The availability, price, and characteristics of low sodium salt based on an online salt market survey in China: Implications for scaling up its use.

Low sodium salt (LSS) is an effective way to reduce the primary source of sodium from home cooking. To investigate the availability, price and characteristics of LSS, price gap between LSS and regular salt, and the potential size of subsidy needed to equalize the price of LSS and regular salt. A market survey of salts was conducted using two major online shopping sites JD and Taobao from November to December 2022. Of 360 salts, 76 (21.1%) are LSS and 284 (78.9%) are regular salt. The average proportion of potassium chloride is low (16.8%), and half of the brands contain less than 15% and only 6.6% contains ≥25%. The mean price of LSS is slightly but not significantly higher than that of regular salts (1.82 versus 1.67 yuan/100 g, p = .07). In the lowest quartile by price, the cost of LSS is significantly higher than regular salts (difference 0.13, p = .0048). Further, when comparing the lowest price LSS to the lowest price regular since within the same brand, the mean price LSS is 2.11-fold that of the regular salt (1.66 versus 0.79 yuan/100 g, p < .05). The price of iodized LSS is also significantly higher than that of iodized regular salt (1.86 verse 1.44 yuan/100 g, p = .044). An annual subsidy based on the difference in price in the first quartile would cost 4.75 yuan per capita. A variety of LSS are available in China's salt market.

Salt Intake Estimation from Urine Samples in South Asian Population: Scoping Review.

The World Health Organization recommended reducing one's salt intake below 5 g/day to prevent disability and death from cardiovascular and other chronic diseases. This review aimed to identify salt estimation at the population level in South Asian countries, namely Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka. We searched electronic databases and government websites for the literature and reports published between January 2011 and October 2021 and also consulted key informants for unpublished reports. We included studies that assessed salt intake from urinary sodium excretion, either spot urine or a 24 h urine sample, on a minimum of 100 samples in South Asian countries. We included 12 studies meeting the criteria after screening 2043 studies, out of which five followed nationally representative methods. This review revealed that salt intake in South Asian countries ranges from 6.7-13.3 g/day. The reported lowest level of salt intake was in Bangladesh and India, and the highest one was in Nepal. The estimated salt intake reported in the nationally representative studies were ranging from 8 g/day (in India) to 12.1 g/day (in Afghanistan). Salt consumption in men (8.9-12.5 g/day) was reported higher than in women (7.1-12.5 g/day). Despite the global target of population salt intake reduction, people in South Asian countries consume a much higher amount of salt than the WHO-recommended level.

It is strongly recommended to not conduct, fund, or publish research studies that use spot urine samples with estimating equations to assess individuals' sodium (salt) intake in association with health outcomes: a policy statement of the World Hypertension League, International Society of Hypertension and Resolve to Save Lives.

Spot urine samples with estimating equations have been used to assess individuals' sodium (salt) intake in association with health outcomes. There is large random and systematic error in estimating sodium intake using this method and spurious health outcome associations. Substantial controversy has resulted from false claims the method is valid. Hence, the World Hypertension League, International Society of Hypertension and Resolve to Save Lives, supported by 21 other health organizations, have issued this policy statement that strongly recommends that research using spot urine samples with estimating equations to assess individuals' sodium (salt) intake in association with health outcomes should not be conducted, funded or published. Literature reviews on the health impacts of reducing dietary sodium that include studies that have used spot and short duration timed urine samples with estimating equations need to explicitly acknowledge that the method is not recommended to be used and is associated with spurious health outcome associations.

Double burden of malnutrition in Nepal: A trend analysis of protein-energy malnutrition and High Body Mass Index using the data from Global Burden of Disease 2010-2019.

BACKGROUND: The co-existence of undernutrition and overnutrition is a global public health threat. We aim to report the burden of both nutritional deficiency (Protein-Energy Malnutrition) and overweight (high Body Mass Index) in Nepal over a decade (2010-2019) and observe the changes through trend charts. METHODS: We did a secondary data analysis using the Institute for Health Metrics and Evaluation (IHME)'s Global Burden of Disease (GBD) database to download age-standardized data on Protein Energy Malnutrition (PEM) and high Body Mass Index (BMI). We presented the trend of death, Disability Adjusted Life Years (DALYs), Years of Life Lost (YLL), and Years Lost due to Disability (YLD) of PEM and high BMI in Nepal from 2010 to 2019 and also compared data for 2019 among South Asian countries. RESULTS: Between 2010 and 2019, in Nepal, the Disability Adjusted Life Years (DALYs) due to PEM were declining while high BMI was in increasing trend. Sex-specific trends revealed that females had higher DALYs for PEM than males. In contrast, males had higher DALYs for high BMI than females. In 2019, Nepal had the highest death rate for PEM (5.22 per 100,000 populations) than any other South Asian country. The burden of PEM in terms of DALY was higher in under-five children (912 per 100,000 populations) and elderly above 80 years old (808.9 per 100,000 populations), while the population aged 65-69 years had the highest burden of high BMI (5893 per 100,000 populations). In the last decade, the DALYs for risk factors contributing to PEM such as child growth failure (stunting and wasting), unsafe water, sanitation and handwashing, and sub-optimal breastfeeding have declined in Nepal. On the contrary, the DALYs for risk factors contributing to high BMI, such as a diet high in sugar-sweetened beverages, a diet high in trans fatty acid, and low physical activity, have increased. This could be a possible explanation for the increasing trend of high BMI and decreasing trend of PEM. CONCLUSION: Rapidly growing prevalence of high BMI and the persistent existence of undernutrition indicate the double burden of malnutrition in Nepal. Public health initiatives should be planned to address this problem.

Delayed Finalization of Sodium Targets in the United States May Cost Over 250 000 Lives by 2031.

BACKGROUND: The US Food and Drug Administration (FDA) proposed 2- and 10-year voluntary sodium-reduction targets for >150 packaged- and prepared-food categories in 2016 and finalized the short-term targets in 2021. METHODS: We modeled the health benefits of implementing the newly finalized sodium targets, and the net health losses because of the 4.3-year delay in finalizing the sodium targets in different compliance scenarios in adults aged ≥30, using the National Health and Nutrition Examination Survey (NHANES) 2015 to 2016 cycle. The health impact was estimated by multiplying the projected reduction in population sodium intake by the annual health benefits resulting from every 1000-mg reduction in daily sodium intake. RESULTS: Under certain assumptions, the FDA's finalization of the short-term targets in Oct 2021 and possible finalization of the long-term targets by April 2024 is projected to save up to 445 979 (95% CI, 17 349-787 352) lives in the coming 10 years. The net number of unnecessary deaths because of FDA's delay is projected to be as high as 264 644 (95% CI, 10 295-467 215) according to our prediction. CONCLUSIONS: These findings highlight the enormous health costs due to the FDA's delay in finalizing the sodium-reduction targets, and the great potential health benefits of industry compliance with the FDA's finalization of its short- and long-term targets in the coming 10 years.

Priority Actions to Advance Population Sodium Reduction.

High sodium intake is estimated to cause approximately 3 million deaths per year worldwide. The estimated average sodium intake of 3.95 g/day far exceeds the recommended intake. Population sodium reduction should be a global priority, while simultaneously ensuring universal salt iodization. This article identifies high priority strategies that address major sources of sodium: added to packaged food, added to food consumed outside the home, and added in the home. To be included, strategies needed to be scalable and sustainable, have large benefit, and applicable to one of four measures of effectiveness: (1) Rigorously evaluated with demonstrated success in reducing sodium; (2) suggestive evidence from lower quality evaluations or modeling; (3) rigorous evaluations of similar interventions not specifically for sodium reduction; or (4) an innovative approach for sources of sodium that are not sufficiently addressed by an existing strategy. We identified seven priority interventions. Four target packaged food: front-of-pack labeling, packaged food reformulation targets, regulating food marketing to children, and taxes on high sodium foods. One targets food consumed outside the home: food procurement policies for public institutions. Two target sodium added at home: mass media campaigns and population uptake of low-sodium salt. In conclusion, governments have many tools to save lives by reducing population sodium intake.

Sustainability of 'mHealth' interventions in sub- Saharan Africa: a stakeholder analysis of an electronic community case management project in Malawi.

Background: The global health community and funding agencies are currently engaged in ensuring that worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa. Methods: Between January and March 2017, a qualitative approach was used to carry out and analyse 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions with regards to the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers. Results: Overall, our analysis found that the programme was successful in achieving its goals. However, there are many challenges to the wider implementation and sustainability of this programme, including the absence of monetary resources, limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management. Conclusions: Future developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. These developments should also focus on building local capacity by educating trainers and ensuring that training methods and guidelines are appropriately accredited based on national policies. Our findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to develop an evidence-based policy for the utilization of technology for healthcare delivery across developing countries.

Barriers and facilitators of diabetes services in Nepal: a qualitative evaluation.

For the past three decades, the burden of diabetes in Nepal has been steadily increasing, with an estimated 3% annual increase since the year 2000. Although the burden is increasing, the methods of addressing the challenge have remained largely unchanged. This study sought to assess the current state of diabetes services provided by health facilities and to identify the major barriers that people with diabetes commonly face in Nepal. For this qualitative study, we selected five health facilities of varying levels and locations. At each site, we employed three unique methods: a process evaluation of the diabetes treatment and prevention services available, in-depth interviews with patients and focus group discussions with community members without diabetes. We used thematic analysis to analyse the data. Our findings were organized into the five categories of the Ecological Model: Individual, Interpersonal, Organizational, Community and Public Policy. Sub-optimal knowledge and behaviors of patients often contributed to poor diabetes management, especially related to diet control, physical activity and initiation of drug treatment. Social support was often lacking. Organizational challenges included health provider shortages, long wait times, high patient loads and minimal time available to spend with patients, often resulting in incomprehensive care. Public policy challenges include limited services in rural settings and financial burden. The scarcity of financial and human resources for health in Nepal often results in the inability of the current healthcare system to provide comprehensive prevention and management services for chronic diseases. A multilevel, coordinated approach is necessary to address these concerns. In the short-term, adding community-based supplementary solutions outside of the traditional hospital-based model could help to increase access to affordable services.

The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial.

BACKGROUND: There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi. METHODS/DESIGN: This is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017. DISCUSSION: This is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02763345 . Registered on 3 May 2016.