key: cord-0731312-qz43cl4g authors: Chailimpamontree, Worawon; Kantachuvesiri, Surasak; Aekplakorn, Wichai; Lappichetpaiboon, Raweewan; Sripaiboonkij Thokanit, Nintita; Vathesatogkit, Prin; Kunjang, Ananthaya; Boonyagarn, Natthida; Sukhonthachit, Penmat; Chuaykarn, Narinphop; Sonkhammee, Patthrapon; Khunsaard, Payong; Nuntapanich, Phassakon; Charoenbut, Pattaraporn; Thongchai, Comsun; Uttarachai, Apinya; Kwankhoom, Wisrut; Rattanakanahutanon, Fuangfah; Ruangchai, Krich; Yanti, Nadchar; Sasang, Natnapa; Bunluesin, Sushera; Garg, Renu title: Estimated dietary sodium intake in Thailand: A nationwide population survey with 24‐hour urine collections date: 2021-01-08 journal: J Clin Hypertens (Greenwich) DOI: 10.1111/jch.14147 sha: 84c3f13e8b153d2f82bdaffcecea225a8cb7dca6 doc_id: 731312 cord_uid: qz43cl4g Thailand has committed to reducing population sodium intake by 30% by 2025. However, reliable nationally representative data are unavailable for monitoring progress toward the goal. We estimated dietary sodium consumption using 24‐hour urinary analyses in a nationally representative, cross‐sectional population‐based survey. We selected 2388 adults (aged ≥ 18 years) from the North, South, North‐east, Central Regions, and Bangkok, using multi‐stage cluster sampling. Mean sodium excretion was inflated by 10% to adjust for non‐urinary sources. Multivariate logistic regression was performed to assess factors associated with sodium consumption ≥ 2000 mg. Among 1599 (67%) who completed urine collection, mean age was 43 years, 53% were female, and 30% had hypertension. Mean dietary sodium intake (mg/day) was 3636 (±1722), highest in South (4108 ± 1677), and lowest in North‐east (3316 ± 1608). Higher sodium consumption was independently associated with younger age (Adjusted Odds Ratio (AOR) 2.81; 95% Confidence interval (CI): 1.53‐5.17; p = .001); higher education (AOR 1.79; 95% CI: 1.19‐2.67; p = .005), BMI ≥ 25 (AOR 1.55; 95% CI: 1.09‐2.21; p=.016), and hypertension (AOR 1.58; 95% CI: 1.02‐2.44; p = .038). Urine potassium excretion was 1221 mg/day with little variation across Regions. Estimated dietary sodium consumption in Thai adults is nearly twice as high as recommended levels. These data provide a benchmark for future monitoring. High intake of sodium was the leading dietary risk factor associated with 3 million deaths and 70 million disability-adjusted life-years (DALYs) lost in 2017, worldwide. 1 Excess sodium consumption is associated with raised blood pressure and increased cardiovascular risk and chronic kidney disease. 2, 3 The World Health Organization recommends limiting daily sodium intake to less than 2000 mg to reduce the risk of hypertension and associated cardiovascular disease. 4 Cardiovascular disease was responsible for an estimated 145 000 deaths or 29% of all deaths in Thailand in 2016. 5 Stroke and ischemic heart disease have consistently ranked as the top two causes of mortality in Thai population during the past decade. 6 Of concern, the prevalence of hypertension has steadily increased from 21% in 2003 to 25% in 2014. 7 Recognizing the high and rising burden of cardiovascular disease, the National Health Assembly in 2015 adopted a resolution committing to reduce sodium consumption in Thai population by 30% by 2025. 8 Subsequently, a multipronged national sodium reduction strategy was developed to achieve this goal. 9 Regular monitoring with valid data is critical for tracking the progress in sodium reduction efforts. Available studies on sodium consumption in Thailand are not nationally representative in scope or have methodological limitations. One nationwide study used a 7-day dietary recall in combination with weighing household condiments and estimated the daily intake at 10.8 grams of salt (4320 mg sodium). 10 Another national-level survey using food frequency questionnaire found that daily sodium consumption varied from 2473 mg among children (aged 1-5 years) and 3265 mg per day among adults. 11 Both studies used indirect methods and are likely to underestimate sodium consumption. 12, 13 Studies using 24-hour urinary analyses are considered to provide more accurate measurement of sodium intake. 14 Limited number of Thai studies has been conducted using 24hour urine collections, and these were in a small sample of high-risk patients, unrepresentative and unreliable for a national benchmark. 15 To provide robust data for monitoring the progress toward the national sodium reduction target, this study aims to estimate dietary sodium intake using 24-hour urine collection methodology from a representative nationally drawn sample. The study also describes variations in sodium intake by geographical regions and examines factors associated high sodium consumption. This was a nationwide, population-based cross-sectional survey using 24-hour urine collections. The survey was conducted between April 2019 and May 2020. We included both urban and rural areas in four Regions of Thailand (North, South, North-east, Central) plus the Bangkok metropolitan area to represent the entire country. Study participants included adults aged 18 years and older who were eligible and provided informed consent. Participants were excluded if they: had a known history of end-stage renal disease; started diuretic within the previous 2 weeks; were pregnant, breastfeeding, or menstruating; refused to provide consent; used salt supplements, and sodium retaining medicines; or were on steroid therapy. We calculated the sample size for estimating population mean using the software, N4stuides. 16 We assumed the standard deviation of sodium intake to be 3.8 g/d based on a previous report of an estimated variation of mean sodium intake in Thai population. 17 We used an effect size of 0.21 and significance level (alpha) of 0.05, to calculate the required sample size to be 250 for each of the eight strata, that is, men and women in four age groups (18-29, 30-44, 45-59, 60 and above). The field study was supported by the Thai Health Promotion Foundation and WHO through financial support from the Resolve to Save Lives urinary analyses in a nationally representative, cross-sectional population-based survey. We selected 2388 adults (aged ≥ 18 years) from the North, South, Northeast, Central Regions, and Bangkok, using multi-stage cluster sampling. Mean sodium excretion was inflated by 10% to adjust for non-urinary sources. Multivariate logistic regression was performed to assess factors associated with sodium consump- Regions. Estimated dietary sodium consumption in Thai adults is nearly twice as high as recommended levels. These data provide a benchmark for future monitoring. To account for the possibility of 20 percent refusal to participate, we adjusted the total expected sample size to 2400. There are 76 provinces in 13 Health Service Areas in 4 geographic Regions of Thailand. We used multi-stage stratified-cluster random sampling to select participants. First, in each of the four geographic Regions of Thailand, we randomly selected two to three provinces, one province from each Health Service Area. A total of 13 provinces and Bangkok metropolitan area were selected. Secondly, for each province, we randomly selected two districts, one urban and one rural. Thus, in total, 28 districts in 14 provinces were selected. Finally, patients in each sampled district were randomly selected from eight strata, stratified by sex and four age groups: 18-29, 30-44, 45-59, 60 and above. Updated population registries maintained by district health office were used for the sampling universe, and samples were proportionally drawn from each strata. In each region, a multidisciplinary team was trained to collect demographic, anthropometric, and clinical data as well as 24-hour urine specimens from all consenting participants. A structured questionnaire was used to collect data on age, sex, occupation, education level and income, medical history, and current medication consumed. Height was measured to the nearest 1 centimeter. Weight was measured using calibrated Tanita HD-380 portable electronic scales (USA) to the nearest 100 grams. Body mass index (BMI) was calculated by dividing weight in kilograms by height in meters squared (kg/m 2 ). Blood pressure was measured using a digital blood pressure device, Omron HEM-7130-L (Omron Healthcare). Participants were asked to rest for 15 minutes before measurement. Blood pressure was measured 3 times at 15-minute intervals. The first measurement was discarded, and an average of the last two readings was used. Hypertension was defined as anyone with systolic blood pressure ≥ 140 and or diastolic blood pressure ≥ 90 mm Hg or taking medication for hypertension. We analyzed data with sample weighted against the Thai popu- Of 2400 sampled participants, 2388 consented to participate in the study and provided a 24-urine specimen. Among these, 1599 participants (67%) completed a 24-hour urine collection, significantly high proportion of participants who did not complete urine collection in Bangkok (59%); this proportion was the lowest in the South (13%) ( Overall weighted mean 24-hour urine sodium excretion in Thailand was 3305 mg (Table 3) . Sodium excretion was highest in the South (Table 3) . Potassium excretion was similar in men and women and across age groups (data not shown). The overall mean urine Na/K ratio was 5, and it was highest in the Central Region (5.5 ± 2.6). Apart from regional variations, there were notable differences in sodium intake by socio-demographic and clinical characteristics of the population ( Figure 1 ). Mean sodium intake was higher among participants with secondary level of education 3784 mg (95% CI 3565-3903) than those with primary education 3347 mg (95% CI: 3192-3503). There was a doseresponse relationship between sodium intake and BMI. Participants with hypertension had higher sodium intake 3788 mg (95% CI: 3615-3961) than those without hypertension 3561 mg (95% CI: 3449-3673). When adjusted for available confounding factors as shown in Table 4 The first nationally representative population-based survey in Interestingly, estimated sodium intake in Thailand was lower than in Our study shows that higher sodium intake (above 2000 mg/day) was independently associated with hypertension, overweight and obesity, higher education, and younger age group. An earlier national survey also found that sodium intake was higher sodium among younger population 11 which may explained partly due to higher caloric intake and consumption of fast food among young people. 32, 33 There is growing empirical evidence in support of a positive relationship between sodium intake and BMI [34] [35] [36] which may result from increased consumption of sugar-sweetened beverages 32,37 and calorie dense fast food. 38 High salt intake is also reported to be associated with greater deposition of subcutaneous abdominal adipose tissue and body fat. 39, 40 The evidence of a positive association between BMI and salt intake in our study and other studies underscores the importance of addressing behavioral and metabolic risk factors through comprehensive multipronged strategies. Such comprehensive efforts comprising engagement with food industry for reformulation, introduction of front-of-pack warning labels, increasing the availability of low sodium recipes in schools and workplace settings, and restricting marketing of unhealthy food and beverages in conjunction with mass public awareness campaigns have led to an extensive decrease in energy, total sugar, and sodium content for the most frequently consumed packaged food products in Chile 41 and a 24% reduction in dietary sodium consumption in South Korea. 42 Similar approaches are needed in Thailand. Consistent with other studies, our study demonstrated a significant positive relationship between high sodium intake and hypertension. 43, 44 Increased sodium sensitivity is cited as a possible reason for higher consumption among hypertensive patients. 45 Thailand has a high prevalence of raised blood pressure with an estimated 13.2 million estimated to have hypertension. 7 Currently, 7 million patients are registered for treatment for hypertension and have regular contact with a public health facility once in three months. 46 These encounters can be used as opportunities to offer nutrition counseling for sodium reduction both to patients and to their relatives. Intervention research should be undertaken to assess the effectiveness and impact of different nutrition counseling strategies on sodium consumption and blood pressure control among patients with hypertension. In addition to high sodium intake, an imbalanced diet with low potassium consumption is also an important determinant of raised blood pressure. 43, 47 The WHO recommends a minimum daily intake of 3,510 mg of potassium and a 1:1 sodium to potassium (Na/K) ratio. 48 The mean urinary potassium excretion in this study was It also helped to establish a rigorous survey protocol which can be replicated for future monitoring. The study also has some limitations. First, urine completion rates varied by population characteristics and were significantly lower in the Central Region. We were unable to adjust for these differences which may have skewed our findings toward producing an overall estimate influenced by populations that are over-represented in the study. Second, despite our best efforts to ensure complete urine collection, it is possible that some participants may not have provided complete urine collections. We overcame this limitation to a great extent by using stringent and objective inclusion criteria based on urine volume and creatinine excretion. Yet it is possible that some specimens may have been incomplete. Further analysis excluding those potentially incomplete specimens did not substantially change the estimates. Based on these analyses, we believe that the overall impact of the incomplete urine collection in our study is that it resulted in underestimating sodium and potassium excretion. Third, although we weighted our data to account for sampling probability based on age structure of each area, it was not possible to adjust for all potential confounders. Finally, although we aimed to collect urine specimens on all days of the week, most participants F I G U R E 1 Forest plot of weighted mean sodium consumption, by population characteristics (Data expressed as mean and 95% CI) provided specimens on weekends. Eating patterns on weekends can be variable-working population may prefer to eat at home whereas others may prefer to go out on weekends. These eating patterns may have skewed sodium consumption estimates in our study in one or the other direction. It is important to take this into account while planning and implementing the next survey, so that urine collection protocol in the next round is as consistent as possible to the protocol implemented in this round. The first nationally representative population-based survey using Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study Sodium Intake and Hypertension Dietary sodium and health: more than just blood pressure Guideline: sodium intake for adults and children. Geneva: World Health Organization Institute for Health Metrics and Evaluation (IHME) World Health Organization. Country Office for T. 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