy, The University of Sydney, Sydney, Australia
| | - Steven Allender
- Global Obesity Centre, School of Health and Social Development, Institute for Health Transformation, Deakin University, Melbourne, Australia
| | - Thomas Lung
- George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, Sydney, New South Wales, 2046, Australia
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, Sydney, New South Wales, 2046, Australia.,George Institute for Global Health, Oxford University, Oxford, UK.,Johns Hopkins University, Baltimore, USA
| | - Kris Rogers
- George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, Sydney, New South Wales, 2046, Australia
| | | | - Ateca Kama
- Ministry of Health and Medical Services, Suva, Fiji
| | - Donald Wilson
- Pacific Research Centre for the Prevention of Obesity and Non-Communicable Diseases, Fiji National University, Suva, Fiji
| | - Sarah Mounsey
- Menzies Centre for Health Policy, The University of Sydney, Sydney, Australia
| | - Rebecca Dodd
- George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, Sydney, New South Wales, 2046, Australia
| | - Erica Reeve
- Global Obesity Centre, School of Health and Social Development, Institute for Health Transformation, Deakin University, Melbourne, Australia
| | - Briar Louise McKenzie
- George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, Sydney, New South Wales, 2046, Australia
| | - Claire Johnson
- George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, Sydney, New South Wales, 2046, Australia
| | - Colin Bell
- Global Obesity Centre, School of Health and Social Development, Institute for Health Transformation, Deakin University, Melbourne, Australia
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7
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Santos JA, Tekle D, Rosewarne E, Flexner N, Cobb L, Al-Jawaldeh A, Kim WJ, Breda J, Whiting S, Campbell N, Neal B, Webster J, Trieu K. A Systematic Review of Salt Reduction Initiatives Around the World: A Midterm Evaluation of Progress Towards the 2025 Global Non-Communicable Diseases Salt Reduction Target. Adv Nutr 2021; 12:1768-1780. [PMID: 33693460 PMCID: PMC8483946 DOI: 10.1093/advances/nmab008] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 12/14/2022] Open
Abstract
In 2013, the WHO recommended that all member states aim to reduce population salt intake by 30% by 2025. The year 2019 represents the midpoint, making it a critical time to assess countries' progress towards this target. This review aims to identify all national salt reduction initiatives around the world in 2019, and to quantify countries' progress in achieving the salt reduction target. Relevant data were identified through searches of peer-reviewed and gray literature, supplemented with responses from prefilled country questionnaires sent to known country leads of salt reduction or salt champions, WHO regional representatives, and international experts to request further information. Core characteristics of each country's strategy, including evaluations of program impact, were extracted and summarized. A total of 96 national salt reduction initiatives were identified, representing a 28% increase in the number reported in 2014. About 90% of the initiatives were multifaceted in approach, and 60% had a regulatory component. Approaches include interventions in settings (n= 74), food reformulation (n = 68), consumer education (n = 50), front-of-pack labeling (n = 48), and salt taxation (n = 5). Since 2014, there has been an increase in the number of countries implementing each of the approaches, except consumer education. Data on program impact were limited. There were 3 countries that reported a substantial decrease (>2 g/day), 9 that reported a moderate decrease (1-2 g/day), and 5 that reported a slight decrease (<1 g/day) in the mean salt intake over time, but none have yet met the targeted 30% relative reduction in salt intake from baseline. In summary, there has been an increase in the number of salt reduction initiatives around the world since 2014. More countries are now opting for structural or regulatory approaches. However, efforts must be urgently accelerated and replicated in other countries and more rigorous monitoring and evaluation of strategies is needed to achieve the salt reduction target.
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Affiliation(s)
- Joseph Alvin Santos
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Dejen Tekle
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Emalie Rosewarne
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Nadia Flexner
- University of Toronto, Toronto, Ontario, Canada
- Pan American Health Organization—World Health Organization Regional Office for the Americas, Washington, DC, USA
| | - Laura Cobb
- Resolve to Save Lives, An Initiative of Vital Strategies, New York City, NY, USA
| | - Ayoub Al-Jawaldeh
- World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Warrick Junsuk Kim
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Joao Breda
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Stephen Whiting
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | | | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
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Barriers, Enablers, and Perceptions on Dietary Salt Reduction in the Out-of-Home Sectors: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18158099. [PMID: 34360392 PMCID: PMC8345971 DOI: 10.3390/ijerph18158099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
In this review, we have investigated the perceptions, barriers, and enabling factors that were responsible for a dietary salt reduction in the out-of-home sectors. For this purpose, we examined different knowledge databases such as Google Scholar, Ebscohost, MEDLINE (PubMed), Ovid, and Cochrane Library for research articles from September to December 2020. The inclusion criteria for the research articles were that they had to be published in English and had to be a qualitative or quantitative study that was conducted after 2010. These studies also had to report the various enablers, barriers, and perceptions regarding salt reduction in the out-of-home sectors. After implementing the inclusion criteria, we successfully screened a total of 440 studies, out of which 65 articles fulfilled all the criteria. The perceived barriers that hindered salt reduction among the out-of-home sectors included lack of menu and food variabilities, loss of sales due to salt reduction, lack of technical skills for implementing the salt reduction processes for cooking or reformulation, and an absence of environmental and systemic support for reducing the salt concentration. Furthermore, the enablers for salt reduction included the intervention programs, easy accessibility to salt substitutes, salt intake measurement, educational availability, and a gradual reduction in the salt levels. With regards to the behavior or perceptions, the effect of organizational and individual characteristics on their salt intake were reported. The majority of the people were not aware of their salt intake or the effect of salt on their health. These people also believed that low salt food was recognized as tasteless. In conclusion, the enablers, barriers, and perceptions regarding salt reduction in the out-of-home sectors were multifaceted. Therefore, for the implementation of the strategies, policies, and initiatives for addressing the barriers, the policymakers need to encourage a multisectoral collaboration for reducing the salt intake in the population.
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Santos JA, McKenzie B, Rosewarne E, Hogendorf M, Trieu K, Woodward M, Cobb LK, Dodd R, Webster J. Strengthening Knowledge to Practice on Effective Salt Reduction Interventions in Low- and Middle-Income Countries. Curr Nutr Rep 2021; 10:211-225. [PMID: 34224108 DOI: 10.1007/s13668-021-00365-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The objective of this review was to consolidate available published information on the implementation and evaluation of salt reduction interventions in low- and middle-income countries (LMICs). RECENT FINDINGS The Science of Salt database (made up of studies identified in a weekly Medline search) was used to retrieve articles related to the implementation of salt reduction interventions from June 2013 to February 2020. Studies that measured the effects of the interventions in LMICs, based on four outcome measures-salt intake; sodium levels in foods; knowledge, attitudes, and behaviours (KABs) towards salt; and blood pressure-were included. Results were summarised overall and according to subgroups of intervention type, duration, sample size, country's income class, and regional classification. The review identified 32 studies, representing 13 upper middle-income and four lower middle-income countries. The main salt reduction interventions were education, food reformulation, and salt substitution; and many interventions were multi-faceted. More studies reported a positive effect of the interventions (decreased salt intake (12/17); lower sodium levels in foods or compliance with agreed targets (6/6); improved KAB (17/19); and decreased blood pressure (10/14)) than a null effect, and no study reported a negative effect of the intervention. However, many studies were of small scale and targeted specific groups, and none was from low-income countries. Consumer education, food reformulation, and salt substitution, either alone or in combination, were effective in their target populations. Supporting scale-up of salt reduction interventions in LMICs is essential to cover broader populations and to increase their public health impact.
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Affiliation(s)
- Joseph Alvin Santos
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia.
| | - Briar McKenzie
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia
| | - Emalie Rosewarne
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia
| | - Martyna Hogendorf
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia.,Independent Nutrition Consultant, Geneva, Switzerland
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia.,The George Institute for Global Health, School of Public Health, Imperial College, London, UK
| | - Laura K Cobb
- Resolve to Save Lives, an Initiative of Vital Strategies, New York, USA
| | - Rebecca Dodd
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, Sydney, NSW, 2042, Australia
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Mercer T, Nulu S, Vedanthan R. Innovative Implementation Strategies for Hypertension Control in Low- and Middle-Income Countries: a Narrative Review. Curr Hypertens Rep 2020; 22:39. [PMID: 32405820 DOI: 10.1007/s11906-020-01045-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the most recent and innovative implementation strategies for hypertension control in low- and middle-income countries (LMICs). RECENT FINDINGS Implementation strategies from Latin America, Africa, and Asia were organized across three levels: community, health system, and policy/population. Multicomponent interventions involving task-shifting strategies, with or without mobile health tools, had the most supporting evidence, with policy or population-level interventions having the least, focused only on salt reduction with mixed results. More research is needed to better understand how context affects intervention implementation. There is an emerging evidence base for implementation strategies for hypertension control and CVD risk reduction in LMICs at the community and health system levels, but further research is needed to determine the most effective policy and population-level strategies. How to best account for local context in adapting and implementing these evidence-based interventions in LMICs still remains largely unknown. Accelerating the translation of this implementation research into policy and practice is imperative to improve health and save lives globally.
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Affiliation(s)
- Tim Mercer
- Department of Population Health, Division of Global Health, The University of Texas at Austin Dell Medical School, 1601 Trinity St., Bldg. B, Austin, TX, 78712, USA.
| | - Shanti Nulu
- Department of Internal Medicine, Division of Cardiology, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
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Santos JA, Rosewarne E, Hogendorf M, Trieu K, Pillay A, Ieremia M, Naseri LTT, Tukana I, Snowdon W, Petersen K, Webster J. Estimating mean population salt intake in Fiji and Samoa using spot urine samples. Nutr J 2019; 18:55. [PMID: 31506072 PMCID: PMC6737719 DOI: 10.1186/s12937-019-0484-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is an increasing interest in finding less costly and burdensome alternatives to measuring population-level salt intake than 24-h urine collection, such as spot urine samples. However, little is known about their usefulness in developing countries like Fiji and Samoa. The purpose of this study was to evaluate the capacity of spot urine samples to estimate mean population salt intake in Fiji and Samoa. METHODS The study involved secondary analyses of urine data from cross-sectional surveys conducted in Fiji and Samoa between 2012 and 2016. Mean salt intake was estimated from spot urine samples using six equations, and compared with the measured salt intake from 24-h urine samples. Differences and agreement between the two methods were examined through paired samples t-test, intraclass correlation coefficient analysis, and Bland-Altman plots and analyses. RESULTS A total of 414 participants from Fiji and 725 participants from Samoa were included. Unweighted mean salt intake based on 24-h urine collection was 10.58 g/day (95% CI 9.95 to 11.22) in Fiji and 7.09 g/day (95% CI 6.83 to 7.36) in Samoa. In both samples, the INTERSALT equation with potassium produced the closest salt intake estimate to the 24-h urine (difference of - 0.92 g/day, 95% CI - 1.67 to - 0.18 in the Fiji sample and + 1.53 g/day, 95% CI 1.28 to 1.77 in the Samoa sample). The presence of proportional bias was evident for all equations except for the Kawasaki equation. CONCLUSION These data suggest that additional studies where both 24-h urine and spot urine samples are collected are needed to further assess whether methods based on spot urine samples can be confidently used to estimate mean population salt intake in Fiji and Samoa.
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Affiliation(s)
- Joseph Alvin Santos
- The George Institute for Global Health, The University of New South Wales, Sydney, 2052 Australia
| | - Emalie Rosewarne
- The George Institute for Global Health, The University of New South Wales, Sydney, 2052 Australia
| | - Martyna Hogendorf
- The George Institute for Global Health, The University of New South Wales, Sydney, 2052 Australia
| | - Kathy Trieu
- The George Institute for Global Health, The University of New South Wales, Sydney, 2052 Australia
| | - Arti Pillay
- Pacific Research Centre for the Prevention of Obesity and Noncommunicable Diseases, Fiji National University, Nasinu, Fiji
| | | | | | - Isimeli Tukana
- National Wellness Centre, Ministry of Health and Medical Services, Suva, Fiji
| | - Wendy Snowdon
- Global Obesity Centre, Deakin University, Geelong, 3216 Australia
| | - Kristina Petersen
- The George Institute for Global Health, The University of New South Wales, Sydney, 2052 Australia
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA 16802 USA
| | - Jacqui Webster
- The George Institute for Global Health, The University of New South Wales, Sydney, 2052 Australia
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Thout SR, Santos JA, McKenzie B, Trieu K, Johnson C, McLean R, Arcand J, Campbell NRC, Webster J. The Science of Salt: Updating the evidence on global estimates of salt intake. J Clin Hypertens (Greenwich) 2019; 21:710-721. [PMID: 31033166 PMCID: PMC8030574 DOI: 10.1111/jch.13546] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/26/2019] [Indexed: 09/11/2023]
Abstract
The Global Burden of Disease (GBD) 2010 study estimated national salt intake for 187 countries based on data available up to 2010. The purpose of this review was to identify studies that have measured salt intake in a nationally representative population using the 24-hour urine collection method since 2010, with a view to updating evidence on population salt intake globally. Studies published from January 2011 to September 2018 were searched for from MEDLINE, Scopus, and Embase databases using relevant terms. Studies that provided nationally representative estimates of salt intake among the healthy adult population based on the 24-hour urine collection were included. Measured salt intake was extracted and compared with the GBD estimates. Of the 115 identified studies assessed for eligibility, 13 studies were included: Four studies were from Europe, and one each from the United States, Canada, Benin, India, Samoa, Fiji, Barbados, Australia, and New Zealand. Mean daily salt intake ranged from 6.75 g/d in Barbados to 10.66 g/d in Portugal. Measured mean population salt intake in Italy, England, Canada, and Barbados was lower, and in Fiji, Samoa, and Benin was higher, in recent surveys compared to the GBD 2010 estimates. Despite global targets to reduce population salt intake, only 13 countries have published nationally representative salt intake data since the GBD 2010 study. In all countries, salt intake levels remain higher than the World Health Organization's recommendation, highlighting the need for additional global efforts to lower salt intake and monitor salt reduction strategies.
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Affiliation(s)
- Sudhir Raj Thout
- The George Institute for Global Health IndiaANR CenterHyderabadIndia
| | - Joseph Alvin Santos
- The George Institute for Global HealthUniversity of New South WalesSydneyNSWAustralia
| | - Briar McKenzie
- The George Institute for Global HealthUniversity of New South WalesSydneyNSWAustralia
| | - Kathy Trieu
- The George Institute for Global HealthUniversity of New South WalesSydneyNSWAustralia
| | - Claire Johnson
- The George Institute for Global HealthUniversity of New South WalesSydneyNSWAustralia
| | - Rachael McLean
- Department of Preventive & Social MedicineUniversity of OtagoDunedinNew Zealand
| | - JoAnne Arcand
- Faculty of Health SciencesOntario Tech UniversityOshawaOntarioCanada
| | - Norman R. C. Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of AlbertaUniversity of CalgaryCalgaryAlbertaCanada
| | - Jacqui Webster
- The George Institute for Global HealthUniversity of New South WalesSydneyNSWAustralia
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13
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Mean Dietary Salt Intake in Vanuatu: A Population Survey of 755 Participants on Efate Island. Nutrients 2019; 11:nu11040916. [PMID: 31022856 PMCID: PMC6521272 DOI: 10.3390/nu11040916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 03/27/2019] [Accepted: 04/08/2019] [Indexed: 11/17/2022] Open
Abstract
Non-communicable diseases are responsible for 63% of global deaths, with a higher burden in low- and middle-income countries. Hypertension is the leading cause of cardiovascular-disease-related deaths worldwide, and approximately 1.7 million deaths are directly attributable to excess salt intake annually. There has been little research conducted on the level of salt consumption amongst the population of Vanuatu. Based on data from other Pacific Island countries and knowledge of changing regional diets, it was predicted that salt intake would exceed the World Health Organization’s (WHO) recommended maximum of 5 g per day. The current study aimed to provide Vanuatu with a preliminary baseline assessment of population salt intake on Efate Island. A cross-sectional survey collected demographic, clinical, and urine data from participants aged 18 to 69 years in rural and urban communities on Efate Island in October 2016 and February 2017. Mean salt intake was determined to be 7.2 (SD 2.3) g/day from spot urine samples, and 5.9 (SD 3.6) g/day from 24-h urine samples, both of which exceed the WHO recommended maximum. Based on the spot urine samples, males had significantly higher salt intake than females (7.8 g compared to 6.5 g; p < 0.001) and almost 85% of the population consumed more than the WHO recommended maximum daily amount. A coordinated government strategy is recommended to reduce salt consumption, including fiscal policies, engagement with the food industry, and education and awareness-raising to promote behavior change.
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Abstract
OBJECTIVE Pacific Island countries are experiencing a high burden of diet-related non-communicable diseases; and consumption of fat, sugar and salt are important modifiable risk factors contributing to this. The present study systematically reviewed and summarized available literature on dietary intakes of fat, sugar and salt in the Pacific Islands. DESIGN Electronic databases (PubMed, Scopus, ScienceDirect and GlobalHealth) were searched from 2005 to January 2018. Grey literature was also searched and key stakeholders were consulted for additional information. Study eligibility was assessed by two authors and quality was evaluated using a modified tool for assessing dietary intake studies. RESULTS Thirty-one studies were included, twenty-two contained information on fat, seventeen on sugar and fourteen on salt. Dietary assessment methods varied widely and six different outcome measures for fat, sugar and salt intake - absolute intake, household expenditure, percentage contribution to energy intake, sources, availability and dietary behaviours - were used. Absolute intake of fat ranged from 25·4 g/d in Solomon Islands to 98·9 g/d in Guam, while salt intake ranged from 5·6 g/d in Kiribati to 10·3 g/d in Fiji. Only Guam reported on absolute sugar intake (47·3 g/d). Peer-reviewed research studies used higher-quality dietary assessment methods, while reports from national surveys had better participation rates but mostly utilized indirect methods to quantify intake. CONCLUSIONS Despite the established and growing crisis of diet-related diseases in the Pacific, there is inadequate evidence about what Pacific Islanders are eating. Pacific Island countries need nutrition monitoring systems to fully understand the changing diets of Pacific Islanders and inform effective policy interventions.
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Trieu K, Webster J, Jan S, Hope S, Naseri T, Ieremia M, Bell C, Snowdon W, Moodie M. Process evaluation of Samoa's national salt reduction strategy (MASIMA): what interventions can be successfully replicated in lower-income countries? Implement Sci 2018; 13:107. [PMID: 30081926 PMCID: PMC6080534 DOI: 10.1186/s13012-018-0802-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Evidence for recommended interventions to reduce population salt intake come from high-income countries, but it is unknown if these can be successfully replicated in low- and middle-income countries. This process evaluation investigated the reach, dose/adoption, fidelity, cost, and context of a national salt reduction program of interventions in Samoa. METHODS Monitoring and Action on Salt in Samoa (MASIMA) was a pre- and post-intervention study of a government-led strategy to lower population salt intake comprising awareness campaigns, community mobilization and policy and environmental changes. Data relating to the five process evaluation dimensions were collected from routinely collected data, a post-intervention survey and stakeholder interviews. Chi-squared tests assessed differences in quantitative survey responses among groups. Thematic analysis of qualitative interview responses was undertaken and triangulated with the quantitative data. RESULTS Awareness campaigns, school nutrition standards, and community mobilization interventions were implemented with moderate reach and fidelity. Higher than expected costs of campaigns and limited opportunity (one-off) to mobilize community leaders to disseminate salt reduction messages were key implementation challenges, which meant intervention dose was low. Environmental-level initiatives including engagement with the food industry to voluntary reduce salt in foods and the introduction of salt-related regulations were more challenging to implement within 18-months, particularly given the delay in the passing of the Food Act which provides for enforcement of regulations. Contextual factors that hindered the interventions' mechanism of effect include the food culture, higher cost, and lower availability of healthy low-salt foods relative to unhealthy foods and salty taste preference. CONCLUSION Although individual and community-based interventions helped increase awareness about the importance of salt reduction in Samoa, legislative backing was needed to alter the food environment to achieve population reduction in salt intake. It was not possible to engage the food industry to lower salt in foods through a voluntary approach in Samoa's current context, although such initiatives were successful in some high-income countries. Future individual and environmental-level interventions to reduce salt intake need to address the contextual influences of food choices. In Samoa, this means salt reduction strategies need to ensure consuming lower salt is affordable, widely available, and perceived as flavorsome.
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Affiliation(s)
- Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia. .,Sydney School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, Australia.
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Sydney School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Sydney School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, Australia
| | - Silvia Hope
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Australia.,Global Obesity Centre, Faculty of Health, Deakin University, Geelong, Australia
| | | | | | - Colin Bell
- Global Obesity Centre, Faculty of Health, Deakin University, Geelong, Australia
| | - Wendy Snowdon
- Global Obesity Centre, Faculty of Health, Deakin University, Geelong, Australia
| | - Marj Moodie
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, Geelong, Australia.,Global Obesity Centre, Faculty of Health, Deakin University, Geelong, Australia
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