INTRODUCTIONThe Chinese diet is well known to be high in sodium. Laboratory analysis of sodium intake per person in studies conducted between 2009 and 2011, showed that 5.4 g of sodium was consumed per day (more than twice the tolerable upper intake level for sodium, which is 2 g/day), for 20 provinces in China [1,2]. A causal relationship between high sodium intake and increased blood pressure levels has also been well established [3,4]. The prevalence of hypertension increased from 10.4% in 1991 to 22.7% in 2009 , and particularly affects those ≥ 60 years (58.2%), followed by those aged 45–59 years (40.1%), and then 18–44 years old (17.5%) . Patients with hypertension were most prevalent in the Northern region of China (29.5%), compared with patients in the Central (24.9%) and Southern (17.4%) regions . Due to the high level of sodium intake and the high prevalence of hypertension among the elderly population in the Northern region, interventions aimed at reducing sodium intake among this particular age group have common in China.To address the problem of high salt intake, it is critical to first identify the barriers, attitudes, and dietary behaviors related to sodium reduction. To conduct a survey of Knowledge, Attitudes, and Practices (KAPs), the Chinese Ministry of Health selected the Shandong province as the pilot area for a national sodium reduction project in 2011 . The findings of this survey revealed that 80% of participants favored reduced-sodium diets, while approximately one in three participants entertained misconceptions, such as lowered sodium intake would lead to impaired physical health . Designing an effective nutrition intervention program is dependent on understanding the misbeliefs and KAPs related to sodium reduction within a community.The People’s Republic of China consists of primarily Han Chinese, as well as people from 55 diverse minority nationalities . Two million Korean–Chinese, the 13th largest minority population, officially live in China, and more than half of them live in Yanbian Korean Autonomous Prefecture in Northeastern China [8,9]. Several studies have revealed substantial health and nutrition inequalities between the Han and minority populations, suggesting that minorities generally have worse nutritional statuses and poorer health [10,11]. Additionally, ethnic minorities, especially the Korean–Chinese, often have limited access to health care information and community health centers.Almost nothing is known about the personal and environmental factors that inhibit sodium reduction among the elderly Korean–Chinese population in Yanbian, China. In the present study, we conducted a needs assessment of nutrition education regarding sodium reduction. By realizing and understanding the individual and ecological challenges related to sodium reduction for this population, it is hoped that an effective sodium reduction program can be developed.
1. Descriptive researchTo implement this study, we obtained institutional review board approval at Kyonggi University. We conducted descriptive research for a pilot study aimed at reducing dietary sodium intake among the elderly Korean–Chinese people at the Danling Elderly Community Center in Yanbian in 2016. Because the specific aims of this research were to identify the factors affecting sodium reduction and the current status of KAPs related to sodium reduction, we focused on these factors and report the results herein as baseline information.We first collected demographic and health information from the participants, including age, sex, education, household composition, and subjective health status. For sodium-related information, we obtained data from the participants regarding the barriers, attitudes, awareness, willingness, dietary behaviors, and knowledge regarding sodium reduction. We then assessed the barriers to reduction of sodium intake, namely: 1) difficulty when eating with others, 2) preference for soup, 3) lack of taste, 4) preference for salt-preserved dishes, 5) limited choices when eating at restaurants, 6) complicated cooking process, and 7) lack of knowledge about specific information or methods of sodium reduction. Subsequently, the participants’ attitudes toward sodium reduction were tested in part using the following two items: 1) “Dishes should be well seasoned with salt,” and 2) “A reduced-sodium diet will improve my health.” Awareness of sodium reduction was examined using one item: 1) “I am aware of the amount of sodium in foods and dishes.” Finally, willingness to reduce sodium intake was explored in part using the following four items: 1) “I am willing to buy fresh and natural foods,” 2) “I request reduced-sodium dishes at restaurants,” 3) I choose dishes according to my native taste and smell of food,” and 4) “I am willing to cook reduced-sodium food.” The participants answered each item on a 5-point Likert scale that ranged from 1 (strongly disagree) to 5 (strongly agree).To determine the participants’ dietary behaviors related to sodium reduction, we asked how frequently they consumed salty foods (e.g., processed foods, soup, and salt-preserved dishes), to which they responded “never,” “seldom,” “sometimes,” “often,” or “almost always.” Finally, to test the participants’ nutrition knowledge about sodium reduction, a 9-item questionnaire (which included questions about salt intake and disease, the relationship between sodium and salt, the tolerable upper intake level of sodium, requirement of salt, learning to prefer less salty food, sodium excretion, nutrition labeling of sodium, and amount of sodium in soybean paste and instant noodle) was distributed; the participants responded with “yes,” “no,” or “I don’t know.” This descriptive research was useful for identifying the current status of barriers, attitudes, and dietary behaviors among elderly Korean–Chinese population.
2. Focus group interviewWe included subjects who agreed to participate in this focus group interview. One focus group interview was conducted with the elderly Korean–Chinese population at the Danling Elderly Community Center in August 2016 . A facilitator guided the interview, which included four main inquiries: 1) awareness of sodium consumption; 2) barriers to decreasing sodium intake; 3) factors affecting sodium consumption; and 4) suggestions for education about salt reduction (Table 1). The interview was recorded for transcription per the approval of the participants. Overall, the focus group discussion lasted for approximately 1 hour. Subsequently, we reviewed the transcripts and assigned codes to each piece of information obtained through the key questions and classified similar answers into themes .
1. Findings from the descriptive researchThis pilot study included 21 participants (3 males and 18 females), who were an average age of 71 years (Table 2). Half of the participants had graduated from middle school, and almost two in three (65%) indicated that they almost never eat away from home. Additionally, about half of the participants (47.4%) had been diagnosed with hypertension and almost one in two lived alone (52.4%).Our review of the questionnaire revealed that the participants ranked the barriers to sodium reduction in the following order: 1) difficulty having a meal with others (4.05 points), 2) preference for liquid-based dishes (e.g., soup and stew) (3.86 points), 3) lack of taste (3.85 points), 4) preference for salt-preserved dishes (3.67 points), 5) limited options when eating at restaurants (3.50 points), 6) complicated cooking process (2.95 points), and 7) lack of knowledge about specific information or methods of sodium reduction (2.86 points) (Table 3).The score for attitude was very high for the item “A reduced-sodium diet will improve my health” (4.50 points), while the score regarding awareness of sodium in foods and dishes was comparatively low (3.45 points) (Table 4). Regarding the participants’ willingness to reduce their sodium intake, three out of the four items on this questionnaire scored over 4 points: 1) “I am willing to buy fresh and natural foods” (4.20 points), 2) “I choose dishes according to my native taste and smell of foods” (4.10 points), and 3) “I am willing to cook reduced-sodium food” (4.10 points). The last item on this questionnaire, “I request reduced-sodium dishes at restaurants,” had a relatively low score by comparison (3.76 points).Of the dietary behaviors related to a higher intake of sodium, the most common were frequent consumption of kimchi (Korean pickled cabbage) (often/almost always, 47.6%) and addition of salt or soy sauce to a dish or soup that is not salty enough (often/almost always, 42.9%) (Table 5). Among the healthy eating behaviors related to a lower intake of sodium, the most common was consumption of vegetables and fruits (often/almost always, 57.1%). On the other hand, eating out at restaurants or consuming processed foods (e.g., cookies, crackers, and instant noodles) were less common dietary behaviors (often/almost always, 9.5% and 4.8%, respectively).The average score of nutrition knowledge was 53.3 points (standard deviation, 18.8; range, 0–90). Of the nine questions, the relationship between sodium and salt had the lowest proportion (23.8%) of participants who answered correctly (Table 6). In addition, only one in three participants knew about the sodium information displayed on the nutrition labels of processed foods.
2. Findings from the focus group interviewEight participants (1 males and 7 females) were included in the focus group interview (Table 7). The average age of the participants was 67 years, half of them had graduated high school, and almost two in three (62.5%) lived alone.A few participants admitted to habitually consuming salted dishes (Table 8). Although they acknowledged that they could modify their dietary habits and adopt new ones through will-power, they generally never thought of abandoning their current habits. Other participants indicated that taste was a barrier to reducing their sodium intake, although some admitted that they automatically assume unsalted foods are not tasty. The participants also considered consumption of salt-preserved dishes as part of their food culture, which has been passed down over centuries up to the present settlement of the Korean–Chinese population. Notably, a few participants admitted that restaurant dishes were very salty and complained about the unhealthy food environment at restaurants; nevertheless, they seemed unwilling to actively change this environment. Moreover, the participants expressed certain misbelieves about salt, stating that eating healthy salts, such as bay-salt and bamboo salt, was healthy. Finally, the participants indicated that checking the amount of sodium on nutrition labels of food products or by using a salimeter would be a burden.Some factors were identified as heavily associated with salt consumption (Table 9). For example, the participants who strongly believed in the health benefits of sodium reduction were generally more willing to reduce their salt intake. Overall, the popular, salt-preserved Korean dishes were the main factor contributing to high salt consumption. Most Korean–Chinese frequently consume kimchi, as well as pickled meat or vegetables in the summer, and soybean soup in winter. However, eating with children or grandchildren was noted as a critical contributor to the use of less salt in the elderly participants; because of their strong familial ties, the participants indicated that their family’s health was more important than their taste preferences.Finally, the participants also offered suggestions on salt reduction education (Table 10). First, they suggested the use of visual materials, such as video clips, in demonstrating certain severe symptoms or clinical outcomes of disease due to high salt intake. Second, they suggested incorporating practical food education and cooking classes consisting low-sodium recipes. Third, they emphasized that continuous education would be crucial in ensuring that sodium reduction practices were maintained.
DISCUSSIONOur findings showed that the top three barriers to sodium reduction among the elderly Korean–Chinese population were: 1) the difficulties associated with having meals with others, 2) a preference for liquid-based dishes, and 3) the lack of taste in low-sodium dishes. Some of the participants also appeared unable to make sodium-reduction choices due to peer pressure and an unhealthy atmosphere. To overcome these barriers, a sodium reduction campaign at the community level is necessary for all age groups, to increase awareness about sodium reduction. Moreover, we need to develop reduced-sodium recipes for liquid-based dishes and offer cooking classes that teach low-sodium recipes. Girgis et al.  found that most consumers did not notice any difference in flavor in white bread when the amount of sodium was gradually reduced by 25% over a period of 6 weeks. We suggest applying this gradual sodium reduction strategy to elderly Korean–Chinese who consume high-sodium diets.In this study, we also observed that the most common dietary behaviors related to sodium intake were the consumption of pickled dishes (e.g., kimchi) and sauce (e.g., soy sauce and soybean paste). Therefore, technically and financially supporting the development of tasty, low-sodium recipes, particularly those that modify the most frequently consumed high-sodium dishes, is crucial. For example, more savory soybean paste sauce can be achieved by adding nuts or mashed tofu as a salt substitute. According to the focus group participants, a habitual salty diet is the biggest barrier to sodium reduction. Gardner et al.  argued that new habit formation takes approximately 10 weeks, and noted that repeating a single specific behavior over this period is essential to successfully form the new habit. It is clear that a multidimensional approach is crucial to eliminate the barriers to sodium reduction.Environmental factors could also strongly affect one’s dietary intake . Thus, monitoring the sodium content of restaurant foods would be a useful intervention to address problems with high sodium content. The 2009 China Health and Nutrition Survey ranked the main sources of sodium intake in the following order: 1) added salt, 2) soy sauce, and 3) processed foods . Unlike western countries, where the primary source of sodium is processed foods, over 70% of sodium intake in China is a result of adding salt during/after cooking (both at restaurants and at home) [17,18]. The participants in the present study similarly complained that restaurant meals were very salty. Nevertheless, they rarely requested a reduced-sodium dish when eating out. To curb this, we suggest information regarding the sodium content of restaurant foods be shared with the community, and to recommend low-sodium menus to the public after conducting future research regarding the monitoring of sodium content in restaurant foods. One study indicated that providing sodium information on restaurant menus, similar to the nutrition labels provided on processed foods, could lead consumers to make reduced-sodium menu choices . The elderly Korean–Chinese participants in our focus group discussion suggested a nutrition education program that includes visual education materials (i.e., video clips) about salt and disease, and a step-by-step education process.The health belief model argues that one’s health behavior is determined by their own perceived susceptibility to a problem, and the perceived severity of the problem . Thus, education regarding the high prevalence of hypertension, such as the complications, symptoms, and treatment costs of the disease, could play a key role in encouraging people to reduce their sodium intake by increasing their perceived susceptibility to and the perceived severity of the problem. In the United Kingdom, a national salt reduction campaign successfully in reduced the proportion of adults who added table salt to their food by 10% in 5 years . Developing visual educational aids and implementing sodium reduction campaigns are thus effective strategies of a successful nutrition education program.To date, there has been scarce information on factors related to sodium reduction among the elderly Korean–Chinese population. However, this study successfully revealed several reasons why many continue to consume substantial amounts of sodium. As far as we know, this is the first study to assess the barriers against, awareness of, and willingness toward sodium reduction for this group of nutritionally vulnerable people by employing both quantitative and qualitative data analyses. Limitation of this study is that we could not test any hypotheses nor generalize the findings due to the small sample size . Nevertheless, this study provides essential preliminary information that could help develop a large-scale nutrition intervention program to reduce sodium intake among the elderly Korean–Chinese population in Yanbian. The health belief model describes that one’s health behavior is determined by perceived susceptibility and perceived severity . In particular, we suggest that education regarding the high prevalence of hypertension, including the complications, symptoms, and treatment costs of the disease, be encouraged, to help people reduce their sodium intake.