Population-based salt intake survey to support the national salt reduction programme for Malaysia

Lead Research Organisation: Queen Mary, University of London
Department Name: Wolfson Institute

Abstract

Cardiovascular disease including strokes, heart attacks and heart failure, is the leading cause of death and disability in Malaysia and worldwide. Hypertension is an important risk factor for cardiovascular disease, responsible for over 60% of strokes and almost 50% of coronary heart disease. High salt intake is the major cause of hypertension, accounting for about half of the disease burden attributable to blood pressure. Reducing salt intake to the World Health Organisation recommended level of 5 gram/day could prevent approximately 1.65 million cardiovascular deaths per year globally. There is also evidence that a reduction in salt intake may have many other beneficial effects on health. For example, a lower salt intake is associated with a reduced risk of stomach cancer, related to a lower risk of obesity directly or indirectly through a reduction in soft drink consumption, and associated with a reduced risk of kidney diseases and osteoporosis. Indeed, salt reduction is one of the most cost-effective public health policies to reduce non-communicable diseases. The World Health Organisation has recommended salt reduction as one of the top three priority actions to tackle the global non-communicable disease crisis.

In Malaysia, the prevalence of hypertension is high with approximately one third of the adult population having hypertension in 2011. This figure continues to rise. It is estimated that 7.6 million adults would have hypertension by 2020. Salt intake in Malaysia is likely to be very high. The Ministry of Health Malaysia started a salt reduction initiative in 2010. However, the progress has been very slow and there is still lack of key contemporary data upon which to formulate policy and engage key stakeholders. We propose to carry out a cross-sectional study to determine the level of salt intake among the Malaysian adult population using the gold standard method, i.e. 24h urine collection. Additionally, we will assess the main sources of salt in the diet using food frequency questionnaire, and assess the knowledge, attitude and practice towards dietary salt among the Malaysian adult population by completing a standardised questionnaire.

Our study will provide valuable data which are urgently needed for the development and effective implementation of a national salt reduction programme in Malaysia. This will lower salt intake across the whole population and thereby prevent many thousands of unnecessary deaths from strokes, heart attacks and heart failure each year, and also lead to major cost-savings to individuals, their families and the health services.

Although our study will be carried out in Malaysia, the research findings and the evidence-based salt reduction strategy developed in our study could potentially be generalisable to many other developing countries, particularly South East Asia. A reduction in salt intake, even by a small amount, across the whole population around the world will have enormous benefits in reducing the huge burden attributable to chronic non-communicable diseases.

Technical Summary

We will carry out a cross-sectional study in 1100 adults aged over 18 years. The participants will be randomly selected by a multi-stage stratified cluster sampling of Living Quarters (LQs) throughout Malaysia.

The data collection will include
(1) Complete a general questionnaire on basic demographics, disease history and medication use.
(2) Complete a questionnaire which assesses knowledge, attitude and practice about salt.
(3) Complete the food frequency questionnaire (FFQ). Trained dietitian or nutritionist will interview the participants using a pre-tested and validated FFQ including 94 food items.
(4) Do a brief physical examination including blood pressure, body weight, height, waist and hip circumference using a standardised protocol.
(5) Complete one 24h urine collection which is the gold standard method in determining the level of dietary salt intake. All participants will be given both oral and printed instructions on how to accurately collect 24-h urine. We will measure urine volume, sodium, potassium and creatinine. Ion-selective electrode method will be used for sodium and potassium analysis and Jaffe method for creatinine. Twenty-four hour urinary creatinine together with urine volume will be used to determine if the collection is likely to be complete.

The primary outcome of the study is salt intake as measured by 24-hour urinary sodium excretion. The secondary outcomes are the main sources of salt in the diet, knowledge levels, attitude and current practices relating to salt.

Planned Impact

Humans only need a very small amount of salt from the diet, i.e. less than 1 gram per day to maintain normal physiological function. However, the vast majority of the population including children eat far more salt than they need (on average most adult populations in the world eat 9-12 times that level). This high salt intake has many harmful effects on health.

Our project will provide new evidence that will lead to a reduction in population salt intake. Almost everyone stands to benefit from a reduction in salt intake because almost everyone eats far more salt than they require. The immediate benefit from a reduction in salt intake is to lower blood pressure. For adults, this will have an immediate and significant benefit on reducing the risk of suffering a stroke, heart attack or heart failure. For children, a lower salt intake will prevent the development of hypertension and thereby cardiovascular disease when they grow older. From a population viewpoint, even a modest reduction in salt intake across the whole population will have a large impact on reducing the appalling burden of cardiovascular disease in the population. Furthermore, a reduction in salt intake may also have other beneficial effects on health, for example, salt reduction may help reduce obesity and lower the risk of stomach cancer, kidney disease and osteoporosis.

A reduction in salt intake not only saves lives, but also saves money to individuals and the health service. A paper in the Lancet demonstrates that a 15% reduction in population salt intake could avert 8.5 million cardiovascular deaths over 10 years in 23 developing countries and result in major cost-savings to individuals, their families and the health services. Indeed, such a modest reduction in salt intake is more, or at the very least just, as cost-effective as tobacco control in terms of reducing cardiovascular disease, the leading cause of death and disability in Malaysia and worldwide.

Publications

10 25 50
 
Description Meeting with the President of the Malaysian Hypertension Society discussing various approaches to effectively reduce salt intake in Malaysia, e.g. influencing policy makers, health professionals, the food industry and educating the general public.
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
 
Description To Support the National"Salt Reduction Strategy To Prevent And Control NCD for Malaysia 2015-2020 especially under the strategy of Product Reformulation,was strengtened from voluntary to proposed mandatory and in the process of getting the approval from top management.
Geographic Reach National 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
Impact The support to change the reformulation activities to reduce salt content in processed foods from voluntary to mandatory activities was received through many engagement with food industries especially in pursuing them to reduce salt content through setting of target especially in 3 categories of foods namely sauces, canned foods and instant noodles. The Draft policy or regulatory has been presented to the top NCD meeting during end of December 2018 and now awaing for further approval before going forward with the recommendation.
 
Description CKD Study 
Organisation Hospital Kuala Lumpur
Country Malaysia 
Sector Hospitals 
PI Contribution Providing information related to the determination of CKD prevalence in Malaysia - socio-demography, anthropometry and 24-hour urinary minerals.
Collaborator Contribution The findings has improved the existing data about CKD prevalence in Malaysia, including East Malaysia, which will facilitate further health-care planning including healthcare priorities and program activities.
Impact (1) Centre for Non-Communicable Disease, Institute for Public Health, Ministry of Health Malaysia (2) Nephrology Department, Hospital Kuala Lumpur (3) Nephrology Department, Hospital Pulau Pinang (4) Nephrology Department, Hospital Serdang (5) Nephrology DEpartment, Hospital Sultanah Aminah, Johor Bahru
Start Year 2017
 
Description CKD Study 
Organisation Hospital Sultanah Aminah, Johor Bahru
Country Malaysia 
Sector Hospitals 
PI Contribution Providing information related to the determination of CKD prevalence in Malaysia - socio-demography, anthropometry and 24-hour urinary minerals.
Collaborator Contribution The findings has improved the existing data about CKD prevalence in Malaysia, including East Malaysia, which will facilitate further health-care planning including healthcare priorities and program activities.
Impact (1) Centre for Non-Communicable Disease, Institute for Public Health, Ministry of Health Malaysia (2) Nephrology Department, Hospital Kuala Lumpur (3) Nephrology Department, Hospital Pulau Pinang (4) Nephrology Department, Hospital Serdang (5) Nephrology DEpartment, Hospital Sultanah Aminah, Johor Bahru
Start Year 2017
 
Description CKD Study 
Organisation Serdang Hospital
PI Contribution Providing information related to the determination of CKD prevalence in Malaysia - socio-demography, anthropometry and 24-hour urinary minerals.
Collaborator Contribution The findings has improved the existing data about CKD prevalence in Malaysia, including East Malaysia, which will facilitate further health-care planning including healthcare priorities and program activities.
Impact (1) Centre for Non-Communicable Disease, Institute for Public Health, Ministry of Health Malaysia (2) Nephrology Department, Hospital Kuala Lumpur (3) Nephrology Department, Hospital Pulau Pinang (4) Nephrology Department, Hospital Serdang (5) Nephrology DEpartment, Hospital Sultanah Aminah, Johor Bahru
Start Year 2017
 
Description Development and validation of spot urine equation to determine 24-hr sodium intake among Malaysian population. 
Organisation Ministry of Health Malaysia
Department Institute for Medical Research
Country Malaysia 
Sector Public 
PI Contribution This is an ancillary study of the MyCoSS, Collaboration between Institute for Public Health, Institute for Medical Research and Universiti Kebangsaan Malaysia. The MyCoSS study provided information needed in developing the equation such as socio-demography data, anthropometry, urinary electrolytes (24-hour sodium and creatinine).
Collaborator Contribution The objective of this study was to develop and validate an equation using spot urine concentration to predict 24-hr sodium excretion for the Malaysian population. The 24-hr urine collection is highly burdensome, time and cost intensive for a large population study. However Malaysia need to develop equation based on spot urine and anthropometric measures to estimate 24-hr urinary sodium excretion. Prediction equations from spot urine have been developed to estimate sodium intake for the Malaysian population, particularly to assist in monitoring sodium intake in future studies.
Impact Development of the equation to predict 24-hr sodium excretion for the Malaysian population. This study involve Institute for Medical Research Ministry of Health Malaysia and Universiti Kebangsaan Malaysia.
Start Year 2017
 
Description IPH & QMUL 
Organisation Institute for Public Health
PI Contribution Researchers from Queen Mary University of London (QMUL) contribute to the study MyCoSS (Malaysian Community Salt Survey): a population study to determine salt intake to support salt reduction strategies in Malaysia.
Collaborator Contribution Researchers from the Institute for Public Health are carrying out all of the fieldwork for MyCoSS study.
Impact • The study is on-going; • A paper on the study protocol has been submitted to a journal. • The collaboration is multidisciplinary involving experts in Public Health, Epidemiology, Nutrition, Hypertension, and Medical Statistics.
Start Year 2017
 
Description Investigating bioavailability of isoflavone and its association with cardiovascular risks among Malaysians 
Organisation National University of Malaysia
Country Malaysia 
Sector Academic/University 
PI Contribution Providing information needed related to the study - socio-demographic information.
Collaborator Contribution Outcome of the study will provide a better understanding on the role of isoflavone and occurrence of CVD. This study will serve as a valuable baseline data of isoflavone status that could be used to prospectively investigate its protective value not just on vascular health but other NCDs including cancer and mental health.
Impact Soy isoflavone intake among Malaysian population. Association between intake of soy isoflavones and blood pressure among multiethnic Malaysian adults. Faculty of Health Sciences, National University of Malaysia
Start Year 2017
 
Description MoH Malaysia & QMUL 
Organisation Ministry of Health Malaysia
Country Malaysia 
Sector Public 
PI Contribution Researchers from Queen Mary University of London (QMUL) work with the Ministry of Health Malaysia to develop an evidence-based salt reduction strategy and set salt reduction targets.
Collaborator Contribution Ministry of Health Malaysia takes responsibility for the development and implementation of a salt reduction programme to reduce population salt consumption in Malaysia.
Impact The collaboration is multidisciplinary involving the food industry, dietitians, nutritionists, academics, Disease Control Division and Nutrition Division, Ministry of Health.
Start Year 2017
 
Description QMUL, IPH & Universiti Kebangsaan Malaysia 
Organisation National University of Malaysia
Country Malaysia 
Sector Academic/University 
PI Contribution Through this collaboration, a new study has been developed, i.e. "The role of selectively expressed zona glomerulosa (ZG) genes on aldosterone and cell function in physiological and pathological adaptation to salt excess among adults in Malaysia". This study will use the 24-hour urine samples collected in MyCoSS study. QMUL researchers provide advice on the new study.
Collaborator Contribution Researchers at Universiti Kebangsaan Malaysia will be responsible for the study - "The role of selectively expressed zona glomerulosa (ZG) genes on aldosterone and cell function in physiological and pathological adaptation to salt excess among adults in Malaysia". Researchers at IPH are responsible for the original MyCoSS study.
Impact The collaboration is multi-disciplinary involving public health specialists, epidemiologists, hypertension specialists, nutritionists and biochemists. This study aims to determine the prevalence of non-suppressible aldosterone production (24-hour urinary aldosterone > 12µg) in subjects with high salt intake (24-hour urinary sodium > 200 mmol) in a general population cohort. The findings will create awareness of the spectrum of autonomous aldosterone production, promoting local research in this area among the Malaysian population especially the Malay ethnicity as no research is currently being done in this area.
Start Year 2017
 
Description Developing salt reduction strategy for Malaysia 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact This meeting is organized at the beginning of the collaboration between Ministry of Health Malaysia and Queen Mary University of London UK on the Salt reduction strategy for Malaysia.

The objectives include

• To introduce to the participants on the chronology of salt reduction initiatives in Malaysia and the "Salt Reduction Strategy To Prevent and Control NCD in Malaysia (2015-2020)" by MOH, Malaysia;
• To highlight the progress achievements of the programme since 2011;
• To learn and discuss / benchmarking Malaysia's salt reduction compared with the World Action on Salt and Health (WASH) and UK salt reduction activities and achievements;
• To discuss way forward on Salt Reduction Strategy to Prevent and Control NCD in Malaysia - gaps, barriers and enablers.

After the discussion and comments especially by the input of the UK team, it was concluded that an immediate action must be taken soon to push the reformulation activities in Malaysia by getting the baseline data of the salt content in sauces (major brands) in Malaysia which is listed as one of the main sources of salt in the diet as evidenced in MySalt 2015 study. The NCD section, Disease Control Division at the Ministry of Health will be coordinating this. The proposal needs to be prepared using the baseline data to reformulate the sauces for further action.
Year(s) Of Engagement Activity 2017
 
Description Malaysia Hypertension Society conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact Professor Graham MacGregor gave a presentation on Salt Reduction - From Evidence to Practice in the Malaysia Society of Hypertension conference. The attendees were a mix of academics, health professionals, policy makers and students. The presentation was very well received and significantly increased the knowledge and impact of salt reduction in Malaysia.
Year(s) Of Engagement Activity 2018
 
Description Meeting with the food industry Malaysia 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact The objectives are

• To follow up the progress of activities for Product reformulation in Malaysia;

• To present the plan of action (activities), target and indicators planned by the TWG of Product Reformulation to reduce Salt Content in Malaysia;

• To have a sharing experience by Food Industry esp. TESCO Stores from UK on Product Reformulation to reduce salt;

• To highlight the "product survey findings " done by National University of Malaysia;

• To Discuss and get a consensus on the target for salt reformulation for the categories of foods selected.

CONCLUSION OF DISCUSSION AND COMMENTS

• Mandatory labelling of salt/sodium is a pressing issue and will be brought forward in the coming high level meeting "Cabinet Committee On Creating a Health Promoting Environment'(JKPHS) chaired by the Dept Prime Minister or other top level meeting to speed-up its process that is currently at the level of the Attorney General's office.

• Smaller Technical Working Groups for each food product will be formed with the following objectives:
i. To discuss and resolve technical issues on salt reduction reformulation.
ii. To set achievable, reasonable and gradual targets of salt levels in food products.
iii. Agreed on the schedule of the targets.

• Global company like NESTLE & UNILEVERS should follow the Global standard which is already set and done for them like in the UK to reformulate their products to reduce salt content .

• Legislation should be made to reduce salt content in food products subsequently to reduce population's blood pressure, morbidity and death due to strokes and heart attacks.

• Labelling of salt in nutrition labels instead of sodium will be in the long term plan of salt reduction strategy in Malaysia.

• An effort to measure salt intake among population of Malaysia like the Malaysian Community Salt Study (MyCoSS) should be incorporated into the National Health And Morbidity Survey (NHMS) which should be done every 4 years to monitor the progress of salt intake while doing the product reformulation to reduce Salt Content.
Year(s) Of Engagement Activity 2017
 
Description Oral presentations at the 9th National Public Health Conference 2018 at the Royale Chulan Seremban 15-18 July 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Three research team members presented findings from MyCoSS related to:
1. Estimating sodium intake using 24-hour urinary excretion: a population study in Malaysia
2. Development and validation of spot urine sodium equation to predict 24-hour urine sodium excretion among Malaysian adults
3. Knowledge, attitudes and practices to salt intake in Malaysia: preliminary findings from MyCoSS

Attendees were policy makers, stakeholders, academicians, medical practitioners, public health specialists, researchers and allied health professionals.
Year(s) Of Engagement Activity 2018
URL http://pppkam.org.my/pka2018/
 
Description Poster presentations at the 50 th Asia-Pacific Academic Consortium for Public Health (APACPH) Conference, 12-14 September 2018, in Kota Kinabalu, Sabah, Malaysia. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Research team members disseminate findings of MyCoSS in six posters as below:

1. Rashidah - Salt intake in the Malaysian population: methodology of the Malaysian community salt survey 2017-2018 (MyCoSS)
2. Shahida - Factors associated with high sodium intake among Malaysian adults
3. Syafinaz - High sodium intake and its relationship with BMI of Malaysian adults
4. Fatimah - Predicting high sodium intake among Malaysia population using spot urine
5. Azian - KAP towards salt intake by gender and educational level: results from MyCoSS
6. Ruhaya - Relationship between high blood pressure and anthropometric indices in Malaysian

Attendees were academicians, researchers, stakeholders and post-graduate students from different countries.
Year(s) Of Engagement Activity 2018
URL http://www.apacph.org/wp/2017/08/50th-apacph-conference/
 
Description Presentation of MyCoSS findings in the Public Health (Non-Communicable Diseases) Committee Meeting, 14 February 2019 at the Disease Control Division, Ministry of Health Malaysia 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Principle Investigator presented the main findings of MyCoSS to the committee, chaired by the Deputy Director General of Health (Public Health), Ministry of Health. Discussion focused on the detail findings and use of the findings in implementation of salt reduction strategy in Malaysia.
Year(s) Of Engagement Activity 2019
 
Description Salt reduction seminar at National University of Malaysia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact Dr. Feng He, Professor Graham MacGregor and Ms. Viola Michael all gave presentations on salt reductions in the UK, Malaysia and worldwide. There was also a round table discussion. The attendees include academics, health professionals and students. The presentations significantly increased the knowledge and impact of salt reduction in Malaysia.
Year(s) Of Engagement Activity 2018
 
Description Salt reduction seminars at SUNWAY University, Malaysia 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Schools
Results and Impact Professor Graham MacGregor gave presentations on salt reductions in two events organized by SUNWAY University, Malaysia. One event is "Distinguished speaker talk" at Sunway University, and the other is "Public Forum". The attendees include academics, health professionals, students and the public. The presentations significantly increased the knowledge and impact of salt reduction in Malaysia.
Year(s) Of Engagement Activity 2018