Sodium Reduction Interventions Research Articles

Switching the World’s Salt Supply—Learning from Iodization to Achieve Potassium Enrichment

Sodium is an essential dietary component, but excess sodium intake can lead to high blood pressure and an increased risk of cardiovascular disease. Many national and international bodies, including the World Health Organization, have advocated for population-wide sodium reduction interventions. Most have been unsuccessful due to inadequate sodium reduction by food industry and difficulties in persuading consumers to add less salt to food. Recent research highlights potassium-enriched salt as a new, feasible, acceptable, and scalable approach to reducing the harms caused by excess sodium and inadequate potassium consumption. Modeling shows that a global switch from regular salt to potassium-enriched salt has the potential to avert millions of strokes, heart attacks, and premature deaths worldwide each year. There will be many challenges in switching the world’s salt supply to potassium-enriched salt, but the success of universal salt iodization shows that making a global change to the manufacture and use of salt is a tractable proposition. This in-depth review of universal salt iodization identified the importance of a multisectoral effort with strong global leadership, the support of multilateral organizations, engagement with the salt industry, empowered incountry teams, strong participation of national governments, understanding the salt supply chain, and a strategic advocacy and communication plan. Key challenges to the implementation of the iodization program were costs to government, industry, and consumers, industry concerns about consumer acceptability, variance in the size and capabilities of salt producers, inconsistent quality control, ineffective regulation, and trade-related regulatory issues. Many of the opportunities and challenges to universal salt iodization will likely also be applicable to switching the global salt supply to iodized and potassium-enriched salt.

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.

EFFECTS AND ASSOCIATED BEHAVIOUR CHANGE TECHNIQUES OF EHEALTH-BASED INTERVENTIONS ON SODIUM REDUCTION AMONG ADULTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: To evaluate the effects of eHealth-based interventions on sodium and blood pressure reduction in adults, and identify study characteristics and behaviour change techniques (BCTs) associated with greater sodium reduction effects. Design and method: A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted in 5 databases including RCTs published from January 2000 to September 2022. The 24-hour urinary sodium (24HUNa, primary outcome of this review), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were meta-analysed using random-effects models. I2 statistic was used to assess heterogeneity among studies, with I2 > 50% considered substantial heterogeneity. Publication bias and robustness of the results were evaluated by the Egger test and sensitivity analysis, respectively. The contents of sodium reduction interventions were mapped to BCT Taxonomy (V1). Subgroup analyses of 24HUNa were performed according to study characteristics, including participants’ health status (hypertension vs. heart failure vs. healthy adults), urinary measurement (24-hour urine vs. spot urine), trial period (1-6 months vs. 7-12 months vs. 13-18 months), intervention mode (individual- vs. group-based), and BCTs. Results: Twenty-eight RCTs (5720 participants, mean age: 54.72 ± 10.80) were included. eHealth-based interventions significantly reduced 24HUNa (mean difference, MD = - 0.34 g/24 hours, 95% CI: - 0.45 to - 0.23; I2 = 49%, equivalent to 0.85 g/salt reduction per day) and SBP (MD = - 2.84 mmHg, 95% CI: - 4.02 to - 1.66; I2 = 35%), but not DBP (MD = - 0.93 mmHg, 95% CI: -1.95 to 0.08; I2 = 56%). No publication bias was detected. The effects on 24UHNa and SBP remained significant in sensitivity analyses. Twenty-nine BCTs were identified and predominantly were goal setting and behaviour feedback. Subgroup analyses showed using BCTs (goal setting, problem solving, feedback on behaviour, self-monitoring of behaviour, instruction on how to perform the behaviour, or demonstration of the behaviour) associated with a large significant reduction in sodium intake. No significant differences were observed for other study characteristics. Conclusions: eHealth-based interventions effectively reduced sodium intake and SBP in adults. The identified useful BCTs for sodium reduction should be tested in future trials.

Sodium reduction in processed foods, including processed meats, in Africa: A systemic review

The use of sodium in processed foods, including meats, has been in existent over centuries. Its use is mainly as a food and meat processing aid, and a preservative and flavourant. Even with modern methods of food processing, sodium is still essential in food and meat derivatives due to different dietary demands by consumers. Sodium chloride, sodium nitrate and nitrite are common in meat processing for various uses such as curing, smoking and brining. Due to the increasing global sodium intake, chronic adverse health effects, such as cardiovascular diseases, hypertension, stroke, cancers, among others, have also been on the rise, particularly in urban areas. African countries have a proportional increase of dietary sodium due to the adoption of western diets with high sodium and saturated fats. Subsequently, South Africa promulgated legislation that prescribed the first mandatory sodium limits in 2013. The purpose of this review is to determine, (1) the sodium reduction interventions agreed by African states in forums and meetings in the past five years (2017-2021) and, (2) sodium reduction strategies recommended through research by African scholars. This systemic review was conducted from English literature published between 2017 and 2021, using Science web, MEDLINE, CINAHL, PsycINFO, Science Direct, PubMed, Google Scholar, with a specific focus on African countries. From the findings of this systemic review, there were minimal sodium reduction interventions by African states, emanating from published forums and meetings, to establish collaborated sodium reduction strategies in processed foods. The studies conducted by African scholars in the past five years recommended sodium reduction interventions, such as legislative framework, product reformulation, monitoring models and consumer awareness, with most studies done in South Africa. It is evident that to have a meaningful impact on the control and reduction of dietary sodium, African countries require existing diplomacies to collaborate on sodium reduction efforts with public and private partnerships; this can be coordinated through inter-trade treaties among the African states. This requires an increase in research, commitment and the will to reduce dietary sodium in processed foods and meat by all member states. Key words: sodium, reduction, processed, meat, processing, effects, hypertension, nitrate, nitrite

Building capacity in reducing population dietary sodium intake in the Americas

To present some resources developed as part of the technical support of the Pan American Health Organization (PAHO) to Member States to reduce population dietary sodium intake, and to discuss the main challenges and opportunities to accelerate action toward sodium intake reduction in the Americas. Sources of information include a mapping of salt reduction policies conducted in 2019, reports from working group meetings, interviews conducted in 2020 and 2021 in seven countries, and technical documents developed around the Updated PAHO Regional Sodium Reduction Targets. These tools show that, despite progress, challenges to succeed in this agenda persist. Priority given to sodium reduction is low in most countries, with insufficient resource allocation. There is a lack of intersectoral coordinated action, and a systemic approach to food systems is commonly missing. Surveillance mechanisms of sodium intake are insufficient, and industry interference in policy processes is commonly identified, undermining policy progress and success. There are also important regional opportunities to address these challenges. These include common ground for future collaborations by updating, strengthening, and complementing these existing tools, and technical and financial support for data generation. PAHO is committed to continue to support countries in the process of promoting, implementing, and monitoring cost-effective sodium reduction interventions. One key policy priority in this agenda is the adoption of the Updated PAHO Regional Sodium Reduction Targets with a mandatory approach, together with the comprehensive and complementary implementation of other strategies. Strong political will and commitment of countries will be critical to translate goals into concrete achievements in the Americas.

Factors Associated With the Use of a Salt Substitute in Rural China

Lowering sodium intake reduces blood pressure and may reduce the risk of cardiovascular diseases. The use of reduced-sodium salt (a salt substitute) may achieve sodium reduction, but its effectiveness may be associated with the context of its use. To identify factors associated with the use of salt substitutes in rural populations in China within the Salt Substitute and Stroke Study, a large-scale cluster randomized trial. This sequential mixed-methods qualitative evaluation, conducted from July 2 to August 28, 2018, in rural communities across 3 provinces in China, included a quantitative survey, collection of 24-hour urine samples, and face-to-face interviews. A random subsample of trial participants, selected from the 3 provinces, completed the quantitative survey (n = 1170) and provided urine samples (n = 1025). Interview respondents were purposively selected from the intervention group based on their different ranges of urinary sodium excretion levels. Statistical analysis was performed from September 18, 2018, to February 22, 2019. The intervention group of the Salt Substitute and Stroke Study was provided with the free salt substitute while the control group continued to use regular salt. Knowledge, attitudes, and behaviors regarding the use of the salt substitute were measured using quantitative surveys, and urinary sodium levels were measured using 24-hour urine samples. Contextual factors were explored through semistructured interviews and integrated findings from surveys and interviews. A total of 1170 individuals participated in the quantitative survey. Among the 1025 participants with successful urine samples, the mean (SD) age was 67.4 (7.5) years, and 502 (49.0%) were female. The estimated salt intake of participants who believed that high salt intake was good for health was higher; however, it was not significantly different (0.84 g/d [95% CI, -0.04 to 1.72 g/d]) from those who believed that high salt intake was bad for health. Thirty individuals participated in the qualitative interviews (18 women [60.0%]; mean [SD] age, 70.3 [6.0] years). Quantitative and qualitative data indicated high acceptability of and adherence to the salt substitute. Contextual factors negatively associated with the use of the salt substitute included a lack of knowledge about the benefits associated with salt reduction and consumption of high-sodium pickled foods. In addition, reduced antihypertensive medication was reported by a few participants using the salt substitute. This study suggests that lack of comprehensive understanding of sodium reduction and salt substitutes and habitual consumption of high-sodium foods (such as pickled foods) were the main barriers to the use of salt substitutes to reduce sodium intake. These factors should be considered in future population-based, sodium-reduction interventions.

Approaches for Implementing Healthy Food Interventions in Settings With Limited Resources: A Case Study of Sodium Reduction Interventions in Emergency Food Programs Addressing Food Insecurity.

This study describes how recipients of the Centers for Disease Control and Prevention funded Sodium Reduction in Communities Program (SRCP) worked with emergency food programs to improve access to healthy food to address chronic conditions. SRCP recipients partnered with emergency food programs to implement sodium reduction strategies including nutrition standards, procurement practices, environmental strategies, and behavioral economics approaches. SRCP recipients and emergency food programs in Washington County and Benton County, Arkansas and King County, Washington. SRCP recipient staff, emergency food program staff, and key stakeholders. We conducted semi-structured interviews with key stakeholders and systematic review of program documents. Data were analyzed using effects matrices for each recipient. Matrices were organized using select implementation science constructs and compared in a cross-case analysis. Despite limited resources, emergency food programs can implement sodium reduction interventions which may provide greater access to healthy foods and lead to reductions in health disparities. Emergency food programs successfully implemented sodium reduction interventions by building on the external and internal settings; selecting strategies that align with existing processes; implementing change incrementally and engaging staff, volunteers, and clients; and sustaining changes. Findings contribute to understanding the ways in which emergency food programs and other organizations with limited resources have implemented public health nutrition interventions addressing food insecurity and improving access to healthy foods. These strategies may be transferable to other settings with limited resources.

Reducing Sodium Intake in Community Meals Programs: Evaluation of the Sodium Reduction in Communities Program, Arkansas, 2016-2019.

The Sodium Reduction in Communities Program (SRCP) aims to reduce dietary sodium intake through policy, systems, and environmental approaches. We evaluated progress of 3 years of SRCP activities in 3 community meals programs in northwest Arkansas. These activities sought to reduce dietary sodium intake through implementation of 1) food service guidelines, 2) procurement practices, 3) food preparation practices, and 4) environmental strategies. Mean reductions of 579 mg (−40%) in sodium served per diner and 525 mg (−22%) in sodium per 1,000 kcal served per diner were found from baseline to Year 1. Mean reductions of 499 mg (−35%) in sodium served per diner and 372 mg (−16%) in sodium per 1,000 kcal served per diner were sustained from baseline to Year 3. These results highlight the effectiveness and sustainability of sodium reduction interventions in community meals programs, whose diners experience food insecurity, have low incomes, and are at high risk for hypertension.

EARLY EVIDENCE FOR THE EFFECTIVENESS OF SOUTH AFRICA'S LEGISLATION ON SALT RESTRICTION IN FOODS: THE AFRICAN-PREDICT STUDY

Objective: South Africa was one of the first countries to adopt mandatory regulation in 2016 to lower the salt content of a wide range of processed foods. To assess the effectiveness of this regulation, we determined the change in salt intake of young adults over a mean follow-up time of 4.56-years spanning the implementation of the regulation. Since young populations have a higher salt intake, salt reduction may have a greater long-term impact as a preventative strategy in this age group. Design and method: This study included baseline (N = 668; aged 24.9 ± 3 years; 47.8% black; 40.7% men) and follow-up data for the first 311 participants (aged 29.9 ± 3.09 years; 51.1% black; 43.4% men) tracked over time as part of the African-PREDICT study. Participants had baseline data before 30th June 2016, and follow-up from 2018 - 2020. Estimated salt intake at baseline and follow-up was calculated from 24-hour urinary sodium excretion. Results: The median salt intake of the population (N = 668) at baseline was 7.88 g/day (IQR: 5.67). In those followed (N = 311), salt intake reduced from baseline [median (IQR): 7.91 g/day (5.83)] to follow-up [median (IQR): 7.26 g/day (5.30)] in the total group [median difference (IQR): -0.82 g/day (7.02); p = 0.007], with a greater reduction observed in black adults [N = 159, median difference (IQR): -1.35 g/day (7.91); p = 0.003]. Reduced salt intake was more pronounced in black adults from a low (p = 0.007) and middle socio-economic status (p = 0.009), compared to a high socio-economic status (p = 0.27). Conclusions: Our preliminary findings suggest that South Africa's mandatory salt reduction regulation for processed foods has been effective in lowering salt intake in young adults by a magnitude of ∼0.82 g salt/day. Our study supports the effectiveness of “upstream” sodium reduction interventions at population level that may impact on the health and economic burden of countries.

Sodium Levels in Packaged Foods Sold in 14 Latin American and Caribbean Countries: A Food Label Analysis.

Population-wide sodium reduction is a cost-effective approach to address the adverse health effects associated with excess sodium consumption. Latin American and Caribbean (LAC) countries consume excess dietary sodium. Packaged foods are a major contributor to sodium intake and a target for sodium reduction interventions. This study examined sodium levels in 12 categories of packaged foods sold in 14 LAC (n = 16,357). Mean sodium levels and percentiles were examined. Sodium levels were compared to regional sodium reduction targets. In this baseline analysis, 82% of foods met the regional target and 47% met the lower target. The greatest proportion of products meeting the regional target were uncooked pasta and noodles (98%), flavored cookies/crackers (97%), seasonings for sides/main dishes (96%), mayonnaise (94%), and cured/preserved meats (91%). A large proportion of foods met the lower target among uncooked pasta and noodles (88%), cooked pasta and noodles (88%), and meat/fish seasonings (88%). The highest the highest median sodium levels were among condiments (7778 mg/100 g), processed meats (870 mg/100 g), mayonnaise (755 mg/100 g), bread products (458 mg/100 g), cheese (643 mg/100 g), and snack foods (625 mg/100 g). These baseline data suggest that sodium reduction targets may need to be more stringent to enable effective lowering of sodium intake.

Sodium intake and blood pressure in children and adolescents: a systematic review and meta-analysis of experimental and observational studies

High sodium intake is a cause of elevated blood pressure in adults. In children and adolescents, less evidence is available and findings are equivocal. We systematically reviewed the evidence from experimental and observational studies on the association between sodium intake and blood pressure in children and adolescents. A systematic search of the Medline, Embase, CINAHL and CENTRAL databases up to March 2017 was conducted and supplemented by a manual search of bibliographies and unpublished studies. Experimental and observational studies involving children or adolescents between 0 and 18 years of age were included. Random-effects meta-analyses were performed by pooling data across all studies, separately for experimental and observational studies, and restricting to studies with sodium intake and blood pressure measurement methods of high quality. Subgroup meta-analyses, sensitivity analyses and meta-regressions were conducted to investigate sources of heterogeneity and confounding. The dose-response relationship was also investigated. Of the 6572 publications identified, 85 studies (14 experimental; 71 observational, including 60 cross-sectional, 6 cohort and 5 case-control studies) with 58531 participants were included. In experimental studies, sodium reduction interventions decreased systolic blood pressure by 0.6 mm Hg [95% confidence interval (CI): 0.5, 0.8] and diastolic blood pressure by 1.2 mm Hg (95% CI: 0.4, 1.9). The meta-analysis of 18 experimental and observational studies (including 3406 participants) with sodium intake and blood pressure measurement methods of high quality showed that, for every additional gram of sodium intake per day, systolic blood pressure increased by 0.8 mm Hg (95% CI: 0.4, 1.3) and diastolic blood pressure by 0.7 mm Hg (95% CI: 0.0, 1.4). The association was stronger among children with overweight and with low potassium intake. A quasi-linear relationship was found between sodium intake and blood pressure. Sodium intake is positively associated with blood pressure in children and adolescents, with consistent findings in experimental and observational studies. Since blood pressure tracks across the life course, our findings support the reduction of sodium intake during childhood and adolescence to lower blood pressure and prevent the development of hypertension.

Clinical Implications

HomeHypertensionVol. 70, No. 5Clinical Implications Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBClinical Implications Originally published1 Nov 2017https://doi.org/10.1161/HYPERTENSIONAHA.117.10343Hypertension. 2017;70:847Biochemical Nonadherence Screening Improves BP (p 1042)Download figureDownload PowerPointNonadherence to antihypertensive treatment is difficult to diagnose and treat. Our previous studies showed that liquid chromatography tandem mass spectrometry–based analysis provides an objective confirmation of the presence/absence of prescribed antihypertensive medications in bodily fluids and as such is diagnostically useful. In this issue of Hypertension, we also show that the biochemical analysis of urine/serum is associated with improvement in blood pressure control in hypertensive patients who are nonadherent to blood pressure–lowering therapy. The magnitude of blood pressure reduction on follow-up appointments was very powerful and similar to that normally achieved by 2 antihypertensive medications. This encouraging clinical effect is most likely explained by the improvement in adherence to antihypertensive treatment—the drop in blood pressure correlated with a biochemically confirmed improvement in adherence. Most importantly, a majority of initially nonadherent hypertensive patients responded to the initial biochemical analysis with an improvement in adherence and >50% of them converted to full adherence. The test helps clinicians to discuss nonadherence with their patients, explore their understanding of hypertension, and tailor interventions to improve nonadherence (eg, through reduction in polypharmacy and provision of pill boxes). Collectively, these data show that liquid chromatography tandem mass spectrometry–based analysis has a therapeutic potential in management of hypertension.DASH Diet, Sodium, and Blood Pressure Over Time (p 923)Download figureDownload PowerPointAlthough both sodium reduction and the Dietary Approaches to Stop Hypertension (DASH) diet are known to lower blood pressure, the amounts of time needed for either dietary intervention to achieve its full effects are unknown. In this study, we used weekly blood pressure measurements of the DASH-Sodium trial to answer this important question. Our study reports that in adults with pre-hypertension or Stage 1 hypertension, the blood pressure-lowering effects of the DASH diet occur within 1 week of initiation, and these effects are maintained up to 12 weeks. This suggests that continued consumption of the DASH diet sustains its blood pressure–lowering effects without wearing off. Meanwhile, sodium reduction progressively lowers blood pressure over 4 weeks with the possibility that even greater blood pressure reductions occur after 4 weeks. These findings suggest that sodium reduction beyond 4 weeks may be needed to experience the full effect from sodium restriction. These findings are useful for physicians counseling their patients on the adoption of lifestyle interventions. Whereas early effects can occur, full effects, especially for sodium reduction, may not occur within a month. Similarly, researchers studying the effects of sodium reduction and other interventions on blood pressure might want to extend interventions beyond 4 weeks if a trial is to document the greatest possible effect. Still, reductions in blood pressure before 4 weeks can be detected and can be substantial, but the magnitude of effect is smaller than what could occur with a longer intervention.Blood Pressure Variability in Atrial Fibrillation (p 862)Download figureDownload PowerPointSystolic blood pressure visit-to-visit variability (SBP-VVV) is a well-known predictor of major adverse clinical events in hypertensive subjects, as well as in the general population. Several studies have shown that a progressively increasing SBP-VVV is associated with a gradually higher risk for cardiac events, cerebrovascular events, and cardiovascular and all-cause death. In the context of atrial fibrillation, the role of hypertension in determining a higher risk for both thromboembolic and bleeding events is well established, but the role of SBP-VVV in determining outcomes in atrial fibrillation patients is unknown. In the current study, we demonstrate that an increased blood pressure variability is associated with a worse quality of anticoagulation control, underpinning a possible link between an overall low patients’ adherence to medications and physicians’ recommendations. Second, and perhaps more importantly, we show for the first time that a progressively higher SBP-VVV is independently associated with a proportionally increased risk for stroke, major bleeding, and death. When considering a composite clinical outcome of stroke/major bleeding/cardiovascular death, we confirm that patients with the largest variability (third and fourth quartiles of SBP-VVV) had an increasingly higher risk of adverse outcomes. Educational and therapeutic interventions to reduce SBP-VVV, as well as to improve oral anticoagulation control, are needed among atrial fibrillation patients to help reduce major adverse clinical outcomes. Previous Back to top Next FiguresReferencesRelatedDetails November 2017Vol 70, Issue 5 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.117.10343 Originally publishedNovember 1, 2017 PDF download Advertisement

A systematic review of economic evaluations of population-based sodium reduction interventions

ObjectiveTo summarise evidence describing the cost-effectiveness of population-based interventions targeting sodium reduction.MethodsA systematic search of published and grey literature databases and websites was conducted using specified key words. Characteristics of identified economic evaluations were recorded, and included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.ResultsTwenty studies met the study inclusion criteria and received a full paper review. Fourteen studies were identified as full economic evaluations in that they included both costs and benefits associated with an intervention measured against a comparator. Most studies were modelling exercises based on scenarios for achieving salt reduction and assumed effects on health outcomes. All 14 studies concluded that their specified intervention(s) targeting reductions in population sodium consumption were cost-effective, and in the majority of cases, were cost saving. Just over half the studies (8/14) were assessed as being of ‘excellent’ reporting quality, five studies fell into the ‘very good’ quality category and one into the ‘good’ category. All of the identified evaluations were based on modelling, whereby inputs for all the key parameters including the effect size were either drawn from published datasets, existing literature or based on expert advice.ConclusionDespite a clear increase in evaluations of salt reduction programs in recent years, this review identified relatively few economic evaluations of population salt reduction interventions. None of the studies were based on actual implementation of intervention(s) and the associated collection of new empirical data. The studies universally showed that population-based salt reduction strategies are likely to be cost effective or cost saving. However, given the reliance on modelling, there is a need for the effectiveness of new interventions to be evaluated in the field using strong study designs and parallel economic evaluations.

Sodium Intake and All-Cause Mortality Over 20 Years in the Trials of Hypertension Prevention

BackgroundThe relationship between lower sodium intake and total mortality remains controversial. ObjectivesThis study examined the relationship between well-characterized measures of sodium intake estimated from urinary sodium excretion and long-term mortality. MethodsTwo trials, phase I (1987 to 1990), over 18 months, and phase II (1990 to 1995), over 36 months, were undertaken in TOHP (Trials of Hypertension Prevention), which implemented sodium reduction interventions. The studies included multiple 24-h urine samples collected from pre-hypertensive adults 30 to 54 years of age during the trials. Post-trial deaths were ascertained over a median 24 years, using the National Death Index. The associations between mortality and the randomized interventions as well as with average sodium intake were examined. ResultsAmong 744 phase I and 2,382 phase II participants randomized to sodium reduction or control, 251 deaths occurred, representing a nonsignificant 15% lower risk in the active intervention (hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.66 to 1.09; p = 0.19). Among 2,974 participants not assigned to an active sodium intervention, 272 deaths occurred. There was a direct linear association between average sodium intake and mortality, with an HR of 0.75, 0.95, and 1.00 (references) and 1.07 (p trend = 0.30) for <2,300, 2,300 to <3,600, 3,600 to <4,800, and ≥4,800 mg/24 h, respectively; and with an HR of 1.12 per 1,000 mg/24 h (95% CI: 1.00 to 1.26; p = 0.05). There was no evidence of a J-shaped or nonlinear relationship. The HR per unit increase in sodium/potassium ratio was 1.13 (95% CI: 1.01 to 1.27; p = 0.04). ConclusionsWe found an increased risk of mortality for high-sodium intake and a direct relationship with total mortality, even at the lowest levels of sodium intake. These results are consistent with a benefit of reduced sodium and sodium/potassium intake on total mortality over a 20-year period.

The health gains and cost savings of dietary salt reduction interventions, with equity and age distributional aspects.

BackgroundA “diet high in sodium” is the second most important dietary risk factor for health loss identified in the Global Burden of Disease Study 2013. We therefore aimed to model health gains and costs (savings) of salt reduction interventions related to salt substitution and maximum levels in bread, including by ethnicity and age. We also ranked these four interventions compared to eight other modelled interventions.MethodsA Markov macro-simulation model was used to estimate QALYs gained and net health system costs for four dietary sodium reduction interventions, discounted at 3 % per annum. The setting was New Zealand (NZ) (2.3 million adults, aged 35+ years) which has detailed individual-level administrative cost data.ResultsThe health gain was greatest for an intervention where most (59 %) of the sodium in processed foods was replaced by potassium and magnesium salts. This intervention gained 294,000 QALYs over the remaining lifetime of the cohort (95 % UI: 238,000 to 359,000; 0.13 QALY per 35+ year old). Such salt substitution also produced the highest net cost-savings of NZ$ 1.5 billion (US$ 1.0 billion) (95 % UI: NZ$ 1.1 to 2.0 billion). All interventions generated relatively larger per capita QALYs for men vs women and for the indigenous Māori population vs non-Māori (e.g., 0.16 vs 0.12 QALYs per adult for the 59 % salt substitution intervention). Of relevance to workforce productivity, in the first 10 years post-intervention, 22 % of the QALY gain was among those aged <65 years (and 37 % for those aged <70).ConclusionsThe benefits are consistent with the international literature, with large health gains and cost savings possible from some, but not all, sodium reduction interventions. Health gain appears likely to occur among working-age adults and all interventions contributed to reducing health inequalities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3102-1) contains supplementary material, which is available to authorized users.

What Can Nutrition Education Offer To Improve Dietary Sodium Restriction Interventions For Heart Failure Patients?

Heart failure (HF) affects 26 million people worldwide and accounts for over a million hospitalizations annually with 50% of these patients readmitted within six months. A sodium‐restricted diet (SRD) is consistently recommended for HF self‐management to reduce hospitalizations; however, low adherence makes it difficult to test SRD efficacy. This has implications for patient outcomes as well as the quality of evidence used for recommendations. Therefore, interventions that effectively achieve sodium restriction are necessary. Research in the field of nutrition education suggests that effective interventions focus on behavior over information dissemination; operationalize behavior theories and mediators; and attend to social‐ecological influences on behavior at individual, interpersonal, environmental, and policy levels. In this review, we critically examined sodium reduction interventions for HF patients through a nutrition education lens.We queried PubMed, CINAHL, and Cochrane databases with relevant search terms for reports of studies published in English January 2000–October 2015. We included randomized controlled trials of interventions for HF patients that evaluated sodium restriction as a primary or secondary outcome. Of 213 studies initially identified, 174 were excluded by title. 2 reviewers assessed 39 abstracts and included 7 studies in this analysis. Reviewers noted behavior, theory, strategies, levels of influence, setting, methods, and outcomes.6 interventions reduced dietary sodium intake (n=5) or increased SRD adherence (n=1). Successful interventions had a clear behavioral target, were delivered by an RN or RD, and included counseling and/or feedback based on dietary assessments. The unsuccessful intervention was a mailed DVD with no clear behavior, individualization, or feedback. Half of the successful interventions (n=3) were theory‐based. All studies intervened at the individual level, and 2 (both successful) intervened at the individual and interpersonal levels. No interventions included environmental or policy elements. It is important to note that no interventions achieved the 1500mg/day recommended sodium intake level for adults with HF.Interventions successful in reducing dietary sodium were behaviorally focused and included clinician‐provided nutrition counseling with personalized plans and/or feedback. This is consistent with prior findings that information is not sufficient to influence behavior. To achieve the recommended level of sodium intake, interventions for HF patients must be improved. Future interventions might test the inclusion of environmental or policy strategies that influence food access in patients’ homes and neighborhoods. This review was limited by inconsistency in reporting of behavior change strategies used. For example, interventions reporting patients received counseling did not precisely explain what the counseling entailed (e.g., motivational interviewing, goal setting). Future sodium restriction intervention evaluations should emulate drug treatment trials by carefully presenting the intervention “ingredients” so more precise conclusions can be drawn about what makes interventions successful.Support or Funding InformationThis study was funded by National Institutes of Health Training Grant #HL007343

Abstract 15512: Sodium Intake and All-Ccuse Mortality Over 20 Years of Follow-up

Introduction: While several studies suggest beneficial effects of lower sodium on cardiovascular disease, the relationship with total mortality remains controversial. Some have reported a J-shaped curve, but this may be due to poor quality exposures or confounding bias. Methods: Two trials [Phase 1 (1987-90) and Phase 2 (1990-5) of the Trials of Hypertension Prevention] implemented sodium reduction interventions, over 18 months in Phase I and 36 months in Phase II. Multiple 24-hour urine specimens were collected from pre-hypertensive adults aged 30-54. In extended post-trial follow-up, deaths were ascertained through December 31, 2013 using the National Death Index. We assessed the relation of the randomized sodium interventions, as well as average sodium excretion among those not assigned to an active sodium intervention, with all-cause mortality through 23-26 years. Results and Conclusions: Among 744 Phase I and 2382 Phase II participants randomized to sodium reduction or control, 251 deaths occurred, with a nonsignificant 15% lower risk among those in the active intervention (RR=0.85, 95% CI=0.66-1.09, p=0.19). Among 3021 usual care participants, 273 deaths occurred. There was a direct but nonsignificant association of average sodium excretion with mortality, with hazard ratios (HRs) of 0.73, 0.97, 1.00 (reference), and 1.03 (p-trend = 0.38) over &lt;2300, 2300-&lt;3600, 3600-&lt;4800, and &gt;=4800 mg/d after adjustment for trial variables, with an HR=1.10 per 1000 mg/day (95% CI = 0.98-1.24, p=0.09). There was no evidence of a J-shape or other nonlinear relation. The sodium/potassium ratio had an HR=1.11 per unit (95% CI = 0.99-1.25, p=0.07). While the results did not reach statistical significance, they are consistent with a benefit of sodium reduction on total mortality over a period of over 20 years. This study, with carefully characterized measures of sodium intake, found no inverse relation with total mortality, even at the lowest levels of sodium intake.

Health and economic impacts of eight different dietary salt reduction interventions.

BackgroundGiven the high importance of dietary sodium (salt) as a global disease risk factor, our objective was to compare the impact of eight sodium reduction interventions, including feasible and more theoretical ones, to assist prioritisation.MethodsEpidemiological modelling and cost-utility analysis were performed using a Markov macro-simulation model. The setting was New Zealand (NZ) (2.3 million citizens, aged 35+ years) which has detailed individual-level administrative cost data.ResultsOf the most feasible interventions, the largest health gains were from (in descending order): (i) mandatory 25% reduction in sodium levels in all processed foods; (ii) the package of interventions performed in the United Kingdom (UK); (iii) mandatory 25% reduction in sodium levels in bread, processed meats and sauces; (iv) media campaign (as per a previous UK one); (v) voluntary food labelling as currently used in NZ; (vi) dietary counselling as currently used in NZ. Even larger health gains came from the more theoretical options of a “sinking lid” on the amount of food salt released to the national market to achieve an average adult intake of 2300 mg sodium/day (211,000 QALYs gained, 95% uncertainty interval: 170,000 – 255,000), and from a salt tax. All the interventions produced net cost savings (except counselling – albeit still cost-effective). Cost savings were especially large with the sinking lid (NZ$ 1.1 billion, US$ 0.7 billion). Also the salt tax would raise revenue (up to NZ$ 452 million/year). Health gain per person was greater for Māori (indigenous population) men and women compared to non-Māori.ConclusionsThis study substantially expands on the range of previously modelled salt reduction interventions and suggests that some of these might achieve major health gains and major cost savings (particularly the regulatory interventions). They could also reduce ethnic inequalities in health.

Lessons Learned from Community-Based Approaches to Sodium Reduction

This article describes lessons from a Centers for Disease Control and Prevention initiative encompassing sodium reduction interventions in six communities. A multiple case study design was used. This evaluation examined data from programs implemented in six communities located in New York (Broome County, Schenectady County, and New York City); California (Los Angeles County and Shasta County); and Kansas (Shawnee County). Participants (n = 80) included program staff, program directors, state-level staff, and partners. Measures for this evaluation included challenges, facilitators, and lessons learned from implementing sodium reduction strategies. The project team conducted a document review of program materials and semistructured interviews 12 to 14 months after implementation. The team coded and analyzed data deductively and inductively. Five lessons for implementing community-based sodium reduction approaches emerged: (1) build relationships with partners to understand their concerns, (2) involve individuals knowledgeable about specific venues early, (3) incorporate sodium reduction efforts and messaging into broader nutrition efforts, (4) design the program to reduce sodium gradually to take into account consumer preferences and taste transitions, and (5) identify ways to address the cost of lower-sodium products. The experiences of the six communities may assist practitioners in planning community-based sodium reduction interventions. Addressing sodium reduction using a community-based approach can foster meaningful change in dietary sodium consumption.

Early adulthood: an overlooked age group in national sodium reduction initiatives in South Korea.

BACKGROUND/OBJECTIVESSouth Korean's sodium consumption level is more than twice the upper limit level suggested by the WHO. Steep increases in the prevalence of hypertension and cardiovascular disease in Korea necessitate more effective sodium reduction programs. This study was conducted in order to compare sodium intake-related eating behaviors and key psychosocial factors according to age group and gender.SUBJECTS/METHODSUsing an online survey, a total of 1,564 adults (20-59 years old) considered to be geographically representative of South Korea were recruited and surveyed. The major outcomes were perceived behaviors, knowledge, intentions, and self-efficacy related to sodium intake.RESULTSThe results show that perceived behavior and level of self-efficacy related to low sodium consumption differed by age and gender. Female participants showed better behavior and intention towards low sodium intake than male counterparts. Young participants in their 20s showed the lowest intention to change their current sodium intake as well as lowest self-efficacy measures.CONCLUSIONSFuture sodium reduction interventions should be developed with tailored messages targeting different age and gender groups. Specifically, interventions can be planned and implemented at the college level or for workers in their early career to increase their intention and self-efficacy as a means of preventing future health complications associated with high sodium intake.