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Leveraging ongoing research to evaluate the health impacts of South Africa's salt reduction strategy: a prospective nested cohort within the WHO-SAGE multicountry, longitudinal study
  1. Karen Charlton1,
  2. Lisa J Ware2,
  3. Elias Menyanu1,
  4. Richard Berko Biritwum3,
  5. Nirmala Naidoo4,
  6. Chiné Pieterse2,
  7. Savathree (Lorna) Madurai5,
  8. Jeannine Baumgartner6,
  9. George A Asare7,
  10. Elizabeth Thiele8,
  11. Aletta E Schutte2,9,
  12. Paul Kowal4,10
  1. 1School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
  2. 2Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
  3. 3Department of Community Health, University of Ghana, Legon, Ghana
  4. 4World Health Organization (WHO), Geneva, Switzerland
  5. 5Global Clinical & Viral Laboratories, Durban, South Africa
  6. 6Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
  7. 7Chemical Pathology Unit, Department of Medical Laboratory Sciences, University of Ghana, Legon, Ghana
  8. 8Vassar College, Poughkeepsie, New York, USA
  9. 9MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
  10. 10University of Newcastle Research Centre for Generational Health and Ageing, Newcastle, New South Wales, Australia
  1. Correspondence to Lisa J Ware; lisa.jayne.ware{at}


Introduction Attempting to curb the rising epidemic of hypertension, South Africa implemented legislation in June 2016 mandating maximum sodium levels in a range of manufactured foods that contribute significantly to population salt intake. This natural experiment, comparing two African countries with and without salt legislation, will provide timely information on the impact of legislative approaches addressing the food supply to improve blood pressure in African populations. This article outlines the design of this ongoing prospective nested cohort study.

Methods and analysis Baseline sodium intake was assessed in a nested cohort of the WHO Study on global AGEing and adult health (WHO-SAGE) wave 2 (2014–2015), a multinational longitudinal study on the health and well-being of adults and the ageing process. The South African cohort consisted of randomly selected households (n=4030) across the country. Spot and 24-hour urine samples are collected in a random subsample (n=1200) and sodium, potassium, creatinine and iodine analysed. Salt behaviour and sociodemographic data are captured using face-to-face interviews, alongside blood pressure and anthropometric measures. Ghana, the selected control country with no formal salt policy, provided a nested subsample (n=1200) contributing spot and 24-hour urine samples from the SAGE Ghana cohort (n=5000). Follow-up interviews and urine collection (wave 3) in both countries will take place in 2017 (postlegislation) to assess change in population-level sodium intake and blood pressure.

Ethics and dissemination SAGE was approved by the WHO Ethics Review Committee (reference number RPC149) with local approval from the North-West University Human Research Ethics Committee and University of the Witwatersrand Human Research Ethics Committee (South Africa), and University of Ghana Medical School Ethics and Protocol Review Committee (Ghana). The results of the study will be published in peer-reviewed international journals, presented at national and international conferences, and summarised as research and policy briefs.

  • Salt reduction
  • Sub-Saharan Africa

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  • KC and LJW contributed equally.

  • Contributors KC, PK and NN designed research. LJW, RBB, EM, CP and AES implemented research. S(L)M, GAA, JB and ET were responsible for laboratory analyses. KC, PK and LJW were equal contributors to the paper drafting. All authors reviewed and approved the final version. KC and PK have primary responsibility for final content. All authors read and approved the final manuscript.

  • Funding This work is supported by an agreement with the CDC Foundation with financial support provided by Bloomberg Philanthropies and a Partnerships & Research Development Fund (PRDF) grant from the Australia Africa Universities Network. SAGE is supported by the WHO and the Division of Behavioral and Social Research (BSR) at the National Institute on Aging (NIA), US National Institutes of Health, through Interagency Agreements (OGHA 04034785; YA1323-08-CN-0020; Y1-AG-1005-01) with the WHO and a Research Project Grant 1 R01 AG034479.

  • Disclaimer The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the WHO or the funding bodies. KC takes responsibility for the contents of this article.

  • Competing interests None.

  • Ethics approval The WHO Ethics Review Committee approved the study (RPC149). Local ethical approval was obtained from the North-West University Human Research Ethics Committee (Potchefstroom, South Africa), University of the Witwatersrand Human Research Ethics Committee (Johannesburg, South Africa), and University of Ghana Medical School Ethics and Protocol Review Committee (Accra, Ghana).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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