Award Title: NIHR Global Health Research Unit Action on Salt China (ASC), Queen Mary University of London
Funder: Department of Health and Social Care

Abstract: Salt reduction lowers blood pressure and reduces cardiovascular disease including strokes, heart attacks and heart failure. China is the largest developing country in the world. Salt intake in China is very high with an average daily intake of 12-14 g/d.  Over 244 million Chinese adults had hypertension in 2012 and raised blood pressure attributed to 2.33 million cardiovascular deaths. _x000D_
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To support China to reduce its population salt intake, the UK–China Collaboration Unit – Action on Salt China (ASC) has been set up, built upon an established collaboration between QMUL (Queen Mary University of London) and TGI (The George Institute for Global Health) China. The aim of ASC is to develop and implement a comprehensive, effective and sustainable salt reduction program in China. The goal is to achieve a 15% reduction in salt intake by 2021, and contribute to China’s commitment of achieving WHO’s target of 30% reduction of population salt intake by 2025.  _x000D_
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ASC has developed a strategic plan with a series of coherent programs including (1) health education to increase salt awareness; (2) community, school and family-based education programs to encourage individuals to reduce salt used at home; (3) reducing salt in restaurant meals; and (4) reformulation by setting salt targets for processed food, improving nutritional labelling and providing tools to help consumers to choose foods with less salt. Four cluster randomized control trials will be carried out in 6 provinces in 2018-2019, to test a series of salt reduction intervention packages targeting different settings and populations, and scale-up activities will be conducted in 2020-2021. Baseline, mid-term and final assessment of salt intake will be carried out through the gold standard method of 24h urine collection, to assess effects of the interventions. _x000D_
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ASC will also launch public health campaign, to engage food industry, catering sector, media and the general public to reduce salt. The progress and outcomes of ASC activities will be delivered through ASC communication tools, including quarterly newsletter, website, press release, and through other communication approaches such as WHO bulletin and WASH (World Action on Salt and Health) website and social media.  Research outputs generated from the project will be translated into population wide policies to ensure sustainability beyond the project duration. _x000D_
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ASC is led by QMUL in UK and TGI (China), in partnership with several Chinese governmental organizations including three institutions from Chinese Centre for Disease Control and Prevention (China CDC) - Division of Health and NCD Control and Community Health (NCD Division), National Centre for Chronic and Non-communicable Diseases Control and Prevention (NCD Centre), and National Institute for Nutrition and Health (NINH); Chinese Centre for Health Education (CCHE) and China National Centre for Food Safety Risk Assessment (CFSA). _x000D_
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A reduction in salt intake will benefit the whole population in China. ASC will deliver measurable health gains to many people. It will also make academic advances and deliver new scientific knowledge, which will benefit many Chinese researchers. The project commenced on June 1, 2017 and will be completed on March 31, 2021. The total amount awarded is GBP 6,607,474.

Lay Abstract: Global Health is a key area of focus at QMUL, supported by our internationally recognised medical research (we are ranked among the top 5 Medical Schools in the UK for Clinical Medicine and Population Health, 2014 REF); strong clinical expertise through our partnership with Barts Health NHS Trust; strong interdisciplinary teams across QMUL in Life Sciences (QMUL is ranked 9th among UK multi-disciplinary universities and a track record of productive international collaborations). Global Health is a key strand of QMUL’s Life Sciences Initiative (LSI), a multidisciplinary endeavour involving all three of our Faculties. QMUL is a leading health research school with extensive global health experience. _x000D_
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Excessive salt intake is linked to over 1.6 million deaths globally each year, about 80% of which occur in developing countries[1]. WHO requires member states to reduce salt by 30% by 2025[2]. Average salt intake in China is high at 12-14 g/d[3]. Salt reduction will have enormous health benefits. _x000D_
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The success of the UK’s salt reduction programme[4] was largely attributable to the work of CASH[5]. Following the success of CASH, WASH (World Action on Salt and Health)[6] was set up in 2005 with a mission of reducing salt globally. WASH has helped many countries develop a salt reduction strategy. _x000D_
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CASH and WASH brought together broad expertise in nutrition and health (23 experts in UK and over 540 members from 100 countries) which will provide strong support to ASC. QMUL will provide scientific, infrastructure, personnel, financial and administrative support with an in-kind of £227,437. _x000D_
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CASH and The George Institute for Global Health China (TGI China) have had many years’ collaboration in NCDs prevention. TGI China is a leading health research institute benefiting from strong links with health authorities in China, especially those related to salt reduction. This application will strengthen our collaboration with TGI China and further expand our partnership in China to health authorities including Chinese Center for Health Education (CCHE), China National Centre for Food Safety Risk Assessment (CFSA) and three departments/institutes from Chinese Centre for Disease Control and Prevention (China CDC) including Division of Health and NCD Control and Community Health (NCD Division), National Centre for Chronic and Non-communicable Disease Control and Prevention (NCD centre) and National Institute for Nutrition and Health (NINH), which have all agreed to be involved. _x000D_
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Lifestyle intervention is a priority of the Chinese government, however, there is lack of a comprehensive salt reduction programme. Almost half of the Chinese live in rural areas where many are poor with very high salt intake and limited access to health information. By 2015, there were 592 poverty-stricken counties with more than 55 million living on less than US$1/day. This application is highly relevant to China’s agenda on health and development. Exporting our experience and expertise will help China strengthen their current effort and capacity in salt reduction. Building relationships with key stakeholders in China to produce champions for the cause of salt reduction will assist in sustainability. _x000D_
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To benefit the poorer people and maximise the value for money, we will target 5 provinces (Xinjiang, Gansu, Shaanxi, Jilin, Heilongjiang) with high salt intake, large population (>20 million each) and lower GDP. A multidisciplinary team will be formed with engagement from health authorities, research institutes, universities,  NGOs, food industry and other social sectors from both UK and China to develop specific research programmes to target the main contributors of salt (food prepared at home, pre-packaged and restaurant food)[7, 8]. Each programme will be led by a delegated participating team who have the expertise and authority in the specific area. Local and central governments will be involved to ensure swift translation of practice to policies. _x000D_
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Programme 1: Health education and promotion _x000D_
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This will be a nation-wide salt reduction education with various formats depending on the settings to increase salt awareness and master salt reduction skills. Health education and promotion will be a key programme and the basis of all other programmes._x000D_
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Programme 2: Reducing salt in home cooking _x000D_
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About 80% salt is added by the consumer[7, 8] and a priority is to educate the person who does the cooking at home to use less salt. Tailored health education will be delivered by community health workers, women’s federation, family planning workers and the “new family planning – family capacity building” scheme which aims to increase health literacy of family members. Moreover, we will educate primary schoolchildren to instruct their families to reduce salt. Our previous study, i.e. School-based Education Programme to reduce salt (School-EduSalt) demonstrates that this approach is effective in lowering salt intake by about 25% in both children and adults in northern China[9]. To facilitate the implementation of the School-EduSalt programme, we will develop a smartphone app (AppSalt) to combine School-EduSalt with our previous work on KnowSalt app[10] (an app to estimate salt intake and identify major sources of salt) to allow family members to acquire salt reduction knowledge, set salt target, assess salt intake and monitor progress. _x000D_
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Programme 3: Reducing salt from pre-packaged food _x000D_
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China became the world’s biggest consumer of pre-packaged food[11]. Most of them are extremely high in salt[12, 13]. The UK is a great example to work with food industry to set incremental lower salt targets to reduce salt in over 80 categories of food. We will deploy similar strategies in China to reduce the salt level in pre-packaged food. Additionally we will work with relevant authorities to amend nutrition labelling regulations on pre-packaged food and urge the adoption of a front-of-pack (FoP) labelling (e.g. traffic light system) to allow consumers to choose healthier food. Furthermore, we will promote the tool, Foodwitch China (a smartphone application have been developed by TGI)[14] to help consumers choose healthy food._x000D_
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Programme 4:  Reducing salt from food eating out of home_x000D_
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More and more people eat out of home nowadays. We will work with restaurants and other food outlets to create healthy eating environment. We will launch various campaigns to target restaurants and canteens in schools, universities, work places and hospitals and train chefs to develop lower salt menu. We aim to set standards on salt in restaurant food and adopt menu labelling. _x000D_
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Short term objectives (1-2 years):_x000D_
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•	Set up governance structure and strategies, and outline scope of work_x000D_
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•	Finalise protocols _x000D_
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•	Develop and pilot education materials and tools _x000D_
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•	Set up mechanisms for restaurants and food manufacturers to reduce salt_x000D_
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•	Launch all programmes_x000D_
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•	Complete baseline survey_x000D_
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Medium term objectives (2-3 years):_x000D_
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•	One-third of the target population are aware of the key messages and skills on salt reduction _x000D_
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•	One-fifth of the target population know the amount and source of salt _x000D_
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•	One-third restaurants will remind the consumers to select lower salt food _x000D_
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•	Key food manufacturers commit to reduce salt   _x000D_
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•	Facilitate the amendment of nutrition labelling regulations including adoption of FoP_x000D_
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•	Conduct mid-term progress assessment _x000D_
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Long term objectives (3-4 years): _x000D_
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•	Two-third of the target population are aware of the key messages and skills on salt reduction _x000D_
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•	Three-fifth of the target population know the amount and source of salt_x000D_
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•	Two-third restaurants will remind the consumers to select lower salt food _x000D_
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•	Preliminary salt targets achieved by the key food manufacturers _x000D_
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•	Facilitate the finalisation of new nutrition labelling regulation/standards_x000D_
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•	Conduct final progress assessment and salt intake survey_x000D_
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•	Develop sustainability strategies _x000D_
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•	Disseminate the result through various approaches _x000D_
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In the 1st two years all of the programmes will be initiated. The focus will be on the design, setting up mechanisms to engage stakeholders and launching all programmes.   _x000D_
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Each of the Chinese partners involved have unique platforms for promoting healthy lifestyle and salt reduction (see additional information). We have obtained their written support to prioritise salt reduction work. In addition, we have planned various communication and dissemination programmes including conferences, trainings, publications, website etc. to enable us to engage more stakeholders (e.g. food industry, local health authorities) throughout the award period which will be valuable for translating knowledge into practice and policies as well as spreading the messages widely. _x000D_
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To ensure sustainability beyond the duration of this award, we will seek to translate research outputs into population wide policies. Due to the huge cost savings that would occur, particularly the prevention of strokes which are very common in China, we have a high likelihood of success in persuading the central and provincial government to adopt the programmes and make them a national policy in China as we have done in several other countries. Furthermore, many of our Chinese partners have the capacity to set or influence policies._x000D_
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Acknowledging the importance of capacity building, we plan to retain £200,000 to allow outstanding young researchers in China to apply for this funding to conduct pilot projects that are of global relevance and importance. _x000D_
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Our team have expertise in a wide area of health research, especially NCD and lifestyle. We will have regular review on emerging global health issues or research requirements by regular communication, exchanging ideas, collaboration and engagement with stakeholders, so as to retain a responsive capacity to respond to emerging health challenges.

Research Activity Codes: 3.5 RESOURCES AND INFRASTRUCTURE (PREVENTION);7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT)
Health Categories: CARDIOVASCULAR;STROKE;GENERIC HEALTH RELEVANCE