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Salt intake in China is over twice the maximum recommendation of the World Health Organization. Unlike most developed countries where salt intake is mainly derived from prepackaged foods, around 80% of the salt consumed in China is added during cooking.
Action on Salt China (ASC), initiated in 2017, aims to develop, implement, and evaluate a comprehensive and tailored salt reduction program for national scaling-up.
ASC consists of six programs working in synergy to increase salt awareness and to reduce the amount of salt used during cooking at home and in restaurants, as well as in processed foods. Since September 2018, two health campaigns on health education and processed foods have respectively started, in parallel with four open-label cluster randomized controlled trials (RCTs) in six provinces across China: (1) app-based intervention study (AIS), in which a mobile app is used to achieve and sustain salt reduction in school children and their families; (2) home cook-based intervention study (HIS), in which family cooks receive support in using less salt; (3) restaurant-based intervention study (RIS) targeting restaurant consumers, cooks, and managers; and (4) comprehensive intervention study (CIS), which is a real-world implementation and evaluation of all available interventions in the three other RCTs. To explore the barriers, facilitators, and effectiveness of delivering a comprehensive salt reduction intervention, these RCTs will last for 1 year (stage 1), followed by nationwide implementation (stage 2). In AIS, HIS, and CIS, the primary outcome of salt reduction will be evaluated by 24-hour urinary sodium excretion in 6030 participants, including 5436 adults and 594 school children around 8-9 years old. In RIS, the salt content of meals will be measured by laboratory food analysis of the 5 best-selling dishes from 192 restaurants. Secondary outcomes will include process evaluation; changes in knowledge, attitude, and practice on salt intake; and economic evaluation.
All RCTs have been approved by Queen Mary Research Ethics Committee and the Institutional Review Boards of leading institutes in China. The research started in June 2017 and is expected to be completed around March 2021. The baseline investigations of the four RCTs were completed in May 2019.
The ASC project is progressing smoothly. The intervention packages and tailored components will be promoted for salt reduction in China, and could be adopted by other countries.
Chinese Clinical Trial Registry. AIS: ChiCTR1800017553; https://tinyurl.com/vdr8rpr. HIS: ChiCTR1800016804; https://tinyurl.com/w8c7x3w. RIS: ChiCTR1800019694; https://tinyurl.com/uqkjgfw. CIS: ChiCTR1800018119; https://tinyurl.com/s3ajldw.
DERR1-10.2196/15933
Humans only require a very small amount of salt (ie, around 1 g/day) to maintain physiological function [
China is the largest developing country, accounting for one fifth of the global population. Salt intake in China is among the highest in the world, with adults consuming on average above 10 g/day [
In most developed countries, where 80% of salt intake is derived from prepackaged food, the major strategy of salt reduction is to set salt targets; that is, to encourage food producers to gradually reduce the amount of salt used in their food products [
The central government of China has set a target of a 20% reduction in mean population salt intake by 2030 as one of the key components of China’s health development agenda “Healthy China 2030” [
To overcome the above challenges, a collaboration unit called “Action on Salt China” (ASC) was established in June 2017, funded by the UK National Institute for Health Research (NIHR). ASC was built upon an existing collaboration between Queen Mary University of London in the United Kingdom, and The George Institute for Global Health (TGI) in China, as well as previous research and implementation experience on salt reduction [
ASC is running two national health campaigns and four randomized controlled trials (RCTs) testing interventions on major sources of salt intake. Although the protocol and results of each RCT will be published separately, it is worthwhile to report the overall design of ASC so as to improve public understanding of its rationale and design as a whole. With this aim, this paper introduces ASC’s overall goals and strategies, governance, proposed solutions to main challenges in salt reduction, uniformed design of intervention packages and evaluations, plan for scaling-up, as well as other ancillary work.
The goal of ASC is to reduce salt intake by 15% by 2021 in the six target provinces in China. The specific objectives are to reduce salt intake by at least 1 g/day (about 17 mmol/day) at home, and to reduce salt use by at least 0.5 g (about 8.5 mmol) per 100 g in restaurant dishes. To reach these goals, several programs targeting the major sources of salt intake in China have been developed and are being implemented.
To achieve these goals and objectives, the ASC project developed six programs targeting the low health literacy related to salt reduction and the three sources of salt intake in China: home cooking, restaurant foods, and prepackaged foods. Program 1 is a salt reduction education campaign, which will form the basis of all the other programs. Program 2, app-based intervention study (AIS), is a primary school-based program delivering salt reduction activities for the homes of school children, based on the assumption that parents and grandparents are more likely to change their habit of high salt intake for the sake of the health of their children and grandchildren [
The governance and management structure of the ASC unit and programs are illustrated in
Governance and specific programs of Action on Salt China (ASC) program. PI: principal investigator; China CDC: China Centers for Disease Control; CCHE: Chinese Center for Health Education; NINH: National Institute for Nutrition and Health, China CDC; TGI China: The George Institute for Global Health China; QMUL: Queen Mary University of London; NCD Division: Division of NCD Control and Community Health, China CDC; NCD Center: National Center for Chronic and Non-communicable Disease Control and Prevention, China CDC; CFSA: China National Center for Food Safety Risk Assessment; Beihang: Beihang University (Or Beijing University of Aeronautics and Astronautics).
A two-stage strategy is adopted to ensure that the proposed salt reduction programs are well prepared, evaluated, and tailored. At stage 1 (first 2 years), the intervention packages in each program will be developed and evaluated, before being scaled-up and integrated as policies at stage 2.
At stage 1, the different intervention packages of Programs 2-5 will be evaluated with open-label cluster RCTs in various settings. The four RCTs will be conducted collaboratively under the same governance and time frame. Evaluation will be performed using standardized questionnaires, physical examinations, laboratory tests, and data collection systems that are as identical as possible so that the data collected across the RCTs can be pooled together for overall salt intake estimation and overall effectiveness evaluation.
The key features of the six programs of ASC at stage 1, including the theories and key intervention components of the four RCTs (Programs 2-5 at stage 1), are summarized in
The study participants are grade 3 primary school students (8-9 years old) and their parents/grandparents (1 student and 2 adults for each family) in AIS, home cooks and their family members (1 home cook and one other adult member for each family) in HIS, and adults (1 adult from each participating family) in CIS. Although the participant recruitment may vary among AIS, HIS, and CIS, in all cases, these will be local residents with no plan to move out of the city or village within 24 months, and agree to participate in the studies. The exclusion criteria are (1) pregnant women and those actively lactating; (2) individuals who are currently participating in any other clinical trials; (3) those with severe psychiatric or physical diseases that might impact intervention and follow-up; (4) individuals who are unable or not suitable to collect 24-hour urine due to the following conditions: aconuresis; acute/chronic urinary tract infection, vaginal infection and perianal infection; acute hemorrhagic diseases in the urinary tract, vagina, and digestive tract; and severe vomiting and diarrheic symptoms. In RIS, the study subjects are restaurants with dish salt content as the primary outcome, which will be evaluated using the average sodium content of the 5 best-selling dishes.
At the end of stage 1, the education materials and the effective intervention packages or components will be combined as a scale-up intervention package on salt reduction (SIPS) for broad use at stage 2. A final evaluation to assess the impact of the scaling-up and the lasting effectiveness of the intervention packages will be carried out at the end of 1 year of scale-up. The SIPS will subsequently be further promoted over a larger scale across China using existing platforms and resources such as China’s Healthy Lifestyle for All Initiative of the China CDC and the Chinese Center for Health Education.
To avoid contamination in control groups, all RCTs are being conducted in different counties or districts of the six provinces: Heilongjiang, Hebei, Hunan, Jiangxi, Sichuan, and Qinghai, which cover the north, south, central, east, and west part of China (
To facilitate implementation, ASCloud, a cloud-based information system, has been designed and developed by Beihang University to support health education and promotion to the public, restaurants, and food industry; intervention delivery; and project and data management for all programs. This is based on our experience in delivering research projects [
Key features of the six programs in Action on Salt China (ASC) at stage 1.
Programs | Purposes | Rationale/design | Coverage at stage 1 | Output by the end of stage 1 |
Program 1: health education and promotion | To improve KAPa on salt reduction in the public, restaurants, and food industry; to provide a basis for the other programs | Various types of education materials were developed to improve the KAP targeting major barriers to salt reduction and sources of salt intake using evidence-based key messages | Within study sites of the intervention arms of all 4 RCTsb in 6 Chinese provincesc | Materials (eg, manuals, fact sheets, leaflets, stickers, public advertisements, short videos, and loudspeaker audio messages) targeted at various populations and settings |
Program 2: application-based intervention study (AIS) | To achieve and sustain salt reduction in school children and their families | A cRCTd to test the feasibility and effectiveness of an app-based platform (AppSalt) for salt reduction. Goal setting, self-monitoring, and self-reward are the major components [ |
54 primary schools in 3 of the 6 provinces | Finalized AppSalt platform; report on effectiveness of salt reduction as measured by repeated 24-hour urinary sodium excretion; report on feasibility from the perspective of the schools, students, and families |
Program 3: home cook-based intervention study (HIS) | To support families, mainly through family cooks, to reduce salt use in home cooking | A cRCT to test the effectiveness and acceptability of a community-based intervention package. Standardized education, salt intake evaluation, individualized recommendations, and reminders are the major components of intervention based on a health belief model [ |
60 communities from the 6 provinces | Intervention package; report on effectiveness of salt reduction measured by 24-hour urinary sodium excretion; report on feasibility |
Program 4: restaurant-based intervention study (RIS) | To reduce salt intake when eating out by reducing salt use by restaurant cooks | A cRCT to test the feasibility and effectiveness of a restaurant salt reduction package. Social cognitive theory [ |
192 restaurants in the 6 provinces | Restaurant intervention package; report on the effectiveness of salt reduction as measured by whole food sodium analysis for each of the restaurants’ 5 best-selling dishes; report on feasibility. |
Program 5: comprehensive intervention study (CIS) | To explore the experience, barriers, facilitators, and effectiveness of delivering a comprehensive salt reduction intervention | A cRCT at the township/ street level to simulate the scale-up of the intervention clusters and to test its effectiveness. The World Health Organization conceptual framework [ |
48 towns /streets in the 6 provinces | Process evaluation report; report of effectiveness of salt reduction as measured by 24-hour urinary sodium excretion. |
Program 6: prepackaged food salt reduction | To encourage and support consumers to choose prepackaged foods with lower salt content (P6.1), and to work with the food industry to reduce salt use in prepackaged foods (P6.2) | Besides setting voluntary salt targetse, consumers are encouraged to choose foods with less salt, and food manufacturers are persuaded to reformulate the products that are high in salt. A health belief model [ |
Participating consumers and food producers | The FoodSwitchf app (already downloaded by more than 1 million users); a website designed to raise food manufacturers’ awareness of the high salt content of their products and display ranking by salt content in product categories; by late 2019, more than 100 products have already been reformulated to contain less salt |
aKAP: knowledge, attitude, and practice.
bRCT: randomized controlled trial.
cThe 6 provinces are Heilongjiang, Hebei, Hunan, Jiangxi, Sichuan, and Qinghai, which cover the north, south, central, east, and west part of China.
dcRCT: cluster randomized controlled trial.
eSetting incremental targets for the salt content of major contributors to salt intake (eg, sauces).
fFoodSwitch is a smartphone app that can provide consumers with the nutrition information of a prepackaged food product (including sodium; in China, food products are labeled with sodium rather than salt in which 1 g sodium = 2.5 g salt) and a list of similar food products for making healthier choices, especially with respect to sodium reduction.
The study sites of the Action on Salt China (ASC) cluster of randomized controlled trials.
The evaluation method of the effectiveness or impact of the proposed interventions has been specifically designed for each program. In all RCTs, the 1-year effectiveness of the intervention will be assessed by comparing the salt reduction achieved between the intervention and control arms from baseline to the end of stage 1, and the sustained effectiveness over the following year will be assessed by comparing the salt reduction achieved between the intervention and control arms of AIS, HIS, and CIS from baseline to the end of stage 2.
The sample sizes indicated in
Secondary outcomes will consist of process evaluation, changes in KAP on salt intake, and economic evaluation. Overall KAP on salt, and overall salt intake levels will also be estimated by pooling the data collected in AIS, HIS, and CIS at baseline, at the end of stage 1, and at the end of stage 2.
Statisticians will be blinded to the intervention assignments during data analysis. An intention-to-treat approach will be adopted for analysis of the primary outcomes. The effect of the intervention on the outcomes will be tested using linear mixed models. For AIS, HIS, and CIS, participants will be nested within family units and families nested within clusters (schools, villages, or towns). Group (intervention, control), time (baseline, end of trial), and time-by-group interaction will be included in the model, with the interaction effect indicating differential change according to group from baseline to the end of the trial. We will adjust for the stratification and potential confounding variables at randomization.
Design for the evaluation of the four cluster randomized controlled trials in Action on Salt China (ASC) Programs 2-5.
Our study will have three major data outputs: (1) data obtained from the evaluation of each RCT’s effectiveness (
All cleaned and locked datasets for each RCT, together with the study design, questionnaires, code lists, and definitions of databases and variables, will be stored in TGI China, with a unique ID number attached but no personal identifiers, following an established standard operating procedure for data security. To guarantee data security, the mobile app developer (ie, the Information Technology team at Beihang University) will follow the “Mobile Application Information Service Regulation” issued by the Cyberspace Administration of China in 2016 [
Data collection in the four randomized controlled trials in Action on Salt China (ASC) Programs 2-5.
Questionnaires | Baseline | Year 1 and 2 follow-up | ||||
AISa | HISb | RISc,d | CISe | |||
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Sex | ✓ | ✓ | ✓ | ✓ | —f |
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Age | ✓ | ✓ | ✓ | ✓ | — |
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Education | ✓ | ✓ | ✓ | ✓ | — |
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Marriage | ✓ | ✓ | ✓ | ✓ | — |
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Income | ✓ | ✓ | ✓ | ✓ | — |
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Medical Insurance | ✓ | ✓ | ✓ | ✓ | — |
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Preference for salt | ✓ | ✓ | ✓ | ✓ | As baseline |
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Awareness of salt recommendation | ✓ | ✓ | ✓ | ✓ | As baseline |
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Awareness of salt and hypertension | ✓ | ✓ | ✓ | ✓ | As baseline |
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Awareness of low-sodium salt | ✓ | ✓ | ✓ | ✓ | As baseline |
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Awareness of salt labeling | ✓ | ✓ | ✓ | ✓ | As baseline |
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Attitude to low-salt diet | ✓ | ✓ | ✓ | ✓ | As baseline |
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Attitude to low-salt behavior | ✓ | ✓ | ✓ | ✓ | As baseline |
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Salt use during cooking | ✓ | ✓ | ✓ | ✓ | As baseline |
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Frequency of eating out | ✓ | ✓ | ✓ | ✓ | As baseline |
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Ordering dishes with reduced salt when eating out | ✓ | ✓ | ✓ | ✓ | As baseline |
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Smoking | ✓ | ✓ | — | ✓ | As baseline |
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Drinking | ✓ | ✓ | — | ✓ | As baseline |
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Physical activity | ✓ | ✓ | — | ✓ | As baseline |
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Hypertension | ✓ | ✓ | — | ✓ | As baseline |
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Anti-hypertensive medication use | ✓ | ✓ | — | ✓ | As baseline |
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Other chronic diseases | ✓ | ✓ | — | ✓ | As baseline |
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Height | ✓ | ✓ | — | ✓ | As baselineg |
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Weight | ✓ | ✓ | — | ✓ | As baseline |
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Waist circumference | ✓ | ✓ | — | ✓ | As baseline |
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Blood pressure | ✓ | ✓ | — | ✓ | As baseline |
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Heart rate | ✓ | ✓ | — | ✓ | As baseline |
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Sodium | ✓ | ✓ | — | ✓ | As baseline |
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Potassium | ✓ | ✓ | — | ✓ | As baseline |
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Creatinine | ✓ | ✓ | — | ✓ | As baseline |
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Albumin | ✓ | ✓ | — | ✓ | As baseline |
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Calcium | ✓ | ✓ | — | ✓ | As baseline |
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Salt-specific environmental factors | — | — | ✓ | — | As baseline |
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Recipe of the 50 best-selling dishes | — | — | ✓ | — | — |
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Percentage of consumers who choose lower salt foods | — | — | ✓ | — | — |
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Usage of salt and highly salted foods | — | — | ✓ | — | As baseline |
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Provision of salt reduction services | — | — | ✓ | — | As baseline |
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Sodium content of the 5 best-selling dishes | — | — | ✓ | — | As baseline |
aAIS: app-based intervention study.
bHIS: home cook-based intervention study.
cRIS: restaurant-based intervention study.
dThe primary outcome of RIS is the change of salt use among the study restaurants measured by whole food sodium analysis for the 5 best-selling dishes in each restaurant. Twenty consumers will be invited to take part in a simple survey at baseline and at the end of 2 follow-ups.
eCIS: comprehensive intervention study.
fNot applicable.
gOnly the height of children in AIS will be measured during the follow-up visit at year 1 and year 2.
hThe quality control for 24-hour urine collection refers to the protocol of AIS [
During development of the overall design of ASC and the specific protocols for each RCT, people from the target populations and those involved in the implementation of the interventions were consulted at least once through meetings, teleconference, and site visits. The consulted individuals included primary school teachers, parents of primary school children, family cooks, consumers of prepackaged food, food producers, restaurant staff, community residents, and policy makers. All ideas on new interventions, opinions on the feasibility of specific interventions, and suggestions to improve their design and implementation were carefully considered. All participants will be informed of the study progress by regular communication via the ASC newsletter, WeChat, and website. Upon completion of the study, we will disseminate the results to all participants and discuss the translation of our study findings to practice.
The duration of ASC is from June 1, 2017 to March 31, 2021, with March 31, 2020 as the split point for stage 1 and stage 2. The preparation of the 4 RCTs and their baseline investigations were completed at the end of March 2019. Protocols of the intervention packages or intervention components that proved to be effective at stage 1 will be made available and scaled up by combining them into an existing national initiative such as Healthy Lifestyle Campaign for All [
All trials have been approved by Queen Mary Research Ethics Committee in the United Kingdom (QMERC2018/13 for AIS, QMERC2018/15 for HIS, QMERC2018/16 for CIS, and QMERC2018/14 for RIS) and the Institutional Review Boards of Peking University (IRB00001052-18051 for AIS), Chinese CDC (No. 201801 for HIS), National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC (No. 201807 for CIS), and National Institute for Nutrition and Health, China CDC (20180314 for RIS). Written informed consent forms have been obtained from all participants according to well-established practices. For children, participant assent and parental written consent have been obtained. All participants are free to discontinue their participation at any time with no explanation required.
By the end of 2019, three steering committee meetings have been convened. Nine presentations have been made in international (four) and national (five) meetings. The Chinese National Health Commission, especially the divisions of disease control, food safety, and health education, is looking forward to adopting the evidence-based salt reduction packages in ASC in 2020, which could help support the Healthy China Initiatives launched in July 2019 [
Program 1: Health education and promotion
KAP (knowledge, attitude, and practice) questionnaire: pilot tested and now in use by all RCTs (randomized controlled trial).
Education materials: 1 manual, 3 leaflets, 2 public advertisements (15 s and 30 s), 3 short videos targeting 3 major settings for salt intake (home cooking, eating out, and groceries), 8 loudspeaker audio messages for rural village use, and several others; ready for use in RCTs.
Programs 2-5: app-based intervention study (AIS), home cook-based intervention study (HIS), restaurant-based intervention study (RIS), comprehensive intervention study (CIS)
Intervention package development for all 4 RCTs: completed.
Participant recruitment: 592 children and 1184 adults recruited for AIS, 1576 home cooks recruited for HIS, 2694 residents recruited for CIS, and 192 restaurants recruited for RIS.
Baseline surveys: completed, including 24-hour urine collection in AIS, HIS, and CIS, and whole food sodium analysis for the 5 best-selling dishes of each participating restaurant in RIS.
Randomization: Schools/communities/restaurants randomly assigned to intervention and control arms after completion of baseline surveys.
Intervention implementation: Ongoing
RCT follow-up assessment: completed by the end of January 2020 for AIS, HIS, and CIS, and will be completed by the end of May 2020 for RIS.
Program 6: Prepackaged food salt reduction
FoodSwitch was released June 16, 2019 and has been downloaded by over 10,000 users as of November 2019. It can be found by searching “Shi Xian Zhi” in most app markets and WeChat (a popular communication app in China), and can be used by consumers to choose lower-salt prepackaged foods. Shi Xian Zhi is Chinese pinyin, with Shi indicating food, and Xian Zhi for prophet.
ASC’s official website now provides a purpose-built page for food producers, based on the data collected through FoodSwitch.
The information system (ASCloud)
ASC’s official website [
Several smartphone apps and WeChat applets (ie, very small apps) have also been developed to help consumers choose foods with less salt (FoodSwitch, Shi Xian Zhi in Chinese pinyin), to help families estimate their salt intake (KnowSalt, Jia Ting Yong Yan Ce Liang in Chinese pinyin, used in HIS and CIS), to help deliver a series of health education and activities on salt reduction in schools for the school children and their families (AppSalt, Jian Yan, used in AIS), and to help project implementation and quality control (one app per RCT). Jian Yan is Chinese pinyin, with Jian meaning health and Yan meaning salt.
Laboratory tests
One top-level central laboratory has been contracted for the assay of all urine samples collected in AIS, HIS, and CIS, and the whole food sodium analysis in RIS.
ASC is a research unit led by a strong multidisciplinary team with members from international and national institutes engaging in nearly all relevant areas on salt reduction in China. The ASC program is comprehensive, including a salt awareness campaign, legislation support, and RCTs evaluating the strategies dealing with key challenges on salt reduction in China. ASC uses innovative digital health technologies to support the delivery of interventions as well as project and data management. The real-time monitoring and process evaluation can help to increase the fidelity of complex interventions.
As a unit, the six programs of ASC will provide a set of novel approaches to reduce salt intake in China. The expected outputs of ASC include: (1) several evidence-based intervention packages addressing major sources of salt intake; (2) evidence-based salt reduction strategies and experience on policy advocacy along with scaling-up in different regions and populations; and (3) study reports and publications to highlight the gaps, needs, barriers and facilitators, and strategies in salt reduction among different populations. All these major outputs will make significant contributions to the national policies, programs, and initiatives on the prevention and control of noncommunicable diseases as well as the promotion of healthy diets and healthy lifestyle in China. Owing to the strong policy support, multidisciplinary research team, and close partnership with all key national agencies, ASC is most likely to succeed in achieving its intended objectives.
To date, ASC has already made significant progress in achieving its academic impact. As shown in
The findings of this study will be disseminated widely through conference presentations, peer-reviewed publications, press releases, and social media. In China, the results and effective interventions will be disseminated nationwide through the existing system of health education, disease control, and prevention. Furthermore, the results will be disseminated worldwide through World Action on Salt and Health [
The interventions for each program of ASC are complex. Low compliance to the intervention may lead to negative results for the primary outcomes. In addition, the implementation of collecting 24-hour urine is very demanding. Fidelity to interventions and quality control for effectiveness evaluation are both critical to the success of the programs. With the widespread implementation of Healthy China 2030 initiatives, salt reduction is being promoted by many other programs. Therefore, it might be very difficult to distinguish the contributions of ASC from those of other programs.
The ASC project is progressing smoothly. The intervention packages and components evaluated at stage 1 will provide strong support for salt reduction in China, and could potentially be adopted by many other countries worldwide.
Structure of Action on Salt (ASC) information system (ASCloud) developed by Beihang University. AIS: app-based intervention study; HIS: home cook-based intervention study; RIS: restaurant-based intervention study; CIS: comprehensive intervention study; mEDC: mobile phone app based on an electronic data collection system; PM: project management; MS: management system; NINH: National Institute for Nutrition and Health, China CDC; TGI: The George Institute for Global Health; NCD Division: Division of NCD Control and Community Health, China CDC; NCD Center: National Center for Chronic and Non-communicable Disease Control and Prevention, China CDC; CFSA: China National Center for Food Safety Risk Assessment.
Peer review comments and responses from National Institute for Health Research.
CONSORT-eHEALTH checklist (V 1.6.1).
app-based intervention study
Action on Salt China
Chinese Center for Health Education
China National Center for Food Safety Risk Assessment
Chinese Center for Disease Control and Prevention
comprehensive intervention study
cardiovascular disease
home cook-based intervention study
knowledge, attitude, and practice
mobile device-based electronic data capture system
National Institute for Health Research
randomized controlled trial
restaurant-based intervention study
scale-up intervention package on salt reduction
The George Institute
World Health Organization
The authors would like to thank the staff from the local CDCs, community health service centers, schools, and restaurants, and the participants who shared their opinions on the development of the intervention programs. This research was commissioned by the National Institute for Health Research (NIHR) (NIHR Global Health Research Unit Action on Salt China [ASC] at Queen Mary University of London) using Official Development Assistance (ODA) funding (16/136/77). The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
PZ and FH conceived the project and contributed equally to the work. PZ designed the study and drafted the paper together with Xinhua Li, FH, and Yuan Li. CL, JW, JM, BZ, HW, YH Li, J Han, RL, J He, Xian Li, CW, MT, and GM participated in the design of specific programs in this study and reviewed the manuscript. Y Liu led the development of ASCloud, the information system used in this study. Xinhua Li facilitated patient and public involvement and was responsible for setting up the study at each site.
None declared.