Sodium intake awareness -
Current salt intakes in the Eastern Mediterranean Region EMR are very high with an average intake of more than 12 g per person per day, which is more than double the recommended level by the WHO Bread is a popular staple food in the GCC countries, and it is one of the main contributors of salt in the diet Salt reduction interventions in the Eastern Mediterranean region focus on awareness campaigns to assist consumers in making informed choices and product reformulation to reduce salt content in processed foods Notwithstanding, hypertension and heart disease prevalence is increasing among younger population and therefore salt reduction strategies should be addressed with serious measures The Ministry of Health and prevention MOHAP in the UAE is leading the salt intake reduction strategies and activities focusing on product reformulation and empowering consumers with the knowledge needed to make healthier choices Similar findings were also reported in cross sectional studies in the UAE 15 , Similarly, a salt reduction program implementation in villages around China suggested positive effect on salt-related knowledge and attitudes of the study sample, which in turn contributed to a reduction in salt consumption That being the case, increasing the population knowledge and investing in intervention strategies related to salt reduction may assist in reducing the risk of high blood pressure and act as a preventative measure against CVDs.
Moreover, the h dietary recall revealed a high percentage of students exceeding the recommended level of dietary sodium intake Based on this population specific evidence, the current educational intervention study was designed to determine the impact of a nutrition education intervention on salt-related knowledge, attitudes, and practices among the UAE university students.
This study was approved from the University of Sharjah Research Ethics Committee UOS-REC reference number: RECS. This study was conducted according to the stated principles in the Declaration of Helsinki A written informed consent form was obtained from all participants. About students, aged 18—24 years old showed interest in the study, out of which, only 90 students met the following inclusion criteria: not having a history of hypertension, coronary artery disease or heart failure and no prior education about cardiovascular diseases.
Three were previously diagnosed with hypertension or cardiovascular disease excluded due to prior knowledge of cardiovascular diseases , eight did not complete the study survey, and twelve were lost to follow-up Figure 1.
The calculation revealed the need for a sample of 57 participants to be included in the study. Anthropometric measurements including height and weight were determined. Height was measured without shoes and recorded to the nearest 0. Weight was measured with light clothing on and recorded to the nearest 0.
Measurements were performed using a calibrated medical scale and stadiometer SECA ; Seca, Hamburg, Germany. A pre-intervention bilingual English and Arabic multicomponent, self-administered questionnaire was administered to students. This questionnaire was previously validated in student's population and adult population aged 20—60 years old in the UAE 15 , The details of the KAP questionnaire have been described elsewhere 15 , The full version of the questionnaire is available a Supplementary File.
After completing the pre-intervention assessment, students attended an educational workshop on the importance of salt reduction.
The educational material was given to participants through a single 1-h interactive session via power point presentation followed by 30 min activities to ensure involvement of the participant. The 1-h educational presentation included information on definition of salt, differences between salt and sodium, salt intake recommendation compared to average salt consumption, food labels reading to identify low, medium, and high salt foods, strategies for salt intake reduction along with meal alternatives ideas, and information about salt related diseases.
The 30 min activities post presentation included guessing games such as estimation of sodium amount in various provided food samples, categorization of some commonly consumed dishes to low and high sodium content, and differentiation between two salad dishes: one contained salt in the dressing and the other one with spices and herbs substituting the salt.
Toward the end of the session a leaflet was distributed to each participant including a summarized version of the information provided in the session.
The post-intervention questionnaire was conducted immediately after the students attended the educational workshop and read the leaflet.
The post-intervention assessment questionnaire included only the knowledge and attitude sections of the KAP questionnaire because salt-related behavior would require time to change.
Therefore, the change in practices was assessed in the 4-week follow-up. After 4 weeks of the intervention session, students were invited again to complete a follow-up KAP questionnaire.
The KAP questionnaire included all three components; knowledge, attitudes, and practices, and was repeated to assess the long-term impact of the educational workshop and the material provided. Continuous data were expressed as mean ± standard deviation SD , and categorical data were expressed as counts and percentages.
Comparisons between baseline, immediate post-intervention, and 4 weeks post-intervention were conducted using the McNemar test. Knowledge scores ranged from 0 to 29 based on the number of correct answers, attitude scores ranged from 0 to 5 based on positive attitudes toward salt, and practice score ranged from 0 to 13 based on the number of positive practice responses 15 , Scores were calculated for all components in the pre-intervention and in the 4-weeks follow up.
However, only knowledge and attitude scores were calculated immediately post-intervention. Comparison between knowledge scores at baseline, immediate post-intervention, and 4 weeks post-intervention was conducted using the paired sample t -test.
Participants were stratified based on based on their responses to seven of the practice questions to low-risk, moderate-risk and high-risk groups Consequently, participants with zero points were categorized as low risk for high salt consumption, participants with 1 point as moderate risk, and with 2 or more points as high risk Data was analyzed using SPSS software 27 , version A total of 90 students participated in the study.
Key demographic variables are shown in Table 1. The majority of the participants were enrolled in applied science majors Almost half of the participants had normal BMI The number and percentage of students who answered knowledge related questions correctly is shown in Table 2.
During pre-intervention, sodium percentage in salt was identified correctly by only A high proportion answered correctly to higher salt intake and its relation to a disease risk factors; hypertension Similarly, most of the students knew that reducing the salt intake will improve the general health Most of the participants categorized the salt contact in the following foods correctly: instant noodle Whereas, less than a third answered correctly for Iranian bread Table 2.
Regarding attitude toward salt Table 3 , Table 3. Regarding practice habits as shown in Table 4 , Only Furthermore, When asked about measures taken to reduce salt intake, Table 4.
Knowledge and attitude were reassessed immediately after the educational session. As shown in Table 2 , there was a significant improvement in answering correctly about the percentage of sodium in salt Moreover, significant increases in identifying most food items as high or low sodium food sources were evident post-intervention except for Egyptian rice, milk, salad dressing oil, poultry, corn flakes, and chicken cubes.
Likewise, students were able to correctly identify the relationship of high dietary salt intake to health and disease Table 2. As presented in Table 2 , there was a significant increase in the correct answers for most knowledge related questions from baseline pre-intervention to the 4-weeks follow up.
Percentage of sodium in salt was identified correctly by The remaining practices showed an increase in positive responses; however, no significant improvement was found between the pre-investigation and the 4-weeks follow-up.
The average knowledge score at baseline was It increased significantly to A similar trend was observed for attitude scores, where the average attitude score pre-intervention was 1.
Moreover, the practice score increased from 2. Figure 2. Mean knowledge scores of pre-test, post-test, and follow up. The p -value indicates the statistical significance of the paired sample t -test.
At baseline, Moreover, at baseline, Figure 3. Risk of high-salt consumption categories for student's pre-test and at 4-weeks follow up low risk, moderate risk, and high risk. The p -value indicates the statistical significance of the McNemar test.
The aim of this study was to determine the efficiency of applying evidence-based nutrition intervention on salt related knowledge, attitudes, and practices among non-medical students at the University of Sharjah using a validated multi-component questionnaire and an educational interactive session.
Parameters were measured before and after the intervention to allow comparison. The results revealed that salt-related knowledge improved significantly immediately post-intervention, but it was the knowledge was not fully retained until the 4-weeks follow-up, however it remained above the baseline.
Moreover, improvement in the high-risk for salt consumption group was recorded, as a shift was observed toward the moderate-risk group and a trend toward practice category improving from baseline to the follow-up was shown.
These findings were consistent with the previous study among the UOS students For example, the mean knowledge score in this study was Also consistent with the results of health science students in Bangladesh on salt related knowledge Moreover, more than half of the students in the current study estimated that they consume just the right amount of salt.
However, the same study estimated that more than two-thirds of the participants exceeded the WHO recommendations These findings suggest that perceived intake does not necessarily reflect actual intake.
Most of the students were aware of the obvious adverse health effects associated with high salt intake. Similar findings were reported in several studies in the UAE, European countries and the Lebanon investigating salt related knowledge, attitude, and behavior 15 , 16 , 28 , Also, more than three in four students indicated that salt reduction would actively improve their health and blood pressure which was in contrast to a study reported among adults in Montenegro where less than half of the participants had the same indication Furthermore, findings showed that less than a quarter of the participants check food labels and use the information on food labels to guide their purchasing decisions.
More worryingly, a very small proportion of students check for salt content on the food label and use it to guide their food choices. Findings in a study among adult consumers in Lebanon revealed much lower proportion for checking food labels than those reported in the UAE; stating that food labels are not adequately utilized by participants Therefore, an awareness of the health risks associated with high salt consumption is recommended to increase salt label usage and purchases of low salt foods.
With respect to knowledge, in all questions, the percentage of correct answers of the immediate post-intervention was significantly better compared to the pre-intervention baseline. After 4 weeks follow-up, the percentage of correct answers showed that retention of knowledge of students slightly decreased in comparison to the immediate post-intervention, however remained above baseline.
A similar pattern was seen in a previous study conducted in Lebanon Similarly, a cohort study conducted at Lurio University, Mozambique, evaluating knowledge retention showed a decrease in knowledge after 6 months compared to post-test Despite the difference in the follow up time intervals, the general trend of decline in knowledge is consistent.
Moreover, historically a similar decay in knowledge-retention over time following an educational program is shown in other studies 32 , Due to the fact that knowledge is an important driver of attitudes and practices, it is expected that a decline in knowledge will be accompanied by similar drop in favorable attitude responses As it is evident in our results, after 4 weeks there was a decrease in the positive attitude response compared to baseline simultaneously with the decline in knowledge, however knowledge remained above baseline.
Therefore, conducting frequent periodical educational sessions along with testing knowledge has been used effectively to ensure long-term knowledge retention 35 , Aligning with our study, such strategy where students are educated on aspects of knowledge and followed-up must be implemented.
Several salt related practices showed significant improvements after the 4 weeks follow up, such as trying to purchase low-salt food and rarely adding salt to food at the table. However, no significant improvement was found in other salt-related practices such as using stock cubes during cooking and adding salt before tasting the food.
The results are consistent to what was found in the intervention study performed in Iran, in which it was shown a significant increase in the mean and standard deviation of KAP among the intervention group, and a significant decrease in the mean salt intake Nonetheless, in a study investigating the impact of community-based salt reduction program in Australia, the proportion of participants reporting salt reducing practices such as avoiding processed foods and checking food labels decreased significantly Our results indicate a trend toward an improve in the salt-related practices from baseline to the 4-weeks follow-up such as trying to buy low-salt food, rarely adding salt during cooking or at the table and trying to reduce salt intake by using spices.
Evidence suggests that intervention strategies including peer group education has shown similar positive impact on salt-related practices and salt consumption.
A study among adults having at least one risk factor of CVD indicated beneficial effects of peer group intervention on cardiovascular risk factors, with significant improvements in total score and more specifically on tobacco cessation Moreover, a national consumer awareness campaign about the negative effect of salt on health in the United Kingdom has shown promising results as it indicated a significant decline in using salt at the table Another randomized clinical trial depicted a lower dietary sodium intake among the intervention group There are several limitations to this study.
The findings may not be generalized to all young adults in the UAE as our study was restricted to the non-medical major university students. Including participants who showed an interest in the study self-selection is likely to create a group of more motivated persons which could affect sample representativeness.
In addition, the questionnaire included the use of self-reported attitudes and practices, that possibly might cause some respondent bias or misreporting of data that may not accurately reflect actual attitudes and practices. Another limitation to this study was the use of a single contact intervention due to time constraint.
Hence, future studies with multiple interactions are encouraged to induce long-term benefits. Our study showed a significant increase in knowledge and positive salt related attitude immediately post-intervention. This increase remained significant after the 4-weeks follow-up.
However, there was a tendency to have a slight decline in knowledge after 4-weeks as it was only a single contact. A complementary educational method is advised to enhance retention of knowledge and probably have an impact on salt-related attitudes and practices.
On the other hand, it was evident that changes in practice were not as prominent as changes in knowledge and attitude. This is possibly related to poor dietary habits and high consumption of fatty food, snacks, sugar, and fast food that is evident in this age group.
In conclusion, it is crucial to conduct several specifically designed awareness sessions and space them over time in conjunction with creative intervention programs focusing on the proper way of reading and using food and salt labels.
Moreover, it is suggested to deliver nutrition related message using social media, given that this generation is most influenced by these platforms.
It is also suggested to mandate at least one nutrition education course for all university students as well as ensuring the provision of a wide variety of healthy food options with low salt content at the university campus cafeteria and healthy vending machine snacks.
Future research should also focus more on a long-term knowledge retention to investigate the impact of salt-reduction interventions on related attitude, practice, and overall health.
Conducting similar studies on a large scale is recommended to be able to generalize results to the young adult population. The datasets presented in this study can be found in online repositories. The studies involving human participants were reviewed and approved by the University of Sharjah Research Ethics Committee UOS-REC reference number: RECS.
LC, MH, AJ, MM, and AA: conceptualization and methodology. LC, MM, and SS: formal analysis. LC, MH, RAD, RAR, SA, AA, SQ, and FM: investigation. LC, SS, MM, and AA: writing—original draft preparation. LC, MH, AJ, MM, RAD, RAR, SA, AA, SQ, FM, SS, LS, and AA: writing—review and editing.
MM: visualization. LC: supervision. All authors have read and agreed to the published version of the manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.
The reported use of the sodium label in our study was significantly lower than a similar study conducted in New York City Moreover, in our logistic regression analysis, although we found that educational levels meant a higher awareness of the sodium label and better understanding of the relationship between salt and sodium, it did not transfer to the use of the sodium label when other factors were controlled.
This means that although people with relatively high education levels were equipped with some basic knowledge and understanding of the sodium label, this knowledge did not result in them reading the NIP when shopping. This may be partially due to that health is not always the top driver of food choice.
Compared to the traditional NIP on the back of pack, front-of pack FoP labelling may be another effective way to convey sodium or salt information to the public. FoP labelling has been adopted by some countries to provide clearer information on nutrition information of food.
FoP labelling has been proven in various studies to be easier to understand and more effective for consumers in helping them to choose healthier foods [ 17 , 18 , 24 , 25 ]. In addition, FoP labelling is believed to encourage food manufactures to reformulate their foods.
In the s, Finland introduced legislation to require food products containing a high level of salt to carry a high salt warning [ 15 ]. As a result, food companies reformulated their products and some high salt products disappeared completely from many shops.
Assisting consumers to choose lower-salt foods should not be limited to nutrition labelling itself. Smartphone applications by various research groups to help the public choose healthier food. Consumers scan the barcode on the package of the food and the nutritional information is presented in traffic light colour-coded format.
In addition, healthier alternatives will be listed underneath the NIP of the scanned food [ 26 ]. A recent study has shown that SaltSwitch helpful consumers choose low-salt foods [ 26 ]. However, evidence has shown that the implementation of education and awareness-raising interventions alone are unlikely to be adequate in reducing population salt intake to the recommended levels [ 28 ].
New methods of health promotion on salt reduction should also be considered, for example, advocacy in schools. A study conducted in Northern China showed that integrating salt reduction into routine education for primary school children to be very successful.
Several limitations existed in our study. Firstly, the survey was conducted in central districts of Beijing, where the level of awareness of sodium labels is higher than average. Secondly, as the study sample was not population-representative the results may not be representative of the whole country.
Thirdly, nearly all the questions we designed were single or multiple choice. This may skew results due to a limited choice for answers on the questionnaire.
Our survey showed that the participants had a good understanding of the harmful effects of salt, but the awareness and use of sodium labels was very low in Beijing. There may be less awareness of salt and NIPs nationwide. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, Baugh V, Bekedam H, Billo N, Casswell S, et al.
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School based education programme to reduce salt intake in children and their families school-EduSalt : cluster randomised controlled trial. BMJ Clinical research ed. Download references. We express our appreciation to all participants in this study for their participation and co-operation, to the leaders and staffs of Xicheng District Center for Disease Control and Prevention and Haidian District Administration Center for Community Health Service for their co-operation and organization in the data collection.
However, some data is available from the corresponding author. The George Institute for Global Health at Peking University Health Science Center, Level 18, Tower B, Horizon Tower, No. Department of Social Medicine and Health education, School of Public Health, Peking University, No.
Xicheng District Center for Disease Control and Prevention, No. Haidian District Administration Center for Community Health Service, No. You can also search for this author in PubMed Google Scholar.
PZ and WN designed this research, and gave directions for the analysis and interpretation of data for the work. YH and SY conducted the data collection with the help from LL and HW. The manuscript was drafted by YH and critically revised by LH, YL and other authors. YH and LH equally contributed to this research.
All the authors participated the work of questionnaire design, and gave constructive suggestions for the implementation of this survey, and all reviewed the manuscript and approved the publication. Correspondence to Puhong Zhang. Ethical approval was given by the medical ethics committee of Peking University Institutional Review Board PU IRB with the following reference number IRB—Exempt.
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Open Access This article is distributed under the terms of the Creative Commons Attribution 4. Reprints and permissions. He, Y. et al. Awareness, understanding and use of sodium information labelled on pre-packaged food in Beijing:a cross-sectional study.
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