Features of nutrition behavior of Kazakhstani adult population 2021: cross-sectional study

doi:10.21203/rs.3.rs-3339483/v1

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Features of nutrition behavior of Kazakhstani adult population 2021: cross-sectional study

https://doi.org/10.21203/rs.3.rs-3339483/v1

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The external environment, diet, and lifestyle are the major determinants influencing the development of health disorders. Chronic cardiovascular diseases, cancers, chronic respiratory diseases, diseases of digestive system and diabetes mellitus are the five major groups of non-communicable diseases (NCDs) and the main cause of global mortality worldwide, which in turn determine the high trend in the occurrence of causes of death in middle and high-income developing countries. NCDs have become due to the incidence of premature mortality, preventable morbidity and disability in more than 60% of cases in the world. In addition, by 2030 according to experts from the World Health Organization (WHO), the proportion of noncommunicable diseases has increased by 75% of deaths, which is 52 million people in the world. We aimed to identify eating habits among adults in Zhambyl region, Kazakhstan. We used a cross-sectional study of the risk factors of NCDs in people aged 18 to 69 years using the standardized and adapted STEPS tool in the Republic of Kazakhstan. The study consists of four phases. Average usual consumption of fruit is 5 days a week, usually two servings, the usual consumption of vegetables is slightly more (6 days a week, 5 servings a day). As can be seen from data, salt or salty sauces are never added to food before eating or directly during meals, 25.3% of respondents, with slightly more of them among men (27%) than among women (24.2%). Other individuals add salt or salty sauces to food: always-20.2%, often-12.2%, sometimes-20.7%, and rarely-21.7%. Individuals who add salt or salty sauces to food always and often are significantly more among women (34.4%) than men (28.8%). Naturally, the majority of the population adds salty spices or salty sauces during cooking 98.7% of the respondents: always and often-75.3%, sometimes and rarely-23.5%. Finally, excessive consumption of table salt (more than 5 grams per day), fatty and fried foods, as well as insufficient consumption of fruits and vegetables (less than 5 servings per day) are among one of the main risk factors in the development of non-communicable diseases.

non-communicable diseases

risk factors

salt

ultra-processed products

Non-communicable diseases continue to be important public health problems in the world, such as diabetes, cardiovascular diseases, mental illness, gastrointestinal disorders and cancer [1]. The main risk factors of NCDs can be classified into the categories of self-management, genetic factors, environmental factors, factors of medical conditions and socio-demographic factors. Nutrition interventions are essential in managing the risk of NCDs. The most effective preventative strategy is the one that leads to changes in lifestyle with respect to diet, physical activities, cessation of smoking, and the control of metabolic disorders [2].

1.1. Stress

Recent study showed that stress was significantly associated with unhealthy dietary patterns (high in fat, sweets, salt, and fast food and low in fruits, vegetables, fish, and unsaturated fats) [3]. Greater levels of perceived stress were associated with higher fat intake [4]. Unhealthy dietary patterns-characterized by high intakes of refined grains, processed meat, and foods high in saturated fat or sugar-were associated with lower birth weight [5].

Taste is primarily a nutrient sensing system. In contrast to the sheer infinite number of existing odor qualities, there are only a handful primary taste qualities: sweet, salt, umami, bitter, and sour [6].

1.2. Ultra-processed products

Ultra-processed products dominate the food supplies of high-income countries, and that their consumption is now rapidly increasing in middle-income countries, characteristically energy-dense, fatty, sugary or salty, accompanied by dramatic increases of related chronic NCDs [7]. Consumption of ultra-processed foods has been pointed out as a risk factor for increasing obesity, as measured by BMI, among both adolescents and adults. Moreover, there was association between consumption of ultra-processed food and body fat during childhood and adolescence, individuals who are obese at an early age tend to remain obese throughout life [8]. According to the results of cross-sectional survey more than one-third (34%) of the surveyed students were either overweight or obese, 93.7% did not consume the daily recommended five or more servings of fruits and vegetables, and 80% did not participate in at least 30 min of moderate-intensity activity at least 5days per week [9].

1.3. Fat-rich products

There is currently a great concern that over consumption of fat-rich products is leading to increased incidences of chronic human diseases, such as obesity, coronary heart disease, and diabetes. Consequently, the food industry is trying to develop reduced fat products with physicochemical and sensory properties that match those of their full-fat counterparts [10]. The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events [11]. Unsaturated fatty rich oils like safflower-, sunflower-, rapeseed-, flaxseed-, corn-, olive-, soybean-, palm-, and coconut-oil were more effective in reducing LDL Cholesterol (LDL-C) (-0.42 mmol/l to -0.20 mmol/l) as compared to saturated fatty acids (SFA) rich food like butter or lard [12].

1.4. Salt intake

Salt (NaCl) is an essential ingested nutrient. Cardiovascular diseases, abnormal blood pressure, stroke, and hypertension resulting in death are highlight prevalent conditions associated with elevated levels of salt consumption, the actual cellular and molecular mechanisms in peripheral tissues and the brain by which high/low salt concentrations are encoded or recognized remain unclear, as is the effect of salt intake on consumption behavior [13]. The consequences of a high dietary salt intake are primarily elevated blood pressure with a higher risk for cardiovascular diseases, but also a higher probability of developing kidney diseases and stomach cancer. To efficiently achieve a consistent reduction in dietary salt intake, sodium content of food should be reduced and eating behavior modified. [14]. Moreover, Henry suggested over 20 years ago that the ‘salt (NaCl) consumption of a society is a measure of the social stress to which it is exposed’, and that stress, through its effect on increasing salt intake, is an important factor in the development of hypertension [15]. Generally, eating salty food items increases thirst. After an abrupt increase in sodium intake, fluid intake is increased in the first few days, but urine volume does not change. The extra fluid drunk is responsible for an increase in body weight [16].

Excess salt intake raises blood pressure and thus increases the risk of cardiovascular disease (CVD), which is the leading cause of death and disability in the world. The World Health Organization (WHO) has set an interim global target of reducing population salt intake by 30% by 2025 and recommends all adults reduce their salt intake to less than 5 g/day [17]. The Chinese government’s action plan ‘Healthy China 2030’ includes nutritional recommendations to reduce the intake of salt, sugar and oil [18]. In Kazakhstan National project "Quality and affordable healthcare for every citizen "Healthy Nation" was approved and dated October 12, 2021 No. 725. However, there are not enough activities on this issue [19].

Especially in Western countries, salt added in food preparation accounts for the lion’s share of the daily dietary salt intake with estimated 75–80% of total salt intake. The remaining 20–25% of salt occurs naturally in foods or is added at the table or during cooking [20].

We conducted a cross-sectional study among 1200 participants to study eating habits among adults aged 18 to 69 years of Zhambyl region, Kazakhstan. As we know, Zhambyl region is considered a densely populated region of the southern part of Kazakhstan.

3.1. Study Design and Setting

We used a cross-sectional study of the risk factors of NCDs in people aged 18 to 69 years using the standardized and adapted STEPS tool in the Republic of Kazakhstan.

This pilot study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Asfendiyarov Kazakh National Medical University (#12(118) from 28 September 2021).

This is a cross-sectional study of the risk factors of NCDs in people aged 18 to 69 years using the standardized and adapted STEPS tool in the Republic of Kazakhstan.

The study consist of four phases. The first phase was preparatory where we prepared a research protocol, research documents. Before this study, each respondent signed a written informed consent.

3.2. Inclusion criteria

People aged 18 to 69 years of Zhambyl region.
Willingness to provide informed consent.

3.3. Exclusion criteria

The population permanently residing in any residential institution, including social service institutions; hospitals or other health facilities; establishments owned by religious organizations; and those who are in detention houses, medical, and labor dispensaries or correctional institutions.
Persons who do not have a permanent place of residence.

The second phase was interviews using a standardized and adapted STEPS questionnaire, which includes socio-demographic data, behavioral data, and questions related to NCDs. The questionnaire was administered in Kazakh/Russian by bilingual interviewers of the participants' choice. The questionnaire took no more than 40 minutes to complete. The third phase was physical examination included measurements of height, weight, waist circumference, hip circumference, heart rate (HR), and blood pressure (BP) from a standardized clinical examination. The physical examination took no more than 20 minutes. The last phase was Laboratory Tests. After the interview and physical examination phases participants were instructed and directed by interviewers to the INVIVO laboratory (INVIVO) for laboratory tests, glucometry and spirometry. This step took no more than 30 minutes.

3.4. Data Collection

Data was collected digitally. Questionnaire responses, printouts, and test results were combined into report forms labeled with the unique number of each participant in the study. All variables of interest were entered into a password-protected computer by data entry staff and manually checked by a second staff member to detect and correct data entry errors.

3.5. Statistical Analysis

All data were entered into an Excel spreadsheet and then exported to the SPSS version 24.0 for Windows. The type of data distribution was tested using the Kolmogorov-Smirnov test. Because the data distribution was normal, descriptive statistics were generated by computing the mean and the standard deviation (SD). Student’s t-test was applied to evaluate differences in means. Qualitative data are presented in absolute numbers and percentages. Pearson’s chi-square (χ2) test was used to evaluate differences in frequencies. The critical value was considered significant at p < 0.05.

Characteristics of fruit and vegetable consumption by the population of Zhambyl region compiled according to the respondents' answers are presented in Table 1, from which it follows that the average usual consumption of fruit is 5 days a week, usually two servings, the usual consumption of vegetables is slightly more (6 days a week, 5 servings a day). There is no significant difference in the figures by gender.

At the time of the study, almost all the results of laboratory data were within the normal range, except for the average cholesterol level (total) in women - 5.30 mmol / l (SD = 1.24), p =.012, T-test -2.508.

According to survey, the characteristics of the use of salt and appetite enhancers are presented in Table 2. As can be seen from data, salt or salty sauces are never added to food before eating or directly during meals, 25.3% of respondents, with slightly more of them among men (27%) than among women (24.2%). Other individuals add salt or salty sauces to food: always-20.2%, often-12.2%, sometimes-20.7%, and rarely - 21.7%. Individuals who add salt or salty sauces to food always and often are significantly more among women (34.4%) than men (28.8%). Men, in turn, outnumber those who add salt or salty sauces to food sometimes and rarely - 44.1%, among women there are 41.4%.

Naturally, the majority of the population adds salty spices or salty sauces during cooking 98.7% of the respondents: always and often - 75.3%, sometimes and rarely - 23.5%.

To the question "How often do you use processed foods with high salt content" 39.8% of the respondents answered always and often, their share being higher among men (41.9%) than women (38.5%).

When comparing the answers of men and women regarding the reduction of salt consumption in the diet, it can be emphasized that for women the reduction of salt consumption is most important (42.8%), while among men it is significant for 25.5%, which confirms the level of statistical significance (Pearson Chi-square = 38.524, p<0.001).

Table 3 presents the results of the survey on the importance of healthcare providers' recommendations regarding health risks. We observed the low level of enlightenment work between health workers according to the data: Recommendation for cessation of tobacco use was 25.7% for men and 11.6% for women; for reducing salt intake in meals was 28.8% for men and 38.2% for women; daily consumption of at least five servings of fruit or vegetables was 27.0% for men and 41.4% for women; reducing fat intake was 34.5% for men and 53.3% for women; exercise or increased physical activity was 34.5% for men and 42.5% for women; maintaining a healthy weight or losing weight was 32.3% for men and 43.9% for women.

According to WHO-STEPS survey risk factors have been estimated among adult population of the Zhambyl region in Kazakhstan yet, but most of all it was described factors like alcohol, smoking, etc [21]. Overall, in the given article we showed data of consumed fruit, vegetables and salt. We can judge that the residents of Zhambyl region have a weekly fruit intake in their diet tends to be closer to the norm. According to the WHO recommendation, the Healthy diet bulletin, eating at least 400 g or five servings of fruits and vegetables a day reduces the risk of developing NCDs and helps ensure adequate dietary fibre intake on a daily basis. This amount of fresh fruit and vegetables has been shown to reduce the risk of many non-communicable diseases and to provide adequate fibre, which is a major prevention of digestive diseases.

The biggest problem which we found that 80,6% of respondents consume large of salt or salty sauces (Pearson Chi-square 12.187, p < 0.001).

Salt intake at less than 5 g per day (equivalent to sodium intake of less than 2 g per day) is known to help prevent arterial hypertension, reduce the risk of cardiovascular diseases, stroke, and development of ascites in cirrhosis in adults [22].

In recent years, three studies have been conducted in Kazakhstan with the support of the World Health Organization (WHO), which found that this country has one of the highest salt intakes in the world: approximately 17 g per day, which is almost four times the maximum the rate recommended by the WHO [23].

According to our findings, it is encouraging to note that the residents of Zhambyl region have a place of possible risk of NCD reduction in the near future. According to Mozaffarian D [24], et al. reducing salt intake to the WHO recommended level of less than 5 g per day could prevent 1.7 million deaths annually.

WHO suggests reducing saturated fat intake to less than 10% of total energy intake and trans fats to less than 1% of total energy intake. This also reduces the risk of being overweight or obese and developing NCDs [25].

The data suggest that preventive work by primary health care workers in Zhambyl region is weak and the majority of the population is not informed about the risks of developing NCDs.

Finally, excessive consumption of table salt (more than 5 grams per day), fatty and fried foods, as well as insufficient consumption of fruits and vegetables (less than 5 servings per day) are among one of the main risk factors in the development of non-communicable diseases.

Preventive work by Primary healthcare staff in the Zhambyl region is poorly organized and the majority of the population is not informed about the reduction in the risks of developing NCDs (consumption of table salt up to 5 g per day, daily consumption of 5 servings of fruits and vegetables, restriction of use fried and fatty foods, etc.).

Data availability:

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest: The authors declare no competing conflict interest.

Funding statement:

The study was supported by the grant of the Ministry of Healthcare of the Republic of Kazakhstan “National Programme for the Introduction of Personalized and Preventive Medicine in The Republic of Kazakhstan (2021–2023)” [Grant number OR12165486].

Acknowledgements: This research is devoted to people participating in the study.

Authors’ Contributions: All authors contributed to study conception and design. All authors have read and approve the final manuscript. All authors contributed to data interpretation, drafting and critical revision of the article and approved the final submitted version.

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Table 1 – Behavioral Characteristics of consumption of fruits and vegetables

The variable	Gender															Statistical test
	Male					Female					Total					U-test	p-valuation
	M	SD	Min	Median	Max	M	SD	Min	Median	Max	Ср	SD	Min	Median	Max	U-test	p-valuation
How many days a week do you usually consume fruit?	5	2	1	5	7	5	2	1	6	7	5	2	1	6	7	-7.333	<0.001
How many servings of fruit do you consume on one of these days? (Think of any one day when you consumed fruit.)	2	2	1	2	15	2	1	1	2	10	2	1	1	2	15	-2.402	.016
How many days a week do you usually eat vegetables?	6	2	1	7	7	6	1	1	7	7	6	2	1	7	7	-4.356	<0.001
How many servings of vegetables do you consume on one of these days? (Think of any one day when you consumed fruit)	5	37	1	2	700	5	23	1	2	300	5	29	1	2	700	-1.866	.062
* U test - Mann-Whitney statistical test

Table 2 - Behavioral Characteristics of salt intake and appetite enhancers use

		Gender						Statistical test
		Male		Female		Total		χ²	p-valuation
		n	%	N	%	n	%	χ²	p-valuation
How often do you add salt or salty sauces to your food before you eat it or directly with your meal?	Always	75	16.9%	165	22.1%	240	20.2%	5.467	.243
	Often	53	11.9%	92	12.3%	145	12.2%
	Sometimes	99	22.3%	148	19.8%	247	20.7%
	Rare	97	21.8%	161	21.6%	258	21.7%
	Never	120	27.0%	181	24.2%	301	25.3%
How often is salt, salty spices, or salty sauces added during cooking in your home?	Always	282	63.2%	505	67.4%	787	65.9%	3.001	.558
	Often	43	9.6%	69	9.2%	112	9.4%
	Sometimes	74	16.6%	114	15.2%	188	15.7%
	Rare	41	9.2%	52	6.9%	93	7.8%
	Never	6	1.3%	9	1.2%	15	1.3%
How often do you eat processed foods with high salt content?	Always	64	14.3%	84	11.2%	148	12.4%	5.469	.242
	Often	124	27.6%	204	27.3%	328	27.4%
	Sometimes	147	32.7%	233	31.1%	380	31.7%
	Rare	100	22.3%	191	25.5%	291	24.3%
	Never	14	3.1%	36	4.8%	50	4.2%
How much salt or salty sauces do you think you consume?	Too Much	3	.7%	7	.9%	10	.8%	1.846	.764
	Much	52	11.6%	82	11.1%	134	11.3%
	Medium	301	67.2%	518	69.9%	819	68.9%
	Few	82	18.3%	116	15.7%	198	16.7%
	Too little	10	2.2%	18	2.4%	28	2.4%
How important is it for you to reduce salt in your diet?	It's very important	107	25.5%	304	42.8%	411	36.4%	38.524	<0.001
	Not so important	256	61.1%	357	50.2%	613	54.2%
	Not at all	56	13.4%	50	7.0%	106	9.4%
Do you think eating a lot of salt or salty sauces can cause serious health problems for you?	Yes	270	71.2%	549	80.6%	819	77.3%	12.187	<0.001
	No	109	28.8%	132	19.4%	241	22.7%

Table 3- Recommendations received from medical professionals regarding health risks

		Gender						Statistical test
		Male		Female		Total		χ²	p-valuation
		n	%	n	%	n	%	χ²	p-valuation
Stop using tobacco products or don't start at all	Yes	116	25.7%	87	11.6%	203	16.9%	39.608	<0.001
Stop using tobacco products or don't start at all	No	336	74.3%	662	88.4%	998	83.1%
Reduce salt intake in food	Yes	130	28.8%	286	38.2%	416	34.6%	11.056	<0.001
Reduce salt intake in food	No	322	71.2%	463	61.8%	785	65.4%
Eat at least five servings of fruits and/or vegetables daily	Yes	122	27.0%	310	41.4%	432	36.0%	25.370	<0.001
	No	330	73.0%	439	58.6%	769	64.0%
Reduce the amount of fat in your meals	Yes	156	34.5%	350	46.7%	506	42.1%	17.253	<0.001
Reduce the amount of fat in your meals	No	296	65.5%	399	53.3%	695	57.9%
Start exercising or increase your level of physical activity	Yes	156	34.5%	318	42.5%	474	39.5%	7.445	.006^*
	No	296	65.5%	431	57.5%	727	60.5%
Maintain a normal (healthy) body weight or lose weight	Yes	146	32.3%	329	43.9%	475	39.6%	15.932	<0.001
Maintain a normal (healthy) body weight or lose weight	No	306	67.7%	420	56.1%	726	60.4%

No competing interests reported.

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Features of nutrition behavior of Kazakhstani adult population 2021: cross-sectional study

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Abstract

1. Introduction

1.1. Stress

1.2. Ultra-processed products

1.3. Fat-rich products

1.4. Salt intake

2. Objectives

3. Methods

3.1. Study Design and Setting

3.2. Inclusion criteria

3.3. Exclusion criteria

3.4. Data Collection

3.5. Statistical Analysis

4. Research results

5. Discussion

6. Conclusions

Declarations

References

Tables

Additional Declarations

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