• Discouraging the practice of adding salt to rice important, say health experts

The majority of Sri Lankan adults and adolescents are not adequately aware of the recommended amount of daily salt consumption.

This finding was made in an original research article on “Salt and health: Public awareness, attitudes, and practices in Sri Lanka to inform a behaviour change communication campaign to reduce dietary salt”, which was authored by A.U. Jayatilleke, N. Gunawardena, S. Dhanapala, and R. Pendse (all four attached to the World Health Organisation [WHO] Country Office for Sri Lanka, Colombo), A. de Silva (attached to the WHO Regional Office for South East Asia, New Delhi, India), and C. Wickramasinghe, L. Gamlath, T. Siriwardena, J. Vidanapathirana, S. Gunawardena, V. Kumarapeli, A.M.A.A.P. Alagiyawanna, I. Thalagala, A. Wickramasinghe, P. Kumari, and P. Ranatunga (all 11 attached to the Health and Indigenous Medical Services Ministry) and published in Journal of the College of Community Physicians of Sri Lanka 28(3) in November 2022.

Jayatilleke et al., through this national-level survey, sought to assess the knowledge, attitudes, and practices of adolescents aged 15-18 years and adults (males and females aged 19-69 years) with regard to salt and health. They conducted an islandwide, cross-sectional household survey during August-September 2019, in 10 districts (the sample subjects had been residents in the said districts for over six months), and included 500 each in each category of adult males, adult females, and adolescents, with a total of 1,500 participants. A multi-stage, cluster (28 clusters with 54 eligible study units each [36 adults including 18 males and 18 females, and 18 adolescents], living in a Medical Officer of Health area) sampling technique was used to select a representative sample. The Colombo District was also included since it is the most populous district. 

An interviewer-administered, multi-component knowledge, attitude and practice survey questionnaire on salt and health was developed. The researchers estimated the approximate per capita dietary salt intake indirectly based on the number of monthly purchases of salt for households and calculated the per capita salt consumption according to the number of household members consuming the amount of purchased salt.

Of the 1,016 households surveyed, the median household size was four (two-five individuals). The mean age of the 1,016 adult participants was 46 years (35-58 years). Among them, 26.7% had hypertension, followed by heart disease (7.6%) and kidney disease (2%). The 505 adolescent participants had a median age of 16 years (15-18 years). Television (TV) use, which was the most accessed information source, was significantly higher among adult females (81.3%) and female adolescents (78.7%) compared to adult males (71.9%) and male adolescents (69.3%).

Only 40.1% of adults and 39.6% of adolescents were aware of the WHO’s recommended daily salt consumption amount (five grams). A significantly higher proportion of adult females knew the correct daily allowance of salt compared to adult males (43.3% versus 36.8%) and that a high salt intake is a risk factor for hypertension (83.3% females versus 70.1% males). These findings were not apparent among adolescents.

Approximately half the adults (48.3%) and adolescents (45.7%) believed that they eat “just the right amount of salt”, with no significant difference between males and females among adults as well as adolescents. Further, 55.2% of adults and 39.4% of adolescents opined that it is very important to lower their own dietary salt consumption. This attitude was demonstrated significantly in a higher proportion among female adults compared to male adults. The majority of adults (72%) and adolescents (68.5%) believed that it is “very easy” or “easy” to reduce their dietary salt consumption, with no significant gender difference.

The median total monthly household salt purchased was 1,100 grams (700-1,450 grams). Approximate estimates indicated that the per capita consumption of salt was 9.2 grams per day, almost double the recommended amount among adult respondents. Further, among those who reported cooking at home (761), approximately half (346) said that they add salt to rice and almost all (631/96.2%) reported that they add salt prior to or while cooking food.

Of the sample, 169/16.7% of adults and 68/13.7% of adolescents reported that they add salt while eating food already cooked with salt. The practice of eating processed food was quite high among both adults and adolescents, with 94.9% of adults and 98.2% of adolescents reporting their consumption to be at least once a week while 14% of adults and 18.2% of adolescents reported three or more times a week.

The present study results indicated that the participants’ per capita consumption of salt was 9.2 grams per day, which is almost double the recommended daily requirement of salt. A reason for this could be that the majority of Sri Lankan adults (59.9%) and adolescents (60.4%) are not adequately aware of the recommended amounts of daily salt consumption. This could be the main deterrent and crucial knowledge gap that affects Sri Lanka’s efforts to implement the NSRS’s aim to reduce population level dietary salt consumption, and therefore, this needs to be addressed urgently.

In addition to the high consumption of salt at home, 94.9% of adults and 98.2% of adolescents reported that they consume processed foods or snacks at least once a week, which adds to their per capita salt intake. According to an Australian study, in a typical Western diet, processed foods contribute three-quarters or more to the sodium intake. This study indicates that in Sri Lanka too, processed food could be a significant contributor to the high salt intake of adults and adolescents. These findings taken together with the findings that approximately half of the adults (48.3%) and adolescents (45.9%) believe that they are eating just the right amount of salt is alarming and hence reiterates the need for the NSRS to implement an effective behaviour change communication campaign. 

The vast majority of adults and adolescents know that high salt consumption is not good for health and is associated with hypertension and believe that it is important to reduce their salt consumption, which can be considered as indicators of success. Almost 75% of adults and adolescents using TVs as their main source of health information should inform the NSRS on how to design the communication campaign. Since the use of social media was only 9.2% and 13.3% among these adults and adolescents respectively, such campaigns are unlikely to reach the majority of the population in Sri Lanka. 

In the 2019 Global Digital Overview, it was stated that only 24% of South Asians use social media landscapes. This study’s findings confirm, per J. Powles, S. Fahimi, R. Micha, S. Khatibzadeh, P. Shi, M. Ezzati, R.E. Engell, S.S. Lim, G. Danaei, D. Mozaffarian, and the Global Burden of Diseases Nutrition and Chronic Diseases Expert Group’s “Global, regional, and national sodium intakes in 1990 and 2010: A systematic analysis of 24-hour urinary sodium excretion and dietary surveys worldwide”, that local information platforms dominate the online platforms in Asian countries. 

According to D.G. Liem’s “Infants’ and children’s salt taste perception and liking: A review”, decreasing the exposure to salty-tasting foods during early infancy is recommended. Only around 22% of adults and adolescents knew that salt is not an essential element of infants’ diet. The maternal and child health programmes in Sri Lanka can be effectively utilised to have a long-term positive effect on the whole community and to create a generation that is used to low-salt diets.

The study indicated that more than half the participants add salt to rice, indicating ineffective efforts to reduce salt consumption in the past years in Sri Lanka. Moreover, Sri Lankans mainly consume homemade food rather than packaged foods, and therefore, discouraging the practice of adding salt to rice could be an important intervention to reduce salt consumption. Because home-cooked food is prepared mostly by females and salt or seasoning cubes are added to food, this highlights the need to target adult females in communication campaigns on salt reduction.

A limitation of the present study is that it assessed salt consumption indirectly by inquiring into the monthly family household salt consumption, which can only be considered a proxy indicator and one that does not quantify the salt consumption of the study units by direct measurement.

Being unaware of the recommended dietary salt intake, the practice of adding salt to rice, and consuming higher amounts of salt than recommended, while believing that they consume the right amount are some of the key gaps. Knowing the association between salt and health, agreeing that personal dietary salt reduction is important and mostly eating home-cooked food are the strengths on which this communication campaign can be based. The survey identified adult females to be a key target group for the campaign and the TV to be the mode of delivery.

The majority of Sri Lankan adults (59.9%) and adolescents (60.4%) are not adequately aware of the recommended daily salt consumption. Not being aware of the recommended dietary salt intake and the practice of adding salt to rice can lead to a higher consumption of salt than recommended. They, however, believe that they consume just the right amount of salt. These are the key gaps among the participants. Adult females could be a key target group for the salt reduction campaign, with the TV as the best mode of message delivery.