Reducing Sodium Intake in Children: A Public Health Investment

Tracking of blood pressure levels from childhood

The overall goal of this review is to summarize what is currently known regarding the tracking of blood pressure levels from early childhood into later adulthood and to describe the factors contributing to increased hypertension prevalence across the lifespan. This review describes 4 theoretical constructs of blood pressure trajectory across the lifespan: forward development, forward tracking, forward reversal, and maintenance of normal blood pressure levels.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Spot urinary sodium-to-potassium ratio is associated with blood pressure levels in healthy adolescents: the Wakayama Study

The spot urinary sodium-to-potassium (Na/K) ratio is a simple measure of salt loading and has been shown to be associated with elevated blood pressure (BP) in middle-aged and older adults. This study aimed to evaluate the association between the spot urinary Na/K ratio and BP in 457 healthy adolescents aged 12-15 years in a school-based setting. The mean urinary Na/K ratio was 4.99 ± 2.76, and no significant difference was found between the boys and girls. When the participants were stratified based on urinary Na/K ratio quartile, age- and sex-adjusted systolic and diastolic BP gradually increased as Na/K ratio increased (systolic BP: 106.1, 106.9, 108.2, and 111.5 mmHg, Ptrend < 0.001; diastolic BP: 62.0, 62.4, 63.1, 64.3 mmHg, Ptrend = 0.022). The systolic and diastolic BP were more closely associated with urinary Na/K ratio than with Na and K levels, as well as estimated daily salt intake. In the multiple regression analysis, the urinary Na/K ratio was significantly associated with systolic BP (β = 0.144, P < 0.001) and diastolic BP (β = 0.114, P = 0.015) independent of potential confounding factors. An additional subgroup analysis revealed that the BP of the group with both high salt intake (≥8.5 g/day) and high Na/K ratio (≥6.60) was significantly higher than that of the group with high salt intake alone (systolic BP, 115.0 vs. 109.1 mmHg, P < 0.001; diastolic BP, 66.0 vs. 62.5 mmHg, P = 0.017). These results suggest that the urinary Na/K ratio is associated with BP levels in healthy adolescents and may be useful for assessing salt loading and its effects on BP elevation.

The Global Burden of premature cardiovascular disease, 1990-2019

Aims

Premature cardiovascular disease (pCVD) definition varies in literature, with age cut-offs ranging from 50-65 years. While there is some literature available on pCVD in North America, comprehensive data on its global burden is still lacking which hinders the development of efficient strategies for early detection and prevention. In this study we aimed to investigate the global trends in pCVD related morbidity and mortality from 1990 to 2019.

Methods

The 1990-2019 Global Burden of Disease (GBD) database was utilized to examine global trends in cardiovascular disease-related total mortality, mortality rates, and Disability-Adjusted Life Years (DALYs) within individuals aged 15-49 years. The findings were further analyzed based on factors such as age, sex, and Socio-Demographic Index (SDI).

Results

From 1990 to 2019, the number of global annual pCVD deaths increased by 25%, from 992,067 (95% UI 1,042,261 - 946,383) to 1,241,484 (95% UI 1,339,193 -1,146,252). The rate of associated mortality decreased by 13%. Metabolic conditions were the most significant risk factors for pCVD mortality. Ischemic heart disease and stroke are the leading causes of death across all age groups. pCVD mortality presented progressive widening between high and low SDI regions. Additionally, sex-specific disparities in CVD mortality were significantly greater in the premature age group as compared to all-age groups.

Conclusion

pCVD is an increasingly significant global cause of morbidity and mortality that disproportionately affects males and individuals living in less privileged regions. Furthermore, ischemic heart disease and stroke were identified as the main drivers of pCVD global burden.

Does the Mediterranean Dietary Pattern Promote Lower Sodium Urinary Excretion in Children?

An adequate sodium intake is related to various health benefits. Parallelly, the Mediterranean diet (MD) is a dietary pattern known for its many positive impacts on health. Nonetheless, the association between adherence to the MD and sodium urinary excretion is scarce, even more in children. This study aimed to assess the association between MD adherence and the excretion of sodium, as a proxy of intake. This cross-sectional analysis comprised 295 children (46.8% females, aged 7-11 years, mean age: 8.53 ± 0.73 years) from 20 schools within Porto, Portugal. MD adherence was evaluated utilizing the alternate Mediterranean score (aMED). Higher scores denote a healthier dietary pattern (0-8). Sodium excretion was estimated by 24-h urine collection. The association between adherence to MD and Na excretion was estimated by logistic regression, adjusting for confounders. Children in the higher sodium excretion group had a higher intake of legumes, a higher body mass index and parents with lower education levels compared to children in the lower sodium excretion group. In logistic regression analysis, sodium urinary excretion was not associated with higher MD adherence, even after adjustment for confounders. High MD adherence could not be associated with lower sodium excretion in children.

Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia

OBJECTIVE

In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention.

DESIGN

Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models.

SETTING

Victoria, Australia.

PARTICIPANTS

Children aged 4-12 years.

RESULTS

Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged.

CONCLUSION

These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

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.

Implementation of Flexibilities to the National School Lunch and Breakfast Programs and Their Impact on Schools in Missouri

BACKGROUND

In 2018, the United States Department of Agriculture (USDA) issued flexibilities to the National School Lunch and Breakfast Programs, relaxing the nutrition standards for milk, whole grains, and sodium. This study examines the implementation decision-making among Missouri school food services and the impact of implementing these flexibilities on the meals served.

METHODS

We developed a survey using the Consolidated Framework of Implementation to determine schools' implementation of the flexibilities and factors related to implementation. To determine how the implementation of flexibilities affected participation, we merged the survey results with school-level meal county data from the Missouri Department of Elementary and Secondary Education. We used ordinary least squares regression to examine how flexibility adoption related to the number of meals served.

RESULTS

Most schools implemented the wheat, milk, and sodium flexibilities. Common reasons for implementation were increasing participation, meeting students' preferences, expanding menu variety, and saving money. The implementation of flexibilities was associated with more lunches and breakfasts being served per month, particularly among free and reduced-price meals.

CONCLUSIONS

Continued research is needed to determine how the increased uptake of school meals that do not fully meet dietary guidelines by low-income students results in inequities in health outcomes. The findings can inform the design and implementation of future policies, especially as new rules related to flexibility design are determined.

Missing data and other challenges in assessing inappropriate marketing of baby foods in the Russian Federation: a cross-sectional study

OBJECTIVES

We used the WHO draft nutrient profile model (NPM) to evaluate baby foods targeted at infants and young children (IYC) aged 6-36 months in the Russian Federation to assess their suitability for marketing.

DESIGN

A cross-sectional study in Moscow (Russian Federation).

SETTING

Nutrition information of baby food was primarily collected from retailer websites, with some complementary data from physical stores. Both specialist stores for IYC and general supermarkets were included.

PARTICIPANTS

Two hundred and thirty baby food products targeted to IYC were selected. Breastmilk substitutes and products targeted at children over 3 years old were excluded.

MAIN OUTCOME MEASURES

Per cent of missing nutrition data, per cent of products with added sugar or sweetener and exceeded sodium or salts, per cent of products marketed as suitable for IYC under 6 months.

RESULTS

Most products were 'ready-to-eat', including fruit (n=42, 18.5%) and vegetable (n=29, 12.8%) purees, meat, fish or cheese purees (n =26, 11.5%); 'dry or instant cereal/starchy foods' (n=27, 11.9%), including predominantly dry cereals, 'juices and other drinks' (n=26, 11.5%). 95% (n=219/230) of products were missing total sugar information, 78% (n=180/230) were missing either sodium or salt, and 25% (n=57/230) were missing total fat. Among products with sugar and sodium information, 41% (n=94/230) included added sugar or sweeteners, and 48% (n=24/50) exceeded the NPM sodium threshold. 40% of products (n=92/230) were marketed as suitable for IYC aged under 6 months.

CONCLUSION

Baby foods marketed for IYC showed a high per cent of missing nutrition information and disparity with WHO's guidelines for complementary feeding, age of introduction, sugar and salt content. Stronger regulation is needed in this area to minimise higher risk of non-communicable diseases (NCDs) in later life.

Sodium Intake Tracked from Infancy and Salt Taste Preference during Adolescence: Follow-up of a Randomized Controlled Field Trial in Brazil

Background

Effective interventions to promote healthy sodium intakes require understanding factors driving liking for salt taste.

Objectives

To examine effects of an early feeding intervention among low-income mothers on their children's energy and sodium intake and salt taste preferences at 12 years; and to identify age-related changes in dietary sodium sources.

Methods

Secondary analyses were conducted on dietary intake and taste preference data collected from children in a longitudinal trial (NCT00629629). Mothers randomized to the intervention group received counseling on healthy eating practices for 1 year postpartum; the control group received no counseling. Two-day dietary recalls were obtained at 1 year (intervention end) and at 4-, 8-, and 12-year follow-up visits, from which foods were categorized as unprocessed, processed, or ultra-processed. At the 12-year visit, children's most preferred concentration of salt was measured using a validated, forced-choice, paired-comparison tracking method, and pubertal stage was self-assessed.

Results

The intervention group had reduced energy intake compared with controls in all food categories at 1 year (P = 0.04) but not at the other time points. Sodium intake from processed foods increased from 4 to 12 years and from ultra-processed foods from 1 to 4; intake from unprocessed foods decreased from 1 to 8 year (all P < 0.01). At 12 years, children in early stages of puberty (Tanner stages 1-3; P = 0.04) or in the ≥75th percentile of sodium intake (P < 0.01) preferred significantly higher concentrations of salt than the other children.

Conclusions

Both dietary intake of sodium and early puberty were associated with preferences for higher salt concentrations. Childhood and adolescence are important periods for understanding how experience and growth shape diet by changing salt taste.

Clinical Trial Registration

This manuscript reports secondary analysis of data collected in trial NCT00629629 (2001-3) and follow-up [https://clinicaltrials.gov/ct2/show/NCT00629629?term=NCT00629629&draw=2&rank=1].

School Menu Review Programme (PReME): evaluation of compliance with dietary recommendations during the period 2006-2020 in Catalonia

BACKGROUND

The School Menu Review Programme (PReME) has been offering complimentary revisions of meal plans to all schools in Catalonia since 2006. This study aims to assess the evolution of compliance with PReME's recommendations in the meals provided by school cafeterias in Catalonia during the period 2006-2020.

METHODS

Pre-post study with a sample of 6,387 meal plans from 2221 schools assessed during the period. The information was collected mainly by public health specialists within the annual technical and sanitary inspection of school kitchens and cafeterias. Meal plans were evaluated by Dietitian-Nutritionists team according to the criteria of the National Health System's "Consensus document on nutrition in schools" and the Public Health Agency of Catalonia's current guide "Healthy eating at school". Reports were sent to each participating school. A few months later, a new meal plan and another questionnaire were collected and evaluated in comparison with the first meal plan. Compliance with the recommendations was analysed based on the type of canteen management and the school category.

RESULTS

Compliance improved during the study period. The percentage of schools that complied with dietary recommendations in relation to the five PReME indicators (fresh fruit, pulses, daily vegetables, fresh food and olive oil for dressing) has steadily increased since PReME began, (over 70% in all indictors; p =  < 0.001), with variations depending on school category and cafeteria management. Furthermore, an improvement in the levels of compliance with de recommended food frequencies was observed. with statistically significant differences for all items (p < 0.001), except for pulses whose compliance had been high since the beginning of the study (p = 0.216).

CONCLUSIONS

The positive evolution in compliance with PReME's recommendations provides evidence of the programme's effectiveness, with an improvement in the quality of school meals delivered in Catalonia.

Reducing Sodium Content of Foods Served in Arkansas's Largest School District: Evaluation of the Sodium Reduction in Communities Program

Purpose and Objectives

The Centers for Disease Control and Prevention’s Sodium Reduction in Communities Program aims to reduce dietary sodium intake through policy, systems, and environmental approaches. The objective of our study was to evaluate changes in sodium levels over 5 years (2016–2021) in food served in school lunches as an outcome of a Sodium Reduction in Communities program in Arkansas’s largest school district.

Intervention Approach

We collaborated with Springdale Public Schools (SPS) to reduce dietary sodium intake in school lunches through increased implementation of 1) food service guidelines, 2) procurement practices, 3) food preparation practices, and 4) environmental strategies. These activities were maintained from year 1 through year 5. Implementation priorities were informed each year by evaluation findings from the preceding year.

Evaluation Methods

We collected lunch service records and information on nutritional content of menu items for the 30 schools under the direction of SPS’s Child Nutrition Department. We used a pretest–posttest quantitative evaluation design to analyze annual changes in the sodium content of meals, from baseline through year 5.

Results

From baseline through year 1, SPS reduced sodium served per diner, per entrée offered, and per entrée served. These reductions were maintained from baseline through 5 years of follow-up. Mean sodium per 1,000 kcal per diner served was 1,740 mg at baseline and was lower in each of the 5 follow-up years: 1,488 mg (14% decrease) in year 1; 1,495 mg (14% decrease) in year 2; 1,612 mg (7% decrease) in year 3; 1,560 mg (10% decrease) in year 4; and 1,532 mg (12% decrease) in year 5. Energy served per diner remained stable.

Implications for Public Health

Our study provides evidence for sustained sodium reduction strategies in a large ethnically and socioeconomically diverse school district, pointing to the potential benefit of implementing similar strategies in other school districts. The study also shows how program evaluation can be used to support sustainability.

Obesity and Cardiometabolic Risk Factors: From Childhood to Adulthood

Obesity has become a major epidemic in the 21st century. It increases the risk of dyslipidemia, hypertension, and type 2 diabetes, which are known cardiometabolic risk factors and components of the metabolic syndrome. Although overt cardiovascular (CV) diseases such as stroke or myocardial infarction are the domain of adulthood, it is evident that the CV continuum begins very early in life. Recognition of risk factors and early stages of CV damage, at a time when these processes are still reversible, and the development of prevention strategies are major pillars in reducing CV morbidity and mortality in the general population. In this review, we will discuss the role of well-known but also novel risk factors linking obesity and increased CV risk from prenatal age to adulthood, including the role of perinatal factors, diet, nutrigenomics, and nutri-epigenetics, hyperuricemia, dyslipidemia, hypertension, and cardiorespiratory fitness. The importance of 'tracking' of these risk factors on adult CV health is highlighted and the economic impact of childhood obesity as well as preventive strategies are discussed.

Dietary intake of Indigenous Australian infants and young children in the Gomeroi gaaynggal cohort

AIM

The nutritional quality of foods consumed by infants and young children to complement breastfeeding or formula feeding influences growth and development. The aim of this study was to identify the dietary intake of Indigenous infants and young children in the Gomeroi gaaynggal cohort, and evaluate the nutritional adequacy of their intake compared with Australian recommendations.

METHODS

Dietary intake was assessed using diet recalls at approximately 9-, 12- and 24-month visits. Nutrient values of foods were obtained from AUSNUT 2011-13 and nutrient intake compared to the Australian Nutrient Reference Values. Foods were categorised into food groups and intakes compared to the Australian Guide to Healthy Eating.

RESULTS

A total of 206 infants and young children were included in the study. Of these, 95 individual children had dietary data collected between 7.6 and 24.7 months. Infant formula and breastfeeding rates were highest among infants (70% and 20%, respectively). Cow's milk intake was highest among young children (75%). Infants and young children in the cohort met most macro- and micronutrient intake recommendations. Few young children met recommendation for iron (42%), no infant met recommendation for omega-3 fatty acids and almost all exceeded recommendation for sodium. Most young children met daily dairy and fruit recommendations although intake of discretionary foods was high.

CONCLUSIONS

This study found that diets of Indigenous infants and young children met most key nutrient reference targets. Potential target areas that require dietary optimisation have been identified and will be the focus of community-led strategies in adequate infant nutrition promotion.

Elemental Impurities in Pediatric Calcium Carbonate Preparations-High Throughput Quantification and Risk Assessment

Calcium carbonate which is extracted from the Earth in combination with other mineral impurities, is largely used in preparations for pediatric supplements. Elemental impurities in drug products pose toxicological concerns without therapeutic benefits. Thus, it is very urgent to assess the safety of chronic exposure to elements that may be present in trace amounts. In the present study, we developed high throughput ICP-MS method for the quantitative determination of 62 elemental impurities in high matric calcium carbonate samples and validated according to USP 233. Calcium carbonate preparations which state clearly used for child (including neonates, infants, toddlers and children) from 9 manufactures and two types of raw materials (light calcium carbonate and ground calcium carbonate) were investigated in terms of the content and variability of 62 elemental impurities. According to the results, ground calcium carbonate was more suitable to be used in pediatric preparations concerning elemental impurities. Parts of elemental impurities in CaCO₃ preparations which are derived from the raw materials and the preparation process, may cause potential risks for children. These results indicate that it is necessary to establish a modern instrumental analysis method to evaluate and control elemental impurities in CaCO₃ raw materials and preparations.

Population-based Cardiovascular Disease Prevention Measures Aimed at Reducing Salt Intake: Analysis of International Strategies and Prospects for Implementation in the Russian Federation

High salt intake is an important risk factor for cardiovascular diseases (CVD), closely related to the level of blood pressure in the population. The purpose of the review: to study population-based interventions for CVD prevention, aimed at reducing salt intake; to assess the potential for their implementation in the Russian Federation. We presented population-based strategies for dietary salt intake reduction used in different countries. The main components of strategies aimed to correct this risk factor in the Russian Federation were identified. The main components of the population-based approach to reducing salt intake are: determining population salt consumption, identifying sources of salt in the diet, monitoring of salt content in products, engaging with the food industry, consumer awareness campaigns, changes in product labeling, tax measures. An integrated approach to the problem is the most successful. Measures which were highly effective have not yet been fully implemented in the Russian Federation. At the moment, taxation of high-salt foods and tax subsidies for healthy food are not applied. Food manufacturers are not sufficiently involved - there are no legislatively introduced measures to reduce salt through food reformulation. Firstly it has to be applied to diet-forming products that are consumed daily, such as bakery and dairy products, and meat products.

An Increase in SNAP Benefits Did Not Impact Food Security or Diet Quality in Youth

BACKGROUND

Low diet quality during childhood and adolescence is associated with adverse health outcomes later in life. Diet quality is generally poor in American youth, particularly in youth of low socioeconomic status. The Supplemental Nutrition Assistance Program (SNAP) is the primary safety net to help low-income households afford a healthy diet. Yet self-selection into the program creates challenges in estimating the relationship between SNAP and diet outcomes.

OBJECTIVE

This study examined how the increase in SNAP benefits during the American Recovery and Reinvestment Act (ARRA) affected food security and diet quality in low-income youth.

DESIGN

This analysis used a difference-in-differences design and data from the National Health and Nutrition Examination Survey 2007-2008 to 2011-2012 waves.

PARTICIPANTS/SETTING

The sample included children and adolescents aged 2 to 18 years with household income ≤250% of the Federal Poverty Line. Food security and diet outcomes in SNAP-eligible youth (n = 2,797) were examined, with children in nearly SNAP-eligible households serving as a comparison group (n = 1,169). The diet quality analysis stratified the sample by age range.

MAIN OUTCOME MEASURES

The study assessed food security and 6 dietary outcomes: 2 nutrients (sodium and fiber), 3 food categories (fruit, vegetables, and sugar-sweetened beverages), and 1 measure of overall diet quality (Healthy Eating Index 2010).

STATISTICAL ANALYSIS PERFORMED

Logistic regression and linear regression were used to estimate the relationship between SNAP eligibility and child food security and diet.

RESULTS

In unadjusted analysis, approximately 64% of SNAP-eligible children were food secure before ARRA and 73% were food secure while ARRA was in effect. Using logistic regression in a difference-in-differences framework, the ARRA SNAP benefit increase was not significantly associated with food security (odds ratio 1.37, P = 0.43). Diet quality of SNAP-eligible children was low, scoring a 46 out of 100 on the Healthy Eating Index 2010. Measures of diet quality did not significantly change from the pre-ARRA period to the ARRA period; this did not differ by age range.

CONCLUSIONS

The increase in SNAP benefits during ARRA did not significantly impact food security or diet quality in low-income children and adolescents. Additional research to better understand how SNAP benefits impact dietary choice is warranted.

Trends in Sodium Intake in Children and Adolescents in the US and the Impact of US Department of Agriculture Guidelines: NHANES 2003-2016

OBJECTIVE

To examine trends in sodium intake and the impact of nutritional guidelines in the US pediatric population.

STUDY DESIGN

Sodium intake data collected between 2003 and 2016 in the US National Health and Nutrition Examination Surveys (NHANES) were analyzed. Trends in intake for individuals aged 4-17 years and subgroups based on age, sex, and race and ethnicity were examined. Adherence to US Department of Agriculture guidelines was assessed.

RESULTS

A total of 16 013 individuals (50.6% male) were included in the analysis. The median sodium intake was 2840 mg/day (95% CI, 2805-2875 mg/day), decreasing from 2912 mg/day (95% CI 2848-2961 mg/day) in 2003-2004 to 2787 mg/day (95% CI, 2677-2867 mg/day) in 2015-2016 (P = .005). Intake increased with age (2507 mg/day for individuals aged 4-8, 2934 mg/day for those aged 9-13 years, and 3124 mg/day for those aged 14-17 years; P < .001) and was greater in males than in females (3053 mg/day vs 2624 mg/day; P < .001). Caucasians, Hispanics, and African Americans consumed 2860, 2733, and 2880 mg/day, respectively (P < .001). Population adherence to US Department of Agriculture recommendations was 25.0% in 2003-2010 and 25.5% in 2011-2016 (P = .677). No age, sex, or racial/ethnicity subgroup had an adherence rate >30% after implementation of pediatric guidelines in 2010.

CONCLUSIONS

Sodium intake remains elevated in all pediatric population segments, and guideline adherence is poor. A greater effort to reduce sodium consumption is needed to mitigate future cardiovascular disease risk.

Is too much salt harmful? Yes

The contribution of high sodium intake to hypertension and to the severity of immune-mediated diseases is still being heatedly debated in medical literature and in the lay media. This review aims to demonstrate two conflicting views on the topic, with the first part citing the detrimental effects of excessive salt consumption. Sodium plays a central role in volume and blood pressure homeostasis, and the positive correlation between sodium intake and blood pressure has been extensively researched. Despite the fact that the average of global daily salt consumption exceeds recommendations of international associations, health damage from excessive salt intake is still controversial. Individual differences in salt sensitivity are in great part attributed to this contradiction. Patients suffering from certain diseases as well as other vulnerable groups-either minors or individuals of full age-exhibit more pronounced blood pressure reduction when consuming a low-sodium diet. Furthermore, findings from the last two decades give insight into the concept of extrarenal sodium storage; however, the long-term consequences of this phenomenon are lesser known. Evidence of the relationship between sodium and autoimmune diseases are cited in the review, too. Nevertheless, further clinical trials are needed to clarify their interplay. In conclusion, for salt-sensitive risk groups in the population, even stricter limits of sodium consumption should be set than for young, healthy individuals. Therefore, the question raised in the title should be rephrased as follows: "how much salt is harmful" and "for whom is elevated salt intake harmful?"

Variability in Dietary Quality of Elementary School Lunch Menus with Changes in National School Lunch Program Nutrition Standards

National School Lunch Program (NSLP) standards recently changed significantly. The Healthy, Hunger-Free Kids Act (HHFKA) presumably improved the dietary quality (DQ) of meals, whereas Child Nutrition Program (CNP) Flexibilities appear to decrease DQ. This variability has not been quantified. Our objective was to determine differences in DQ between elementary school lunch menus meeting NSLP standards: School Meal Initiative (SMI), HHFKA, CNP Flexibilities, and evidence-based best practices (BP). A base menu was portioned per NSLP standards and analyzed for nutrient content and DQ. Statistical analyses included 1-factor ANOVA, Kruskal-Wallis, and Dunnett's test. The BP menu had higher whole fruit and whole grain Healthy Eating Index scores than SMI (Ps < 0.0083). The BP and HHFKA menus had higher refined grain and added sugars scores than SMI (Ps < 0.0083). The SMI menu had lower total vegetable and saturated fat scores than all menus (Ps < 0.0083). This study informs policy toward improving standards, positively affecting child health and academic performance through higher-DQ lunches.

A qualitative investigation of school age children, their parents and school staff on their participation in the Digital Education to LImit Salt in the Home (DELISH) program

This study explored the views of participants who completed a 5-week, online, interactive, family-based, salt reduction education program (Digital Education to LImit Salt in the Home). A secondary aim was to explore the views of school staff on the delivery of food and nutrition education in schools. Children aged 7-10 years, their parents and principals/teachers from participating schools located in Victoria, Australia, completed a semi-structured evaluation interview. Audio-recordings of interviews were transcribed verbatim and analysed using NVivo. Twenty-eight interviews (13 children; 11 parents; 4 school staff) were included. Thematic analysis revealed that the program was well received by all groups. Children reported that the interactivity of the education sessions helped them to learn. Parents thought the program was interesting and important, and reported learning skills to reduce salt in the family diet. School staff supported the delivery of nutrition education in schools but indicated difficulties in sourcing well-packed nutrition resources aligned with the curriculum. It appears that there is support from parents and teachers in the delivery of innovative, engaging, nutrition education in schools, however such programs need to be of high quality, aligned with the school curriculum and readily available for incorporation within the school's teaching program.

Comparing Diet Quality of School Meals versus Food Brought from Home

Purpose: Consuming nutritious food is essential to learning. The purpose of this research was to determine the diet quality of elementary school lunches, both those in meal programs and those bringing food from home, in urban and rural locations in Saskatchewan.Methods: Using a School Food Checklist and digital photography we compared food group servings and diet quality in 3 school types: urban schools with a meal program and urban and rural schools without a meal program. The total sample was 773 students.Results: Only 55% of students brought the minimum number of servings for grain products and meat and alternatives, with fewer bringing the minimum for vegetables and fruit (25.6%-34.9%), whole grains (24.1%), and milk and alternatives (14.1%). Students bringing food from home had significantly more calories in their lunches from minimally nutritious foods. Students in meal programs had the highest diet quality scores using the Healthy Eating Index adapted for school hours.Conclusions: The diet quality of elementary students' lunches needs improvement, although students in meal programs have healthier diets. Interventions targeting what children eat at school should focus on increasing the number of students meeting recommendations for healthy foods while decreasing minimally nutritious foods brought to school.

Nutritional assessment of the school menus offered in Spain's Mediterranean area

OBJECTIVES

The aim of this study was to perform a nutritional assessment of the menus served in school canteens and to verify their effects on the nutrition of schoolchildren.

METHODS

We selected three collective catering companies that offered ~53 500 menus/d in 369 schools in Spain's Mediterranean area (Valencian Community). The study included four public schools with different management models as well as different supply patterns. Considering the weight of the servings, the caloric contribution of the menus was estimated.

RESULTS

Great diversity was seen both in the same school throughout the week and between the four schools (School 1: 298-946 kcal; School 2: 465-1185 kcal; School 3: 395-656 kcal; and School 4: 374-966 kcal). The energy intake from carbohydrates complied with the recommendations in three of the four schools, the energy provided from proteins was adequate in all of the schools, and the energy from lipids was higher than the recommended values in Schools 1 and 2, lower in School 3, and compliant in School 4. The most abundant fatty acids in the menus were oleic, linoleic, and palmitic acids. The sodium content in the rated menus was 229 ± 72 mg/100 g. The highest salt content came from menus that included a precooked dish, processed meat, or both.

CONCLUSION

It is necessary to review school menus and adjust the size of the servings to the age of the children. Correct nutritional education is essential for both kitchen staff and school canteen monitors.

The association of parents' behaviors related to salt with 24 h urinary sodium excretion of their children: A Spanish cross-sectional study

BACKGROUND

Sodium intake is excessive among Spanish children, but the salt use behaviors of parents and children are unknown. This study aims to determine behaviors related to salt intake in both schoolchildren and parents and the relationship between parental behaviors and 24 h urinary sodium excretion (UNa-24h) in children.

SUBJECTS AND METHODS

A convenience sample was taken from a cross-sectional analysis. Parents completed a self-reported questionnaire about their behaviors related to salt, and their responses were compared with the UNa-24h of their own children. The median test was used to identify differences in UNa-24h according to behaviors. Logistic regression was used to assess the relationship between the behaviors of parents and high sodium excretion in the children and the risk of children's use of table salt, adjusting for age, sex, and BMI. Multinomial logistic regression models, adjusted by the covariates, were used to study the children's salt preferences.

RESULTS

A total of 329 schoolchildren from different Spanish provinces were included in the study (mean age: 9.0 ± 1.2 years, 157 girls). The majority of families (parents mean age: 42.0 ± 5.2 years) reported adding salt to food during cooking (92%), and 59% of them never looked at the sodium content on food labels. However, none of these behaviors were related to UNa-24h (p > 0.05). The use of iodized salt (53%), the presence of a salt shaker on the table (6%), and the use of table salt by fathers (57%), mothers (52%) or children (17%) increased the odds (p < 0.05) of children having a higher UNa-24h. Checking sodium content on food labels and the use of table salt by the children or father was associated with a lower preference for salty foods (p < 0.05).

CONCLUSIONS

It is important to make parents aware of the relationship between their behaviors regarding the use of discretionary salt and their children's sodium intake. Our data suggest that salt-specific education programs on how to reduce salt both in-home and outside the home should be implemented to improve behavior skills related to salt consumption in parents and children.

A cross sectional study of salt content in bakery bread in Zagreb, Croatia

Reducing salt content in bread is the essential part of a national strategy for salt reduction with the goal of long-term national general health improvement. In this study we have analysed salt content in three types of bread available in 25 small and five national industrial bakeries in Zagreb, Croatia. Samples of white wheat bread, dark wheat bread, and other types of bread were collected, and the salt content was determined with the Mohr method. Salt content varied widely between bakeries, with an average content of 2.30±0.22 g per 100 g of bread, which is almost twice the threshold content (1.4 %) defined by the Croatian National Regulation on Cereals and Cereal Products. Further efforts are necessary to teach bakers how to reduce salt content without affecting quality or flavour. These should go hand in hand with continuous monitoring of how the legal provisions are implemented.

Innovation to Create a Healthy and Sustainable Food System: A Science Advisory From the American Heart Association

Current dietary intakes of North Americans are inconsistent with the Dietary Guidelines for Americans . This occurs in the context of a food system that precludes healthy foods as the default choices. To develop a food system that is both healthy and sustainable requires innovation. This science advisory from the American Heart Association describes both innovative approaches to developing a healthy and sustainable food system and the current evidence base for the associations between these approaches and positive changes in dietary behaviors, dietary intakes, and when available, health outcomes. Innovation can occur through policy, private sector, public health, medical, community, or individual-level approaches and could ignite and further public-private partnerships. New product innovations, reformulations, taxes, incentives, product placement/choice architecture, innovative marketing practices, menu and product labeling, worksite wellness initiatives, community campaigns, nutrition prescriptions, mobile health technologies, and gaming offer potential benefits. Some innovations have been observed to increase the purchasing of healthy foods or have increased diversity in food choices, but there remains limited evidence linking these innovations with health outcomes. The demonstration of evidence-based improvements in health outcomes is challenging for any preventive interventions, especially those related to diet, because of competing lifestyle and environmental risk factors that are difficult to quantify. A key next step in creating a healthier and more sustainable food system is to build innovative system-level approaches that improve individual behaviors, strengthen industry and community efforts, and align policies with evidence-based recommendations. To enable healthier food choices and favorably impact cardiovascular health, immediate action is needed to promote favorable innovation at all levels of the food system.

How a Public Health Goal Became a National Law: The Healthy, Hunger-Free Kids Act of 2010

This case study provides insights into policy strategy and advocacy best practices that resulted in passage of the Healthy, Hunger-Free Kids Act of 2010, a public health law that resulted in improvements to school foods and beverages across the country. Congress reauthorizes child nutrition programs such as the National School Lunch Program and School Breakfast Program every 5 years. The Healthy, Hunger-Free Kids Act of 2010 is the legislation that reauthorized the child nutrition programs through September 30, 2015, and continues in effect today. We conducted stakeholder interviews and reviewed the legislative and regulatory history of the Healthy, Hunger-Free Kids Act of 2010 and advocates' files. We formed an external advisory committee which helped to develop the interview questions and list of interviewees and reviewed the content of the case study. This case study focuses on the provisions that address the nutritional quality of school meals, snacks, and beverages and covers the period from 2004 to 2016. Overall, the case study demonstrates a number of key lessons to help inform other nutrition and public health policy initiatives, as well as continued implementation and defense of school nutrition. For instance, how advocates used research to develop and advocate for policy change, compromises that were needed to advance the policies, changes in attitudes about school food policy over time, framing and messaging, the role of state and local policy that contributed to national change, and how challenges were resolved between stakeholders.

Salt Preference and Ability to Discriminate between Salt Content of Two Commercially Available Products of Australian Primary Schoolchildren

Australian children consume too much salt, primarily from processed foods where salt is often used to enhance flavour. Few studies have assessed children's salt preference in commercially available foods. This study aims to assess (1) children's preference and ability to discriminate between salt levels in two commercially available foods and (2) if preference or ability to discriminate between salt levels changes after an education program. Chips and corn flakes were tasted at three levels of salt concentration. Children ranked which they liked best (preference) and which was saltiest (ability to discriminate). The proportion of children across categorical responses was assessed (Chi squared and McNemar's test) together with changes in preference and ability to discriminate between salt levels from timepoint 1 (T1) to timepoint 2 (T2). Ninety-two children (57% female, mean age 9.1 years (SD 0.8)) participated. At T1 approximately one-half and two-thirds of children preferred the highest salt chip and cornflake, respectively, (both p < 0.05). Fifty-seven percent and 63% of children identified the highest level of salt in chips and cornflakes as the saltiest, respectively. Preference and ability to discriminate between salt levels were unchanged between timepoints. Results support product reformulation to decrease salt content of foods provided to children.

Digital Education to Limit Salt in the Home (DELISH) Program Improves Knowledge, Self-Efficacy, and Behaviors Among Children

OBJECTIVE

To determine the efficacy of a Web-based salt reduction program on children's salt-related knowledge, attitudes, and behaviors (KABs), self-efficacy, and intake of dietary salt.

DESIGN

Pretest and posttest. An online survey determined KABs and self-efficacy and a 24-hour urine collection revealed salt intake.

SETTING

Victoria, Australia.

PARTICIPANTS

Child-parent dyads (n = 102) recruited from 5 government schools.

INTERVENTION

A 5-week behavior-based education program delivered via weekly online interactive education sessions.

MAIN OUTCOME MEASURES

Change in KABs, self-efficacy, and daily salt intake.

ANALYSIS

Changes in outcomes were assessed using McNemar test, paired t test, and Cohen's δ (CD).

RESULTS

A total of 83 children participated (mean age, 9.2 years [SD, 0.8 years]; 59% girls); 35% to 76% of children viewed weekly education session. Children with complete survey data (n = 75) had improved scores for salt-related knowledge (+3.6 ± 0.4 points; P < .001; CD: 1.16), behaviors (+1.3 ± 0.1 points; P < .001; CD: 1.08), and self-efficacy (+0.9 ± 0.2 points; P < .001; CD: 0.64), but not attitude. Children with valid urine collections (n = 51) showed no change in salt intake.

CONCLUSIONS AND IMPLICATIONS

Participation resulted in improvement of salt related knowledge, self-efficacy and behavior. Further research is required to confirm these results using a more robust study design which includes a control group. In addition, the long term impact on children's salt intakes of comparable education programs needs to be assessed.

Trends in Dietary Sodium from Food Sources in Australian Children and Adolescents from 2007 to 2011/12

BACKGROUND

In western countries, most children eat more sodium than is recommended. In Australia in 2009, voluntary sodium reformulation targets were adopted for nine categories of processed foods, but the impact of this initiative on children's sodium intake has not been assessed.

OBJECTIVE

To compare sodium consumption of Australian children aged 2 to 16 years from 2007 to 2011/12.

DESIGN

Cross-sectional analysis of data from the 2007 Children's Nutrition and Physical Activity Survey (n=4,487) and the 2011/12 National Nutrition and Physical Activity Survey (n=2,548).

PARTICIPANTS/SETTING

A nationally representative sample of 6,705 Australian children aged 2 to 16 years who provided plausible 24-hour dietary recall data according to Goldberg cutoffs for misreporting of energy intake.

MAIN OUTCOME MEASURES

Mean intakes of energy, sodium, and sodium density (mg/1,000 kcal) were assessed via one 24-hour dietary recall; measurement error models with up to two 24-hour dietary recalls were used to estimate usual sodium intake and the proportion of children exceeding the age-specific upper level for sodium.

STATISTICAL ANALYSES PREFORMED

Statistical analysis incorporated survey weights and accounted for the complex survey design. Two-sample t-tests and two-sample test of proportions were used to assess differences in continuous and categorical variables between survey years.

RESULTS

Dietary sodium declined by 8% between 2007 and 2011/12 (-188±SE 31 mg/day; P<0.001), and this was in conjunction with a 5% reduction in energy intake (98±19 kcal/day; P<0.001). When stratified by age group, significant reductions in sodium intake remained across all four age groups (ie, 2-3 years, 4-8 years, 9-13 years, and 14-16 years); similarly, with the exception of 2- to 3-year-old children, reductions in energy intake were observed across all other age groups. Overall sodium density declined by 2% (-29 mg/1,000 kcal/day; P=0.01); however, in age subgroup analysis the decline in sodium density only remained among children aged 2 to 3 years. The upper level for sodium was exceeded by 94% or more children in 2007 and 78% or more in 2011/2012.

CONCLUSION

Although results suggest a small reduction in reported sodium intake over 5 years, most children in 2011/12 had a sodium intake that exceeded the recommended upper level. Ongoing efforts to reduce sodium in the diets of Australian children are required.

Changes in School Food Preparation Methods Result in Healthier Cafeteria Lunches in Elementary Schools

INTRODUCTION

The purpose of this study is to examine the impact of a districtwide food best practices and preparation changes in elementary schools lunches, implemented as part of the LiveWell@School childhood obesity program, funded by LiveWell Colorado/Kaiser Permanente Community Health Initiative.

METHODS

Longitudinal study examining how school changes in best practices for food preparation impacted the types of side items offered from 2009 to 2015 in elementary school cafeterias in a high-need school district in southern Colorado. Specifically, this study examined changes in side items (fruits, vegetables, potatoes, breads, and desserts). In Phase 1 (2009-2010), baseline data were collected. During Phase 2 (2010-2011), breaded and processed foods (e.g., frozen nuggets, pre-packaged pizza) were removed and school chefs were trained on scratch cooking methods. Phase 3 (2011-2012) saw an increased use of fresh/frozen fruits and vegetables after a new commodity order. During Phase 4 (2013-2015), chef consulting and training took place. The frequency of side offerings was tracked across phases. Analyses were completed in Fall 2016. Because of limited sample sizes, data from Phases 2 to 4 (intervention phases) were combined for potatoes and desserts. Descriptive statistics were calculated. After adjusting for length of time for each phase, Pearson chi-square tests were conducted to examine changes in offerings of side items by phase.

RESULTS

Fresh fruit offerings increased and canned fruit decreased in Phases 1-4 (p=0.001). A significant difference was observed for vegetables (p=0.001), with raw and steamed vegetables increasing and canned vegetables decreasing from Phase 1 to 4. Fresh potatoes (low in sodium) increased and fried potatoes (high in sodium) decreased from Phase 1 to Phases 2-4 (p=0.001). Breads were eliminated entirely in Phase 2, and dessert changes were not significant (p=0.927).

CONCLUSIONS

This approach to promoting healthier lunch sides is a promising paradigm for improving elementary cafeteria food offerings.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Fast food consumption and its associations with obesity and hypertension among children: results from the baseline data of the Childhood Obesity Study in China Mega-cities

BACKGROUND

China has seen rapid increase in obesity and hypertension prevalence and fast food consumption over the past decade. We examined status and risk factors for Western- and Chinese fast food consumption and their associations with health outcomes in Chinese children, and examined how maternal factors were associated with child health outcomes.

METHODS

Data of 1626 students aged 7-16 (11.6 ± 2.0) years and their parents in four mega-cities across China (Beijing, Shanghai, Nanjing, and Xi'an) were collected in the 2015 baseline survey of the Childhood Obesity Study in China Mega-cities. Weight, height, waist circumference, and blood pressure were measured. Food intake was assessed using questionnaire. Mixed models were used to examine the associations.

RESULTS

Among the children, 11.1% were obese, 19.7% were centrally obese, and 9.0% had hypertension. Obesity prevalence was much higher in boys than in girls (15.2% vs. 6.9% and 27.4% vs. 11.7%, respectively, both P < 0.001). About half (51.9% and 43.6%) of children consumed Western and Chinese fast food, respectively, over the past 3 months. Compared to those with college or above maternal education level, those with elementary school or below maternal education level were 49% more likely to consume Western fast food (odds ratio [OR] and 95% confidence interval [CI]: 1.49 [1.10-2.03]). Chinese fast food consumption rate increased by 12% with each year of increase in child's age (OR and 95% CI: 1.12 [1.02-1.23]). No significant associations between fast food consumption and health outcomes were detected. Adjusting for Western fast food consumption, children with lower maternal education were 71% and 43% more likely to have obesity and central obesity (ORs and 95% CIs: 1.71 [1.12-2.61] and 1.43 [1.00-2.03], respectively), and maternal body mass index was positively associated with child obesity, central obesity, and hypertension (ORs and 95% CIs: 1.11 [1.06-1.17], 1.12 [1.07-1.17], and 1.09 [1.03-1.15], respectively). Results were similar when Chinese fast food consumption was adjusted for.

CONCLUSIONS

The prevalence of fast food consumption, obesity and hypertension is high among children in major cities in China. Maternal factors affect child outcomes.

Dietary intake and sources of sodium and potassium among Australian schoolchildren: results from the cross-sectional Salt and Other Nutrients in Children (SONIC) study

OBJECTIVES

To examine sodium and potassium urinary excretion by socioeconomic status (SES), discretionary salt use habits and dietary sources of sodium and potassium in a sample of Australian schoolchildren.

DESIGN

Cross-sectional study.

SETTING

Primary schools located in Victoria, Australia.

PARTICIPANTS

666 of 780 children aged 4-12 years who participated in the Salt and Other Nutrients in Children study returned a complete 24-hour urine collection.

PRIMARY AND SECONDARY OUTCOME MEASURES

24-hour urine collection for the measurement of sodium and potassium excretion and 24-hour dietary recall for the assessment of food sources. Parent and child reported use of discretionary salt. SES defined by parental highest level of education.

RESULTS

Participants were 9.3 years (95% CI 9.0 to 9.6) of age and 55% were boys. Mean urinary sodium and potassium excretion was 103 (95% CI 99 to 108) mmol/day (salt equivalent 6.1 g/day) and 47 (95% CI 45 to 49) mmol/day, respectively. Mean molar Na:K ratio was 2.4 (95% CI 2.3 to 2.5). 72% of children exceeded the age-specific upper level for sodium intake. After adjustment for age, sex and day of urine collection, children from a low socioeconomic background excreted 10.0 (95% CI 17.8 to 2.1) mmol/day more sodium than those of high socioeconomic background (p=0.04). The major sources of sodium were bread (14.8%), mixed cereal-based dishes (9.9%) and processed meat (8.5%). The major sources of potassium were dairy milk (11.5%), potatoes (7.1%) and fruit/vegetable juice (5.4%). Core foods provided 55.3% of dietary sodium and 75.5% of potassium while discretionary foods provided 44.7% and 24.5%, respectively.

CONCLUSIONS

For most children, sodium intake exceeds dietary recommendations and there is some indication that children of lower socioeconomic background have the highest intakes. Children are consuming about two times more sodium than potassium. To improve sodium and potassium intakes in schoolchildren, product reformulation of lower salt core foods combined with strategies that seek to reduce the consumption of discretionary foods are required.

Externalizing behavior is prospectively associated with intake of added sugar and sodium among low socioeconomic status preschoolers in a sex-specific manner

BACKGROUND

High intake of added sugar and sodium is a public health concern for preschool-aged children living in the US. Externalizing behavior may predict higher consumption of added sugar and/or sodium; however, previous studies have mostly been cross-sectional. The aim was to evaluate whether externalizing behavior is prospectively related to added sugar and intake in a sex-specific manner among preschoolers.

METHODS

This was a secondary analysis of 524 preschool children (48% male) from Michigan who participated in an obesity prevention trial that occurred during one school year from 2011 to 2015. Teacher-assessed externalizing behaviors and three 24-h dietary recalls were completed at baseline and follow-up. We used linear mixed effects regression to evaluate the association between externalizing behavior at baseline and added sugar (% of total Calories) and sodium intake (mg/1000 Calories) at follow-up. In adjusted analysis, we included baseline income-to-needs ratio, child race/ethnicity, and baseline overweight status. All models were adjusted for total energy intake and accounted for clustering by classroom.

RESULTS

Baseline externalizing behavior was positively associated with added sugar intake at follow-up among boys; after adjustment for confounders, every 5 points lower externalizing T-score (corresponding to higher externalizing behavior) was associated with a 0.6 higher percentage of added sugar per total Calories (95% CI 0.2 to 1.1; P value = 0.004). In contrast, girls with higher levels of externalizing behavior had lower consumption of added sugars; after confounder adjustment, every 5 points lower externalizing T-score was related to 0.6 lower percentage intake (95% CI -1.0 to -0.1; P value = 0.01). Baseline externalizing behavior was inversely associated with sodium intake at follow-up among boys. After potential confounder adjustment, for every 5 points lower externalizing behavior T-score, there was a 22 mg/1000 Cal lower sodium intake (95% CI -45 to 1; P value = 0.06). In contrast, after adjustment for confounders, every 5 points lower externalizing T-score among girls was related to 24 mg/1000 Cal higher sodium intake (95% CI 1 to 46; P value = 0.04).

CONCLUSIONS

Externalizing behavior among preschool-aged children was prospectively related to added sugar and sodium intake in a sex-dependent manner.

TRIAL REGISTRATION

NCT01398358 Registered 19 July 2011.

The Development of a Web-Based Program to Reduce Dietary Salt Intake in Schoolchildren: Study Protocol

BACKGROUND

Salt intake of schoolchildren in the Australian state of Victoria is high. To protect future cardiovascular health, interventions that seek to reduce the amount of salt in children's diets are required.

OBJECTIVE

We sought to develop and pilot test a Web-based program (Digital Education to Limit Salt Intake in the Home [DELISH]) that aims to reduce dietary salt intake among schoolchildren and to improve child and parent knowledge, attitudes, and behaviors related to salt intake. This paper presents the DELISH study protocol, along with pilot findings used to inform the development of the program.

METHODS

The DELISH program is a 5-week Web-based intervention that targets schoolchildren aged 7-10 years and their parents. This is a single-arm study with a pretest and posttest design. We will assess change in salt intake through analysis of 24-hour urinary sodium excretion. Children and parents will complete online surveys assessing knowledge, attitudes, and behaviors related to salt intake. We will assess feasibility of the program via process measures, which include metrics to describe intervention uptake (eg, number of children who complete Web-based sessions and of parents who view online newsletters) and evaluation surveys and interviews conducted with children, parents, and schoolteachers. The first 2 Web sessions developed for children were pilot tested in 19 children aged 8-12 years.

RESULTS

Findings from pilot testing indicated that most children (session 1: 18/19, 95%; and session 2: 19/19, 100%) enjoyed completing each session and liked the inclusion of comic strips and interactive games. Commonly reported areas of improvement related to sessions being text and content heavy. Based on these findings, we simplified sessions and developed 3 additional sessions for use in the DELISH program. The DELISH program was implemented during June-December 2016. We expect to have results from this study at the end of 2017.

CONCLUSIONS

To our knowledge, this is the first Australian study to examine the effectiveness of a Web-based program to reduce salt intake among children in primary school. If shown to be acceptable and effective in lowering salt intake, the DELISH program could be tested using a more rigorous randomized controlled trial design.

Dietary sodium, dietary potassium, and systolic blood pressure in US adolescents

Both high sodium and low potassium diets are associated with hypertension, but whether these risk factors are distinct or overlapping has not been thoroughly investigated. The authors evaluated the relationship between dietary sodium, potassium, and high systolic blood pressure among 4716 adolescents aged 12 to 14 years who participated in the National Health and Nutrition Examination Survey from 1999 to 2012. There was no association with blood pressure across most values of sodium or potassium intake. However, participants who reported sodium intake ≥7500 mg/d, potassium <700 mg/d, or sodium-potassium ratio ≥2.5 had increased odds for high systolic blood pressure (≥95th percentile for age, sex, and height). Although the high sodium and low potassium groups did not overlap, 49.2% of these adolescents also had a sodium-potassium ratio ≥2.5. In young adolescents, both excessive sodium and limited potassium are associated with high systolic blood pressure, but the balance between sodium and potassium intake may be more useful in explaining blood pressure in this population.

[Measurement of dietary sodium intake in a group of children from one to 18 months of age in a pediatric service in Cali, Colombia]

INTRODUCTION

The fatty streaks in an arterial wall can appear from the third year of age, and they show an association with atherogenic risk factors such as hypertension and sodium in the diet. Given the difficulty of data gathering, few studies report the intake of sodium in the diet.

OBJECTIVE

To determine average sodium intake in the diet of children between one and 18 months of age through a three-day dietary survey.

MATERIALS AND METHODS

This was a cross-sectional study with 48 children without renal disease or diet restrictions seen in pediatric practice between January and June, 2011. It included a dietary survey for the parents, nutritional status classification by anthropometry, and blood pressure measurements. Sodium content and other nutrients in the diet program were analyzed with the International Food Consumption Program (CERES), anthropometry with the World Health Organization Anthro program, and Epi-info for socio-demographic characteristics.

RESULTS

In total, 69% of children had high sodium consumption, 6.2% had high blood pressure, and 20.7% were overweight and obese.

CONCLUSIONS

The prevalence of hypertension exceeds that reported for Colombia (1-3%). Two of the three children with high blood pressure had high sodium intake and they were overweight and obese, with values above those reported for Colombian children (16%). We suggest to measure blood pressure early, and to restrict salt and sugar in food for infants and children under two years of age. Also, larger studies should be conducted to collect population data on sodium intake and develop appropriate and timely intervention strategies to reduce risks in adulthood.

Nutrient and Food Group Intakes of Manitoba Children and Youth: A Population-Based Analysis by Pulse and Soy Consumption Status

Poor eating habits among children are associated with negative health outcomes. The objective of this study was to use pulse/soy consumption as an indicator to evaluate the eating profile of young Manitobans. Data from the Canadian Community Health Survey Cycle 2.2 were used for analysis and restricted to Manitoba residents aged 2 to 18 years (n = 1840). Consumers were identified as individuals who reported eating at least 1 pulse/soy product during their recall. On any given day, 8.2% of Manitobans reported consumption of pulses/soy. Intakes of fibre, protein, magnesium, and zinc were higher in consumers only when expressed relative to total caloric intake. Consumers also reported increased intakes of meat and alternatives. Total intakes of vitamin D, fibre, and fruit and vegetable consumption were low among all groups. Sodium intakes in both groups were high when compared with levels recommended by health professionals. These results indicate that there are many dietary issues affecting Manitoba children, suggesting the need for more research targeting dietary habits of children and youth, the quality of the food supply, and effective strategies in nutrition education.

Reducing Sodium Intake in Children: A Public Health Investment

The antecedents of elevated blood pressure (BP) and its major consequences (cardiovascular disease and stroke) begin in childhood. Higher levels of BP early in life track into adulthood and are associated with subclinical target organ damage in children and adults. Diet behaviors, including the choice of high sodium containing foods, are established during childhood. On average, children, ages 2-19, consume more than 3,100 mg of sodium per day, with substantially greater sodium intakes in boys than girls. Importantly, studies show that lowering sodium intake in children lowers blood pressure. In view of this evidence, U.S. Dietary Guidelines recommend a reduced sodium intake in children. Current federal nutrition standards include a step-wise reduction in the sodium levels of school meals. The ultimate goal is to help children achieve daily sodium intakes that do not exceed upper levels recommended by the Institute of Medicine and the Dietary Guidelines for Americans. In summary, available data are sufficiently strong to recommend a lower sodium intake beginning in early in life as an effective and well-tolerated approach to reducing BP in children. Current efforts to weaken nutrition standards for school meals undermine an effective strategy aimed at improving the health of our children and our nation.