Food Science and TechnologyVolume 37, Issue 1 p. 32-35 FeaturesFree Access Assault on salt Intake First published: 08 March 2023 https://doi.org/10.1002/fsat.3701_8.xAboutSectionsPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat SoniaPombo, Registered Nutritionist and Campaign Lead at Action on Salt based at Queen Mary University of London explains the urgent need to reduce salt intake and progress on reformulation of foods to reduce salt. Is salt reformulation a magic wand for public health? Are we eating ourselves into an early grave? Our typical diet of foods high in salt, sugar, and saturated fat (HFSS) is leading us to suffer more from obesity, type 2 diabetes, raised blood pressure, cardiovascular disease, and cancer – all of which are severe and life-threatening conditions. Obesity has been dominating the media and policymakers’ attention in recent years. With the majority of adults in England now living with overweight and obesity, it's no surprise as to why. Solving the obesity crisis is hugely complex and requires all hands- on deck for any meaningful impact and lasting change. However, within all of this is a simple, cheap, and effective approach to improving public health. Such an approach requires minimal effort and yet has been shown to reduce the risk of cardiovascular disease–the cause of one in four deaths in the UK. We are talking about reducing salt intake. Why focusing on salt? Decades of consistent, high-quality research has linked excessive salt intake to raised blood pressure[1], a major risk factor for heart attacks and stroke, and the leading causes of death and disability worldwide[2]. Two people in the UK suffer from these often-debilitating conditions every five minutes. The strain this is having, not only on the individual and their families but also on the National Health System, cannot be ignored. The recommended salt intake in the UK is less than 6g a day for an adult. However, the latest figures show we are eating 40% more than this (8.4g/ day). Whilst that might not sound like a significant amount, at a population level it has a profound effect. For every 1g reduction in population salt intake, it's thought that more than 4,000 premature deaths could be prevented each year, with annual health savings to the NHS at £288m[3]. Reducing salt intake has therefore been identified as one of the most cost-effective measures that any country should take to improve population health outcomes[4]. But exactly how can we do this, and where does responsibility lie? Knowledge isn't necessarily power Some might argue that changes need to come from within and indeed education programmes designed to raise awareness and encourage individual change do exist. Front of pack labelling is one such example, making it clearer and easier for the public to understand what is in their food and the effects it may have on their health. The hope is that we will use this knowledge to make better informed choices and ultimately shift our behaviour towards healthier lifestyles. Whilst important to address, an individualistic view alone will not solve the issue, particularly for salt. Most of the salt we eat in our diet is already present in the foods we buy and therefore simply telling people what they should or shouldn't eat will not make any meaningful change to population health. So how can we cut back on our salt, when everything we buy is full of it? From sliced bread to biscuits, Friday night takeaways to so called ‘healthy’ salads – everything has added salt. In fact, three quarters of the salt we eat is already in the foods we buy and it's impossible to take it out once it has been added. What's therefore needed is more upstream interventions to address the problem at the source and improve the nutritional quality of the foods we all buy so that we can all live healthier lives. This has the added benefit of addressing the availability of healthier food and, if done correctly, benefits the whole population from all walks of life. Reformulation is a marathon, not a sprint The UK initiated a voluntary salt reduction programme in the early 2000's, putting greater focus on industry efforts to reduce the salt content in the foods they produce. Voluntary salt reduction targets have been in place since 2006 covering ~80 categories of food, with various iterations since published to encourage companies to gradually reduce salt content over time[5]. The food industry took on this challenge with valour (or perhaps it was the veiled threat of legislation) with impressive results. Where Kellogg's once filled our Cornflakes with a wincing 2.4g/100g salt in 2004, they now have 1.13g/100g. Many other breakfast cereals have had their salt content cut by half, with 20-30% reductions in soups and pasta sauces. Bread is now 30% lower in salt too – a significant win when you consider it is the leading source of salt in our diets[6]. All of this has been done right under our noses, and therein lies the beauty of reformulation. Many companies have taken to making gradual and unobtrusive reductions in salt across all foods, allowing our palates to adapt. As such, we've barely noticed the difference and have continued to buy and enjoy the same foods year on year. Reformulation is not unusual for the food industry. The process of updating and improving recipes has always occurred, even before the days of salt reduction. But has the guidance from government to incorporate gradual reductions in salt been worth the hassle? Undoubtedly so. Since the start of the UK programme, population salt intakes have fallen and with it blood pressure too – with more significantly fewer reported deaths from strokes and heart attacks[7]. So, whether you are actively looking to reduce your salt intake or not, we are all benefiting from these small and gradual changes. And even if we were just to maintain these levels, by 2050 it is estimated this alone will have prevented nearly 200,000 premature heart disease and strokes[8]. Best practices in salt reduction Salt provides a combination of physical, chemical and sensorial properties for food, and there are a variety of different strategies and technologies available to manufacturers to reduce the level of salt in their foods. The simplest and cheapest approach is to gradually reduce the amount of added salt to food over time, allowing consumers tastes preferences to adapt accordingly. Other strategies include reducing the size of the salt crystal so that smaller crystals cover a wider surface area, meaning less salt for an overall saltier profile. On the other hand, alternative ingredients, reduced sodium salts, and alternative processing techniques such as high pressure could be used. Salt reduction feasibility varies depending on the food category in question, and granted there are some foods where salt may be required for safety purposes. In these instances, a viable alternative would be to use salt replacers such as potassium chloride. These have similar processing, microbiological and sensorial functionalities and are increasingly being used across many products. Not only does potassium salt reduce the amount of sodium (the harmful element of salt) in foods, but the increased potassium content helps to lower our blood pressure, reducing our risk of stroke, heart disease and death[9]. With that said, some manufacturers are reluctant to use this due its additional cost or hindrance to clean labelling. Regardless, there is always scope for reductions as evidenced in many of Action on Salt's food product surveys[10] – with many companies successfully producing commercially popular foods with less salt. UK salt reduction model The UK salt reduction model has inspired the world and, to date, more than 90 countries now have some form of salt reduction policy in place. In fact, 57 countries have salt targets, including 19 sets of mandated targets. The World Health Organisation (WHO) has released Global Sodium Benchmarks to accelerate progress which have since been adopted by the Pan American Health Organisation (PAHO) and, in many cases, these salt reduction targets are more ambitious than the UK. In parallel with this and the ever-increasing body of evidence implicating salt in cardiovascular disease (CVD), international salt reduction work is gaining momentum. Too much of a good thing The UK was once flying the flag of success for salt reduction, but fast forward ten years and its salt intake has remained relatively unchanged. The voluntary nature of the salt reduction programme has meant we've had to rely heavily on the food industry's willingness to make the necessary changes, with the Government firmly holding that stick and pushing for more progress. The food industry can and must play a vital role in helping people reduce their salt consumption – but not all companies are prepared to step up and play their part by reformulating their products. We are now too reliant on a handful of responsible manufacturers that want to do the right thing, whilst the others sit on their hands, knowing there's no penalty for failing to participate voluntarily. This is evident in the government's last progress report on salt[11] with retailers progressing further than manufacturers. All big companies have the same understanding and capabilities to reduce salt, but for some reason some are succeeding more than others. Time for a level playing field So much more could be achieved with clear, comprehensive mandatory salt reduction targets to create a level-playing field and maximise the impact on our health. Mandatory, comprehensive salt reduction targets are a proportionate intervention that would require all companies to work towards the same standards in the same way that many companies have reduced sugar in drinks as a result of the Soft Drinks Industry Levy. It's difficult, though, to see how further progress can be possible without legislation when we are faced with a food industry that makes vast levels of profit from cheap processed food high in salt as well as calories, fats, and sugars. What is really needed is a real shift in our environment by making healthier foods more prominent and accessible for all. Many investors are increasingly acknowledging their role in building healthier societies[12] and recognise the importance of good health – not only on the public but for their workers and their profits, with health becoming embedded in many business models. For the UK's 7.6m people living with stroke or heart disease, the 16m of us who have high blood pressure and everyone who eats processed and prepared foods from shops, restaurants, fast food outlets and takeaways – salt reduction is vital. But to achieve this, we need food companies to be part of the solution, not the problem. Sonia Pombo, Nutritionist, Campaign Manager, Queen Mary University London email s.pombo@qmul.ac.uk web qmul.ac.uk/wiph/people/profiles/sonia-pombo.html References 1Ma, Y., He, F. J., Sun, Q., Yuan, C., Kieneker, L. M. et al. 2022. 24-Hour Urinary Sodium and Potassium Excretion and Cardiovascular Risk. New England Journal of Medicine 386: 252- 263. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa2109794 2Roth, G. A., Mensah, G. A., Johnson, C. O., Addolorato, G., Ammirati, E., Baddour, L. M. et al. 2020. Global Burden of Cardiovascular Diseases and Risk Factors, 1990–2019: Update From the GBD 2019 Study. Journal of the American College of Cardiology. 76: 2982– 3021. Available from: https://www.sciencedirect.com/science/article/pii/S0735109720377755?via%3Dihub 3 Department of Health. 2015. Salt reduction – onwards and downwards! Available from : https://webarchive.nationalarchives.gov.uk/20180201175801/https://responsibilitydeal.dh.gov.uk/salt-reduction-onwards-and-downwards/ 4 World Health Organisation. 2020. Salt reduction Available from: https://www.who.int/news-room/fact-sheets/detail/salt-reduction 5Public Health England. Salt reduction: Targets for 2024 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/915406/2024_salt_reduction_targets_070920-FINAL-1.pdf 6Ni Mhurchu, C., Capelin, C., Dunford, E. K., Webster, J. L., Neal, B. C., Jebb, S. A. 2011. Sodium content of processed foods in the United Kingdom: analysis of 44,000 foods purchased by 21,000 households. American Journal of Clinical Nutrition 93: 594- 600. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3561609/ 7He, F. J., Pombo-Rodrigues, S., Macgregor, G. A. 2014. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open. 4: e004549. Available from: https://bmjopen.bmj.com/content/4/4/e004549 8Alonso, S., Tan, M., Wang, C., Kent, S., Cobiac, L. et. al. 2021. Impact of the 2003 to 2018 Population Salt Intake Reduction Program in England. Hypertension 77: 1086- 1094. Available from : https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.120.16649 9Neal, B., Wu, Y., Feng, X., Zhang, R., Zhang, Y. et al. 2021. Effect of Salt Substitution on Cardiovascular Events and Death. New England Journal of Medicine 385: 1067- 1077. Available from: https://www.nejm.org/doi/full/10.1056/nejmoa2105675 10 Action on Salt. 2023. Salt surveys. Available at: https://www.actiononsalt.org.uk/salt-surveys/ 11 Public Health England. 2020. Salt targets 2017: second progress report. Available from: https://www.gov.uk/government/publications/salt-targets-2017-second-progress-report 12Share Action. 2022. Global investor alliance managing $5.7 trillion unites to improve population health. Available from : https://shareaction.org/news/global-investor-alliance-managing-5-7-trillion-unites-to-improve-population-health Volume37, Issue1March 2023Pages 32-35 ReferencesRelatedInformation