Excessive salt (sodium chloride) intake contributes to increased risk of noncommunicable diseases like hypertension and associated cardiovascular complications (1,2). Thirty percent of the cases of hypertension and related diseases, as well as 1.65 million annual deaths from cardiovascular events, are attributed by high dietary salt (3,4).
The majority of the adult population around the world consume salt in average higher than the World Health Organization (WHO) recommended level (<5 g per day), and in Asian countries, it is two times higher (>11.7 g/day) (3). The South East Asian countries like India, Thailand, Nepal, Sri Lanka, Indonesia, Vietnam, and Malaysia, all have high salt intake (5-18). The main sources of excess salt intake among these countries are both salt containing food cooked at home and foods eaten out of home (19-24). Young people like university students, consume excess salt (>10 g/day) from processed foods and instantly cooked meals both at home and at the hostel (22,23).
The situation is not better in Bangladesh. Sixty to seventy-two percent Bangladeshi people consume salt higher than the recommended dietary intake (25), though this is a little lower (66.3%) among the health professionals (academicians as well as clinicians) (24).
The overall perception of salt intake among the general population is also very low. Only 38.8% of the general population considers about lowering their salt intake (26) including those living in the coastal areas (27). Despite being aware of the consequences of extra salt intake, 64.3% of the undergraduate students of Dhaka add extra salt while taking a meal (28). Given benefits of dietary salt reduction (29), it is important to examine salt intake behavior among the young people. This study has been conducted as a series of dietary salt studies (3,24,30), conducted by the Department of Noncommunicable Diseases of Bangladesh University of Health Sciences (BUHS) in order to assess the salt intake behavior of the BUHS family members to help designing a customized salt reduction strategy. In this study we focused on the undergraduate students of the BUHS to get a clear picture regarding the current salt intake knowledge, attitudes and behavior, in order to promote a healthy dietary behavior among them. We present the following article in accordance with the STROBE reporting checklist (available at http://dx.doi.org/10.21037/jxym-20-47).
A cross-sectional study was conducted among the undergraduate students of BUHS from January to February, 2019. We chose BUHS purposively as it is only the private health sciences related university in Bangladesh. It is a non-profit private medical university of Bangladesh situated in the north-eastern part of Dhaka city. BUHS can attract students from all walks of life because of relatively low fees. It conducts programs under four faculties for both undergraduate and postgraduate students in its own campus. The students spend a considerable amount of time in the campus for academic activities. They frequently visit the cafeteria in the campus premise and food junctions in the adjacent areas for breakfast, mid-day snacks and lunch.
The undergraduate students of all departments (Biochemistry & Molecular Biology; Microbiology and Immunology; Community Nutrition; Health Promotion & Health Education; Reproductive & Child Health; Occupational and Environmental Health; Epidemiology and Biostatistics; Radiology & Imaging Technology; Applied Laboratory Sciences) of Bangladesh University of Health Sciences were considered as the study population. The total number of undergraduate students was 511 excluding foreign and discontinued students during the study period. If anyone was unwilling to participate, absent or discontinued during the data collection period were excluded from the study. The foreign students were excluded due to having a different cultural background including food habits compared to the Bangladeshi students. Thus, selecting the Bangladeshi students only gave a coherent picture on their salt intake behavior. Purposive sampling technique was used in this study. The estimated sample size was 209, considering 64.3% (28) prevalence of salt intake behavior among the undergraduate medical and nonmedical student in Bangladesh. Nevertheless, due to the examination and semester break, finally data could be collected from only 147 students.
Data were collected using a self-administered structured questionnaire adopted from the dietary salt module of the WHO STEP-wise approach to Surveillance (STEPS) instrument version 3.1. A validated Bengali version of this module was used in this study which was taken from the published studies conducted by the Department of Noncommunicable Diseases, BUHS (30).
A list of undergraduate students and class routine were collected from the registrar office of BUHS. Permission was taken from all the heads of the departments. All faculty members were informed about the study. Following the class routine, questionnaire was distributed to the students at the end of the lecture sessions with a brief explanation. A demonstration was done how to respond for the question on amount of added salt while taking a meal. A flat full spoon was considered to have 5 g of salt (30). Students were asked to drop the completed questionnaire into a drop-box.
The questionnaire also had questions on use of salt during preparing food, consumption of processed food containing a high level of salt, perceptions regarding effects of extra salt on health and activities focusing on its control, using table salt or salty sauce etc. The key variables were arranged into three groups like, knowledge (e.g., perception towards consequence of excess salt consumption, importance of lowering salt consumption), attitude (e.g., perception towards the amount of consuming salt) and practice (e.g., consumption of add salt).
Data processing and analysis
The completed questionnaires were reviewed for consistency for cleaning. Then the data were entered in an Excel sheet and logical checks were done by running sorting and frequency distribution. Finally, data were analyzed using the Statistical Product and Service Solutions (SPSS) version 22.0 for Windows (SPSS, Inc., Chicago, IL, USA). Descriptive (frequency, percentage, mean and standard deviation) analysis was done as appropriate for categorical and quantitative variables. Chi-square test was performed to compare the categories setting α level at 0.05.
This cross-sectional study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and no invasive procedure was involved. As it was a class room activity of the students of the Department of Noncommunicable Disease (NCD) of BUHS, the verbal permission was taken from the all respective head of the departments as well as from the Chairman of the Ethical Review Committee of the Bangladesh University of Health Sciences and informed consent was taken from all the participants.
There were 73 men and 74 women (total =147). Their mean age was 22.3 years (SD, 3.2), where average age of men 23.2±3.4 years and women 21.3±2.4 years. More than six out of ten (65.3%) respondents resided at home, and the rest were staying at hostel (Table 1).
The median amount of daily added salt intake was 3.0 g and the difference between sexes was negligible (Table 2). However, this difference was not statistically significant. Nearly one-third (29.9%) of the respondents had knowledge regarding health effect of dietary salt intake and 87.8% perceived that dietary salt reduction was important (Table 3). More than half (52.4%) thought that they were taking the right amount of salt or less. Only 4.1% perceived that they consume too much dietary salt. An overwhelming majority (93.2%) responded positively when they were asked if they knew about the health problems that excess salt consumption can create (Table 3).
The frequency of adding salt to the meal during eating appeared to be low. A similar pattern was also observed regarding adding salty sauce or tasting salt during cooking meal or meal preparation. More than two-third of the respondents (70.7% including always, often and sometimes) consumed processed foods containing high level of salt. Chips and crackers (29.9%) were the top choices among this category. Street vendors (53.7%) followed by the university cafeteria (18.7%) were the two commonest sources of processed foods with a high salt level (Table 4).
More than seven out of ten (72.8%) of the students were avoiding processed food as their control activity of salt intake habit. Avoidance of eating outside or buying foods with low salt/sodium content, were observed in more than half of the students’ responses. Looking at the salt/sodium content label on food items was found in 41.5% of the respondents (Table 5).
The present study explored the added salt intake, knowledge, attitudes and behavior among the undergraduate students of BUHS. Majority had relevant knowledge but added salt and salty processed food intake was high indeed. Only some of them were trying to reduce salt intake.
The proportion of students taking salt during the meal is lower than the previously reported study by Mondal et al. for a similar age group (28). The possible reasons for lower consumption could be the different awareness programs on salts and hypertension by the University as well as monitoring of the canteen by the faculty members.
The prevalence of excess salt intake is also much less than the rest of the Bangladeshi population (94%) (25). The median daily added salt intake while taking a meal alone (3 g) was 60% of the WHO recommended intake (<5 g) (31). Presumably their total salt intake was much higher than this limit.
The prevalence of salt consumption can vary from population to population (adult vs. younger; doctor vs. nurses; students vs. faculties; urban vs. rural) and country to country. The reason for variation could be, some methodological issues related to measuring the salt consumption like subjective (asking question) or objective (24-hour urine, or spot urine examination) measurements. Moreover, different cultural issues, cooking practices and different canteen or cafeteria based dietary habits may be another possible reason for consumption variation.
More than half of the respondents in the current study thought that they consumed the right amount of salt. This figure is higher than the students of similar age in another study but less than nurses working in a hospital nearby (3,28). A common theme across different studies including this one revealed that the majority of respondents were aware of the health hazards related to excess salt consumption. The awareness on the necessity of reducing dietary salt consumption is moderate among the students. An interesting finding was the low frequency of added salt during meal while other study reported it as a more common phenomenon (28). The use of salty sauce was shown to be of similar pattern where consumption seemed to be low. A high percentage of respondents had a habit of occasionally consuming processed food with salt content. This figure is higher than previously conducted studies which may be due to increase in the convenient source of these foods available in street vendors or university cafeteria (23,30).
Avoiding processed food was the principal activity for these students to lower salt consumption. This is quite higher than the students of a similar age who were using a similar strategy to do the same (28). An encouraging number was observed regarding purchasing food with low sodium content or consulting the food label to check the sodium content.
Only one out of three respondents had the knowledge regarding the health effect of daily salt consumption and interestingly there were no difference between men and women. Lowering the salt intake during meal has not been very different between men and women. Significant difference has been observed between men and women regarding practice of added salt intake during meal. To the best of our knowledge no local study has been reported these data among the men and women students in Bangladesh. But above-mentioned study (28) reported among the medical and nonmedical students which is also reported significant.
This study had also some limitations that the amount of salt intake was for added salt only. We could not measure 24-hour urine examination because it needed lab procedures and high cost was involved. The findings of the study cannot be generalized for all undergraduate students of Bangladesh as this study was conducted among only health sciences students, but we got some idea regarding rest of the students in the country. Our response rate was low (70.3%). Therefore, the analysis suffers from a threat of validity especially for the subgroups, which should be interpreted cautiously. This study has laid down a good foundation for future studies.
The findings in the present study denote that young students are more aware of the health hazards of consuming excess salt, and try to restrict their salt intake. In spite of this, the habit of consuming processed food is fairly common among the students. This is an area of concern as processed food is a source of significant amount to daily extra salt intake. The University Authority should restrict the selling of high salt containing processed food in the university canteen and facilitate keeping healthy food items.
We are grateful to the Prof. Dr. Faridul Alam, Vice-Chancellor, BUHS; Prof. Dr. Pradip Sen Gupta, Register, BUHS; Prof. Dr. Anower Hussain, Dean, Faculty of Public Health, BUHS; Prof. M A Hafiz, Chairman, ERC, BUHS; Dr. Fardina Rahman Omi, TA, Department of NCD; All Departmental Head and faculties of the respective departments for their kind cooperation in permission and data collection. We are also grateful to the student’s participants.
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at http://dx.doi.org/10.21037/jxym-20-47
Data Sharing Statement: Available at http://dx.doi.org/10.21037/jxym-20-47
Peer Review File: Available at http://dx.doi.org/10.21037/jxym-20-47
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jxym-20-47). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This cross-sectional study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). As it was a class room activity of the students of the Department of Noncommunicable Disease (NCD) of BUHS, the verbal permission was taken from the all respective head of the departments as well as from the Chairman of the Ethical Review Committee of the Bangladesh University of Health Sciences and informed consent was taken from all the participants.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
- Strazzullo P, D’Elia L, Kandala NB, et al. Salt intake, stroke, and cardiovascular disease: Meta-analysis of prospective studies. BMJ 2009;339:b4567. [Crossref] [PubMed]
- World health Organization. Salt reduction [Internet]. [cited 2020 May 29]. Available online: https://www.who.int/news-room/fact-sheets/detail/salt-reduction
- Mondal R, Sarker RC, Sayrin R, et al. Knowledge, Attitude and Practice towards Dietary Salt Intake among Nurses Working in a Cardiac Hospital in Bangladesh. Cardiovasc J 2019;12:53-8. [Crossref]
- Mozaffarian D, Fahimi S, Singh GM, et al. Global sodium consumption and death from cardiovascular causes. N Engl J Med 2014;371:624-34. [Crossref] [PubMed]
- Chen Y, Factor-Litvak P, Howe GR, et al. Nutritional influence on risk of high blood pressure in Bangladesh: a population-based cross-sectional study. Am J Clin Nutr 2006;84:1224-32. [Crossref] [PubMed]
- Mittal R, Dasgupta J, Mukherjee A, et al. ICMR Task Force Study. Salt consumption pattern in India. Indian Council of Medical Research, New Delhi, 1996.
- Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ 1988;297:319-28. [Crossref] [PubMed]
- Radhika G, Sathya RM, Sudha V, et al. Dietary salt intake and hypertension in an urban south Indian population-- J Assoc Physicians India 2007;55:405-11. [CURES - 53]. [PubMed]
- Thrift AG, Evans RG, Kalyanram K, et al. Gender-specific effects of caste and salt on hypertension in poverty: a population-based study. J Hypertens 2011;29:443-50. [Crossref] [PubMed]
- Kamso S, Rumawas JS, Lukito W, et al. Determinants of blood pressure among Indonesian elderly individuals who are of normal and over-weight: a cross sectional study in an urban population. Asia Pac J Clin Nutr 2007;16:546-53. [PubMed]
- National Social Economy Survey, Indonesian Statistic (BPS); 2011.
- Kawasaki T, Itoh K, Uezono K, et al. Investigation of high salt intake in a Nepalese population with low blood pressure. J Hum Hypertens 1993;7:131-40. [PubMed]
- Vaidya A, Pathak RP, Pandey MR. Prevalence of hypertension in Nepalese community triples in 25 years: a repeat cross‐sectional study in rural Kathmandu. Ind Heart J 2012;64:128-31.
- Mahadeva K, Karunanayake E. Salt intake in Ceylon. Br J Nutr 1970;24:811-14. [Crossref] [PubMed]
- Tran TM, Komatsu T, Nguyen TK, et al. Blood pressure, serum cholesterol concentration and their related factors in urban and rural elderly of Ho Chi Minh City. J Nutr Sci Vitaminol (Tokyo) 2001;47:147-55. [Crossref] [PubMed]
- Karupaiah T, Swee WCS, Liew SY, et al. Dietary health behaviors of women living in high rise dwellings: a case study of an urban community in Malaysia. J Community Health 2013;38:163-71. [Crossref] [PubMed]
- Gan WY, Mohd Nasir MT, Zalilah MS, et al. Difference in eating behaviours, dietary intake and body weight status between male and female Malaysian university students. Malays J Nutr 2011;17:213-28. [PubMed]
- World Health Organization. World Health Organization Guideline: Sodium intake for adults and children. World Health Organization, Geneva, Switzerland, 2012.
- Brown IJ, Tzoulaki I, Candelas V, et al. Salt intakes around the world: implications for public health. Int J Epidemiol 2009;38:791-813. [Crossref] [PubMed]
- Andarwulan N, Nuraida L, Madanijah S, et al. Free glutamate content of condiment and seasonings and their intake in Bogor and Jakarta, Indonesia. Food Nutr Sci 2011;2:764-9. [Crossref]
- Chotechuang N. Taste active components in Thai foods: a review of Thai traditional seasonings. J Nutr Food Sci 2012. [Crossref]
- Jiet LJ, Soma R. High salt diets in young university adults and the correlation with blood pressure, protein intake and fat free mass. Bioscience Horizons: The International Journal of Student Research 2017. doi: 10.1093/biohorizons/hzx003. [Crossref]
- Begum SK, Kavuri NSS, Uppalapati MC, et al. Assessment of the nutritional behaviour among college students - A survey. Int J Pharm Pharm Sci 2018;10:46-49. [Crossref]
- Zaman MS, Barua L, Bushra S, et al. Salt Intake Behavior Among the Faculties and Doctors of Bangladesh University of Health Sciences. Cardiovasc J 2016;8:94-8. [Crossref]
- Zaman MM, Choudhury SR, Ahmed J, et al. Salt intake in an adult population of Bangladesh. Global Heart 2017;12:265-6. [Crossref] [PubMed]
- Mondal R, Rajib S, Banik PC, et al. Knowledge, Attitude and Behavior Towards Dietary Salt Intake Among Bangladeshi Population. SMU Med J 2017;4:170-8.
- Rasheed S, Siddique AK, Sharmin T, et al. Salt Intake and Health Risk in Climate Change Vulnerable Coastal Bangladesh: What Role Do Beliefs and Practices Play? PLoS One 2016;11:e0152783. [Crossref] [PubMed]
- Mondal R, Sarker RC, Banik PC. Knowledge attitude and behaviour towards dietary salt intake among Bangladeshi medical and nonmedical undergraduate students. Int J Percept Public Health 2017;2:31-7. [Crossref]
- He FJ, Li J, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomized trials. BMJ 2013;346:f1325. [Crossref] [PubMed]
- Ahsan MM, Saha AK, Sadia L, et al. Salt intake behaviors among type 2 diabetic patients of a tertiary level hospital in Dhaka city. Mymensingh Med J 2020;29:162-8. [PubMed]
- Magalhães P, Sanhangala EJ, Dombele IM, et al. Knowledge, attitude and behaviour regarding dietary salt intake among medical students in Angola. Cardiovasc J Afr 2015;26:57-62. [Crossref] [PubMed]
Cite this article as: Biswas J, Haque MM, Mahbub MS, Nurani RN, Shah NA, Barua L, Banik PC, Faruque M, Zaman MM. Salt intake behavior among the undergraduate students of Bangladesh University of Health Sciences. J Xiangya Med 2020;5:24.