Sources of Dietary Salt in North and South India Estimated from 24 Hour Dietary Recall

Recent data on salt intake levels in India show consumption is around 11 g per day, higher than the World Health Organization’s (WHO) recommended intake of 5 g per day. However, high-quality data on sources of salt in diets to inform a salt reduction strategy are mostly absent. A cross-sectional survey of 1283 participants was undertaken in rural, urban, and slum areas in North (n = 526) and South (n = 757) India using an age-, area-, and sex-stratified sampling strategy. Data from two 24-h dietary recall surveys were transcribed into a purpose-built nutrient database. Weighted salt intake was estimated from the average of the two recall surveys, and major contributors to salt intake were identified. Added salt contributed the most to total salt intake, with proportions of 87.7% in South India and 83.5% in North India (p < 0.001). The main food sources of salt in the south were from meat, poultry, and eggs (6.3%), followed by dairy and dairy products (2.6%), and fish and seafood (1.6%). In the north, the main sources were dairy and dairy products (6.4%), followed by bread and bakery products (3.3%), and fruits and vegetables (2.1%). Salt intake in India is high, and this research confirms it comes mainly from added salt. Urgent action is needed to implement a program to achieve the WHO salt reduction target of a 30% reduction by 2025. The data here suggest the focus needs to be on changing consumer behavior combined with low sodium, salt substitution.

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Salt intake and its sources in children, adolescents and adults in Isfahan, Islamic Republic of Iran

Eastern Mediterranean Health Journal ◽

10.26719/emhj.20.142 ◽

2020 ◽

Author(s):

Noushin Mohammadifard ◽

Atena Mahdavi ◽

Alireza Khosravi ◽

Ahmad Esmaillzadeh ◽

Awat Feizi ◽

...

Keyword(s):

Children And Adolescents ◽

Salt Intake ◽

World Health ◽

Food Sources ◽

Islamic Republic ◽

Dietary Salt ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Islamic Republic Of Iran ◽

Added Salt

Background: There is little evidence about salt intake and its food sources in the Iranian population, especially in children and adolescents. Aims: To investigate salt intake and dietary sources in Isfahan, Islamic Republic of Iran. Methods: This was a cross-sectional survey conducted in 2014–2015. We randomly selected 1384 adults (50.3% female, 49.7% male) aged > 18 years [mean 37.9 (10.6) years], and 786 children and adolescents (50.9% male, 49.1% female) aged 618 years [mean 12.5 (3.4) years]. All participants underwent a dietary assessment for salt intake, using a validated food frequency questionnaire. Results: The total salt intake was 10.9 (3.4) g/day in adults and 10.3 (2.9) g/day in children and adolescents. Added salt was the primary source of salt intake, followed by bread and cheese in both groups. Salt intake was related significantly to being younger, male, a smoker, less educated and physically active in the adult group. In children and adolescents, it was significantly associated with increasing age, male sex, low physical activity and parents’ education level (all P < 0.05). Conclusions: Salt intake in Isfahan was more than twice that recommended by the World Health Organization. The main source of sodium was added salt, followed bread and cheese. Future national studies are warranted to assess the dietary salt intake and its main sources in different provinces in the Islamic Republic of Iran.

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Sources of dietary sodium and implications for a statewide salt reduction initiative in Victoria, Australia

British Journal Of Nutrition ◽

10.1017/s000711452000032x ◽

2020 ◽

Vol 123 (10) ◽

pp. 1165-1175 ◽

Cited By ~ 2

Author(s):

Kristy A. Bolton ◽

Jacqui Webster ◽

Elizabeth K. Dunford ◽

Stephen Jan ◽

Mark Woodward ◽

...

Keyword(s):

Fast Food ◽

Salt Intake ◽

Dietary Sodium ◽

Food Sources ◽

Retail Sector ◽

Food Markets ◽

Salt Reduction ◽

Dietary Recall ◽

Processed Meats ◽

Fresh Food

AbstractIn Victoria, Australia, a statewide salt reduction partnership was launched in 2015. The aim was to measure Na intake, food sources of Na (level of processing, purchase origin) and discretionary salt use in a cross-section of Victorian adults prior to a salt reduction initiative. In 2016/2017, participants completed a 24-h urine collection (n 338) and a subsample completed a 24-h dietary recall (n 142). Participants were aged 41·2 (sd 13·9) years, and 56 % were females. Mean 24-h urinary excretion was 138 (95 % CI 127, 149) mmol/d for Na. Salt equivalent was 8·1 (95 % CI 7·4, 8·7) g/d, equating to about 8·9 (95 % CI 8·1, 9·6) g/d after 10 % adjustment for non-urinary losses. Mean 24-h intake estimated by diet recall was 118 (95 % CI 103, 133) mmol/d for Na (salt 6·9 (95 % CI 6·0, 7·8 g/d)). Leading dietary sources of Na were cereal-based mixed dishes (12 %), English muffins, flat/savoury/sweet breads (9 %), regular breads/rolls (9 %), gravies and savoury sauces (7 %) and processed meats (7 %). Over one-third (38 %) of Na consumed was derived from discretionary foods. Half of all Na consumed came from ultra-processed foods. Dietary Na derived from foods was obtained from retail stores (51 %), restaurants and fast-food/takeaway outlets (28 %) and fresh food markets (9 %). One-third (32 %) of participants reported adding salt at the table and 61 % added salt whilst cooking. This study revealed that salt intake was above recommended levels with diverse sources of intake. Results from this study suggest a multi-faceted salt reduction strategy focusing on the retail sector, and food reformulation would most likely benefit Victorians and has been used to inform the ongoing statewide salt reduction initiative.

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Salt intake and its sources in children, adolescents and adults in the Islamic Republic of Iran

Eastern Mediterranean Health Journal ◽

10.26719/2021.27.3.279 ◽

2021 ◽

Vol 27 (3) ◽

pp. 279-286

Author(s):

Noushin Mohammadifard ◽

Atena Mahdavi ◽

Alireza Khosravi ◽

Ahmad Esmaillzadeh ◽

Awat Feizi ◽

...

Keyword(s):

Children And Adolescents ◽

Salt Intake ◽

World Health ◽

Food Sources ◽

Islamic Republic ◽

Dietary Salt ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Islamic Republic Of Iran ◽

Added Salt

Background: There is little evidence about salt intake and its food sources in the Iranian population, especially in children and adolescents. Aims: To investigate salt intake and dietary sources in Isfahan, Islamic Republic of Iran. Methods: This was a cross-sectional survey conducted in 2014–2015. We randomly selected 1384 adults (50.3% female, 49.7% male) aged > 18 years [mean 37.9 (10.6) years], and 786 children and adolescents (50.9% male, 49.1% female) aged 6-18 years [mean 12.5 (3.4) years]. All participants underwent a dietary assessment for salt intake, using a validated food frequency questionnaire. Results: The total salt intake was 10.9 (3.4) g/day in adults and 10.3 (2.9) g/day in children and adolescents. Added salt was the primary source of salt intake, followed by bread and cheese in both groups. Salt intake was related significantly to being younger, male, a smoker, less educated and physically active in the adult group. In children and adolescents, it was significantly associated with increasing age, male sex, low physical activity and parents’ education level (all P < 0.05). Conclusions: Salt intake in Isfahan was more than twice that recommended by the World Health Organization. The main source of sodium was added salt, followed bread and cheese. Future national studies are warranted to assess the dietary salt intake and its main sources in different provinces in the Islamic Republic of Iran.

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Salt and cardiovascular disease in PURE: A large sample size cannot make up for erroneous estimations

Journal of the Renin-Angiotensin-Aldosterone System ◽

10.1177/1470320318810015 ◽

2018 ◽

Vol 19 (4) ◽

pp. 147032031881001 ◽

Cited By ~ 8

Author(s):

Monique Tan ◽

Feng J He ◽

Graham A MacGregor

Keyword(s):

Cardiovascular Disease ◽

Salt Intake ◽

Total Mortality ◽

World Health ◽

Large Sample Size ◽

Salt Reduction ◽

Spot Urine ◽

Urban Rural ◽

Methodological Problems

The latest Prospective Urban Rural Epidemiology (PURE) study claims that salt reduction should be confined to settings where its intake exceeds 12.7 g/day and that eating less than 11.1 g/day of salt could increase cardiovascular risk. More specifically, Mente et al. suggested that (a) salt intake was positively associated with stroke only when it exceeded 12.7 g/day, (b) salt intake was inversely associated with myocardial infarction and total mortality, and (c) these associations were largely independent of blood pressure. These provocative findings challenge the robust evidence on the role of salt reduction in the prevention of cardiovascular disease and call into question the World Health Organization’s global recommendation to reduce salt intake to less than 5 g/day. However, Mente et al.’s re-analysis of the PURE data has several severe methodological problems, including erroneous estimations of salt intake from a single spot urine using the problematic Kawasaki formula. As such, these implausible results cannot be used to refute the strong evidence supporting the benefits of salt reduction for the general population worldwide.

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Sodium and potassium intake, blood pressure, and cardiovascular prevention

ESC CardioMed ◽

10.1093/med/9780198784906.003.0568 ◽

2018 ◽

pp. 2431-2444

Author(s):

Francesco P. Cappuccio

Keyword(s):

Blood Pressure ◽

Cardiovascular Disease ◽

World Health Organization ◽

Salt Intake ◽

World Health ◽

Salt Reduction ◽

Potassium Intake ◽

Salt Consumption ◽

The World ◽

Health Organization

Salt consumption is now much greater than needed for survival. High salt intake increases blood pressure in both animals and humans. Conversely, a reduction in salt intake causes a dose-dependent reduction in blood pressure in men and women of all ages and ethnic groups, and in patients already on medication. The risk of strokes and heart attacks rises with increasing blood pressure, but can be decreased by antihypertensive drugs. However, most cardiovascular disease events occur in individuals with ‘normal’ blood pressure levels. Non-pharmacological prevention is therefore the only option to reduce such events. Reduction in population salt intake reduces the number of vascular events. It is one of the most important public health measures to reduce the global cardiovascular burden. Salt reduction policies are powerful, rapid, equitable, and cost saving. The World Health Organization recommends reducing salt consumption below 5 g per day aiming at a global 30% reduction by 2025. A high potassium intake lowers blood pressure in people with and without hypertension. Its beneficial effects extend beyond blood pressure, and may include a reduction in the risk of stroke (independent of blood pressure changes). Potassium intake in the Western world is relatively low, and a lower potassium intake is associated with increased risks of cardiovascular disease, especially stroke. A moderate increase in potassium intake, either as supplement or with diet, reduces blood pressure, and the World Health Organization has issued global recommendations for a target dietary potassium intake of at least 90 mmol/day (≥3510 mg/day) for adults.

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Assessment of Sodium Knowledge and Urinary Sodium Excretion among Regions of the United Arab Emirates: A Cross-Sectional Study

Nutrients ◽

10.3390/nu12092747 ◽

2020 ◽

Vol 12 (9) ◽

pp. 2747

Author(s):

Amjad H. Jarrar ◽

Lily Stojanovska ◽

Vasso Apostolopoulos ◽

Leila Cheikh Ismail ◽

Jack Feehan ◽

...

Keyword(s):

United Arab Emirates ◽

Sodium Excretion ◽

Salt Intake ◽

Urinary Sodium Excretion ◽

World Health ◽

High Potassium ◽

Cross Sectional ◽

Salt Reduction ◽

High Salt Intake ◽

The Impact

Non-communicable diseases (NCDs) such as cardiovascular disease, cancer and diabetes, are increasing worldwide and cause 65% to 78% of deaths in the Gulf Cooperation Council (GCC). A random sample of 477 healthy adults were recruited in the United Arab Emirates (UAE) in the period March–June 2015. Demographic, lifestyle, medical, anthropometric and sodium excretion data were collected. A questionnaire was used to measure knowledge, attitude and practice regarding salt. Mean sodium and potassium excretion were 2713.4 ± 713 mg/day and 1803 ± 618 mg/day, respectively, significantly higher than the World Health Organization (WHO) recommendations for sodium (2300 mg/day) and lower for potassium (3150 mg/day). Two-thirds (67.4%) exceeded sodium guidelines, with males 2.6 times more likely to consume excessively. The majority of the participants add salt during cooking (82.5%) and whilst eating (66%), and 75% identified processed food as high source of salt. Most (69.1%) were aware that excessive salt could cause disease. Most of the UAE population consumes excess sodium and insufficient potassium, likely increasing the risk of NCDs. Despite most participants being aware that high salt intake is associated with adverse health outcomes, this did not translate into salt reduction action. Low-sodium, high-potassium dietary interventions such as the Mediterranean diet are vital in reducing the impact of NCDs in the UAE.

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Salt and potassium intake among adult Ghanaians: WHO-SAGE Ghana Wave 3

BMC Nutrition ◽

10.1186/s40795-020-00379-y ◽

2020 ◽

Vol 6 (1) ◽

Author(s):

Elias K. Menyanu ◽

Barbara Corso ◽

Nadia Minicuci ◽

Ilaria Rocco ◽

Joanna Russell ◽

...

Keyword(s):

Salt Intake ◽

Population Based ◽

Dietary Sodium ◽

World Health ◽

Adult Health ◽

Salt Reduction ◽

Hypertension Prevalence ◽

Salt Consumption ◽

Consumption Data

Abstract Though Ghana has high hypertension prevalence, the country lacks current national salt consumption data required to build and enhance advocacy for salt reduction. We explored the characteristics of a randomly selected sub sample that had valid urine collection, along with matched survey, anthropometric and BP data (n = 839, mean age = 60y), from the World Health Organization’s Study on global AGEing and adult health (WHO-SAGE), Ghana Wave 3, n = 3053). We also investigated the relationship between salt intake and blood pressure (BP) among the cohort. BP was measured in triplicate and 24 h urine was collected for the determination of urinary sodium (Na), potassium (K), creatinine (Cr) and iodine levels. Hypertension prevalence was 44.3%. Median salt intake was 8.3 g/day, higher in women compared to men (8.6, interquartile range (IQR) 7.5 g/day vs 7.5, IQR 7.4 g/day, p < 0.01), younger participants (18–49 y) compared to older ones (50+ y) (9.7, IQR 7.9 g/day vs 8.1, IQR 7.1 g/day, p < 0.01) and those with higher Body Mass Index (BMI) (> 30 kg/m2) compared to a healthy BMI (18.5–24.9 kg/m2) (10.04, IQR 5.1 g/day vs 6.2, IQR 5.6 g/day, p < 0.01). More than three quarters (77%, n = 647) of participants had salt intakes above the WHO maximum recommendation of 5 g/d, and nearly two thirds (65%, n = 548) had daily K intakes below the recommended level of 90 mmol. Dietary sodium to potassium (Na: K) ratios above 2 mmol/mmol were positively associated with increasing BP with age. Population-based interventions to reduce salt intake and increase K consumption are needed.

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Salt reduction in bread: Is it enough? Preliminary results of a HIA in Portugal

European Journal of Public Health ◽

10.1093/eurpub/ckz187.027 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

J Santos ◽

P Braz ◽

A Costa ◽

L Costa ◽

M Santos ◽

...

Keyword(s):

Blood Pressure ◽

Statistical Difference ◽

Salt Intake ◽

Statistical Significance ◽

Systolic Pressure ◽

Health Impact ◽

World Health ◽

Salt Reduction ◽

Aggregated Data ◽

The Impact

Abstract Issue Health Impact Assessment (HIA) is a methodology that aims at assessing the impact of policies in health. A pilot HIA is in progress to kick off the implementation of this methodology in Portugal with the support of the World Health Organization (WHO). In this context, the impact of a nation-wide policy that intends to achieve a maximum of 1 g of salt/100 gr in bread is under assessment. Description of the issue In 2017, Portugal approved a protocol between the industry and other stakeholders to gradually decrease the amount of salt in bread, as this is the main source of salt intake. The purpose of this study was to assess the impact in blood pressure from current (1.4 gr) to 1 g (29% reduction) of salt in bread. Data from two different surveys regarding blood pressure and salt intake was gathered. We estimated the decrease in blood pressure with respect to current average values according to sex, age, education and region. Results It is expected that a reduction of 29% in salt intake through bread contributes to a general decrease in systolic pressure for normotensive people (from 120.4mmHg to 120.0mmHg, p = 0.85) and hypertensive people (from 151.0mmHg to 150.1mmHg, p = 0.68), although not statistically significant. Older hypertensive individuals (65 to 75 years) are the group with the largest benefit (152.8mmHg to 152.0mmHg) but no statistical difference was found. Disaggregation by sex, region and education also didn’t show any statistical difference. Lessons The impact in blood pressure from a 29% reduction in salt intake from bread seems very small. We found no statistical significance between the current and expected values in blood pressure either for total or group stratification. The absence of statistical effect might be due to sample size as our sources only allowed us to work with aggregated data. Key messages Quality and access to data is needed to assess impact of policies. to increase effects in blood pressure either salt reduction from bread must be larger or a wider range of products should be considered.

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Reducing Salt Intake in China with “Action on Salt China” (ASC): Protocol for Campaigns and Randomized Controlled Trials (Preprint)

10.2196/preprints.15933 ◽

2019 ◽

Author(s):

Puhong Zhang ◽

Feng J He ◽

Yuan Li ◽

Changning Li ◽

Jing Wu ◽

...

Keyword(s):

Randomized Controlled Trials ◽

School Children ◽

Intervention Study ◽

Salt Intake ◽

Mobile App ◽

World Health ◽

Controlled Trials ◽

Processed Foods ◽

Salt Reduction ◽

Randomized Controlled

BACKGROUND Salt intake in China is over twice the maximum recommendation of the World Health Organization. Unlike most developed countries where salt intake is mainly derived from prepackaged foods, around 80% of the salt consumed in China is added during cooking. OBJECTIVE Action on Salt China (ASC), initiated in 2017, aims to develop, implement, and evaluate a comprehensive and tailored salt reduction program for national scaling-up. METHODS ASC consists of six programs working in synergy to increase salt awareness and to reduce the amount of salt used during cooking at home and in restaurants, as well as in processed foods. Since September 2018, two health campaigns on health education and processed foods have respectively started, in parallel with four open-label cluster randomized controlled trials (RCTs) in six provinces across China: (1) app-based intervention study (AIS), in which a mobile app is used to achieve and sustain salt reduction in school children and their families; (2) home cook-based intervention study (HIS), in which family cooks receive support in using less salt; (3) restaurant-based intervention study (RIS) targeting restaurant consumers, cooks, and managers; and (4) comprehensive intervention study (CIS), which is a real-world implementation and evaluation of all available interventions in the three other RCTs. To explore the barriers, facilitators, and effectiveness of delivering a comprehensive salt reduction intervention, these RCTs will last for 1 year (stage 1), followed by nationwide implementation (stage 2). In AIS, HIS, and CIS, the primary outcome of salt reduction will be evaluated by 24-hour urinary sodium excretion in 6030 participants, including 5436 adults and 594 school children around 8-9 years old. In RIS, the salt content of meals will be measured by laboratory food analysis of the 5 best-selling dishes from 192 restaurants. Secondary outcomes will include process evaluation; changes in knowledge, attitude, and practice on salt intake; and economic evaluation. RESULTS All RCTs have been approved by Queen Mary Research Ethics Committee and the Institutional Review Boards of leading institutes in China. The research started in June 2017 and is expected to be completed around March 2021. The baseline investigations of the four RCTs were completed in May 2019. CONCLUSIONS The ASC project is progressing smoothly. The intervention packages and tailored components will be promoted for salt reduction in China, and could be adopted by other countries. CLINICALTRIAL Chinese Clinical Trial Registry. AIS: ChiCTR1800017553; https://tinyurl.com/vdr8rpr. HIS: ChiCTR1800016804; https://tinyurl.com/w8c7x3w. RIS: ChiCTR1800019694; https://tinyurl.com/uqkjgfw. CIS: ChiCTR1800018119; https://tinyurl.com/s3ajldw. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/15933

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Impact of the 2003 to 2018 Population Salt Intake Reduction Program in England

Hypertension ◽

10.1161/hypertensionaha.120.16649 ◽

2021 ◽

Vol 77 (4) ◽

pp. 1086-1094

Author(s):

Sergi Alonso ◽

Monique Tan ◽

Changqiong Wang ◽

Seamus Kent ◽

Linda Cobiac ◽

...

Keyword(s):

Health Care ◽

Salt Intake ◽

Health Care Cost ◽

Adult Population ◽

Population Level ◽

World Health ◽

Dietary Salt ◽

Salt Reduction ◽

Life Years ◽

Reduction Program

The United Kingdom was among the first countries to introduce a salt reduction program in 2003 to reduce cardiovascular disease (CVD) incidence risk. Despite its initial success, the program has stalled recently and is yet to achieve national and international targets. We used age- and sex-stratified salt intake of 19 to 64 years old participants in the National Diet and Nutrition Surveys 2000 to 2018 and a multistate life table model to assess the effects of the voluntary dietary salt reduction program on premature CVD, quality-adjusted survival, and health care and social care costs in England. The program reduced population-level salt intake from 9.38 grams/day per adult (SE, 0.16) in 2000 to 8.38 grams/day per adult (SE, 0.17) in 2018. Compared with a scenario of persistent 2000 levels, assuming that the population-level salt intake is maintained at 2018 values, by 2050, the program is projected to avoid 83 140 (95% CI, 73 710–84 520) premature ischemic heart disease (IHD) cases and 110 730 (95% CI, 98 390–112 260) premature strokes, generating 542 850 (95% CI, 529 020–556 850) extra quality-adjusted life-years and £1640 million (95% CI, £1570–£1660) health care cost savings for the adult population of England. We also projected the gains of achieving the World Health Organization target of 5 grams/day per adult by 2030, which by 2050 would avert further 87 870 (95% CI, 82 050–88 470) premature IHD cases, 126 010 (95% CI, 118 600–126 460) premature strokes and achieve £1260 million (95% CI, £1180–£1260) extra health care savings compared with maintaining 2018 levels. Strengthening the salt reduction program to achieve further reductions in population salt intake and CVD burden should be a high priority.

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