Potassium-enriched salt: a new era for UK salt reduction?

BackgroundHypertension is a serious public health problem. Potassium-enriched salt is suggested as a tool for lowering blood pressure. However, its flavor and taste acceptability is essential for population-based salt reduction strategy and needs to be well-understood. This trial assessed the flavor and taste acceptability of six different potassium-enriched iodized salts in the general population.MethodsWe conducted this crossover trial from May to June 2016, enrolling 100 normal volunteer subjects aged 11 to 64 years. We compared regular sodium chloride salt (placebo) with six different potassium-enriched (sodium reduced) iodized salt (experiment), including 0 %, 5 %, 10 %, 15 %, 20 %, 25 %, and 30 %. The participants served as their own control and received a placebo and a sequence of the experiments. They tasted the two salts sequentially and stated their preference and acceptance. Each subject received all salts.ResultsMore than 80 % of participants who either did not distinguish between the two salts even in high potassium-enriched salts or preferred potassium-enriched salt (P < 0.001). The number of participants who preferred the flavor of potassium-enriched salt was greater than the number of subjects who preferred the flavor of regular sodium chloride.ConclusionOur findings indicated that the six different potassium-enriched salts had a public acceptability of at least 80 % among normal subjects from the general population. Although the acceptability of the potassium-enriched salts by a more general population group would require to be confirmed, universal use of this salt may help us achieve the target of 30 % relative reduction in mean population intake of sodium by 2025.

Does potassium-enriched salt or sodium reduction reduce cardiovascular mortality and medical expenses?

UK population salt reduction: an experiment in public health

To describe the UK Food Standards Agency's (FSA) salt reduction programme undertaken between 2003 and 2010 and to discuss its effectiveness. Relevant scientific papers, campaign materials and evaluations and consultation responses to the FSA's salt reduction programme were used. Adult salt intakes, monitored using urinary Na data collected from UK-wide surveys, indicate a statistically significant reduction in the population's average salt intake from 9·5 g/d in 2000-2001 to 8·6 g/d in 2008, which is likely to have health benefits. Reducing salt intake will have an impact on blood pressure; an estimated 6 % of deaths from CHD in the UK can be avoided if the number of people with high blood pressure is reduced by 50 %. Salt levels in food, monitored using commercial label data and information collected through an industry self-reporting framework, indicated that substantial reductions of up to 70 % in some foods had been achieved. The FSA's consumer campaign evaluation showed increased awareness of the benefits of reducing salt intake on health, with 43 % of adults in 2009 claiming to have made a special effort to reduce salt in their diet compared with 34 % of adults in 2004, before the campaign commenced. The UK's salt reduction programme successfully reduced the average salt intake of the population and increased consumers' awareness. Significant challenges remain in achieving the population average salt intake of 6 g/d recommended by the UK's Scientific Advisory Committee on Nutrition. However, the UK has demonstrated the success of its programme and this approach is now being implemented elsewhere in the world.

Waiter, There's Potassium in My Soup!

Dentists should be at the forefront in the fight against sugar

Cardiovascular disease (CVD), including stroke, heart attack and heart failure, is the leading cause of death and disability worldwide. Raised blood pressure (BP) is a major cause of CVD, responsible for 62% of stroke and 49% of coronary heart disease cases.1 There is much evidence for a causal relationship between salt intake and BP.2 The current salt intake in many countries around the world is between 9 g/d and 12 g/d (ie, 3.6–4.8 g of sodium). Randomized trials have demonstrated that a modest reduction in salt intake lowers BP in individuals with raised BP and also in those with "normal" BP. Furthermore, there is a dose-response relationship. Within the range of 12 g/d to 3 g/d, the lower the salt intake, the lower the BP.3 Because raised BP throughout its range is a major cause of CVD, salt reduction would reduce cardiovascular risk. It was estimated that a reduction of 6 g/d in salt intake would reduce stroke by 24% and coronary heart disease by 18%. This would prevent approximately 35,000 stroke and coronary heart disease deaths a year in the United Kingdom3 and approximately 2.5 million deaths worldwide. Both prospective studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of CVD.4,5 Salt reduction is one of the most cost-effective interventions to reduce CVD in both developed and developing countries.6–12 For example, the UK salt reduction campaign, which resulted in a fall in salt intake by approximately 10% (ie, from 9.5 g/d in 2003 to 8.6 g/d by May 2008),13 cost just £15 million and led to approximately 6000 fewer CVD deaths per year, saving the UK economy approximately £1.5 billion per annum according to the recent report by the UK government's health advisory agency, the National Institute for Health and Clinical Excellence.14,15 In most developed countries, approximately 80% of salt consumed is added to foods at the stage of manufacturing,16 and the consumers have no say over how much salt is added. Therefore, to achieve a reduction in population salt intake, it is imperative that the food industry make a gradual and sustained reduction in the amount of salt that is added to all foods. This approach has been successful in the United Kingdom and is now being expanded worldwide. World Salt Awareness Week was introduced by the salt reduction action group World Action on Salt and Health (WASH) in 2008.17 The event serves as a platform for international experts in the fields of hypertension and nephrology to raise the profile of the importance of salt reduction to both the public and health professionals worldwide. The United Kingdom is one of the countries leading the way in salt reduction and is setting an example for other countries to follow. In 1996, 22 experts on salt and BP set up an action group, Consensus Action on Salt and Health (CASH), following the government's rejection of the 1994 Committee on Medical Aspects of Food and Nutrition Policy (COMA) panel's recommendation to reduce salt intake.18,19 CASH has waged a highly successful campaign to persuade food manufacturers and suppliers to universally and gradually reduce the salt content of processed foods, educate the public in becoming more aware of the impact of salt on their health, and translate the evidence into public health policy. CASH persuaded the UK Department of Health to change its stance on salt, finally resulting in the Chief Medical Officer endorsing the original recommendations of the 1994 COMA report to reduce salt intake to <6 g/d in adults, and also ensured that the UK Food Standards Agency (FSA) took on the task of reducing salt intake. A nationwide strategy to reduce population salt intake was developed based on the UK's average salt intake of 9.5 g/d20 as measured by 24-hour urinary sodium (Table). In order to reach the target of 6 g, a total reduction of 3.5 g (ie, 40%) was needed. Therefore, the food industry, who contribute approximately 80% of the salt in the UK diet, would need to reduce the amount of salt added to foods from 7.6 g to 4.6 g (40% reduction) and the public would need to reduce the amount of salt they add to foods themselves from 1.4 g to 0.9 g (40% reduction). The aim was to implement a step-wise reduction in salt added to foods, ie, a 10% to 20% reduction, repeated at 1- to 2-year intervals. Such reductions are not detectable by human salt taste receptors.21 Through product survey work and a large-scale public awareness campaign, CASH has continued to ensure that the food industry and consumers are making these reductions. This population-based approach benefits everyone, not just the educated and better-off in society, addressing the severe health inequalities seen both in the United Kingdom and throughout the world. Since 2001, CASH has held an annual National Salt Awareness event to raise awareness of the dangers of a high-salt diet.18 It has covered many themes, including: "Salt in the Diet," highlighting the high levels of salt present in processed foods and ready-meals; "Salt: the Forgotten Element," reminding consumers to consider eating less salt as part of a healthy diet; "Salt and the Consumer," educating consumers about food labels and choosing lower-salt options; "Salt and Ethnic Groups," focussing on black people of African or Caribbean descent who have a much higher risk of dying from a stroke than the general UK population; and "Salt and the Elderly," which focused on the older population who will gain immediate and significant benefits from a reduction in salt intake in terms of preventing strokes and heart attacks. National Salt Awareness Week is now a well-recognized event in the United Kingdom, generating significant media coverage that enables the message of salt reduction to reach those who would be otherwise unaware of the dangers of a high-salt diet. In 2010, the United Kingdom celebrated Salt Awareness Week with national media coverage following a public opinion survey showing that people do not know how salt can damage their health. More than 500 supporting events were held across the country by health professionals, universities, schools, and workplaces. The Week saw a Parliamentary Reception at the House of Commons, with representation from the UK government, experts from industry, and the United Kingdom's leading health charities, including the British Heart Foundation, The Stroke Association, National Osteoporosis Society, and Cancer Research UK. Following the success of the salt reduction campaign in the United Kingdom through the work of CASH, an international group World Action on Salt and Health (WASH) was established in 2005.17,22 The aim of WASH is to set up similar groups modeled on CASH to reduce salt intake with an appropriate strategy relevant to the needs of that particular country, and to stimulate actions from the government and/or department of health, the food industry, the media, and the public. Progress is being made worldwide as more countries sign up to take action to reduce salt intake. WASH is currently supported by more than 400 members from 81 countries (Figure). Action groups on salt reduction around the world. The red dots indicate locations of World Action on Salt and Health (WASH) members. Based on the success of the UK Salt Awareness Week, WASH extended the invitation to its members to participate in World Salt Awareness Week in 2008. This event has had great success in many countries, including both developed and developing nations, as the movement to reduce salt gathers momentum worldwide. Countries can focus on the suggested theme of World Salt Awareness Week and tailor it to their needs or draw on previous themes, depending on what progress has been made on salt reduction in their country. Activities have ranged from involvement with hypertension and renal experts, and representatives from the health and education ministries, to engaging with consumers, the media, and the food industry. World Salt Awareness Weeks generate significant publicity and help to raise awareness of the need for salt reduction strategies in many countries. While it is not possible to detail all the great work made by these countries, some examples of activities are outlined below, particularly those that occurred during the past year's World Salt Awareness Week, which was held on February 1–7, 2010. The Australian division of World Action on Salt and Health (AWASH)23 celebrated World Salt Awareness Week 2010 by coinciding the Week with the release of new research that showed that more than 70% of processed meats, cheeses, and sauces contain unacceptably high levels of salt in Australia. AWASH used this opportunity to gain significant media coverage to raise awareness and call the Australian government to take action to set salt targets for processed and takeaway foods. AWASH has gained support from the Australian government and has recently released a template for the food industry to provide details of salt reduction efforts and action plans. In Canada, the federally funded Canadian Stroke Network (CSN)24 used World Salt Awareness Week to award their annual "Salt Lick Award." The Salt Lick Award highlights foods that are inappropriately high in salt with the aim of alerting the consumers and, more productively, the industry to take action. In 2010, this event focused on salt in children's diets, and the Salt Lick Award was given to Gerber Graduates Lil' Entrees as the Chicken and Pasta Wheel Pickups dinner served up the salt equivalent of two orders of medium McDonald's fries (500 mg sodium). The Italian Society of Human Nutrition (SINU) and The Working Group for Reduction of Salt Intake in Italy (GIRCSI) produced leaflets, posters, and press releases to promote World Salt Awareness Week 2010. These were disseminated through food service companies and through SINU and GIRCSI members. More than 50 web sites in Italy publicized the Week. In Croatia, the Croatian Action on Salt and Health (CRASH) participates in World Salt Awareness Week and has previously organized several educational activities for the general population, physicians, and nurses. The Croatian Ministry of Health supports the activities of CRASH and the National Salt Reduction Program. The National Heart Foundation of Bangladesh held a press conference on February 3, 2010, and printed and distributed posters and brochures to raise awareness of salt and health. Different national leading newspapers of the country published news highlighting how excessive intake of salt can damage health. In Pakistan, a main seminar was held in Islamabad, which had both good media and public support. Further promotion of World Salt Awareness Week was continued at the Pakistan Hypertension Meeting in Faisalabad on February 27–28, 2010. In the Caribbean, Barbados supported World Salt Awareness Week. Media attention was generated in the national paper by advertising the benefits of a low-salt diet and the work being carried out in the Caribbean to raise awareness among consumers. In addition, free BP assessments were offered to the public at various locations across Barbados. The National Health Fund of Jamaica distributed flyers and posters within the community and released radio advertisements detailing the harm of having too much salt in your diet. They also conducted free BP assessments in their Customer Care Department and printed silicon armbands for adults and children reminding them to "Drop the Salt: Protect Your Health." World Salt Awareness Week 2011 has been confirmed for March 21–27, 2011. The theme will be "Salt and Men's Health." The aim is to raise awareness of the dangers of a high-salt diet in young men. It has been shown that, on average, men live approximately 7 years less than women, and are more likely to suffer and die prematurely from CVD. The Health Survey for England showed that between the ages of 45 to 54 years, the prevalence of stroke and ischemic heart disease was 12.5% in men and only 5.0% in women, and at the ages of 55 to 64 years, it was 25.1% and 12.6% for men and women, respectively.25 Men have higher BP than women, particularly at a younger age; are less likely to have their BP measured; and are less likely to take action to reduce it when it is raised or take BP-lowering drugs. Compared with women, men eat more salt (9.7 g/d vs 7.7 g/d in the United Kingdom, as measured by 24-hour urinary sodium)13 and less fruit and vegetables (3.5 vs 3.9 portions per day); only 25% of men compared with 29% of women have reached the recommended level of ≥5 portions per day of fruit and vegetables.25 The current recommended maximum salt intake for adults is 6 g/d in the United Kingdom and the United States irrespective of whether the person is male or female.26 As men have a much higher salt intake than women, in order for men to achieve this target, they need to reduce their salt intake by a greater extent, ie, by an average of 3.7 g/d (from 9.7 g/d to 6 g/d), whereas women need to reduce it by only 1.7 g/d (from 7.7 g/d to 6 g/d). A public campaign to make men more aware of the risks they are running and to make them more responsible for their own health would help prevent many men from dying when they are still at a productive age and are often responsible for dependents. We would like to welcome all WASH members and health professionals to participate in World Salt Awareness Week 2011 to raise awareness of this important issue. There is overwhelming evidence that the current high-salt intake of 9 g/d to 12 g/d is the major factor increasing BP and, thereby, a major cause of cardiovascular disease worldwide. A reduction in salt intake to the recommended level of <5 g/d to 6 g/d will be very beneficial to human health, along with major cost savings in all countries around the world. Several countries, eg, Finland and the United Kingdom, have already reduced the amount of salt consumed by a combined policy of engaging with the food industry to decrease the amount of salt added to foods, promoting the use of clear labeling on food products, increasing public awareness of the harmful effects of salt on health, and encouraging consumers to use less salt during their own food preparations. Many other countries, eg, the United States, Australia, and Canada are also stepping up their activities. The major challenge now is to spread this out worldwide. World Salt Awareness Week is a prime opportunity to deliver this message and spur countries into action to reduce their salt intake by raising awareness. It also helps to focus the efforts of countries that are yet to develop salt reduction strategies, and to provide useful tools and guidance to assist them to be able to do so successfully. World Salt Awareness Week has proved successful in countries who have participated thus far. More activities from WASH members participating in World Salt Awareness Week will help promulgate this message further and move us closer to achieving the World Health Organization target salt intake of <5 g/d. WASH would like to extend its membership to new members. Joining WASH does not require any time or financial commitments, just support in salt reduction activities worldwide. We value information-sharing, feedback, and input from your country, and encourage members to participate in activities such as World Salt Awareness Week, and in particular, by setting up an action group in your own country. To join, please e-mail WASH ([email protected]) or visit the WASH web site for more information (http://www.worldactiononsalt.com). Disclosure: All the authors declared no competing interests.

The United Kingdom has successfully implemented a salt reduction programme. We carried out a comprehensive analysis of the programme with an aim of providing a step-by-step guide of developing and implementing a national salt reduction strategy, which other countries could follow. The key components include (1) setting up an action group with strong leadership and scientific credibility; (2) determining salt intake by measuring 24-h urinary sodium, identifying the sources of salt by dietary record; (3) setting a target for population salt intake and developing a salt reduction strategy; (4) setting progressively lower salt targets for different categories of food, with a clear time frame for the industry to achieve; (5) working with the industry to reformulate food with less salt; (6) engaging and recruiting of ministerial support and potential threat of regulation by the Department of Health (DH); (7) clear nutritional labelling; (8) consumer awareness campaign; and (9) monitoring progress by (a) frequent surveys and media publicity of salt content in food, including naming and shaming, (b) repeated 24-h urinary sodium at 3-5 year intervals. Since the salt reduction programme started in 2003/2004, significant progress has been made as demonstrated by the reductions in salt content in many processed food and a 15% reduction in 24-h urinary sodium over 7 years (from 9.5 to 8.1 g per day, P<0.05). The UK salt reduction programme reduced the population's salt intake by gradual reformulation on a voluntary basis. Several countries are following the United Kingdom's lead. The challenge now is to engage other countries with appropriate local modifications. A reduction in salt intake worldwide will result in major public health improvements and cost savings.

The out-of-home (OOH) food sector has a growing importance on the UK population diet, but the nutritional quality of the most influential OOH menu items has not yet been comprehensively characterised(1). It is also unclear how OOH food healthiness should be assessed. The primary study objectives were to assess the compliance of best-selling menu items in the UK with the ongoing calorie, salt, and sugar reduction programmes(2) and to compare the use of UK official healthiness assessment models and metrics,(3,4) using data collected in 2023/24. A secondary objective was to examine item-level changes in nutritional composition over time using 2021 data for a subset of menu items.A cross-sectional survey of the 10 best-selling menu items of the 20 largest OOH companies in the UK was conducted online between September 2023 and March 2024, with manual imputation of missing nutrition data. Candidate healthiness assessment approaches included the UK Nutrient Profile Model (NPM)(3), Multiple Traffic Light Labelling (MTL),(4) and the targets, guidelines, and levy threshold included in the UK calorie, salt, and sugar reduction programmes.(2) Longitudinal item-level changes in nutrition composition were assessed retrospectively using archived August 2021 web-extracted data.After excluding items where data imputation was not possible, 189 menu items were included in 2023/24, consisting mostly of main meals (25%), starter/side dish/small plates (18%), and sandwiches (18%). 59% of 184 products met their respective maximum calorie, salt, and/or sugar target/guideline; and 8 of the 20 applicable average target/guidelines were achieved. Depending on the healthiness assessment approach used, 46-78% of the menu items would not be deemed healthy. The NPM yielded the most lenient assessment due to not accounting for portion size; combining it with either category-specific or across-the-board maximum thresholds resulted in more stringent assessments. 117 food and 23 drink menu items could be tracked from 2021 to 2023/24; an increase in the median [interquartile range] salt content per serve was found in food (from 2.0g [1.3–3.7g] to 2.2g [1.4–3.8g], p=0.004). No other change in nutrition composition was observed over time at the menu item level.This study comprehensively highlights the generally poor nutritional quality of best-selling OOH menu items in the UK, the lack of success of current voluntary programmes in driving impactful OOH product reformulation, and the limitations of the NPM for OOH application. Limitations include uncertainty around nutrition data accuracy (as either extracted from company websites or estimated using single purchases) and assessment of compliance with the calorie, salt, and sugar reduction programmes based solely on reformulation or portion size adjustments, not capturing mechanisms such as shifting sales. Our findings suggest that healthiness assessment in the OOH sector requires using either category-specific or across-the-board maximum thresholds for energy and ‘negative’ nutrients (e.g., salt, sugars) per serve.

Excessive sodium intake is responsible for 3 million deaths a year globally. The UK is one of 64 countries to have a salt reduction program to help reduce the population's sodium intake. It is a voluntary scheme with 108 category-specific salt content targets for the grocery and out-of-home sectors. This study aimed to estimate the potential impact of the 2024 targets on cardiovascular outcomes and health care costs for UK adults. Long-term health modeling was based on the adult population in England. Changes in salt intake (g/d), whether the targets were met, were estimated using consumption data from the National Diet and Nutrition Survey 2018/19. Impact on ischemic heart disease and stroke, quality-adjusted life years, and health care costs were estimated using PRIMEtime, a proportional multistate life table model. If the salt reduction targets set for 2024 had been met, then salt intake would have reduced from 6.06 g/d (95% CI, 5.18-6.31) to 4.94 g/d (4.73-5.15), a reduction of 1.12 g/d (1.05-1.20). This would lead to 103 000 (UI, 41 000-161 000) fewer cases of ischemic heart disease and 25 000 (10 000-39 000) fewer cases of stroke over 20 years. A modeled 243 000 (94 000-383 000) quality-adjusted life years would be saved with a net saving of £1.00 billion (£0.35-1.73 billion) to the National Health Service over the remaining lifetime of the adult population. Reformulation of products to meet the targets could result in substantial reductions in cardiovascular disease without changes in dietary behaviors. Policymakers should consider options to strengthen salt reduction policies, including effective systems for monitoring and enforcement.

Shared Primacy of Sodium and Potassium on Cardiovascular Risk

Emerging opportunities for monitoring the nutritional content of processed foods

Objective: The UK is reducing salt intake. We provide an insight into the programme with an aim of helping other countries to follow. Methods: The key to the UK policy is (1) Setting up action group with strong leadership; (2) Determining salt consumption by measuring 24-hour urinary sodium (UNa) in a random sample of the population, identifying the major sources of salt, and developing a salt reduction strategy; (3) Encouraging industry reformulation, through progressively lower voluntary salt targets for >80 categories of foods, with a clear timeframe; (4) Consumer awareness campaign; (5) Clear nutritional labelling of foods; (6) Monitoring progress by (a) frequent surveys of salt content in foods with naming and shaming as well as praising individual companies, (b) repeated 24-hour UNa at 2-3 year intervals. Findings: (1) Product surveys consistently demonstrate significant reductions in the salt content of foods, e.g. 20% reduction of the salt content in bread from 2001 to 2011. (2) The average salt intake in the population as measured by 24-hour UNa decreased from 9.5 g/d in 2001 to 8.1 g/d in 2011 (i.e. 15% reduction, P < 0.05). Conclusions: The UK salt reduction programme is successfully reducing the salt intake of the whole UK population by gradual reformulation on a voluntary basis. Several countries, e.g. the US, Canada and Australia, are following the UK's lead. The challenge now is to engage all other countries around the world with appropriate local modifications. A reduction in salt intake worldwide will result in major public health improvements and cost-savings.

The aim of this study was to assess the changes in salt intake and concomitant changes in blood pressure (BP) and cardiovascular disease (CVD) mortality in England from 2003 to 2018. National surveys and death registration data were used for the analysis of salt intake as measured by 24-h urinary sodium excretion (449-1069 participants per year), BP (2651-6738 participants per year) and CVD mortality. A decline in salt intake from 9.38 (SD 4.64) to 7.58 (3.41) g/d was observed between 2003 and 2014 ( P < 0.01), followed by an increase to 8.39 (4.13) g/d in 2018 ( P < 0.01). Similar trends in BP and CVD mortality were also observed between 2003 and 2018. SBP/DBP decreased from 125.3 (15.92)/74.48 (11.33) mmHg to 122.57 (14.92)/73.33 (10.75) mmHg between 2003 and 2014 ( P < 0.01), followed by a plateau up to 2018 [122.04 (14.64)/73.84 (10.54) mmHg, P > 0.05]. Likewise, a fall in stroke and ischaemic heart disease mortality rates was observed between 2003 and 2014, from 12.24 and 43.44 cases per 100 000, to 8.19 and 27.23 cases per 100 000 ( P < 0.01), respectively, followed by a plateau afterwards ( P > 0.05). The UK salt reduction programme was initially successful in reducing population salt intake by 19% (from 9.38 g/d in 2003 to 7.58 g/d in 2014). However, in recent years, the programme stalled and thus led to an interruption in the decline of salt intake. BP and CVD mortality reduction was also interrupted when salt reduction stalled. The changes in salt intake may have played an important role in the concomitant changes in BP and CVD mortality. Urgent action is needed to reinvigorate the UK's once world-leading salt reduction programme.

Reducing children’s sugar intake through food reformulation: methods for estimating sugar reduction program targets, using New Zealand as a case study