Associations Between Salt-Restriction Spoons and Long-Term Changes in Urinary Na+/K+ Ratios and Blood Pressure: Findings From a Population-Based Cohort

Exploratory study on the relationship between urinary sodium/potassium ratio, salt intake, and the antihypertensive effect of esaxerenone: the ENaK Study

Excessive salt intake is one of the causes of hypertension, and reducing salt intake is important for managing the risk of hypertension and subsequent cardiovascular events. Esaxerenone, a mineralocorticoid receptor blocker, has the potential to exert an antihypertensive effect in hypertensive patients with excessive salt intake, but evidence is still lacking, especially in clinical settings. We aimed to determine if baseline sodium/potassium ratio and baseline estimated 24-h urinary sodium excretion can predict the antihypertensive effect of esaxerenone in patients with essential hypertension inadequately controlled with an angiotensin receptor blocker (ARB) or a calcium channel blocker (CCB). This was an exploratory, open-label, interventional study with a 4-week observation period and a 12-week treatment period. Esaxerenone was orally administered once daily in accordance with the Japanese package insert. In total, 126 patients met the eligibility criteria and were enrolled (ARB subcohort, 67; CCB subcohort, 59); all were included in the full analysis set (FAS) and safety analysis. In the FAS, morning home systolic blood pressure (SBP)/diastolic blood pressure (DBP) significantly decreased from baseline to end of treatment (primary efficacy endpoint) (-11.9 ± 10.9/ - 6.4 ± 6.8 mmHg, both p < 0.001); a similar trend was observed in both subcohorts. Significant reductions were also shown in bedtime home and office SBP/DBP (all p < 0.001). Each BP change was consistent regardless of the urinary sodium/potassium ratio or estimated 24-h urinary sodium excretion at baseline. The urinary albumin-creatinine ratio (UACR) and N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly decreased from baseline to Week 12 in the total population and both subcohorts. No new safety concerns were raised. Esaxerenone significantly decreased morning home, bedtime home, and office BP; UACR; and NT-proBNP in this patient population, regardless of concomitant ARB or CCB use. The antihypertensive effect of esaxerenone was independent of the urinary sodium/potassium ratio and estimated 24-h urinary sodium excretion at baseline.

Associations between estimation of salt intake and salt-restriction spoons and hypertension status in patients with poorly controlled hypertension: a community-based study from Huzhou City, Eastern China

BACKGROUND

As the prevalence of hypertension increases in China, it is advised to use salt-restriction spoons (SRS) as a lifestyle modification. This study aimed to examine the associations between estimated salt consumption, SRS usage, and the hypertension status in individuals with poorly controlled hypertension.

METHODS

Data was collected in Huzhou City, Zhejiang Province, in 2021 using convenience sampling. The analysis involved ordinal logistic regression and restricted cubic splines to assess the relevant factors.

RESULTS

The study found that 73.34% of the 1215 patients had uncontrolled blood pressure (BP). Urinary excretion was assessed through the utilization of the Kawasaki, INTERSALT, and Tanaka formulas. The outcomes of these three methodologies revealed average daily sodium excretion values of 208.70 (65.65), 154.78 (33.91), and 162.61 (40.87) mmol, respectively. The prevalence of utilizing SRS was found to be 37.78% in this study. Despite the acknowledgment among SRS users of the potential hazards associated with excessive salt consumption, there exists a contradictory pattern of attitudes and behaviors concerning salt reduction. Among individuals with different levels of salt intake (quartiles 1-4, Q1 vs Q4), there was a positive association between limiting salt and hypertension status when controlling for other variables (Kawasaki adjusted OR = 0.58, 95% CI = 0.43-0.79; INTERSALT adjusted OR = 0.62, 95% CI = 0.41-0.92; Tanaka adjusted OR = 0.61, 95% CI = 0.45-0.92, p < 0.05). Our research also revealed that using or used SRS was a protective factor for blood BP control (adjusted OR = 0.79, 95% CI = 0.64-0.99, P < 0.05). The restricted cubic spline plots illustrated a monotonic upward relationship between estimated 24-h urinary Na and BP (P-overall association < 0.05; P-non-linear association > 0.05).

CONCLUSIONS

The use of dietary SRS could result in decrease in daily salt intake for BP control in patients with poorly controlled hypertension. To reduce the impact of high BP in China, additional studies are required to create interventions that can enhance the results for patients.

Effect of home cook interventions for salt reduction in China: cluster randomised controlled trial

OBJECTIVE

To determine the effects of salt reduction interventions designed for home cooks and family members.

DESIGN

Cluster randomised controlled trial.

SETTING

Six provinces in northern, central, and southern China from 15 October 2018 to 30 December 2019.

PARTICIPANTS

60 communities from six provinces (10 communities from each province) were randomised; each community comprised 26 people (two people from each of 13 families).

INTERVENTIONS

Participants in the intervention group received 12 month interventions, including supportive environment building for salt reduction, six education sessions on salt reduction, and salt intake monitoring by seven day weighed record of salt and salty condiments. The control group did not receive any of the interventions.

MAIN OUTCOME MEASURE

Difference between the two groups in change in salt intake measured by 24 hour urinary sodium during the 12 month follow-up.

RESULTS

1576 participants (775 (49.2%) men; mean age 55.8 (standard deviation 10.8) years) from 788 families (one home cook and one other adult in each family) completed the baseline assessment. After baseline assessment, 30 communities with 786 participants were allocated to the intervention group and 30 communities with 790 participants to the control group. During the trial, 157 (10%) participants were lost to follow-up, and the remaining 706 participants in the intervention group and 713 participants in the control group completed the follow-up assessment. During the 12 month follow-up, the urinary sodium excretion decreased from 4368.7 (standard deviation 1880.3) mg per 24 hours to 3977.0 (1688.8) mg per 24 hours in the intervention group and from 4418.7 (1973.7) mg per 24 hours to 4330.9 (1859.8) mg per 24 hours in the control group. Compared with the control group, adjusted mixed linear model analysis showed that the 24 hour urinary sodium excretion in the intervention group was reduced by 336.8 (95% confidence interval 127.9 to 545.7) mg per 24 hours (P=0.002); the systolic and diastolic blood pressures were reduced by 2.0 (0.4 to 3.5) (P=0.01) and 1.1 (0.1 to 2.0) mm Hg (P=0.03), respectively; and the knowledge, attitude, and behaviours in the intervention group improved significantly.

CONCLUSIONS

The community based salt reduction package targeting home cooks and family members was effective in lowering salt intake and blood pressure. This intervention has the potential to be widely applied in China and other countries where home cooking remains a major source of salt intake.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800016804.

Development of a short-form Chinese health literacy scale for low salt consumption (CHLSalt-22) and its validation among hypertensive patients

Background

With the accelerated pace of people’s life and the changing dietary patterns, the number of chronic diseases is increasing and occurring at a younger age in today’s society. The speedily rising hypertensive patients have become one of the main risk factors for chronic diseases. People should focus on health literacy related to salt consumption and reach a better quality of life. Currently, there is a lack of local assessment tools for low salt consumption in mainland China.

Objective

To develop a short-form version of the Chinese Health Literacy Scale For Low Salt Consumption instrument for use in mainland China.

Methods

A cross-sectional design was conducted on a sample of 1472 people in Liaoxi, China. Participants completed a sociodemographic questionnaire, the Chinese version of the CHLSalt-22, the measuring change in restriction of salt (sodium) in the diet in hypertensives (MCRSDH-SUST), the Brief Illness Perception Questionnaire (BIPQ), and the Benefit-Finding Scales (BFS) to test the hypothesis. Exploratory factor analysis and confirmatory factor analyses were performed to examine the underlying factor structure of the CHLSalt-22. One month later, 37 patients who participated in the first test were recruited to evaluate the test-retest reliability.

Results

The CHLSalt-22 demonstrated adequate internal consistency, good test-retest reliability, satisfactory construct validity, convergent validity and discriminant validity. The CHLSalt-22 count scores were correlated with age, sex, body mass index (BMI), education level, income, occupation, the Measuring Change in Restriction of Salt (sodium) in Diet in Hypertensives (MCRSDH-SUST), the Brief Illness Perception Questionnaire (BIPQ), and the Benefit-Finding Scales (BFS).

Conclusion

The results indicate that the Chinese Health Literacy Scale For Low Salt Consumption (CHLSalt-22) version has good reliability and validity and can be considered a tool to assess health literacy related to salt consumption in health screenings.

The Magnitude of Salt Intake Behaviors and Its Predictors among Saqez Urban Population of Kurdistan District in Iran: A Cross-Sectional Study

Background

Controlling and reducing salt intake are one of the solutions to overcome hypertension. This study aimed at determining the predictors related to salt control methods in Saqez urban population.

Methods and Materials

In the present cross-sectional study, the sample population was randomly selected through cluster sampling. Data collection was performed using valid questionnaires, demographic, family economic status, knowledge, perception, intention, salt intake behaviors, and salt control methods, along with measuring body mass index (BMI) and hypertension levels. Descriptive, analytical statistical methods and multivariate logistic regression analysis were used to determine the predictors of desirable salt control methods. The variables of sex, age, family economic status, knowledge, perception, perceived social support, self-efficacy, and intention were analyzed as independent variables. Data analysis was performed using SPSS software version 24 at a significance level of 0.05.

Results

Out of 766 participants, 73% were women, with mean (M) 32.83, standard deviation (SD) 9.52 years, and 77.2% were married. There were significant sex differences in employment (P=0.01) and economic status (P=0.016). The M (SD) of blood pressure (systolic/diastolic) was 110.65 (0.0212) (P=0.441). The salt intake control methods between men and women did not show significant differences (P=0.368). Among totally 88.5%, 87.7% men and 88.9% women followed desirable behaviors. The predictors that determine the adoption of salt control methods were sex (man) (OR = 0.71, 95% CI (0.38–1.29)), age (OR = 1.02, 95% CI = (0.99–1.05)), SES/FAS (medium, high level) (OR = 1.37, 95% CI = (0.754–2.47); OR = 0.46, 95% CI = (0.047–4.55)), blood pressure (OR = 1.33, 95% CI = (0.16–11.23)), knowledge (have) (OR = 1.01, 95% CI = (0.39–1.63)), intent to reduce salt (OR = 1.047, 95% CI = (1.03–1.06)), perceived salt reduction importance (OR = 1.02, 95% CI = (1.01–1.04)), perceived emotional support (health staff) (OR = 1.02, 95% CI = (1.01–1.04)), media (OR = 1.01, 95% CI = 0.99–1.02), perceived practical support (spouse) (OR = 1.02, 95% CI = 0.99–1.04)), and perceived self-efficacy (OR = 1.01, 95% CI = (0.99–1.03)).

Conclusion

The support of health staff and spouse seems to be effective in controlling the salt intake behaviors of healthy individuals. In parallel with the development and change of people's lifestyles, new approaches (legal and services) for salt control based on the support of media and social media were expected.

Use of Salt-Restriction Spoons and Its Associations with Urinary Sodium and Potassium in the Zhejiang Province of China: Results of a Population-Based Survey

In China, a major source of sodium is salt added during cooking. In this context, use of a salt-restriction spoon (SRS) has been promoted in public health campaigns and by health care providers. To describe use of and factors associated with SRS use, knowledge of correct use, and actual correct use. This study is a population-based, representative survey of 7512 residents, aged 18 to 69 years, of China’s Zhejiang Province. The survey, which was conducted in 2017 using a multistage random sampling strategy, collected demographic information, SRS use, and physical measurements; a 24-h urine collection was obtained from 1,496 of the participants. The mean age of the participants was 44.8 years, 50.1% were females, and over 1/3 (35.3%) were classified as hypertensive. Mean 24-h urinary sodium and potassium excretions were 167.3(72.2) mmol/24 h and 38.2(18.2) mmol/24 h, respectively. Only 12.0% (899/7512) of participants once used or were currently using SRS; of the 899 users, 73.4% knew how to use the SRS correctly, and just 46.5% actually used it correctly. SRS use was more commonly associated with behavioral factors rather than socio-demographic factors. Initiation of SRS use by health care providers was associated with correct technical knowledge of SRS. Lower sodium-to-potassium ratio was associated with SRS use, while SRS use was not associated with urinary sodium and potassium excretion. Use of SRS was uncommon in Zhejiang Province of China. Given that a common source of sodium in China is salt added during cooking, use of SRS is an appealing strategy, ideally as part of a multi-component campaign.

China CDC in Action - Hypertension Prevention and Control

Hypertension contributes to a quarter of all-cause mortality in China. The Chinese government has put forward aims to control and prevent hypertension, and China CDC and other professional public health institutions have carried out a series of related efforts including the promotion of related policies and legislation, the improvement of modifiable risk factors of hypertension in the population, and promoting the National Primary Public Health Services to discover and manage patients with hypertension. China CDC has conducted multiple hypertension-related campaigns such as advocating for salt reduction, weight loss, and increased physical activity. Additionally, on behalf of the Chinese government, China CDC has organized and carried out the construction of national demonstration areas for the comprehensive prevention and control of chronic diseases. As of 2020, 488 national demonstration areas have been established, covering 17.1% of all counties and districts. In these areas, the lifestyle and health literacy of the population and community-based hypertension management measures have been improved. The Healthy China 2030 calls for a transition from disease treatment to a focus on health, which requires a strategy of hypertension prevention and control that focuses on the whole population rather than on high-risk populations. The Primary Health Care, Medicine and Health Promotion Law was officially implemented on June 1, 2020 and provides the legal basis for this strategy change in the prevention and control of hypertension. Ongoing public health legislation should involve non-communicable diseases such as hypertension in addition to communicable diseases.

Associations Between Salt-Restriction Spoons and Long-Term Changes in Urinary Na+/K+ Ratios and Blood Pressure: Findings From a Population-Based Cohort

Background There have been few studies on the relationship between long-term changes in sodium intake and blood pressure. A method of reducing sodium intake in a population that is known for high-sodium intake based on homemade cooking is also needed. Methods and Results Our study was based on a baseline survey of 15 350 individuals aged 18 to 69 years with multistage random sampling and a 3-year salt-restriction campaign across Shandong Province, China. We included 339 individuals from six districts/counties in this cohort study, and the 24-hour urinary sodium-potassium ratio (Na⁺/K⁺) served as an indicator of sodium intake. The average change in ratio was 2.39 (95% CI, 2.17-2.61) from 6.81 (95% CI, 6.41-7.21) at baseline to 4.41 (95% CI, 4.18-4.64) during the resurvey. Following a reduction from low to high quartiles of urinary Na⁺/K⁺ ratio, the average increases were 10.9 (95% CI, 8.9-12.9), 9.2 (95% CI, 6.9-11.5), 6.3 (95% CI, 4.0-8.6), and 5.3 (95% CI, 2.9-7.7) mm Hg for systolic blood pressure (P for trend=0.019) and 3.8 (95% CI, 2.4-5.2), 2.9 (95% CI, 1.7-4.2), 1.6 (95% CI, 0.4-2.8), and -0.3 (95% CI, -1.4-0.8) mm Hg for diastolic blood pressure (P for trend=0.002), respectively. A reduction in salt intake was evident for people using a 2-g salt-restriction spoon for cooking (-3.49 versus -2.22; P=0.027) after adjustment of confounding factors, compared with nonusers. Similar findings were obtained for other salt-restriction spoon-based indicators. Conclusions Our study indicated that using a salt-restriction spoon for cooking was associated with reduced salt intake that led to a blunting of blood pressure deterioration. This finding further supports the salt-restriction spoon-based strategy for people whose primary salt intake is from homemade cooking.