General Questions

Question 1a. What is the World Health Organisation (WHO)? The World Health Organisation is an international organisation, a special division ofthe United Nations, that takes care of the public health in the world. (www.WHO.int)b. What does WHO stand for?

World Health Organisationc. Does the WHO set a recommendation for maximum salt intake?

Yes, the global goal set by WHO is to reduce salt intake to less than 5 g per person per day by 2025.

Question 2a. What is the average salt intake in the country where you have done your practical

assignment? Make use of official consumer intake data (if possible), and refer to thesource(s). From http://www.who.int/dietphysicalactivity/Elliot-brown-2007.pdfon page 45, 4841 mg/d average for men, and 4518 mg/d for women, sampledfrom 500 men and 510 women between 1995-1996. According tohttp://www.kidney.hk/index.php?loc=dash it was 8.0 g/day during1989-1991, and raised to 9.4 g/day during 1996-1998, and to 9.9 g/dayduring 2000-2002.

b. What is the average salt intake in the Netherlands? Adult men consume an average of 9.9 gram of salt per day, and adult women consume an average of 7.5 gram per day. Boys consume an average of 8.3 gram per day and girls 6.8 gram per day.

c. Explain the differences between the intake in your country and the average intakein the Netherlands. The Dutch culinary is more savory than the Hong Kong culinary, butthe Hong Kong people are eating more and more western food, which canbe salty, such as French fries.

d. Is there a recommendation for maximum salt intake (a ‘target’) in the countrywhere you are doing your practical assignment? Make use of official standards (ifpossible), and refer to the source(s). The Hong Kong Nephrology Group follows the WHO and aims for 5 g/dwith the DASH diet adoption. (http://www.kidney.hk/index.php?loc=dash) MAAR IN TABEL 1 STAAT WEER DAT CHINA EEN RICHTLIJN HEEFT VAN 6 GRAM PER DAG?????? Wil je even voor me nakijken plz? Hong Kong is China niet, dus ik zou ‘t zo laten.

e. What is the recommendation for maximum salt intake in the Netherlands? Makeuse of official standards and refer to the source(s). According tohttp://www.rivm.nl/bibliotheek/rapporten/350050007.pdf, on page 3, therecommended maximum salt intake per day is 6 g/day.

f. Explain the differences between the targets for salt in your country and theNetherlands (evidence based). The Chinese are prone to dietary salt-induced hypertension becausethey lack an efficient mechanism to facilitate the excretion of saltby the kidney. (http://www.kidney.hk/index.php?loc=dash). Dutch peoplehowever take their salt mostly from bread, meat products and cheese,which are the main products a Dutch person eats.(http://www.rivm.nl/bibliotheek/rapporten/350050007.pdf).

Questions Article Lancet;Question 3What does Cochrane Review entail (or mean)? A Cochrane Review is a systematic review and meta-analysis whichsummarize and interpret the results of medical research. They arestored in the Cochrane Library, which was named after Archie Cochrane,who was a Scottish doctor, and pioneer of evidence-based medicine.

Question 4Name two reasons why the writer of this article believes that the results of the CochraneReview done by Rod Taylor et al differ from the common knowledge that a reduced saltintake is advisable for public health. Because one of the trials in heart failure should not have beenincluded, because the participants were severely salt and waterdepleted due to aggressive diuretic therapy. Also, these participantswere randomly assigned to a reduced salt intake, and while the dose ofdiuretics was not adjusted downwards, a lower salt intake is likely toworsen the salt and water depletion and therefore resulted in worseoutcomes.Lilly, er wordt gevraagd naar 2 redenen. Je hebt er maar 1 gegeven. Een 2de reden waarom de bevindingen van Cochrane niet klopt, is dat men hun statistieken niet kennen. Eerste reden hierboven zegt men dat 1 van de 7 proeven een vertekend beeld geeft. En van de resterende 6 proeven heeft men een trend niet opgemerkt, dus kennen de onderzoekers hun statistieken niet om tot de juiste conclusies te komen.

Question 5What is your opinion of all the comments made in this article on the Cochrane Reviewdone by Taylor et al? Give per comment an explanation in your own words.

* ’ One of these trials in heart failure, in our view, should not have been included because the participants were severely salt and water depleted due to aggressive diuretic therapy. While on these treatments, participants were randomly assigned to a reduced salt intake or their usual salt intake. In view of the fact that the dose of diuretics was not adjusted downwards, a lower salt intake is likely to worsen the salt and water depletion and therefore, unsurprisingly, resulted in worse outcomes” People with heart failure should not have participated this research. As they have to regulate their water and salt intake due tot their diuretics intakePeople undergoing a treatment for heart failure should not be included in their study. Since their water and salt intake are regulated by their diuretics.

* ‘ Such a trial is impractical because of logistical and financial constraints, and the ethical issues of putting a group of people on a high salt diet for many years’ You can’t put people on a high salt diet for many years, this will be bad for their health, as the outcomes of other studies show that people have to restrict their salt intake. Je mag hier mss ook even vermelden dat het financieel niet haalbaar is om 28000 mensen op te volgen gedurende 5 jaar tijdIt is not ethical to put people on a high salt diet for a long term. Furthermore it is also not economical to follow up 28000 people for 5 years.

* In our view, Taylor and colleagues Cochrane review and the accompanying press release reflect poorly on the reputation of the Cochrane library and the authors. The daily express published that salt is healthy to eat now. This is not true ,there is not enough research to state this. And the WHO recommends a reduced salt intake to prevent cardiovascular disease.

* This trend of consistent reductions in all clinical outcomes seems to have been overlooked Their findings are not accurate because they ignored the consistent reduction in all clinical outcomes and therefore didn’t use the correct statistical methods for analysing the data. They should have combined the results (for hypertensive and normotensives).They seemed to have used an improper method to analyse their data. Which results in incorrect conclusions.

Question 6How would you translate the information of this article to your daily activities as adietician? There are so many studies that show the substantial benefits of reducing the average intake of salt. A reason to prevent that one gets cardiovascular disease or to reduce the effects, it is of great importance to reduce the average salt intake by 6 grams a day or less. This applies not only to this disease in particular, but other health issues as well. That’s why if you want to maintain a healthy life, it’s important to pay attention to your salt intake. I would recommend my patients to reduce their intake of salt to maintain a healthy life and reduce the chance on getting cardiovascular disease and other health issues. I could state the fact that studies have several shown the importance to reduce the intake of salt. Questions Article BMJ;Question 7 On page 3 right column the authors mention some advantages of salt for the foodindustry. See sentence ‘Yet the use of salt in food is indirectly a source of revenue for foodand beverage manufacturers more widely’.

a. What does the word ‘revenue’ mean in this context? Revenue in this context means income.b. Describe in your own words the 3 different advantages of salt for the food

industry (mentioned by the authors). First advantage: when you take more salt in, it will reduce your taste for saltiness and makes food more tasty so it would increase the demands. Second advantage: Salt in meat products in combination with other water binding chemicals, increase the amount of water that can bind into the meat so it will increase the weight of the meat up to 20% at no cost. Third advantage: High salt intake makes a person more thirsty and demands for sugary drinks.

c. Mention advantages of salt reduction for the food industry?

- The UK experience indicates that in the early stages of a salt reduction program it is possible to take 5-15% of the salt out of a product gradually without noticeable change in flavor, sales, or complaints about taste.

- As salt intake falls, the salt taste receptors in the mouth adapt and become more sensitive to lower concentrations of salt within months. Once salt intake is reduced, people prefer the taste of food with less salt. Lilly, ik heb de zinnen weggelaten waarin je zegt dat men de kosten kunnen drukken. Voor zover ik weet, is zout goedkoop. Als je zout verlaagt, moet je iets anders verhogen om je verpakking te vullen. Dus hou ’t bij die zinnen die er nu staan. Er staat mention, dus gewoon ff vermelden , niet te veel bij lullen la. Deze zinnen komen letterlijk uit de tekst. Dus niet nodig om anders te verwoorden.

-The International Council for the Control of Iodine Deficiency Disorders estimates that about 1.5 billion people worldwide live in areas of iodine deficiency. In 1996, in conjunction with WHO and Unicef, they started a universal salt iodization program, using salt as a vehicle to deliver

supplementary iodine in the diet. If salt intake is reduced, these policies will remain compatible, cost effective, and of great public health benefit, if the level of iodine fortification can be adjusted to changing sodium intake.

Question 8 In the Conclusion four different approaches to reduce population salt intake are discussed

a. In your opinion which approach(es) is (/are) already in use successfully in yourcountry? Explain. (Communication, Reformulation, Monitoring and Regulation: ik moest uitzoeken welke van deze 4 van toepassing zijn in Hongkong, maar ik weet eigenlijk niet wat ik hier moet neerklakken… Maar ik zal ff citeren wat Karen heeft gezegd: Lilly: “What is the average salt intake in Hong Kong? Is there a recommendation for maximum salt intake in Hong Kong?”Karen: “Recommendation is less than 2000 mg daily but the average intake is way more than this. I don’t have the figure.”Communication toch? Je hebt toch dingen gevonden van DASH waar ze mensen gaan proberen sensibiliseren via de jockey club en scholen? Door menu’s aan te bieden met weinig zout.

b. In your opinion which approach(es) should be used more or at least furtherinvestigated in your country? Explain.Kun je hier wat voor me verzinnen? Lol Neen, helaas kan dit niet. Ik heb geen tijd om zaken op te zoeken wat men in HK wel of niet doet. Ofwel zeg je gewoon dat je gevonden hebt dat men wel campagnes doen op scholen enzo, maar verder is het moelijk om meer informatie te vinden wat ment al dan niet doet. Als je niet weet, wat men al doet, kan je ook moeilijk zeggen wat er beter moet.Question 9What is your opinion on the public health policy in the Netherlands on salt and thedifferences with the country you are doing your practical assignment?

I think the maximum of 6 gram salt intake per person per day in The Netherlands is a good advice, because this recommendation won't increase the chance of high bloodpressure and other diseases. There is no difference between the recommendation of salt intake in The Netherlands and Hong Kong. Je spreekt jezelf hier een beetje tegen. Boven zei je dat HK 5g/dag is. Misschien kan je hier zeggen dat 6g/dag niet slecht is en dat men in HK de target van WHO volgt. (Hmm, volgens mij klopt dit antwoord niet?????) Question 10Take a look at table 2

a. Explain the 3rd column ‘Documented baseline levels of salt intake’ in your ownwords. Include in your answer the meaning of ‘baseline’. This is the lowest amount of salt intake reported in the surveys.Baseline means the lowest amount for comparison.

b. What are the 2 different methods that were used to assess salt intake. Describe in afew sentences. The two methods that were used to assess salt intake were: urine samples and dietary surveys. - 24-hour urine test: a simple diagnostic procedure that measures the components of urine. Sodium can be detected from the urine test, and this measures the amount of salt a person consumes.- Dietary survey: from a dietary survey or a daily dietary history, the amount of consumed salt a day can be detected.

c. Compare the results in the table for the Netherlands and the country where you arenow. Mention the differences. [Note; if your country is not included in the table, use acountry that is comparable.) In China it is much higher than in the Netherlands, but no surveys are being executed to keep it in control.Je kan mss ff melden dat hk veel lager is en dat men in hk de target van WHO volgt van 5g/day ipv 6g/day in China. Hmm, goed antwoord? =S