Abstract
High salt/sodium intake is associated with an increased risk of hypertension, which is a major risk factor for cardiovascular diseases. This paper aims to examine the association between salt consumption and salt‐related knowledge, attitudes, and practices (KAP) in Nepal. The cross‐sectional data used in this study were collected as part of the community‐based management of non‐communicable diseases project (COBIN) to understand the amount and KAP related to salt consumption in Nepal. Multivariate hierarchical logistic regression was performed to assess the association of salt‐related KAP and determinants of high salt consumption in Nepal. The mean per capita salt intake was 8.0 (±3.7) g/day, with 81.6% of the population reporting higher intake than the WHO recommendation of <5 g/day. People of upper castes [adjusted odds ratio (aOR) = 0.7; 95% confidence interval (CI): 0.5‐0.9], people in large families (aOR = 0.6; 95% CI: 0.5‐0.7), respondents who were advised to lower salt intake (aOR = 0.6; 95% CI: 0.4‐0.9) and who checked salt/sodium labels in food (aOR = 0.6; 95% CI: 0.4‐0.9) were less likely to consume higher amounts of salt. Similarly, people who added extra salt to their food at the table (aOR = 1.4; 95 CI: 1.1‐1.9) and who reported consuming high amounts of salt (aOR = 1.5; 95% CI: 1.1‐2.3) were more likely to have high salt intake. High salt intake was documented in this population. This study suggests the need for culturally tailored community‐based behavior modification through health education and dietary counseling to effectively reduce salt consumption and thereby support a reduction in hypertension and cardiovascular diseases in Nepal.
Keywords: attitudes, blood pressure, dietary salt, hypertension, knowledge, Nepal, practices, salt consumption, sodium
1. INTRODUCTION
High dietary intake of sodium is associated with high blood pressure, a major risk factor for cardiovascular disease (CVD).1 It is estimated that high sodium consumption is responsible for 1.65 million deaths from heart disease, stroke, and related causes each year.2 The World Health Organization (WHO) has recommended a daily salt intake of <5 g/person/day (<2 g sodium/person/day) for adults to reduce blood pressure and prevent developing CVDs.3 It is estimated that the current average salt consumption is 9‐12 g/day in many countries4 and higher intakes are found in Asia.5 In 2012, the WHO member states adopted the voluntary global target of a 30% reduction in mean population salt/sodium intake by 2025.6 In order to achieve this target, the current status of knowledge, attitudes, and practices (KAP) related to salt consumption must be known. However, population‐based studies on these factors are lacking in most low‐ and middle‐income countries (LMICs).
Several studies conducted in Nepal have attempted to estimate the prevalence and risk factors of hypertension and CVDs7, 8, 9, 10, 11; however, data on incidence of hypertension and KAP related to salt consumption are lacking. A study conducted in three cities of South Asia reported that the overall age and non‐response rate adjusted incidence rate was 82.6 per 1000 person‐years [95% confidence interval (CI): 80.8‐84.4], whereas the incidence rate adjusted only for non‐response rate was 74.6 per 1000 person‐years (95% CI: 70.5‐79.1).12 To our knowledge, no studies have explored the relationship of salt‐related awareness and practices with salt consumption, or examined the determinants of high salt consumption in Nepal. Assessing salt‐related KAP is timely because Nepal plans to develop national salt reduction strategies, guidelines, and programs.13 KAP reveal underlying causes of the problem and aid in the future design and promotion of appropriate programs.
2. METHODS
2.1. Study design and location
The current study analyzes data from the population‐based survey of “community‐based management of non‐communicable diseases in Nepal (COBIN).” The detailed protocol and methodology of the project have been published elsewhere.14, 15 The study area is Pokhara Municipality (formerly known as Lekhnath Municipality) in Kaski district of Western Nepal.
2.2. Study tools and questionnaire
The study was based on the WHO STEPwise approach to non‐communicable disease risk factor surveillance (STEPS).16 The survey was conducted using the modified STEPS instrument which was previously used for a nationwide study in Nepal.17
2.3. Sample size estimations
For the COBIN trial, a survey sample size of 2882 was calculated according to the WHO standard formula for STEPS using 96% CI (z = 1.96) and 5% margin of error (α). The prevalence of hypertension was taken as 25% from the recent 2013 STEPS survey of Nepal17 with the design effect of one (for random sampling) and response rate 80% as per the guideline. From a total of 2882 eligible participants, data were collected from 2815 participants.
2.4. Socio‐demographic variables
Age, sex education, ethnicity, occupation, marital status, income, and family size were included as the socio‐demographic variables to observe a potential association with salt consumption. Three categories were used to capture ethnicity: (a) Dalit castes; (b) Relatively disadvantaged castes which included disadvantaged Janajati castes, disadvantaged non‐Dalit terrain castes and religious minorities castes; (c) Advantaged castes which included upper castes and advantaged Janajati castes. Family size of a household was calculated by average number of people in a household who consumed morning and evening meals. Family size was then dichotomized based on median value (4) of family members; small families were defined as those with four or fewer members in the household and large families included those with more than four members.
2.5. Estimation of salt consumption
Dietary salt consumption was estimated using a standard questionnaire that was administered to the person responsible for preparing meals in the household. Respondents were asked to recall the amount of salt used during the food preparation and added at the table by each person in the household in the last 24 hours. One‐week intensive training, including field testing, was provided to enumerators to standardize data collection. They were trained to appropriately use kitchen scales to measure the actual amount of salt added during food preparation and at the table. Total salt added during cooking in the morning and evening meals together with the number of people who consumed morning and evening meals were calculated for adults. This was converted into total daily household salt consumption and average salt consumption of the household. Individual dietary salt intake [grams per day (g/day)] was then estimated by dividing the daily household consumption by the average of total number of people who consumed meals. Salt intake was then dichotomized into high salt intake (≥ 5g/day) or low salt intake (<5 g/day) based on the WHO recommendation.
2.6. Knowledge, attitudes, and practices related to salt consumption
Salt‐related KAP of the respondents were considered as the primary exposure variable for the study. The knowledge‐related question was, “Does a high salt content in your diet cause serious health problems?” The first attitude‐related question was, “How much salt do you think you consume?” and the second was, “How important to you is lowering the salt in your diet?” The practice‐related questions included, “How often do you add salt to your food before you eat it or as you are eating it at the table?” “How often is salt added in cooking or preparing foods in your household?” and “How often do you eat processed food high in salt?” Additional practice‐related questions covered topics such as: (a) avoiding/minimizing consumption of processed foods (b) checking the salt/sodium label for foods (c) avoiding adding extra salt in food at the table (d) buying low salt/sodium alternatives (e) cooking meals without adding salt, (f) use of spices or salt substitutes, and (g) never eating salt.
2.7. Behavioral and biological variables
A history of raised blood pressure, taking prescribed antihypertensive drugs during the past 2 weeks, lifestyle advice given by doctor or health worker concerning lower salt intake, treatment of hypertension with traditional medicine, self‐reported history of CVDs, family history of hypertension, body mass index (BMI; classified as normal [<25 kg/m2], overweight [≥25 kg/m2‐< 30 kg/m2], and obese [≥30 kg/m2])15; and hypertension status (classified as normotension: mean systolic BP [SBP] <120 mm Hg and diastolic BP [DBP] <80 mm Hg, prehypertension: mean SBP ≥ 120‐< 140 mm Hg and DBP ≥ 80‐< 90 mm Hg, hypertension: mean SBP ≥ 140 mm Hg and/or a DBP ≥ 90 mm Hg and/or treatment with antihypertensive drug)14 were included as behavioral and biological variables.
2.8. Statistical analysis
Data analysis was performed in Stata version 14.2. Descriptive statistics were conducted for socio‐demographic, behavioral, biological, and KAP‐related variables. Results were expressed as frequencies and as mean (±standard deviation) for categorical and continuous variables, respectively. Logistic regression was applied to examine the relationship between exposure and outcome variables. Variables which were significantly associated with salt consumption at P < 0.05 in univariate analysis were then entered in multivariate modeling through hierarchical regression fashion. Variables were categorized into three different groups based on their characteristics; socio‐demographic, behavioral/biological, and salt‐related KAP; and were entered in three different steps. In model 1, socio‐demographic variables were entered, followed by behavioral and biological variables in model 2 while controlling for socio‐demographic variables. In model 3, salt‐related KAP variables were entered while controlling for variables of model 1 and 2. Figure 1 represents the analytical framework which guided the multivariate analyses of socio‐demographic, behavioral, biological, and KAP‐related variables with salt consumption. Hosmer and Lemeshow's goodness‐of‐fit was applied to observe the model fit. Multicollinearity among independent variables was checked by collinearity diagnostics test in Stata. Variance influence factor (VIF) value of <10 or tolerance (1/VIF) value of >0.1 indicated no multicollinearity.
Figure 1.
An analytical conceptual framework of associated factors for salt consumption
2.9. Ethical approval
The ethical review committee of the Nepal Health Research Council approved the study (reference number 1065). Before the interviews, all study participants were informed about the study objectives, procedures, and their role in the study. With the assurance of confidentiality and voluntary participation, written informed consent was obtained from all participants before data collection.
3. RESULTS
3.1. Mean salt consumption
Mean per capita salt consumption was 8.0 (±3.7) g/day (Table 1) and four‐fifths (81.6%) of the respondents consumed ≥5 g salt per day (Table 2). Among 2815 respondents, 1843 (65.5%) were women. Sixty percent of respondents were in the age group 35‐54, two‐fifths (41.6%) had studied up to high school, and 71.1% belonged to advantaged castes. Eighteen percent of total respondents were aware of their hypertension status in the past 12 months and 18.2% of them were counseled to lower salt intake in their diet (Table 2).
Table 1.
Characteristics of the respondents
| Characteristics | Mean (±SD; n = 2815) |
|---|---|
| Age (y) | 45.2 (10.2) |
| Salt intake (g/d) | 8.0 (3.7) |
| Family size | 4.1 (1.7) |
| BMI (kg/m2) | 24.9 (4.4) |
| SBP (mm Hg) | 124.3 (18.6) |
| DBP (mm Hg) | 81.2 (11.2) |
Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; g, gram; SBP, systolic blood pressure.
Table 2.
Socio‐demographic, behavioral, and biological characteristics
| Characteristics | Salt consumptiona | Total n (%) | P‐valueb | |
|---|---|---|---|---|
| Low n (%) | High n (%) | |||
| Proportion of salt intake | 519 (18.4) | 2296 (81.6) | 2815 (100.0) | – |
| Educational status | ||||
| Up to primary level | 265 (18.0) | 1202 (82.0) | 1466 (52.1) | 0.1 |
| Up to high school | 232 (19.8) | 938 (80.2) | 1170 (41.6) | |
| Higher education | 23 (12.9) | 156 (87.1) | 179 (6.4) | |
| Ethnicity | ||||
| Dalit castes | 57 (13.8) | 356 (86.2) | 413 (14.7) | <0.001 |
| Relatively disadvantaged castes | 120 (30.0) | 280 (70.0) | 400 (14.2) | |
| Advantaged castes | 342 (17.1) | 1660 (82.9) | 2002 (71.1) | |
| Marital status | ||||
| Unmarried | 8 (11.1) | 64 (89.9) | 72 (2.6) | 0.2 |
| Married | 465 (18.5) | 2053 (81.5) | 2518 (89.5) | |
| Separated/divorced/widowed | 46 (20.4) | 179 (79.6) | 225 (8.0) | |
| Occupational status | ||||
| Job employed | 196 (18.2) | 883 (81.8) | 578 (20.5) | 0.9 |
| Job unemployed | 106 (18.3) | 472 (81.7) | 1079 (38.3) | |
| Agriculture/labor/other | 217 (18.7) | 941 (81.3) | 1158 (41.1) | |
| Family size | ||||
| Small (≤4 people) | 277 (15.5) | 1514 (84.5) | 1791 (63.6) | <0.001 |
| Large (>4 people) | 242 (23.6) | 782 (76.4) | 1024 (36.4) | |
| History of raised BP in past 12 mo | ||||
| Yes | 113 (22.2) | 396 (77.8) | 509 (18.1) | <0.05 |
| No | 406 (17.6) | 1900 (82.4) | 2306 (81.9) | |
| Treatment and lifestyle advice | ||||
| Prescribed antihypertensive drugs | ||||
| Yes | 73 (23.6) | 237 (76.5) | 310 (11.0) | <0.05 |
| No | 446 (17.8) | 2059 (82.2) | 2505 (89.0) | |
| Advised to lower salt intake | ||||
| Yes | 127 (24.8) | 386 (75.2) | 513 (18.2) | <0.001 |
| No | 392 (17.0) | 1910 (83) | 2302 (81.8) | |
| Treatment with traditional medicine of HTN | ||||
| Yes | 12 (28.6) | 30 (71.4) | 42 (1.5) | 0.1 |
| No | 507 (18.3) | 2296 (81.7) | 2773 (98.5) | |
| Self‐reported history of CVDs | ||||
| Yes | 11 (18.6) | 48 (81.4) | 59 (2.1) | 1.0 |
| No | 508 (18.4) | 2248 (81.6) | 2756 (97.9) | |
| Family history of HTN | ||||
| Yes | 200 (19.0) | 852 (81.0) | 1052 (37.4) | 0.5 |
| No | 319 (18.1) | 1444 (81.9) | 1763 (62.6) | |
| Hypertension status | ||||
| Normotensive | 180 (16.7) | 895 (83.3) | 1075 (38.2) | <0.05 |
| Pre‐hypertensive | 156 (17.3) | 746 (82.7) | 902 (32.0) | |
| Hypertensive | 183 (21.8) | 655 (78.2) | 838 (29.8) | |
| Currently on treatment of HTN | ||||
| Yes | 65 (25.3) | 192 (74.7) | 257 (9.1) | <0.01 |
| No | 454 (17.8) | 2104 (82.3) | 2558(90.9) | |
Abbreviations: Avg., average; BP, blood pressure; CVDs, cardiovascular diseases; HTN, hypertension.
Presented as row %.
P value was obtained by comparing the proportion of low and high salt consumption with each socio‐demographic, behavioral, and biological characteristics using X2 analysis.
3.2. Salt‐related knowledge, attitudes, and practices
3.2.1. Salt‐related knowledge and attitudes
Out of 2815 respondents, 86.3% answered that high salt intake would cause health problems. Two‐thirds (66.1%) reported that they consumed just the right amount of salt but 88.7% reported that it is very important or somewhat important to reduce salt in their food (Table 3).
Table 3.
Salt‐related knowledge attitudes and practices
| Characteristics | Salt consumptiona | Total n (%) | P‐valueb | |
|---|---|---|---|---|
| Low n (%) | High n (%) | |||
| Salt‐related knowledge | ||||
| High salt intake causes health problem | ||||
| Yes | 450 (18.5) | 1978 (81.5) | 2428 (86.3) | 0.9 |
| No | 55 (18.4) | 244 (81.6) | 299 (10.6) | |
| Don't know | 14 (15.9) | 74 (84.1) | 88 (3.1) | |
| Salt‐related attitudes | ||||
| Self‐reported salt consumption | ||||
| Far too much/too much | 59 (14.2) | 357 (85.8) | 416 (14.8) | <0.001 |
| Just the right amount | 316 (17.0) | 1544 (83.0) | 1860 (66.1) | |
| Far too little/too little | 144 (26.7) | 395 (73.3) | 539 (19.2) | |
| Importance of reducing salt in food | ||||
| Very important/somewhat important | 460 (18.4) | 2036 (81.6) | 2496 (88.7) | 0.8 |
| Not at all important | 44 (19.6) | 181 (80.4) | 225 (8) | |
| Don't know | 15 (16.0) | 79 (84.0) | 94 (3.3) | |
| Salt‐related practices | ||||
| Add extra salt in food at the table | ||||
| Always/often | 32 (13.0) | 215 (87.0) | 247 (8.8) | <0.001 |
| Sometimes | 103 (13.8) | 643 (86.2) | 746 (26.5) | |
| Rarely/never | 384 (21.1) | 1438 (78.9) | 1822 (64.7) | |
| Consume processed salty food | ||||
| Always/often | 40 (16.8) | 198 (83.2) | 238 (8.5) | <0.01 |
| Sometimes | 218 (16.3) | 1122 (83.7) | 1340 (47.6) | |
| Rarely/never | 261 (21.1) | 976 (78.9) | 1237 (43.9) | |
| Regular action taken to control salt intake | ||||
| Avoid/minimize consumption of processed foods | ||||
| Yes | 57 (29.5) | 136 (70.5) | 193 (6.9) | <0.001 |
| No | 462 (17.6) | 2160 (82.4) | 2622 (93.1) | |
| Check salt/sodium label in food | ||||
| Yes | 59 (36.4) | 103 (63.6) | 162 (5.8) | <0.001 |
| No | 460 (17.3) | 2193 (82.7) | 2653 (94.2) | |
| Avoid adding extra salt in food at the table | ||||
| Yes | 191 (23.8) | 611 (76.2) | 802 (28.5) | <0.001 |
| No | 328 (16.3) | 1685 (83.7) | 2013 (71.5) | |
| Buy low salt/sodium alternatives | ||||
| Yes | 47 (32.0) | 100 (68.0) | 147 (5.2) | <0.001 |
| No | 472 (17.7) | 2196 (82.3) | 2668 (94.8) | |
Presented as row %.
P value was obtained by comparing the proportion of low and high salt consumption with each salt‐related knowledge, attitudes, and practices using chi‐square analysis.
3.2.2. Salt‐related practices and regular action taken to reduce salt consumption
Two‐thirds (64.7%) of the respondents reported that they rarely or never added extra salt in their food at the table and 47.6% mentioned that they sometimes consumed processed food high in salt. One‐fourth (28.5%) of the population reported avoiding adding extra salt in food at the table; other salt reduction measures were not as commonly reported (Table 3).
3.2.3. Association between socio‐demographic, behavioral, biological characteristics, and KAP related to salt consumption
The advantaged castes (adjusted odds ratio [aOR] 0.7; 95% confidence interval [CI]: 0.5‐0.9) and relatively disadvantaged castes (aOR 0.4; 95% CI: 0.2‐0.5) were less likely to consume more than the recommended daily intake of salt compared to Dalit castes. Having >4 family members was significantly associated with consuming low salt (aOR 0.6; 95% CI: 0.5‐0.7). Respondents who were advised to lower salt intake by a doctor or other health worker were less likely (aOR 0.6; 95% CI: 0.4‐0.9) to consume high salt compared to those who did not receive advice from a health care worker. The odds of high salt intake as measured during daily use increased significantly if the respondents reported that they added extra salt sometimes in their food at the table compared to rarely or never added. Respondents who felt they consumed far too much or too much salt (aOR 1.5; 95% CI; 1.1‐ 2.3) and just the right amount of salt (aOR 1.4; 95% CI: 1.1‐1.8) were more likely to consume high levels of salt. Checking the salt/sodium content on nutrition labels was significantly associated with decreased salt consumption (aOR 0.6; 95% CI; 0.4‐0.9; Table 4).
Table 4.
Multivariate analysis of socio‐demographic, behavioral, biological characteristics, and KAP with salt consumption
| Characteristics | OR (95% CI) | |||
|---|---|---|---|---|
|
Unadjusted (Univariate analysis) |
Adjusted | |||
|
Model 1 (Socio‐demographic variables) |
Model 2 (Socio‐demographic + Behavioral/biological variables) |
Model 3 (Socio‐demographic + Behavioral/biological + KAP variables) |
||
| Socio‐demographic | ||||
| Ethnicity | ||||
| Dalit castes | 1 (Ref) | 1 (Ref) | 1 (Ref) | 1 (Ref) |
| Relatively disadvantaged castes | 0.4 (0.3‐0.5)a | 0.4 (0.3‐0.5)a | 0.4 (0.2‐0.5)a | 0.4 (0.2‐0.5) a |
| Advantaged castes | 0.8 (0.6‐1.0) | 0.7 (0.6‐1.0) | 0.7 (0.5‐1.0) | 0.7 (0.5‐0.9) a |
| Family size | ||||
| Small (≤4 people) | 1 (Ref) | 1 (Ref) | 1 (Ref) | 1 (Ref) |
| Large (>4 people) | 0.6 (0.5‐0.7) a | 0.6 (0.5‐0.7) a | 0.6 (0.5‐0.7) a | 0.6 (0.5‐0.7) a |
| Behavioral and biological | ||||
| History of raised BP in past 12 months | ||||
| Yes | 0.7 (0.6‐0.9) a | – | 1.8 (1.1‐2.9) a | 1.6 (0.9‐2.6) |
| Prescribed antihypertensive drug | ||||
| Yes | 0.7 (0.5‐0.9)a | – | 1.3 (0.7‐2.5) | 1.3 (0.6‐2.5) |
| Advised to lower salt intake | ||||
| Yes | 0.6 (0.5‐0.8) a | – | 0.4 (0.3‐0.7) a | 0.6 (0.3‐0.9) a |
| Hypertension status | ||||
| Normotensive | 1 (Ref) | – | 1 (Ref) | 1 (Ref) |
| Pre‐hypertensive | 1 (0.8‐1.2) | – | 1 (0.8‐1.3) | 1.1 (0.8‐1.4) |
| Hypertensive | 0.7 (0.6‐0.9) a | – | 0.9 (0.7‐1.1) | 1 (0.7‐1.3) |
| Currently on treatment of HTN | ||||
| Yes | 0.6 (0.5‐0.9) a | – | 0.7 (0.4‐1.3) | 0.8 (0.4‐1.5) |
| Salt‐related KAP | ||||
| Add extra salt in food at the table | ||||
| Rarely/never | 1 (Ref) | – | – | 1 (Ref) |
| Sometimes | 1.7 (1.3‐2.1) a | – | – | 1.4 (1.1‐1.9) a |
| Always/often | 1.8 (1.2‐2.6) a | – | – | 1.3 (0.8‐1.9) |
| Consume processed salty food | ||||
| Rarely/never | 1 (Ref) | – | – | 1 (Ref) |
| Sometimes | 1.4 (1.1‐1.7) a | – | – | 1.2 (0.9‐1.5) |
| Always/often | 1.3 (0.9‐1.9) | – | – | 1.2 (0.8‐1.7) |
| Self‐reported salt consumption | ||||
| Far too little/too little | 1 (Ref) | – | – | 1 (Ref) |
| Just the right amount | 1.8 (1.4‐2.2) a | – | – | 1.4 (1.1‐1.8) a |
| Far too much/too much | 2.2 (1.6‐3) a | – | – | 1.5 (1.1‐2.3) a |
| Avoid consumption of processed foods | ||||
| Yes | 0.5 (0.4‐0.7) a | – | – | 0.9 (0.6‐1.4) |
| Check salt/sodium label in food | ||||
| Yes | 0.4 (0.3‐0.5) a | – | – | 0.6 (0.4‐0.9) a |
| Avoid adding extra salt in food at the table | ||||
| Yes | 0.6 (0.5‐0.8) a | – | – | 1 (0.8‐1.3) |
| Buy low salt/sodium alternatives | ||||
| Yes | 0.5 (0.3‐0.7) a | – | – | 0.9 (0.6‐1.4) |
Abbreviations: BP, blood pressure; 95% CI, 95% confidence interval; HTN, hypertension; KAP, knowledge attitudes and practices; OR odds ratio; Ref, reference.
Significant association, Adjusted OR obtained from multivariable analyses adjusted for other factors in the same column.
4. DISCUSSION
The average mean salt consumption level in our study (8 g/day) is comparable to studies from Nepal,17 Bhutan,18 India,19, 20 and China21, 22 and differ from other results found in China,23, 24, 25 Bangladesh,26 and India.27 It is slightly lower than the one study in Nepal using the gold standard 24‐hour urine collection measurement method, which documented salt consumption as 10‐13 g/day.28 Methodological differences in salt intake may result in different estimates for salt consumption.29 Both measurements show salt consumption in Nepal is well above the WHO global recommendation, indicating action should be taken to improve intake.
Salt consumption largely depends on cultural context and dietary habits.30 Our study showed that the advantaged castes and relatively disadvantaged castes were significantly less likely to consume high salt than Dalit castes. Previous literature suggests that food behaviors vary among different social and economic groups; higher classes may be able to afford and adopt healthier food practices.31 Janajati and upper castes are socially and economically advantaged compared the Dalit castes in Nepal,32 and may be more likely to be aware of, practice, and maintain healthier dietary practices. This might explain the observed association in our study; however, there is no previous study available in Nepal to confirm this result.
In Nepal, the major salt consumption pattern is discretionary, usually added during cooking but also occasionally at the table. The 2013 STEPS survey from Nepal showed that 97.8% of respondents always added salt while cooking, whereas 4.7% added salt at the table.17 The consumption of processed food, unlike other developed countries, has been reported as relatively low in Nepal (one in 10 people).17 However, a repeat cross‐sectional study in 1981 and 2006 found that the proportion of those consuming a high amount of salt in Nepal increased from 56% to 90%10; this increase was reported as one of the highest among LMICs.33
Lifestyle advice given to promote lower salt intakes has had a positive effect on lowering salt consumption. Studies have reported the importance of a doctor or health worker's counseling on dietary salt control to lower blood pressure among hypertensive patients.34, 35, 36, 37, 38 Adherence to salt restriction is considered equally important as an antihypertensive drug.39 The findings of salt‐related knowledge of this study are similar to the findings of the 2016 STEPS survey in Samoa.40 Our study respondents had better knowledge than those in a previous national survey of Nepal,17 Sri Lanka,41 and a study of Lebanon,42 but slightly poorer knowledge than in a national survey of Bhutan.18 Similarly, positive attitudes regarding the importance of lowering salt intake was found to be higher in this study compared to other similar studies.17, 18, 43
Adding salt to food during cooking in our study was found to be significantly associated with high consumption of salt; comparable findings were observed in Samoa40 and in Australia.44 Adding salt during cooking is the single major source of salt intake in Nepal, and traditional salty foods condiments such as chutney and pickles are often eaten with meals as well. Daily salt consumption is driven by taste preference, and few people actually measure and add salt while cooking based on the understanding that very little salt is actually necessary for a healthy daily diet.45 People with a poor understanding of the risks of consuming too much salt may be more likely to be driven entirely by taste preference and may be less likely to measure salt while preparing food. This may result in the current practice of adding excess salt but provides an opportunity for increasing the tools available to facilitate behavior change during food preparation. Habit modifying interventions, such as promotion of measuring spoons45 and use of local salt substitutes such as herbs, spices, vinegar, lemon juice, garlic, or sesame may be effective measures to reduce salt intake in this setting.
This study revealed that respondents had a reasonable knowledge of the adverse effects of high salt consumption and favorable attitudes toward salt reduction; however, almost none of the respondents had regularly acted to control their salt intake. A similar finding was observed in an Australian study.46 This speaks to the need for appropriate awareness programs and culturally tailored, community‐based salt reduction interventions to bridge the gap between self‐reported knowledge and attitudes with actual practices.
Our results showed that a majority of respondents reported that their salt consumption was just the right amount or too little; however, when measured they consumed higher amounts of salt than recommended. This finding has been previously demonstrated in many settings,18, 40, 47, 48 which indicates a gap in perceived and actual salt intake. Respondents have been found to rate the overall healthfulness of their diet as higher than what was calculated by researchers using the Healthy Eating Index. This optimism leads consumers to false perceptions of their diet quality.49 Increasing awareness that the current levels of salt used in the household pose health risks may help align individuals' current knowledge about the risks of a high salt diet with their actual (rather than perceived) use patterns.
The major strength of this study is that it is the first to explore the association between salt‐related KAP and salt consumption based on the WHO STEPS survey in Nepal. Moreover, this study also estimated the socio‐demographic, behavioral, and biological factors associated with high salt consumption. The WHO STEPS instrument has previously been validated and applied in national surveys of Nepal17 Bhutan,18 Samoa,40 and Sri Lanka41; KAP‐related questions similar to those used in this study have also been used in many previous settings.26, 42, 43, 44, 46, 48 Utilizing the standardized STEPS instrument combined with measurement of salt used in cooking at the household level enhances our understanding of the connection between perceived and actual salt use. Use of a standard kitchen scale to measure the amount of salt added during cooking provided a more accurate estimation of household salt use compared to self‐report. Some limitations should be considered when interpreting the results. Salt intake calculation was done on a household basis and not individually, which resulted in a crude method unable to provide an exact per capita salt intake. Therefore, salt intake could not be estimated by sex, age group, and BMI. There is a need for estimation of sodium/salt intake by the 24‐hour urine collection method in the current context of changing lifestyles and food habits in Nepal. Although we used already validated tools from the WHO, some of the questions may be leading which might have resulted in biased answers. In addition, this study only captured the amount of salt added during morning and evening cooking and used at the table. It did not include the salt intake of processed foods, traditional salty foods, and other sodium‐containing instant foods consumed during day time. Although this may lead to underestimation of total salt intake, 82% of participants still consumed more than the WHO recommended level of salt and it is clear that appropriate strategies for reduction of salt consumption are needed. Salt reduction at the population level is recommended as one of the “best buy” interventions by the WHO in terms of high cost‐effectiveness and feasibility to reduce high blood pressure, which can save millions of lives and future health care costs.50, 51, 52 This study population knew the harmful effects of high salt consumption and had positive attitudes to lower salt intake, but were unaware of how much salt they were actually adding to their food. There is an opportunity to modify behavior as recommended by the WHO through health education and dietary counseling to effectively reduce salt consumption in a setting like Nepal where a major source of dietary salt is added during cooking or by salt use at the table.30 Culturally tailored community‐based public health awareness campaigning, limiting salt in processed foods, and appropriate labeling of salt/sodium content are some strategies that may reduce population salt intake and thereby support a reduction in hypertension and CVDs in Nepal.
CONFLICT OF INTEREST
The authors report no specific funding in relation to this research and no conflicts of interest to disclose.
AUTHOR CONTRIBUTIONS
KG and DN contributed in the conception of the work. KG wrote the first draft of the manuscript. KG and TBA analyzed the data. KG, TBA, AR, PK, MEH, and DN revised the manuscript. All the authors approved the final version of the manuscript.
ACKNOWLEDGMENTS
The authors would like to thank all the respondents who participated in the study. Special thanks to data enumerators of Nepal Development Society.
Ghimire K, Adhikari TB, Rijal A, Kallestrup P, Henry ME, Neupane D. Knowledge, attitudes, and practices related to salt consumption in Nepal: Findings from the community‐based management of non‐communicable diseases project in Nepal (COBIN). J Clin Hypertens. 2019;21:739–748. 10.1111/jch.13544
REFERENCES
- 1. He FJ, Li J, MacGregor GA. Effect of longer term modest salt reduction on blood pressure: cochrane systematic review and meta‐analysis of randomised trials. BMJ. 2013;346:f1325. [DOI] [PubMed] [Google Scholar]
- 2. Mozaffarian D, Fahimi S, Singh GM, et al. Global sodium consumption and death from cardiovascular causes. N Engl J Med. 2014;371(7):624‐634. [DOI] [PubMed] [Google Scholar]
- 3. World Health Organization . Reducing salt intake in populations: Report of a WHO forum and technical meeting, Paris, France. Geneva, Switzerland: World Health Organization; 2007. [Google Scholar]
- 4. Ha SK. Dietary salt intake and hypertension. Electrolyte Blood Press. 2014;12(1):7‐18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Campbell NR, Lackland DT, Niebylski ML. 2014 dietary salt fact sheet of the world hypertension league, international society of hypertension, pan American health organization technical advisory group on cardiovascular disease prevention through dietary salt reduction, the world health organization collaborating centre on population salt reduction, and world action on salt & health. J Clin Hypertens (Greenwich). 2015;17(1):7‐9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. World Health Organization . A Comprehensive Global Monitoring Framework Including Indicators and a Set of Voluntary Global Targets for the Prevention and Control of Noncommunicable Diseases. Geneva, Switzerland: World Health Organization; 2012. [Google Scholar]
- 7. Bhandari GP, Angdembe MR, Dhimal M, Neupane S, Bhusal C. State of non‐communicable diseases in Nepal. BMC Public Health. 2014;14(1):23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Neupane D, McLachlan CS, Sharma R, et al. Prevalence of hypertension in member countries of south Asian association for regional cooperation (SAARC): systematic review and meta‐analysis. Medicine. 2014;93(13):e74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Dhungana RR, Devkota S, Khanal MK, et al. Prevalence of cardiovascular health risk behaviors in a remote rural community of Sindhuli district, Nepal. BMC Cardiovasc Disord. 2014;14(1):92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Vaidya A, Pathak RP, Pandey MR. Prevalence of hypertension in Nepalese community triples in 25 years: a repeat cross‐sectional study in rural Kathmandu. Indian Heart J. 2012;64(2):128‐131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Sharma D, Bkc M, Rajbhandari S, et al. Study of prevalence, awareness, and control of hypertension in a suburban area of Kathmandu. Nepal. Indian Heart J. 2006;58(1):34‐37. [PubMed] [Google Scholar]
- 12. Prabhakaran D, Jeemon P, Ghosh S, et al. Prevalence and incidence of hypertension: results from a representative cohort of over 16,000 adults in three cities of. South Asia. 2017;69(4):434‐441. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. World Health Organization . Report of the Expert Meeting on Population Sodium Reduction Strategies for Prevention and Control of Noncommunicable Diseases in the South‐East Asia Region, Report of the Regional Meeting. New Delhi, India: World Health Organization; 2012. [Google Scholar]
- 14. Neupane D, McLachlan CS, Christensen B, Karki A, Perry HB, Kallestrup P. Community‐based intervention for blood pressure reduction in Nepal (COBIN trial): study protocol for a cluster‐randomized controlled trial. Trials. 2016;17(1):292. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Neupane D, Shrestha A, Mishra SR, et al. Awareness, prevalence, treatment, and control of hypertension in western Nepal. Am J Hypertens. 2017;30(9):907‐913. [DOI] [PubMed] [Google Scholar]
- 16. World Health Organization . Noncommunicable diseases and their risk factors 2014. http://www.who.int/chp/steps/resources/updates/en/.Accessed 25 August, 2018.
- 17. Aryal KK, Neupane S, Mehata S, et al. Non Communicable Diseases Risk Factors: STEPS Survey Nepal. Kathmandu, Nepal: Nepal Health Research Council; 2013. [Google Scholar]
- 18. World Health Organization . National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan 2014.World Health Organization; 2016. 9290225009.
- 19. Beegom R, Singh RB. Association of higher saturated fat intake with higher risk of hypertension in an urban population of Trivandrum in south India. Int J Cardiol. 1997;58(1):63‐70. [DOI] [PubMed] [Google Scholar]
- 20. Radhika G, Sathya R, Sudha V, Ganesan A, Mohan V. Dietary salt intake and hypertension in an urban south Indian population–[CURES‐53]. J Assoc Physicians India. 2007;55(6):405‐411. [PubMed] [Google Scholar]
- 21. Ruixing Y, Weixiong L, Hanjun Y, et al. Diet, lifestyle, and blood pressure of the middle‐aged and elderly in the Guangxi Bai Ku Yao and Han populations. Am J Hypertens. 2008;21(4):382‐387. [DOI] [PubMed] [Google Scholar]
- 22. Qin YU, Li T, Lou P, et al. Salt intake, knowledge of salt intake, and blood pressure control in Chinese hypertensive patients. J Am Soc Hypertens. 2014;8(12):909‐914. [DOI] [PubMed] [Google Scholar]
- 23. Sun Z, Zheng L, Detrano R, et al. The accelerating epidemic of hypertension among rural Chinese women: results from Liaoning Province. Am J Hypertens. 2008;21(7):784‐788. [DOI] [PubMed] [Google Scholar]
- 24. Sun Z, Zheng L, Xu C, et al. Prevalence of prehypertension, hypertension and associated risk factors in Mongolian and Han Chinese populations in Northeast China. Int J Cardiol. 2008;128(2):250‐254. [DOI] [PubMed] [Google Scholar]
- 25. Li J, Xu C, Sun Z, et al. Prevalence and risk factors for isolated untreated systolic hypertension in rural Mongolian and Han populations. Acta Cardiol. 2008;63(3):389‐393. [DOI] [PubMed] [Google Scholar]
- 26. Zaman MM, Choudhury SR, Ahmed J, Khandaker RK, Rouf MA, Malik A. Salt Intake in an adult population of Bangladesh. Glob Heart. 2017;12(3):265‐266. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Thrift AG, Evans RG, Kalyanram K, Kartik K, Fitzgerald SM, Srikanth V. Gender‐specific effects of caste and salt on hypertension in poverty: a population‐based study. J Hypertens. 2011;29(3):443‐450. [DOI] [PubMed] [Google Scholar]
- 28. Kawasaki T, Itoh K, Uezono K, et al. Investigation of high salt intake in a Nepalese population with low blood pressure. J Hum Hypertens. 1993;7(2):131‐140. [PubMed] [Google Scholar]
- 29. McLaren L, Heidinger S, Dutton DJ, Tarasuk V, Campbell NR. A repeated cross‐sectional study of socio‐economic inequities in dietary sodium consumption among Canadian adults: implications for national sodium reduction strategies. Int J Equity Health. 2014;13(1):44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Brown IJ, Tzoulaki I, Candeias V, Elliott P. Salt intakes around the world: implications for public health. Int J Epidemiol. 2009;38(3):791–813. [DOI] [PubMed] [Google Scholar]
- 31. Lallukka T, Laaksonen M, Rahkonen O, Roos E, Lahelma E. Multiple socio‐economic circumstances and healthy food habits. Eur J Clin Nutr. 2007;61(6):701. [DOI] [PubMed] [Google Scholar]
- 32. Bennett L, Dahal DR, Govindasamy P. Caste ethnic and regional identity in Nepal: Further analysis of the 2006 Nepal Demographic and Health Survey. Calverton, MD: Macro International Inc.; 2008. [Google Scholar]
- 33. Subasinghe AK, Arabshahi S, Busingye D, et al. Association between salt and hypertension in rural and urban populations of low to middle income countries: a systematic review and meta‐analysis of population based studies. Asia Pac J Clin Nutr. 2016;25(2):402‐413. [DOI] [PubMed] [Google Scholar]
- 34. Patton K, Meyers J, Lewis B. Enhancement of compliance among patients with hypertension. Am J Manag Care. 1997;3(11):1693‐1698. [PubMed] [Google Scholar]
- 35. Khan MS, Bawany FI, Mirza A, Hussain M, Khan A, Lashari MN. Frequency and predictors of non‐compliance to dietary recommendations among hypertensive patients. J Community Health. 2014;39(4):732‐736. [DOI] [PubMed] [Google Scholar]
- 36. Korhonen M, Kastarinen M, Uusitupa M, Puska P, Nissinen A. The effect of intensified diet counseling on the diet of hypertensive subjects in primary health care: a 2‐year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland. Prev Med. 2003;36(1):8‐16. [DOI] [PubMed] [Google Scholar]
- 37. Cohen SJ, Weinberger MH, Fineberg NS, Miller JZ, Grim CE, Luft FC. The effect of a household partner and home urine monitoring on adherence to a sodium restricted diet. Soc Sci Med. 1991;32(9):1057‐1061. [DOI] [PubMed] [Google Scholar]
- 38. Woollard J, Beilin L, Lord T, Puddey I, MacAdam D, Rouse I. A controlled trial of nurse counselling on lifestyle change for hypertensives treated in general practice: preliminary results. Clin Exp Pharmacol Physiol. 1995;22(6–7):466‐468. [DOI] [PubMed] [Google Scholar]
- 39. Lahdenperä TS, Kyngäs HA. Compliance and its evaluation in patients with hypertension. J Clin Nurs. 2000;9(6):826‐833. [Google Scholar]
- 40. Webster J, Su'a S, Ieremia M, et al. Salt intakes, knowledge, and behavior in Samoa: monitoring salt‐consumption patterns through the world health organization's surveillance of noncommunicable disease risk factors (STEPS). J Clin Hypertens (Greenwich). 2016;18(9):884‐891. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. World Health Organization . Non Communicable Disease Risk Factor Survey. Sri Lanka: World Health Organization; 2015. [Google Scholar]
- 42. Nasreddine L, Akl C, Al‐Shaar L, Almedawar MM, Isma'eel H. Consumer knowledge, attitudes and salt‐related behavior in the Middle‐East: the case of Lebanon. Nutrients. 2014;6(11):5079‐5102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43. Claro RM, Linders H, Ricardo CZ, Legetic B, Campbell NR. Consumer attitudes, knowledge, and behavior related to salt consumption in sentinel countries of the Americas. Rev Panam Salud Publica. 2012;32:265‐273. [DOI] [PubMed] [Google Scholar]
- 44. Nowson C, Lim K, Grimes C, et al. Dietary salt intake and discretionary salt use in two general population samples in Australia: 2011 and 2014. Nutrients. 2015;7(12):10501‐10512. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Cornélio M, Gallani MC, Godin G, Rodrigues R, Nadruz W Jr, Mendez R. Behavioural determinants of salt consumption among hypertensive individuals. J Hum Nutr Diet. 2012;25(4):334‐344. [DOI] [PubMed] [Google Scholar]
- 46. Webster JL, Li N, Dunford EK, Nowson CA, Neal BC. Consumer awareness and self‐reported behaviours related to salt consumption in Australia. Asia Pac J Clin Nutr. 2010;19(4):550‐554. [PubMed] [Google Scholar]
- 47. Land M‐A, Wu J, Selwyn A, et al. Effects of a community‐based salt reduction program in a regional Australian population. BMC Public Health. 2016;16(1):388. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48. Marakis G, Tsigarida E, Mila S, Panagiotakos DB. Knowledge, attitudes and behaviour of Greek adults towards salt consumption: a Hellenic food authority project. Public Health Nutr. 2014;17(8):1877‐1893. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49. Variyam JN, Shim Y, Blaylock J. Consumer misperceptions of diet quality. J Nutr Educ. 2001;33(6):314‐321. [DOI] [PubMed] [Google Scholar]
- 50. He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens. 2009;23(6):363. [DOI] [PubMed] [Google Scholar]
- 51. World Health Organization . Global Status Report on Noncommunicable Diseases 2010. Geneva, Switzerland: World Health Organization; 2011:924456422X. [Google Scholar]
- 52. Joffres MR, Campbell NR, Manns B, Tu K. Estimate of the benefits of a population‐based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. Can J Cardiol. 2007;23(6):437‐443. [DOI] [PMC free article] [PubMed] [Google Scholar]