Abstract

Background: In Southeast Asia (SEA), the incidence of hypertension is the third highest in the world, including among older people. The Joint National Committee VIII (JNC VIII) recommends managing hypertension through lifestyle modifications, including adopting a low-salt diet.

Objective: This scoping review summarized information on low-salt diet practices in SEA.

Methods: This scoping review followed the scoping review methodological framework, comprising five steps. A focused search of relevant literature was conducted across several databases, including English- and Indonesian-language publications, from 2013 to 2023.

Results: A total of 31 studies were reviewed. Most of the studies in this research, specifically 17, found that the low-salt diet practice involved reducing or regulating the amount of salt used in cooking. Challenges and opportunities related to low-salt dietary practices were identified and categorized into four factors: individual, environmental, social, and spiritual.

Conclusion: Hypertensive older people in SEA still demonstrate poor adherence to a low-salt diet. More research is needed to determine effective interventions that can improve compliance with a low-salt diet among hypertensive older adults in SEA. Such interventions should take cultural aspects into account and involve families in implementing the practice.

Keywords: Low-salt diet, older people, hypertension, Southeast Asia, scoping review.

INTRODUCTION

Hypertension is a medical condition where a person's systolic blood pressure is ≥ 140 mmHg and diastolic blood pressure is ≥ 90 mmHg [1]. The prevalence of hypertension remains relatively high globally, and the incidence rate increases with age. [2]. Two of the most common complications of hypertension are coronary heart disease (CHD), renal failure, and stroke, which cause approximately 51 percent and 62 percent of global deaths, respectively [3, 4]. In Southeast Asia (SEA), the incidence of hypertension is the third highest in the world at 25 percent [5]. This highlights the need for appropriate management of hypertension, especially in older individuals, both globally and in SEA.

The Joint National Committee VIII (JNC VIII) recommends managing hypertension by making lifestyle modifications, including adopting a low-salt diet [6, 7]. The incidence of hypertension and its complications is closely related to poor dietary habits, particularly the excessive consumption of salt [8, 9]. This can lead to increased blood pressure, resulting in hypertension, and can increase complications and mortality rates [10, 11]. Furthermore, high salt intake can diminish the effectiveness of antihypertensive drugs [12]. This highlights the importance of reducing salt intake among older persons with hypertension.

According to the WHO, adults should consume less than 5 grams (2 grams of sodium) daily [13]. However, a 2017 study [9] found that the global average intake was about 15.24 g (6 g of sodium) per day. Salt intake was even higher in Asian countries, particularly in SEA, where it ranged from 3.17 grams to 10.80 grams per day [14]. Previous reviews suggest that the SEA countries still rely heavily on consuming salty, oily, and coconut milk- based foods [15]. Additionally, older individuals tend to consume more salt due to a decline in their ability to taste and smell, leading them to prefer saltier foods [16]. Therefore, it can be concluded that the aging population in SEA and cultural factors hinder the adoption of low- salt dietary practices, leading to high salt consumption in the region.

It is essential to obtain scientific evidence on the effectiveness of low-salt diets in lowering blood pressure [7]. Previous reviews have primarily focused on hypertension management in general, with some scoping reviews addressing self-care management in hypertensive patients in SEA [15, 17]. There have been some systematic reviews on low-salt diets, but these have only focused on patients with heart failure [18]. Additionally, there have been systematic reviews of low-salt diets in rural areas [19] and a scoping review summarizing sodium-reduction strategies in the diet [20]. However, there is a lack of studies examining how hypertensive older adults in SEA implement low- salt dietary practices. To develop effective intervention strategies, it is crucial to have an in-depth understanding of low-salt dietary practices among hypertensive older adults in SEA.

METHODS

This scoping review aimed to summarize information from previous studies, provide an overview of low- salt dietary practices, and identify the challenges and opportunities of low-salt diets among hypertensive older adults to improve these practices in the future. The review followed the methodological framework proposed by Arksey and O'Malley [21]. It was designed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) [22]. It has been registered with the Open Science Framework (https://osf.io/x8kur_v1).

The research questions in this scoping review are: How do older adults with hypertension in SEA practice low-salt dietary habits? SEA countries include Brunei, Malaysia, Indonesia, Thailand, Singapore, the Philippines, Vietnam, Laos, Cambodia, Myanmar, and East Timor (Timor Leste).

Search Strategy

This review aimed to investigate low-salt diets among hypertensive older adults in SEA. This study examined how older adults in the region practice low-salt dietary habits and identified the challenges and opportunities of low-salt diets among this population. To gather relevant documents, a search was conducted on several databases, including PubMed, ScienceDirect, Cochrane, EBSCO, Wiley, Global Index Medicus, Garuda, and Google Scholar. The keywords used in this study are listed in Table 1.

In addition, we conducted a Google Scholar search to identify additional references relevant to this review that may have been overlooked in the previous database search. Initially, we retrieved titles, abstracts, and content to determine terms and other keywords, including alternative contextually and culturally appropriate options.

Inclusion and Exclusion Criteria

The inclusion and exclusion criteria for this review were based on the Population of Context Concepts (PCC) model as seen in Table 2 [23]. The population in this review is older people diagnosed with hypertension according to the age limit specified in the country where the study was conducted. The concept is low-salt diet practices, and the study was conducted in Southeast Asia countries.

For this review, we included qualitative and quantitative studies conducted in the SEA region, studies conducted elsewhere, studies that addressed complications of other diseases, studies that included children and young adults, studies that included pregnant women, and literature reviews. The search for articles was limited to full articles published in English and Indonesian between 2013 and 2023, as hypertension incidence has increased over the last 10 years.

Data Extraction and Analysis

All results from the articles were entered into Mendeley, the reference manager used during the preparation of this research. Afterwards, a duplicate check was performed on the application to ensure the same article was not used. The search results were exported to the Rayyan software program, and a duplicate check was conducted again. To ensure the validity of the articles, they were re-screened using the predetermined exclusion and inclusion criteria. For sampling the title, abstract, and full text, 25 articles were randomly selected (AMI and IAP) using the JBI Manual method [23]. During the sampling stage, 8 percent of the articles were in disagreement, and a reviewer discussion was held to achieve 100 percent agreement.

We extracted data about the characteristics of the journal articles relevant to our research topic. Specifically, we identified the year and country where the research was conducted, the study's purpose, the population studied, and whether the study examined a connection to the practice of a low-salt diet in hypertensive older individuals. Additionally, we looked at the challenges and opportunities associated with low-salt diet practices. Our goal was to simplify the process of extracting necessary data for our research preparation.

To identify relevant results, the literature was scanned for specific keywords. For this review, all articles were thoroughly analyzed based on their titles, abstracts, and full texts and checked for discrepancies and duplication. The analyzed articles contained information on low-salt dietary practices among older adults with hypertension in SEA.

RESULTS

To briefly explain the research process, we started by filtering through titles that matched the research question. This resulted in 3460 articles for further screening. We further filtered the articles, resulting in 456 screened by title and abstract. Out of these, 120 articles were eligible for full-text screening. We excluded articles that did not fit the criteria for hypertension, were not related to low- salt diet practices, were not conducted within the SEA region, or were literature reviews. Our selection process resulted in the final inclusion of 31 articles for analysis. The entire search process, article filtering results, and script extraction criteria after the initial search are shown in Fig. (1).

Descriptive and Methodological Characteristics

We examined 31 studies from 8 countries, including 11 conducted in Thailand, 10 in Indonesia, 4 in Malaysia, 2 in Myanmar, and 1 each in Cambodia, Singapore, Vietnam, and Timor Leste. However, no relevant articles were found for the Philippines, Laos, and Brunei. Table 3 illustrates 23 studies on low-salt diet practices using quantitative methods, comprising 12 observational studies and 11 cross-sectional studies. Table 4 presents 8 studies on low-salt diet practices that used qualitative methods. The largest sample size among the included studies was found in a Thai study with 2,552 samples [31]. The number of samples used in the other studies ranged from 6 to 1,599. Regarding the study setting, 14 quantitative studies were conducted in rural areas, 5 in urban areas, and 4 nationwide. For the qualitative studies, 5 were conducted in rural areas, 2 in urban areas, and 1 nationwide. Overall, the study population ranged from 45 to 90 years old, according to the 31 included studies.

Practice of Low-Salt Diet in Older People with Hypertension

Among hypertensive older adults in SEA, the most common low-salt dietary practice is reducing or regulating salt intake when cooking. This was mentioned in 14 quantitative studies and 3 qualitative studies. Other low-salt dietary practices include reducing or limiting consumption of salty or high-salt foods (10 studies), not adding salt at meals (2 studies), avoiding instant or ready-to-eat foods (5 studies), and reading nutrition labels on packaged foods to choose low-salt products (4 studies). Some hypertensive older adults also used other seasonings to flavor food (2 studies) and reduced their use of other flavor enhancers, such as soy sauce and MSG (3 studies). One study each showed that hypertensive older adults reduced the consumption of fried foods, replaced high-salt snacks with fruit, replaced sodium salt with potassium salt, cooked at home, and ate out less.

Quantitative studies have shown that hypertensive older individuals have poor compliance with low-salt diets. Meanwhile, in the qualitative studies, most participants explained why they were unable to fully implement low- salt diet practices and the factors that supported and motivated them to improve compliance. These findings will be discussed in detail in the next section.

Challenges and Opportunities for Low-Salt Diet Practices

Our study focused on identifying challenges and opportunities for the successful implementation of a low-salt diet in SEA. We classified these challenges and opportunities into four categories: individual, environmental, social, and spiritual factors. The article's text describes these categories in detail, and we also provide a summary of the participants' statements in Table 5. Some of the challenges are related to individual factors such as "eating habits that are difficult to change", "long-standing preference for salty flavors", "perceptions that still focus on cultural beliefs", and "declining cognitive abilities". On the other hand, opportunities arise from individuals such as "motivation to recover" and "hope to be free from recurrent physiological problems". Environmental factors such as "difficult access to healthy food" and "abundance of high- salt foods available" are considered challenges. Social factors such as "misperceptions about low-salt diets" and "dietary patterns that are not culturally adapted" are also challenges. At the same time, "family support, peer support, and support from health service providers" are opportunities. Finally, spiritual factors offer opportunities for "reassurance to maintain a low-salt diet and "spiritual growth".

DISCUSSION

This study aimed to examine low-salt diet practices among older patients with hypertension in SEA countries. The evidence suggests that hypertensive older adults in SEA are not effectively implementing low-salt diets. This aligns with previous studies, which found that African, SEA, and Eastern Mediterranean countries are among the least active in promoting salt reduction [55]. Poor lifestyle choices and a lack of patient self-care awareness are contributing factors to the global increase in the prevalence of chronic diseases, including hypertension and other cardiovascular diseases [15, 56-59], and this may explain why SEA has the third-highest number of hypertension cases in the world. Therefore, this study highlights the importance of lifestyle management strategies for hypertensive older adults, particularly in the context of low-salt dietary practices.

The main finding of this review indicates that the most common practice among hypertensive older adults in SEA to reduce salt intake is to reduce the amount of salt in their daily diet. However, previous studies have yielded different results, with the most common low-salt dietary practice globally being the use of salt substitutes in cooking (51.5%). These studies were conducted in Europe (39%), South America (25%), and North America (18%) [20]. In the Eastern Mediterranean [59] and SEA [60], industry players are implementing initiatives to reduce salt consumption through food product reformulation. This difference stems from the primary source of salt in these countries. In SEA countries, salt is added during cooking and through condiments like soy sauce and fish sauce, which are also used during cooking [61]. On the other hand, in different countries, salt is consumed chiefly through processed foods such as bread, cereal products, ready meals, and processed meats [62-64]. Therefore, it is crucial to identify and address the primary dietary source of salt in the diets of hypertensive older individuals before providing interventions to improve their low-salt nutritional practices.

During our review, we identified challenges and opportunities in implementing low-salt diet practices for hypertensive older adults. The studies we examined involved participants following a low-salt diet and faced various challenges during implementation. One significant challenge was SEA's traditional food culture. In these communities, consuming salty and fermented foods has been a part of their traditional food culture. Due to the availability of salt and seasonal fish, indigenous people have used salt to preserve food, helping them overcome the unpredictability of nature and enabling them to consume fish consistently, a key part of their diet [63]. Further research is needed to identify effective interventions that can improve adherence to an appropriate low-salt diet. These interventions should take cultural aspects into account and involve families in implementing this practice. Therefore, future study is recommended to address this shortcoming.

Another interesting finding in our review was that many families had misconceptions about what a low-salt diet entails. Despite cooking with reduced salt, they still added high-salt products such as soy sauce and roddae to their cooking meals. This highlights the importance of reinforcing knowledge and educating consumers on the benefits of a low-salt diet [65]. Inadequate education can lead to misconceptions about low-salt diet practices [66], so it is essential to provide health education and skill training to consumers, especially those caring for older persons with hypertension [67]. Nurses can play a vital role in educating families and hypertensive older adults about the importance of a low-salt diet and dispelling misconceptions about it. Future studies should focus on innovative and appropriate approaches to providing health education.

We identified some opportunities for improving the implementation of low-salt diet practices for hypertensive older individuals, which are presented in Fig. (2). One of the opportunities is the involvement of family support in the process, because health behavior change is influenced by the family structure (for example: living with extended family) and the support of family members can increase adherence to low-salt diet practices [66]. Therefore, in future studies, it is essential to involve families in efforts to improve low-salt diet practices.

Nurses and healthcare providers in the community have a significant responsibility to assist hypertensive older adults in managing and improving their low- salt diet practices. It is essential to take participants' cultural beliefs into account and involve their families in their efforts. The government should also consider implementing salt-reduction strategies that use salt substitutes. For the food industry, it is also necessary to reformulate food products into low-salt alternatives.

The findings provide insights into how older adults adopt a low-salt diet without any help from healthcare professionals. The findings also highlight the challenges these individuals face when following a low-salt diet. This information can be helpful for nurses and other healthcare providers when designing interventions to encourage hypertensive older adults to adopt a low-salt diet.

CONCLUSION

Our review is the first to examine the natural low-salt dietary habits of hypertensive older adults in SEA, usually without any intervention. After analyzing the articles, we found that most hypertensive older adults in SEA do not follow a low-salt diet. We also identified several challenges and opportunities in implementing low-salt dietary habits among hypertensive older adults. Despite this finding, intervention studies are still needed to improve adherence to low-salt diets among hypertensive older people in SEA. These studies should consider cultural factors and involve families in implementing the practice, as the practice of low-salt diets among hypertensive older people in SEA remains relatively poor.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

The authors appreciate the substantial contributions of everyone who participated in this study.

AUTHORS' CONTRIBUTION

Study conception and design : IAP, AMI, ELS

GENERATIVE AI AND AI-ASSISTED TECHNOLOGIES IN THE WRITING PROCESS

During the preparation of this work the authors limitedly used ChatGPT (GPT-4, OpenAI) to get language suggestions and do minor proofreading in some parts of the manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

REFERENCES

1. Whelton PK, Carey RM, Aronow WS, Casey DEJ, Collins KJ, Dennison HC, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertens 2018; 71: e13-115. DOI: https://doi.org/10.1161/HYP.0000000000000065

2. Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: A report of the American College of Cardiology Foundation Task Force on clinical expert consensus documents developed in collaboration with the American Academy of Neurology, American. J Am Coll Cardiol 2011; 57: 2037-114. DOI: https://doi.org/10.1016/j.jacc.2011.01.008

3. World Health Organization. A global brief on hypertension: silent killer, global public health crisis: World Health Day 2013. Available at: https://www.who.int/publications/i/item/a-global-brief-on-hypertension-silent-killer-global-public-health-crisis-world-health-day-2013

4. Sitoresmi H, Masyitha Irwan A, Sjattar EL, Usman S. The effect of foot massage in lowering intradialytic blood pressure at Hemodialysis Unit in Indonesian Hospital. Clin Epidemiol Glob Heal 2020; 8: 1272-6. DOI: https://doi.org/10.1016/j.cegh.2020.04.026

5. World Health Organization. Global report on hypertension: The race against a silent killer. Available at: https://www.who.int/publications/i/item/9789240081062

6. Flack JM, Adekola B. Blood pressure and the new ACC/AHA hypertension guidelines. Trends Cardiovasc Med 2020; 30: 160-4. DOI: https://doi.org/10.1016/j.tcm.2019.05.003

7. Muhadi, JNC V. JNC 8: Evidence-based guideline penanganan pasien hipertensi dewasa. Cermin Dunia Kedokt 2016; 43: 54-9.

8. Nan X, Lu H, Wu J, Xue M, Qian Y, Wang W, et al. The interactive association between sodium intake, alcohol consumption and hypertension among elderly in northern China: A cross-sectional study. BMC Geriatrics 2021; 21: 135. DOI: https://doi.org/10.1186/s12877-021-02090-4

9. Afshin A, Sur PJ, Fay KA, Cornaby L, Ferrara G, Salama JS, et al. Health effects of dietary risks in 195 countries, 1990-2017: A systematic analysis for the global burden of disease study 2017. Lancet 2019; 393: 1958-72. DOI: https://doi.org/10.1016/S0140-6736(19)30041-8

10. Fitri Y, Rusmikawati R, Zulfah S, Nurbaiti N. [Sodium and potassium intake as a factor causing hypertension in the elderly]. AcTion Aceh Nutr J 2018; 3: 158-63. DOI: http://dx.doi.org/10.30867/action.v3i2.117

11. Cook KA, Modena BD, Simon RA. Improvement in asthma control using a minimally burdensome and proactive smartphone application. J Allergy Clin Immunol Pract 2016; 4: 730-7.e1. DOI: https://doi.org/10.1016/j.jaip.2016.03.005

12. Heerspink HJL, Holtkamp FA, Parving H-H, Navis GJ, Lewis JB, Ritz E, et al. Moderation of dietary sodium potentiates the renal and cardiovascular protective effects of angiotensin receptor blockers. Kidney Int 2012; 82: 330-7. DOI: https://doi.org/10.1038/ki.2012.74

13. Domnariu CD, Cucu A, Furtunescu FL. World Health Organization guidelines on salt intake in adults and children. Acta Med Trans 2013; 18: 166-8.

14. Shafrina AA, Sulastri D, Burhan IR. [The relationship between salt consumption levels and hypertension incidence in Southeast Asia]. J Ilmu Kesehat Indones 2021; 2: 202-11. DOI: https://doi.org/10.25077/jikesi.v2i3.452

15. Irwan AM, Potempa K, Abikusno N, Syahrul S. Self-care management for hypertension in Southeast Asia: A scoping review. J Multidiscip Healthc 2022: 2015-32. DOI: https://doi.org/10.2147/JMDH.S367638

16. Othman F, Ambak R, Siew Man C, Mohd Zaki NA, Ahmad MH, Abdul Aziz NS, et al. Factors associated with high sodium intake assessed from 24-hour urinary excretion and the potential effect of energy intake. J Nutr Metab 2019; 2019: 6781597. DOI: https://doi.org/10.1155/2019/6781597

17. Spies LA, Bader SG, Opollo JG, Gray J. Nurse-Led interventions for hypertension: A scoping review with implications for evidence- based practice. Worldviews Evidence-Based Nurs 2018; 15: 247-56. DOI: https://doi.org/10.1111/wvn.12297

18. Mahtani KR, Heneghan C, Onakpoya I, Tierney S, Aronson JK, Roberts N, et al. Reduced salt intake for heart failure: A systematic review. JAMA Intern Med 2018; 178: 1693-700. DOI: https://doi.org/10.1001/jamainternmed.2018.4673

19. Asri M, Irwan AM, Sjattar EL, Hardianto Y. Effectiveness of a low- salt diet in rural hypertensive patients: A systematic review. Clin Epidemiol Glob Heal 2022; 15: 101024. DOI: https://doi.org/10.1016/j.cegh.2022.101024

20. Dunteman AN, McKenzie EN, Yang Y, Lee Y, Lee S. Compendium of sodium reduction strategies in foods: A scoping review. Compr Rev Food Sci Food Saf 2022; 21: 1300-35. DOI: https://doi.org/10.1111/1541-4337.12915

21. Arksey H, O'Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol 2005; 8: 19-32. DOI: https://doi.org/10.1080/1364557032000119616

22. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med 2018; 169: 467-73. DOI: https://doi.org/10.7326/M18-0850

23. Peters MDJ, Godfrey CM, McInerney P, Soares CB, Khalil H, Parker D. The Joanna Briggs Institute reviewers' manual 2015: methodology for JBI scoping reviews 2015. Available at: https://reben.com.br/revista/wp-content/uploads/2020/10/Scoping.pdf

24. Mizutani M, Tashiro J, Sugiarto H, Maftuhah, Riyanto, Mock J, et al. Identifying correlates of salt reduction practices among rural, middle-aged Muslim Indonesians with hypertension through structural equation modeling. Nutr Health 2023; 29: 85-95. DOI: https://doi.org/10.1177/02601060211057624

25. Rusmevichientong P, Nguyen H, Morales C, Jaynes J, Wood MM. Food choices and hypertension among rural Thais: Evidence from a discrete choice experiment. Int J Public Health 2022; 67: 1604850. DOI: https://doi.org/10.3389/ijph.2022.1604850

26. Taufandas MJSM, Hermawati N. [Relationship between family support and hypertension diet compliance in the elderly in Ladon Hall, Wanasaba Community Health Center Working Area]. J Med Hutama 2021; 2: 801-15.

27. Maghfiroh D, Kusuma FHD, Adi RC. [The relationship between family support and a low-salt diet at the elderly posyandu in the Wagir Community Health Center Area, Malang Regency]. Nurs News J Ilm Keperawatan 2018; 3(1): 431-8.

28. Arindari DR, Puspita R. [Relationship between family support and hypertension diet compliance in the elderly at Ariodillah Public Health Center]. Excell Midwifery J 2022; 5: 94-103.

29. Anonyma P. [The relationship between hypertension diet compliance and elderly exercise with blood pressure reduction in the elderly]. J Stethosc 2022; 3(2): 1.

30. Alvita GW. [The relationship between dietary patterns and a history of hypertension in the elderly in Tenggeles Village, Kudus]. J Keperawatan Dan Kesehat Masy Cendekia Utama 2018; 7: 1-9. DOI: https://doi.org/10.31596/jcu.v0i0.208

31. Apidechkul T, Tamornpark R, Chomchoei C, Upala P, Yeemard F. Association between lifestyle behaviors and hypertension among hill tribe adults in Thailand: A cross-sectional study. J Racial Ethn Heal Disparities 2022; 9: 1517-27. DOI: https://doi.org/10.1007/s40615-021-01090-9

32. Srikan P, Callen B, Phillips K, Tavakoli A, Brockett R, Hanucharurnkul S, et al. Testing a model of sodium reduction in hypertensive older Thai adults. J Nutr Gerontol Geriatr 2017; 36: 48-62. DOI: https://doi.org/10.1080/21551197.2016.1274278

33. Buranakitjaroen P, Phoojaroenchanachai M. The prevalence of high sodium intake among hypertensive patients at hypertension clinic, Siriraj Hospital. J Med Assoc Thai 2013; Suppl 2: S1-8.

34. Chailimpamontree W, Kantachuvesiri S, Aekplakorn W, Lappichetpaiboon R, Sripaiboonkij Thokanit N, Vathesatogkit P, et al. Estimated dietary sodium intake in Thailand: A nationwide population survey with 24-hour urine collections. J Clin Hypertens (Greenwich) 2021; 23: 744-54. DOI: https://doi.org/10.1111/jch.14147

35. Rusmevichientong P, Morales C, Castorena G, Sapbamrer R, Seesen M, Siviroj P. Dietary salt-related determinants of hypertension in rural northern Thailand. Environ Res Public Health 2021; 18(2): 377. DOI: https://doi.org/10.3390/ijerph18020377

36. Cho H, Kim SM, Jeong SS, Kim SB. Comparison of salt taste thresholds and salt usage behaviours between adults in Myanmar and Korea. Asia Pac J Clin Nutr 2016; 25: 879-84. DOI: https://doi.org/10.6133/apjcn.092015.32

37. Karupaiah T, Wong K, Chinna K, Arasu K, Chee WSS. Metering self-reported adherence to clinical outcomes in Malaysian patients with hypertension: Applying the stages of change model to healthful behaviors in the CORFIS study. Heal Educ Behav Off Publ Soc Public Heal Educ 2015; 42: 339-51. DOI: https://doi.org/10.1177/1090198114558588

38. Haron H, Kamal NF, Yahya HM, Shahar S. Knowledge, attitude and practice (KAP) of Malay elderly on salt intake and its relationship with blood pressure. Front Public Heal 2020; 8: 559071. DOI: https://doi.org/10.3389/fpubh.2020.559071

39. Mansor W, Harith S, Taha CSC, Ong YQ. Knowledge, Attitude and practice towards salt intake of its associated factors among hypertensive FELDA residence in Terengganu. Malaysian Appl Biol 2021; 50: 125-33.

40. Thuong CNH, Thuan TT, Hanh VTX, Tuan HNA, Dang TN. Factors associated to treatment adherence in elderly people with hypertension: A cross-sectional study in Ho Chi Minh city. Clin Epidemiol Glob Health 2022; 16: 101099. DOI: https://doi.org/10.1016/j.cegh.2022.101099

41. Pinto J, da Silva Belo O, Pires AM, da Costa Fernandes M, Pereira AG, Gaio EC, et al. The factors influence to incidence of hypertension in Baucau Municipality, Republica Democratica de Timor Leste. KESANS Int J Heal Sci 2022; 1: 1010-8.

42. Nohan AF, Adznam SN, Jamaluddin R, Norazman CW. Diet quality and its associated factors among community dwelling older adults in Urban District in Kuala Lumpur, Malaysia. Malaysian J Med Heal Sci 2020; 16: 153-62.

43. Htun YM, Win KS, Naung Y, Soe K. Prevalence, awareness and risk factors of hypertension in Hmawbi Cantonment Area, Yangon Region, Myanmar. South East Asia J Public Heal 2016; 6: 20-6.

44. Barkah A, Suara M. [The relationship between hypertension diet compliance and the incidence of hypertension in the elderly]. J Antara Keperawatan 2020; 1: 109-115. DOI: https://doi.org/10.37063/jurnalantarakeperawatan.v1i3.25

45. da Costa Nunes CF, Yuniarti T, Darwati LE. The Effect of diet hypertension on the event of hypertension in the elderly. Proc Int Conf Nurs Heal Sci 2022; 3: 111-8.

46. Safutri W, Maesaroh S, Sagita YD. [Relationship between diet compliance with hypertension and hypertension incidents in the elderly at Posbindu Ptm, Raman Endra Village, East Lampung Regency in 2021]. J Matern Aisyah (Jaman Aisyah) 2022; 3: 12-9. DOI: https://doi.org/10.30604/jaman.v3i1.403

47. Yan LS, Suharto F, Eridia. [Diet experience of elderly women with hypertension]. J Ilm Keperawatan Indones 2018; 2: 65-82.

48. Steinman L, Heang H, van Pelt M, Ide N, Cui H, Rao M, et al. Facilitators and barriers to chronic disease self-management and mobile health interventions for people living with diabetes and hypertension in Cambodia: Qualitative study. JMIR MHealth UHealth 2020; 8: e13536. DOI: https://doi.org/10.2196/13536

49. Chantakeeree C, Sormunen M, Jullamate P, Turunen H. Understanding perspectives on health-promoting behaviours among older adults with hypertension. Int J Qual Stud Health Well- Being 2022; 17: 2103943. DOI: https://doi.org/10.1080/17482631.2022.2103943

50. Tan ST, Quek RYC, Haldane V, Koh JJK, Han EKL, Ong SE, et al. The social determinants of chronic disease management: perspectives of elderly patients with hypertension from low socio- economic background in Singapore. Int J Equity Health 2019; 18: 1. DOI: https://doi.org/10.1186/s12939-018-0897-7

51. Sutipan P, Intarakamhang U. Healthy lifestyle behavioral needs among the elderly with hypertension in Chiang Mai, Thailand. J Behav Sci 2017; 12(1): 1-12.

52. Woodham NS, Taneepanichskul S, Somrongthong R, Auamkul N. Self-care management among elderly patients with hypertension and poor adherence to treatment, living in rural Thailand: A qualitative study. Pak J Public Health 2018; 8(2): 84-9.

53. Udompittayason W, Boonyasopun U, Songwathana P. Perspectives on hypertension among Thai-Melayu elderly in a province of Southern Thailand: An ethnographic study. J Res Nursing-Midwifery Heal Sci 2015; 35: 45-60.

54. Jayasvasti I, Jayasvasti M, Pengpid S, Peltzer K, Nanthananate P. Participants' views on lifestyle intervention program enhancing long-term health-related behaviors improvement among prehypertension and/or prediabetes mellitus older adults: A qualitative study examined in Thailand at Health Promoting Hospitals. Inquiry 2021; 58: 469580211025209. DOI: https://doi.org/10.1177/00469580211025209

55. Trieu K, Neal B, Hawkes C, Dunford E, Campbell N, Rodriguez- Fernandez R, et al. Salt reduction initiatives around the world-a systematic review of progress towards the global target. PLoS One 2015; 10: 1-22. DOI: https://doi.org/10.1371/journal.pone.0130247

56. Fiqri AM, Sjattar EL, Irwan AM. Cognitive behavioral therapy for self-care behaviors with type 2 diabetes mellitus patients: A systematic review. Diabetes Metab Syndr Clin Res Rev 2022; 16: 102538. DOI: https://doi.org/10.1016/j.dsx.2022.102538

57. Zuraida E, Irwan AM, Sjattar EL. Self-management education programs for patients with heart failure: A literature review. Cent Eur J Nurs Midwifery 2021; 12: 279-94. DOI: https://doi.org/10.15452/CEJNM.2020.11.0025

58. Irwan AM, Balabagno AO. Factors related to self-care among older persons of Makassarese Tribe, Indonesia. Philipp J Nurs 2014; 84: 24-30.

59. Al-Jawaldeh A, Taktouk M, Chatila A, Naalbandian S, Al-Thani AAM, Alkhalaf MM, et al. Salt reduction initiatives in the eastern mediterranean region and evaluation of progress towards the 2025 global target: A systematic review. Nutrients 2021; 13(8): 2676. DOI: https://doi.org/10.3390/nu13082676

60. Ghimire K, Mishra SR, Satheesh G, Neupane D, Sharma A, Panda R, et al. Salt intake and salt-reduction strategies in South Asia: From evidence to action. J Clin Hypertens 2021; 23: 1815-29. DOI: https://doi.org/10.1111/jch.14365

61. Batcagan-Abueg AP, Lee JJM, Chan P, Rebello SA, Amarra MS V. Salt intakes and salt reduction initiatives in Southeast Asia: A review. Asia Pac J Clin Nutr 2013; 22: 683-97.

62. Santos JA, McKenzie B, Rosewarne E, Hogendorf M, Trieu K, Woodward M, et al. Strengthening knowledge to practice on effective salt reduction interventions in low- and middle-income countries. Curr Nutr Rep 2021; 10: 211-25. DOI: https://doi.org/10.1007/s13668-021-00365-1

63. Sofi M, Khor GL. Sodium consumption in Southeast Asia: An updated review of intake levels and dietary sources in six countries. In: Bendich A, Deckelbaum R, Eds. Preventive Nutrition 2015; Springer, Cham pp. 765-92. DOI: https://doi.org/10.1007/978-3-319-22431-2

64. Menyanu E, Russell J, Charlton K. Dietary sources of salt in low- and middle-income countries: A systematic literature review. Int J Environ Res Public Health 2019; 16: 2082. DOI: https://doi.org/10.3390/ijerph16112082

65. Santos JA, McKenzie B, Rosewarne E, Hogendorf M, Trieu K, Woodward M, et al. Strengthening knowledge to practice on effective salt reduction interventions in low- and middle-income countries. Curr Nutr Rep 2021; 10: 211-25. DOI: https://doi.org/10.1007/s13668-021-00365-1

66. Chan A, Chan SW chi, Khanam M, Kinsman L. Factors affecting reductions in dietary salt consumption in people of Chinese descent: An integrative review. J Adv Nurs 2022; 78: 1919-37. DOI: https://doi.org/10.1111/jan.15237

67. Sari MM, Syahrul S, Malasari S. Training of caregiver towards family independence level in caring for elderly with hypertension. Indones Contemp Nurs J 2016: 1-7. DOI: https://doi.org/10.20956/icon.v1i1.3218