Salt Intake- Related Knowledge, Attitudes, and Practices among Jordanian Adults

1. Introduction

Non-communicable diseases (NCDS) are the world’s commonest killers and the leading cause of death in the WHO Eastern Mediterranean Region (EMR). Commonly known as chronic or lifestyle-related diseases, they include cardiovascular diseases, cancers, chronic respiratory diseases and diabetes (1). Many of these deaths are preventable through lifestyle-related changes and cost-effective interventions implemented by national governments (2). Globally, two thirds (63%) of deaths are attributable to NCDs, with low- and middle-income countries (LMICs) bearing 86% of the burden of these deaths occurring prematurely (3). Raised blood pressure is a major cause of premature deaths worldwide. The complications arising from increased blood pressure contribute to 9.4 million deaths every year (4). Raised blood pressure is reported to cause at least 45% of deaths due to heart diseases and 51% of deaths due to stroke (16). Globally, raised blood pressure is evident in 1 in 4 men and 1 in 5 women in 2015.

In Jordan, 78% of all deaths in 2016 were due to NCDs (5). The prevalence of hypertension has doubled from 16% in 1995 to 32% in 2009, while the prevalence of DM increased significantly from 13% in 1994 to 17% in 2004(6,7). Moreover, researchers estimated that by the year 2050, 3.8 million (37%) Jordanian citizens would have hypertension, 3.0 million (30%) will have DM, and 2.9 million (29%) will have dyslipidemia (8). A systematic review from 10 Arab countries reported an overall prevalence of hypertension of 29.5% (9). The high rate of obesity and physical inactivity coupled with high salt and fat intake explains the high prevalence of hypertension in Jordan as well as other Arab countries (10).

Consuming a healthy diet throughout life helps protect against malnutrition in all its forms and NCDs such as heart disease, stroke, diabetes, and cancer. As detailed data regarding salt consumption in the Jordanian population is lacking, a cross-sectional study on salt consumption in Jordan revealed that participants were consuming at least double the current WHO recommended daily sodium allowance of 2 g (5 g salt) (11). These results are consistent with the reported results from Tehran, where an average sodium level of 130 mmol/day was reported, with higher intake in males at 151 mmol/day, compared with 117 mmol/day in females (12). A report from Saudi Arabia demonstrated a mean sodium level of 153 mmol/ day and 118 mmol/day (6.7–9 g salt) in males and females, respectively(13 ). Results from the INTERSALT study also revealed that salt ingestion in Italy, Finland and Portugal were between 9 and 12 g/day, while people in the Netherlands, Denmark and Belgium ingested between 8 and 9 g/day(14 ).

Like other countries in EMR, people in Jordan consume higher energy, fats, free sugars, and salt/sodium. Furthermore, many people are not eating enough fruit, vegetables, and other dietary fibres such as whole grains. Jordanian citizens currently consume high sodium and low potassium diet and are mostly unaware of its negative impact on their health. Hence, it is crucial for healthcare providers to intervene and adopt long-term strategies to control salt intake to reduce its negative effects in Jordan and elsewhere (11). The most recent STEPwise survey in Jordan (15) showed that the fruit and vegetable consumption is considered low, where 84% consumed less than five portions per day, as recommended by the WHO. The average number of servings per day of vegetables were two and of fruit was one, where half of the sample (50%) consumed 1-2 servings of vegetables or fruit per day (16)

Several epidemiological, experimental, and clinical studies positively correlated excessive sodium consumption with hypertension (17). High sodium intake increases the risk of cardiovascular disease and mortality and may have other harmful effects, including increased risk of stroke, heart failure, osteoporosis, obesity, gastric cancer, and chronic kidney disease (18). A meta-analysis of 31 trials shows that reduction of sodium consumption by 75 mmol/day (equivalent to 4 g salt) led to an average decrease of 5.0 mmHg systolic blood pressure (BP) and 2.7 mmHg diastolic BP in hypertensive patients (19). High potassium consumption has been found to be beneficial in preventing hypertension and cardiovascular events (20). Keeping salt intake to less than five g/day (equivalent to sodium intake of less than two g/day) helps prevent hypertension and reduces the risk of heart disease and stroke in the adult population (16). One-third of the people in the Jordan STEP survey were found to always add salt to their food, with the mean daily salt intake in all respondents being 11 g/day (6), which revealed the high daily intake of salt among Jordanians, being double that recommended by the WHO.

Cost-effective interventions to reduce the impact of NCDs are widely available, and their implementation can avert premature death and prevent economic losses, which have been estimated to account for USD 7 trillion over the timeframe of 2015-2030(3). NCDs can be prevented by changing policies and actively engaging all sectors through a whole government and whole society approach. Among these are the strengthening of NCDs surveillance system at all levels, the improvement of NCDs programs at the primary healthcare level and the promotion of a healthy lifestyle through awareness campaigns within the community. This can positively reflect on reducing NCDs morbidity and mortality rates in Jordan and pave the way for achieving sustainable development goals by 2030(21). Although high salt consumption is considered a worldwide public health problem, its magnitude is highly variable among different communities; therefore, it is essential to study locally salt consumption habits in Jordan and specifically in the capital Amman.

2. Materials and Methods

The study population is the Jordanian adults aged above 18 years residing in the Capital, Amman. The total Amman population is estimated at 2,182,151 persons in 2021.

Study Design

A cross-sectional study was conducted among adults living in Amman to assess the knowledge, attitude and practices related to salt intake.

Sampling

A multi-stage sampling technique was used to select representative sample from the population of Amman. In the first stage, well-defined geopolitical areas were selected from each district of Amman governorate. In the second stage, a random sample of households using a systematic sampling technique was selected from in each selected area. Within each selected household, only one person was selected and interviewed. For this KAP study, the number of households included in the study was determined using the appropriate formula for estimation of single proportion using cluster sampling approach. At 95% confidence interval (CI), 5% precision and 10% nonresponse rate and assuming that the expected proportion of population with adequate knowledge is 50% the sample size calculated was 856 persons.

Institutional Review Board Statement

“The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Jordan University of Science and Technology IRB #637/2021, ” (approval number: 53/637/2021) was approved by the IRB committee on the 8th of October 2021.

Questionnaire

Data were collected using a structured, validated questionnaire administered by trained interviewers. The questionnaire is developed based on previous similar surveys(14,32 ). The questionnaire included items on the socio-demographic characteristics and health characteristics of participants, including previous diagnoses of diabetes, high cholesterol and triglyceride levels and hypertension. The questionnaire was prepared in English (Appendix 1) and translated to Arabic using backward forward translation method. The questionnaire was checked for clarity, consistency, and cultural acceptability. The questionnaire contained 41 questions divided into sections to examine people’s knowledge, attitudes, and practices and potential interventions

Demographics and general health information section

This section describes the characteristics of people under study and confirms the inclusion criteria of sampling.

Knowledge Section:

Knowledge is the understanding of a person, this study examined people’s awareness on salt and its intake.

Attitudes Section:

Attitudes are people’s feelings towards negative or positive statements. So, a person’s subjective norm and attitude along with perceived control can be used to decide his/her intent to be involved in a behavior such as irrational or rational use of salt.

Practices Section:

Theory of Planned Behavior defines intentions as key factors in the performance of behaviors (practices) since it captures motivational factors influencing a behavior. So, any factor that predict intentions can affect the performance of behaviors, and beliefs of this behavior state the person’s intention to carry it out such as salt usage.

Sources of receiving health information and the preferred method for obtaining information

This section explores Media and other communication channels usage habits and client preference to inform behavior and awareness future planning

Data collection

Research assistants (data collectors) were recruited and trained by research supervisors. Data were collected through face-to-face interviews with an automated household questionnaire. Ethical considerations were strictly followed, and informed consent was obtained from the respondents before each interview. Different measures were undertaken to ensure quality of the collected data. The supervisors and research assistants (data collectors) were recruited based on their good knowledge of the local context, as well as experience in data collection and working among local communities. The data collectors received training on the interpretation and use of the data collection tools to enable them collect quality data. The data collectors worked under the direct supervision to ensure that the team focused on the objectives of the study, and data collected as planned for. Data cleaning was carried out involving both field and office editing of the collected data. In the field, the supervisor sought to ensure that data was properly entered onto the questionnaires. At office level, data was further checked and screened for inconsistencies by core team.

Statistical analysis

Data were entered and analyzed using the Statistical Package for Social Sciences software IBM SPSSS (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp). Means, standard deviations, and percentages were used to describe the data. Gender-specific estimates were reported. Because the samples were self-weighted, weights in analysis were not included. Chi-square was used to compare percentages. A p-value of less than 0.05 was considered statistically significant.

3. Results

Participants’ characteristics

A total of 1354 persons (1042 (77.0%) females and 312 (23.0%) males) were included in the study. Table 1 shows the participants’ sociodemographic and clinical characteristics. Almost half of the participants were younger than 40 years and 45.6% had university education. Males were significantly more educated than females. Of all participants, 6.9% reported having cardiovascular disease and 22.4% reported having hypertension. Almost 9.3% and 14% of females and 59.6% and 9.3% of males reported smoking cigarettes and waterpipe every day, respectively.

Salt intake- related knowledge

Table 2 shows respondents’ knowledge about salt intake according to gender. Almost 70.8% of participants didn’t know the maximum salt intake amount per day for adults. However, they knew the relation between the access intake and illnesses such as hypertension (96.1%) and kidney stone (86.2%). Almost two thirds of the participants (65.0%) said it very important to lower salt intake. Almost 6.4% reported that salt is high in bread, pizza (27.5%), Pasta, Rice and other non-cooked grains (5.3%), cheese (89.3%), canned meat (47.0%), Canned food such as canned vegetables, tuna, sardine and canned mushrooms (31.8%), yogurt containing products (79.0%), readymade sauces (58.3%), nuts (58.0%), pickles and Olives (87.8%). Less than half of participants (40.8%) reported that there is a type of salt that is used in food making which is harmless regardless of its quantity (Table 3).

Salt intake practices

As shown in Table 4, almost three quarters (77.4%) of persons reported using iodized salt. Only 17.1% reported reading food label. Of those, 41.4% reported that they benefited from food labels in finding out the amount of salt in food items. About 67.7% of respondents don’t buy food if it contains high. Almost half of participants (48.2%) always add salt while cooking and 14.6 % add table salt always after cooking. The most common reported practices to reduce salt intake included using spices other than salt while cooking (67.2%) and avoiding or decreasing amount of salt rich food (64.2%) (Table 5).

Table 6 shows the frequency of eating common foods. Almost 87.2% of participants reported eating three or less Arabic breads daily and 62.1% of participants reported eating pickles and olives at least once per day.

Source of health information

Table 7 shows the main sources of health information. The most common source reported by participants was social media (72.7%) followed by Google (64.0%) and health centers (64.3%). Table 8 shows the preferred source of information on salt intake and health. The majority (82.8%) of respondents preferred health centers and 78.2% preferred social media source of information on salt intake and health.

Reasons of high salt intake

Table 9 shows the participants’ reported reasons of high salt intake. The main reasons of high salt intake included high cost of low salt food (72.1%), not reading food labels (78.2%), and limited options available at restaurants (72.1%).

Table 10 shows the respondents’ recommendation on best options to reduce salt intake. The majority of participants thought of different strategies to reduce salt intake including educating the public and the community about the importance of decreasing salt intake, amending food specifications to reduce salt Increasing awareness for restaurant’s owners to use low salt options, and establishing a bonus system for factories producing low salt food.

4. Discussion

For designing salt reduction policies, it is essential to know and understand the population patterns for salt intake, their views on it, and the potential impact of salt on health. There are available data regarding salt consumption in most developed and developing countries and there is a wide variation among different nations and population groups in salt consumption. It is necessary to study the profile of sodium intake on a national scale because of its relation with most common illnesses such as high blood pressure. Several studies showed an increased intake of salt is associated with increased prevalence of cardiovascular diseases (22-25). Although limited, studies in Jordan have shown both rising hypertension over time and high salt consumption (10,15). Studying salt consumption in the Jordanian population will guide future efforts to address this critical health concern.

Actions to decrease salt intake are essential to reduce hypertension and its burden. Studying Knowledge, Attitudes and Practices towards dietary salt amongst the public is a valuable tool to guide the design of appropriate intervention programs, for example, a public education or awareness campaign, advocacy efforts related to food labelling, or as a tool to engage the food industry in reformulation to reduce levels of salt in their products. Knowledge and attitudes define the role of people in specific health-related activities, which assess the part of their intentions. These intentions are valued by many researchers and are recognized as key predictors of actual behaviours and practices (26 ). This study helped to demonstrate variations regarding salt consumption.

This study showed high rates of self-reported non-communicable diseases as 22.4% were previously diagnosed with hypertension, 13.7% were previously diagnosed with diabetes, 15.9% were previously diagnosed with high cholesterol levels, and 6.9% were previously diagnosed with heart disease. One should consider that these estimates are underestimated because a high proportion of Jordanian adults have undiagnosed diseases such as diabetes and hypertension. The study showed that almost 9.3% and 14% of females and 59.6% and 9.3% of males reported smoking cigarettes and waterpipe every day, respectively. This finding is consistent with the findings of other studies in Jordan (15).

Our study showed that people have limited knowledge of issues pertaining to salt intake. Most respondents did not know the maximum amount of salt intake allowed per day for healthy adults. However, they knew that too many salty sauces cause serious health problems such as hypertension and kidney stones, with 65% of participants saying it is essential to lower salt in their diet where female showed relatively higher knowledge. The Stepwise survey showed that 49% of people believed in the high importance of lowering salt in their diets and 89% believed that too much salt could cause serious health while female. Females showed more awareness compared to males of the harmful effects of salt on health.(15). Only 29.2% participants knew the amount of salt intake allowed per day. Females (31.5%) had higher knowledge around the allowed salt intake amount per day than males (21.5%). This finding is not consistent with the findings from Tehran study, where males had higher knowledge of salt intake than females (27).

Overall, participants’ attitudes were generally negative, where only 17% were interested in reading the nutritional label on food items. Around half of the participants think that there is a type of salt that can be added to the food that is harmless regardless of its quantity. That indicate inadequate interest in reducing salt intake. Subsequently more effort is needed to address knowledge gap to influence this negative attitude

On the other hand, most of the participants’ practices were incorrect. The existing literature showed that checking food labels for salt content is considered one of the most important measures to control salt intake [39]. However, 82.9% of our participants do not check food labels for salt content. Compared this with other studies, 38.3% of people in Lebanon check food labels for salt content regularly (28). This finding should be considered when planning educational campaigns in Jordan to raise community awareness about checking food labels for salt content.

More than half of the participants reported feeling thirsty after eating, which could indicate that the food they consumed contains a high amount of salt because elevation of plasma osmolality stimulate thirst (29). Almost half of participants (48.2%) reported that they always add salt while cooking and 14.6 % add table salt always after cooking.

In a study conducted in Jordan, 68 bread samples were collected from 13 different bakeries from Amman. The mean salt content was 1.19±0.21 g /100 g bread, while the mean salt content in local bread “Shrak” was 2.06±0.19 100 g [44]. According to the national guideline of nutrition, the estimated salt content in bread is 1g in one piece of Arabic bread and in one big slice of pizza is around 1.2g. In addition, two table spoons of salsa contains around 0.5g of salt while five pieces of salty biscuit contains around 0.5g of salt (30). On average, 70.4% of people reported eating two or less pieces of Arabic bread daily. A rough estimates show that people ingest two gram or less of sodium from bread which is considered an acceptable amount. However, the intake of salt remains high. For example a study showed that 46.8% of participants always add salty spices such as Maggi or chicken broth when cooking their daily meals, 61.1% eat at least once pickles and olives per day and 18.6% eat salty biscuits and chips 3-4 times weekly. The majority of participants thought that the amount of salt in bread, pizza, pasta, rice, canned meat, canned vegetables and non-cooked grains was average. Around 40% of participants also noted that ready-made sauces such as soya sauces and nuts have an acceptable amount of salt, however large amounts of sodium can be hidden in canned, processed and convenience foods. Some High-Sodium Foods are Smoked, cured, salted or canned meat, sausage, Frozen breaded meats and dinners, such as burritos and pizza. Salted nuts. Beans canned with salt added.(31). There is a dire need for increasing public awareness messaging around salt intake and its risks, through educational materials development and implementing community awareness strategies.

Participants were also found to eat only up to two servings of fruits and vegetables per day. This result matches what was found previously in the literature, where Jordanians usually eat little fruits and vegetables (15). Around 40% of participants eat one to two salty biscuits and chips per day.

The most common reported practices to reduce salt intake included using spices other than salt while cooking and avoiding or decreasing amount of salt rich food followed by not adding salt when cooking or add a very small amount, avoiding eating outside a lot, buying alternative products with low salt content, reading the salt content on the food labels. Similar practices were reported in the stepwise survey (15)

On the other hand, social media platforms constitute the most widely preferred media to receive health information generally and around salt intake in particular. Approximately 87% of participants think that working through community awareness campaigns can help promote salt reduction while preferring places such as malls, bakeries, schools and universities to conduct these awareness campaigns. Furthermore, 85.2% of participants thought that community organizations and associations could support efforts to reduce salt intake.

Food is an essential aspect of Jordanian culture. Jordanians serve family, friends, and guests with great pride in their homes, no matter how modest their means. In villages, meals are a community event with immediate and extended family present. In addition, Jordanians commonly use food to express their hospitality and generosity subsequently on of the main barriers to using low salt foods, participants thought that the difficulty in eating with others, addition to limited options available at restaurants, and insufficient knowledge about decreasing sodium. As for the best ways to reduce salt intake, participants thought that providing individual counselling services should be the primary method.

5. Conclusions

This study showed that Jordanian adults have limited knowledge around salt intake and their practices of high salt intake are inappropriate. Therefore, it is necessary to take immediate steps to adopt long-term strategies to reduce salt intake among the Jordanian population and lessen the negative impacts on community health. The following are recommended:

• Several strategies need to be adopted in Jordan to limit salt intake, such as increasing knowledge of the population around the significant sources of sodium in the diet and reformulating certain food products available in the market. This entails educational materials development and conduction of community awareness strategies to enhance consumer awareness on salt intake and educate the population on reading and interpreting food labels. This should be disseminated through interactive awareness campaigns in public places, such as malls, bakeries, schools, universities, hospitals, and public and private health centers. Furthermore, targeting males and those with younger age groups should focus with this awareness interventions as males had a relatively higher percentage for not buying alternative products with low salt content even if they are available.
• Although male and female participants have adequate knowledge regarding salt consumption, their practices and attitudes were not. This shows a mismatch in the behavioral theory, where knowledge is expected to match the attitudes and practices of people. Therefore, the focus should not only be on awareness campaigns, but should be complemented by well-designed behavioral change programs.
• Enforcement of food labelling policy measures such as labelling food items moreover, we need to simplify for the community through using the traffic light approach to be more user friendly
• Furthermore, targeting food manufacturers to change the food culture around the salt intake is needed to decrease the salt intake malpractice. This can be done through social media chef influencers to promote cooking using low salt items. Giving incentives for manufacturers to announce low salt healthy food options can also be a target as a public health intervention. besides increasing availability of low-sodium foods at school, worksite and restaurants,
• Develop a local food composition table and make it accessible for professionals and publics
• Nutrition counselling should be a service provided in primary health care centers, and there is a need to invest in this area and build capacity for this service