Salt Reduction Initiatives Research Articles

Salt intake reduction strategies in the Eastern Mediterranean Region.

The high burden of noncommunicable diseases (NCDs), particularly cardiovascular diseases (CVDs), in countries of the Eastern Mediterranean Region requires an immediate public health attention. The World Health Organization (WHO) has recommended salt reduction as a "best buy", recognizing it as one of the most cost-effective approaches in preventing NCDs and reducing CVDs and medical costs. In the context of the global target to reduce salt intake by 30% by 2025, the objective of this review is to present an up-to-date overview of the current salt reduction initiatives in the Region by highlighting regional and national policies, strategies, and activities that aim at characterizing and/or reducing the intakes of dietary salt. This review details the WHO policies and strategies which address salt reduction in the WHO Eastern Mediterranean Region. The high intake levels of sodium in the countries of the Region are emphasized. The policies and strategies in place to address this situation are described, however, there is a need for more data on intake levels. There are a number of salt reduction initiatives currently being undertaken in the countries of the Region. The WHO should continue to play a key role in providing evidence-based tools for the planning, implementation, and surveillance of national salt reduction initiatives.

A Survey of Sodium Chloride Content in Italian Artisanal and Industrial Bread.

A nationwide survey on salt content in both artisanal and industrial bread was undertaken in Italy to establish a baseline for salt reduction initiatives. Excess sodium intake in the diet is associated with high blood pressure and the risk of cardiovascular diseases. Bread has been identified as a major contributor to salt intake in the Italian diet. Most of the bread consumed in Italy comes from artisanal bakeries so 135 artisanal bread were sampled in 56 locations from Northern to Southern Italy together with 19 samples of industrial bread representative of the entire Italian production. Sodium chloride content was analysed according to the Volhardt’s method. A salt content between 0.7% and 2.3% g/100 g (as is basis) was found, with a mean value of 1.5% (Standard Deviation, 0.3). However, the majority of samples (58%) had a content below 1.5%, with 12% having a very low salt content (between 0.5% and 1.0%), whereas the remaining 42% had a salt content higher than the mean value with a very high salt content (>2.0%) recorded for 3% of samples. As regards the industrial bread, an average content of 1.6% was found (SD, 0.3). In this group, most of the samples (56%) had a very high content between 2.0% and 2.5%, whereas 5% only had a content between 1.1% and 1.5%. Statistics on salt content are also reported for the different categories of bread.

P6581Decrease in prevalence of hypertension in 15 years: a success story of a population through salt reduction initiatives

P6581Decrease in prevalence of hypertension in 15 years: a success story of a population through salt reduction initiatives

Barriers to Dietary Salt Reduction among Hypertensive Patients

Despite knowing the ill consequences of high salt intake, many hypertensive patients in Nepal continue to consume high levels of salt in their diet. Hence, this study aims to reveal the barriers to dietary salt reduction among hypertensive patients in Nepal. A barrier analysis was conducted in the outpatient department of Sahid Gangalal National Heart Center, Nepal among 180 hypertensive patients under physician advice to reduce salt in their diet. A logistic regression modeling was used to calculate odds ratios (ORs) for the barriers. Low self-efficacy (OR=0.04; 95%CI: 0.01-0.24) was a significant barrier to dietary salt reduction among study participants, as well as lack of taste (23.3% Compliant vs. 53.3% Non-Compliant) and lack of family support (5.6% compliant vs. 27.8% noncompliant).Difficulty in remembering to eat low salt (OR=3.89; 95%CI: 1.28-11.87) was a barrier for males. There were differences seen by gender in barriers: among female participants, low perceived social acceptability (OR=0.05; 95%CI: 0.01-0.32), and living in a joint rather than nuclear family (OR=0.21; 95%CI: 0.06-0.77) were significant barriers to dietary salt reduction. Presence of a son (7.8% Compliant vs.30.0% Non-Compliant) and/or husband (1.1% Compliant vs. 11.1% Non-Compliant) had an influence on females' decisions to reduce salt. Perceived self-efficacy, reminder to action, social acceptability, and family structure were barriers to dietary salt reduction among hypertensive patients in Nepal. Presence of a son and/or husband had an influence on females' decisions to reduce salt. Addressing the modifiable barriers identified in this study is important for successful salt reduction initiatives in Nepal. The inclusion of a son and/or husband in nutritional counseling may be beneficial to achieve salt reduction in this population.

Applying a Consumer Behavior Lens to Salt Reduction Initiatives.

Reformulation of food products to reduce salt content has been a central strategy for achieving population level salt reduction. In this paper, we reflect on current reformulation strategies and consider how consumer behavior determines the ultimate success of these strategies. We consider the merits of adopting a ‘health by stealth’, silent approach to reformulation compared to implementing a communications strategy which draws on labeling initiatives in tandem with reformulation efforts. We end this paper by calling for a multi-actor approach which utilizes co-design, participatory tools to facilitate the involvement of all stakeholders, including, and especially, consumers, in making decisions around how best to achieve population-level salt reduction.

Modeled changes in US sodium intake from reducing sodium concentrations of commercially processed and prepared foods to meet voluntary standards established in North America: NHANES

Background: Approximately 2 in 3 US adults have prehypertension or hypertension that increases their risk of cardiovascular disease. Reducing sodium intake can decrease blood pressure and prevent hypertension. Approximately 9 in 10 Americans consume excess sodium (≥2300 mg/d). Voluntary sodium standards for commercially processed and prepared foods were established in North America, but their impact on sodium intake is unclear.Objective: We modelled the potential impact on US sodium intake of applying voluntary sodium standards for foods.Design: We used NHANES 2007-2010 data for 17,933 participants aged ≥1 y to model predicted US daily mean sodium intake and the prevalence of excess sodium intake with the use of the standards of the New York City's National Salt Reduction Initiative (NSRI) and Health Canada for commercially processed and prepared foods. The Food and Nutrient Database for Dietary Studies food codes corresponding to foods reported by NHANES participants were matched to NSRI and Health Canada food categories, and the published sales-weighted mean percent reductions were applied.Results: The US population aged ≥1 y could have reduced their usual daily mean sodium intake of 3417 mg by 698 mg (95% CI: 683, 714 mg) by applying NSRI 2014 targets and by 615 mg (95% CI: 597, 634 mg) by applying Health Canada's 2016 benchmarks. Significant reductions could have occurred, regardless of age, sex, race/ethnicity, income, education, or hypertension status, up to a mean reduction in sodium intake of 850 mg/d in men aged ≥19 y by applying NSRI targets. The proportion of adults aged ≥19 y who consume ≥2300 mg/d would decline from 88% (95% CI: 86%, 91%) to 71% (95% CI: 68%, 73%) by applying NSRI targets and to 74% (95% CI: 71%, 76%) by applying Health Canada benchmarks.Conclusion: If established sodium standards are applied to commercially processed and prepared foods, a significant reduction of US sodium intake could occur.

Sodium and Potassium Intake in Healthy Adults in Thessaloniki Greater Metropolitan Area-The Salt Intake in Northern Greece (SING) Study.

A reduction in population sodium (as salt) consumption is a global health priority, as well as one of the most cost-effective strategies to reduce the burden of cardiovascular disease. High potassium intake is also recommended to reduce cardiovascular disease. To establish effective policies for setting targets and monitoring effectiveness within each country, the current level of consumption should be known. Greece lacks data on actual sodium and potassium intake. The aim of the present study was therefore to assess dietary salt (using sodium as biomarker) and potassium intakes in a sample of healthy adults in northern Greece, and to determine whether adherence to a Mediterranean diet is related to different sodium intakes or sodium-to-potassium ratio. A cross-sectional survey was carried out in the Thessaloniki greater metropolitan area (northern Greece) (n = 252, aged 18–75 years, 45.2% males). Participants’ dietary sodium and potassium intakes were determined by 24-hour urinary sodium and potassium excretions. In addition, we estimated their adherence to Mediterranean diet by the use of an 11-item MedDietScore (range 0–55). The mean sodium excretion was 175 (SD 72) mmol/day, equivalent to 4220 (1745) mg of sodium or 10.7 (4.4) g of salt per day, and the potassium excretion was 65 (25) mmol/day, equivalent to 3303 (1247) mg per day. Men had higher sodium and potassium excretions compared to women. Only 5.6% of the sample had salt intake <5 g/day, which is the target intake recommended by the World Health Organization. Mean sodium-to-potassium excretion ratio was 2.82 (1.07). There was no significant difference in salt or potassium intake or their ratio across MedDietScore quartiles. No significant relationships were found between salt intake and adherence to a Mediterranean diet, suggesting that the perception of the health benefits of the Mediterranean diet does not hold when referring to salt consumption. These results suggest the need for a larger, nation-wide survey on salt intake in Greece and underline the importance of continuation of salt reduction initiatives in Greece.

Salt reduction in China: a state-of-the-art review.

ObjectiveThis study aimed to reveal the latest evidence on salt reduction initiatives in China in order to identify the contextual cost-effective interventions, as well as the barriers encountered during China’s long march to reach its population salt reduction goal.BackgroundPopulation-based salt reduction has been considered as one of the most cost-effective strategies in the world for the prevention and control of noncommunicable diseases. China, along with its sustained economic growth, faces increasing burdens from chronic diseases such as cardiovascular and kidney diseases. With policy support and cross-sector collaboration, various salt reduction initiatives have been adopted in China in order to reduce such dietary risk, especially since the beginning of this millennium.MethodsThis study conducted structured literature reviews in both English and Chinese databases and synthesized the latest evidence on the association of salt intake and health, as well as salt intake among Chinese and population-based salt reduction strategies in China and around the world.FindingsDietary salt restriction has been found to contribute to the reduction of blood pressure among both the normotensives and hypertensives bringing associated reduced disease burdens and great public health benefits. With gender, ethnic, and regional variations, salt intake levels in the population in China are well above the recommended threshold and physiological need. Admittedly, excessive salt intake precipitates the high prevalence of hypertension and cardiovascular disease among the Chinese. Considering that the majority of the dietary salt is added during cooking in China, salt substitutes, salt restriction tools, and health education are the most common salt reduction initiatives with varying levels of effectiveness and acceptability among the Chinese population.ImplicationOverwhelming evidence is in support of a well-coordinated nationwide salt restriction initiative as a key public health strategy for the prevention and control of hypertension and its related diseases. Orchestrated efforts from the government, industries, academia, health professionals, and the general public are required to achieve China’s long-term goal for salt reduction.

Analysis of a voluntary initiative to reduce sodium in processed and ultra-processed food products in Argentina: the views of public and private sector representatives.

The Less Salt, More Life program was the first voluntary salt reduction initiative in Argentina. This article analyzes the perspectives of the stakeholders involved in this voluntary agreement between the Ministry of Health and the food industry to gradually reduce sodium content in processed foods. This exploratory case study used a qualitative approach including 29 in-depth interviews with stakeholders from the public and private sectors and identified the role of the different stakeholders and their perceptions regarding the challenges encountered in the policy process that contribute to the debate on public-private partnerships in health policies. The article also discusses the initiative's main challenges and controversies.

The Science of Salt: A Regularly Updated Systematic Review of the Implementation of Salt Reduction Interventions (November 2015 to February 2016)

The objective of this periodic review was to identify, summarize, and appraise studies relating to the implementation of salt reduction strategies that were retrieved between November 2015 and February 2016. From the established MEDLINE search, 56 studies were identified as relevant to the implementation of salt reduction initiatives. Detailed appraisal was performed on seven studies that evaluated the impact of salt reduction interventions. While study quality varied, all had one or more risks related to bias. There was consistent evidence, from three studies, demonstrating that setting-based structural interventions to improve the nutritional composition of foods were effective in reducing salt but mixed evidence in relation to the effectiveness of behavioral interventions. The development of an evaluation guidance framework that supports scientific rigor and external validity would aid future design and interpretation of studies evaluating salt reduction interventions, particularly for low-resource countries.

US Food Industry Progress During the National Salt Reduction Initiative: 2009–2014

To assess the US packaged food industry's progress from 2009 to 2014, when the National Salt Reduction Initiative had voluntary, category-specific sodium targets with the goal of reducing sodium in packaged and restaurant foods by 25% over 5 years. Using the National Salt Reduction Initiative Packaged Food Database, we assessed target achievement and change in sales-weighted mean sodium density in top-selling products in 61 food categories in 2009 (n = 6336), 2012 (n = 6898), and 2014 (n = 7396). In 2009, when the targets were established, no categories met National Salt Reduction Initiative 2012 or 2014 targets. By 2014, 26% of categories met 2012 targets and 3% met 2014 targets. From 2009 to 2014, the sales-weighted mean sodium density declined significantly in almost half of all food categories (43%; 26/61 categories). Overall, sales-weighted mean sodium density declined significantly (by 6.8%; P < .001). National target setting with monitoring through a partnership of local, state, and national health organizations proved feasible, but industry progress was modest. The US Food and Drug Administration's proposed voluntary targets will be an important step in achieving more substantial sodium reductions.

“Reaching its limits”: industry perspectives on salt reduction

Purpose – The purpose of this paper is to explore the barriers to, and implications of, salt reduction initiatives within the UK food manufacturing industry. Design/methodology/approach – In total, 13 technical and new product development (NPD) managers were purposefully sampled from businesses supplying foods within the chilled convenience food sector. Data were generated using semi-structured interviews incorporating the critical incident technique. Thematic and comparative analyses identified similarities and differences in the challenges facing different product categories within the sector. Findings – Barriers to further salt reduction included: manufacturing limitations; NPD constraints; food safety, quality and shelf-life trade-offs; and organoleptic acceptance. No single barrier dominated industry concerns and many barriers were interlinked. Overarching issues of competitive inequality between signatories and non-participants to voluntary salt reduction agreements, and the experience of product reformulation having reached its limits were prevalent. Originality/value – This research provides a food industry perspective on the identified barriers faced by UK food processors and manufacturers in advancing salt reduction within the chilled convenience sector.

Dietary salt intake estimation by routine healthcare workers in an urban slum of Chandigarh: A feasibility study

Context: Hypertension is an important modifiable risk factor for cardiovascular disease (CVD). From numerous studies, it was observed that excess dietary salt is responsible for 17-30% of high blood pressure and increases the risk of blood pressure-related CVD events in normotensives also. Employing the most appropriate method is important to assess the baseline consumption as well as to evaluate the impact of potential salt reduction initiatives. Aim and Objective: The aim and objective of this study is to collect salt data at population level by health workers, with a standard questionnaire, as they regularly visit household level for other national programs. Methods: A cross-sectional study was conducted in an urban slum of Chandigarh for salt data collection using the WHO STEPS instrument version 3.1. Sample size of 255 was calculated by Epi Info software. However, we have taken 300 participants for our study. Six health staff from Urban Health Training Centre, Indira Colony, Department of Community Medicine, PGIMER, Chandigarh, were involved. They were trained regarding filling the questionnaire. Investigator then re-interviewed 20% of the respondents interviewed by health workers, and a comparison of agreement was done. Results: The range of agreement was observed to be 55-90%, and percentage agreement varies between 63% and 83%, except in 3 questions which could be considered reasonable for initiating public health interventions. Conclusion: From this study, we can conclude that even in resource-poor settings, it is possible to collect salt data by proper training of health workers, and thus, we can initiate evidence-based salt reduction interventions in the community.

Dietary Salt Intake and Discretionary Salt Use in Two General Population Samples in Australia: 2011 and 2014.

The limited Australian measures to reduce population sodium intake through national initiatives targeting sodium in the food supply have not been evaluated. The aim was, thus, to assess if there has been a change in salt intake and discretionary salt use between 2011 and 2014 in the state of Victoria, Australia. Adults drawn from a population sample provided 24 h urine collections and reported discretionary salt use in 2011 and 2014. The final sample included 307 subjects who participated in both surveys, 291 who participated in 2011 only, and 135 subjects who participated in 2014 only. Analysis included adjustment for age, gender, metropolitan area, weekend collection and participation in both surveys, where appropriate. In 2011, 598 participants: 53% female, age 57.1(12.0)(SD) years and in 2014, 442 participants: 53% female, age 61.2(10.7) years provided valid urine collections, with no difference in the mean urinary salt excretion between 2011: 7.9 (7.6, 8.2) (95% CI) g/salt/day and 2014: 7.8 (7.5, 8.1) g/salt/day (p = 0.589), and no difference in discretionary salt use: 35% (2011) and 36% (2014) reported adding salt sometimes or often/always at the table (p = 0.76). Those that sometimes or often/always added salt at the table and when cooking had 0.7 (0.7, 0.8) g/salt/day (p = 0.0016) higher salt excretion. There is no indication over this 3-year period that national salt reduction initiatives targeting the food supply have resulted in a population reduction in salt intake. More concerted efforts are required to reduce the salt content of manufactured foods, together with a consumer education campaign targeting the use of discretionary salt.

Salt Reduction Initiatives around the World - A Systematic Review of Progress towards the Global Target.

ObjectiveTo quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025.MethodsA systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework.ResultsA total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt.ConclusionThe large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.

Developing a national salt reduction strategy for Mongolia.

The increase in prevalence of risk factors such as hypertension has contributed to an incremental rise in non-communicable diseases (NCDs) in Mongolia over recent decades, such that they now account for 80% of all deaths in the country. Salt reduction is one of the most cost-effective interventions to reduce the burden of NCDs. In 2011, the Ministry of Health (MOH) instigated the development of a national salt reduction strategy for Mongolia. As part of a 2-week national consultation and training program on salt reduction, it established an inter-sectoral working party and organized a series of bilateral meetings and visits to factories. Actions arising included a baseline survey of population salt consumption patterns and the implementation of a series of pilot salt reduction initiatives. The results of the baseline assessment revealed that average daily intake of salt, based on 24 hour urine samples from a representative national sample (n=1,027), was 11.06±5.99 g in 2011, more than double the World Health Organization (WHO) five grams recommendation. Moreover, while most participants knew that salt was bad for health, few were taking efforts to reduce intake, and many were consuming highly salty meals and tea; salt in tea alone was estimated to contribute 30% of daily salt intake. A pilot Pinch Salt intervention to reduce salt consumption of factory workers was undertaken in Ulaanbaatar (UB) city between 2012 and 2013, and was associated with a reduction of 2.8 g of salt intake. Ongoing food industry initiatives have led to significant reductions in salt levels in bread, and companies producing processed meat have indicated a willingness to reduce salt. Relevant stakeholders have also supported the campaign by participating in annual World Salt Awareness Week events. The activities to date have demonstrated the potential for action and there is now a need scale these up to a national level to ensure that Mongolia is in a strong position to achieve a 30% reduction in population salt intake by 2025. The main goal of the Mongolian national salt reduction strategy is to create a social, economic and legal environment that supports salt reduction, including by influencing food supply, increasing partnerships between government and relevant stakeholders, and creating an enabling environment to support improved consumer choices. The strategy will be implemented from 2015 to 2025, with an interim review of progress in 2020. Given that Mongolia has one of the highest rates of stroke in the world, which is strongly associated with population-wide blood pressure (BP) levels, the addition of a population-based stroke surveillance program would provide a reliable direct assessment of the impact of these salt reduction initiatives on the health of the Mongolian people. The results from this research would likely be widely generalizable to other populations experiencing similar lifestyle transitional changes.

Salt reduction in Australia: from advocacy to action.

As part of its endorsement of the World Health Organization's Global Action Plan to prevent non-communicable diseases, the Federal Government of Australia has committed to a 30% reduction in average population salt intake by 2025. Currently, mean daily salt intake levels are 8-9 g, varying by sex, region and population group. A number of salt reduction initiatives have been established over the last decade, but key elements for a co-ordinated population-level strategy are still missing. The objective of this review is to provide a comprehensive overview of existing population-level salt reduction activities in Australia and identify opportunities for further action. A review of the published literature and stakeholder activities was undertaken to identify and document current activities. The activities were then assessed against a pre-defined framework for salt reduction strategies. A range of initiatives were identified from the review. The Australian Division of World Action on Salt and Health (AWASH) was established in 2005 and in 2007 launched its Drop the Salt! Campaign. This united non-governmental organisations (NGOs), health and medical and food industry organisations in a co-ordinated advocacy effort to encourage government to develop a national strategy to reduce salt. Subsequently, in 2010 the Federal Government launched its Food and Health Dialogue (FHD) with a remit to improve the health of the food supply in Australia through voluntary partnerships with food industry, government and non-government public health organisations. The focus of the FHD to date has been on voluntary reformulation of foods, primarily through salt reduction targets. More recently, in December 2014, the government's Health Star Rating system was launched. This front of pack labelling scheme uses stars to highlight the nutritional profile of packaged foods. Both government initiatives have clear targets or criteria for industry to meet, however, both are voluntary and the extent of industry uptake is not yet clear. There is also no parallel public awareness campaign to try and influence consumer behaviour relating to salt and no agreed mechanism for monitoring national changes in salt intake. The Victorian Health Promotion Foundation (VicHealth) has recently instigated a State-level partnership to advance action and will launch its strategy in 2015. In conclusion, salt reduction activities are currently being implemented through a variety of different programs but additional efforts and more robust national monitoring mechanisms are required to ensure that Australia is on track to achieve the proposed 30% reduction in salt intake within the next decade.

Expansion of the National Salt Reduction Initiative: A Mathematical Model of Benefits and Risks of Population-Level Sodium Reduction.

The National Salt Reduction Initiative, in which food producers agree to lower sodium to levels deemed feasible for different foods, is expected to significantly reduce sodium intake if expanded to a large sector of food manufacturers. Given recent data on the relationship between sodium intake, hypertension, and associated cardiovascular disease at a population level, we sought to examine risks and benefits of the program. To estimate the impact of further expanding the initiative on hypertension, myocardial infarction (MI) and stroke incidence, and related mortality, given food consumption patterns across the United States, we developed and validated a stochastic microsimulation model of hypertension, MI, and stroke morbidity and mortality, using data from food producers on sodium reduction among foods, linked to 24-hour dietary recalls, blood pressure, and cardiovascular histories from the National Health and Nutrition Examination Survey. Expansion of the initiative to ensure all restaurants and manufacturers reach agreed-upon sodium targets would be expected to avert from 0.9 to 3.0 MIs (a 1.6%-5.4% reduction) and 0.5 to 2.8 strokes (a 1.1%-6.2% reduction) per 10,000 Americans per year over the next decade, after incorporating consumption patterns and variations in the effect of sodium reduction on blood pressure among different demographic groups. Even high levels of consumer addition of table salt or substitution among food categories would be unlikely to neutralize this benefit. However, if recent epidemiological associations between very low sodium and increased mortality are causal, then older women may be at risk of increased mortality from excessively low sodium intake. An expanded National Salt Reduction Initiative is likely to significantly reduce hypertension and hypertension-related cardiovascular morbidity but may be accompanied by potential risks to older women.

Abstract P031: Significant Predicted Change in Usual Sodium Intake for the U.S. Population From Meeting Sodium Standards for Commercially-Packaged and Restaurant Foods: National Health and Nutrition Examination Survey, 2007-2010

Background: A 400 mg daily reduction in the average sodium intake of the U.S. population is projected to save up to 28,000 lives and $7 billion health care dollars annually. In 2010, the Institute of Medicine recommended setting standards for the sodium content of commercially-packaged and restaurant foods to reduce U.S.sodium intake given the majority of sodium intake is from these foods. We assessed this hypothesis. Methods: We developed models using 2007-2010 data for 17,979 participants one year and older participating in two 24-hour dietary recalls, a part of the What We Eat in America component of the National Health and Nutrition Examination Survey. We projected the sodium content in foods reported by survey respondents based on percent changes in sales weighted averages from baseline for specific food categories using New York City’s National Salt Reduction Initiative (NSRI) 2014 targets or Health Canada’s 2016 sodium benchmarks. To predict the changes in usual sodium intake from foods for the U.S. population aged &gt; 1 year we used analyses accounting for the complex survey design with measurement error models to adjust for within person day-to-day variation in intake. Results: Based on a conservative estimate of the foods included in specific categories, if NSRI targets had been met in 2007-10, we estimated that the U.S. population aged &gt; 1 year could have reduced their average usual daily mean sodium intake of 3343 mg by 14%, or 484 mg (95% Confidence Interval [CI], 471 mg, 498 mg). If Health Canada’s benchmarks were met, the US population could have reduced their average usual daily sodium intake by 18% or 612 mg (95% CI, 594 mg, 630 mg). Across age, sex, and race-ethnic population subgroups, the average predicted relative reductions in sodium intake by group ranged from 13% -15% using NSRI targets and 16%-19% using Health Canada’s benchmarks. If sodium standards had been met, we estimated the proportion of adults aged 19 years and older consuming &gt; 2300 mg daily would have declined from 87% (95% CI, 84%, 89%) to 75% (95% CI, 72%, 77%) using NSRI targets or to 70% (95% CI, 68%, 73%) using Health Canada benchmarks. The proportion of adults consuming &gt; 1500 mg daily would have declined from 99% to 96%-97%. Conclusion: Results suggest that if U.S. commercially-packaged and restaurant foods had met established sodium standards, a significant reduction in sodium intake could have occurred across age, sex, and race-ethnic groups in the U.S. population.

Targets and Timelines for Reducing Salt in Processed Food in the Americas

Reducing dietary salt is one of the most effective interventions to lessen the burden of premature death and disability. In high-income countries and those in nutrition transition, processed foods are a significant if not the main source of dietary salt. Reformulating these products to reduce their salt content is recommended as a best buy to prevent chronic diseases across populations. In the Americas, there are targets and timelines for reduced salt content of processed foods in 8 countries--Argentina, Brazil, Canada, Chile, Ecuador, Mexico, and the National Salt Reduction Initiative in the United States and Paraguay. While there are common elements across the countries, there are notable differences in their approaches: 4 countries have exclusively voluntary targets, 2 countries have combined voluntary and regulated components, and 1 country has only regulations. The countries have set different types of targets and in some cases combined them: averages, sales-weighted averages, upper limits, and percentage reductions. The foods to which the targets apply vary from single categories to comprehensive categories accounting for all processed products. The most accessible and transparent targets are upper limits per food category. Most likely to have a substantive and sustained impact on salt intake across whole populations is the combination of sales-weighted averages and upper limits. To assist all countries with policies to improve the overall nutritional value of processed foods, the authors call for food companies to supply food composition data and product sales volume data to transparent and open-access platforms and for global companies to supply the products that meet the strictest targets to all markets. Countries participating in common markets at the subregional level can consider harmonizing targets, nutrition labels, and warning labels.