269The second important concern is the education. Behavioral intervention studies
have previously demonstrated that knowledge is a key contributing factor to adher-
ence to low-salt diet [ 63 ] and that lack of knowledge is a key barrier in dietary
modification and adherence [ 64 ]. Dietary advice to lower salt intake routinely given
to patients with CKD in the form of an information sheet is ineffective. By contrast,
the dietitian-led intervention may be of more value in decreasing sodium intake
[ 65 ]. There is compelling evidence from behavioral sciences that sustained lifestyle
changes require a dedicated, behavioral approach [ 66 – 68 ]. However, such
approaches are not yet part of the clinical routine in renal care. Thus it is of para-
mount importance to educate patients actively to decrease sodium intake.
Cultural background and orientation are also important issues regarding salt
intake. Efforts to understand their cultural mores interpret and convey health-
promotion messages in culturally appropriate ways will probably result with a posi-
tive response in CKD patients [ 69 ].
A part from personalized care, national strategies regarding reducing salt intake
is of paramount importance. The vitality of this action is already recognized and a
review of salt reduction strategies undertaken in 2010 identified 32 national salt
reduction strategies worldwide [ 70 ].
Although the limitation of salt intake as a national strategy seems a hard issue, salt
reduction strategy has highlighted feasibility, demonstrating a 15% reduction in pop-
ulation salt intake between 2003 and 2011 in United Kingdom with average blood
pressure in the adult population falling by 3/1.4 mm Hg over the same period [ 71 ].
It is important to remember that estimation of salt intake is a hard issue. The gold
standard for the assessment of sodium intake is from well-collected 24-h urine, as
dietary recall and food frequency questionnaires are notoriously unreliable due to
fact that only 15% of the sodium ingested is added during cooking or during meals,
whereas the remainder is present in the food in hidden form, as additives in pro-
cessed foods [ 72 ]. For this reason, new, simple, and accurate methods should be
performed to investigate sodium intake.
The potential strategies and suggested investigations regarding sodium restric-
tion are summarized in Table 16.2.
Table 16.2 The potential strategies and suggested investigations regarding sodium restriction
Planning prospective, placebo-controlled studies regarding reducing sodium intake and RHT
and exploring whether these studies will translate into better health outcomes
New, simple, and accurate methods should be performed to investigate sodium intake
Understand the cultural norms, beliefs, habits, and barriers regarding high sodium intake
Exploring strategies to reduce sodium intake nationally
Individual education to decrease sodium intake (better in the form of active education rather
than passive dietary advice)
Explain the health gains regarding decreased sodium intake16 Treatment of Hypertension in Light of the New Guidelines: Salt Intake