Removing barriers to sodium reduction: Focusing on practice

Abstract

Hypertension, as the most common preventable risk factor for cardiovascular disease and all-cause mortality, has become a public health burden worldwide.1 It is estimated that 1.13 billion people globally have hypertension, but fewer than one in five hypertensive patients have the problem under control.2 Among many established risk factors for hypertension, excessive sodium intake is of great concern.3 Numerous evidence from animal studies, epidemiological studies, clinical trials, and meta-analyses of trials have demonstrated that dietary sodium reduction is associated with decreased blood pressure and reduced risk of cardiovascular disease and all-cause mortality.4 In fact, reducing dietary sodium intake has been recommended in hypertension guidelines and population dietary policies in many countries.5 Although considerable effort has been made in reducing salt intake since 2013, the current global salt consumption levels of 9–12 g/day is still far exceeding 5 g/day, recommended by the World Health Organization (WHO).6, 7 In response to the unsatisfying results of recent attempts in dietary sodium reduction, a group of Thai researchers, Sirichai and colleagues, developed a user-friendly salt meter device to monitor sodium intake.8 A randomized controlled trial is conducted among uncontrolled hypertensive patients to evaluate the efficacy of using salt-meter combined with dietary education in reducing dietary salt consumption. The device uses the alternating electrical current to determine the concentration of sodium chloride in food (such as curry, soup, or broth), which is displayed as corresponding emotional faces on the screen. The study shows that compared with only dietary education, additional implementation of salt meter performs better in reducing 24-h urine sodium excretion and blood pressure in uncontrolled hypertensive patients after the 8-week intervention. More importantly, during the follow-up period, all patients who received the salt meters were in good compliance in usage. They concluded that the salt meter would help in dietary salt intake reduction, and therefore blood pressure management in uncontrolled hypertensive patients in real life. General broad recommendations on sodium reduction have been considered to be among the most cost-effective strategies for promoting general population health outcomes. Improvements of knowledge, attitudes, and practices (KAP) on salt intakes are considered as the key components of effective sodium reduction strategies. Among the three components, improvement of knowledge is fundamental and essential for stimulating a positive attitude towards sodium reduction, which would influence the behaviors of the individuals and the groups, determining the efficiency of sodium reduction strategies. The most recommended sodium-related behaviors include the use of scaled salt spoons, the evaluation of sodium content in processed food, and the implementation of educational campaigns. However, shifting the dietary habit in high salt-intake population is not easy and requires multidimensional approaches. Previous observational studies showed that despite good levels of knowledge and favorable attitudes towards sodium reduction, only a small proportion of subjects had taken action to reduce salt intake (Table 1).9-14 Complementary approaches are needed to remove the barrier to salt reduction and increase the accessibility of a low-sodium lifestyle. The new salt meter device developed by Sirichai and colleagues was a commendable example of assisting in dietary sodium reduction. The device provides a tool to help people to be more salt-conscious and to choose healthier alternatives in a visual manner; it makes complex measures more accessible, apprehensible, and applicable. Such initiatives contribute to lowering sodium intake as a practice component of KAP. Future efforts are expected in the modification of device design to measure solid food for broader application. In addition, the contribution of the salt meter merits further validation in a large, long-term follow-up study. Taken together, the salt meter provides new possibilities for sodium reduction practice and may help promote individual dietary change and public sodiumreduction initiatives. None. The authors have no competing interests. Yu Yan and Jianjun Mu contributed to the conception of this work. Yu Yan wrote the manuscript and Jianjun Mu critically revised it for important intellectual. Both authors approved the final version of the manuscript. None.