Salt Reduction Strategies Research Articles

Leveraging ongoing research to evaluate the health impacts of South Africa's salt reduction strategy: a prospective nested cohort within the WHO-SAGE multicountry, longitudinal study

IntroductionAttempting to curb the rising epidemic of hypertension, South Africa implemented legislation in June 2016 mandating maximum sodium levels in a range of manufactured foods that contribute significantly to population...

The flavor and acceptability of six different potassium-enriched (sodium reduced) iodized salts: a single-blind, randomized, crossover design.

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.

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.

PS 18-24 Salt Reduction Strategy in Thailand

PS 18-24 Salt Reduction Strategy in Thailand

PS 18-15 SALT AND POTASSIUM INTAKE, AND BLOOD PRESSURE IN SOUTH AFRICAN ADULTS

Objective: Attempts to curb the hypertension epidemic have resulted in varied salt reduction strategies across the globe. In June 2016, South Africa implements legislation limiting maximum sodium levels in a range of foods previously identified as contributing significantly to population sodium intake. This study was designed to establish baseline sodium and potassium intake, as well as blood pressure (BP) prior to legislation coming into effect. Design and Method: Participants were recruited using a nested cohort design within the World Health Organization Study on global AGEing and adult health (WHOSAGE), a multi-national longitudinal study of the health and well-being of adults and the ageing process (18+ years, with an emphasis on adults 50+ years). The SAGE-South Africa cohort consists of randomly selected households (n = 4583 adults) across the country. Spot and 24-hour urine samples were collected in a random sub-sample and sodium, potassium and creatinine analysed. BP, anthropometry, and sociodemographic data were collected at the same time, as part of SAGE Wave2. Results: Median age of the group was 55 years (IQR 24; n = 450; 80% female). Daily salt and potassium excretion varied greatly, with a median of 6.7 g salt/day (1–43 g/day), 1.3 g potassium/day (0.2–8.5 g/day) and a molar sodium-to-potassium ratio of 3.3 (0.3–16.0). Previous diagnosis of hypertension was low (22%) but BP readings and medication use revealed 42% to be currently hypertensive (71% untreated; 15% treated uncontrolled; 14% treated controlled). In comparison to WHO recommendations, 69% had a salt intake above 5 g/day, 91% had a potassium intake below 90 mmol/d and 96% had Na:K ratio >1. Only 3 (<1%) participants achieved all three recommendations. Conclusions: Given the high prevalence of hypertension and untreated hypertension among South African adults, the sodium legislation is a welcome step in reducing population BP. Further investigation and intervention for increasing population potassium intakes could be a next step.

Pro: Reducing salt intake at population level: is it really a public health priority?

A reduction in salt intake reduces blood pressure, stroke and other cardiovascular events, including chronic kidney disease, by as much as 23% (i.e. 1.25 million deaths worldwide). It is effective in both genders, any age, ethnic group, and in high-, medium- and low-income countries. Population salt reduction programmes are both feasible and effective (preventive imperative). Salt reduction programmes are cost-saving in all settings (high-, middle- and low-income countries) (economic imperative). Public health policies are powerful, rapid, equitable and cost-saving (political imperative). The important shift in public health has not occurred without obstinate opposition from organizations concerned primarily with the profits deriving from population high salt intake and less with public health benefits. A key component of the denial strategy is misinformation (with 'pseudo' controversies). In general, poor science has been used to create uncertainty and to support inaction. This paper summarizes the evidence in favour of a global salt reduction strategy and analyses the peddling of well-worn myths behind the false controversies.

Projected Impact of Salt Restriction on Prevention of Cardiovascular Disease in China: A Modeling Study

ObjectivesTo estimate the effects of achieving China’s national goals for dietary salt (NaCl) reduction or implementing culturally-tailored dietary salt restriction strategies on cardiovascular disease (CVD) prevention.MethodsThe CVD Policy Model was used to project blood pressure lowering and subsequent downstream prevented CVD that could be achieved by population-wide salt restriction in China. Outcomes were annual CVD events prevented, relative reductions in rates of CVD incidence and mortality, quality-adjusted life-years (QALYs) gained, and CVD treatment costs saved.ResultsReducing mean dietary salt intake to 9.0 g/day gradually over 10 years could prevent approximately 197 000 incident annual CVD events [95% uncertainty interval (UI): 173 000–219 000], reduce annual CVD mortality by approximately 2.5% (2.2–2.8%), gain 303 000 annual QALYs (278 000–329 000), and save approximately 1.4 billion international dollars (Int$) in annual CVD costs (Int$; 1.2–1.6 billion). Reducing mean salt intake to 6.0 g/day could approximately double these benefits. Implementing cooking salt-restriction spoons could prevent 183 000 fewer incident CVD cases (153 000–215 000) and avoid Int$1.4 billion in CVD treatment costs annually (1.2–1.7 billion). Implementing a cooking salt substitute strategy could lead to approximately three times the health benefits of the salt-restriction spoon program. More than three-quarters of benefits from any dietary salt reduction strategy would be realized in hypertensive adults.ConclusionChina could derive substantial health gains from implementation of population-wide dietary salt reduction policies. Most health benefits from any dietary salt reduction program would be realized in adults with hypertension.

Health and Sustainable Development Challenges of the 21st Century: A Comparative Analysis of Salt Reduction Strategies

Health and Sustainable Development Challenges of the 21st Century: A Comparative Analysis of Salt Reduction Strategies

Dietary sodium and iodine in remote Indigenous Australian communities: will salt-reduction strategies increase risk of iodine deficiency? A cross-sectional analysis and simulation study.

BackgroundExcess salt intake is a global issue. Effective salt-reduction strategies are needed, however, as salt is a vehicle for iodine fortification, these strategies may also reduce iodine intake. This study examines the case of the remote Indigenous Australian population; we employed an innovative, objective method to assess sodium and iodine intakes against requirements and modelled the potential effects of salt-reduction strategies on estimated sodium and iodine intakes.DesignStore-sales data were collected from 20 remote Indigenous community stores in 2012–14 representing the main source of food for 2 years for ~8300 individuals. Estimated average sodium and iodine intakes were compared against recommendations (nutrient reference values weighted to age and gender distribution). Linear programming was employed to simulate potential effects of salt-reduction strategies on estimated sodium and iodine intakes.ResultsEstimated average sodium intake was 2770 (range within communities 2410–3450) mg/day, far exceeding the population-weighted upper limit (2060 mg/day). Discretionary (added) salt, bread and processed meat were the biggest contributors providing 46 % of all sodium. Estimated average iodine intake was within recommendations at 206 (186–246) μg/day. The following scenarios enabled modelling of estimated average salt intake to within recommendations: 1) 67 % reduction in sodium content of bread and discretionary salt intake, 2) 38 % reduction in sodium content of all processed foods, 3) 30 % reduction in sodium content of all processed foods and discretionary salt intake. In all scenarios, simulated average iodine intakes remained within recommendations.ConclusionsSalt intakes of the remote Indigenous Australian population are far above recommendations, likely contributing to the high prevalence of hypertension and cardiovascular mortality experienced by this population. Salt-reduction strategies could considerably reduce salt intake in this population without increasing risk of iodine deficiency at the population-level. These data add to the global evidence informing salt-reduction strategies and the evidence that these strategies can be synergistically implemented with iodine deficiency elimination programmes.Trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN12613000694718.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2686-1) contains supplementary material, which is available to authorized users.

A Meta-Analysis of Effect of Dietary Salt Restriction on Blood Pressure in Chinese Adults.

The aim of this study was to estimate the effects of dietary salt reduction on blood pressure (BP) in Chinese adults and the effects of China-specific cooking salt-reduction strategies (the use of salt substitutes and salt-restriction spoons). The PubMed and China National Knowledge Infrastructure databases were searched for studies satisfying the search criteria. Outcomes extracted from each included study were 24-h urinary sodium excretion, salt (sodium chloride) intake, and BP before and after dietary salt lowering. A random-effects meta-analysis was performed, and results were evaluated for evidence of publication bias and heterogeneity. Because most studies aggregated results for hypertensive and normotensive participants, estimates were made for hypertensive participants only and for hypertensive and normotensive participants combined. Six salt-restriction experiment studies (3,153 participants), 4 cooking salt-restriction spoon studies (3,715 participants), and 4 cooking salt-substitute studies (1,730 participants) were analyzed. In salt-restriction experiment studies, the pooled estimate of mean change in 24-h urinary sodium excretion in hypertensive participants was-163.0 mmol/day (95% confidence interval [CI]:-233.5 to-92.5 mmol/day), which was associated with a mean reduction of-8.9 mm Hg (95% CI:-14.1 to-3.7 mm Hg) in systolic BP. Each 1.00-g dietary salt reduction in hypertensive participants was associated with a reduction of 0.94 mm Hg in systolic BP (95% CI: 0.69 to 1.03 mm Hg). These systolic BP reductions in hypertensive participants were 1.71 times greater compared with the mixed hypertensive and normotensive group. Salt-restriction spoon studies demonstrated a 1.46-g decrease in daily salt intake level. The effect of salt-substitute use on systolic BP control was substantial among the hypertensive participants (-4.2 mm Hg; 95% CI:-7.0 to-1.3 mm Hg), but the change did not reach statistical significance in hypertensive and normotensive participants combined (-2.31 mm Hg; 95% CI:-5.57 to 0.94 mm Hg). Salt restriction lowers mean BP in Chinese adults, with the strongest effect among hypertensive participants. Future studies of salt-restriction strategies should be report results stratified by hypertension status and adjust for medication use.

The health impacts of dietary sodium and a low-salt diet

High salt intake is now endemic worldwide. It contributes to the generation and maintenance of high blood pressure, which is now the biggest risk factor for global disease. There is now compelling evidence to support salt reduction in hypertensives and a substantial body of evidence to support salt reduction in the general population to reduce risk of death from cardiovascular disease. In specific diseases such as heart failure and chronic kidney disease, guidelines support the World Health Organization target for reduced salt intake at 5g daily. Achieving a diet that is lower in salt has challenges, but is more likely to be achieved through salt reduction strategies particularly focused on processed food and through educational programs. To be effective, these interventions require collaboration between industry, health agencies and governments.

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.

Applicability of salt reduction strategies in pizza crust

In an effort to reduce population-wide sodium intake from processed foods, due to major health concerns, several different strategies for sodium reduction in pizza crust without any topping were evaluated by sensory analyses. It was possible to reduce sodium by 10% in one single step or to replace 30% of NaCl by KCl without a noticeable loss of salty taste. The late addition of coarse-grained NaCl (crystal size: 0.4–1.4mm) to pizza dough led to an enhancement of saltiness through taste contrast and an accelerated sodium delivery measured in the mouth and in a model mastication simulator. Likewise, the application of an aqueous salt solution to one side of the pizza crust led to an enhancement of saltiness perception through faster sodium availability, leading to a greater contrast in sodium concentration. Each of these two strategies allowed a sodium reduction of up to 25% while maintaining taste quality.

PP.02.33

Objective: As a results of the MINISAL study, that indicated an excess salt intake in Italy, we planned a “The Lower Salt Community Project”, a trial of feasibility, acceptability and safety of a strategy of moderate and gradual reduction of salt intake (15% over 18 months) in an Italian community in the area of Cilento. Design and method: The baseline salt intake was evaluated by 24-hour urinary sodium excretion in randomized samples of the Cilento community and of a control community in a separate area. The control community undertakes the same anthropometrical, nutritional, biochemical and blood pressure (BP) measurements at baseline and at end of the study as the target community, but is the object of simple observation with no kind of active intervention during the follow-up period. Main outcome measure will be the differential change in dietary salt intake at the end of the study between the two communities. Secondary endpoints will be the changes in BP, nutritional, anthropometric, metabolic and hormonal variables, potential target of dietary salt reduction. The active intervention is currently being implemented through the collaboration with local authorities, GPs and health organizations, opinion makers and local schools. Interaction with restaurants, pizzerias, local food producers and catering organizations are being carried out. A crucial role is played by the interaction with media (private TV networks, radios and local newspapers) and by the activation of an INTERNET website and social network profiles. Results: At baseline, the two randomized samples (aged between 35–75 years) were similar for sex, age, BMI, SBP/DBP and urinary volume. The average salt intake was 9.0 g/day and over 90% of the population had a consumption higher than the recommended standard dietary intake of 5 g/day. Conclusions: The results of this feasibility trial will provide information on the possibility to implement similar salt reduction strategies at the regional and national levels.

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.

Evaluation of salt content in school meals

OBJECTIVE: High blood pressure is a major rick factor for cardiovascular disease, and it is closely associated with salt intake. Schools are considered ideal environments to promote health and proper eating habits. Therefore the objective of this study was to evaluate the amount of salt in meals served in school canteens and consumers' perceptions about salt. METHODS: Meals, including all the components (bread, soup, and main dish) were retrieved from school canteens. Salt was quantified by a portable salt meter. For food perception we constructed a questionnaire that was administered to high school students. RESULTS: A total of 798 food samples were analysed. Bread had the highest salt content with a mean of 1.35 g/100 g (SD=0.12). Salt in soups ranged from 0.72 g/100 g to 0.80 g/100 g (p=0.05) and, in main courses, from 0.71 g/100 to 0.97 g/100g (p=0.05). The salt content of school meals is high with a mean value of 2.83 to 3.82 g of salt per meal. Moreover, a high percentage of students consider meals neither salty nor bland, which shows they are used to the intensity/amount of salt consumed. CONCLUSION: The salt content of school meals is high, ranging from 2 to 5 times more than the Recommended Dietary Allowances for children, clearly exceeding the needs for this population, which may pose a health risk. Healthy choices are only possible in environments where such choices are possible. Therefore, salt reduction strategies aimed at the food industry and catering services should be implemented, with children and young people targeted as a major priority.

Salt reduction: Moving from consumer awareness to action

Globally, the average daily dietary salt intake is more than double the recommended level. Given the major role that salt plays in the development of cardiovascular disease, it is important to reduce total salt intake. Key sources of salt in the diet include commercially prepared or manufactured food products and discretionary salt added by consumers during cooking and consumption. Therefore a significant lowering in the current salt intake requires a shift in both commercial foods and consumer behaviour. In terms of commercial foods, the challenge is to achieve further reductions in the salt content while maintaining good taste, stability and texture to ensure consumers will like (or even prefer) these reformulated products. However, a change in consumer behaviour is also required to ensure that lower salt products are accepted and that consumers do not add salt back during cooking. Consumer behaviour change in this area remains complex and has received relatively little attention so far. It is hard for consumers to estimate their salt intake and, while most campaigns focus on raising awareness of reducing salt, this awareness may not always lead to action. The development of scalable and effective salt-reduction behaviour change interventions requires a more in-depth understanding of the relevant consumer behaviours and their determinants, as well as the development of practical behaviour change techniques and facilitators (e.g., provision of appealing lower salt products). Moreover, to speed up the salt reduction progress from ‘awareness’ to ‘action’, key stakeholders need to take responsibility and agree on actions for executing product reformulation and creating consumer behaviour change programmes. This review is intended to inform and support the ongoing development of effective action-oriented global strategies for salt reduction.

Dissolution of NaCl crystals in artificial saliva and water by video-microscopy

Abstract Excess sodium as salt (NaCl) added to foods may be harmful to humans. Most salt intake comes from processed foods, therefore salt reduction strategies should be developed by the food industry. One strategy seeks to optimize the delivery of salt ions inside the mouth. To accomplish this purpose, the dissolution characteristics of salt crystals in saliva must be understood. However, relatively scarce information is available on this topic. This study compares the dissolution of five commercial salts in deionized water and two formulations of artificial saliva, at four temperatures and in the absence of agitation. Salt dissolution was quantified in vitro by analysis of video-microscopy images taken at different times. Higher dissolution rates of salt crystals were found in water than in artificial saliva, and at higher temperatures. Video-microscopy was instrumental to reveal that some crystals were fragmented during dissolution while others remained as a unit of decreasing size until complete solubilization. Increased surface area after fragmentation led to pyramid-shape crystals having the highest dissolution rates. Hence, significant changes can be achieved in the dissolution of salt depending on the crystal structure and its dissolution pattern.

Progress on Salt Reduction in the Pacific Islands: From Strategies to Action

Most populations are consuming too much salt which is the main contributor of high blood pressure, a leading risk factor of cardiovascular disease and stroke. The South Pacific Office of the World Health Organization has been facilitating the development of salt reduction strategies in Pacific Island Countries and areas (PICs). The objective of this analysis was to review progress to date and identify regional actions needed to support PICs and ensure they achieve the global target to reduce population salt intake by 30% by 2025. Relevant available national food, health and non-communicable disease (NCD) plans from all 22 PICs were reviewed. NCD co-ordinators provided updates and relayed experiences through semi-structured interviews. All activities were systematically categorised according to an existing salt reduction framework for the development of salt reduction strategies. Salt reduction consultations had been held in 14 countries and final strategies or action plans developed in nine of these, with drafts available in a further three. Three other countries had integrated salt reduction into NCD strategic plans. Baseline monitoring of salt intake had been undertaken in three countries, salt levels in foods in nine countries and salt knowledge, attitude and behaviour surveys in four countries. Most countries were at early stages of implementation and identified limited resources as a barrier to action. Planned salt reduction strategies included work with food industry or importers, implementing regional salt reduction targets, reducing salt levels in school and hospital meals, behaviour change campaigns, and monitoring and evaluation. There had been good progress on salt reduction planning in PICs. The need for increased capacity to effectively implement agreed activities, supported by regional standards and the establishment of improved monitoring systems, were identified as important steps to ensure the potential cardiovascular health benefits of salt reduction could be fully realised in the region.

Protocol for developing the evidence base for a national salt reduction programme for India

IntroductionThe scientific evidence base in support of salt reduction is strong but the data required to translate these insights into reduced population salt intake are mostly absent. The aim of...