【作者】 徐建伟；

【导师】 马冠生；

【作者基本信息】 中国疾病预防控制中心 ， 营养与食品卫生学， 2014， 博士

【摘要】 研究背景高血压已成为当前我国迫切需要应对的重大公共卫生问题,通过降低人群食盐摄入量以预防和控制高血压,已经被证明是最具成本效果的人群策略,在国际上得到广泛认可。我国居民食盐摄入水平一直居高不下,虽然《中国慢性病防治工作规划》已提出了明确的减盐工作目标,但我国的减盐工作仍处于起步和探索阶段,具体实施中缺乏明确的策略和措施、干预手段单一、缺乏深入的定性分析等急需解决的问题,且国内尚没有进行系统的研究,因此非常有必要去深入探讨我国开展减盐行动的实施策略和方法,这将为我国减盐政策制定提供科学依据,对推动我国减盐工作具有重要意义。研究目的通过分析人群膳食钠摄入来源,分别对家庭主厨、餐饮单位和食品企业减盐相关工作的调查研究,了解减盐关键人群的知识、态度、行为及其主要影响因素,分析减盐工作的阻碍和促进因素,为我国开展减盐工作提出策略和建议。研究对象与方法采用定量与定性相结合的方法,定量数据来源于2011年省部联合减盐防控高血压项目基线调查,包括烟台市1508名人群问卷调查和体格测量、213名膳食调查、191名24小时尿钠数据,以及山东全省1072家餐饮单位、434家食品生产企业的问卷调查和626份预包装食品的实验室检测数据。定性研究是在定量调查基础上选择重点地区和关键人群开展,包括30名家庭主厨的小组和个人访谈、15家餐饮单位的28名厨师或负责人的个人访谈、7家食品生产企业14名管理者和研发人员的个人访谈。同时查阅和梳理国内外减盐文献和政策资料,对我国开展减盐工作进行SWOT分析。采用问卷调查、体格测量、膳食调查、24小时尿液、小组访谈、个人访谈、文献评阅等资料收集方法,采用EpiData3.1软件和Exce12007软件建立数据库,数据分析采用SAS9.3软件,综合运用描述性统计分析、多因素分析方法、主题框架分析法、SWOT分析等方法对资料进行分析。研究结果1.调查对象人均每日钠摄入量为6087mg,主要来源依次为调味品5001mg(82.2%)、谷类593mg(9.7%)、鱼虾类155mg(2.6%)。来源于加工食品的人均每日膳食钠摄入量为586mg,占钠摄入总量的9.6%。调查对象24小时尿钠为201.5±77.7mmol/d,尿钾为46.8±23.2mmol/d,钠钾比为4.9±2.2,92.1%的调查对象(96.9%的男性和87.1%的女性)超过了每人每天6克盐的量。在调整了年龄、性别和体质指数后,24小时尿钠和收缩压呈正相关,尿钠减少100mmol/d(6g/d盐),收缩压相应降低4.0mmHg.2.调查对象高血压患病率为25.1%,高血压知晓率、治疗率和控制率分别为24.9%、19.1%和9.5%。高血压诊断标准知晓率为36.5%,每人每天6克盐知晓率为22.8%。钠／盐含量关注率为8.2%,吃盐过量自评率为20.1%,低盐饮食赞成率为90.8%,打算减盐的意愿率为86.3%,而主动减盐措施率为34.2%。多因素分析表明减盐知识、态度、已婚人群和女性对减盐行为有影响。定性研究发现多数居民减盐意识淡薄,影响口味、心存侥幸和家人反对是不愿意减盐的主要原因,而饮食习惯难改变、限盐工具使用不便、低钠盐价格高等都影响减盐措施的长期坚持。3.餐饮单位平均每人次食盐、酱油、面酱、味精(鸡精)消耗量分别为6.4g、7.1g、2.4g和2.0g,其中食堂消耗量最低。餐饮单位负责人高血压诊断标准、每人每天6克盐知晓率分别为62.5%和62.0%,其中小吃店负责人最低,打算减盐的意愿率为92.3%。定性研究发现,绝大多数厨师都是凭经验来加盐,且并不清楚具体的加盐量。“饭菜口味让顾客满意”是餐饮单位负责人优先考虑的,而对于减盐工作积极性不高,怕影响客源和效益是主要原因。厨师在烹调中少放盐在技术上并没有困难,而使用限盐工具、使用鲁菜标准的可行性并不高,最关键还是要满足顾客的需求。4.九类食品生产企业平均食盐加入量为2%,调味品和酱菜类企业食盐加入量分别高达12%和7%,68.4%的企业在生产中使用了其他的含钠添加剂。酱油、酱腌菜和酱是市售预包装食品中食盐含量最高的三类食品,大多数同类预包装食品钠含量差异较大。食品企业负责人高血压诊断标准、每天每人6克盐知晓率分别为79.9%和73.9%,减盐意愿率为89.6%,有39%的企业负责人认为不能够降低盐含量。定性研究发现,食品企业人员对食品的钠含量较为关注,而影响口味和销量、研发存在风险等是不愿意减盐的主要原因,减盐中还面临卫生标准限制、低盐定义不明确、没有利润优势、缺乏社会环境等诸多困难。5. SWOT分析显示我国开展减盐行动具有符合我国预防为主的卫生方针、遏制高血压危害的有效举措、最具成本效果的人群策略的优势；具有口味改变很难,以及我国的减盐技术条件有待完善的劣势；面临国际和国内的政策环境支持、居民健康需求的日益增长、国外减盐实践的成功经验、慢性病防控策略和体系初步形成的机会；全社会的低盐认识不足、我国各地饮食习惯差异很大、企业单纯追求经济效益的障碍、多部门共同参与的机制难以形成的挑战。研究结论研究人群钠摄入量处于较高水平,来源上仍是以家庭烹调为主,但餐饮单位和加工食品也是不容忽视的重要来源。居民减盐核心知识知晓率很低,多数人没有意识到自己摄盐过量,家庭主厨减盐缺乏有效的措施。餐饮单位开展减盐行动的意愿并不高,厨师烹调时少放盐在操作上并没有困难,但关键还是要满足顾客的需求。食品生产企业生产低盐产品在技术上是可行的,但减盐还面临诸多困难,还应通过提高消费者低盐意识,采用市场手段来推动餐饮单位和食品企业减盐。策略和建议如下：一：建立国家层面的、完整而有效的减盐行动体系和工作机制,制定《我国减盐行动中长期规划》,建立“国家减盐行动工作组”。二：建立完善的减盐行动监测和评估体系,开展人群24小时尿钠的探索研究、开展主要菜品、预包装食品钠含量的连续监测,以评估减盐过程和效果。三：提高全民的低盐意识是根本之策,应加大减盐的健康教育宣传力度。重点普及“高血压诊断标准”和“每人每天6克盐”等核心信息,在发放减盐支持性工具同时重点讲解正确使用方法,宣传中要把握好“度”。四：餐饮行业应形成低盐的饮食文化,在日常服务中提供消费者的低盐意识。在学校和工作场所食堂开展减盐干预试点。五：实施营养标签是一项非常重要的策略,应加大宣贯力度。并尽快完善加工食品减盐的相应配套标准,适时出台加工食品“健康标识”体系。更多还原

【Abstract】 BackgroundHypertension has become a major public health problem in our country. Salt reduction has been proven to be the most cost-effective population policy of prevent and control high blood pressure, and widely recognized internationally. Salt intake level of Chinese population has been high. Although the China chronic disease prevention and control planning has put for-ward a clear salt reduction targets, but our salt reduction and hypertension prevention and control work is still in its initial and exploratory stage. There is still lack of clear strategies and measures, and there is not yet in-depth qualitative analysis and a systematic study. It is necessary to further investigate the implementation of the strategies and methods of salt re-duction to prevention and control of hypertension. Our salt reduction research will provide a scientific basis and significance promote China’s salt reduction work.ObjectivesThrough salt reduction and hypertension-related research work among study population, and to understand slat reduction knowledge, attitudes and behavior of family chef, catering and food production enterprise key person and its main influencing factors, and to analysis salt reduction hinder the work and the promotion of factors, and to seek the strategy and recom-mendations for salt reduction in China.Subjects and methodsThis study carried out the investigation combining the qualitative survey and quantitative survey. Quantitative survey data from the2011baseline survey of Shandong&Ministry of Health Action on Salt and Hypertension project, including1508population surveys and phys-ical measurements,213dietary survey,191the24-hour urine sodium data in Yantai, and questionnaires data of1072catering units,434food production enterprises and626pre-packaged food laboratory test data in Shandong province. We selected key areas and key populations to conduct qualitative research, including30family chefs groups discussion,28chefs and key person personal interviews among15catering units,14managers and research-ers personal interviews among7food production enterprise. Meanwhile we collected and or-ganized the literature about salt reduction policy information, and carried out SWOT analysis. This study used questionnaires, physical measurements, dietary surveys,24-hour urine, group discussion, individual interviews, literature review and other data collection methods. Data-base was build through EpiData3.1and Excel2007software. SAS9.3software was used in analysis. Descriptive statistical analysis, multivariate analysis methods, thematic framework analysis, SWOT analysis were used for analyzing of data.Results1. The amount of individual dietary sodium intake was6087mg, mainly derived from condi-ments5001mg (82.2%),grains593mg(9.7%),fish155mg(2.6%). Sodium from processed food was586mg accounted for9.6%of the total sodium intake. The mean Na, K and Na:K outputs over24hours were201.5±77.7mmol/day,46.8±23.2mmol/day and4.9±2.2, respectively. Overall,92.1%of the subjects (96.9%of men and87.1%of women) had intakes of over6g salt (NaCl)/d. After adjusting for sex, age, and BMI,24-hour urinary sodium and systolic blood pressure was positively correlated. Each100mmol/d (6g/d salt) increase in sodium in-take was associated with a4.0mmHg increase in systolic blood pressure.2. The prevalence of hypertension was25.1%. The awareness rate of hypertension24.9%, The treatment rate was19.1%.The control rate was9.5%. The awareness rate of diagnostic criteria of hypertension was36.5%. The awareness rate of6grams of salt per day was22.8%. Con-cerns rate of sodium was8.2%, self-evaluation rate of excess salt was20.1%, and approv-al rate of low salt diet was90.8%. The willingness rate of intend salt reduction was86.3%. The behavior rate of salt reduction was34.2%. Awareness, willingness, married people and women were affect behavior of salt reduction. Qualitative research found that the majority of residents less salt consciousness. Two main reasons were affect the taste and fluke mind. Changing eating habits, salt restriction tools inconvenience, higher low-sodium salt prices were affected reduction measures implementation.3. The average per person salt, soy sauce, sauce, monosodium consumption in catering units were6.4g,7.1g,2.4g and2.0g, respectively. The minimum consumption was canteen. The awareness rate of diagnostic criteria of hypertension was62.5%. The awareness rate of6grams of salt per day was62.0%.The awareness of slat and hypertension was higher in cater-ing units. The willingness rate of intend salt reduction was92.3%. Qualitative study found most chefs add salt according to experience, and do not know the specific amount."The food taste to make the customer satisfied" is the catering unit chief priority. The motivation of salt reduction was not high in catering units. The main reasons were fear of affecting tourists and efficiency. Cooking less salt is no difficulty for the chefs, but mainly to meet customer needs.4. The average amount of salt was2%in nine categories of food production enterprises. The average amounts of salt in condiments and pickles enterprises were12%and7%. Salt content in soy sauce, pickles and sauce were higher among available pre-packaged food. The aware-ness rate of diagnostic criteria of hypertension was79.9%. The awareness rate of6grams of salt per day was73.9%. The willingness rate of intend salt reduction was89.6%, but39%of business executives believe that you cannot reduce the salt content. Qualitative study found that key person in food companies were more concerned about food sodium content. The main reasons were affect taste and sales, have uncertain risk. There were many difficulties in reducing salt, including the restriction of health standards, undefined low-salt food, and lack of social environment.5. The SWOT analysis of salt reduction initiatives found that:①Strengths:Effectively action; comply with the health policy; most cost-effective population strategy.②Weakness:Chang-ing taste is difficult, and our salt reduction technology conditions need to be improved.③Opportunities:International and domestic policy supports; the increasing health need among the residents; foreign successful experience; chronic diseases prevention and control system has been initially formed,④threatens:Awareness of salt reduction was still lower; region-al differences in dietary habits in china; catering and food enterprises pursuit economic bene-fit; it is difficult to form multi-sectoral participation mechanism.ConclusionsThe amount of individual sodium intake was at a high level. The main source of sodium was still family cooking, but catering units and processed food are becoming important sources. The awareness of core knowledge of salt reduction was very low, and most people don’t real-ize their excess intake salt. The willingness of salt reduction in family chefs is higher, but the behavior rate of salt reduction was lower. Salt reduction initiatives and enthusiasm in catering units were not enough. Chef cooking less salt is not difficult, but the key is to meet the needs of customers. It is technically feasible that food production enterprise production low salt product, but still faces many difficulties. We should also increasing the low-diet awareness of consumer, and through market means to promote the catering units and food companies to reduce salt. Strategies and recommendations:1:Create a national level, the complete and effective salt reduction system and working me-chanism. Develop "action plan of salt reduction for China", set up "the national salt reduction working group".2:Establish an available monitoring and evaluation systems. Conduct exploring study of24hours urinary sodium; carry out the main dishes, pre-packaged food sodium monitoring, to assess the effects of salt process and reduction.3:Raising people’s awareness of salt reduction is fundamental policy, and health education and promotion should increase efforts."Hypertension diagnosis standard" and "6grams of salt per person per day" were the key information. Distribute salt supporting tools and focus on the correct use method.4:Catering industry should form a low-salt diet culture, and increase awareness of low salt among consumers in daily service. School and workplace canteens should reduce salt firstly.5:Implement nutrition labeling is a very important strategy, and we should further efforts to propagandize nutrition labels.Develop and improve the standard salt content of processed foods, and release healthy food labeling in appropriate time.更多还原