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There is robust evidence that a reduction in salt intake lowers blood pressure and reduces the risk of strokes, heart attacks, and heart failure.1 But how can population wide salt consumption be reduced effectively? Several developed countries have been successful in reducing their populations’ salt intake mainly by setting incrementally lower salt targets for processed foods, which account for approximately 70-80% of salt intake.2 Developing countries, however, are lagging behind. China is the largest developing country with a population of 1.4 billion. Salt intake in China is very high, with an average intake per person of more than double the World Health Organisation’s (WHO) recommended maximum.3 Unlike developed countries, in China approximately 80% salt is …
Feng-heSichuanChinaUnited-kingdomYuan-liFujianGrahama-macgregorPuhong-zhangWorld-health-organisationWorld-actionBlood-pressure-united-kingdomObjective To determine whether a smartphone application based education programme can lower salt intake in schoolchildren and their families.
Design Parallel, cluster randomised controlled trial, with schools randomly assigned to either intervention or control group (1:1).
Setting 54 primary schools from three provinces in northern, central, and southern China, from 15 September 2018 to 27 December 2019.
Participants 592 children (308 (52.0%) boys; mean age 8.58 (standard deviation 0.41) years) in grade 3 of primary school (about 11 children per school) and 1184 adult family members (551 (46.5%) men; mean age 45.80 (12.87) years).
Intervention Children in the intervention group were taught, with support of the app, about salt reduction and assigned homework to encourage their families to participate in activities to reduce salt consumption.
Main outcome measures Primary outcome was the difference in salt intake change (measured by 24 hour urinary sodium excretion) at 12 month follow-up, between the intervention and control groups.
Results After baseline assessment, 297 children and 594 adult family members (from 27 schools) were allocated to the intervention group, and 295 children and 590 adult family members (from 27 schools) were allocated to the control group. During the trial, 27 (4.6%) children and 112 (9.5%) adults were lost to follow-up, owing to children having moved to another school or adults unable to attend follow-up assessments. The remaining 287 children and 546 adults (from 27 schools) in the intervention group and 278 children and 526 adults (from 27 schools) in the control group completed the 12 month follow-up assessment. Mean salt intake at baseline was 5.5 g/day (standard deviation 1.9) in children and 10.0 g/day (3.5) in adults in the intervention group, and 5.6 g/day (2.1) in children and 10.0 g/day (3.6) in adults in the control group. During the study, salt intake of the children increased in both intervention and control groups but to a lesser extent in the intervention group (mean effect of intervention after adjusting for confounding factors −0.25 g/day, 95% confidence interval −0.61 to 0.12, P=0.18). In adults, salt intake decreased in both intervention and control groups but to a greater extent in the intervention group (mean effect −0.82 g/day, −1.24 to −0.40, P<0.001). The mean effect on systolic blood pressure was −0.76 mm Hg (−2.37 to 0.86, P=0.36) in children and −1.64 mm Hg (−3.01 to −0.27, P=0.02) in adults.
Conclusions The app based education programme delivered through primary school, using a child-to-parent approach, was effective in lowering salt intake and systolic blood pressure in adults, but the effects were not significant in children. Although this novel approach could potentially be scaled up to larger populations, the programme needs further strengthening to reduce salt intake across the whole population, including schoolchildren.
Trial registration Chinese Clinical Trial Registry ChiCTR1800017553.
Relevant anonymised patient level data will be made available one year after publication of the primary manuscript on request from the corresponding author. Request for data sharing will be handled in line with the relevant regulations for data access and sharing in China and will need the approval of the trial steering committee, Peking University Institutional Review Board and Queen Mary (University of London) Ethics of Research Committee.
PekingBeijingChinaYuan-liFujianHebeiJilinLuzhouSichuanFeng-heHunanJiangsuObjective To determine the effects of salt reduction interventions designed for home cooks and family members.
Design Cluster randomised controlled trial.
Setting Six provinces in northern, central, and southern China from 15 October 2018 to 30 December 2019.
Participants 60 communities from six provinces (10 communities from each province) were randomised; each community comprised 26 people (two people from each of 13 families).
Interventions Participants in the intervention group received 12 month interventions, including supportive environment building for salt reduction, six education sessions on salt reduction, and salt intake monitoring by seven day weighed record of salt and salty condiments. The control group did not receive any of the interventions.
Main outcome measure Difference between the two groups in change in salt intake measured by 24 hour urinary sodium during the 12 month follow-up.
Results 1576 participants (775 (49.2%) men; mean age 55.8 (standard deviation 10.8) years) from 788 families (one home cook and one other adult in each family) completed the baseline assessment. After baseline assessment, 30 communities with 786 participants were allocated to the intervention group and 30 communities with 790 participants to the control group. During the trial, 157 (10%) participants were lost to follow-up, and the remaining 706 participants in the intervention group and 713 participants in the control group completed the follow-up assessment. During the 12 month follow-up, the urinary sodium excretion decreased from 4368.7 (standard deviation 1880.3) mg per 24 hours to 3977.0 (1688.8) mg per 24 hours in the intervention group and from 4418.7 (1973.7) mg per 24 hours to 4330.9 (1859.8) mg per 24 hours in the control group. Compared with the control group, adjusted mixed linear model analysis showed that the 24 hour urinary sodium excretion in the intervention group was reduced by 336.8 (95% confidence interval 127.9 to 545.7) mg per 24 hours (P=0.002); the systolic and diastolic blood pressures were reduced by 2.0 (0.4 to 3.5) (P=0.01) and 1.1 (0.1 to 2.0) mm Hg (P=0.03), respectively; and the knowledge, attitude, and behaviours in the intervention group improved significantly.
Conclusions The community based salt reduction package targeting home cooks and family members was effective in lowering salt intake and blood pressure. This intervention has the potential to be widely applied in China and other countries where home cooking remains a major source of salt intake.
Trial registration Chinese Clinical Trial Registry ChiCTR1800016804.
Relevant anonymised individual level data will be made available one year after publication of the primary manuscript on request from the corresponding authors. Request for data sharing will be handled in line with the relevant regulations for data access and sharing in China and will need the approval of the trial steering committee and the Institutional Review Board of the Chinese Center for Disease Control and Prevention.
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