An Interventional Study of Salt and Sugar Reduction in Foods Sold On a University/College Campus in Malaysia
Phase: NA
Conditions: Cardiovascular Diseases
Sponsor: Sunway University

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Cover page 
 
ID: 20241904 
 
Topic:  Reducing Salt and Sugar in 
Campus Foods: A Malaysian Study 
 
NCT number: Not assigned yet 
Date of Document: 18 June 2024 
 
 
 

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Research Background: 
Cardiovascular disease stands as a significant global health challenge, ranking among 
the primary causes of premature death and disability, especially in developing 
countries. The burden of cardiovascular disease persists as the primary cause of 
death in Malaysia. 
 
In Malaysia, high blood pressure (BP) has consistently emerged as a leading 
contributor to premature mortality. The 2019 National Health and Morbidity Survey 
(NHMS) revealed a 30% prevalence of hypertension among Malaysian adults aged 18 
and above. Alarmingly, despite the prevalence increasing with age, nearly two-thirds 
of hypertensive individuals remain undiagnosed (1).  
 
Research indicates that a mere 2mmHg rise in systolic blood pressure (BP) 
significantly elevates mortality rates from stroke and ischemic heart disease in adults. 
Research has also shown the association of salt/sodium intake to BP and that the 
reduction in salt/sodium intake is also associated with lower BPs and low CV deaths. 
 
The mean intake of salt in Malaysia is 7.9gm/day much higher than that recommended 
by WHO of <5 gm /day (2). In fact, the WHO has set the reduction of population salt 
intake by 30% by 2025.  
  
According to the Malaysian Adult Nutrition Survey (MANS 2014), 70% of Malaysians 
regularly dine out, especially in urban areas and Peninsular Malaysia (3). In 2019, 
household spending on out-of-home foods increased to 11.2% from 8.7% in 
2004/2005 (4). The trend of consuming meals away from home, particularly during 
breakfast, has gained popularity in countries like Uganda (5) and Malaysia.  
 
From a study conducted among Malaysians by Arifen and colleagues (6), consumers 
and food operators in Malaysia perceive high salt intake in the out-of-home food sector. 
Food operators stress the need for a comprehensive salt reduction policy involving all 
stakeholders. Consumers face limited awareness and knowledge, counterproductive 
practices among food operators, and challenges in accessing affordable low-sodium 
products. Food operators encounter a lack of standardized guidelines, effective 
enforcement, and uncooperative consumer practices. The interviews among food 
vendors, caterers and consumers identify barriers such as food quality and salt prices, 
advocating for awareness campaigns, stricter regulations for manufactured foods, and 
enhanced enforcement.  
 
University students and staff members on campus, especially those who frequently 
eat out and spend considerable time on campus, form a crucial demographic facing 
challenges related to high salt and sugar intake in out-of-home food. Recognizing the 
prevalence of this lifestyle among these population, it becomes imperative to 
understand the perceptions and experiences of both students and campus 
communities regarding salt and sugar consumption. Furthermore, serving lowered salt 
foods at workplaces have been shown to be able to reduce salt intake by at least 0.5 
g/day. 
 
In this study, we aim to shed light on the dynamics of the university campus food 
environment, where students and campus communities heavily depend on vendors 
for their meals. The insights gained will not only benefit the individuals who regularly 

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eat out but will also contribute to creating a healthier food landscape on university 
campuses, impacting the overall well-being of the individuals. This study holds 
significance in addressing the shared responsibility between individuals who use out-
of-home food and vendors in promoting a healthier lifestyle within the university 
community. 
 
Thus, this study aims to assess the effects of salt and sugar reduction in foods sold 
on campus at the university. For the first part of the study, the knowledge, attitude, 
and practice (KAP) of dietary salt and sugar intake among the university students and 
staff will be assessed. For the second part of the study, KAP, barriers and enablers of 
salt and sugar reduction among campus canteen staff will be conducted. Concurrently, 
a third part of the study involves a 6-month interventional study on salt and sugar 
reduction in foods sold on campus. For this part of the study, firstly, the sodium and 
sugar contents of selected foods sold on campus will be assessed. Then, selected 
participants will be invited to participate in the interventional where they will be 
exposed to foods sold on campus that have reduced salt and sugar. 
 
The project acknowledges the interconnectedness of diet and cardiovascular health,  

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Figure 1: Diagram of the study design 

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Study methodology 
This study will be conducted among the the university community comprising of 
students and staff. 
 
Part 1: KAP on dietary salt and sugar intake 
It will be open to the entire community, and the community has the right not to do the 
survey or withdraw at any point. 
 
Sample size calculation 
Using Raosoft sample size online calculator (http://www.raosoft.com/samplesize.html), 
a minimum sample size of 370 is needed in order to achieve a 5% margin of error, 95% 
confidence level,  
 
Instrument 
The online validated questionnaire will assess: 
1. Socio-demographic and lifestyle factors – questions such as age, gender, ethnicity, 
medical history, smoking and alcohol-drinking practices 
2. KAP towards dietary salt and sugar intakes, and diabetes 
3. Barriers and enablers for salt reduction  
 
Inclusion criteria 
1. Students and staff aged 18 years and above 
2. Able to provide informed consent (verbal/written) to participate 
3. Understands English  
 
Exclusion criteria   
1. Individuals with acute illness, psychological or psychiatric conditions 
 
Compensation to participants 
No compensation but they are entitled to enter a lucky draw to win three lucky draw 
food hampers. 
 
Part 2: KAP, Perception, Barriers and Enablers of Salt and Sugar Reduction 
among Campus Canteen Staff 
 
Sample size calculation 
The estimated number of campus canteen staff that are involved in food preparation 
is around 65 people, and given an estimate response rate of 80%, the targeted number 
of participants is around 50 people.  
 
Instrument 
A questionnaire on KAP, perceptions, barriers and enablers to salt and sugar reduction 
will be administered among the canteen staff that are involved in food preparation. 
 
The online validated questionnaire will assess: 
1. KAP towards salt and sugar usage in food preparation (including on campus) and 
in dietary intake 
2. Perception, barriers and enablers for salt reduction during food preparation on 
campus 
 

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Inclusion criteria 
1. Canteen staff that are involved in food preparation aged 18 years and above 
2. Able to provide informed consent (verbal/written) to participate 
3. Understands English  
 
Exclusion criteria   
1. Individuals with acute illness, psychological or psychiatric conditions 
 
Compensation to participants 
They will be given RM 10 for each successful completion of questionnaire. 
 
Part 3: An interventional study for 6 months will expose them to foods sold on 
campus that have reduced salt and sugar.  
Study A 
Selected samples of food sold on campus will be analysed for their sodium and sugar 
contents at baseline and also 3 months after the intervention of salt and sugar 
reduction. This will be performed using dry ashing method, followed by flame atomic 
absorption spectrometry (FAAS) at the Department of Nutrition, Universiti Putra 
Malaysia. 
 
A targeted 5 food samples per vendor for 17 vendors – taken at baseline and 3 months 
after invention will yield a total number of 170 samples. 
 
Study B 
Before the actual lowering of salt and sugar in foods sold at SEG, all the food vendors 
will be briefed on the amount of salt and sugar to be reduced for all the foods sold. 
 
Sample size calculation 
According to WHO/PAHO Regional Expert Group for Cardiovascular Disease 
Prevention through Population-wide Dietary Salt Reduction Sub-group for Research 
and Surveillance (7), to meet the 0.5 g difference in sodium (salt), the sample size 
required will be 150 per arm.  
 
Therefore, a total of 150 participants who eat often foods sold on campus will be 
selected from Part 1 in a randomized manner and they form the intervention group 
who will be eating the foods sold on campus that have reduced salt and sugar. Another 
150 participants who do not eat often the food sold on campus will be the control group. 
 
Participants will need to provide urine samples for the measurement of urinary sodium, 
potassium, chloride, and creatinine, have body composition and anthropometric 
measurements taken, perform 24-hour dietary records, perform saltiness intensity 
perception and pleasantness ratings of the foods on campus, at three timepoints - at 
the start of the study, after 3 months and after 6 months. 
 
Inclusion and exclusion criteria  
 
Inclusion criteria for intervention group 
1. Individuals who eat on campus food for at least 3 meals per week 
2. Consent to participate  
 

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Inclusion criteria for control Group 
1. Individuals who do not eat on campus food or for <3 meals per week 
2. Consent to participate  
 
Exclusion criteria   
Individuals with acute illness, psychological or psychiatric conditions 
 
Compensation to participants 
They will be given RM 10 for each successful completion of questionnaire, dietary 
records, anthropometric and body composition measurements, saltiness intensity 
perception and pleasantness ratings, and providing urine samples at three timepoints 
- at the start of the study, after 3 months and after 6 months (maximum RM 30 per 
participant). 
 
Instruments 
Urine analysis 
Intervention and control participants will provide two spot urine samples - first morning 
void and last void in the evening before leaving campus, at three timepoints - at the 
start of the study, after 3 months and after 6 months. This will yield a total of 300 × 2 
× 3 = 1800 samples. Urine electrolytes (sodium, potassium, chloride) and creatinine 
will be measured using the potentiometry method (Alinity Abbott) at the laboratory 
department.  
 
Assessment of saltiness intensity perception and pleasantness ratings 
Participants will receive verbal and written English instructions and then completed 
two rating scales assessing the intensity of saltiness of the selected foods sold on 
campus they perceived (hereafter referred to as ‘intensity perception’), and the extent 
to which they liked or disliked this level of saltiness of the selected foods sold on 
campus (hereafter referred to as ‘pleasantness rating’). The perceived saltiness 
intensity will be measured by using the generalised Labelled Magnitude Scale (gLMS) 
(8) where the participants will be asked to make a horizontal marking on the paper 
versions of it. A 100 mm scale was constructed with six different descriptors which 
were ‘‘barely detectable’’,‘‘weak’’, ‘‘moderate’’, ‘‘strong’’, ‘‘very strong’’ and ‘‘strongest 
imaginable sensation of any kind’’ were spaced at 1.4 mm, 6 mm, 17 mm, 35 mm, 53 
mm, and 100 mm, respectively. For pleasantness, the Labelled Affective Magnitude 
(LAM) scale (9) will be used. It is a 100 mm scale that is constructed with 11 different 
levels – ‘‘greatest imaginable disliking’’ (0 mm), ‘‘dislike extremely’’(12 mm), ‘‘dislike 
very much’’ (22 mm), ‘‘dislike moderately’’(34 mm), ‘‘dislike slightly’’ (45 mm), ‘‘neither 
like or dislike’’(50 mm), ‘‘like slightly’’ (56 mm), ‘‘like moderately’’ (68 mm), ‘‘like very 
much’’ (78 mm), ‘‘like extremely’’ (87 mm), ‘‘greatest imaginable liking’’ (100 mm). 
  
Anthropometric and body composition measurements 
Clinical measurements indicative of vascular health namely systolic blood pressure 
(SBP), diastolic blood pressure (DBP) and pulse rate will be taken using an automated 
blood pressure monitor (HEM-7121, Omron, Japan) after the subjects have rested for 
5 min. The height, waist and hip circumferences will be measured using a measuring 
tape and waist-hip ratio (WHR) will be calculated by dividing waist circumference by 
hip circumference. A bio-impedance body composition scale (Omron HBF-375 Karada 
Scan) will be used to determine weight, body mass index (BMI), total body fat (TBF), 
visceral fat (VF), subcutaneous fat (SF), skeletal muscle percentage (SM) and resting 

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metabolism rate (RM). The cut-off points for overweight, obesity, overall adiposity 
(TBF) and central adiposity (WHR) are ≥23 kg/m2, ≥25 kg/m2 (10), 20% (males) or 
30% (females) (11) and 0.90 (males) or 0.85 (females)(12), respectively. 
  
Data analysis 
All statistical analysis will be done using the Statistical Package for Social Sciences 
(SPSS) version 27. The prevalence of KAP will be computed. Continuous data will be 
described as mean and standard deviation if the distribution is normal. However, when 
the data is a skewed distribution; median and interquartile range (25-75th percentiles) 
will be used. Categorical data will be reported as proportions (percentage). Chi-square 
test or Fisher exact tests will be used for the categories or dichotomous predictors. 
Factors associated with KAP towards intention to reduce salt and sugar intake will be 
determined using multiple logistic regression analysis. 
 
The change in amount of salt and sugar reduced in food and the change in the amount 
of salt intake by participants will be analysed by a comparisons of means All analyses 
will be done with 95% confidence intervals (CI), and the level of significance will be 
set at p<0.05.     
 
Ethics approval  
Ethics approval will be obtained from the Ethics Committee of the Organization. 
 
 

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I, _______________________________________________________  
  
consent to participate in the study of  
  
An Interventional Study of Salt and Sugar 
Reduction in Foods Sold On Campus 
  
I understand the procedures described above. My questions have been 
answered to my satisfaction, and I acknowledge that I am participating in this 
study of my own free will. I understand that I may refuse to participate or stop 
participating at any time.  
  
By signing this consent form, I agree to the collection of my name, contact 
number, and email address, solely for the purpose of follow-up in Part 2 of the 
study.  All my information obtained in this study will be kept and handled 
confidentially, in accordance with the Malaysian Personal Data Protection Act 
2010 ("PDPA")  
  
Participant  
Investigator conducting the 
informed consent  
  
Signature: ____________________  
  
Signature: ____________________  
Date       : ____________________  
Date       : _____________________  
Contact No : __________________  Name      : ____________________  
-mail: _______________________