Review of behaviour change interventions to reduce population salt intake

A comprehensive review on cardiovascular disorders development due to salt intake: an emphasis on policy implementation

Excessive salt consumption has been linked with the emergence of hypertension, which further leads to cardiovascular disease development among other medical conditions. This has resulted in leading world institutions such as the WHO coming up with relevant plans to minimize its use. Lower-middle-income countries (LMICs) have greatest burden of noncommunicable diseases (NCDs), with hypertension being a common condition. Reduction of salt intake is a great control measure in minimizing the rise in prevalence of hypertension or cardiovascular diseases. Many countries have agreed and even formulated their salt reduction policies as recommended by the WHO, however, the challenge is widely noted in implementation. Thus, few countries have been able to achieve the global WHO recommended standards of daily salt intake. Salt is the main source of sodium in our diets, which is an essential component responsible for the balance of the extracellular fluid volume but may lead to salt-induced hypertension when used excessively. The achievement of salt reduction is predicated on multiple factors such as knowledge, attitude and practice of the public. Therefore, localizing interventions with strategies such as public media campaigns, reformulation of processed foods (mandatory and voluntary) and front-of-packaging labelling awareness. Some of the reasons for failure in implementation include economic challenges, lack of visionary leadership, stakeholder struggles and poor planning and execution of strategies. This review aims to elaborate on the development of cardiovascular diseases or hypertension due to salt usage and the recent advancement regarding salt reduction policies. Further, we assess the need for proper implementation with the United Kingdom as a case study. In conclusion, most governments have made the right decisions in developing or recommending salt reduction strategies to the food industry. However, more focus is needed to ensure effective implementation of the plans.

Chronic Kidney Disease Risk Awareness, Dietary Intake, and Food Security Among Black Male College Students

OBJECTIVES

Nutrition, lifestyle factors, and awareness of chronic kidney disease (CKD) risk are vital tools for preventing or delaying its development and progression in Black American (BA) males. Few published studies assess awareness of CKD risk in BA male college students despite being at high risk. This study aimed to 1) assess the awareness of CKD risk among BA male college students and 2) identify dietary and lifestyle habits related to CKD risk.

METHODS

This was a cross-sectional online survey utilizing a network sampling technique. Inclusion criteria were self-identification as a BA male and current enrollment in a university. Participants were recruited through publicly available social media sites and emails. The online questionnaire contained demographic, health status, and food security items. Pearson's correlations explored associations between continuous variables; independent samples t-tests compared mean scores of responses between perceived risk of disease groups.

RESULTS

Sixty-seven participants completed the survey. Only 22.4% perceived they were at increased risk for kidney disease, while 49.3% felt at increased risk for developing hypertension (HTN). More respondents (32.8%) also felt at increased risk for developing diabetes than kidney disease. Dietary sodium restriction was reported by 34.3%, while only 14.9% had been advised to do so by a health-care provider. Half of the respondents were deemed food insecure, and 17.86% were categorized as experiencing very low food security.

CONCLUSION

Awareness of CKD risk is low for BA male college students and lags behind awareness of HTN and diabetes risk. There may be a lack of knowledge regarding CKD as a long-term complication of HTN and diabetes. Dietary sodium restriction is marginal, and food security is a significant challenge in this high-risk group. Educational initiatives are needed to increase awareness of CKD risk among BA male college students.

Effect of Low-salt Food Preparation Demonstration Compared to Routine Health Education on Salt Intake and Blood Pressure among Patients with Hypertension Seeking Care from a Selected Urban Primary Health Centre, Puducherry

BACKGROUND

Daily salt consumption is one of the causal factors for hypertension. As per the World Health Organization estimates, 1.28 billion people aged 30-79 years have hypertension worldwide.

AIM

The aim of this study was to assess the effect of a low-salt food preparation demonstration (FPD) in reducing salt intake and blood pressure amongst patients with hypertension.

SUBJECTS AND METHODS

It was a pilot parallel-arm non-randomised controlled trial conducted in Puducherry, South India. Eligible participants were patients with hypertension, aged 30-59 years, seeking care at JIPMER Urban Health Centre and involved in home cooking. The data were collected through house-to-house visits. The intervention group (IG) received a low-salt FPD and routine health education (RHE), whereas RHE was given to the control group (CG). Differences-in-difference analysis was performed to assess the mean changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), daily salt intake and household salt consumption (HSC) across the groups.

RESULTS

Out of 130 patients enrolled, 101 (77.6%) were included in the final analysis. Post-intervention, results were statistically significant in both IG and CG for SBP, DBP and HSC. However, the IG showed greater mean reduction in SBP of 2.1 mmHg (95% confidence interval [CI]: -3.0, -0.92), DBP of 2.2 mmHg (95% CI: -3.0, -1.4) and HSC of 112.7 g/day (95% CI: -169.4, -56.1).

CONCLUSION

Participants who received FPD reported greater reductions in blood pressure compared to those who received only RHE. Further studies with longer follow-up periods may confirm these findings and provide a better understanding of the impact of such interventions.

Long-Term Effects of a Comprehensive Intervention Strategy for Salt Reduction in China: Scale-Up of a Cluster Randomized Controlled Trial

BACKGROUND

Salt intake in China was high and a series of salt reduction measures were accordingly carried out recently. Our study aimed to assess the long-term effect of a scale-up community randomized controlled trial (RCT); Methods: Individuals between the ages of 18 and 75, from six provinces in China, were recruited and randomized into control (n = 1347) and intervention (n = 1346) groups. A one-year salt reduction intervention was first implemented in the intervention group, followed by a two-year scale-up intervention in both groups. The 24 h urine sample, anthropometric measurement, and knowledge, attitude, and practice (KAP) of salt reduction, as well as lifestyle information, were collected at baseline, after one-year RCT (mid-term evaluation, n = 2456), and two-year scale-up intervention (terminal evaluation, n = 2267); Results: Both control (351.82 mg/24 h, p < 0.001) and intervention (192.84 mg/24 h, p = 0.006) groups showed a decrease in 24 h urinary sodium excretion from baseline to terminal evaluation. Except for an increase in 24 h urinary potassium excretion (85.03 mg/24 h, p = 0.004) and a decrease in systolic blood pressure (SBP) (2.95 mm Hg, p < 0.001) in the intervention group at the mid-term assessment, no statistically significant differences in other indicators were found between two groups. The KAP of salt reduction in two groups was gradually improved; Conclusions: After one-year RCT and two-year scale-up, all participants showed a decreasing trend in 24 h urinary sodium excretion and an increase in salt reduction KAP. The community salt reduction intervention package has the potential for broader application across other regions in China.

Assessing Knowledge, Attitudes and Behaviours toward Salt and Sugar Consumption in the Central Division of Fiji

OBJECTIVES

This study aimed to assess salt and sugar-related knowledge, attitudes and behaviours (KAB) of adults in the Central Division of Fiji.

METHODS

A randomised stratified sample of 700 adults were selected. Questions on salt and sugar-related KABs were developed. The survey took place from March to June 2022. For analyses, population and sample weights were applied, and differences between predefined subgroups (sex, age, ethnicity and area) were compared using weighted chi-square tests.

RESULTS

534 adults participated (response rate 76%). Over 80% of participants (82% (95% CI 78.5 to 84.9%)) identified that consuming too much salt or salty sauce can lead to hypertension. More than 90% recognised that consuming too much sugar can lead to diabetes (92.3% (89.7 to 94.3%)). Approximately 80% of participants thought it was somewhat or very important to lower salt and sugar intake in their diet (79.8% (76.1 to 83.0) and 84.2% (80.8 to 87.1%), respectively). However, almost 40% reported adding salt or salty sauces when cooking (37.3% (32.7 to 42.2%)) and 65% (60.6 to 68.5%) adding sugar to drinks daily.

CONCLUSIONS

Despite having positive knowledge and attitudes, many people reported behaviours likely to contribute to excess salt and sugar intake, highlighting the need for interventions that support behaviour change and the creation of healthier food environments.

Salt and sugar intakes of adults in the central division of Fiji: findings from a nutrition survey in 2022

Background

Excess salt and sugar consumption contribute to diseases, such as diabetes and hypertension. This study aimed to estimate salt and sugar intakes and main sources, in a population of adults in the Central Division of Fiji.

Methods

One adult per household was randomly selected to participate (n = 700). Sociodemographic characteristics; blood pressure, weight, and height; a 24-h diet recall; and spot-urine samples were collected, with 24-h urine samples from a sub-sample (n = 200). Sugar intake was estimated from the 24-h diet recalls and salt intake from the spot-urines. 24-hr diet recall was used to identify main sources of salt and sugar by food groups.

Findings

534 adults (response rate 76%, 50% women, mean age 42 years) participated. Salt intake was 8.8 g/day (95% CI, 8.7-9.0), and free sugar intake was 74.1 g/day (67.5-80.7), 16.1% of total energy intake (15.0-17.1%). Main sources of salt were mixed cooked dishes (40.9% (38.2-43.5)), and bread and bakery products (28.7% (26.5-31.0)). Main sources of sugar were table sugars, honey, and related products (24.3% (21.7-26.8)), non-alcoholic beverages (21.4% (18.8-24.0)) and bread and bakery products (18.0% (16.2-19.9)).

Interpretation

Salt and sugar intakes exceeded World Health Organization recommendations in this sample of adults. Given dietary sources were foods high in salt and sugar, along with the addition to food or drinks, interventions focused on behavior along with environmental strategies to encourage healthier choices are needed.

Funding

NHMRC and GACD grant APP1169322.

Technology-supported behavior change interventions for reducing sodium intake in adults: a systematic review and meta-analysis

The effects of technology-supported behavior change interventions for reducing sodium intake on health outcomes in adults are inconclusive. Effective intervention characteristics associated with sodium reduction have yet to be identified. A systematic review and meta-analysis were conducted, searching randomized controlled trials (RCTs) published between January 2000 and April 2023 across 5 databases (PROSPERO: CRD42022357905). Meta-analyses using random-effects models were performed on 24-h urinary sodium (24HUNa), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Subgroup analysis and meta-regression of 24HUNa were performed to identify effective intervention characteristics. Eighteen RCTs involving 3505 participants (51.5% female, mean age 51.6 years) were included. Technology-supported behavior change interventions for reducing sodium intake significantly reduced 24HUNa (mean difference [MD] -0.39 gm/24 h, 95% confidence interval [CI] -0.50 to -0.27; I2 = 24%), SBP (MD -2.67 mmHg, 95% CI -4.06 to -1.29; I2 = 40%), and DBP (MD -1.39 mmHg, 95% CI -2.31 to -0.48; I2 = 31%), compared to control conditions. Interventions delivered more frequently (≤weekly) were associated with a significantly larger effect size in 24HUNa reduction compared to less frequent interventions (>weekly). Other intervention characteristics, such as intervention delivery via instant messaging and participant-family dyad involvement, were associated with larger, albeit non-significant, effect sizes in 24HUNa reduction when compared to other subgroups. Technology-supported behavior change interventions aimed at reducing sodium intake were effective in reducing 24HUNa, SBP, and DBP at post-intervention. Effective intervention characteristics identified in this review should be considered to develop sodium intake reduction interventions and tested in future trials, particularly for its long-term effects.

Behavior Change Interventions to Address Unhealthy Food Consumption: A Scoping Review

High intakes of sodium, sugar, saturated fats, and trans-fats contributed to 187.7 million disability adjusted life years from noncommunicable diseases globally. Understanding of the global evidence on interventions to reduce consumption of various types of unhealthy food across diverse contexts is needed. We conducted a scoping review to examine the existing evidence on behavior change interventions (BCIs) to address unhealthy food consumption. Through a systematic search of 3 databases conducted in December 2022, 2730 records were retrieved, and 145 studies met the eligibility criteria for review. Only 19% of the studies (n = 28) were from low- and middle-income countries. The key target group for most BCIs was adults ≥20 y (n = 79). Interventions were conducted across 7 types of settings: schools (n = 52), digital (n = 30), community (n = 28), home (n = 14), health facility (n = 12), worksite (n = 6), and market (n = 3). There were 4 mutually inclusive intervention types-information, education, and communication (n = 141); food/beverage substitution (n = 10); interactive games (n = 7); and labeling/warnings at point-of-purchase (n = 3). The study outcomes included consumption of sugar-sweetened beverages (n = 74), packaged salty snacks/fast food (n = 61), sweets (n = 43), and saturated fat (n = 41). Drivers of food choice behaviors, such as knowledge, attitudes, and beliefs; motivation and expectancies; and self-efficacy were reported in 43% of studies. On the basis of reported impact of BCIs on study outcomes, more interventions targeted at adults had positive impacts compared with those targeted at children; intervention packages, including multiple information, education, and communication components also reported impacts more often than single informational interventions. Interpretation of the findings was complicated by the lack of comparability in interventions, evaluation designs, outcome measures of unhealthy food consumption, duration of interventions, and study contexts. Future studies should invest in critical yet underrepresented regions, examine behavioral determinants of unhealthy food consumption and the sustainability of behavior change, and conduct further analysis of effectiveness from experimental studies.

Assessing Dietary Salt Intake and Pilot-Testing a Home-Based Intervention to Lower Salt Intake Among Filipino College Students

PURPOSE

To assess the knowledge, attitude, and behaviors related to dietary salt intake and develop a home-based intervention that helps lower salt intake among Filipino college students.

DESIGN

Two-phase program development study utilizing descriptive and quasi-experimental design.

METHODS

Phase 1 determined the knowledge, attitude, and behaviors alongside the frequency of dietary salt intake of a consecutive sample (n = 118). Phase 2 involved the development and pilot-testing of a home-based intervention wherein a random sample (n = 35) selected from Phase 1 joined for pilot-testing. The study was conducted from October - November 2021 and utilized valid and reliable measures to test the knowledge, attitude, and behavior of the participants.

FINDINGS

Initial assessment showed knowledge regarding health risks of high salt intake and positive attitude toward health-promoting behaviors. Post-intervention showed improvement in attitude (p = 0.0004) and behavior (p = 0.001) related to dietary salt intake alongside health literacy (p = 0.036). There was no significant change in knowledge (p = 0.054).

CONCLUSION

The home-based intervention involving the use of health education materials is successful in improving dietary salt intake patterns.

CLINICAL EVIDENCE

Community health nurses may utilize home-based interventions to help develop health-promoting behaviors among young adults.

Effects of Behavioral Interventions for Salt Reduction on Blood Pressure and Urinary Sodium Excretion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Hypertension is a prevalent cardiovascular condition, with excessive sodium intake being a significant risk factor. Various studies have investigated measures to reduce salt intake, including integrated lifestyle interventions and health education. However, the effectiveness of behavioral interventions focused solely on salt reduction remains unclear. This systematic review and meta-analysis aimed to investigate the effects of a behavioral intervention based on salt reduction on blood pressure and urinary sodium excretion. A comprehensive search of the Cochrane Central Register of Controlled Trials, EMBASE, PubMed, and Web of Science was conducted to identify relevant literature. Study and intervention characteristics were extracted for descriptive synthesis, and the quality of the included studies was assessed. A total of 10 studies, comprising 4,667 participants (3,796 adults and 871 children), were included. The interventions involved the provision of salt-restriction spoons or devices, salt-reduction education, self-monitoring devices for urinary sodium, and salt-reduction cooking classes. Meta-analysis results showed that behavioral interventions focused on salt reduction significantly reduced systolic blood pressure (SBP) (-1.17 mmHg; 95% CI, -1.86 to -0.49), diastolic blood pressure (DBP) (-0.58 mmHg; 95% CI, -1.07 to -0.08) and urinary sodium excretion (-21.88 mmol/24 hours; 95% CI, -32.12 to -11.64). These findings suggest that behavioral change interventions centered on salt reduction can effectively lower salt intake levels and decrease blood pressure levels. However, to enhance effectiveness, behavioral interventions for salt reduction should be combined with other salt-reduction strategies.

Melatonin supplementation reduces nighttime blood pressure but does not affect blood pressure reactivity in normotensive adults on a high-sodium diet

High-sodium diets (HSDs) can cause exaggerated increases in blood pressure (BP) during physiological perturbations that cause sympathetic activation, which is related to cardiovascular risk. Melatonin supplementation has been shown to play a role in BP regulation. Our aim was to examine the effects of melatonin taken during an HSD on 24-h BP and BP reactivity during isometric handgrip (IHG) exercise, postexercise ischemia (PEI), and the cold pressor test (CPT). Twenty-two participants (11 men/11 women, 26.5 ± 3.1 yr, BMI: 24.1 ± 1.8 kg/m2, BP: 111 ± 9/67 ± 7 mmHg) were randomized to a 10-day HSD (6,900 mg sodium/day) that was supplemented with either 10 mg/day of melatonin (HSD + MEL) or placebo (HSD + PL). Twenty-four-hour ambulatory BP monitoring was assessed starting on day 9. Mean arterial pressure (MAP) was quantified during the last 30 s of IHG at 40% of maximal voluntary contraction and CPT, and during 3 min of PEI. Melatonin did not change 24-h MAP (HSD + PL: 83 ± 6 mmHg; HSD + MEL: 82 ± 5 mmHg; P = 0.23) but decreased nighttime peripheral (HSD + PL: 105 ± 10 mmHg; HSD + MEL: 100 ± 10 mmHg; P = 0.01) and central systolic BP (HSD + PL: 97 ± 9 mmHg; HSD + MEL: 93 ± 8 mmHg; P = 0.04) on the HSD compared with the HSD + PL. The absolute and percent change in MAP during IHG was not different between conditions (all P > 0.05). In conclusion, melatonin supplementation did not alter BP reactivity to the perturbations tested on an HSD but may be beneficial in lowering BP in young healthy normotensive adults.NEW & NOTEWORTHY BP reactivity was assessed during isometric handgrip (IHG) exercise, postexercise ischemia (PEI), and the cold pressor test (CPT) after 10 days of a high-sodium diet with and without melatonin supplementation. Melatonin did not alter BP reactivity in healthy normotensive men and women. However, melatonin did decrease nighttime peripheral and central systolic BP, suggesting it may be beneficial in lowering BP even in those with a normal BP.

Effective and Scalable Interventions to Reduce Sodium Intake: a Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

High-sodium intake is a main risk factor for increased blood pressure and cardiovascular disease, the leading cause of death worldwide. Reducing sodium intake at the population level is one of the most cost-effective strategies to address this. The aim of the present systematic review and meta-analysis are to examine data from recent studies that measure the effectiveness and scalability of interventions aimed at reducing sodium intake at both the population and individual level.

RECENT FINDINGS

Worldwide, sodium intake is higher than the World Health Organization recommendations. Structural interventions such as mandatory reformulation of foods, food labeling, taxes or subsidies, and communication campaigns have shown to be the most effective in reducing the population's sodium consumption. Interventions in education, particularly those that use a social marketing framework with short duration, food reformulation, and combined strategies, have the potential to decrease sodium intake.

Reducing Dietary Sodium Intake among Young Adults in Ghana: A Call to Action

The positive association between excessive dietary sodium intake, hypertension, and cardiovascular disease (CVD) has been widely investigated in observational studies and clinical trials. Reducing sodium intake is a proven strategy to prevent hypertension and the onset of CVD, a major cause of morbidity and mortality globally. Africa has the youngest population globally, which is key to the continent's sustainable development. However, in Africa, the epidemics of hypertension and CVD negatively impact life expectancy and economic growth. Ghana, like other African countries, is no exception. The factors contributing to the increasing burden of CVD and excessive sodium consumption are multi-faceted and multi-level, including individual lifestyle, neighborhood and built environments, and socio-economic and health policies. Thus, the implementation of evidence-based interventions such as the World Health Organization Best Buys that target the multi-level determinants of sodium consumption is urgently needed in Ghana and other African countries. The aim of this commentary is to highlight factors that contribute to excessive sodium consumption. Second, the commentary will showcase lessons of successful implementation of sodium reduction interventions in other countries. Such lessons may help avert CVD in young adults in Ghana and Africa.

Effectiveness of a Health Education Program in Hypertensive Patients with Dyslipidemia and/or Microalbuminuria: A Quasi-Experimental Study in Vinh Long Province, Vietnam

INTRODUCTION

Hypertension, a major health concern, is associated with significant mortality and disease burden worldwide, including Vietnam. Comprehensive interventions targeting medication, lifestyle modifications, dyslipidemia (DLP), and microalbuminuria (MAU) are vital for effective hypertension management and reducing the risk of cardiovascular disease complications (CDV). While medication interventions have proven efficacy, the evidence regarding the effectiveness of community-based health education interventions in managing DLP and MAU is limited. Therefore, this study aims to evaluate the effectiveness of community health education interventions in reducing hypertension risk factors and achieving hypertension management objectives, as well as managing DLP and MAU among hypertension patients.

METHODS

A quasi-experimental study was conducted on 330 hypertensive patients with dyslipidemia (DLP) and/or microalbuminuria (MAU) who were divided into a control group (n = 164) and an intervention group (n = 166). The control group received standard national hypertension management, while the intervention group received additional intensive health education provided by trained volunteers. The effectiveness of the intervention was assessed by comparing outcomes such as lifestyle factors, BMI control, treatment adherence, hypertension control, and DLP and MAU status between the two groups before and after a two-year intervention period.

RESULTS

The health education intervention resulted in significant reductions in dietary risk factors, specifically in fruit and vegetable consumption (p < 0.001). There was a lower prevalence of high salt intake in the intervention group compared to the control group (p = 0.002), while no significant differences were observed in other dietary factors. Smoking habits and low physical activity significantly decreased in the intervention group, with a notable disparity in physical activity proportions (p < 0.001). Both groups showed significant improvements in achieving hypertension management targets, with the intervention group demonstrating superior outcomes. The intervention was effective in reducing the prevalence of risk factors, particularly treatment non-adherence, blood pressure control, and low physical activity. Additionally, the intervention group had a higher likelihood of achieving DLP and MAU control compared to the control group.

CONCLUSIONS

This study underscored the additional positive impact of incorporating health education by non-professional educators in achieving favorable outcomes, including better control of BMI, blood pressure, medication adherence, and management of dyslipidemia (DLP) and microalbuminuria (MAU). Further research is warranted to fully explore the potential of health education in primary healthcare settings and maximize its effectiveness.

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.

Motivating non-physician health workers to reduce the behavioral risk factors of non-communicable diseases in the community: a field trial study

BACKGROUND

Non-communicable diseases behavioral risk factors can be improved if effective interventions are designed considering the health system's capabilities and local resources. This study evaluated the effectiveness of interventions that aimed at increasing non-physician community health workers' motivation in reducing non-communicable diseases behavioral risk factors in the community.

METHODS

A randomized field trial study was conducted in 32 community health centers in 4 Iranian districts after a baseline population survey on the status of NCDs of 30-70-year-old individuals (n = 1225). The interventions were performed to improve insufficient physical activity, insufficient fruit consumption, insufficient vegetable consumption, high salt intake, and tobacco use. Four intervention packages were implemented in 24 community health centers; the other 8 centers were used as control groups. The non-physician community health workers performed the interventions. The packages additively included goal-setting, evidence-based education, operational planning, and incentive payments. A second survey was conducted 1 year after the start of the interventions to identify the effects on an independent random sample of 30-70-year-old individuals (n = 1221). Difference-in-difference method was used to quantify the interventions' effects.

RESULTS

The average age of participants in both surveys was about 49 years. Also, about half of the participants were female, and about 43% were illiterate or had a primary school education. The interventions had statistically significant effects only on decreasing the prevalence of insufficient physical activity. The package with all the intervention components decreased the odds of insufficient physical activity to 0.24 (95% CI, 0.08, 0.72). The package with operational planning but no performance-based financing did not change the odds of insufficient physical activity.

CONCLUSIONS

This study highlighted the importance of components, design, and implementation details of interventions intended to reduce NCDs behavioral risk factors. Some risk factors, such as insufficient physical activity, seem more easily modifiable with limited low-cost interventions in a one-year horizon. However, risk factors related to healthy food consumption and tobacco use need more extensive interventions.

TRIAL REGISTRATION

This trial was registered on the Iranian Registry of Clinical Trials (IRCT20081205001488N2) on 3 June 2018 ( https://en.irct.ir/trial/774 ).

Protocol for the implementation and evaluation of a community-based behavior change intervention to reduce dietary salt intake in India

Excess dietary salt intake is well established as a leading cause of high blood pressure and associated cardiovascular disease, yet current salt intake in India is nearly 11 g per day, more than twice World Health Organization maximum recommended intake of 5 g per day. Although dietary survey data from India indicate that the main sources of dietary salt are salt added during cooking at home, and few salt reduction efforts have focused on interventions at the household level. As a result, there is little evidence of the effectiveness of behavior change programs to reduce salt intake at the household level. The study aims to develop and implement a community based behavioral change intervention to reduce salt intake delivered by front line community-based health volunteers; and evaluate the preliminary effectiveness, acceptability, and feasibility of delivering a salt reduction behavior change program and potential to support future scale-up. The study is a pre-post intervention design, and outcomes will be evaluated from a random sample of 1500 participants from 28 villages in two primary health centers in Siddipet, Telangana. Primary outcome is change in salt-related KAB (knowledge, attitude, and behavior) score, and secondary outcomes will be changes in salt intake measured by 24 h urinary sodium excretion and change in scores using the subscales of the COM-B ("capability", "opportunity", "motivation" and "behavior") tool. Findings will be used to inform future public health policies to support implementation of scalable community-based interventions to reduce salt intake and control hypertension, the leading-cause of death in India.

Effect of salt reduction interventions in lowering blood pressure: A comprehensive systematic review and meta-analysis of controlled clinical trials

BACKGROUND

Excessive salt intake results in hypertension (HTN), which is a major risk factor for cardiovascular disease (CVD). This review and meta-analysis aimed to evaluate the effect of salt reduction interventions on systolic blood pressure (SBP) and diastolic blood pressure (DBP).

METHODS

Studies were identified via systematic searches of the databases, including PubMed, Embase, Scopus, and Web of Science. All the studies examining the effectiveness of salt reduction interventions on blood pressure (BP), regardless of age, sex, and HTN status, were included in the systematic review, and eligible studies were used in the meta-analysis. A random-effect model was applied for quantitative data synthesis.

RESULTS

A total of 50 trials extracted from 40 articles (21 trials on nutrition education,10 on self-help materials,17 on salt substitutes, and 2 on food reformulation) were included in the systematic review. The pooled results of 44 eligible trials showed that salt substitution and nutrition education interventions had significant effects on both SBP (WMD: -7.44 mmHg, P<0.001 and WMD: -2.75 mmHg, P<0.001, respectively), and DBP (WMD: -3.77 mmHg, P<0.001 and WMD: -2.11 mmHg, P<0.001, respectively). Furthermore, using self-help materials led to a significant reduction in SBP among subjects aged 25-60 years (WMD: -2.60 mmHg, P = 0.008); it also decreased both SBP and DBP among those who were hypertensive (WMD: -3.87 mmHg, P = 0.003 and WMD: -2.91 mmHg, P<0.001, respectively).

CONCLUSION

Our results supported that salt substitution and nutrition education are effective nutrition strategies to lower BP. It seems that multi-component approaches could be more effective in improving BP status. However, further trials are required.

Implementation of non-pharmacological interventions for the treatment of hypertension in primary care: a narrative review of effectiveness, cost-effectiveness, barriers, and facilitators

BACKGROUND

The current guidelines for the prevention, detection, evaluation, and management of hypertension recommend six types of non-pharmacological interventions: alcohol reduction, salt intake reduction, increased potassium intake, physical activity, weight loss, and heart-healthy diets. However, the non-pharmacological interventions are still not widely used in primary care. In this paper, we, therefore, reviewed and summarised the evidence on the effectiveness, cost-effectiveness, barriers, and facilitators of non-pharmacological interventions for the treatment of hypertension in primary care.

METHODS

A thorough literature search was conducted in Embase, Google Scholar, and PubMed databases, to identify the most recent reviews or, in their absence, primary studies on alcohol reduction, salt intake reduction, potassium supplementation, physical activity, weight reduction, heart-healthy diets, and other non-pharmacological interventions for the treatment of hypertension in primary care.

RESULTS

Alcohol reduction is a non-pharmacological intervention for the treatment of hypertension in primary care with proven effectiveness, feasibility, and acceptability. Interventions for sodium intake reduction, physical activity, and weight reduction are effective but there is insufficient evidence regarding their feasibility and acceptability in primary care settings. Evidence on the effectiveness of potassium intake and heart-healthy diets is limited and inconsistent. There is a lack of evidence on the cost-effectiveness of non-pharmacological interventions in the treatment of hypertension. The most common barriers to deliver such interventions related to healthcare providers include a lack of time, knowledge, self-confidence, resources, clear guidelines, and financial incentives. The most common barriers related to patients include a lack of motivation and educational resources. Less evidence is available on facilitators of implementing non-pharmacological interventions in primary care. Besides, facilitators differed by different types of interventions.

CONCLUSIONS

Available evidence suggests that more pragmatic, clinically feasible, and logistically simple interventions are required for sodium intake reduction, physical activity, and weight reduction in primary care settings. Future studies should provide further evidence on the effectiveness of weight control, potassium intake, and heart-healthy diets. More research is also needed on cost-effectiveness and facilitators of all types of effective non-pharmacological interventions for the treatment of hypertension in primary care.

Salt-related practices and its association with 24-hour urinary sodium excretion in an Uruguayan population cohort

Objectives.

To evaluate the association between knowledge, attitudes, and behavior (KAB) towards sodium use and sodium intake measured by 24-hour urinary collection in an adult cohort from Uruguay (Genotype Phenotype and Environment of Hypertension Study, GEFA-HT-UY).

Methods.

In a cross-sectional study (n = 159), a single 24-hour urinary sample, participants' physical, biochemical and blood pressure measurements and questionnaire data were collected. The association between KAB and 24-hour urinary sodium excretion was assessed using general linear models.

Results.

Mean age of participants was 49.8±15.5 years, 67.9% were women, and mean 24-hour urinary sodium excretion was 3.6±1.7 g/day. Although 90.6% of participants exceeded the maximum recommended intake as indicated by urinary sodium excretion, more than half misperceived their actual intake, reporting consuming “the right amount.” Almost three-quarters of the participants reported being concerned about the amount of sodium in their diet, but only 52.8% reported taking action to control it. Lack of procedural knowledge was observed. There was no association between KAB and sodium use and intake assessed by 24-hour urinary sodium excretion.

Conclusions.

The lack of association between KAB towards the use of sodium and intake measured by 24-hour urinary excretion reflects the need to support people with opportunities and motivations to reduce sodium consumption. Structural actions to promote an adequate food environment, such as the effective implementation of the front-of-package nutrition labeling in Uruguay, are positive steps.

A mobile phone application intervention to promote healthy salt intake among adults: Protocol for a randomized controlled study (Preprint)

Background

There is sound evidence associating high salt intake and a greater risk of cardiovascular and noncardiovascular diseases. High salt intake has been observed in several populations worldwide. Therefore, promoting healthier salt consumption has been encouraged as a low-cost strategy to reduce this risk factor. However, these strategies need to be sound, built on theoretical and methodological bases, and consider the target population’s context.

Objective

This protocol aims to describe a mobile phone app intervention to promote healthy salt intake among adults.

Methods

This is an experimental and longitudinal study protocol conducted in three modules. Module 1 refers to the planning of the intervention based on the Behaviour Change Wheel framework. Module 2 is the development of the mobile phone app intervention based on the date of module 1. In module 3, the intervention will be evaluated using a randomized controlled study, with three steps of data collection in a 2-month follow-up in a sample of 86 adults (43 participants for each group: the control group and intervention group) recruited from the primary health care centers of a Brazilian town. The discretionary salt intake questionnaire will assess salt consumption, the app usability will be assessed using the System Usability Scale, and psychosocial variables (habit, intention, and self-efficacy) will also be measured.

Results

Recruitment began in October 2021, and the follow-up will end in August 2022. The results of this study are expected to be published in 2023.

Conclusions

Results from this study will help people to control salt intake when cooking at home, will stimulate self-care, will work as an alternative or supportive method in the relationship between health care professionals and patients, and will contribute to implementing the app intervention to promote healthy salt intake on a large scale.

Trial Registration

The Brazilian Clinical Trials Registry RBR-4s8qyyq; https://ensaiosclinicos.gov.br/rg/RBR-4s8qyyq

International Registered Report Identifier (IRRID)

DERR1-10.2196/37853

Reducing salt intake: a systematic review and meta-analysis of behavior change interventions in adults

CONTEXT

Prolonged high salt (sodium) intake can increase the risk of hypertension and cardiovascular disease. Behavioral interventions may help reduce sodium intake at the population level.

OBJECTIVE

The effectiveness of behavior change interventions to reduce sodium intake in adults was investigated in this systematic review and meta-analysis.

DATA SOURCE

The PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and EMBASE databases were searched.

DATA EXTRACTION

Narrative synthesis and random-effects meta-analyses were used to determine intervention efficacy. A total of 61 trials (46 controlled trials and 15 quasi-experimental studies) were included.

RESULTS

Behavior change interventions resulted in significant improvements in salt consumption behavior (eg, decrease in purchase of salty foods; increase in use of salt substitutes), leading to reductions in sodium intake as measured by urinary sodium in 32 trials (N = 7840 participants; mean difference, -486.19 mg/d [95%CI, -669.44 to -302.95]; P < 0.001; I2 = 92%) and dietary sodium in 19 trials (N = 3750 participants; mean difference -399.86 mg/d [95%CI, -581.51 to -218.20]; P < 0.001; I2 = 96%), equivalent to a reduction of >1 g of salt intake daily. Effects were not significantly different based on baseline sodium intakes, blood pressure status, disease status, the use of behavior change theories, or the main method of intervention delivery (ie, online vs face-to-face).

CONCLUSION

Behavior change interventions are effective at improving salt consumption practices and appear to reduce salt intake by >1 g/d.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020185639.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam

OBJECTIVE

To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC).

DESIGN

Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy.

SETTING

Argentina, Mongolia, South Africa and Vietnam.

PARTICIPANTS

Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes.

RESULTS

Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts.

CONCLUSIONS

Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

Ischemic Heart Disease in Nigeria: Exploring the Challenges, Current Status, and Impact of Lifestyle Interventions on Its Primary Healthcare System

The burden of ischemic heart disease in Nigeria calls for an evidence-based, innovative, and interdisciplinary approach towards decreasing health inequalities resulting from individual lifestyle and poor socioeconomic status in order to uphold the holistic health of individuals to achieve global sustainability and health equity. The poor diagnosis and management of ischemic heart disease in Nigeria contributes to the inadequate knowledge of its prognosis among individuals, which often results in a decreased ability to seek help and self-care. Hence, current policies aimed at altering lifestyle behaviour to minimize exposure to cardiovascular risk factors may be less suitable for Nigeria's diverse culture. Mitigating the burden of ischemic heart disease through the equitable access to health services and respect for the autonomy and beliefs of individuals in view of achieving Universal Health Coverage (UHC) requires comprehensive measures to accommodate, as much as possible, every individual, notwithstanding their values and socioeconomic status.

Interventions That Successfully Reduced Adults Salt Intake-A Systematic Review

Background: Adequate sodium intake is important for lowering blood pressure and thus reducing cardiovascular disease risk and other complications. The aim of this review is to identify recent interventions around the world that have been successful in reducing salt intake. Methods: A search in the PubMed, Web of Science and Scopus databases was performed. We include studies published in the last 10 years; randomized trials, pilot intervention without a control arm or experimental study; adult participants; and interventions that successfully reduced salt intake. Study quality was assessed. Results: We included 21 studies, 16 randomized intervention trials and five nonrandomized intervention studies. Eleven interventions described health and nutritional education, seven interventions described nutritional education plus other interventions, and three studies used salt meters to reduce sodium intake. Conclusion: Health and nutritional education, nutritional education plus other interventions and estimates of salt intake showed success in the reduction of salt consumption. There is no evidence that one type of intervention analyzed is more effective than other in reducing salt consumption, so we must analyze each in which individuals or subpopulations will have the intervention performed and use the most suitable approaches to lead to better results.

Preventing Multimorbidity with Lifestyle Interventions in Sub-Saharan Africa: A New Challenge for Public Health in Low and Middle-Income Countries

Objectives: Low and Middle-Income Countries are experiencing a fast-paced epidemiological rise in clusters of non-communicable diseases such as diabetes and cardiovascular disease, forming an imminent rise in multimorbidity. However, preventing multimorbidity has received little attention in LMICs, especially in Sub-Saharan African Countries. Methods: Narrative review which scoped the most recent evidence in LMICs about multimorbidity determinants and appropriated them for potential multimorbidity prevention strategies. Results: MMD in LMICs is affected by several determinants including increased age, female sex, environment, lower socio-economic status, obesity, and lifestyle behaviours, especially poor nutrition, and physical inactivity. Multimorbidity public health interventions in LMICs, especially in Sub-Saharan Africa are currently impeded by local and regional economic disparity, underdeveloped healthcare systems, and concurrent prevalence of communicable and non-communicable diseases. However, lifestyle interventions that are targeted towards preventing highly prevalent multimorbidity clusters, especially hypertension, diabetes, and cardiovascular disease, can provide early prevention of multimorbidity, especially within Sub-Saharan African countries with emerging economies and socio-economic disparity. Conclusion: Future public health initiatives should consider targeted lifestyle interventions and appropriate policies and guidelines in preventing multimorbidity in LMICs.

High Adherence to Mediterranean Diet Is Not Associated with an Improved Sodium and Potassium Intake

Prevention and control of hypertension and cerebro-cardiovascular diseases are associated with adequate sodium and potassium intake and adherence to a Mediterranean dietary pattern. The aim of this study was to assess the association between adherence to a Mediterranean diet (MD) and the excretion of sodium and potassium as surrogate measures of intake. This is a cross-sectional analysis as part of a larger study (the iMC SALT randomized controlled trial) among workers of a public university. A food frequency questionnaire was used to assess the adherence to MD, using the alternative Mediterranean diet (aMED) score; sodium and potassium excretions were estimated by 24-h urine collections. Sociodemographic and other lifestyle characteristics were also obtained. The associations between the adherence to MD and Na and K excretion were calculated by logistic regression, adjusting for confounding variables. From the 109 selected participants, seven were excluded considering urine screening and completeness criteria, leaving a final sample of 102 subjects (48% male, average age 47 years). Mean sodium and potassium excretion were 3216 mg/day and 2646 mg/day, respectively. Sodium and potassium excretion were significantly higher in men, but no differences were found according to different levels of MD adherence. In logistic regression analysis, sodium, potassium, and sodium-to-potassium ratio urinary excretion tertiles were not associated with MD adherence (low/moderate versus high), even after adjustment for confounding variables. A high adherence to MD was thus not associated with a different level of sodium and potassium intake.

Política mundial de yodación de sal: desafíos

Objetivo Identificar los desafíos que conlleva la implementación de la política mundial de yodación de sal para el consumo humano. Métodos Se realizó una revisión de la literatura publicada entre el año 2000 y 2021 en PubMed, con los términos MeSH yodo, política pública, cloruro de sodio y los términos complementarios yodo/deficiencia, exceso. Se obtuvieron 141 artículos y se revisaron 50 aplicando como criterio de inclusión el abordaje de la implementación de la política de yodación. Resultados Se identificaron siete desafíos: sostenibilidad de la política, eliminar la brecha entre la explotación y la comercialización de la sal, prevenir la fortificación indiscriminada de los alimentos, promover la educación sobre la ingesta de sal yodada, controlar la ingesta excesiva de yodo, equilibrar la ingesta óptima de yodo con la reducción del consumo de cloruro de sodio y producir suficiente información oficial sobre la política. Conclusión La yodación universal de la sal es una política que requiere mayor sensibilidad a las situaciones locales de cada país para mitigar efectivamente el problema de salud pública de los desórdenes por deficiencia y exceso en la ingesta de yodo alrededor del mundo.

An evaluation of the Victorian Salt Reduction Partnership's advocacy strategy for policy change

BACKGROUND

Public health advocacy strategies facilitate policy change by bringing key health issues to the forefront of public and political discourse, influencing decision-makers and public opinion, and increasing policy demand. The Victorian Salt Reduction Partnership (VSRP) was established in 2014 in response to inadequate government action to improve population diets in Australia. This study aimed to evaluate the success of the VSRP's advocacy strategy in achieving policy change.

METHODS

Documentation of VSRP activities and outputs were collected, and semi-structured interviews conducted as part of a comprehensive process evaluation. For this study, the Kotter Plus 10-step public health advocacy evaluation framework was used to guide data extraction, analysis, and synthesis.

RESULTS

A sense of urgency for salt reduction was generated by producing evidence and outlining the potential impact of a state-based salt reduction programme. This enabled the creation of a coalition with diverse skills and expertise, which facilitated the development of an innovative and collaborative advocacy action plan. A clear change vision was established, but communication of the vision to decision-makers was lacking, which reduced the impact of the programme as decision-makers were not provided with a clear incentive for policy change. As a result, while programme outputs were achieved, these did not translate to achieving broader strategic goals during a limited-term intervention in a political climate unconcerned with salt.

CONCLUSIONS

The Kotter Plus 10-step framework was a useful tool for evaluating the success of the VSRP advocacy strategy. The framework enabled the identification of key strengths, including the creation of the guiding coalition, and areas where efforts could be improved in future similar strategies, such as effective communication within partnerships and to decision-makers, to better influence policy and improve public health impact.

Strengthening Knowledge to Practice on Effective Salt Reduction Interventions in Low- and Middle-Income Countries

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.

Sodium intake, health implications, and the role of population-level strategies

Evidence to date suggests that high sodium intake affects health adversely, yet the role of a population-level strategy to reduce sodium intake is often contested. This review focuses on current available evidence on regional sodium intake levels, health implications of sodium intake, and population-level strategies implemented worldwide. The limitations in evidence, the difficulties in implementing population-wide strategies to reduce sodium intake, and the need for such strategies are critically reviewed. Evidence clearly shows that sodium has an adverse effect on blood pressure, cardiovascular disease, and mortality. However, whether reduced sodium intake benefits all individuals or only hypertensive individuals is still unclear. Methodological issues and publication bias in current evidence are other matters of concern in sodium-related research. While it is essential to continue working toward the World Health Organization's target of 30% reduction in sodium intake, due consideration should be given to improving the quality of research, reducing bias in publications, and reviewing evidence more critically.

Development of an Intervention to Promote Physical Activity and Reduce Dietary Sodium Intake for Preventing Hypertension and Chronic Disease in Filipino Americans

Hypertension is a common chronic health condition affecting Filipino Americans. This pilot study examined the feasibility of addressing high rates of hypertension among Filipino Americans through the implementation of a culturally tailored education intervention. Filipino Americans living in the Greater Philadelphia Area were recruited through community-based organizations for participation and were engaged using a community-based participatory research (CBPR) framework. The study included pre- and post-intervention blood pressure measurements, self-reported body mass index, and questionnaires about physical activity and salt intake. The intervention to promote physical activity and reduce salt intake was conducted through two educational sessions and was accompanied by follow-up at 3 months and by the collection of urine samples for 24-h urinary sodium intake biomarker analysis. Following intervention, a non-statistically significant decrease in urine sodium was observed in both the intervention and the control groups. For systolic blood pressure, a reduction of 12.6 mmHg and an increase in 5.3 mmHg was observed in the intervention and control groups, respectively. Diastolic pressure decreased 3.8 mmHg for the intervention group and increased 5.6 mmHg among controls. The culturally tailored education intervention reported here represents a promising tool for blood pressure reduction in high-risk ethnic populations. The methods used were effective for the recruitment and retention of ethnic minorities in a community-based setting.

Household Cooking and Eating out: Food Practices and Perceptions of Salt/Sodium Consumption in Costa Rica

This research aims to study the food practices and perceptions related to excessive consumption of salt/sodium when cooking and eating outside the home in a study population representing the wide intergenerational and sociocultural diversity of Costa Rica. Key communities from around the country, cultural experts, and key informants were selected. Four qualitative research techniques were applied. Data was systematized based on the Social Ecological Model. Women are generally in charge of cooking and family food purchases. Salt is perceived as a basic ingredient, used in small amounts that can be reduced-but not eliminated-when cooking. Changes in food preparations and emotions associated with the consumption of homemade food with salt were identified. The population likes to eat out, where the establishments selected depend mainly on age group and income. Beyond cultural and geographical differences, age aspects are suggested as being the main differentiators, in terms of use of salt, seasonings, and condiments in the preparation of food at home, the recipes prepared, and the selection of establishments in which to eat out. The deeply rooted values and meanings associated with salt in food indicate that the implementation of salt reduction strategies in Costa Rica is challenging.

Measuring Food Literacy: Progressing the Development of an International Food Literacy Survey Using a Content Validity Study

Background: The term "food literacy" is increasingly used to describe the knowledge, skills and behaviours needed to meet food needs. The aim of this research was to determine content validity for an International Food Literacy Survey. Methods: The literature was searched for existing items to form an item pool to measure the eleven components of food literacy. Expert consensus was investigated through two related online surveys. Round 1 participants were researchers who had been involved in the development of a food literacy measure (n = 18). Round 2 participants were authors of papers who had used the term (n = 85). Level of agreement was determined quantitatively using the Content Validity Index and compared to open ended qualitative comments. Results: Consensus was achieved on 119 items. Components varied in the ease with which existing validated items could be found and the number of items achieving consensus. Items related to food prepared within the home were more likely to achieve consensus. Additional issues included limited shared understanding of the scope of the term, the validity of items varying according to context and a limited health focus. Conclusions: This study provides a valuable basis upon which to progress the development of a measure.

A Systematic Scoping Review of Media Campaigns to Develop a Typology to Evaluate Their Collective Impact on Promoting Healthy Hydration Behaviors and Reducing Sugary Beverage Health Risks

Interventions to discourage sugary beverages and encourage water consumption have produced modest and unsustainable behavioral changes to reduce obesity and noncommunicable disease risks. This systematic scoping review examined media campaigns to develop a typology to support healthy hydration nonalcoholic beverage behaviors. Our three-step methodology included the following: (1) review and summarize expert-recommended healthy beverage guidelines; (2) review six English-language electronic databases guided by PRISMA to describe existing campaign types by issue, goal and underlying theory; and (3) develop a media campaign typology to support policies, systems and environments to encourage healthy hydration behaviors. Results showed no international consensus for healthy beverage guidelines, though we describe expert-recommended healthy beverage guidelines for the United States. Of 909 records identified, we included 24 articles describing distinct media campaigns and nine sources that defined models, schemes or taxonomies. The final media campaign typology included: (1) corporate advertising, marketing or entertainment; (2) corporate social responsibility, public relations/cause marketing; (3) social marketing; (4) public information, awareness, education/ health promotion; (5) media advocacy/countermarketing; and (6) political or public policy. This proof-of-concept media campaign typology can be used to evaluate their collective impact and support for a social change movement to reduce sugary beverage health risks and to encourage healthy hydration behaviors.

From Salt to Stroke-Evaluation of a Media Campaign for Sodium Reduction in Philadelphia

Excess dietary sodium contributes to the burden of chronic disease, including cardiovascular disease and stroke. Media-based health education campaigns are one strategy to raise awareness among populations at greater risk for stroke, including African Americans. During 2014–2015, the Philadelphia Department of Public Health conducted a health education campaign using radio, print news, and transit ads, to promote awareness of the link between dietary sodium, hypertension and stroke, and encourage reduced consumption of high sodium foods. Using a repeated cross-sectional design, street intercept surveys were conducted with ~400 Philadelphia residents representing the campaign's priority audience (African Americans ages 35–55) before and 6–13 weeks after the campaign, to evaluate both process (campaign exposure) and impact (recall of key health messages). Thirty percent of post-campaign respondents reported familiarity with one of the most engaging radio spots, and 17% provided accurate unaided recall of its key content, with greater recall among older respondents and frequent radio listeners. Forty-one percent of post-campaign respondents named stroke as a consequence of excess salt consumption, compared to only 17% of pre-campaign respondents, with greater awareness of the salt-stroke connection among those accurately recalling the radio spot from the campaign. Results suggest that priority populations for sodium reduction can be effectively reached through radio and transit campaigns. From a pragmatic perspective, street intercept surveys may offer one low resource strategy for evaluating public health education campaigns conducted by local health departments, especially among urban populations.

Developing and Testing an Instrument to Measure the Factors Affecting the Salt Restriction Behaviors among Women

Background: High salt intake is considered as one of the most important causes of hypertension and cardiovascular diseases. Measuring and identifying factors contributing to people's salt intake behaviors is important to evaluate effectiveness of interventions focusing on salt reduction behaviors. The purpose of this study was to develop and test a new theory of planned behavior (TPB)- based instrument to measure factors influencing three different salt intake behaviors (adding salt during cooking, at the table, purchasing salty food) among women.

Study design: A mixed-method study.

Methods: After the face and content validity of developed instrument were established, a representative sample of women (N= 300, age (SD):42.82(12.10)) were recruited to assess the construct validity using Partial Least Square confirmatory factor analysis. Coefficient alpha and composite reliability (CR) were used to establish reliability of instrument. The content validity index (CVI) and content validity ratio (CVR) were used to assess the content validity.

Results: Assessing validity and reliability of instrument led to 56-item questionnaire. CVI was more than 0.70 and CVR more than 0.56. Internal consistency as assessed by Cronbach's alpha was acceptable. Convergent and discriminant validity were established. The GOF index for behavior one was 0.250, for behavior two was 0.414 and behavior three was 0.374. The results of confirmatory factor analysis indicate that TPB model has an acceptable fit with data.

Conclusion: Our instrument provides a validated and reliable tool for assessing different aspects of salt intake behaviors in women to evaluate effectiveness of interventions focusing on salt reduction behaviors.

Unpack the Salt: an evaluation of the Victorian Salt Reduction Partnership's media advocacy activities to highlight the salt content of different foods

BACKGROUND

Australians are consuming almost double the recommended maximum salt intake. The Victorian Salt Reduction Partnership was established to coordinate efforts to reduce salt intake in the state of Victoria. As part of an intervention strategy, media advocacy strategies were used to raise public awareness and stimulate industry and government action on salt reduction. This study aimed to evaluate the Victorian Salt Reduction Partnership's media advocacy activities by determining the extent to which activities contributed to the overall strategy aims and the effectiveness of the activities in gaining media and industry engagement.

METHODS

A framework for evaluating media advocacy strategies used in complex public health interventions was used to guide this evaluation. Media advocacy activities were monitored and documented throughout the intervention period. A content analysis of media release press statements was performed. Indicators of media coverage (media items, cumulative audience reach, advertising space rate) and food industry engagement (number of meetings, number and type of follow up actions) were tracked.

RESULTS

Six media releases were issued between March 2017 and November 2018 on different processed food categories including breads, cooking sauces, ready meals, dips and crackers, processed meats and Asian-style sauces. Three main themes were identified in the qualitative analysis of the press statements: general information on salt and health, salt levels in foods, and calls to action for consumers, industry and/or government. These themes were aligned with the overall intervention strategy. Media items (print and online news, radio and TV) generated by each release ranged from 36 to 274, and cumulative audience reach (opportunities to see) ranged from 2.3 to 7.5 million Australians per release. One to three food manufacturers were met with per media release.

CONCLUSIONS

Disseminating sodium-monitoring data through media releases can be used as a tool to gain access to the media and reach consumers with salt reduction messages, and to engage food manufacturers in discussions about salt reduction. Characteristics of media advocacy activities, including alignment with the overall strategy, and external factors outside the of control of the program implementers, can influence media and industry engagement. When planning future nutrition interventions that include media advocacy activities, internal and external factors impacting outcomes, should be considered, documented and evaluated.

Is a Consumer Perception of Salt Modification a Sensory or a Behavioural Phenomenon? Insights from a Bread Study

Salt plays a major role in food manufacturing and affects the technological and sensory properties of foods. At the same time, high dietary salt intake increases the risk of cardiovascular diseases and represents a considerable public health concern. In many populations, bread is a major contributor to salt intake and is therefore targeted by health policies recommending salt reduction reformulations. However, producers are often reluctant to reduce salt content due to fears of potential negative effects on consumer acceptability and drops in sales. The present work aims to assess the effect of salt content on consumers’ hedonic liking and perception of saltiness intensity, as well as the interaction of these two. The study was conducted using two market-leading bread types (white and multigrain) and bread samples with the national average (reference), reduced (−15%) and increased (+10%) salt levels. A sensory evaluation study (n = 200) was done including a questionnaire on attitudes and behaviour regarding bread and salt, enabling the exploration of individual differences in reactions to modified levels of salt content. The latter only affected hedonic liking for the multigrain sample with 15% salt reduction but not for others, which discloses the importance of the bread matrix; and it did not affect the perception of saltiness intensity. Penalty analysis revealed that perceived non-optimal saltiness results in significantly penalised hedonic liking scores. Segmentation based on perceived saltiness disclosed the explanatory importance of underlying consumer behaviour dimensions which should be considered in designing bread reformulations.

Curtis C, Frieden TR, Cobb LK. Priority Actions to Advance Population Sodium Reduction

High sodium intake is estimated to cause approximately 3 million deaths per year worldwide. The estimated average sodium intake of 3.95 g/day far exceeds the recommended intake. Population sodium reduction should be a global priority, while simultaneously ensuring universal salt iodization. This article identifies high priority strategies that address major sources of sodium: added to packaged food, added to food consumed outside the home, and added in the home. To be included, strategies needed to be scalable and sustainable, have large benefit, and applicable to one of four measures of effectiveness: (1) Rigorously evaluated with demonstrated success in reducing sodium; (2) suggestive evidence from lower quality evaluations or modeling; (3) rigorous evaluations of similar interventions not specifically for sodium reduction; or (4) an innovative approach for sources of sodium that are not sufficiently addressed by an existing strategy. We identified seven priority interventions. Four target packaged food: front-of-pack labeling, packaged food reformulation targets, regulating food marketing to children, and taxes on high sodium foods. One targets food consumed outside the home: food procurement policies for public institutions. Two target sodium added at home: mass media campaigns and population uptake of low-sodium salt. In conclusion, governments have many tools to save lives by reducing population sodium intake.

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.

Screening tool for identifying adults with excessive salt intake among community-dwelling adults: a population-based cohort study

BACKGROUND

Excessive salt intake is widely known to be a cause of hypertension, cardiovascular events, and so on. However, simple tools for screening excessive salt intake are lacking.

OBJECTIVE

We aimed to develop a simple screening tool to identify community-dwelling adults with excessive salt intake.

METHODS

The present study involved participants who received health check-ups in Fukushima, Japan, in 2016 and 2017. We defined data from the 2016 check-up as the derivation set, and data from those who received check-ups in 2017 but not 2016 as the validation set. The outcome measure was excessive salt intake, defined as the estimated daily salt intake of 1 SD or more. Candidate predictors associated with the outcome were extracted using the Delphi method by an expert panel and narrowed down with clinical expertise and stepwise backward selection. The screening tool was developed using a coefficient-based multivariable scoring method and externally validated.

RESULTS

A total of 1101 participants were included in the derivation set and 249 in the validation set. At the conclusion of the deviation process, 8 predictors were selected and scored. The areas under the receiver operating characteristic curve for derivation and external validation were 0.70 (95% CI: 0.67, 0.74) and 0.71 (95% CI: 0.62, 0.80), respectively. The calibration slope and intercept for external validation were 1.16 and -0.03, respectively.

CONCLUSION

We developed a screening tool to identify adults with excessive salt intake. By extracting groups with excessive salt intake, target populations needing intervention for salt reduction can be highlighted efficiently.

Effect of salt substitution on community-wide blood pressure and hypertension incidence

Replacement of regular salt with potassium-enriched substitutes reduces blood pressure in controlled situations, mainly among people with hypertension. We report on a population-wide implementation of this strategy in a stepped-wedge cluster randomized trial (NCT01960972). The regular salt in enrolled households was retrieved and replaced, free of charge, with a combination of 75% NaCl and 25% KCl. A total of 2,376 participants were enrolled in 6 villages in Tumbes, Peru. The fully adjusted intention-to-treat analysis showed an average reduction of 1.29 mm Hg (95% confidence interval (95% CI) (-2.17, -0.41)) in systolic and 0.76 mm Hg (95% CI (-1.39, -0.13)) in diastolic blood pressure. Among participants without hypertension at baseline, in the time- and cluster-adjusted model, the use of the salt substitute was associated with a 51% (95% CI (29%, 66%)) reduced risk of developing hypertension compared with the control group. In 24-h urine samples, there was no evidence of differences in sodium levels (mean difference 0.01; 95% CI (0.25, -0.23)), but potassium levels were higher at the end of the study than at baseline (mean difference 0.63; 95% CI (0.78, 0.47)). Our results support a case for implementing a pragmatic, population-wide, salt-substitution strategy for reducing blood pressure and hypertension incidence.

Community awareness of diet needs associated with hypertension and type 2 diabetes mellitus in Hatcliffe, Zimbabwe

BACKGROUND

Diet is an important modifiable risk factor for non-communicable diseases (NCDs) like hypertension (HTN) and type 2 diabetes mellitus (T2DM). A NCD is a disease that cannot be transmitted from person to person. Dietary risk factors account for 5.8% of all-cause mortality in Sub-Saharan Africa (SSA). There has been an increase in the consumption of 'westernized 'diets in SSA. The westernized diets consumed in low-income countries are usually high in salt content, fatty, processed and fast foods; and hence accelerate the development of HTN and T2DM. Previous studies carried out in Zimbabwe showed low levels of knowledge and awareness of HTN and T2DM; and the dietary needs for patients with those conditions. The aim of this study was to explore the dietary habits and awareness of HTN and T2DM of both males and females in a high-density area (HDA) of Zimbabwe.

METHODS

We conducted household-based cross-sectional study in a high density area of Hatcliffe, which has a population of close to 50,000 residents. Face to face interviews were conducted using hand-held mobile devices loaded with KoBo Toolbox. We selected two consenting adults, a male and female, from every fourth household in selected areas of Hatcliffe.

RESULTS

In this study all the 492 participants that were interviewed responded. Eighty eight point 6% (88.6%) of the participants in the study did not know if they were hypertensive or not. In addition, 91.7% of the participants had never voluntarily checked for hypertension. Similarly, 97.6% of the participants did not know if they had T2DM or not. Ninety eight percent (98%) of the participants had not voluntarily checked their blood glucose level.

CONCLUSIONS

The majority of the participants in the study were not aware if they had HTN or T2DM. The participants in the study perceived that the salt they consume is the right quantity. There is a high consumption of vegetable oil in most meals prepared.

Dietary Intake and Sources of Potassium in a Cross-Sectional Study of Australian Adults

A diet rich in potassium is important to reduce the risk of cardiovascular disease. This study assessed potassium intake; food sources of potassium (including NOVA level of processing, purchase origin of these foods); and sodium-to-potassium ratio (Na:K) in a cross-section of Australian adults. Data collection included 24-h urines (n = 338) and a 24-h diet recall (subsample n = 142). The mean (SD) age of participants was 41.2 (13.9) years and 56% were females. Mean potassium (95%CI) 24-h urinary excretion was 76.8 (73.0–80.5) mmol/day compared to 92.9 (86.6–99.1) by 24-h diet recall. Na:K was 1.9 (1.8–2.0) from the urine excretion and 1.4 (1.2–1.7) from diet recall. Foods contributing most to potassium were potatoes (8%), dairy milk (6%), dishes where cereal is the main ingredient (6%) and coffee/coffee substitutes (5%). Over half of potassium (56%) came from minimally processed foods, with 22% from processed and 22% from ultraprocessed foods. Almost two-thirds of potassium consumed was from foods purchased from food stores (58%), then food service sector (15%), and fresh food markets (13%). Overall, potassium levels were lower than recommended to reduce chronic disease risk. Multifaceted efforts are required for population-wide intervention—aimed at increasing fruit, vegetable, and other key sources of potassium intake; reducing consumption of processed foods; and working in supermarket/food service sector settings to improve the healthiness of foods available.