Assessing sodium-dietary intake, awareness, and salt use practices in Nepal: A community-based study
Creators: name: Ghimire, Kamal
Publisher: name: Torrens University Australia
Year: 2024
Subjects: classificationCode: 320101
subject: Cardiology (incl. cardiovascular diseases)

description: Introduction: High sodium intake is one of the risk factors for hypertension, which consequently increases the risk for cardiovascular diseases. The World Health Organization (WHO) recommends daily salt intake of &lt; 5 g for adults and reducing dietary salt intake is one of the most feasible and cost-effective public health interventions. However, there is a lack of population studies on salt intake in developing countries like Nepal, which has delayed the development of national salt reduction policies and programs. The aim of this thesis is to establish an evidence base for salt intake and related factors in Nepal to aid in designing an appropriate salt reduction strategy. Methods: This thesis is based on two types of studies, which are a systematic review of studies from eight South Asian countries and a cross-sectional study conducted in Western Nepal. In the systematic review, we computed descriptive statistics and forest plots to present salt-related information. In the cross-sectional study, we collected data on background information, saltrelated knowledge, attitudes, and behaviours (KAB) and urine samples (both spot and 24-hour) from 451 randomly selected participants. We compared mean (±SD) salt intake estimated from nine spot urine-based equations against measured 24-hour urine samples, using paired t-test, Pearson correlation coefficient, intraclass correlation coefficient, and Bland-Altman plots. Furthermore, we used general linear models to explore the associations between salt-related KAB and 24-hour salt excretion. We considered p values &lt; 0.05 [(95% confidence interval (95% CI)] as significant for all analyses. Results: In the systematic review in Chapter 3, we found that the mean salt intake in South Asian countries was approximately 10 g/day (95% CI: 9.12, 10.10). The main source of salt intake was discretionary salt use during cooking or at the table, and most countries lacked fully implemented salt reduction strategies. In the cross-sectional study (Chapters 4) the mean salt xvi intake based on 24-hour urine samples was 13.2± 4.72 g/day. The corresponding estimates for different equations were: Kawasaki: 15.44±5.92 g/day, Tanaka: 11.06±3.17 g/day, Mage: 15.22±16.72 g/day, Toft: 10.66±3.35 g/day, INTERSALT with potassium: 8.57±1.72 g/day, INTERSALT without potassium: 8.51±1.73 g/day, Whitton: 7.88±1.94 g/day, Uechi simplemean: 18.13±19.92 g/day, and Uechi regression: 12.07±1.77 g/day. Compared to the 24-hour estimates, all equations showed significant mean differences and proportional biases in the Bland-Altman plots. Further analyses in Chapter 5 found that although most participants knew the risks of high salt intake (83%) and felt important to reduce intake (87%), only 10% reported doing so. Participants who perceived themselves as consuming more salt had higher urinary salt excretion (14.42 g/day; 95% CI: 13.45, 15.39, p = 0.03) and were more likely to add extra salt [(Odds ratio (OR) = 3.08; 95% CI: 1.50, 6.33, p &lt; 0.01)], and consume processed foods (OR = 1.95; 95% CI: 1.20, 3.15, p &lt; 0.01), but less likely to take salt control actions (OR = 0.16; 95% CI: 0.07, 0.37, p &lt; 0.001) compared to their respective counterparts. Conclusions: Salt intake in South Asian countries, including Nepal, is twice the WHO recommendation due to widespread discretionary salt use. While salt reduction initiatives are still in planning stages, community-wide awareness strategies are needed to reduce salt intake. Current spot urine equations have limitations in estimating salt intake in Nepal, and there is a gap between knowledge, attitudes, and actual salt-related behaviour among the population. Nepal urgently requires tailored national salt reduction programs to achieve the 30% reduction in mean population salt intake by 2025. Further studies are needed to test the effectiveness and scalability of multifaceted interventions to address multiple sources of salt intake in Nepal.