Sodium Intake Among Children And Adolescents: A Critique Of Population Dietary Data And Its Adverse Implications

Target Population and Research Methods

Children and the adolescents fall under the category of the special population as they are at the peak of growth. They are growing mentally, physically, developmentally, socio-emotionally and cognitive functioning. Secondly, their immunity is low therefore they need special care/protection against disease-causing organisms. They have a special nutrition for the growth of the above systems ¹. One of the components of their foods is salt (sodium chloride). It is of importance as it primarily regulates body fluid, important in nerve impulses transmission, in muscle contraction, in cardiac functioning ². For this benefits to be achieved. The right quantity should be taken to avoid toxicity when in excess or inadequacy when taken in small amounts. In excess, it puts the population in danger of developing hypertension which later translates to cardiovascular illness. It can also cause convulsions which translates to a comma and then death.

This essay will evaluate the following; critique the population (children) dietary databasing it on the sodium intake as stipulated by the NNPAS. Secondly, an interpretation of the population dietary data will be evaluated and compared with the Nutrient Reference Value for Sodium. Thirdly, link the sodium intake and the adverse incomes in their health status. Fourthly, solutions to their current sodium intake and the changes that one would recommend so as to improve the sodium intake levels. Lastly, a conclusion summarizing the essay. 

Search strategy

For the sources to be reliable and eligible a systematic approach had to be developed so as to determine which literature was most suitable for the research question. PICO was developed to help with this. (Table 1)

Population	Children and early adolescents.
Intervention	Explore the sodium chloride intake among this group and its effects on their health.
Counter Intervention	Culture and social influences on the sodium chloride intake to this target population.
Outcome	Ensure that the target population takes the recommended amount of sodium chloride.

Table 1. PICO. From the PICO keywords were obtained. The keywords included sodium chloride intake, special population, nutrition for the children and youth. They were used on the scientifically and consistently databases. The search tools included Medline, WebMD, MIH library, clinical trials.gov, Cochrane library, and another web of science knowledge. The above keywords were used to on Boolean Operator AND. It was overwhelming the sources of information contained there. It was sufficient for the research.

Selecting the Literature and Exclusion/Inclusion Criteria.

The target population as identified from PICO is children and youths. For the research to be successful, the target group needed to be narrowed further. The table below illustrates the exclusion and inclusion criteria.

Inclusion criteria	Exclusion criteria
Children Adolescents Hypertensive Cardiovascular history American Latinos Asians African-American Literate and illiterate All published materials that are relevant to the study Worldwide research	People above 19 years old. Published materials older than 10 years.

Table 2

To enable an in-depth research, understanding what the question addresses and the effectiveness of the intervention, I opted for one research method. Out of all the sources obtained, 5 were the ones I used as randomized control trials, which were selected as dictated by the traditional hierarchy of evidence ^3,4.

Critique of Population Dietary Data

After obtaining the articles. They were hand searched on the internet so as to identify the relevance and eligibility of the articles. They appeared relevant and have been identified throughout and they have led to the outcome of the research.

Outcome Consideration for Inclusion table 3

No	Consideration criteria
1	Nutritional intake by the adolescents and children.
2	Cultural and social influences on sodium chloride intake among this population.
3	Signs and symptoms of sodium chloride sufficiency and toxicity.
4	Ways to ensure the right quantity of sodium chloride is taken by the population.

                                               Table 4, PRISMA flow diagram (Moher, The PRISMA Group, 2009)       

CASP, 2014 and Consort, 2010, were the checklists used to check the validity and reliability of the articles gathered above so as to ensure that the research question was answered effectively and whether the recommendations arrived on later on are either strong or weak ⁵. They have also used to appraisal the quantitative research ⁶. Sodium chloride intake among the adolescent and children is a very wide topic/research. This research will cover the most essential or key areas that came up. They will be analyzed throughout the research, consistently using the 5 articles. The trials in the articles identified will be evaluated for their quality and critical appraisal. There will be analyzed of randomization methods, performance bias, treatment blindness, was their interventions on the above or did the trial end un-followed. 

Appendix 1, contains a data extraction table in which the synthesis of the findings and results of the literature that was obtained from the research articles are recorded ⁷. This will help in identifying the methodology used and the successfulness of the research. It also enables the reader in evaluating the strengths and the weaknesses of the research ⁸. It is also useful in summarizing the obtained results and checking whether the interventions that were put in place were successful. While doing this especially critical appraisal it was easy to come up with two themes for the study.  This led to the formulation of appendix 2 which illustrates which papers have similar results and the researches that have strength/holds more weight ⁹. After synthesizing the literature, it enables the researcher to critically analyze the context and the research approach that had differing results/ findings. This will be covered below in the result section.

No	Authors, year	Title	strengths	Weakness
1	Fayet-Moore, F., McConnell, A., Kim, J., & Mathias, K. C. (2017)	Identifying eating occasion-based opportunities to improve the overall diets of Australian adolescents	The findings obtained were objective and descriptive. The study area was large therefore a wide coverage representing the population.	The research was prone to be biased.
2	Leyvraz, M., Taffé, P., Chatelan, A., Paradis, G., Tabin, R., Bovet, P., … & Chiolero, A. (2016)	Sodium intake and blood pressure in children and adolescents: protocol for a systematic review and meta-analysis	A large sample was involved therefore it represented the target population.	The research was prone to be biases.
3	Quader, Z. S., Gillespie, C., Sliwa, S. A., Ahuja, J. K., Burdg, J. P., Moshfegh, A., … & Cogswell, M. E. (2017)	Sodium intake among US school-aged children: National Health and Nutrition Examination Survey,	The sample size used was large therefore the data obtained was representative of the population.	The research was prone to be biases.
4	Yang Q, Zhang Z, Kuklina EV, Fang J, Ayala C, Hong Y, Loustalot F, Dai S, Gunn JP, Tian N, Cogswell ME.	Sodium intake and blood pressure among US children and adolescents	The findings obtained were objective and descriptive.	The data obtained was limited to US.
5	Maalouf J, Cogswell ME, Yuan K, Martin C, Gunn JP, Pehrsson P, Merritt R, Bowman B.	Top sources of dietary sodium from birth to age 24 months,	The findings obtained were objective and descriptive. The study area was large therefore a wide coverage representing the population.	The research was prone to be biases.

Population-based dietary data

According to National Nutrition and Physical Activity Survey (NNPAS) & Australian Bureau of Statistics, 2017) the adolescents in Australia have a very poor dietary intake that risks them to the inadequacy of micro-nutrients and excessive intake of unhealthy foods and sodium. The meal occasions starting with breakfast, 81% of the population misses the meal, they were found to take 47% of the free sugars that provided calcium and magnesium at 34% and 31% respectively. The sodium content of the food was 415mg/1000kj. The average intake of sodium among children as found to be 3255mg per day among children aged 6 to 18 year. It was higher among the adolescents 14-18years at 3565 mg per day. This is so high as the NNPAS, (2012) recommends children aged 2-3 year, 4-8 years, 9-13 years to take an average of 1483, 2058, 2461 mg per day respectively and adolescents at 2760mg per day.

Linking Sodium Intake to Adverse Health Outcomes

Children and adolescents require an adequate supply of nutrition throughout so as to attain optimum growth, health, and development. The nutritional requirement for this group markedly increases from childhood to adolescence for the requirement of both the micro and macro-nutrients ¹⁰. Despite this a majority of them inadequately take calcium, magnesium, iron and vitamin A. Their diets are also of poor quality, their fruits, vegetables, lean proteins and dairy products is very low although they take very high levels of sodium, free sugars and foods that has highest proportion of energy (National Nutrition and Physical Activity Survey (NNPAS) 2017, Australian Bureau of Statistics 2017).

A large percentage of the adolescents in Australia are at the risk of micronutrients intake inadequacy and an excessive intake of unhealthy dietary ¹¹. The study found out that most children and adolescents in Australia skip breakfast take a lot of beverages, fewer fruits and vegetables and a lot of sodium. 

Nutritional issues (adverse effects of sodium intake) in children and adolescents.

Hypertension is one of the major risk factors for cardiovascular which is modifiable ¹².  It is a major cause of mortality and morbidity worldwide. It has been noted that elevated blood pressure has roots from the early life and that it tracks from the childhood to adulthood ¹³. In addition to this, the hypertensive intermediate markers; organ damage, for example, carotid artery thickening and left ventricular hypertrophy has been identified in children and adolescents ¹⁴ This shows that to avoid cardiovascular complications later on in life the predisposing factors should be dealt with early in life. Many studies have concluded that high sodium intake is the number one cause of the elevated blood pressure in the adult life ¹⁵. A positive correlation has been identified between high sodium intake and high blood pressure.

Secondly, 90% of children and adolescents consume dietary sodium in excess and in every nine children aged between 8-17 years one of them has blood pressure which is above their normal ranges according to their age, height, and sex ¹⁶. The mean sodium intake as found to be 3256 mg/day excluding the table salts ¹².  This excessed their recommended sodium intake by far. These large amounts were attributed to the high fast food and beverages intake. This increases their risk of getting blood pressure as adults. 

Lastly, sodium intake in children and adolescent is an area of concern as it is highly compared to that of the adults ¹⁷. This high intake has been associated with the high blood pressure which is one of the leading risks for heart diseases and cerebral vascular accident later on in life as adults. This study found out that the children and the adolescents with increased blood pressure have a history of high sodium intake ¹⁸. It also suggested that the infants and children sodium intake preference is shaped by their dietary exposure. Therefore, less exposure to sodium the less they want. The high intake is attributed to their high intake of fast foods, for example, pizza, cheese, chicken, and bread.

Recommendations to Improve Sodium Intake Levels

As explained above the children and adolescents are taking high amounts of sodium which predisposes them to elevated high blood pressure and future cardiovascular diseases ¹⁹. It is therefore important to reduce the sodium intake of this target group. In addition to this, the sodium intake is shaped by the childhood intake. The following ways to be used in reducing sodium intake ²⁰.  The most important is parent’s/family education which will involve; shopping in a grocery store food with the lowest sodium levels should be picked ¹³. Secondly, when cooking the cooking salt should be reduced or alternatives used, soak dry cereals overnight then drain the water before cooking, encourage children to eat more fruits and vegetables to replace the unhealthy snacks ^21,22. 

References

Bochud M, Marques-Vidal P, Burnier M, Paccaud F. Dietary salt intake and cardiovascular disease: summarizing the evidence. Public Health Reviews. 2011 Dec;33(2):530.

Chiolero A, Santschi V, Burnand B, Platt RW, Paradis G. Meta-analyses: with confidence or prediction intervals?. European journal of epidemiology. 2012 Oct 1;27(10):823-5.

Dong B, Wang HJ, Wang Z, Liu JS, Ma J. Trends in blood pressure and body mass index among Chinese children and adolescents from 2005 to 2010. American journal of hypertension. 2013 Apr 17;26(8):997-1004.

Fayet-Moore, F., McConnell, A., Kim, J., & Mathias, K. C. (2017). Identifying eating occasion-based opportunities to improve the overall diets of Australian adolescents. Nutrients, 9(6), 608.

Gillman MW. Primordial prevention of cardiovascular disease. Circulation. 2015 Jan 20: CIRCULATIONAHA-115.

He FJ, Li J, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomized trials. BMJ. 2013 Apr 4;346:f1325.

Higgins JP. Cochrane handbook for systematic reviews of interventions. Version 5.1. 0 [updated March 2011]. The Cochrane Collaboration. www. Cochrane-handbook. org. 2011.

Leyvraz M, Taffé P, Chatelan A, Paradis G, Tabin R, Bovet P, Bochud M, Chiolero A. Sodium intake and blood pressure in children and adolescents: protocol for a systematic review and meta-analysis. BMJ Open. 2016 Sep 1;6(9):e012518.

Leyvraz, M., Taffé, P., Chatelan, A., Paradis, G., Tabin, R., Bovet, P., … & Chiolero, A. (2016). Sodium intake and blood pressure in children and adolescents: protocol for a systematic review and meta-analysis. BMJ Open, 6(9), e012518.

Maalouf J, Cogswell ME, Yuan K, Martin C, Gunn JP, Pehrsson P, Merritt R, Bowman B. Top sources of dietary sodium from birth to age 24 mo, United States, 2003–2010–. The American journal of clinical nutrition. 2015 Mar 1;101(5):1021-8.

Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews. 2015 Dec;4(1):1.

Narchi H. Assessment and Management of Hypertension in Children and Adolescents: Part B–Investigations and Management. Journal of Medical Sciences. 2011 Jan 1;4(1):14-24.

Quader, Z. S., Gillespie, C., Sliwa, S. A., Ahuja, J. K., Burdg, J. P., Moshfegh, A., … & Cogswell, M. E. (2017). Sodium intake among US school-aged children: National Health and Nutrition Examination Survey, 2011-2012. Journal of the Academy of Nutrition and Dietetics, 117(1), 39-47.

Schünemann H, Bro?ek J, Guyatt G, Oxman A. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Updated October. 2013;2013.

Shi L, Krupp D, Remer T. Salt, fruit and vegetable consumption and blood pressure development: a longitudinal investigation in healthy children. British Journal of Nutrition. 2014 Feb;111(4):662-71.

Wells G, Shea B. O’Connell Det alThe Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. 2015.

World Health Organization. Effect of reduced sodium intake on blood pressure, and potential adverse effects in children. May; 2014.

Yang Q, Zhang Z, Kuklina EV, Fang J, Ayala C, Hong Y, Loustalot F, Dai S, Gunn JP, Tian N, Cogswell ME. Sodium intake and blood pressure among US children and adolescents. Pediatrics. 2012 Sep 17: peds-2011.