**4. Discussion**

This study showed that sodium intake of the participants exceeds WHO recommendations with concurrent low intakes of potassium. Moreover, most of the participants were unaware that their consumption was beyond the recommended levels of the WHO, however, most were able to identify some common sources of sodium, such as stock cubes and processed foods, as well as its deleterious e ffect on health. To our knowledge, this is the first study in the UAE reporting 24-h urinary sodium excretion. A 24-h collection period is necessary to capture the marked diurnal variation in sodium, chloride and water excretion. Electrolyte excretion in healthy individuals normally reaches the maximum at or before midday, and the minimum at night towards the end of sleep [25]. This study is also the first to report on potassium excretion in the UAE, another critical indicator of dietary hypertension risk.

The results from the current study were similar to the results in a study conducted in Eastern Saudi Arabia that showed the mean intake of sodium assessed by 24-h sodium excretion to be 3200 ± 1100 mg/day and 2700 ± 850 mg/day for men and women, respectively [26]. Similar findings were noted in a Jordan study using 24-h urinary sodium excretion, which showed that the average sodium intake was 4100 mg/day (10.4 g/day salt) and sodium intake was higher in males, 4300 mg, compared with 4000 mg by females. It was clear that the Jordanian participants consumed at least double the current WHO recommended daily sodium amount of 2000 mg (5 g salt) [27]. Likewise, a study conducted in Oman using the National Nutrition Survey based on a 24-h dietary recall noted the average intake of salt to be 11–12 g/day [28], again significantly higher than the WHO recommendation. Two further studies analyzing food consumption in Kuwait [29,30] reported the average salt intake to be within 8–10 g/day. These results, and our own, are strong indicators that consumption of sodium exceeds the WHO recommendations in the GCC countries. It is well known high sodium intake is associated with hypertension and stroke, as well as contributes to myocardial infarction and heart and kidney failure [31,32]. Consequently, this prevalent increase in sodium consumption is likely to contribute to the incidence of NCDs in the UAE. Globally, the mean intake of sodium is high in East Asia, Central Asia, Eastern Europe, Central Europe and the Middle East/North Africa, in the range of 3900–4200 mg/day, which is equivalent to 9.75–10.5 g/day of salt [33], far exceeding the WHO recommendations, and is similar to our findings. While higher than the recommendations, the results of our study would sugges<sup>t</sup> that the UAE was at the lower end of the scale of sodium intake in these geographic areas, however, comparisons between urinary excretion and sodium intake must be drawn with care. This may reflect the relatively high levels of education and other key socio-economic indicators when compared to these countries, which may manifest in more health-promoting behaviors. Urinary excretion of sodium as a function of intake has also been assessed in other nations, with generally higher socio-economic and health indicators. For example, in Japan and the United Kingdom (UK), sodium intake was 4470 ± 1600 mg/day and 3289 mg/day, respectively, and was attributed to a high intake of canned and processed foods [34,35].

High dietary sodium and low dietary potassium intakes are associated with hypertension and increased risk of cardiovascular disease (CVD) [36]. In the current study, the sodium to potassium ratio was 1.64 ± 0.55, suggesting that not only did sodium intake exceed WHO recommendations but insu fficient dietary potassium was also prevalent. The amount of potassium excreted in 24-h urine is well correlated with dietary potassium intake [37]. A high urinary sodium–potassium ratio is an indicator of a need to reduce sodium and increase potassium intake [1,3]. The WHO has suggested that achieving guidelines for sodium and potassium intake would yield a sodium–potassium ratio close to 1.00 [23,24].

In our study, 67.4% of the participants exceeded the WHO recommendations for salt intake, with more males (51.6%) than females exceeding the recommendations. This finding is consistent with previous studies conducted in Kuwait, where males (74.7%) and females (50.9%) exceeded recommendations [29]. Similarly, a study conducted in Eastern Saudi Arabia also found that males tend to consume more sodium compared to females [26]. This finding is also consistent outside the GCC

countries. In Brazil, 90% of the of study population exceeded WHO recommendations for salt intake with excess consumption again more common in males [38]. Another study aimed to estimate sodium intake in New York City, noting the mean sodium intake to be 3239 mg/day, with 81% of participants exceeding recommendations [39]. Brown et al. (2013), reported that sodium intake tends to be higher in men than women, based on 5693 participants recruited in 1984–1987 aged 20–59 years from 29 North American and European samples [31]; the findings again echoed those in our study. The sex di fferences in sodium excretion could have a number of causes, however, it is likely that increased appetite and calorie consumption is a major driver behind the variance. It is also possible that socio-cultural norms lead men to make more salt-heavy diet choices in both social and home situations, both in the UAE and globally. This is particularly relevant when viewed against the increased risk profile of a number of NCDs in men, and also makes it more challenging for males to meet sodium guidelines, as they are required to reduce their intake considerably compared to women.

The data on urinary potassium excretion is also of significant importance to the health of the population of the UAE. It is well known that potassium is a key part of e ffective blood pressure regulation, because of its role in e ffective sodium clearance. The mean potassium intake shown in this study was well below the WHO guidelines, providing opportunities for improvement of the health of the UAE. Encouraging a varied diet, high in fruit and leafy vegetables, would provide a ready means of improving health outcomes. Potassium is not amenable to fortification, due to the negative consequences of excessive intake and a flavor-masking e ffect of common chemical formats of the mineral, which means improving diet quality is the major means of increasing intake in the community.

It was also found that 82.5% of the participants in this study added salt sometimes or always during cooking, which is similar to that noted in Lebanon, where 100% of the participants have been found to add salt during cooking [40]. In the current study, the majority of participants reported that they added stock cubes and additional table salt while eating, sometimes or always. These findings are similar to the Lebanon study which showed that 60% of the participants used table salt [40]. Likewise, 61% of university students in the UAE reported adding salt while cooking, and 14% of the participants often added salt to food even before tasting it [21].

Despite the fact that 67.4% of the participants exceeded the WHO recommended salt intake in the current study, only 20.0% reported that their consumption was beyond the recommended threshold (Table 3). In light of our data showing widespread sodium excess, this suggests that many people are unaware of how much they are consuming. In this regard, education and public awareness programs are required so that the general population is more aware of salt portion sizes and the sodium content of processed foods, drinks and other foods in general.

Interestingly, about 60% of the participants claimed to be taking measures to control their salt intake, again similar to reports from Lebanon (65.8%) [40]. These findings are also similar to a study conducted in five sentinel countries of the Americas (Argentina, Canada, Chile, Costa Rica and Ecuador), where almost 90% of the participants reported excess intake of salt is associated with adverse health conditions, and over 60% of the participants indicated they were conscious of their salt intake and taking measures to reduce it. They also found that more than 30% of their participants believed that reducing dietary salt intake was highly important [41]. Most of these studies reported that the majority of the participants were aware that high salt intake was associated with adverse health outcomes, however, this awareness does not translate into e ffective behavioral change in salt reduction. These interesting findings have some important implications for strategies to reduce sodium intake. One of the mainstays of sodium reduction is public education, however, these results would indicate that the general knowledge is adequate. However, education campaigns on e ffective ways to reduce intake, while increasing potassium and hydration, would play a role in the general reduction in sodium across the UAE, alongside e ffective regulations and sodium targets.

The results of the current study indicate that there is prevalent high sodium and low potassium intake within the general population of the UAE, which consequently may increase the risk of hypertension, CVD and other NCDs. This emphasizes the need for coordinated salt reduction programs to aid in the reduction of NCDs in the UAE. Strategies such as educational campaigns, regulation of sodium content of widely consumed food items and setting targets for sodium intake will allow for a more cohesive approach to improving the health of the UAE in this regard. In the last two decades, a number of countries have put sodium reduction strategies in place, and they have generally been somewhat successful, however, there are still significant strides to be made [42]. The most e ffective population interventions are likely to be salt reduction targets in common food stu ffs, specific to the geographical areas and the local cuisines. In the metropolitan centers of the UAE, this will likely need to target processed and fast foods, which are becoming more of a staple in the Emirati diet, however, future research to identify significant sources of sodium in the UAE is needed to guide policy makers. Other nations with successful sodium reduction strategies have used salt targets, typically between 5–8 g/day [42], to help guide these regulations and interventions. Decreasing the sodium consumption of the UAE will also require regulation of industry to o ffer more low-salt options, as well as improve standards on labeling and nutritional declaration on packaged foodstu ffs.

The Mediterranean diet could play a role in combatting the widespread salt imbalance in the UAE. The Mediterranean diet is inherently low in sodium and high in potassium due to its high vegetable and low meat and processed food content. The Mediterranean diet is also accessible to the local region, as it contains a number of similarities to traditional food practices in the Arab nations, such as an emphasis on vegetables, dairy, grains and spices, however, the Emirati cuisine traditionally features meat products more strongly [43]. The Mediterranean diet has been shown to reduce hypertension [44], however, there is some debate surrounding the role of sodium in this. Some authors have found that the Mediterranean diet does not readily o ffer reductions in sodium [45], however, this may be due to variations in adherence and specific components of the diet, as well as the amount of other minerals, such as potassium, which are abundant in plant-rich diets.

Despite the significant findings, a limitation of this study was that urinary sodium was assessed by a single 24-h urine collection and this may not represent the average sodium intake in a person due to daily individual variability. However, a single urine measurement is considered a more accurate measure of sodium intake at a population level [18], though it may possibly be less accurate for individuals. There is also a potential that the recruited population may have been broadly healthier, as they were likely more health conscious, better educated and possibly of a higher socio-economic status. Future studies should account for key socio-economic indicators, such as years of education and household income in both their recruitment and analysis to ensure a representative sample of the population. This may have led to an underestimation of the UAE's sodium intake found in this study. Additionally, while the KAP questionnaire used in this study captures some important facets of the participants' knowledge and behavior surrounding salt, there is further room for additional information, particularly surrounding important sources of sodium in the modern diet. An expanded questionnaire, and other measures such as food diaries, would provide more reliable information on the true intake of sodium, and how that compares to the participants' knowledge. Despite these limitations, the study described was statistically sound and powered to reliably identify the sodium practices in the UAE. The large sample, with demographically representative participants, and the validated analytical methods, are also strengths of the research presented here.
