Developing effective pragmatic preventive strategies for chronic non-communicable diseases in resource-constrained settings is a challenge that needs to be addressed. In addition, there has been little research coverage and discussion of non-clinical, population-based approaches as an avenue to tackle CVDs in developing settings . Therefore, our understanding of non-pharmacological intervention strategies for non-communicable diseases, such as hypertension, in resource-poor settings is limited, if not absent.
The complex context of LMIC can provide a variety of scenarios that could identify new areas for innovation, relevant at both local and international levels. For example, there are both challenges and opportunities related to salt substitution in Peru. A previous successful public health measure involved promoting iodine-supplemented salt as a vehicle to prevent iodine deficit disorders, such as goiter , and in commercial spheres, the slogan “Consuma salud… consuma sal”, or “Buy health… buy salt”, is being promoted. This is a challenge for our intervention because salt has been marketed as a positive health measure, and we now propose to promote the replacement of regular salt with a substitute. Changes associated with growth and urbanization also poses an additional challenge for implementation research. However, these circumstances also provide an opportunity, because the success of this measure demonstrates the successful collaboration of government and industry in Peru. This underscores the importance and relevance of understanding the local context, and we can utilize this knowledge taking advantage of this past successful partnership to explore the introduction of a salt substitute to be tested at a wide community intervention. Thus, the data gathered in this study will provide a strong platform to address potential interventions that are locally relevant and that could be applicable to other settings in Latin America and, eventually, to settings in other LMIC countries.
Previous reports demonstrated that salt reduction may play an important role in reducing blood pressure levels among hypertensive and normotensive people [13, 41, 42], and may reduce cardiovascular disease . Similarly, the increase of dietary potassium can reduce mean systolic and diastolic blood pressure levels [44, 45], and could contribute to the prevention of hypertension, especially in populations with elevated blood pressure [13, 46]. However, as pointed out by the Committee on the Consequences of Sodium Reduction in Populations , most of the evidence on clinical outcomes came from observational prospective cohort studies. Moreover, data examining the effect of dietary sodium in combination with other electrolytes, particularly potassium, on health outcomes, is needed . Thus, the results of this study are of potential interest as an approach to gradually reduce sodium intake in resource-constrained settings.
In most developed countries, a reduction in salt intake can be achieved by a gradual and sustained reduction in the amount of salt added to food by the food industry. In other countries, especially LMIC, where most of the salt consumed comes from salt added during cooking or from sauces, a different public health campaign would be required to encourage consumers to use less salt .
The study described here may be the first pragmatic intervention in a Latin-American country to implement a salt substitute at the population level, and it could yield a significant impact on public health. Replacing ordinary salt with a substitute containing low-sodium and high-potassium significantly reduced blood pressure levels among hypertensive participants of a randomized controlled trial conducted in a clinical setting in Tibet , as well as hypertensive and normotensive participants in rural areas of China [17, 48]. In consequence, a salt substitute may be an effective adjuvant treatment for patients with hypertension and effective in preventing hypertension in normotensive individuals. Nevertheless, population-based approaches are needed to guarantee appropriate scaling-up in other contexts.
Strategies for salt intake reduction have been addressed as potentially very cost-effective measures . In the long-term, a population-based approach, such as reducing salt intake, would have an effect in the entire population. Therefore, including larger population groups as beneficiaries of preventative interventions, and not only high-risk individuals, might render such approaches attractive because it could be more cost-effective. In the same vein, scaling up this intervention at the population level might offer a very simple, low-cost lifestyle approach to blood pressure reduction and control in resource-constrained settings .
The development and evaluation of a strategy for implementing the salt substitute at the community level, with participation of multiple stakeholders, will produce strong evidence to aid policy makers and public health specialists in the implementation of affordable prevention strategies at a LMIC level . Our results will include a cost-effectiveness analysis component, which will provide more arguments for the policy debate. In planning for scalability, we are involving key decision makers at the central government level. We have also initiated communications with Peru’s Parliament representatives in order to make them aware, early in the process of research, of the potential public gains of these types of interventions. Closer to the health sector, we have enabled the interaction of the Peruvian Society for Nutrition as well as the Peruvian National Institute of Health. The latter is already tasked with ongoing monitoring of the salt supplementation with iodine, and will be a key foundation partner to explore potential links and discussions with industry.